hospital_name,last_updated_on,version,location_name,hospital_address,type_2_npi,license_number|FL,"To the best of its knowledge and belief, this hospital has included all applicable standard charge information in accordance with the requirements of 45 CFR 180.50, and the information encoded is true, accurate, and complete as of the date in the file. This hospital has included all payer-specific negotiated charges in dollars that can be expressed as a dollar amount. For payer-specific negotiated charges that cannot be expressed as a dollar amount in the machine-readable file or not knowable in advance, the hospital attests that the payer-specific negotiated charge is based on a contractual algorithm, percentage or formula that precludes the provision of a dollar amount and has provided all necessary information available to the hospital for the public to be able to derive the dollar amount, including, but not limited to, the specific fee schedule or components referenced in such percentage, algorithm or formula.",attester_name,,,,,,,,,,,,,,,,,, Johns Hopkins All Children's Hospital,4/1/2026,3.0.0,Johns Hopkins All Children's Hospital,"501 Sixth Avenue South, Saint Petersburg, FL 33701",1427114099,4042,TRUE,Cory Domayer,,,,,,,,,,,,,,,,,, description,code|1,code|1|type,code|2,code|2|type,code|3,code|3|type,billing_class,setting,drug_unit_of_measurement,drug_type_of_measurement,modifiers,standard_charge|gross,standard_charge|discounted_cash,payer_name,plan_name,standard_charge|negotiated_dollar,standard_charge|negotiated_percentage,standard_charge|negotiated_algorithm,median_amount,10th_percentile,90th_percentile,count,standard_charge|methodology,standard_charge|min,standard_charge|max,additional_generic_notes "Endo, single, urinary tract",2040,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Endo, single, urinary tract",2040,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],6666,6666,6666,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Endo, single, urinary tract",2040,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. "Endo, single, urinary tract",2040,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. "Endo, single, urinary tract",2040,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Endo, single, urinary tract",2040,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],11361.68,11361.68,11361.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Endo, single, urinary tract",2040,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],,,,0,other,,,No services performed during 15-month lookback period. "Endo, single, urinary tract",2040,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Endo, single, urinary tract",2040,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Endo, single, urinary tract",2040,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Endo, single, urinary tract",2040,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. "Endo, single, urinary tract",2040,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. "Endo, single, urinary tract",2040,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Endo, single, urinary tract",2040,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Endo, single, urinary tract",2040,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. "Endo, single, urinary tract",2040,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Endo, single, urinary tract",2040,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. "Endo, single, urinary tract",2040,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. "Endo, single, urinary tract",2040,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Endo, single, urinary tract",2040,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Endo, single, urinary tract",2040,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. "Endo, single, urinary tract",2040,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",8898.92,8898.92,8898.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Endo, single, urinary tract",2040,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. "Endo, single, urinary tract",2040,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",3887.66,3887.66,3887.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Endo, single, urinary tract",2040,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. "Endo, single, urinary tract",2040,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",,,,0,other,,,No services performed during 15-month lookback period. "Endo, single, urinary tract",2040,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. "Endo, single, pulmonary",2042,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Endo, single, pulmonary",2042,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],5953.5,4430.67,7823.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Endo, single, pulmonary",2042,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",9192.89,9192.89,9192.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Endo, single, pulmonary",2042,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. "Endo, single, pulmonary",2042,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Endo, single, pulmonary",2042,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],7140,6614.11,7516.86,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Endo, single, pulmonary",2042,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],6848.6,5700.24,7514.97,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Endo, single, pulmonary",2042,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,11803.67,10026.49,12287.48,1 through 10,percent of total billed charges,,, "Endo, single, pulmonary",2042,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Endo, single, pulmonary",2042,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Endo, single, pulmonary",2042,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. "Endo, single, pulmonary",2042,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. "Endo, single, pulmonary",2042,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Endo, single, pulmonary",2042,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Endo, single, pulmonary",2042,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. "Endo, single, pulmonary",2042,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Endo, single, pulmonary",2042,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",3390.46,2868.83,3420.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Endo, single, pulmonary",2042,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. "Endo, single, pulmonary",2042,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Endo, single, pulmonary",2042,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,5691,5691,5691,1 through 10,percent of total billed charges,,, "Endo, single, pulmonary",2042,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. "Endo, single, pulmonary",2042,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",3139.66,3139.66,4728.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Endo, single, pulmonary",2042,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",2967.98,2103.1,3906.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Endo, single, pulmonary",2042,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",3081.52,2787.98,3986.8,24,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Endo, single, pulmonary",2042,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",3430.41,3430.41,3774.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Endo, single, pulmonary",2042,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",7919.58,6337.74,8794.58,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Endo, single, pulmonary",2042,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Clinic Visits and Related Services,5012,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Clinic Visits and Related Services,5012,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",290.86,290.86,290.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Clinic Visits and Related Services,5012,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Clinic Visits and Related Services,5012,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],,,,0,other,,,No services performed during 15-month lookback period. Clinic Visits and Related Services,5012,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Clinic Visits and Related Services,5012,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],2479.22,1838.37,4762.68,21,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Clinic Visits and Related Services,5012,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],189.99,189.99,189.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Clinic Visits and Related Services,5012,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,55.51,55.51,55.51,1 through 10,percent of total billed charges,,, Clinic Visits and Related Services,5012,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Clinic Visits and Related Services,5012,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Clinic Visits and Related Services,5012,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Clinic Visits and Related Services,5012,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Clinic Visits and Related Services,5012,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Clinic Visits and Related Services,5012,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Clinic Visits and Related Services,5012,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Clinic Visits and Related Services,5012,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Clinic Visits and Related Services,5012,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",169.39,169.39,395.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Clinic Visits and Related Services,5012,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Clinic Visits and Related Services,5012,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Clinic Visits and Related Services,5012,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Clinic Visits and Related Services,5012,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Clinic Visits and Related Services,5012,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",562.22,483.41,625.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Clinic Visits and Related Services,5012,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Clinic Visits and Related Services,5012,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",520.24,259.35,703.22,21,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Clinic Visits and Related Services,5012,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",232.79,232.79,232.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Clinic Visits and Related Services,5012,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Clinic Visits and Related Services,5012,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Type A ED Visits,5021,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Type A ED Visits,5021,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",591.88,591.88,591.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Type A ED Visits,5021,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 1 Type A ED Visits,5021,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],,,,0,other,,,No services performed during 15-month lookback period. Level 1 Type A ED Visits,5021,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Type A ED Visits,5021,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],,,,0,other,,,No services performed during 15-month lookback period. Level 1 Type A ED Visits,5021,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],,,,0,other,,,No services performed during 15-month lookback period. Level 1 Type A ED Visits,5021,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Level 1 Type A ED Visits,5021,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Type A ED Visits,5021,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Type A ED Visits,5021,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Type A ED Visits,5021,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Type A ED Visits,5021,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Type A ED Visits,5021,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Type A ED Visits,5021,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Type A ED Visits,5021,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Type A ED Visits,5021,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",326.78,326.78,326.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Type A ED Visits,5021,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Type A ED Visits,5021,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Type A ED Visits,5021,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Type A ED Visits,5021,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Type A ED Visits,5021,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",351.13,267.27,2111.64,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Type A ED Visits,5021,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Type A ED Visits,5021,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",284.42,198.9,372.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Type A ED Visits,5021,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",3971.84,3971.84,3971.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Type A ED Visits,5021,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Type A ED Visits,5021,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Type A ED Visits,5022,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Type A ED Visits,5022,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],1090,721,2088,34,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Type A ED Visits,5022,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",323.77,206.12,433.09,21,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Type A ED Visits,5022,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 2 Type A ED Visits,5022,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Type A ED Visits,5022,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],1221,927.5,8298.24,18,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Type A ED Visits,5022,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],1090,688.71,2146,79,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Type A ED Visits,5022,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],976.8,781.44,14321.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Type A ED Visits,5022,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,859.86,859.86,859.86,1 through 10,percent of total billed charges,,, Level 2 Type A ED Visits,5022,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,571.67,298.18,7667.68,29,percent of total billed charges,,, Level 2 Type A ED Visits,5022,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Type A ED Visits,5022,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Type A ED Visits,5022,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Type A ED Visits,5022,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Type A ED Visits,5022,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",430.82,430.82,430.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Type A ED Visits,5022,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Type A ED Visits,5022,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",319.52,214.47,485.69,114,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Type A ED Visits,5022,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",304.24,304.24,304.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Type A ED Visits,5022,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Type A ED Visits,5022,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Type A ED Visits,5022,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Type A ED Visits,5022,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",321.57,201.34,1891.06,20,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Type A ED Visits,5022,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",306.96,195.18,485.69,298,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Type A ED Visits,5022,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",312.8,203.97,562.83,375,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Type A ED Visits,5022,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",305.12,106.91,503.85,22,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Type A ED Visits,5022,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",1090,221,2881,58,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Type A ED Visits,5022,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",1221,1221,1221,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Type A ED Visits,5023,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Type A ED Visits,5023,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],291.12,291.12,291.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Type A ED Visits,5023,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],1704.97,1078,2536.14,456,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Type A ED Visits,5023,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",414.97,305.97,679.06,304,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Type A ED Visits,5023,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,1304.91,539.4,1400.67,1 through 10,percent of total billed charges,,, Level 3 Type A ED Visits,5023,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],1723,781.17,2576,969,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Type A ED Visits,5023,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],1820,1050,2782,212,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Type A ED Visits,5023,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],1334.53,445.6,1900,35,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Type A ED Visits,5023,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,795.61,466.93,1312.8,392,percent of total billed charges,,, Level 3 Type A ED Visits,5023,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,1104,828,1440.6,15,percent of total billed charges,,, Level 3 Type A ED Visits,5023,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",443.52,289.75,1084.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Type A ED Visits,5023,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Type A ED Visits,5023,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Type A ED Visits,5023,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Type A ED Visits,5023,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",395.86,301.25,1146.85,28,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Type A ED Visits,5023,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Type A ED Visits,5023,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",329.89,242.82,561.02,1174,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Type A ED Visits,5023,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",325.98,270.62,1659.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Type A ED Visits,5023,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Type A ED Visits,5023,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,1100.25,1100.25,1420.92,1 through 10,percent of total billed charges,,, Level 3 Type A ED Visits,5023,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",284.55,284.55,284.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Type A ED Visits,5023,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",351.74,239.24,587.64,178,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Type A ED Visits,5023,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",329.89,242.07,538.77,3768,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Type A ED Visits,5023,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",336.17,246.68,580.04,4529,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Type A ED Visits,5023,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",351.55,115.48,680,182,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Type A ED Visits,5023,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",1765,519,2863.07,624,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Type A ED Visits,5023,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",1840,827.5,2611,18,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Type A ED Visits,5024,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Type A ED Visits,5024,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],2603,1278.29,3053,293,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Type A ED Visits,5024,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",534.06,376.19,1496.03,157,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Type A ED Visits,5024,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 4 Type A ED Visits,5024,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,1083.7,1083.7,1083.7,1 through 10,percent of total billed charges,,, Level 4 Type A ED Visits,5024,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],2576,1237.99,4000.09,624,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Type A ED Visits,5024,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],2576,1830.07,3189.92,140,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Type A ED Visits,5024,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],1900,836.96,2705.01,31,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Type A ED Visits,5024,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,1442.6,1292.73,4366.71,1 through 10,percent of total billed charges,,, Level 4 Type A ED Visits,5024,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,1314.23,591.48,3024.42,199,percent of total billed charges,,, Level 4 Type A ED Visits,5024,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",445.05,445.05,931.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Type A ED Visits,5024,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Type A ED Visits,5024,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Type A ED Visits,5024,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Type A ED Visits,5024,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",521.26,383.71,1011.39,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Type A ED Visits,5024,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Type A ED Visits,5024,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",403.73,286.12,943.77,617,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Type A ED Visits,5024,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",476.28,306.96,977.82,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Type A ED Visits,5024,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,539.72,539.72,539.72,1 through 10,percent of total billed charges,,, Level 4 Type A ED Visits,5024,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,997.01,997.01,997.01,1 through 10,percent of total billed charges,,, Level 4 Type A ED Visits,5024,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Type A ED Visits,5024,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",466.96,314.8,1518.97,106,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Type A ED Visits,5024,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",427.12,287.95,952.17,1662,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Type A ED Visits,5024,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",436.75,291.19,1006.9,2255,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Type A ED Visits,5024,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",488.19,142.81,1286.73,99,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Type A ED Visits,5024,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",2851.15,1248.64,6418.75,467,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Type A ED Visits,5024,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",2405,1522.36,2905,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 5 Type A ED Visits,5025,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 5 Type A ED Visits,5025,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],2840,1613.98,3960.38,45,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 5 Type A ED Visits,5025,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",542.96,406.34,1317.9,23,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 5 Type A ED Visits,5025,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 5 Type A ED Visits,5025,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 5 Type A ED Visits,5025,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],2677.19,2100,11318.95,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 5 Type A ED Visits,5025,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],2576,1581.78,9435.38,98,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 5 Type A ED Visits,5025,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],1900,1900,2102.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 5 Type A ED Visits,5025,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,3199.1,1354.67,8029.18,23,percent of total billed charges,,, Level 5 Type A ED Visits,5025,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 5 Type A ED Visits,5025,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 5 Type A ED Visits,5025,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 5 Type A ED Visits,5025,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 5 Type A ED Visits,5025,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 5 Type A ED Visits,5025,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",854.62,854.62,854.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 5 Type A ED Visits,5025,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 5 Type A ED Visits,5025,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",633.63,329.89,1960.32,78,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 5 Type A ED Visits,5025,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1138.65,613.19,1671.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 5 Type A ED Visits,5025,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 5 Type A ED Visits,5025,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 5 Type A ED Visits,5025,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 5 Type A ED Visits,5025,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",679.38,460.83,2497.13,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 5 Type A ED Visits,5025,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",604.21,328.92,1904.18,181,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 5 Type A ED Visits,5025,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",737.26,316.01,2020.08,345,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 5 Type A ED Visits,5025,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",507.92,201.54,2256.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 5 Type A ED Visits,5025,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",3068,1735.11,8006.89,61,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 5 Type A ED Visits,5025,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Critical Care,5041,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Critical Care,5041,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],6325.35,4971.29,12501,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Critical Care,5041,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",2049.75,2049.75,2049.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Critical Care,5041,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Critical Care,5041,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Critical Care,5041,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],2805.11,2493.59,16066,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Critical Care,5041,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],11001.09,9501.51,16121.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Critical Care,5041,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,6046.79,4132.8,36079.3,1 through 10,percent of total billed charges,,, Critical Care,5041,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Critical Care,5041,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Critical Care,5041,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Critical Care,5041,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Critical Care,5041,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Critical Care,5041,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Critical Care,5041,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Critical Care,5041,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Critical Care,5041,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1558.45,740.72,2071.05,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Critical Care,5041,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Critical Care,5041,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Critical Care,5041,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Critical Care,5041,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Critical Care,5041,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1768.56,1768.56,1768.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Critical Care,5041,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1473.01,475.49,2483.21,33,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Critical Care,5041,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1406.69,439.38,2256.22,55,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Critical Care,5041,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",2369.24,2369.24,2934.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Critical Care,5041,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",3076.38,2468.63,8019.24,24,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Critical Care,5041,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Skin Procedures,5051,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Skin Procedures,5051,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],2608.91,1337.7,2903,48,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Skin Procedures,5051,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",670.39,513.43,891.42,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Skin Procedures,5051,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 1 Skin Procedures,5051,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Skin Procedures,5051,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],1268.94,656.52,1794.98,25,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Skin Procedures,5051,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],1206.26,831.37,1730.86,99,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Skin Procedures,5051,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],1124.66,681.52,2158.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Skin Procedures,5051,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,1219.55,935.18,3189.61,39,percent of total billed charges,,, Level 1 Skin Procedures,5051,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Skin Procedures,5051,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",536.53,536.53,536.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Skin Procedures,5051,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Skin Procedures,5051,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Skin Procedures,5051,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Skin Procedures,5051,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",516.76,516.76,516.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Skin Procedures,5051,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Skin Procedures,5051,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",560.93,533.36,612.23,52,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Skin Procedures,5051,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Skin Procedures,5051,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Skin Procedures,5051,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,428.82,428.82,428.82,1 through 10,percent of total billed charges,,, Level 1 Skin Procedures,5051,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Skin Procedures,5051,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",577.64,543.61,587.64,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Skin Procedures,5051,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",560.93,474.97,669.75,174,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Skin Procedures,5051,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",579.71,538.51,715.7,189,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Skin Procedures,5051,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",614.35,466.24,813.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Skin Procedures,5051,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",2611.52,992.06,3068,81,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Skin Procedures,5051,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",2461,2461,2461,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Skin Procedures,5052,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Skin Procedures,5052,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],2840,2584.8,4166.66,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Skin Procedures,5052,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",636.42,294.08,1074.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Skin Procedures,5052,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 2 Skin Procedures,5052,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Skin Procedures,5052,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],2703.86,2703.86,2703.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Skin Procedures,5052,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],2048.2,1223.28,5306.63,28,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Skin Procedures,5052,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,2640.96,1471.32,6248.37,12,percent of total billed charges,,, Level 2 Skin Procedures,5052,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Level 2 Skin Procedures,5052,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Skin Procedures,5052,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Skin Procedures,5052,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Skin Procedures,5052,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Skin Procedures,5052,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Skin Procedures,5052,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Skin Procedures,5052,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Skin Procedures,5052,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1323.89,822.18,1690.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Skin Procedures,5052,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Skin Procedures,5052,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Skin Procedures,5052,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Skin Procedures,5052,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Skin Procedures,5052,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",885.66,885.66,900.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Skin Procedures,5052,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",820.21,567.68,941.24,35,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Skin Procedures,5052,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",855.49,549.35,1657.19,48,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Skin Procedures,5052,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",982.1,982.1,982.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Skin Procedures,5052,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",2608.22,2100.22,3115.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Skin Procedures,5052,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",2120.84,2120.84,2120.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Skin Procedures,5053,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Skin Procedures,5053,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",2664.47,2664.47,2664.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Skin Procedures,5053,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 3 Skin Procedures,5053,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],,,,0,other,,,No services performed during 15-month lookback period. Level 3 Skin Procedures,5053,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Skin Procedures,5053,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],2608.22,2123.46,3790.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Skin Procedures,5053,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],9925.51,9925.51,9925.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Skin Procedures,5053,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,2343.42,2343.42,2343.42,1 through 10,percent of total billed charges,,, Level 3 Skin Procedures,5053,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Level 3 Skin Procedures,5053,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Skin Procedures,5053,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Skin Procedures,5053,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Skin Procedures,5053,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Skin Procedures,5053,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Skin Procedures,5053,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Skin Procedures,5053,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Skin Procedures,5053,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1512.4,1512.4,1512.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Skin Procedures,5053,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Skin Procedures,5053,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Skin Procedures,5053,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Skin Procedures,5053,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Skin Procedures,5053,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1211.46,1211.46,1721.64,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Skin Procedures,5053,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Skin Procedures,5053,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",795.33,498.79,1104.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Skin Procedures,5053,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",3987.03,3987.03,3987.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Skin Procedures,5053,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Skin Procedures,5053,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Skin Procedures,5054,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Skin Procedures,5054,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],11964.46,11964.46,11964.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Skin Procedures,5054,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",2035.76,2035.76,2035.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Skin Procedures,5054,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 4 Skin Procedures,5054,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Skin Procedures,5054,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],6957,5954.63,7139.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Skin Procedures,5054,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],7270.73,7270.73,7947.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Skin Procedures,5054,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,2456.06,2456.06,5976.13,1 through 10,percent of total billed charges,,, Level 4 Skin Procedures,5054,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Level 4 Skin Procedures,5054,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Skin Procedures,5054,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Skin Procedures,5054,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Skin Procedures,5054,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Skin Procedures,5054,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Skin Procedures,5054,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Skin Procedures,5054,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Skin Procedures,5054,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1695.99,1695.99,1775,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Skin Procedures,5054,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Skin Procedures,5054,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Skin Procedures,5054,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Skin Procedures,5054,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Skin Procedures,5054,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",3072.8,3072.8,3072.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Skin Procedures,5054,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1747.29,1747.29,2582.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Skin Procedures,5054,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",2991.42,1754.44,3104.32,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Skin Procedures,5054,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",4723.8,3972.84,5279,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Skin Procedures,5054,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Skin Procedures,5054,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Level 5 Skin Procedures,5055,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 5 Skin Procedures,5055,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],6153,6153,6153,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 5 Skin Procedures,5055,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 5 Skin Procedures,5055,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 5 Skin Procedures,5055,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 5 Skin Procedures,5055,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],11746.8,11746.8,11746.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 5 Skin Procedures,5055,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],,,,0,other,,,No services performed during 15-month lookback period. Level 5 Skin Procedures,5055,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Level 5 Skin Procedures,5055,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 5 Skin Procedures,5055,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 5 Skin Procedures,5055,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 5 Skin Procedures,5055,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 5 Skin Procedures,5055,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 5 Skin Procedures,5055,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 5 Skin Procedures,5055,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 5 Skin Procedures,5055,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 5 Skin Procedures,5055,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 5 Skin Procedures,5055,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 5 Skin Procedures,5055,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 5 Skin Procedures,5055,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 5 Skin Procedures,5055,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 5 Skin Procedures,5055,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 5 Skin Procedures,5055,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 5 Skin Procedures,5055,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 5 Skin Procedures,5055,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 5 Skin Procedures,5055,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",,,,0,other,,,No services performed during 15-month lookback period. Level 5 Skin Procedures,5055,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],3895.39,1803.33,5512.5,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1231.92,1106.06,4155.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],6426.25,4805.77,8805.23,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],6715.23,6150.47,8495.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,5314.98,5314.98,5883.54,1 through 10,percent of total billed charges,,, Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",839.48,736.88,1049.27,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,5656.07,5656.07,5656.07,1 through 10,percent of total billed charges,,, Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",865.36,865.36,865.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",767,658.02,1285.42,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",956.89,781.59,2472.61,23,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",3861.73,2042.34,5216.95,21,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,100,100,100,1 through 10,percent of total billed charges,,, Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],3087,2469.6,4269,17,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",4079.97,3351.87,5143.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],7141.57,6940.85,7147.87,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],6612.59,4935.43,7140.87,53,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,12340.12,12340.12,12340.12,1 through 10,percent of total billed charges,,, Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,6653.6,3778.05,11232.9,19,percent of total billed charges,,, Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",2754.47,1954.55,3503.53,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,891.6,891.6,891.6,1 through 10,percent of total billed charges,,, Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",2857.5,2465.97,3908.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",2798.79,1928.9,4364.34,24,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",2753.44,1398.16,3558.23,62,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",3071.65,2196.86,3212.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",4294.1,2739.18,9697.14,37,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",4454.04,4454.04,4454.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],4177.8,3692,10138.48,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",4209.3,4016.52,4502.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],11141.9,8949.38,11414.24,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],9283.94,5939.98,11077.33,39,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,12622.13,12622.13,12622.13,1 through 10,percent of total billed charges,,, Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,11005.64,2212.19,19293.87,11,percent of total billed charges,,, Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",3514.49,2793.62,4005.53,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",3750.97,2020.75,4232.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",3554.83,2881.52,4067.13,21,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",3642.37,2872.98,4305.77,62,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",4378.51,4378.51,4378.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",8735.58,4673.49,10213.91,25,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],5038,5038,5038,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",5758.42,5758.42,5758.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],12264.29,12263.44,12377.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],11379,11379,11379,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,25531.79,25531.79,25531.79,1 through 10,percent of total billed charges,,, Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",10499.62,10499.62,10499.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",2175.48,2175.48,2175.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",2737.91,2737.91,4866.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",2836.02,2220.73,5140.13,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",2265.2,2265.2,2265.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",14229.19,14229.19,14229.19,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",11448.78,11448.78,11448.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],7692.92,7692.92,7773,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",18503.3,18503.3,18503.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],,,,0,other,,,No services performed during 15-month lookback period. Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],,,,0,other,,,No services performed during 15-month lookback period. Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",16773.34,16773.34,16773.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",16798.28,16595.06,17160.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",19603.31,19603.31,19603.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],,,,0,other,,,No services performed during 15-month lookback period. Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],,,,0,other,,,No services performed during 15-month lookback period. Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],,,,0,other,,,No services performed during 15-month lookback period. Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",5009.15,5009.15,5009.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Strapping and Cast Application,5101,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Strapping and Cast Application,5101,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",443.78,443.78,443.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Strapping and Cast Application,5101,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 1 Strapping and Cast Application,5101,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],,,,0,other,,,No services performed during 15-month lookback period. Level 1 Strapping and Cast Application,5101,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Strapping and Cast Application,5101,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],,,,0,other,,,No services performed during 15-month lookback period. Level 1 Strapping and Cast Application,5101,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],,,,0,other,,,No services performed during 15-month lookback period. Level 1 Strapping and Cast Application,5101,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Level 1 Strapping and Cast Application,5101,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Strapping and Cast Application,5101,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Strapping and Cast Application,5101,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Strapping and Cast Application,5101,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Strapping and Cast Application,5101,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Strapping and Cast Application,5101,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Strapping and Cast Application,5101,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Strapping and Cast Application,5101,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Strapping and Cast Application,5101,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Strapping and Cast Application,5101,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Strapping and Cast Application,5101,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Strapping and Cast Application,5101,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Strapping and Cast Application,5101,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Strapping and Cast Application,5101,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Strapping and Cast Application,5101,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Strapping and Cast Application,5101,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Strapping and Cast Application,5101,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",648.62,648.62,648.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Strapping and Cast Application,5101,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Strapping and Cast Application,5101,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Strapping and Cast Application,5102,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Strapping and Cast Application,5102,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],550.42,209.77,2010.38,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Strapping and Cast Application,5102,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",595.95,115.65,1153.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Strapping and Cast Application,5102,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 2 Strapping and Cast Application,5102,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,2082.18,2082.18,2082.18,1 through 10,percent of total billed charges,,, Level 2 Strapping and Cast Application,5102,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],3525.46,1371.37,8570.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Strapping and Cast Application,5102,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],,,,0,other,,,No services performed during 15-month lookback period. Level 2 Strapping and Cast Application,5102,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,1473.05,688.7,9009,13,percent of total billed charges,,, Level 2 Strapping and Cast Application,5102,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Level 2 Strapping and Cast Application,5102,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Strapping and Cast Application,5102,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Strapping and Cast Application,5102,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Strapping and Cast Application,5102,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Strapping and Cast Application,5102,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Strapping and Cast Application,5102,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Strapping and Cast Application,5102,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Strapping and Cast Application,5102,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",411.7,205.85,1485.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Strapping and Cast Application,5102,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Strapping and Cast Application,5102,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Strapping and Cast Application,5102,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Strapping and Cast Application,5102,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Strapping and Cast Application,5102,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",547.18,547.18,547.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Strapping and Cast Application,5102,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",911.1,911.1,1113.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Strapping and Cast Application,5102,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",526.27,206.29,909.17,75,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Strapping and Cast Application,5102,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",364.05,364.05,364.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Strapping and Cast Application,5102,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",1560,984.6,2188,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Strapping and Cast Application,5102,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Musculoskeletal Procedures,5111,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Musculoskeletal Procedures,5111,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],2840,2040,3053,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Musculoskeletal Procedures,5111,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 1 Musculoskeletal Procedures,5111,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Musculoskeletal Procedures,5111,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Musculoskeletal Procedures,5111,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],2079.33,2079.33,2079.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Musculoskeletal Procedures,5111,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],2035.73,1161.84,7071.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Musculoskeletal Procedures,5111,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,1929.8,854,2705.61,1 through 10,percent of total billed charges,,, Level 1 Musculoskeletal Procedures,5111,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Level 1 Musculoskeletal Procedures,5111,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Musculoskeletal Procedures,5111,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Musculoskeletal Procedures,5111,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Musculoskeletal Procedures,5111,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Musculoskeletal Procedures,5111,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Musculoskeletal Procedures,5111,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Musculoskeletal Procedures,5111,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Musculoskeletal Procedures,5111,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1163.08,1163.08,1207.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Musculoskeletal Procedures,5111,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Musculoskeletal Procedures,5111,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Musculoskeletal Procedures,5111,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,2139.65,2139.65,2139.65,1 through 10,percent of total billed charges,,, Level 1 Musculoskeletal Procedures,5111,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Musculoskeletal Procedures,5111,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1207.4,1207.4,1287.27,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Musculoskeletal Procedures,5111,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1161.36,865.83,1187.01,33,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Musculoskeletal Procedures,5111,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1183.48,1025.08,1231,36,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Musculoskeletal Procedures,5111,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1273.86,1273.86,1273.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Musculoskeletal Procedures,5111,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",2609.38,325.73,3068,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Musculoskeletal Procedures,5111,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Musculoskeletal Procedures,5112,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Musculoskeletal Procedures,5112,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],2840,570.17,11289.92,20,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Musculoskeletal Procedures,5112,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1506.48,1430.52,1994.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Musculoskeletal Procedures,5112,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 2 Musculoskeletal Procedures,5112,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Musculoskeletal Procedures,5112,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],7072.9,6041.37,7186.03,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Musculoskeletal Procedures,5112,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],6549.73,4757.36,6620.32,55,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Musculoskeletal Procedures,5112,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],1900,1900,1900,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Musculoskeletal Procedures,5112,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,7863.28,7863.28,7863.28,1 through 10,percent of total billed charges,,, Level 2 Musculoskeletal Procedures,5112,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,6118.38,4010.32,9692.94,1 through 10,percent of total billed charges,,, Level 2 Musculoskeletal Procedures,5112,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Musculoskeletal Procedures,5112,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Musculoskeletal Procedures,5112,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Musculoskeletal Procedures,5112,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Musculoskeletal Procedures,5112,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Musculoskeletal Procedures,5112,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Musculoskeletal Procedures,5112,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1248.57,1135.71,3287.27,18,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Musculoskeletal Procedures,5112,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1160.15,1160.15,1160.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Musculoskeletal Procedures,5112,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Musculoskeletal Procedures,5112,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Musculoskeletal Procedures,5112,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Musculoskeletal Procedures,5112,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1436.19,1206.66,2292.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Musculoskeletal Procedures,5112,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1262.75,1185.24,2087.25,35,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Musculoskeletal Procedures,5112,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1298.14,1183.48,2964.99,66,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Musculoskeletal Procedures,5112,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1419.48,1419.48,1519.38,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Musculoskeletal Procedures,5112,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",3006.82,1639.09,5021.72,35,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Musculoskeletal Procedures,5112,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Musculoskeletal Procedures,5113,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Musculoskeletal Procedures,5113,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],5071,4407.73,8122,17,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Musculoskeletal Procedures,5113,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",4286.07,3862.15,9146.65,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Musculoskeletal Procedures,5113,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 3 Musculoskeletal Procedures,5113,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Musculoskeletal Procedures,5113,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],10695.33,5124.33,13139.38,29,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Musculoskeletal Procedures,5113,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],12263.01,10574.47,13294.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Musculoskeletal Procedures,5113,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],37447.29,37447.29,37447.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Musculoskeletal Procedures,5113,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,24408.6,15446.73,30011.98,1 through 10,percent of total billed charges,,, Level 3 Musculoskeletal Procedures,5113,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,17145.73,8171.6,26973.2,14,percent of total billed charges,,, Level 3 Musculoskeletal Procedures,5113,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Musculoskeletal Procedures,5113,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Musculoskeletal Procedures,5113,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Musculoskeletal Procedures,5113,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Musculoskeletal Procedures,5113,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",3696,3696,3696,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Musculoskeletal Procedures,5113,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Musculoskeletal Procedures,5113,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",4608.85,3287.27,7977.61,17,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Musculoskeletal Procedures,5113,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Musculoskeletal Procedures,5113,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Musculoskeletal Procedures,5113,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Musculoskeletal Procedures,5113,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Musculoskeletal Procedures,5113,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",3611.32,3471.97,5152.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Musculoskeletal Procedures,5113,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",3784.62,3249.88,7995.6,28,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Musculoskeletal Procedures,5113,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",4903.96,3297.61,8361.02,54,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Musculoskeletal Procedures,5113,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",8560.82,3588.77,8805.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Musculoskeletal Procedures,5113,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",9697.03,4023.95,11361.78,24,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Musculoskeletal Procedures,5113,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Musculoskeletal Procedures,5114,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Musculoskeletal Procedures,5114,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],6294.34,3569,13260.48,30,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Musculoskeletal Procedures,5114,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",9657.12,9175.97,10073.76,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Musculoskeletal Procedures,5114,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 4 Musculoskeletal Procedures,5114,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Musculoskeletal Procedures,5114,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],12404.07,9452.38,17807.82,17,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Musculoskeletal Procedures,5114,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],11398.83,7121.13,16769.84,46,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Musculoskeletal Procedures,5114,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],29338.85,29338.85,29338.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Musculoskeletal Procedures,5114,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,27769.75,27516.96,32079.36,1 through 10,percent of total billed charges,,, Level 4 Musculoskeletal Procedures,5114,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,16557.02,10230.36,24233.41,13,percent of total billed charges,,, Level 4 Musculoskeletal Procedures,5114,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Musculoskeletal Procedures,5114,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Musculoskeletal Procedures,5114,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Musculoskeletal Procedures,5114,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Musculoskeletal Procedures,5114,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",5277,5277,5277,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Musculoskeletal Procedures,5114,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Musculoskeletal Procedures,5114,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",8350.09,7849.36,11350.14,21,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Musculoskeletal Procedures,5114,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",8084.24,8084.24,8084.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Musculoskeletal Procedures,5114,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Musculoskeletal Procedures,5114,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,1200,1200,1200,1 through 10,percent of total billed charges,,, Level 4 Musculoskeletal Procedures,5114,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Musculoskeletal Procedures,5114,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",8987.32,8276.87,14348.98,18,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Musculoskeletal Procedures,5114,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",8306.18,7900.66,10264.28,56,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Musculoskeletal Procedures,5114,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",8646.67,7782.39,11698.6,97,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Musculoskeletal Procedures,5114,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",9145.31,9145.31,9145.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Musculoskeletal Procedures,5114,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",15009.4,7835.09,26591.48,45,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Musculoskeletal Procedures,5114,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Level 5 Musculoskeletal Procedures,5115,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 5 Musculoskeletal Procedures,5115,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],4871,4871,4871,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 5 Musculoskeletal Procedures,5115,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",9653.87,9653.87,9653.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 5 Musculoskeletal Procedures,5115,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 5 Musculoskeletal Procedures,5115,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 5 Musculoskeletal Procedures,5115,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],10516.77,10516.77,13603.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 5 Musculoskeletal Procedures,5115,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],16113.17,16113.17,21010.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 5 Musculoskeletal Procedures,5115,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,24921.74,24921.74,24921.74,1 through 10,percent of total billed charges,,, Level 5 Musculoskeletal Procedures,5115,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,19026.15,19026.15,25758.37,1 through 10,percent of total billed charges,,, Level 5 Musculoskeletal Procedures,5115,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Level 5 Musculoskeletal Procedures,5115,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 5 Musculoskeletal Procedures,5115,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 5 Musculoskeletal Procedures,5115,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 5 Musculoskeletal Procedures,5115,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 5 Musculoskeletal Procedures,5115,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 5 Musculoskeletal Procedures,5115,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 5 Musculoskeletal Procedures,5115,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",8908.43,8908.43,8908.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 5 Musculoskeletal Procedures,5115,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 5 Musculoskeletal Procedures,5115,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 5 Musculoskeletal Procedures,5115,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 5 Musculoskeletal Procedures,5115,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 5 Musculoskeletal Procedures,5115,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",8819.44,8394.51,13009.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 5 Musculoskeletal Procedures,5115,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",8722.57,7875.01,11741.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 5 Musculoskeletal Procedures,5115,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",9217.66,8215.62,12813.85,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 5 Musculoskeletal Procedures,5115,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",20400.16,12484.56,22643.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 5 Musculoskeletal Procedures,5115,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 5 Musculoskeletal Procedures,5115,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Airway Endoscopy,5151,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Airway Endoscopy,5151,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],1000,1000,1000,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Airway Endoscopy,5151,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",713.06,713.06,713.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Airway Endoscopy,5151,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 1 Airway Endoscopy,5151,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Airway Endoscopy,5151,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],,,,0,other,,,No services performed during 15-month lookback period. Level 1 Airway Endoscopy,5151,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],,,,0,other,,,No services performed during 15-month lookback period. Level 1 Airway Endoscopy,5151,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Level 1 Airway Endoscopy,5151,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Airway Endoscopy,5151,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Airway Endoscopy,5151,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Airway Endoscopy,5151,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Airway Endoscopy,5151,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Airway Endoscopy,5151,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Airway Endoscopy,5151,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Airway Endoscopy,5151,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Airway Endoscopy,5151,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",345.23,345.23,345.23,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Airway Endoscopy,5151,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Airway Endoscopy,5151,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Airway Endoscopy,5151,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Airway Endoscopy,5151,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Airway Endoscopy,5151,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1225.57,1225.57,1225.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Airway Endoscopy,5151,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Airway Endoscopy,5151,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",582.47,582.47,582.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Airway Endoscopy,5151,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",11549.57,11549.57,11549.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Airway Endoscopy,5151,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Airway Endoscopy,5151,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Airway Endoscopy,5152,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Airway Endoscopy,5152,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 2 Airway Endoscopy,5152,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],,,,0,other,,,No services performed during 15-month lookback period. Level 2 Airway Endoscopy,5152,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Airway Endoscopy,5152,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Airway Endoscopy,5152,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],10485.87,10485.87,10485.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Airway Endoscopy,5152,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],,,,0,other,,,No services performed during 15-month lookback period. Level 2 Airway Endoscopy,5152,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Level 2 Airway Endoscopy,5152,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Airway Endoscopy,5152,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Airway Endoscopy,5152,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Airway Endoscopy,5152,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Airway Endoscopy,5152,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Airway Endoscopy,5152,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Airway Endoscopy,5152,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Airway Endoscopy,5152,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Airway Endoscopy,5152,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Airway Endoscopy,5152,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Airway Endoscopy,5152,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Airway Endoscopy,5152,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Airway Endoscopy,5152,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Airway Endoscopy,5152,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Airway Endoscopy,5152,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Airway Endoscopy,5152,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Airway Endoscopy,5152,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Airway Endoscopy,5152,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Airway Endoscopy,5152,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Airway Endoscopy,5153,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Airway Endoscopy,5153,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],4885.07,3692,5953.5,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Airway Endoscopy,5153,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",3861.18,3278.62,4421.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Airway Endoscopy,5153,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 3 Airway Endoscopy,5153,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Airway Endoscopy,5153,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],6615.26,4943.67,7140,25,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Airway Endoscopy,5153,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],6677.1,6073.83,7586.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Airway Endoscopy,5153,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,5974.12,4144.21,9622.7,1 through 10,percent of total billed charges,,, Level 3 Airway Endoscopy,5153,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Level 3 Airway Endoscopy,5153,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Airway Endoscopy,5153,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Airway Endoscopy,5153,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Airway Endoscopy,5153,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Airway Endoscopy,5153,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Airway Endoscopy,5153,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Airway Endoscopy,5153,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Airway Endoscopy,5153,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",2942.33,2737.13,4267.58,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Airway Endoscopy,5153,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",3266.46,3266.46,3266.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Airway Endoscopy,5153,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Airway Endoscopy,5153,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Airway Endoscopy,5153,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Airway Endoscopy,5153,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",3471.05,3458.61,4013.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Airway Endoscopy,5153,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",3752.44,2711.48,4883.65,30,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Airway Endoscopy,5153,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",3207.52,2737,5942.2,86,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Airway Endoscopy,5153,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",5279.55,4172.26,7527.7,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Airway Endoscopy,5153,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",7132.64,7132.64,7132.64,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Airway Endoscopy,5153,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Airway Endoscopy,5154,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Airway Endoscopy,5154,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],7938.25,6945.75,9478.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Airway Endoscopy,5154,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",3550.38,3387.67,3564.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Airway Endoscopy,5154,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 4 Airway Endoscopy,5154,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Airway Endoscopy,5154,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],11922.8,11922.8,11922.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Airway Endoscopy,5154,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],12824.42,12824.42,12824.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Airway Endoscopy,5154,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Level 4 Airway Endoscopy,5154,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Airway Endoscopy,5154,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Airway Endoscopy,5154,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Airway Endoscopy,5154,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Airway Endoscopy,5154,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Airway Endoscopy,5154,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Airway Endoscopy,5154,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Airway Endoscopy,5154,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Airway Endoscopy,5154,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",3163.69,2897.77,4400.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Airway Endoscopy,5154,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Airway Endoscopy,5154,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Airway Endoscopy,5154,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Airway Endoscopy,5154,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Airway Endoscopy,5154,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",2853.45,2853.45,2853.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Airway Endoscopy,5154,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",6828.58,3184.36,7555.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Airway Endoscopy,5154,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",3461.05,2952.96,6245.58,17,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Airway Endoscopy,5154,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",12216.56,12216.56,15301.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Airway Endoscopy,5154,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Airway Endoscopy,5154,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Level 5 Airway Endoscopy,5155,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 5 Airway Endoscopy,5155,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],16806.25,16806.25,16806.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 5 Airway Endoscopy,5155,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",7111.99,7111.99,13564.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 5 Airway Endoscopy,5155,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 5 Airway Endoscopy,5155,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 5 Airway Endoscopy,5155,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],11353.58,9189.17,12203.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 5 Airway Endoscopy,5155,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],12278.32,12278.32,12278.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 5 Airway Endoscopy,5155,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,18929.01,18929.01,18929.01,1 through 10,percent of total billed charges,,, Level 5 Airway Endoscopy,5155,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Level 5 Airway Endoscopy,5155,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 5 Airway Endoscopy,5155,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 5 Airway Endoscopy,5155,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 5 Airway Endoscopy,5155,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 5 Airway Endoscopy,5155,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 5 Airway Endoscopy,5155,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 5 Airway Endoscopy,5155,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 5 Airway Endoscopy,5155,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",10226.98,10226.98,10281.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 5 Airway Endoscopy,5155,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 5 Airway Endoscopy,5155,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 5 Airway Endoscopy,5155,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 5 Airway Endoscopy,5155,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 5 Airway Endoscopy,5155,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",9874.87,9874.87,13997.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 5 Airway Endoscopy,5155,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",12197.76,12197.76,12197.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 5 Airway Endoscopy,5155,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",2698.12,587.08,10591.32,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 5 Airway Endoscopy,5155,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",10839.82,10839.82,10839.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 5 Airway Endoscopy,5155,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",14544.04,12267.34,17938.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 5 Airway Endoscopy,5155,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",15334.37,15334.37,15334.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 ENT Procedures,5161,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 ENT Procedures,5161,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],2272,2272,2469.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 ENT Procedures,5161,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 1 ENT Procedures,5161,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 ENT Procedures,5161,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 ENT Procedures,5161,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],14417.37,14417.37,14417.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 ENT Procedures,5161,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],11800.2,11209.58,19294.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 ENT Procedures,5161,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,9862.43,7845.03,14230.44,1 through 10,percent of total billed charges,,, Level 1 ENT Procedures,5161,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Level 1 ENT Procedures,5161,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 ENT Procedures,5161,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 ENT Procedures,5161,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 ENT Procedures,5161,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 ENT Procedures,5161,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 ENT Procedures,5161,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 ENT Procedures,5161,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 ENT Procedures,5161,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1950.33,1950.33,1950.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 ENT Procedures,5161,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 ENT Procedures,5161,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 ENT Procedures,5161,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 ENT Procedures,5161,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 ENT Procedures,5161,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",2314.2,2314.2,3892.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 ENT Procedures,5161,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 ENT Procedures,5161,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",2129.2,2129.2,2151.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 ENT Procedures,5161,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",822.12,822.12,967.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 ENT Procedures,5161,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",2438,2438,2482.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 ENT Procedures,5161,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 ENT Procedures,5162,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 ENT Procedures,5162,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],2840,2840,3087,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 ENT Procedures,5162,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 2 ENT Procedures,5162,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 ENT Procedures,5162,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 ENT Procedures,5162,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],10574.02,10574.02,10574.02,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 ENT Procedures,5162,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],,,,0,other,,,No services performed during 15-month lookback period. Level 2 ENT Procedures,5162,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],9102.22,9102.22,9102.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 ENT Procedures,5162,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,7594.83,7594.83,7594.83,1 through 10,percent of total billed charges,,, Level 2 ENT Procedures,5162,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 ENT Procedures,5162,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 ENT Procedures,5162,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 ENT Procedures,5162,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 ENT Procedures,5162,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 ENT Procedures,5162,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 ENT Procedures,5162,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 ENT Procedures,5162,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 ENT Procedures,5162,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 ENT Procedures,5162,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 ENT Procedures,5162,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 ENT Procedures,5162,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 ENT Procedures,5162,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",267.6,267.6,267.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 ENT Procedures,5162,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",2211.6,2211.6,2960.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 ENT Procedures,5162,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",2886.54,2886.54,3994.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 ENT Procedures,5162,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",106.91,106.91,106.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 ENT Procedures,5162,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 ENT Procedures,5162,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 ENT Procedures,5163,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 ENT Procedures,5163,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],4208,3642.5,6498.62,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 ENT Procedures,5163,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",3646.5,3536,3674.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 ENT Procedures,5163,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 3 ENT Procedures,5163,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 ENT Procedures,5163,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],4850.52,3456.84,6612,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 ENT Procedures,5163,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],6617.2,5230.35,7141.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 ENT Procedures,5163,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,2552.69,1781.02,5418.95,20,percent of total billed charges,,, Level 3 ENT Procedures,5163,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Level 3 ENT Procedures,5163,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 ENT Procedures,5163,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 ENT Procedures,5163,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 ENT Procedures,5163,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 ENT Procedures,5163,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 ENT Procedures,5163,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 ENT Procedures,5163,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 ENT Procedures,5163,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",3086.55,2160.3,4834.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 ENT Procedures,5163,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 ENT Procedures,5163,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 ENT Procedures,5163,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 ENT Procedures,5163,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 ENT Procedures,5163,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",3060.9,2083.35,4770.9,32,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 ENT Procedures,5163,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 ENT Procedures,5163,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",3171.48,2698.39,4167.65,78,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 ENT Procedures,5163,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",3492.86,3492.86,3492.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 ENT Procedures,5163,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",5281.72,4120.9,7528.84,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 ENT Procedures,5163,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",6287.09,6287.09,6287.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 ENT Procedures,5164,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 ENT Procedures,5164,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],5182,2000,7656.81,34,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 ENT Procedures,5164,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",4588.67,3647.52,7921.34,20,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 ENT Procedures,5164,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 4 ENT Procedures,5164,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 ENT Procedures,5164,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],10740.08,8015.95,12685,19,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 ENT Procedures,5164,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],9862.59,5776.55,11368.68,66,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 ENT Procedures,5164,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,5562.74,2629.55,10079.05,38,percent of total billed charges,,, Level 4 ENT Procedures,5164,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Level 4 ENT Procedures,5164,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 ENT Procedures,5164,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 ENT Procedures,5164,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 ENT Procedures,5164,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,9355.33,9355.33,9355.33,1 through 10,percent of total billed charges,,, Level 4 ENT Procedures,5164,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 ENT Procedures,5164,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 ENT Procedures,5164,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 ENT Procedures,5164,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",4459.83,3086.55,5491.59,55,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 ENT Procedures,5164,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 ENT Procedures,5164,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 ENT Procedures,5164,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,4410.43,4410.43,4410.43,1 through 10,percent of total billed charges,,, Level 4 ENT Procedures,5164,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 ENT Procedures,5164,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",4954.69,3292.62,5201.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 ENT Procedures,5164,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",3327.28,3080.82,5331.71,84,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 ENT Procedures,5164,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",3914.23,3162.08,6188.07,215,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 ENT Procedures,5164,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",4974.49,3447.5,7563.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 ENT Procedures,5164,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",9692.64,6194.74,12203.71,62,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 ENT Procedures,5164,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",10984.88,10984.88,10984.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 5 ENT Procedures,5165,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 5 ENT Procedures,5165,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],5182,3894.19,11811,51,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 5 ENT Procedures,5165,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",3802.66,3672.84,7652.51,21,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 5 ENT Procedures,5165,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 5 ENT Procedures,5165,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 5 ENT Procedures,5165,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],10889.17,7042.86,12283.44,23,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 5 ENT Procedures,5165,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],11353,7164.08,12078.23,91,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 5 ENT Procedures,5165,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],50331.05,50331.05,50331.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 5 ENT Procedures,5165,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,17333.35,17333.35,17333.35,1 through 10,percent of total billed charges,,, Level 5 ENT Procedures,5165,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,6570.59,4395.27,19292.23,49,percent of total billed charges,,, Level 5 ENT Procedures,5165,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 5 ENT Procedures,5165,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 5 ENT Procedures,5165,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 5 ENT Procedures,5165,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 5 ENT Procedures,5165,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 5 ENT Procedures,5165,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 5 ENT Procedures,5165,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",4022.43,3147.73,6752.08,85,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 5 ENT Procedures,5165,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",3224.68,3224.68,3224.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 5 ENT Procedures,5165,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 5 ENT Procedures,5165,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 5 ENT Procedures,5165,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 5 ENT Procedures,5165,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",4695.39,3346.36,6188.18,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 5 ENT Procedures,5165,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",3224.68,3125.14,5301.78,151,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 5 ENT Procedures,5165,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",3364.53,3207.24,5650.9,285,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 5 ENT Procedures,5165,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",3531.77,3447.5,7058.01,28,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 5 ENT Procedures,5165,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",9722.8,5536.64,15861.14,70,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 5 ENT Procedures,5165,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",8374.58,8374.58,8725,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Cochlear Implant Procedure,5166,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cochlear Implant Procedure,5166,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],61894.46,61894.46,61894.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Cochlear Implant Procedure,5166,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",59264.97,59264.97,59763.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Cochlear Implant Procedure,5166,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Cochlear Implant Procedure,5166,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cochlear Implant Procedure,5166,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],,,,0,other,,,No services performed during 15-month lookback period. Cochlear Implant Procedure,5166,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],,,,0,other,,,No services performed during 15-month lookback period. Cochlear Implant Procedure,5166,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,79487.61,79487.61,79487.61,1 through 10,percent of total billed charges,,, Cochlear Implant Procedure,5166,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Cochlear Implant Procedure,5166,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cochlear Implant Procedure,5166,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Cochlear Implant Procedure,5166,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Cochlear Implant Procedure,5166,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cochlear Implant Procedure,5166,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cochlear Implant Procedure,5166,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Cochlear Implant Procedure,5166,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cochlear Implant Procedure,5166,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",51754.18,51754.18,51754.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Cochlear Implant Procedure,5166,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Cochlear Implant Procedure,5166,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cochlear Implant Procedure,5166,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cochlear Implant Procedure,5166,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Cochlear Implant Procedure,5166,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",35293.96,35293.96,35293.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Cochlear Implant Procedure,5166,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",50342.31,50342.31,50342.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Cochlear Implant Procedure,5166,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",35273.27,338.7,51549.58,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Cochlear Implant Procedure,5166,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Cochlear Implant Procedure,5166,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",,,,0,other,,,No services performed during 15-month lookback period. Cochlear Implant Procedure,5166,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Vascular Procedures,5181,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Vascular Procedures,5181,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",2220.81,2220.81,2220.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Vascular Procedures,5181,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 1 Vascular Procedures,5181,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],,,,0,other,,,No services performed during 15-month lookback period. Level 1 Vascular Procedures,5181,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Vascular Procedures,5181,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],4427.3,4427.3,4427.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Vascular Procedures,5181,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],,,,0,other,,,No services performed during 15-month lookback period. Level 1 Vascular Procedures,5181,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,10127.62,10127.62,10127.62,1 through 10,percent of total billed charges,,, Level 1 Vascular Procedures,5181,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Level 1 Vascular Procedures,5181,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Vascular Procedures,5181,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Vascular Procedures,5181,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Vascular Procedures,5181,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Vascular Procedures,5181,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Vascular Procedures,5181,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Vascular Procedures,5181,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Vascular Procedures,5181,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1826.03,1826.03,1826.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Vascular Procedures,5181,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Vascular Procedures,5181,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Vascular Procedures,5181,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Vascular Procedures,5181,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Vascular Procedures,5181,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1195.28,1169.63,1763.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Vascular Procedures,5181,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Vascular Procedures,5181,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1497.75,1200.61,2007.11,17,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Vascular Procedures,5181,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",2928,2928,2928,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Vascular Procedures,5181,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Vascular Procedures,5181,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Vascular Procedures,5182,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Vascular Procedures,5182,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],2872,2872,3087,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Vascular Procedures,5182,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1541.98,1541.98,1541.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Vascular Procedures,5182,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 2 Vascular Procedures,5182,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Vascular Procedures,5182,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],6617.79,6021.92,7389.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Vascular Procedures,5182,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],7389.8,7389.8,7389.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Vascular Procedures,5182,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,7079.14,7047.08,9832.92,1 through 10,percent of total billed charges,,, Level 2 Vascular Procedures,5182,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Level 2 Vascular Procedures,5182,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Vascular Procedures,5182,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",7722.63,7722.63,7722.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Vascular Procedures,5182,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Vascular Procedures,5182,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Vascular Procedures,5182,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Vascular Procedures,5182,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Vascular Procedures,5182,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Vascular Procedures,5182,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1666.76,1666.76,1666.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Vascular Procedures,5182,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Vascular Procedures,5182,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Vascular Procedures,5182,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Vascular Procedures,5182,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Vascular Procedures,5182,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1787.29,1787.29,1787.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Vascular Procedures,5182,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1622.44,1622.44,1622.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Vascular Procedures,5182,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1296.48,1244.2,4104.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Vascular Procedures,5182,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1975.66,1975.66,1975.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Vascular Procedures,5182,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",5025.58,5025.55,5031.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Vascular Procedures,5182,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Vascular Procedures,5183,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Vascular Procedures,5183,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],46517.67,6089.04,62558.26,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Vascular Procedures,5183,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 3 Vascular Procedures,5183,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Vascular Procedures,5183,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Vascular Procedures,5183,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],3464.05,3098.8,11483.89,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Vascular Procedures,5183,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],3061.7,3061.7,3061.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Vascular Procedures,5183,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,31923.83,10740.41,35672.07,1 through 10,percent of total billed charges,,, Level 3 Vascular Procedures,5183,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Level 3 Vascular Procedures,5183,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Vascular Procedures,5183,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Vascular Procedures,5183,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Vascular Procedures,5183,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Vascular Procedures,5183,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Vascular Procedures,5183,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Vascular Procedures,5183,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Vascular Procedures,5183,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1967.33,1967.33,1967.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Vascular Procedures,5183,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Vascular Procedures,5183,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Vascular Procedures,5183,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,19297.75,19297.75,19297.75,1 through 10,percent of total billed charges,,, Level 3 Vascular Procedures,5183,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Vascular Procedures,5183,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",4710.34,4547.87,5244.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Vascular Procedures,5183,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",4517.25,3235.5,39908.02,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Vascular Procedures,5183,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",4786.33,3375.56,5547.32,41,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Vascular Procedures,5183,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",4276.8,4276.8,4276.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Vascular Procedures,5183,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",16509.57,11964.04,19764.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Vascular Procedures,5183,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",10769.45,10769.45,10769.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Vascular Procedures,5184,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Vascular Procedures,5184,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 4 Vascular Procedures,5184,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],,,,0,other,,,No services performed during 15-month lookback period. Level 4 Vascular Procedures,5184,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Vascular Procedures,5184,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Vascular Procedures,5184,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],10670.32,10670.32,61233.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Vascular Procedures,5184,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],,,,0,other,,,No services performed during 15-month lookback period. Level 4 Vascular Procedures,5184,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Level 4 Vascular Procedures,5184,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Vascular Procedures,5184,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Vascular Procedures,5184,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Vascular Procedures,5184,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Vascular Procedures,5184,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Vascular Procedures,5184,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Vascular Procedures,5184,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Vascular Procedures,5184,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Vascular Procedures,5184,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Vascular Procedures,5184,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Vascular Procedures,5184,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Vascular Procedures,5184,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Vascular Procedures,5184,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Vascular Procedures,5184,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Vascular Procedures,5184,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Vascular Procedures,5184,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",10499.88,10402.25,10588.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Vascular Procedures,5184,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",21581.49,21581.49,21695.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Vascular Procedures,5184,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Vascular Procedures,5184,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Endovascular Procedures,5191,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Endovascular Procedures,5191,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],35270.53,35270.53,35270.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Endovascular Procedures,5191,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 1 Endovascular Procedures,5191,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Endovascular Procedures,5191,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Endovascular Procedures,5191,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],3485.14,2954.07,46997.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Endovascular Procedures,5191,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],,,,0,other,,,No services performed during 15-month lookback period. Level 1 Endovascular Procedures,5191,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,37962.44,37962.44,37962.44,1 through 10,percent of total billed charges,,, Level 1 Endovascular Procedures,5191,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Level 1 Endovascular Procedures,5191,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Endovascular Procedures,5191,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",4106.76,4106.76,4106.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Endovascular Procedures,5191,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Endovascular Procedures,5191,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Endovascular Procedures,5191,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Endovascular Procedures,5191,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Endovascular Procedures,5191,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Endovascular Procedures,5191,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",14275.12,14275.12,14275.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Endovascular Procedures,5191,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Endovascular Procedures,5191,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Endovascular Procedures,5191,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Endovascular Procedures,5191,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Endovascular Procedures,5191,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",4825.83,4825.83,4825.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Endovascular Procedures,5191,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",4335.04,4158.15,13315.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Endovascular Procedures,5191,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",4711.1,4106.69,13286.7,20,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Endovascular Procedures,5191,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",4638.36,4638.36,4638.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Endovascular Procedures,5191,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",15584.86,15584.86,17615.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Endovascular Procedures,5191,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Endovascular Procedures,5193,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Endovascular Procedures,5193,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],4504.8,4504.8,4504.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Endovascular Procedures,5193,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 3 Endovascular Procedures,5193,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Endovascular Procedures,5193,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Endovascular Procedures,5193,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],12370.25,12370.25,12454.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Endovascular Procedures,5193,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],11472.86,11472.86,11594.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Endovascular Procedures,5193,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,20137.06,20137.06,20137.06,1 through 10,percent of total billed charges,,, Level 3 Endovascular Procedures,5193,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Level 3 Endovascular Procedures,5193,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Endovascular Procedures,5193,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",12446.34,12446.34,12446.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Endovascular Procedures,5193,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Endovascular Procedures,5193,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Endovascular Procedures,5193,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Endovascular Procedures,5193,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Endovascular Procedures,5193,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Endovascular Procedures,5193,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",15792.74,15792.74,15792.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Endovascular Procedures,5193,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",17484.25,17484.25,17484.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Endovascular Procedures,5193,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Endovascular Procedures,5193,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Endovascular Procedures,5193,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Endovascular Procedures,5193,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",602.56,602.56,602.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Endovascular Procedures,5193,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Endovascular Procedures,5193,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",16448.81,16122.29,24226.29,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Endovascular Procedures,5193,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",3000,700,22346.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Endovascular Procedures,5193,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Endovascular Procedures,5193,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Endovascular Procedures,5194,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Endovascular Procedures,5194,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 4 Endovascular Procedures,5194,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],,,,0,other,,,No services performed during 15-month lookback period. Level 4 Endovascular Procedures,5194,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Endovascular Procedures,5194,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Endovascular Procedures,5194,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],14358.08,14358.08,14358.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Endovascular Procedures,5194,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],12489.68,12489.68,12489.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Endovascular Procedures,5194,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Level 4 Endovascular Procedures,5194,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Endovascular Procedures,5194,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Endovascular Procedures,5194,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Endovascular Procedures,5194,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Endovascular Procedures,5194,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Endovascular Procedures,5194,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Endovascular Procedures,5194,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Endovascular Procedures,5194,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Endovascular Procedures,5194,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Endovascular Procedures,5194,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Endovascular Procedures,5194,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Endovascular Procedures,5194,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Endovascular Procedures,5194,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Endovascular Procedures,5194,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",16274.12,16274.12,16274.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Endovascular Procedures,5194,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Endovascular Procedures,5194,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Endovascular Procedures,5194,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",10375.13,10375.13,10375.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Endovascular Procedures,5194,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Endovascular Procedures,5194,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],12028.43,12028.43,12028.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],18957.51,18957.51,18959.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],,,,0,other,,,No services performed during 15-month lookback period. Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,18570.42,18570.42,18570.42,1 through 10,percent of total billed charges,,, Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",11264.77,11264.77,11264.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",11263.57,11263.57,11263.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",22503.04,22503.04,22503.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],,,,0,other,,,No services performed during 15-month lookback period. Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],18563.52,18563.52,18563.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],,,,0,other,,,No services performed during 15-month lookback period. Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",13370.42,13370.42,13370.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 ICD and Similar Procedures,5231,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 ICD and Similar Procedures,5231,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 1 ICD and Similar Procedures,5231,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],,,,0,other,,,No services performed during 15-month lookback period. Level 1 ICD and Similar Procedures,5231,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 ICD and Similar Procedures,5231,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 ICD and Similar Procedures,5231,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],,,,0,other,,,No services performed during 15-month lookback period. Level 1 ICD and Similar Procedures,5231,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],,,,0,other,,,No services performed during 15-month lookback period. Level 1 ICD and Similar Procedures,5231,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,62836.51,62836.51,62836.51,1 through 10,percent of total billed charges,,, Level 1 ICD and Similar Procedures,5231,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Level 1 ICD and Similar Procedures,5231,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 ICD and Similar Procedures,5231,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 ICD and Similar Procedures,5231,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 ICD and Similar Procedures,5231,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 ICD and Similar Procedures,5231,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 ICD and Similar Procedures,5231,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 ICD and Similar Procedures,5231,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 ICD and Similar Procedures,5231,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 ICD and Similar Procedures,5231,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 ICD and Similar Procedures,5231,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 ICD and Similar Procedures,5231,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 ICD and Similar Procedures,5231,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 ICD and Similar Procedures,5231,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 ICD and Similar Procedures,5231,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 ICD and Similar Procedures,5231,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",32947.21,32947.21,32947.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 ICD and Similar Procedures,5231,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 ICD and Similar Procedures,5231,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 ICD and Similar Procedures,5231,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 ICD and Similar Procedures,5232,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 ICD and Similar Procedures,5232,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],58359.5,58359.5,58359.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 ICD and Similar Procedures,5232,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 2 ICD and Similar Procedures,5232,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 ICD and Similar Procedures,5232,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 ICD and Similar Procedures,5232,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],,,,0,other,,,No services performed during 15-month lookback period. Level 2 ICD and Similar Procedures,5232,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],,,,0,other,,,No services performed during 15-month lookback period. Level 2 ICD and Similar Procedures,5232,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Level 2 ICD and Similar Procedures,5232,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 ICD and Similar Procedures,5232,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 ICD and Similar Procedures,5232,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 ICD and Similar Procedures,5232,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 ICD and Similar Procedures,5232,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 ICD and Similar Procedures,5232,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 ICD and Similar Procedures,5232,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 ICD and Similar Procedures,5232,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 ICD and Similar Procedures,5232,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 ICD and Similar Procedures,5232,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 ICD and Similar Procedures,5232,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 ICD and Similar Procedures,5232,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 ICD and Similar Procedures,5232,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 ICD and Similar Procedures,5232,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 ICD and Similar Procedures,5232,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 ICD and Similar Procedures,5232,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 ICD and Similar Procedures,5232,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 ICD and Similar Procedures,5232,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 ICD and Similar Procedures,5232,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1607.16,1607.16,1607.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],,,,0,other,,,No services performed during 15-month lookback period. Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],2739.33,2739.33,4085.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],,,,0,other,,,No services performed during 15-month lookback period. Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",2761.08,2761.08,2761.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",3722.05,3722.05,3722.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1459.14,1250.02,7680.05,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",1697.33,1697.33,1697.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],,,,0,other,,,No services performed during 15-month lookback period. Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],6652.23,6652.23,198233.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],,,,0,other,,,No services performed during 15-month lookback period. Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",4127.33,4127.33,4127.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",3758.29,3563.86,30468.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Upper GI Procedures,5301,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Upper GI Procedures,5301,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],3692,2887.9,7924.52,35,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Upper GI Procedures,5301,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1859.5,1795.6,1971.52,21,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Upper GI Procedures,5301,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 1 Upper GI Procedures,5301,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Upper GI Procedures,5301,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],5387.28,4044.96,7628.31,27,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Upper GI Procedures,5301,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],5188.54,3082.09,6785.24,87,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Upper GI Procedures,5301,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,4843.13,3494.64,6745.68,33,percent of total billed charges,,, Level 1 Upper GI Procedures,5301,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Level 1 Upper GI Procedures,5301,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Upper GI Procedures,5301,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Upper GI Procedures,5301,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Upper GI Procedures,5301,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Upper GI Procedures,5301,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Upper GI Procedures,5301,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Upper GI Procedures,5301,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Upper GI Procedures,5301,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1596.78,1494.18,1827.63,36,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Upper GI Procedures,5301,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1545.48,1545.48,1545.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Upper GI Procedures,5301,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Upper GI Procedures,5301,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Upper GI Procedures,5301,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Upper GI Procedures,5301,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1653.12,1587.2,1753.42,20,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Upper GI Procedures,5301,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1571.13,1519.83,1750.68,62,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Upper GI Procedures,5301,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1627.2,1548.78,1810.18,181,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Upper GI Procedures,5301,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1748.84,1692.66,1776.93,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Upper GI Procedures,5301,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",4998.72,1264.9,5701.49,39,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Upper GI Procedures,5301,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Upper GI Procedures,5302,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Upper GI Procedures,5302,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],3969,2469.6,5512.5,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Upper GI Procedures,5302,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",2065.58,2065.58,2065.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Upper GI Procedures,5302,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 2 Upper GI Procedures,5302,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Upper GI Procedures,5302,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],7524.01,7514,13924.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Upper GI Procedures,5302,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],6965.47,5704.67,7514,21,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Upper GI Procedures,5302,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,6229.78,3551.24,12941.36,25,percent of total billed charges,,, Level 2 Upper GI Procedures,5302,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Level 2 Upper GI Procedures,5302,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Upper GI Procedures,5302,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Upper GI Procedures,5302,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Upper GI Procedures,5302,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Upper GI Procedures,5302,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Upper GI Procedures,5302,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Upper GI Procedures,5302,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Upper GI Procedures,5302,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",2332.99,1571.13,6444.64,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Upper GI Procedures,5302,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Upper GI Procedures,5302,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Upper GI Procedures,5302,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Upper GI Procedures,5302,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Upper GI Procedures,5302,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1622.43,1494.18,2661.07,33,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Upper GI Procedures,5302,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Upper GI Procedures,5302,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1883.87,1522.64,4422.88,120,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Upper GI Procedures,5302,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",5881.79,5026.08,7555.97,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Upper GI Procedures,5302,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Upper GI Procedures,5302,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Upper GI Procedures,5303,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Upper GI Procedures,5303,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 3 Upper GI Procedures,5303,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],,,,0,other,,,No services performed during 15-month lookback period. Level 3 Upper GI Procedures,5303,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Upper GI Procedures,5303,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Upper GI Procedures,5303,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],12267.05,12267.05,12271.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Upper GI Procedures,5303,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],,,,0,other,,,No services performed during 15-month lookback period. Level 3 Upper GI Procedures,5303,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,9461.42,9461.42,9461.42,1 through 10,percent of total billed charges,,, Level 3 Upper GI Procedures,5303,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Level 3 Upper GI Procedures,5303,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Upper GI Procedures,5303,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Upper GI Procedures,5303,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Upper GI Procedures,5303,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Upper GI Procedures,5303,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Upper GI Procedures,5303,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Upper GI Procedures,5303,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Upper GI Procedures,5303,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",7152.09,7152.09,7152.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Upper GI Procedures,5303,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Upper GI Procedures,5303,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Upper GI Procedures,5303,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Upper GI Procedures,5303,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Upper GI Procedures,5303,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",6639.04,6639.04,6639.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Upper GI Procedures,5303,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Upper GI Procedures,5303,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",5736.46,5465.5,7736.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Upper GI Procedures,5303,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",6702.1,6702.1,6702.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Upper GI Procedures,5303,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Upper GI Procedures,5303,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Lower GI Procedures,5311,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Lower GI Procedures,5311,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],2297.6,2297.6,2297.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Lower GI Procedures,5311,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 1 Lower GI Procedures,5311,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Lower GI Procedures,5311,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Lower GI Procedures,5311,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],3306.18,3306.18,3306.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Lower GI Procedures,5311,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],,,,0,other,,,No services performed during 15-month lookback period. Level 1 Lower GI Procedures,5311,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Level 1 Lower GI Procedures,5311,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Lower GI Procedures,5311,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Lower GI Procedures,5311,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Lower GI Procedures,5311,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Lower GI Procedures,5311,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Lower GI Procedures,5311,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Lower GI Procedures,5311,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Lower GI Procedures,5311,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Lower GI Procedures,5311,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",2175.43,2175.43,2175.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Lower GI Procedures,5311,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Lower GI Procedures,5311,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Lower GI Procedures,5311,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Lower GI Procedures,5311,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Lower GI Procedures,5311,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1609.73,1609.73,1609.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Lower GI Procedures,5311,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1600.49,1600.49,1600.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Lower GI Procedures,5311,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Lower GI Procedures,5311,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1825.73,1825.73,1825.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Lower GI Procedures,5311,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",7531.6,7531.6,7531.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Lower GI Procedures,5311,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Lower GI Procedures,5312,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Lower GI Procedures,5312,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],5538,3692,6500.24,27,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Lower GI Procedures,5312,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1902.7,1829.09,2254.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Lower GI Procedures,5312,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 2 Lower GI Procedures,5312,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Lower GI Procedures,5312,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],6268,5705.16,6283.31,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Lower GI Procedures,5312,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],4354.66,1995,6269.64,66,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Lower GI Procedures,5312,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,9354,7725.85,12012.69,13,percent of total billed charges,,, Level 2 Lower GI Procedures,5312,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Level 2 Lower GI Procedures,5312,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Lower GI Procedures,5312,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Lower GI Procedures,5312,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Lower GI Procedures,5312,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Lower GI Procedures,5312,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Lower GI Procedures,5312,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Lower GI Procedures,5312,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,1868.34,1868.34,1868.34,1 through 10,percent of total billed charges,,, Level 2 Lower GI Procedures,5312,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1620.47,1511.85,1664.81,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Lower GI Procedures,5312,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Lower GI Procedures,5312,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,3904.87,3904.87,3904.87,1 through 10,percent of total billed charges,,, Level 2 Lower GI Procedures,5312,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Lower GI Procedures,5312,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Lower GI Procedures,5312,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1658.47,1625.24,2320.55,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Lower GI Procedures,5312,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1587.86,1510.91,2023.91,37,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Lower GI Procedures,5312,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1644.26,1565.84,1880.53,87,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Lower GI Procedures,5312,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1991.88,1991.88,2538.38,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Lower GI Procedures,5312,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",7532.06,4483.12,7926.92,26,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Lower GI Procedures,5312,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",6778.4,6778.4,6778.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Lower GI Procedures,5313,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Lower GI Procedures,5313,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],100,100,100,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Lower GI Procedures,5313,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",3980.81,3980.81,3980.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Lower GI Procedures,5313,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 3 Lower GI Procedures,5313,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Lower GI Procedures,5313,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],10023.54,10023.54,10023.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Lower GI Procedures,5313,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],9272.04,9272.04,10008.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Lower GI Procedures,5313,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Level 3 Lower GI Procedures,5313,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Lower GI Procedures,5313,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Lower GI Procedures,5313,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Lower GI Procedures,5313,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Lower GI Procedures,5313,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Lower GI Procedures,5313,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Lower GI Procedures,5313,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Lower GI Procedures,5313,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,269.44,269.44,269.44,1 through 10,percent of total billed charges,,, Level 3 Lower GI Procedures,5313,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",3608.58,3608.58,4984.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Lower GI Procedures,5313,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Lower GI Procedures,5313,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Lower GI Procedures,5313,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Lower GI Procedures,5313,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Lower GI Procedures,5313,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",3904.24,3904.24,3904.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Lower GI Procedures,5313,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",3559.95,3559.95,3559.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Lower GI Procedures,5313,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",3711.49,2442.66,4352.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Lower GI Procedures,5313,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",3702.55,3702.55,3702.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Lower GI Procedures,5313,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",9693.71,9693.71,9693.71,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Lower GI Procedures,5313,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Complex GI Procedures,5331,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Complex GI Procedures,5331,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],6563,6563,6563,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Complex GI Procedures,5331,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Complex GI Procedures,5331,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Complex GI Procedures,5331,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Complex GI Procedures,5331,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],,,,0,other,,,No services performed during 15-month lookback period. Complex GI Procedures,5331,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],,,,0,other,,,No services performed during 15-month lookback period. Complex GI Procedures,5331,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Complex GI Procedures,5331,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Complex GI Procedures,5331,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Complex GI Procedures,5331,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Complex GI Procedures,5331,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Complex GI Procedures,5331,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Complex GI Procedures,5331,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Complex GI Procedures,5331,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Complex GI Procedures,5331,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Complex GI Procedures,5331,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Complex GI Procedures,5331,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Complex GI Procedures,5331,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Complex GI Procedures,5331,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Complex GI Procedures,5331,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Complex GI Procedures,5331,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Complex GI Procedures,5331,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Complex GI Procedures,5331,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Complex GI Procedures,5331,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Complex GI Procedures,5331,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",,,,0,other,,,No services performed during 15-month lookback period. Complex GI Procedures,5331,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],6809.73,5182,11646.15,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",7508.61,6705.65,8430.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],12206.03,8153,12268.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],11354.13,10442.01,11867.8,32,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,6157.41,5949.63,10239.2,1 through 10,percent of total billed charges,,, Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,12188.83,12188.83,12188.83,1 through 10,percent of total billed charges,,, Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,350,350,350,1 through 10,percent of total billed charges,,, Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",7309.91,4612.9,9370.13,17,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",7823.95,7823.95,7823.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",6748.47,6748.47,7773.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",5823.18,5066.6,7926.55,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",6590.58,3524.85,8155.96,44,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",14795.41,10758.39,17991.54,20,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",10539.6,10539.6,10539.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],10230,7178.5,29986.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",8485.67,8485.67,8544.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],11108.65,10914.61,12853,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],11353.56,9494.12,12261,18,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,9155.51,5382.75,9746.15,1 through 10,percent of total billed charges,,, Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",7071.37,7071.37,7071.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",4678.32,4678.32,4678.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,250,250,250,1 through 10,percent of total billed charges,,, Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",7373.62,5778.86,20572.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,7245.78,7245.78,7245.78,1 through 10,percent of total billed charges,,, Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",6441.73,5591.5,8328.59,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",7514.07,5472.15,9522.48,23,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",13596.54,13596.54,14516.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",11366.25,10507.5,17071.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Laparoscopy and Related Services,5361,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Laparoscopy and Related Services,5361,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],4871,3177.77,8201,30,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Laparoscopy and Related Services,5361,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",7505.43,7396.95,9737.32,17,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Laparoscopy and Related Services,5361,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 1 Laparoscopy and Related Services,5361,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Laparoscopy and Related Services,5361,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],12070.9,9148.36,12715.27,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Laparoscopy and Related Services,5361,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],10613.39,8517.23,12187.89,63,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Laparoscopy and Related Services,5361,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,10738.35,9167.43,14414.72,19,percent of total billed charges,,, Level 1 Laparoscopy and Related Services,5361,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Level 1 Laparoscopy and Related Services,5361,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Laparoscopy and Related Services,5361,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Laparoscopy and Related Services,5361,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Laparoscopy and Related Services,5361,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Laparoscopy and Related Services,5361,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Laparoscopy and Related Services,5361,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Laparoscopy and Related Services,5361,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Laparoscopy and Related Services,5361,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",6669.75,5292.91,8534.04,27,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Laparoscopy and Related Services,5361,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",5867.19,5867.19,5867.19,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Laparoscopy and Related Services,5361,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Laparoscopy and Related Services,5361,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Laparoscopy and Related Services,5361,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Laparoscopy and Related Services,5361,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",6664.89,6373.41,8740.19,17,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Laparoscopy and Related Services,5361,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",6438.9,5488.28,7849.6,44,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Laparoscopy and Related Services,5361,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",6550.51,5566.7,7601.41,86,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Laparoscopy and Related Services,5361,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",6650.68,3454.56,7293.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Laparoscopy and Related Services,5361,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",19616.5,15030.61,24723.33,44,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Laparoscopy and Related Services,5361,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",17160.21,12464.02,17698.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Laparoscopy and Related Services,5362,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Laparoscopy and Related Services,5362,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 2 Laparoscopy and Related Services,5362,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],,,,0,other,,,No services performed during 15-month lookback period. Level 2 Laparoscopy and Related Services,5362,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Laparoscopy and Related Services,5362,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Laparoscopy and Related Services,5362,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],,,,0,other,,,No services performed during 15-month lookback period. Level 2 Laparoscopy and Related Services,5362,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],,,,0,other,,,No services performed during 15-month lookback period. Level 2 Laparoscopy and Related Services,5362,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Level 2 Laparoscopy and Related Services,5362,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Laparoscopy and Related Services,5362,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Laparoscopy and Related Services,5362,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Laparoscopy and Related Services,5362,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Laparoscopy and Related Services,5362,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Laparoscopy and Related Services,5362,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Laparoscopy and Related Services,5362,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Laparoscopy and Related Services,5362,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Laparoscopy and Related Services,5362,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Laparoscopy and Related Services,5362,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Laparoscopy and Related Services,5362,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Laparoscopy and Related Services,5362,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Laparoscopy and Related Services,5362,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Laparoscopy and Related Services,5362,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",9205.1,9205.1,9205.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Laparoscopy and Related Services,5362,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Laparoscopy and Related Services,5362,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Laparoscopy and Related Services,5362,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Laparoscopy and Related Services,5362,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Laparoscopy and Related Services,5362,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Urology and Related Services,5371,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Urology and Related Services,5371,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],2840,2840,2840,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Urology and Related Services,5371,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",477.52,477.52,477.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Urology and Related Services,5371,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 1 Urology and Related Services,5371,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Urology and Related Services,5371,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],2804.76,2804.76,2804.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Urology and Related Services,5371,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],2117.94,2087.25,4341.23,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Urology and Related Services,5371,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Level 1 Urology and Related Services,5371,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Urology and Related Services,5371,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Urology and Related Services,5371,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Urology and Related Services,5371,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Urology and Related Services,5371,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Urology and Related Services,5371,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Urology and Related Services,5371,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Urology and Related Services,5371,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Urology and Related Services,5371,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",315.21,307.01,528.19,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Urology and Related Services,5371,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Urology and Related Services,5371,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Urology and Related Services,5371,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Urology and Related Services,5371,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Urology and Related Services,5371,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",2343.14,2343.14,2343.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Urology and Related Services,5371,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",528.19,315.21,549.85,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Urology and Related Services,5371,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",321.21,282.59,722.1,78,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Urology and Related Services,5371,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",2593,2593,3228,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Urology and Related Services,5371,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Urology and Related Services,5371,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Urology and Related Services,5372,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Urology and Related Services,5372,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],14805.79,14805.79,14805.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Urology and Related Services,5372,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",2944.77,2944.77,2944.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Urology and Related Services,5372,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 2 Urology and Related Services,5372,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Urology and Related Services,5372,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],5811.89,5811.89,5811.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Urology and Related Services,5372,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],,,,0,other,,,No services performed during 15-month lookback period. Level 2 Urology and Related Services,5372,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Level 2 Urology and Related Services,5372,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Urology and Related Services,5372,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Urology and Related Services,5372,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Urology and Related Services,5372,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Urology and Related Services,5372,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Urology and Related Services,5372,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Urology and Related Services,5372,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Urology and Related Services,5372,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Urology and Related Services,5372,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Urology and Related Services,5372,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Urology and Related Services,5372,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Urology and Related Services,5372,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Urology and Related Services,5372,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Urology and Related Services,5372,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",2325.3,2325.3,2325.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Urology and Related Services,5372,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Urology and Related Services,5372,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",2468.86,2468.86,2651.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Urology and Related Services,5372,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Urology and Related Services,5372,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Urology and Related Services,5372,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Urology and Related Services,5373,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Urology and Related Services,5373,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],3774.22,1175,5953.5,18,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Urology and Related Services,5373,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",3475.56,2915.45,5151.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Urology and Related Services,5373,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 3 Urology and Related Services,5373,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Urology and Related Services,5373,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],7520.89,7269.18,7527.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Urology and Related Services,5373,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],6963.89,5093.11,7522.06,27,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Urology and Related Services,5373,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,5202.21,4841.52,5814.04,1 through 10,percent of total billed charges,,, Level 3 Urology and Related Services,5373,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Level 3 Urology and Related Services,5373,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Urology and Related Services,5373,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Urology and Related Services,5373,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Urology and Related Services,5373,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Urology and Related Services,5373,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Urology and Related Services,5373,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Urology and Related Services,5373,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Urology and Related Services,5373,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",2976.89,2887.17,3169.32,41,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Urology and Related Services,5373,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Urology and Related Services,5373,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Urology and Related Services,5373,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Urology and Related Services,5373,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Urology and Related Services,5373,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",3154,3073.39,5232.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Urology and Related Services,5373,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",2938.47,2887.17,3109.85,65,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Urology and Related Services,5373,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",3020.59,2547.28,3191.64,113,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Urology and Related Services,5373,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",3236.13,3162.13,3381.75,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Urology and Related Services,5373,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",9476.66,5521.68,11323.91,32,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Urology and Related Services,5373,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Urology and Related Services,5374,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Urology and Related Services,5374,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],7055.5,4499.65,14153.26,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Urology and Related Services,5374,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",5271.95,5271.95,7464.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Urology and Related Services,5374,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 4 Urology and Related Services,5374,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Urology and Related Services,5374,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],12263.94,11946.07,12686.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Urology and Related Services,5374,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],11123.01,7938.18,12276.44,29,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Urology and Related Services,5374,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],3819.51,3819.51,3819.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Urology and Related Services,5374,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,8880.15,6327.29,16172.1,1 through 10,percent of total billed charges,,, Level 4 Urology and Related Services,5374,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Urology and Related Services,5374,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Urology and Related Services,5374,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Urology and Related Services,5374,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Urology and Related Services,5374,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Urology and Related Services,5374,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Urology and Related Services,5374,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Urology and Related Services,5374,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",6064.57,2989.77,7048.32,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Urology and Related Services,5374,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Urology and Related Services,5374,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Urology and Related Services,5374,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Urology and Related Services,5374,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Urology and Related Services,5374,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",2640.54,2640.54,2640.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Urology and Related Services,5374,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",4458.73,2938.47,6480.43,30,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Urology and Related Services,5374,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",4518,2994.45,6473.18,65,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Urology and Related Services,5374,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",4855.81,4726.29,6929.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Urology and Related Services,5374,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",13154.24,7975.72,19218.29,28,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Urology and Related Services,5374,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",13012.01,13012.01,13012.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 5 Urology and Related Services,5375,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 5 Urology and Related Services,5375,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],9024.5,9024.5,38889.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 5 Urology and Related Services,5375,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",7576.51,7576.51,7576.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 5 Urology and Related Services,5375,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 5 Urology and Related Services,5375,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 5 Urology and Related Services,5375,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],10795.41,10795.41,11922.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 5 Urology and Related Services,5375,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],12266.62,12266.62,12266.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 5 Urology and Related Services,5375,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,11444.33,11444.33,11444.33,1 through 10,percent of total billed charges,,, Level 5 Urology and Related Services,5375,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Level 5 Urology and Related Services,5375,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 5 Urology and Related Services,5375,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 5 Urology and Related Services,5375,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 5 Urology and Related Services,5375,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 5 Urology and Related Services,5375,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 5 Urology and Related Services,5375,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 5 Urology and Related Services,5375,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 5 Urology and Related Services,5375,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",5011.47,4873.9,8689.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 5 Urology and Related Services,5375,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 5 Urology and Related Services,5375,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 5 Urology and Related Services,5375,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 5 Urology and Related Services,5375,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 5 Urology and Related Services,5375,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",9209.22,9209.22,9209.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 5 Urology and Related Services,5375,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",7581.87,6862.28,11076.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 5 Urology and Related Services,5375,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",8698.56,6499.32,9515.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 5 Urology and Related Services,5375,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",4714.8,4714.8,4714.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 5 Urology and Related Services,5375,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",18340.36,18340.36,18340.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 5 Urology and Related Services,5375,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Level 6 Urology and Related Services,5376,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 6 Urology and Related Services,5376,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 6 Urology and Related Services,5376,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],,,,0,other,,,No services performed during 15-month lookback period. Level 6 Urology and Related Services,5376,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 6 Urology and Related Services,5376,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 6 Urology and Related Services,5376,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],11131.65,11131.65,11131.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 6 Urology and Related Services,5376,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],,,,0,other,,,No services performed during 15-month lookback period. Level 6 Urology and Related Services,5376,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Level 6 Urology and Related Services,5376,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 6 Urology and Related Services,5376,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 6 Urology and Related Services,5376,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 6 Urology and Related Services,5376,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 6 Urology and Related Services,5376,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 6 Urology and Related Services,5376,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 6 Urology and Related Services,5376,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 6 Urology and Related Services,5376,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 6 Urology and Related Services,5376,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",6454.78,6454.78,6454.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 6 Urology and Related Services,5376,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 6 Urology and Related Services,5376,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 6 Urology and Related Services,5376,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 6 Urology and Related Services,5376,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 6 Urology and Related Services,5376,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 6 Urology and Related Services,5376,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 6 Urology and Related Services,5376,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",8150.83,8150.83,8150.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 6 Urology and Related Services,5376,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",7485.31,7485.31,7485.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 6 Urology and Related Services,5376,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",,,,0,other,,,No services performed during 15-month lookback period. Level 6 Urology and Related Services,5376,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Gynecologic Procedures,5412,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Gynecologic Procedures,5412,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 2 Gynecologic Procedures,5412,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],,,,0,other,,,No services performed during 15-month lookback period. Level 2 Gynecologic Procedures,5412,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Gynecologic Procedures,5412,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Gynecologic Procedures,5412,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],,,,0,other,,,No services performed during 15-month lookback period. Level 2 Gynecologic Procedures,5412,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],,,,0,other,,,No services performed during 15-month lookback period. Level 2 Gynecologic Procedures,5412,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Level 2 Gynecologic Procedures,5412,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Gynecologic Procedures,5412,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Gynecologic Procedures,5412,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Gynecologic Procedures,5412,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Gynecologic Procedures,5412,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Gynecologic Procedures,5412,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Gynecologic Procedures,5412,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Gynecologic Procedures,5412,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Gynecologic Procedures,5412,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Gynecologic Procedures,5412,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Gynecologic Procedures,5412,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Gynecologic Procedures,5412,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Gynecologic Procedures,5412,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Gynecologic Procedures,5412,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Gynecologic Procedures,5412,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Gynecologic Procedures,5412,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",473.34,473.34,473.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Gynecologic Procedures,5412,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Gynecologic Procedures,5412,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Gynecologic Procedures,5412,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Gynecologic Procedures,5414,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Gynecologic Procedures,5414,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 4 Gynecologic Procedures,5414,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],,,,0,other,,,No services performed during 15-month lookback period. Level 4 Gynecologic Procedures,5414,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Gynecologic Procedures,5414,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Gynecologic Procedures,5414,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],11142.48,11142.48,11142.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Gynecologic Procedures,5414,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],,,,0,other,,,No services performed during 15-month lookback period. Level 4 Gynecologic Procedures,5414,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,4017.31,4017.31,4017.31,1 through 10,percent of total billed charges,,, Level 4 Gynecologic Procedures,5414,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Level 4 Gynecologic Procedures,5414,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Gynecologic Procedures,5414,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Gynecologic Procedures,5414,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Gynecologic Procedures,5414,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Gynecologic Procedures,5414,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Gynecologic Procedures,5414,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Gynecologic Procedures,5414,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Gynecologic Procedures,5414,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Gynecologic Procedures,5414,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Gynecologic Procedures,5414,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Gynecologic Procedures,5414,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Gynecologic Procedures,5414,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Gynecologic Procedures,5414,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",3979.22,3979.22,3979.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Gynecologic Procedures,5414,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",3952.25,3952.25,4354.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Gynecologic Procedures,5414,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",4121.87,4024.89,4198.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Gynecologic Procedures,5414,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",3252.85,3252.85,3252.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Gynecologic Procedures,5414,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Gynecologic Procedures,5414,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Level 5 Gynecologic Procedures,5415,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 5 Gynecologic Procedures,5415,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 5 Gynecologic Procedures,5415,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],,,,0,other,,,No services performed during 15-month lookback period. Level 5 Gynecologic Procedures,5415,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 5 Gynecologic Procedures,5415,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 5 Gynecologic Procedures,5415,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],10432.39,10432.39,10432.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 5 Gynecologic Procedures,5415,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],,,,0,other,,,No services performed during 15-month lookback period. Level 5 Gynecologic Procedures,5415,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Level 5 Gynecologic Procedures,5415,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 5 Gynecologic Procedures,5415,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 5 Gynecologic Procedures,5415,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 5 Gynecologic Procedures,5415,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 5 Gynecologic Procedures,5415,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 5 Gynecologic Procedures,5415,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 5 Gynecologic Procedures,5415,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 5 Gynecologic Procedures,5415,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 5 Gynecologic Procedures,5415,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 5 Gynecologic Procedures,5415,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 5 Gynecologic Procedures,5415,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 5 Gynecologic Procedures,5415,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 5 Gynecologic Procedures,5415,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 5 Gynecologic Procedures,5415,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 5 Gynecologic Procedures,5415,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 5 Gynecologic Procedures,5415,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 5 Gynecologic Procedures,5415,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",14759.61,14759.61,14759.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 5 Gynecologic Procedures,5415,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 5 Gynecologic Procedures,5415,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Nerve Procedures,5431,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Nerve Procedures,5431,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 1 Nerve Procedures,5431,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],,,,0,other,,,No services performed during 15-month lookback period. Level 1 Nerve Procedures,5431,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Nerve Procedures,5431,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Nerve Procedures,5431,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],2500,2500,2500,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Nerve Procedures,5431,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],,,,0,other,,,No services performed during 15-month lookback period. Level 1 Nerve Procedures,5431,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,9636.84,9636.84,9636.84,1 through 10,percent of total billed charges,,, Level 1 Nerve Procedures,5431,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Level 1 Nerve Procedures,5431,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Nerve Procedures,5431,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Nerve Procedures,5431,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Nerve Procedures,5431,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Nerve Procedures,5431,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Nerve Procedures,5431,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Nerve Procedures,5431,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Nerve Procedures,5431,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Nerve Procedures,5431,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Nerve Procedures,5431,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Nerve Procedures,5431,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Nerve Procedures,5431,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Nerve Procedures,5431,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",3254.65,3254.65,3254.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Nerve Procedures,5431,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Nerve Procedures,5431,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",2401.39,2192.27,8251.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Nerve Procedures,5431,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",9703.68,9703.68,9703.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Nerve Procedures,5431,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Nerve Procedures,5431,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Nerve Procedures,5432,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Nerve Procedures,5432,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],9867.84,9867.84,9867.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Nerve Procedures,5432,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 2 Nerve Procedures,5432,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Nerve Procedures,5432,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Nerve Procedures,5432,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],11376.27,11376.27,13708.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Nerve Procedures,5432,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],,,,0,other,,,No services performed during 15-month lookback period. Level 2 Nerve Procedures,5432,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,30959.86,30959.86,30959.86,1 through 10,percent of total billed charges,,, Level 2 Nerve Procedures,5432,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Level 2 Nerve Procedures,5432,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Nerve Procedures,5432,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Nerve Procedures,5432,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Nerve Procedures,5432,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Nerve Procedures,5432,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Nerve Procedures,5432,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Nerve Procedures,5432,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Nerve Procedures,5432,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Nerve Procedures,5432,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Nerve Procedures,5432,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Nerve Procedures,5432,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Nerve Procedures,5432,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Nerve Procedures,5432,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Nerve Procedures,5432,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Nerve Procedures,5432,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",11698.13,9597.42,16496.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Nerve Procedures,5432,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Nerve Procedures,5432,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Nerve Procedures,5432,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Nerve Injections,5441,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Nerve Injections,5441,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],4745.9,4308,6174,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Nerve Injections,5441,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",931.44,575.58,1257.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Nerve Injections,5441,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 1 Nerve Injections,5441,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Nerve Injections,5441,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],3380.37,3380.37,3937.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Nerve Injections,5441,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],2995.37,2140.73,7062.33,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Nerve Injections,5441,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,3990.92,3632.57,6232.02,1 through 10,percent of total billed charges,,, Level 1 Nerve Injections,5441,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Level 1 Nerve Injections,5441,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Nerve Injections,5441,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Nerve Injections,5441,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Nerve Injections,5441,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Nerve Injections,5441,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Nerve Injections,5441,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Nerve Injections,5441,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Nerve Injections,5441,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",627.15,452.3,1320.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Nerve Injections,5441,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Nerve Injections,5441,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Nerve Injections,5441,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Nerve Injections,5441,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Nerve Injections,5441,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1067.46,783.19,1371.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Nerve Injections,5441,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Nerve Injections,5441,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1066.47,586.82,1424.1,32,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Nerve Injections,5441,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",2364.25,1424,2470.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Nerve Injections,5441,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Nerve Injections,5441,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Nerve Injections,5442,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Nerve Injections,5442,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],2872,1488.89,4538.77,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Nerve Injections,5442,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1663.17,1479.86,2013.94,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Nerve Injections,5442,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 2 Nerve Injections,5442,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Nerve Injections,5442,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],4733.72,3510.22,9082.68,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Nerve Injections,5442,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],,,,0,other,,,No services performed during 15-month lookback period. Level 2 Nerve Injections,5442,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],9968.31,9968.31,9968.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Nerve Injections,5442,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,5506.63,3130.25,13023.52,1 through 10,percent of total billed charges,,, Level 2 Nerve Injections,5442,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Nerve Injections,5442,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Nerve Injections,5442,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Nerve Injections,5442,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Nerve Injections,5442,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Nerve Injections,5442,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Nerve Injections,5442,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Nerve Injections,5442,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1300.19,1278.03,1397.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Nerve Injections,5442,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Nerve Injections,5442,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Nerve Injections,5442,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Nerve Injections,5442,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Nerve Injections,5442,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1356.54,1356.54,1356.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Nerve Injections,5442,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1371.83,1294.88,1676.19,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Nerve Injections,5442,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1319.54,1033.37,1450.24,76,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Nerve Injections,5442,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1418.2,1418.2,1487.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Nerve Injections,5442,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",1424,712,5184.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Nerve Injections,5442,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Nerve Injections,5443,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Nerve Injections,5443,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",2717.54,2717.54,2717.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Nerve Injections,5443,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 3 Nerve Injections,5443,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],,,,0,other,,,No services performed during 15-month lookback period. Level 3 Nerve Injections,5443,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Nerve Injections,5443,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],11519.5,11519.5,11519.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Nerve Injections,5443,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],9143.15,9143.15,9143.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Nerve Injections,5443,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,11665.14,11665.14,11665.14,1 through 10,percent of total billed charges,,, Level 3 Nerve Injections,5443,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Level 3 Nerve Injections,5443,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Nerve Injections,5443,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Nerve Injections,5443,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Nerve Injections,5443,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Nerve Injections,5443,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Nerve Injections,5443,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Nerve Injections,5443,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Nerve Injections,5443,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Nerve Injections,5443,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Nerve Injections,5443,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Nerve Injections,5443,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Nerve Injections,5443,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Nerve Injections,5443,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1766.89,1766.89,1766.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Nerve Injections,5443,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Nerve Injections,5443,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",3753.21,3753.21,3753.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Nerve Injections,5443,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",6293.24,6293.24,6293.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Nerve Injections,5443,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Nerve Injections,5443,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],,,,0,other,,,No services performed during 15-month lookback period. Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],,,,0,other,,,No services performed during 15-month lookback period. Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],,,,0,other,,,No services performed during 15-month lookback period. Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",27479.14,27479.14,28059.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],,,,0,other,,,No services performed during 15-month lookback period. Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],,,,0,other,,,No services performed during 15-month lookback period. Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],,,,0,other,,,No services performed during 15-month lookback period. Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,21009.98,21009.98,21009.98,1 through 10,percent of total billed charges,,, Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",28138.21,28138.21,29022.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",39890.07,39890.07,40140.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Implantation of Drug Infusion Device,5471,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Implantation of Drug Infusion Device,5471,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Implantation of Drug Infusion Device,5471,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],,,,0,other,,,No services performed during 15-month lookback period. Implantation of Drug Infusion Device,5471,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Implantation of Drug Infusion Device,5471,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Implantation of Drug Infusion Device,5471,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],,,,0,other,,,No services performed during 15-month lookback period. Implantation of Drug Infusion Device,5471,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],,,,0,other,,,No services performed during 15-month lookback period. Implantation of Drug Infusion Device,5471,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Implantation of Drug Infusion Device,5471,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Implantation of Drug Infusion Device,5471,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Implantation of Drug Infusion Device,5471,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Implantation of Drug Infusion Device,5471,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Implantation of Drug Infusion Device,5471,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Implantation of Drug Infusion Device,5471,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Implantation of Drug Infusion Device,5471,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Implantation of Drug Infusion Device,5471,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Implantation of Drug Infusion Device,5471,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Implantation of Drug Infusion Device,5471,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Implantation of Drug Infusion Device,5471,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Implantation of Drug Infusion Device,5471,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Implantation of Drug Infusion Device,5471,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Implantation of Drug Infusion Device,5471,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",17823.1,17823.1,17823.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Implantation of Drug Infusion Device,5471,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Implantation of Drug Infusion Device,5471,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Implantation of Drug Infusion Device,5471,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Implantation of Drug Infusion Device,5471,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",,,,0,other,,,No services performed during 15-month lookback period. Implantation of Drug Infusion Device,5471,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Laser Eye Procedures,5481,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Laser Eye Procedures,5481,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Laser Eye Procedures,5481,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],,,,0,other,,,No services performed during 15-month lookback period. Laser Eye Procedures,5481,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Laser Eye Procedures,5481,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Laser Eye Procedures,5481,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],,,,0,other,,,No services performed during 15-month lookback period. Laser Eye Procedures,5481,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],,,,0,other,,,No services performed during 15-month lookback period. Laser Eye Procedures,5481,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Laser Eye Procedures,5481,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Laser Eye Procedures,5481,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Laser Eye Procedures,5481,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Laser Eye Procedures,5481,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Laser Eye Procedures,5481,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Laser Eye Procedures,5481,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Laser Eye Procedures,5481,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Laser Eye Procedures,5481,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Laser Eye Procedures,5481,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",2248.05,2248.05,2248.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Laser Eye Procedures,5481,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Laser Eye Procedures,5481,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Laser Eye Procedures,5481,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Laser Eye Procedures,5481,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Laser Eye Procedures,5481,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Laser Eye Procedures,5481,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Laser Eye Procedures,5481,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",2395.43,2395.43,2395.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Laser Eye Procedures,5481,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Laser Eye Procedures,5481,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",,,,0,other,,,No services performed during 15-month lookback period. Laser Eye Procedures,5481,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Intraocular Procedures,5491,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Intraocular Procedures,5491,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 1 Intraocular Procedures,5491,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],,,,0,other,,,No services performed during 15-month lookback period. Level 1 Intraocular Procedures,5491,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Intraocular Procedures,5491,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Intraocular Procedures,5491,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],6513.8,4933.43,6970.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Intraocular Procedures,5491,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],7156.21,7156.21,7156.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Intraocular Procedures,5491,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Level 1 Intraocular Procedures,5491,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Intraocular Procedures,5491,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Intraocular Procedures,5491,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Intraocular Procedures,5491,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Intraocular Procedures,5491,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Intraocular Procedures,5491,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Intraocular Procedures,5491,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",3497.39,3497.39,3497.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Intraocular Procedures,5491,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Intraocular Procedures,5491,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Intraocular Procedures,5491,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Intraocular Procedures,5491,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Intraocular Procedures,5491,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Intraocular Procedures,5491,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Intraocular Procedures,5491,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",5179.9,5179.9,5179.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Intraocular Procedures,5491,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",2668.54,1652.6,3392.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Intraocular Procedures,5491,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",2764.6,1726.53,3509.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Intraocular Procedures,5491,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",9924.7,9924.7,9924.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Intraocular Procedures,5491,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Intraocular Procedures,5491,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Intraocular Procedures,5492,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Intraocular Procedures,5492,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 2 Intraocular Procedures,5492,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],,,,0,other,,,No services performed during 15-month lookback period. Level 2 Intraocular Procedures,5492,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Intraocular Procedures,5492,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Intraocular Procedures,5492,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],10755.98,9986.66,11363.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Intraocular Procedures,5492,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],,,,0,other,,,No services performed during 15-month lookback period. Level 2 Intraocular Procedures,5492,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,19838.42,19838.42,21545.44,1 through 10,percent of total billed charges,,, Level 2 Intraocular Procedures,5492,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Level 2 Intraocular Procedures,5492,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Intraocular Procedures,5492,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Intraocular Procedures,5492,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Intraocular Procedures,5492,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Intraocular Procedures,5492,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Intraocular Procedures,5492,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Intraocular Procedures,5492,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Intraocular Procedures,5492,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",4816.99,4816.99,4957.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Intraocular Procedures,5492,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Intraocular Procedures,5492,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Intraocular Procedures,5492,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Intraocular Procedures,5492,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Intraocular Procedures,5492,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",4765.69,4765.69,4816.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Intraocular Procedures,5492,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Intraocular Procedures,5492,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",2719.38,2719.38,2719.38,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Intraocular Procedures,5492,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",13899.46,13899.46,13899.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Intraocular Procedures,5492,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Intraocular Procedures,5492,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Intraocular Procedures,5493,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Intraocular Procedures,5493,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 3 Intraocular Procedures,5493,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],,,,0,other,,,No services performed during 15-month lookback period. Level 3 Intraocular Procedures,5493,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Intraocular Procedures,5493,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Intraocular Procedures,5493,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],,,,0,other,,,No services performed during 15-month lookback period. Level 3 Intraocular Procedures,5493,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],,,,0,other,,,No services performed during 15-month lookback period. Level 3 Intraocular Procedures,5493,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Level 3 Intraocular Procedures,5493,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Intraocular Procedures,5493,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Intraocular Procedures,5493,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Intraocular Procedures,5493,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Intraocular Procedures,5493,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Intraocular Procedures,5493,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Intraocular Procedures,5493,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Intraocular Procedures,5493,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Intraocular Procedures,5493,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Intraocular Procedures,5493,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Intraocular Procedures,5493,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Intraocular Procedures,5493,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Intraocular Procedures,5493,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Intraocular Procedures,5493,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Intraocular Procedures,5493,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Intraocular Procedures,5493,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",5394.68,5394.68,5394.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Intraocular Procedures,5493,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",9516.09,9516.09,9516.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Intraocular Procedures,5493,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Intraocular Procedures,5493,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. "Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. "Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],,,,0,other,,,No services performed during 15-month lookback period. "Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. "Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],4622.5,4622.5,4622.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],,,,0,other,,,No services performed during 15-month lookback period. "Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,4623.56,4623.56,4623.56,1 through 10,percent of total billed charges,,, "Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. "Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. "Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. "Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",615.9,615.9,615.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. "Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. "Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",724.09,724.09,969.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. "Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",630.98,630.98,683.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",2592.96,2592.96,2592.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. "Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. "Level 2 Extraocular, Repair, and Plastic Eye Procedures",5502,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Level 2 Extraocular, Repair, and Plastic Eye Procedures",5502,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. "Level 2 Extraocular, Repair, and Plastic Eye Procedures",5502,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],,,,0,other,,,No services performed during 15-month lookback period. "Level 2 Extraocular, Repair, and Plastic Eye Procedures",5502,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. "Level 2 Extraocular, Repair, and Plastic Eye Procedures",5502,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Level 2 Extraocular, Repair, and Plastic Eye Procedures",5502,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],,,,0,other,,,No services performed during 15-month lookback period. "Level 2 Extraocular, Repair, and Plastic Eye Procedures",5502,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],,,,0,other,,,No services performed during 15-month lookback period. "Level 2 Extraocular, Repair, and Plastic Eye Procedures",5502,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Level 2 Extraocular, Repair, and Plastic Eye Procedures",5502,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Level 2 Extraocular, Repair, and Plastic Eye Procedures",5502,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Level 2 Extraocular, Repair, and Plastic Eye Procedures",5502,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. "Level 2 Extraocular, Repair, and Plastic Eye Procedures",5502,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. "Level 2 Extraocular, Repair, and Plastic Eye Procedures",5502,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Level 2 Extraocular, Repair, and Plastic Eye Procedures",5502,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Level 2 Extraocular, Repair, and Plastic Eye Procedures",5502,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. "Level 2 Extraocular, Repair, and Plastic Eye Procedures",5502,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Level 2 Extraocular, Repair, and Plastic Eye Procedures",5502,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. "Level 2 Extraocular, Repair, and Plastic Eye Procedures",5502,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. "Level 2 Extraocular, Repair, and Plastic Eye Procedures",5502,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Level 2 Extraocular, Repair, and Plastic Eye Procedures",5502,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Level 2 Extraocular, Repair, and Plastic Eye Procedures",5502,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. "Level 2 Extraocular, Repair, and Plastic Eye Procedures",5502,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",2119.19,2119.19,2119.19,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Level 2 Extraocular, Repair, and Plastic Eye Procedures",5502,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. "Level 2 Extraocular, Repair, and Plastic Eye Procedures",5502,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",2246.98,2246.98,2246.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Level 2 Extraocular, Repair, and Plastic Eye Procedures",5502,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. "Level 2 Extraocular, Repair, and Plastic Eye Procedures",5502,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",,,,0,other,,,No services performed during 15-month lookback period. "Level 2 Extraocular, Repair, and Plastic Eye Procedures",5502,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. "Level 3 Extraocular, Repair, and Plastic Eye Procedures",5503,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Level 3 Extraocular, Repair, and Plastic Eye Procedures",5503,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],6014.17,750,12298,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Level 3 Extraocular, Repair, and Plastic Eye Procedures",5503,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",5448.65,3775.91,5829.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Level 3 Extraocular, Repair, and Plastic Eye Procedures",5503,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. "Level 3 Extraocular, Repair, and Plastic Eye Procedures",5503,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Level 3 Extraocular, Repair, and Plastic Eye Procedures",5503,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],6269.56,4192.05,7160.32,24,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Level 3 Extraocular, Repair, and Plastic Eye Procedures",5503,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],7215.97,6741.23,8038.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Level 3 Extraocular, Repair, and Plastic Eye Procedures",5503,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,10820.65,10820.65,10820.65,1 through 10,percent of total billed charges,,, "Level 3 Extraocular, Repair, and Plastic Eye Procedures",5503,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,7413.1,4409.76,12517.67,13,percent of total billed charges,,, "Level 3 Extraocular, Repair, and Plastic Eye Procedures",5503,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Level 3 Extraocular, Repair, and Plastic Eye Procedures",5503,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. "Level 3 Extraocular, Repair, and Plastic Eye Procedures",5503,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. "Level 3 Extraocular, Repair, and Plastic Eye Procedures",5503,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Level 3 Extraocular, Repair, and Plastic Eye Procedures",5503,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Level 3 Extraocular, Repair, and Plastic Eye Procedures",5503,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. "Level 3 Extraocular, Repair, and Plastic Eye Procedures",5503,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,1140.98,1140.98,1140.98,1 through 10,percent of total billed charges,,, "Level 3 Extraocular, Repair, and Plastic Eye Procedures",5503,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",4568.18,2160.68,4867.58,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Level 3 Extraocular, Repair, and Plastic Eye Procedures",5503,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. "Level 3 Extraocular, Repair, and Plastic Eye Procedures",5503,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Level 3 Extraocular, Repair, and Plastic Eye Procedures",5503,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Level 3 Extraocular, Repair, and Plastic Eye Procedures",5503,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. "Level 3 Extraocular, Repair, and Plastic Eye Procedures",5503,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",4960.01,2662.07,5040.62,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Level 3 Extraocular, Repair, and Plastic Eye Procedures",5503,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",4612.5,1965.29,4816.28,37,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Level 3 Extraocular, Repair, and Plastic Eye Procedures",5503,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",4706.19,2028.86,4960.31,55,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Level 3 Extraocular, Repair, and Plastic Eye Procedures",5503,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",5100.32,2881.44,5303.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Level 3 Extraocular, Repair, and Plastic Eye Procedures",5503,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",14242.31,9694.53,15620.13,19,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Level 3 Extraocular, Repair, and Plastic Eye Procedures",5503,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",224,224,224,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Level 4 Extraocular, Repair, and Plastic Eye Procedures",5504,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Level 4 Extraocular, Repair, and Plastic Eye Procedures",5504,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],7773,7773,7773,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Level 4 Extraocular, Repair, and Plastic Eye Procedures",5504,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. "Level 4 Extraocular, Repair, and Plastic Eye Procedures",5504,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. "Level 4 Extraocular, Repair, and Plastic Eye Procedures",5504,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Level 4 Extraocular, Repair, and Plastic Eye Procedures",5504,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],11358.22,11356.88,11366.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Level 4 Extraocular, Repair, and Plastic Eye Procedures",5504,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],,,,0,other,,,No services performed during 15-month lookback period. "Level 4 Extraocular, Repair, and Plastic Eye Procedures",5504,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,8527.02,8527.02,8527.02,1 through 10,percent of total billed charges,,, "Level 4 Extraocular, Repair, and Plastic Eye Procedures",5504,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Level 4 Extraocular, Repair, and Plastic Eye Procedures",5504,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Level 4 Extraocular, Repair, and Plastic Eye Procedures",5504,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. "Level 4 Extraocular, Repair, and Plastic Eye Procedures",5504,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. "Level 4 Extraocular, Repair, and Plastic Eye Procedures",5504,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Level 4 Extraocular, Repair, and Plastic Eye Procedures",5504,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Level 4 Extraocular, Repair, and Plastic Eye Procedures",5504,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. "Level 4 Extraocular, Repair, and Plastic Eye Procedures",5504,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Level 4 Extraocular, Repair, and Plastic Eye Procedures",5504,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. "Level 4 Extraocular, Repair, and Plastic Eye Procedures",5504,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. "Level 4 Extraocular, Repair, and Plastic Eye Procedures",5504,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Level 4 Extraocular, Repair, and Plastic Eye Procedures",5504,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Level 4 Extraocular, Repair, and Plastic Eye Procedures",5504,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. "Level 4 Extraocular, Repair, and Plastic Eye Procedures",5504,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",3205.94,3205.94,3205.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Level 4 Extraocular, Repair, and Plastic Eye Procedures",5504,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",3245.05,3245.05,3245.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Level 4 Extraocular, Repair, and Plastic Eye Procedures",5504,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",3186.25,3163.67,4986.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Level 4 Extraocular, Repair, and Plastic Eye Procedures",5504,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. "Level 4 Extraocular, Repair, and Plastic Eye Procedures",5504,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",,,,0,other,,,No services performed during 15-month lookback period. "Level 4 Extraocular, Repair, and Plastic Eye Procedures",5504,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Imaging without Contrast,5521,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Imaging without Contrast,5521,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],240,100.45,2803,418,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Imaging without Contrast,5521,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",118.94,114.8,880.83,163,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Imaging without Contrast,5521,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 1 Imaging without Contrast,5521,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,341.5,341.5,341.5,1 through 10,percent of total billed charges,,, Level 1 Imaging without Contrast,5521,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],350,257.59,2576,760,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Imaging without Contrast,5521,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],378,312.8,2578,238,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Imaging without Contrast,5521,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],1700,226.45,2827.94,18,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Imaging without Contrast,5521,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,670.8,248.4,3227.4,1 through 10,percent of total billed charges,,, Level 1 Imaging without Contrast,5521,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,326.25,186.3,1757.32,336,percent of total billed charges,,, Level 1 Imaging without Contrast,5521,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",154.06,99.12,906.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Imaging without Contrast,5521,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Imaging without Contrast,5521,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,445,445,445,1 through 10,percent of total billed charges,,, Level 1 Imaging without Contrast,5521,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Imaging without Contrast,5521,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",251.99,200.9,2628.38,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Imaging without Contrast,5521,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Imaging without Contrast,5521,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",179.41,104.08,559.89,437,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Imaging without Contrast,5521,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",104.08,104.08,304.24,17,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Imaging without Contrast,5521,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,106.04,106.04,106.04,1 through 10,percent of total billed charges,,, Level 1 Imaging without Contrast,5521,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,2989.2,2989.2,2989.2,1 through 10,percent of total billed charges,,, Level 1 Imaging without Contrast,5521,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Imaging without Contrast,5521,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",109.03,109.03,792,146,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Imaging without Contrast,5521,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",259.6,100.45,847.67,1002,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Imaging without Contrast,5521,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",182.83,102.37,894,1926,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Imaging without Contrast,5521,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",196.5,113.99,1042.38,81,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Imaging without Contrast,5521,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",179.57,161.61,2978,527,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Imaging without Contrast,5521,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",179.57,159.57,2155,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Imaging without Contrast,5522,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Imaging without Contrast,5522,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],370.95,80.08,2740,494,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Imaging without Contrast,5522,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",295.56,118.94,948.19,196,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Imaging without Contrast,5522,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 2 Imaging without Contrast,5522,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,323.04,323.04,323.04,1 through 10,percent of total billed charges,,, Level 2 Imaging without Contrast,5522,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],582,285.34,2576,916,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Imaging without Contrast,5522,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],582,302.4,2432.1,279,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Imaging without Contrast,5522,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],1900,1700,7661.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Imaging without Contrast,5522,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,414,342.45,2521.1,1 through 10,percent of total billed charges,,, Level 2 Imaging without Contrast,5522,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,414,245.25,1916.13,380,percent of total billed charges,,, Level 2 Imaging without Contrast,5522,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",293.93,170.87,399.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Imaging without Contrast,5522,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Imaging without Contrast,5522,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,161.63,161.63,161.63,1 through 10,percent of total billed charges,,, Level 2 Imaging without Contrast,5522,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Imaging without Contrast,5522,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",295.56,200.9,946.79,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Imaging without Contrast,5522,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,655,655,1387.75,1 through 10,percent of total billed charges,,, Level 2 Imaging without Contrast,5522,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",258.62,104.08,850.6,428,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Imaging without Contrast,5522,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",179.41,104.08,407.17,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Imaging without Contrast,5522,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,552.32,552.32,552.32,1 through 10,percent of total billed charges,,, Level 2 Imaging without Contrast,5522,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,110.11,101.36,611.66,1 through 10,percent of total billed charges,,, Level 2 Imaging without Contrast,5522,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Imaging without Contrast,5522,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",187.96,109.03,597.45,207,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Imaging without Contrast,5522,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",258.62,104.08,839.43,926,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Imaging without Contrast,5522,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",263.54,106.06,866.8,2062,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Imaging without Contrast,5522,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",196.72,113.99,593.87,89,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Imaging without Contrast,5522,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",252.18,226.96,3003.02,625,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Imaging without Contrast,5522,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",252.18,252.18,322.8,23,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Imaging without Contrast,5523,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Imaging without Contrast,5523,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],1400.83,491.69,6235.84,250,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Imaging without Contrast,5523,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",415.75,295.56,649.04,106,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Imaging without Contrast,5523,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 3 Imaging without Contrast,5523,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,5016.34,5016.34,5016.34,1 through 10,percent of total billed charges,,, Level 3 Imaging without Contrast,5523,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],2247.51,629,8511.86,152,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Imaging without Contrast,5523,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],2081.12,554.21,7380.83,479,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Imaging without Contrast,5523,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],3918.8,3918.8,6250,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Imaging without Contrast,5523,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,1896.96,1778.4,3154.46,1 through 10,percent of total billed charges,,, Level 3 Imaging without Contrast,5523,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,1778.4,922.95,5309.91,201,percent of total billed charges,,, Level 3 Imaging without Contrast,5523,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",346.46,346.46,346.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Imaging without Contrast,5523,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Imaging without Contrast,5523,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,715.03,715.03,715.03,1 through 10,percent of total billed charges,,, Level 3 Imaging without Contrast,5523,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Imaging without Contrast,5523,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",410.29,410.29,736.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Imaging without Contrast,5523,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Imaging without Contrast,5523,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",378.65,359.01,832.45,209,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Imaging without Contrast,5523,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",320.34,258.62,363.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Imaging without Contrast,5523,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,60.07,60.07,60.07,1 through 10,percent of total billed charges,,, Level 3 Imaging without Contrast,5523,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,5375.38,5375.38,5375.38,1 through 10,percent of total billed charges,,, Level 3 Imaging without Contrast,5523,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Imaging without Contrast,5523,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",381.11,376.1,763.49,136,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Imaging without Contrast,5523,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",363.78,359.01,742.46,485,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Imaging without Contrast,5523,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",370.71,263.54,796.11,1157,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Imaging without Contrast,5523,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",398.43,393.2,1030.65,43,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Imaging without Contrast,5523,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",524.34,356.37,2868,294,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Imaging without Contrast,5523,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",2761,389.43,2905.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Imaging without Contrast,5524,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Imaging without Contrast,5524,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],3513.9,1471.14,4201.41,429,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Imaging without Contrast,5524,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",857.25,777.35,1091.61,168,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Imaging without Contrast,5524,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 4 Imaging without Contrast,5524,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,3335.67,2779.72,4368.14,1 through 10,percent of total billed charges,,, Level 4 Imaging without Contrast,5524,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],3097,1404,3345,870,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Imaging without Contrast,5524,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],3291.43,1950.84,3345,248,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Imaging without Contrast,5524,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],2325.52,2325.52,2325.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Imaging without Contrast,5524,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,2575.8,2348.1,2803.8,1 through 10,percent of total billed charges,,, Level 4 Imaging without Contrast,5524,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,2273.1,978.58,3055.95,326,percent of total billed charges,,, Level 4 Imaging without Contrast,5524,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",831.55,421.15,909.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Imaging without Contrast,5524,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Imaging without Contrast,5524,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Imaging without Contrast,5524,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Imaging without Contrast,5524,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",886.57,704.24,1091.61,18,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Imaging without Contrast,5524,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,5221.75,5221.75,5221.75,1 through 10,percent of total billed charges,,, Level 4 Imaging without Contrast,5524,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",796.2,680.18,955.16,431,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Imaging without Contrast,5524,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",955.16,687.76,1283.34,23,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Imaging without Contrast,5524,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,75,75,75,1 through 10,percent of total billed charges,,, Level 4 Imaging without Contrast,5524,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,569.8,344,772.05,1 through 10,percent of total billed charges,,, Level 4 Imaging without Contrast,5524,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Imaging without Contrast,5524,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",839.56,720.51,1168,133,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Imaging without Contrast,5524,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",801.4,680.18,976.78,785,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Imaging without Contrast,5524,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",816.67,438.12,1102.91,1944,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Imaging without Contrast,5524,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",834.15,484.33,1046.13,135,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Imaging without Contrast,5524,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",2975,1063.71,3374.6,484,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Imaging without Contrast,5524,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",2645,687.76,2940,18,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Imaging with Contrast,5571,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Imaging with Contrast,5571,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],875.27,322.45,1787.7,76,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Imaging with Contrast,5571,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",596.14,333.63,763.46,43,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Imaging with Contrast,5571,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 1 Imaging with Contrast,5571,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Imaging with Contrast,5571,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],350,280,2107.5,164,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Imaging with Contrast,5571,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],378,302.4,2239.16,59,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Imaging with Contrast,5571,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,2331,2331,2331,1 through 10,percent of total billed charges,,, Level 1 Imaging with Contrast,5571,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,791.55,351.72,2307.26,48,percent of total billed charges,,, Level 1 Imaging with Contrast,5571,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Level 1 Imaging with Contrast,5571,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1419.81,283.1,1587.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Imaging with Contrast,5571,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Imaging with Contrast,5571,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,150.48,150.48,150.48,1 through 10,percent of total billed charges,,, Level 1 Imaging with Contrast,5571,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Imaging with Contrast,5571,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Imaging with Contrast,5571,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Imaging with Contrast,5571,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",297.26,209.4,608.67,85,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Imaging with Contrast,5571,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Imaging with Contrast,5571,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Imaging with Contrast,5571,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Imaging with Contrast,5571,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Imaging with Contrast,5571,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",499.37,198.65,1022.95,23,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Imaging with Contrast,5571,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",472.16,189.62,606.24,165,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Imaging with Contrast,5571,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",302.92,52.28,633.54,481,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Imaging with Contrast,5571,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",517.12,113.99,655.08,33,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Imaging with Contrast,5571,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",597.27,340,1362.13,105,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Imaging with Contrast,5571,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",927,927,927,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Imaging with Contrast,5572,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Imaging with Contrast,5572,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],1945.95,946.9,8972.66,157,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Imaging with Contrast,5572,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",760.33,690.82,1170.1,56,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Imaging with Contrast,5572,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 2 Imaging with Contrast,5572,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Imaging with Contrast,5572,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],4091.99,1543.35,12524.63,386,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Imaging with Contrast,5572,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],5513.78,2432,12652.8,126,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Imaging with Contrast,5572,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,4259.5,2074.68,10208.5,136,percent of total billed charges,,, Level 2 Imaging with Contrast,5572,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,7337.87,7337.87,7337.87,1 through 10,percent of total billed charges,,, Level 2 Imaging with Contrast,5572,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Level 2 Imaging with Contrast,5572,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",753.62,620.86,946.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Imaging with Contrast,5572,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Imaging with Contrast,5572,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Imaging with Contrast,5572,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Imaging with Contrast,5572,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",896.82,896.82,896.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Imaging with Contrast,5572,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Imaging with Contrast,5572,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",645.56,608.67,992.12,130,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Imaging with Contrast,5572,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",645.56,645.56,645.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Imaging with Contrast,5572,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Imaging with Contrast,5572,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,1029.67,1029.67,1029.67,1 through 10,percent of total billed charges,,, Level 2 Imaging with Contrast,5572,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Imaging with Contrast,5572,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",671.3,633.25,1267.78,62,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Imaging with Contrast,5572,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",645.56,604.47,922.08,255,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Imaging with Contrast,5572,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",657.86,79.03,960.74,553,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Imaging with Contrast,5572,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",707.03,662.04,1576.18,39,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Imaging with Contrast,5572,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",872.08,500,2577.48,234,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Imaging with Contrast,5572,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",872.08,621.89,1718.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Imaging with Contrast,5573,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Imaging with Contrast,5573,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],1921.88,944.85,2872,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Imaging with Contrast,5573,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1416.54,1416.54,1416.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Imaging with Contrast,5573,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 3 Imaging with Contrast,5573,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Imaging with Contrast,5573,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],5346.78,1995.46,8797.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Imaging with Contrast,5573,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],4310.65,4310.65,8686,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Imaging with Contrast,5573,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,4651.17,4651.17,4651.17,1 through 10,percent of total billed charges,,, Level 3 Imaging with Contrast,5573,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,2453.55,1752.3,4134.6,1 through 10,percent of total billed charges,,, Level 3 Imaging with Contrast,5573,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Level 3 Imaging with Contrast,5573,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Imaging with Contrast,5573,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Imaging with Contrast,5573,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Imaging with Contrast,5573,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Imaging with Contrast,5573,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1602.16,1602.16,1602.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Imaging with Contrast,5573,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Imaging with Contrast,5573,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1348.69,1348.69,1348.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Imaging with Contrast,5573,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Imaging with Contrast,5573,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Imaging with Contrast,5573,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Imaging with Contrast,5573,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Imaging with Contrast,5573,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1214.27,874.95,1418.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Imaging with Contrast,5573,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1166.99,1159.07,1348.69,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Imaging with Contrast,5573,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1189.21,595.81,1374.38,20,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Imaging with Contrast,5573,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",1381.85,1132.85,2465,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Imaging with Contrast,5573,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Imaging with Contrast,5573,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],2264.96,1151.51,3288.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",936.55,936.55,936.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],2882,2084.98,3113,21,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],3113,2882,3221,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,1797.75,903.24,2766.34,1 through 10,percent of total billed charges,,, Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1083.03,572,3179.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",597.65,597.65,597.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",626.1,615.88,735.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",931.56,572,1888.77,22,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",609.03,582.89,1579.35,53,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",619.61,619.61,619.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",1983.83,900.13,2752.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],2741.14,1757.96,6743,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1215.95,1215.95,1215.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],7387.69,3125.96,9394.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],6195.97,2244.73,9389.18,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,2164.62,1579.23,2887.97,1 through 10,percent of total billed charges,,, Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",894.43,778.72,1654.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",919.06,919.06,919.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1536.91,1536.91,1536.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",850.93,634.79,1622.19,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1359.98,819.7,1664.78,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1222.32,1222.32,1222.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",3429.14,3408.82,3436.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],3513.73,3513.73,3513.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],2388.19,2388.19,2883.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],,,,0,other,,,No services performed during 15-month lookback period. Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1308.91,1308.91,1308.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1626.93,1341.21,1915.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1392.58,1386.12,2532.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",9561.85,9561.85,9561.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],8038.72,7586.7,18033.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",2728.29,2344.73,2947.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],9341.35,9004.54,10087,21,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],10087,5989.6,10087,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,5580.45,4760.4,6285.6,1 through 10,percent of total billed charges,,, Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",2438.53,2438.53,2438.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",2522.78,2522.78,2522.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",2131.02,2045.29,3185.23,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",2315.91,2090.71,2634.82,35,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",4013.51,3761.33,6589.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",5000.49,5000.49,5000.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Pathology,5671,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Pathology,5671,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],52.03,13.49,49478.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Pathology,5671,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 1 Pathology,5671,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Pathology,5671,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Pathology,5671,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],397.53,344.74,8825.27,29,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Pathology,5671,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],397.53,372.24,777.5,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Pathology,5671,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,737.1,569.7,923.4,1 through 10,percent of total billed charges,,, Level 1 Pathology,5671,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Level 1 Pathology,5671,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Pathology,5671,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Pathology,5671,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Pathology,5671,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Pathology,5671,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Pathology,5671,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Pathology,5671,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Pathology,5671,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",103.84,103.84,6473.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Pathology,5671,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Pathology,5671,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Pathology,5671,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Pathology,5671,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Pathology,5671,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",108.79,80.68,375.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Pathology,5671,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",103.84,77.02,136.43,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Pathology,5671,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",105.82,73.22,302.11,35,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Pathology,5671,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",2862.26,2862.26,2862.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Pathology,5671,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",89.21,89.21,113.78,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Pathology,5671,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",89.21,89.21,89.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Pathology,5672,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Pathology,5672,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],466.89,466.89,921.23,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Pathology,5672,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",734.04,734.04,734.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Pathology,5672,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 2 Pathology,5672,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Pathology,5672,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],3110.66,828.47,16697.12,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Pathology,5672,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],963.15,870.97,2131.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Pathology,5672,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,994.5,994.5,994.5,1 through 10,percent of total billed charges,,, Level 2 Pathology,5672,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Level 2 Pathology,5672,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Pathology,5672,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Pathology,5672,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Pathology,5672,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Pathology,5672,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Pathology,5672,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Pathology,5672,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Pathology,5672,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",431.32,401.43,6651.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Pathology,5672,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",672.05,672.05,672.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Pathology,5672,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Pathology,5672,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Pathology,5672,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Pathology,5672,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",163.28,163.28,163.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Pathology,5672,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",493.66,399.18,823.8,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Pathology,5672,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",439.54,314.76,935.8,36,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Pathology,5672,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",22881.19,22881.19,22881.19,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Pathology,5672,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",1095.12,192.32,116048.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Pathology,5672,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Pathology,5673,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Pathology,5673,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],353.86,353.86,353.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Pathology,5673,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],3112.69,2432.42,17013.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Pathology,5673,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",22842.46,22842.46,22842.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Pathology,5673,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Pathology,5673,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],5167.82,1059.88,9271.32,34,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Pathology,5673,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],2070.95,750.93,3858.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Pathology,5673,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,1576.84,540.9,5470.2,1 through 10,percent of total billed charges,,, Level 3 Pathology,5673,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Level 3 Pathology,5673,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Pathology,5673,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Pathology,5673,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Pathology,5673,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Pathology,5673,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Pathology,5673,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Pathology,5673,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Pathology,5673,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",559.57,246.7,753.28,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Pathology,5673,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Pathology,5673,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Pathology,5673,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Pathology,5673,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Pathology,5673,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",510.54,510.54,903.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Pathology,5673,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",425.41,63.3,863.08,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Pathology,5673,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",521.78,317.06,1152.25,144,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Pathology,5673,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",691.76,43.79,16974.16,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Pathology,5673,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Pathology,5673,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Pathology,5674,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Pathology,5674,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 4 Pathology,5674,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],,,,0,other,,,No services performed during 15-month lookback period. Level 4 Pathology,5674,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Pathology,5674,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Pathology,5674,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],,,,0,other,,,No services performed during 15-month lookback period. Level 4 Pathology,5674,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],,,,0,other,,,No services performed during 15-month lookback period. Level 4 Pathology,5674,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Level 4 Pathology,5674,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Pathology,5674,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Pathology,5674,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Pathology,5674,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Pathology,5674,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Pathology,5674,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Pathology,5674,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Pathology,5674,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Pathology,5674,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Pathology,5674,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Pathology,5674,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Pathology,5674,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Pathology,5674,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Pathology,5674,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Pathology,5674,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Pathology,5674,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",4177.66,4177.66,4177.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Pathology,5674,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Pathology,5674,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Pathology,5674,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Drug Administration,5691,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Drug Administration,5691,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 1 Drug Administration,5691,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],,,,0,other,,,No services performed during 15-month lookback period. Level 1 Drug Administration,5691,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Drug Administration,5691,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Drug Administration,5691,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],1939.22,1939.22,2789.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Drug Administration,5691,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],9982.06,9982.06,9982.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Drug Administration,5691,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Level 1 Drug Administration,5691,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Drug Administration,5691,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Drug Administration,5691,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Drug Administration,5691,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Drug Administration,5691,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Drug Administration,5691,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Drug Administration,5691,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Drug Administration,5691,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Drug Administration,5691,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Drug Administration,5691,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Drug Administration,5691,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Drug Administration,5691,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Drug Administration,5691,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Drug Administration,5691,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",4416.7,4416.7,4416.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Drug Administration,5691,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",4215.95,2231.03,7943.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Drug Administration,5691,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",2351.95,2325.81,3316.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Drug Administration,5691,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",7655.7,4054.09,9518.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Drug Administration,5691,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Drug Administration,5691,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Drug Administration,5692,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Drug Administration,5692,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],582.41,280.53,135967.69,24,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Drug Administration,5692,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",175.13,112.57,435.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Drug Administration,5692,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 2 Drug Administration,5692,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Drug Administration,5692,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],239,156,25381.82,35,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Drug Administration,5692,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],176.9,176.9,1565.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Drug Administration,5692,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,3253.44,132.3,85920.31,26,percent of total billed charges,,, Level 2 Drug Administration,5692,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Level 2 Drug Administration,5692,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Drug Administration,5692,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Drug Administration,5692,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Drug Administration,5692,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Drug Administration,5692,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Drug Administration,5692,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Drug Administration,5692,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Drug Administration,5692,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1876.72,1876.72,1876.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Drug Administration,5692,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Drug Administration,5692,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Drug Administration,5692,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Drug Administration,5692,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Drug Administration,5692,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",103.19,103.19,253.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Drug Administration,5692,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",124.15,93.25,182.39,33,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Drug Administration,5692,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",126.52,100.38,23935.44,87,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Drug Administration,5692,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",25985.31,102.13,26077.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Drug Administration,5692,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",294,167.06,27428.1,21,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Drug Administration,5692,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Drug Administration,5693,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Drug Administration,5693,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],2690,946.69,12981.29,415,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Drug Administration,5693,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1401.29,593.26,12827.87,134,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Drug Administration,5693,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 3 Drug Administration,5693,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Drug Administration,5693,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],2593.08,1008.77,8477.89,157,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Drug Administration,5693,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],2569.39,535.75,9031.28,691,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Drug Administration,5693,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],1700,754.32,3930.33,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Drug Administration,5693,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,4376.09,4376.09,5227.84,1 through 10,percent of total billed charges,,, Level 3 Drug Administration,5693,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,2927.51,1234.27,10937.22,216,percent of total billed charges,,, Level 3 Drug Administration,5693,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1051.91,1051.91,1051.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Drug Administration,5693,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Drug Administration,5693,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,2151.38,2151.38,2151.38,1 through 10,percent of total billed charges,,, Level 3 Drug Administration,5693,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Drug Administration,5693,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1159.89,881.24,1254.27,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Drug Administration,5693,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Drug Administration,5693,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1078.28,505.53,4196.86,269,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Drug Administration,5693,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",528.26,528.26,528.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Drug Administration,5693,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,2298.24,2298.24,2298.24,1 through 10,percent of total billed charges,,, Level 3 Drug Administration,5693,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,3000,3000,3000,1 through 10,percent of total billed charges,,, Level 3 Drug Administration,5693,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Drug Administration,5693,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1350.73,548.41,4577.92,136,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Drug Administration,5693,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1207.38,579.56,2365.5,741,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Drug Administration,5693,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1286.81,493.01,5323.86,1814,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Drug Administration,5693,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1262.63,522.38,2085.77,65,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Drug Administration,5693,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",3068.92,900,7693.53,441,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Drug Administration,5693,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",7251.65,913.65,9326.34,26,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Drug Administration,5694,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Drug Administration,5694,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],6420.61,1142.17,72006.33,151,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Drug Administration,5694,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",2509.43,691.71,2808.74,51,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Drug Administration,5694,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 4 Drug Administration,5694,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Drug Administration,5694,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],1668.5,751,7569.38,83,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Drug Administration,5694,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],3840.91,1262.37,16567.55,302,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Drug Administration,5694,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],8658.68,5261.9,13587.58,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Drug Administration,5694,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,2783.26,855.52,22852.16,88,percent of total billed charges,,, Level 4 Drug Administration,5694,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Drug Administration,5694,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Drug Administration,5694,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Drug Administration,5694,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Drug Administration,5694,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Drug Administration,5694,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Drug Administration,5694,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Drug Administration,5694,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",2278.03,954.17,4263.34,50,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Drug Administration,5694,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",6156.25,6156.25,6156.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Drug Administration,5694,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Drug Administration,5694,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Drug Administration,5694,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Drug Administration,5694,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",2155.28,1340.36,7335.58,81,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Drug Administration,5694,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1258.58,218.58,4524.82,233,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Drug Administration,5694,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",2321.43,590.61,7478.93,461,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Drug Administration,5694,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1005.14,267.49,3789.55,48,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Drug Administration,5694,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",2459.88,667.03,13726.83,125,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Drug Administration,5694,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",9538.71,8826.18,9685.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],611.25,246.44,780.08,141,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",81.3,32.41,156.9,93,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],425.68,146.95,624.69,334,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],445.97,265.2,848.24,87,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],420,420,2017.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,711.2,711.2,711.2,1 through 10,percent of total billed charges,,, Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,418.68,279,700.2,156,percent of total billed charges,,, Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",231.42,224.47,339.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,358.75,358.75,358.75,1 through 10,percent of total billed charges,,, Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",58.88,35.41,189.06,201,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",258.79,235.76,344.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,479.25,479.25,479.25,1 through 10,percent of total billed charges,,, Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",276.11,79.94,400.12,76,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",242.98,138.19,307.54,556,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",77.76,41.12,198.94,1172,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",58.88,39.73,321.11,54,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",815,300,889,187,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",761,761,801,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],659.13,276.95,1219.58,460,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",199.74,60.45,629.68,272,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,4491.72,4491.72,4491.72,1 through 10,percent of total billed charges,,, Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],348,209.3,1324.19,922,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],348,271.01,1093,281,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],1700,1124.8,2092,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,538.8,324.51,1608,17,percent of total billed charges,,, Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,491.85,289.35,1192,392,percent of total billed charges,,, Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",200.04,166.63,524.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",131.61,65.67,189.25,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,784.75,784.75,784.75,1 through 10,percent of total billed charges,,, Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",138.19,57.08,537.39,527,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",291.96,174.96,340.71,24,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,100,100,100,1 through 10,percent of total billed charges,,, Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,50,50,50,1 through 10,percent of total billed charges,,, Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",183.29,182.57,577.2,367,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",275.95,174.27,537.39,1401,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",178.29,62.87,561.46,2980,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",151.35,57.08,588.57,186,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",422.5,238.89,1093,595,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",863.93,272,1307,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],3639.87,1364.4,7369.5,37,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1162.83,382.92,2167.34,19,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],2978,1206.02,9611.01,60,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],3129.33,2382.4,9762.59,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,3934.8,1124.55,7010.08,23,percent of total billed charges,,, Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",968.15,968.15,968.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1154.92,1154.92,1154.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1010.55,331.21,1247.41,26,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1038.09,341.99,1143.51,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1010.55,313.96,1807.81,62,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1029.8,341.44,1830.32,172,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1176.5,1085.28,2345.09,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",1485,392,3133.44,32,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],5329.18,3926.74,6458.96,78,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1265.8,1226.44,1265.8,51,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],3017,2573.6,3217,45,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],2978,1696.59,3217,142,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,3430.8,3430.8,3430.8,1 through 10,percent of total billed charges,,, Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,3430.8,2744.64,4278.6,45,percent of total billed charges,,, Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",539.63,539.63,539.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1226.44,1226.44,1226.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1107.57,1073.13,1107.57,78,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1107.57,1107.57,1107.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,212.02,212.02,212.02,1 through 10,percent of total billed charges,,, Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1160.31,1124.23,1160.31,44,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1107.57,1073.13,1107.57,176,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1128.67,1093.57,1128.67,602,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1213.05,1175.33,1213.05,26,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",2739,1824.97,2882,92,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",2593,2593,2593,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Minor Procedures,5731,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Minor Procedures,5731,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 1 Minor Procedures,5731,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],,,,0,other,,,No services performed during 15-month lookback period. Level 1 Minor Procedures,5731,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Minor Procedures,5731,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Minor Procedures,5731,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],34319.61,34319.61,34319.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Minor Procedures,5731,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],,,,0,other,,,No services performed during 15-month lookback period. Level 1 Minor Procedures,5731,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Level 1 Minor Procedures,5731,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Minor Procedures,5731,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Minor Procedures,5731,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Minor Procedures,5731,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Minor Procedures,5731,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Minor Procedures,5731,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Minor Procedures,5731,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Minor Procedures,5731,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Minor Procedures,5731,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Minor Procedures,5731,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Minor Procedures,5731,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Minor Procedures,5731,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 1 Minor Procedures,5731,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Minor Procedures,5731,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Minor Procedures,5731,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Minor Procedures,5731,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",229.79,229.79,229.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 1 Minor Procedures,5731,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Minor Procedures,5731,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",,,,0,other,,,No services performed during 15-month lookback period. Level 1 Minor Procedures,5731,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Minor Procedures,5732,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Minor Procedures,5732,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],148.21,90.16,270.13,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Minor Procedures,5732,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",114.9,8.71,123.94,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Minor Procedures,5732,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 2 Minor Procedures,5732,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Minor Procedures,5732,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],132,105.6,266.29,18,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Minor Procedures,5732,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],132,100,261.21,58,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Minor Procedures,5732,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,63.36,63.36,63.36,1 through 10,percent of total billed charges,,, Level 2 Minor Procedures,5732,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,104.4,59.4,130.5,13,percent of total billed charges,,, Level 2 Minor Procedures,5732,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Level 2 Minor Procedures,5732,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Minor Procedures,5732,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Minor Procedures,5732,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Minor Procedures,5732,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Minor Procedures,5732,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Minor Procedures,5732,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Minor Procedures,5732,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",66.39,7.92,108.44,24,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Minor Procedures,5732,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",71.85,71.85,71.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Minor Procedures,5732,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Minor Procedures,5732,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 2 Minor Procedures,5732,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 2 Minor Procedures,5732,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",120.93,105.33,25404.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Minor Procedures,5732,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",71.85,66.39,132.82,54,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Minor Procedures,5732,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",102.45,7.92,122.9,96,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Minor Procedures,5732,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",78.69,8.71,110.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Minor Procedures,5732,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",191,105.6,435,48,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 2 Minor Procedures,5732,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Minor Procedures,5733,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Minor Procedures,5733,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],380.24,168.2,473.23,263,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Minor Procedures,5733,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",71.24,67.74,195.18,151,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Minor Procedures,5733,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 3 Minor Procedures,5733,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Minor Procedures,5733,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],322,133,378,526,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Minor Procedures,5733,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],348,119,378,201,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Minor Procedures,5733,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],256,256,256,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Minor Procedures,5733,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,327,245.25,327,1 through 10,percent of total billed charges,,, Level 3 Minor Procedures,5733,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,245.25,111.89,355.59,215,percent of total billed charges,,, Level 3 Minor Procedures,5733,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",59.37,56.45,103.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Minor Procedures,5733,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Minor Procedures,5733,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Minor Procedures,5733,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Minor Procedures,5733,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",71.24,67.74,71.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Minor Procedures,5733,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,472.75,472.75,472.75,1 through 10,percent of total billed charges,,, Level 3 Minor Procedures,5733,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",62.34,59.27,216.88,163,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Minor Procedures,5733,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",62.34,62.34,62.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Minor Procedures,5733,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,71.54,71.54,71.54,1 through 10,percent of total billed charges,,, Level 3 Minor Procedures,5733,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,545,545,545,1 through 10,percent of total billed charges,,, Level 3 Minor Procedures,5733,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Minor Procedures,5733,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",65.31,62.1,204.38,126,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Minor Procedures,5733,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",62.34,59.27,170.78,487,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Minor Procedures,5733,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",63.53,60.4,174.04,937,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Minor Procedures,5733,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",68.28,64.92,187.05,69,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Minor Procedures,5733,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",277,112.75,652,342,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Minor Procedures,5733,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",249,199,262,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Minor Procedures,5734,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Minor Procedures,5734,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],370.96,88.2,2552.44,52,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Minor Procedures,5734,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",281.66,99.41,728.8,27,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Minor Procedures,5734,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 4 Minor Procedures,5734,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Minor Procedures,5734,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],871.71,468.41,4126.55,24,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Minor Procedures,5734,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],924.02,481.15,2567.7,108,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Minor Procedures,5734,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,510,289.75,1257.49,39,percent of total billed charges,,, Level 4 Minor Procedures,5734,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Level 4 Minor Procedures,5734,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Minor Procedures,5734,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",237.36,237.36,562.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Minor Procedures,5734,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Minor Procedures,5734,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Minor Procedures,5734,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Minor Procedures,5734,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Minor Procedures,5734,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Minor Procedures,5734,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",247.58,104.81,576.65,50,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Minor Procedures,5734,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",218.1,214.83,253.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Minor Procedures,5734,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 4 Minor Procedures,5734,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,12158.4,12158.4,12158.4,1 through 10,percent of total billed charges,,, Level 4 Minor Procedures,5734,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 4 Minor Procedures,5734,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",228.48,162.31,311.42,22,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Minor Procedures,5734,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",222.26,136.96,442.82,128,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Minor Procedures,5734,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",265.67,73.22,495.96,434,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Minor Procedures,5734,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",131.08,128.77,407.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Minor Procedures,5734,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",380.78,35.3,6073.59,44,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 4 Minor Procedures,5734,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Level 5 Minor Procedures,5735,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 5 Minor Procedures,5735,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 5 Minor Procedures,5735,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],,,,0,other,,,No services performed during 15-month lookback period. Level 5 Minor Procedures,5735,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 5 Minor Procedures,5735,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 5 Minor Procedures,5735,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],4288.89,4288.89,4288.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 5 Minor Procedures,5735,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],,,,0,other,,,No services performed during 15-month lookback period. Level 5 Minor Procedures,5735,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Level 5 Minor Procedures,5735,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 5 Minor Procedures,5735,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 5 Minor Procedures,5735,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",268.78,268.78,268.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 5 Minor Procedures,5735,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 5 Minor Procedures,5735,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 5 Minor Procedures,5735,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 5 Minor Procedures,5735,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 5 Minor Procedures,5735,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 5 Minor Procedures,5735,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",260.07,260.07,260.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 5 Minor Procedures,5735,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 5 Minor Procedures,5735,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 5 Minor Procedures,5735,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 5 Minor Procedures,5735,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 5 Minor Procedures,5735,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",264.98,264.98,382.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 5 Minor Procedures,5735,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 5 Minor Procedures,5735,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",272.82,265.02,457.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 5 Minor Procedures,5735,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",2467.06,2467.06,2467.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 5 Minor Procedures,5735,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 5 Minor Procedures,5735,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Electronic Analysis of Devices,5743,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Electronic Analysis of Devices,5743,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],3053,3053,3053,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Electronic Analysis of Devices,5743,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1953.28,1953.28,1953.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Electronic Analysis of Devices,5743,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Level 3 Electronic Analysis of Devices,5743,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Electronic Analysis of Devices,5743,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],6111.77,6111.77,10963.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Electronic Analysis of Devices,5743,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],5113.96,5113.96,5113.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Electronic Analysis of Devices,5743,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,4030.34,3208.69,10863.9,1 through 10,percent of total billed charges,,, Level 3 Electronic Analysis of Devices,5743,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Level 3 Electronic Analysis of Devices,5743,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Electronic Analysis of Devices,5743,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Electronic Analysis of Devices,5743,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Electronic Analysis of Devices,5743,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Electronic Analysis of Devices,5743,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Electronic Analysis of Devices,5743,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Electronic Analysis of Devices,5743,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Electronic Analysis of Devices,5743,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1025.68,1025.68,1025.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Electronic Analysis of Devices,5743,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Electronic Analysis of Devices,5743,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Electronic Analysis of Devices,5743,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Level 3 Electronic Analysis of Devices,5743,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Electronic Analysis of Devices,5743,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",897.43,732.3,1959.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Electronic Analysis of Devices,5743,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Electronic Analysis of Devices,5743,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1140.35,724.77,1730.01,22,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Electronic Analysis of Devices,5743,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",3068.02,2454.41,3228,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Level 3 Electronic Analysis of Devices,5743,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Level 3 Electronic Analysis of Devices,5743,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Pulmonary Treatment,5791,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Pulmonary Treatment,5791,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],1044.36,1019.66,1155.61,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Pulmonary Treatment,5791,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",402.8,402.8,469.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Pulmonary Treatment,5791,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Pulmonary Treatment,5791,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Pulmonary Treatment,5791,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],799.9,552.93,2841.39,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Pulmonary Treatment,5791,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],746.4,746.4,1688.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Pulmonary Treatment,5791,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,1329.27,1165.02,1593.42,1 through 10,percent of total billed charges,,, Pulmonary Treatment,5791,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Pulmonary Treatment,5791,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Pulmonary Treatment,5791,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Pulmonary Treatment,5791,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Pulmonary Treatment,5791,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Pulmonary Treatment,5791,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Pulmonary Treatment,5791,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Pulmonary Treatment,5791,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Pulmonary Treatment,5791,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",352.45,352.45,384.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Pulmonary Treatment,5791,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Pulmonary Treatment,5791,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Pulmonary Treatment,5791,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Pulmonary Treatment,5791,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Pulmonary Treatment,5791,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",286,286,286,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Pulmonary Treatment,5791,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",410.09,283.67,2729.97,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Pulmonary Treatment,5791,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",359.16,283.07,962.31,56,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Pulmonary Treatment,5791,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",117.75,117.75,117.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Pulmonary Treatment,5791,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",238.36,114,7141.74,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Pulmonary Treatment,5791,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Ventilation Initiation and Management,5801,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Ventilation Initiation and Management,5801,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Ventilation Initiation and Management,5801,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],,,,0,other,,,No services performed during 15-month lookback period. Ventilation Initiation and Management,5801,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Ventilation Initiation and Management,5801,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Ventilation Initiation and Management,5801,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],12973.22,12973.22,12973.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Ventilation Initiation and Management,5801,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],,,,0,other,,,No services performed during 15-month lookback period. Ventilation Initiation and Management,5801,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Ventilation Initiation and Management,5801,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Ventilation Initiation and Management,5801,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Ventilation Initiation and Management,5801,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Ventilation Initiation and Management,5801,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Ventilation Initiation and Management,5801,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Ventilation Initiation and Management,5801,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Ventilation Initiation and Management,5801,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Ventilation Initiation and Management,5801,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Ventilation Initiation and Management,5801,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Ventilation Initiation and Management,5801,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Ventilation Initiation and Management,5801,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Ventilation Initiation and Management,5801,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Ventilation Initiation and Management,5801,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Ventilation Initiation and Management,5801,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",2308.85,2308.85,2308.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Ventilation Initiation and Management,5801,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Ventilation Initiation and Management,5801,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",3841.3,3633.26,24351.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Ventilation Initiation and Management,5801,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Ventilation Initiation and Management,5801,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",,,,0,other,,,No services performed during 15-month lookback period. Ventilation Initiation and Management,5801,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Cryoprecipitate each unit,9511,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cryoprecipitate each unit,9511,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Cryoprecipitate each unit,9511,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],,,,0,other,,,No services performed during 15-month lookback period. Cryoprecipitate each unit,9511,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Cryoprecipitate each unit,9511,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cryoprecipitate each unit,9511,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],1054.65,1054.65,1054.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Cryoprecipitate each unit,9511,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],,,,0,other,,,No services performed during 15-month lookback period. Cryoprecipitate each unit,9511,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Cryoprecipitate each unit,9511,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cryoprecipitate each unit,9511,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cryoprecipitate each unit,9511,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Cryoprecipitate each unit,9511,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Cryoprecipitate each unit,9511,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cryoprecipitate each unit,9511,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cryoprecipitate each unit,9511,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Cryoprecipitate each unit,9511,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cryoprecipitate each unit,9511,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Cryoprecipitate each unit,9511,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Cryoprecipitate each unit,9511,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cryoprecipitate each unit,9511,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cryoprecipitate each unit,9511,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Cryoprecipitate each unit,9511,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Cryoprecipitate each unit,9511,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Cryoprecipitate each unit,9511,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Cryoprecipitate each unit,9511,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Cryoprecipitate each unit,9511,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",,,,0,other,,,No services performed during 15-month lookback period. Cryoprecipitate each unit,9511,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. RBC leukocytes reduced,9512,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. RBC leukocytes reduced,9512,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. RBC leukocytes reduced,9512,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],,,,0,other,,,No services performed during 15-month lookback period. RBC leukocytes reduced,9512,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. RBC leukocytes reduced,9512,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. RBC leukocytes reduced,9512,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],6652.95,3406.56,15579.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." RBC leukocytes reduced,9512,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],,,,0,other,,,No services performed during 15-month lookback period. RBC leukocytes reduced,9512,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. RBC leukocytes reduced,9512,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. RBC leukocytes reduced,9512,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. RBC leukocytes reduced,9512,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. RBC leukocytes reduced,9512,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. RBC leukocytes reduced,9512,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. RBC leukocytes reduced,9512,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. RBC leukocytes reduced,9512,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. RBC leukocytes reduced,9512,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. RBC leukocytes reduced,9512,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1316.2,1124.04,1354.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." RBC leukocytes reduced,9512,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. RBC leukocytes reduced,9512,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. RBC leukocytes reduced,9512,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. RBC leukocytes reduced,9512,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. RBC leukocytes reduced,9512,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",4225.38,3891.61,5330.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." RBC leukocytes reduced,9512,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1662.69,1662.69,1662.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." RBC leukocytes reduced,9512,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",3563.86,2070.48,4150.48,88,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." RBC leukocytes reduced,9512,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",1570.92,1570.92,1570.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." RBC leukocytes reduced,9512,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. RBC leukocytes reduced,9512,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Blood split unit,9520,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Blood split unit,9520,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],4155.33,4155.33,4314.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Blood split unit,9520,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1812.4,1508.33,2929.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Blood split unit,9520,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Blood split unit,9520,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Blood split unit,9520,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],3210.27,1986.02,4579.62,19,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Blood split unit,9520,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],,,,0,other,,,No services performed during 15-month lookback period. Blood split unit,9520,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,3595.92,3595.92,5509.8,1 through 10,percent of total billed charges,,, Blood split unit,9520,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Blood split unit,9520,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Blood split unit,9520,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Blood split unit,9520,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Blood split unit,9520,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Blood split unit,9520,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Blood split unit,9520,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Blood split unit,9520,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Blood split unit,9520,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1569.83,1200.99,2903.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Blood split unit,9520,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Blood split unit,9520,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Blood split unit,9520,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Blood split unit,9520,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Blood split unit,9520,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",2001.89,1585.74,2052.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Blood split unit,9520,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Blood split unit,9520,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1302.3,1237.37,2197.77,56,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Blood split unit,9520,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",386.12,120.54,4687.58,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Blood split unit,9520,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Blood split unit,9520,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. RBC leukoreduced irradiated,9522,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. RBC leukoreduced irradiated,9522,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],128755.99,128755.99,128755.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." RBC leukoreduced irradiated,9522,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. RBC leukoreduced irradiated,9522,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. RBC leukoreduced irradiated,9522,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. RBC leukoreduced irradiated,9522,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],2517.9,1744.71,10045.37,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." RBC leukoreduced irradiated,9522,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],2287.97,2040.59,2801.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." RBC leukoreduced irradiated,9522,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,2807.97,2285.73,174050.91,1 through 10,percent of total billed charges,,, RBC leukoreduced irradiated,9522,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. RBC leukoreduced irradiated,9522,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. RBC leukoreduced irradiated,9522,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. RBC leukoreduced irradiated,9522,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. RBC leukoreduced irradiated,9522,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,1554.35,1554.35,3039.71,1 through 10,percent of total billed charges,,, RBC leukoreduced irradiated,9522,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. RBC leukoreduced irradiated,9522,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. RBC leukoreduced irradiated,9522,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. RBC leukoreduced irradiated,9522,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1848.74,1848.74,1848.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." RBC leukoreduced irradiated,9522,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. RBC leukoreduced irradiated,9522,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. RBC leukoreduced irradiated,9522,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. RBC leukoreduced irradiated,9522,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. RBC leukoreduced irradiated,9522,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",6021.21,6021.21,6021.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." RBC leukoreduced irradiated,9522,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1406.19,1303.59,2347.69,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." RBC leukoreduced irradiated,9522,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1311.16,1119.32,4263.03,27,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." RBC leukoreduced irradiated,9522,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",1988.85,1271.65,28836.19,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." RBC leukoreduced irradiated,9522,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. RBC leukoreduced irradiated,9522,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Plate pheres leukoredu irrad,9530,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Plate pheres leukoredu irrad,9530,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],2232.4,2232.4,2232.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Plate pheres leukoredu irrad,9530,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Plate pheres leukoredu irrad,9530,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Plate pheres leukoredu irrad,9530,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Plate pheres leukoredu irrad,9530,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],4769.29,4769.29,5562.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Plate pheres leukoredu irrad,9530,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],,,,0,other,,,No services performed during 15-month lookback period. Plate pheres leukoredu irrad,9530,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Plate pheres leukoredu irrad,9530,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Plate pheres leukoredu irrad,9530,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Plate pheres leukoredu irrad,9530,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Plate pheres leukoredu irrad,9530,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Plate pheres leukoredu irrad,9530,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,2055.44,2055.44,2055.44,1 through 10,percent of total billed charges,,, Plate pheres leukoredu irrad,9530,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Plate pheres leukoredu irrad,9530,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Plate pheres leukoredu irrad,9530,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Plate pheres leukoredu irrad,9530,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Plate pheres leukoredu irrad,9530,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Plate pheres leukoredu irrad,9530,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Plate pheres leukoredu irrad,9530,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Plate pheres leukoredu irrad,9530,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Plate pheres leukoredu irrad,9530,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1742.83,1742.83,1742.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Plate pheres leukoredu irrad,9530,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Plate pheres leukoredu irrad,9530,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1689.18,1689.18,1689.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Plate pheres leukoredu irrad,9530,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",2166.48,2166.48,2166.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Plate pheres leukoredu irrad,9530,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Plate pheres leukoredu irrad,9530,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Platelets pheresis path redu,9536,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Platelets pheresis path redu,9536,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],70851.61,9583.4,131517.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Platelets pheresis path redu,9536,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Platelets pheresis path redu,9536,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Platelets pheresis path redu,9536,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Platelets pheresis path redu,9536,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],2656.43,1446.52,7378.9,18,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Platelets pheresis path redu,9536,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],2433.87,1547.65,5907.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Platelets pheresis path redu,9536,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,7268.6,7268.6,7268.6,1 through 10,percent of total billed charges,,, Platelets pheresis path redu,9536,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Platelets pheresis path redu,9536,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Platelets pheresis path redu,9536,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Platelets pheresis path redu,9536,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Platelets pheresis path redu,9536,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Platelets pheresis path redu,9536,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Platelets pheresis path redu,9536,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Platelets pheresis path redu,9536,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Platelets pheresis path redu,9536,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",2912.33,1657.59,4655.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Platelets pheresis path redu,9536,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Platelets pheresis path redu,9536,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Platelets pheresis path redu,9536,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Platelets pheresis path redu,9536,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Platelets pheresis path redu,9536,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",13166.37,1657.59,25096.71,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Platelets pheresis path redu,9536,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Platelets pheresis path redu,9536,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1741.46,1246.65,25369.11,25,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Platelets pheresis path redu,9536,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",29535.93,2780.02,188413.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Platelets pheresis path redu,9536,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Platelets pheresis path redu,9536,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Non-OPPS Clinic Services,N700,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Non-OPPS Clinic Services,N700,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",290.86,290.86,290.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Non-OPPS Clinic Services,N700,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Non-OPPS Clinic Services,N700,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],,,,0,other,,,No services performed during 15-month lookback period. Non-OPPS Clinic Services,N700,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Non-OPPS Clinic Services,N700,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],189.99,189.99,189.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Non-OPPS Clinic Services,N700,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],262.01,262.01,262.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Non-OPPS Clinic Services,N700,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Non-OPPS Clinic Services,N700,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Non-OPPS Clinic Services,N700,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Non-OPPS Clinic Services,N700,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Non-OPPS Clinic Services,N700,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Non-OPPS Clinic Services,N700,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Non-OPPS Clinic Services,N700,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Non-OPPS Clinic Services,N700,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Non-OPPS Clinic Services,N700,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Non-OPPS Clinic Services,N700,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Non-OPPS Clinic Services,N700,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Non-OPPS Clinic Services,N700,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Non-OPPS Clinic Services,N700,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Non-OPPS Clinic Services,N700,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Non-OPPS Clinic Services,N700,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Non-OPPS Clinic Services,N700,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Non-OPPS Clinic Services,N700,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",232.7,232.7,259.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Non-OPPS Clinic Services,N700,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",232.79,232.79,232.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Non-OPPS Clinic Services,N700,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Non-OPPS Clinic Services,N700,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Clinical Diagnostic Lab Services,N800,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Clinical Diagnostic Lab Services,N800,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],295.09,295.09,295.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Clinical Diagnostic Lab Services,N800,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],181.47,36.45,818.5,1080,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Clinical Diagnostic Lab Services,N800,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",158.96,40.62,500.83,455,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Clinical Diagnostic Lab Services,N800,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,726.1,377.14,1168.58,1 through 10,percent of total billed charges,,, Clinical Diagnostic Lab Services,N800,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],496.84,129.25,1671.38,2174,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Clinical Diagnostic Lab Services,N800,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],514.7,122.4,1784.47,675,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Clinical Diagnostic Lab Services,N800,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],567.45,228.8,2587.2,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Clinical Diagnostic Lab Services,N800,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,616.2,121.5,1780.2,25,percent of total billed charges,,, Clinical Diagnostic Lab Services,N800,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,405.45,92.7,1404.9,1170,percent of total billed charges,,, Clinical Diagnostic Lab Services,N800,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",95.17,29.98,221.05,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Clinical Diagnostic Lab Services,N800,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",88.92,62.17,154.19,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Clinical Diagnostic Lab Services,N800,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,36.69,36.69,36.69,1 through 10,percent of total billed charges,,, Clinical Diagnostic Lab Services,N800,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,27.5,27.5,198.75,1 through 10,percent of total billed charges,,, Clinical Diagnostic Lab Services,N800,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",85.08,69.5,774.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Clinical Diagnostic Lab Services,N800,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,199.75,199.75,199.75,1 through 10,percent of total billed charges,,, Clinical Diagnostic Lab Services,N800,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",129.59,41.08,370.21,1073,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Clinical Diagnostic Lab Services,N800,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",107.55,30.8,230.39,33,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Clinical Diagnostic Lab Services,N800,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,285.03,225.51,1077.08,1 through 10,percent of total billed charges,,, Clinical Diagnostic Lab Services,N800,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,224.4,21.7,1733.15,24,percent of total billed charges,,, Clinical Diagnostic Lab Services,N800,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Clinical Diagnostic Lab Services,N800,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",153.65,38.91,398.29,697,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Clinical Diagnostic Lab Services,N800,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",122.53,36.81,359.91,2764,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Clinical Diagnostic Lab Services,N800,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",142.29,37.85,427.09,6903,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Clinical Diagnostic Lab Services,N800,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",118.93,39.64,408.66,256,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Clinical Diagnostic Lab Services,N800,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",70.2,14.57,298.97,1637,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Clinical Diagnostic Lab Services,N800,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",60.96,11.66,413.45,36,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Therapy Services,N801,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Therapy Services,N801,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],663.89,210.93,2206.37,2230,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Therapy Services,N801,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",419.59,86.33,1498.74,779,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Therapy Services,N801,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Therapy Services,N801,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,345.06,80,1153.13,13,percent of total billed charges,,, Therapy Services,N801,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],591.8,182.58,1822.75,1269,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Therapy Services,N801,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],548.1,183.54,1825.44,3607,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Therapy Services,N801,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],340,85,680,46,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Therapy Services,N801,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,637.2,285,1241.4,35,percent of total billed charges,,, Therapy Services,N801,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,544.95,159.75,1556.1,2244,percent of total billed charges,,, Therapy Services,N801,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",416.32,337.48,1603.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Therapy Services,N801,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Therapy Services,N801,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Therapy Services,N801,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Therapy Services,N801,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",416.32,347,499.58,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Therapy Services,N801,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,35,35,105,12,percent of total billed charges,,, Therapy Services,N801,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",420.86,141.44,2525.16,3016,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Therapy Services,N801,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",420.86,75.54,1683.44,44,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Therapy Services,N801,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,217.07,217.07,217.07,1 through 10,percent of total billed charges,,, Therapy Services,N801,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,448.95,200,1884.23,1 through 10,percent of total billed charges,,, Therapy Services,N801,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Therapy Services,N801,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",336.8,132.13,570.28,134,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Therapy Services,N801,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",354.35,75.54,1219.42,1864,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Therapy Services,N801,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",428.88,128.53,2079.13,15672,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Therapy Services,N801,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",330.92,82.73,413.65,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Therapy Services,N801,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",1018,310,3120,2643,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Therapy Services,N801,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",1284,355,2340,99,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Durable Medical Equipment,N805,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Durable Medical Equipment,N805,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],655.5,655.5,655.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Durable Medical Equipment,N805,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Durable Medical Equipment,N805,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Durable Medical Equipment,N805,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Durable Medical Equipment,N805,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],152.4,104.4,152.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Durable Medical Equipment,N805,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],152.4,152.4,152.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Durable Medical Equipment,N805,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,312.75,312.75,312.75,1 through 10,percent of total billed charges,,, Durable Medical Equipment,N805,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,171.45,171.45,171.45,1 through 10,percent of total billed charges,,, Durable Medical Equipment,N805,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Durable Medical Equipment,N805,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Durable Medical Equipment,N805,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Durable Medical Equipment,N805,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Durable Medical Equipment,N805,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Durable Medical Equipment,N805,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Durable Medical Equipment,N805,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Durable Medical Equipment,N805,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Durable Medical Equipment,N805,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Durable Medical Equipment,N805,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Durable Medical Equipment,N805,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Durable Medical Equipment,N805,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Durable Medical Equipment,N805,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Durable Medical Equipment,N805,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Durable Medical Equipment,N805,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",307.92,307.92,307.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Durable Medical Equipment,N805,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",160.94,155.02,395,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Durable Medical Equipment,N805,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Durable Medical Equipment,N805,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. "Observation, Other",N811,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Observation, Other",N811,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],2078.4,2078.4,2078.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Observation, Other",N811,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",516.84,516.84,516.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Observation, Other",N811,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. "Observation, Other",N811,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Observation, Other",N811,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],1325.31,1325.31,10397.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Observation, Other",N811,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],,,,0,other,,,No services performed during 15-month lookback period. "Observation, Other",N811,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Observation, Other",N811,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Observation, Other",N811,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Observation, Other",N811,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. "Observation, Other",N811,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. "Observation, Other",N811,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Observation, Other",N811,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Observation, Other",N811,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. "Observation, Other",N811,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Observation, Other",N811,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1064.45,1064.45,1064.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Observation, Other",N811,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. "Observation, Other",N811,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Observation, Other",N811,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Observation, Other",N811,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. "Observation, Other",N811,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",5931.53,5931.53,5931.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Observation, Other",N811,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",51.3,51.3,51.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Observation, Other",N811,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",213.37,84.88,5969.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Observation, Other",N811,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",208.72,208.72,208.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Observation, Other",N811,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",7042.69,7042.69,7042.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Observation, Other",N811,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Non-covered Services,N900,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Non-covered Services,N900,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],278.2,60,3040.68,79,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Non-covered Services,N900,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",137.84,50.32,704.39,93,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Non-covered Services,N900,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Non-covered Services,N900,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Non-covered Services,N900,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],199.2,50.93,1750.84,142,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Non-covered Services,N900,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],248.44,50,2195.5,43,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Non-covered Services,N900,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,144,51.75,1369.8,77,percent of total billed charges,,, Non-covered Services,N900,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Non-covered Services,N900,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Non-covered Services,N900,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",92.86,92.86,92.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Non-covered Services,N900,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Non-covered Services,N900,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Non-covered Services,N900,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Non-covered Services,N900,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",105.4,105.4,105.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Non-covered Services,N900,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,2062.75,2062.75,2062.75,1 through 10,percent of total billed charges,,, Non-covered Services,N900,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",120.6,65.16,567.46,125,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Non-covered Services,N900,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",71.85,71.85,97.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Non-covered Services,N900,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Non-covered Services,N900,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Non-covered Services,N900,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Non-covered Services,N900,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",80.27,28.21,131.34,59,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Non-covered Services,N900,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",88.55,66.39,146.25,306,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Non-covered Services,N900,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",91.35,67.66,561.68,900,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Non-covered Services,N900,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",107.7,72.71,345.42,36,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Non-covered Services,N900,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",261,67,1641,117,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Non-covered Services,N900,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Packaged Services,N902,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Packaged Services,N902,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Packaged Services,N902,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],,,,0,other,,,No services performed during 15-month lookback period. Packaged Services,N902,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Packaged Services,N902,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Packaged Services,N902,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],1689.5,1689.5,1689.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Packaged Services,N902,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],,,,0,other,,,No services performed during 15-month lookback period. Packaged Services,N902,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,881.81,881.81,881.81,1 through 10,percent of total billed charges,,, Packaged Services,N902,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Packaged Services,N902,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Packaged Services,N902,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Packaged Services,N902,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Packaged Services,N902,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Packaged Services,N902,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Packaged Services,N902,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Packaged Services,N902,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Packaged Services,N902,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Packaged Services,N902,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Packaged Services,N902,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Packaged Services,N902,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Packaged Services,N902,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Packaged Services,N902,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",523.46,523.46,523.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Packaged Services,N902,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Packaged Services,N902,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",1044.05,455.02,1389.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Packaged Services,N902,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",2465.9,2465.9,2465.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Packaged Services,N902,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Packaged Services,N902,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Not Recognized by OPPS,N905,APC,,,,,facility,outpatient,,,,,,Advent Health,All Commercial Plans,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Not Recognized by OPPS,N905,APC,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6979] [Cardiac Cath (%BC): 72.4] [Lithotripsy ($): 29491] [Observation (%BC): 72.4 Maximum Reimbursement 13019] [Emergency Department ($): 3160] [Other Cardiac Testing (%BC): 72.4] [Sleep Studies (%BC): 72.4] [Chemotherapy (%BC): 72.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 72.4] [Physical Therapy (%BC): 72.4] [Speech Therapy (%BC): 72.4] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 54.1] [All Other OP (%BC): 72.4],219,219,219,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Not Recognized by OPPS,N905,APC,,,,,facility,outpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",29.32,29.32,29.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Not Recognized by OPPS,N905,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.],,,,0,other,,,No services performed during 15-month lookback period. Not Recognized by OPPS,N905,APC,,,,,facility,outpatient,,,,,,Avmed,All Commercial Plans,,54,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Not Recognized by OPPS,N905,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 3 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 4 (%BC): 43.73 Maximum Reimbursement 14282] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9256] [Cardiac Cath ($): 12288] [Lithotripsy ($): 9830] [PTCA (%BC): 46.55 Maximum Reimbursement 65232] [Observation (%BC): 47.97 Maximum Reimbursement 15852] [Emergency Department ($): 2745] [Cardiology ($): 3300] [EEG ($): 3172] [Chemotherapy (%BC): 57.69 Maximum Reimbursement 65232] [Nuclear Medicine ($): 3071] [Radiation Therapy ($): 3134] [CT Scan OP ($): 2181] [MRI OP (%BC): 50.89 Maximum Reimbursement 28044] [Positron Emission Tomography ($): 9953] [Laboratory (%BC): 52.46 Maximum Reimbursement 5816] [Occupational Therapy (%BC): 52.46 Maximum Reimbursement 8554] [Physical Therapy (%BC): 52.46] [Speech Therapy (%BC): 52.46] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 53.84 Maximum Reimbursement 28044] [All Other OP (%BC): 48.98 Maximum Reimbursement 15852],52.6,52.6,52.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Not Recognized by OPPS,N905,APC,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 3 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 4 (%BC): 47.20 Maximum Reimbursement 15424] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 9996] [Cardiac Cath ($): 13271] [Lithotripsy ($): 10616] [PTCA (%BC): 50.26 Maximum Reimbursement 70450] [Observation (%BC): 51.79 Maximum Reimbursement 17120] [Emergency Department ($): 2964] [Cardiology ($): 3565] [EEG ($): 3428] [Chemotherapy (%BC): 62.33 Maximum Reimbursement 70450] [Nuclear Medicine ($): 3318] [Radiation Therapy ($): 3385] [CT Scan OP ($): 2355] [MRI OP (%BC): 54.96 Maximum Reimbursement 30288] [Positron Emission Tomography ($): 10749] [Laboratory (%BC): 56.66 Maximum Reimbursement 6282] [Occupational Therapy (%BC): 56.66 Maximum Reimbursement 9239] [Physical Therapy (%BC): 56.66] [Speech Therapy (%BC): 56.66] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 40] [IV Therapy (%BC): 58.15 Maximum Reimbursement 30288] [All Other OP (%BC): 52.88 Maximum Reimbursement 17120],,,,0,other,,,No services performed during 15-month lookback period. Not Recognized by OPPS,N905,APC,,,,,facility,outpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 80] [Lithotripsy ($): 7480] [Observation (%BC): 80 Maximum Reimbursement 4400] [Emergency Department (%BC): 80 Maximum Reimbursement 1900] [CT Scan OP ($): 522] [MRI OP ($): 1250] [Positron Emission Tomography ($): 2090] [Occupational Therapy ($): 85] [Physical Therapy ($): 85] [Respiratory Services/Therapy (%BC): 80] [Speech Therapy ($): 85] [OP High Cost Drugs (%BC): 70] [Other Outpatient Implant (%BC): 70] [All Other OP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Not Recognized by OPPS,N905,APC,,,,,facility,outpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Not Recognized by OPPS,N905,APC,,,,,facility,outpatient,,,,,,Cigna,Hmo,,45,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Not Recognized by OPPS,N905,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Not Recognized by OPPS,N905,APC,,,,,facility,outpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Not Recognized by OPPS,N905,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Prime Other Commercial Plan,,70,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Not Recognized by OPPS,N905,APC,,,,,facility,outpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Not Recognized by OPPS,N905,APC,,,,,facility,outpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Not Recognized by OPPS,N905,APC,,,,,facility,outpatient,,,,,,Gulf Coast Provider Network,All Commercial Plans,,75,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Not Recognized by OPPS,N905,APC,,,,,facility,outpatient,,,,,,Humana,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Not Recognized by OPPS,N905,APC,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Not Recognized by OPPS,N905,APC,,,,,facility,outpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Not Recognized by OPPS,N905,APC,,,,,facility,outpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Not Recognized by OPPS,N905,APC,,,,,facility,outpatient,,,,,,Prestige,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Not Recognized by OPPS,N905,APC,,,,,facility,outpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",37.5,37.5,41.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Not Recognized by OPPS,N905,APC,,,,,facility,outpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Not Recognized by OPPS,N905,APC,,,,,facility,outpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",42.56,42.56,42.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Not Recognized by OPPS,N905,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5664] [Observation ($): 9031] [Emergency Department ($): 3463] [Urgent Care ($): 1015] [Cardiac Rehabilitation Therapy ($): 555] [Cardiac Stress Test ($): 1057] [Cardiology ($): 15759] [Echocardiology ($): 3192] [EKG/ECG ($): 312] [Electrophysiology Ablation ($): 53655] [Electrophysiology and Mapping Studies ($): 12864] [Holter Monitor/Telemetry ($): 1487] [Peripheral Vascular Lab ($): 501] [EEG ($): 1676] [EMG ($): 442] [MEG ($): 1581] [Neuropsychological Testing and Biofeedback ($): 281] [Sleep Studies ($): 3092] [Chemotherapy ($): 442] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 695] [Radiation Therapy ($): 281] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 587] [Peritoneal Dialysis, CAPD, and CCPD ($): 766] [Occupational Therapy ($): 587] [Physical Therapy ($): 587] [Resp. Services/Therapy ($): 129] [Speech Therapy ($): 587] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3386] [Ambulance--Land ($): 564] [Hyperbarics ($): 2217] [IV Therapy ($): 1051] [Pulmonary Function ($): 325] [Pulmonary Rehabilitation ($): 428] [Trauma ($): 7956]",78,78,78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Not Recognized by OPPS,N905,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://ahca.myflorida.com/medicaid/]",,,,0,other,,,No services performed during 15-month lookback period. Not Recognized by OPPS,N905,APC,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5097] [Observation ($): 8127] [Emergency Department ($): 3117] [Urgent Care ($): 913] [Cardiac Rehabilitation Therapy ($): 499] [Cardiac Stress Test ($): 951] [Cardiology ($): 14184] [Echocardiology ($): 2873] [EKG/ECG ($): 281] [Electrophysiology Ablation ($): 48290] [Electrophysiology and Mapping Studies ($): 11577] [Holter Monitor/Telemetry ($): 1338] [Peripheral Vascular Lab ($): 452] [EEG ($): 1510] [EMG ($): 398] [MEG ($): 1424] [Neuropsychological Testing and Biofeedback ($): 253] [Sleep Studies ($): 2782] [Chemotherapy ($): 398] [Nuclear Medicine Fee Schedule: FEE SCHEDULE] [Oncology ($): 626] [Radiation Therapy ($): 253] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services ($): FEE SCHEDULE] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Positron Emission Tomography ($): FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 528] [Peritoneal Dialysis, CAPD, and CCPD ($): 690] [Occupational Therapy ($): 528] [Physical Therapy ($): 528] [Resp. Services/Therapy ($): 116] [Speech Therapy ($): 528] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air ($): 3048] [Ambulance--Land ($): 507] [Hyperbarics ($): 1996] [IV Therapy ($): 946] [Pulmonary Function ($): 292] [Pulmonary Rehabilitation ($): 385] [Trauma ($): 7159]",,,,0,other,,,No services performed during 15-month lookback period. Liver Transplant And/Or Intestinal Transplant,11,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,45918.89,,,,,,,fee schedule,45918.89,45918.89, Liver Transplant And/Or Intestinal Transplant,11,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,45918.89,,,,,,,fee schedule,45918.89,45918.89, Liver Transplant And/Or Intestinal Transplant,11,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,45918.89,,,,,,,fee schedule,45918.89,45918.89, Liver Transplant And/Or Intestinal Transplant,11,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,45918.89,,,,,,,fee schedule,45918.89,45918.89, Liver Transplant And/Or Intestinal Transplant,11,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,45918.89,,,,,,,fee schedule,45918.89,45918.89, Liver Transplant And/Or Intestinal Transplant,11,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,45918.89,,,,,,,fee schedule,45918.89,45918.89, Liver Transplant And/Or Intestinal Transplant,11,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,45918.89,,,,,,,fee schedule,45918.89,45918.89, Liver Transplant And/Or Intestinal Transplant,11,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,45918.89,,,,,,,fee schedule,45918.89,45918.89, Liver Transplant And/Or Intestinal Transplant,11,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,45918.89,,,,,,,fee schedule,45918.89,45918.89, Liver Transplant And/Or Intestinal Transplant,11,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,45918.89,,,,,,,fee schedule,45918.89,45918.89, Liver Transplant And/Or Intestinal Transplant,11,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,45918.89,,,,,,,fee schedule,45918.89,45918.89, Liver Transplant And/Or Intestinal Transplant,12,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,52268.01,,,,,,,fee schedule,52268.01,52268.01, Liver Transplant And/Or Intestinal Transplant,12,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,52268.01,,,,,,,fee schedule,52268.01,52268.01, Liver Transplant And/Or Intestinal Transplant,12,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,52268.01,,,,,,,fee schedule,52268.01,52268.01, Liver Transplant And/Or Intestinal Transplant,12,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,52268.01,,,,,,,fee schedule,52268.01,52268.01, Liver Transplant And/Or Intestinal Transplant,12,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,52268.01,,,,,,,fee schedule,52268.01,52268.01, Liver Transplant And/Or Intestinal Transplant,12,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,52268.01,,,,,,,fee schedule,52268.01,52268.01, Liver Transplant And/Or Intestinal Transplant,12,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,52268.01,,,,,,,fee schedule,52268.01,52268.01, Liver Transplant And/Or Intestinal Transplant,12,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,52268.01,,,,,,,fee schedule,52268.01,52268.01, Liver Transplant And/Or Intestinal Transplant,12,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,52268.01,,,,,,,fee schedule,52268.01,52268.01, Liver Transplant And/Or Intestinal Transplant,12,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,52268.01,,,,,,,fee schedule,52268.01,52268.01, Liver Transplant And/Or Intestinal Transplant,12,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,52268.01,,,,,,,fee schedule,52268.01,52268.01, Liver Transplant And/Or Intestinal Transplant,13,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,67633.35,,,,,,,fee schedule,67633.35,67633.35, Liver Transplant And/Or Intestinal Transplant,13,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,67633.35,,,,,,,fee schedule,67633.35,67633.35, Liver Transplant And/Or Intestinal Transplant,13,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,67633.35,,,,,,,fee schedule,67633.35,67633.35, Liver Transplant And/Or Intestinal Transplant,13,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,67633.35,,,,,,,fee schedule,67633.35,67633.35, Liver Transplant And/Or Intestinal Transplant,13,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,67633.35,,,,,,,fee schedule,67633.35,67633.35, Liver Transplant And/Or Intestinal Transplant,13,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,67633.35,,,,,,,fee schedule,67633.35,67633.35, Liver Transplant And/Or Intestinal Transplant,13,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,67633.35,,,,,,,fee schedule,67633.35,67633.35, Liver Transplant And/Or Intestinal Transplant,13,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,67633.35,,,,,,,fee schedule,67633.35,67633.35, Liver Transplant And/Or Intestinal Transplant,13,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,67633.35,,,,,,,fee schedule,67633.35,67633.35, Liver Transplant And/Or Intestinal Transplant,13,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,67633.35,,,,,,,fee schedule,67633.35,67633.35, Liver Transplant And/Or Intestinal Transplant,13,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,67633.35,,,,,,,fee schedule,67633.35,67633.35, Liver Transplant And/Or Intestinal Transplant,14,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,130271.26,,,,,,,fee schedule,130271.26,130271.26, Liver Transplant And/Or Intestinal Transplant,14,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,130271.26,,,,,,,fee schedule,130271.26,130271.26, Liver Transplant And/Or Intestinal Transplant,14,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,130271.26,,,,,,,fee schedule,130271.26,130271.26, Liver Transplant And/Or Intestinal Transplant,14,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,130271.26,,,,,,,fee schedule,130271.26,130271.26, Liver Transplant And/Or Intestinal Transplant,14,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,130271.26,,,,,,,fee schedule,130271.26,130271.26, Liver Transplant And/Or Intestinal Transplant,14,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,130271.26,,,,,,,fee schedule,130271.26,130271.26, Liver Transplant And/Or Intestinal Transplant,14,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,130271.26,,,,,,,fee schedule,130271.26,130271.26, Liver Transplant And/Or Intestinal Transplant,14,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,130271.26,,,,,,,fee schedule,130271.26,130271.26, Liver Transplant And/Or Intestinal Transplant,14,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,130271.26,,,,,,,fee schedule,130271.26,130271.26, Liver Transplant And/Or Intestinal Transplant,14,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,130271.26,,,,,,,fee schedule,130271.26,130271.26, Liver Transplant And/Or Intestinal Transplant,14,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,130271.26,,,,,,,fee schedule,130271.26,130271.26, Heart And/Or Lung Transplant,21,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,85322.8,,,,,,,fee schedule,85322.8,85322.8, Heart And/Or Lung Transplant,21,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,85322.8,,,,,,,fee schedule,85322.8,85322.8, Heart And/Or Lung Transplant,21,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,85322.8,,,,,,,fee schedule,85322.8,85322.8, Heart And/Or Lung Transplant,21,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,85322.8,,,,,,,fee schedule,85322.8,85322.8, Heart And/Or Lung Transplant,21,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,85322.8,,,,,,,fee schedule,85322.8,85322.8, Heart And/Or Lung Transplant,21,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,85322.8,,,,,,,fee schedule,85322.8,85322.8, Heart And/Or Lung Transplant,21,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,85322.8,,,,,,,fee schedule,85322.8,85322.8, Heart And/Or Lung Transplant,21,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,85322.8,,,,,,,fee schedule,85322.8,85322.8, Heart And/Or Lung Transplant,21,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,85322.8,,,,,,,fee schedule,85322.8,85322.8, Heart And/Or Lung Transplant,21,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,85322.8,,,,,,,fee schedule,85322.8,85322.8, Heart And/Or Lung Transplant,21,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,85322.8,,,,,,,fee schedule,85322.8,85322.8, Heart And/Or Lung Transplant,22,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,96536.8,,,,,,,fee schedule,96536.8,96536.8, Heart And/Or Lung Transplant,22,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,96536.8,,,,,,,fee schedule,96536.8,96536.8, Heart And/Or Lung Transplant,22,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,96536.8,,,,,,,fee schedule,96536.8,96536.8, Heart And/Or Lung Transplant,22,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,96536.8,,,,,,,fee schedule,96536.8,96536.8, Heart And/Or Lung Transplant,22,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,96536.8,,,,,,,fee schedule,96536.8,96536.8, Heart And/Or Lung Transplant,22,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,96536.8,,,,,,,fee schedule,96536.8,96536.8, Heart And/Or Lung Transplant,22,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,96536.8,,,,,,,fee schedule,96536.8,96536.8, Heart And/Or Lung Transplant,22,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,96536.8,,,,,,,fee schedule,96536.8,96536.8, Heart And/Or Lung Transplant,22,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,96536.8,,,,,,,fee schedule,96536.8,96536.8, Heart And/Or Lung Transplant,22,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,96536.8,,,,,,,fee schedule,96536.8,96536.8, Heart And/Or Lung Transplant,22,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,96536.8,,,,,,,fee schedule,96536.8,96536.8, Heart And/Or Lung Transplant,23,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,127485.58,,,,,,,fee schedule,127485.58,127485.58, Heart And/Or Lung Transplant,23,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,127485.58,,,,,,,fee schedule,127485.58,127485.58, Heart And/Or Lung Transplant,23,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,127485.58,,,,,,,fee schedule,127485.58,127485.58, Heart And/Or Lung Transplant,23,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,127485.58,,,,,,,fee schedule,127485.58,127485.58, Heart And/Or Lung Transplant,23,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,127485.58,,,,,,,fee schedule,127485.58,127485.58, Heart And/Or Lung Transplant,23,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,127485.58,,,,,,,fee schedule,127485.58,127485.58, Heart And/Or Lung Transplant,23,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,127485.58,,,,,,,fee schedule,127485.58,127485.58, Heart And/Or Lung Transplant,23,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,127485.58,,,,,,,fee schedule,127485.58,127485.58, Heart And/Or Lung Transplant,23,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,127485.58,,,,,,,fee schedule,127485.58,127485.58, Heart And/Or Lung Transplant,23,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,127485.58,,,,,,,fee schedule,127485.58,127485.58, Heart And/Or Lung Transplant,23,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,127485.58,,,,,,,fee schedule,127485.58,127485.58, Heart And/Or Lung Transplant,24,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,234039.39,,,,,,,fee schedule,234039.39,234039.39, Heart And/Or Lung Transplant,24,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,234039.39,,,,,,,fee schedule,234039.39,234039.39, Heart And/Or Lung Transplant,24,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,234039.39,,,,,,,fee schedule,234039.39,234039.39, Heart And/Or Lung Transplant,24,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,234039.39,,,,,,,fee schedule,234039.39,234039.39, Heart And/Or Lung Transplant,24,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,234039.39,,,,,,,fee schedule,234039.39,234039.39, Heart And/Or Lung Transplant,24,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,234039.39,,,,,,,fee schedule,234039.39,234039.39, Heart And/Or Lung Transplant,24,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,234039.39,,,,,,,fee schedule,234039.39,234039.39, Heart And/Or Lung Transplant,24,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,234039.39,,,,,,,fee schedule,234039.39,234039.39, Heart And/Or Lung Transplant,24,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,234039.39,,,,,,,fee schedule,234039.39,234039.39, Heart And/Or Lung Transplant,24,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,234039.39,,,,,,,fee schedule,234039.39,234039.39, Heart And/Or Lung Transplant,24,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,234039.39,,,,,,,fee schedule,234039.39,234039.39, Tracheostomy With Mv >96 Hours With Extensive Procedure,41,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,40115.33,,,,,,,fee schedule,40115.33,40115.33, Tracheostomy With Mv >96 Hours With Extensive Procedure,41,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,40115.33,,,,,,,fee schedule,40115.33,40115.33, Tracheostomy With Mv >96 Hours With Extensive Procedure,41,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,40115.33,,,,,,,fee schedule,40115.33,40115.33, Tracheostomy With Mv >96 Hours With Extensive Procedure,41,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,40115.33,,,,,,,fee schedule,40115.33,40115.33, Tracheostomy With Mv >96 Hours With Extensive Procedure,41,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,40115.33,,,,,,,fee schedule,40115.33,40115.33, Tracheostomy With Mv >96 Hours With Extensive Procedure,41,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,40115.33,,,,,,,fee schedule,40115.33,40115.33, Tracheostomy With Mv >96 Hours With Extensive Procedure,41,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,40115.33,,,,,,,fee schedule,40115.33,40115.33, Tracheostomy With Mv >96 Hours With Extensive Procedure,41,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,40115.33,,,,,,,fee schedule,40115.33,40115.33, Tracheostomy With Mv >96 Hours With Extensive Procedure,41,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,40115.33,,,,,,,fee schedule,40115.33,40115.33, Tracheostomy With Mv >96 Hours With Extensive Procedure,41,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,40115.33,,,,,,,fee schedule,40115.33,40115.33, Tracheostomy With Mv >96 Hours With Extensive Procedure,41,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,40115.33,,,,,,,fee schedule,40115.33,40115.33, Tracheostomy With Mv >96 Hours With Extensive Procedure,42,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,57982.64,,,,,,,fee schedule,57982.64,57982.64, Tracheostomy With Mv >96 Hours With Extensive Procedure,42,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,57982.64,,,,,,,fee schedule,57982.64,57982.64, Tracheostomy With Mv >96 Hours With Extensive Procedure,42,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,57982.64,,,,,,,fee schedule,57982.64,57982.64, Tracheostomy With Mv >96 Hours With Extensive Procedure,42,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,57982.64,,,,,,,fee schedule,57982.64,57982.64, Tracheostomy With Mv >96 Hours With Extensive Procedure,42,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,57982.64,,,,,,,fee schedule,57982.64,57982.64, Tracheostomy With Mv >96 Hours With Extensive Procedure,42,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,57982.64,,,,,,,fee schedule,57982.64,57982.64, Tracheostomy With Mv >96 Hours With Extensive Procedure,42,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,57982.64,,,,,,,fee schedule,57982.64,57982.64, Tracheostomy With Mv >96 Hours With Extensive Procedure,42,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,57982.64,,,,,,,fee schedule,57982.64,57982.64, Tracheostomy With Mv >96 Hours With Extensive Procedure,42,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,57982.64,,,,,,,fee schedule,57982.64,57982.64, Tracheostomy With Mv >96 Hours With Extensive Procedure,42,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,57982.64,,,,,,,fee schedule,57982.64,57982.64, Tracheostomy With Mv >96 Hours With Extensive Procedure,42,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,57982.64,,,,,,,fee schedule,57982.64,57982.64, Tracheostomy With Mv >96 Hours With Extensive Procedure,43,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,90734.66,,,,,,,fee schedule,90734.66,90734.66, Tracheostomy With Mv >96 Hours With Extensive Procedure,43,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,90734.66,,,,,,,fee schedule,90734.66,90734.66, Tracheostomy With Mv >96 Hours With Extensive Procedure,43,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,90734.66,,,,,,,fee schedule,90734.66,90734.66, Tracheostomy With Mv >96 Hours With Extensive Procedure,43,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,90734.66,,,,,,,fee schedule,90734.66,90734.66, Tracheostomy With Mv >96 Hours With Extensive Procedure,43,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,90734.66,,,,,,,fee schedule,90734.66,90734.66, Tracheostomy With Mv >96 Hours With Extensive Procedure,43,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,90734.66,,,,,,,fee schedule,90734.66,90734.66, Tracheostomy With Mv >96 Hours With Extensive Procedure,43,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,90734.66,,,,,,,fee schedule,90734.66,90734.66, Tracheostomy With Mv >96 Hours With Extensive Procedure,43,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,90734.66,,,,,,,fee schedule,90734.66,90734.66, Tracheostomy With Mv >96 Hours With Extensive Procedure,43,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,90734.66,,,,,,,fee schedule,90734.66,90734.66, Tracheostomy With Mv >96 Hours With Extensive Procedure,43,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,90734.66,,,,,,,fee schedule,90734.66,90734.66, Tracheostomy With Mv >96 Hours With Extensive Procedure,43,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,90734.66,,,,,,,fee schedule,90734.66,90734.66, Tracheostomy With Mv >96 Hours With Extensive Procedure,44,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,131580.46,,,,,,,fee schedule,131580.46,131580.46, Tracheostomy With Mv >96 Hours With Extensive Procedure,44,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,131580.46,,,,,,,fee schedule,131580.46,131580.46, Tracheostomy With Mv >96 Hours With Extensive Procedure,44,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,131580.46,,,,,,,fee schedule,131580.46,131580.46, Tracheostomy With Mv >96 Hours With Extensive Procedure,44,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,131580.46,,,,,,,fee schedule,131580.46,131580.46, Tracheostomy With Mv >96 Hours With Extensive Procedure,44,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,131580.46,,,,,,,fee schedule,131580.46,131580.46, Tracheostomy With Mv >96 Hours With Extensive Procedure,44,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,131580.46,,,,,,,fee schedule,131580.46,131580.46, Tracheostomy With Mv >96 Hours With Extensive Procedure,44,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,131580.46,,,,,,,fee schedule,131580.46,131580.46, Tracheostomy With Mv >96 Hours With Extensive Procedure,44,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,131580.46,,,,,,,fee schedule,131580.46,131580.46, Tracheostomy With Mv >96 Hours With Extensive Procedure,44,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,131580.46,,,,,,,fee schedule,131580.46,131580.46, Tracheostomy With Mv >96 Hours With Extensive Procedure,44,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,131580.46,,,,,,,fee schedule,131580.46,131580.46, Tracheostomy With Mv >96 Hours With Extensive Procedure,44,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,131580.46,,,,,,,fee schedule,131580.46,131580.46, Tracheostomy With Mv >96 Hours Without Extensive Procedure,51,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,23295.39,,,,,,,fee schedule,23295.39,23295.39, Tracheostomy With Mv >96 Hours Without Extensive Procedure,51,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,23295.39,,,,,,,fee schedule,23295.39,23295.39, Tracheostomy With Mv >96 Hours Without Extensive Procedure,51,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,23295.39,,,,,,,fee schedule,23295.39,23295.39, Tracheostomy With Mv >96 Hours Without Extensive Procedure,51,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,23295.39,,,,,,,fee schedule,23295.39,23295.39, Tracheostomy With Mv >96 Hours Without Extensive Procedure,51,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,23295.39,,,,,,,fee schedule,23295.39,23295.39, Tracheostomy With Mv >96 Hours Without Extensive Procedure,51,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,23295.39,,,,,,,fee schedule,23295.39,23295.39, Tracheostomy With Mv >96 Hours Without Extensive Procedure,51,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,23295.39,,,,,,,fee schedule,23295.39,23295.39, Tracheostomy With Mv >96 Hours Without Extensive Procedure,51,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,23295.39,,,,,,,fee schedule,23295.39,23295.39, Tracheostomy With Mv >96 Hours Without Extensive Procedure,51,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,23295.39,,,,,,,fee schedule,23295.39,23295.39, Tracheostomy With Mv >96 Hours Without Extensive Procedure,51,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,23295.39,,,,,,,fee schedule,23295.39,23295.39, Tracheostomy With Mv >96 Hours Without Extensive Procedure,51,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,23295.39,,,,,,,fee schedule,23295.39,23295.39, Tracheostomy With Mv >96 Hours Without Extensive Procedure,52,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,44357.02,,,,,,,fee schedule,44357.02,44357.02, Tracheostomy With Mv >96 Hours Without Extensive Procedure,52,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,44357.02,,,,,,,fee schedule,44357.02,44357.02, Tracheostomy With Mv >96 Hours Without Extensive Procedure,52,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,44357.02,,,,,,,fee schedule,44357.02,44357.02, Tracheostomy With Mv >96 Hours Without Extensive Procedure,52,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,44357.02,,,,,,,fee schedule,44357.02,44357.02, Tracheostomy With Mv >96 Hours Without Extensive Procedure,52,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,44357.02,,,,,,,fee schedule,44357.02,44357.02, Tracheostomy With Mv >96 Hours Without Extensive Procedure,52,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,44357.02,,,,,,,fee schedule,44357.02,44357.02, Tracheostomy With Mv >96 Hours Without Extensive Procedure,52,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,44357.02,,,,,,,fee schedule,44357.02,44357.02, Tracheostomy With Mv >96 Hours Without Extensive Procedure,52,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,44357.02,,,,,,,fee schedule,44357.02,44357.02, Tracheostomy With Mv >96 Hours Without Extensive Procedure,52,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,44357.02,,,,,,,fee schedule,44357.02,44357.02, Tracheostomy With Mv >96 Hours Without Extensive Procedure,52,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,44357.02,,,,,,,fee schedule,44357.02,44357.02, Tracheostomy With Mv >96 Hours Without Extensive Procedure,52,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,44357.02,,,,,,,fee schedule,44357.02,44357.02, Tracheostomy With Mv >96 Hours Without Extensive Procedure,53,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,66523.18,,,,,,,fee schedule,66523.18,66523.18, Tracheostomy With Mv >96 Hours Without Extensive Procedure,53,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,66523.18,,,,,,,fee schedule,66523.18,66523.18, Tracheostomy With Mv >96 Hours Without Extensive Procedure,53,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,66523.18,,,,,,,fee schedule,66523.18,66523.18, Tracheostomy With Mv >96 Hours Without Extensive Procedure,53,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,66523.18,,,,,,,fee schedule,66523.18,66523.18, Tracheostomy With Mv >96 Hours Without Extensive Procedure,53,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,66523.18,,,,,,,fee schedule,66523.18,66523.18, Tracheostomy With Mv >96 Hours Without Extensive Procedure,53,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,66523.18,,,,,,,fee schedule,66523.18,66523.18, Tracheostomy With Mv >96 Hours Without Extensive Procedure,53,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,66523.18,,,,,,,fee schedule,66523.18,66523.18, Tracheostomy With Mv >96 Hours Without Extensive Procedure,53,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,66523.18,,,,,,,fee schedule,66523.18,66523.18, Tracheostomy With Mv >96 Hours Without Extensive Procedure,53,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,66523.18,,,,,,,fee schedule,66523.18,66523.18, Tracheostomy With Mv >96 Hours Without Extensive Procedure,53,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,66523.18,,,,,,,fee schedule,66523.18,66523.18, Tracheostomy With Mv >96 Hours Without Extensive Procedure,53,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,66523.18,,,,,,,fee schedule,66523.18,66523.18, Tracheostomy With Mv >96 Hours Without Extensive Procedure,54,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,91663.45,,,,,,,fee schedule,91663.45,91663.45, Tracheostomy With Mv >96 Hours Without Extensive Procedure,54,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,91663.45,,,,,,,fee schedule,91663.45,91663.45, Tracheostomy With Mv >96 Hours Without Extensive Procedure,54,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,91663.45,,,,,,,fee schedule,91663.45,91663.45, Tracheostomy With Mv >96 Hours Without Extensive Procedure,54,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,91663.45,,,,,,,fee schedule,91663.45,91663.45, Tracheostomy With Mv >96 Hours Without Extensive Procedure,54,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,91663.45,,,,,,,fee schedule,91663.45,91663.45, Tracheostomy With Mv >96 Hours Without Extensive Procedure,54,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,91663.45,,,,,,,fee schedule,91663.45,91663.45, Tracheostomy With Mv >96 Hours Without Extensive Procedure,54,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,91663.45,,,,,,,fee schedule,91663.45,91663.45, Tracheostomy With Mv >96 Hours Without Extensive Procedure,54,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,91663.45,,,,,,,fee schedule,91663.45,91663.45, Tracheostomy With Mv >96 Hours Without Extensive Procedure,54,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,91663.45,,,,,,,fee schedule,91663.45,91663.45, Tracheostomy With Mv >96 Hours Without Extensive Procedure,54,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,91663.45,,,,,,,fee schedule,91663.45,91663.45, Tracheostomy With Mv >96 Hours Without Extensive Procedure,54,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,91663.45,,,,,,,fee schedule,91663.45,91663.45, Pancreas Transplant,61,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,39268.41,,,,,,,fee schedule,39268.41,39268.41, Pancreas Transplant,61,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,39268.41,,,,,,,fee schedule,39268.41,39268.41, Pancreas Transplant,61,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,39268.41,,,,,,,fee schedule,39268.41,39268.41, Pancreas Transplant,61,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,39268.41,,,,,,,fee schedule,39268.41,39268.41, Pancreas Transplant,61,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,39268.41,,,,,,,fee schedule,39268.41,39268.41, Pancreas Transplant,61,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,39268.41,,,,,,,fee schedule,39268.41,39268.41, Pancreas Transplant,61,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,39268.41,,,,,,,fee schedule,39268.41,39268.41, Pancreas Transplant,61,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,39268.41,,,,,,,fee schedule,39268.41,39268.41, Pancreas Transplant,61,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,39268.41,,,,,,,fee schedule,39268.41,39268.41, Pancreas Transplant,61,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,39268.41,,,,,,,fee schedule,39268.41,39268.41, Pancreas Transplant,61,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,39268.41,,,,,,,fee schedule,39268.41,39268.41, Pancreas Transplant,62,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,56535.81,,,,,,,fee schedule,56535.81,56535.81, Pancreas Transplant,62,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,56535.81,,,,,,,fee schedule,56535.81,56535.81, Pancreas Transplant,62,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,56535.81,,,,,,,fee schedule,56535.81,56535.81, Pancreas Transplant,62,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,56535.81,,,,,,,fee schedule,56535.81,56535.81, Pancreas Transplant,62,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,56535.81,,,,,,,fee schedule,56535.81,56535.81, Pancreas Transplant,62,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,56535.81,,,,,,,fee schedule,56535.81,56535.81, Pancreas Transplant,62,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,56535.81,,,,,,,fee schedule,56535.81,56535.81, Pancreas Transplant,62,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,56535.81,,,,,,,fee schedule,56535.81,56535.81, Pancreas Transplant,62,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,56535.81,,,,,,,fee schedule,56535.81,56535.81, Pancreas Transplant,62,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,56535.81,,,,,,,fee schedule,56535.81,56535.81, Pancreas Transplant,62,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,56535.81,,,,,,,fee schedule,56535.81,56535.81, Pancreas Transplant,63,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,65577.44,,,,,,,fee schedule,65577.44,65577.44, Pancreas Transplant,63,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,65577.44,,,,,,,fee schedule,65577.44,65577.44, Pancreas Transplant,63,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,65577.44,,,,,,,fee schedule,65577.44,65577.44, Pancreas Transplant,63,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,65577.44,,,,,,,fee schedule,65577.44,65577.44, Pancreas Transplant,63,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,65577.44,,,,,,,fee schedule,65577.44,65577.44, Pancreas Transplant,63,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,65577.44,,,,,,,fee schedule,65577.44,65577.44, Pancreas Transplant,63,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,65577.44,,,,,,,fee schedule,65577.44,65577.44, Pancreas Transplant,63,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,65577.44,,,,,,,fee schedule,65577.44,65577.44, Pancreas Transplant,63,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,65577.44,,,,,,,fee schedule,65577.44,65577.44, Pancreas Transplant,63,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,65577.44,,,,,,,fee schedule,65577.44,65577.44, Pancreas Transplant,63,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,65577.44,,,,,,,fee schedule,65577.44,65577.44, Pancreas Transplant,64,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,85092.72,,,,,,,fee schedule,85092.72,85092.72, Pancreas Transplant,64,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,85092.72,,,,,,,fee schedule,85092.72,85092.72, Pancreas Transplant,64,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,85092.72,,,,,,,fee schedule,85092.72,85092.72, Pancreas Transplant,64,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,85092.72,,,,,,,fee schedule,85092.72,85092.72, Pancreas Transplant,64,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,85092.72,,,,,,,fee schedule,85092.72,85092.72, Pancreas Transplant,64,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,85092.72,,,,,,,fee schedule,85092.72,85092.72, Pancreas Transplant,64,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,85092.72,,,,,,,fee schedule,85092.72,85092.72, Pancreas Transplant,64,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,85092.72,,,,,,,fee schedule,85092.72,85092.72, Pancreas Transplant,64,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,85092.72,,,,,,,fee schedule,85092.72,85092.72, Pancreas Transplant,64,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,85092.72,,,,,,,fee schedule,85092.72,85092.72, Pancreas Transplant,64,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,85092.72,,,,,,,fee schedule,85092.72,85092.72, Allogeneic Bone Marrow Transplant,71,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,54478.48,,,,,,,fee schedule,54478.48,54478.48, Allogeneic Bone Marrow Transplant,71,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,54478.48,,,,,,,fee schedule,54478.48,54478.48, Allogeneic Bone Marrow Transplant,71,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,54478.48,,,,,,,fee schedule,54478.48,54478.48, Allogeneic Bone Marrow Transplant,71,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,54478.48,,,,,,,fee schedule,54478.48,54478.48, Allogeneic Bone Marrow Transplant,71,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,54478.48,,,,,,,fee schedule,54478.48,54478.48, Allogeneic Bone Marrow Transplant,71,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,54478.48,,,,,,,fee schedule,54478.48,54478.48, Allogeneic Bone Marrow Transplant,71,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,54478.48,,,,,,,fee schedule,54478.48,54478.48, Allogeneic Bone Marrow Transplant,71,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,54478.48,,,,,,,fee schedule,54478.48,54478.48, Allogeneic Bone Marrow Transplant,71,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,54478.48,,,,,,,fee schedule,54478.48,54478.48, Allogeneic Bone Marrow Transplant,71,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,54478.48,,,,,,,fee schedule,54478.48,54478.48, Allogeneic Bone Marrow Transplant,71,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,54478.48,,,,,,,fee schedule,54478.48,54478.48, Allogeneic Bone Marrow Transplant,72,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,61715.46,,,,,,,fee schedule,61715.46,61715.46, Allogeneic Bone Marrow Transplant,72,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,61715.46,,,,,,,fee schedule,61715.46,61715.46, Allogeneic Bone Marrow Transplant,72,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,61715.46,,,,,,,fee schedule,61715.46,61715.46, Allogeneic Bone Marrow Transplant,72,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,61715.46,,,,,,,fee schedule,61715.46,61715.46, Allogeneic Bone Marrow Transplant,72,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,61715.46,,,,,,,fee schedule,61715.46,61715.46, Allogeneic Bone Marrow Transplant,72,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,61715.46,,,,,,,fee schedule,61715.46,61715.46, Allogeneic Bone Marrow Transplant,72,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,61715.46,,,,,,,fee schedule,61715.46,61715.46, Allogeneic Bone Marrow Transplant,72,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,61715.46,,,,,,,fee schedule,61715.46,61715.46, Allogeneic Bone Marrow Transplant,72,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,61715.46,,,,,,,fee schedule,61715.46,61715.46, Allogeneic Bone Marrow Transplant,72,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,61715.46,,,,,,,fee schedule,61715.46,61715.46, Allogeneic Bone Marrow Transplant,72,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,61715.46,,,,,,,fee schedule,61715.46,61715.46, Allogeneic Bone Marrow Transplant,73,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,87637.73,,,,,,,fee schedule,87637.73,87637.73, Allogeneic Bone Marrow Transplant,73,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,87637.73,,,,,,,fee schedule,87637.73,87637.73, Allogeneic Bone Marrow Transplant,73,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,87637.73,,,,,,,fee schedule,87637.73,87637.73, Allogeneic Bone Marrow Transplant,73,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,87637.73,,,,,,,fee schedule,87637.73,87637.73, Allogeneic Bone Marrow Transplant,73,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,87637.73,,,,,,,fee schedule,87637.73,87637.73, Allogeneic Bone Marrow Transplant,73,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,87637.73,,,,,,,fee schedule,87637.73,87637.73, Allogeneic Bone Marrow Transplant,73,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,87637.73,,,,,,,fee schedule,87637.73,87637.73, Allogeneic Bone Marrow Transplant,73,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,87637.73,,,,,,,fee schedule,87637.73,87637.73, Allogeneic Bone Marrow Transplant,73,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,87637.73,,,,,,,fee schedule,87637.73,87637.73, Allogeneic Bone Marrow Transplant,73,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,87637.73,,,,,,,fee schedule,87637.73,87637.73, Allogeneic Bone Marrow Transplant,73,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,87637.73,,,,,,,fee schedule,87637.73,87637.73, Allogeneic Bone Marrow Transplant,74,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,137793.37,,,,,,,fee schedule,137793.37,137793.37, Allogeneic Bone Marrow Transplant,74,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,137793.37,,,,,,,fee schedule,137793.37,137793.37, Allogeneic Bone Marrow Transplant,74,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,137793.37,,,,,,,fee schedule,137793.37,137793.37, Allogeneic Bone Marrow Transplant,74,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,137793.37,,,,,,,fee schedule,137793.37,137793.37, Allogeneic Bone Marrow Transplant,74,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,137793.37,,,,,,,fee schedule,137793.37,137793.37, Allogeneic Bone Marrow Transplant,74,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,137793.37,,,,,,,fee schedule,137793.37,137793.37, Allogeneic Bone Marrow Transplant,74,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,137793.37,,,,,,,fee schedule,137793.37,137793.37, Allogeneic Bone Marrow Transplant,74,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,137793.37,,,,,,,fee schedule,137793.37,137793.37, Allogeneic Bone Marrow Transplant,74,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,137793.37,,,,,,,fee schedule,137793.37,137793.37, Allogeneic Bone Marrow Transplant,74,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,137793.37,,,,,,,fee schedule,137793.37,137793.37, Allogeneic Bone Marrow Transplant,74,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,137793.37,,,,,,,fee schedule,137793.37,137793.37, Autologous Bone Marrow Transplant Or T-Cell Immunotherapy,81,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,28597.15,,,,,,,fee schedule,28597.15,28597.15, Autologous Bone Marrow Transplant Or T-Cell Immunotherapy,81,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,28597.15,,,,,,,fee schedule,28597.15,28597.15, Autologous Bone Marrow Transplant Or T-Cell Immunotherapy,81,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,28597.15,,,,,,,fee schedule,28597.15,28597.15, Autologous Bone Marrow Transplant Or T-Cell Immunotherapy,81,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,28597.15,,,,,,,fee schedule,28597.15,28597.15, Autologous Bone Marrow Transplant Or T-Cell Immunotherapy,81,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,28597.15,,,,,,,fee schedule,28597.15,28597.15, Autologous Bone Marrow Transplant Or T-Cell Immunotherapy,81,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,28597.15,,,,,,,fee schedule,28597.15,28597.15, Autologous Bone Marrow Transplant Or T-Cell Immunotherapy,81,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,28597.15,,,,,,,fee schedule,28597.15,28597.15, Autologous Bone Marrow Transplant Or T-Cell Immunotherapy,81,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,28597.15,,,,,,,fee schedule,28597.15,28597.15, Autologous Bone Marrow Transplant Or T-Cell Immunotherapy,81,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,28597.15,,,,,,,fee schedule,28597.15,28597.15, Autologous Bone Marrow Transplant Or T-Cell Immunotherapy,81,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,28597.15,,,,,,,fee schedule,28597.15,28597.15, Autologous Bone Marrow Transplant Or T-Cell Immunotherapy,81,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,28597.15,,,,,,,fee schedule,28597.15,28597.15, Autologous Bone Marrow Transplant Or T-Cell Immunotherapy,82,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,33857.26,,,,,,,fee schedule,33857.26,33857.26, Autologous Bone Marrow Transplant Or T-Cell Immunotherapy,82,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,33857.26,,,,,,,fee schedule,33857.26,33857.26, Autologous Bone Marrow Transplant Or T-Cell Immunotherapy,82,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,33857.26,,,,,,,fee schedule,33857.26,33857.26, Autologous Bone Marrow Transplant Or T-Cell Immunotherapy,82,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,33857.26,,,,,,,fee schedule,33857.26,33857.26, Autologous Bone Marrow Transplant Or T-Cell Immunotherapy,82,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,33857.26,,,,,,,fee schedule,33857.26,33857.26, Autologous Bone Marrow Transplant Or T-Cell Immunotherapy,82,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,33857.26,,,,,,,fee schedule,33857.26,33857.26, Autologous Bone Marrow Transplant Or T-Cell Immunotherapy,82,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,33857.26,,,,,,,fee schedule,33857.26,33857.26, Autologous Bone Marrow Transplant Or T-Cell Immunotherapy,82,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,33857.26,,,,,,,fee schedule,33857.26,33857.26, Autologous Bone Marrow Transplant Or T-Cell Immunotherapy,82,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,33857.26,,,,,,,fee schedule,33857.26,33857.26, Autologous Bone Marrow Transplant Or T-Cell Immunotherapy,82,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,33857.26,,,,,,,fee schedule,33857.26,33857.26, Autologous Bone Marrow Transplant Or T-Cell Immunotherapy,82,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,33857.26,,,,,,,fee schedule,33857.26,33857.26, Autologous Bone Marrow Transplant Or T-Cell Immunotherapy,83,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,43136.03,,,,,,,fee schedule,43136.03,43136.03, Autologous Bone Marrow Transplant Or T-Cell Immunotherapy,83,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,43136.03,,,,,,,fee schedule,43136.03,43136.03, Autologous Bone Marrow Transplant Or T-Cell Immunotherapy,83,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,43136.03,,,,,,,fee schedule,43136.03,43136.03, Autologous Bone Marrow Transplant Or T-Cell Immunotherapy,83,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,43136.03,,,,,,,fee schedule,43136.03,43136.03, Autologous Bone Marrow Transplant Or T-Cell Immunotherapy,83,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,43136.03,,,,,,,fee schedule,43136.03,43136.03, Autologous Bone Marrow Transplant Or T-Cell Immunotherapy,83,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,43136.03,,,,,,,fee schedule,43136.03,43136.03, Autologous Bone Marrow Transplant Or T-Cell Immunotherapy,83,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,43136.03,,,,,,,fee schedule,43136.03,43136.03, Autologous Bone Marrow Transplant Or T-Cell Immunotherapy,83,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,43136.03,,,,,,,fee schedule,43136.03,43136.03, Autologous Bone Marrow Transplant Or T-Cell Immunotherapy,83,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,43136.03,,,,,,,fee schedule,43136.03,43136.03, Autologous Bone Marrow Transplant Or T-Cell Immunotherapy,83,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,43136.03,,,,,,,fee schedule,43136.03,43136.03, Autologous Bone Marrow Transplant Or T-Cell Immunotherapy,83,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,43136.03,,,,,,,fee schedule,43136.03,43136.03, Autologous Bone Marrow Transplant Or T-Cell Immunotherapy,84,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,61286.35,,,,,,,fee schedule,61286.35,61286.35, Autologous Bone Marrow Transplant Or T-Cell Immunotherapy,84,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,61286.35,,,,,,,fee schedule,61286.35,61286.35, Autologous Bone Marrow Transplant Or T-Cell Immunotherapy,84,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,61286.35,,,,,,,fee schedule,61286.35,61286.35, Autologous Bone Marrow Transplant Or T-Cell Immunotherapy,84,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,61286.35,,,,,,,fee schedule,61286.35,61286.35, Autologous Bone Marrow Transplant Or T-Cell Immunotherapy,84,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,61286.35,,,,,,,fee schedule,61286.35,61286.35, Autologous Bone Marrow Transplant Or T-Cell Immunotherapy,84,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,61286.35,,,,,,,fee schedule,61286.35,61286.35, Autologous Bone Marrow Transplant Or T-Cell Immunotherapy,84,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,61286.35,,,,,,,fee schedule,61286.35,61286.35, Autologous Bone Marrow Transplant Or T-Cell Immunotherapy,84,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,61286.35,,,,,,,fee schedule,61286.35,61286.35, Autologous Bone Marrow Transplant Or T-Cell Immunotherapy,84,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,61286.35,,,,,,,fee schedule,61286.35,61286.35, Autologous Bone Marrow Transplant Or T-Cell Immunotherapy,84,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,61286.35,,,,,,,fee schedule,61286.35,61286.35, Autologous Bone Marrow Transplant Or T-Cell Immunotherapy,84,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,61286.35,,,,,,,fee schedule,61286.35,61286.35, Extracorporeal Membrane Oxygenation (Ecmo),91,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,42290.52,,,,,,,fee schedule,42290.52,42290.52, Extracorporeal Membrane Oxygenation (Ecmo),91,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,42290.52,,,,,,,fee schedule,42290.52,42290.52, Extracorporeal Membrane Oxygenation (Ecmo),91,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,42290.52,,,,,,,fee schedule,42290.52,42290.52, Extracorporeal Membrane Oxygenation (Ecmo),91,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,42290.52,,,,,,,fee schedule,42290.52,42290.52, Extracorporeal Membrane Oxygenation (Ecmo),91,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,42290.52,,,,,,,fee schedule,42290.52,42290.52, Extracorporeal Membrane Oxygenation (Ecmo),91,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,42290.52,,,,,,,fee schedule,42290.52,42290.52, Extracorporeal Membrane Oxygenation (Ecmo),91,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,42290.52,,,,,,,fee schedule,42290.52,42290.52, Extracorporeal Membrane Oxygenation (Ecmo),91,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,42290.52,,,,,,,fee schedule,42290.52,42290.52, Extracorporeal Membrane Oxygenation (Ecmo),91,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,42290.52,,,,,,,fee schedule,42290.52,42290.52, Extracorporeal Membrane Oxygenation (Ecmo),91,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,42290.52,,,,,,,fee schedule,42290.52,42290.52, Extracorporeal Membrane Oxygenation (Ecmo),91,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,42290.52,,,,,,,fee schedule,42290.52,42290.52, Extracorporeal Membrane Oxygenation (Ecmo),92,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,57751.85,,,,,,,fee schedule,57751.85,57751.85, Extracorporeal Membrane Oxygenation (Ecmo),92,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,57751.85,,,,,,,fee schedule,57751.85,57751.85, Extracorporeal Membrane Oxygenation (Ecmo),92,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,57751.85,,,,,,,fee schedule,57751.85,57751.85, Extracorporeal Membrane Oxygenation (Ecmo),92,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,57751.85,,,,,,,fee schedule,57751.85,57751.85, Extracorporeal Membrane Oxygenation (Ecmo),92,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,57751.85,,,,,,,fee schedule,57751.85,57751.85, Extracorporeal Membrane Oxygenation (Ecmo),92,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,57751.85,,,,,,,fee schedule,57751.85,57751.85, Extracorporeal Membrane Oxygenation (Ecmo),92,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,57751.85,,,,,,,fee schedule,57751.85,57751.85, Extracorporeal Membrane Oxygenation (Ecmo),92,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,57751.85,,,,,,,fee schedule,57751.85,57751.85, Extracorporeal Membrane Oxygenation (Ecmo),92,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,57751.85,,,,,,,fee schedule,57751.85,57751.85, Extracorporeal Membrane Oxygenation (Ecmo),92,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,57751.85,,,,,,,fee schedule,57751.85,57751.85, Extracorporeal Membrane Oxygenation (Ecmo),92,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,57751.85,,,,,,,fee schedule,57751.85,57751.85, Extracorporeal Membrane Oxygenation (Ecmo),93,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,115066.83,,,,,,,fee schedule,115066.83,115066.83, Extracorporeal Membrane Oxygenation (Ecmo),93,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,115066.83,,,,,,,fee schedule,115066.83,115066.83, Extracorporeal Membrane Oxygenation (Ecmo),93,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,115066.83,,,,,,,fee schedule,115066.83,115066.83, Extracorporeal Membrane Oxygenation (Ecmo),93,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,115066.83,,,,,,,fee schedule,115066.83,115066.83, Extracorporeal Membrane Oxygenation (Ecmo),93,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,115066.83,,,,,,,fee schedule,115066.83,115066.83, Extracorporeal Membrane Oxygenation (Ecmo),93,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,115066.83,,,,,,,fee schedule,115066.83,115066.83, Extracorporeal Membrane Oxygenation (Ecmo),93,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,115066.83,,,,,,,fee schedule,115066.83,115066.83, Extracorporeal Membrane Oxygenation (Ecmo),93,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,115066.83,,,,,,,fee schedule,115066.83,115066.83, Extracorporeal Membrane Oxygenation (Ecmo),93,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,115066.83,,,,,,,fee schedule,115066.83,115066.83, Extracorporeal Membrane Oxygenation (Ecmo),93,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,115066.83,,,,,,,fee schedule,115066.83,115066.83, Extracorporeal Membrane Oxygenation (Ecmo),93,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,115066.83,,,,,,,fee schedule,115066.83,115066.83, Extracorporeal Membrane Oxygenation (Ecmo),94,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,171214.46,,,,,,,fee schedule,171214.46,171214.46, Extracorporeal Membrane Oxygenation (Ecmo),94,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,171214.46,,,,,,,fee schedule,171214.46,171214.46, Extracorporeal Membrane Oxygenation (Ecmo),94,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,171214.46,,,,,,,fee schedule,171214.46,171214.46, Extracorporeal Membrane Oxygenation (Ecmo),94,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,171214.46,,,,,,,fee schedule,171214.46,171214.46, Extracorporeal Membrane Oxygenation (Ecmo),94,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,171214.46,,,,,,,fee schedule,171214.46,171214.46, Extracorporeal Membrane Oxygenation (Ecmo),94,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,171214.46,,,,,,,fee schedule,171214.46,171214.46, Extracorporeal Membrane Oxygenation (Ecmo),94,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,171214.46,,,,,,,fee schedule,171214.46,171214.46, Extracorporeal Membrane Oxygenation (Ecmo),94,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,171214.46,,,,,,,fee schedule,171214.46,171214.46, Extracorporeal Membrane Oxygenation (Ecmo),94,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,171214.46,,,,,,,fee schedule,171214.46,171214.46, Extracorporeal Membrane Oxygenation (Ecmo),94,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,171214.46,,,,,,,fee schedule,171214.46,171214.46, Extracorporeal Membrane Oxygenation (Ecmo),94,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,171214.46,,,,,,,fee schedule,171214.46,171214.46, Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,111,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,68240.32,,,,,,,fee schedule,68240.32,68240.32, Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,111,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,68240.32,,,,,,,fee schedule,68240.32,68240.32, Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,111,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,68240.32,,,,,,,fee schedule,68240.32,68240.32, Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,111,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,68240.32,,,,,,,fee schedule,68240.32,68240.32, Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,111,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,68240.32,,,,,,,fee schedule,68240.32,68240.32, Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,111,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,68240.32,,,,,,,fee schedule,68240.32,68240.32, Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,111,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,68240.32,,,,,,,fee schedule,68240.32,68240.32, Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,111,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,68240.32,,,,,,,fee schedule,68240.32,68240.32, Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,111,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,68240.32,,,,,,,fee schedule,68240.32,68240.32, Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,111,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,68240.32,,,,,,,fee schedule,68240.32,68240.32, Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,111,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,68240.32,,,,,,,fee schedule,68240.32,68240.32, Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,112,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,138558.42,,,,,,,fee schedule,138558.42,138558.42, Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,112,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,138558.42,,,,,,,fee schedule,138558.42,138558.42, Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,112,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,138558.42,,,,,,,fee schedule,138558.42,138558.42, Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,112,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,138558.42,,,,,,,fee schedule,138558.42,138558.42, Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,112,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,138558.42,,,,,,,fee schedule,138558.42,138558.42, Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,112,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,138558.42,,,,,,,fee schedule,138558.42,138558.42, Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,112,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,138558.42,,,,,,,fee schedule,138558.42,138558.42, Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,112,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,138558.42,,,,,,,fee schedule,138558.42,138558.42, Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,112,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,138558.42,,,,,,,fee schedule,138558.42,138558.42, Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,112,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,138558.42,,,,,,,fee schedule,138558.42,138558.42, Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,112,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,138558.42,,,,,,,fee schedule,138558.42,138558.42, Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,113,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,174290.21,,,,,,,fee schedule,174290.21,174290.21, Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,113,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,174290.21,,,,,,,fee schedule,174290.21,174290.21, Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,113,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,174290.21,,,,,,,fee schedule,174290.21,174290.21, Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,113,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,174290.21,,,,,,,fee schedule,174290.21,174290.21, Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,113,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,174290.21,,,,,,,fee schedule,174290.21,174290.21, Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,113,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,174290.21,,,,,,,fee schedule,174290.21,174290.21, Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,113,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,174290.21,,,,,,,fee schedule,174290.21,174290.21, Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,113,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,174290.21,,,,,,,fee schedule,174290.21,174290.21, Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,113,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,174290.21,,,,,,,fee schedule,174290.21,174290.21, Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,113,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,174290.21,,,,,,,fee schedule,174290.21,174290.21, Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,113,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,174290.21,,,,,,,fee schedule,174290.21,174290.21, Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,114,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,234193.96,,,,,,,fee schedule,234193.96,234193.96, Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,114,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,234193.96,,,,,,,fee schedule,234193.96,234193.96, Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,114,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,234193.96,,,,,,,fee schedule,234193.96,234193.96, Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,114,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,234193.96,,,,,,,fee schedule,234193.96,234193.96, Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,114,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,234193.96,,,,,,,fee schedule,234193.96,234193.96, Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,114,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,234193.96,,,,,,,fee schedule,234193.96,234193.96, Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,114,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,234193.96,,,,,,,fee schedule,234193.96,234193.96, Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,114,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,234193.96,,,,,,,fee schedule,234193.96,234193.96, Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,114,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,234193.96,,,,,,,fee schedule,234193.96,234193.96, Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,114,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,234193.96,,,,,,,fee schedule,234193.96,234193.96, Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,114,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,234193.96,,,,,,,fee schedule,234193.96,234193.96, Open Craniotomy For Trauma,201,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,14871.31,,,,,,,fee schedule,14871.31,14871.31, Open Craniotomy For Trauma,201,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,14871.31,,,,,,,fee schedule,14871.31,14871.31, Open Craniotomy For Trauma,201,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,14871.31,,,,,,,fee schedule,14871.31,14871.31, Open Craniotomy For Trauma,201,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,14871.31,,,,,,,fee schedule,14871.31,14871.31, Open Craniotomy For Trauma,201,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,14871.31,,,,,,,fee schedule,14871.31,14871.31, Open Craniotomy For Trauma,201,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,14871.31,,,,,,,fee schedule,14871.31,14871.31, Open Craniotomy For Trauma,201,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,14871.31,,,,,,,fee schedule,14871.31,14871.31, Open Craniotomy For Trauma,201,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,14871.31,,,,,,,fee schedule,14871.31,14871.31, Open Craniotomy For Trauma,201,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,14871.31,,,,,,,fee schedule,14871.31,14871.31, Open Craniotomy For Trauma,201,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,14871.31,,,,,,,fee schedule,14871.31,14871.31, Open Craniotomy For Trauma,201,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,14871.31,,,,,,,fee schedule,14871.31,14871.31, Open Craniotomy For Trauma,202,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,19228.74,,,,,,,fee schedule,19228.74,19228.74, Open Craniotomy For Trauma,202,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,19228.74,,,,,,,fee schedule,19228.74,19228.74, Open Craniotomy For Trauma,202,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,19228.74,,,,,,,fee schedule,19228.74,19228.74, Open Craniotomy For Trauma,202,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,19228.74,,,,,,,fee schedule,19228.74,19228.74, Open Craniotomy For Trauma,202,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,19228.74,,,,,,,fee schedule,19228.74,19228.74, Open Craniotomy For Trauma,202,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,19228.74,,,,,,,fee schedule,19228.74,19228.74, Open Craniotomy For Trauma,202,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,19228.74,,,,,,,fee schedule,19228.74,19228.74, Open Craniotomy For Trauma,202,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,19228.74,,,,,,,fee schedule,19228.74,19228.74, Open Craniotomy For Trauma,202,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,19228.74,,,,,,,fee schedule,19228.74,19228.74, Open Craniotomy For Trauma,202,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,19228.74,,,,,,,fee schedule,19228.74,19228.74, Open Craniotomy For Trauma,202,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,19228.74,,,,,,,fee schedule,19228.74,19228.74, Open Craniotomy For Trauma,203,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,27479.2,,,,,,,fee schedule,27479.2,27479.2, Open Craniotomy For Trauma,203,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,27479.2,,,,,,,fee schedule,27479.2,27479.2, Open Craniotomy For Trauma,203,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,27479.2,,,,,,,fee schedule,27479.2,27479.2, Open Craniotomy For Trauma,203,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,27479.2,,,,,,,fee schedule,27479.2,27479.2, Open Craniotomy For Trauma,203,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,27479.2,,,,,,,fee schedule,27479.2,27479.2, Open Craniotomy For Trauma,203,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,27479.2,,,,,,,fee schedule,27479.2,27479.2, Open Craniotomy For Trauma,203,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,27479.2,,,,,,,fee schedule,27479.2,27479.2, Open Craniotomy For Trauma,203,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,27479.2,,,,,,,fee schedule,27479.2,27479.2, Open Craniotomy For Trauma,203,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,27479.2,,,,,,,fee schedule,27479.2,27479.2, Open Craniotomy For Trauma,203,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,27479.2,,,,,,,fee schedule,27479.2,27479.2, Open Craniotomy For Trauma,203,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,27479.2,,,,,,,fee schedule,27479.2,27479.2, Open Craniotomy For Trauma,204,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,39799.15,,,,,,,fee schedule,39799.15,39799.15, Open Craniotomy For Trauma,204,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,39799.15,,,,,,,fee schedule,39799.15,39799.15, Open Craniotomy For Trauma,204,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,39799.15,,,,,,,fee schedule,39799.15,39799.15, Open Craniotomy For Trauma,204,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,39799.15,,,,,,,fee schedule,39799.15,39799.15, Open Craniotomy For Trauma,204,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,39799.15,,,,,,,fee schedule,39799.15,39799.15, Open Craniotomy For Trauma,204,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,39799.15,,,,,,,fee schedule,39799.15,39799.15, Open Craniotomy For Trauma,204,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,39799.15,,,,,,,fee schedule,39799.15,39799.15, Open Craniotomy For Trauma,204,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,39799.15,,,,,,,fee schedule,39799.15,39799.15, Open Craniotomy For Trauma,204,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,39799.15,,,,,,,fee schedule,39799.15,39799.15, Open Craniotomy For Trauma,204,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,39799.15,,,,,,,fee schedule,39799.15,39799.15, Open Craniotomy For Trauma,204,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,39799.15,,,,,,,fee schedule,39799.15,39799.15, Open Craniotomy Except Trauma,211,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,17547.59,,,,,,,fee schedule,17547.59,17547.59, Open Craniotomy Except Trauma,211,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,17547.59,,,,,,,fee schedule,17547.59,17547.59, Open Craniotomy Except Trauma,211,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,17547.59,,,,,,,fee schedule,17547.59,17547.59, Open Craniotomy Except Trauma,211,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,17547.59,,,,,,,fee schedule,17547.59,17547.59, Open Craniotomy Except Trauma,211,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,17547.59,,,,,,,fee schedule,17547.59,17547.59, Open Craniotomy Except Trauma,211,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,17547.59,,,,,,,fee schedule,17547.59,17547.59, Open Craniotomy Except Trauma,211,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,17547.59,,,,,,,fee schedule,17547.59,17547.59, Open Craniotomy Except Trauma,211,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,17547.59,,,,,,,fee schedule,17547.59,17547.59, Open Craniotomy Except Trauma,211,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,17547.59,,,,,,,fee schedule,17547.59,17547.59, Open Craniotomy Except Trauma,211,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,17547.59,,,,,,,fee schedule,17547.59,17547.59, Open Craniotomy Except Trauma,211,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,17547.59,,,,,,,fee schedule,17547.59,17547.59, Open Craniotomy Except Trauma,212,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,23209.29,,,,,,,fee schedule,23209.29,23209.29, Open Craniotomy Except Trauma,212,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,23209.29,,,,,,,fee schedule,23209.29,23209.29, Open Craniotomy Except Trauma,212,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,23209.29,,,,,,,fee schedule,23209.29,23209.29, Open Craniotomy Except Trauma,212,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,23209.29,,,,,,,fee schedule,23209.29,23209.29, Open Craniotomy Except Trauma,212,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,23209.29,,,,,,,fee schedule,23209.29,23209.29, Open Craniotomy Except Trauma,212,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,23209.29,,,,,,,fee schedule,23209.29,23209.29, Open Craniotomy Except Trauma,212,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,23209.29,,,,,,,fee schedule,23209.29,23209.29, Open Craniotomy Except Trauma,212,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,23209.29,,,,,,,fee schedule,23209.29,23209.29, Open Craniotomy Except Trauma,212,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,23209.29,,,,,,,fee schedule,23209.29,23209.29, Open Craniotomy Except Trauma,212,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,23209.29,,,,,,,fee schedule,23209.29,23209.29, Open Craniotomy Except Trauma,212,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,23209.29,,,,,,,fee schedule,23209.29,23209.29, Open Craniotomy Except Trauma,213,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,32060.37,,,,,,,fee schedule,32060.37,32060.37, Open Craniotomy Except Trauma,213,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,32060.37,,,,,,,fee schedule,32060.37,32060.37, Open Craniotomy Except Trauma,213,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,32060.37,,,,,,,fee schedule,32060.37,32060.37, Open Craniotomy Except Trauma,213,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,32060.37,,,,,,,fee schedule,32060.37,32060.37, Open Craniotomy Except Trauma,213,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,32060.37,,,,,,,fee schedule,32060.37,32060.37, Open Craniotomy Except Trauma,213,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,32060.37,,,,,,,fee schedule,32060.37,32060.37, Open Craniotomy Except Trauma,213,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,32060.37,,,,,,,fee schedule,32060.37,32060.37, Open Craniotomy Except Trauma,213,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,32060.37,,,,,,,fee schedule,32060.37,32060.37, Open Craniotomy Except Trauma,213,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,32060.37,,,,,,,fee schedule,32060.37,32060.37, Open Craniotomy Except Trauma,213,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,32060.37,,,,,,,fee schedule,32060.37,32060.37, Open Craniotomy Except Trauma,213,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,32060.37,,,,,,,fee schedule,32060.37,32060.37, Open Craniotomy Except Trauma,214,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,45556.83,,,,,,,fee schedule,45556.83,45556.83, Open Craniotomy Except Trauma,214,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,45556.83,,,,,,,fee schedule,45556.83,45556.83, Open Craniotomy Except Trauma,214,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,45556.83,,,,,,,fee schedule,45556.83,45556.83, Open Craniotomy Except Trauma,214,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,45556.83,,,,,,,fee schedule,45556.83,45556.83, Open Craniotomy Except Trauma,214,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,45556.83,,,,,,,fee schedule,45556.83,45556.83, Open Craniotomy Except Trauma,214,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,45556.83,,,,,,,fee schedule,45556.83,45556.83, Open Craniotomy Except Trauma,214,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,45556.83,,,,,,,fee schedule,45556.83,45556.83, Open Craniotomy Except Trauma,214,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,45556.83,,,,,,,fee schedule,45556.83,45556.83, Open Craniotomy Except Trauma,214,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,45556.83,,,,,,,fee schedule,45556.83,45556.83, Open Craniotomy Except Trauma,214,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,45556.83,,,,,,,fee schedule,45556.83,45556.83, Open Craniotomy Except Trauma,214,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,45556.83,,,,,,,fee schedule,45556.83,45556.83, Ventricular Shunt Procedures,221,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,10643.03,,,,,,,fee schedule,10643.03,10643.03, Ventricular Shunt Procedures,221,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,10643.03,,,,,,,fee schedule,10643.03,10643.03, Ventricular Shunt Procedures,221,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,10643.03,,,,,,,fee schedule,10643.03,10643.03, Ventricular Shunt Procedures,221,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,10643.03,,,,,,,fee schedule,10643.03,10643.03, Ventricular Shunt Procedures,221,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,10643.03,,,,,,,fee schedule,10643.03,10643.03, Ventricular Shunt Procedures,221,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,10643.03,,,,,,,fee schedule,10643.03,10643.03, Ventricular Shunt Procedures,221,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,10643.03,,,,,,,fee schedule,10643.03,10643.03, Ventricular Shunt Procedures,221,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,10643.03,,,,,,,fee schedule,10643.03,10643.03, Ventricular Shunt Procedures,221,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,10643.03,,,,,,,fee schedule,10643.03,10643.03, Ventricular Shunt Procedures,221,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,10643.03,,,,,,,fee schedule,10643.03,10643.03, Ventricular Shunt Procedures,221,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,10643.03,,,,,,,fee schedule,10643.03,10643.03, Ventricular Shunt Procedures,222,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,13402.6,,,,,,,fee schedule,13402.6,13402.6, Ventricular Shunt Procedures,222,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,13402.6,,,,,,,fee schedule,13402.6,13402.6, Ventricular Shunt Procedures,222,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,13402.6,,,,,,,fee schedule,13402.6,13402.6, Ventricular Shunt Procedures,222,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,13402.6,,,,,,,fee schedule,13402.6,13402.6, Ventricular Shunt Procedures,222,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,13402.6,,,,,,,fee schedule,13402.6,13402.6, Ventricular Shunt Procedures,222,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,13402.6,,,,,,,fee schedule,13402.6,13402.6, Ventricular Shunt Procedures,222,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,13402.6,,,,,,,fee schedule,13402.6,13402.6, Ventricular Shunt Procedures,222,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,13402.6,,,,,,,fee schedule,13402.6,13402.6, Ventricular Shunt Procedures,222,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,13402.6,,,,,,,fee schedule,13402.6,13402.6, Ventricular Shunt Procedures,222,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,13402.6,,,,,,,fee schedule,13402.6,13402.6, Ventricular Shunt Procedures,222,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,13402.6,,,,,,,fee schedule,13402.6,13402.6, Ventricular Shunt Procedures,223,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,19674.08,,,,,,,fee schedule,19674.08,19674.08, Ventricular Shunt Procedures,223,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,19674.08,,,,,,,fee schedule,19674.08,19674.08, Ventricular Shunt Procedures,223,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,19674.08,,,,,,,fee schedule,19674.08,19674.08, Ventricular Shunt Procedures,223,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,19674.08,,,,,,,fee schedule,19674.08,19674.08, Ventricular Shunt Procedures,223,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,19674.08,,,,,,,fee schedule,19674.08,19674.08, Ventricular Shunt Procedures,223,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,19674.08,,,,,,,fee schedule,19674.08,19674.08, Ventricular Shunt Procedures,223,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,19674.08,,,,,,,fee schedule,19674.08,19674.08, Ventricular Shunt Procedures,223,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,19674.08,,,,,,,fee schedule,19674.08,19674.08, Ventricular Shunt Procedures,223,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,19674.08,,,,,,,fee schedule,19674.08,19674.08, Ventricular Shunt Procedures,223,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,19674.08,,,,,,,fee schedule,19674.08,19674.08, Ventricular Shunt Procedures,223,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,19674.08,,,,,,,fee schedule,19674.08,19674.08, Ventricular Shunt Procedures,224,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,35599.1,,,,,,,fee schedule,35599.1,35599.1, Ventricular Shunt Procedures,224,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,35599.1,,,,,,,fee schedule,35599.1,35599.1, Ventricular Shunt Procedures,224,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,35599.1,,,,,,,fee schedule,35599.1,35599.1, Ventricular Shunt Procedures,224,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,35599.1,,,,,,,fee schedule,35599.1,35599.1, Ventricular Shunt Procedures,224,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,35599.1,,,,,,,fee schedule,35599.1,35599.1, Ventricular Shunt Procedures,224,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,35599.1,,,,,,,fee schedule,35599.1,35599.1, Ventricular Shunt Procedures,224,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,35599.1,,,,,,,fee schedule,35599.1,35599.1, Ventricular Shunt Procedures,224,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,35599.1,,,,,,,fee schedule,35599.1,35599.1, Ventricular Shunt Procedures,224,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,35599.1,,,,,,,fee schedule,35599.1,35599.1, Ventricular Shunt Procedures,224,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,35599.1,,,,,,,fee schedule,35599.1,35599.1, Ventricular Shunt Procedures,224,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,35599.1,,,,,,,fee schedule,35599.1,35599.1, Spinal Procedures,231,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,12830.92,,,,,,,fee schedule,12830.92,12830.92, Spinal Procedures,231,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,12830.92,,,,,,,fee schedule,12830.92,12830.92, Spinal Procedures,231,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,12830.92,,,,,,,fee schedule,12830.92,12830.92, Spinal Procedures,231,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,12830.92,,,,,,,fee schedule,12830.92,12830.92, Spinal Procedures,231,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,12830.92,,,,,,,fee schedule,12830.92,12830.92, Spinal Procedures,231,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,12830.92,,,,,,,fee schedule,12830.92,12830.92, Spinal Procedures,231,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,12830.92,,,,,,,fee schedule,12830.92,12830.92, Spinal Procedures,231,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,12830.92,,,,,,,fee schedule,12830.92,12830.92, Spinal Procedures,231,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,12830.92,,,,,,,fee schedule,12830.92,12830.92, Spinal Procedures,231,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,12830.92,,,,,,,fee schedule,12830.92,12830.92, Spinal Procedures,231,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,12830.92,,,,,,,fee schedule,12830.92,12830.92, Spinal Procedures,232,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,18152.44,,,,,,,fee schedule,18152.44,18152.44, Spinal Procedures,232,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,18152.44,,,,,,,fee schedule,18152.44,18152.44, Spinal Procedures,232,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,18152.44,,,,,,,fee schedule,18152.44,18152.44, Spinal Procedures,232,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,18152.44,,,,,,,fee schedule,18152.44,18152.44, Spinal Procedures,232,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,18152.44,,,,,,,fee schedule,18152.44,18152.44, Spinal Procedures,232,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,18152.44,,,,,,,fee schedule,18152.44,18152.44, Spinal Procedures,232,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,18152.44,,,,,,,fee schedule,18152.44,18152.44, Spinal Procedures,232,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,18152.44,,,,,,,fee schedule,18152.44,18152.44, Spinal Procedures,232,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,18152.44,,,,,,,fee schedule,18152.44,18152.44, Spinal Procedures,232,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,18152.44,,,,,,,fee schedule,18152.44,18152.44, Spinal Procedures,232,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,18152.44,,,,,,,fee schedule,18152.44,18152.44, Spinal Procedures,233,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,28610.56,,,,,,,fee schedule,28610.56,28610.56, Spinal Procedures,233,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,28610.56,,,,,,,fee schedule,28610.56,28610.56, Spinal Procedures,233,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,28610.56,,,,,,,fee schedule,28610.56,28610.56, Spinal Procedures,233,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,28610.56,,,,,,,fee schedule,28610.56,28610.56, Spinal Procedures,233,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,28610.56,,,,,,,fee schedule,28610.56,28610.56, Spinal Procedures,233,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,28610.56,,,,,,,fee schedule,28610.56,28610.56, Spinal Procedures,233,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,28610.56,,,,,,,fee schedule,28610.56,28610.56, Spinal Procedures,233,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,28610.56,,,,,,,fee schedule,28610.56,28610.56, Spinal Procedures,233,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,28610.56,,,,,,,fee schedule,28610.56,28610.56, Spinal Procedures,233,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,28610.56,,,,,,,fee schedule,28610.56,28610.56, Spinal Procedures,233,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,28610.56,,,,,,,fee schedule,28610.56,28610.56, Spinal Procedures,234,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,41538.17,,,,,,,fee schedule,41538.17,41538.17, Spinal Procedures,234,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,41538.17,,,,,,,fee schedule,41538.17,41538.17, Spinal Procedures,234,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,41538.17,,,,,,,fee schedule,41538.17,41538.17, Spinal Procedures,234,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,41538.17,,,,,,,fee schedule,41538.17,41538.17, Spinal Procedures,234,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,41538.17,,,,,,,fee schedule,41538.17,41538.17, Spinal Procedures,234,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,41538.17,,,,,,,fee schedule,41538.17,41538.17, Spinal Procedures,234,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,41538.17,,,,,,,fee schedule,41538.17,41538.17, Spinal Procedures,234,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,41538.17,,,,,,,fee schedule,41538.17,41538.17, Spinal Procedures,234,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,41538.17,,,,,,,fee schedule,41538.17,41538.17, Spinal Procedures,234,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,41538.17,,,,,,,fee schedule,41538.17,41538.17, Spinal Procedures,234,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,41538.17,,,,,,,fee schedule,41538.17,41538.17, Open Extracranial Vascular Procedures,241,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,7479.76,,,,,,,fee schedule,7479.76,7479.76, Open Extracranial Vascular Procedures,241,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,7479.76,,,,,,,fee schedule,7479.76,7479.76, Open Extracranial Vascular Procedures,241,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,7479.76,,,,,,,fee schedule,7479.76,7479.76, Open Extracranial Vascular Procedures,241,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,7479.76,,,,,,,fee schedule,7479.76,7479.76, Open Extracranial Vascular Procedures,241,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,7479.76,,,,,,,fee schedule,7479.76,7479.76, Open Extracranial Vascular Procedures,241,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,7479.76,,,,,,,fee schedule,7479.76,7479.76, Open Extracranial Vascular Procedures,241,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,7479.76,,,,,,,fee schedule,7479.76,7479.76, Open Extracranial Vascular Procedures,241,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,7479.76,,,,,,,fee schedule,7479.76,7479.76, Open Extracranial Vascular Procedures,241,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,7479.76,,,,,,,fee schedule,7479.76,7479.76, Open Extracranial Vascular Procedures,241,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,7479.76,,,,,,,fee schedule,7479.76,7479.76, Open Extracranial Vascular Procedures,241,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,7479.76,,,,,,,fee schedule,7479.76,7479.76, Open Extracranial Vascular Procedures,242,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,9914.67,,,,,,,fee schedule,9914.67,9914.67, Open Extracranial Vascular Procedures,242,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,9914.67,,,,,,,fee schedule,9914.67,9914.67, Open Extracranial Vascular Procedures,242,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,9914.67,,,,,,,fee schedule,9914.67,9914.67, Open Extracranial Vascular Procedures,242,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,9914.67,,,,,,,fee schedule,9914.67,9914.67, Open Extracranial Vascular Procedures,242,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,9914.67,,,,,,,fee schedule,9914.67,9914.67, Open Extracranial Vascular Procedures,242,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,9914.67,,,,,,,fee schedule,9914.67,9914.67, Open Extracranial Vascular Procedures,242,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,9914.67,,,,,,,fee schedule,9914.67,9914.67, Open Extracranial Vascular Procedures,242,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,9914.67,,,,,,,fee schedule,9914.67,9914.67, Open Extracranial Vascular Procedures,242,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,9914.67,,,,,,,fee schedule,9914.67,9914.67, Open Extracranial Vascular Procedures,242,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,9914.67,,,,,,,fee schedule,9914.67,9914.67, Open Extracranial Vascular Procedures,242,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,9914.67,,,,,,,fee schedule,9914.67,9914.67, Open Extracranial Vascular Procedures,243,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,17660.51,,,,,,,fee schedule,17660.51,17660.51, Open Extracranial Vascular Procedures,243,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,17660.51,,,,,,,fee schedule,17660.51,17660.51, Open Extracranial Vascular Procedures,243,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,17660.51,,,,,,,fee schedule,17660.51,17660.51, Open Extracranial Vascular Procedures,243,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,17660.51,,,,,,,fee schedule,17660.51,17660.51, Open Extracranial Vascular Procedures,243,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,17660.51,,,,,,,fee schedule,17660.51,17660.51, Open Extracranial Vascular Procedures,243,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,17660.51,,,,,,,fee schedule,17660.51,17660.51, Open Extracranial Vascular Procedures,243,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,17660.51,,,,,,,fee schedule,17660.51,17660.51, Open Extracranial Vascular Procedures,243,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,17660.51,,,,,,,fee schedule,17660.51,17660.51, Open Extracranial Vascular Procedures,243,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,17660.51,,,,,,,fee schedule,17660.51,17660.51, Open Extracranial Vascular Procedures,243,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,17660.51,,,,,,,fee schedule,17660.51,17660.51, Open Extracranial Vascular Procedures,243,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,17660.51,,,,,,,fee schedule,17660.51,17660.51, Open Extracranial Vascular Procedures,244,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,27618.24,,,,,,,fee schedule,27618.24,27618.24, Open Extracranial Vascular Procedures,244,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,27618.24,,,,,,,fee schedule,27618.24,27618.24, Open Extracranial Vascular Procedures,244,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,27618.24,,,,,,,fee schedule,27618.24,27618.24, Open Extracranial Vascular Procedures,244,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,27618.24,,,,,,,fee schedule,27618.24,27618.24, Open Extracranial Vascular Procedures,244,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,27618.24,,,,,,,fee schedule,27618.24,27618.24, Open Extracranial Vascular Procedures,244,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,27618.24,,,,,,,fee schedule,27618.24,27618.24, Open Extracranial Vascular Procedures,244,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,27618.24,,,,,,,fee schedule,27618.24,27618.24, Open Extracranial Vascular Procedures,244,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,27618.24,,,,,,,fee schedule,27618.24,27618.24, Open Extracranial Vascular Procedures,244,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,27618.24,,,,,,,fee schedule,27618.24,27618.24, Open Extracranial Vascular Procedures,244,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,27618.24,,,,,,,fee schedule,27618.24,27618.24, Open Extracranial Vascular Procedures,244,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,27618.24,,,,,,,fee schedule,27618.24,27618.24, Other Nervous System And Related Procedures,261,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,10421.42,,,,,,,fee schedule,10421.42,10421.42, Other Nervous System And Related Procedures,261,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,10421.42,,,,,,,fee schedule,10421.42,10421.42, Other Nervous System And Related Procedures,261,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,10421.42,,,,,,,fee schedule,10421.42,10421.42, Other Nervous System And Related Procedures,261,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,10421.42,,,,,,,fee schedule,10421.42,10421.42, Other Nervous System And Related Procedures,261,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,10421.42,,,,,,,fee schedule,10421.42,10421.42, Other Nervous System And Related Procedures,261,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,10421.42,,,,,,,fee schedule,10421.42,10421.42, Other Nervous System And Related Procedures,261,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,10421.42,,,,,,,fee schedule,10421.42,10421.42, Other Nervous System And Related Procedures,261,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,10421.42,,,,,,,fee schedule,10421.42,10421.42, Other Nervous System And Related Procedures,261,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,10421.42,,,,,,,fee schedule,10421.42,10421.42, Other Nervous System And Related Procedures,261,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,10421.42,,,,,,,fee schedule,10421.42,10421.42, Other Nervous System And Related Procedures,261,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,10421.42,,,,,,,fee schedule,10421.42,10421.42, Other Nervous System And Related Procedures,262,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,15514.26,,,,,,,fee schedule,15514.26,15514.26, Other Nervous System And Related Procedures,262,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,15514.26,,,,,,,fee schedule,15514.26,15514.26, Other Nervous System And Related Procedures,262,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,15514.26,,,,,,,fee schedule,15514.26,15514.26, Other Nervous System And Related Procedures,262,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,15514.26,,,,,,,fee schedule,15514.26,15514.26, Other Nervous System And Related Procedures,262,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,15514.26,,,,,,,fee schedule,15514.26,15514.26, Other Nervous System And Related Procedures,262,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,15514.26,,,,,,,fee schedule,15514.26,15514.26, Other Nervous System And Related Procedures,262,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,15514.26,,,,,,,fee schedule,15514.26,15514.26, Other Nervous System And Related Procedures,262,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,15514.26,,,,,,,fee schedule,15514.26,15514.26, Other Nervous System And Related Procedures,262,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,15514.26,,,,,,,fee schedule,15514.26,15514.26, Other Nervous System And Related Procedures,262,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,15514.26,,,,,,,fee schedule,15514.26,15514.26, Other Nervous System And Related Procedures,262,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,15514.26,,,,,,,fee schedule,15514.26,15514.26, Other Nervous System And Related Procedures,263,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,20626.16,,,,,,,fee schedule,20626.16,20626.16, Other Nervous System And Related Procedures,263,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,20626.16,,,,,,,fee schedule,20626.16,20626.16, Other Nervous System And Related Procedures,263,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,20626.16,,,,,,,fee schedule,20626.16,20626.16, Other Nervous System And Related Procedures,263,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,20626.16,,,,,,,fee schedule,20626.16,20626.16, Other Nervous System And Related Procedures,263,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,20626.16,,,,,,,fee schedule,20626.16,20626.16, Other Nervous System And Related Procedures,263,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,20626.16,,,,,,,fee schedule,20626.16,20626.16, Other Nervous System And Related Procedures,263,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,20626.16,,,,,,,fee schedule,20626.16,20626.16, Other Nervous System And Related Procedures,263,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,20626.16,,,,,,,fee schedule,20626.16,20626.16, Other Nervous System And Related Procedures,263,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,20626.16,,,,,,,fee schedule,20626.16,20626.16, Other Nervous System And Related Procedures,263,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,20626.16,,,,,,,fee schedule,20626.16,20626.16, Other Nervous System And Related Procedures,263,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,20626.16,,,,,,,fee schedule,20626.16,20626.16, Other Nervous System And Related Procedures,264,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,32310.21,,,,,,,fee schedule,32310.21,32310.21, Other Nervous System And Related Procedures,264,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,32310.21,,,,,,,fee schedule,32310.21,32310.21, Other Nervous System And Related Procedures,264,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,32310.21,,,,,,,fee schedule,32310.21,32310.21, Other Nervous System And Related Procedures,264,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,32310.21,,,,,,,fee schedule,32310.21,32310.21, Other Nervous System And Related Procedures,264,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,32310.21,,,,,,,fee schedule,32310.21,32310.21, Other Nervous System And Related Procedures,264,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,32310.21,,,,,,,fee schedule,32310.21,32310.21, Other Nervous System And Related Procedures,264,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,32310.21,,,,,,,fee schedule,32310.21,32310.21, Other Nervous System And Related Procedures,264,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,32310.21,,,,,,,fee schedule,32310.21,32310.21, Other Nervous System And Related Procedures,264,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,32310.21,,,,,,,fee schedule,32310.21,32310.21, Other Nervous System And Related Procedures,264,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,32310.21,,,,,,,fee schedule,32310.21,32310.21, Other Nervous System And Related Procedures,264,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,32310.21,,,,,,,fee schedule,32310.21,32310.21, Other Open Craniotomy,271,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,13487.29,,,,,,,fee schedule,13487.29,13487.29, Other Open Craniotomy,271,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,13487.29,,,,,,,fee schedule,13487.29,13487.29, Other Open Craniotomy,271,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,13487.29,,,,,,,fee schedule,13487.29,13487.29, Other Open Craniotomy,271,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,13487.29,,,,,,,fee schedule,13487.29,13487.29, Other Open Craniotomy,271,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,13487.29,,,,,,,fee schedule,13487.29,13487.29, Other Open Craniotomy,271,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,13487.29,,,,,,,fee schedule,13487.29,13487.29, Other Open Craniotomy,271,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,13487.29,,,,,,,fee schedule,13487.29,13487.29, Other Open Craniotomy,271,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,13487.29,,,,,,,fee schedule,13487.29,13487.29, Other Open Craniotomy,271,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,13487.29,,,,,,,fee schedule,13487.29,13487.29, Other Open Craniotomy,271,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,13487.29,,,,,,,fee schedule,13487.29,13487.29, Other Open Craniotomy,271,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,13487.29,,,,,,,fee schedule,13487.29,13487.29, Other Open Craniotomy,272,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,18526.5,,,,,,,fee schedule,18526.5,18526.5, Other Open Craniotomy,272,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,18526.5,,,,,,,fee schedule,18526.5,18526.5, Other Open Craniotomy,272,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,18526.5,,,,,,,fee schedule,18526.5,18526.5, Other Open Craniotomy,272,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,18526.5,,,,,,,fee schedule,18526.5,18526.5, Other Open Craniotomy,272,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,18526.5,,,,,,,fee schedule,18526.5,18526.5, Other Open Craniotomy,272,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,18526.5,,,,,,,fee schedule,18526.5,18526.5, Other Open Craniotomy,272,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,18526.5,,,,,,,fee schedule,18526.5,18526.5, Other Open Craniotomy,272,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,18526.5,,,,,,,fee schedule,18526.5,18526.5, Other Open Craniotomy,272,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,18526.5,,,,,,,fee schedule,18526.5,18526.5, Other Open Craniotomy,272,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,18526.5,,,,,,,fee schedule,18526.5,18526.5, Other Open Craniotomy,272,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,18526.5,,,,,,,fee schedule,18526.5,18526.5, Other Open Craniotomy,273,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,26924.47,,,,,,,fee schedule,26924.47,26924.47, Other Open Craniotomy,273,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,26924.47,,,,,,,fee schedule,26924.47,26924.47, Other Open Craniotomy,273,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,26924.47,,,,,,,fee schedule,26924.47,26924.47, Other Open Craniotomy,273,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,26924.47,,,,,,,fee schedule,26924.47,26924.47, Other Open Craniotomy,273,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,26924.47,,,,,,,fee schedule,26924.47,26924.47, Other Open Craniotomy,273,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,26924.47,,,,,,,fee schedule,26924.47,26924.47, Other Open Craniotomy,273,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,26924.47,,,,,,,fee schedule,26924.47,26924.47, Other Open Craniotomy,273,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,26924.47,,,,,,,fee schedule,26924.47,26924.47, Other Open Craniotomy,273,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,26924.47,,,,,,,fee schedule,26924.47,26924.47, Other Open Craniotomy,273,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,26924.47,,,,,,,fee schedule,26924.47,26924.47, Other Open Craniotomy,273,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,26924.47,,,,,,,fee schedule,26924.47,26924.47, Other Open Craniotomy,274,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,38341.73,,,,,,,fee schedule,38341.73,38341.73, Other Open Craniotomy,274,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,38341.73,,,,,,,fee schedule,38341.73,38341.73, Other Open Craniotomy,274,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,38341.73,,,,,,,fee schedule,38341.73,38341.73, Other Open Craniotomy,274,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,38341.73,,,,,,,fee schedule,38341.73,38341.73, Other Open Craniotomy,274,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,38341.73,,,,,,,fee schedule,38341.73,38341.73, Other Open Craniotomy,274,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,38341.73,,,,,,,fee schedule,38341.73,38341.73, Other Open Craniotomy,274,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,38341.73,,,,,,,fee schedule,38341.73,38341.73, Other Open Craniotomy,274,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,38341.73,,,,,,,fee schedule,38341.73,38341.73, Other Open Craniotomy,274,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,38341.73,,,,,,,fee schedule,38341.73,38341.73, Other Open Craniotomy,274,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,38341.73,,,,,,,fee schedule,38341.73,38341.73, Other Open Craniotomy,274,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,38341.73,,,,,,,fee schedule,38341.73,38341.73, Other Percutaneous Intracranial Procedures,291,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,13519.05,,,,,,,fee schedule,13519.05,13519.05, Other Percutaneous Intracranial Procedures,291,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,13519.05,,,,,,,fee schedule,13519.05,13519.05, Other Percutaneous Intracranial Procedures,291,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,13519.05,,,,,,,fee schedule,13519.05,13519.05, Other Percutaneous Intracranial Procedures,291,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,13519.05,,,,,,,fee schedule,13519.05,13519.05, Other Percutaneous Intracranial Procedures,291,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,13519.05,,,,,,,fee schedule,13519.05,13519.05, Other Percutaneous Intracranial Procedures,291,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,13519.05,,,,,,,fee schedule,13519.05,13519.05, Other Percutaneous Intracranial Procedures,291,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,13519.05,,,,,,,fee schedule,13519.05,13519.05, Other Percutaneous Intracranial Procedures,291,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,13519.05,,,,,,,fee schedule,13519.05,13519.05, Other Percutaneous Intracranial Procedures,291,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,13519.05,,,,,,,fee schedule,13519.05,13519.05, Other Percutaneous Intracranial Procedures,291,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,13519.05,,,,,,,fee schedule,13519.05,13519.05, Other Percutaneous Intracranial Procedures,291,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,13519.05,,,,,,,fee schedule,13519.05,13519.05, Other Percutaneous Intracranial Procedures,292,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,16956.86,,,,,,,fee schedule,16956.86,16956.86, Other Percutaneous Intracranial Procedures,292,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,16956.86,,,,,,,fee schedule,16956.86,16956.86, Other Percutaneous Intracranial Procedures,292,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,16956.86,,,,,,,fee schedule,16956.86,16956.86, Other Percutaneous Intracranial Procedures,292,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,16956.86,,,,,,,fee schedule,16956.86,16956.86, Other Percutaneous Intracranial Procedures,292,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,16956.86,,,,,,,fee schedule,16956.86,16956.86, Other Percutaneous Intracranial Procedures,292,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,16956.86,,,,,,,fee schedule,16956.86,16956.86, Other Percutaneous Intracranial Procedures,292,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,16956.86,,,,,,,fee schedule,16956.86,16956.86, Other Percutaneous Intracranial Procedures,292,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,16956.86,,,,,,,fee schedule,16956.86,16956.86, Other Percutaneous Intracranial Procedures,292,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,16956.86,,,,,,,fee schedule,16956.86,16956.86, Other Percutaneous Intracranial Procedures,292,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,16956.86,,,,,,,fee schedule,16956.86,16956.86, Other Percutaneous Intracranial Procedures,292,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,16956.86,,,,,,,fee schedule,16956.86,16956.86, Other Percutaneous Intracranial Procedures,293,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,24350.52,,,,,,,fee schedule,24350.52,24350.52, Other Percutaneous Intracranial Procedures,293,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,24350.52,,,,,,,fee schedule,24350.52,24350.52, Other Percutaneous Intracranial Procedures,293,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,24350.52,,,,,,,fee schedule,24350.52,24350.52, Other Percutaneous Intracranial Procedures,293,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,24350.52,,,,,,,fee schedule,24350.52,24350.52, Other Percutaneous Intracranial Procedures,293,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,24350.52,,,,,,,fee schedule,24350.52,24350.52, Other Percutaneous Intracranial Procedures,293,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,24350.52,,,,,,,fee schedule,24350.52,24350.52, Other Percutaneous Intracranial Procedures,293,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,24350.52,,,,,,,fee schedule,24350.52,24350.52, Other Percutaneous Intracranial Procedures,293,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,24350.52,,,,,,,fee schedule,24350.52,24350.52, Other Percutaneous Intracranial Procedures,293,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,24350.52,,,,,,,fee schedule,24350.52,24350.52, Other Percutaneous Intracranial Procedures,293,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,24350.52,,,,,,,fee schedule,24350.52,24350.52, Other Percutaneous Intracranial Procedures,293,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,24350.52,,,,,,,fee schedule,24350.52,24350.52, Other Percutaneous Intracranial Procedures,294,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,32512.06,,,,,,,fee schedule,32512.06,32512.06, Other Percutaneous Intracranial Procedures,294,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,32512.06,,,,,,,fee schedule,32512.06,32512.06, Other Percutaneous Intracranial Procedures,294,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,32512.06,,,,,,,fee schedule,32512.06,32512.06, Other Percutaneous Intracranial Procedures,294,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,32512.06,,,,,,,fee schedule,32512.06,32512.06, Other Percutaneous Intracranial Procedures,294,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,32512.06,,,,,,,fee schedule,32512.06,32512.06, Other Percutaneous Intracranial Procedures,294,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,32512.06,,,,,,,fee schedule,32512.06,32512.06, Other Percutaneous Intracranial Procedures,294,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,32512.06,,,,,,,fee schedule,32512.06,32512.06, Other Percutaneous Intracranial Procedures,294,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,32512.06,,,,,,,fee schedule,32512.06,32512.06, Other Percutaneous Intracranial Procedures,294,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,32512.06,,,,,,,fee schedule,32512.06,32512.06, Other Percutaneous Intracranial Procedures,294,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,32512.06,,,,,,,fee schedule,32512.06,32512.06, Other Percutaneous Intracranial Procedures,294,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,32512.06,,,,,,,fee schedule,32512.06,32512.06, Percutaneous Intracranial And Extracranial Vascular Procedures,301,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,11717.92,,,,,,,fee schedule,11717.92,11717.92, Percutaneous Intracranial And Extracranial Vascular Procedures,301,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,11717.92,,,,,,,fee schedule,11717.92,11717.92, Percutaneous Intracranial And Extracranial Vascular Procedures,301,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,11717.92,,,,,,,fee schedule,11717.92,11717.92, Percutaneous Intracranial And Extracranial Vascular Procedures,301,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,11717.92,,,,,,,fee schedule,11717.92,11717.92, Percutaneous Intracranial And Extracranial Vascular Procedures,301,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,11717.92,,,,,,,fee schedule,11717.92,11717.92, Percutaneous Intracranial And Extracranial Vascular Procedures,301,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,11717.92,,,,,,,fee schedule,11717.92,11717.92, Percutaneous Intracranial And Extracranial Vascular Procedures,301,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,11717.92,,,,,,,fee schedule,11717.92,11717.92, Percutaneous Intracranial And Extracranial Vascular Procedures,301,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,11717.92,,,,,,,fee schedule,11717.92,11717.92, Percutaneous Intracranial And Extracranial Vascular Procedures,301,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,11717.92,,,,,,,fee schedule,11717.92,11717.92, Percutaneous Intracranial And Extracranial Vascular Procedures,301,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,11717.92,,,,,,,fee schedule,11717.92,11717.92, Percutaneous Intracranial And Extracranial Vascular Procedures,301,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,11717.92,,,,,,,fee schedule,11717.92,11717.92, Percutaneous Intracranial And Extracranial Vascular Procedures,302,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,20124.36,,,,,,,fee schedule,20124.36,20124.36, Percutaneous Intracranial And Extracranial Vascular Procedures,302,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,20124.36,,,,,,,fee schedule,20124.36,20124.36, Percutaneous Intracranial And Extracranial Vascular Procedures,302,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,20124.36,,,,,,,fee schedule,20124.36,20124.36, Percutaneous Intracranial And Extracranial Vascular Procedures,302,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,20124.36,,,,,,,fee schedule,20124.36,20124.36, Percutaneous Intracranial And Extracranial Vascular Procedures,302,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,20124.36,,,,,,,fee schedule,20124.36,20124.36, Percutaneous Intracranial And Extracranial Vascular Procedures,302,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,20124.36,,,,,,,fee schedule,20124.36,20124.36, Percutaneous Intracranial And Extracranial Vascular Procedures,302,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,20124.36,,,,,,,fee schedule,20124.36,20124.36, Percutaneous Intracranial And Extracranial Vascular Procedures,302,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,20124.36,,,,,,,fee schedule,20124.36,20124.36, Percutaneous Intracranial And Extracranial Vascular Procedures,302,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,20124.36,,,,,,,fee schedule,20124.36,20124.36, Percutaneous Intracranial And Extracranial Vascular Procedures,302,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,20124.36,,,,,,,fee schedule,20124.36,20124.36, Percutaneous Intracranial And Extracranial Vascular Procedures,302,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,20124.36,,,,,,,fee schedule,20124.36,20124.36, Percutaneous Intracranial And Extracranial Vascular Procedures,303,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,25788.88,,,,,,,fee schedule,25788.88,25788.88, Percutaneous Intracranial And Extracranial Vascular Procedures,303,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,25788.88,,,,,,,fee schedule,25788.88,25788.88, Percutaneous Intracranial And Extracranial Vascular Procedures,303,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,25788.88,,,,,,,fee schedule,25788.88,25788.88, Percutaneous Intracranial And Extracranial Vascular Procedures,303,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,25788.88,,,,,,,fee schedule,25788.88,25788.88, Percutaneous Intracranial And Extracranial Vascular Procedures,303,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,25788.88,,,,,,,fee schedule,25788.88,25788.88, Percutaneous Intracranial And Extracranial Vascular Procedures,303,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,25788.88,,,,,,,fee schedule,25788.88,25788.88, Percutaneous Intracranial And Extracranial Vascular Procedures,303,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,25788.88,,,,,,,fee schedule,25788.88,25788.88, Percutaneous Intracranial And Extracranial Vascular Procedures,303,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,25788.88,,,,,,,fee schedule,25788.88,25788.88, Percutaneous Intracranial And Extracranial Vascular Procedures,303,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,25788.88,,,,,,,fee schedule,25788.88,25788.88, Percutaneous Intracranial And Extracranial Vascular Procedures,303,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,25788.88,,,,,,,fee schedule,25788.88,25788.88, Percutaneous Intracranial And Extracranial Vascular Procedures,303,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,25788.88,,,,,,,fee schedule,25788.88,25788.88, Percutaneous Intracranial And Extracranial Vascular Procedures,304,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,34752.18,,,,,,,fee schedule,34752.18,34752.18, Percutaneous Intracranial And Extracranial Vascular Procedures,304,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,34752.18,,,,,,,fee schedule,34752.18,34752.18, Percutaneous Intracranial And Extracranial Vascular Procedures,304,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,34752.18,,,,,,,fee schedule,34752.18,34752.18, Percutaneous Intracranial And Extracranial Vascular Procedures,304,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,34752.18,,,,,,,fee schedule,34752.18,34752.18, Percutaneous Intracranial And Extracranial Vascular Procedures,304,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,34752.18,,,,,,,fee schedule,34752.18,34752.18, Percutaneous Intracranial And Extracranial Vascular Procedures,304,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,34752.18,,,,,,,fee schedule,34752.18,34752.18, Percutaneous Intracranial And Extracranial Vascular Procedures,304,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,34752.18,,,,,,,fee schedule,34752.18,34752.18, Percutaneous Intracranial And Extracranial Vascular Procedures,304,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,34752.18,,,,,,,fee schedule,34752.18,34752.18, Percutaneous Intracranial And Extracranial Vascular Procedures,304,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,34752.18,,,,,,,fee schedule,34752.18,34752.18, Percutaneous Intracranial And Extracranial Vascular Procedures,304,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,34752.18,,,,,,,fee schedule,34752.18,34752.18, Percutaneous Intracranial And Extracranial Vascular Procedures,304,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,34752.18,,,,,,,fee schedule,34752.18,34752.18, Spinal Disorders And Injuries,401,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,7966.75,,,,,,,fee schedule,7966.75,7966.75, Spinal Disorders And Injuries,401,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,7966.75,,,,,,,fee schedule,7966.75,7966.75, Spinal Disorders And Injuries,401,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,7966.75,,,,,,,fee schedule,7966.75,7966.75, Spinal Disorders And Injuries,401,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,7966.75,,,,,,,fee schedule,7966.75,7966.75, Spinal Disorders And Injuries,401,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,7966.75,,,,,,,fee schedule,7966.75,7966.75, Spinal Disorders And Injuries,401,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,7966.75,,,,,,,fee schedule,7966.75,7966.75, Spinal Disorders And Injuries,401,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,7966.75,,,,,,,fee schedule,7966.75,7966.75, Spinal Disorders And Injuries,401,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,7966.75,,,,,,,fee schedule,7966.75,7966.75, Spinal Disorders And Injuries,401,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,7966.75,,,,,,,fee schedule,7966.75,7966.75, Spinal Disorders And Injuries,401,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,7966.75,,,,,,,fee schedule,7966.75,7966.75, Spinal Disorders And Injuries,401,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,7966.75,,,,,,,fee schedule,7966.75,7966.75, Spinal Disorders And Injuries,402,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,10880.88,,,,,,,fee schedule,10880.88,10880.88, Spinal Disorders And Injuries,402,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,10880.88,,,,,,,fee schedule,10880.88,10880.88, Spinal Disorders And Injuries,402,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,10880.88,,,,,,,fee schedule,10880.88,10880.88, Spinal Disorders And Injuries,402,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,10880.88,,,,,,,fee schedule,10880.88,10880.88, Spinal Disorders And Injuries,402,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,10880.88,,,,,,,fee schedule,10880.88,10880.88, Spinal Disorders And Injuries,402,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,10880.88,,,,,,,fee schedule,10880.88,10880.88, Spinal Disorders And Injuries,402,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,10880.88,,,,,,,fee schedule,10880.88,10880.88, Spinal Disorders And Injuries,402,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,10880.88,,,,,,,fee schedule,10880.88,10880.88, Spinal Disorders And Injuries,402,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,10880.88,,,,,,,fee schedule,10880.88,10880.88, Spinal Disorders And Injuries,402,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,10880.88,,,,,,,fee schedule,10880.88,10880.88, Spinal Disorders And Injuries,402,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,10880.88,,,,,,,fee schedule,10880.88,10880.88, Spinal Disorders And Injuries,403,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,15038.57,,,,,,,fee schedule,15038.57,15038.57, Spinal Disorders And Injuries,403,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,15038.57,,,,,,,fee schedule,15038.57,15038.57, Spinal Disorders And Injuries,403,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,15038.57,,,,,,,fee schedule,15038.57,15038.57, Spinal Disorders And Injuries,403,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,15038.57,,,,,,,fee schedule,15038.57,15038.57, Spinal Disorders And Injuries,403,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,15038.57,,,,,,,fee schedule,15038.57,15038.57, Spinal Disorders And Injuries,403,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,15038.57,,,,,,,fee schedule,15038.57,15038.57, Spinal Disorders And Injuries,403,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,15038.57,,,,,,,fee schedule,15038.57,15038.57, Spinal Disorders And Injuries,403,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,15038.57,,,,,,,fee schedule,15038.57,15038.57, Spinal Disorders And Injuries,403,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,15038.57,,,,,,,fee schedule,15038.57,15038.57, Spinal Disorders And Injuries,403,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,15038.57,,,,,,,fee schedule,15038.57,15038.57, Spinal Disorders And Injuries,403,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,15038.57,,,,,,,fee schedule,15038.57,15038.57, Spinal Disorders And Injuries,404,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,21088.45,,,,,,,fee schedule,21088.45,21088.45, Spinal Disorders And Injuries,404,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,21088.45,,,,,,,fee schedule,21088.45,21088.45, Spinal Disorders And Injuries,404,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,21088.45,,,,,,,fee schedule,21088.45,21088.45, Spinal Disorders And Injuries,404,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,21088.45,,,,,,,fee schedule,21088.45,21088.45, Spinal Disorders And Injuries,404,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,21088.45,,,,,,,fee schedule,21088.45,21088.45, Spinal Disorders And Injuries,404,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,21088.45,,,,,,,fee schedule,21088.45,21088.45, Spinal Disorders And Injuries,404,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,21088.45,,,,,,,fee schedule,21088.45,21088.45, Spinal Disorders And Injuries,404,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,21088.45,,,,,,,fee schedule,21088.45,21088.45, Spinal Disorders And Injuries,404,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,21088.45,,,,,,,fee schedule,21088.45,21088.45, Spinal Disorders And Injuries,404,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,21088.45,,,,,,,fee schedule,21088.45,21088.45, Spinal Disorders And Injuries,404,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,21088.45,,,,,,,fee schedule,21088.45,21088.45, Nervous System Malignancy,411,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,6489.57,,,,,,,fee schedule,6489.57,6489.57, Nervous System Malignancy,411,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,6489.57,,,,,,,fee schedule,6489.57,6489.57, Nervous System Malignancy,411,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,6489.57,,,,,,,fee schedule,6489.57,6489.57, Nervous System Malignancy,411,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,6489.57,,,,,,,fee schedule,6489.57,6489.57, Nervous System Malignancy,411,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,6489.57,,,,,,,fee schedule,6489.57,6489.57, Nervous System Malignancy,411,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,6489.57,,,,,,,fee schedule,6489.57,6489.57, Nervous System Malignancy,411,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,6489.57,,,,,,,fee schedule,6489.57,6489.57, Nervous System Malignancy,411,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,6489.57,,,,,,,fee schedule,6489.57,6489.57, Nervous System Malignancy,411,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,6489.57,,,,,,,fee schedule,6489.57,6489.57, Nervous System Malignancy,411,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,6489.57,,,,,,,fee schedule,6489.57,6489.57, Nervous System Malignancy,411,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,6489.57,,,,,,,fee schedule,6489.57,6489.57, Nervous System Malignancy,412,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,7577.16,,,,,,,fee schedule,7577.16,7577.16, Nervous System Malignancy,412,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,7577.16,,,,,,,fee schedule,7577.16,7577.16, Nervous System Malignancy,412,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,7577.16,,,,,,,fee schedule,7577.16,7577.16, Nervous System Malignancy,412,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,7577.16,,,,,,,fee schedule,7577.16,7577.16, Nervous System Malignancy,412,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,7577.16,,,,,,,fee schedule,7577.16,7577.16, Nervous System Malignancy,412,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,7577.16,,,,,,,fee schedule,7577.16,7577.16, Nervous System Malignancy,412,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,7577.16,,,,,,,fee schedule,7577.16,7577.16, Nervous System Malignancy,412,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,7577.16,,,,,,,fee schedule,7577.16,7577.16, Nervous System Malignancy,412,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,7577.16,,,,,,,fee schedule,7577.16,7577.16, Nervous System Malignancy,412,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,7577.16,,,,,,,fee schedule,7577.16,7577.16, Nervous System Malignancy,412,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,7577.16,,,,,,,fee schedule,7577.16,7577.16, Nervous System Malignancy,413,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,10410.83,,,,,,,fee schedule,10410.83,10410.83, Nervous System Malignancy,413,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,10410.83,,,,,,,fee schedule,10410.83,10410.83, Nervous System Malignancy,413,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,10410.83,,,,,,,fee schedule,10410.83,10410.83, Nervous System Malignancy,413,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,10410.83,,,,,,,fee schedule,10410.83,10410.83, Nervous System Malignancy,413,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,10410.83,,,,,,,fee schedule,10410.83,10410.83, Nervous System Malignancy,413,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,10410.83,,,,,,,fee schedule,10410.83,10410.83, Nervous System Malignancy,413,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,10410.83,,,,,,,fee schedule,10410.83,10410.83, Nervous System Malignancy,413,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,10410.83,,,,,,,fee schedule,10410.83,10410.83, Nervous System Malignancy,413,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,10410.83,,,,,,,fee schedule,10410.83,10410.83, Nervous System Malignancy,413,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,10410.83,,,,,,,fee schedule,10410.83,10410.83, Nervous System Malignancy,413,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,10410.83,,,,,,,fee schedule,10410.83,10410.83, Nervous System Malignancy,414,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,14999.05,,,,,,,fee schedule,14999.05,14999.05, Nervous System Malignancy,414,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,14999.05,,,,,,,fee schedule,14999.05,14999.05, Nervous System Malignancy,414,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,14999.05,,,,,,,fee schedule,14999.05,14999.05, Nervous System Malignancy,414,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,14999.05,,,,,,,fee schedule,14999.05,14999.05, Nervous System Malignancy,414,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,14999.05,,,,,,,fee schedule,14999.05,14999.05, Nervous System Malignancy,414,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,14999.05,,,,,,,fee schedule,14999.05,14999.05, Nervous System Malignancy,414,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,14999.05,,,,,,,fee schedule,14999.05,14999.05, Nervous System Malignancy,414,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,14999.05,,,,,,,fee schedule,14999.05,14999.05, Nervous System Malignancy,414,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,14999.05,,,,,,,fee schedule,14999.05,14999.05, Nervous System Malignancy,414,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,14999.05,,,,,,,fee schedule,14999.05,14999.05, Nervous System Malignancy,414,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,14999.05,,,,,,,fee schedule,14999.05,14999.05, Degenerative Nervous System Disorders Except Multiple Sclerosis,421,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5761.21,,,,,,,fee schedule,5761.21,5761.21, Degenerative Nervous System Disorders Except Multiple Sclerosis,421,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5761.21,,,,,,,fee schedule,5761.21,5761.21, Degenerative Nervous System Disorders Except Multiple Sclerosis,421,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5761.21,,,,,,,fee schedule,5761.21,5761.21, Degenerative Nervous System Disorders Except Multiple Sclerosis,421,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5761.21,,,,,,,fee schedule,5761.21,5761.21, Degenerative Nervous System Disorders Except Multiple Sclerosis,421,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5761.21,,,,,,,fee schedule,5761.21,5761.21, Degenerative Nervous System Disorders Except Multiple Sclerosis,421,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5761.21,,,,,,,fee schedule,5761.21,5761.21, Degenerative Nervous System Disorders Except Multiple Sclerosis,421,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5761.21,,,,,,,fee schedule,5761.21,5761.21, Degenerative Nervous System Disorders Except Multiple Sclerosis,421,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5761.21,,,,,,,fee schedule,5761.21,5761.21, Degenerative Nervous System Disorders Except Multiple Sclerosis,421,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5761.21,,,,,,,fee schedule,5761.21,5761.21, Degenerative Nervous System Disorders Except Multiple Sclerosis,421,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5761.21,,,,,,,fee schedule,5761.21,5761.21, Degenerative Nervous System Disorders Except Multiple Sclerosis,421,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5761.21,,,,,,,fee schedule,5761.21,5761.21, Degenerative Nervous System Disorders Except Multiple Sclerosis,422,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,7375.31,,,,,,,fee schedule,7375.31,7375.31, Degenerative Nervous System Disorders Except Multiple Sclerosis,422,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,7375.31,,,,,,,fee schedule,7375.31,7375.31, Degenerative Nervous System Disorders Except Multiple Sclerosis,422,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,7375.31,,,,,,,fee schedule,7375.31,7375.31, Degenerative Nervous System Disorders Except Multiple Sclerosis,422,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,7375.31,,,,,,,fee schedule,7375.31,7375.31, Degenerative Nervous System Disorders Except Multiple Sclerosis,422,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,7375.31,,,,,,,fee schedule,7375.31,7375.31, Degenerative Nervous System Disorders Except Multiple Sclerosis,422,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,7375.31,,,,,,,fee schedule,7375.31,7375.31, Degenerative Nervous System Disorders Except Multiple Sclerosis,422,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,7375.31,,,,,,,fee schedule,7375.31,7375.31, Degenerative Nervous System Disorders Except Multiple Sclerosis,422,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,7375.31,,,,,,,fee schedule,7375.31,7375.31, Degenerative Nervous System Disorders Except Multiple Sclerosis,422,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,7375.31,,,,,,,fee schedule,7375.31,7375.31, Degenerative Nervous System Disorders Except Multiple Sclerosis,422,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,7375.31,,,,,,,fee schedule,7375.31,7375.31, Degenerative Nervous System Disorders Except Multiple Sclerosis,422,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,7375.31,,,,,,,fee schedule,7375.31,7375.31, Degenerative Nervous System Disorders Except Multiple Sclerosis,423,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,10455.3,,,,,,,fee schedule,10455.3,10455.3, Degenerative Nervous System Disorders Except Multiple Sclerosis,423,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,10455.3,,,,,,,fee schedule,10455.3,10455.3, Degenerative Nervous System Disorders Except Multiple Sclerosis,423,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,10455.3,,,,,,,fee schedule,10455.3,10455.3, Degenerative Nervous System Disorders Except Multiple Sclerosis,423,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,10455.3,,,,,,,fee schedule,10455.3,10455.3, Degenerative Nervous System Disorders Except Multiple Sclerosis,423,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,10455.3,,,,,,,fee schedule,10455.3,10455.3, Degenerative Nervous System Disorders Except Multiple Sclerosis,423,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,10455.3,,,,,,,fee schedule,10455.3,10455.3, Degenerative Nervous System Disorders Except Multiple Sclerosis,423,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,10455.3,,,,,,,fee schedule,10455.3,10455.3, Degenerative Nervous System Disorders Except Multiple Sclerosis,423,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,10455.3,,,,,,,fee schedule,10455.3,10455.3, Degenerative Nervous System Disorders Except Multiple Sclerosis,423,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,10455.3,,,,,,,fee schedule,10455.3,10455.3, Degenerative Nervous System Disorders Except Multiple Sclerosis,423,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,10455.3,,,,,,,fee schedule,10455.3,10455.3, Degenerative Nervous System Disorders Except Multiple Sclerosis,423,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,10455.3,,,,,,,fee schedule,10455.3,10455.3, Degenerative Nervous System Disorders Except Multiple Sclerosis,424,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,19262.61,,,,,,,fee schedule,19262.61,19262.61, Degenerative Nervous System Disorders Except Multiple Sclerosis,424,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,19262.61,,,,,,,fee schedule,19262.61,19262.61, Degenerative Nervous System Disorders Except Multiple Sclerosis,424,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,19262.61,,,,,,,fee schedule,19262.61,19262.61, Degenerative Nervous System Disorders Except Multiple Sclerosis,424,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,19262.61,,,,,,,fee schedule,19262.61,19262.61, Degenerative Nervous System Disorders Except Multiple Sclerosis,424,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,19262.61,,,,,,,fee schedule,19262.61,19262.61, Degenerative Nervous System Disorders Except Multiple Sclerosis,424,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,19262.61,,,,,,,fee schedule,19262.61,19262.61, Degenerative Nervous System Disorders Except Multiple Sclerosis,424,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,19262.61,,,,,,,fee schedule,19262.61,19262.61, Degenerative Nervous System Disorders Except Multiple Sclerosis,424,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,19262.61,,,,,,,fee schedule,19262.61,19262.61, Degenerative Nervous System Disorders Except Multiple Sclerosis,424,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,19262.61,,,,,,,fee schedule,19262.61,19262.61, Degenerative Nervous System Disorders Except Multiple Sclerosis,424,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,19262.61,,,,,,,fee schedule,19262.61,19262.61, Degenerative Nervous System Disorders Except Multiple Sclerosis,424,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,19262.61,,,,,,,fee schedule,19262.61,19262.61, "Multiple Sclerosis, Other Demyelinating Disease And Inflammatory Neuropathies",431,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,7949.81,,,,,,,fee schedule,7949.81,7949.81, "Multiple Sclerosis, Other Demyelinating Disease And Inflammatory Neuropathies",431,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,7949.81,,,,,,,fee schedule,7949.81,7949.81, "Multiple Sclerosis, Other Demyelinating Disease And Inflammatory Neuropathies",431,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,7949.81,,,,,,,fee schedule,7949.81,7949.81, "Multiple Sclerosis, Other Demyelinating Disease And Inflammatory Neuropathies",431,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,7949.81,,,,,,,fee schedule,7949.81,7949.81, "Multiple Sclerosis, Other Demyelinating Disease And Inflammatory Neuropathies",431,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,7949.81,,,,,,,fee schedule,7949.81,7949.81, "Multiple Sclerosis, Other Demyelinating Disease And Inflammatory Neuropathies",431,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,7949.81,,,,,,,fee schedule,7949.81,7949.81, "Multiple Sclerosis, Other Demyelinating Disease And Inflammatory Neuropathies",431,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,7949.81,,,,,,,fee schedule,7949.81,7949.81, "Multiple Sclerosis, Other Demyelinating Disease And Inflammatory Neuropathies",431,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,7949.81,,,,,,,fee schedule,7949.81,7949.81, "Multiple Sclerosis, Other Demyelinating Disease And Inflammatory Neuropathies",431,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,7949.81,,,,,,,fee schedule,7949.81,7949.81, "Multiple Sclerosis, Other Demyelinating Disease And Inflammatory Neuropathies",431,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,7949.81,,,,,,,fee schedule,7949.81,7949.81, "Multiple Sclerosis, Other Demyelinating Disease And Inflammatory Neuropathies",431,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,7949.81,,,,,,,fee schedule,7949.81,7949.81, "Multiple Sclerosis, Other Demyelinating Disease And Inflammatory Neuropathies",432,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,11673.46,,,,,,,fee schedule,11673.46,11673.46, "Multiple Sclerosis, Other Demyelinating Disease And Inflammatory Neuropathies",432,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,11673.46,,,,,,,fee schedule,11673.46,11673.46, "Multiple Sclerosis, Other Demyelinating Disease And Inflammatory Neuropathies",432,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,11673.46,,,,,,,fee schedule,11673.46,11673.46, "Multiple Sclerosis, Other Demyelinating Disease And Inflammatory Neuropathies",432,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,11673.46,,,,,,,fee schedule,11673.46,11673.46, "Multiple Sclerosis, Other Demyelinating Disease And Inflammatory Neuropathies",432,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,11673.46,,,,,,,fee schedule,11673.46,11673.46, "Multiple Sclerosis, Other Demyelinating Disease And Inflammatory Neuropathies",432,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,11673.46,,,,,,,fee schedule,11673.46,11673.46, "Multiple Sclerosis, Other Demyelinating Disease And Inflammatory Neuropathies",432,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,11673.46,,,,,,,fee schedule,11673.46,11673.46, "Multiple Sclerosis, Other Demyelinating Disease And Inflammatory Neuropathies",432,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,11673.46,,,,,,,fee schedule,11673.46,11673.46, "Multiple Sclerosis, Other Demyelinating Disease And Inflammatory Neuropathies",432,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,11673.46,,,,,,,fee schedule,11673.46,11673.46, "Multiple Sclerosis, Other Demyelinating Disease And Inflammatory Neuropathies",432,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,11673.46,,,,,,,fee schedule,11673.46,11673.46, "Multiple Sclerosis, Other Demyelinating Disease And Inflammatory Neuropathies",432,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,11673.46,,,,,,,fee schedule,11673.46,11673.46, "Multiple Sclerosis, Other Demyelinating Disease And Inflammatory Neuropathies",433,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,17186.94,,,,,,,fee schedule,17186.94,17186.94, "Multiple Sclerosis, Other Demyelinating Disease And Inflammatory Neuropathies",433,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,17186.94,,,,,,,fee schedule,17186.94,17186.94, "Multiple Sclerosis, Other Demyelinating Disease And Inflammatory Neuropathies",433,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,17186.94,,,,,,,fee schedule,17186.94,17186.94, "Multiple Sclerosis, Other Demyelinating Disease And Inflammatory Neuropathies",433,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,17186.94,,,,,,,fee schedule,17186.94,17186.94, "Multiple Sclerosis, Other Demyelinating Disease And Inflammatory Neuropathies",433,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,17186.94,,,,,,,fee schedule,17186.94,17186.94, "Multiple Sclerosis, Other Demyelinating Disease And Inflammatory Neuropathies",433,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,17186.94,,,,,,,fee schedule,17186.94,17186.94, "Multiple Sclerosis, Other Demyelinating Disease And Inflammatory Neuropathies",433,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,17186.94,,,,,,,fee schedule,17186.94,17186.94, "Multiple Sclerosis, Other Demyelinating Disease And Inflammatory Neuropathies",433,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,17186.94,,,,,,,fee schedule,17186.94,17186.94, "Multiple Sclerosis, Other Demyelinating Disease And Inflammatory Neuropathies",433,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,17186.94,,,,,,,fee schedule,17186.94,17186.94, "Multiple Sclerosis, Other Demyelinating Disease And Inflammatory Neuropathies",433,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,17186.94,,,,,,,fee schedule,17186.94,17186.94, "Multiple Sclerosis, Other Demyelinating Disease And Inflammatory Neuropathies",433,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,17186.94,,,,,,,fee schedule,17186.94,17186.94, "Multiple Sclerosis, Other Demyelinating Disease And Inflammatory Neuropathies",434,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,30509.08,,,,,,,fee schedule,30509.08,30509.08, "Multiple Sclerosis, Other Demyelinating Disease And Inflammatory Neuropathies",434,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,30509.08,,,,,,,fee schedule,30509.08,30509.08, "Multiple Sclerosis, Other Demyelinating Disease And Inflammatory Neuropathies",434,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,30509.08,,,,,,,fee schedule,30509.08,30509.08, "Multiple Sclerosis, Other Demyelinating Disease And Inflammatory Neuropathies",434,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,30509.08,,,,,,,fee schedule,30509.08,30509.08, "Multiple Sclerosis, Other Demyelinating Disease And Inflammatory Neuropathies",434,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,30509.08,,,,,,,fee schedule,30509.08,30509.08, "Multiple Sclerosis, Other Demyelinating Disease And Inflammatory Neuropathies",434,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,30509.08,,,,,,,fee schedule,30509.08,30509.08, "Multiple Sclerosis, Other Demyelinating Disease And Inflammatory Neuropathies",434,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,30509.08,,,,,,,fee schedule,30509.08,30509.08, "Multiple Sclerosis, Other Demyelinating Disease And Inflammatory Neuropathies",434,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,30509.08,,,,,,,fee schedule,30509.08,30509.08, "Multiple Sclerosis, Other Demyelinating Disease And Inflammatory Neuropathies",434,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,30509.08,,,,,,,fee schedule,30509.08,30509.08, "Multiple Sclerosis, Other Demyelinating Disease And Inflammatory Neuropathies",434,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,30509.08,,,,,,,fee schedule,30509.08,30509.08, "Multiple Sclerosis, Other Demyelinating Disease And Inflammatory Neuropathies",434,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,30509.08,,,,,,,fee schedule,30509.08,30509.08, Intracranial Hemorrhage,441,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,6445.1,,,,,,,fee schedule,6445.1,6445.1, Intracranial Hemorrhage,441,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,6445.1,,,,,,,fee schedule,6445.1,6445.1, Intracranial Hemorrhage,441,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,6445.1,,,,,,,fee schedule,6445.1,6445.1, Intracranial Hemorrhage,441,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,6445.1,,,,,,,fee schedule,6445.1,6445.1, Intracranial Hemorrhage,441,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,6445.1,,,,,,,fee schedule,6445.1,6445.1, Intracranial Hemorrhage,441,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,6445.1,,,,,,,fee schedule,6445.1,6445.1, Intracranial Hemorrhage,441,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,6445.1,,,,,,,fee schedule,6445.1,6445.1, Intracranial Hemorrhage,441,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,6445.1,,,,,,,fee schedule,6445.1,6445.1, Intracranial Hemorrhage,441,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,6445.1,,,,,,,fee schedule,6445.1,6445.1, Intracranial Hemorrhage,441,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,6445.1,,,,,,,fee schedule,6445.1,6445.1, Intracranial Hemorrhage,441,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,6445.1,,,,,,,fee schedule,6445.1,6445.1, Intracranial Hemorrhage,442,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,8340.1,,,,,,,fee schedule,8340.1,8340.1, Intracranial Hemorrhage,442,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,8340.1,,,,,,,fee schedule,8340.1,8340.1, Intracranial Hemorrhage,442,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,8340.1,,,,,,,fee schedule,8340.1,8340.1, Intracranial Hemorrhage,442,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,8340.1,,,,,,,fee schedule,8340.1,8340.1, Intracranial Hemorrhage,442,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,8340.1,,,,,,,fee schedule,8340.1,8340.1, Intracranial Hemorrhage,442,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,8340.1,,,,,,,fee schedule,8340.1,8340.1, Intracranial Hemorrhage,442,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,8340.1,,,,,,,fee schedule,8340.1,8340.1, Intracranial Hemorrhage,442,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,8340.1,,,,,,,fee schedule,8340.1,8340.1, Intracranial Hemorrhage,442,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,8340.1,,,,,,,fee schedule,8340.1,8340.1, Intracranial Hemorrhage,442,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,8340.1,,,,,,,fee schedule,8340.1,8340.1, Intracranial Hemorrhage,442,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,8340.1,,,,,,,fee schedule,8340.1,8340.1, Intracranial Hemorrhage,443,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,11819.55,,,,,,,fee schedule,11819.55,11819.55, Intracranial Hemorrhage,443,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,11819.55,,,,,,,fee schedule,11819.55,11819.55, Intracranial Hemorrhage,443,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,11819.55,,,,,,,fee schedule,11819.55,11819.55, Intracranial Hemorrhage,443,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,11819.55,,,,,,,fee schedule,11819.55,11819.55, Intracranial Hemorrhage,443,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,11819.55,,,,,,,fee schedule,11819.55,11819.55, Intracranial Hemorrhage,443,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,11819.55,,,,,,,fee schedule,11819.55,11819.55, Intracranial Hemorrhage,443,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,11819.55,,,,,,,fee schedule,11819.55,11819.55, Intracranial Hemorrhage,443,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,11819.55,,,,,,,fee schedule,11819.55,11819.55, Intracranial Hemorrhage,443,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,11819.55,,,,,,,fee schedule,11819.55,11819.55, Intracranial Hemorrhage,443,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,11819.55,,,,,,,fee schedule,11819.55,11819.55, Intracranial Hemorrhage,443,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,11819.55,,,,,,,fee schedule,11819.55,11819.55, Intracranial Hemorrhage,444,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,18226.54,,,,,,,fee schedule,18226.54,18226.54, Intracranial Hemorrhage,444,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,18226.54,,,,,,,fee schedule,18226.54,18226.54, Intracranial Hemorrhage,444,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,18226.54,,,,,,,fee schedule,18226.54,18226.54, Intracranial Hemorrhage,444,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,18226.54,,,,,,,fee schedule,18226.54,18226.54, Intracranial Hemorrhage,444,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,18226.54,,,,,,,fee schedule,18226.54,18226.54, Intracranial Hemorrhage,444,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,18226.54,,,,,,,fee schedule,18226.54,18226.54, Intracranial Hemorrhage,444,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,18226.54,,,,,,,fee schedule,18226.54,18226.54, Intracranial Hemorrhage,444,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,18226.54,,,,,,,fee schedule,18226.54,18226.54, Intracranial Hemorrhage,444,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,18226.54,,,,,,,fee schedule,18226.54,18226.54, Intracranial Hemorrhage,444,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,18226.54,,,,,,,fee schedule,18226.54,18226.54, Intracranial Hemorrhage,444,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,18226.54,,,,,,,fee schedule,18226.54,18226.54, Cva And Precerebral Occlusion With Infarction,451,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5868.49,,,,,,,fee schedule,5868.49,5868.49, Cva And Precerebral Occlusion With Infarction,451,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5868.49,,,,,,,fee schedule,5868.49,5868.49, Cva And Precerebral Occlusion With Infarction,451,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5868.49,,,,,,,fee schedule,5868.49,5868.49, Cva And Precerebral Occlusion With Infarction,451,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5868.49,,,,,,,fee schedule,5868.49,5868.49, Cva And Precerebral Occlusion With Infarction,451,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5868.49,,,,,,,fee schedule,5868.49,5868.49, Cva And Precerebral Occlusion With Infarction,451,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5868.49,,,,,,,fee schedule,5868.49,5868.49, Cva And Precerebral Occlusion With Infarction,451,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5868.49,,,,,,,fee schedule,5868.49,5868.49, Cva And Precerebral Occlusion With Infarction,451,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5868.49,,,,,,,fee schedule,5868.49,5868.49, Cva And Precerebral Occlusion With Infarction,451,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5868.49,,,,,,,fee schedule,5868.49,5868.49, Cva And Precerebral Occlusion With Infarction,451,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5868.49,,,,,,,fee schedule,5868.49,5868.49, Cva And Precerebral Occlusion With Infarction,451,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5868.49,,,,,,,fee schedule,5868.49,5868.49, Cva And Precerebral Occlusion With Infarction,452,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,7549.64,,,,,,,fee schedule,7549.64,7549.64, Cva And Precerebral Occlusion With Infarction,452,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,7549.64,,,,,,,fee schedule,7549.64,7549.64, Cva And Precerebral Occlusion With Infarction,452,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,7549.64,,,,,,,fee schedule,7549.64,7549.64, Cva And Precerebral Occlusion With Infarction,452,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,7549.64,,,,,,,fee schedule,7549.64,7549.64, Cva And Precerebral Occlusion With Infarction,452,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,7549.64,,,,,,,fee schedule,7549.64,7549.64, Cva And Precerebral Occlusion With Infarction,452,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,7549.64,,,,,,,fee schedule,7549.64,7549.64, Cva And Precerebral Occlusion With Infarction,452,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,7549.64,,,,,,,fee schedule,7549.64,7549.64, Cva And Precerebral Occlusion With Infarction,452,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,7549.64,,,,,,,fee schedule,7549.64,7549.64, Cva And Precerebral Occlusion With Infarction,452,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,7549.64,,,,,,,fee schedule,7549.64,7549.64, Cva And Precerebral Occlusion With Infarction,452,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,7549.64,,,,,,,fee schedule,7549.64,7549.64, Cva And Precerebral Occlusion With Infarction,452,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,7549.64,,,,,,,fee schedule,7549.64,7549.64, Cva And Precerebral Occlusion With Infarction,453,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,10520.93,,,,,,,fee schedule,10520.93,10520.93, Cva And Precerebral Occlusion With Infarction,453,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,10520.93,,,,,,,fee schedule,10520.93,10520.93, Cva And Precerebral Occlusion With Infarction,453,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,10520.93,,,,,,,fee schedule,10520.93,10520.93, Cva And Precerebral Occlusion With Infarction,453,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,10520.93,,,,,,,fee schedule,10520.93,10520.93, Cva And Precerebral Occlusion With Infarction,453,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,10520.93,,,,,,,fee schedule,10520.93,10520.93, Cva And Precerebral Occlusion With Infarction,453,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,10520.93,,,,,,,fee schedule,10520.93,10520.93, Cva And Precerebral Occlusion With Infarction,453,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,10520.93,,,,,,,fee schedule,10520.93,10520.93, Cva And Precerebral Occlusion With Infarction,453,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,10520.93,,,,,,,fee schedule,10520.93,10520.93, Cva And Precerebral Occlusion With Infarction,453,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,10520.93,,,,,,,fee schedule,10520.93,10520.93, Cva And Precerebral Occlusion With Infarction,453,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,10520.93,,,,,,,fee schedule,10520.93,10520.93, Cva And Precerebral Occlusion With Infarction,453,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,10520.93,,,,,,,fee schedule,10520.93,10520.93, Cva And Precerebral Occlusion With Infarction,454,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,17442.43,,,,,,,fee schedule,17442.43,17442.43, Cva And Precerebral Occlusion With Infarction,454,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,17442.43,,,,,,,fee schedule,17442.43,17442.43, Cva And Precerebral Occlusion With Infarction,454,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,17442.43,,,,,,,fee schedule,17442.43,17442.43, Cva And Precerebral Occlusion With Infarction,454,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,17442.43,,,,,,,fee schedule,17442.43,17442.43, Cva And Precerebral Occlusion With Infarction,454,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,17442.43,,,,,,,fee schedule,17442.43,17442.43, Cva And Precerebral Occlusion With Infarction,454,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,17442.43,,,,,,,fee schedule,17442.43,17442.43, Cva And Precerebral Occlusion With Infarction,454,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,17442.43,,,,,,,fee schedule,17442.43,17442.43, Cva And Precerebral Occlusion With Infarction,454,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,17442.43,,,,,,,fee schedule,17442.43,17442.43, Cva And Precerebral Occlusion With Infarction,454,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,17442.43,,,,,,,fee schedule,17442.43,17442.43, Cva And Precerebral Occlusion With Infarction,454,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,17442.43,,,,,,,fee schedule,17442.43,17442.43, Cva And Precerebral Occlusion With Infarction,454,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,17442.43,,,,,,,fee schedule,17442.43,17442.43, Nonspecific Cva And Precerebral Occlusion Without Infarction,461,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5987.06,,,,,,,fee schedule,5987.06,5987.06, Nonspecific Cva And Precerebral Occlusion Without Infarction,461,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5987.06,,,,,,,fee schedule,5987.06,5987.06, Nonspecific Cva And Precerebral Occlusion Without Infarction,461,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5987.06,,,,,,,fee schedule,5987.06,5987.06, Nonspecific Cva And Precerebral Occlusion Without Infarction,461,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5987.06,,,,,,,fee schedule,5987.06,5987.06, Nonspecific Cva And Precerebral Occlusion Without Infarction,461,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5987.06,,,,,,,fee schedule,5987.06,5987.06, Nonspecific Cva And Precerebral Occlusion Without Infarction,461,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5987.06,,,,,,,fee schedule,5987.06,5987.06, Nonspecific Cva And Precerebral Occlusion Without Infarction,461,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5987.06,,,,,,,fee schedule,5987.06,5987.06, Nonspecific Cva And Precerebral Occlusion Without Infarction,461,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5987.06,,,,,,,fee schedule,5987.06,5987.06, Nonspecific Cva And Precerebral Occlusion Without Infarction,461,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5987.06,,,,,,,fee schedule,5987.06,5987.06, Nonspecific Cva And Precerebral Occlusion Without Infarction,461,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5987.06,,,,,,,fee schedule,5987.06,5987.06, Nonspecific Cva And Precerebral Occlusion Without Infarction,461,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5987.06,,,,,,,fee schedule,5987.06,5987.06, Nonspecific Cva And Precerebral Occlusion Without Infarction,462,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,7419.07,,,,,,,fee schedule,7419.07,7419.07, Nonspecific Cva And Precerebral Occlusion Without Infarction,462,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,7419.07,,,,,,,fee schedule,7419.07,7419.07, Nonspecific Cva And Precerebral Occlusion Without Infarction,462,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,7419.07,,,,,,,fee schedule,7419.07,7419.07, Nonspecific Cva And Precerebral Occlusion Without Infarction,462,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,7419.07,,,,,,,fee schedule,7419.07,7419.07, Nonspecific Cva And Precerebral Occlusion Without Infarction,462,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,7419.07,,,,,,,fee schedule,7419.07,7419.07, Nonspecific Cva And Precerebral Occlusion Without Infarction,462,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,7419.07,,,,,,,fee schedule,7419.07,7419.07, Nonspecific Cva And Precerebral Occlusion Without Infarction,462,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,7419.07,,,,,,,fee schedule,7419.07,7419.07, Nonspecific Cva And Precerebral Occlusion Without Infarction,462,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,7419.07,,,,,,,fee schedule,7419.07,7419.07, Nonspecific Cva And Precerebral Occlusion Without Infarction,462,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,7419.07,,,,,,,fee schedule,7419.07,7419.07, Nonspecific Cva And Precerebral Occlusion Without Infarction,462,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,7419.07,,,,,,,fee schedule,7419.07,7419.07, Nonspecific Cva And Precerebral Occlusion Without Infarction,462,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,7419.07,,,,,,,fee schedule,7419.07,7419.07, Nonspecific Cva And Precerebral Occlusion Without Infarction,463,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,9599.19,,,,,,,fee schedule,9599.19,9599.19, Nonspecific Cva And Precerebral Occlusion Without Infarction,463,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,9599.19,,,,,,,fee schedule,9599.19,9599.19, Nonspecific Cva And Precerebral Occlusion Without Infarction,463,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,9599.19,,,,,,,fee schedule,9599.19,9599.19, Nonspecific Cva And Precerebral Occlusion Without Infarction,463,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,9599.19,,,,,,,fee schedule,9599.19,9599.19, Nonspecific Cva And Precerebral Occlusion Without Infarction,463,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,9599.19,,,,,,,fee schedule,9599.19,9599.19, Nonspecific Cva And Precerebral Occlusion Without Infarction,463,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,9599.19,,,,,,,fee schedule,9599.19,9599.19, Nonspecific Cva And Precerebral Occlusion Without Infarction,463,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,9599.19,,,,,,,fee schedule,9599.19,9599.19, Nonspecific Cva And Precerebral Occlusion Without Infarction,463,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,9599.19,,,,,,,fee schedule,9599.19,9599.19, Nonspecific Cva And Precerebral Occlusion Without Infarction,463,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,9599.19,,,,,,,fee schedule,9599.19,9599.19, Nonspecific Cva And Precerebral Occlusion Without Infarction,463,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,9599.19,,,,,,,fee schedule,9599.19,9599.19, Nonspecific Cva And Precerebral Occlusion Without Infarction,463,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,9599.19,,,,,,,fee schedule,9599.19,9599.19, Nonspecific Cva And Precerebral Occlusion Without Infarction,464,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,17326.68,,,,,,,fee schedule,17326.68,17326.68, Nonspecific Cva And Precerebral Occlusion Without Infarction,464,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,17326.68,,,,,,,fee schedule,17326.68,17326.68, Nonspecific Cva And Precerebral Occlusion Without Infarction,464,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,17326.68,,,,,,,fee schedule,17326.68,17326.68, Nonspecific Cva And Precerebral Occlusion Without Infarction,464,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,17326.68,,,,,,,fee schedule,17326.68,17326.68, Nonspecific Cva And Precerebral Occlusion Without Infarction,464,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,17326.68,,,,,,,fee schedule,17326.68,17326.68, Nonspecific Cva And Precerebral Occlusion Without Infarction,464,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,17326.68,,,,,,,fee schedule,17326.68,17326.68, Nonspecific Cva And Precerebral Occlusion Without Infarction,464,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,17326.68,,,,,,,fee schedule,17326.68,17326.68, Nonspecific Cva And Precerebral Occlusion Without Infarction,464,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,17326.68,,,,,,,fee schedule,17326.68,17326.68, Nonspecific Cva And Precerebral Occlusion Without Infarction,464,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,17326.68,,,,,,,fee schedule,17326.68,17326.68, Nonspecific Cva And Precerebral Occlusion Without Infarction,464,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,17326.68,,,,,,,fee schedule,17326.68,17326.68, Nonspecific Cva And Precerebral Occlusion Without Infarction,464,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,17326.68,,,,,,,fee schedule,17326.68,17326.68, Transient Ischemia,471,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5503.6,,,,,,,fee schedule,5503.6,5503.6, Transient Ischemia,471,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5503.6,,,,,,,fee schedule,5503.6,5503.6, Transient Ischemia,471,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5503.6,,,,,,,fee schedule,5503.6,5503.6, Transient Ischemia,471,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5503.6,,,,,,,fee schedule,5503.6,5503.6, Transient Ischemia,471,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5503.6,,,,,,,fee schedule,5503.6,5503.6, Transient Ischemia,471,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5503.6,,,,,,,fee schedule,5503.6,5503.6, Transient Ischemia,471,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5503.6,,,,,,,fee schedule,5503.6,5503.6, Transient Ischemia,471,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5503.6,,,,,,,fee schedule,5503.6,5503.6, Transient Ischemia,471,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5503.6,,,,,,,fee schedule,5503.6,5503.6, Transient Ischemia,471,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5503.6,,,,,,,fee schedule,5503.6,5503.6, Transient Ischemia,471,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5503.6,,,,,,,fee schedule,5503.6,5503.6, Transient Ischemia,472,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,6290.54,,,,,,,fee schedule,6290.54,6290.54, Transient Ischemia,472,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,6290.54,,,,,,,fee schedule,6290.54,6290.54, Transient Ischemia,472,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,6290.54,,,,,,,fee schedule,6290.54,6290.54, Transient Ischemia,472,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,6290.54,,,,,,,fee schedule,6290.54,6290.54, Transient Ischemia,472,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,6290.54,,,,,,,fee schedule,6290.54,6290.54, Transient Ischemia,472,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,6290.54,,,,,,,fee schedule,6290.54,6290.54, Transient Ischemia,472,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,6290.54,,,,,,,fee schedule,6290.54,6290.54, Transient Ischemia,472,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,6290.54,,,,,,,fee schedule,6290.54,6290.54, Transient Ischemia,472,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,6290.54,,,,,,,fee schedule,6290.54,6290.54, Transient Ischemia,472,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,6290.54,,,,,,,fee schedule,6290.54,6290.54, Transient Ischemia,472,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,6290.54,,,,,,,fee schedule,6290.54,6290.54, Transient Ischemia,473,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,7877.11,,,,,,,fee schedule,7877.11,7877.11, Transient Ischemia,473,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,7877.11,,,,,,,fee schedule,7877.11,7877.11, Transient Ischemia,473,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,7877.11,,,,,,,fee schedule,7877.11,7877.11, Transient Ischemia,473,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,7877.11,,,,,,,fee schedule,7877.11,7877.11, Transient Ischemia,473,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,7877.11,,,,,,,fee schedule,7877.11,7877.11, Transient Ischemia,473,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,7877.11,,,,,,,fee schedule,7877.11,7877.11, Transient Ischemia,473,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,7877.11,,,,,,,fee schedule,7877.11,7877.11, Transient Ischemia,473,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,7877.11,,,,,,,fee schedule,7877.11,7877.11, Transient Ischemia,473,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,7877.11,,,,,,,fee schedule,7877.11,7877.11, Transient Ischemia,473,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,7877.11,,,,,,,fee schedule,7877.11,7877.11, Transient Ischemia,473,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,7877.11,,,,,,,fee schedule,7877.11,7877.11, Transient Ischemia,474,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,12713.06,,,,,,,fee schedule,12713.06,12713.06, Transient Ischemia,474,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,12713.06,,,,,,,fee schedule,12713.06,12713.06, Transient Ischemia,474,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,12713.06,,,,,,,fee schedule,12713.06,12713.06, Transient Ischemia,474,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,12713.06,,,,,,,fee schedule,12713.06,12713.06, Transient Ischemia,474,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,12713.06,,,,,,,fee schedule,12713.06,12713.06, Transient Ischemia,474,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,12713.06,,,,,,,fee schedule,12713.06,12713.06, Transient Ischemia,474,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,12713.06,,,,,,,fee schedule,12713.06,12713.06, Transient Ischemia,474,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,12713.06,,,,,,,fee schedule,12713.06,12713.06, Transient Ischemia,474,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,12713.06,,,,,,,fee schedule,12713.06,12713.06, Transient Ischemia,474,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,12713.06,,,,,,,fee schedule,12713.06,12713.06, Transient Ischemia,474,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,12713.06,,,,,,,fee schedule,12713.06,12713.06, "Peripheral, Cranial And Autonomic Nerve Disorders",481,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5352.57,,,,,,,fee schedule,5352.57,5352.57, "Peripheral, Cranial And Autonomic Nerve Disorders",481,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5352.57,,,,,,,fee schedule,5352.57,5352.57, "Peripheral, Cranial And Autonomic Nerve Disorders",481,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5352.57,,,,,,,fee schedule,5352.57,5352.57, "Peripheral, Cranial And Autonomic Nerve Disorders",481,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5352.57,,,,,,,fee schedule,5352.57,5352.57, "Peripheral, Cranial And Autonomic Nerve Disorders",481,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5352.57,,,,,,,fee schedule,5352.57,5352.57, "Peripheral, Cranial And Autonomic Nerve Disorders",481,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5352.57,,,,,,,fee schedule,5352.57,5352.57, "Peripheral, Cranial And Autonomic Nerve Disorders",481,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5352.57,,,,,,,fee schedule,5352.57,5352.57, "Peripheral, Cranial And Autonomic Nerve Disorders",481,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5352.57,,,,,,,fee schedule,5352.57,5352.57, "Peripheral, Cranial And Autonomic Nerve Disorders",481,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5352.57,,,,,,,fee schedule,5352.57,5352.57, "Peripheral, Cranial And Autonomic Nerve Disorders",481,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5352.57,,,,,,,fee schedule,5352.57,5352.57, "Peripheral, Cranial And Autonomic Nerve Disorders",481,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5352.57,,,,,,,fee schedule,5352.57,5352.57, "Peripheral, Cranial And Autonomic Nerve Disorders",482,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,6486.74,,,,,,,fee schedule,6486.74,6486.74, "Peripheral, Cranial And Autonomic Nerve Disorders",482,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,6486.74,,,,,,,fee schedule,6486.74,6486.74, "Peripheral, Cranial And Autonomic Nerve Disorders",482,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,6486.74,,,,,,,fee schedule,6486.74,6486.74, "Peripheral, Cranial And Autonomic Nerve Disorders",482,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,6486.74,,,,,,,fee schedule,6486.74,6486.74, "Peripheral, Cranial And Autonomic Nerve Disorders",482,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,6486.74,,,,,,,fee schedule,6486.74,6486.74, "Peripheral, Cranial And Autonomic Nerve Disorders",482,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,6486.74,,,,,,,fee schedule,6486.74,6486.74, "Peripheral, Cranial And Autonomic Nerve Disorders",482,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,6486.74,,,,,,,fee schedule,6486.74,6486.74, "Peripheral, Cranial And Autonomic Nerve Disorders",482,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,6486.74,,,,,,,fee schedule,6486.74,6486.74, "Peripheral, Cranial And Autonomic Nerve Disorders",482,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,6486.74,,,,,,,fee schedule,6486.74,6486.74, "Peripheral, Cranial And Autonomic Nerve Disorders",482,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,6486.74,,,,,,,fee schedule,6486.74,6486.74, "Peripheral, Cranial And Autonomic Nerve Disorders",482,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,6486.74,,,,,,,fee schedule,6486.74,6486.74, "Peripheral, Cranial And Autonomic Nerve Disorders",483,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,9305.59,,,,,,,fee schedule,9305.59,9305.59, "Peripheral, Cranial And Autonomic Nerve Disorders",483,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,9305.59,,,,,,,fee schedule,9305.59,9305.59, "Peripheral, Cranial And Autonomic Nerve Disorders",483,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,9305.59,,,,,,,fee schedule,9305.59,9305.59, "Peripheral, Cranial And Autonomic Nerve Disorders",483,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,9305.59,,,,,,,fee schedule,9305.59,9305.59, "Peripheral, Cranial And Autonomic Nerve Disorders",483,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,9305.59,,,,,,,fee schedule,9305.59,9305.59, "Peripheral, Cranial And Autonomic Nerve Disorders",483,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,9305.59,,,,,,,fee schedule,9305.59,9305.59, "Peripheral, Cranial And Autonomic Nerve Disorders",483,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,9305.59,,,,,,,fee schedule,9305.59,9305.59, "Peripheral, Cranial And Autonomic Nerve Disorders",483,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,9305.59,,,,,,,fee schedule,9305.59,9305.59, "Peripheral, Cranial And Autonomic Nerve Disorders",483,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,9305.59,,,,,,,fee schedule,9305.59,9305.59, "Peripheral, Cranial And Autonomic Nerve Disorders",483,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,9305.59,,,,,,,fee schedule,9305.59,9305.59, "Peripheral, Cranial And Autonomic Nerve Disorders",483,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,9305.59,,,,,,,fee schedule,9305.59,9305.59, "Peripheral, Cranial And Autonomic Nerve Disorders",484,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,16116.99,,,,,,,fee schedule,16116.99,16116.99, "Peripheral, Cranial And Autonomic Nerve Disorders",484,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,16116.99,,,,,,,fee schedule,16116.99,16116.99, "Peripheral, Cranial And Autonomic Nerve Disorders",484,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,16116.99,,,,,,,fee schedule,16116.99,16116.99, "Peripheral, Cranial And Autonomic Nerve Disorders",484,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,16116.99,,,,,,,fee schedule,16116.99,16116.99, "Peripheral, Cranial And Autonomic Nerve Disorders",484,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,16116.99,,,,,,,fee schedule,16116.99,16116.99, "Peripheral, Cranial And Autonomic Nerve Disorders",484,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,16116.99,,,,,,,fee schedule,16116.99,16116.99, "Peripheral, Cranial And Autonomic Nerve Disorders",484,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,16116.99,,,,,,,fee schedule,16116.99,16116.99, "Peripheral, Cranial And Autonomic Nerve Disorders",484,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,16116.99,,,,,,,fee schedule,16116.99,16116.99, "Peripheral, Cranial And Autonomic Nerve Disorders",484,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,16116.99,,,,,,,fee schedule,16116.99,16116.99, "Peripheral, Cranial And Autonomic Nerve Disorders",484,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,16116.99,,,,,,,fee schedule,16116.99,16116.99, "Peripheral, Cranial And Autonomic Nerve Disorders",484,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,16116.99,,,,,,,fee schedule,16116.99,16116.99, Bacterial And Tuberculous Infections Of Nervous System,491,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,8876.49,,,,,,,fee schedule,8876.49,8876.49, Bacterial And Tuberculous Infections Of Nervous System,491,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,8876.49,,,,,,,fee schedule,8876.49,8876.49, Bacterial And Tuberculous Infections Of Nervous System,491,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,8876.49,,,,,,,fee schedule,8876.49,8876.49, Bacterial And Tuberculous Infections Of Nervous System,491,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,8876.49,,,,,,,fee schedule,8876.49,8876.49, Bacterial And Tuberculous Infections Of Nervous System,491,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,8876.49,,,,,,,fee schedule,8876.49,8876.49, Bacterial And Tuberculous Infections Of Nervous System,491,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,8876.49,,,,,,,fee schedule,8876.49,8876.49, Bacterial And Tuberculous Infections Of Nervous System,491,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,8876.49,,,,,,,fee schedule,8876.49,8876.49, Bacterial And Tuberculous Infections Of Nervous System,491,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,8876.49,,,,,,,fee schedule,8876.49,8876.49, Bacterial And Tuberculous Infections Of Nervous System,491,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,8876.49,,,,,,,fee schedule,8876.49,8876.49, Bacterial And Tuberculous Infections Of Nervous System,491,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,8876.49,,,,,,,fee schedule,8876.49,8876.49, Bacterial And Tuberculous Infections Of Nervous System,491,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,8876.49,,,,,,,fee schedule,8876.49,8876.49, Bacterial And Tuberculous Infections Of Nervous System,492,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,10892.17,,,,,,,fee schedule,10892.17,10892.17, Bacterial And Tuberculous Infections Of Nervous System,492,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,10892.17,,,,,,,fee schedule,10892.17,10892.17, Bacterial And Tuberculous Infections Of Nervous System,492,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,10892.17,,,,,,,fee schedule,10892.17,10892.17, Bacterial And Tuberculous Infections Of Nervous System,492,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,10892.17,,,,,,,fee schedule,10892.17,10892.17, Bacterial And Tuberculous Infections Of Nervous System,492,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,10892.17,,,,,,,fee schedule,10892.17,10892.17, Bacterial And Tuberculous Infections Of Nervous System,492,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,10892.17,,,,,,,fee schedule,10892.17,10892.17, Bacterial And Tuberculous Infections Of Nervous System,492,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,10892.17,,,,,,,fee schedule,10892.17,10892.17, Bacterial And Tuberculous Infections Of Nervous System,492,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,10892.17,,,,,,,fee schedule,10892.17,10892.17, Bacterial And Tuberculous Infections Of Nervous System,492,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,10892.17,,,,,,,fee schedule,10892.17,10892.17, Bacterial And Tuberculous Infections Of Nervous System,492,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,10892.17,,,,,,,fee schedule,10892.17,10892.17, Bacterial And Tuberculous Infections Of Nervous System,492,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,10892.17,,,,,,,fee schedule,10892.17,10892.17, Bacterial And Tuberculous Infections Of Nervous System,493,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,15682.94,,,,,,,fee schedule,15682.94,15682.94, Bacterial And Tuberculous Infections Of Nervous System,493,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,15682.94,,,,,,,fee schedule,15682.94,15682.94, Bacterial And Tuberculous Infections Of Nervous System,493,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,15682.94,,,,,,,fee schedule,15682.94,15682.94, Bacterial And Tuberculous Infections Of Nervous System,493,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,15682.94,,,,,,,fee schedule,15682.94,15682.94, Bacterial And Tuberculous Infections Of Nervous System,493,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,15682.94,,,,,,,fee schedule,15682.94,15682.94, Bacterial And Tuberculous Infections Of Nervous System,493,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,15682.94,,,,,,,fee schedule,15682.94,15682.94, Bacterial And Tuberculous Infections Of Nervous System,493,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,15682.94,,,,,,,fee schedule,15682.94,15682.94, Bacterial And Tuberculous Infections Of Nervous System,493,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,15682.94,,,,,,,fee schedule,15682.94,15682.94, Bacterial And Tuberculous Infections Of Nervous System,493,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,15682.94,,,,,,,fee schedule,15682.94,15682.94, Bacterial And Tuberculous Infections Of Nervous System,493,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,15682.94,,,,,,,fee schedule,15682.94,15682.94, Bacterial And Tuberculous Infections Of Nervous System,493,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,15682.94,,,,,,,fee schedule,15682.94,15682.94, Bacterial And Tuberculous Infections Of Nervous System,494,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,24289.12,,,,,,,fee schedule,24289.12,24289.12, Bacterial And Tuberculous Infections Of Nervous System,494,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,24289.12,,,,,,,fee schedule,24289.12,24289.12, Bacterial And Tuberculous Infections Of Nervous System,494,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,24289.12,,,,,,,fee schedule,24289.12,24289.12, Bacterial And Tuberculous Infections Of Nervous System,494,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,24289.12,,,,,,,fee schedule,24289.12,24289.12, Bacterial And Tuberculous Infections Of Nervous System,494,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,24289.12,,,,,,,fee schedule,24289.12,24289.12, Bacterial And Tuberculous Infections Of Nervous System,494,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,24289.12,,,,,,,fee schedule,24289.12,24289.12, Bacterial And Tuberculous Infections Of Nervous System,494,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,24289.12,,,,,,,fee schedule,24289.12,24289.12, Bacterial And Tuberculous Infections Of Nervous System,494,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,24289.12,,,,,,,fee schedule,24289.12,24289.12, Bacterial And Tuberculous Infections Of Nervous System,494,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,24289.12,,,,,,,fee schedule,24289.12,24289.12, Bacterial And Tuberculous Infections Of Nervous System,494,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,24289.12,,,,,,,fee schedule,24289.12,24289.12, Bacterial And Tuberculous Infections Of Nervous System,494,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,24289.12,,,,,,,fee schedule,24289.12,24289.12, Non-Bacterial Infections Of Nervous System Except Viral Meningitis,501,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,6019.52,,,,,,,fee schedule,6019.52,6019.52, Non-Bacterial Infections Of Nervous System Except Viral Meningitis,501,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,6019.52,,,,,,,fee schedule,6019.52,6019.52, Non-Bacterial Infections Of Nervous System Except Viral Meningitis,501,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,6019.52,,,,,,,fee schedule,6019.52,6019.52, Non-Bacterial Infections Of Nervous System Except Viral Meningitis,501,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,6019.52,,,,,,,fee schedule,6019.52,6019.52, Non-Bacterial Infections Of Nervous System Except Viral Meningitis,501,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,6019.52,,,,,,,fee schedule,6019.52,6019.52, Non-Bacterial Infections Of Nervous System Except Viral Meningitis,501,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,6019.52,,,,,,,fee schedule,6019.52,6019.52, Non-Bacterial Infections Of Nervous System Except Viral Meningitis,501,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,6019.52,,,,,,,fee schedule,6019.52,6019.52, Non-Bacterial Infections Of Nervous System Except Viral Meningitis,501,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,6019.52,,,,,,,fee schedule,6019.52,6019.52, Non-Bacterial Infections Of Nervous System Except Viral Meningitis,501,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,6019.52,,,,,,,fee schedule,6019.52,6019.52, Non-Bacterial Infections Of Nervous System Except Viral Meningitis,501,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,6019.52,,,,,,,fee schedule,6019.52,6019.52, Non-Bacterial Infections Of Nervous System Except Viral Meningitis,501,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,6019.52,,,,,,,fee schedule,6019.52,6019.52, Non-Bacterial Infections Of Nervous System Except Viral Meningitis,502,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,10818.06,,,,,,,fee schedule,10818.06,10818.06, Non-Bacterial Infections Of Nervous System Except Viral Meningitis,502,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,10818.06,,,,,,,fee schedule,10818.06,10818.06, Non-Bacterial Infections Of Nervous System Except Viral Meningitis,502,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,10818.06,,,,,,,fee schedule,10818.06,10818.06, Non-Bacterial Infections Of Nervous System Except Viral Meningitis,502,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,10818.06,,,,,,,fee schedule,10818.06,10818.06, Non-Bacterial Infections Of Nervous System Except Viral Meningitis,502,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,10818.06,,,,,,,fee schedule,10818.06,10818.06, Non-Bacterial Infections Of Nervous System Except Viral Meningitis,502,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,10818.06,,,,,,,fee schedule,10818.06,10818.06, Non-Bacterial Infections Of Nervous System Except Viral Meningitis,502,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,10818.06,,,,,,,fee schedule,10818.06,10818.06, Non-Bacterial Infections Of Nervous System Except Viral Meningitis,502,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,10818.06,,,,,,,fee schedule,10818.06,10818.06, Non-Bacterial Infections Of Nervous System Except Viral Meningitis,502,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,10818.06,,,,,,,fee schedule,10818.06,10818.06, Non-Bacterial Infections Of Nervous System Except Viral Meningitis,502,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,10818.06,,,,,,,fee schedule,10818.06,10818.06, Non-Bacterial Infections Of Nervous System Except Viral Meningitis,502,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,10818.06,,,,,,,fee schedule,10818.06,10818.06, Non-Bacterial Infections Of Nervous System Except Viral Meningitis,503,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,16455.76,,,,,,,fee schedule,16455.76,16455.76, Non-Bacterial Infections Of Nervous System Except Viral Meningitis,503,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,16455.76,,,,,,,fee schedule,16455.76,16455.76, Non-Bacterial Infections Of Nervous System Except Viral Meningitis,503,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,16455.76,,,,,,,fee schedule,16455.76,16455.76, Non-Bacterial Infections Of Nervous System Except Viral Meningitis,503,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,16455.76,,,,,,,fee schedule,16455.76,16455.76, Non-Bacterial Infections Of Nervous System Except Viral Meningitis,503,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,16455.76,,,,,,,fee schedule,16455.76,16455.76, Non-Bacterial Infections Of Nervous System Except Viral Meningitis,503,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,16455.76,,,,,,,fee schedule,16455.76,16455.76, Non-Bacterial Infections Of Nervous System Except Viral Meningitis,503,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,16455.76,,,,,,,fee schedule,16455.76,16455.76, Non-Bacterial Infections Of Nervous System Except Viral Meningitis,503,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,16455.76,,,,,,,fee schedule,16455.76,16455.76, Non-Bacterial Infections Of Nervous System Except Viral Meningitis,503,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,16455.76,,,,,,,fee schedule,16455.76,16455.76, Non-Bacterial Infections Of Nervous System Except Viral Meningitis,503,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,16455.76,,,,,,,fee schedule,16455.76,16455.76, Non-Bacterial Infections Of Nervous System Except Viral Meningitis,503,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,16455.76,,,,,,,fee schedule,16455.76,16455.76, Non-Bacterial Infections Of Nervous System Except Viral Meningitis,504,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,28170.86,,,,,,,fee schedule,28170.86,28170.86, Non-Bacterial Infections Of Nervous System Except Viral Meningitis,504,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,28170.86,,,,,,,fee schedule,28170.86,28170.86, Non-Bacterial Infections Of Nervous System Except Viral Meningitis,504,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,28170.86,,,,,,,fee schedule,28170.86,28170.86, Non-Bacterial Infections Of Nervous System Except Viral Meningitis,504,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,28170.86,,,,,,,fee schedule,28170.86,28170.86, Non-Bacterial Infections Of Nervous System Except Viral Meningitis,504,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,28170.86,,,,,,,fee schedule,28170.86,28170.86, Non-Bacterial Infections Of Nervous System Except Viral Meningitis,504,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,28170.86,,,,,,,fee schedule,28170.86,28170.86, Non-Bacterial Infections Of Nervous System Except Viral Meningitis,504,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,28170.86,,,,,,,fee schedule,28170.86,28170.86, Non-Bacterial Infections Of Nervous System Except Viral Meningitis,504,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,28170.86,,,,,,,fee schedule,28170.86,28170.86, Non-Bacterial Infections Of Nervous System Except Viral Meningitis,504,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,28170.86,,,,,,,fee schedule,28170.86,28170.86, Non-Bacterial Infections Of Nervous System Except Viral Meningitis,504,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,28170.86,,,,,,,fee schedule,28170.86,28170.86, Non-Bacterial Infections Of Nervous System Except Viral Meningitis,504,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,28170.86,,,,,,,fee schedule,28170.86,28170.86, Viral Meningitis,511,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4816.18,,,,,,,fee schedule,4816.18,4816.18, Viral Meningitis,511,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4816.18,,,,,,,fee schedule,4816.18,4816.18, Viral Meningitis,511,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4816.18,,,,,,,fee schedule,4816.18,4816.18, Viral Meningitis,511,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4816.18,,,,,,,fee schedule,4816.18,4816.18, Viral Meningitis,511,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4816.18,,,,,,,fee schedule,4816.18,4816.18, Viral Meningitis,511,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4816.18,,,,,,,fee schedule,4816.18,4816.18, Viral Meningitis,511,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4816.18,,,,,,,fee schedule,4816.18,4816.18, Viral Meningitis,511,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4816.18,,,,,,,fee schedule,4816.18,4816.18, Viral Meningitis,511,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4816.18,,,,,,,fee schedule,4816.18,4816.18, Viral Meningitis,511,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4816.18,,,,,,,fee schedule,4816.18,4816.18, Viral Meningitis,511,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4816.18,,,,,,,fee schedule,4816.18,4816.18, Viral Meningitis,512,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,6533.32,,,,,,,fee schedule,6533.32,6533.32, Viral Meningitis,512,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,6533.32,,,,,,,fee schedule,6533.32,6533.32, Viral Meningitis,512,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,6533.32,,,,,,,fee schedule,6533.32,6533.32, Viral Meningitis,512,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,6533.32,,,,,,,fee schedule,6533.32,6533.32, Viral Meningitis,512,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,6533.32,,,,,,,fee schedule,6533.32,6533.32, Viral Meningitis,512,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,6533.32,,,,,,,fee schedule,6533.32,6533.32, Viral Meningitis,512,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,6533.32,,,,,,,fee schedule,6533.32,6533.32, Viral Meningitis,512,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,6533.32,,,,,,,fee schedule,6533.32,6533.32, Viral Meningitis,512,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,6533.32,,,,,,,fee schedule,6533.32,6533.32, Viral Meningitis,512,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,6533.32,,,,,,,fee schedule,6533.32,6533.32, Viral Meningitis,512,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,6533.32,,,,,,,fee schedule,6533.32,6533.32, Viral Meningitis,513,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,10240.74,,,,,,,fee schedule,10240.74,10240.74, Viral Meningitis,513,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,10240.74,,,,,,,fee schedule,10240.74,10240.74, Viral Meningitis,513,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,10240.74,,,,,,,fee schedule,10240.74,10240.74, Viral Meningitis,513,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,10240.74,,,,,,,fee schedule,10240.74,10240.74, Viral Meningitis,513,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,10240.74,,,,,,,fee schedule,10240.74,10240.74, Viral Meningitis,513,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,10240.74,,,,,,,fee schedule,10240.74,10240.74, Viral Meningitis,513,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,10240.74,,,,,,,fee schedule,10240.74,10240.74, Viral Meningitis,513,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,10240.74,,,,,,,fee schedule,10240.74,10240.74, Viral Meningitis,513,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,10240.74,,,,,,,fee schedule,10240.74,10240.74, Viral Meningitis,513,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,10240.74,,,,,,,fee schedule,10240.74,10240.74, Viral Meningitis,513,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,10240.74,,,,,,,fee schedule,10240.74,10240.74, Viral Meningitis,514,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,16263.09,,,,,,,fee schedule,16263.09,16263.09, Viral Meningitis,514,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,16263.09,,,,,,,fee schedule,16263.09,16263.09, Viral Meningitis,514,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,16263.09,,,,,,,fee schedule,16263.09,16263.09, Viral Meningitis,514,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,16263.09,,,,,,,fee schedule,16263.09,16263.09, Viral Meningitis,514,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,16263.09,,,,,,,fee schedule,16263.09,16263.09, Viral Meningitis,514,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,16263.09,,,,,,,fee schedule,16263.09,16263.09, Viral Meningitis,514,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,16263.09,,,,,,,fee schedule,16263.09,16263.09, Viral Meningitis,514,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,16263.09,,,,,,,fee schedule,16263.09,16263.09, Viral Meningitis,514,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,16263.09,,,,,,,fee schedule,16263.09,16263.09, Viral Meningitis,514,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,16263.09,,,,,,,fee schedule,16263.09,16263.09, Viral Meningitis,514,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,16263.09,,,,,,,fee schedule,16263.09,16263.09, Alteration In Consciousness,521,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4766.07,,,,,,,fee schedule,4766.07,4766.07, Alteration In Consciousness,521,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4766.07,,,,,,,fee schedule,4766.07,4766.07, Alteration In Consciousness,521,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4766.07,,,,,,,fee schedule,4766.07,4766.07, Alteration In Consciousness,521,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4766.07,,,,,,,fee schedule,4766.07,4766.07, Alteration In Consciousness,521,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4766.07,,,,,,,fee schedule,4766.07,4766.07, Alteration In Consciousness,521,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4766.07,,,,,,,fee schedule,4766.07,4766.07, Alteration In Consciousness,521,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4766.07,,,,,,,fee schedule,4766.07,4766.07, Alteration In Consciousness,521,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4766.07,,,,,,,fee schedule,4766.07,4766.07, Alteration In Consciousness,521,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4766.07,,,,,,,fee schedule,4766.07,4766.07, Alteration In Consciousness,521,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4766.07,,,,,,,fee schedule,4766.07,4766.07, Alteration In Consciousness,521,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4766.07,,,,,,,fee schedule,4766.07,4766.07, Alteration In Consciousness,522,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,6110.57,,,,,,,fee schedule,6110.57,6110.57, Alteration In Consciousness,522,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,6110.57,,,,,,,fee schedule,6110.57,6110.57, Alteration In Consciousness,522,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,6110.57,,,,,,,fee schedule,6110.57,6110.57, Alteration In Consciousness,522,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,6110.57,,,,,,,fee schedule,6110.57,6110.57, Alteration In Consciousness,522,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,6110.57,,,,,,,fee schedule,6110.57,6110.57, Alteration In Consciousness,522,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,6110.57,,,,,,,fee schedule,6110.57,6110.57, Alteration In Consciousness,522,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,6110.57,,,,,,,fee schedule,6110.57,6110.57, Alteration In Consciousness,522,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,6110.57,,,,,,,fee schedule,6110.57,6110.57, Alteration In Consciousness,522,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,6110.57,,,,,,,fee schedule,6110.57,6110.57, Alteration In Consciousness,522,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,6110.57,,,,,,,fee schedule,6110.57,6110.57, Alteration In Consciousness,522,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,6110.57,,,,,,,fee schedule,6110.57,6110.57, Alteration In Consciousness,523,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,8852.49,,,,,,,fee schedule,8852.49,8852.49, Alteration In Consciousness,523,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,8852.49,,,,,,,fee schedule,8852.49,8852.49, Alteration In Consciousness,523,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,8852.49,,,,,,,fee schedule,8852.49,8852.49, Alteration In Consciousness,523,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,8852.49,,,,,,,fee schedule,8852.49,8852.49, Alteration In Consciousness,523,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,8852.49,,,,,,,fee schedule,8852.49,8852.49, Alteration In Consciousness,523,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,8852.49,,,,,,,fee schedule,8852.49,8852.49, Alteration In Consciousness,523,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,8852.49,,,,,,,fee schedule,8852.49,8852.49, Alteration In Consciousness,523,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,8852.49,,,,,,,fee schedule,8852.49,8852.49, Alteration In Consciousness,523,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,8852.49,,,,,,,fee schedule,8852.49,8852.49, Alteration In Consciousness,523,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,8852.49,,,,,,,fee schedule,8852.49,8852.49, Alteration In Consciousness,523,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,8852.49,,,,,,,fee schedule,8852.49,8852.49, Alteration In Consciousness,524,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,15481.8,,,,,,,fee schedule,15481.8,15481.8, Alteration In Consciousness,524,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,15481.8,,,,,,,fee schedule,15481.8,15481.8, Alteration In Consciousness,524,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,15481.8,,,,,,,fee schedule,15481.8,15481.8, Alteration In Consciousness,524,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,15481.8,,,,,,,fee schedule,15481.8,15481.8, Alteration In Consciousness,524,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,15481.8,,,,,,,fee schedule,15481.8,15481.8, Alteration In Consciousness,524,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,15481.8,,,,,,,fee schedule,15481.8,15481.8, Alteration In Consciousness,524,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,15481.8,,,,,,,fee schedule,15481.8,15481.8, Alteration In Consciousness,524,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,15481.8,,,,,,,fee schedule,15481.8,15481.8, Alteration In Consciousness,524,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,15481.8,,,,,,,fee schedule,15481.8,15481.8, Alteration In Consciousness,524,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,15481.8,,,,,,,fee schedule,15481.8,15481.8, Alteration In Consciousness,524,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,15481.8,,,,,,,fee schedule,15481.8,15481.8, Seizure,531,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4260.74,,,,,,,fee schedule,4260.74,4260.74, Seizure,531,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4260.74,,,,,,,fee schedule,4260.74,4260.74, Seizure,531,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4260.74,,,,,,,fee schedule,4260.74,4260.74, Seizure,531,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4260.74,,,,,,,fee schedule,4260.74,4260.74, Seizure,531,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4260.74,,,,,,,fee schedule,4260.74,4260.74, Seizure,531,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4260.74,,,,,,,fee schedule,4260.74,4260.74, Seizure,531,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4260.74,,,,,,,fee schedule,4260.74,4260.74, Seizure,531,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4260.74,,,,,,,fee schedule,4260.74,4260.74, Seizure,531,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4260.74,,,,,,,fee schedule,4260.74,4260.74, Seizure,531,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4260.74,,,,,,,fee schedule,4260.74,4260.74, Seizure,531,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4260.74,,,,,,,fee schedule,4260.74,4260.74, Seizure,532,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5809.91,,,,,,,fee schedule,5809.91,5809.91, Seizure,532,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5809.91,,,,,,,fee schedule,5809.91,5809.91, Seizure,532,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5809.91,,,,,,,fee schedule,5809.91,5809.91, Seizure,532,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5809.91,,,,,,,fee schedule,5809.91,5809.91, Seizure,532,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5809.91,,,,,,,fee schedule,5809.91,5809.91, Seizure,532,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5809.91,,,,,,,fee schedule,5809.91,5809.91, Seizure,532,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5809.91,,,,,,,fee schedule,5809.91,5809.91, Seizure,532,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5809.91,,,,,,,fee schedule,5809.91,5809.91, Seizure,532,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5809.91,,,,,,,fee schedule,5809.91,5809.91, Seizure,532,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5809.91,,,,,,,fee schedule,5809.91,5809.91, Seizure,532,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5809.91,,,,,,,fee schedule,5809.91,5809.91, Seizure,533,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,9179.26,,,,,,,fee schedule,9179.26,9179.26, Seizure,533,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,9179.26,,,,,,,fee schedule,9179.26,9179.26, Seizure,533,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,9179.26,,,,,,,fee schedule,9179.26,9179.26, Seizure,533,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,9179.26,,,,,,,fee schedule,9179.26,9179.26, Seizure,533,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,9179.26,,,,,,,fee schedule,9179.26,9179.26, Seizure,533,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,9179.26,,,,,,,fee schedule,9179.26,9179.26, Seizure,533,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,9179.26,,,,,,,fee schedule,9179.26,9179.26, Seizure,533,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,9179.26,,,,,,,fee schedule,9179.26,9179.26, Seizure,533,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,9179.26,,,,,,,fee schedule,9179.26,9179.26, Seizure,533,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,9179.26,,,,,,,fee schedule,9179.26,9179.26, Seizure,533,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,9179.26,,,,,,,fee schedule,9179.26,9179.26, Seizure,534,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,17314.69,,,,,,,fee schedule,17314.69,17314.69, Seizure,534,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,17314.69,,,,,,,fee schedule,17314.69,17314.69, Seizure,534,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,17314.69,,,,,,,fee schedule,17314.69,17314.69, Seizure,534,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,17314.69,,,,,,,fee schedule,17314.69,17314.69, Seizure,534,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,17314.69,,,,,,,fee schedule,17314.69,17314.69, Seizure,534,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,17314.69,,,,,,,fee schedule,17314.69,17314.69, Seizure,534,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,17314.69,,,,,,,fee schedule,17314.69,17314.69, Seizure,534,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,17314.69,,,,,,,fee schedule,17314.69,17314.69, Seizure,534,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,17314.69,,,,,,,fee schedule,17314.69,17314.69, Seizure,534,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,17314.69,,,,,,,fee schedule,17314.69,17314.69, Seizure,534,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,17314.69,,,,,,,fee schedule,17314.69,17314.69, Migraine And Other Headaches,541,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5244.59,,,,,,,fee schedule,5244.59,5244.59, Migraine And Other Headaches,541,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5244.59,,,,,,,fee schedule,5244.59,5244.59, Migraine And Other Headaches,541,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5244.59,,,,,,,fee schedule,5244.59,5244.59, Migraine And Other Headaches,541,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5244.59,,,,,,,fee schedule,5244.59,5244.59, Migraine And Other Headaches,541,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5244.59,,,,,,,fee schedule,5244.59,5244.59, Migraine And Other Headaches,541,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5244.59,,,,,,,fee schedule,5244.59,5244.59, Migraine And Other Headaches,541,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5244.59,,,,,,,fee schedule,5244.59,5244.59, Migraine And Other Headaches,541,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5244.59,,,,,,,fee schedule,5244.59,5244.59, Migraine And Other Headaches,541,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5244.59,,,,,,,fee schedule,5244.59,5244.59, Migraine And Other Headaches,541,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5244.59,,,,,,,fee schedule,5244.59,5244.59, Migraine And Other Headaches,541,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5244.59,,,,,,,fee schedule,5244.59,5244.59, Migraine And Other Headaches,542,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,6290.54,,,,,,,fee schedule,6290.54,6290.54, Migraine And Other Headaches,542,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,6290.54,,,,,,,fee schedule,6290.54,6290.54, Migraine And Other Headaches,542,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,6290.54,,,,,,,fee schedule,6290.54,6290.54, Migraine And Other Headaches,542,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,6290.54,,,,,,,fee schedule,6290.54,6290.54, Migraine And Other Headaches,542,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,6290.54,,,,,,,fee schedule,6290.54,6290.54, Migraine And Other Headaches,542,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,6290.54,,,,,,,fee schedule,6290.54,6290.54, Migraine And Other Headaches,542,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,6290.54,,,,,,,fee schedule,6290.54,6290.54, Migraine And Other Headaches,542,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,6290.54,,,,,,,fee schedule,6290.54,6290.54, Migraine And Other Headaches,542,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,6290.54,,,,,,,fee schedule,6290.54,6290.54, Migraine And Other Headaches,542,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,6290.54,,,,,,,fee schedule,6290.54,6290.54, Migraine And Other Headaches,542,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,6290.54,,,,,,,fee schedule,6290.54,6290.54, Migraine And Other Headaches,543,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,8028.85,,,,,,,fee schedule,8028.85,8028.85, Migraine And Other Headaches,543,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,8028.85,,,,,,,fee schedule,8028.85,8028.85, Migraine And Other Headaches,543,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,8028.85,,,,,,,fee schedule,8028.85,8028.85, Migraine And Other Headaches,543,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,8028.85,,,,,,,fee schedule,8028.85,8028.85, Migraine And Other Headaches,543,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,8028.85,,,,,,,fee schedule,8028.85,8028.85, Migraine And Other Headaches,543,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,8028.85,,,,,,,fee schedule,8028.85,8028.85, Migraine And Other Headaches,543,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,8028.85,,,,,,,fee schedule,8028.85,8028.85, Migraine And Other Headaches,543,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,8028.85,,,,,,,fee schedule,8028.85,8028.85, Migraine And Other Headaches,543,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,8028.85,,,,,,,fee schedule,8028.85,8028.85, Migraine And Other Headaches,543,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,8028.85,,,,,,,fee schedule,8028.85,8028.85, Migraine And Other Headaches,543,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,8028.85,,,,,,,fee schedule,8028.85,8028.85, Migraine And Other Headaches,544,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,11729.21,,,,,,,fee schedule,11729.21,11729.21, Migraine And Other Headaches,544,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,11729.21,,,,,,,fee schedule,11729.21,11729.21, Migraine And Other Headaches,544,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,11729.21,,,,,,,fee schedule,11729.21,11729.21, Migraine And Other Headaches,544,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,11729.21,,,,,,,fee schedule,11729.21,11729.21, Migraine And Other Headaches,544,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,11729.21,,,,,,,fee schedule,11729.21,11729.21, Migraine And Other Headaches,544,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,11729.21,,,,,,,fee schedule,11729.21,11729.21, Migraine And Other Headaches,544,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,11729.21,,,,,,,fee schedule,11729.21,11729.21, Migraine And Other Headaches,544,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,11729.21,,,,,,,fee schedule,11729.21,11729.21, Migraine And Other Headaches,544,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,11729.21,,,,,,,fee schedule,11729.21,11729.21, Migraine And Other Headaches,544,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,11729.21,,,,,,,fee schedule,11729.21,11729.21, Migraine And Other Headaches,544,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,11729.21,,,,,,,fee schedule,11729.21,11729.21, Head Trauma With Coma > 1 Hour Or Hemorrhage,551,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5466.2,,,,,,,fee schedule,5466.2,5466.2, Head Trauma With Coma > 1 Hour Or Hemorrhage,551,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5466.2,,,,,,,fee schedule,5466.2,5466.2, Head Trauma With Coma > 1 Hour Or Hemorrhage,551,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5466.2,,,,,,,fee schedule,5466.2,5466.2, Head Trauma With Coma > 1 Hour Or Hemorrhage,551,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5466.2,,,,,,,fee schedule,5466.2,5466.2, Head Trauma With Coma > 1 Hour Or Hemorrhage,551,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5466.2,,,,,,,fee schedule,5466.2,5466.2, Head Trauma With Coma > 1 Hour Or Hemorrhage,551,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5466.2,,,,,,,fee schedule,5466.2,5466.2, Head Trauma With Coma > 1 Hour Or Hemorrhage,551,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5466.2,,,,,,,fee schedule,5466.2,5466.2, Head Trauma With Coma > 1 Hour Or Hemorrhage,551,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5466.2,,,,,,,fee schedule,5466.2,5466.2, Head Trauma With Coma > 1 Hour Or Hemorrhage,551,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5466.2,,,,,,,fee schedule,5466.2,5466.2, Head Trauma With Coma > 1 Hour Or Hemorrhage,551,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5466.2,,,,,,,fee schedule,5466.2,5466.2, Head Trauma With Coma > 1 Hour Or Hemorrhage,551,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5466.2,,,,,,,fee schedule,5466.2,5466.2, Head Trauma With Coma > 1 Hour Or Hemorrhage,552,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,7651.97,,,,,,,fee schedule,7651.97,7651.97, Head Trauma With Coma > 1 Hour Or Hemorrhage,552,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,7651.97,,,,,,,fee schedule,7651.97,7651.97, Head Trauma With Coma > 1 Hour Or Hemorrhage,552,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,7651.97,,,,,,,fee schedule,7651.97,7651.97, Head Trauma With Coma > 1 Hour Or Hemorrhage,552,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,7651.97,,,,,,,fee schedule,7651.97,7651.97, Head Trauma With Coma > 1 Hour Or Hemorrhage,552,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,7651.97,,,,,,,fee schedule,7651.97,7651.97, Head Trauma With Coma > 1 Hour Or Hemorrhage,552,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,7651.97,,,,,,,fee schedule,7651.97,7651.97, Head Trauma With Coma > 1 Hour Or Hemorrhage,552,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,7651.97,,,,,,,fee schedule,7651.97,7651.97, Head Trauma With Coma > 1 Hour Or Hemorrhage,552,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,7651.97,,,,,,,fee schedule,7651.97,7651.97, Head Trauma With Coma > 1 Hour Or Hemorrhage,552,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,7651.97,,,,,,,fee schedule,7651.97,7651.97, Head Trauma With Coma > 1 Hour Or Hemorrhage,552,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,7651.97,,,,,,,fee schedule,7651.97,7651.97, Head Trauma With Coma > 1 Hour Or Hemorrhage,552,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,7651.97,,,,,,,fee schedule,7651.97,7651.97, Head Trauma With Coma > 1 Hour Or Hemorrhage,553,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,11846.37,,,,,,,fee schedule,11846.37,11846.37, Head Trauma With Coma > 1 Hour Or Hemorrhage,553,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,11846.37,,,,,,,fee schedule,11846.37,11846.37, Head Trauma With Coma > 1 Hour Or Hemorrhage,553,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,11846.37,,,,,,,fee schedule,11846.37,11846.37, Head Trauma With Coma > 1 Hour Or Hemorrhage,553,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,11846.37,,,,,,,fee schedule,11846.37,11846.37, Head Trauma With Coma > 1 Hour Or Hemorrhage,553,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,11846.37,,,,,,,fee schedule,11846.37,11846.37, Head Trauma With Coma > 1 Hour Or Hemorrhage,553,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,11846.37,,,,,,,fee schedule,11846.37,11846.37, Head Trauma With Coma > 1 Hour Or Hemorrhage,553,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,11846.37,,,,,,,fee schedule,11846.37,11846.37, Head Trauma With Coma > 1 Hour Or Hemorrhage,553,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,11846.37,,,,,,,fee schedule,11846.37,11846.37, Head Trauma With Coma > 1 Hour Or Hemorrhage,553,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,11846.37,,,,,,,fee schedule,11846.37,11846.37, Head Trauma With Coma > 1 Hour Or Hemorrhage,553,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,11846.37,,,,,,,fee schedule,11846.37,11846.37, Head Trauma With Coma > 1 Hour Or Hemorrhage,553,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,11846.37,,,,,,,fee schedule,11846.37,11846.37, Head Trauma With Coma > 1 Hour Or Hemorrhage,554,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,20509.71,,,,,,,fee schedule,20509.71,20509.71, Head Trauma With Coma > 1 Hour Or Hemorrhage,554,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,20509.71,,,,,,,fee schedule,20509.71,20509.71, Head Trauma With Coma > 1 Hour Or Hemorrhage,554,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,20509.71,,,,,,,fee schedule,20509.71,20509.71, Head Trauma With Coma > 1 Hour Or Hemorrhage,554,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,20509.71,,,,,,,fee schedule,20509.71,20509.71, Head Trauma With Coma > 1 Hour Or Hemorrhage,554,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,20509.71,,,,,,,fee schedule,20509.71,20509.71, Head Trauma With Coma > 1 Hour Or Hemorrhage,554,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,20509.71,,,,,,,fee schedule,20509.71,20509.71, Head Trauma With Coma > 1 Hour Or Hemorrhage,554,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,20509.71,,,,,,,fee schedule,20509.71,20509.71, Head Trauma With Coma > 1 Hour Or Hemorrhage,554,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,20509.71,,,,,,,fee schedule,20509.71,20509.71, Head Trauma With Coma > 1 Hour Or Hemorrhage,554,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,20509.71,,,,,,,fee schedule,20509.71,20509.71, Head Trauma With Coma > 1 Hour Or Hemorrhage,554,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,20509.71,,,,,,,fee schedule,20509.71,20509.71, Head Trauma With Coma > 1 Hour Or Hemorrhage,554,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,20509.71,,,,,,,fee schedule,20509.71,20509.71, "Brain Contusion Or Laceration And Complicated Skull Fracture, Coma < 1 Hour Or No Coma",561,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5295.4,,,,,,,fee schedule,5295.4,5295.4, "Brain Contusion Or Laceration And Complicated Skull Fracture, Coma < 1 Hour Or No Coma",561,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5295.4,,,,,,,fee schedule,5295.4,5295.4, "Brain Contusion Or Laceration And Complicated Skull Fracture, Coma < 1 Hour Or No Coma",561,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5295.4,,,,,,,fee schedule,5295.4,5295.4, "Brain Contusion Or Laceration And Complicated Skull Fracture, Coma < 1 Hour Or No Coma",561,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5295.4,,,,,,,fee schedule,5295.4,5295.4, "Brain Contusion Or Laceration And Complicated Skull Fracture, Coma < 1 Hour Or No Coma",561,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5295.4,,,,,,,fee schedule,5295.4,5295.4, "Brain Contusion Or Laceration And Complicated Skull Fracture, Coma < 1 Hour Or No Coma",561,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5295.4,,,,,,,fee schedule,5295.4,5295.4, "Brain Contusion Or Laceration And Complicated Skull Fracture, Coma < 1 Hour Or No Coma",561,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5295.4,,,,,,,fee schedule,5295.4,5295.4, "Brain Contusion Or Laceration And Complicated Skull Fracture, Coma < 1 Hour Or No Coma",561,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5295.4,,,,,,,fee schedule,5295.4,5295.4, "Brain Contusion Or Laceration And Complicated Skull Fracture, Coma < 1 Hour Or No Coma",561,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5295.4,,,,,,,fee schedule,5295.4,5295.4, "Brain Contusion Or Laceration And Complicated Skull Fracture, Coma < 1 Hour Or No Coma",561,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5295.4,,,,,,,fee schedule,5295.4,5295.4, "Brain Contusion Or Laceration And Complicated Skull Fracture, Coma < 1 Hour Or No Coma",561,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5295.4,,,,,,,fee schedule,5295.4,5295.4, "Brain Contusion Or Laceration And Complicated Skull Fracture, Coma < 1 Hour Or No Coma",562,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,7335.79,,,,,,,fee schedule,7335.79,7335.79, "Brain Contusion Or Laceration And Complicated Skull Fracture, Coma < 1 Hour Or No Coma",562,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,7335.79,,,,,,,fee schedule,7335.79,7335.79, "Brain Contusion Or Laceration And Complicated Skull Fracture, Coma < 1 Hour Or No Coma",562,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,7335.79,,,,,,,fee schedule,7335.79,7335.79, "Brain Contusion Or Laceration And Complicated Skull Fracture, Coma < 1 Hour Or No Coma",562,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,7335.79,,,,,,,fee schedule,7335.79,7335.79, "Brain Contusion Or Laceration And Complicated Skull Fracture, Coma < 1 Hour Or No Coma",562,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,7335.79,,,,,,,fee schedule,7335.79,7335.79, "Brain Contusion Or Laceration And Complicated Skull Fracture, Coma < 1 Hour Or No Coma",562,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,7335.79,,,,,,,fee schedule,7335.79,7335.79, "Brain Contusion Or Laceration And Complicated Skull Fracture, Coma < 1 Hour Or No Coma",562,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,7335.79,,,,,,,fee schedule,7335.79,7335.79, "Brain Contusion Or Laceration And Complicated Skull Fracture, Coma < 1 Hour Or No Coma",562,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,7335.79,,,,,,,fee schedule,7335.79,7335.79, "Brain Contusion Or Laceration And Complicated Skull Fracture, Coma < 1 Hour Or No Coma",562,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,7335.79,,,,,,,fee schedule,7335.79,7335.79, "Brain Contusion Or Laceration And Complicated Skull Fracture, Coma < 1 Hour Or No Coma",562,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,7335.79,,,,,,,fee schedule,7335.79,7335.79, "Brain Contusion Or Laceration And Complicated Skull Fracture, Coma < 1 Hour Or No Coma",562,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,7335.79,,,,,,,fee schedule,7335.79,7335.79, "Brain Contusion Or Laceration And Complicated Skull Fracture, Coma < 1 Hour Or No Coma",563,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,11185.06,,,,,,,fee schedule,11185.06,11185.06, "Brain Contusion Or Laceration And Complicated Skull Fracture, Coma < 1 Hour Or No Coma",563,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,11185.06,,,,,,,fee schedule,11185.06,11185.06, "Brain Contusion Or Laceration And Complicated Skull Fracture, Coma < 1 Hour Or No Coma",563,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,11185.06,,,,,,,fee schedule,11185.06,11185.06, "Brain Contusion Or Laceration And Complicated Skull Fracture, Coma < 1 Hour Or No Coma",563,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,11185.06,,,,,,,fee schedule,11185.06,11185.06, "Brain Contusion Or Laceration And Complicated Skull Fracture, Coma < 1 Hour Or No Coma",563,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,11185.06,,,,,,,fee schedule,11185.06,11185.06, "Brain Contusion Or Laceration And Complicated Skull Fracture, Coma < 1 Hour Or No Coma",563,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,11185.06,,,,,,,fee schedule,11185.06,11185.06, "Brain Contusion Or Laceration And Complicated Skull Fracture, Coma < 1 Hour Or No Coma",563,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,11185.06,,,,,,,fee schedule,11185.06,11185.06, "Brain Contusion Or Laceration And Complicated Skull Fracture, Coma < 1 Hour Or No Coma",563,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,11185.06,,,,,,,fee schedule,11185.06,11185.06, "Brain Contusion Or Laceration And Complicated Skull Fracture, Coma < 1 Hour Or No Coma",563,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,11185.06,,,,,,,fee schedule,11185.06,11185.06, "Brain Contusion Or Laceration And Complicated Skull Fracture, Coma < 1 Hour Or No Coma",563,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,11185.06,,,,,,,fee schedule,11185.06,11185.06, "Brain Contusion Or Laceration And Complicated Skull Fracture, Coma < 1 Hour Or No Coma",563,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,11185.06,,,,,,,fee schedule,11185.06,11185.06, "Brain Contusion Or Laceration And Complicated Skull Fracture, Coma < 1 Hour Or No Coma",564,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,19959.92,,,,,,,fee schedule,19959.92,19959.92, "Brain Contusion Or Laceration And Complicated Skull Fracture, Coma < 1 Hour Or No Coma",564,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,19959.92,,,,,,,fee schedule,19959.92,19959.92, "Brain Contusion Or Laceration And Complicated Skull Fracture, Coma < 1 Hour Or No Coma",564,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,19959.92,,,,,,,fee schedule,19959.92,19959.92, "Brain Contusion Or Laceration And Complicated Skull Fracture, Coma < 1 Hour Or No Coma",564,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,19959.92,,,,,,,fee schedule,19959.92,19959.92, "Brain Contusion Or Laceration And Complicated Skull Fracture, Coma < 1 Hour Or No Coma",564,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,19959.92,,,,,,,fee schedule,19959.92,19959.92, "Brain Contusion Or Laceration And Complicated Skull Fracture, Coma < 1 Hour Or No Coma",564,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,19959.92,,,,,,,fee schedule,19959.92,19959.92, "Brain Contusion Or Laceration And Complicated Skull Fracture, Coma < 1 Hour Or No Coma",564,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,19959.92,,,,,,,fee schedule,19959.92,19959.92, "Brain Contusion Or Laceration And Complicated Skull Fracture, Coma < 1 Hour Or No Coma",564,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,19959.92,,,,,,,fee schedule,19959.92,19959.92, "Brain Contusion Or Laceration And Complicated Skull Fracture, Coma < 1 Hour Or No Coma",564,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,19959.92,,,,,,,fee schedule,19959.92,19959.92, "Brain Contusion Or Laceration And Complicated Skull Fracture, Coma < 1 Hour Or No Coma",564,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,19959.92,,,,,,,fee schedule,19959.92,19959.92, "Brain Contusion Or Laceration And Complicated Skull Fracture, Coma < 1 Hour Or No Coma",564,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,19959.92,,,,,,,fee schedule,19959.92,19959.92, Hour Or No Coma,571,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5231.88,,,,,,,fee schedule,5231.88,5231.88, Hour Or No Coma,571,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5231.88,,,,,,,fee schedule,5231.88,5231.88, Hour Or No Coma,571,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5231.88,,,,,,,fee schedule,5231.88,5231.88, Hour Or No Coma,571,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5231.88,,,,,,,fee schedule,5231.88,5231.88, Hour Or No Coma,571,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5231.88,,,,,,,fee schedule,5231.88,5231.88, Hour Or No Coma,571,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5231.88,,,,,,,fee schedule,5231.88,5231.88, Hour Or No Coma,571,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5231.88,,,,,,,fee schedule,5231.88,5231.88, Hour Or No Coma,571,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5231.88,,,,,,,fee schedule,5231.88,5231.88, Hour Or No Coma,571,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5231.88,,,,,,,fee schedule,5231.88,5231.88, Hour Or No Coma,571,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5231.88,,,,,,,fee schedule,5231.88,5231.88, Hour Or No Coma,571,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5231.88,,,,,,,fee schedule,5231.88,5231.88, Hour Or No Coma,572,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,7566.57,,,,,,,fee schedule,7566.57,7566.57, Hour Or No Coma,572,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,7566.57,,,,,,,fee schedule,7566.57,7566.57, Hour Or No Coma,572,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,7566.57,,,,,,,fee schedule,7566.57,7566.57, Hour Or No Coma,572,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,7566.57,,,,,,,fee schedule,7566.57,7566.57, Hour Or No Coma,572,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,7566.57,,,,,,,fee schedule,7566.57,7566.57, Hour Or No Coma,572,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,7566.57,,,,,,,fee schedule,7566.57,7566.57, Hour Or No Coma,572,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,7566.57,,,,,,,fee schedule,7566.57,7566.57, Hour Or No Coma,572,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,7566.57,,,,,,,fee schedule,7566.57,7566.57, Hour Or No Coma,572,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,7566.57,,,,,,,fee schedule,7566.57,7566.57, Hour Or No Coma,572,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,7566.57,,,,,,,fee schedule,7566.57,7566.57, Hour Or No Coma,572,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,7566.57,,,,,,,fee schedule,7566.57,7566.57, Hour Or No Coma,573,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,10572.45,,,,,,,fee schedule,10572.45,10572.45, Hour Or No Coma,573,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,10572.45,,,,,,,fee schedule,10572.45,10572.45, Hour Or No Coma,573,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,10572.45,,,,,,,fee schedule,10572.45,10572.45, Hour Or No Coma,573,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,10572.45,,,,,,,fee schedule,10572.45,10572.45, Hour Or No Coma,573,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,10572.45,,,,,,,fee schedule,10572.45,10572.45, Hour Or No Coma,573,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,10572.45,,,,,,,fee schedule,10572.45,10572.45, Hour Or No Coma,573,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,10572.45,,,,,,,fee schedule,10572.45,10572.45, Hour Or No Coma,573,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,10572.45,,,,,,,fee schedule,10572.45,10572.45, Hour Or No Coma,573,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,10572.45,,,,,,,fee schedule,10572.45,10572.45, Hour Or No Coma,573,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,10572.45,,,,,,,fee schedule,10572.45,10572.45, Hour Or No Coma,573,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,10572.45,,,,,,,fee schedule,10572.45,10572.45, Hour Or No Coma,574,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,17860.25,,,,,,,fee schedule,17860.25,17860.25, Hour Or No Coma,574,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,17860.25,,,,,,,fee schedule,17860.25,17860.25, Hour Or No Coma,574,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,17860.25,,,,,,,fee schedule,17860.25,17860.25, Hour Or No Coma,574,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,17860.25,,,,,,,fee schedule,17860.25,17860.25, Hour Or No Coma,574,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,17860.25,,,,,,,fee schedule,17860.25,17860.25, Hour Or No Coma,574,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,17860.25,,,,,,,fee schedule,17860.25,17860.25, Hour Or No Coma,574,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,17860.25,,,,,,,fee schedule,17860.25,17860.25, Hour Or No Coma,574,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,17860.25,,,,,,,fee schedule,17860.25,17860.25, Hour Or No Coma,574,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,17860.25,,,,,,,fee schedule,17860.25,17860.25, Hour Or No Coma,574,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,17860.25,,,,,,,fee schedule,17860.25,17860.25, Hour Or No Coma,574,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,17860.25,,,,,,,fee schedule,17860.25,17860.25, Other Disorders Of Nervous System,581,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,6044.23,,,,,,,fee schedule,6044.23,6044.23, Other Disorders Of Nervous System,581,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,6044.23,,,,,,,fee schedule,6044.23,6044.23, Other Disorders Of Nervous System,581,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,6044.23,,,,,,,fee schedule,6044.23,6044.23, Other Disorders Of Nervous System,581,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,6044.23,,,,,,,fee schedule,6044.23,6044.23, Other Disorders Of Nervous System,581,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,6044.23,,,,,,,fee schedule,6044.23,6044.23, Other Disorders Of Nervous System,581,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,6044.23,,,,,,,fee schedule,6044.23,6044.23, Other Disorders Of Nervous System,581,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,6044.23,,,,,,,fee schedule,6044.23,6044.23, Other Disorders Of Nervous System,581,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,6044.23,,,,,,,fee schedule,6044.23,6044.23, Other Disorders Of Nervous System,581,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,6044.23,,,,,,,fee schedule,6044.23,6044.23, Other Disorders Of Nervous System,581,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,6044.23,,,,,,,fee schedule,6044.23,6044.23, Other Disorders Of Nervous System,581,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,6044.23,,,,,,,fee schedule,6044.23,6044.23, Other Disorders Of Nervous System,582,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,8809.44,,,,,,,fee schedule,8809.44,8809.44, Other Disorders Of Nervous System,582,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,8809.44,,,,,,,fee schedule,8809.44,8809.44, Other Disorders Of Nervous System,582,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,8809.44,,,,,,,fee schedule,8809.44,8809.44, Other Disorders Of Nervous System,582,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,8809.44,,,,,,,fee schedule,8809.44,8809.44, Other Disorders Of Nervous System,582,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,8809.44,,,,,,,fee schedule,8809.44,8809.44, Other Disorders Of Nervous System,582,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,8809.44,,,,,,,fee schedule,8809.44,8809.44, Other Disorders Of Nervous System,582,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,8809.44,,,,,,,fee schedule,8809.44,8809.44, Other Disorders Of Nervous System,582,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,8809.44,,,,,,,fee schedule,8809.44,8809.44, Other Disorders Of Nervous System,582,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,8809.44,,,,,,,fee schedule,8809.44,8809.44, Other Disorders Of Nervous System,582,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,8809.44,,,,,,,fee schedule,8809.44,8809.44, Other Disorders Of Nervous System,582,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,8809.44,,,,,,,fee schedule,8809.44,8809.44, Other Disorders Of Nervous System,583,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,12223.25,,,,,,,fee schedule,12223.25,12223.25, Other Disorders Of Nervous System,583,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,12223.25,,,,,,,fee schedule,12223.25,12223.25, Other Disorders Of Nervous System,583,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,12223.25,,,,,,,fee schedule,12223.25,12223.25, Other Disorders Of Nervous System,583,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,12223.25,,,,,,,fee schedule,12223.25,12223.25, Other Disorders Of Nervous System,583,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,12223.25,,,,,,,fee schedule,12223.25,12223.25, Other Disorders Of Nervous System,583,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,12223.25,,,,,,,fee schedule,12223.25,12223.25, Other Disorders Of Nervous System,583,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,12223.25,,,,,,,fee schedule,12223.25,12223.25, Other Disorders Of Nervous System,583,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,12223.25,,,,,,,fee schedule,12223.25,12223.25, Other Disorders Of Nervous System,583,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,12223.25,,,,,,,fee schedule,12223.25,12223.25, Other Disorders Of Nervous System,583,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,12223.25,,,,,,,fee schedule,12223.25,12223.25, Other Disorders Of Nervous System,583,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,12223.25,,,,,,,fee schedule,12223.25,12223.25, Other Disorders Of Nervous System,584,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,16460,,,,,,,fee schedule,16460,16460, Other Disorders Of Nervous System,584,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,16460,,,,,,,fee schedule,16460,16460, Other Disorders Of Nervous System,584,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,16460,,,,,,,fee schedule,16460,16460, Other Disorders Of Nervous System,584,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,16460,,,,,,,fee schedule,16460,16460, Other Disorders Of Nervous System,584,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,16460,,,,,,,fee schedule,16460,16460, Other Disorders Of Nervous System,584,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,16460,,,,,,,fee schedule,16460,16460, Other Disorders Of Nervous System,584,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,16460,,,,,,,fee schedule,16460,16460, Other Disorders Of Nervous System,584,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,16460,,,,,,,fee schedule,16460,16460, Other Disorders Of Nervous System,584,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,16460,,,,,,,fee schedule,16460,16460, Other Disorders Of Nervous System,584,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,16460,,,,,,,fee schedule,16460,16460, Other Disorders Of Nervous System,584,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,16460,,,,,,,fee schedule,16460,16460, Anoxic And Other Severe Brain Damage,591,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5293.99,,,,,,,fee schedule,5293.99,5293.99, Anoxic And Other Severe Brain Damage,591,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5293.99,,,,,,,fee schedule,5293.99,5293.99, Anoxic And Other Severe Brain Damage,591,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5293.99,,,,,,,fee schedule,5293.99,5293.99, Anoxic And Other Severe Brain Damage,591,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5293.99,,,,,,,fee schedule,5293.99,5293.99, Anoxic And Other Severe Brain Damage,591,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5293.99,,,,,,,fee schedule,5293.99,5293.99, Anoxic And Other Severe Brain Damage,591,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5293.99,,,,,,,fee schedule,5293.99,5293.99, Anoxic And Other Severe Brain Damage,591,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5293.99,,,,,,,fee schedule,5293.99,5293.99, Anoxic And Other Severe Brain Damage,591,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5293.99,,,,,,,fee schedule,5293.99,5293.99, Anoxic And Other Severe Brain Damage,591,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5293.99,,,,,,,fee schedule,5293.99,5293.99, Anoxic And Other Severe Brain Damage,591,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5293.99,,,,,,,fee schedule,5293.99,5293.99, Anoxic And Other Severe Brain Damage,591,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5293.99,,,,,,,fee schedule,5293.99,5293.99, Anoxic And Other Severe Brain Damage,592,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,8579.36,,,,,,,fee schedule,8579.36,8579.36, Anoxic And Other Severe Brain Damage,592,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,8579.36,,,,,,,fee schedule,8579.36,8579.36, Anoxic And Other Severe Brain Damage,592,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,8579.36,,,,,,,fee schedule,8579.36,8579.36, Anoxic And Other Severe Brain Damage,592,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,8579.36,,,,,,,fee schedule,8579.36,8579.36, Anoxic And Other Severe Brain Damage,592,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,8579.36,,,,,,,fee schedule,8579.36,8579.36, Anoxic And Other Severe Brain Damage,592,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,8579.36,,,,,,,fee schedule,8579.36,8579.36, Anoxic And Other Severe Brain Damage,592,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,8579.36,,,,,,,fee schedule,8579.36,8579.36, Anoxic And Other Severe Brain Damage,592,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,8579.36,,,,,,,fee schedule,8579.36,8579.36, Anoxic And Other Severe Brain Damage,592,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,8579.36,,,,,,,fee schedule,8579.36,8579.36, Anoxic And Other Severe Brain Damage,592,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,8579.36,,,,,,,fee schedule,8579.36,8579.36, Anoxic And Other Severe Brain Damage,592,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,8579.36,,,,,,,fee schedule,8579.36,8579.36, Anoxic And Other Severe Brain Damage,593,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,11864.72,,,,,,,fee schedule,11864.72,11864.72, Anoxic And Other Severe Brain Damage,593,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,11864.72,,,,,,,fee schedule,11864.72,11864.72, Anoxic And Other Severe Brain Damage,593,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,11864.72,,,,,,,fee schedule,11864.72,11864.72, Anoxic And Other Severe Brain Damage,593,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,11864.72,,,,,,,fee schedule,11864.72,11864.72, Anoxic And Other Severe Brain Damage,593,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,11864.72,,,,,,,fee schedule,11864.72,11864.72, Anoxic And Other Severe Brain Damage,593,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,11864.72,,,,,,,fee schedule,11864.72,11864.72, Anoxic And Other Severe Brain Damage,593,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,11864.72,,,,,,,fee schedule,11864.72,11864.72, Anoxic And Other Severe Brain Damage,593,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,11864.72,,,,,,,fee schedule,11864.72,11864.72, Anoxic And Other Severe Brain Damage,593,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,11864.72,,,,,,,fee schedule,11864.72,11864.72, Anoxic And Other Severe Brain Damage,593,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,11864.72,,,,,,,fee schedule,11864.72,11864.72, Anoxic And Other Severe Brain Damage,593,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,11864.72,,,,,,,fee schedule,11864.72,11864.72, Anoxic And Other Severe Brain Damage,594,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,17531.36,,,,,,,fee schedule,17531.36,17531.36, Anoxic And Other Severe Brain Damage,594,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,17531.36,,,,,,,fee schedule,17531.36,17531.36, Anoxic And Other Severe Brain Damage,594,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,17531.36,,,,,,,fee schedule,17531.36,17531.36, Anoxic And Other Severe Brain Damage,594,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,17531.36,,,,,,,fee schedule,17531.36,17531.36, Anoxic And Other Severe Brain Damage,594,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,17531.36,,,,,,,fee schedule,17531.36,17531.36, Anoxic And Other Severe Brain Damage,594,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,17531.36,,,,,,,fee schedule,17531.36,17531.36, Anoxic And Other Severe Brain Damage,594,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,17531.36,,,,,,,fee schedule,17531.36,17531.36, Anoxic And Other Severe Brain Damage,594,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,17531.36,,,,,,,fee schedule,17531.36,17531.36, Anoxic And Other Severe Brain Damage,594,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,17531.36,,,,,,,fee schedule,17531.36,17531.36, Anoxic And Other Severe Brain Damage,594,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,17531.36,,,,,,,fee schedule,17531.36,17531.36, Anoxic And Other Severe Brain Damage,594,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,17531.36,,,,,,,fee schedule,17531.36,17531.36, Orbit And Eye Procedures,731,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,7594.8,,,,,,,fee schedule,7594.8,7594.8, Orbit And Eye Procedures,731,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,7594.8,,,,,,,fee schedule,7594.8,7594.8, Orbit And Eye Procedures,731,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,7594.8,,,,,,,fee schedule,7594.8,7594.8, Orbit And Eye Procedures,731,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,7594.8,,,,,,,fee schedule,7594.8,7594.8, Orbit And Eye Procedures,731,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,7594.8,,,,,,,fee schedule,7594.8,7594.8, Orbit And Eye Procedures,731,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,7594.8,,,,,,,fee schedule,7594.8,7594.8, Orbit And Eye Procedures,731,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,7594.8,,,,,,,fee schedule,7594.8,7594.8, Orbit And Eye Procedures,731,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,7594.8,,,,,,,fee schedule,7594.8,7594.8, Orbit And Eye Procedures,731,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,7594.8,,,,,,,fee schedule,7594.8,7594.8, Orbit And Eye Procedures,731,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,7594.8,,,,,,,fee schedule,7594.8,7594.8, Orbit And Eye Procedures,731,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,7594.8,,,,,,,fee schedule,7594.8,7594.8, Orbit And Eye Procedures,732,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,10294.38,,,,,,,fee schedule,10294.38,10294.38, Orbit And Eye Procedures,732,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,10294.38,,,,,,,fee schedule,10294.38,10294.38, Orbit And Eye Procedures,732,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,10294.38,,,,,,,fee schedule,10294.38,10294.38, Orbit And Eye Procedures,732,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,10294.38,,,,,,,fee schedule,10294.38,10294.38, Orbit And Eye Procedures,732,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,10294.38,,,,,,,fee schedule,10294.38,10294.38, Orbit And Eye Procedures,732,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,10294.38,,,,,,,fee schedule,10294.38,10294.38, Orbit And Eye Procedures,732,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,10294.38,,,,,,,fee schedule,10294.38,10294.38, Orbit And Eye Procedures,732,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,10294.38,,,,,,,fee schedule,10294.38,10294.38, Orbit And Eye Procedures,732,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,10294.38,,,,,,,fee schedule,10294.38,10294.38, Orbit And Eye Procedures,732,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,10294.38,,,,,,,fee schedule,10294.38,10294.38, Orbit And Eye Procedures,732,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,10294.38,,,,,,,fee schedule,10294.38,10294.38, Orbit And Eye Procedures,733,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,15398.52,,,,,,,fee schedule,15398.52,15398.52, Orbit And Eye Procedures,733,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,15398.52,,,,,,,fee schedule,15398.52,15398.52, Orbit And Eye Procedures,733,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,15398.52,,,,,,,fee schedule,15398.52,15398.52, Orbit And Eye Procedures,733,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,15398.52,,,,,,,fee schedule,15398.52,15398.52, Orbit And Eye Procedures,733,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,15398.52,,,,,,,fee schedule,15398.52,15398.52, Orbit And Eye Procedures,733,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,15398.52,,,,,,,fee schedule,15398.52,15398.52, Orbit And Eye Procedures,733,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,15398.52,,,,,,,fee schedule,15398.52,15398.52, Orbit And Eye Procedures,733,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,15398.52,,,,,,,fee schedule,15398.52,15398.52, Orbit And Eye Procedures,733,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,15398.52,,,,,,,fee schedule,15398.52,15398.52, Orbit And Eye Procedures,733,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,15398.52,,,,,,,fee schedule,15398.52,15398.52, Orbit And Eye Procedures,733,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,15398.52,,,,,,,fee schedule,15398.52,15398.52, Orbit And Eye Procedures,734,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,27279.47,,,,,,,fee schedule,27279.47,27279.47, Orbit And Eye Procedures,734,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,27279.47,,,,,,,fee schedule,27279.47,27279.47, Orbit And Eye Procedures,734,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,27279.47,,,,,,,fee schedule,27279.47,27279.47, Orbit And Eye Procedures,734,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,27279.47,,,,,,,fee schedule,27279.47,27279.47, Orbit And Eye Procedures,734,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,27279.47,,,,,,,fee schedule,27279.47,27279.47, Orbit And Eye Procedures,734,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,27279.47,,,,,,,fee schedule,27279.47,27279.47, Orbit And Eye Procedures,734,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,27279.47,,,,,,,fee schedule,27279.47,27279.47, Orbit And Eye Procedures,734,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,27279.47,,,,,,,fee schedule,27279.47,27279.47, Orbit And Eye Procedures,734,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,27279.47,,,,,,,fee schedule,27279.47,27279.47, Orbit And Eye Procedures,734,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,27279.47,,,,,,,fee schedule,27279.47,27279.47, Orbit And Eye Procedures,734,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,27279.47,,,,,,,fee schedule,27279.47,27279.47, Eye Infections And Other Eye Disorders,821,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4641.15,,,,,,,fee schedule,4641.15,4641.15, Eye Infections And Other Eye Disorders,821,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4641.15,,,,,,,fee schedule,4641.15,4641.15, Eye Infections And Other Eye Disorders,821,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4641.15,,,,,,,fee schedule,4641.15,4641.15, Eye Infections And Other Eye Disorders,821,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4641.15,,,,,,,fee schedule,4641.15,4641.15, Eye Infections And Other Eye Disorders,821,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4641.15,,,,,,,fee schedule,4641.15,4641.15, Eye Infections And Other Eye Disorders,821,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4641.15,,,,,,,fee schedule,4641.15,4641.15, Eye Infections And Other Eye Disorders,821,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4641.15,,,,,,,fee schedule,4641.15,4641.15, Eye Infections And Other Eye Disorders,821,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4641.15,,,,,,,fee schedule,4641.15,4641.15, Eye Infections And Other Eye Disorders,821,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4641.15,,,,,,,fee schedule,4641.15,4641.15, Eye Infections And Other Eye Disorders,821,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4641.15,,,,,,,fee schedule,4641.15,4641.15, Eye Infections And Other Eye Disorders,821,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4641.15,,,,,,,fee schedule,4641.15,4641.15, Eye Infections And Other Eye Disorders,822,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,6015.29,,,,,,,fee schedule,6015.29,6015.29, Eye Infections And Other Eye Disorders,822,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,6015.29,,,,,,,fee schedule,6015.29,6015.29, Eye Infections And Other Eye Disorders,822,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,6015.29,,,,,,,fee schedule,6015.29,6015.29, Eye Infections And Other Eye Disorders,822,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,6015.29,,,,,,,fee schedule,6015.29,6015.29, Eye Infections And Other Eye Disorders,822,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,6015.29,,,,,,,fee schedule,6015.29,6015.29, Eye Infections And Other Eye Disorders,822,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,6015.29,,,,,,,fee schedule,6015.29,6015.29, Eye Infections And Other Eye Disorders,822,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,6015.29,,,,,,,fee schedule,6015.29,6015.29, Eye Infections And Other Eye Disorders,822,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,6015.29,,,,,,,fee schedule,6015.29,6015.29, Eye Infections And Other Eye Disorders,822,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,6015.29,,,,,,,fee schedule,6015.29,6015.29, Eye Infections And Other Eye Disorders,822,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,6015.29,,,,,,,fee schedule,6015.29,6015.29, Eye Infections And Other Eye Disorders,822,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,6015.29,,,,,,,fee schedule,6015.29,6015.29, Eye Infections And Other Eye Disorders,823,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,8848.25,,,,,,,fee schedule,8848.25,8848.25, Eye Infections And Other Eye Disorders,823,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,8848.25,,,,,,,fee schedule,8848.25,8848.25, Eye Infections And Other Eye Disorders,823,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,8848.25,,,,,,,fee schedule,8848.25,8848.25, Eye Infections And Other Eye Disorders,823,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,8848.25,,,,,,,fee schedule,8848.25,8848.25, Eye Infections And Other Eye Disorders,823,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,8848.25,,,,,,,fee schedule,8848.25,8848.25, Eye Infections And Other Eye Disorders,823,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,8848.25,,,,,,,fee schedule,8848.25,8848.25, Eye Infections And Other Eye Disorders,823,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,8848.25,,,,,,,fee schedule,8848.25,8848.25, Eye Infections And Other Eye Disorders,823,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,8848.25,,,,,,,fee schedule,8848.25,8848.25, Eye Infections And Other Eye Disorders,823,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,8848.25,,,,,,,fee schedule,8848.25,8848.25, Eye Infections And Other Eye Disorders,823,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,8848.25,,,,,,,fee schedule,8848.25,8848.25, Eye Infections And Other Eye Disorders,823,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,8848.25,,,,,,,fee schedule,8848.25,8848.25, Eye Infections And Other Eye Disorders,824,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,15183.96,,,,,,,fee schedule,15183.96,15183.96, Eye Infections And Other Eye Disorders,824,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,15183.96,,,,,,,fee schedule,15183.96,15183.96, Eye Infections And Other Eye Disorders,824,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,15183.96,,,,,,,fee schedule,15183.96,15183.96, Eye Infections And Other Eye Disorders,824,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,15183.96,,,,,,,fee schedule,15183.96,15183.96, Eye Infections And Other Eye Disorders,824,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,15183.96,,,,,,,fee schedule,15183.96,15183.96, Eye Infections And Other Eye Disorders,824,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,15183.96,,,,,,,fee schedule,15183.96,15183.96, Eye Infections And Other Eye Disorders,824,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,15183.96,,,,,,,fee schedule,15183.96,15183.96, Eye Infections And Other Eye Disorders,824,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,15183.96,,,,,,,fee schedule,15183.96,15183.96, Eye Infections And Other Eye Disorders,824,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,15183.96,,,,,,,fee schedule,15183.96,15183.96, Eye Infections And Other Eye Disorders,824,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,15183.96,,,,,,,fee schedule,15183.96,15183.96, Eye Infections And Other Eye Disorders,824,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,15183.96,,,,,,,fee schedule,15183.96,15183.96, Major Cranial Or Facial Bone Procedures,891,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,13220.51,,,,,,,fee schedule,13220.51,13220.51, Major Cranial Or Facial Bone Procedures,891,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,13220.51,,,,,,,fee schedule,13220.51,13220.51, Major Cranial Or Facial Bone Procedures,891,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,13220.51,,,,,,,fee schedule,13220.51,13220.51, Major Cranial Or Facial Bone Procedures,891,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,13220.51,,,,,,,fee schedule,13220.51,13220.51, Major Cranial Or Facial Bone Procedures,891,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,13220.51,,,,,,,fee schedule,13220.51,13220.51, Major Cranial Or Facial Bone Procedures,891,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,13220.51,,,,,,,fee schedule,13220.51,13220.51, Major Cranial Or Facial Bone Procedures,891,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,13220.51,,,,,,,fee schedule,13220.51,13220.51, Major Cranial Or Facial Bone Procedures,891,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,13220.51,,,,,,,fee schedule,13220.51,13220.51, Major Cranial Or Facial Bone Procedures,891,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,13220.51,,,,,,,fee schedule,13220.51,13220.51, Major Cranial Or Facial Bone Procedures,891,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,13220.51,,,,,,,fee schedule,13220.51,13220.51, Major Cranial Or Facial Bone Procedures,891,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,13220.51,,,,,,,fee schedule,13220.51,13220.51, Major Cranial Or Facial Bone Procedures,892,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,17284.34,,,,,,,fee schedule,17284.34,17284.34, Major Cranial Or Facial Bone Procedures,892,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,17284.34,,,,,,,fee schedule,17284.34,17284.34, Major Cranial Or Facial Bone Procedures,892,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,17284.34,,,,,,,fee schedule,17284.34,17284.34, Major Cranial Or Facial Bone Procedures,892,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,17284.34,,,,,,,fee schedule,17284.34,17284.34, Major Cranial Or Facial Bone Procedures,892,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,17284.34,,,,,,,fee schedule,17284.34,17284.34, Major Cranial Or Facial Bone Procedures,892,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,17284.34,,,,,,,fee schedule,17284.34,17284.34, Major Cranial Or Facial Bone Procedures,892,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,17284.34,,,,,,,fee schedule,17284.34,17284.34, Major Cranial Or Facial Bone Procedures,892,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,17284.34,,,,,,,fee schedule,17284.34,17284.34, Major Cranial Or Facial Bone Procedures,892,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,17284.34,,,,,,,fee schedule,17284.34,17284.34, Major Cranial Or Facial Bone Procedures,892,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,17284.34,,,,,,,fee schedule,17284.34,17284.34, Major Cranial Or Facial Bone Procedures,892,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,17284.34,,,,,,,fee schedule,17284.34,17284.34, Major Cranial Or Facial Bone Procedures,893,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,29659.33,,,,,,,fee schedule,29659.33,29659.33, Major Cranial Or Facial Bone Procedures,893,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,29659.33,,,,,,,fee schedule,29659.33,29659.33, Major Cranial Or Facial Bone Procedures,893,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,29659.33,,,,,,,fee schedule,29659.33,29659.33, Major Cranial Or Facial Bone Procedures,893,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,29659.33,,,,,,,fee schedule,29659.33,29659.33, Major Cranial Or Facial Bone Procedures,893,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,29659.33,,,,,,,fee schedule,29659.33,29659.33, Major Cranial Or Facial Bone Procedures,893,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,29659.33,,,,,,,fee schedule,29659.33,29659.33, Major Cranial Or Facial Bone Procedures,893,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,29659.33,,,,,,,fee schedule,29659.33,29659.33, Major Cranial Or Facial Bone Procedures,893,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,29659.33,,,,,,,fee schedule,29659.33,29659.33, Major Cranial Or Facial Bone Procedures,893,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,29659.33,,,,,,,fee schedule,29659.33,29659.33, Major Cranial Or Facial Bone Procedures,893,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,29659.33,,,,,,,fee schedule,29659.33,29659.33, Major Cranial Or Facial Bone Procedures,893,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,29659.33,,,,,,,fee schedule,29659.33,29659.33, Major Cranial Or Facial Bone Procedures,894,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,39775.15,,,,,,,fee schedule,39775.15,39775.15, Major Cranial Or Facial Bone Procedures,894,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,39775.15,,,,,,,fee schedule,39775.15,39775.15, Major Cranial Or Facial Bone Procedures,894,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,39775.15,,,,,,,fee schedule,39775.15,39775.15, Major Cranial Or Facial Bone Procedures,894,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,39775.15,,,,,,,fee schedule,39775.15,39775.15, Major Cranial Or Facial Bone Procedures,894,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,39775.15,,,,,,,fee schedule,39775.15,39775.15, Major Cranial Or Facial Bone Procedures,894,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,39775.15,,,,,,,fee schedule,39775.15,39775.15, Major Cranial Or Facial Bone Procedures,894,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,39775.15,,,,,,,fee schedule,39775.15,39775.15, Major Cranial Or Facial Bone Procedures,894,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,39775.15,,,,,,,fee schedule,39775.15,39775.15, Major Cranial Or Facial Bone Procedures,894,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,39775.15,,,,,,,fee schedule,39775.15,39775.15, Major Cranial Or Facial Bone Procedures,894,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,39775.15,,,,,,,fee schedule,39775.15,39775.15, Major Cranial Or Facial Bone Procedures,894,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,39775.15,,,,,,,fee schedule,39775.15,39775.15, Other Major Head And Neck Procedures,911,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,12984.78,,,,,,,fee schedule,12984.78,12984.78, Other Major Head And Neck Procedures,911,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,12984.78,,,,,,,fee schedule,12984.78,12984.78, Other Major Head And Neck Procedures,911,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,12984.78,,,,,,,fee schedule,12984.78,12984.78, Other Major Head And Neck Procedures,911,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,12984.78,,,,,,,fee schedule,12984.78,12984.78, Other Major Head And Neck Procedures,911,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,12984.78,,,,,,,fee schedule,12984.78,12984.78, Other Major Head And Neck Procedures,911,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,12984.78,,,,,,,fee schedule,12984.78,12984.78, Other Major Head And Neck Procedures,911,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,12984.78,,,,,,,fee schedule,12984.78,12984.78, Other Major Head And Neck Procedures,911,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,12984.78,,,,,,,fee schedule,12984.78,12984.78, Other Major Head And Neck Procedures,911,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,12984.78,,,,,,,fee schedule,12984.78,12984.78, Other Major Head And Neck Procedures,911,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,12984.78,,,,,,,fee schedule,12984.78,12984.78, Other Major Head And Neck Procedures,911,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,12984.78,,,,,,,fee schedule,12984.78,12984.78, Other Major Head And Neck Procedures,912,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,20724.97,,,,,,,fee schedule,20724.97,20724.97, Other Major Head And Neck Procedures,912,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,20724.97,,,,,,,fee schedule,20724.97,20724.97, Other Major Head And Neck Procedures,912,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,20724.97,,,,,,,fee schedule,20724.97,20724.97, Other Major Head And Neck Procedures,912,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,20724.97,,,,,,,fee schedule,20724.97,20724.97, Other Major Head And Neck Procedures,912,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,20724.97,,,,,,,fee schedule,20724.97,20724.97, Other Major Head And Neck Procedures,912,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,20724.97,,,,,,,fee schedule,20724.97,20724.97, Other Major Head And Neck Procedures,912,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,20724.97,,,,,,,fee schedule,20724.97,20724.97, Other Major Head And Neck Procedures,912,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,20724.97,,,,,,,fee schedule,20724.97,20724.97, Other Major Head And Neck Procedures,912,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,20724.97,,,,,,,fee schedule,20724.97,20724.97, Other Major Head And Neck Procedures,912,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,20724.97,,,,,,,fee schedule,20724.97,20724.97, Other Major Head And Neck Procedures,912,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,20724.97,,,,,,,fee schedule,20724.97,20724.97, Other Major Head And Neck Procedures,913,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,30958.66,,,,,,,fee schedule,30958.66,30958.66, Other Major Head And Neck Procedures,913,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,30958.66,,,,,,,fee schedule,30958.66,30958.66, Other Major Head And Neck Procedures,913,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,30958.66,,,,,,,fee schedule,30958.66,30958.66, Other Major Head And Neck Procedures,913,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,30958.66,,,,,,,fee schedule,30958.66,30958.66, Other Major Head And Neck Procedures,913,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,30958.66,,,,,,,fee schedule,30958.66,30958.66, Other Major Head And Neck Procedures,913,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,30958.66,,,,,,,fee schedule,30958.66,30958.66, Other Major Head And Neck Procedures,913,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,30958.66,,,,,,,fee schedule,30958.66,30958.66, Other Major Head And Neck Procedures,913,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,30958.66,,,,,,,fee schedule,30958.66,30958.66, Other Major Head And Neck Procedures,913,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,30958.66,,,,,,,fee schedule,30958.66,30958.66, Other Major Head And Neck Procedures,913,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,30958.66,,,,,,,fee schedule,30958.66,30958.66, Other Major Head And Neck Procedures,913,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,30958.66,,,,,,,fee schedule,30958.66,30958.66, Other Major Head And Neck Procedures,914,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,46333.18,,,,,,,fee schedule,46333.18,46333.18, Other Major Head And Neck Procedures,914,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,46333.18,,,,,,,fee schedule,46333.18,46333.18, Other Major Head And Neck Procedures,914,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,46333.18,,,,,,,fee schedule,46333.18,46333.18, Other Major Head And Neck Procedures,914,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,46333.18,,,,,,,fee schedule,46333.18,46333.18, Other Major Head And Neck Procedures,914,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,46333.18,,,,,,,fee schedule,46333.18,46333.18, Other Major Head And Neck Procedures,914,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,46333.18,,,,,,,fee schedule,46333.18,46333.18, Other Major Head And Neck Procedures,914,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,46333.18,,,,,,,fee schedule,46333.18,46333.18, Other Major Head And Neck Procedures,914,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,46333.18,,,,,,,fee schedule,46333.18,46333.18, Other Major Head And Neck Procedures,914,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,46333.18,,,,,,,fee schedule,46333.18,46333.18, Other Major Head And Neck Procedures,914,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,46333.18,,,,,,,fee schedule,46333.18,46333.18, Other Major Head And Neck Procedures,914,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,46333.18,,,,,,,fee schedule,46333.18,46333.18, Facial Bone Procedures Except Major Cranial Or Facial Bone Procedures,921,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,11727.1,,,,,,,fee schedule,11727.1,11727.1, Facial Bone Procedures Except Major Cranial Or Facial Bone Procedures,921,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,11727.1,,,,,,,fee schedule,11727.1,11727.1, Facial Bone Procedures Except Major Cranial Or Facial Bone Procedures,921,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,11727.1,,,,,,,fee schedule,11727.1,11727.1, Facial Bone Procedures Except Major Cranial Or Facial Bone Procedures,921,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,11727.1,,,,,,,fee schedule,11727.1,11727.1, Facial Bone Procedures Except Major Cranial Or Facial Bone Procedures,921,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,11727.1,,,,,,,fee schedule,11727.1,11727.1, Facial Bone Procedures Except Major Cranial Or Facial Bone Procedures,921,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,11727.1,,,,,,,fee schedule,11727.1,11727.1, Facial Bone Procedures Except Major Cranial Or Facial Bone Procedures,921,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,11727.1,,,,,,,fee schedule,11727.1,11727.1, Facial Bone Procedures Except Major Cranial Or Facial Bone Procedures,921,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,11727.1,,,,,,,fee schedule,11727.1,11727.1, Facial Bone Procedures Except Major Cranial Or Facial Bone Procedures,921,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,11727.1,,,,,,,fee schedule,11727.1,11727.1, Facial Bone Procedures Except Major Cranial Or Facial Bone Procedures,921,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,11727.1,,,,,,,fee schedule,11727.1,11727.1, Facial Bone Procedures Except Major Cranial Or Facial Bone Procedures,921,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,11727.1,,,,,,,fee schedule,11727.1,11727.1, Facial Bone Procedures Except Major Cranial Or Facial Bone Procedures,922,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,14690.63,,,,,,,fee schedule,14690.63,14690.63, Facial Bone Procedures Except Major Cranial Or Facial Bone Procedures,922,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,14690.63,,,,,,,fee schedule,14690.63,14690.63, Facial Bone Procedures Except Major Cranial Or Facial Bone Procedures,922,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,14690.63,,,,,,,fee schedule,14690.63,14690.63, Facial Bone Procedures Except Major Cranial Or Facial Bone Procedures,922,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,14690.63,,,,,,,fee schedule,14690.63,14690.63, Facial Bone Procedures Except Major Cranial Or Facial Bone Procedures,922,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,14690.63,,,,,,,fee schedule,14690.63,14690.63, Facial Bone Procedures Except Major Cranial Or Facial Bone Procedures,922,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,14690.63,,,,,,,fee schedule,14690.63,14690.63, Facial Bone Procedures Except Major Cranial Or Facial Bone Procedures,922,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,14690.63,,,,,,,fee schedule,14690.63,14690.63, Facial Bone Procedures Except Major Cranial Or Facial Bone Procedures,922,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,14690.63,,,,,,,fee schedule,14690.63,14690.63, Facial Bone Procedures Except Major Cranial Or Facial Bone Procedures,922,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,14690.63,,,,,,,fee schedule,14690.63,14690.63, Facial Bone Procedures Except Major Cranial Or Facial Bone Procedures,922,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,14690.63,,,,,,,fee schedule,14690.63,14690.63, Facial Bone Procedures Except Major Cranial Or Facial Bone Procedures,922,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,14690.63,,,,,,,fee schedule,14690.63,14690.63, Facial Bone Procedures Except Major Cranial Or Facial Bone Procedures,923,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,21545.78,,,,,,,fee schedule,21545.78,21545.78, Facial Bone Procedures Except Major Cranial Or Facial Bone Procedures,923,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,21545.78,,,,,,,fee schedule,21545.78,21545.78, Facial Bone Procedures Except Major Cranial Or Facial Bone Procedures,923,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,21545.78,,,,,,,fee schedule,21545.78,21545.78, Facial Bone Procedures Except Major Cranial Or Facial Bone Procedures,923,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,21545.78,,,,,,,fee schedule,21545.78,21545.78, Facial Bone Procedures Except Major Cranial Or Facial Bone Procedures,923,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,21545.78,,,,,,,fee schedule,21545.78,21545.78, Facial Bone Procedures Except Major Cranial Or Facial Bone Procedures,923,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,21545.78,,,,,,,fee schedule,21545.78,21545.78, Facial Bone Procedures Except Major Cranial Or Facial Bone Procedures,923,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,21545.78,,,,,,,fee schedule,21545.78,21545.78, Facial Bone Procedures Except Major Cranial Or Facial Bone Procedures,923,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,21545.78,,,,,,,fee schedule,21545.78,21545.78, Facial Bone Procedures Except Major Cranial Or Facial Bone Procedures,923,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,21545.78,,,,,,,fee schedule,21545.78,21545.78, Facial Bone Procedures Except Major Cranial Or Facial Bone Procedures,923,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,21545.78,,,,,,,fee schedule,21545.78,21545.78, Facial Bone Procedures Except Major Cranial Or Facial Bone Procedures,923,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,21545.78,,,,,,,fee schedule,21545.78,21545.78, Facial Bone Procedures Except Major Cranial Or Facial Bone Procedures,924,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,37916.15,,,,,,,fee schedule,37916.15,37916.15, Facial Bone Procedures Except Major Cranial Or Facial Bone Procedures,924,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,37916.15,,,,,,,fee schedule,37916.15,37916.15, Facial Bone Procedures Except Major Cranial Or Facial Bone Procedures,924,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,37916.15,,,,,,,fee schedule,37916.15,37916.15, Facial Bone Procedures Except Major Cranial Or Facial Bone Procedures,924,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,37916.15,,,,,,,fee schedule,37916.15,37916.15, Facial Bone Procedures Except Major Cranial Or Facial Bone Procedures,924,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,37916.15,,,,,,,fee schedule,37916.15,37916.15, Facial Bone Procedures Except Major Cranial Or Facial Bone Procedures,924,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,37916.15,,,,,,,fee schedule,37916.15,37916.15, Facial Bone Procedures Except Major Cranial Or Facial Bone Procedures,924,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,37916.15,,,,,,,fee schedule,37916.15,37916.15, Facial Bone Procedures Except Major Cranial Or Facial Bone Procedures,924,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,37916.15,,,,,,,fee schedule,37916.15,37916.15, Facial Bone Procedures Except Major Cranial Or Facial Bone Procedures,924,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,37916.15,,,,,,,fee schedule,37916.15,37916.15, Facial Bone Procedures Except Major Cranial Or Facial Bone Procedures,924,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,37916.15,,,,,,,fee schedule,37916.15,37916.15, Facial Bone Procedures Except Major Cranial Or Facial Bone Procedures,924,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,37916.15,,,,,,,fee schedule,37916.15,37916.15, Cleft Lip And Palate Repair,951,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,7021.72,,,,,,,fee schedule,7021.72,7021.72, Cleft Lip And Palate Repair,951,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,7021.72,,,,,,,fee schedule,7021.72,7021.72, Cleft Lip And Palate Repair,951,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,7021.72,,,,,,,fee schedule,7021.72,7021.72, Cleft Lip And Palate Repair,951,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,7021.72,,,,,,,fee schedule,7021.72,7021.72, Cleft Lip And Palate Repair,951,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,7021.72,,,,,,,fee schedule,7021.72,7021.72, Cleft Lip And Palate Repair,951,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,7021.72,,,,,,,fee schedule,7021.72,7021.72, Cleft Lip And Palate Repair,951,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,7021.72,,,,,,,fee schedule,7021.72,7021.72, Cleft Lip And Palate Repair,951,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,7021.72,,,,,,,fee schedule,7021.72,7021.72, Cleft Lip And Palate Repair,951,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,7021.72,,,,,,,fee schedule,7021.72,7021.72, Cleft Lip And Palate Repair,951,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,7021.72,,,,,,,fee schedule,7021.72,7021.72, Cleft Lip And Palate Repair,951,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,7021.72,,,,,,,fee schedule,7021.72,7021.72, Cleft Lip And Palate Repair,952,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,7448,,,,,,,fee schedule,7448,7448, Cleft Lip And Palate Repair,952,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,7448,,,,,,,fee schedule,7448,7448, Cleft Lip And Palate Repair,952,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,7448,,,,,,,fee schedule,7448,7448, Cleft Lip And Palate Repair,952,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,7448,,,,,,,fee schedule,7448,7448, Cleft Lip And Palate Repair,952,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,7448,,,,,,,fee schedule,7448,7448, Cleft Lip And Palate Repair,952,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,7448,,,,,,,fee schedule,7448,7448, Cleft Lip And Palate Repair,952,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,7448,,,,,,,fee schedule,7448,7448, Cleft Lip And Palate Repair,952,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,7448,,,,,,,fee schedule,7448,7448, Cleft Lip And Palate Repair,952,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,7448,,,,,,,fee schedule,7448,7448, Cleft Lip And Palate Repair,952,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,7448,,,,,,,fee schedule,7448,7448, Cleft Lip And Palate Repair,952,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,7448,,,,,,,fee schedule,7448,7448, Cleft Lip And Palate Repair,953,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,11888.01,,,,,,,fee schedule,11888.01,11888.01, Cleft Lip And Palate Repair,953,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,11888.01,,,,,,,fee schedule,11888.01,11888.01, Cleft Lip And Palate Repair,953,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,11888.01,,,,,,,fee schedule,11888.01,11888.01, Cleft Lip And Palate Repair,953,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,11888.01,,,,,,,fee schedule,11888.01,11888.01, Cleft Lip And Palate Repair,953,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,11888.01,,,,,,,fee schedule,11888.01,11888.01, Cleft Lip And Palate Repair,953,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,11888.01,,,,,,,fee schedule,11888.01,11888.01, Cleft Lip And Palate Repair,953,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,11888.01,,,,,,,fee schedule,11888.01,11888.01, Cleft Lip And Palate Repair,953,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,11888.01,,,,,,,fee schedule,11888.01,11888.01, Cleft Lip And Palate Repair,953,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,11888.01,,,,,,,fee schedule,11888.01,11888.01, Cleft Lip And Palate Repair,953,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,11888.01,,,,,,,fee schedule,11888.01,11888.01, Cleft Lip And Palate Repair,953,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,11888.01,,,,,,,fee schedule,11888.01,11888.01, Cleft Lip And Palate Repair,954,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,24745.75,,,,,,,fee schedule,24745.75,24745.75, Cleft Lip And Palate Repair,954,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,24745.75,,,,,,,fee schedule,24745.75,24745.75, Cleft Lip And Palate Repair,954,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,24745.75,,,,,,,fee schedule,24745.75,24745.75, Cleft Lip And Palate Repair,954,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,24745.75,,,,,,,fee schedule,24745.75,24745.75, Cleft Lip And Palate Repair,954,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,24745.75,,,,,,,fee schedule,24745.75,24745.75, Cleft Lip And Palate Repair,954,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,24745.75,,,,,,,fee schedule,24745.75,24745.75, Cleft Lip And Palate Repair,954,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,24745.75,,,,,,,fee schedule,24745.75,24745.75, Cleft Lip And Palate Repair,954,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,24745.75,,,,,,,fee schedule,24745.75,24745.75, Cleft Lip And Palate Repair,954,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,24745.75,,,,,,,fee schedule,24745.75,24745.75, Cleft Lip And Palate Repair,954,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,24745.75,,,,,,,fee schedule,24745.75,24745.75, Cleft Lip And Palate Repair,954,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,24745.75,,,,,,,fee schedule,24745.75,24745.75, Tonsil And Adenoid Procedures,971,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4905.11,,,,,,,fee schedule,4905.11,4905.11, Tonsil And Adenoid Procedures,971,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4905.11,,,,,,,fee schedule,4905.11,4905.11, Tonsil And Adenoid Procedures,971,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4905.11,,,,,,,fee schedule,4905.11,4905.11, Tonsil And Adenoid Procedures,971,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4905.11,,,,,,,fee schedule,4905.11,4905.11, Tonsil And Adenoid Procedures,971,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4905.11,,,,,,,fee schedule,4905.11,4905.11, Tonsil And Adenoid Procedures,971,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4905.11,,,,,,,fee schedule,4905.11,4905.11, Tonsil And Adenoid Procedures,971,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4905.11,,,,,,,fee schedule,4905.11,4905.11, Tonsil And Adenoid Procedures,971,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4905.11,,,,,,,fee schedule,4905.11,4905.11, Tonsil And Adenoid Procedures,971,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4905.11,,,,,,,fee schedule,4905.11,4905.11, Tonsil And Adenoid Procedures,971,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4905.11,,,,,,,fee schedule,4905.11,4905.11, Tonsil And Adenoid Procedures,971,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4905.11,,,,,,,fee schedule,4905.11,4905.11, Tonsil And Adenoid Procedures,972,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,7651.27,,,,,,,fee schedule,7651.27,7651.27, Tonsil And Adenoid Procedures,972,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,7651.27,,,,,,,fee schedule,7651.27,7651.27, Tonsil And Adenoid Procedures,972,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,7651.27,,,,,,,fee schedule,7651.27,7651.27, Tonsil And Adenoid Procedures,972,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,7651.27,,,,,,,fee schedule,7651.27,7651.27, Tonsil And Adenoid Procedures,972,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,7651.27,,,,,,,fee schedule,7651.27,7651.27, Tonsil And Adenoid Procedures,972,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,7651.27,,,,,,,fee schedule,7651.27,7651.27, Tonsil And Adenoid Procedures,972,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,7651.27,,,,,,,fee schedule,7651.27,7651.27, Tonsil And Adenoid Procedures,972,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,7651.27,,,,,,,fee schedule,7651.27,7651.27, Tonsil And Adenoid Procedures,972,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,7651.27,,,,,,,fee schedule,7651.27,7651.27, Tonsil And Adenoid Procedures,972,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,7651.27,,,,,,,fee schedule,7651.27,7651.27, Tonsil And Adenoid Procedures,972,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,7651.27,,,,,,,fee schedule,7651.27,7651.27, Tonsil And Adenoid Procedures,973,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,12075.04,,,,,,,fee schedule,12075.04,12075.04, Tonsil And Adenoid Procedures,973,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,12075.04,,,,,,,fee schedule,12075.04,12075.04, Tonsil And Adenoid Procedures,973,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,12075.04,,,,,,,fee schedule,12075.04,12075.04, Tonsil And Adenoid Procedures,973,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,12075.04,,,,,,,fee schedule,12075.04,12075.04, Tonsil And Adenoid Procedures,973,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,12075.04,,,,,,,fee schedule,12075.04,12075.04, Tonsil And Adenoid Procedures,973,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,12075.04,,,,,,,fee schedule,12075.04,12075.04, Tonsil And Adenoid Procedures,973,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,12075.04,,,,,,,fee schedule,12075.04,12075.04, Tonsil And Adenoid Procedures,973,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,12075.04,,,,,,,fee schedule,12075.04,12075.04, Tonsil And Adenoid Procedures,973,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,12075.04,,,,,,,fee schedule,12075.04,12075.04, Tonsil And Adenoid Procedures,973,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,12075.04,,,,,,,fee schedule,12075.04,12075.04, Tonsil And Adenoid Procedures,973,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,12075.04,,,,,,,fee schedule,12075.04,12075.04, Tonsil And Adenoid Procedures,974,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,19541.39,,,,,,,fee schedule,19541.39,19541.39, Tonsil And Adenoid Procedures,974,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,19541.39,,,,,,,fee schedule,19541.39,19541.39, Tonsil And Adenoid Procedures,974,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,19541.39,,,,,,,fee schedule,19541.39,19541.39, Tonsil And Adenoid Procedures,974,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,19541.39,,,,,,,fee schedule,19541.39,19541.39, Tonsil And Adenoid Procedures,974,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,19541.39,,,,,,,fee schedule,19541.39,19541.39, Tonsil And Adenoid Procedures,974,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,19541.39,,,,,,,fee schedule,19541.39,19541.39, Tonsil And Adenoid Procedures,974,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,19541.39,,,,,,,fee schedule,19541.39,19541.39, Tonsil And Adenoid Procedures,974,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,19541.39,,,,,,,fee schedule,19541.39,19541.39, Tonsil And Adenoid Procedures,974,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,19541.39,,,,,,,fee schedule,19541.39,19541.39, Tonsil And Adenoid Procedures,974,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,19541.39,,,,,,,fee schedule,19541.39,19541.39, Tonsil And Adenoid Procedures,974,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,19541.39,,,,,,,fee schedule,19541.39,19541.39, "Other Ear, Nose, Mouth And Throat Procedures",981,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,7030.89,,,,,,,fee schedule,7030.89,7030.89, "Other Ear, Nose, Mouth And Throat Procedures",981,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,7030.89,,,,,,,fee schedule,7030.89,7030.89, "Other Ear, Nose, Mouth And Throat Procedures",981,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,7030.89,,,,,,,fee schedule,7030.89,7030.89, "Other Ear, Nose, Mouth And Throat Procedures",981,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,7030.89,,,,,,,fee schedule,7030.89,7030.89, "Other Ear, Nose, Mouth And Throat Procedures",981,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,7030.89,,,,,,,fee schedule,7030.89,7030.89, "Other Ear, Nose, Mouth And Throat Procedures",981,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,7030.89,,,,,,,fee schedule,7030.89,7030.89, "Other Ear, Nose, Mouth And Throat Procedures",981,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,7030.89,,,,,,,fee schedule,7030.89,7030.89, "Other Ear, Nose, Mouth And Throat Procedures",981,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,7030.89,,,,,,,fee schedule,7030.89,7030.89, "Other Ear, Nose, Mouth And Throat Procedures",981,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,7030.89,,,,,,,fee schedule,7030.89,7030.89, "Other Ear, Nose, Mouth And Throat Procedures",981,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,7030.89,,,,,,,fee schedule,7030.89,7030.89, "Other Ear, Nose, Mouth And Throat Procedures",981,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,7030.89,,,,,,,fee schedule,7030.89,7030.89, "Other Ear, Nose, Mouth And Throat Procedures",982,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,11692.51,,,,,,,fee schedule,11692.51,11692.51, "Other Ear, Nose, Mouth And Throat Procedures",982,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,11692.51,,,,,,,fee schedule,11692.51,11692.51, "Other Ear, Nose, Mouth And Throat Procedures",982,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,11692.51,,,,,,,fee schedule,11692.51,11692.51, "Other Ear, Nose, Mouth And Throat Procedures",982,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,11692.51,,,,,,,fee schedule,11692.51,11692.51, "Other Ear, Nose, Mouth And Throat Procedures",982,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,11692.51,,,,,,,fee schedule,11692.51,11692.51, "Other Ear, Nose, Mouth And Throat Procedures",982,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,11692.51,,,,,,,fee schedule,11692.51,11692.51, "Other Ear, Nose, Mouth And Throat Procedures",982,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,11692.51,,,,,,,fee schedule,11692.51,11692.51, "Other Ear, Nose, Mouth And Throat Procedures",982,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,11692.51,,,,,,,fee schedule,11692.51,11692.51, "Other Ear, Nose, Mouth And Throat Procedures",982,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,11692.51,,,,,,,fee schedule,11692.51,11692.51, "Other Ear, Nose, Mouth And Throat Procedures",982,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,11692.51,,,,,,,fee schedule,11692.51,11692.51, "Other Ear, Nose, Mouth And Throat Procedures",982,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,11692.51,,,,,,,fee schedule,11692.51,11692.51, "Other Ear, Nose, Mouth And Throat Procedures",983,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,17903.3,,,,,,,fee schedule,17903.3,17903.3, "Other Ear, Nose, Mouth And Throat Procedures",983,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,17903.3,,,,,,,fee schedule,17903.3,17903.3, "Other Ear, Nose, Mouth And Throat Procedures",983,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,17903.3,,,,,,,fee schedule,17903.3,17903.3, "Other Ear, Nose, Mouth And Throat Procedures",983,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,17903.3,,,,,,,fee schedule,17903.3,17903.3, "Other Ear, Nose, Mouth And Throat Procedures",983,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,17903.3,,,,,,,fee schedule,17903.3,17903.3, "Other Ear, Nose, Mouth And Throat Procedures",983,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,17903.3,,,,,,,fee schedule,17903.3,17903.3, "Other Ear, Nose, Mouth And Throat Procedures",983,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,17903.3,,,,,,,fee schedule,17903.3,17903.3, "Other Ear, Nose, Mouth And Throat Procedures",983,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,17903.3,,,,,,,fee schedule,17903.3,17903.3, "Other Ear, Nose, Mouth And Throat Procedures",983,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,17903.3,,,,,,,fee schedule,17903.3,17903.3, "Other Ear, Nose, Mouth And Throat Procedures",983,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,17903.3,,,,,,,fee schedule,17903.3,17903.3, "Other Ear, Nose, Mouth And Throat Procedures",983,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,17903.3,,,,,,,fee schedule,17903.3,17903.3, "Other Ear, Nose, Mouth And Throat Procedures",984,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,28718.54,,,,,,,fee schedule,28718.54,28718.54, "Other Ear, Nose, Mouth And Throat Procedures",984,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,28718.54,,,,,,,fee schedule,28718.54,28718.54, "Other Ear, Nose, Mouth And Throat Procedures",984,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,28718.54,,,,,,,fee schedule,28718.54,28718.54, "Other Ear, Nose, Mouth And Throat Procedures",984,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,28718.54,,,,,,,fee schedule,28718.54,28718.54, "Other Ear, Nose, Mouth And Throat Procedures",984,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,28718.54,,,,,,,fee schedule,28718.54,28718.54, "Other Ear, Nose, Mouth And Throat Procedures",984,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,28718.54,,,,,,,fee schedule,28718.54,28718.54, "Other Ear, Nose, Mouth And Throat Procedures",984,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,28718.54,,,,,,,fee schedule,28718.54,28718.54, "Other Ear, Nose, Mouth And Throat Procedures",984,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,28718.54,,,,,,,fee schedule,28718.54,28718.54, "Other Ear, Nose, Mouth And Throat Procedures",984,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,28718.54,,,,,,,fee schedule,28718.54,28718.54, "Other Ear, Nose, Mouth And Throat Procedures",984,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,28718.54,,,,,,,fee schedule,28718.54,28718.54, "Other Ear, Nose, Mouth And Throat Procedures",984,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,28718.54,,,,,,,fee schedule,28718.54,28718.54, "Ear, Nose, Mouth, Throat And Cranial Or Facial Malignancies",1101,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,6861.51,,,,,,,fee schedule,6861.51,6861.51, "Ear, Nose, Mouth, Throat And Cranial Or Facial Malignancies",1101,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,6861.51,,,,,,,fee schedule,6861.51,6861.51, "Ear, Nose, Mouth, Throat And Cranial Or Facial Malignancies",1101,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,6861.51,,,,,,,fee schedule,6861.51,6861.51, "Ear, Nose, Mouth, Throat And Cranial Or Facial Malignancies",1101,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,6861.51,,,,,,,fee schedule,6861.51,6861.51, "Ear, Nose, Mouth, Throat And Cranial Or Facial Malignancies",1101,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,6861.51,,,,,,,fee schedule,6861.51,6861.51, "Ear, Nose, Mouth, Throat And Cranial Or Facial Malignancies",1101,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,6861.51,,,,,,,fee schedule,6861.51,6861.51, "Ear, Nose, Mouth, Throat And Cranial Or Facial Malignancies",1101,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,6861.51,,,,,,,fee schedule,6861.51,6861.51, "Ear, Nose, Mouth, Throat And Cranial Or Facial Malignancies",1101,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,6861.51,,,,,,,fee schedule,6861.51,6861.51, "Ear, Nose, Mouth, Throat And Cranial Or Facial Malignancies",1101,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,6861.51,,,,,,,fee schedule,6861.51,6861.51, "Ear, Nose, Mouth, Throat And Cranial Or Facial Malignancies",1101,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,6861.51,,,,,,,fee schedule,6861.51,6861.51, "Ear, Nose, Mouth, Throat And Cranial Or Facial Malignancies",1101,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,6861.51,,,,,,,fee schedule,6861.51,6861.51, "Ear, Nose, Mouth, Throat And Cranial Or Facial Malignancies",1102,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,7841.82,,,,,,,fee schedule,7841.82,7841.82, "Ear, Nose, Mouth, Throat And Cranial Or Facial Malignancies",1102,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,7841.82,,,,,,,fee schedule,7841.82,7841.82, "Ear, Nose, Mouth, Throat And Cranial Or Facial Malignancies",1102,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,7841.82,,,,,,,fee schedule,7841.82,7841.82, "Ear, Nose, Mouth, Throat And Cranial Or Facial Malignancies",1102,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,7841.82,,,,,,,fee schedule,7841.82,7841.82, "Ear, Nose, Mouth, Throat And Cranial Or Facial Malignancies",1102,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,7841.82,,,,,,,fee schedule,7841.82,7841.82, "Ear, Nose, Mouth, Throat And Cranial Or Facial Malignancies",1102,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,7841.82,,,,,,,fee schedule,7841.82,7841.82, "Ear, Nose, Mouth, Throat And Cranial Or Facial Malignancies",1102,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,7841.82,,,,,,,fee schedule,7841.82,7841.82, "Ear, Nose, Mouth, Throat And Cranial Or Facial Malignancies",1102,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,7841.82,,,,,,,fee schedule,7841.82,7841.82, "Ear, Nose, Mouth, Throat And Cranial Or Facial Malignancies",1102,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,7841.82,,,,,,,fee schedule,7841.82,7841.82, "Ear, Nose, Mouth, Throat And Cranial Or Facial Malignancies",1102,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,7841.82,,,,,,,fee schedule,7841.82,7841.82, "Ear, Nose, Mouth, Throat And Cranial Or Facial Malignancies",1102,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,7841.82,,,,,,,fee schedule,7841.82,7841.82, "Ear, Nose, Mouth, Throat And Cranial Or Facial Malignancies",1103,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,10794.07,,,,,,,fee schedule,10794.07,10794.07, "Ear, Nose, Mouth, Throat And Cranial Or Facial Malignancies",1103,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,10794.07,,,,,,,fee schedule,10794.07,10794.07, "Ear, Nose, Mouth, Throat And Cranial Or Facial Malignancies",1103,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,10794.07,,,,,,,fee schedule,10794.07,10794.07, "Ear, Nose, Mouth, Throat And Cranial Or Facial Malignancies",1103,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,10794.07,,,,,,,fee schedule,10794.07,10794.07, "Ear, Nose, Mouth, Throat And Cranial Or Facial Malignancies",1103,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,10794.07,,,,,,,fee schedule,10794.07,10794.07, "Ear, Nose, Mouth, Throat And Cranial Or Facial Malignancies",1103,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,10794.07,,,,,,,fee schedule,10794.07,10794.07, "Ear, Nose, Mouth, Throat And Cranial Or Facial Malignancies",1103,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,10794.07,,,,,,,fee schedule,10794.07,10794.07, "Ear, Nose, Mouth, Throat And Cranial Or Facial Malignancies",1103,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,10794.07,,,,,,,fee schedule,10794.07,10794.07, "Ear, Nose, Mouth, Throat And Cranial Or Facial Malignancies",1103,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,10794.07,,,,,,,fee schedule,10794.07,10794.07, "Ear, Nose, Mouth, Throat And Cranial Or Facial Malignancies",1103,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,10794.07,,,,,,,fee schedule,10794.07,10794.07, "Ear, Nose, Mouth, Throat And Cranial Or Facial Malignancies",1103,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,10794.07,,,,,,,fee schedule,10794.07,10794.07, "Ear, Nose, Mouth, Throat And Cranial Or Facial Malignancies",1104,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,18539.2,,,,,,,fee schedule,18539.2,18539.2, "Ear, Nose, Mouth, Throat And Cranial Or Facial Malignancies",1104,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,18539.2,,,,,,,fee schedule,18539.2,18539.2, "Ear, Nose, Mouth, Throat And Cranial Or Facial Malignancies",1104,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,18539.2,,,,,,,fee schedule,18539.2,18539.2, "Ear, Nose, Mouth, Throat And Cranial Or Facial Malignancies",1104,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,18539.2,,,,,,,fee schedule,18539.2,18539.2, "Ear, Nose, Mouth, Throat And Cranial Or Facial Malignancies",1104,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,18539.2,,,,,,,fee schedule,18539.2,18539.2, "Ear, Nose, Mouth, Throat And Cranial Or Facial Malignancies",1104,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,18539.2,,,,,,,fee schedule,18539.2,18539.2, "Ear, Nose, Mouth, Throat And Cranial Or Facial Malignancies",1104,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,18539.2,,,,,,,fee schedule,18539.2,18539.2, "Ear, Nose, Mouth, Throat And Cranial Or Facial Malignancies",1104,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,18539.2,,,,,,,fee schedule,18539.2,18539.2, "Ear, Nose, Mouth, Throat And Cranial Or Facial Malignancies",1104,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,18539.2,,,,,,,fee schedule,18539.2,18539.2, "Ear, Nose, Mouth, Throat And Cranial Or Facial Malignancies",1104,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,18539.2,,,,,,,fee schedule,18539.2,18539.2, "Ear, Nose, Mouth, Throat And Cranial Or Facial Malignancies",1104,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,18539.2,,,,,,,fee schedule,18539.2,18539.2, Vertigo And Other Labyrinth Disorders,1111,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4977.8,,,,,,,fee schedule,4977.8,4977.8, Vertigo And Other Labyrinth Disorders,1111,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4977.8,,,,,,,fee schedule,4977.8,4977.8, Vertigo And Other Labyrinth Disorders,1111,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4977.8,,,,,,,fee schedule,4977.8,4977.8, Vertigo And Other Labyrinth Disorders,1111,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4977.8,,,,,,,fee schedule,4977.8,4977.8, Vertigo And Other Labyrinth Disorders,1111,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4977.8,,,,,,,fee schedule,4977.8,4977.8, Vertigo And Other Labyrinth Disorders,1111,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4977.8,,,,,,,fee schedule,4977.8,4977.8, Vertigo And Other Labyrinth Disorders,1111,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4977.8,,,,,,,fee schedule,4977.8,4977.8, Vertigo And Other Labyrinth Disorders,1111,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4977.8,,,,,,,fee schedule,4977.8,4977.8, Vertigo And Other Labyrinth Disorders,1111,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4977.8,,,,,,,fee schedule,4977.8,4977.8, Vertigo And Other Labyrinth Disorders,1111,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4977.8,,,,,,,fee schedule,4977.8,4977.8, Vertigo And Other Labyrinth Disorders,1111,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4977.8,,,,,,,fee schedule,4977.8,4977.8, Vertigo And Other Labyrinth Disorders,1112,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5548.77,,,,,,,fee schedule,5548.77,5548.77, Vertigo And Other Labyrinth Disorders,1112,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5548.77,,,,,,,fee schedule,5548.77,5548.77, Vertigo And Other Labyrinth Disorders,1112,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5548.77,,,,,,,fee schedule,5548.77,5548.77, Vertigo And Other Labyrinth Disorders,1112,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5548.77,,,,,,,fee schedule,5548.77,5548.77, Vertigo And Other Labyrinth Disorders,1112,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5548.77,,,,,,,fee schedule,5548.77,5548.77, Vertigo And Other Labyrinth Disorders,1112,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5548.77,,,,,,,fee schedule,5548.77,5548.77, Vertigo And Other Labyrinth Disorders,1112,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5548.77,,,,,,,fee schedule,5548.77,5548.77, Vertigo And Other Labyrinth Disorders,1112,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5548.77,,,,,,,fee schedule,5548.77,5548.77, Vertigo And Other Labyrinth Disorders,1112,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5548.77,,,,,,,fee schedule,5548.77,5548.77, Vertigo And Other Labyrinth Disorders,1112,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5548.77,,,,,,,fee schedule,5548.77,5548.77, Vertigo And Other Labyrinth Disorders,1112,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5548.77,,,,,,,fee schedule,5548.77,5548.77, Vertigo And Other Labyrinth Disorders,1113,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,7264.5,,,,,,,fee schedule,7264.5,7264.5, Vertigo And Other Labyrinth Disorders,1113,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,7264.5,,,,,,,fee schedule,7264.5,7264.5, Vertigo And Other Labyrinth Disorders,1113,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,7264.5,,,,,,,fee schedule,7264.5,7264.5, Vertigo And Other Labyrinth Disorders,1113,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,7264.5,,,,,,,fee schedule,7264.5,7264.5, Vertigo And Other Labyrinth Disorders,1113,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,7264.5,,,,,,,fee schedule,7264.5,7264.5, Vertigo And Other Labyrinth Disorders,1113,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,7264.5,,,,,,,fee schedule,7264.5,7264.5, Vertigo And Other Labyrinth Disorders,1113,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,7264.5,,,,,,,fee schedule,7264.5,7264.5, Vertigo And Other Labyrinth Disorders,1113,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,7264.5,,,,,,,fee schedule,7264.5,7264.5, Vertigo And Other Labyrinth Disorders,1113,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,7264.5,,,,,,,fee schedule,7264.5,7264.5, Vertigo And Other Labyrinth Disorders,1113,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,7264.5,,,,,,,fee schedule,7264.5,7264.5, Vertigo And Other Labyrinth Disorders,1113,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,7264.5,,,,,,,fee schedule,7264.5,7264.5, Vertigo And Other Labyrinth Disorders,1114,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,12611.43,,,,,,,fee schedule,12611.43,12611.43, Vertigo And Other Labyrinth Disorders,1114,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,12611.43,,,,,,,fee schedule,12611.43,12611.43, Vertigo And Other Labyrinth Disorders,1114,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,12611.43,,,,,,,fee schedule,12611.43,12611.43, Vertigo And Other Labyrinth Disorders,1114,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,12611.43,,,,,,,fee schedule,12611.43,12611.43, Vertigo And Other Labyrinth Disorders,1114,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,12611.43,,,,,,,fee schedule,12611.43,12611.43, Vertigo And Other Labyrinth Disorders,1114,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,12611.43,,,,,,,fee schedule,12611.43,12611.43, Vertigo And Other Labyrinth Disorders,1114,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,12611.43,,,,,,,fee schedule,12611.43,12611.43, Vertigo And Other Labyrinth Disorders,1114,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,12611.43,,,,,,,fee schedule,12611.43,12611.43, Vertigo And Other Labyrinth Disorders,1114,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,12611.43,,,,,,,fee schedule,12611.43,12611.43, Vertigo And Other Labyrinth Disorders,1114,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,12611.43,,,,,,,fee schedule,12611.43,12611.43, Vertigo And Other Labyrinth Disorders,1114,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,12611.43,,,,,,,fee schedule,12611.43,12611.43, Infections Of Upper Respiratory Tract,1131,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,2852.73,,,,,,,fee schedule,2852.73,2852.73, Infections Of Upper Respiratory Tract,1131,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,2852.73,,,,,,,fee schedule,2852.73,2852.73, Infections Of Upper Respiratory Tract,1131,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,2852.73,,,,,,,fee schedule,2852.73,2852.73, Infections Of Upper Respiratory Tract,1131,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,2852.73,,,,,,,fee schedule,2852.73,2852.73, Infections Of Upper Respiratory Tract,1131,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,2852.73,,,,,,,fee schedule,2852.73,2852.73, Infections Of Upper Respiratory Tract,1131,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,2852.73,,,,,,,fee schedule,2852.73,2852.73, Infections Of Upper Respiratory Tract,1131,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,2852.73,,,,,,,fee schedule,2852.73,2852.73, Infections Of Upper Respiratory Tract,1131,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,2852.73,,,,,,,fee schedule,2852.73,2852.73, Infections Of Upper Respiratory Tract,1131,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,2852.73,,,,,,,fee schedule,2852.73,2852.73, Infections Of Upper Respiratory Tract,1131,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,2852.73,,,,,,,fee schedule,2852.73,2852.73, Infections Of Upper Respiratory Tract,1131,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,2852.73,,,,,,,fee schedule,2852.73,2852.73, Infections Of Upper Respiratory Tract,1132,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4122.41,,,,,,,fee schedule,4122.41,4122.41, Infections Of Upper Respiratory Tract,1132,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4122.41,,,,,,,fee schedule,4122.41,4122.41, Infections Of Upper Respiratory Tract,1132,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4122.41,,,,,,,fee schedule,4122.41,4122.41, Infections Of Upper Respiratory Tract,1132,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4122.41,,,,,,,fee schedule,4122.41,4122.41, Infections Of Upper Respiratory Tract,1132,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4122.41,,,,,,,fee schedule,4122.41,4122.41, Infections Of Upper Respiratory Tract,1132,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4122.41,,,,,,,fee schedule,4122.41,4122.41, Infections Of Upper Respiratory Tract,1132,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4122.41,,,,,,,fee schedule,4122.41,4122.41, Infections Of Upper Respiratory Tract,1132,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4122.41,,,,,,,fee schedule,4122.41,4122.41, Infections Of Upper Respiratory Tract,1132,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4122.41,,,,,,,fee schedule,4122.41,4122.41, Infections Of Upper Respiratory Tract,1132,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4122.41,,,,,,,fee schedule,4122.41,4122.41, Infections Of Upper Respiratory Tract,1132,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4122.41,,,,,,,fee schedule,4122.41,4122.41, Infections Of Upper Respiratory Tract,1133,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,6421.81,,,,,,,fee schedule,6421.81,6421.81, Infections Of Upper Respiratory Tract,1133,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,6421.81,,,,,,,fee schedule,6421.81,6421.81, Infections Of Upper Respiratory Tract,1133,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,6421.81,,,,,,,fee schedule,6421.81,6421.81, Infections Of Upper Respiratory Tract,1133,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,6421.81,,,,,,,fee schedule,6421.81,6421.81, Infections Of Upper Respiratory Tract,1133,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,6421.81,,,,,,,fee schedule,6421.81,6421.81, Infections Of Upper Respiratory Tract,1133,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,6421.81,,,,,,,fee schedule,6421.81,6421.81, Infections Of Upper Respiratory Tract,1133,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,6421.81,,,,,,,fee schedule,6421.81,6421.81, Infections Of Upper Respiratory Tract,1133,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,6421.81,,,,,,,fee schedule,6421.81,6421.81, Infections Of Upper Respiratory Tract,1133,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,6421.81,,,,,,,fee schedule,6421.81,6421.81, Infections Of Upper Respiratory Tract,1133,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,6421.81,,,,,,,fee schedule,6421.81,6421.81, Infections Of Upper Respiratory Tract,1133,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,6421.81,,,,,,,fee schedule,6421.81,6421.81, Infections Of Upper Respiratory Tract,1134,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,12368.64,,,,,,,fee schedule,12368.64,12368.64, Infections Of Upper Respiratory Tract,1134,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,12368.64,,,,,,,fee schedule,12368.64,12368.64, Infections Of Upper Respiratory Tract,1134,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,12368.64,,,,,,,fee schedule,12368.64,12368.64, Infections Of Upper Respiratory Tract,1134,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,12368.64,,,,,,,fee schedule,12368.64,12368.64, Infections Of Upper Respiratory Tract,1134,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,12368.64,,,,,,,fee schedule,12368.64,12368.64, Infections Of Upper Respiratory Tract,1134,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,12368.64,,,,,,,fee schedule,12368.64,12368.64, Infections Of Upper Respiratory Tract,1134,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,12368.64,,,,,,,fee schedule,12368.64,12368.64, Infections Of Upper Respiratory Tract,1134,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,12368.64,,,,,,,fee schedule,12368.64,12368.64, Infections Of Upper Respiratory Tract,1134,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,12368.64,,,,,,,fee schedule,12368.64,12368.64, Infections Of Upper Respiratory Tract,1134,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,12368.64,,,,,,,fee schedule,12368.64,12368.64, Infections Of Upper Respiratory Tract,1134,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,12368.64,,,,,,,fee schedule,12368.64,12368.64, Dental Diseases And Disorders,1141,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,3464.63,,,,,,,fee schedule,3464.63,3464.63, Dental Diseases And Disorders,1141,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,3464.63,,,,,,,fee schedule,3464.63,3464.63, Dental Diseases And Disorders,1141,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,3464.63,,,,,,,fee schedule,3464.63,3464.63, Dental Diseases And Disorders,1141,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,3464.63,,,,,,,fee schedule,3464.63,3464.63, Dental Diseases And Disorders,1141,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,3464.63,,,,,,,fee schedule,3464.63,3464.63, Dental Diseases And Disorders,1141,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,3464.63,,,,,,,fee schedule,3464.63,3464.63, Dental Diseases And Disorders,1141,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,3464.63,,,,,,,fee schedule,3464.63,3464.63, Dental Diseases And Disorders,1141,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,3464.63,,,,,,,fee schedule,3464.63,3464.63, Dental Diseases And Disorders,1141,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,3464.63,,,,,,,fee schedule,3464.63,3464.63, Dental Diseases And Disorders,1141,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,3464.63,,,,,,,fee schedule,3464.63,3464.63, Dental Diseases And Disorders,1141,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,3464.63,,,,,,,fee schedule,3464.63,3464.63, Dental Diseases And Disorders,1142,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4785.13,,,,,,,fee schedule,4785.13,4785.13, Dental Diseases And Disorders,1142,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4785.13,,,,,,,fee schedule,4785.13,4785.13, Dental Diseases And Disorders,1142,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4785.13,,,,,,,fee schedule,4785.13,4785.13, Dental Diseases And Disorders,1142,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4785.13,,,,,,,fee schedule,4785.13,4785.13, Dental Diseases And Disorders,1142,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4785.13,,,,,,,fee schedule,4785.13,4785.13, Dental Diseases And Disorders,1142,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4785.13,,,,,,,fee schedule,4785.13,4785.13, Dental Diseases And Disorders,1142,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4785.13,,,,,,,fee schedule,4785.13,4785.13, Dental Diseases And Disorders,1142,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4785.13,,,,,,,fee schedule,4785.13,4785.13, Dental Diseases And Disorders,1142,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4785.13,,,,,,,fee schedule,4785.13,4785.13, Dental Diseases And Disorders,1142,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4785.13,,,,,,,fee schedule,4785.13,4785.13, Dental Diseases And Disorders,1142,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4785.13,,,,,,,fee schedule,4785.13,4785.13, Dental Diseases And Disorders,1143,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,7174.87,,,,,,,fee schedule,7174.87,7174.87, Dental Diseases And Disorders,1143,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,7174.87,,,,,,,fee schedule,7174.87,7174.87, Dental Diseases And Disorders,1143,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,7174.87,,,,,,,fee schedule,7174.87,7174.87, Dental Diseases And Disorders,1143,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,7174.87,,,,,,,fee schedule,7174.87,7174.87, Dental Diseases And Disorders,1143,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,7174.87,,,,,,,fee schedule,7174.87,7174.87, Dental Diseases And Disorders,1143,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,7174.87,,,,,,,fee schedule,7174.87,7174.87, Dental Diseases And Disorders,1143,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,7174.87,,,,,,,fee schedule,7174.87,7174.87, Dental Diseases And Disorders,1143,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,7174.87,,,,,,,fee schedule,7174.87,7174.87, Dental Diseases And Disorders,1143,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,7174.87,,,,,,,fee schedule,7174.87,7174.87, Dental Diseases And Disorders,1143,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,7174.87,,,,,,,fee schedule,7174.87,7174.87, Dental Diseases And Disorders,1143,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,7174.87,,,,,,,fee schedule,7174.87,7174.87, Dental Diseases And Disorders,1144,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,19893.57,,,,,,,fee schedule,19893.57,19893.57, Dental Diseases And Disorders,1144,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,19893.57,,,,,,,fee schedule,19893.57,19893.57, Dental Diseases And Disorders,1144,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,19893.57,,,,,,,fee schedule,19893.57,19893.57, Dental Diseases And Disorders,1144,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,19893.57,,,,,,,fee schedule,19893.57,19893.57, Dental Diseases And Disorders,1144,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,19893.57,,,,,,,fee schedule,19893.57,19893.57, Dental Diseases And Disorders,1144,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,19893.57,,,,,,,fee schedule,19893.57,19893.57, Dental Diseases And Disorders,1144,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,19893.57,,,,,,,fee schedule,19893.57,19893.57, Dental Diseases And Disorders,1144,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,19893.57,,,,,,,fee schedule,19893.57,19893.57, Dental Diseases And Disorders,1144,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,19893.57,,,,,,,fee schedule,19893.57,19893.57, Dental Diseases And Disorders,1144,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,19893.57,,,,,,,fee schedule,19893.57,19893.57, Dental Diseases And Disorders,1144,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,19893.57,,,,,,,fee schedule,19893.57,19893.57, "Other Ear, Nose, Mouth, Throat And Cranial Or Facial Diagnoses",1151,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4024.31,,,,,,,fee schedule,4024.31,4024.31, "Other Ear, Nose, Mouth, Throat And Cranial Or Facial Diagnoses",1151,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4024.31,,,,,,,fee schedule,4024.31,4024.31, "Other Ear, Nose, Mouth, Throat And Cranial Or Facial Diagnoses",1151,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4024.31,,,,,,,fee schedule,4024.31,4024.31, "Other Ear, Nose, Mouth, Throat And Cranial Or Facial Diagnoses",1151,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4024.31,,,,,,,fee schedule,4024.31,4024.31, "Other Ear, Nose, Mouth, Throat And Cranial Or Facial Diagnoses",1151,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4024.31,,,,,,,fee schedule,4024.31,4024.31, "Other Ear, Nose, Mouth, Throat And Cranial Or Facial Diagnoses",1151,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4024.31,,,,,,,fee schedule,4024.31,4024.31, "Other Ear, Nose, Mouth, Throat And Cranial Or Facial Diagnoses",1151,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4024.31,,,,,,,fee schedule,4024.31,4024.31, "Other Ear, Nose, Mouth, Throat And Cranial Or Facial Diagnoses",1151,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4024.31,,,,,,,fee schedule,4024.31,4024.31, "Other Ear, Nose, Mouth, Throat And Cranial Or Facial Diagnoses",1151,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4024.31,,,,,,,fee schedule,4024.31,4024.31, "Other Ear, Nose, Mouth, Throat And Cranial Or Facial Diagnoses",1151,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4024.31,,,,,,,fee schedule,4024.31,4024.31, "Other Ear, Nose, Mouth, Throat And Cranial Or Facial Diagnoses",1151,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4024.31,,,,,,,fee schedule,4024.31,4024.31, "Other Ear, Nose, Mouth, Throat And Cranial Or Facial Diagnoses",1152,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5893.9,,,,,,,fee schedule,5893.9,5893.9, "Other Ear, Nose, Mouth, Throat And Cranial Or Facial Diagnoses",1152,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5893.9,,,,,,,fee schedule,5893.9,5893.9, "Other Ear, Nose, Mouth, Throat And Cranial Or Facial Diagnoses",1152,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5893.9,,,,,,,fee schedule,5893.9,5893.9, "Other Ear, Nose, Mouth, Throat And Cranial Or Facial Diagnoses",1152,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5893.9,,,,,,,fee schedule,5893.9,5893.9, "Other Ear, Nose, Mouth, Throat And Cranial Or Facial Diagnoses",1152,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5893.9,,,,,,,fee schedule,5893.9,5893.9, "Other Ear, Nose, Mouth, Throat And Cranial Or Facial Diagnoses",1152,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5893.9,,,,,,,fee schedule,5893.9,5893.9, "Other Ear, Nose, Mouth, Throat And Cranial Or Facial Diagnoses",1152,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5893.9,,,,,,,fee schedule,5893.9,5893.9, "Other Ear, Nose, Mouth, Throat And Cranial Or Facial Diagnoses",1152,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5893.9,,,,,,,fee schedule,5893.9,5893.9, "Other Ear, Nose, Mouth, Throat And Cranial Or Facial Diagnoses",1152,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5893.9,,,,,,,fee schedule,5893.9,5893.9, "Other Ear, Nose, Mouth, Throat And Cranial Or Facial Diagnoses",1152,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5893.9,,,,,,,fee schedule,5893.9,5893.9, "Other Ear, Nose, Mouth, Throat And Cranial Or Facial Diagnoses",1152,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5893.9,,,,,,,fee schedule,5893.9,5893.9, "Other Ear, Nose, Mouth, Throat And Cranial Or Facial Diagnoses",1153,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,8791.79,,,,,,,fee schedule,8791.79,8791.79, "Other Ear, Nose, Mouth, Throat And Cranial Or Facial Diagnoses",1153,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,8791.79,,,,,,,fee schedule,8791.79,8791.79, "Other Ear, Nose, Mouth, Throat And Cranial Or Facial Diagnoses",1153,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,8791.79,,,,,,,fee schedule,8791.79,8791.79, "Other Ear, Nose, Mouth, Throat And Cranial Or Facial Diagnoses",1153,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,8791.79,,,,,,,fee schedule,8791.79,8791.79, "Other Ear, Nose, Mouth, Throat And Cranial Or Facial Diagnoses",1153,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,8791.79,,,,,,,fee schedule,8791.79,8791.79, "Other Ear, Nose, Mouth, Throat And Cranial Or Facial Diagnoses",1153,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,8791.79,,,,,,,fee schedule,8791.79,8791.79, "Other Ear, Nose, Mouth, Throat And Cranial Or Facial Diagnoses",1153,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,8791.79,,,,,,,fee schedule,8791.79,8791.79, "Other Ear, Nose, Mouth, Throat And Cranial Or Facial Diagnoses",1153,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,8791.79,,,,,,,fee schedule,8791.79,8791.79, "Other Ear, Nose, Mouth, Throat And Cranial Or Facial Diagnoses",1153,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,8791.79,,,,,,,fee schedule,8791.79,8791.79, "Other Ear, Nose, Mouth, Throat And Cranial Or Facial Diagnoses",1153,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,8791.79,,,,,,,fee schedule,8791.79,8791.79, "Other Ear, Nose, Mouth, Throat And Cranial Or Facial Diagnoses",1153,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,8791.79,,,,,,,fee schedule,8791.79,8791.79, "Other Ear, Nose, Mouth, Throat And Cranial Or Facial Diagnoses",1154,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,16349.9,,,,,,,fee schedule,16349.9,16349.9, "Other Ear, Nose, Mouth, Throat And Cranial Or Facial Diagnoses",1154,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,16349.9,,,,,,,fee schedule,16349.9,16349.9, "Other Ear, Nose, Mouth, Throat And Cranial Or Facial Diagnoses",1154,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,16349.9,,,,,,,fee schedule,16349.9,16349.9, "Other Ear, Nose, Mouth, Throat And Cranial Or Facial Diagnoses",1154,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,16349.9,,,,,,,fee schedule,16349.9,16349.9, "Other Ear, Nose, Mouth, Throat And Cranial Or Facial Diagnoses",1154,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,16349.9,,,,,,,fee schedule,16349.9,16349.9, "Other Ear, Nose, Mouth, Throat And Cranial Or Facial Diagnoses",1154,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,16349.9,,,,,,,fee schedule,16349.9,16349.9, "Other Ear, Nose, Mouth, Throat And Cranial Or Facial Diagnoses",1154,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,16349.9,,,,,,,fee schedule,16349.9,16349.9, "Other Ear, Nose, Mouth, Throat And Cranial Or Facial Diagnoses",1154,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,16349.9,,,,,,,fee schedule,16349.9,16349.9, "Other Ear, Nose, Mouth, Throat And Cranial Or Facial Diagnoses",1154,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,16349.9,,,,,,,fee schedule,16349.9,16349.9, "Other Ear, Nose, Mouth, Throat And Cranial Or Facial Diagnoses",1154,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,16349.9,,,,,,,fee schedule,16349.9,16349.9, "Other Ear, Nose, Mouth, Throat And Cranial Or Facial Diagnoses",1154,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,16349.9,,,,,,,fee schedule,16349.9,16349.9, Major Respiratory And Chest Procedures,1201,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,13866.29,,,,,,,fee schedule,13866.29,13866.29, Major Respiratory And Chest Procedures,1201,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,13866.29,,,,,,,fee schedule,13866.29,13866.29, Major Respiratory And Chest Procedures,1201,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,13866.29,,,,,,,fee schedule,13866.29,13866.29, Major Respiratory And Chest Procedures,1201,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,13866.29,,,,,,,fee schedule,13866.29,13866.29, Major Respiratory And Chest Procedures,1201,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,13866.29,,,,,,,fee schedule,13866.29,13866.29, Major Respiratory And Chest Procedures,1201,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,13866.29,,,,,,,fee schedule,13866.29,13866.29, Major Respiratory And Chest Procedures,1201,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,13866.29,,,,,,,fee schedule,13866.29,13866.29, Major Respiratory And Chest Procedures,1201,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,13866.29,,,,,,,fee schedule,13866.29,13866.29, Major Respiratory And Chest Procedures,1201,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,13866.29,,,,,,,fee schedule,13866.29,13866.29, Major Respiratory And Chest Procedures,1201,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,13866.29,,,,,,,fee schedule,13866.29,13866.29, Major Respiratory And Chest Procedures,1201,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,13866.29,,,,,,,fee schedule,13866.29,13866.29, Major Respiratory And Chest Procedures,1202,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,17173.53,,,,,,,fee schedule,17173.53,17173.53, Major Respiratory And Chest Procedures,1202,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,17173.53,,,,,,,fee schedule,17173.53,17173.53, Major Respiratory And Chest Procedures,1202,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,17173.53,,,,,,,fee schedule,17173.53,17173.53, Major Respiratory And Chest Procedures,1202,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,17173.53,,,,,,,fee schedule,17173.53,17173.53, Major Respiratory And Chest Procedures,1202,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,17173.53,,,,,,,fee schedule,17173.53,17173.53, Major Respiratory And Chest Procedures,1202,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,17173.53,,,,,,,fee schedule,17173.53,17173.53, Major Respiratory And Chest Procedures,1202,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,17173.53,,,,,,,fee schedule,17173.53,17173.53, Major Respiratory And Chest Procedures,1202,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,17173.53,,,,,,,fee schedule,17173.53,17173.53, Major Respiratory And Chest Procedures,1202,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,17173.53,,,,,,,fee schedule,17173.53,17173.53, Major Respiratory And Chest Procedures,1202,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,17173.53,,,,,,,fee schedule,17173.53,17173.53, Major Respiratory And Chest Procedures,1202,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,17173.53,,,,,,,fee schedule,17173.53,17173.53, Major Respiratory And Chest Procedures,1203,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,25849.58,,,,,,,fee schedule,25849.58,25849.58, Major Respiratory And Chest Procedures,1203,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,25849.58,,,,,,,fee schedule,25849.58,25849.58, Major Respiratory And Chest Procedures,1203,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,25849.58,,,,,,,fee schedule,25849.58,25849.58, Major Respiratory And Chest Procedures,1203,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,25849.58,,,,,,,fee schedule,25849.58,25849.58, Major Respiratory And Chest Procedures,1203,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,25849.58,,,,,,,fee schedule,25849.58,25849.58, Major Respiratory And Chest Procedures,1203,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,25849.58,,,,,,,fee schedule,25849.58,25849.58, Major Respiratory And Chest Procedures,1203,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,25849.58,,,,,,,fee schedule,25849.58,25849.58, Major Respiratory And Chest Procedures,1203,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,25849.58,,,,,,,fee schedule,25849.58,25849.58, Major Respiratory And Chest Procedures,1203,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,25849.58,,,,,,,fee schedule,25849.58,25849.58, Major Respiratory And Chest Procedures,1203,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,25849.58,,,,,,,fee schedule,25849.58,25849.58, Major Respiratory And Chest Procedures,1203,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,25849.58,,,,,,,fee schedule,25849.58,25849.58, Major Respiratory And Chest Procedures,1204,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,40979.2,,,,,,,fee schedule,40979.2,40979.2, Major Respiratory And Chest Procedures,1204,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,40979.2,,,,,,,fee schedule,40979.2,40979.2, Major Respiratory And Chest Procedures,1204,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,40979.2,,,,,,,fee schedule,40979.2,40979.2, Major Respiratory And Chest Procedures,1204,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,40979.2,,,,,,,fee schedule,40979.2,40979.2, Major Respiratory And Chest Procedures,1204,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,40979.2,,,,,,,fee schedule,40979.2,40979.2, Major Respiratory And Chest Procedures,1204,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,40979.2,,,,,,,fee schedule,40979.2,40979.2, Major Respiratory And Chest Procedures,1204,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,40979.2,,,,,,,fee schedule,40979.2,40979.2, Major Respiratory And Chest Procedures,1204,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,40979.2,,,,,,,fee schedule,40979.2,40979.2, Major Respiratory And Chest Procedures,1204,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,40979.2,,,,,,,fee schedule,40979.2,40979.2, Major Respiratory And Chest Procedures,1204,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,40979.2,,,,,,,fee schedule,40979.2,40979.2, Major Respiratory And Chest Procedures,1204,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,40979.2,,,,,,,fee schedule,40979.2,40979.2, Other Respiratory And Chest Procedures,1211,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,10730.55,,,,,,,fee schedule,10730.55,10730.55, Other Respiratory And Chest Procedures,1211,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,10730.55,,,,,,,fee schedule,10730.55,10730.55, Other Respiratory And Chest Procedures,1211,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,10730.55,,,,,,,fee schedule,10730.55,10730.55, Other Respiratory And Chest Procedures,1211,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,10730.55,,,,,,,fee schedule,10730.55,10730.55, Other Respiratory And Chest Procedures,1211,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,10730.55,,,,,,,fee schedule,10730.55,10730.55, Other Respiratory And Chest Procedures,1211,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,10730.55,,,,,,,fee schedule,10730.55,10730.55, Other Respiratory And Chest Procedures,1211,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,10730.55,,,,,,,fee schedule,10730.55,10730.55, Other Respiratory And Chest Procedures,1211,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,10730.55,,,,,,,fee schedule,10730.55,10730.55, Other Respiratory And Chest Procedures,1211,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,10730.55,,,,,,,fee schedule,10730.55,10730.55, Other Respiratory And Chest Procedures,1211,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,10730.55,,,,,,,fee schedule,10730.55,10730.55, Other Respiratory And Chest Procedures,1211,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,10730.55,,,,,,,fee schedule,10730.55,10730.55, Other Respiratory And Chest Procedures,1212,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,14064.61,,,,,,,fee schedule,14064.61,14064.61, Other Respiratory And Chest Procedures,1212,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,14064.61,,,,,,,fee schedule,14064.61,14064.61, Other Respiratory And Chest Procedures,1212,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,14064.61,,,,,,,fee schedule,14064.61,14064.61, Other Respiratory And Chest Procedures,1212,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,14064.61,,,,,,,fee schedule,14064.61,14064.61, Other Respiratory And Chest Procedures,1212,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,14064.61,,,,,,,fee schedule,14064.61,14064.61, Other Respiratory And Chest Procedures,1212,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,14064.61,,,,,,,fee schedule,14064.61,14064.61, Other Respiratory And Chest Procedures,1212,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,14064.61,,,,,,,fee schedule,14064.61,14064.61, Other Respiratory And Chest Procedures,1212,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,14064.61,,,,,,,fee schedule,14064.61,14064.61, Other Respiratory And Chest Procedures,1212,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,14064.61,,,,,,,fee schedule,14064.61,14064.61, Other Respiratory And Chest Procedures,1212,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,14064.61,,,,,,,fee schedule,14064.61,14064.61, Other Respiratory And Chest Procedures,1212,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,14064.61,,,,,,,fee schedule,14064.61,14064.61, Other Respiratory And Chest Procedures,1213,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,21751.16,,,,,,,fee schedule,21751.16,21751.16, Other Respiratory And Chest Procedures,1213,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,21751.16,,,,,,,fee schedule,21751.16,21751.16, Other Respiratory And Chest Procedures,1213,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,21751.16,,,,,,,fee schedule,21751.16,21751.16, Other Respiratory And Chest Procedures,1213,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,21751.16,,,,,,,fee schedule,21751.16,21751.16, Other Respiratory And Chest Procedures,1213,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,21751.16,,,,,,,fee schedule,21751.16,21751.16, Other Respiratory And Chest Procedures,1213,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,21751.16,,,,,,,fee schedule,21751.16,21751.16, Other Respiratory And Chest Procedures,1213,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,21751.16,,,,,,,fee schedule,21751.16,21751.16, Other Respiratory And Chest Procedures,1213,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,21751.16,,,,,,,fee schedule,21751.16,21751.16, Other Respiratory And Chest Procedures,1213,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,21751.16,,,,,,,fee schedule,21751.16,21751.16, Other Respiratory And Chest Procedures,1213,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,21751.16,,,,,,,fee schedule,21751.16,21751.16, Other Respiratory And Chest Procedures,1213,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,21751.16,,,,,,,fee schedule,21751.16,21751.16, Other Respiratory And Chest Procedures,1214,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,34349.18,,,,,,,fee schedule,34349.18,34349.18, Other Respiratory And Chest Procedures,1214,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,34349.18,,,,,,,fee schedule,34349.18,34349.18, Other Respiratory And Chest Procedures,1214,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,34349.18,,,,,,,fee schedule,34349.18,34349.18, Other Respiratory And Chest Procedures,1214,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,34349.18,,,,,,,fee schedule,34349.18,34349.18, Other Respiratory And Chest Procedures,1214,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,34349.18,,,,,,,fee schedule,34349.18,34349.18, Other Respiratory And Chest Procedures,1214,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,34349.18,,,,,,,fee schedule,34349.18,34349.18, Other Respiratory And Chest Procedures,1214,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,34349.18,,,,,,,fee schedule,34349.18,34349.18, Other Respiratory And Chest Procedures,1214,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,34349.18,,,,,,,fee schedule,34349.18,34349.18, Other Respiratory And Chest Procedures,1214,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,34349.18,,,,,,,fee schedule,34349.18,34349.18, Other Respiratory And Chest Procedures,1214,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,34349.18,,,,,,,fee schedule,34349.18,34349.18, Other Respiratory And Chest Procedures,1214,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,34349.18,,,,,,,fee schedule,34349.18,34349.18, Respiratory System Diagnosis With Ventilator Support > 96 Hours,1301,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,20747.56,,,,,,,fee schedule,20747.56,20747.56, Respiratory System Diagnosis With Ventilator Support > 96 Hours,1301,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,20747.56,,,,,,,fee schedule,20747.56,20747.56, Respiratory System Diagnosis With Ventilator Support > 96 Hours,1301,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,20747.56,,,,,,,fee schedule,20747.56,20747.56, Respiratory System Diagnosis With Ventilator Support > 96 Hours,1301,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,20747.56,,,,,,,fee schedule,20747.56,20747.56, Respiratory System Diagnosis With Ventilator Support > 96 Hours,1301,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,20747.56,,,,,,,fee schedule,20747.56,20747.56, Respiratory System Diagnosis With Ventilator Support > 96 Hours,1301,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,20747.56,,,,,,,fee schedule,20747.56,20747.56, Respiratory System Diagnosis With Ventilator Support > 96 Hours,1301,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,20747.56,,,,,,,fee schedule,20747.56,20747.56, Respiratory System Diagnosis With Ventilator Support > 96 Hours,1301,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,20747.56,,,,,,,fee schedule,20747.56,20747.56, Respiratory System Diagnosis With Ventilator Support > 96 Hours,1301,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,20747.56,,,,,,,fee schedule,20747.56,20747.56, Respiratory System Diagnosis With Ventilator Support > 96 Hours,1301,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,20747.56,,,,,,,fee schedule,20747.56,20747.56, Respiratory System Diagnosis With Ventilator Support > 96 Hours,1301,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,20747.56,,,,,,,fee schedule,20747.56,20747.56, Respiratory System Diagnosis With Ventilator Support > 96 Hours,1302,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,25044.29,,,,,,,fee schedule,25044.29,25044.29, Respiratory System Diagnosis With Ventilator Support > 96 Hours,1302,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,25044.29,,,,,,,fee schedule,25044.29,25044.29, Respiratory System Diagnosis With Ventilator Support > 96 Hours,1302,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,25044.29,,,,,,,fee schedule,25044.29,25044.29, Respiratory System Diagnosis With Ventilator Support > 96 Hours,1302,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,25044.29,,,,,,,fee schedule,25044.29,25044.29, Respiratory System Diagnosis With Ventilator Support > 96 Hours,1302,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,25044.29,,,,,,,fee schedule,25044.29,25044.29, Respiratory System Diagnosis With Ventilator Support > 96 Hours,1302,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,25044.29,,,,,,,fee schedule,25044.29,25044.29, Respiratory System Diagnosis With Ventilator Support > 96 Hours,1302,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,25044.29,,,,,,,fee schedule,25044.29,25044.29, Respiratory System Diagnosis With Ventilator Support > 96 Hours,1302,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,25044.29,,,,,,,fee schedule,25044.29,25044.29, Respiratory System Diagnosis With Ventilator Support > 96 Hours,1302,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,25044.29,,,,,,,fee schedule,25044.29,25044.29, Respiratory System Diagnosis With Ventilator Support > 96 Hours,1302,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,25044.29,,,,,,,fee schedule,25044.29,25044.29, Respiratory System Diagnosis With Ventilator Support > 96 Hours,1302,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,25044.29,,,,,,,fee schedule,25044.29,25044.29, Respiratory System Diagnosis With Ventilator Support > 96 Hours,1303,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,30551.43,,,,,,,fee schedule,30551.43,30551.43, Respiratory System Diagnosis With Ventilator Support > 96 Hours,1303,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,30551.43,,,,,,,fee schedule,30551.43,30551.43, Respiratory System Diagnosis With Ventilator Support > 96 Hours,1303,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,30551.43,,,,,,,fee schedule,30551.43,30551.43, Respiratory System Diagnosis With Ventilator Support > 96 Hours,1303,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,30551.43,,,,,,,fee schedule,30551.43,30551.43, Respiratory System Diagnosis With Ventilator Support > 96 Hours,1303,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,30551.43,,,,,,,fee schedule,30551.43,30551.43, Respiratory System Diagnosis With Ventilator Support > 96 Hours,1303,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,30551.43,,,,,,,fee schedule,30551.43,30551.43, Respiratory System Diagnosis With Ventilator Support > 96 Hours,1303,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,30551.43,,,,,,,fee schedule,30551.43,30551.43, Respiratory System Diagnosis With Ventilator Support > 96 Hours,1303,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,30551.43,,,,,,,fee schedule,30551.43,30551.43, Respiratory System Diagnosis With Ventilator Support > 96 Hours,1303,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,30551.43,,,,,,,fee schedule,30551.43,30551.43, Respiratory System Diagnosis With Ventilator Support > 96 Hours,1303,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,30551.43,,,,,,,fee schedule,30551.43,30551.43, Respiratory System Diagnosis With Ventilator Support > 96 Hours,1303,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,30551.43,,,,,,,fee schedule,30551.43,30551.43, Respiratory System Diagnosis With Ventilator Support > 96 Hours,1304,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,40497.15,,,,,,,fee schedule,40497.15,40497.15, Respiratory System Diagnosis With Ventilator Support > 96 Hours,1304,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,40497.15,,,,,,,fee schedule,40497.15,40497.15, Respiratory System Diagnosis With Ventilator Support > 96 Hours,1304,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,40497.15,,,,,,,fee schedule,40497.15,40497.15, Respiratory System Diagnosis With Ventilator Support > 96 Hours,1304,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,40497.15,,,,,,,fee schedule,40497.15,40497.15, Respiratory System Diagnosis With Ventilator Support > 96 Hours,1304,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,40497.15,,,,,,,fee schedule,40497.15,40497.15, Respiratory System Diagnosis With Ventilator Support > 96 Hours,1304,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,40497.15,,,,,,,fee schedule,40497.15,40497.15, Respiratory System Diagnosis With Ventilator Support > 96 Hours,1304,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,40497.15,,,,,,,fee schedule,40497.15,40497.15, Respiratory System Diagnosis With Ventilator Support > 96 Hours,1304,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,40497.15,,,,,,,fee schedule,40497.15,40497.15, Respiratory System Diagnosis With Ventilator Support > 96 Hours,1304,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,40497.15,,,,,,,fee schedule,40497.15,40497.15, Respiratory System Diagnosis With Ventilator Support > 96 Hours,1304,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,40497.15,,,,,,,fee schedule,40497.15,40497.15, Respiratory System Diagnosis With Ventilator Support > 96 Hours,1304,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,40497.15,,,,,,,fee schedule,40497.15,40497.15, Cystic Fibrosis - Pulmonary Disease,1311,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,8006.27,,,,,,,fee schedule,8006.27,8006.27, Cystic Fibrosis - Pulmonary Disease,1311,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,8006.27,,,,,,,fee schedule,8006.27,8006.27, Cystic Fibrosis - Pulmonary Disease,1311,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,8006.27,,,,,,,fee schedule,8006.27,8006.27, Cystic Fibrosis - Pulmonary Disease,1311,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,8006.27,,,,,,,fee schedule,8006.27,8006.27, Cystic Fibrosis - Pulmonary Disease,1311,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,8006.27,,,,,,,fee schedule,8006.27,8006.27, Cystic Fibrosis - Pulmonary Disease,1311,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,8006.27,,,,,,,fee schedule,8006.27,8006.27, Cystic Fibrosis - Pulmonary Disease,1311,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,8006.27,,,,,,,fee schedule,8006.27,8006.27, Cystic Fibrosis - Pulmonary Disease,1311,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,8006.27,,,,,,,fee schedule,8006.27,8006.27, Cystic Fibrosis - Pulmonary Disease,1311,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,8006.27,,,,,,,fee schedule,8006.27,8006.27, Cystic Fibrosis - Pulmonary Disease,1311,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,8006.27,,,,,,,fee schedule,8006.27,8006.27, Cystic Fibrosis - Pulmonary Disease,1311,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,8006.27,,,,,,,fee schedule,8006.27,8006.27, Cystic Fibrosis - Pulmonary Disease,1312,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,13106.17,,,,,,,fee schedule,13106.17,13106.17, Cystic Fibrosis - Pulmonary Disease,1312,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,13106.17,,,,,,,fee schedule,13106.17,13106.17, Cystic Fibrosis - Pulmonary Disease,1312,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,13106.17,,,,,,,fee schedule,13106.17,13106.17, Cystic Fibrosis - Pulmonary Disease,1312,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,13106.17,,,,,,,fee schedule,13106.17,13106.17, Cystic Fibrosis - Pulmonary Disease,1312,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,13106.17,,,,,,,fee schedule,13106.17,13106.17, Cystic Fibrosis - Pulmonary Disease,1312,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,13106.17,,,,,,,fee schedule,13106.17,13106.17, Cystic Fibrosis - Pulmonary Disease,1312,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,13106.17,,,,,,,fee schedule,13106.17,13106.17, Cystic Fibrosis - Pulmonary Disease,1312,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,13106.17,,,,,,,fee schedule,13106.17,13106.17, Cystic Fibrosis - Pulmonary Disease,1312,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,13106.17,,,,,,,fee schedule,13106.17,13106.17, Cystic Fibrosis - Pulmonary Disease,1312,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,13106.17,,,,,,,fee schedule,13106.17,13106.17, Cystic Fibrosis - Pulmonary Disease,1312,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,13106.17,,,,,,,fee schedule,13106.17,13106.17, Cystic Fibrosis - Pulmonary Disease,1313,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,17508.07,,,,,,,fee schedule,17508.07,17508.07, Cystic Fibrosis - Pulmonary Disease,1313,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,17508.07,,,,,,,fee schedule,17508.07,17508.07, Cystic Fibrosis - Pulmonary Disease,1313,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,17508.07,,,,,,,fee schedule,17508.07,17508.07, Cystic Fibrosis - Pulmonary Disease,1313,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,17508.07,,,,,,,fee schedule,17508.07,17508.07, Cystic Fibrosis - Pulmonary Disease,1313,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,17508.07,,,,,,,fee schedule,17508.07,17508.07, Cystic Fibrosis - Pulmonary Disease,1313,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,17508.07,,,,,,,fee schedule,17508.07,17508.07, Cystic Fibrosis - Pulmonary Disease,1313,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,17508.07,,,,,,,fee schedule,17508.07,17508.07, Cystic Fibrosis - Pulmonary Disease,1313,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,17508.07,,,,,,,fee schedule,17508.07,17508.07, Cystic Fibrosis - Pulmonary Disease,1313,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,17508.07,,,,,,,fee schedule,17508.07,17508.07, Cystic Fibrosis - Pulmonary Disease,1313,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,17508.07,,,,,,,fee schedule,17508.07,17508.07, Cystic Fibrosis - Pulmonary Disease,1313,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,17508.07,,,,,,,fee schedule,17508.07,17508.07, Cystic Fibrosis - Pulmonary Disease,1314,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,20592.29,,,,,,,fee schedule,20592.29,20592.29, Cystic Fibrosis - Pulmonary Disease,1314,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,20592.29,,,,,,,fee schedule,20592.29,20592.29, Cystic Fibrosis - Pulmonary Disease,1314,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,20592.29,,,,,,,fee schedule,20592.29,20592.29, Cystic Fibrosis - Pulmonary Disease,1314,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,20592.29,,,,,,,fee schedule,20592.29,20592.29, Cystic Fibrosis - Pulmonary Disease,1314,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,20592.29,,,,,,,fee schedule,20592.29,20592.29, Cystic Fibrosis - Pulmonary Disease,1314,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,20592.29,,,,,,,fee schedule,20592.29,20592.29, Cystic Fibrosis - Pulmonary Disease,1314,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,20592.29,,,,,,,fee schedule,20592.29,20592.29, Cystic Fibrosis - Pulmonary Disease,1314,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,20592.29,,,,,,,fee schedule,20592.29,20592.29, Cystic Fibrosis - Pulmonary Disease,1314,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,20592.29,,,,,,,fee schedule,20592.29,20592.29, Cystic Fibrosis - Pulmonary Disease,1314,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,20592.29,,,,,,,fee schedule,20592.29,20592.29, Cystic Fibrosis - Pulmonary Disease,1314,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,20592.29,,,,,,,fee schedule,20592.29,20592.29, Bpd And Other Chronic Respiratory Diseases Arising In Perinatal Period,1321,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,3350.3,,,,,,,fee schedule,3350.3,3350.3, Bpd And Other Chronic Respiratory Diseases Arising In Perinatal Period,1321,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,3350.3,,,,,,,fee schedule,3350.3,3350.3, Bpd And Other Chronic Respiratory Diseases Arising In Perinatal Period,1321,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,3350.3,,,,,,,fee schedule,3350.3,3350.3, Bpd And Other Chronic Respiratory Diseases Arising In Perinatal Period,1321,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,3350.3,,,,,,,fee schedule,3350.3,3350.3, Bpd And Other Chronic Respiratory Diseases Arising In Perinatal Period,1321,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,3350.3,,,,,,,fee schedule,3350.3,3350.3, Bpd And Other Chronic Respiratory Diseases Arising In Perinatal Period,1321,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,3350.3,,,,,,,fee schedule,3350.3,3350.3, Bpd And Other Chronic Respiratory Diseases Arising In Perinatal Period,1321,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,3350.3,,,,,,,fee schedule,3350.3,3350.3, Bpd And Other Chronic Respiratory Diseases Arising In Perinatal Period,1321,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,3350.3,,,,,,,fee schedule,3350.3,3350.3, Bpd And Other Chronic Respiratory Diseases Arising In Perinatal Period,1321,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,3350.3,,,,,,,fee schedule,3350.3,3350.3, Bpd And Other Chronic Respiratory Diseases Arising In Perinatal Period,1321,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,3350.3,,,,,,,fee schedule,3350.3,3350.3, Bpd And Other Chronic Respiratory Diseases Arising In Perinatal Period,1321,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,3350.3,,,,,,,fee schedule,3350.3,3350.3, Bpd And Other Chronic Respiratory Diseases Arising In Perinatal Period,1322,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5606.65,,,,,,,fee schedule,5606.65,5606.65, Bpd And Other Chronic Respiratory Diseases Arising In Perinatal Period,1322,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5606.65,,,,,,,fee schedule,5606.65,5606.65, Bpd And Other Chronic Respiratory Diseases Arising In Perinatal Period,1322,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5606.65,,,,,,,fee schedule,5606.65,5606.65, Bpd And Other Chronic Respiratory Diseases Arising In Perinatal Period,1322,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5606.65,,,,,,,fee schedule,5606.65,5606.65, Bpd And Other Chronic Respiratory Diseases Arising In Perinatal Period,1322,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5606.65,,,,,,,fee schedule,5606.65,5606.65, Bpd And Other Chronic Respiratory Diseases Arising In Perinatal Period,1322,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5606.65,,,,,,,fee schedule,5606.65,5606.65, Bpd And Other Chronic Respiratory Diseases Arising In Perinatal Period,1322,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5606.65,,,,,,,fee schedule,5606.65,5606.65, Bpd And Other Chronic Respiratory Diseases Arising In Perinatal Period,1322,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5606.65,,,,,,,fee schedule,5606.65,5606.65, Bpd And Other Chronic Respiratory Diseases Arising In Perinatal Period,1322,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5606.65,,,,,,,fee schedule,5606.65,5606.65, Bpd And Other Chronic Respiratory Diseases Arising In Perinatal Period,1322,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5606.65,,,,,,,fee schedule,5606.65,5606.65, Bpd And Other Chronic Respiratory Diseases Arising In Perinatal Period,1322,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5606.65,,,,,,,fee schedule,5606.65,5606.65, Bpd And Other Chronic Respiratory Diseases Arising In Perinatal Period,1323,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,9439.69,,,,,,,fee schedule,9439.69,9439.69, Bpd And Other Chronic Respiratory Diseases Arising In Perinatal Period,1323,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,9439.69,,,,,,,fee schedule,9439.69,9439.69, Bpd And Other Chronic Respiratory Diseases Arising In Perinatal Period,1323,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,9439.69,,,,,,,fee schedule,9439.69,9439.69, Bpd And Other Chronic Respiratory Diseases Arising In Perinatal Period,1323,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,9439.69,,,,,,,fee schedule,9439.69,9439.69, Bpd And Other Chronic Respiratory Diseases Arising In Perinatal Period,1323,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,9439.69,,,,,,,fee schedule,9439.69,9439.69, Bpd And Other Chronic Respiratory Diseases Arising In Perinatal Period,1323,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,9439.69,,,,,,,fee schedule,9439.69,9439.69, Bpd And Other Chronic Respiratory Diseases Arising In Perinatal Period,1323,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,9439.69,,,,,,,fee schedule,9439.69,9439.69, Bpd And Other Chronic Respiratory Diseases Arising In Perinatal Period,1323,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,9439.69,,,,,,,fee schedule,9439.69,9439.69, Bpd And Other Chronic Respiratory Diseases Arising In Perinatal Period,1323,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,9439.69,,,,,,,fee schedule,9439.69,9439.69, Bpd And Other Chronic Respiratory Diseases Arising In Perinatal Period,1323,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,9439.69,,,,,,,fee schedule,9439.69,9439.69, Bpd And Other Chronic Respiratory Diseases Arising In Perinatal Period,1323,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,9439.69,,,,,,,fee schedule,9439.69,9439.69, Bpd And Other Chronic Respiratory Diseases Arising In Perinatal Period,1324,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,13193.69,,,,,,,fee schedule,13193.69,13193.69, Bpd And Other Chronic Respiratory Diseases Arising In Perinatal Period,1324,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,13193.69,,,,,,,fee schedule,13193.69,13193.69, Bpd And Other Chronic Respiratory Diseases Arising In Perinatal Period,1324,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,13193.69,,,,,,,fee schedule,13193.69,13193.69, Bpd And Other Chronic Respiratory Diseases Arising In Perinatal Period,1324,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,13193.69,,,,,,,fee schedule,13193.69,13193.69, Bpd And Other Chronic Respiratory Diseases Arising In Perinatal Period,1324,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,13193.69,,,,,,,fee schedule,13193.69,13193.69, Bpd And Other Chronic Respiratory Diseases Arising In Perinatal Period,1324,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,13193.69,,,,,,,fee schedule,13193.69,13193.69, Bpd And Other Chronic Respiratory Diseases Arising In Perinatal Period,1324,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,13193.69,,,,,,,fee schedule,13193.69,13193.69, Bpd And Other Chronic Respiratory Diseases Arising In Perinatal Period,1324,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,13193.69,,,,,,,fee schedule,13193.69,13193.69, Bpd And Other Chronic Respiratory Diseases Arising In Perinatal Period,1324,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,13193.69,,,,,,,fee schedule,13193.69,13193.69, Bpd And Other Chronic Respiratory Diseases Arising In Perinatal Period,1324,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,13193.69,,,,,,,fee schedule,13193.69,13193.69, Bpd And Other Chronic Respiratory Diseases Arising In Perinatal Period,1324,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,13193.69,,,,,,,fee schedule,13193.69,13193.69, Respiratory Failure,1331,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4442.12,,,,,,,fee schedule,4442.12,4442.12, Respiratory Failure,1331,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4442.12,,,,,,,fee schedule,4442.12,4442.12, Respiratory Failure,1331,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4442.12,,,,,,,fee schedule,4442.12,4442.12, Respiratory Failure,1331,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4442.12,,,,,,,fee schedule,4442.12,4442.12, Respiratory Failure,1331,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4442.12,,,,,,,fee schedule,4442.12,4442.12, Respiratory Failure,1331,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4442.12,,,,,,,fee schedule,4442.12,4442.12, Respiratory Failure,1331,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4442.12,,,,,,,fee schedule,4442.12,4442.12, Respiratory Failure,1331,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4442.12,,,,,,,fee schedule,4442.12,4442.12, Respiratory Failure,1331,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4442.12,,,,,,,fee schedule,4442.12,4442.12, Respiratory Failure,1331,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4442.12,,,,,,,fee schedule,4442.12,4442.12, Respiratory Failure,1331,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4442.12,,,,,,,fee schedule,4442.12,4442.12, Respiratory Failure,1332,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5918.6,,,,,,,fee schedule,5918.6,5918.6, Respiratory Failure,1332,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5918.6,,,,,,,fee schedule,5918.6,5918.6, Respiratory Failure,1332,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5918.6,,,,,,,fee schedule,5918.6,5918.6, Respiratory Failure,1332,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5918.6,,,,,,,fee schedule,5918.6,5918.6, Respiratory Failure,1332,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5918.6,,,,,,,fee schedule,5918.6,5918.6, Respiratory Failure,1332,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5918.6,,,,,,,fee schedule,5918.6,5918.6, Respiratory Failure,1332,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5918.6,,,,,,,fee schedule,5918.6,5918.6, Respiratory Failure,1332,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5918.6,,,,,,,fee schedule,5918.6,5918.6, Respiratory Failure,1332,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5918.6,,,,,,,fee schedule,5918.6,5918.6, Respiratory Failure,1332,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5918.6,,,,,,,fee schedule,5918.6,5918.6, Respiratory Failure,1332,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5918.6,,,,,,,fee schedule,5918.6,5918.6, Respiratory Failure,1333,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,8708.51,,,,,,,fee schedule,8708.51,8708.51, Respiratory Failure,1333,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,8708.51,,,,,,,fee schedule,8708.51,8708.51, Respiratory Failure,1333,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,8708.51,,,,,,,fee schedule,8708.51,8708.51, Respiratory Failure,1333,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,8708.51,,,,,,,fee schedule,8708.51,8708.51, Respiratory Failure,1333,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,8708.51,,,,,,,fee schedule,8708.51,8708.51, Respiratory Failure,1333,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,8708.51,,,,,,,fee schedule,8708.51,8708.51, Respiratory Failure,1333,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,8708.51,,,,,,,fee schedule,8708.51,8708.51, Respiratory Failure,1333,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,8708.51,,,,,,,fee schedule,8708.51,8708.51, Respiratory Failure,1333,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,8708.51,,,,,,,fee schedule,8708.51,8708.51, Respiratory Failure,1333,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,8708.51,,,,,,,fee schedule,8708.51,8708.51, Respiratory Failure,1333,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,8708.51,,,,,,,fee schedule,8708.51,8708.51, Respiratory Failure,1334,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,14280.58,,,,,,,fee schedule,14280.58,14280.58, Respiratory Failure,1334,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,14280.58,,,,,,,fee schedule,14280.58,14280.58, Respiratory Failure,1334,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,14280.58,,,,,,,fee schedule,14280.58,14280.58, Respiratory Failure,1334,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,14280.58,,,,,,,fee schedule,14280.58,14280.58, Respiratory Failure,1334,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,14280.58,,,,,,,fee schedule,14280.58,14280.58, Respiratory Failure,1334,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,14280.58,,,,,,,fee schedule,14280.58,14280.58, Respiratory Failure,1334,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,14280.58,,,,,,,fee schedule,14280.58,14280.58, Respiratory Failure,1334,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,14280.58,,,,,,,fee schedule,14280.58,14280.58, Respiratory Failure,1334,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,14280.58,,,,,,,fee schedule,14280.58,14280.58, Respiratory Failure,1334,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,14280.58,,,,,,,fee schedule,14280.58,14280.58, Respiratory Failure,1334,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,14280.58,,,,,,,fee schedule,14280.58,14280.58, Pulmonary Embolism,1341,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4236.04,,,,,,,fee schedule,4236.04,4236.04, Pulmonary Embolism,1341,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4236.04,,,,,,,fee schedule,4236.04,4236.04, Pulmonary Embolism,1341,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4236.04,,,,,,,fee schedule,4236.04,4236.04, Pulmonary Embolism,1341,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4236.04,,,,,,,fee schedule,4236.04,4236.04, Pulmonary Embolism,1341,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4236.04,,,,,,,fee schedule,4236.04,4236.04, Pulmonary Embolism,1341,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4236.04,,,,,,,fee schedule,4236.04,4236.04, Pulmonary Embolism,1341,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4236.04,,,,,,,fee schedule,4236.04,4236.04, Pulmonary Embolism,1341,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4236.04,,,,,,,fee schedule,4236.04,4236.04, Pulmonary Embolism,1341,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4236.04,,,,,,,fee schedule,4236.04,4236.04, Pulmonary Embolism,1341,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4236.04,,,,,,,fee schedule,4236.04,4236.04, Pulmonary Embolism,1341,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4236.04,,,,,,,fee schedule,4236.04,4236.04, Pulmonary Embolism,1342,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5668.75,,,,,,,fee schedule,5668.75,5668.75, Pulmonary Embolism,1342,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5668.75,,,,,,,fee schedule,5668.75,5668.75, Pulmonary Embolism,1342,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5668.75,,,,,,,fee schedule,5668.75,5668.75, Pulmonary Embolism,1342,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5668.75,,,,,,,fee schedule,5668.75,5668.75, Pulmonary Embolism,1342,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5668.75,,,,,,,fee schedule,5668.75,5668.75, Pulmonary Embolism,1342,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5668.75,,,,,,,fee schedule,5668.75,5668.75, Pulmonary Embolism,1342,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5668.75,,,,,,,fee schedule,5668.75,5668.75, Pulmonary Embolism,1342,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5668.75,,,,,,,fee schedule,5668.75,5668.75, Pulmonary Embolism,1342,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5668.75,,,,,,,fee schedule,5668.75,5668.75, Pulmonary Embolism,1342,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5668.75,,,,,,,fee schedule,5668.75,5668.75, Pulmonary Embolism,1342,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5668.75,,,,,,,fee schedule,5668.75,5668.75, Pulmonary Embolism,1343,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,8994.35,,,,,,,fee schedule,8994.35,8994.35, Pulmonary Embolism,1343,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,8994.35,,,,,,,fee schedule,8994.35,8994.35, Pulmonary Embolism,1343,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,8994.35,,,,,,,fee schedule,8994.35,8994.35, Pulmonary Embolism,1343,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,8994.35,,,,,,,fee schedule,8994.35,8994.35, Pulmonary Embolism,1343,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,8994.35,,,,,,,fee schedule,8994.35,8994.35, Pulmonary Embolism,1343,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,8994.35,,,,,,,fee schedule,8994.35,8994.35, Pulmonary Embolism,1343,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,8994.35,,,,,,,fee schedule,8994.35,8994.35, Pulmonary Embolism,1343,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,8994.35,,,,,,,fee schedule,8994.35,8994.35, Pulmonary Embolism,1343,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,8994.35,,,,,,,fee schedule,8994.35,8994.35, Pulmonary Embolism,1343,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,8994.35,,,,,,,fee schedule,8994.35,8994.35, Pulmonary Embolism,1343,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,8994.35,,,,,,,fee schedule,8994.35,8994.35, Pulmonary Embolism,1344,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,14682.87,,,,,,,fee schedule,14682.87,14682.87, Pulmonary Embolism,1344,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,14682.87,,,,,,,fee schedule,14682.87,14682.87, Pulmonary Embolism,1344,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,14682.87,,,,,,,fee schedule,14682.87,14682.87, Pulmonary Embolism,1344,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,14682.87,,,,,,,fee schedule,14682.87,14682.87, Pulmonary Embolism,1344,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,14682.87,,,,,,,fee schedule,14682.87,14682.87, Pulmonary Embolism,1344,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,14682.87,,,,,,,fee schedule,14682.87,14682.87, Pulmonary Embolism,1344,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,14682.87,,,,,,,fee schedule,14682.87,14682.87, Pulmonary Embolism,1344,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,14682.87,,,,,,,fee schedule,14682.87,14682.87, Pulmonary Embolism,1344,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,14682.87,,,,,,,fee schedule,14682.87,14682.87, Pulmonary Embolism,1344,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,14682.87,,,,,,,fee schedule,14682.87,14682.87, Pulmonary Embolism,1344,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,14682.87,,,,,,,fee schedule,14682.87,14682.87, Major Chest And Respiratory Trauma,1351,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5098.49,,,,,,,fee schedule,5098.49,5098.49, Major Chest And Respiratory Trauma,1351,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5098.49,,,,,,,fee schedule,5098.49,5098.49, Major Chest And Respiratory Trauma,1351,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5098.49,,,,,,,fee schedule,5098.49,5098.49, Major Chest And Respiratory Trauma,1351,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5098.49,,,,,,,fee schedule,5098.49,5098.49, Major Chest And Respiratory Trauma,1351,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5098.49,,,,,,,fee schedule,5098.49,5098.49, Major Chest And Respiratory Trauma,1351,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5098.49,,,,,,,fee schedule,5098.49,5098.49, Major Chest And Respiratory Trauma,1351,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5098.49,,,,,,,fee schedule,5098.49,5098.49, Major Chest And Respiratory Trauma,1351,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5098.49,,,,,,,fee schedule,5098.49,5098.49, Major Chest And Respiratory Trauma,1351,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5098.49,,,,,,,fee schedule,5098.49,5098.49, Major Chest And Respiratory Trauma,1351,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5098.49,,,,,,,fee schedule,5098.49,5098.49, Major Chest And Respiratory Trauma,1351,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5098.49,,,,,,,fee schedule,5098.49,5098.49, Major Chest And Respiratory Trauma,1352,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,6456.4,,,,,,,fee schedule,6456.4,6456.4, Major Chest And Respiratory Trauma,1352,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,6456.4,,,,,,,fee schedule,6456.4,6456.4, Major Chest And Respiratory Trauma,1352,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,6456.4,,,,,,,fee schedule,6456.4,6456.4, Major Chest And Respiratory Trauma,1352,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,6456.4,,,,,,,fee schedule,6456.4,6456.4, Major Chest And Respiratory Trauma,1352,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,6456.4,,,,,,,fee schedule,6456.4,6456.4, Major Chest And Respiratory Trauma,1352,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,6456.4,,,,,,,fee schedule,6456.4,6456.4, Major Chest And Respiratory Trauma,1352,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,6456.4,,,,,,,fee schedule,6456.4,6456.4, Major Chest And Respiratory Trauma,1352,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,6456.4,,,,,,,fee schedule,6456.4,6456.4, Major Chest And Respiratory Trauma,1352,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,6456.4,,,,,,,fee schedule,6456.4,6456.4, Major Chest And Respiratory Trauma,1352,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,6456.4,,,,,,,fee schedule,6456.4,6456.4, Major Chest And Respiratory Trauma,1352,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,6456.4,,,,,,,fee schedule,6456.4,6456.4, Major Chest And Respiratory Trauma,1353,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,9403.7,,,,,,,fee schedule,9403.7,9403.7, Major Chest And Respiratory Trauma,1353,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,9403.7,,,,,,,fee schedule,9403.7,9403.7, Major Chest And Respiratory Trauma,1353,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,9403.7,,,,,,,fee schedule,9403.7,9403.7, Major Chest And Respiratory Trauma,1353,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,9403.7,,,,,,,fee schedule,9403.7,9403.7, Major Chest And Respiratory Trauma,1353,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,9403.7,,,,,,,fee schedule,9403.7,9403.7, Major Chest And Respiratory Trauma,1353,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,9403.7,,,,,,,fee schedule,9403.7,9403.7, Major Chest And Respiratory Trauma,1353,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,9403.7,,,,,,,fee schedule,9403.7,9403.7, Major Chest And Respiratory Trauma,1353,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,9403.7,,,,,,,fee schedule,9403.7,9403.7, Major Chest And Respiratory Trauma,1353,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,9403.7,,,,,,,fee schedule,9403.7,9403.7, Major Chest And Respiratory Trauma,1353,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,9403.7,,,,,,,fee schedule,9403.7,9403.7, Major Chest And Respiratory Trauma,1353,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,9403.7,,,,,,,fee schedule,9403.7,9403.7, Major Chest And Respiratory Trauma,1354,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,16650.56,,,,,,,fee schedule,16650.56,16650.56, Major Chest And Respiratory Trauma,1354,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,16650.56,,,,,,,fee schedule,16650.56,16650.56, Major Chest And Respiratory Trauma,1354,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,16650.56,,,,,,,fee schedule,16650.56,16650.56, Major Chest And Respiratory Trauma,1354,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,16650.56,,,,,,,fee schedule,16650.56,16650.56, Major Chest And Respiratory Trauma,1354,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,16650.56,,,,,,,fee schedule,16650.56,16650.56, Major Chest And Respiratory Trauma,1354,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,16650.56,,,,,,,fee schedule,16650.56,16650.56, Major Chest And Respiratory Trauma,1354,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,16650.56,,,,,,,fee schedule,16650.56,16650.56, Major Chest And Respiratory Trauma,1354,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,16650.56,,,,,,,fee schedule,16650.56,16650.56, Major Chest And Respiratory Trauma,1354,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,16650.56,,,,,,,fee schedule,16650.56,16650.56, Major Chest And Respiratory Trauma,1354,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,16650.56,,,,,,,fee schedule,16650.56,16650.56, Major Chest And Respiratory Trauma,1354,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,16650.56,,,,,,,fee schedule,16650.56,16650.56, Respiratory Malignancy,1361,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,6004.7,,,,,,,fee schedule,6004.7,6004.7, Respiratory Malignancy,1361,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,6004.7,,,,,,,fee schedule,6004.7,6004.7, Respiratory Malignancy,1361,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,6004.7,,,,,,,fee schedule,6004.7,6004.7, Respiratory Malignancy,1361,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,6004.7,,,,,,,fee schedule,6004.7,6004.7, Respiratory Malignancy,1361,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,6004.7,,,,,,,fee schedule,6004.7,6004.7, Respiratory Malignancy,1361,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,6004.7,,,,,,,fee schedule,6004.7,6004.7, Respiratory Malignancy,1361,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,6004.7,,,,,,,fee schedule,6004.7,6004.7, Respiratory Malignancy,1361,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,6004.7,,,,,,,fee schedule,6004.7,6004.7, Respiratory Malignancy,1361,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,6004.7,,,,,,,fee schedule,6004.7,6004.7, Respiratory Malignancy,1361,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,6004.7,,,,,,,fee schedule,6004.7,6004.7, Respiratory Malignancy,1361,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,6004.7,,,,,,,fee schedule,6004.7,6004.7, Respiratory Malignancy,1362,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,7203.81,,,,,,,fee schedule,7203.81,7203.81, Respiratory Malignancy,1362,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,7203.81,,,,,,,fee schedule,7203.81,7203.81, Respiratory Malignancy,1362,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,7203.81,,,,,,,fee schedule,7203.81,7203.81, Respiratory Malignancy,1362,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,7203.81,,,,,,,fee schedule,7203.81,7203.81, Respiratory Malignancy,1362,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,7203.81,,,,,,,fee schedule,7203.81,7203.81, Respiratory Malignancy,1362,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,7203.81,,,,,,,fee schedule,7203.81,7203.81, Respiratory Malignancy,1362,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,7203.81,,,,,,,fee schedule,7203.81,7203.81, Respiratory Malignancy,1362,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,7203.81,,,,,,,fee schedule,7203.81,7203.81, Respiratory Malignancy,1362,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,7203.81,,,,,,,fee schedule,7203.81,7203.81, Respiratory Malignancy,1362,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,7203.81,,,,,,,fee schedule,7203.81,7203.81, Respiratory Malignancy,1362,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,7203.81,,,,,,,fee schedule,7203.81,7203.81, Respiratory Malignancy,1363,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,9993.02,,,,,,,fee schedule,9993.02,9993.02, Respiratory Malignancy,1363,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,9993.02,,,,,,,fee schedule,9993.02,9993.02, Respiratory Malignancy,1363,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,9993.02,,,,,,,fee schedule,9993.02,9993.02, Respiratory Malignancy,1363,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,9993.02,,,,,,,fee schedule,9993.02,9993.02, Respiratory Malignancy,1363,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,9993.02,,,,,,,fee schedule,9993.02,9993.02, Respiratory Malignancy,1363,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,9993.02,,,,,,,fee schedule,9993.02,9993.02, Respiratory Malignancy,1363,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,9993.02,,,,,,,fee schedule,9993.02,9993.02, Respiratory Malignancy,1363,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,9993.02,,,,,,,fee schedule,9993.02,9993.02, Respiratory Malignancy,1363,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,9993.02,,,,,,,fee schedule,9993.02,9993.02, Respiratory Malignancy,1363,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,9993.02,,,,,,,fee schedule,9993.02,9993.02, Respiratory Malignancy,1363,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,9993.02,,,,,,,fee schedule,9993.02,9993.02, Respiratory Malignancy,1364,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,15331.47,,,,,,,fee schedule,15331.47,15331.47, Respiratory Malignancy,1364,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,15331.47,,,,,,,fee schedule,15331.47,15331.47, Respiratory Malignancy,1364,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,15331.47,,,,,,,fee schedule,15331.47,15331.47, Respiratory Malignancy,1364,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,15331.47,,,,,,,fee schedule,15331.47,15331.47, Respiratory Malignancy,1364,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,15331.47,,,,,,,fee schedule,15331.47,15331.47, Respiratory Malignancy,1364,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,15331.47,,,,,,,fee schedule,15331.47,15331.47, Respiratory Malignancy,1364,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,15331.47,,,,,,,fee schedule,15331.47,15331.47, Respiratory Malignancy,1364,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,15331.47,,,,,,,fee schedule,15331.47,15331.47, Respiratory Malignancy,1364,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,15331.47,,,,,,,fee schedule,15331.47,15331.47, Respiratory Malignancy,1364,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,15331.47,,,,,,,fee schedule,15331.47,15331.47, Respiratory Malignancy,1364,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,15331.47,,,,,,,fee schedule,15331.47,15331.47, Major Respiratory Infections And Inflammations,1371,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4276.97,,,,,,,fee schedule,4276.97,4276.97, Major Respiratory Infections And Inflammations,1371,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4276.97,,,,,,,fee schedule,4276.97,4276.97, Major Respiratory Infections And Inflammations,1371,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4276.97,,,,,,,fee schedule,4276.97,4276.97, Major Respiratory Infections And Inflammations,1371,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4276.97,,,,,,,fee schedule,4276.97,4276.97, Major Respiratory Infections And Inflammations,1371,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4276.97,,,,,,,fee schedule,4276.97,4276.97, Major Respiratory Infections And Inflammations,1371,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4276.97,,,,,,,fee schedule,4276.97,4276.97, Major Respiratory Infections And Inflammations,1371,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4276.97,,,,,,,fee schedule,4276.97,4276.97, Major Respiratory Infections And Inflammations,1371,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4276.97,,,,,,,fee schedule,4276.97,4276.97, Major Respiratory Infections And Inflammations,1371,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4276.97,,,,,,,fee schedule,4276.97,4276.97, Major Respiratory Infections And Inflammations,1371,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4276.97,,,,,,,fee schedule,4276.97,4276.97, Major Respiratory Infections And Inflammations,1371,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4276.97,,,,,,,fee schedule,4276.97,4276.97, Major Respiratory Infections And Inflammations,1372,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5271.41,,,,,,,fee schedule,5271.41,5271.41, Major Respiratory Infections And Inflammations,1372,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5271.41,,,,,,,fee schedule,5271.41,5271.41, Major Respiratory Infections And Inflammations,1372,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5271.41,,,,,,,fee schedule,5271.41,5271.41, Major Respiratory Infections And Inflammations,1372,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5271.41,,,,,,,fee schedule,5271.41,5271.41, Major Respiratory Infections And Inflammations,1372,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5271.41,,,,,,,fee schedule,5271.41,5271.41, Major Respiratory Infections And Inflammations,1372,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5271.41,,,,,,,fee schedule,5271.41,5271.41, Major Respiratory Infections And Inflammations,1372,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5271.41,,,,,,,fee schedule,5271.41,5271.41, Major Respiratory Infections And Inflammations,1372,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5271.41,,,,,,,fee schedule,5271.41,5271.41, Major Respiratory Infections And Inflammations,1372,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5271.41,,,,,,,fee schedule,5271.41,5271.41, Major Respiratory Infections And Inflammations,1372,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5271.41,,,,,,,fee schedule,5271.41,5271.41, Major Respiratory Infections And Inflammations,1372,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5271.41,,,,,,,fee schedule,5271.41,5271.41, Major Respiratory Infections And Inflammations,1373,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,7780.42,,,,,,,fee schedule,7780.42,7780.42, Major Respiratory Infections And Inflammations,1373,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,7780.42,,,,,,,fee schedule,7780.42,7780.42, Major Respiratory Infections And Inflammations,1373,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,7780.42,,,,,,,fee schedule,7780.42,7780.42, Major Respiratory Infections And Inflammations,1373,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,7780.42,,,,,,,fee schedule,7780.42,7780.42, Major Respiratory Infections And Inflammations,1373,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,7780.42,,,,,,,fee schedule,7780.42,7780.42, Major Respiratory Infections And Inflammations,1373,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,7780.42,,,,,,,fee schedule,7780.42,7780.42, Major Respiratory Infections And Inflammations,1373,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,7780.42,,,,,,,fee schedule,7780.42,7780.42, Major Respiratory Infections And Inflammations,1373,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,7780.42,,,,,,,fee schedule,7780.42,7780.42, Major Respiratory Infections And Inflammations,1373,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,7780.42,,,,,,,fee schedule,7780.42,7780.42, Major Respiratory Infections And Inflammations,1373,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,7780.42,,,,,,,fee schedule,7780.42,7780.42, Major Respiratory Infections And Inflammations,1373,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,7780.42,,,,,,,fee schedule,7780.42,7780.42, Major Respiratory Infections And Inflammations,1374,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,14641.93,,,,,,,fee schedule,14641.93,14641.93, Major Respiratory Infections And Inflammations,1374,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,14641.93,,,,,,,fee schedule,14641.93,14641.93, Major Respiratory Infections And Inflammations,1374,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,14641.93,,,,,,,fee schedule,14641.93,14641.93, Major Respiratory Infections And Inflammations,1374,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,14641.93,,,,,,,fee schedule,14641.93,14641.93, Major Respiratory Infections And Inflammations,1374,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,14641.93,,,,,,,fee schedule,14641.93,14641.93, Major Respiratory Infections And Inflammations,1374,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,14641.93,,,,,,,fee schedule,14641.93,14641.93, Major Respiratory Infections And Inflammations,1374,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,14641.93,,,,,,,fee schedule,14641.93,14641.93, Major Respiratory Infections And Inflammations,1374,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,14641.93,,,,,,,fee schedule,14641.93,14641.93, Major Respiratory Infections And Inflammations,1374,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,14641.93,,,,,,,fee schedule,14641.93,14641.93, Major Respiratory Infections And Inflammations,1374,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,14641.93,,,,,,,fee schedule,14641.93,14641.93, Major Respiratory Infections And Inflammations,1374,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,14641.93,,,,,,,fee schedule,14641.93,14641.93, Bronchiolitis And Rsv Pneumonia,1381,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,2479.37,,,,,,,fee schedule,2479.37,2479.37, Bronchiolitis And Rsv Pneumonia,1381,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,2479.37,,,,,,,fee schedule,2479.37,2479.37, Bronchiolitis And Rsv Pneumonia,1381,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,2479.37,,,,,,,fee schedule,2479.37,2479.37, Bronchiolitis And Rsv Pneumonia,1381,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,2479.37,,,,,,,fee schedule,2479.37,2479.37, Bronchiolitis And Rsv Pneumonia,1381,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,2479.37,,,,,,,fee schedule,2479.37,2479.37, Bronchiolitis And Rsv Pneumonia,1381,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,2479.37,,,,,,,fee schedule,2479.37,2479.37, Bronchiolitis And Rsv Pneumonia,1381,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,2479.37,,,,,,,fee schedule,2479.37,2479.37, Bronchiolitis And Rsv Pneumonia,1381,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,2479.37,,,,,,,fee schedule,2479.37,2479.37, Bronchiolitis And Rsv Pneumonia,1381,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,2479.37,,,,,,,fee schedule,2479.37,2479.37, Bronchiolitis And Rsv Pneumonia,1381,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,2479.37,,,,,,,fee schedule,2479.37,2479.37, Bronchiolitis And Rsv Pneumonia,1381,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,2479.37,,,,,,,fee schedule,2479.37,2479.37, Bronchiolitis And Rsv Pneumonia,1382,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4079.36,,,,,,,fee schedule,4079.36,4079.36, Bronchiolitis And Rsv Pneumonia,1382,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4079.36,,,,,,,fee schedule,4079.36,4079.36, Bronchiolitis And Rsv Pneumonia,1382,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4079.36,,,,,,,fee schedule,4079.36,4079.36, Bronchiolitis And Rsv Pneumonia,1382,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4079.36,,,,,,,fee schedule,4079.36,4079.36, Bronchiolitis And Rsv Pneumonia,1382,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4079.36,,,,,,,fee schedule,4079.36,4079.36, Bronchiolitis And Rsv Pneumonia,1382,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4079.36,,,,,,,fee schedule,4079.36,4079.36, Bronchiolitis And Rsv Pneumonia,1382,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4079.36,,,,,,,fee schedule,4079.36,4079.36, Bronchiolitis And Rsv Pneumonia,1382,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4079.36,,,,,,,fee schedule,4079.36,4079.36, Bronchiolitis And Rsv Pneumonia,1382,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4079.36,,,,,,,fee schedule,4079.36,4079.36, Bronchiolitis And Rsv Pneumonia,1382,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4079.36,,,,,,,fee schedule,4079.36,4079.36, Bronchiolitis And Rsv Pneumonia,1382,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4079.36,,,,,,,fee schedule,4079.36,4079.36, Bronchiolitis And Rsv Pneumonia,1383,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,7115.59,,,,,,,fee schedule,7115.59,7115.59, Bronchiolitis And Rsv Pneumonia,1383,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,7115.59,,,,,,,fee schedule,7115.59,7115.59, Bronchiolitis And Rsv Pneumonia,1383,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,7115.59,,,,,,,fee schedule,7115.59,7115.59, Bronchiolitis And Rsv Pneumonia,1383,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,7115.59,,,,,,,fee schedule,7115.59,7115.59, Bronchiolitis And Rsv Pneumonia,1383,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,7115.59,,,,,,,fee schedule,7115.59,7115.59, Bronchiolitis And Rsv Pneumonia,1383,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,7115.59,,,,,,,fee schedule,7115.59,7115.59, Bronchiolitis And Rsv Pneumonia,1383,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,7115.59,,,,,,,fee schedule,7115.59,7115.59, Bronchiolitis And Rsv Pneumonia,1383,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,7115.59,,,,,,,fee schedule,7115.59,7115.59, Bronchiolitis And Rsv Pneumonia,1383,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,7115.59,,,,,,,fee schedule,7115.59,7115.59, Bronchiolitis And Rsv Pneumonia,1383,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,7115.59,,,,,,,fee schedule,7115.59,7115.59, Bronchiolitis And Rsv Pneumonia,1383,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,7115.59,,,,,,,fee schedule,7115.59,7115.59, Bronchiolitis And Rsv Pneumonia,1384,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,13932.63,,,,,,,fee schedule,13932.63,13932.63, Bronchiolitis And Rsv Pneumonia,1384,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,13932.63,,,,,,,fee schedule,13932.63,13932.63, Bronchiolitis And Rsv Pneumonia,1384,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,13932.63,,,,,,,fee schedule,13932.63,13932.63, Bronchiolitis And Rsv Pneumonia,1384,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,13932.63,,,,,,,fee schedule,13932.63,13932.63, Bronchiolitis And Rsv Pneumonia,1384,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,13932.63,,,,,,,fee schedule,13932.63,13932.63, Bronchiolitis And Rsv Pneumonia,1384,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,13932.63,,,,,,,fee schedule,13932.63,13932.63, Bronchiolitis And Rsv Pneumonia,1384,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,13932.63,,,,,,,fee schedule,13932.63,13932.63, Bronchiolitis And Rsv Pneumonia,1384,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,13932.63,,,,,,,fee schedule,13932.63,13932.63, Bronchiolitis And Rsv Pneumonia,1384,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,13932.63,,,,,,,fee schedule,13932.63,13932.63, Bronchiolitis And Rsv Pneumonia,1384,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,13932.63,,,,,,,fee schedule,13932.63,13932.63, Bronchiolitis And Rsv Pneumonia,1384,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,13932.63,,,,,,,fee schedule,13932.63,13932.63, Other Pneumonia,1391,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,3584.61,,,,,,,fee schedule,3584.61,3584.61, Other Pneumonia,1391,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,3584.61,,,,,,,fee schedule,3584.61,3584.61, Other Pneumonia,1391,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,3584.61,,,,,,,fee schedule,3584.61,3584.61, Other Pneumonia,1391,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,3584.61,,,,,,,fee schedule,3584.61,3584.61, Other Pneumonia,1391,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,3584.61,,,,,,,fee schedule,3584.61,3584.61, Other Pneumonia,1391,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,3584.61,,,,,,,fee schedule,3584.61,3584.61, Other Pneumonia,1391,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,3584.61,,,,,,,fee schedule,3584.61,3584.61, Other Pneumonia,1391,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,3584.61,,,,,,,fee schedule,3584.61,3584.61, Other Pneumonia,1391,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,3584.61,,,,,,,fee schedule,3584.61,3584.61, Other Pneumonia,1391,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,3584.61,,,,,,,fee schedule,3584.61,3584.61, Other Pneumonia,1391,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,3584.61,,,,,,,fee schedule,3584.61,3584.61, Other Pneumonia,1392,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4912.17,,,,,,,fee schedule,4912.17,4912.17, Other Pneumonia,1392,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4912.17,,,,,,,fee schedule,4912.17,4912.17, Other Pneumonia,1392,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4912.17,,,,,,,fee schedule,4912.17,4912.17, Other Pneumonia,1392,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4912.17,,,,,,,fee schedule,4912.17,4912.17, Other Pneumonia,1392,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4912.17,,,,,,,fee schedule,4912.17,4912.17, Other Pneumonia,1392,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4912.17,,,,,,,fee schedule,4912.17,4912.17, Other Pneumonia,1392,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4912.17,,,,,,,fee schedule,4912.17,4912.17, Other Pneumonia,1392,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4912.17,,,,,,,fee schedule,4912.17,4912.17, Other Pneumonia,1392,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4912.17,,,,,,,fee schedule,4912.17,4912.17, Other Pneumonia,1392,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4912.17,,,,,,,fee schedule,4912.17,4912.17, Other Pneumonia,1392,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4912.17,,,,,,,fee schedule,4912.17,4912.17, Other Pneumonia,1393,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,7399.31,,,,,,,fee schedule,7399.31,7399.31, Other Pneumonia,1393,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,7399.31,,,,,,,fee schedule,7399.31,7399.31, Other Pneumonia,1393,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,7399.31,,,,,,,fee schedule,7399.31,7399.31, Other Pneumonia,1393,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,7399.31,,,,,,,fee schedule,7399.31,7399.31, Other Pneumonia,1393,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,7399.31,,,,,,,fee schedule,7399.31,7399.31, Other Pneumonia,1393,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,7399.31,,,,,,,fee schedule,7399.31,7399.31, Other Pneumonia,1393,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,7399.31,,,,,,,fee schedule,7399.31,7399.31, Other Pneumonia,1393,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,7399.31,,,,,,,fee schedule,7399.31,7399.31, Other Pneumonia,1393,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,7399.31,,,,,,,fee schedule,7399.31,7399.31, Other Pneumonia,1393,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,7399.31,,,,,,,fee schedule,7399.31,7399.31, Other Pneumonia,1393,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,7399.31,,,,,,,fee schedule,7399.31,7399.31, Other Pneumonia,1394,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,12099.04,,,,,,,fee schedule,12099.04,12099.04, Other Pneumonia,1394,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,12099.04,,,,,,,fee schedule,12099.04,12099.04, Other Pneumonia,1394,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,12099.04,,,,,,,fee schedule,12099.04,12099.04, Other Pneumonia,1394,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,12099.04,,,,,,,fee schedule,12099.04,12099.04, Other Pneumonia,1394,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,12099.04,,,,,,,fee schedule,12099.04,12099.04, Other Pneumonia,1394,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,12099.04,,,,,,,fee schedule,12099.04,12099.04, Other Pneumonia,1394,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,12099.04,,,,,,,fee schedule,12099.04,12099.04, Other Pneumonia,1394,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,12099.04,,,,,,,fee schedule,12099.04,12099.04, Other Pneumonia,1394,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,12099.04,,,,,,,fee schedule,12099.04,12099.04, Other Pneumonia,1394,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,12099.04,,,,,,,fee schedule,12099.04,12099.04, Other Pneumonia,1394,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,12099.04,,,,,,,fee schedule,12099.04,12099.04, Chronic Obstructive Pulmonary Disease,1401,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4017.25,,,,,,,fee schedule,4017.25,4017.25, Chronic Obstructive Pulmonary Disease,1401,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4017.25,,,,,,,fee schedule,4017.25,4017.25, Chronic Obstructive Pulmonary Disease,1401,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4017.25,,,,,,,fee schedule,4017.25,4017.25, Chronic Obstructive Pulmonary Disease,1401,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4017.25,,,,,,,fee schedule,4017.25,4017.25, Chronic Obstructive Pulmonary Disease,1401,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4017.25,,,,,,,fee schedule,4017.25,4017.25, Chronic Obstructive Pulmonary Disease,1401,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4017.25,,,,,,,fee schedule,4017.25,4017.25, Chronic Obstructive Pulmonary Disease,1401,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4017.25,,,,,,,fee schedule,4017.25,4017.25, Chronic Obstructive Pulmonary Disease,1401,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4017.25,,,,,,,fee schedule,4017.25,4017.25, Chronic Obstructive Pulmonary Disease,1401,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4017.25,,,,,,,fee schedule,4017.25,4017.25, Chronic Obstructive Pulmonary Disease,1401,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4017.25,,,,,,,fee schedule,4017.25,4017.25, Chronic Obstructive Pulmonary Disease,1401,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4017.25,,,,,,,fee schedule,4017.25,4017.25, Chronic Obstructive Pulmonary Disease,1402,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4888.17,,,,,,,fee schedule,4888.17,4888.17, Chronic Obstructive Pulmonary Disease,1402,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4888.17,,,,,,,fee schedule,4888.17,4888.17, Chronic Obstructive Pulmonary Disease,1402,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4888.17,,,,,,,fee schedule,4888.17,4888.17, Chronic Obstructive Pulmonary Disease,1402,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4888.17,,,,,,,fee schedule,4888.17,4888.17, Chronic Obstructive Pulmonary Disease,1402,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4888.17,,,,,,,fee schedule,4888.17,4888.17, Chronic Obstructive Pulmonary Disease,1402,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4888.17,,,,,,,fee schedule,4888.17,4888.17, Chronic Obstructive Pulmonary Disease,1402,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4888.17,,,,,,,fee schedule,4888.17,4888.17, Chronic Obstructive Pulmonary Disease,1402,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4888.17,,,,,,,fee schedule,4888.17,4888.17, Chronic Obstructive Pulmonary Disease,1402,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4888.17,,,,,,,fee schedule,4888.17,4888.17, Chronic Obstructive Pulmonary Disease,1402,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4888.17,,,,,,,fee schedule,4888.17,4888.17, Chronic Obstructive Pulmonary Disease,1402,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4888.17,,,,,,,fee schedule,4888.17,4888.17, Chronic Obstructive Pulmonary Disease,1403,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,6626.49,,,,,,,fee schedule,6626.49,6626.49, Chronic Obstructive Pulmonary Disease,1403,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,6626.49,,,,,,,fee schedule,6626.49,6626.49, Chronic Obstructive Pulmonary Disease,1403,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,6626.49,,,,,,,fee schedule,6626.49,6626.49, Chronic Obstructive Pulmonary Disease,1403,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,6626.49,,,,,,,fee schedule,6626.49,6626.49, Chronic Obstructive Pulmonary Disease,1403,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,6626.49,,,,,,,fee schedule,6626.49,6626.49, Chronic Obstructive Pulmonary Disease,1403,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,6626.49,,,,,,,fee schedule,6626.49,6626.49, Chronic Obstructive Pulmonary Disease,1403,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,6626.49,,,,,,,fee schedule,6626.49,6626.49, Chronic Obstructive Pulmonary Disease,1403,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,6626.49,,,,,,,fee schedule,6626.49,6626.49, Chronic Obstructive Pulmonary Disease,1403,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,6626.49,,,,,,,fee schedule,6626.49,6626.49, Chronic Obstructive Pulmonary Disease,1403,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,6626.49,,,,,,,fee schedule,6626.49,6626.49, Chronic Obstructive Pulmonary Disease,1403,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,6626.49,,,,,,,fee schedule,6626.49,6626.49, Chronic Obstructive Pulmonary Disease,1404,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,11746.15,,,,,,,fee schedule,11746.15,11746.15, Chronic Obstructive Pulmonary Disease,1404,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,11746.15,,,,,,,fee schedule,11746.15,11746.15, Chronic Obstructive Pulmonary Disease,1404,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,11746.15,,,,,,,fee schedule,11746.15,11746.15, Chronic Obstructive Pulmonary Disease,1404,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,11746.15,,,,,,,fee schedule,11746.15,11746.15, Chronic Obstructive Pulmonary Disease,1404,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,11746.15,,,,,,,fee schedule,11746.15,11746.15, Chronic Obstructive Pulmonary Disease,1404,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,11746.15,,,,,,,fee schedule,11746.15,11746.15, Chronic Obstructive Pulmonary Disease,1404,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,11746.15,,,,,,,fee schedule,11746.15,11746.15, Chronic Obstructive Pulmonary Disease,1404,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,11746.15,,,,,,,fee schedule,11746.15,11746.15, Chronic Obstructive Pulmonary Disease,1404,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,11746.15,,,,,,,fee schedule,11746.15,11746.15, Chronic Obstructive Pulmonary Disease,1404,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,11746.15,,,,,,,fee schedule,11746.15,11746.15, Chronic Obstructive Pulmonary Disease,1404,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,11746.15,,,,,,,fee schedule,11746.15,11746.15, Asthma,1411,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,3336.89,,,,,,,fee schedule,3336.89,3336.89, Asthma,1411,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,3336.89,,,,,,,fee schedule,3336.89,3336.89, Asthma,1411,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,3336.89,,,,,,,fee schedule,3336.89,3336.89, Asthma,1411,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,3336.89,,,,,,,fee schedule,3336.89,3336.89, Asthma,1411,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,3336.89,,,,,,,fee schedule,3336.89,3336.89, Asthma,1411,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,3336.89,,,,,,,fee schedule,3336.89,3336.89, Asthma,1411,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,3336.89,,,,,,,fee schedule,3336.89,3336.89, Asthma,1411,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,3336.89,,,,,,,fee schedule,3336.89,3336.89, Asthma,1411,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,3336.89,,,,,,,fee schedule,3336.89,3336.89, Asthma,1411,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,3336.89,,,,,,,fee schedule,3336.89,3336.89, Asthma,1411,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,3336.89,,,,,,,fee schedule,3336.89,3336.89, Asthma,1412,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4780.19,,,,,,,fee schedule,4780.19,4780.19, Asthma,1412,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4780.19,,,,,,,fee schedule,4780.19,4780.19, Asthma,1412,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4780.19,,,,,,,fee schedule,4780.19,4780.19, Asthma,1412,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4780.19,,,,,,,fee schedule,4780.19,4780.19, Asthma,1412,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4780.19,,,,,,,fee schedule,4780.19,4780.19, Asthma,1412,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4780.19,,,,,,,fee schedule,4780.19,4780.19, Asthma,1412,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4780.19,,,,,,,fee schedule,4780.19,4780.19, Asthma,1412,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4780.19,,,,,,,fee schedule,4780.19,4780.19, Asthma,1412,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4780.19,,,,,,,fee schedule,4780.19,4780.19, Asthma,1412,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4780.19,,,,,,,fee schedule,4780.19,4780.19, Asthma,1412,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4780.19,,,,,,,fee schedule,4780.19,4780.19, Asthma,1413,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,6568.61,,,,,,,fee schedule,6568.61,6568.61, Asthma,1413,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,6568.61,,,,,,,fee schedule,6568.61,6568.61, Asthma,1413,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,6568.61,,,,,,,fee schedule,6568.61,6568.61, Asthma,1413,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,6568.61,,,,,,,fee schedule,6568.61,6568.61, Asthma,1413,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,6568.61,,,,,,,fee schedule,6568.61,6568.61, Asthma,1413,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,6568.61,,,,,,,fee schedule,6568.61,6568.61, Asthma,1413,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,6568.61,,,,,,,fee schedule,6568.61,6568.61, Asthma,1413,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,6568.61,,,,,,,fee schedule,6568.61,6568.61, Asthma,1413,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,6568.61,,,,,,,fee schedule,6568.61,6568.61, Asthma,1413,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,6568.61,,,,,,,fee schedule,6568.61,6568.61, Asthma,1413,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,6568.61,,,,,,,fee schedule,6568.61,6568.61, Asthma,1414,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,11106.02,,,,,,,fee schedule,11106.02,11106.02, Asthma,1414,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,11106.02,,,,,,,fee schedule,11106.02,11106.02, Asthma,1414,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,11106.02,,,,,,,fee schedule,11106.02,11106.02, Asthma,1414,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,11106.02,,,,,,,fee schedule,11106.02,11106.02, Asthma,1414,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,11106.02,,,,,,,fee schedule,11106.02,11106.02, Asthma,1414,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,11106.02,,,,,,,fee schedule,11106.02,11106.02, Asthma,1414,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,11106.02,,,,,,,fee schedule,11106.02,11106.02, Asthma,1414,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,11106.02,,,,,,,fee schedule,11106.02,11106.02, Asthma,1414,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,11106.02,,,,,,,fee schedule,11106.02,11106.02, Asthma,1414,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,11106.02,,,,,,,fee schedule,11106.02,11106.02, Asthma,1414,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,11106.02,,,,,,,fee schedule,11106.02,11106.02, Interstitial And Alveolar Lung Diseases,1421,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5099.2,,,,,,,fee schedule,5099.2,5099.2, Interstitial And Alveolar Lung Diseases,1421,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5099.2,,,,,,,fee schedule,5099.2,5099.2, Interstitial And Alveolar Lung Diseases,1421,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5099.2,,,,,,,fee schedule,5099.2,5099.2, Interstitial And Alveolar Lung Diseases,1421,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5099.2,,,,,,,fee schedule,5099.2,5099.2, Interstitial And Alveolar Lung Diseases,1421,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5099.2,,,,,,,fee schedule,5099.2,5099.2, Interstitial And Alveolar Lung Diseases,1421,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5099.2,,,,,,,fee schedule,5099.2,5099.2, Interstitial And Alveolar Lung Diseases,1421,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5099.2,,,,,,,fee schedule,5099.2,5099.2, Interstitial And Alveolar Lung Diseases,1421,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5099.2,,,,,,,fee schedule,5099.2,5099.2, Interstitial And Alveolar Lung Diseases,1421,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5099.2,,,,,,,fee schedule,5099.2,5099.2, Interstitial And Alveolar Lung Diseases,1421,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5099.2,,,,,,,fee schedule,5099.2,5099.2, Interstitial And Alveolar Lung Diseases,1421,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5099.2,,,,,,,fee schedule,5099.2,5099.2, Interstitial And Alveolar Lung Diseases,1422,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,6586.96,,,,,,,fee schedule,6586.96,6586.96, Interstitial And Alveolar Lung Diseases,1422,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,6586.96,,,,,,,fee schedule,6586.96,6586.96, Interstitial And Alveolar Lung Diseases,1422,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,6586.96,,,,,,,fee schedule,6586.96,6586.96, Interstitial And Alveolar Lung Diseases,1422,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,6586.96,,,,,,,fee schedule,6586.96,6586.96, Interstitial And Alveolar Lung Diseases,1422,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,6586.96,,,,,,,fee schedule,6586.96,6586.96, Interstitial And Alveolar Lung Diseases,1422,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,6586.96,,,,,,,fee schedule,6586.96,6586.96, Interstitial And Alveolar Lung Diseases,1422,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,6586.96,,,,,,,fee schedule,6586.96,6586.96, Interstitial And Alveolar Lung Diseases,1422,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,6586.96,,,,,,,fee schedule,6586.96,6586.96, Interstitial And Alveolar Lung Diseases,1422,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,6586.96,,,,,,,fee schedule,6586.96,6586.96, Interstitial And Alveolar Lung Diseases,1422,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,6586.96,,,,,,,fee schedule,6586.96,6586.96, Interstitial And Alveolar Lung Diseases,1422,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,6586.96,,,,,,,fee schedule,6586.96,6586.96, Interstitial And Alveolar Lung Diseases,1423,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,9977.49,,,,,,,fee schedule,9977.49,9977.49, Interstitial And Alveolar Lung Diseases,1423,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,9977.49,,,,,,,fee schedule,9977.49,9977.49, Interstitial And Alveolar Lung Diseases,1423,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,9977.49,,,,,,,fee schedule,9977.49,9977.49, Interstitial And Alveolar Lung Diseases,1423,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,9977.49,,,,,,,fee schedule,9977.49,9977.49, Interstitial And Alveolar Lung Diseases,1423,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,9977.49,,,,,,,fee schedule,9977.49,9977.49, Interstitial And Alveolar Lung Diseases,1423,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,9977.49,,,,,,,fee schedule,9977.49,9977.49, Interstitial And Alveolar Lung Diseases,1423,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,9977.49,,,,,,,fee schedule,9977.49,9977.49, Interstitial And Alveolar Lung Diseases,1423,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,9977.49,,,,,,,fee schedule,9977.49,9977.49, Interstitial And Alveolar Lung Diseases,1423,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,9977.49,,,,,,,fee schedule,9977.49,9977.49, Interstitial And Alveolar Lung Diseases,1423,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,9977.49,,,,,,,fee schedule,9977.49,9977.49, Interstitial And Alveolar Lung Diseases,1423,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,9977.49,,,,,,,fee schedule,9977.49,9977.49, Interstitial And Alveolar Lung Diseases,1424,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,15541.79,,,,,,,fee schedule,15541.79,15541.79, Interstitial And Alveolar Lung Diseases,1424,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,15541.79,,,,,,,fee schedule,15541.79,15541.79, Interstitial And Alveolar Lung Diseases,1424,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,15541.79,,,,,,,fee schedule,15541.79,15541.79, Interstitial And Alveolar Lung Diseases,1424,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,15541.79,,,,,,,fee schedule,15541.79,15541.79, Interstitial And Alveolar Lung Diseases,1424,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,15541.79,,,,,,,fee schedule,15541.79,15541.79, Interstitial And Alveolar Lung Diseases,1424,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,15541.79,,,,,,,fee schedule,15541.79,15541.79, Interstitial And Alveolar Lung Diseases,1424,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,15541.79,,,,,,,fee schedule,15541.79,15541.79, Interstitial And Alveolar Lung Diseases,1424,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,15541.79,,,,,,,fee schedule,15541.79,15541.79, Interstitial And Alveolar Lung Diseases,1424,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,15541.79,,,,,,,fee schedule,15541.79,15541.79, Interstitial And Alveolar Lung Diseases,1424,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,15541.79,,,,,,,fee schedule,15541.79,15541.79, Interstitial And Alveolar Lung Diseases,1424,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,15541.79,,,,,,,fee schedule,15541.79,15541.79, "Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses",1431,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4229.69,,,,,,,fee schedule,4229.69,4229.69, "Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses",1431,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4229.69,,,,,,,fee schedule,4229.69,4229.69, "Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses",1431,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4229.69,,,,,,,fee schedule,4229.69,4229.69, "Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses",1431,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4229.69,,,,,,,fee schedule,4229.69,4229.69, "Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses",1431,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4229.69,,,,,,,fee schedule,4229.69,4229.69, "Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses",1431,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4229.69,,,,,,,fee schedule,4229.69,4229.69, "Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses",1431,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4229.69,,,,,,,fee schedule,4229.69,4229.69, "Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses",1431,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4229.69,,,,,,,fee schedule,4229.69,4229.69, "Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses",1431,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4229.69,,,,,,,fee schedule,4229.69,4229.69, "Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses",1431,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4229.69,,,,,,,fee schedule,4229.69,4229.69, "Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses",1431,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4229.69,,,,,,,fee schedule,4229.69,4229.69, "Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses",1432,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,6004,,,,,,,fee schedule,6004,6004, "Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses",1432,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,6004,,,,,,,fee schedule,6004,6004, "Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses",1432,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,6004,,,,,,,fee schedule,6004,6004, "Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses",1432,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,6004,,,,,,,fee schedule,6004,6004, "Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses",1432,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,6004,,,,,,,fee schedule,6004,6004, "Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses",1432,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,6004,,,,,,,fee schedule,6004,6004, "Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses",1432,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,6004,,,,,,,fee schedule,6004,6004, "Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses",1432,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,6004,,,,,,,fee schedule,6004,6004, "Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses",1432,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,6004,,,,,,,fee schedule,6004,6004, "Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses",1432,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,6004,,,,,,,fee schedule,6004,6004, "Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses",1432,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,6004,,,,,,,fee schedule,6004,6004, "Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses",1433,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,9278.77,,,,,,,fee schedule,9278.77,9278.77, "Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses",1433,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,9278.77,,,,,,,fee schedule,9278.77,9278.77, "Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses",1433,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,9278.77,,,,,,,fee schedule,9278.77,9278.77, "Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses",1433,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,9278.77,,,,,,,fee schedule,9278.77,9278.77, "Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses",1433,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,9278.77,,,,,,,fee schedule,9278.77,9278.77, "Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses",1433,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,9278.77,,,,,,,fee schedule,9278.77,9278.77, "Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses",1433,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,9278.77,,,,,,,fee schedule,9278.77,9278.77, "Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses",1433,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,9278.77,,,,,,,fee schedule,9278.77,9278.77, "Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses",1433,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,9278.77,,,,,,,fee schedule,9278.77,9278.77, "Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses",1433,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,9278.77,,,,,,,fee schedule,9278.77,9278.77, "Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses",1433,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,9278.77,,,,,,,fee schedule,9278.77,9278.77, "Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses",1434,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,15314.53,,,,,,,fee schedule,15314.53,15314.53, "Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses",1434,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,15314.53,,,,,,,fee schedule,15314.53,15314.53, "Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses",1434,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,15314.53,,,,,,,fee schedule,15314.53,15314.53, "Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses",1434,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,15314.53,,,,,,,fee schedule,15314.53,15314.53, "Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses",1434,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,15314.53,,,,,,,fee schedule,15314.53,15314.53, "Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses",1434,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,15314.53,,,,,,,fee schedule,15314.53,15314.53, "Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses",1434,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,15314.53,,,,,,,fee schedule,15314.53,15314.53, "Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses",1434,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,15314.53,,,,,,,fee schedule,15314.53,15314.53, "Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses",1434,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,15314.53,,,,,,,fee schedule,15314.53,15314.53, "Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses",1434,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,15314.53,,,,,,,fee schedule,15314.53,15314.53, "Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses",1434,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,15314.53,,,,,,,fee schedule,15314.53,15314.53, "Respiratory Signs, Symptoms And Miscellaneous Diagnoses",1441,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4328.5,,,,,,,fee schedule,4328.5,4328.5, "Respiratory Signs, Symptoms And Miscellaneous Diagnoses",1441,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4328.5,,,,,,,fee schedule,4328.5,4328.5, "Respiratory Signs, Symptoms And Miscellaneous Diagnoses",1441,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4328.5,,,,,,,fee schedule,4328.5,4328.5, "Respiratory Signs, Symptoms And Miscellaneous Diagnoses",1441,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4328.5,,,,,,,fee schedule,4328.5,4328.5, "Respiratory Signs, Symptoms And Miscellaneous Diagnoses",1441,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4328.5,,,,,,,fee schedule,4328.5,4328.5, "Respiratory Signs, Symptoms And Miscellaneous Diagnoses",1441,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4328.5,,,,,,,fee schedule,4328.5,4328.5, "Respiratory Signs, Symptoms And Miscellaneous Diagnoses",1441,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4328.5,,,,,,,fee schedule,4328.5,4328.5, "Respiratory Signs, Symptoms And Miscellaneous Diagnoses",1441,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4328.5,,,,,,,fee schedule,4328.5,4328.5, "Respiratory Signs, Symptoms And Miscellaneous Diagnoses",1441,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4328.5,,,,,,,fee schedule,4328.5,4328.5, "Respiratory Signs, Symptoms And Miscellaneous Diagnoses",1441,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4328.5,,,,,,,fee schedule,4328.5,4328.5, "Respiratory Signs, Symptoms And Miscellaneous Diagnoses",1441,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4328.5,,,,,,,fee schedule,4328.5,4328.5, "Respiratory Signs, Symptoms And Miscellaneous Diagnoses",1442,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,6037.17,,,,,,,fee schedule,6037.17,6037.17, "Respiratory Signs, Symptoms And Miscellaneous Diagnoses",1442,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,6037.17,,,,,,,fee schedule,6037.17,6037.17, "Respiratory Signs, Symptoms And Miscellaneous Diagnoses",1442,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,6037.17,,,,,,,fee schedule,6037.17,6037.17, "Respiratory Signs, Symptoms And Miscellaneous Diagnoses",1442,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,6037.17,,,,,,,fee schedule,6037.17,6037.17, "Respiratory Signs, Symptoms And Miscellaneous Diagnoses",1442,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,6037.17,,,,,,,fee schedule,6037.17,6037.17, "Respiratory Signs, Symptoms And Miscellaneous Diagnoses",1442,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,6037.17,,,,,,,fee schedule,6037.17,6037.17, "Respiratory Signs, Symptoms And Miscellaneous Diagnoses",1442,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,6037.17,,,,,,,fee schedule,6037.17,6037.17, "Respiratory Signs, Symptoms And Miscellaneous Diagnoses",1442,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,6037.17,,,,,,,fee schedule,6037.17,6037.17, "Respiratory Signs, Symptoms And Miscellaneous Diagnoses",1442,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,6037.17,,,,,,,fee schedule,6037.17,6037.17, "Respiratory Signs, Symptoms And Miscellaneous Diagnoses",1442,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,6037.17,,,,,,,fee schedule,6037.17,6037.17, "Respiratory Signs, Symptoms And Miscellaneous Diagnoses",1442,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,6037.17,,,,,,,fee schedule,6037.17,6037.17, "Respiratory Signs, Symptoms And Miscellaneous Diagnoses",1443,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,8603.35,,,,,,,fee schedule,8603.35,8603.35, "Respiratory Signs, Symptoms And Miscellaneous Diagnoses",1443,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,8603.35,,,,,,,fee schedule,8603.35,8603.35, "Respiratory Signs, Symptoms And Miscellaneous Diagnoses",1443,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,8603.35,,,,,,,fee schedule,8603.35,8603.35, "Respiratory Signs, Symptoms And Miscellaneous Diagnoses",1443,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,8603.35,,,,,,,fee schedule,8603.35,8603.35, "Respiratory Signs, Symptoms And Miscellaneous Diagnoses",1443,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,8603.35,,,,,,,fee schedule,8603.35,8603.35, "Respiratory Signs, Symptoms And Miscellaneous Diagnoses",1443,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,8603.35,,,,,,,fee schedule,8603.35,8603.35, "Respiratory Signs, Symptoms And Miscellaneous Diagnoses",1443,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,8603.35,,,,,,,fee schedule,8603.35,8603.35, "Respiratory Signs, Symptoms And Miscellaneous Diagnoses",1443,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,8603.35,,,,,,,fee schedule,8603.35,8603.35, "Respiratory Signs, Symptoms And Miscellaneous Diagnoses",1443,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,8603.35,,,,,,,fee schedule,8603.35,8603.35, "Respiratory Signs, Symptoms And Miscellaneous Diagnoses",1443,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,8603.35,,,,,,,fee schedule,8603.35,8603.35, "Respiratory Signs, Symptoms And Miscellaneous Diagnoses",1443,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,8603.35,,,,,,,fee schedule,8603.35,8603.35, "Respiratory Signs, Symptoms And Miscellaneous Diagnoses",1444,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,13719.49,,,,,,,fee schedule,13719.49,13719.49, "Respiratory Signs, Symptoms And Miscellaneous Diagnoses",1444,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,13719.49,,,,,,,fee schedule,13719.49,13719.49, "Respiratory Signs, Symptoms And Miscellaneous Diagnoses",1444,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,13719.49,,,,,,,fee schedule,13719.49,13719.49, "Respiratory Signs, Symptoms And Miscellaneous Diagnoses",1444,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,13719.49,,,,,,,fee schedule,13719.49,13719.49, "Respiratory Signs, Symptoms And Miscellaneous Diagnoses",1444,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,13719.49,,,,,,,fee schedule,13719.49,13719.49, "Respiratory Signs, Symptoms And Miscellaneous Diagnoses",1444,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,13719.49,,,,,,,fee schedule,13719.49,13719.49, "Respiratory Signs, Symptoms And Miscellaneous Diagnoses",1444,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,13719.49,,,,,,,fee schedule,13719.49,13719.49, "Respiratory Signs, Symptoms And Miscellaneous Diagnoses",1444,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,13719.49,,,,,,,fee schedule,13719.49,13719.49, "Respiratory Signs, Symptoms And Miscellaneous Diagnoses",1444,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,13719.49,,,,,,,fee schedule,13719.49,13719.49, "Respiratory Signs, Symptoms And Miscellaneous Diagnoses",1444,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,13719.49,,,,,,,fee schedule,13719.49,13719.49, "Respiratory Signs, Symptoms And Miscellaneous Diagnoses",1444,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,13719.49,,,,,,,fee schedule,13719.49,13719.49, Acute Bronchitis And Related Symptoms,1451,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,3919.85,,,,,,,fee schedule,3919.85,3919.85, Acute Bronchitis And Related Symptoms,1451,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,3919.85,,,,,,,fee schedule,3919.85,3919.85, Acute Bronchitis And Related Symptoms,1451,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,3919.85,,,,,,,fee schedule,3919.85,3919.85, Acute Bronchitis And Related Symptoms,1451,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,3919.85,,,,,,,fee schedule,3919.85,3919.85, Acute Bronchitis And Related Symptoms,1451,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,3919.85,,,,,,,fee schedule,3919.85,3919.85, Acute Bronchitis And Related Symptoms,1451,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,3919.85,,,,,,,fee schedule,3919.85,3919.85, Acute Bronchitis And Related Symptoms,1451,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,3919.85,,,,,,,fee schedule,3919.85,3919.85, Acute Bronchitis And Related Symptoms,1451,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,3919.85,,,,,,,fee schedule,3919.85,3919.85, Acute Bronchitis And Related Symptoms,1451,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,3919.85,,,,,,,fee schedule,3919.85,3919.85, Acute Bronchitis And Related Symptoms,1451,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,3919.85,,,,,,,fee schedule,3919.85,3919.85, Acute Bronchitis And Related Symptoms,1451,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,3919.85,,,,,,,fee schedule,3919.85,3919.85, Acute Bronchitis And Related Symptoms,1452,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4828.18,,,,,,,fee schedule,4828.18,4828.18, Acute Bronchitis And Related Symptoms,1452,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4828.18,,,,,,,fee schedule,4828.18,4828.18, Acute Bronchitis And Related Symptoms,1452,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4828.18,,,,,,,fee schedule,4828.18,4828.18, Acute Bronchitis And Related Symptoms,1452,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4828.18,,,,,,,fee schedule,4828.18,4828.18, Acute Bronchitis And Related Symptoms,1452,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4828.18,,,,,,,fee schedule,4828.18,4828.18, Acute Bronchitis And Related Symptoms,1452,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4828.18,,,,,,,fee schedule,4828.18,4828.18, Acute Bronchitis And Related Symptoms,1452,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4828.18,,,,,,,fee schedule,4828.18,4828.18, Acute Bronchitis And Related Symptoms,1452,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4828.18,,,,,,,fee schedule,4828.18,4828.18, Acute Bronchitis And Related Symptoms,1452,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4828.18,,,,,,,fee schedule,4828.18,4828.18, Acute Bronchitis And Related Symptoms,1452,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4828.18,,,,,,,fee schedule,4828.18,4828.18, Acute Bronchitis And Related Symptoms,1452,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4828.18,,,,,,,fee schedule,4828.18,4828.18, Acute Bronchitis And Related Symptoms,1453,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,6555.91,,,,,,,fee schedule,6555.91,6555.91, Acute Bronchitis And Related Symptoms,1453,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,6555.91,,,,,,,fee schedule,6555.91,6555.91, Acute Bronchitis And Related Symptoms,1453,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,6555.91,,,,,,,fee schedule,6555.91,6555.91, Acute Bronchitis And Related Symptoms,1453,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,6555.91,,,,,,,fee schedule,6555.91,6555.91, Acute Bronchitis And Related Symptoms,1453,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,6555.91,,,,,,,fee schedule,6555.91,6555.91, Acute Bronchitis And Related Symptoms,1453,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,6555.91,,,,,,,fee schedule,6555.91,6555.91, Acute Bronchitis And Related Symptoms,1453,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,6555.91,,,,,,,fee schedule,6555.91,6555.91, Acute Bronchitis And Related Symptoms,1453,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,6555.91,,,,,,,fee schedule,6555.91,6555.91, Acute Bronchitis And Related Symptoms,1453,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,6555.91,,,,,,,fee schedule,6555.91,6555.91, Acute Bronchitis And Related Symptoms,1453,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,6555.91,,,,,,,fee schedule,6555.91,6555.91, Acute Bronchitis And Related Symptoms,1453,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,6555.91,,,,,,,fee schedule,6555.91,6555.91, Acute Bronchitis And Related Symptoms,1454,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,10839.94,,,,,,,fee schedule,10839.94,10839.94, Acute Bronchitis And Related Symptoms,1454,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,10839.94,,,,,,,fee schedule,10839.94,10839.94, Acute Bronchitis And Related Symptoms,1454,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,10839.94,,,,,,,fee schedule,10839.94,10839.94, Acute Bronchitis And Related Symptoms,1454,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,10839.94,,,,,,,fee schedule,10839.94,10839.94, Acute Bronchitis And Related Symptoms,1454,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,10839.94,,,,,,,fee schedule,10839.94,10839.94, Acute Bronchitis And Related Symptoms,1454,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,10839.94,,,,,,,fee schedule,10839.94,10839.94, Acute Bronchitis And Related Symptoms,1454,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,10839.94,,,,,,,fee schedule,10839.94,10839.94, Acute Bronchitis And Related Symptoms,1454,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,10839.94,,,,,,,fee schedule,10839.94,10839.94, Acute Bronchitis And Related Symptoms,1454,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,10839.94,,,,,,,fee schedule,10839.94,10839.94, Acute Bronchitis And Related Symptoms,1454,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,10839.94,,,,,,,fee schedule,10839.94,10839.94, Acute Bronchitis And Related Symptoms,1454,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,10839.94,,,,,,,fee schedule,10839.94,10839.94, Major Cardiothoracic Repair Of Heart Anomaly,1601,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,24620.83,,,,,,,fee schedule,24620.83,24620.83, Major Cardiothoracic Repair Of Heart Anomaly,1601,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,24620.83,,,,,,,fee schedule,24620.83,24620.83, Major Cardiothoracic Repair Of Heart Anomaly,1601,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,24620.83,,,,,,,fee schedule,24620.83,24620.83, Major Cardiothoracic Repair Of Heart Anomaly,1601,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,24620.83,,,,,,,fee schedule,24620.83,24620.83, Major Cardiothoracic Repair Of Heart Anomaly,1601,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,24620.83,,,,,,,fee schedule,24620.83,24620.83, Major Cardiothoracic Repair Of Heart Anomaly,1601,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,24620.83,,,,,,,fee schedule,24620.83,24620.83, Major Cardiothoracic Repair Of Heart Anomaly,1601,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,24620.83,,,,,,,fee schedule,24620.83,24620.83, Major Cardiothoracic Repair Of Heart Anomaly,1601,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,24620.83,,,,,,,fee schedule,24620.83,24620.83, Major Cardiothoracic Repair Of Heart Anomaly,1601,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,24620.83,,,,,,,fee schedule,24620.83,24620.83, Major Cardiothoracic Repair Of Heart Anomaly,1601,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,24620.83,,,,,,,fee schedule,24620.83,24620.83, Major Cardiothoracic Repair Of Heart Anomaly,1601,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,24620.83,,,,,,,fee schedule,24620.83,24620.83, Major Cardiothoracic Repair Of Heart Anomaly,1602,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,34815.7,,,,,,,fee schedule,34815.7,34815.7, Major Cardiothoracic Repair Of Heart Anomaly,1602,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,34815.7,,,,,,,fee schedule,34815.7,34815.7, Major Cardiothoracic Repair Of Heart Anomaly,1602,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,34815.7,,,,,,,fee schedule,34815.7,34815.7, Major Cardiothoracic Repair Of Heart Anomaly,1602,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,34815.7,,,,,,,fee schedule,34815.7,34815.7, Major Cardiothoracic Repair Of Heart Anomaly,1602,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,34815.7,,,,,,,fee schedule,34815.7,34815.7, Major Cardiothoracic Repair Of Heart Anomaly,1602,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,34815.7,,,,,,,fee schedule,34815.7,34815.7, Major Cardiothoracic Repair Of Heart Anomaly,1602,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,34815.7,,,,,,,fee schedule,34815.7,34815.7, Major Cardiothoracic Repair Of Heart Anomaly,1602,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,34815.7,,,,,,,fee schedule,34815.7,34815.7, Major Cardiothoracic Repair Of Heart Anomaly,1602,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,34815.7,,,,,,,fee schedule,34815.7,34815.7, Major Cardiothoracic Repair Of Heart Anomaly,1602,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,34815.7,,,,,,,fee schedule,34815.7,34815.7, Major Cardiothoracic Repair Of Heart Anomaly,1602,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,34815.7,,,,,,,fee schedule,34815.7,34815.7, Major Cardiothoracic Repair Of Heart Anomaly,1603,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,46470.1,,,,,,,fee schedule,46470.1,46470.1, Major Cardiothoracic Repair Of Heart Anomaly,1603,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,46470.1,,,,,,,fee schedule,46470.1,46470.1, Major Cardiothoracic Repair Of Heart Anomaly,1603,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,46470.1,,,,,,,fee schedule,46470.1,46470.1, Major Cardiothoracic Repair Of Heart Anomaly,1603,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,46470.1,,,,,,,fee schedule,46470.1,46470.1, Major Cardiothoracic Repair Of Heart Anomaly,1603,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,46470.1,,,,,,,fee schedule,46470.1,46470.1, Major Cardiothoracic Repair Of Heart Anomaly,1603,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,46470.1,,,,,,,fee schedule,46470.1,46470.1, Major Cardiothoracic Repair Of Heart Anomaly,1603,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,46470.1,,,,,,,fee schedule,46470.1,46470.1, Major Cardiothoracic Repair Of Heart Anomaly,1603,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,46470.1,,,,,,,fee schedule,46470.1,46470.1, Major Cardiothoracic Repair Of Heart Anomaly,1603,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,46470.1,,,,,,,fee schedule,46470.1,46470.1, Major Cardiothoracic Repair Of Heart Anomaly,1603,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,46470.1,,,,,,,fee schedule,46470.1,46470.1, Major Cardiothoracic Repair Of Heart Anomaly,1603,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,46470.1,,,,,,,fee schedule,46470.1,46470.1, Major Cardiothoracic Repair Of Heart Anomaly,1604,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,100259.04,,,,,,,fee schedule,100259.04,100259.04, Major Cardiothoracic Repair Of Heart Anomaly,1604,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,100259.04,,,,,,,fee schedule,100259.04,100259.04, Major Cardiothoracic Repair Of Heart Anomaly,1604,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,100259.04,,,,,,,fee schedule,100259.04,100259.04, Major Cardiothoracic Repair Of Heart Anomaly,1604,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,100259.04,,,,,,,fee schedule,100259.04,100259.04, Major Cardiothoracic Repair Of Heart Anomaly,1604,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,100259.04,,,,,,,fee schedule,100259.04,100259.04, Major Cardiothoracic Repair Of Heart Anomaly,1604,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,100259.04,,,,,,,fee schedule,100259.04,100259.04, Major Cardiothoracic Repair Of Heart Anomaly,1604,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,100259.04,,,,,,,fee schedule,100259.04,100259.04, Major Cardiothoracic Repair Of Heart Anomaly,1604,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,100259.04,,,,,,,fee schedule,100259.04,100259.04, Major Cardiothoracic Repair Of Heart Anomaly,1604,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,100259.04,,,,,,,fee schedule,100259.04,100259.04, Major Cardiothoracic Repair Of Heart Anomaly,1604,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,100259.04,,,,,,,fee schedule,100259.04,100259.04, Major Cardiothoracic Repair Of Heart Anomaly,1604,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,100259.04,,,,,,,fee schedule,100259.04,100259.04, Implantable Heart Assist Systems,1611,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,100625.34,,,,,,,fee schedule,100625.34,100625.34, Implantable Heart Assist Systems,1611,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,100625.34,,,,,,,fee schedule,100625.34,100625.34, Implantable Heart Assist Systems,1611,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,100625.34,,,,,,,fee schedule,100625.34,100625.34, Implantable Heart Assist Systems,1611,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,100625.34,,,,,,,fee schedule,100625.34,100625.34, Implantable Heart Assist Systems,1611,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,100625.34,,,,,,,fee schedule,100625.34,100625.34, Implantable Heart Assist Systems,1611,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,100625.34,,,,,,,fee schedule,100625.34,100625.34, Implantable Heart Assist Systems,1611,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,100625.34,,,,,,,fee schedule,100625.34,100625.34, Implantable Heart Assist Systems,1611,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,100625.34,,,,,,,fee schedule,100625.34,100625.34, Implantable Heart Assist Systems,1611,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,100625.34,,,,,,,fee schedule,100625.34,100625.34, Implantable Heart Assist Systems,1611,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,100625.34,,,,,,,fee schedule,100625.34,100625.34, Implantable Heart Assist Systems,1611,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,100625.34,,,,,,,fee schedule,100625.34,100625.34, Implantable Heart Assist Systems,1612,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,100625.34,,,,,,,fee schedule,100625.34,100625.34, Implantable Heart Assist Systems,1612,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,100625.34,,,,,,,fee schedule,100625.34,100625.34, Implantable Heart Assist Systems,1612,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,100625.34,,,,,,,fee schedule,100625.34,100625.34, Implantable Heart Assist Systems,1612,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,100625.34,,,,,,,fee schedule,100625.34,100625.34, Implantable Heart Assist Systems,1612,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,100625.34,,,,,,,fee schedule,100625.34,100625.34, Implantable Heart Assist Systems,1612,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,100625.34,,,,,,,fee schedule,100625.34,100625.34, Implantable Heart Assist Systems,1612,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,100625.34,,,,,,,fee schedule,100625.34,100625.34, Implantable Heart Assist Systems,1612,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,100625.34,,,,,,,fee schedule,100625.34,100625.34, Implantable Heart Assist Systems,1612,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,100625.34,,,,,,,fee schedule,100625.34,100625.34, Implantable Heart Assist Systems,1612,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,100625.34,,,,,,,fee schedule,100625.34,100625.34, Implantable Heart Assist Systems,1612,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,100625.34,,,,,,,fee schedule,100625.34,100625.34, Implantable Heart Assist Systems,1613,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,136755.88,,,,,,,fee schedule,136755.88,136755.88, Implantable Heart Assist Systems,1613,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,136755.88,,,,,,,fee schedule,136755.88,136755.88, Implantable Heart Assist Systems,1613,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,136755.88,,,,,,,fee schedule,136755.88,136755.88, Implantable Heart Assist Systems,1613,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,136755.88,,,,,,,fee schedule,136755.88,136755.88, Implantable Heart Assist Systems,1613,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,136755.88,,,,,,,fee schedule,136755.88,136755.88, Implantable Heart Assist Systems,1613,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,136755.88,,,,,,,fee schedule,136755.88,136755.88, Implantable Heart Assist Systems,1613,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,136755.88,,,,,,,fee schedule,136755.88,136755.88, Implantable Heart Assist Systems,1613,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,136755.88,,,,,,,fee schedule,136755.88,136755.88, Implantable Heart Assist Systems,1613,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,136755.88,,,,,,,fee schedule,136755.88,136755.88, Implantable Heart Assist Systems,1613,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,136755.88,,,,,,,fee schedule,136755.88,136755.88, Implantable Heart Assist Systems,1613,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,136755.88,,,,,,,fee schedule,136755.88,136755.88, Implantable Heart Assist Systems,1614,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,174650.86,,,,,,,fee schedule,174650.86,174650.86, Implantable Heart Assist Systems,1614,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,174650.86,,,,,,,fee schedule,174650.86,174650.86, Implantable Heart Assist Systems,1614,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,174650.86,,,,,,,fee schedule,174650.86,174650.86, Implantable Heart Assist Systems,1614,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,174650.86,,,,,,,fee schedule,174650.86,174650.86, Implantable Heart Assist Systems,1614,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,174650.86,,,,,,,fee schedule,174650.86,174650.86, Implantable Heart Assist Systems,1614,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,174650.86,,,,,,,fee schedule,174650.86,174650.86, Implantable Heart Assist Systems,1614,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,174650.86,,,,,,,fee schedule,174650.86,174650.86, Implantable Heart Assist Systems,1614,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,174650.86,,,,,,,fee schedule,174650.86,174650.86, Implantable Heart Assist Systems,1614,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,174650.86,,,,,,,fee schedule,174650.86,174650.86, Implantable Heart Assist Systems,1614,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,174650.86,,,,,,,fee schedule,174650.86,174650.86, Implantable Heart Assist Systems,1614,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,174650.86,,,,,,,fee schedule,174650.86,174650.86, Cardiac Valve Procedures With Ami Or Complex Principal Diagnosis,1621,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,31048.99,,,,,,,fee schedule,31048.99,31048.99, Cardiac Valve Procedures With Ami Or Complex Principal Diagnosis,1621,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,31048.99,,,,,,,fee schedule,31048.99,31048.99, Cardiac Valve Procedures With Ami Or Complex Principal Diagnosis,1621,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,31048.99,,,,,,,fee schedule,31048.99,31048.99, Cardiac Valve Procedures With Ami Or Complex Principal Diagnosis,1621,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,31048.99,,,,,,,fee schedule,31048.99,31048.99, Cardiac Valve Procedures With Ami Or Complex Principal Diagnosis,1621,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,31048.99,,,,,,,fee schedule,31048.99,31048.99, Cardiac Valve Procedures With Ami Or Complex Principal Diagnosis,1621,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,31048.99,,,,,,,fee schedule,31048.99,31048.99, Cardiac Valve Procedures With Ami Or Complex Principal Diagnosis,1621,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,31048.99,,,,,,,fee schedule,31048.99,31048.99, Cardiac Valve Procedures With Ami Or Complex Principal Diagnosis,1621,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,31048.99,,,,,,,fee schedule,31048.99,31048.99, Cardiac Valve Procedures With Ami Or Complex Principal Diagnosis,1621,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,31048.99,,,,,,,fee schedule,31048.99,31048.99, Cardiac Valve Procedures With Ami Or Complex Principal Diagnosis,1621,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,31048.99,,,,,,,fee schedule,31048.99,31048.99, Cardiac Valve Procedures With Ami Or Complex Principal Diagnosis,1621,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,31048.99,,,,,,,fee schedule,31048.99,31048.99, Cardiac Valve Procedures With Ami Or Complex Principal Diagnosis,1622,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,37261.19,,,,,,,fee schedule,37261.19,37261.19, Cardiac Valve Procedures With Ami Or Complex Principal Diagnosis,1622,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,37261.19,,,,,,,fee schedule,37261.19,37261.19, Cardiac Valve Procedures With Ami Or Complex Principal Diagnosis,1622,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,37261.19,,,,,,,fee schedule,37261.19,37261.19, Cardiac Valve Procedures With Ami Or Complex Principal Diagnosis,1622,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,37261.19,,,,,,,fee schedule,37261.19,37261.19, Cardiac Valve Procedures With Ami Or Complex Principal Diagnosis,1622,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,37261.19,,,,,,,fee schedule,37261.19,37261.19, Cardiac Valve Procedures With Ami Or Complex Principal Diagnosis,1622,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,37261.19,,,,,,,fee schedule,37261.19,37261.19, Cardiac Valve Procedures With Ami Or Complex Principal Diagnosis,1622,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,37261.19,,,,,,,fee schedule,37261.19,37261.19, Cardiac Valve Procedures With Ami Or Complex Principal Diagnosis,1622,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,37261.19,,,,,,,fee schedule,37261.19,37261.19, Cardiac Valve Procedures With Ami Or Complex Principal Diagnosis,1622,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,37261.19,,,,,,,fee schedule,37261.19,37261.19, Cardiac Valve Procedures With Ami Or Complex Principal Diagnosis,1622,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,37261.19,,,,,,,fee schedule,37261.19,37261.19, Cardiac Valve Procedures With Ami Or Complex Principal Diagnosis,1622,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,37261.19,,,,,,,fee schedule,37261.19,37261.19, Cardiac Valve Procedures With Ami Or Complex Principal Diagnosis,1623,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,49286.83,,,,,,,fee schedule,49286.83,49286.83, Cardiac Valve Procedures With Ami Or Complex Principal Diagnosis,1623,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,49286.83,,,,,,,fee schedule,49286.83,49286.83, Cardiac Valve Procedures With Ami Or Complex Principal Diagnosis,1623,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,49286.83,,,,,,,fee schedule,49286.83,49286.83, Cardiac Valve Procedures With Ami Or Complex Principal Diagnosis,1623,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,49286.83,,,,,,,fee schedule,49286.83,49286.83, Cardiac Valve Procedures With Ami Or Complex Principal Diagnosis,1623,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,49286.83,,,,,,,fee schedule,49286.83,49286.83, Cardiac Valve Procedures With Ami Or Complex Principal Diagnosis,1623,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,49286.83,,,,,,,fee schedule,49286.83,49286.83, Cardiac Valve Procedures With Ami Or Complex Principal Diagnosis,1623,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,49286.83,,,,,,,fee schedule,49286.83,49286.83, Cardiac Valve Procedures With Ami Or Complex Principal Diagnosis,1623,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,49286.83,,,,,,,fee schedule,49286.83,49286.83, Cardiac Valve Procedures With Ami Or Complex Principal Diagnosis,1623,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,49286.83,,,,,,,fee schedule,49286.83,49286.83, Cardiac Valve Procedures With Ami Or Complex Principal Diagnosis,1623,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,49286.83,,,,,,,fee schedule,49286.83,49286.83, Cardiac Valve Procedures With Ami Or Complex Principal Diagnosis,1623,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,49286.83,,,,,,,fee schedule,49286.83,49286.83, Cardiac Valve Procedures With Ami Or Complex Principal Diagnosis,1624,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,67377.86,,,,,,,fee schedule,67377.86,67377.86, Cardiac Valve Procedures With Ami Or Complex Principal Diagnosis,1624,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,67377.86,,,,,,,fee schedule,67377.86,67377.86, Cardiac Valve Procedures With Ami Or Complex Principal Diagnosis,1624,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,67377.86,,,,,,,fee schedule,67377.86,67377.86, Cardiac Valve Procedures With Ami Or Complex Principal Diagnosis,1624,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,67377.86,,,,,,,fee schedule,67377.86,67377.86, Cardiac Valve Procedures With Ami Or Complex Principal Diagnosis,1624,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,67377.86,,,,,,,fee schedule,67377.86,67377.86, Cardiac Valve Procedures With Ami Or Complex Principal Diagnosis,1624,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,67377.86,,,,,,,fee schedule,67377.86,67377.86, Cardiac Valve Procedures With Ami Or Complex Principal Diagnosis,1624,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,67377.86,,,,,,,fee schedule,67377.86,67377.86, Cardiac Valve Procedures With Ami Or Complex Principal Diagnosis,1624,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,67377.86,,,,,,,fee schedule,67377.86,67377.86, Cardiac Valve Procedures With Ami Or Complex Principal Diagnosis,1624,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,67377.86,,,,,,,fee schedule,67377.86,67377.86, Cardiac Valve Procedures With Ami Or Complex Principal Diagnosis,1624,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,67377.86,,,,,,,fee schedule,67377.86,67377.86, Cardiac Valve Procedures With Ami Or Complex Principal Diagnosis,1624,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,67377.86,,,,,,,fee schedule,67377.86,67377.86, Cardiac Valve Procedures Without Ami Or Complex Principal Diagnosis,1631,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,26216.58,,,,,,,fee schedule,26216.58,26216.58, Cardiac Valve Procedures Without Ami Or Complex Principal Diagnosis,1631,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,26216.58,,,,,,,fee schedule,26216.58,26216.58, Cardiac Valve Procedures Without Ami Or Complex Principal Diagnosis,1631,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,26216.58,,,,,,,fee schedule,26216.58,26216.58, Cardiac Valve Procedures Without Ami Or Complex Principal Diagnosis,1631,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,26216.58,,,,,,,fee schedule,26216.58,26216.58, Cardiac Valve Procedures Without Ami Or Complex Principal Diagnosis,1631,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,26216.58,,,,,,,fee schedule,26216.58,26216.58, Cardiac Valve Procedures Without Ami Or Complex Principal Diagnosis,1631,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,26216.58,,,,,,,fee schedule,26216.58,26216.58, Cardiac Valve Procedures Without Ami Or Complex Principal Diagnosis,1631,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,26216.58,,,,,,,fee schedule,26216.58,26216.58, Cardiac Valve Procedures Without Ami Or Complex Principal Diagnosis,1631,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,26216.58,,,,,,,fee schedule,26216.58,26216.58, Cardiac Valve Procedures Without Ami Or Complex Principal Diagnosis,1631,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,26216.58,,,,,,,fee schedule,26216.58,26216.58, Cardiac Valve Procedures Without Ami Or Complex Principal Diagnosis,1631,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,26216.58,,,,,,,fee schedule,26216.58,26216.58, Cardiac Valve Procedures Without Ami Or Complex Principal Diagnosis,1631,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,26216.58,,,,,,,fee schedule,26216.58,26216.58, Cardiac Valve Procedures Without Ami Or Complex Principal Diagnosis,1632,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,31281.9,,,,,,,fee schedule,31281.9,31281.9, Cardiac Valve Procedures Without Ami Or Complex Principal Diagnosis,1632,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,31281.9,,,,,,,fee schedule,31281.9,31281.9, Cardiac Valve Procedures Without Ami Or Complex Principal Diagnosis,1632,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,31281.9,,,,,,,fee schedule,31281.9,31281.9, Cardiac Valve Procedures Without Ami Or Complex Principal Diagnosis,1632,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,31281.9,,,,,,,fee schedule,31281.9,31281.9, Cardiac Valve Procedures Without Ami Or Complex Principal Diagnosis,1632,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,31281.9,,,,,,,fee schedule,31281.9,31281.9, Cardiac Valve Procedures Without Ami Or Complex Principal Diagnosis,1632,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,31281.9,,,,,,,fee schedule,31281.9,31281.9, Cardiac Valve Procedures Without Ami Or Complex Principal Diagnosis,1632,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,31281.9,,,,,,,fee schedule,31281.9,31281.9, Cardiac Valve Procedures Without Ami Or Complex Principal Diagnosis,1632,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,31281.9,,,,,,,fee schedule,31281.9,31281.9, Cardiac Valve Procedures Without Ami Or Complex Principal Diagnosis,1632,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,31281.9,,,,,,,fee schedule,31281.9,31281.9, Cardiac Valve Procedures Without Ami Or Complex Principal Diagnosis,1632,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,31281.9,,,,,,,fee schedule,31281.9,31281.9, Cardiac Valve Procedures Without Ami Or Complex Principal Diagnosis,1632,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,31281.9,,,,,,,fee schedule,31281.9,31281.9, Cardiac Valve Procedures Without Ami Or Complex Principal Diagnosis,1633,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,42385.09,,,,,,,fee schedule,42385.09,42385.09, Cardiac Valve Procedures Without Ami Or Complex Principal Diagnosis,1633,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,42385.09,,,,,,,fee schedule,42385.09,42385.09, Cardiac Valve Procedures Without Ami Or Complex Principal Diagnosis,1633,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,42385.09,,,,,,,fee schedule,42385.09,42385.09, Cardiac Valve Procedures Without Ami Or Complex Principal Diagnosis,1633,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,42385.09,,,,,,,fee schedule,42385.09,42385.09, Cardiac Valve Procedures Without Ami Or Complex Principal Diagnosis,1633,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,42385.09,,,,,,,fee schedule,42385.09,42385.09, Cardiac Valve Procedures Without Ami Or Complex Principal Diagnosis,1633,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,42385.09,,,,,,,fee schedule,42385.09,42385.09, Cardiac Valve Procedures Without Ami Or Complex Principal Diagnosis,1633,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,42385.09,,,,,,,fee schedule,42385.09,42385.09, Cardiac Valve Procedures Without Ami Or Complex Principal Diagnosis,1633,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,42385.09,,,,,,,fee schedule,42385.09,42385.09, Cardiac Valve Procedures Without Ami Or Complex Principal Diagnosis,1633,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,42385.09,,,,,,,fee schedule,42385.09,42385.09, Cardiac Valve Procedures Without Ami Or Complex Principal Diagnosis,1633,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,42385.09,,,,,,,fee schedule,42385.09,42385.09, Cardiac Valve Procedures Without Ami Or Complex Principal Diagnosis,1633,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,42385.09,,,,,,,fee schedule,42385.09,42385.09, Cardiac Valve Procedures Without Ami Or Complex Principal Diagnosis,1634,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,58958.01,,,,,,,fee schedule,58958.01,58958.01, Cardiac Valve Procedures Without Ami Or Complex Principal Diagnosis,1634,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,58958.01,,,,,,,fee schedule,58958.01,58958.01, Cardiac Valve Procedures Without Ami Or Complex Principal Diagnosis,1634,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,58958.01,,,,,,,fee schedule,58958.01,58958.01, Cardiac Valve Procedures Without Ami Or Complex Principal Diagnosis,1634,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,58958.01,,,,,,,fee schedule,58958.01,58958.01, Cardiac Valve Procedures Without Ami Or Complex Principal Diagnosis,1634,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,58958.01,,,,,,,fee schedule,58958.01,58958.01, Cardiac Valve Procedures Without Ami Or Complex Principal Diagnosis,1634,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,58958.01,,,,,,,fee schedule,58958.01,58958.01, Cardiac Valve Procedures Without Ami Or Complex Principal Diagnosis,1634,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,58958.01,,,,,,,fee schedule,58958.01,58958.01, Cardiac Valve Procedures Without Ami Or Complex Principal Diagnosis,1634,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,58958.01,,,,,,,fee schedule,58958.01,58958.01, Cardiac Valve Procedures Without Ami Or Complex Principal Diagnosis,1634,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,58958.01,,,,,,,fee schedule,58958.01,58958.01, Cardiac Valve Procedures Without Ami Or Complex Principal Diagnosis,1634,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,58958.01,,,,,,,fee schedule,58958.01,58958.01, Cardiac Valve Procedures Without Ami Or Complex Principal Diagnosis,1634,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,58958.01,,,,,,,fee schedule,58958.01,58958.01, Coronary Bypass With Ami Or Complex Principal Diagnosis,1651,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,28439.76,,,,,,,fee schedule,28439.76,28439.76, Coronary Bypass With Ami Or Complex Principal Diagnosis,1651,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,28439.76,,,,,,,fee schedule,28439.76,28439.76, Coronary Bypass With Ami Or Complex Principal Diagnosis,1651,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,28439.76,,,,,,,fee schedule,28439.76,28439.76, Coronary Bypass With Ami Or Complex Principal Diagnosis,1651,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,28439.76,,,,,,,fee schedule,28439.76,28439.76, Coronary Bypass With Ami Or Complex Principal Diagnosis,1651,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,28439.76,,,,,,,fee schedule,28439.76,28439.76, Coronary Bypass With Ami Or Complex Principal Diagnosis,1651,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,28439.76,,,,,,,fee schedule,28439.76,28439.76, Coronary Bypass With Ami Or Complex Principal Diagnosis,1651,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,28439.76,,,,,,,fee schedule,28439.76,28439.76, Coronary Bypass With Ami Or Complex Principal Diagnosis,1651,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,28439.76,,,,,,,fee schedule,28439.76,28439.76, Coronary Bypass With Ami Or Complex Principal Diagnosis,1651,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,28439.76,,,,,,,fee schedule,28439.76,28439.76, Coronary Bypass With Ami Or Complex Principal Diagnosis,1651,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,28439.76,,,,,,,fee schedule,28439.76,28439.76, Coronary Bypass With Ami Or Complex Principal Diagnosis,1651,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,28439.76,,,,,,,fee schedule,28439.76,28439.76, Coronary Bypass With Ami Or Complex Principal Diagnosis,1652,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,31737.83,,,,,,,fee schedule,31737.83,31737.83, Coronary Bypass With Ami Or Complex Principal Diagnosis,1652,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,31737.83,,,,,,,fee schedule,31737.83,31737.83, Coronary Bypass With Ami Or Complex Principal Diagnosis,1652,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,31737.83,,,,,,,fee schedule,31737.83,31737.83, Coronary Bypass With Ami Or Complex Principal Diagnosis,1652,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,31737.83,,,,,,,fee schedule,31737.83,31737.83, Coronary Bypass With Ami Or Complex Principal Diagnosis,1652,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,31737.83,,,,,,,fee schedule,31737.83,31737.83, Coronary Bypass With Ami Or Complex Principal Diagnosis,1652,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,31737.83,,,,,,,fee schedule,31737.83,31737.83, Coronary Bypass With Ami Or Complex Principal Diagnosis,1652,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,31737.83,,,,,,,fee schedule,31737.83,31737.83, Coronary Bypass With Ami Or Complex Principal Diagnosis,1652,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,31737.83,,,,,,,fee schedule,31737.83,31737.83, Coronary Bypass With Ami Or Complex Principal Diagnosis,1652,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,31737.83,,,,,,,fee schedule,31737.83,31737.83, Coronary Bypass With Ami Or Complex Principal Diagnosis,1652,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,31737.83,,,,,,,fee schedule,31737.83,31737.83, Coronary Bypass With Ami Or Complex Principal Diagnosis,1652,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,31737.83,,,,,,,fee schedule,31737.83,31737.83, Coronary Bypass With Ami Or Complex Principal Diagnosis,1653,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,39361.57,,,,,,,fee schedule,39361.57,39361.57, Coronary Bypass With Ami Or Complex Principal Diagnosis,1653,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,39361.57,,,,,,,fee schedule,39361.57,39361.57, Coronary Bypass With Ami Or Complex Principal Diagnosis,1653,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,39361.57,,,,,,,fee schedule,39361.57,39361.57, Coronary Bypass With Ami Or Complex Principal Diagnosis,1653,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,39361.57,,,,,,,fee schedule,39361.57,39361.57, Coronary Bypass With Ami Or Complex Principal Diagnosis,1653,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,39361.57,,,,,,,fee schedule,39361.57,39361.57, Coronary Bypass With Ami Or Complex Principal Diagnosis,1653,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,39361.57,,,,,,,fee schedule,39361.57,39361.57, Coronary Bypass With Ami Or Complex Principal Diagnosis,1653,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,39361.57,,,,,,,fee schedule,39361.57,39361.57, Coronary Bypass With Ami Or Complex Principal Diagnosis,1653,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,39361.57,,,,,,,fee schedule,39361.57,39361.57, Coronary Bypass With Ami Or Complex Principal Diagnosis,1653,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,39361.57,,,,,,,fee schedule,39361.57,39361.57, Coronary Bypass With Ami Or Complex Principal Diagnosis,1653,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,39361.57,,,,,,,fee schedule,39361.57,39361.57, Coronary Bypass With Ami Or Complex Principal Diagnosis,1653,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,39361.57,,,,,,,fee schedule,39361.57,39361.57, Coronary Bypass With Ami Or Complex Principal Diagnosis,1654,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,52968.13,,,,,,,fee schedule,52968.13,52968.13, Coronary Bypass With Ami Or Complex Principal Diagnosis,1654,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,52968.13,,,,,,,fee schedule,52968.13,52968.13, Coronary Bypass With Ami Or Complex Principal Diagnosis,1654,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,52968.13,,,,,,,fee schedule,52968.13,52968.13, Coronary Bypass With Ami Or Complex Principal Diagnosis,1654,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,52968.13,,,,,,,fee schedule,52968.13,52968.13, Coronary Bypass With Ami Or Complex Principal Diagnosis,1654,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,52968.13,,,,,,,fee schedule,52968.13,52968.13, Coronary Bypass With Ami Or Complex Principal Diagnosis,1654,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,52968.13,,,,,,,fee schedule,52968.13,52968.13, Coronary Bypass With Ami Or Complex Principal Diagnosis,1654,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,52968.13,,,,,,,fee schedule,52968.13,52968.13, Coronary Bypass With Ami Or Complex Principal Diagnosis,1654,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,52968.13,,,,,,,fee schedule,52968.13,52968.13, Coronary Bypass With Ami Or Complex Principal Diagnosis,1654,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,52968.13,,,,,,,fee schedule,52968.13,52968.13, Coronary Bypass With Ami Or Complex Principal Diagnosis,1654,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,52968.13,,,,,,,fee schedule,52968.13,52968.13, Coronary Bypass With Ami Or Complex Principal Diagnosis,1654,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,52968.13,,,,,,,fee schedule,52968.13,52968.13, Coronary Bypass Without Ami Or Complex Principal Diagnosis,1661,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,23885.42,,,,,,,fee schedule,23885.42,23885.42, Coronary Bypass Without Ami Or Complex Principal Diagnosis,1661,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,23885.42,,,,,,,fee schedule,23885.42,23885.42, Coronary Bypass Without Ami Or Complex Principal Diagnosis,1661,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,23885.42,,,,,,,fee schedule,23885.42,23885.42, Coronary Bypass Without Ami Or Complex Principal Diagnosis,1661,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,23885.42,,,,,,,fee schedule,23885.42,23885.42, Coronary Bypass Without Ami Or Complex Principal Diagnosis,1661,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,23885.42,,,,,,,fee schedule,23885.42,23885.42, Coronary Bypass Without Ami Or Complex Principal Diagnosis,1661,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,23885.42,,,,,,,fee schedule,23885.42,23885.42, Coronary Bypass Without Ami Or Complex Principal Diagnosis,1661,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,23885.42,,,,,,,fee schedule,23885.42,23885.42, Coronary Bypass Without Ami Or Complex Principal Diagnosis,1661,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,23885.42,,,,,,,fee schedule,23885.42,23885.42, Coronary Bypass Without Ami Or Complex Principal Diagnosis,1661,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,23885.42,,,,,,,fee schedule,23885.42,23885.42, Coronary Bypass Without Ami Or Complex Principal Diagnosis,1661,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,23885.42,,,,,,,fee schedule,23885.42,23885.42, Coronary Bypass Without Ami Or Complex Principal Diagnosis,1661,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,23885.42,,,,,,,fee schedule,23885.42,23885.42, Coronary Bypass Without Ami Or Complex Principal Diagnosis,1662,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,27740.34,,,,,,,fee schedule,27740.34,27740.34, Coronary Bypass Without Ami Or Complex Principal Diagnosis,1662,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,27740.34,,,,,,,fee schedule,27740.34,27740.34, Coronary Bypass Without Ami Or Complex Principal Diagnosis,1662,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,27740.34,,,,,,,fee schedule,27740.34,27740.34, Coronary Bypass Without Ami Or Complex Principal Diagnosis,1662,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,27740.34,,,,,,,fee schedule,27740.34,27740.34, Coronary Bypass Without Ami Or Complex Principal Diagnosis,1662,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,27740.34,,,,,,,fee schedule,27740.34,27740.34, Coronary Bypass Without Ami Or Complex Principal Diagnosis,1662,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,27740.34,,,,,,,fee schedule,27740.34,27740.34, Coronary Bypass Without Ami Or Complex Principal Diagnosis,1662,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,27740.34,,,,,,,fee schedule,27740.34,27740.34, Coronary Bypass Without Ami Or Complex Principal Diagnosis,1662,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,27740.34,,,,,,,fee schedule,27740.34,27740.34, Coronary Bypass Without Ami Or Complex Principal Diagnosis,1662,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,27740.34,,,,,,,fee schedule,27740.34,27740.34, Coronary Bypass Without Ami Or Complex Principal Diagnosis,1662,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,27740.34,,,,,,,fee schedule,27740.34,27740.34, Coronary Bypass Without Ami Or Complex Principal Diagnosis,1662,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,27740.34,,,,,,,fee schedule,27740.34,27740.34, Coronary Bypass Without Ami Or Complex Principal Diagnosis,1663,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,34643.49,,,,,,,fee schedule,34643.49,34643.49, Coronary Bypass Without Ami Or Complex Principal Diagnosis,1663,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,34643.49,,,,,,,fee schedule,34643.49,34643.49, Coronary Bypass Without Ami Or Complex Principal Diagnosis,1663,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,34643.49,,,,,,,fee schedule,34643.49,34643.49, Coronary Bypass Without Ami Or Complex Principal Diagnosis,1663,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,34643.49,,,,,,,fee schedule,34643.49,34643.49, Coronary Bypass Without Ami Or Complex Principal Diagnosis,1663,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,34643.49,,,,,,,fee schedule,34643.49,34643.49, Coronary Bypass Without Ami Or Complex Principal Diagnosis,1663,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,34643.49,,,,,,,fee schedule,34643.49,34643.49, Coronary Bypass Without Ami Or Complex Principal Diagnosis,1663,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,34643.49,,,,,,,fee schedule,34643.49,34643.49, Coronary Bypass Without Ami Or Complex Principal Diagnosis,1663,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,34643.49,,,,,,,fee schedule,34643.49,34643.49, Coronary Bypass Without Ami Or Complex Principal Diagnosis,1663,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,34643.49,,,,,,,fee schedule,34643.49,34643.49, Coronary Bypass Without Ami Or Complex Principal Diagnosis,1663,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,34643.49,,,,,,,fee schedule,34643.49,34643.49, Coronary Bypass Without Ami Or Complex Principal Diagnosis,1663,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,34643.49,,,,,,,fee schedule,34643.49,34643.49, Coronary Bypass Without Ami Or Complex Principal Diagnosis,1664,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,47220.33,,,,,,,fee schedule,47220.33,47220.33, Coronary Bypass Without Ami Or Complex Principal Diagnosis,1664,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,47220.33,,,,,,,fee schedule,47220.33,47220.33, Coronary Bypass Without Ami Or Complex Principal Diagnosis,1664,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,47220.33,,,,,,,fee schedule,47220.33,47220.33, Coronary Bypass Without Ami Or Complex Principal Diagnosis,1664,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,47220.33,,,,,,,fee schedule,47220.33,47220.33, Coronary Bypass Without Ami Or Complex Principal Diagnosis,1664,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,47220.33,,,,,,,fee schedule,47220.33,47220.33, Coronary Bypass Without Ami Or Complex Principal Diagnosis,1664,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,47220.33,,,,,,,fee schedule,47220.33,47220.33, Coronary Bypass Without Ami Or Complex Principal Diagnosis,1664,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,47220.33,,,,,,,fee schedule,47220.33,47220.33, Coronary Bypass Without Ami Or Complex Principal Diagnosis,1664,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,47220.33,,,,,,,fee schedule,47220.33,47220.33, Coronary Bypass Without Ami Or Complex Principal Diagnosis,1664,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,47220.33,,,,,,,fee schedule,47220.33,47220.33, Coronary Bypass Without Ami Or Complex Principal Diagnosis,1664,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,47220.33,,,,,,,fee schedule,47220.33,47220.33, Coronary Bypass Without Ami Or Complex Principal Diagnosis,1664,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,47220.33,,,,,,,fee schedule,47220.33,47220.33, Other Cardiothoracic And Thoracic Vascular Procedures,1671,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,19065.7,,,,,,,fee schedule,19065.7,19065.7, Other Cardiothoracic And Thoracic Vascular Procedures,1671,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,19065.7,,,,,,,fee schedule,19065.7,19065.7, Other Cardiothoracic And Thoracic Vascular Procedures,1671,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,19065.7,,,,,,,fee schedule,19065.7,19065.7, Other Cardiothoracic And Thoracic Vascular Procedures,1671,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,19065.7,,,,,,,fee schedule,19065.7,19065.7, Other Cardiothoracic And Thoracic Vascular Procedures,1671,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,19065.7,,,,,,,fee schedule,19065.7,19065.7, Other Cardiothoracic And Thoracic Vascular Procedures,1671,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,19065.7,,,,,,,fee schedule,19065.7,19065.7, Other Cardiothoracic And Thoracic Vascular Procedures,1671,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,19065.7,,,,,,,fee schedule,19065.7,19065.7, Other Cardiothoracic And Thoracic Vascular Procedures,1671,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,19065.7,,,,,,,fee schedule,19065.7,19065.7, Other Cardiothoracic And Thoracic Vascular Procedures,1671,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,19065.7,,,,,,,fee schedule,19065.7,19065.7, Other Cardiothoracic And Thoracic Vascular Procedures,1671,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,19065.7,,,,,,,fee schedule,19065.7,19065.7, Other Cardiothoracic And Thoracic Vascular Procedures,1671,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,19065.7,,,,,,,fee schedule,19065.7,19065.7, Other Cardiothoracic And Thoracic Vascular Procedures,1672,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,24162.78,,,,,,,fee schedule,24162.78,24162.78, Other Cardiothoracic And Thoracic Vascular Procedures,1672,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,24162.78,,,,,,,fee schedule,24162.78,24162.78, Other Cardiothoracic And Thoracic Vascular Procedures,1672,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,24162.78,,,,,,,fee schedule,24162.78,24162.78, Other Cardiothoracic And Thoracic Vascular Procedures,1672,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,24162.78,,,,,,,fee schedule,24162.78,24162.78, Other Cardiothoracic And Thoracic Vascular Procedures,1672,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,24162.78,,,,,,,fee schedule,24162.78,24162.78, Other Cardiothoracic And Thoracic Vascular Procedures,1672,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,24162.78,,,,,,,fee schedule,24162.78,24162.78, Other Cardiothoracic And Thoracic Vascular Procedures,1672,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,24162.78,,,,,,,fee schedule,24162.78,24162.78, Other Cardiothoracic And Thoracic Vascular Procedures,1672,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,24162.78,,,,,,,fee schedule,24162.78,24162.78, Other Cardiothoracic And Thoracic Vascular Procedures,1672,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,24162.78,,,,,,,fee schedule,24162.78,24162.78, Other Cardiothoracic And Thoracic Vascular Procedures,1672,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,24162.78,,,,,,,fee schedule,24162.78,24162.78, Other Cardiothoracic And Thoracic Vascular Procedures,1672,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,24162.78,,,,,,,fee schedule,24162.78,24162.78, Other Cardiothoracic And Thoracic Vascular Procedures,1673,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,32942.58,,,,,,,fee schedule,32942.58,32942.58, Other Cardiothoracic And Thoracic Vascular Procedures,1673,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,32942.58,,,,,,,fee schedule,32942.58,32942.58, Other Cardiothoracic And Thoracic Vascular Procedures,1673,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,32942.58,,,,,,,fee schedule,32942.58,32942.58, Other Cardiothoracic And Thoracic Vascular Procedures,1673,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,32942.58,,,,,,,fee schedule,32942.58,32942.58, Other Cardiothoracic And Thoracic Vascular Procedures,1673,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,32942.58,,,,,,,fee schedule,32942.58,32942.58, Other Cardiothoracic And Thoracic Vascular Procedures,1673,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,32942.58,,,,,,,fee schedule,32942.58,32942.58, Other Cardiothoracic And Thoracic Vascular Procedures,1673,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,32942.58,,,,,,,fee schedule,32942.58,32942.58, Other Cardiothoracic And Thoracic Vascular Procedures,1673,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,32942.58,,,,,,,fee schedule,32942.58,32942.58, Other Cardiothoracic And Thoracic Vascular Procedures,1673,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,32942.58,,,,,,,fee schedule,32942.58,32942.58, Other Cardiothoracic And Thoracic Vascular Procedures,1673,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,32942.58,,,,,,,fee schedule,32942.58,32942.58, Other Cardiothoracic And Thoracic Vascular Procedures,1673,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,32942.58,,,,,,,fee schedule,32942.58,32942.58, Other Cardiothoracic And Thoracic Vascular Procedures,1674,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,51898.89,,,,,,,fee schedule,51898.89,51898.89, Other Cardiothoracic And Thoracic Vascular Procedures,1674,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,51898.89,,,,,,,fee schedule,51898.89,51898.89, Other Cardiothoracic And Thoracic Vascular Procedures,1674,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,51898.89,,,,,,,fee schedule,51898.89,51898.89, Other Cardiothoracic And Thoracic Vascular Procedures,1674,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,51898.89,,,,,,,fee schedule,51898.89,51898.89, Other Cardiothoracic And Thoracic Vascular Procedures,1674,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,51898.89,,,,,,,fee schedule,51898.89,51898.89, Other Cardiothoracic And Thoracic Vascular Procedures,1674,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,51898.89,,,,,,,fee schedule,51898.89,51898.89, Other Cardiothoracic And Thoracic Vascular Procedures,1674,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,51898.89,,,,,,,fee schedule,51898.89,51898.89, Other Cardiothoracic And Thoracic Vascular Procedures,1674,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,51898.89,,,,,,,fee schedule,51898.89,51898.89, Other Cardiothoracic And Thoracic Vascular Procedures,1674,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,51898.89,,,,,,,fee schedule,51898.89,51898.89, Other Cardiothoracic And Thoracic Vascular Procedures,1674,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,51898.89,,,,,,,fee schedule,51898.89,51898.89, Other Cardiothoracic And Thoracic Vascular Procedures,1674,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,51898.89,,,,,,,fee schedule,51898.89,51898.89, Major Abdominal Vascular Procedures,1691,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,19549.86,,,,,,,fee schedule,19549.86,19549.86, Major Abdominal Vascular Procedures,1691,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,19549.86,,,,,,,fee schedule,19549.86,19549.86, Major Abdominal Vascular Procedures,1691,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,19549.86,,,,,,,fee schedule,19549.86,19549.86, Major Abdominal Vascular Procedures,1691,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,19549.86,,,,,,,fee schedule,19549.86,19549.86, Major Abdominal Vascular Procedures,1691,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,19549.86,,,,,,,fee schedule,19549.86,19549.86, Major Abdominal Vascular Procedures,1691,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,19549.86,,,,,,,fee schedule,19549.86,19549.86, Major Abdominal Vascular Procedures,1691,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,19549.86,,,,,,,fee schedule,19549.86,19549.86, Major Abdominal Vascular Procedures,1691,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,19549.86,,,,,,,fee schedule,19549.86,19549.86, Major Abdominal Vascular Procedures,1691,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,19549.86,,,,,,,fee schedule,19549.86,19549.86, Major Abdominal Vascular Procedures,1691,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,19549.86,,,,,,,fee schedule,19549.86,19549.86, Major Abdominal Vascular Procedures,1691,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,19549.86,,,,,,,fee schedule,19549.86,19549.86, Major Abdominal Vascular Procedures,1692,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,23310.21,,,,,,,fee schedule,23310.21,23310.21, Major Abdominal Vascular Procedures,1692,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,23310.21,,,,,,,fee schedule,23310.21,23310.21, Major Abdominal Vascular Procedures,1692,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,23310.21,,,,,,,fee schedule,23310.21,23310.21, Major Abdominal Vascular Procedures,1692,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,23310.21,,,,,,,fee schedule,23310.21,23310.21, Major Abdominal Vascular Procedures,1692,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,23310.21,,,,,,,fee schedule,23310.21,23310.21, Major Abdominal Vascular Procedures,1692,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,23310.21,,,,,,,fee schedule,23310.21,23310.21, Major Abdominal Vascular Procedures,1692,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,23310.21,,,,,,,fee schedule,23310.21,23310.21, Major Abdominal Vascular Procedures,1692,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,23310.21,,,,,,,fee schedule,23310.21,23310.21, Major Abdominal Vascular Procedures,1692,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,23310.21,,,,,,,fee schedule,23310.21,23310.21, Major Abdominal Vascular Procedures,1692,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,23310.21,,,,,,,fee schedule,23310.21,23310.21, Major Abdominal Vascular Procedures,1692,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,23310.21,,,,,,,fee schedule,23310.21,23310.21, Major Abdominal Vascular Procedures,1693,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,29428.54,,,,,,,fee schedule,29428.54,29428.54, Major Abdominal Vascular Procedures,1693,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,29428.54,,,,,,,fee schedule,29428.54,29428.54, Major Abdominal Vascular Procedures,1693,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,29428.54,,,,,,,fee schedule,29428.54,29428.54, Major Abdominal Vascular Procedures,1693,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,29428.54,,,,,,,fee schedule,29428.54,29428.54, Major Abdominal Vascular Procedures,1693,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,29428.54,,,,,,,fee schedule,29428.54,29428.54, Major Abdominal Vascular Procedures,1693,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,29428.54,,,,,,,fee schedule,29428.54,29428.54, Major Abdominal Vascular Procedures,1693,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,29428.54,,,,,,,fee schedule,29428.54,29428.54, Major Abdominal Vascular Procedures,1693,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,29428.54,,,,,,,fee schedule,29428.54,29428.54, Major Abdominal Vascular Procedures,1693,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,29428.54,,,,,,,fee schedule,29428.54,29428.54, Major Abdominal Vascular Procedures,1693,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,29428.54,,,,,,,fee schedule,29428.54,29428.54, Major Abdominal Vascular Procedures,1693,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,29428.54,,,,,,,fee schedule,29428.54,29428.54, Major Abdominal Vascular Procedures,1694,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,42100.67,,,,,,,fee schedule,42100.67,42100.67, Major Abdominal Vascular Procedures,1694,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,42100.67,,,,,,,fee schedule,42100.67,42100.67, Major Abdominal Vascular Procedures,1694,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,42100.67,,,,,,,fee schedule,42100.67,42100.67, Major Abdominal Vascular Procedures,1694,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,42100.67,,,,,,,fee schedule,42100.67,42100.67, Major Abdominal Vascular Procedures,1694,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,42100.67,,,,,,,fee schedule,42100.67,42100.67, Major Abdominal Vascular Procedures,1694,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,42100.67,,,,,,,fee schedule,42100.67,42100.67, Major Abdominal Vascular Procedures,1694,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,42100.67,,,,,,,fee schedule,42100.67,42100.67, Major Abdominal Vascular Procedures,1694,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,42100.67,,,,,,,fee schedule,42100.67,42100.67, Major Abdominal Vascular Procedures,1694,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,42100.67,,,,,,,fee schedule,42100.67,42100.67, Major Abdominal Vascular Procedures,1694,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,42100.67,,,,,,,fee schedule,42100.67,42100.67, Major Abdominal Vascular Procedures,1694,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,42100.67,,,,,,,fee schedule,42100.67,42100.67, "Permanent Cardiac Pacemaker Implant With Ami, Heart Failure Or Shock",1701,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,16173.45,,,,,,,fee schedule,16173.45,16173.45, "Permanent Cardiac Pacemaker Implant With Ami, Heart Failure Or Shock",1701,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,16173.45,,,,,,,fee schedule,16173.45,16173.45, "Permanent Cardiac Pacemaker Implant With Ami, Heart Failure Or Shock",1701,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,16173.45,,,,,,,fee schedule,16173.45,16173.45, "Permanent Cardiac Pacemaker Implant With Ami, Heart Failure Or Shock",1701,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,16173.45,,,,,,,fee schedule,16173.45,16173.45, "Permanent Cardiac Pacemaker Implant With Ami, Heart Failure Or Shock",1701,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,16173.45,,,,,,,fee schedule,16173.45,16173.45, "Permanent Cardiac Pacemaker Implant With Ami, Heart Failure Or Shock",1701,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,16173.45,,,,,,,fee schedule,16173.45,16173.45, "Permanent Cardiac Pacemaker Implant With Ami, Heart Failure Or Shock",1701,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,16173.45,,,,,,,fee schedule,16173.45,16173.45, "Permanent Cardiac Pacemaker Implant With Ami, Heart Failure Or Shock",1701,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,16173.45,,,,,,,fee schedule,16173.45,16173.45, "Permanent Cardiac Pacemaker Implant With Ami, Heart Failure Or Shock",1701,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,16173.45,,,,,,,fee schedule,16173.45,16173.45, "Permanent Cardiac Pacemaker Implant With Ami, Heart Failure Or Shock",1701,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,16173.45,,,,,,,fee schedule,16173.45,16173.45, "Permanent Cardiac Pacemaker Implant With Ami, Heart Failure Or Shock",1701,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,16173.45,,,,,,,fee schedule,16173.45,16173.45, "Permanent Cardiac Pacemaker Implant With Ami, Heart Failure Or Shock",1702,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,17355.62,,,,,,,fee schedule,17355.62,17355.62, "Permanent Cardiac Pacemaker Implant With Ami, Heart Failure Or Shock",1702,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,17355.62,,,,,,,fee schedule,17355.62,17355.62, "Permanent Cardiac Pacemaker Implant With Ami, Heart Failure Or Shock",1702,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,17355.62,,,,,,,fee schedule,17355.62,17355.62, "Permanent Cardiac Pacemaker Implant With Ami, Heart Failure Or Shock",1702,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,17355.62,,,,,,,fee schedule,17355.62,17355.62, "Permanent Cardiac Pacemaker Implant With Ami, Heart Failure Or Shock",1702,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,17355.62,,,,,,,fee schedule,17355.62,17355.62, "Permanent Cardiac Pacemaker Implant With Ami, Heart Failure Or Shock",1702,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,17355.62,,,,,,,fee schedule,17355.62,17355.62, "Permanent Cardiac Pacemaker Implant With Ami, Heart Failure Or Shock",1702,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,17355.62,,,,,,,fee schedule,17355.62,17355.62, "Permanent Cardiac Pacemaker Implant With Ami, Heart Failure Or Shock",1702,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,17355.62,,,,,,,fee schedule,17355.62,17355.62, "Permanent Cardiac Pacemaker Implant With Ami, Heart Failure Or Shock",1702,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,17355.62,,,,,,,fee schedule,17355.62,17355.62, "Permanent Cardiac Pacemaker Implant With Ami, Heart Failure Or Shock",1702,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,17355.62,,,,,,,fee schedule,17355.62,17355.62, "Permanent Cardiac Pacemaker Implant With Ami, Heart Failure Or Shock",1702,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,17355.62,,,,,,,fee schedule,17355.62,17355.62, "Permanent Cardiac Pacemaker Implant With Ami, Heart Failure Or Shock",1703,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,23559.35,,,,,,,fee schedule,23559.35,23559.35, "Permanent Cardiac Pacemaker Implant With Ami, Heart Failure Or Shock",1703,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,23559.35,,,,,,,fee schedule,23559.35,23559.35, "Permanent Cardiac Pacemaker Implant With Ami, Heart Failure Or Shock",1703,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,23559.35,,,,,,,fee schedule,23559.35,23559.35, "Permanent Cardiac Pacemaker Implant With Ami, Heart Failure Or Shock",1703,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,23559.35,,,,,,,fee schedule,23559.35,23559.35, "Permanent Cardiac Pacemaker Implant With Ami, Heart Failure Or Shock",1703,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,23559.35,,,,,,,fee schedule,23559.35,23559.35, "Permanent Cardiac Pacemaker Implant With Ami, Heart Failure Or Shock",1703,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,23559.35,,,,,,,fee schedule,23559.35,23559.35, "Permanent Cardiac Pacemaker Implant With Ami, Heart Failure Or Shock",1703,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,23559.35,,,,,,,fee schedule,23559.35,23559.35, "Permanent Cardiac Pacemaker Implant With Ami, Heart Failure Or Shock",1703,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,23559.35,,,,,,,fee schedule,23559.35,23559.35, "Permanent Cardiac Pacemaker Implant With Ami, Heart Failure Or Shock",1703,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,23559.35,,,,,,,fee schedule,23559.35,23559.35, "Permanent Cardiac Pacemaker Implant With Ami, Heart Failure Or Shock",1703,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,23559.35,,,,,,,fee schedule,23559.35,23559.35, "Permanent Cardiac Pacemaker Implant With Ami, Heart Failure Or Shock",1703,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,23559.35,,,,,,,fee schedule,23559.35,23559.35, "Permanent Cardiac Pacemaker Implant With Ami, Heart Failure Or Shock",1704,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,34725.36,,,,,,,fee schedule,34725.36,34725.36, "Permanent Cardiac Pacemaker Implant With Ami, Heart Failure Or Shock",1704,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,34725.36,,,,,,,fee schedule,34725.36,34725.36, "Permanent Cardiac Pacemaker Implant With Ami, Heart Failure Or Shock",1704,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,34725.36,,,,,,,fee schedule,34725.36,34725.36, "Permanent Cardiac Pacemaker Implant With Ami, Heart Failure Or Shock",1704,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,34725.36,,,,,,,fee schedule,34725.36,34725.36, "Permanent Cardiac Pacemaker Implant With Ami, Heart Failure Or Shock",1704,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,34725.36,,,,,,,fee schedule,34725.36,34725.36, "Permanent Cardiac Pacemaker Implant With Ami, Heart Failure Or Shock",1704,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,34725.36,,,,,,,fee schedule,34725.36,34725.36, "Permanent Cardiac Pacemaker Implant With Ami, Heart Failure Or Shock",1704,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,34725.36,,,,,,,fee schedule,34725.36,34725.36, "Permanent Cardiac Pacemaker Implant With Ami, Heart Failure Or Shock",1704,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,34725.36,,,,,,,fee schedule,34725.36,34725.36, "Permanent Cardiac Pacemaker Implant With Ami, Heart Failure Or Shock",1704,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,34725.36,,,,,,,fee schedule,34725.36,34725.36, "Permanent Cardiac Pacemaker Implant With Ami, Heart Failure Or Shock",1704,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,34725.36,,,,,,,fee schedule,34725.36,34725.36, "Permanent Cardiac Pacemaker Implant With Ami, Heart Failure Or Shock",1704,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,34725.36,,,,,,,fee schedule,34725.36,34725.36, "Permanent Cardiac Pacemaker Implant Without Ami, Heart Failure Or Shock",1711,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,11216.82,,,,,,,fee schedule,11216.82,11216.82, "Permanent Cardiac Pacemaker Implant Without Ami, Heart Failure Or Shock",1711,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,11216.82,,,,,,,fee schedule,11216.82,11216.82, "Permanent Cardiac Pacemaker Implant Without Ami, Heart Failure Or Shock",1711,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,11216.82,,,,,,,fee schedule,11216.82,11216.82, "Permanent Cardiac Pacemaker Implant Without Ami, Heart Failure Or Shock",1711,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,11216.82,,,,,,,fee schedule,11216.82,11216.82, "Permanent Cardiac Pacemaker Implant Without Ami, Heart Failure Or Shock",1711,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,11216.82,,,,,,,fee schedule,11216.82,11216.82, "Permanent Cardiac Pacemaker Implant Without Ami, Heart Failure Or Shock",1711,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,11216.82,,,,,,,fee schedule,11216.82,11216.82, "Permanent Cardiac Pacemaker Implant Without Ami, Heart Failure Or Shock",1711,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,11216.82,,,,,,,fee schedule,11216.82,11216.82, "Permanent Cardiac Pacemaker Implant Without Ami, Heart Failure Or Shock",1711,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,11216.82,,,,,,,fee schedule,11216.82,11216.82, "Permanent Cardiac Pacemaker Implant Without Ami, Heart Failure Or Shock",1711,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,11216.82,,,,,,,fee schedule,11216.82,11216.82, "Permanent Cardiac Pacemaker Implant Without Ami, Heart Failure Or Shock",1711,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,11216.82,,,,,,,fee schedule,11216.82,11216.82, "Permanent Cardiac Pacemaker Implant Without Ami, Heart Failure Or Shock",1711,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,11216.82,,,,,,,fee schedule,11216.82,11216.82, "Permanent Cardiac Pacemaker Implant Without Ami, Heart Failure Or Shock",1712,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,13584.69,,,,,,,fee schedule,13584.69,13584.69, "Permanent Cardiac Pacemaker Implant Without Ami, Heart Failure Or Shock",1712,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,13584.69,,,,,,,fee schedule,13584.69,13584.69, "Permanent Cardiac Pacemaker Implant Without Ami, Heart Failure Or Shock",1712,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,13584.69,,,,,,,fee schedule,13584.69,13584.69, "Permanent Cardiac Pacemaker Implant Without Ami, Heart Failure Or Shock",1712,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,13584.69,,,,,,,fee schedule,13584.69,13584.69, "Permanent Cardiac Pacemaker Implant Without Ami, Heart Failure Or Shock",1712,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,13584.69,,,,,,,fee schedule,13584.69,13584.69, "Permanent Cardiac Pacemaker Implant Without Ami, Heart Failure Or Shock",1712,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,13584.69,,,,,,,fee schedule,13584.69,13584.69, "Permanent Cardiac Pacemaker Implant Without Ami, Heart Failure Or Shock",1712,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,13584.69,,,,,,,fee schedule,13584.69,13584.69, "Permanent Cardiac Pacemaker Implant Without Ami, Heart Failure Or Shock",1712,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,13584.69,,,,,,,fee schedule,13584.69,13584.69, "Permanent Cardiac Pacemaker Implant Without Ami, Heart Failure Or Shock",1712,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,13584.69,,,,,,,fee schedule,13584.69,13584.69, "Permanent Cardiac Pacemaker Implant Without Ami, Heart Failure Or Shock",1712,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,13584.69,,,,,,,fee schedule,13584.69,13584.69, "Permanent Cardiac Pacemaker Implant Without Ami, Heart Failure Or Shock",1712,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,13584.69,,,,,,,fee schedule,13584.69,13584.69, "Permanent Cardiac Pacemaker Implant Without Ami, Heart Failure Or Shock",1713,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,18413.57,,,,,,,fee schedule,18413.57,18413.57, "Permanent Cardiac Pacemaker Implant Without Ami, Heart Failure Or Shock",1713,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,18413.57,,,,,,,fee schedule,18413.57,18413.57, "Permanent Cardiac Pacemaker Implant Without Ami, Heart Failure Or Shock",1713,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,18413.57,,,,,,,fee schedule,18413.57,18413.57, "Permanent Cardiac Pacemaker Implant Without Ami, Heart Failure Or Shock",1713,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,18413.57,,,,,,,fee schedule,18413.57,18413.57, "Permanent Cardiac Pacemaker Implant Without Ami, Heart Failure Or Shock",1713,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,18413.57,,,,,,,fee schedule,18413.57,18413.57, "Permanent Cardiac Pacemaker Implant Without Ami, Heart Failure Or Shock",1713,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,18413.57,,,,,,,fee schedule,18413.57,18413.57, "Permanent Cardiac Pacemaker Implant Without Ami, Heart Failure Or Shock",1713,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,18413.57,,,,,,,fee schedule,18413.57,18413.57, "Permanent Cardiac Pacemaker Implant Without Ami, Heart Failure Or Shock",1713,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,18413.57,,,,,,,fee schedule,18413.57,18413.57, "Permanent Cardiac Pacemaker Implant Without Ami, Heart Failure Or Shock",1713,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,18413.57,,,,,,,fee schedule,18413.57,18413.57, "Permanent Cardiac Pacemaker Implant Without Ami, Heart Failure Or Shock",1713,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,18413.57,,,,,,,fee schedule,18413.57,18413.57, "Permanent Cardiac Pacemaker Implant Without Ami, Heart Failure Or Shock",1713,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,18413.57,,,,,,,fee schedule,18413.57,18413.57, "Permanent Cardiac Pacemaker Implant Without Ami, Heart Failure Or Shock",1714,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,28238.61,,,,,,,fee schedule,28238.61,28238.61, "Permanent Cardiac Pacemaker Implant Without Ami, Heart Failure Or Shock",1714,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,28238.61,,,,,,,fee schedule,28238.61,28238.61, "Permanent Cardiac Pacemaker Implant Without Ami, Heart Failure Or Shock",1714,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,28238.61,,,,,,,fee schedule,28238.61,28238.61, "Permanent Cardiac Pacemaker Implant Without Ami, Heart Failure Or Shock",1714,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,28238.61,,,,,,,fee schedule,28238.61,28238.61, "Permanent Cardiac Pacemaker Implant Without Ami, Heart Failure Or Shock",1714,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,28238.61,,,,,,,fee schedule,28238.61,28238.61, "Permanent Cardiac Pacemaker Implant Without Ami, Heart Failure Or Shock",1714,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,28238.61,,,,,,,fee schedule,28238.61,28238.61, "Permanent Cardiac Pacemaker Implant Without Ami, Heart Failure Or Shock",1714,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,28238.61,,,,,,,fee schedule,28238.61,28238.61, "Permanent Cardiac Pacemaker Implant Without Ami, Heart Failure Or Shock",1714,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,28238.61,,,,,,,fee schedule,28238.61,28238.61, "Permanent Cardiac Pacemaker Implant Without Ami, Heart Failure Or Shock",1714,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,28238.61,,,,,,,fee schedule,28238.61,28238.61, "Permanent Cardiac Pacemaker Implant Without Ami, Heart Failure Or Shock",1714,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,28238.61,,,,,,,fee schedule,28238.61,28238.61, "Permanent Cardiac Pacemaker Implant Without Ami, Heart Failure Or Shock",1714,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,28238.61,,,,,,,fee schedule,28238.61,28238.61, Percutaneous Cardiac Intervention With Ami,1741,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,13459.06,,,,,,,fee schedule,13459.06,13459.06, Percutaneous Cardiac Intervention With Ami,1741,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,13459.06,,,,,,,fee schedule,13459.06,13459.06, Percutaneous Cardiac Intervention With Ami,1741,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,13459.06,,,,,,,fee schedule,13459.06,13459.06, Percutaneous Cardiac Intervention With Ami,1741,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,13459.06,,,,,,,fee schedule,13459.06,13459.06, Percutaneous Cardiac Intervention With Ami,1741,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,13459.06,,,,,,,fee schedule,13459.06,13459.06, Percutaneous Cardiac Intervention With Ami,1741,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,13459.06,,,,,,,fee schedule,13459.06,13459.06, Percutaneous Cardiac Intervention With Ami,1741,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,13459.06,,,,,,,fee schedule,13459.06,13459.06, Percutaneous Cardiac Intervention With Ami,1741,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,13459.06,,,,,,,fee schedule,13459.06,13459.06, Percutaneous Cardiac Intervention With Ami,1741,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,13459.06,,,,,,,fee schedule,13459.06,13459.06, Percutaneous Cardiac Intervention With Ami,1741,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,13459.06,,,,,,,fee schedule,13459.06,13459.06, Percutaneous Cardiac Intervention With Ami,1741,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,13459.06,,,,,,,fee schedule,13459.06,13459.06, Percutaneous Cardiac Intervention With Ami,1742,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,17054.96,,,,,,,fee schedule,17054.96,17054.96, Percutaneous Cardiac Intervention With Ami,1742,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,17054.96,,,,,,,fee schedule,17054.96,17054.96, Percutaneous Cardiac Intervention With Ami,1742,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,17054.96,,,,,,,fee schedule,17054.96,17054.96, Percutaneous Cardiac Intervention With Ami,1742,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,17054.96,,,,,,,fee schedule,17054.96,17054.96, Percutaneous Cardiac Intervention With Ami,1742,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,17054.96,,,,,,,fee schedule,17054.96,17054.96, Percutaneous Cardiac Intervention With Ami,1742,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,17054.96,,,,,,,fee schedule,17054.96,17054.96, Percutaneous Cardiac Intervention With Ami,1742,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,17054.96,,,,,,,fee schedule,17054.96,17054.96, Percutaneous Cardiac Intervention With Ami,1742,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,17054.96,,,,,,,fee schedule,17054.96,17054.96, Percutaneous Cardiac Intervention With Ami,1742,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,17054.96,,,,,,,fee schedule,17054.96,17054.96, Percutaneous Cardiac Intervention With Ami,1742,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,17054.96,,,,,,,fee schedule,17054.96,17054.96, Percutaneous Cardiac Intervention With Ami,1742,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,17054.96,,,,,,,fee schedule,17054.96,17054.96, Percutaneous Cardiac Intervention With Ami,1743,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,20027.67,,,,,,,fee schedule,20027.67,20027.67, Percutaneous Cardiac Intervention With Ami,1743,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,20027.67,,,,,,,fee schedule,20027.67,20027.67, Percutaneous Cardiac Intervention With Ami,1743,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,20027.67,,,,,,,fee schedule,20027.67,20027.67, Percutaneous Cardiac Intervention With Ami,1743,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,20027.67,,,,,,,fee schedule,20027.67,20027.67, Percutaneous Cardiac Intervention With Ami,1743,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,20027.67,,,,,,,fee schedule,20027.67,20027.67, Percutaneous Cardiac Intervention With Ami,1743,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,20027.67,,,,,,,fee schedule,20027.67,20027.67, Percutaneous Cardiac Intervention With Ami,1743,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,20027.67,,,,,,,fee schedule,20027.67,20027.67, Percutaneous Cardiac Intervention With Ami,1743,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,20027.67,,,,,,,fee schedule,20027.67,20027.67, Percutaneous Cardiac Intervention With Ami,1743,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,20027.67,,,,,,,fee schedule,20027.67,20027.67, Percutaneous Cardiac Intervention With Ami,1743,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,20027.67,,,,,,,fee schedule,20027.67,20027.67, Percutaneous Cardiac Intervention With Ami,1743,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,20027.67,,,,,,,fee schedule,20027.67,20027.67, Percutaneous Cardiac Intervention With Ami,1744,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,28408.7,,,,,,,fee schedule,28408.7,28408.7, Percutaneous Cardiac Intervention With Ami,1744,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,28408.7,,,,,,,fee schedule,28408.7,28408.7, Percutaneous Cardiac Intervention With Ami,1744,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,28408.7,,,,,,,fee schedule,28408.7,28408.7, Percutaneous Cardiac Intervention With Ami,1744,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,28408.7,,,,,,,fee schedule,28408.7,28408.7, Percutaneous Cardiac Intervention With Ami,1744,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,28408.7,,,,,,,fee schedule,28408.7,28408.7, Percutaneous Cardiac Intervention With Ami,1744,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,28408.7,,,,,,,fee schedule,28408.7,28408.7, Percutaneous Cardiac Intervention With Ami,1744,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,28408.7,,,,,,,fee schedule,28408.7,28408.7, Percutaneous Cardiac Intervention With Ami,1744,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,28408.7,,,,,,,fee schedule,28408.7,28408.7, Percutaneous Cardiac Intervention With Ami,1744,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,28408.7,,,,,,,fee schedule,28408.7,28408.7, Percutaneous Cardiac Intervention With Ami,1744,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,28408.7,,,,,,,fee schedule,28408.7,28408.7, Percutaneous Cardiac Intervention With Ami,1744,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,28408.7,,,,,,,fee schedule,28408.7,28408.7, Percutaneous Cardiac Intervention Without Ami,1751,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,15380.17,,,,,,,fee schedule,15380.17,15380.17, Percutaneous Cardiac Intervention Without Ami,1751,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,15380.17,,,,,,,fee schedule,15380.17,15380.17, Percutaneous Cardiac Intervention Without Ami,1751,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,15380.17,,,,,,,fee schedule,15380.17,15380.17, Percutaneous Cardiac Intervention Without Ami,1751,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,15380.17,,,,,,,fee schedule,15380.17,15380.17, Percutaneous Cardiac Intervention Without Ami,1751,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,15380.17,,,,,,,fee schedule,15380.17,15380.17, Percutaneous Cardiac Intervention Without Ami,1751,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,15380.17,,,,,,,fee schedule,15380.17,15380.17, Percutaneous Cardiac Intervention Without Ami,1751,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,15380.17,,,,,,,fee schedule,15380.17,15380.17, Percutaneous Cardiac Intervention Without Ami,1751,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,15380.17,,,,,,,fee schedule,15380.17,15380.17, Percutaneous Cardiac Intervention Without Ami,1751,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,15380.17,,,,,,,fee schedule,15380.17,15380.17, Percutaneous Cardiac Intervention Without Ami,1751,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,15380.17,,,,,,,fee schedule,15380.17,15380.17, Percutaneous Cardiac Intervention Without Ami,1751,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,15380.17,,,,,,,fee schedule,15380.17,15380.17, Percutaneous Cardiac Intervention Without Ami,1752,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,20325.51,,,,,,,fee schedule,20325.51,20325.51, Percutaneous Cardiac Intervention Without Ami,1752,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,20325.51,,,,,,,fee schedule,20325.51,20325.51, Percutaneous Cardiac Intervention Without Ami,1752,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,20325.51,,,,,,,fee schedule,20325.51,20325.51, Percutaneous Cardiac Intervention Without Ami,1752,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,20325.51,,,,,,,fee schedule,20325.51,20325.51, Percutaneous Cardiac Intervention Without Ami,1752,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,20325.51,,,,,,,fee schedule,20325.51,20325.51, Percutaneous Cardiac Intervention Without Ami,1752,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,20325.51,,,,,,,fee schedule,20325.51,20325.51, Percutaneous Cardiac Intervention Without Ami,1752,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,20325.51,,,,,,,fee schedule,20325.51,20325.51, Percutaneous Cardiac Intervention Without Ami,1752,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,20325.51,,,,,,,fee schedule,20325.51,20325.51, Percutaneous Cardiac Intervention Without Ami,1752,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,20325.51,,,,,,,fee schedule,20325.51,20325.51, Percutaneous Cardiac Intervention Without Ami,1752,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,20325.51,,,,,,,fee schedule,20325.51,20325.51, Percutaneous Cardiac Intervention Without Ami,1752,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,20325.51,,,,,,,fee schedule,20325.51,20325.51, Percutaneous Cardiac Intervention Without Ami,1753,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,23317.98,,,,,,,fee schedule,23317.98,23317.98, Percutaneous Cardiac Intervention Without Ami,1753,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,23317.98,,,,,,,fee schedule,23317.98,23317.98, Percutaneous Cardiac Intervention Without Ami,1753,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,23317.98,,,,,,,fee schedule,23317.98,23317.98, Percutaneous Cardiac Intervention Without Ami,1753,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,23317.98,,,,,,,fee schedule,23317.98,23317.98, Percutaneous Cardiac Intervention Without Ami,1753,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,23317.98,,,,,,,fee schedule,23317.98,23317.98, Percutaneous Cardiac Intervention Without Ami,1753,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,23317.98,,,,,,,fee schedule,23317.98,23317.98, Percutaneous Cardiac Intervention Without Ami,1753,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,23317.98,,,,,,,fee schedule,23317.98,23317.98, Percutaneous Cardiac Intervention Without Ami,1753,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,23317.98,,,,,,,fee schedule,23317.98,23317.98, Percutaneous Cardiac Intervention Without Ami,1753,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,23317.98,,,,,,,fee schedule,23317.98,23317.98, Percutaneous Cardiac Intervention Without Ami,1753,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,23317.98,,,,,,,fee schedule,23317.98,23317.98, Percutaneous Cardiac Intervention Without Ami,1753,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,23317.98,,,,,,,fee schedule,23317.98,23317.98, Percutaneous Cardiac Intervention Without Ami,1754,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,31962.26,,,,,,,fee schedule,31962.26,31962.26, Percutaneous Cardiac Intervention Without Ami,1754,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,31962.26,,,,,,,fee schedule,31962.26,31962.26, Percutaneous Cardiac Intervention Without Ami,1754,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,31962.26,,,,,,,fee schedule,31962.26,31962.26, Percutaneous Cardiac Intervention Without Ami,1754,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,31962.26,,,,,,,fee schedule,31962.26,31962.26, Percutaneous Cardiac Intervention Without Ami,1754,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,31962.26,,,,,,,fee schedule,31962.26,31962.26, Percutaneous Cardiac Intervention Without Ami,1754,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,31962.26,,,,,,,fee schedule,31962.26,31962.26, Percutaneous Cardiac Intervention Without Ami,1754,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,31962.26,,,,,,,fee schedule,31962.26,31962.26, Percutaneous Cardiac Intervention Without Ami,1754,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,31962.26,,,,,,,fee schedule,31962.26,31962.26, Percutaneous Cardiac Intervention Without Ami,1754,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,31962.26,,,,,,,fee schedule,31962.26,31962.26, Percutaneous Cardiac Intervention Without Ami,1754,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,31962.26,,,,,,,fee schedule,31962.26,31962.26, Percutaneous Cardiac Intervention Without Ami,1754,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,31962.26,,,,,,,fee schedule,31962.26,31962.26, "Insertion, Revision And Replacements Of Pacemaker And Other Cardiac Devices",1761,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,12945.26,,,,,,,fee schedule,12945.26,12945.26, "Insertion, Revision And Replacements Of Pacemaker And Other Cardiac Devices",1761,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,12945.26,,,,,,,fee schedule,12945.26,12945.26, "Insertion, Revision And Replacements Of Pacemaker And Other Cardiac Devices",1761,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,12945.26,,,,,,,fee schedule,12945.26,12945.26, "Insertion, Revision And Replacements Of Pacemaker And Other Cardiac Devices",1761,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,12945.26,,,,,,,fee schedule,12945.26,12945.26, "Insertion, Revision And Replacements Of Pacemaker And Other Cardiac Devices",1761,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,12945.26,,,,,,,fee schedule,12945.26,12945.26, "Insertion, Revision And Replacements Of Pacemaker And Other Cardiac Devices",1761,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,12945.26,,,,,,,fee schedule,12945.26,12945.26, "Insertion, Revision And Replacements Of Pacemaker And Other Cardiac Devices",1761,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,12945.26,,,,,,,fee schedule,12945.26,12945.26, "Insertion, Revision And Replacements Of Pacemaker And Other Cardiac Devices",1761,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,12945.26,,,,,,,fee schedule,12945.26,12945.26, "Insertion, Revision And Replacements Of Pacemaker And Other Cardiac Devices",1761,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,12945.26,,,,,,,fee schedule,12945.26,12945.26, "Insertion, Revision And Replacements Of Pacemaker And Other Cardiac Devices",1761,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,12945.26,,,,,,,fee schedule,12945.26,12945.26, "Insertion, Revision And Replacements Of Pacemaker And Other Cardiac Devices",1761,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,12945.26,,,,,,,fee schedule,12945.26,12945.26, "Insertion, Revision And Replacements Of Pacemaker And Other Cardiac Devices",1762,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,17648.52,,,,,,,fee schedule,17648.52,17648.52, "Insertion, Revision And Replacements Of Pacemaker And Other Cardiac Devices",1762,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,17648.52,,,,,,,fee schedule,17648.52,17648.52, "Insertion, Revision And Replacements Of Pacemaker And Other Cardiac Devices",1762,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,17648.52,,,,,,,fee schedule,17648.52,17648.52, "Insertion, Revision And Replacements Of Pacemaker And Other Cardiac Devices",1762,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,17648.52,,,,,,,fee schedule,17648.52,17648.52, "Insertion, Revision And Replacements Of Pacemaker And Other Cardiac Devices",1762,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,17648.52,,,,,,,fee schedule,17648.52,17648.52, "Insertion, Revision And Replacements Of Pacemaker And Other Cardiac Devices",1762,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,17648.52,,,,,,,fee schedule,17648.52,17648.52, "Insertion, Revision And Replacements Of Pacemaker And Other Cardiac Devices",1762,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,17648.52,,,,,,,fee schedule,17648.52,17648.52, "Insertion, Revision And Replacements Of Pacemaker And Other Cardiac Devices",1762,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,17648.52,,,,,,,fee schedule,17648.52,17648.52, "Insertion, Revision And Replacements Of Pacemaker And Other Cardiac Devices",1762,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,17648.52,,,,,,,fee schedule,17648.52,17648.52, "Insertion, Revision And Replacements Of Pacemaker And Other Cardiac Devices",1762,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,17648.52,,,,,,,fee schedule,17648.52,17648.52, "Insertion, Revision And Replacements Of Pacemaker And Other Cardiac Devices",1762,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,17648.52,,,,,,,fee schedule,17648.52,17648.52, "Insertion, Revision And Replacements Of Pacemaker And Other Cardiac Devices",1763,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,23718.15,,,,,,,fee schedule,23718.15,23718.15, "Insertion, Revision And Replacements Of Pacemaker And Other Cardiac Devices",1763,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,23718.15,,,,,,,fee schedule,23718.15,23718.15, "Insertion, Revision And Replacements Of Pacemaker And Other Cardiac Devices",1763,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,23718.15,,,,,,,fee schedule,23718.15,23718.15, "Insertion, Revision And Replacements Of Pacemaker And Other Cardiac Devices",1763,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,23718.15,,,,,,,fee schedule,23718.15,23718.15, "Insertion, Revision And Replacements Of Pacemaker And Other Cardiac Devices",1763,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,23718.15,,,,,,,fee schedule,23718.15,23718.15, "Insertion, Revision And Replacements Of Pacemaker And Other Cardiac Devices",1763,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,23718.15,,,,,,,fee schedule,23718.15,23718.15, "Insertion, Revision And Replacements Of Pacemaker And Other Cardiac Devices",1763,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,23718.15,,,,,,,fee schedule,23718.15,23718.15, "Insertion, Revision And Replacements Of Pacemaker And Other Cardiac Devices",1763,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,23718.15,,,,,,,fee schedule,23718.15,23718.15, "Insertion, Revision And Replacements Of Pacemaker And Other Cardiac Devices",1763,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,23718.15,,,,,,,fee schedule,23718.15,23718.15, "Insertion, Revision And Replacements Of Pacemaker And Other Cardiac Devices",1763,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,23718.15,,,,,,,fee schedule,23718.15,23718.15, "Insertion, Revision And Replacements Of Pacemaker And Other Cardiac Devices",1763,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,23718.15,,,,,,,fee schedule,23718.15,23718.15, "Insertion, Revision And Replacements Of Pacemaker And Other Cardiac Devices",1764,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,33436.62,,,,,,,fee schedule,33436.62,33436.62, "Insertion, Revision And Replacements Of Pacemaker And Other Cardiac Devices",1764,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,33436.62,,,,,,,fee schedule,33436.62,33436.62, "Insertion, Revision And Replacements Of Pacemaker And Other Cardiac Devices",1764,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,33436.62,,,,,,,fee schedule,33436.62,33436.62, "Insertion, Revision And Replacements Of Pacemaker And Other Cardiac Devices",1764,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,33436.62,,,,,,,fee schedule,33436.62,33436.62, "Insertion, Revision And Replacements Of Pacemaker And Other Cardiac Devices",1764,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,33436.62,,,,,,,fee schedule,33436.62,33436.62, "Insertion, Revision And Replacements Of Pacemaker And Other Cardiac Devices",1764,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,33436.62,,,,,,,fee schedule,33436.62,33436.62, "Insertion, Revision And Replacements Of Pacemaker And Other Cardiac Devices",1764,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,33436.62,,,,,,,fee schedule,33436.62,33436.62, "Insertion, Revision And Replacements Of Pacemaker And Other Cardiac Devices",1764,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,33436.62,,,,,,,fee schedule,33436.62,33436.62, "Insertion, Revision And Replacements Of Pacemaker And Other Cardiac Devices",1764,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,33436.62,,,,,,,fee schedule,33436.62,33436.62, "Insertion, Revision And Replacements Of Pacemaker And Other Cardiac Devices",1764,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,33436.62,,,,,,,fee schedule,33436.62,33436.62, "Insertion, Revision And Replacements Of Pacemaker And Other Cardiac Devices",1764,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,33436.62,,,,,,,fee schedule,33436.62,33436.62, Cardiac Pacemaker And Defibrillator Revision Except Device Replacement,1771,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,9863.86,,,,,,,fee schedule,9863.86,9863.86, Cardiac Pacemaker And Defibrillator Revision Except Device Replacement,1771,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,9863.86,,,,,,,fee schedule,9863.86,9863.86, Cardiac Pacemaker And Defibrillator Revision Except Device Replacement,1771,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,9863.86,,,,,,,fee schedule,9863.86,9863.86, Cardiac Pacemaker And Defibrillator Revision Except Device Replacement,1771,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,9863.86,,,,,,,fee schedule,9863.86,9863.86, Cardiac Pacemaker And Defibrillator Revision Except Device Replacement,1771,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,9863.86,,,,,,,fee schedule,9863.86,9863.86, Cardiac Pacemaker And Defibrillator Revision Except Device Replacement,1771,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,9863.86,,,,,,,fee schedule,9863.86,9863.86, Cardiac Pacemaker And Defibrillator Revision Except Device Replacement,1771,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,9863.86,,,,,,,fee schedule,9863.86,9863.86, Cardiac Pacemaker And Defibrillator Revision Except Device Replacement,1771,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,9863.86,,,,,,,fee schedule,9863.86,9863.86, Cardiac Pacemaker And Defibrillator Revision Except Device Replacement,1771,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,9863.86,,,,,,,fee schedule,9863.86,9863.86, Cardiac Pacemaker And Defibrillator Revision Except Device Replacement,1771,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,9863.86,,,,,,,fee schedule,9863.86,9863.86, Cardiac Pacemaker And Defibrillator Revision Except Device Replacement,1771,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,9863.86,,,,,,,fee schedule,9863.86,9863.86, Cardiac Pacemaker And Defibrillator Revision Except Device Replacement,1772,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,14960.23,,,,,,,fee schedule,14960.23,14960.23, Cardiac Pacemaker And Defibrillator Revision Except Device Replacement,1772,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,14960.23,,,,,,,fee schedule,14960.23,14960.23, Cardiac Pacemaker And Defibrillator Revision Except Device Replacement,1772,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,14960.23,,,,,,,fee schedule,14960.23,14960.23, Cardiac Pacemaker And Defibrillator Revision Except Device Replacement,1772,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,14960.23,,,,,,,fee schedule,14960.23,14960.23, Cardiac Pacemaker And Defibrillator Revision Except Device Replacement,1772,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,14960.23,,,,,,,fee schedule,14960.23,14960.23, Cardiac Pacemaker And Defibrillator Revision Except Device Replacement,1772,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,14960.23,,,,,,,fee schedule,14960.23,14960.23, Cardiac Pacemaker And Defibrillator Revision Except Device Replacement,1772,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,14960.23,,,,,,,fee schedule,14960.23,14960.23, Cardiac Pacemaker And Defibrillator Revision Except Device Replacement,1772,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,14960.23,,,,,,,fee schedule,14960.23,14960.23, Cardiac Pacemaker And Defibrillator Revision Except Device Replacement,1772,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,14960.23,,,,,,,fee schedule,14960.23,14960.23, Cardiac Pacemaker And Defibrillator Revision Except Device Replacement,1772,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,14960.23,,,,,,,fee schedule,14960.23,14960.23, Cardiac Pacemaker And Defibrillator Revision Except Device Replacement,1772,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,14960.23,,,,,,,fee schedule,14960.23,14960.23, Cardiac Pacemaker And Defibrillator Revision Except Device Replacement,1773,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,18686.71,,,,,,,fee schedule,18686.71,18686.71, Cardiac Pacemaker And Defibrillator Revision Except Device Replacement,1773,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,18686.71,,,,,,,fee schedule,18686.71,18686.71, Cardiac Pacemaker And Defibrillator Revision Except Device Replacement,1773,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,18686.71,,,,,,,fee schedule,18686.71,18686.71, Cardiac Pacemaker And Defibrillator Revision Except Device Replacement,1773,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,18686.71,,,,,,,fee schedule,18686.71,18686.71, Cardiac Pacemaker And Defibrillator Revision Except Device Replacement,1773,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,18686.71,,,,,,,fee schedule,18686.71,18686.71, Cardiac Pacemaker And Defibrillator Revision Except Device Replacement,1773,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,18686.71,,,,,,,fee schedule,18686.71,18686.71, Cardiac Pacemaker And Defibrillator Revision Except Device Replacement,1773,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,18686.71,,,,,,,fee schedule,18686.71,18686.71, Cardiac Pacemaker And Defibrillator Revision Except Device Replacement,1773,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,18686.71,,,,,,,fee schedule,18686.71,18686.71, Cardiac Pacemaker And Defibrillator Revision Except Device Replacement,1773,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,18686.71,,,,,,,fee schedule,18686.71,18686.71, Cardiac Pacemaker And Defibrillator Revision Except Device Replacement,1773,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,18686.71,,,,,,,fee schedule,18686.71,18686.71, Cardiac Pacemaker And Defibrillator Revision Except Device Replacement,1773,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,18686.71,,,,,,,fee schedule,18686.71,18686.71, Cardiac Pacemaker And Defibrillator Revision Except Device Replacement,1774,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,26753.67,,,,,,,fee schedule,26753.67,26753.67, Cardiac Pacemaker And Defibrillator Revision Except Device Replacement,1774,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,26753.67,,,,,,,fee schedule,26753.67,26753.67, Cardiac Pacemaker And Defibrillator Revision Except Device Replacement,1774,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,26753.67,,,,,,,fee schedule,26753.67,26753.67, Cardiac Pacemaker And Defibrillator Revision Except Device Replacement,1774,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,26753.67,,,,,,,fee schedule,26753.67,26753.67, Cardiac Pacemaker And Defibrillator Revision Except Device Replacement,1774,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,26753.67,,,,,,,fee schedule,26753.67,26753.67, Cardiac Pacemaker And Defibrillator Revision Except Device Replacement,1774,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,26753.67,,,,,,,fee schedule,26753.67,26753.67, Cardiac Pacemaker And Defibrillator Revision Except Device Replacement,1774,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,26753.67,,,,,,,fee schedule,26753.67,26753.67, Cardiac Pacemaker And Defibrillator Revision Except Device Replacement,1774,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,26753.67,,,,,,,fee schedule,26753.67,26753.67, Cardiac Pacemaker And Defibrillator Revision Except Device Replacement,1774,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,26753.67,,,,,,,fee schedule,26753.67,26753.67, Cardiac Pacemaker And Defibrillator Revision Except Device Replacement,1774,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,26753.67,,,,,,,fee schedule,26753.67,26753.67, Cardiac Pacemaker And Defibrillator Revision Except Device Replacement,1774,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,26753.67,,,,,,,fee schedule,26753.67,26753.67, External Heart Assist Systems,1781,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,33150.08,,,,,,,fee schedule,33150.08,33150.08, External Heart Assist Systems,1781,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,33150.08,,,,,,,fee schedule,33150.08,33150.08, External Heart Assist Systems,1781,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,33150.08,,,,,,,fee schedule,33150.08,33150.08, External Heart Assist Systems,1781,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,33150.08,,,,,,,fee schedule,33150.08,33150.08, External Heart Assist Systems,1781,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,33150.08,,,,,,,fee schedule,33150.08,33150.08, External Heart Assist Systems,1781,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,33150.08,,,,,,,fee schedule,33150.08,33150.08, External Heart Assist Systems,1781,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,33150.08,,,,,,,fee schedule,33150.08,33150.08, External Heart Assist Systems,1781,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,33150.08,,,,,,,fee schedule,33150.08,33150.08, External Heart Assist Systems,1781,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,33150.08,,,,,,,fee schedule,33150.08,33150.08, External Heart Assist Systems,1781,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,33150.08,,,,,,,fee schedule,33150.08,33150.08, External Heart Assist Systems,1781,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,33150.08,,,,,,,fee schedule,33150.08,33150.08, External Heart Assist Systems,1782,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,36833.5,,,,,,,fee schedule,36833.5,36833.5, External Heart Assist Systems,1782,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,36833.5,,,,,,,fee schedule,36833.5,36833.5, External Heart Assist Systems,1782,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,36833.5,,,,,,,fee schedule,36833.5,36833.5, External Heart Assist Systems,1782,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,36833.5,,,,,,,fee schedule,36833.5,36833.5, External Heart Assist Systems,1782,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,36833.5,,,,,,,fee schedule,36833.5,36833.5, External Heart Assist Systems,1782,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,36833.5,,,,,,,fee schedule,36833.5,36833.5, External Heart Assist Systems,1782,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,36833.5,,,,,,,fee schedule,36833.5,36833.5, External Heart Assist Systems,1782,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,36833.5,,,,,,,fee schedule,36833.5,36833.5, External Heart Assist Systems,1782,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,36833.5,,,,,,,fee schedule,36833.5,36833.5, External Heart Assist Systems,1782,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,36833.5,,,,,,,fee schedule,36833.5,36833.5, External Heart Assist Systems,1782,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,36833.5,,,,,,,fee schedule,36833.5,36833.5, External Heart Assist Systems,1783,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,45237.82,,,,,,,fee schedule,45237.82,45237.82, External Heart Assist Systems,1783,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,45237.82,,,,,,,fee schedule,45237.82,45237.82, External Heart Assist Systems,1783,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,45237.82,,,,,,,fee schedule,45237.82,45237.82, External Heart Assist Systems,1783,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,45237.82,,,,,,,fee schedule,45237.82,45237.82, External Heart Assist Systems,1783,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,45237.82,,,,,,,fee schedule,45237.82,45237.82, External Heart Assist Systems,1783,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,45237.82,,,,,,,fee schedule,45237.82,45237.82, External Heart Assist Systems,1783,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,45237.82,,,,,,,fee schedule,45237.82,45237.82, External Heart Assist Systems,1783,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,45237.82,,,,,,,fee schedule,45237.82,45237.82, External Heart Assist Systems,1783,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,45237.82,,,,,,,fee schedule,45237.82,45237.82, External Heart Assist Systems,1783,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,45237.82,,,,,,,fee schedule,45237.82,45237.82, External Heart Assist Systems,1783,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,45237.82,,,,,,,fee schedule,45237.82,45237.82, External Heart Assist Systems,1784,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,56064.35,,,,,,,fee schedule,56064.35,56064.35, External Heart Assist Systems,1784,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,56064.35,,,,,,,fee schedule,56064.35,56064.35, External Heart Assist Systems,1784,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,56064.35,,,,,,,fee schedule,56064.35,56064.35, External Heart Assist Systems,1784,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,56064.35,,,,,,,fee schedule,56064.35,56064.35, External Heart Assist Systems,1784,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,56064.35,,,,,,,fee schedule,56064.35,56064.35, External Heart Assist Systems,1784,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,56064.35,,,,,,,fee schedule,56064.35,56064.35, External Heart Assist Systems,1784,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,56064.35,,,,,,,fee schedule,56064.35,56064.35, External Heart Assist Systems,1784,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,56064.35,,,,,,,fee schedule,56064.35,56064.35, External Heart Assist Systems,1784,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,56064.35,,,,,,,fee schedule,56064.35,56064.35, External Heart Assist Systems,1784,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,56064.35,,,,,,,fee schedule,56064.35,56064.35, External Heart Assist Systems,1784,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,56064.35,,,,,,,fee schedule,56064.35,56064.35, Defibrillator Implants,1791,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,24804.33,,,,,,,fee schedule,24804.33,24804.33, Defibrillator Implants,1791,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,24804.33,,,,,,,fee schedule,24804.33,24804.33, Defibrillator Implants,1791,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,24804.33,,,,,,,fee schedule,24804.33,24804.33, Defibrillator Implants,1791,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,24804.33,,,,,,,fee schedule,24804.33,24804.33, Defibrillator Implants,1791,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,24804.33,,,,,,,fee schedule,24804.33,24804.33, Defibrillator Implants,1791,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,24804.33,,,,,,,fee schedule,24804.33,24804.33, Defibrillator Implants,1791,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,24804.33,,,,,,,fee schedule,24804.33,24804.33, Defibrillator Implants,1791,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,24804.33,,,,,,,fee schedule,24804.33,24804.33, Defibrillator Implants,1791,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,24804.33,,,,,,,fee schedule,24804.33,24804.33, Defibrillator Implants,1791,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,24804.33,,,,,,,fee schedule,24804.33,24804.33, Defibrillator Implants,1791,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,24804.33,,,,,,,fee schedule,24804.33,24804.33, Defibrillator Implants,1792,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,29343.85,,,,,,,fee schedule,29343.85,29343.85, Defibrillator Implants,1792,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,29343.85,,,,,,,fee schedule,29343.85,29343.85, Defibrillator Implants,1792,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,29343.85,,,,,,,fee schedule,29343.85,29343.85, Defibrillator Implants,1792,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,29343.85,,,,,,,fee schedule,29343.85,29343.85, Defibrillator Implants,1792,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,29343.85,,,,,,,fee schedule,29343.85,29343.85, Defibrillator Implants,1792,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,29343.85,,,,,,,fee schedule,29343.85,29343.85, Defibrillator Implants,1792,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,29343.85,,,,,,,fee schedule,29343.85,29343.85, Defibrillator Implants,1792,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,29343.85,,,,,,,fee schedule,29343.85,29343.85, Defibrillator Implants,1792,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,29343.85,,,,,,,fee schedule,29343.85,29343.85, Defibrillator Implants,1792,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,29343.85,,,,,,,fee schedule,29343.85,29343.85, Defibrillator Implants,1792,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,29343.85,,,,,,,fee schedule,29343.85,29343.85, Defibrillator Implants,1793,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,35491.82,,,,,,,fee schedule,35491.82,35491.82, Defibrillator Implants,1793,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,35491.82,,,,,,,fee schedule,35491.82,35491.82, Defibrillator Implants,1793,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,35491.82,,,,,,,fee schedule,35491.82,35491.82, Defibrillator Implants,1793,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,35491.82,,,,,,,fee schedule,35491.82,35491.82, Defibrillator Implants,1793,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,35491.82,,,,,,,fee schedule,35491.82,35491.82, Defibrillator Implants,1793,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,35491.82,,,,,,,fee schedule,35491.82,35491.82, Defibrillator Implants,1793,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,35491.82,,,,,,,fee schedule,35491.82,35491.82, Defibrillator Implants,1793,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,35491.82,,,,,,,fee schedule,35491.82,35491.82, Defibrillator Implants,1793,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,35491.82,,,,,,,fee schedule,35491.82,35491.82, Defibrillator Implants,1793,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,35491.82,,,,,,,fee schedule,35491.82,35491.82, Defibrillator Implants,1793,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,35491.82,,,,,,,fee schedule,35491.82,35491.82, Defibrillator Implants,1794,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,46604.9,,,,,,,fee schedule,46604.9,46604.9, Defibrillator Implants,1794,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,46604.9,,,,,,,fee schedule,46604.9,46604.9, Defibrillator Implants,1794,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,46604.9,,,,,,,fee schedule,46604.9,46604.9, Defibrillator Implants,1794,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,46604.9,,,,,,,fee schedule,46604.9,46604.9, Defibrillator Implants,1794,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,46604.9,,,,,,,fee schedule,46604.9,46604.9, Defibrillator Implants,1794,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,46604.9,,,,,,,fee schedule,46604.9,46604.9, Defibrillator Implants,1794,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,46604.9,,,,,,,fee schedule,46604.9,46604.9, Defibrillator Implants,1794,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,46604.9,,,,,,,fee schedule,46604.9,46604.9, Defibrillator Implants,1794,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,46604.9,,,,,,,fee schedule,46604.9,46604.9, Defibrillator Implants,1794,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,46604.9,,,,,,,fee schedule,46604.9,46604.9, Defibrillator Implants,1794,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,46604.9,,,,,,,fee schedule,46604.9,46604.9, Other Circulatory System Procedures,1801,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,10751.01,,,,,,,fee schedule,10751.01,10751.01, Other Circulatory System Procedures,1801,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,10751.01,,,,,,,fee schedule,10751.01,10751.01, Other Circulatory System Procedures,1801,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,10751.01,,,,,,,fee schedule,10751.01,10751.01, Other Circulatory System Procedures,1801,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,10751.01,,,,,,,fee schedule,10751.01,10751.01, Other Circulatory System Procedures,1801,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,10751.01,,,,,,,fee schedule,10751.01,10751.01, Other Circulatory System Procedures,1801,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,10751.01,,,,,,,fee schedule,10751.01,10751.01, Other Circulatory System Procedures,1801,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,10751.01,,,,,,,fee schedule,10751.01,10751.01, Other Circulatory System Procedures,1801,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,10751.01,,,,,,,fee schedule,10751.01,10751.01, Other Circulatory System Procedures,1801,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,10751.01,,,,,,,fee schedule,10751.01,10751.01, Other Circulatory System Procedures,1801,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,10751.01,,,,,,,fee schedule,10751.01,10751.01, Other Circulatory System Procedures,1801,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,10751.01,,,,,,,fee schedule,10751.01,10751.01, Other Circulatory System Procedures,1802,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,12230.31,,,,,,,fee schedule,12230.31,12230.31, Other Circulatory System Procedures,1802,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,12230.31,,,,,,,fee schedule,12230.31,12230.31, Other Circulatory System Procedures,1802,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,12230.31,,,,,,,fee schedule,12230.31,12230.31, Other Circulatory System Procedures,1802,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,12230.31,,,,,,,fee schedule,12230.31,12230.31, Other Circulatory System Procedures,1802,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,12230.31,,,,,,,fee schedule,12230.31,12230.31, Other Circulatory System Procedures,1802,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,12230.31,,,,,,,fee schedule,12230.31,12230.31, Other Circulatory System Procedures,1802,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,12230.31,,,,,,,fee schedule,12230.31,12230.31, Other Circulatory System Procedures,1802,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,12230.31,,,,,,,fee schedule,12230.31,12230.31, Other Circulatory System Procedures,1802,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,12230.31,,,,,,,fee schedule,12230.31,12230.31, Other Circulatory System Procedures,1802,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,12230.31,,,,,,,fee schedule,12230.31,12230.31, Other Circulatory System Procedures,1802,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,12230.31,,,,,,,fee schedule,12230.31,12230.31, Other Circulatory System Procedures,1803,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,17684.51,,,,,,,fee schedule,17684.51,17684.51, Other Circulatory System Procedures,1803,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,17684.51,,,,,,,fee schedule,17684.51,17684.51, Other Circulatory System Procedures,1803,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,17684.51,,,,,,,fee schedule,17684.51,17684.51, Other Circulatory System Procedures,1803,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,17684.51,,,,,,,fee schedule,17684.51,17684.51, Other Circulatory System Procedures,1803,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,17684.51,,,,,,,fee schedule,17684.51,17684.51, Other Circulatory System Procedures,1803,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,17684.51,,,,,,,fee schedule,17684.51,17684.51, Other Circulatory System Procedures,1803,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,17684.51,,,,,,,fee schedule,17684.51,17684.51, Other Circulatory System Procedures,1803,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,17684.51,,,,,,,fee schedule,17684.51,17684.51, Other Circulatory System Procedures,1803,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,17684.51,,,,,,,fee schedule,17684.51,17684.51, Other Circulatory System Procedures,1803,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,17684.51,,,,,,,fee schedule,17684.51,17684.51, Other Circulatory System Procedures,1803,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,17684.51,,,,,,,fee schedule,17684.51,17684.51, Other Circulatory System Procedures,1804,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,28484.93,,,,,,,fee schedule,28484.93,28484.93, Other Circulatory System Procedures,1804,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,28484.93,,,,,,,fee schedule,28484.93,28484.93, Other Circulatory System Procedures,1804,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,28484.93,,,,,,,fee schedule,28484.93,28484.93, Other Circulatory System Procedures,1804,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,28484.93,,,,,,,fee schedule,28484.93,28484.93, Other Circulatory System Procedures,1804,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,28484.93,,,,,,,fee schedule,28484.93,28484.93, Other Circulatory System Procedures,1804,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,28484.93,,,,,,,fee schedule,28484.93,28484.93, Other Circulatory System Procedures,1804,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,28484.93,,,,,,,fee schedule,28484.93,28484.93, Other Circulatory System Procedures,1804,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,28484.93,,,,,,,fee schedule,28484.93,28484.93, Other Circulatory System Procedures,1804,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,28484.93,,,,,,,fee schedule,28484.93,28484.93, Other Circulatory System Procedures,1804,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,28484.93,,,,,,,fee schedule,28484.93,28484.93, Other Circulatory System Procedures,1804,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,28484.93,,,,,,,fee schedule,28484.93,28484.93, Lower Extremity Arterial Procedures,1811,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,12972.78,,,,,,,fee schedule,12972.78,12972.78, Lower Extremity Arterial Procedures,1811,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,12972.78,,,,,,,fee schedule,12972.78,12972.78, Lower Extremity Arterial Procedures,1811,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,12972.78,,,,,,,fee schedule,12972.78,12972.78, Lower Extremity Arterial Procedures,1811,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,12972.78,,,,,,,fee schedule,12972.78,12972.78, Lower Extremity Arterial Procedures,1811,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,12972.78,,,,,,,fee schedule,12972.78,12972.78, Lower Extremity Arterial Procedures,1811,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,12972.78,,,,,,,fee schedule,12972.78,12972.78, Lower Extremity Arterial Procedures,1811,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,12972.78,,,,,,,fee schedule,12972.78,12972.78, Lower Extremity Arterial Procedures,1811,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,12972.78,,,,,,,fee schedule,12972.78,12972.78, Lower Extremity Arterial Procedures,1811,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,12972.78,,,,,,,fee schedule,12972.78,12972.78, Lower Extremity Arterial Procedures,1811,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,12972.78,,,,,,,fee schedule,12972.78,12972.78, Lower Extremity Arterial Procedures,1811,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,12972.78,,,,,,,fee schedule,12972.78,12972.78, Lower Extremity Arterial Procedures,1812,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,17823.55,,,,,,,fee schedule,17823.55,17823.55, Lower Extremity Arterial Procedures,1812,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,17823.55,,,,,,,fee schedule,17823.55,17823.55, Lower Extremity Arterial Procedures,1812,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,17823.55,,,,,,,fee schedule,17823.55,17823.55, Lower Extremity Arterial Procedures,1812,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,17823.55,,,,,,,fee schedule,17823.55,17823.55, Lower Extremity Arterial Procedures,1812,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,17823.55,,,,,,,fee schedule,17823.55,17823.55, Lower Extremity Arterial Procedures,1812,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,17823.55,,,,,,,fee schedule,17823.55,17823.55, Lower Extremity Arterial Procedures,1812,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,17823.55,,,,,,,fee schedule,17823.55,17823.55, Lower Extremity Arterial Procedures,1812,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,17823.55,,,,,,,fee schedule,17823.55,17823.55, Lower Extremity Arterial Procedures,1812,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,17823.55,,,,,,,fee schedule,17823.55,17823.55, Lower Extremity Arterial Procedures,1812,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,17823.55,,,,,,,fee schedule,17823.55,17823.55, Lower Extremity Arterial Procedures,1812,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,17823.55,,,,,,,fee schedule,17823.55,17823.55, Lower Extremity Arterial Procedures,1813,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,23807.78,,,,,,,fee schedule,23807.78,23807.78, Lower Extremity Arterial Procedures,1813,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,23807.78,,,,,,,fee schedule,23807.78,23807.78, Lower Extremity Arterial Procedures,1813,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,23807.78,,,,,,,fee schedule,23807.78,23807.78, Lower Extremity Arterial Procedures,1813,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,23807.78,,,,,,,fee schedule,23807.78,23807.78, Lower Extremity Arterial Procedures,1813,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,23807.78,,,,,,,fee schedule,23807.78,23807.78, Lower Extremity Arterial Procedures,1813,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,23807.78,,,,,,,fee schedule,23807.78,23807.78, Lower Extremity Arterial Procedures,1813,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,23807.78,,,,,,,fee schedule,23807.78,23807.78, Lower Extremity Arterial Procedures,1813,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,23807.78,,,,,,,fee schedule,23807.78,23807.78, Lower Extremity Arterial Procedures,1813,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,23807.78,,,,,,,fee schedule,23807.78,23807.78, Lower Extremity Arterial Procedures,1813,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,23807.78,,,,,,,fee schedule,23807.78,23807.78, Lower Extremity Arterial Procedures,1813,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,23807.78,,,,,,,fee schedule,23807.78,23807.78, Lower Extremity Arterial Procedures,1814,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,34648.43,,,,,,,fee schedule,34648.43,34648.43, Lower Extremity Arterial Procedures,1814,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,34648.43,,,,,,,fee schedule,34648.43,34648.43, Lower Extremity Arterial Procedures,1814,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,34648.43,,,,,,,fee schedule,34648.43,34648.43, Lower Extremity Arterial Procedures,1814,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,34648.43,,,,,,,fee schedule,34648.43,34648.43, Lower Extremity Arterial Procedures,1814,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,34648.43,,,,,,,fee schedule,34648.43,34648.43, Lower Extremity Arterial Procedures,1814,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,34648.43,,,,,,,fee schedule,34648.43,34648.43, Lower Extremity Arterial Procedures,1814,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,34648.43,,,,,,,fee schedule,34648.43,34648.43, Lower Extremity Arterial Procedures,1814,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,34648.43,,,,,,,fee schedule,34648.43,34648.43, Lower Extremity Arterial Procedures,1814,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,34648.43,,,,,,,fee schedule,34648.43,34648.43, Lower Extremity Arterial Procedures,1814,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,34648.43,,,,,,,fee schedule,34648.43,34648.43, Lower Extremity Arterial Procedures,1814,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,34648.43,,,,,,,fee schedule,34648.43,34648.43, Other Peripheral Vascular Procedures,1821,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,12223.96,,,,,,,fee schedule,12223.96,12223.96, Other Peripheral Vascular Procedures,1821,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,12223.96,,,,,,,fee schedule,12223.96,12223.96, Other Peripheral Vascular Procedures,1821,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,12223.96,,,,,,,fee schedule,12223.96,12223.96, Other Peripheral Vascular Procedures,1821,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,12223.96,,,,,,,fee schedule,12223.96,12223.96, Other Peripheral Vascular Procedures,1821,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,12223.96,,,,,,,fee schedule,12223.96,12223.96, Other Peripheral Vascular Procedures,1821,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,12223.96,,,,,,,fee schedule,12223.96,12223.96, Other Peripheral Vascular Procedures,1821,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,12223.96,,,,,,,fee schedule,12223.96,12223.96, Other Peripheral Vascular Procedures,1821,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,12223.96,,,,,,,fee schedule,12223.96,12223.96, Other Peripheral Vascular Procedures,1821,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,12223.96,,,,,,,fee schedule,12223.96,12223.96, Other Peripheral Vascular Procedures,1821,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,12223.96,,,,,,,fee schedule,12223.96,12223.96, Other Peripheral Vascular Procedures,1821,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,12223.96,,,,,,,fee schedule,12223.96,12223.96, Other Peripheral Vascular Procedures,1822,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,15032.93,,,,,,,fee schedule,15032.93,15032.93, Other Peripheral Vascular Procedures,1822,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,15032.93,,,,,,,fee schedule,15032.93,15032.93, Other Peripheral Vascular Procedures,1822,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,15032.93,,,,,,,fee schedule,15032.93,15032.93, Other Peripheral Vascular Procedures,1822,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,15032.93,,,,,,,fee schedule,15032.93,15032.93, Other Peripheral Vascular Procedures,1822,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,15032.93,,,,,,,fee schedule,15032.93,15032.93, Other Peripheral Vascular Procedures,1822,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,15032.93,,,,,,,fee schedule,15032.93,15032.93, Other Peripheral Vascular Procedures,1822,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,15032.93,,,,,,,fee schedule,15032.93,15032.93, Other Peripheral Vascular Procedures,1822,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,15032.93,,,,,,,fee schedule,15032.93,15032.93, Other Peripheral Vascular Procedures,1822,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,15032.93,,,,,,,fee schedule,15032.93,15032.93, Other Peripheral Vascular Procedures,1822,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,15032.93,,,,,,,fee schedule,15032.93,15032.93, Other Peripheral Vascular Procedures,1822,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,15032.93,,,,,,,fee schedule,15032.93,15032.93, Other Peripheral Vascular Procedures,1823,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,19206.15,,,,,,,fee schedule,19206.15,19206.15, Other Peripheral Vascular Procedures,1823,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,19206.15,,,,,,,fee schedule,19206.15,19206.15, Other Peripheral Vascular Procedures,1823,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,19206.15,,,,,,,fee schedule,19206.15,19206.15, Other Peripheral Vascular Procedures,1823,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,19206.15,,,,,,,fee schedule,19206.15,19206.15, Other Peripheral Vascular Procedures,1823,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,19206.15,,,,,,,fee schedule,19206.15,19206.15, Other Peripheral Vascular Procedures,1823,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,19206.15,,,,,,,fee schedule,19206.15,19206.15, Other Peripheral Vascular Procedures,1823,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,19206.15,,,,,,,fee schedule,19206.15,19206.15, Other Peripheral Vascular Procedures,1823,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,19206.15,,,,,,,fee schedule,19206.15,19206.15, Other Peripheral Vascular Procedures,1823,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,19206.15,,,,,,,fee schedule,19206.15,19206.15, Other Peripheral Vascular Procedures,1823,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,19206.15,,,,,,,fee schedule,19206.15,19206.15, Other Peripheral Vascular Procedures,1823,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,19206.15,,,,,,,fee schedule,19206.15,19206.15, Other Peripheral Vascular Procedures,1824,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,29976.93,,,,,,,fee schedule,29976.93,29976.93, Other Peripheral Vascular Procedures,1824,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,29976.93,,,,,,,fee schedule,29976.93,29976.93, Other Peripheral Vascular Procedures,1824,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,29976.93,,,,,,,fee schedule,29976.93,29976.93, Other Peripheral Vascular Procedures,1824,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,29976.93,,,,,,,fee schedule,29976.93,29976.93, Other Peripheral Vascular Procedures,1824,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,29976.93,,,,,,,fee schedule,29976.93,29976.93, Other Peripheral Vascular Procedures,1824,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,29976.93,,,,,,,fee schedule,29976.93,29976.93, Other Peripheral Vascular Procedures,1824,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,29976.93,,,,,,,fee schedule,29976.93,29976.93, Other Peripheral Vascular Procedures,1824,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,29976.93,,,,,,,fee schedule,29976.93,29976.93, Other Peripheral Vascular Procedures,1824,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,29976.93,,,,,,,fee schedule,29976.93,29976.93, Other Peripheral Vascular Procedures,1824,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,29976.93,,,,,,,fee schedule,29976.93,29976.93, Other Peripheral Vascular Procedures,1824,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,29976.93,,,,,,,fee schedule,29976.93,29976.93, Percutaneous Structural Cardiac Procedures,1831,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,27062.09,,,,,,,fee schedule,27062.09,27062.09, Percutaneous Structural Cardiac Procedures,1831,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,27062.09,,,,,,,fee schedule,27062.09,27062.09, Percutaneous Structural Cardiac Procedures,1831,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,27062.09,,,,,,,fee schedule,27062.09,27062.09, Percutaneous Structural Cardiac Procedures,1831,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,27062.09,,,,,,,fee schedule,27062.09,27062.09, Percutaneous Structural Cardiac Procedures,1831,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,27062.09,,,,,,,fee schedule,27062.09,27062.09, Percutaneous Structural Cardiac Procedures,1831,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,27062.09,,,,,,,fee schedule,27062.09,27062.09, Percutaneous Structural Cardiac Procedures,1831,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,27062.09,,,,,,,fee schedule,27062.09,27062.09, Percutaneous Structural Cardiac Procedures,1831,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,27062.09,,,,,,,fee schedule,27062.09,27062.09, Percutaneous Structural Cardiac Procedures,1831,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,27062.09,,,,,,,fee schedule,27062.09,27062.09, Percutaneous Structural Cardiac Procedures,1831,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,27062.09,,,,,,,fee schedule,27062.09,27062.09, Percutaneous Structural Cardiac Procedures,1831,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,27062.09,,,,,,,fee schedule,27062.09,27062.09, Percutaneous Structural Cardiac Procedures,1832,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,29391.14,,,,,,,fee schedule,29391.14,29391.14, Percutaneous Structural Cardiac Procedures,1832,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,29391.14,,,,,,,fee schedule,29391.14,29391.14, Percutaneous Structural Cardiac Procedures,1832,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,29391.14,,,,,,,fee schedule,29391.14,29391.14, Percutaneous Structural Cardiac Procedures,1832,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,29391.14,,,,,,,fee schedule,29391.14,29391.14, Percutaneous Structural Cardiac Procedures,1832,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,29391.14,,,,,,,fee schedule,29391.14,29391.14, Percutaneous Structural Cardiac Procedures,1832,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,29391.14,,,,,,,fee schedule,29391.14,29391.14, Percutaneous Structural Cardiac Procedures,1832,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,29391.14,,,,,,,fee schedule,29391.14,29391.14, Percutaneous Structural Cardiac Procedures,1832,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,29391.14,,,,,,,fee schedule,29391.14,29391.14, Percutaneous Structural Cardiac Procedures,1832,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,29391.14,,,,,,,fee schedule,29391.14,29391.14, Percutaneous Structural Cardiac Procedures,1832,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,29391.14,,,,,,,fee schedule,29391.14,29391.14, Percutaneous Structural Cardiac Procedures,1832,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,29391.14,,,,,,,fee schedule,29391.14,29391.14, Percutaneous Structural Cardiac Procedures,1833,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,36666.23,,,,,,,fee schedule,36666.23,36666.23, Percutaneous Structural Cardiac Procedures,1833,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,36666.23,,,,,,,fee schedule,36666.23,36666.23, Percutaneous Structural Cardiac Procedures,1833,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,36666.23,,,,,,,fee schedule,36666.23,36666.23, Percutaneous Structural Cardiac Procedures,1833,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,36666.23,,,,,,,fee schedule,36666.23,36666.23, Percutaneous Structural Cardiac Procedures,1833,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,36666.23,,,,,,,fee schedule,36666.23,36666.23, Percutaneous Structural Cardiac Procedures,1833,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,36666.23,,,,,,,fee schedule,36666.23,36666.23, Percutaneous Structural Cardiac Procedures,1833,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,36666.23,,,,,,,fee schedule,36666.23,36666.23, Percutaneous Structural Cardiac Procedures,1833,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,36666.23,,,,,,,fee schedule,36666.23,36666.23, Percutaneous Structural Cardiac Procedures,1833,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,36666.23,,,,,,,fee schedule,36666.23,36666.23, Percutaneous Structural Cardiac Procedures,1833,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,36666.23,,,,,,,fee schedule,36666.23,36666.23, Percutaneous Structural Cardiac Procedures,1833,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,36666.23,,,,,,,fee schedule,36666.23,36666.23, Percutaneous Structural Cardiac Procedures,1834,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,50459.12,,,,,,,fee schedule,50459.12,50459.12, Percutaneous Structural Cardiac Procedures,1834,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,50459.12,,,,,,,fee schedule,50459.12,50459.12, Percutaneous Structural Cardiac Procedures,1834,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,50459.12,,,,,,,fee schedule,50459.12,50459.12, Percutaneous Structural Cardiac Procedures,1834,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,50459.12,,,,,,,fee schedule,50459.12,50459.12, Percutaneous Structural Cardiac Procedures,1834,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,50459.12,,,,,,,fee schedule,50459.12,50459.12, Percutaneous Structural Cardiac Procedures,1834,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,50459.12,,,,,,,fee schedule,50459.12,50459.12, Percutaneous Structural Cardiac Procedures,1834,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,50459.12,,,,,,,fee schedule,50459.12,50459.12, Percutaneous Structural Cardiac Procedures,1834,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,50459.12,,,,,,,fee schedule,50459.12,50459.12, Percutaneous Structural Cardiac Procedures,1834,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,50459.12,,,,,,,fee schedule,50459.12,50459.12, Percutaneous Structural Cardiac Procedures,1834,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,50459.12,,,,,,,fee schedule,50459.12,50459.12, Percutaneous Structural Cardiac Procedures,1834,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,50459.12,,,,,,,fee schedule,50459.12,50459.12, Acute Myocardial Infarction,1901,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,6123.27,,,,,,,fee schedule,6123.27,6123.27, Acute Myocardial Infarction,1901,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,6123.27,,,,,,,fee schedule,6123.27,6123.27, Acute Myocardial Infarction,1901,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,6123.27,,,,,,,fee schedule,6123.27,6123.27, Acute Myocardial Infarction,1901,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,6123.27,,,,,,,fee schedule,6123.27,6123.27, Acute Myocardial Infarction,1901,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,6123.27,,,,,,,fee schedule,6123.27,6123.27, Acute Myocardial Infarction,1901,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,6123.27,,,,,,,fee schedule,6123.27,6123.27, Acute Myocardial Infarction,1901,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,6123.27,,,,,,,fee schedule,6123.27,6123.27, Acute Myocardial Infarction,1901,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,6123.27,,,,,,,fee schedule,6123.27,6123.27, Acute Myocardial Infarction,1901,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,6123.27,,,,,,,fee schedule,6123.27,6123.27, Acute Myocardial Infarction,1901,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,6123.27,,,,,,,fee schedule,6123.27,6123.27, Acute Myocardial Infarction,1901,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,6123.27,,,,,,,fee schedule,6123.27,6123.27, Acute Myocardial Infarction,1902,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,7081.71,,,,,,,fee schedule,7081.71,7081.71, Acute Myocardial Infarction,1902,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,7081.71,,,,,,,fee schedule,7081.71,7081.71, Acute Myocardial Infarction,1902,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,7081.71,,,,,,,fee schedule,7081.71,7081.71, Acute Myocardial Infarction,1902,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,7081.71,,,,,,,fee schedule,7081.71,7081.71, Acute Myocardial Infarction,1902,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,7081.71,,,,,,,fee schedule,7081.71,7081.71, Acute Myocardial Infarction,1902,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,7081.71,,,,,,,fee schedule,7081.71,7081.71, Acute Myocardial Infarction,1902,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,7081.71,,,,,,,fee schedule,7081.71,7081.71, Acute Myocardial Infarction,1902,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,7081.71,,,,,,,fee schedule,7081.71,7081.71, Acute Myocardial Infarction,1902,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,7081.71,,,,,,,fee schedule,7081.71,7081.71, Acute Myocardial Infarction,1902,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,7081.71,,,,,,,fee schedule,7081.71,7081.71, Acute Myocardial Infarction,1902,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,7081.71,,,,,,,fee schedule,7081.71,7081.71, Acute Myocardial Infarction,1903,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,9460.16,,,,,,,fee schedule,9460.16,9460.16, Acute Myocardial Infarction,1903,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,9460.16,,,,,,,fee schedule,9460.16,9460.16, Acute Myocardial Infarction,1903,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,9460.16,,,,,,,fee schedule,9460.16,9460.16, Acute Myocardial Infarction,1903,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,9460.16,,,,,,,fee schedule,9460.16,9460.16, Acute Myocardial Infarction,1903,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,9460.16,,,,,,,fee schedule,9460.16,9460.16, Acute Myocardial Infarction,1903,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,9460.16,,,,,,,fee schedule,9460.16,9460.16, Acute Myocardial Infarction,1903,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,9460.16,,,,,,,fee schedule,9460.16,9460.16, Acute Myocardial Infarction,1903,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,9460.16,,,,,,,fee schedule,9460.16,9460.16, Acute Myocardial Infarction,1903,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,9460.16,,,,,,,fee schedule,9460.16,9460.16, Acute Myocardial Infarction,1903,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,9460.16,,,,,,,fee schedule,9460.16,9460.16, Acute Myocardial Infarction,1903,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,9460.16,,,,,,,fee schedule,9460.16,9460.16, Acute Myocardial Infarction,1904,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,15812.8,,,,,,,fee schedule,15812.8,15812.8, Acute Myocardial Infarction,1904,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,15812.8,,,,,,,fee schedule,15812.8,15812.8, Acute Myocardial Infarction,1904,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,15812.8,,,,,,,fee schedule,15812.8,15812.8, Acute Myocardial Infarction,1904,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,15812.8,,,,,,,fee schedule,15812.8,15812.8, Acute Myocardial Infarction,1904,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,15812.8,,,,,,,fee schedule,15812.8,15812.8, Acute Myocardial Infarction,1904,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,15812.8,,,,,,,fee schedule,15812.8,15812.8, Acute Myocardial Infarction,1904,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,15812.8,,,,,,,fee schedule,15812.8,15812.8, Acute Myocardial Infarction,1904,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,15812.8,,,,,,,fee schedule,15812.8,15812.8, Acute Myocardial Infarction,1904,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,15812.8,,,,,,,fee schedule,15812.8,15812.8, Acute Myocardial Infarction,1904,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,15812.8,,,,,,,fee schedule,15812.8,15812.8, Acute Myocardial Infarction,1904,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,15812.8,,,,,,,fee schedule,15812.8,15812.8, Cardiac Catheterization For Coronary Artery Disease,1911,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,7450.12,,,,,,,fee schedule,7450.12,7450.12, Cardiac Catheterization For Coronary Artery Disease,1911,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,7450.12,,,,,,,fee schedule,7450.12,7450.12, Cardiac Catheterization For Coronary Artery Disease,1911,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,7450.12,,,,,,,fee schedule,7450.12,7450.12, Cardiac Catheterization For Coronary Artery Disease,1911,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,7450.12,,,,,,,fee schedule,7450.12,7450.12, Cardiac Catheterization For Coronary Artery Disease,1911,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,7450.12,,,,,,,fee schedule,7450.12,7450.12, Cardiac Catheterization For Coronary Artery Disease,1911,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,7450.12,,,,,,,fee schedule,7450.12,7450.12, Cardiac Catheterization For Coronary Artery Disease,1911,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,7450.12,,,,,,,fee schedule,7450.12,7450.12, Cardiac Catheterization For Coronary Artery Disease,1911,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,7450.12,,,,,,,fee schedule,7450.12,7450.12, Cardiac Catheterization For Coronary Artery Disease,1911,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,7450.12,,,,,,,fee schedule,7450.12,7450.12, Cardiac Catheterization For Coronary Artery Disease,1911,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,7450.12,,,,,,,fee schedule,7450.12,7450.12, Cardiac Catheterization For Coronary Artery Disease,1911,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,7450.12,,,,,,,fee schedule,7450.12,7450.12, Cardiac Catheterization For Coronary Artery Disease,1912,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,8860.25,,,,,,,fee schedule,8860.25,8860.25, Cardiac Catheterization For Coronary Artery Disease,1912,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,8860.25,,,,,,,fee schedule,8860.25,8860.25, Cardiac Catheterization For Coronary Artery Disease,1912,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,8860.25,,,,,,,fee schedule,8860.25,8860.25, Cardiac Catheterization For Coronary Artery Disease,1912,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,8860.25,,,,,,,fee schedule,8860.25,8860.25, Cardiac Catheterization For Coronary Artery Disease,1912,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,8860.25,,,,,,,fee schedule,8860.25,8860.25, Cardiac Catheterization For Coronary Artery Disease,1912,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,8860.25,,,,,,,fee schedule,8860.25,8860.25, Cardiac Catheterization For Coronary Artery Disease,1912,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,8860.25,,,,,,,fee schedule,8860.25,8860.25, Cardiac Catheterization For Coronary Artery Disease,1912,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,8860.25,,,,,,,fee schedule,8860.25,8860.25, Cardiac Catheterization For Coronary Artery Disease,1912,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,8860.25,,,,,,,fee schedule,8860.25,8860.25, Cardiac Catheterization For Coronary Artery Disease,1912,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,8860.25,,,,,,,fee schedule,8860.25,8860.25, Cardiac Catheterization For Coronary Artery Disease,1912,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,8860.25,,,,,,,fee schedule,8860.25,8860.25, Cardiac Catheterization For Coronary Artery Disease,1913,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,12075.04,,,,,,,fee schedule,12075.04,12075.04, Cardiac Catheterization For Coronary Artery Disease,1913,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,12075.04,,,,,,,fee schedule,12075.04,12075.04, Cardiac Catheterization For Coronary Artery Disease,1913,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,12075.04,,,,,,,fee schedule,12075.04,12075.04, Cardiac Catheterization For Coronary Artery Disease,1913,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,12075.04,,,,,,,fee schedule,12075.04,12075.04, Cardiac Catheterization For Coronary Artery Disease,1913,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,12075.04,,,,,,,fee schedule,12075.04,12075.04, Cardiac Catheterization For Coronary Artery Disease,1913,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,12075.04,,,,,,,fee schedule,12075.04,12075.04, Cardiac Catheterization For Coronary Artery Disease,1913,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,12075.04,,,,,,,fee schedule,12075.04,12075.04, Cardiac Catheterization For Coronary Artery Disease,1913,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,12075.04,,,,,,,fee schedule,12075.04,12075.04, Cardiac Catheterization For Coronary Artery Disease,1913,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,12075.04,,,,,,,fee schedule,12075.04,12075.04, Cardiac Catheterization For Coronary Artery Disease,1913,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,12075.04,,,,,,,fee schedule,12075.04,12075.04, Cardiac Catheterization For Coronary Artery Disease,1913,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,12075.04,,,,,,,fee schedule,12075.04,12075.04, Cardiac Catheterization For Coronary Artery Disease,1914,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,17983.76,,,,,,,fee schedule,17983.76,17983.76, Cardiac Catheterization For Coronary Artery Disease,1914,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,17983.76,,,,,,,fee schedule,17983.76,17983.76, Cardiac Catheterization For Coronary Artery Disease,1914,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,17983.76,,,,,,,fee schedule,17983.76,17983.76, Cardiac Catheterization For Coronary Artery Disease,1914,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,17983.76,,,,,,,fee schedule,17983.76,17983.76, Cardiac Catheterization For Coronary Artery Disease,1914,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,17983.76,,,,,,,fee schedule,17983.76,17983.76, Cardiac Catheterization For Coronary Artery Disease,1914,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,17983.76,,,,,,,fee schedule,17983.76,17983.76, Cardiac Catheterization For Coronary Artery Disease,1914,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,17983.76,,,,,,,fee schedule,17983.76,17983.76, Cardiac Catheterization For Coronary Artery Disease,1914,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,17983.76,,,,,,,fee schedule,17983.76,17983.76, Cardiac Catheterization For Coronary Artery Disease,1914,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,17983.76,,,,,,,fee schedule,17983.76,17983.76, Cardiac Catheterization For Coronary Artery Disease,1914,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,17983.76,,,,,,,fee schedule,17983.76,17983.76, Cardiac Catheterization For Coronary Artery Disease,1914,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,17983.76,,,,,,,fee schedule,17983.76,17983.76, Cardiac Catheterization For Other Non-Coronary Conditions,1921,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,7786.07,,,,,,,fee schedule,7786.07,7786.07, Cardiac Catheterization For Other Non-Coronary Conditions,1921,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,7786.07,,,,,,,fee schedule,7786.07,7786.07, Cardiac Catheterization For Other Non-Coronary Conditions,1921,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,7786.07,,,,,,,fee schedule,7786.07,7786.07, Cardiac Catheterization For Other Non-Coronary Conditions,1921,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,7786.07,,,,,,,fee schedule,7786.07,7786.07, Cardiac Catheterization For Other Non-Coronary Conditions,1921,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,7786.07,,,,,,,fee schedule,7786.07,7786.07, Cardiac Catheterization For Other Non-Coronary Conditions,1921,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,7786.07,,,,,,,fee schedule,7786.07,7786.07, Cardiac Catheterization For Other Non-Coronary Conditions,1921,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,7786.07,,,,,,,fee schedule,7786.07,7786.07, Cardiac Catheterization For Other Non-Coronary Conditions,1921,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,7786.07,,,,,,,fee schedule,7786.07,7786.07, Cardiac Catheterization For Other Non-Coronary Conditions,1921,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,7786.07,,,,,,,fee schedule,7786.07,7786.07, Cardiac Catheterization For Other Non-Coronary Conditions,1921,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,7786.07,,,,,,,fee schedule,7786.07,7786.07, Cardiac Catheterization For Other Non-Coronary Conditions,1921,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,7786.07,,,,,,,fee schedule,7786.07,7786.07, Cardiac Catheterization For Other Non-Coronary Conditions,1922,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,9982.43,,,,,,,fee schedule,9982.43,9982.43, Cardiac Catheterization For Other Non-Coronary Conditions,1922,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,9982.43,,,,,,,fee schedule,9982.43,9982.43, Cardiac Catheterization For Other Non-Coronary Conditions,1922,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,9982.43,,,,,,,fee schedule,9982.43,9982.43, Cardiac Catheterization For Other Non-Coronary Conditions,1922,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,9982.43,,,,,,,fee schedule,9982.43,9982.43, Cardiac Catheterization For Other Non-Coronary Conditions,1922,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,9982.43,,,,,,,fee schedule,9982.43,9982.43, Cardiac Catheterization For Other Non-Coronary Conditions,1922,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,9982.43,,,,,,,fee schedule,9982.43,9982.43, Cardiac Catheterization For Other Non-Coronary Conditions,1922,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,9982.43,,,,,,,fee schedule,9982.43,9982.43, Cardiac Catheterization For Other Non-Coronary Conditions,1922,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,9982.43,,,,,,,fee schedule,9982.43,9982.43, Cardiac Catheterization For Other Non-Coronary Conditions,1922,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,9982.43,,,,,,,fee schedule,9982.43,9982.43, Cardiac Catheterization For Other Non-Coronary Conditions,1922,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,9982.43,,,,,,,fee schedule,9982.43,9982.43, Cardiac Catheterization For Other Non-Coronary Conditions,1922,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,9982.43,,,,,,,fee schedule,9982.43,9982.43, Cardiac Catheterization For Other Non-Coronary Conditions,1923,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,14561.47,,,,,,,fee schedule,14561.47,14561.47, Cardiac Catheterization For Other Non-Coronary Conditions,1923,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,14561.47,,,,,,,fee schedule,14561.47,14561.47, Cardiac Catheterization For Other Non-Coronary Conditions,1923,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,14561.47,,,,,,,fee schedule,14561.47,14561.47, Cardiac Catheterization For Other Non-Coronary Conditions,1923,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,14561.47,,,,,,,fee schedule,14561.47,14561.47, Cardiac Catheterization For Other Non-Coronary Conditions,1923,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,14561.47,,,,,,,fee schedule,14561.47,14561.47, Cardiac Catheterization For Other Non-Coronary Conditions,1923,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,14561.47,,,,,,,fee schedule,14561.47,14561.47, Cardiac Catheterization For Other Non-Coronary Conditions,1923,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,14561.47,,,,,,,fee schedule,14561.47,14561.47, Cardiac Catheterization For Other Non-Coronary Conditions,1923,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,14561.47,,,,,,,fee schedule,14561.47,14561.47, Cardiac Catheterization For Other Non-Coronary Conditions,1923,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,14561.47,,,,,,,fee schedule,14561.47,14561.47, Cardiac Catheterization For Other Non-Coronary Conditions,1923,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,14561.47,,,,,,,fee schedule,14561.47,14561.47, Cardiac Catheterization For Other Non-Coronary Conditions,1923,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,14561.47,,,,,,,fee schedule,14561.47,14561.47, Cardiac Catheterization For Other Non-Coronary Conditions,1924,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,23795.78,,,,,,,fee schedule,23795.78,23795.78, Cardiac Catheterization For Other Non-Coronary Conditions,1924,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,23795.78,,,,,,,fee schedule,23795.78,23795.78, Cardiac Catheterization For Other Non-Coronary Conditions,1924,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,23795.78,,,,,,,fee schedule,23795.78,23795.78, Cardiac Catheterization For Other Non-Coronary Conditions,1924,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,23795.78,,,,,,,fee schedule,23795.78,23795.78, Cardiac Catheterization For Other Non-Coronary Conditions,1924,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,23795.78,,,,,,,fee schedule,23795.78,23795.78, Cardiac Catheterization For Other Non-Coronary Conditions,1924,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,23795.78,,,,,,,fee schedule,23795.78,23795.78, Cardiac Catheterization For Other Non-Coronary Conditions,1924,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,23795.78,,,,,,,fee schedule,23795.78,23795.78, Cardiac Catheterization For Other Non-Coronary Conditions,1924,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,23795.78,,,,,,,fee schedule,23795.78,23795.78, Cardiac Catheterization For Other Non-Coronary Conditions,1924,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,23795.78,,,,,,,fee schedule,23795.78,23795.78, Cardiac Catheterization For Other Non-Coronary Conditions,1924,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,23795.78,,,,,,,fee schedule,23795.78,23795.78, Cardiac Catheterization For Other Non-Coronary Conditions,1924,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,23795.78,,,,,,,fee schedule,23795.78,23795.78, Acute And Subacute Endocarditis,1931,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,8213.77,,,,,,,fee schedule,8213.77,8213.77, Acute And Subacute Endocarditis,1931,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,8213.77,,,,,,,fee schedule,8213.77,8213.77, Acute And Subacute Endocarditis,1931,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,8213.77,,,,,,,fee schedule,8213.77,8213.77, Acute And Subacute Endocarditis,1931,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,8213.77,,,,,,,fee schedule,8213.77,8213.77, Acute And Subacute Endocarditis,1931,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,8213.77,,,,,,,fee schedule,8213.77,8213.77, Acute And Subacute Endocarditis,1931,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,8213.77,,,,,,,fee schedule,8213.77,8213.77, Acute And Subacute Endocarditis,1931,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,8213.77,,,,,,,fee schedule,8213.77,8213.77, Acute And Subacute Endocarditis,1931,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,8213.77,,,,,,,fee schedule,8213.77,8213.77, Acute And Subacute Endocarditis,1931,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,8213.77,,,,,,,fee schedule,8213.77,8213.77, Acute And Subacute Endocarditis,1931,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,8213.77,,,,,,,fee schedule,8213.77,8213.77, Acute And Subacute Endocarditis,1931,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,8213.77,,,,,,,fee schedule,8213.77,8213.77, Acute And Subacute Endocarditis,1932,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,8963.29,,,,,,,fee schedule,8963.29,8963.29, Acute And Subacute Endocarditis,1932,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,8963.29,,,,,,,fee schedule,8963.29,8963.29, Acute And Subacute Endocarditis,1932,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,8963.29,,,,,,,fee schedule,8963.29,8963.29, Acute And Subacute Endocarditis,1932,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,8963.29,,,,,,,fee schedule,8963.29,8963.29, Acute And Subacute Endocarditis,1932,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,8963.29,,,,,,,fee schedule,8963.29,8963.29, Acute And Subacute Endocarditis,1932,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,8963.29,,,,,,,fee schedule,8963.29,8963.29, Acute And Subacute Endocarditis,1932,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,8963.29,,,,,,,fee schedule,8963.29,8963.29, Acute And Subacute Endocarditis,1932,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,8963.29,,,,,,,fee schedule,8963.29,8963.29, Acute And Subacute Endocarditis,1932,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,8963.29,,,,,,,fee schedule,8963.29,8963.29, Acute And Subacute Endocarditis,1932,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,8963.29,,,,,,,fee schedule,8963.29,8963.29, Acute And Subacute Endocarditis,1932,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,8963.29,,,,,,,fee schedule,8963.29,8963.29, Acute And Subacute Endocarditis,1933,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,12276.19,,,,,,,fee schedule,12276.19,12276.19, Acute And Subacute Endocarditis,1933,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,12276.19,,,,,,,fee schedule,12276.19,12276.19, Acute And Subacute Endocarditis,1933,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,12276.19,,,,,,,fee schedule,12276.19,12276.19, Acute And Subacute Endocarditis,1933,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,12276.19,,,,,,,fee schedule,12276.19,12276.19, Acute And Subacute Endocarditis,1933,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,12276.19,,,,,,,fee schedule,12276.19,12276.19, Acute And Subacute Endocarditis,1933,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,12276.19,,,,,,,fee schedule,12276.19,12276.19, Acute And Subacute Endocarditis,1933,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,12276.19,,,,,,,fee schedule,12276.19,12276.19, Acute And Subacute Endocarditis,1933,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,12276.19,,,,,,,fee schedule,12276.19,12276.19, Acute And Subacute Endocarditis,1933,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,12276.19,,,,,,,fee schedule,12276.19,12276.19, Acute And Subacute Endocarditis,1933,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,12276.19,,,,,,,fee schedule,12276.19,12276.19, Acute And Subacute Endocarditis,1933,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,12276.19,,,,,,,fee schedule,12276.19,12276.19, Acute And Subacute Endocarditis,1934,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,18038.81,,,,,,,fee schedule,18038.81,18038.81, Acute And Subacute Endocarditis,1934,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,18038.81,,,,,,,fee schedule,18038.81,18038.81, Acute And Subacute Endocarditis,1934,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,18038.81,,,,,,,fee schedule,18038.81,18038.81, Acute And Subacute Endocarditis,1934,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,18038.81,,,,,,,fee schedule,18038.81,18038.81, Acute And Subacute Endocarditis,1934,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,18038.81,,,,,,,fee schedule,18038.81,18038.81, Acute And Subacute Endocarditis,1934,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,18038.81,,,,,,,fee schedule,18038.81,18038.81, Acute And Subacute Endocarditis,1934,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,18038.81,,,,,,,fee schedule,18038.81,18038.81, Acute And Subacute Endocarditis,1934,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,18038.81,,,,,,,fee schedule,18038.81,18038.81, Acute And Subacute Endocarditis,1934,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,18038.81,,,,,,,fee schedule,18038.81,18038.81, Acute And Subacute Endocarditis,1934,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,18038.81,,,,,,,fee schedule,18038.81,18038.81, Acute And Subacute Endocarditis,1934,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,18038.81,,,,,,,fee schedule,18038.81,18038.81, Heart Failure,1941,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,3924.09,,,,,,,fee schedule,3924.09,3924.09, Heart Failure,1941,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,3924.09,,,,,,,fee schedule,3924.09,3924.09, Heart Failure,1941,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,3924.09,,,,,,,fee schedule,3924.09,3924.09, Heart Failure,1941,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,3924.09,,,,,,,fee schedule,3924.09,3924.09, Heart Failure,1941,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,3924.09,,,,,,,fee schedule,3924.09,3924.09, Heart Failure,1941,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,3924.09,,,,,,,fee schedule,3924.09,3924.09, Heart Failure,1941,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,3924.09,,,,,,,fee schedule,3924.09,3924.09, Heart Failure,1941,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,3924.09,,,,,,,fee schedule,3924.09,3924.09, Heart Failure,1941,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,3924.09,,,,,,,fee schedule,3924.09,3924.09, Heart Failure,1941,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,3924.09,,,,,,,fee schedule,3924.09,3924.09, Heart Failure,1941,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,3924.09,,,,,,,fee schedule,3924.09,3924.09, Heart Failure,1942,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5489.49,,,,,,,fee schedule,5489.49,5489.49, Heart Failure,1942,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5489.49,,,,,,,fee schedule,5489.49,5489.49, Heart Failure,1942,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5489.49,,,,,,,fee schedule,5489.49,5489.49, Heart Failure,1942,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5489.49,,,,,,,fee schedule,5489.49,5489.49, Heart Failure,1942,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5489.49,,,,,,,fee schedule,5489.49,5489.49, Heart Failure,1942,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5489.49,,,,,,,fee schedule,5489.49,5489.49, Heart Failure,1942,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5489.49,,,,,,,fee schedule,5489.49,5489.49, Heart Failure,1942,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5489.49,,,,,,,fee schedule,5489.49,5489.49, Heart Failure,1942,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5489.49,,,,,,,fee schedule,5489.49,5489.49, Heart Failure,1942,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5489.49,,,,,,,fee schedule,5489.49,5489.49, Heart Failure,1942,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5489.49,,,,,,,fee schedule,5489.49,5489.49, Heart Failure,1943,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,8954.12,,,,,,,fee schedule,8954.12,8954.12, Heart Failure,1943,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,8954.12,,,,,,,fee schedule,8954.12,8954.12, Heart Failure,1943,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,8954.12,,,,,,,fee schedule,8954.12,8954.12, Heart Failure,1943,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,8954.12,,,,,,,fee schedule,8954.12,8954.12, Heart Failure,1943,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,8954.12,,,,,,,fee schedule,8954.12,8954.12, Heart Failure,1943,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,8954.12,,,,,,,fee schedule,8954.12,8954.12, Heart Failure,1943,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,8954.12,,,,,,,fee schedule,8954.12,8954.12, Heart Failure,1943,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,8954.12,,,,,,,fee schedule,8954.12,8954.12, Heart Failure,1943,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,8954.12,,,,,,,fee schedule,8954.12,8954.12, Heart Failure,1943,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,8954.12,,,,,,,fee schedule,8954.12,8954.12, Heart Failure,1943,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,8954.12,,,,,,,fee schedule,8954.12,8954.12, Heart Failure,1944,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,17246.23,,,,,,,fee schedule,17246.23,17246.23, Heart Failure,1944,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,17246.23,,,,,,,fee schedule,17246.23,17246.23, Heart Failure,1944,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,17246.23,,,,,,,fee schedule,17246.23,17246.23, Heart Failure,1944,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,17246.23,,,,,,,fee schedule,17246.23,17246.23, Heart Failure,1944,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,17246.23,,,,,,,fee schedule,17246.23,17246.23, Heart Failure,1944,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,17246.23,,,,,,,fee schedule,17246.23,17246.23, Heart Failure,1944,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,17246.23,,,,,,,fee schedule,17246.23,17246.23, Heart Failure,1944,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,17246.23,,,,,,,fee schedule,17246.23,17246.23, Heart Failure,1944,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,17246.23,,,,,,,fee schedule,17246.23,17246.23, Heart Failure,1944,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,17246.23,,,,,,,fee schedule,17246.23,17246.23, Heart Failure,1944,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,17246.23,,,,,,,fee schedule,17246.23,17246.23, Cardiac Arrest And Shock,1961,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,3564.14,,,,,,,fee schedule,3564.14,3564.14, Cardiac Arrest And Shock,1961,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,3564.14,,,,,,,fee schedule,3564.14,3564.14, Cardiac Arrest And Shock,1961,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,3564.14,,,,,,,fee schedule,3564.14,3564.14, Cardiac Arrest And Shock,1961,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,3564.14,,,,,,,fee schedule,3564.14,3564.14, Cardiac Arrest And Shock,1961,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,3564.14,,,,,,,fee schedule,3564.14,3564.14, Cardiac Arrest And Shock,1961,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,3564.14,,,,,,,fee schedule,3564.14,3564.14, Cardiac Arrest And Shock,1961,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,3564.14,,,,,,,fee schedule,3564.14,3564.14, Cardiac Arrest And Shock,1961,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,3564.14,,,,,,,fee schedule,3564.14,3564.14, Cardiac Arrest And Shock,1961,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,3564.14,,,,,,,fee schedule,3564.14,3564.14, Cardiac Arrest And Shock,1961,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,3564.14,,,,,,,fee schedule,3564.14,3564.14, Cardiac Arrest And Shock,1961,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,3564.14,,,,,,,fee schedule,3564.14,3564.14, Cardiac Arrest And Shock,1962,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4382.13,,,,,,,fee schedule,4382.13,4382.13, Cardiac Arrest And Shock,1962,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4382.13,,,,,,,fee schedule,4382.13,4382.13, Cardiac Arrest And Shock,1962,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4382.13,,,,,,,fee schedule,4382.13,4382.13, Cardiac Arrest And Shock,1962,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4382.13,,,,,,,fee schedule,4382.13,4382.13, Cardiac Arrest And Shock,1962,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4382.13,,,,,,,fee schedule,4382.13,4382.13, Cardiac Arrest And Shock,1962,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4382.13,,,,,,,fee schedule,4382.13,4382.13, Cardiac Arrest And Shock,1962,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4382.13,,,,,,,fee schedule,4382.13,4382.13, Cardiac Arrest And Shock,1962,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4382.13,,,,,,,fee schedule,4382.13,4382.13, Cardiac Arrest And Shock,1962,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4382.13,,,,,,,fee schedule,4382.13,4382.13, Cardiac Arrest And Shock,1962,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4382.13,,,,,,,fee schedule,4382.13,4382.13, Cardiac Arrest And Shock,1962,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4382.13,,,,,,,fee schedule,4382.13,4382.13, Cardiac Arrest And Shock,1963,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,7349.2,,,,,,,fee schedule,7349.2,7349.2, Cardiac Arrest And Shock,1963,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,7349.2,,,,,,,fee schedule,7349.2,7349.2, Cardiac Arrest And Shock,1963,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,7349.2,,,,,,,fee schedule,7349.2,7349.2, Cardiac Arrest And Shock,1963,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,7349.2,,,,,,,fee schedule,7349.2,7349.2, Cardiac Arrest And Shock,1963,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,7349.2,,,,,,,fee schedule,7349.2,7349.2, Cardiac Arrest And Shock,1963,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,7349.2,,,,,,,fee schedule,7349.2,7349.2, Cardiac Arrest And Shock,1963,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,7349.2,,,,,,,fee schedule,7349.2,7349.2, Cardiac Arrest And Shock,1963,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,7349.2,,,,,,,fee schedule,7349.2,7349.2, Cardiac Arrest And Shock,1963,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,7349.2,,,,,,,fee schedule,7349.2,7349.2, Cardiac Arrest And Shock,1963,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,7349.2,,,,,,,fee schedule,7349.2,7349.2, Cardiac Arrest And Shock,1963,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,7349.2,,,,,,,fee schedule,7349.2,7349.2, Cardiac Arrest And Shock,1964,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,14567.82,,,,,,,fee schedule,14567.82,14567.82, Cardiac Arrest And Shock,1964,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,14567.82,,,,,,,fee schedule,14567.82,14567.82, Cardiac Arrest And Shock,1964,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,14567.82,,,,,,,fee schedule,14567.82,14567.82, Cardiac Arrest And Shock,1964,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,14567.82,,,,,,,fee schedule,14567.82,14567.82, Cardiac Arrest And Shock,1964,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,14567.82,,,,,,,fee schedule,14567.82,14567.82, Cardiac Arrest And Shock,1964,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,14567.82,,,,,,,fee schedule,14567.82,14567.82, Cardiac Arrest And Shock,1964,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,14567.82,,,,,,,fee schedule,14567.82,14567.82, Cardiac Arrest And Shock,1964,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,14567.82,,,,,,,fee schedule,14567.82,14567.82, Cardiac Arrest And Shock,1964,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,14567.82,,,,,,,fee schedule,14567.82,14567.82, Cardiac Arrest And Shock,1964,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,14567.82,,,,,,,fee schedule,14567.82,14567.82, Cardiac Arrest And Shock,1964,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,14567.82,,,,,,,fee schedule,14567.82,14567.82, Peripheral And Other Vascular Disorders,1971,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4418.83,,,,,,,fee schedule,4418.83,4418.83, Peripheral And Other Vascular Disorders,1971,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4418.83,,,,,,,fee schedule,4418.83,4418.83, Peripheral And Other Vascular Disorders,1971,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4418.83,,,,,,,fee schedule,4418.83,4418.83, Peripheral And Other Vascular Disorders,1971,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4418.83,,,,,,,fee schedule,4418.83,4418.83, Peripheral And Other Vascular Disorders,1971,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4418.83,,,,,,,fee schedule,4418.83,4418.83, Peripheral And Other Vascular Disorders,1971,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4418.83,,,,,,,fee schedule,4418.83,4418.83, Peripheral And Other Vascular Disorders,1971,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4418.83,,,,,,,fee schedule,4418.83,4418.83, Peripheral And Other Vascular Disorders,1971,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4418.83,,,,,,,fee schedule,4418.83,4418.83, Peripheral And Other Vascular Disorders,1971,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4418.83,,,,,,,fee schedule,4418.83,4418.83, Peripheral And Other Vascular Disorders,1971,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4418.83,,,,,,,fee schedule,4418.83,4418.83, Peripheral And Other Vascular Disorders,1971,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4418.83,,,,,,,fee schedule,4418.83,4418.83, Peripheral And Other Vascular Disorders,1972,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5795.09,,,,,,,fee schedule,5795.09,5795.09, Peripheral And Other Vascular Disorders,1972,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5795.09,,,,,,,fee schedule,5795.09,5795.09, Peripheral And Other Vascular Disorders,1972,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5795.09,,,,,,,fee schedule,5795.09,5795.09, Peripheral And Other Vascular Disorders,1972,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5795.09,,,,,,,fee schedule,5795.09,5795.09, Peripheral And Other Vascular Disorders,1972,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5795.09,,,,,,,fee schedule,5795.09,5795.09, Peripheral And Other Vascular Disorders,1972,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5795.09,,,,,,,fee schedule,5795.09,5795.09, Peripheral And Other Vascular Disorders,1972,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5795.09,,,,,,,fee schedule,5795.09,5795.09, Peripheral And Other Vascular Disorders,1972,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5795.09,,,,,,,fee schedule,5795.09,5795.09, Peripheral And Other Vascular Disorders,1972,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5795.09,,,,,,,fee schedule,5795.09,5795.09, Peripheral And Other Vascular Disorders,1972,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5795.09,,,,,,,fee schedule,5795.09,5795.09, Peripheral And Other Vascular Disorders,1972,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5795.09,,,,,,,fee schedule,5795.09,5795.09, Peripheral And Other Vascular Disorders,1973,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,9125.62,,,,,,,fee schedule,9125.62,9125.62, Peripheral And Other Vascular Disorders,1973,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,9125.62,,,,,,,fee schedule,9125.62,9125.62, Peripheral And Other Vascular Disorders,1973,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,9125.62,,,,,,,fee schedule,9125.62,9125.62, Peripheral And Other Vascular Disorders,1973,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,9125.62,,,,,,,fee schedule,9125.62,9125.62, Peripheral And Other Vascular Disorders,1973,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,9125.62,,,,,,,fee schedule,9125.62,9125.62, Peripheral And Other Vascular Disorders,1973,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,9125.62,,,,,,,fee schedule,9125.62,9125.62, Peripheral And Other Vascular Disorders,1973,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,9125.62,,,,,,,fee schedule,9125.62,9125.62, Peripheral And Other Vascular Disorders,1973,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,9125.62,,,,,,,fee schedule,9125.62,9125.62, Peripheral And Other Vascular Disorders,1973,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,9125.62,,,,,,,fee schedule,9125.62,9125.62, Peripheral And Other Vascular Disorders,1973,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,9125.62,,,,,,,fee schedule,9125.62,9125.62, Peripheral And Other Vascular Disorders,1973,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,9125.62,,,,,,,fee schedule,9125.62,9125.62, Peripheral And Other Vascular Disorders,1974,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,16220.04,,,,,,,fee schedule,16220.04,16220.04, Peripheral And Other Vascular Disorders,1974,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,16220.04,,,,,,,fee schedule,16220.04,16220.04, Peripheral And Other Vascular Disorders,1974,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,16220.04,,,,,,,fee schedule,16220.04,16220.04, Peripheral And Other Vascular Disorders,1974,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,16220.04,,,,,,,fee schedule,16220.04,16220.04, Peripheral And Other Vascular Disorders,1974,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,16220.04,,,,,,,fee schedule,16220.04,16220.04, Peripheral And Other Vascular Disorders,1974,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,16220.04,,,,,,,fee schedule,16220.04,16220.04, Peripheral And Other Vascular Disorders,1974,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,16220.04,,,,,,,fee schedule,16220.04,16220.04, Peripheral And Other Vascular Disorders,1974,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,16220.04,,,,,,,fee schedule,16220.04,16220.04, Peripheral And Other Vascular Disorders,1974,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,16220.04,,,,,,,fee schedule,16220.04,16220.04, Peripheral And Other Vascular Disorders,1974,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,16220.04,,,,,,,fee schedule,16220.04,16220.04, Peripheral And Other Vascular Disorders,1974,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,16220.04,,,,,,,fee schedule,16220.04,16220.04, Angina Pectoris And Coronary Atherosclerosis,1981,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4227.57,,,,,,,fee schedule,4227.57,4227.57, Angina Pectoris And Coronary Atherosclerosis,1981,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4227.57,,,,,,,fee schedule,4227.57,4227.57, Angina Pectoris And Coronary Atherosclerosis,1981,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4227.57,,,,,,,fee schedule,4227.57,4227.57, Angina Pectoris And Coronary Atherosclerosis,1981,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4227.57,,,,,,,fee schedule,4227.57,4227.57, Angina Pectoris And Coronary Atherosclerosis,1981,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4227.57,,,,,,,fee schedule,4227.57,4227.57, Angina Pectoris And Coronary Atherosclerosis,1981,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4227.57,,,,,,,fee schedule,4227.57,4227.57, Angina Pectoris And Coronary Atherosclerosis,1981,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4227.57,,,,,,,fee schedule,4227.57,4227.57, Angina Pectoris And Coronary Atherosclerosis,1981,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4227.57,,,,,,,fee schedule,4227.57,4227.57, Angina Pectoris And Coronary Atherosclerosis,1981,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4227.57,,,,,,,fee schedule,4227.57,4227.57, Angina Pectoris And Coronary Atherosclerosis,1981,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4227.57,,,,,,,fee schedule,4227.57,4227.57, Angina Pectoris And Coronary Atherosclerosis,1981,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4227.57,,,,,,,fee schedule,4227.57,4227.57, Angina Pectoris And Coronary Atherosclerosis,1982,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4991.92,,,,,,,fee schedule,4991.92,4991.92, Angina Pectoris And Coronary Atherosclerosis,1982,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4991.92,,,,,,,fee schedule,4991.92,4991.92, Angina Pectoris And Coronary Atherosclerosis,1982,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4991.92,,,,,,,fee schedule,4991.92,4991.92, Angina Pectoris And Coronary Atherosclerosis,1982,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4991.92,,,,,,,fee schedule,4991.92,4991.92, Angina Pectoris And Coronary Atherosclerosis,1982,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4991.92,,,,,,,fee schedule,4991.92,4991.92, Angina Pectoris And Coronary Atherosclerosis,1982,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4991.92,,,,,,,fee schedule,4991.92,4991.92, Angina Pectoris And Coronary Atherosclerosis,1982,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4991.92,,,,,,,fee schedule,4991.92,4991.92, Angina Pectoris And Coronary Atherosclerosis,1982,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4991.92,,,,,,,fee schedule,4991.92,4991.92, Angina Pectoris And Coronary Atherosclerosis,1982,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4991.92,,,,,,,fee schedule,4991.92,4991.92, Angina Pectoris And Coronary Atherosclerosis,1982,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4991.92,,,,,,,fee schedule,4991.92,4991.92, Angina Pectoris And Coronary Atherosclerosis,1982,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4991.92,,,,,,,fee schedule,4991.92,4991.92, Angina Pectoris And Coronary Atherosclerosis,1983,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,6567.91,,,,,,,fee schedule,6567.91,6567.91, Angina Pectoris And Coronary Atherosclerosis,1983,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,6567.91,,,,,,,fee schedule,6567.91,6567.91, Angina Pectoris And Coronary Atherosclerosis,1983,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,6567.91,,,,,,,fee schedule,6567.91,6567.91, Angina Pectoris And Coronary Atherosclerosis,1983,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,6567.91,,,,,,,fee schedule,6567.91,6567.91, Angina Pectoris And Coronary Atherosclerosis,1983,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,6567.91,,,,,,,fee schedule,6567.91,6567.91, Angina Pectoris And Coronary Atherosclerosis,1983,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,6567.91,,,,,,,fee schedule,6567.91,6567.91, Angina Pectoris And Coronary Atherosclerosis,1983,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,6567.91,,,,,,,fee schedule,6567.91,6567.91, Angina Pectoris And Coronary Atherosclerosis,1983,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,6567.91,,,,,,,fee schedule,6567.91,6567.91, Angina Pectoris And Coronary Atherosclerosis,1983,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,6567.91,,,,,,,fee schedule,6567.91,6567.91, Angina Pectoris And Coronary Atherosclerosis,1983,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,6567.91,,,,,,,fee schedule,6567.91,6567.91, Angina Pectoris And Coronary Atherosclerosis,1983,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,6567.91,,,,,,,fee schedule,6567.91,6567.91, Angina Pectoris And Coronary Atherosclerosis,1984,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,12133.62,,,,,,,fee schedule,12133.62,12133.62, Angina Pectoris And Coronary Atherosclerosis,1984,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,12133.62,,,,,,,fee schedule,12133.62,12133.62, Angina Pectoris And Coronary Atherosclerosis,1984,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,12133.62,,,,,,,fee schedule,12133.62,12133.62, Angina Pectoris And Coronary Atherosclerosis,1984,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,12133.62,,,,,,,fee schedule,12133.62,12133.62, Angina Pectoris And Coronary Atherosclerosis,1984,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,12133.62,,,,,,,fee schedule,12133.62,12133.62, Angina Pectoris And Coronary Atherosclerosis,1984,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,12133.62,,,,,,,fee schedule,12133.62,12133.62, Angina Pectoris And Coronary Atherosclerosis,1984,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,12133.62,,,,,,,fee schedule,12133.62,12133.62, Angina Pectoris And Coronary Atherosclerosis,1984,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,12133.62,,,,,,,fee schedule,12133.62,12133.62, Angina Pectoris And Coronary Atherosclerosis,1984,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,12133.62,,,,,,,fee schedule,12133.62,12133.62, Angina Pectoris And Coronary Atherosclerosis,1984,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,12133.62,,,,,,,fee schedule,12133.62,12133.62, Angina Pectoris And Coronary Atherosclerosis,1984,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,12133.62,,,,,,,fee schedule,12133.62,12133.62, Hypertension,1991,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4363.08,,,,,,,fee schedule,4363.08,4363.08, Hypertension,1991,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4363.08,,,,,,,fee schedule,4363.08,4363.08, Hypertension,1991,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4363.08,,,,,,,fee schedule,4363.08,4363.08, Hypertension,1991,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4363.08,,,,,,,fee schedule,4363.08,4363.08, Hypertension,1991,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4363.08,,,,,,,fee schedule,4363.08,4363.08, Hypertension,1991,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4363.08,,,,,,,fee schedule,4363.08,4363.08, Hypertension,1991,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4363.08,,,,,,,fee schedule,4363.08,4363.08, Hypertension,1991,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4363.08,,,,,,,fee schedule,4363.08,4363.08, Hypertension,1991,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4363.08,,,,,,,fee schedule,4363.08,4363.08, Hypertension,1991,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4363.08,,,,,,,fee schedule,4363.08,4363.08, Hypertension,1991,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4363.08,,,,,,,fee schedule,4363.08,4363.08, Hypertension,1992,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5129.55,,,,,,,fee schedule,5129.55,5129.55, Hypertension,1992,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5129.55,,,,,,,fee schedule,5129.55,5129.55, Hypertension,1992,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5129.55,,,,,,,fee schedule,5129.55,5129.55, Hypertension,1992,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5129.55,,,,,,,fee schedule,5129.55,5129.55, Hypertension,1992,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5129.55,,,,,,,fee schedule,5129.55,5129.55, Hypertension,1992,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5129.55,,,,,,,fee schedule,5129.55,5129.55, Hypertension,1992,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5129.55,,,,,,,fee schedule,5129.55,5129.55, Hypertension,1992,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5129.55,,,,,,,fee schedule,5129.55,5129.55, Hypertension,1992,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5129.55,,,,,,,fee schedule,5129.55,5129.55, Hypertension,1992,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5129.55,,,,,,,fee schedule,5129.55,5129.55, Hypertension,1992,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5129.55,,,,,,,fee schedule,5129.55,5129.55, Hypertension,1993,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,7670.32,,,,,,,fee schedule,7670.32,7670.32, Hypertension,1993,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,7670.32,,,,,,,fee schedule,7670.32,7670.32, Hypertension,1993,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,7670.32,,,,,,,fee schedule,7670.32,7670.32, Hypertension,1993,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,7670.32,,,,,,,fee schedule,7670.32,7670.32, Hypertension,1993,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,7670.32,,,,,,,fee schedule,7670.32,7670.32, Hypertension,1993,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,7670.32,,,,,,,fee schedule,7670.32,7670.32, Hypertension,1993,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,7670.32,,,,,,,fee schedule,7670.32,7670.32, Hypertension,1993,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,7670.32,,,,,,,fee schedule,7670.32,7670.32, Hypertension,1993,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,7670.32,,,,,,,fee schedule,7670.32,7670.32, Hypertension,1993,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,7670.32,,,,,,,fee schedule,7670.32,7670.32, Hypertension,1993,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,7670.32,,,,,,,fee schedule,7670.32,7670.32, Hypertension,1994,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,14430.2,,,,,,,fee schedule,14430.2,14430.2, Hypertension,1994,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,14430.2,,,,,,,fee schedule,14430.2,14430.2, Hypertension,1994,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,14430.2,,,,,,,fee schedule,14430.2,14430.2, Hypertension,1994,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,14430.2,,,,,,,fee schedule,14430.2,14430.2, Hypertension,1994,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,14430.2,,,,,,,fee schedule,14430.2,14430.2, Hypertension,1994,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,14430.2,,,,,,,fee schedule,14430.2,14430.2, Hypertension,1994,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,14430.2,,,,,,,fee schedule,14430.2,14430.2, Hypertension,1994,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,14430.2,,,,,,,fee schedule,14430.2,14430.2, Hypertension,1994,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,14430.2,,,,,,,fee schedule,14430.2,14430.2, Hypertension,1994,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,14430.2,,,,,,,fee schedule,14430.2,14430.2, Hypertension,1994,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,14430.2,,,,,,,fee schedule,14430.2,14430.2, Cardiac Structural And Valvular Disorders,2001,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4871.23,,,,,,,fee schedule,4871.23,4871.23, Cardiac Structural And Valvular Disorders,2001,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4871.23,,,,,,,fee schedule,4871.23,4871.23, Cardiac Structural And Valvular Disorders,2001,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4871.23,,,,,,,fee schedule,4871.23,4871.23, Cardiac Structural And Valvular Disorders,2001,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4871.23,,,,,,,fee schedule,4871.23,4871.23, Cardiac Structural And Valvular Disorders,2001,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4871.23,,,,,,,fee schedule,4871.23,4871.23, Cardiac Structural And Valvular Disorders,2001,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4871.23,,,,,,,fee schedule,4871.23,4871.23, Cardiac Structural And Valvular Disorders,2001,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4871.23,,,,,,,fee schedule,4871.23,4871.23, Cardiac Structural And Valvular Disorders,2001,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4871.23,,,,,,,fee schedule,4871.23,4871.23, Cardiac Structural And Valvular Disorders,2001,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4871.23,,,,,,,fee schedule,4871.23,4871.23, Cardiac Structural And Valvular Disorders,2001,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4871.23,,,,,,,fee schedule,4871.23,4871.23, Cardiac Structural And Valvular Disorders,2001,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4871.23,,,,,,,fee schedule,4871.23,4871.23, Cardiac Structural And Valvular Disorders,2002,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,6535.44,,,,,,,fee schedule,6535.44,6535.44, Cardiac Structural And Valvular Disorders,2002,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,6535.44,,,,,,,fee schedule,6535.44,6535.44, Cardiac Structural And Valvular Disorders,2002,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,6535.44,,,,,,,fee schedule,6535.44,6535.44, Cardiac Structural And Valvular Disorders,2002,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,6535.44,,,,,,,fee schedule,6535.44,6535.44, Cardiac Structural And Valvular Disorders,2002,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,6535.44,,,,,,,fee schedule,6535.44,6535.44, Cardiac Structural And Valvular Disorders,2002,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,6535.44,,,,,,,fee schedule,6535.44,6535.44, Cardiac Structural And Valvular Disorders,2002,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,6535.44,,,,,,,fee schedule,6535.44,6535.44, Cardiac Structural And Valvular Disorders,2002,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,6535.44,,,,,,,fee schedule,6535.44,6535.44, Cardiac Structural And Valvular Disorders,2002,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,6535.44,,,,,,,fee schedule,6535.44,6535.44, Cardiac Structural And Valvular Disorders,2002,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,6535.44,,,,,,,fee schedule,6535.44,6535.44, Cardiac Structural And Valvular Disorders,2002,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,6535.44,,,,,,,fee schedule,6535.44,6535.44, Cardiac Structural And Valvular Disorders,2003,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,9650.72,,,,,,,fee schedule,9650.72,9650.72, Cardiac Structural And Valvular Disorders,2003,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,9650.72,,,,,,,fee schedule,9650.72,9650.72, Cardiac Structural And Valvular Disorders,2003,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,9650.72,,,,,,,fee schedule,9650.72,9650.72, Cardiac Structural And Valvular Disorders,2003,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,9650.72,,,,,,,fee schedule,9650.72,9650.72, Cardiac Structural And Valvular Disorders,2003,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,9650.72,,,,,,,fee schedule,9650.72,9650.72, Cardiac Structural And Valvular Disorders,2003,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,9650.72,,,,,,,fee schedule,9650.72,9650.72, Cardiac Structural And Valvular Disorders,2003,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,9650.72,,,,,,,fee schedule,9650.72,9650.72, Cardiac Structural And Valvular Disorders,2003,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,9650.72,,,,,,,fee schedule,9650.72,9650.72, Cardiac Structural And Valvular Disorders,2003,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,9650.72,,,,,,,fee schedule,9650.72,9650.72, Cardiac Structural And Valvular Disorders,2003,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,9650.72,,,,,,,fee schedule,9650.72,9650.72, Cardiac Structural And Valvular Disorders,2003,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,9650.72,,,,,,,fee schedule,9650.72,9650.72, Cardiac Structural And Valvular Disorders,2004,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,16932.16,,,,,,,fee schedule,16932.16,16932.16, Cardiac Structural And Valvular Disorders,2004,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,16932.16,,,,,,,fee schedule,16932.16,16932.16, Cardiac Structural And Valvular Disorders,2004,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,16932.16,,,,,,,fee schedule,16932.16,16932.16, Cardiac Structural And Valvular Disorders,2004,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,16932.16,,,,,,,fee schedule,16932.16,16932.16, Cardiac Structural And Valvular Disorders,2004,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,16932.16,,,,,,,fee schedule,16932.16,16932.16, Cardiac Structural And Valvular Disorders,2004,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,16932.16,,,,,,,fee schedule,16932.16,16932.16, Cardiac Structural And Valvular Disorders,2004,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,16932.16,,,,,,,fee schedule,16932.16,16932.16, Cardiac Structural And Valvular Disorders,2004,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,16932.16,,,,,,,fee schedule,16932.16,16932.16, Cardiac Structural And Valvular Disorders,2004,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,16932.16,,,,,,,fee schedule,16932.16,16932.16, Cardiac Structural And Valvular Disorders,2004,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,16932.16,,,,,,,fee schedule,16932.16,16932.16, Cardiac Structural And Valvular Disorders,2004,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,16932.16,,,,,,,fee schedule,16932.16,16932.16, Cardiac Arrhythmia And Conduction Disorders,2011,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,3515.45,,,,,,,fee schedule,3515.45,3515.45, Cardiac Arrhythmia And Conduction Disorders,2011,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,3515.45,,,,,,,fee schedule,3515.45,3515.45, Cardiac Arrhythmia And Conduction Disorders,2011,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,3515.45,,,,,,,fee schedule,3515.45,3515.45, Cardiac Arrhythmia And Conduction Disorders,2011,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,3515.45,,,,,,,fee schedule,3515.45,3515.45, Cardiac Arrhythmia And Conduction Disorders,2011,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,3515.45,,,,,,,fee schedule,3515.45,3515.45, Cardiac Arrhythmia And Conduction Disorders,2011,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,3515.45,,,,,,,fee schedule,3515.45,3515.45, Cardiac Arrhythmia And Conduction Disorders,2011,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,3515.45,,,,,,,fee schedule,3515.45,3515.45, Cardiac Arrhythmia And Conduction Disorders,2011,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,3515.45,,,,,,,fee schedule,3515.45,3515.45, Cardiac Arrhythmia And Conduction Disorders,2011,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,3515.45,,,,,,,fee schedule,3515.45,3515.45, Cardiac Arrhythmia And Conduction Disorders,2011,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,3515.45,,,,,,,fee schedule,3515.45,3515.45, Cardiac Arrhythmia And Conduction Disorders,2011,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,3515.45,,,,,,,fee schedule,3515.45,3515.45, Cardiac Arrhythmia And Conduction Disorders,2012,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4729.37,,,,,,,fee schedule,4729.37,4729.37, Cardiac Arrhythmia And Conduction Disorders,2012,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4729.37,,,,,,,fee schedule,4729.37,4729.37, Cardiac Arrhythmia And Conduction Disorders,2012,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4729.37,,,,,,,fee schedule,4729.37,4729.37, Cardiac Arrhythmia And Conduction Disorders,2012,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4729.37,,,,,,,fee schedule,4729.37,4729.37, Cardiac Arrhythmia And Conduction Disorders,2012,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4729.37,,,,,,,fee schedule,4729.37,4729.37, Cardiac Arrhythmia And Conduction Disorders,2012,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4729.37,,,,,,,fee schedule,4729.37,4729.37, Cardiac Arrhythmia And Conduction Disorders,2012,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4729.37,,,,,,,fee schedule,4729.37,4729.37, Cardiac Arrhythmia And Conduction Disorders,2012,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4729.37,,,,,,,fee schedule,4729.37,4729.37, Cardiac Arrhythmia And Conduction Disorders,2012,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4729.37,,,,,,,fee schedule,4729.37,4729.37, Cardiac Arrhythmia And Conduction Disorders,2012,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4729.37,,,,,,,fee schedule,4729.37,4729.37, Cardiac Arrhythmia And Conduction Disorders,2012,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4729.37,,,,,,,fee schedule,4729.37,4729.37, Cardiac Arrhythmia And Conduction Disorders,2013,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,7064.06,,,,,,,fee schedule,7064.06,7064.06, Cardiac Arrhythmia And Conduction Disorders,2013,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,7064.06,,,,,,,fee schedule,7064.06,7064.06, Cardiac Arrhythmia And Conduction Disorders,2013,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,7064.06,,,,,,,fee schedule,7064.06,7064.06, Cardiac Arrhythmia And Conduction Disorders,2013,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,7064.06,,,,,,,fee schedule,7064.06,7064.06, Cardiac Arrhythmia And Conduction Disorders,2013,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,7064.06,,,,,,,fee schedule,7064.06,7064.06, Cardiac Arrhythmia And Conduction Disorders,2013,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,7064.06,,,,,,,fee schedule,7064.06,7064.06, Cardiac Arrhythmia And Conduction Disorders,2013,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,7064.06,,,,,,,fee schedule,7064.06,7064.06, Cardiac Arrhythmia And Conduction Disorders,2013,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,7064.06,,,,,,,fee schedule,7064.06,7064.06, Cardiac Arrhythmia And Conduction Disorders,2013,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,7064.06,,,,,,,fee schedule,7064.06,7064.06, Cardiac Arrhythmia And Conduction Disorders,2013,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,7064.06,,,,,,,fee schedule,7064.06,7064.06, Cardiac Arrhythmia And Conduction Disorders,2013,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,7064.06,,,,,,,fee schedule,7064.06,7064.06, Cardiac Arrhythmia And Conduction Disorders,2014,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,12914.2,,,,,,,fee schedule,12914.2,12914.2, Cardiac Arrhythmia And Conduction Disorders,2014,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,12914.2,,,,,,,fee schedule,12914.2,12914.2, Cardiac Arrhythmia And Conduction Disorders,2014,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,12914.2,,,,,,,fee schedule,12914.2,12914.2, Cardiac Arrhythmia And Conduction Disorders,2014,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,12914.2,,,,,,,fee schedule,12914.2,12914.2, Cardiac Arrhythmia And Conduction Disorders,2014,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,12914.2,,,,,,,fee schedule,12914.2,12914.2, Cardiac Arrhythmia And Conduction Disorders,2014,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,12914.2,,,,,,,fee schedule,12914.2,12914.2, Cardiac Arrhythmia And Conduction Disorders,2014,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,12914.2,,,,,,,fee schedule,12914.2,12914.2, Cardiac Arrhythmia And Conduction Disorders,2014,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,12914.2,,,,,,,fee schedule,12914.2,12914.2, Cardiac Arrhythmia And Conduction Disorders,2014,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,12914.2,,,,,,,fee schedule,12914.2,12914.2, Cardiac Arrhythmia And Conduction Disorders,2014,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,12914.2,,,,,,,fee schedule,12914.2,12914.2, Cardiac Arrhythmia And Conduction Disorders,2014,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,12914.2,,,,,,,fee schedule,12914.2,12914.2, Chest Pain,2031,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4405.42,,,,,,,fee schedule,4405.42,4405.42, Chest Pain,2031,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4405.42,,,,,,,fee schedule,4405.42,4405.42, Chest Pain,2031,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4405.42,,,,,,,fee schedule,4405.42,4405.42, Chest Pain,2031,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4405.42,,,,,,,fee schedule,4405.42,4405.42, Chest Pain,2031,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4405.42,,,,,,,fee schedule,4405.42,4405.42, Chest Pain,2031,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4405.42,,,,,,,fee schedule,4405.42,4405.42, Chest Pain,2031,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4405.42,,,,,,,fee schedule,4405.42,4405.42, Chest Pain,2031,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4405.42,,,,,,,fee schedule,4405.42,4405.42, Chest Pain,2031,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4405.42,,,,,,,fee schedule,4405.42,4405.42, Chest Pain,2031,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4405.42,,,,,,,fee schedule,4405.42,4405.42, Chest Pain,2031,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4405.42,,,,,,,fee schedule,4405.42,4405.42, Chest Pain,2032,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4988.39,,,,,,,fee schedule,4988.39,4988.39, Chest Pain,2032,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4988.39,,,,,,,fee schedule,4988.39,4988.39, Chest Pain,2032,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4988.39,,,,,,,fee schedule,4988.39,4988.39, Chest Pain,2032,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4988.39,,,,,,,fee schedule,4988.39,4988.39, Chest Pain,2032,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4988.39,,,,,,,fee schedule,4988.39,4988.39, Chest Pain,2032,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4988.39,,,,,,,fee schedule,4988.39,4988.39, Chest Pain,2032,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4988.39,,,,,,,fee schedule,4988.39,4988.39, Chest Pain,2032,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4988.39,,,,,,,fee schedule,4988.39,4988.39, Chest Pain,2032,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4988.39,,,,,,,fee schedule,4988.39,4988.39, Chest Pain,2032,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4988.39,,,,,,,fee schedule,4988.39,4988.39, Chest Pain,2032,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4988.39,,,,,,,fee schedule,4988.39,4988.39, Chest Pain,2033,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,6179.03,,,,,,,fee schedule,6179.03,6179.03, Chest Pain,2033,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,6179.03,,,,,,,fee schedule,6179.03,6179.03, Chest Pain,2033,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,6179.03,,,,,,,fee schedule,6179.03,6179.03, Chest Pain,2033,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,6179.03,,,,,,,fee schedule,6179.03,6179.03, Chest Pain,2033,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,6179.03,,,,,,,fee schedule,6179.03,6179.03, Chest Pain,2033,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,6179.03,,,,,,,fee schedule,6179.03,6179.03, Chest Pain,2033,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,6179.03,,,,,,,fee schedule,6179.03,6179.03, Chest Pain,2033,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,6179.03,,,,,,,fee schedule,6179.03,6179.03, Chest Pain,2033,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,6179.03,,,,,,,fee schedule,6179.03,6179.03, Chest Pain,2033,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,6179.03,,,,,,,fee schedule,6179.03,6179.03, Chest Pain,2033,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,6179.03,,,,,,,fee schedule,6179.03,6179.03, Chest Pain,2034,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,9845.51,,,,,,,fee schedule,9845.51,9845.51, Chest Pain,2034,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,9845.51,,,,,,,fee schedule,9845.51,9845.51, Chest Pain,2034,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,9845.51,,,,,,,fee schedule,9845.51,9845.51, Chest Pain,2034,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,9845.51,,,,,,,fee schedule,9845.51,9845.51, Chest Pain,2034,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,9845.51,,,,,,,fee schedule,9845.51,9845.51, Chest Pain,2034,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,9845.51,,,,,,,fee schedule,9845.51,9845.51, Chest Pain,2034,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,9845.51,,,,,,,fee schedule,9845.51,9845.51, Chest Pain,2034,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,9845.51,,,,,,,fee schedule,9845.51,9845.51, Chest Pain,2034,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,9845.51,,,,,,,fee schedule,9845.51,9845.51, Chest Pain,2034,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,9845.51,,,,,,,fee schedule,9845.51,9845.51, Chest Pain,2034,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,9845.51,,,,,,,fee schedule,9845.51,9845.51, Syncope And Collapse,2041,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4928.4,,,,,,,fee schedule,4928.4,4928.4, Syncope And Collapse,2041,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4928.4,,,,,,,fee schedule,4928.4,4928.4, Syncope And Collapse,2041,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4928.4,,,,,,,fee schedule,4928.4,4928.4, Syncope And Collapse,2041,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4928.4,,,,,,,fee schedule,4928.4,4928.4, Syncope And Collapse,2041,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4928.4,,,,,,,fee schedule,4928.4,4928.4, Syncope And Collapse,2041,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4928.4,,,,,,,fee schedule,4928.4,4928.4, Syncope And Collapse,2041,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4928.4,,,,,,,fee schedule,4928.4,4928.4, Syncope And Collapse,2041,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4928.4,,,,,,,fee schedule,4928.4,4928.4, Syncope And Collapse,2041,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4928.4,,,,,,,fee schedule,4928.4,4928.4, Syncope And Collapse,2041,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4928.4,,,,,,,fee schedule,4928.4,4928.4, Syncope And Collapse,2041,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4928.4,,,,,,,fee schedule,4928.4,4928.4, Syncope And Collapse,2042,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5589,,,,,,,fee schedule,5589,5589, Syncope And Collapse,2042,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5589,,,,,,,fee schedule,5589,5589, Syncope And Collapse,2042,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5589,,,,,,,fee schedule,5589,5589, Syncope And Collapse,2042,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5589,,,,,,,fee schedule,5589,5589, Syncope And Collapse,2042,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5589,,,,,,,fee schedule,5589,5589, Syncope And Collapse,2042,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5589,,,,,,,fee schedule,5589,5589, Syncope And Collapse,2042,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5589,,,,,,,fee schedule,5589,5589, Syncope And Collapse,2042,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5589,,,,,,,fee schedule,5589,5589, Syncope And Collapse,2042,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5589,,,,,,,fee schedule,5589,5589, Syncope And Collapse,2042,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5589,,,,,,,fee schedule,5589,5589, Syncope And Collapse,2042,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5589,,,,,,,fee schedule,5589,5589, Syncope And Collapse,2043,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,7169.93,,,,,,,fee schedule,7169.93,7169.93, Syncope And Collapse,2043,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,7169.93,,,,,,,fee schedule,7169.93,7169.93, Syncope And Collapse,2043,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,7169.93,,,,,,,fee schedule,7169.93,7169.93, Syncope And Collapse,2043,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,7169.93,,,,,,,fee schedule,7169.93,7169.93, Syncope And Collapse,2043,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,7169.93,,,,,,,fee schedule,7169.93,7169.93, Syncope And Collapse,2043,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,7169.93,,,,,,,fee schedule,7169.93,7169.93, Syncope And Collapse,2043,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,7169.93,,,,,,,fee schedule,7169.93,7169.93, Syncope And Collapse,2043,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,7169.93,,,,,,,fee schedule,7169.93,7169.93, Syncope And Collapse,2043,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,7169.93,,,,,,,fee schedule,7169.93,7169.93, Syncope And Collapse,2043,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,7169.93,,,,,,,fee schedule,7169.93,7169.93, Syncope And Collapse,2043,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,7169.93,,,,,,,fee schedule,7169.93,7169.93, Syncope And Collapse,2044,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,11571.83,,,,,,,fee schedule,11571.83,11571.83, Syncope And Collapse,2044,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,11571.83,,,,,,,fee schedule,11571.83,11571.83, Syncope And Collapse,2044,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,11571.83,,,,,,,fee schedule,11571.83,11571.83, Syncope And Collapse,2044,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,11571.83,,,,,,,fee schedule,11571.83,11571.83, Syncope And Collapse,2044,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,11571.83,,,,,,,fee schedule,11571.83,11571.83, Syncope And Collapse,2044,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,11571.83,,,,,,,fee schedule,11571.83,11571.83, Syncope And Collapse,2044,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,11571.83,,,,,,,fee schedule,11571.83,11571.83, Syncope And Collapse,2044,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,11571.83,,,,,,,fee schedule,11571.83,11571.83, Syncope And Collapse,2044,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,11571.83,,,,,,,fee schedule,11571.83,11571.83, Syncope And Collapse,2044,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,11571.83,,,,,,,fee schedule,11571.83,11571.83, Syncope And Collapse,2044,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,11571.83,,,,,,,fee schedule,11571.83,11571.83, Cardiomyopathy,2051,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4326.38,,,,,,,fee schedule,4326.38,4326.38, Cardiomyopathy,2051,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4326.38,,,,,,,fee schedule,4326.38,4326.38, Cardiomyopathy,2051,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4326.38,,,,,,,fee schedule,4326.38,4326.38, Cardiomyopathy,2051,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4326.38,,,,,,,fee schedule,4326.38,4326.38, Cardiomyopathy,2051,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4326.38,,,,,,,fee schedule,4326.38,4326.38, Cardiomyopathy,2051,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4326.38,,,,,,,fee schedule,4326.38,4326.38, Cardiomyopathy,2051,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4326.38,,,,,,,fee schedule,4326.38,4326.38, Cardiomyopathy,2051,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4326.38,,,,,,,fee schedule,4326.38,4326.38, Cardiomyopathy,2051,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4326.38,,,,,,,fee schedule,4326.38,4326.38, Cardiomyopathy,2051,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4326.38,,,,,,,fee schedule,4326.38,4326.38, Cardiomyopathy,2051,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4326.38,,,,,,,fee schedule,4326.38,4326.38, Cardiomyopathy,2052,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5363.86,,,,,,,fee schedule,5363.86,5363.86, Cardiomyopathy,2052,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5363.86,,,,,,,fee schedule,5363.86,5363.86, Cardiomyopathy,2052,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5363.86,,,,,,,fee schedule,5363.86,5363.86, Cardiomyopathy,2052,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5363.86,,,,,,,fee schedule,5363.86,5363.86, Cardiomyopathy,2052,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5363.86,,,,,,,fee schedule,5363.86,5363.86, Cardiomyopathy,2052,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5363.86,,,,,,,fee schedule,5363.86,5363.86, Cardiomyopathy,2052,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5363.86,,,,,,,fee schedule,5363.86,5363.86, Cardiomyopathy,2052,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5363.86,,,,,,,fee schedule,5363.86,5363.86, Cardiomyopathy,2052,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5363.86,,,,,,,fee schedule,5363.86,5363.86, Cardiomyopathy,2052,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5363.86,,,,,,,fee schedule,5363.86,5363.86, Cardiomyopathy,2052,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5363.86,,,,,,,fee schedule,5363.86,5363.86, Cardiomyopathy,2053,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,8425.5,,,,,,,fee schedule,8425.5,8425.5, Cardiomyopathy,2053,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,8425.5,,,,,,,fee schedule,8425.5,8425.5, Cardiomyopathy,2053,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,8425.5,,,,,,,fee schedule,8425.5,8425.5, Cardiomyopathy,2053,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,8425.5,,,,,,,fee schedule,8425.5,8425.5, Cardiomyopathy,2053,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,8425.5,,,,,,,fee schedule,8425.5,8425.5, Cardiomyopathy,2053,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,8425.5,,,,,,,fee schedule,8425.5,8425.5, Cardiomyopathy,2053,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,8425.5,,,,,,,fee schedule,8425.5,8425.5, Cardiomyopathy,2053,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,8425.5,,,,,,,fee schedule,8425.5,8425.5, Cardiomyopathy,2053,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,8425.5,,,,,,,fee schedule,8425.5,8425.5, Cardiomyopathy,2053,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,8425.5,,,,,,,fee schedule,8425.5,8425.5, Cardiomyopathy,2053,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,8425.5,,,,,,,fee schedule,8425.5,8425.5, Cardiomyopathy,2054,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,15737.99,,,,,,,fee schedule,15737.99,15737.99, Cardiomyopathy,2054,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,15737.99,,,,,,,fee schedule,15737.99,15737.99, Cardiomyopathy,2054,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,15737.99,,,,,,,fee schedule,15737.99,15737.99, Cardiomyopathy,2054,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,15737.99,,,,,,,fee schedule,15737.99,15737.99, Cardiomyopathy,2054,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,15737.99,,,,,,,fee schedule,15737.99,15737.99, Cardiomyopathy,2054,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,15737.99,,,,,,,fee schedule,15737.99,15737.99, Cardiomyopathy,2054,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,15737.99,,,,,,,fee schedule,15737.99,15737.99, Cardiomyopathy,2054,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,15737.99,,,,,,,fee schedule,15737.99,15737.99, Cardiomyopathy,2054,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,15737.99,,,,,,,fee schedule,15737.99,15737.99, Cardiomyopathy,2054,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,15737.99,,,,,,,fee schedule,15737.99,15737.99, Cardiomyopathy,2054,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,15737.99,,,,,,,fee schedule,15737.99,15737.99, "Malfunction, Reaction, Complication Of Cardiac Or Vascular Device Or Procedure",2061,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5509.96,,,,,,,fee schedule,5509.96,5509.96, "Malfunction, Reaction, Complication Of Cardiac Or Vascular Device Or Procedure",2061,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5509.96,,,,,,,fee schedule,5509.96,5509.96, "Malfunction, Reaction, Complication Of Cardiac Or Vascular Device Or Procedure",2061,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5509.96,,,,,,,fee schedule,5509.96,5509.96, "Malfunction, Reaction, Complication Of Cardiac Or Vascular Device Or Procedure",2061,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5509.96,,,,,,,fee schedule,5509.96,5509.96, "Malfunction, Reaction, Complication Of Cardiac Or Vascular Device Or Procedure",2061,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5509.96,,,,,,,fee schedule,5509.96,5509.96, "Malfunction, Reaction, Complication Of Cardiac Or Vascular Device Or Procedure",2061,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5509.96,,,,,,,fee schedule,5509.96,5509.96, "Malfunction, Reaction, Complication Of Cardiac Or Vascular Device Or Procedure",2061,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5509.96,,,,,,,fee schedule,5509.96,5509.96, "Malfunction, Reaction, Complication Of Cardiac Or Vascular Device Or Procedure",2061,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5509.96,,,,,,,fee schedule,5509.96,5509.96, "Malfunction, Reaction, Complication Of Cardiac Or Vascular Device Or Procedure",2061,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5509.96,,,,,,,fee schedule,5509.96,5509.96, "Malfunction, Reaction, Complication Of Cardiac Or Vascular Device Or Procedure",2061,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5509.96,,,,,,,fee schedule,5509.96,5509.96, "Malfunction, Reaction, Complication Of Cardiac Or Vascular Device Or Procedure",2061,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5509.96,,,,,,,fee schedule,5509.96,5509.96, "Malfunction, Reaction, Complication Of Cardiac Or Vascular Device Or Procedure",2062,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,6606.72,,,,,,,fee schedule,6606.72,6606.72, "Malfunction, Reaction, Complication Of Cardiac Or Vascular Device Or Procedure",2062,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,6606.72,,,,,,,fee schedule,6606.72,6606.72, "Malfunction, Reaction, Complication Of Cardiac Or Vascular Device Or Procedure",2062,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,6606.72,,,,,,,fee schedule,6606.72,6606.72, "Malfunction, Reaction, Complication Of Cardiac Or Vascular Device Or Procedure",2062,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,6606.72,,,,,,,fee schedule,6606.72,6606.72, "Malfunction, Reaction, Complication Of Cardiac Or Vascular Device Or Procedure",2062,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,6606.72,,,,,,,fee schedule,6606.72,6606.72, "Malfunction, Reaction, Complication Of Cardiac Or Vascular Device Or Procedure",2062,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,6606.72,,,,,,,fee schedule,6606.72,6606.72, "Malfunction, Reaction, Complication Of Cardiac Or Vascular Device Or Procedure",2062,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,6606.72,,,,,,,fee schedule,6606.72,6606.72, "Malfunction, Reaction, Complication Of Cardiac Or Vascular Device Or Procedure",2062,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,6606.72,,,,,,,fee schedule,6606.72,6606.72, "Malfunction, Reaction, Complication Of Cardiac Or Vascular Device Or Procedure",2062,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,6606.72,,,,,,,fee schedule,6606.72,6606.72, "Malfunction, Reaction, Complication Of Cardiac Or Vascular Device Or Procedure",2062,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,6606.72,,,,,,,fee schedule,6606.72,6606.72, "Malfunction, Reaction, Complication Of Cardiac Or Vascular Device Or Procedure",2062,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,6606.72,,,,,,,fee schedule,6606.72,6606.72, "Malfunction, Reaction, Complication Of Cardiac Or Vascular Device Or Procedure",2063,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,9925.26,,,,,,,fee schedule,9925.26,9925.26, "Malfunction, Reaction, Complication Of Cardiac Or Vascular Device Or Procedure",2063,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,9925.26,,,,,,,fee schedule,9925.26,9925.26, "Malfunction, Reaction, Complication Of Cardiac Or Vascular Device Or Procedure",2063,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,9925.26,,,,,,,fee schedule,9925.26,9925.26, "Malfunction, Reaction, Complication Of Cardiac Or Vascular Device Or Procedure",2063,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,9925.26,,,,,,,fee schedule,9925.26,9925.26, "Malfunction, Reaction, Complication Of Cardiac Or Vascular Device Or Procedure",2063,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,9925.26,,,,,,,fee schedule,9925.26,9925.26, "Malfunction, Reaction, Complication Of Cardiac Or Vascular Device Or Procedure",2063,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,9925.26,,,,,,,fee schedule,9925.26,9925.26, "Malfunction, Reaction, Complication Of Cardiac Or Vascular Device Or Procedure",2063,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,9925.26,,,,,,,fee schedule,9925.26,9925.26, "Malfunction, Reaction, Complication Of Cardiac Or Vascular Device Or Procedure",2063,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,9925.26,,,,,,,fee schedule,9925.26,9925.26, "Malfunction, Reaction, Complication Of Cardiac Or Vascular Device Or Procedure",2063,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,9925.26,,,,,,,fee schedule,9925.26,9925.26, "Malfunction, Reaction, Complication Of Cardiac Or Vascular Device Or Procedure",2063,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,9925.26,,,,,,,fee schedule,9925.26,9925.26, "Malfunction, Reaction, Complication Of Cardiac Or Vascular Device Or Procedure",2063,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,9925.26,,,,,,,fee schedule,9925.26,9925.26, "Malfunction, Reaction, Complication Of Cardiac Or Vascular Device Or Procedure",2064,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,17289.28,,,,,,,fee schedule,17289.28,17289.28, "Malfunction, Reaction, Complication Of Cardiac Or Vascular Device Or Procedure",2064,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,17289.28,,,,,,,fee schedule,17289.28,17289.28, "Malfunction, Reaction, Complication Of Cardiac Or Vascular Device Or Procedure",2064,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,17289.28,,,,,,,fee schedule,17289.28,17289.28, "Malfunction, Reaction, Complication Of Cardiac Or Vascular Device Or Procedure",2064,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,17289.28,,,,,,,fee schedule,17289.28,17289.28, "Malfunction, Reaction, Complication Of Cardiac Or Vascular Device Or Procedure",2064,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,17289.28,,,,,,,fee schedule,17289.28,17289.28, "Malfunction, Reaction, Complication Of Cardiac Or Vascular Device Or Procedure",2064,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,17289.28,,,,,,,fee schedule,17289.28,17289.28, "Malfunction, Reaction, Complication Of Cardiac Or Vascular Device Or Procedure",2064,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,17289.28,,,,,,,fee schedule,17289.28,17289.28, "Malfunction, Reaction, Complication Of Cardiac Or Vascular Device Or Procedure",2064,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,17289.28,,,,,,,fee schedule,17289.28,17289.28, "Malfunction, Reaction, Complication Of Cardiac Or Vascular Device Or Procedure",2064,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,17289.28,,,,,,,fee schedule,17289.28,17289.28, "Malfunction, Reaction, Complication Of Cardiac Or Vascular Device Or Procedure",2064,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,17289.28,,,,,,,fee schedule,17289.28,17289.28, "Malfunction, Reaction, Complication Of Cardiac Or Vascular Device Or Procedure",2064,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,17289.28,,,,,,,fee schedule,17289.28,17289.28, Other Circulatory System Diagnoses,2071,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4252.27,,,,,,,fee schedule,4252.27,4252.27, Other Circulatory System Diagnoses,2071,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4252.27,,,,,,,fee schedule,4252.27,4252.27, Other Circulatory System Diagnoses,2071,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4252.27,,,,,,,fee schedule,4252.27,4252.27, Other Circulatory System Diagnoses,2071,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4252.27,,,,,,,fee schedule,4252.27,4252.27, Other Circulatory System Diagnoses,2071,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4252.27,,,,,,,fee schedule,4252.27,4252.27, Other Circulatory System Diagnoses,2071,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4252.27,,,,,,,fee schedule,4252.27,4252.27, Other Circulatory System Diagnoses,2071,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4252.27,,,,,,,fee schedule,4252.27,4252.27, Other Circulatory System Diagnoses,2071,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4252.27,,,,,,,fee schedule,4252.27,4252.27, Other Circulatory System Diagnoses,2071,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4252.27,,,,,,,fee schedule,4252.27,4252.27, Other Circulatory System Diagnoses,2071,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4252.27,,,,,,,fee schedule,4252.27,4252.27, Other Circulatory System Diagnoses,2071,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4252.27,,,,,,,fee schedule,4252.27,4252.27, Other Circulatory System Diagnoses,2072,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5570.65,,,,,,,fee schedule,5570.65,5570.65, Other Circulatory System Diagnoses,2072,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5570.65,,,,,,,fee schedule,5570.65,5570.65, Other Circulatory System Diagnoses,2072,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5570.65,,,,,,,fee schedule,5570.65,5570.65, Other Circulatory System Diagnoses,2072,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5570.65,,,,,,,fee schedule,5570.65,5570.65, Other Circulatory System Diagnoses,2072,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5570.65,,,,,,,fee schedule,5570.65,5570.65, Other Circulatory System Diagnoses,2072,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5570.65,,,,,,,fee schedule,5570.65,5570.65, Other Circulatory System Diagnoses,2072,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5570.65,,,,,,,fee schedule,5570.65,5570.65, Other Circulatory System Diagnoses,2072,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5570.65,,,,,,,fee schedule,5570.65,5570.65, Other Circulatory System Diagnoses,2072,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5570.65,,,,,,,fee schedule,5570.65,5570.65, Other Circulatory System Diagnoses,2072,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5570.65,,,,,,,fee schedule,5570.65,5570.65, Other Circulatory System Diagnoses,2072,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5570.65,,,,,,,fee schedule,5570.65,5570.65, Other Circulatory System Diagnoses,2073,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,8052.85,,,,,,,fee schedule,8052.85,8052.85, Other Circulatory System Diagnoses,2073,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,8052.85,,,,,,,fee schedule,8052.85,8052.85, Other Circulatory System Diagnoses,2073,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,8052.85,,,,,,,fee schedule,8052.85,8052.85, Other Circulatory System Diagnoses,2073,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,8052.85,,,,,,,fee schedule,8052.85,8052.85, Other Circulatory System Diagnoses,2073,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,8052.85,,,,,,,fee schedule,8052.85,8052.85, Other Circulatory System Diagnoses,2073,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,8052.85,,,,,,,fee schedule,8052.85,8052.85, Other Circulatory System Diagnoses,2073,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,8052.85,,,,,,,fee schedule,8052.85,8052.85, Other Circulatory System Diagnoses,2073,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,8052.85,,,,,,,fee schedule,8052.85,8052.85, Other Circulatory System Diagnoses,2073,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,8052.85,,,,,,,fee schedule,8052.85,8052.85, Other Circulatory System Diagnoses,2073,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,8052.85,,,,,,,fee schedule,8052.85,8052.85, Other Circulatory System Diagnoses,2073,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,8052.85,,,,,,,fee schedule,8052.85,8052.85, Other Circulatory System Diagnoses,2074,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,15128.21,,,,,,,fee schedule,15128.21,15128.21, Other Circulatory System Diagnoses,2074,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,15128.21,,,,,,,fee schedule,15128.21,15128.21, Other Circulatory System Diagnoses,2074,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,15128.21,,,,,,,fee schedule,15128.21,15128.21, Other Circulatory System Diagnoses,2074,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,15128.21,,,,,,,fee schedule,15128.21,15128.21, Other Circulatory System Diagnoses,2074,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,15128.21,,,,,,,fee schedule,15128.21,15128.21, Other Circulatory System Diagnoses,2074,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,15128.21,,,,,,,fee schedule,15128.21,15128.21, Other Circulatory System Diagnoses,2074,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,15128.21,,,,,,,fee schedule,15128.21,15128.21, Other Circulatory System Diagnoses,2074,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,15128.21,,,,,,,fee schedule,15128.21,15128.21, Other Circulatory System Diagnoses,2074,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,15128.21,,,,,,,fee schedule,15128.21,15128.21, Other Circulatory System Diagnoses,2074,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,15128.21,,,,,,,fee schedule,15128.21,15128.21, Other Circulatory System Diagnoses,2074,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,15128.21,,,,,,,fee schedule,15128.21,15128.21, "Major Stomach, Esophageal And Duodenal Procedures",2201,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,11417.97,,,,,,,fee schedule,11417.97,11417.97, "Major Stomach, Esophageal And Duodenal Procedures",2201,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,11417.97,,,,,,,fee schedule,11417.97,11417.97, "Major Stomach, Esophageal And Duodenal Procedures",2201,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,11417.97,,,,,,,fee schedule,11417.97,11417.97, "Major Stomach, Esophageal And Duodenal Procedures",2201,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,11417.97,,,,,,,fee schedule,11417.97,11417.97, "Major Stomach, Esophageal And Duodenal Procedures",2201,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,11417.97,,,,,,,fee schedule,11417.97,11417.97, "Major Stomach, Esophageal And Duodenal Procedures",2201,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,11417.97,,,,,,,fee schedule,11417.97,11417.97, "Major Stomach, Esophageal And Duodenal Procedures",2201,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,11417.97,,,,,,,fee schedule,11417.97,11417.97, "Major Stomach, Esophageal And Duodenal Procedures",2201,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,11417.97,,,,,,,fee schedule,11417.97,11417.97, "Major Stomach, Esophageal And Duodenal Procedures",2201,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,11417.97,,,,,,,fee schedule,11417.97,11417.97, "Major Stomach, Esophageal And Duodenal Procedures",2201,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,11417.97,,,,,,,fee schedule,11417.97,11417.97, "Major Stomach, Esophageal And Duodenal Procedures",2201,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,11417.97,,,,,,,fee schedule,11417.97,11417.97, "Major Stomach, Esophageal And Duodenal Procedures",2202,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,16395.77,,,,,,,fee schedule,16395.77,16395.77, "Major Stomach, Esophageal And Duodenal Procedures",2202,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,16395.77,,,,,,,fee schedule,16395.77,16395.77, "Major Stomach, Esophageal And Duodenal Procedures",2202,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,16395.77,,,,,,,fee schedule,16395.77,16395.77, "Major Stomach, Esophageal And Duodenal Procedures",2202,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,16395.77,,,,,,,fee schedule,16395.77,16395.77, "Major Stomach, Esophageal And Duodenal Procedures",2202,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,16395.77,,,,,,,fee schedule,16395.77,16395.77, "Major Stomach, Esophageal And Duodenal Procedures",2202,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,16395.77,,,,,,,fee schedule,16395.77,16395.77, "Major Stomach, Esophageal And Duodenal Procedures",2202,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,16395.77,,,,,,,fee schedule,16395.77,16395.77, "Major Stomach, Esophageal And Duodenal Procedures",2202,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,16395.77,,,,,,,fee schedule,16395.77,16395.77, "Major Stomach, Esophageal And Duodenal Procedures",2202,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,16395.77,,,,,,,fee schedule,16395.77,16395.77, "Major Stomach, Esophageal And Duodenal Procedures",2202,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,16395.77,,,,,,,fee schedule,16395.77,16395.77, "Major Stomach, Esophageal And Duodenal Procedures",2202,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,16395.77,,,,,,,fee schedule,16395.77,16395.77, "Major Stomach, Esophageal And Duodenal Procedures",2203,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,24043.51,,,,,,,fee schedule,24043.51,24043.51, "Major Stomach, Esophageal And Duodenal Procedures",2203,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,24043.51,,,,,,,fee schedule,24043.51,24043.51, "Major Stomach, Esophageal And Duodenal Procedures",2203,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,24043.51,,,,,,,fee schedule,24043.51,24043.51, "Major Stomach, Esophageal And Duodenal Procedures",2203,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,24043.51,,,,,,,fee schedule,24043.51,24043.51, "Major Stomach, Esophageal And Duodenal Procedures",2203,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,24043.51,,,,,,,fee schedule,24043.51,24043.51, "Major Stomach, Esophageal And Duodenal Procedures",2203,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,24043.51,,,,,,,fee schedule,24043.51,24043.51, "Major Stomach, Esophageal And Duodenal Procedures",2203,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,24043.51,,,,,,,fee schedule,24043.51,24043.51, "Major Stomach, Esophageal And Duodenal Procedures",2203,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,24043.51,,,,,,,fee schedule,24043.51,24043.51, "Major Stomach, Esophageal And Duodenal Procedures",2203,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,24043.51,,,,,,,fee schedule,24043.51,24043.51, "Major Stomach, Esophageal And Duodenal Procedures",2203,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,24043.51,,,,,,,fee schedule,24043.51,24043.51, "Major Stomach, Esophageal And Duodenal Procedures",2203,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,24043.51,,,,,,,fee schedule,24043.51,24043.51, "Major Stomach, Esophageal And Duodenal Procedures",2204,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,40363.76,,,,,,,fee schedule,40363.76,40363.76, "Major Stomach, Esophageal And Duodenal Procedures",2204,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,40363.76,,,,,,,fee schedule,40363.76,40363.76, "Major Stomach, Esophageal And Duodenal Procedures",2204,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,40363.76,,,,,,,fee schedule,40363.76,40363.76, "Major Stomach, Esophageal And Duodenal Procedures",2204,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,40363.76,,,,,,,fee schedule,40363.76,40363.76, "Major Stomach, Esophageal And Duodenal Procedures",2204,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,40363.76,,,,,,,fee schedule,40363.76,40363.76, "Major Stomach, Esophageal And Duodenal Procedures",2204,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,40363.76,,,,,,,fee schedule,40363.76,40363.76, "Major Stomach, Esophageal And Duodenal Procedures",2204,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,40363.76,,,,,,,fee schedule,40363.76,40363.76, "Major Stomach, Esophageal And Duodenal Procedures",2204,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,40363.76,,,,,,,fee schedule,40363.76,40363.76, "Major Stomach, Esophageal And Duodenal Procedures",2204,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,40363.76,,,,,,,fee schedule,40363.76,40363.76, "Major Stomach, Esophageal And Duodenal Procedures",2204,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,40363.76,,,,,,,fee schedule,40363.76,40363.76, "Major Stomach, Esophageal And Duodenal Procedures",2204,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,40363.76,,,,,,,fee schedule,40363.76,40363.76, "Other Stomach, Esophageal And Duodenal Procedures",2221,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,6325.83,,,,,,,fee schedule,6325.83,6325.83, "Other Stomach, Esophageal And Duodenal Procedures",2221,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,6325.83,,,,,,,fee schedule,6325.83,6325.83, "Other Stomach, Esophageal And Duodenal Procedures",2221,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,6325.83,,,,,,,fee schedule,6325.83,6325.83, "Other Stomach, Esophageal And Duodenal Procedures",2221,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,6325.83,,,,,,,fee schedule,6325.83,6325.83, "Other Stomach, Esophageal And Duodenal Procedures",2221,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,6325.83,,,,,,,fee schedule,6325.83,6325.83, "Other Stomach, Esophageal And Duodenal Procedures",2221,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,6325.83,,,,,,,fee schedule,6325.83,6325.83, "Other Stomach, Esophageal And Duodenal Procedures",2221,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,6325.83,,,,,,,fee schedule,6325.83,6325.83, "Other Stomach, Esophageal And Duodenal Procedures",2221,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,6325.83,,,,,,,fee schedule,6325.83,6325.83, "Other Stomach, Esophageal And Duodenal Procedures",2221,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,6325.83,,,,,,,fee schedule,6325.83,6325.83, "Other Stomach, Esophageal And Duodenal Procedures",2221,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,6325.83,,,,,,,fee schedule,6325.83,6325.83, "Other Stomach, Esophageal And Duodenal Procedures",2221,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,6325.83,,,,,,,fee schedule,6325.83,6325.83, "Other Stomach, Esophageal And Duodenal Procedures",2222,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,10992.39,,,,,,,fee schedule,10992.39,10992.39, "Other Stomach, Esophageal And Duodenal Procedures",2222,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,10992.39,,,,,,,fee schedule,10992.39,10992.39, "Other Stomach, Esophageal And Duodenal Procedures",2222,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,10992.39,,,,,,,fee schedule,10992.39,10992.39, "Other Stomach, Esophageal And Duodenal Procedures",2222,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,10992.39,,,,,,,fee schedule,10992.39,10992.39, "Other Stomach, Esophageal And Duodenal Procedures",2222,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,10992.39,,,,,,,fee schedule,10992.39,10992.39, "Other Stomach, Esophageal And Duodenal Procedures",2222,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,10992.39,,,,,,,fee schedule,10992.39,10992.39, "Other Stomach, Esophageal And Duodenal Procedures",2222,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,10992.39,,,,,,,fee schedule,10992.39,10992.39, "Other Stomach, Esophageal And Duodenal Procedures",2222,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,10992.39,,,,,,,fee schedule,10992.39,10992.39, "Other Stomach, Esophageal And Duodenal Procedures",2222,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,10992.39,,,,,,,fee schedule,10992.39,10992.39, "Other Stomach, Esophageal And Duodenal Procedures",2222,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,10992.39,,,,,,,fee schedule,10992.39,10992.39, "Other Stomach, Esophageal And Duodenal Procedures",2222,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,10992.39,,,,,,,fee schedule,10992.39,10992.39, "Other Stomach, Esophageal And Duodenal Procedures",2223,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,17608.99,,,,,,,fee schedule,17608.99,17608.99, "Other Stomach, Esophageal And Duodenal Procedures",2223,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,17608.99,,,,,,,fee schedule,17608.99,17608.99, "Other Stomach, Esophageal And Duodenal Procedures",2223,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,17608.99,,,,,,,fee schedule,17608.99,17608.99, "Other Stomach, Esophageal And Duodenal Procedures",2223,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,17608.99,,,,,,,fee schedule,17608.99,17608.99, "Other Stomach, Esophageal And Duodenal Procedures",2223,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,17608.99,,,,,,,fee schedule,17608.99,17608.99, "Other Stomach, Esophageal And Duodenal Procedures",2223,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,17608.99,,,,,,,fee schedule,17608.99,17608.99, "Other Stomach, Esophageal And Duodenal Procedures",2223,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,17608.99,,,,,,,fee schedule,17608.99,17608.99, "Other Stomach, Esophageal And Duodenal Procedures",2223,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,17608.99,,,,,,,fee schedule,17608.99,17608.99, "Other Stomach, Esophageal And Duodenal Procedures",2223,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,17608.99,,,,,,,fee schedule,17608.99,17608.99, "Other Stomach, Esophageal And Duodenal Procedures",2223,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,17608.99,,,,,,,fee schedule,17608.99,17608.99, "Other Stomach, Esophageal And Duodenal Procedures",2223,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,17608.99,,,,,,,fee schedule,17608.99,17608.99, "Other Stomach, Esophageal And Duodenal Procedures",2224,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,29936.7,,,,,,,fee schedule,29936.7,29936.7, "Other Stomach, Esophageal And Duodenal Procedures",2224,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,29936.7,,,,,,,fee schedule,29936.7,29936.7, "Other Stomach, Esophageal And Duodenal Procedures",2224,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,29936.7,,,,,,,fee schedule,29936.7,29936.7, "Other Stomach, Esophageal And Duodenal Procedures",2224,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,29936.7,,,,,,,fee schedule,29936.7,29936.7, "Other Stomach, Esophageal And Duodenal Procedures",2224,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,29936.7,,,,,,,fee schedule,29936.7,29936.7, "Other Stomach, Esophageal And Duodenal Procedures",2224,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,29936.7,,,,,,,fee schedule,29936.7,29936.7, "Other Stomach, Esophageal And Duodenal Procedures",2224,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,29936.7,,,,,,,fee schedule,29936.7,29936.7, "Other Stomach, Esophageal And Duodenal Procedures",2224,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,29936.7,,,,,,,fee schedule,29936.7,29936.7, "Other Stomach, Esophageal And Duodenal Procedures",2224,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,29936.7,,,,,,,fee schedule,29936.7,29936.7, "Other Stomach, Esophageal And Duodenal Procedures",2224,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,29936.7,,,,,,,fee schedule,29936.7,29936.7, "Other Stomach, Esophageal And Duodenal Procedures",2224,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,29936.7,,,,,,,fee schedule,29936.7,29936.7, Other Small And Large Bowel Procedures,2231,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,8866.6,,,,,,,fee schedule,8866.6,8866.6, Other Small And Large Bowel Procedures,2231,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,8866.6,,,,,,,fee schedule,8866.6,8866.6, Other Small And Large Bowel Procedures,2231,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,8866.6,,,,,,,fee schedule,8866.6,8866.6, Other Small And Large Bowel Procedures,2231,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,8866.6,,,,,,,fee schedule,8866.6,8866.6, Other Small And Large Bowel Procedures,2231,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,8866.6,,,,,,,fee schedule,8866.6,8866.6, Other Small And Large Bowel Procedures,2231,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,8866.6,,,,,,,fee schedule,8866.6,8866.6, Other Small And Large Bowel Procedures,2231,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,8866.6,,,,,,,fee schedule,8866.6,8866.6, Other Small And Large Bowel Procedures,2231,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,8866.6,,,,,,,fee schedule,8866.6,8866.6, Other Small And Large Bowel Procedures,2231,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,8866.6,,,,,,,fee schedule,8866.6,8866.6, Other Small And Large Bowel Procedures,2231,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,8866.6,,,,,,,fee schedule,8866.6,8866.6, Other Small And Large Bowel Procedures,2231,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,8866.6,,,,,,,fee schedule,8866.6,8866.6, Other Small And Large Bowel Procedures,2232,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,11315.63,,,,,,,fee schedule,11315.63,11315.63, Other Small And Large Bowel Procedures,2232,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,11315.63,,,,,,,fee schedule,11315.63,11315.63, Other Small And Large Bowel Procedures,2232,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,11315.63,,,,,,,fee schedule,11315.63,11315.63, Other Small And Large Bowel Procedures,2232,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,11315.63,,,,,,,fee schedule,11315.63,11315.63, Other Small And Large Bowel Procedures,2232,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,11315.63,,,,,,,fee schedule,11315.63,11315.63, Other Small And Large Bowel Procedures,2232,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,11315.63,,,,,,,fee schedule,11315.63,11315.63, Other Small And Large Bowel Procedures,2232,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,11315.63,,,,,,,fee schedule,11315.63,11315.63, Other Small And Large Bowel Procedures,2232,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,11315.63,,,,,,,fee schedule,11315.63,11315.63, Other Small And Large Bowel Procedures,2232,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,11315.63,,,,,,,fee schedule,11315.63,11315.63, Other Small And Large Bowel Procedures,2232,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,11315.63,,,,,,,fee schedule,11315.63,11315.63, Other Small And Large Bowel Procedures,2232,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,11315.63,,,,,,,fee schedule,11315.63,11315.63, Other Small And Large Bowel Procedures,2233,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,15930.67,,,,,,,fee schedule,15930.67,15930.67, Other Small And Large Bowel Procedures,2233,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,15930.67,,,,,,,fee schedule,15930.67,15930.67, Other Small And Large Bowel Procedures,2233,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,15930.67,,,,,,,fee schedule,15930.67,15930.67, Other Small And Large Bowel Procedures,2233,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,15930.67,,,,,,,fee schedule,15930.67,15930.67, Other Small And Large Bowel Procedures,2233,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,15930.67,,,,,,,fee schedule,15930.67,15930.67, Other Small And Large Bowel Procedures,2233,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,15930.67,,,,,,,fee schedule,15930.67,15930.67, Other Small And Large Bowel Procedures,2233,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,15930.67,,,,,,,fee schedule,15930.67,15930.67, Other Small And Large Bowel Procedures,2233,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,15930.67,,,,,,,fee schedule,15930.67,15930.67, Other Small And Large Bowel Procedures,2233,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,15930.67,,,,,,,fee schedule,15930.67,15930.67, Other Small And Large Bowel Procedures,2233,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,15930.67,,,,,,,fee schedule,15930.67,15930.67, Other Small And Large Bowel Procedures,2233,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,15930.67,,,,,,,fee schedule,15930.67,15930.67, Other Small And Large Bowel Procedures,2234,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,28602.79,,,,,,,fee schedule,28602.79,28602.79, Other Small And Large Bowel Procedures,2234,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,28602.79,,,,,,,fee schedule,28602.79,28602.79, Other Small And Large Bowel Procedures,2234,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,28602.79,,,,,,,fee schedule,28602.79,28602.79, Other Small And Large Bowel Procedures,2234,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,28602.79,,,,,,,fee schedule,28602.79,28602.79, Other Small And Large Bowel Procedures,2234,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,28602.79,,,,,,,fee schedule,28602.79,28602.79, Other Small And Large Bowel Procedures,2234,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,28602.79,,,,,,,fee schedule,28602.79,28602.79, Other Small And Large Bowel Procedures,2234,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,28602.79,,,,,,,fee schedule,28602.79,28602.79, Other Small And Large Bowel Procedures,2234,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,28602.79,,,,,,,fee schedule,28602.79,28602.79, Other Small And Large Bowel Procedures,2234,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,28602.79,,,,,,,fee schedule,28602.79,28602.79, Other Small And Large Bowel Procedures,2234,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,28602.79,,,,,,,fee schedule,28602.79,28602.79, Other Small And Large Bowel Procedures,2234,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,28602.79,,,,,,,fee schedule,28602.79,28602.79, Peritoneal Adhesiolysis,2241,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,9737.53,,,,,,,fee schedule,9737.53,9737.53, Peritoneal Adhesiolysis,2241,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,9737.53,,,,,,,fee schedule,9737.53,9737.53, Peritoneal Adhesiolysis,2241,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,9737.53,,,,,,,fee schedule,9737.53,9737.53, Peritoneal Adhesiolysis,2241,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,9737.53,,,,,,,fee schedule,9737.53,9737.53, Peritoneal Adhesiolysis,2241,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,9737.53,,,,,,,fee schedule,9737.53,9737.53, Peritoneal Adhesiolysis,2241,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,9737.53,,,,,,,fee schedule,9737.53,9737.53, Peritoneal Adhesiolysis,2241,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,9737.53,,,,,,,fee schedule,9737.53,9737.53, Peritoneal Adhesiolysis,2241,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,9737.53,,,,,,,fee schedule,9737.53,9737.53, Peritoneal Adhesiolysis,2241,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,9737.53,,,,,,,fee schedule,9737.53,9737.53, Peritoneal Adhesiolysis,2241,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,9737.53,,,,,,,fee schedule,9737.53,9737.53, Peritoneal Adhesiolysis,2241,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,9737.53,,,,,,,fee schedule,9737.53,9737.53, Peritoneal Adhesiolysis,2242,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,12243.72,,,,,,,fee schedule,12243.72,12243.72, Peritoneal Adhesiolysis,2242,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,12243.72,,,,,,,fee schedule,12243.72,12243.72, Peritoneal Adhesiolysis,2242,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,12243.72,,,,,,,fee schedule,12243.72,12243.72, Peritoneal Adhesiolysis,2242,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,12243.72,,,,,,,fee schedule,12243.72,12243.72, Peritoneal Adhesiolysis,2242,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,12243.72,,,,,,,fee schedule,12243.72,12243.72, Peritoneal Adhesiolysis,2242,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,12243.72,,,,,,,fee schedule,12243.72,12243.72, Peritoneal Adhesiolysis,2242,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,12243.72,,,,,,,fee schedule,12243.72,12243.72, Peritoneal Adhesiolysis,2242,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,12243.72,,,,,,,fee schedule,12243.72,12243.72, Peritoneal Adhesiolysis,2242,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,12243.72,,,,,,,fee schedule,12243.72,12243.72, Peritoneal Adhesiolysis,2242,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,12243.72,,,,,,,fee schedule,12243.72,12243.72, Peritoneal Adhesiolysis,2242,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,12243.72,,,,,,,fee schedule,12243.72,12243.72, Peritoneal Adhesiolysis,2243,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,18330.29,,,,,,,fee schedule,18330.29,18330.29, Peritoneal Adhesiolysis,2243,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,18330.29,,,,,,,fee schedule,18330.29,18330.29, Peritoneal Adhesiolysis,2243,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,18330.29,,,,,,,fee schedule,18330.29,18330.29, Peritoneal Adhesiolysis,2243,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,18330.29,,,,,,,fee schedule,18330.29,18330.29, Peritoneal Adhesiolysis,2243,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,18330.29,,,,,,,fee schedule,18330.29,18330.29, Peritoneal Adhesiolysis,2243,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,18330.29,,,,,,,fee schedule,18330.29,18330.29, Peritoneal Adhesiolysis,2243,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,18330.29,,,,,,,fee schedule,18330.29,18330.29, Peritoneal Adhesiolysis,2243,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,18330.29,,,,,,,fee schedule,18330.29,18330.29, Peritoneal Adhesiolysis,2243,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,18330.29,,,,,,,fee schedule,18330.29,18330.29, Peritoneal Adhesiolysis,2243,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,18330.29,,,,,,,fee schedule,18330.29,18330.29, Peritoneal Adhesiolysis,2243,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,18330.29,,,,,,,fee schedule,18330.29,18330.29, Peritoneal Adhesiolysis,2244,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,28160.98,,,,,,,fee schedule,28160.98,28160.98, Peritoneal Adhesiolysis,2244,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,28160.98,,,,,,,fee schedule,28160.98,28160.98, Peritoneal Adhesiolysis,2244,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,28160.98,,,,,,,fee schedule,28160.98,28160.98, Peritoneal Adhesiolysis,2244,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,28160.98,,,,,,,fee schedule,28160.98,28160.98, Peritoneal Adhesiolysis,2244,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,28160.98,,,,,,,fee schedule,28160.98,28160.98, Peritoneal Adhesiolysis,2244,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,28160.98,,,,,,,fee schedule,28160.98,28160.98, Peritoneal Adhesiolysis,2244,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,28160.98,,,,,,,fee schedule,28160.98,28160.98, Peritoneal Adhesiolysis,2244,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,28160.98,,,,,,,fee schedule,28160.98,28160.98, Peritoneal Adhesiolysis,2244,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,28160.98,,,,,,,fee schedule,28160.98,28160.98, Peritoneal Adhesiolysis,2244,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,28160.98,,,,,,,fee schedule,28160.98,28160.98, Peritoneal Adhesiolysis,2244,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,28160.98,,,,,,,fee schedule,28160.98,28160.98, Anal Procedures,2261,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,6481.8,,,,,,,fee schedule,6481.8,6481.8, Anal Procedures,2261,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,6481.8,,,,,,,fee schedule,6481.8,6481.8, Anal Procedures,2261,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,6481.8,,,,,,,fee schedule,6481.8,6481.8, Anal Procedures,2261,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,6481.8,,,,,,,fee schedule,6481.8,6481.8, Anal Procedures,2261,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,6481.8,,,,,,,fee schedule,6481.8,6481.8, Anal Procedures,2261,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,6481.8,,,,,,,fee schedule,6481.8,6481.8, Anal Procedures,2261,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,6481.8,,,,,,,fee schedule,6481.8,6481.8, Anal Procedures,2261,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,6481.8,,,,,,,fee schedule,6481.8,6481.8, Anal Procedures,2261,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,6481.8,,,,,,,fee schedule,6481.8,6481.8, Anal Procedures,2261,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,6481.8,,,,,,,fee schedule,6481.8,6481.8, Anal Procedures,2261,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,6481.8,,,,,,,fee schedule,6481.8,6481.8, Anal Procedures,2262,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,8162.24,,,,,,,fee schedule,8162.24,8162.24, Anal Procedures,2262,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,8162.24,,,,,,,fee schedule,8162.24,8162.24, Anal Procedures,2262,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,8162.24,,,,,,,fee schedule,8162.24,8162.24, Anal Procedures,2262,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,8162.24,,,,,,,fee schedule,8162.24,8162.24, Anal Procedures,2262,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,8162.24,,,,,,,fee schedule,8162.24,8162.24, Anal Procedures,2262,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,8162.24,,,,,,,fee schedule,8162.24,8162.24, Anal Procedures,2262,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,8162.24,,,,,,,fee schedule,8162.24,8162.24, Anal Procedures,2262,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,8162.24,,,,,,,fee schedule,8162.24,8162.24, Anal Procedures,2262,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,8162.24,,,,,,,fee schedule,8162.24,8162.24, Anal Procedures,2262,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,8162.24,,,,,,,fee schedule,8162.24,8162.24, Anal Procedures,2262,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,8162.24,,,,,,,fee schedule,8162.24,8162.24, Anal Procedures,2263,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,12734.23,,,,,,,fee schedule,12734.23,12734.23, Anal Procedures,2263,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,12734.23,,,,,,,fee schedule,12734.23,12734.23, Anal Procedures,2263,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,12734.23,,,,,,,fee schedule,12734.23,12734.23, Anal Procedures,2263,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,12734.23,,,,,,,fee schedule,12734.23,12734.23, Anal Procedures,2263,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,12734.23,,,,,,,fee schedule,12734.23,12734.23, Anal Procedures,2263,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,12734.23,,,,,,,fee schedule,12734.23,12734.23, Anal Procedures,2263,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,12734.23,,,,,,,fee schedule,12734.23,12734.23, Anal Procedures,2263,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,12734.23,,,,,,,fee schedule,12734.23,12734.23, Anal Procedures,2263,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,12734.23,,,,,,,fee schedule,12734.23,12734.23, Anal Procedures,2263,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,12734.23,,,,,,,fee schedule,12734.23,12734.23, Anal Procedures,2263,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,12734.23,,,,,,,fee schedule,12734.23,12734.23, Anal Procedures,2264,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,18985.95,,,,,,,fee schedule,18985.95,18985.95, Anal Procedures,2264,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,18985.95,,,,,,,fee schedule,18985.95,18985.95, Anal Procedures,2264,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,18985.95,,,,,,,fee schedule,18985.95,18985.95, Anal Procedures,2264,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,18985.95,,,,,,,fee schedule,18985.95,18985.95, Anal Procedures,2264,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,18985.95,,,,,,,fee schedule,18985.95,18985.95, Anal Procedures,2264,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,18985.95,,,,,,,fee schedule,18985.95,18985.95, Anal Procedures,2264,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,18985.95,,,,,,,fee schedule,18985.95,18985.95, Anal Procedures,2264,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,18985.95,,,,,,,fee schedule,18985.95,18985.95, Anal Procedures,2264,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,18985.95,,,,,,,fee schedule,18985.95,18985.95, Anal Procedures,2264,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,18985.95,,,,,,,fee schedule,18985.95,18985.95, Anal Procedures,2264,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,18985.95,,,,,,,fee schedule,18985.95,18985.95, "Hernia Procedures Except Inguinal, Femoral And Umbilical",2271,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,9026.81,,,,,,,fee schedule,9026.81,9026.81, "Hernia Procedures Except Inguinal, Femoral And Umbilical",2271,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,9026.81,,,,,,,fee schedule,9026.81,9026.81, "Hernia Procedures Except Inguinal, Femoral And Umbilical",2271,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,9026.81,,,,,,,fee schedule,9026.81,9026.81, "Hernia Procedures Except Inguinal, Femoral And Umbilical",2271,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,9026.81,,,,,,,fee schedule,9026.81,9026.81, "Hernia Procedures Except Inguinal, Femoral And Umbilical",2271,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,9026.81,,,,,,,fee schedule,9026.81,9026.81, "Hernia Procedures Except Inguinal, Femoral And Umbilical",2271,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,9026.81,,,,,,,fee schedule,9026.81,9026.81, "Hernia Procedures Except Inguinal, Femoral And Umbilical",2271,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,9026.81,,,,,,,fee schedule,9026.81,9026.81, "Hernia Procedures Except Inguinal, Femoral And Umbilical",2271,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,9026.81,,,,,,,fee schedule,9026.81,9026.81, "Hernia Procedures Except Inguinal, Femoral And Umbilical",2271,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,9026.81,,,,,,,fee schedule,9026.81,9026.81, "Hernia Procedures Except Inguinal, Femoral And Umbilical",2271,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,9026.81,,,,,,,fee schedule,9026.81,9026.81, "Hernia Procedures Except Inguinal, Femoral And Umbilical",2271,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,9026.81,,,,,,,fee schedule,9026.81,9026.81, "Hernia Procedures Except Inguinal, Femoral And Umbilical",2272,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,11018.5,,,,,,,fee schedule,11018.5,11018.5, "Hernia Procedures Except Inguinal, Femoral And Umbilical",2272,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,11018.5,,,,,,,fee schedule,11018.5,11018.5, "Hernia Procedures Except Inguinal, Femoral And Umbilical",2272,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,11018.5,,,,,,,fee schedule,11018.5,11018.5, "Hernia Procedures Except Inguinal, Femoral And Umbilical",2272,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,11018.5,,,,,,,fee schedule,11018.5,11018.5, "Hernia Procedures Except Inguinal, Femoral And Umbilical",2272,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,11018.5,,,,,,,fee schedule,11018.5,11018.5, "Hernia Procedures Except Inguinal, Femoral And Umbilical",2272,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,11018.5,,,,,,,fee schedule,11018.5,11018.5, "Hernia Procedures Except Inguinal, Femoral And Umbilical",2272,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,11018.5,,,,,,,fee schedule,11018.5,11018.5, "Hernia Procedures Except Inguinal, Femoral And Umbilical",2272,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,11018.5,,,,,,,fee schedule,11018.5,11018.5, "Hernia Procedures Except Inguinal, Femoral And Umbilical",2272,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,11018.5,,,,,,,fee schedule,11018.5,11018.5, "Hernia Procedures Except Inguinal, Femoral And Umbilical",2272,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,11018.5,,,,,,,fee schedule,11018.5,11018.5, "Hernia Procedures Except Inguinal, Femoral And Umbilical",2272,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,11018.5,,,,,,,fee schedule,11018.5,11018.5, "Hernia Procedures Except Inguinal, Femoral And Umbilical",2273,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,16337.19,,,,,,,fee schedule,16337.19,16337.19, "Hernia Procedures Except Inguinal, Femoral And Umbilical",2273,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,16337.19,,,,,,,fee schedule,16337.19,16337.19, "Hernia Procedures Except Inguinal, Femoral And Umbilical",2273,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,16337.19,,,,,,,fee schedule,16337.19,16337.19, "Hernia Procedures Except Inguinal, Femoral And Umbilical",2273,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,16337.19,,,,,,,fee schedule,16337.19,16337.19, "Hernia Procedures Except Inguinal, Femoral And Umbilical",2273,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,16337.19,,,,,,,fee schedule,16337.19,16337.19, "Hernia Procedures Except Inguinal, Femoral And Umbilical",2273,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,16337.19,,,,,,,fee schedule,16337.19,16337.19, "Hernia Procedures Except Inguinal, Femoral And Umbilical",2273,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,16337.19,,,,,,,fee schedule,16337.19,16337.19, "Hernia Procedures Except Inguinal, Femoral And Umbilical",2273,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,16337.19,,,,,,,fee schedule,16337.19,16337.19, "Hernia Procedures Except Inguinal, Femoral And Umbilical",2273,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,16337.19,,,,,,,fee schedule,16337.19,16337.19, "Hernia Procedures Except Inguinal, Femoral And Umbilical",2273,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,16337.19,,,,,,,fee schedule,16337.19,16337.19, "Hernia Procedures Except Inguinal, Femoral And Umbilical",2273,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,16337.19,,,,,,,fee schedule,16337.19,16337.19, "Hernia Procedures Except Inguinal, Femoral And Umbilical",2274,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,28691.01,,,,,,,fee schedule,28691.01,28691.01, "Hernia Procedures Except Inguinal, Femoral And Umbilical",2274,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,28691.01,,,,,,,fee schedule,28691.01,28691.01, "Hernia Procedures Except Inguinal, Femoral And Umbilical",2274,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,28691.01,,,,,,,fee schedule,28691.01,28691.01, "Hernia Procedures Except Inguinal, Femoral And Umbilical",2274,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,28691.01,,,,,,,fee schedule,28691.01,28691.01, "Hernia Procedures Except Inguinal, Femoral And Umbilical",2274,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,28691.01,,,,,,,fee schedule,28691.01,28691.01, "Hernia Procedures Except Inguinal, Femoral And Umbilical",2274,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,28691.01,,,,,,,fee schedule,28691.01,28691.01, "Hernia Procedures Except Inguinal, Femoral And Umbilical",2274,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,28691.01,,,,,,,fee schedule,28691.01,28691.01, "Hernia Procedures Except Inguinal, Femoral And Umbilical",2274,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,28691.01,,,,,,,fee schedule,28691.01,28691.01, "Hernia Procedures Except Inguinal, Femoral And Umbilical",2274,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,28691.01,,,,,,,fee schedule,28691.01,28691.01, "Hernia Procedures Except Inguinal, Femoral And Umbilical",2274,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,28691.01,,,,,,,fee schedule,28691.01,28691.01, "Hernia Procedures Except Inguinal, Femoral And Umbilical",2274,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,28691.01,,,,,,,fee schedule,28691.01,28691.01, "Inguinal, Femoral And Umbilical Hernia Procedures",2281,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,7623.74,,,,,,,fee schedule,7623.74,7623.74, "Inguinal, Femoral And Umbilical Hernia Procedures",2281,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,7623.74,,,,,,,fee schedule,7623.74,7623.74, "Inguinal, Femoral And Umbilical Hernia Procedures",2281,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,7623.74,,,,,,,fee schedule,7623.74,7623.74, "Inguinal, Femoral And Umbilical Hernia Procedures",2281,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,7623.74,,,,,,,fee schedule,7623.74,7623.74, "Inguinal, Femoral And Umbilical Hernia Procedures",2281,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,7623.74,,,,,,,fee schedule,7623.74,7623.74, "Inguinal, Femoral And Umbilical Hernia Procedures",2281,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,7623.74,,,,,,,fee schedule,7623.74,7623.74, "Inguinal, Femoral And Umbilical Hernia Procedures",2281,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,7623.74,,,,,,,fee schedule,7623.74,7623.74, "Inguinal, Femoral And Umbilical Hernia Procedures",2281,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,7623.74,,,,,,,fee schedule,7623.74,7623.74, "Inguinal, Femoral And Umbilical Hernia Procedures",2281,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,7623.74,,,,,,,fee schedule,7623.74,7623.74, "Inguinal, Femoral And Umbilical Hernia Procedures",2281,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,7623.74,,,,,,,fee schedule,7623.74,7623.74, "Inguinal, Femoral And Umbilical Hernia Procedures",2281,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,7623.74,,,,,,,fee schedule,7623.74,7623.74, "Inguinal, Femoral And Umbilical Hernia Procedures",2282,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,9539.91,,,,,,,fee schedule,9539.91,9539.91, "Inguinal, Femoral And Umbilical Hernia Procedures",2282,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,9539.91,,,,,,,fee schedule,9539.91,9539.91, "Inguinal, Femoral And Umbilical Hernia Procedures",2282,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,9539.91,,,,,,,fee schedule,9539.91,9539.91, "Inguinal, Femoral And Umbilical Hernia Procedures",2282,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,9539.91,,,,,,,fee schedule,9539.91,9539.91, "Inguinal, Femoral And Umbilical Hernia Procedures",2282,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,9539.91,,,,,,,fee schedule,9539.91,9539.91, "Inguinal, Femoral And Umbilical Hernia Procedures",2282,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,9539.91,,,,,,,fee schedule,9539.91,9539.91, "Inguinal, Femoral And Umbilical Hernia Procedures",2282,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,9539.91,,,,,,,fee schedule,9539.91,9539.91, "Inguinal, Femoral And Umbilical Hernia Procedures",2282,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,9539.91,,,,,,,fee schedule,9539.91,9539.91, "Inguinal, Femoral And Umbilical Hernia Procedures",2282,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,9539.91,,,,,,,fee schedule,9539.91,9539.91, "Inguinal, Femoral And Umbilical Hernia Procedures",2282,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,9539.91,,,,,,,fee schedule,9539.91,9539.91, "Inguinal, Femoral And Umbilical Hernia Procedures",2282,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,9539.91,,,,,,,fee schedule,9539.91,9539.91, "Inguinal, Femoral And Umbilical Hernia Procedures",2283,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,13303.08,,,,,,,fee schedule,13303.08,13303.08, "Inguinal, Femoral And Umbilical Hernia Procedures",2283,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,13303.08,,,,,,,fee schedule,13303.08,13303.08, "Inguinal, Femoral And Umbilical Hernia Procedures",2283,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,13303.08,,,,,,,fee schedule,13303.08,13303.08, "Inguinal, Femoral And Umbilical Hernia Procedures",2283,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,13303.08,,,,,,,fee schedule,13303.08,13303.08, "Inguinal, Femoral And Umbilical Hernia Procedures",2283,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,13303.08,,,,,,,fee schedule,13303.08,13303.08, "Inguinal, Femoral And Umbilical Hernia Procedures",2283,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,13303.08,,,,,,,fee schedule,13303.08,13303.08, "Inguinal, Femoral And Umbilical Hernia Procedures",2283,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,13303.08,,,,,,,fee schedule,13303.08,13303.08, "Inguinal, Femoral And Umbilical Hernia Procedures",2283,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,13303.08,,,,,,,fee schedule,13303.08,13303.08, "Inguinal, Femoral And Umbilical Hernia Procedures",2283,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,13303.08,,,,,,,fee schedule,13303.08,13303.08, "Inguinal, Femoral And Umbilical Hernia Procedures",2283,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,13303.08,,,,,,,fee schedule,13303.08,13303.08, "Inguinal, Femoral And Umbilical Hernia Procedures",2283,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,13303.08,,,,,,,fee schedule,13303.08,13303.08, "Inguinal, Femoral And Umbilical Hernia Procedures",2284,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,23774.61,,,,,,,fee schedule,23774.61,23774.61, "Inguinal, Femoral And Umbilical Hernia Procedures",2284,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,23774.61,,,,,,,fee schedule,23774.61,23774.61, "Inguinal, Femoral And Umbilical Hernia Procedures",2284,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,23774.61,,,,,,,fee schedule,23774.61,23774.61, "Inguinal, Femoral And Umbilical Hernia Procedures",2284,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,23774.61,,,,,,,fee schedule,23774.61,23774.61, "Inguinal, Femoral And Umbilical Hernia Procedures",2284,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,23774.61,,,,,,,fee schedule,23774.61,23774.61, "Inguinal, Femoral And Umbilical Hernia Procedures",2284,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,23774.61,,,,,,,fee schedule,23774.61,23774.61, "Inguinal, Femoral And Umbilical Hernia Procedures",2284,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,23774.61,,,,,,,fee schedule,23774.61,23774.61, "Inguinal, Femoral And Umbilical Hernia Procedures",2284,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,23774.61,,,,,,,fee schedule,23774.61,23774.61, "Inguinal, Femoral And Umbilical Hernia Procedures",2284,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,23774.61,,,,,,,fee schedule,23774.61,23774.61, "Inguinal, Femoral And Umbilical Hernia Procedures",2284,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,23774.61,,,,,,,fee schedule,23774.61,23774.61, "Inguinal, Femoral And Umbilical Hernia Procedures",2284,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,23774.61,,,,,,,fee schedule,23774.61,23774.61, Other Digestive System And Abdominal Procedures,2291,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,8800.26,,,,,,,fee schedule,8800.26,8800.26, Other Digestive System And Abdominal Procedures,2291,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,8800.26,,,,,,,fee schedule,8800.26,8800.26, Other Digestive System And Abdominal Procedures,2291,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,8800.26,,,,,,,fee schedule,8800.26,8800.26, Other Digestive System And Abdominal Procedures,2291,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,8800.26,,,,,,,fee schedule,8800.26,8800.26, Other Digestive System And Abdominal Procedures,2291,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,8800.26,,,,,,,fee schedule,8800.26,8800.26, Other Digestive System And Abdominal Procedures,2291,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,8800.26,,,,,,,fee schedule,8800.26,8800.26, Other Digestive System And Abdominal Procedures,2291,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,8800.26,,,,,,,fee schedule,8800.26,8800.26, Other Digestive System And Abdominal Procedures,2291,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,8800.26,,,,,,,fee schedule,8800.26,8800.26, Other Digestive System And Abdominal Procedures,2291,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,8800.26,,,,,,,fee schedule,8800.26,8800.26, Other Digestive System And Abdominal Procedures,2291,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,8800.26,,,,,,,fee schedule,8800.26,8800.26, Other Digestive System And Abdominal Procedures,2291,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,8800.26,,,,,,,fee schedule,8800.26,8800.26, Other Digestive System And Abdominal Procedures,2292,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,12503.44,,,,,,,fee schedule,12503.44,12503.44, Other Digestive System And Abdominal Procedures,2292,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,12503.44,,,,,,,fee schedule,12503.44,12503.44, Other Digestive System And Abdominal Procedures,2292,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,12503.44,,,,,,,fee schedule,12503.44,12503.44, Other Digestive System And Abdominal Procedures,2292,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,12503.44,,,,,,,fee schedule,12503.44,12503.44, Other Digestive System And Abdominal Procedures,2292,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,12503.44,,,,,,,fee schedule,12503.44,12503.44, Other Digestive System And Abdominal Procedures,2292,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,12503.44,,,,,,,fee schedule,12503.44,12503.44, Other Digestive System And Abdominal Procedures,2292,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,12503.44,,,,,,,fee schedule,12503.44,12503.44, Other Digestive System And Abdominal Procedures,2292,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,12503.44,,,,,,,fee schedule,12503.44,12503.44, Other Digestive System And Abdominal Procedures,2292,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,12503.44,,,,,,,fee schedule,12503.44,12503.44, Other Digestive System And Abdominal Procedures,2292,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,12503.44,,,,,,,fee schedule,12503.44,12503.44, Other Digestive System And Abdominal Procedures,2292,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,12503.44,,,,,,,fee schedule,12503.44,12503.44, Other Digestive System And Abdominal Procedures,2293,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,18551.9,,,,,,,fee schedule,18551.9,18551.9, Other Digestive System And Abdominal Procedures,2293,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,18551.9,,,,,,,fee schedule,18551.9,18551.9, Other Digestive System And Abdominal Procedures,2293,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,18551.9,,,,,,,fee schedule,18551.9,18551.9, Other Digestive System And Abdominal Procedures,2293,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,18551.9,,,,,,,fee schedule,18551.9,18551.9, Other Digestive System And Abdominal Procedures,2293,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,18551.9,,,,,,,fee schedule,18551.9,18551.9, Other Digestive System And Abdominal Procedures,2293,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,18551.9,,,,,,,fee schedule,18551.9,18551.9, Other Digestive System And Abdominal Procedures,2293,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,18551.9,,,,,,,fee schedule,18551.9,18551.9, Other Digestive System And Abdominal Procedures,2293,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,18551.9,,,,,,,fee schedule,18551.9,18551.9, Other Digestive System And Abdominal Procedures,2293,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,18551.9,,,,,,,fee schedule,18551.9,18551.9, Other Digestive System And Abdominal Procedures,2293,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,18551.9,,,,,,,fee schedule,18551.9,18551.9, Other Digestive System And Abdominal Procedures,2293,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,18551.9,,,,,,,fee schedule,18551.9,18551.9, Other Digestive System And Abdominal Procedures,2294,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,29720.73,,,,,,,fee schedule,29720.73,29720.73, Other Digestive System And Abdominal Procedures,2294,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,29720.73,,,,,,,fee schedule,29720.73,29720.73, Other Digestive System And Abdominal Procedures,2294,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,29720.73,,,,,,,fee schedule,29720.73,29720.73, Other Digestive System And Abdominal Procedures,2294,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,29720.73,,,,,,,fee schedule,29720.73,29720.73, Other Digestive System And Abdominal Procedures,2294,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,29720.73,,,,,,,fee schedule,29720.73,29720.73, Other Digestive System And Abdominal Procedures,2294,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,29720.73,,,,,,,fee schedule,29720.73,29720.73, Other Digestive System And Abdominal Procedures,2294,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,29720.73,,,,,,,fee schedule,29720.73,29720.73, Other Digestive System And Abdominal Procedures,2294,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,29720.73,,,,,,,fee schedule,29720.73,29720.73, Other Digestive System And Abdominal Procedures,2294,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,29720.73,,,,,,,fee schedule,29720.73,29720.73, Other Digestive System And Abdominal Procedures,2294,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,29720.73,,,,,,,fee schedule,29720.73,29720.73, Other Digestive System And Abdominal Procedures,2294,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,29720.73,,,,,,,fee schedule,29720.73,29720.73, Major Small Bowel Procedures,2301,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,9025.4,,,,,,,fee schedule,9025.4,9025.4, Major Small Bowel Procedures,2301,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,9025.4,,,,,,,fee schedule,9025.4,9025.4, Major Small Bowel Procedures,2301,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,9025.4,,,,,,,fee schedule,9025.4,9025.4, Major Small Bowel Procedures,2301,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,9025.4,,,,,,,fee schedule,9025.4,9025.4, Major Small Bowel Procedures,2301,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,9025.4,,,,,,,fee schedule,9025.4,9025.4, Major Small Bowel Procedures,2301,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,9025.4,,,,,,,fee schedule,9025.4,9025.4, Major Small Bowel Procedures,2301,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,9025.4,,,,,,,fee schedule,9025.4,9025.4, Major Small Bowel Procedures,2301,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,9025.4,,,,,,,fee schedule,9025.4,9025.4, Major Small Bowel Procedures,2301,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,9025.4,,,,,,,fee schedule,9025.4,9025.4, Major Small Bowel Procedures,2301,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,9025.4,,,,,,,fee schedule,9025.4,9025.4, Major Small Bowel Procedures,2301,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,9025.4,,,,,,,fee schedule,9025.4,9025.4, Major Small Bowel Procedures,2302,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,14631.34,,,,,,,fee schedule,14631.34,14631.34, Major Small Bowel Procedures,2302,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,14631.34,,,,,,,fee schedule,14631.34,14631.34, Major Small Bowel Procedures,2302,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,14631.34,,,,,,,fee schedule,14631.34,14631.34, Major Small Bowel Procedures,2302,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,14631.34,,,,,,,fee schedule,14631.34,14631.34, Major Small Bowel Procedures,2302,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,14631.34,,,,,,,fee schedule,14631.34,14631.34, Major Small Bowel Procedures,2302,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,14631.34,,,,,,,fee schedule,14631.34,14631.34, Major Small Bowel Procedures,2302,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,14631.34,,,,,,,fee schedule,14631.34,14631.34, Major Small Bowel Procedures,2302,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,14631.34,,,,,,,fee schedule,14631.34,14631.34, Major Small Bowel Procedures,2302,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,14631.34,,,,,,,fee schedule,14631.34,14631.34, Major Small Bowel Procedures,2302,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,14631.34,,,,,,,fee schedule,14631.34,14631.34, Major Small Bowel Procedures,2302,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,14631.34,,,,,,,fee schedule,14631.34,14631.34, Major Small Bowel Procedures,2303,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,21512.61,,,,,,,fee schedule,21512.61,21512.61, Major Small Bowel Procedures,2303,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,21512.61,,,,,,,fee schedule,21512.61,21512.61, Major Small Bowel Procedures,2303,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,21512.61,,,,,,,fee schedule,21512.61,21512.61, Major Small Bowel Procedures,2303,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,21512.61,,,,,,,fee schedule,21512.61,21512.61, Major Small Bowel Procedures,2303,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,21512.61,,,,,,,fee schedule,21512.61,21512.61, Major Small Bowel Procedures,2303,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,21512.61,,,,,,,fee schedule,21512.61,21512.61, Major Small Bowel Procedures,2303,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,21512.61,,,,,,,fee schedule,21512.61,21512.61, Major Small Bowel Procedures,2303,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,21512.61,,,,,,,fee schedule,21512.61,21512.61, Major Small Bowel Procedures,2303,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,21512.61,,,,,,,fee schedule,21512.61,21512.61, Major Small Bowel Procedures,2303,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,21512.61,,,,,,,fee schedule,21512.61,21512.61, Major Small Bowel Procedures,2303,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,21512.61,,,,,,,fee schedule,21512.61,21512.61, Major Small Bowel Procedures,2304,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,34143.1,,,,,,,fee schedule,34143.1,34143.1, Major Small Bowel Procedures,2304,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,34143.1,,,,,,,fee schedule,34143.1,34143.1, Major Small Bowel Procedures,2304,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,34143.1,,,,,,,fee schedule,34143.1,34143.1, Major Small Bowel Procedures,2304,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,34143.1,,,,,,,fee schedule,34143.1,34143.1, Major Small Bowel Procedures,2304,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,34143.1,,,,,,,fee schedule,34143.1,34143.1, Major Small Bowel Procedures,2304,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,34143.1,,,,,,,fee schedule,34143.1,34143.1, Major Small Bowel Procedures,2304,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,34143.1,,,,,,,fee schedule,34143.1,34143.1, Major Small Bowel Procedures,2304,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,34143.1,,,,,,,fee schedule,34143.1,34143.1, Major Small Bowel Procedures,2304,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,34143.1,,,,,,,fee schedule,34143.1,34143.1, Major Small Bowel Procedures,2304,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,34143.1,,,,,,,fee schedule,34143.1,34143.1, Major Small Bowel Procedures,2304,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,34143.1,,,,,,,fee schedule,34143.1,34143.1, Major Large Bowel Procedures,2311,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,11009.33,,,,,,,fee schedule,11009.33,11009.33, Major Large Bowel Procedures,2311,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,11009.33,,,,,,,fee schedule,11009.33,11009.33, Major Large Bowel Procedures,2311,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,11009.33,,,,,,,fee schedule,11009.33,11009.33, Major Large Bowel Procedures,2311,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,11009.33,,,,,,,fee schedule,11009.33,11009.33, Major Large Bowel Procedures,2311,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,11009.33,,,,,,,fee schedule,11009.33,11009.33, Major Large Bowel Procedures,2311,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,11009.33,,,,,,,fee schedule,11009.33,11009.33, Major Large Bowel Procedures,2311,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,11009.33,,,,,,,fee schedule,11009.33,11009.33, Major Large Bowel Procedures,2311,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,11009.33,,,,,,,fee schedule,11009.33,11009.33, Major Large Bowel Procedures,2311,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,11009.33,,,,,,,fee schedule,11009.33,11009.33, Major Large Bowel Procedures,2311,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,11009.33,,,,,,,fee schedule,11009.33,11009.33, Major Large Bowel Procedures,2311,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,11009.33,,,,,,,fee schedule,11009.33,11009.33, Major Large Bowel Procedures,2312,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,14114.72,,,,,,,fee schedule,14114.72,14114.72, Major Large Bowel Procedures,2312,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,14114.72,,,,,,,fee schedule,14114.72,14114.72, Major Large Bowel Procedures,2312,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,14114.72,,,,,,,fee schedule,14114.72,14114.72, Major Large Bowel Procedures,2312,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,14114.72,,,,,,,fee schedule,14114.72,14114.72, Major Large Bowel Procedures,2312,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,14114.72,,,,,,,fee schedule,14114.72,14114.72, Major Large Bowel Procedures,2312,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,14114.72,,,,,,,fee schedule,14114.72,14114.72, Major Large Bowel Procedures,2312,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,14114.72,,,,,,,fee schedule,14114.72,14114.72, Major Large Bowel Procedures,2312,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,14114.72,,,,,,,fee schedule,14114.72,14114.72, Major Large Bowel Procedures,2312,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,14114.72,,,,,,,fee schedule,14114.72,14114.72, Major Large Bowel Procedures,2312,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,14114.72,,,,,,,fee schedule,14114.72,14114.72, Major Large Bowel Procedures,2312,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,14114.72,,,,,,,fee schedule,14114.72,14114.72, Major Large Bowel Procedures,2313,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,20299.39,,,,,,,fee schedule,20299.39,20299.39, Major Large Bowel Procedures,2313,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,20299.39,,,,,,,fee schedule,20299.39,20299.39, Major Large Bowel Procedures,2313,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,20299.39,,,,,,,fee schedule,20299.39,20299.39, Major Large Bowel Procedures,2313,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,20299.39,,,,,,,fee schedule,20299.39,20299.39, Major Large Bowel Procedures,2313,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,20299.39,,,,,,,fee schedule,20299.39,20299.39, Major Large Bowel Procedures,2313,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,20299.39,,,,,,,fee schedule,20299.39,20299.39, Major Large Bowel Procedures,2313,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,20299.39,,,,,,,fee schedule,20299.39,20299.39, Major Large Bowel Procedures,2313,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,20299.39,,,,,,,fee schedule,20299.39,20299.39, Major Large Bowel Procedures,2313,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,20299.39,,,,,,,fee schedule,20299.39,20299.39, Major Large Bowel Procedures,2313,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,20299.39,,,,,,,fee schedule,20299.39,20299.39, Major Large Bowel Procedures,2313,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,20299.39,,,,,,,fee schedule,20299.39,20299.39, Major Large Bowel Procedures,2314,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,30139.96,,,,,,,fee schedule,30139.96,30139.96, Major Large Bowel Procedures,2314,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,30139.96,,,,,,,fee schedule,30139.96,30139.96, Major Large Bowel Procedures,2314,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,30139.96,,,,,,,fee schedule,30139.96,30139.96, Major Large Bowel Procedures,2314,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,30139.96,,,,,,,fee schedule,30139.96,30139.96, Major Large Bowel Procedures,2314,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,30139.96,,,,,,,fee schedule,30139.96,30139.96, Major Large Bowel Procedures,2314,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,30139.96,,,,,,,fee schedule,30139.96,30139.96, Major Large Bowel Procedures,2314,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,30139.96,,,,,,,fee schedule,30139.96,30139.96, Major Large Bowel Procedures,2314,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,30139.96,,,,,,,fee schedule,30139.96,30139.96, Major Large Bowel Procedures,2314,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,30139.96,,,,,,,fee schedule,30139.96,30139.96, Major Large Bowel Procedures,2314,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,30139.96,,,,,,,fee schedule,30139.96,30139.96, Major Large Bowel Procedures,2314,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,30139.96,,,,,,,fee schedule,30139.96,30139.96, Gastric Fundoplication,2321,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,9018.35,,,,,,,fee schedule,9018.35,9018.35, Gastric Fundoplication,2321,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,9018.35,,,,,,,fee schedule,9018.35,9018.35, Gastric Fundoplication,2321,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,9018.35,,,,,,,fee schedule,9018.35,9018.35, Gastric Fundoplication,2321,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,9018.35,,,,,,,fee schedule,9018.35,9018.35, Gastric Fundoplication,2321,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,9018.35,,,,,,,fee schedule,9018.35,9018.35, Gastric Fundoplication,2321,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,9018.35,,,,,,,fee schedule,9018.35,9018.35, Gastric Fundoplication,2321,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,9018.35,,,,,,,fee schedule,9018.35,9018.35, Gastric Fundoplication,2321,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,9018.35,,,,,,,fee schedule,9018.35,9018.35, Gastric Fundoplication,2321,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,9018.35,,,,,,,fee schedule,9018.35,9018.35, Gastric Fundoplication,2321,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,9018.35,,,,,,,fee schedule,9018.35,9018.35, Gastric Fundoplication,2321,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,9018.35,,,,,,,fee schedule,9018.35,9018.35, Gastric Fundoplication,2322,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,11223.17,,,,,,,fee schedule,11223.17,11223.17, Gastric Fundoplication,2322,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,11223.17,,,,,,,fee schedule,11223.17,11223.17, Gastric Fundoplication,2322,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,11223.17,,,,,,,fee schedule,11223.17,11223.17, Gastric Fundoplication,2322,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,11223.17,,,,,,,fee schedule,11223.17,11223.17, Gastric Fundoplication,2322,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,11223.17,,,,,,,fee schedule,11223.17,11223.17, Gastric Fundoplication,2322,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,11223.17,,,,,,,fee schedule,11223.17,11223.17, Gastric Fundoplication,2322,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,11223.17,,,,,,,fee schedule,11223.17,11223.17, Gastric Fundoplication,2322,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,11223.17,,,,,,,fee schedule,11223.17,11223.17, Gastric Fundoplication,2322,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,11223.17,,,,,,,fee schedule,11223.17,11223.17, Gastric Fundoplication,2322,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,11223.17,,,,,,,fee schedule,11223.17,11223.17, Gastric Fundoplication,2322,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,11223.17,,,,,,,fee schedule,11223.17,11223.17, Gastric Fundoplication,2323,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,17892.71,,,,,,,fee schedule,17892.71,17892.71, Gastric Fundoplication,2323,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,17892.71,,,,,,,fee schedule,17892.71,17892.71, Gastric Fundoplication,2323,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,17892.71,,,,,,,fee schedule,17892.71,17892.71, Gastric Fundoplication,2323,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,17892.71,,,,,,,fee schedule,17892.71,17892.71, Gastric Fundoplication,2323,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,17892.71,,,,,,,fee schedule,17892.71,17892.71, Gastric Fundoplication,2323,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,17892.71,,,,,,,fee schedule,17892.71,17892.71, Gastric Fundoplication,2323,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,17892.71,,,,,,,fee schedule,17892.71,17892.71, Gastric Fundoplication,2323,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,17892.71,,,,,,,fee schedule,17892.71,17892.71, Gastric Fundoplication,2323,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,17892.71,,,,,,,fee schedule,17892.71,17892.71, Gastric Fundoplication,2323,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,17892.71,,,,,,,fee schedule,17892.71,17892.71, Gastric Fundoplication,2323,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,17892.71,,,,,,,fee schedule,17892.71,17892.71, Gastric Fundoplication,2324,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,28707.95,,,,,,,fee schedule,28707.95,28707.95, Gastric Fundoplication,2324,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,28707.95,,,,,,,fee schedule,28707.95,28707.95, Gastric Fundoplication,2324,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,28707.95,,,,,,,fee schedule,28707.95,28707.95, Gastric Fundoplication,2324,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,28707.95,,,,,,,fee schedule,28707.95,28707.95, Gastric Fundoplication,2324,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,28707.95,,,,,,,fee schedule,28707.95,28707.95, Gastric Fundoplication,2324,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,28707.95,,,,,,,fee schedule,28707.95,28707.95, Gastric Fundoplication,2324,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,28707.95,,,,,,,fee schedule,28707.95,28707.95, Gastric Fundoplication,2324,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,28707.95,,,,,,,fee schedule,28707.95,28707.95, Gastric Fundoplication,2324,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,28707.95,,,,,,,fee schedule,28707.95,28707.95, Gastric Fundoplication,2324,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,28707.95,,,,,,,fee schedule,28707.95,28707.95, Gastric Fundoplication,2324,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,28707.95,,,,,,,fee schedule,28707.95,28707.95, Appendectomy With Complex Principal Diagnosis,2331,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,7886.29,,,,,,,fee schedule,7886.29,7886.29, Appendectomy With Complex Principal Diagnosis,2331,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,7886.29,,,,,,,fee schedule,7886.29,7886.29, Appendectomy With Complex Principal Diagnosis,2331,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,7886.29,,,,,,,fee schedule,7886.29,7886.29, Appendectomy With Complex Principal Diagnosis,2331,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,7886.29,,,,,,,fee schedule,7886.29,7886.29, Appendectomy With Complex Principal Diagnosis,2331,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,7886.29,,,,,,,fee schedule,7886.29,7886.29, Appendectomy With Complex Principal Diagnosis,2331,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,7886.29,,,,,,,fee schedule,7886.29,7886.29, Appendectomy With Complex Principal Diagnosis,2331,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,7886.29,,,,,,,fee schedule,7886.29,7886.29, Appendectomy With Complex Principal Diagnosis,2331,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,7886.29,,,,,,,fee schedule,7886.29,7886.29, Appendectomy With Complex Principal Diagnosis,2331,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,7886.29,,,,,,,fee schedule,7886.29,7886.29, Appendectomy With Complex Principal Diagnosis,2331,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,7886.29,,,,,,,fee schedule,7886.29,7886.29, Appendectomy With Complex Principal Diagnosis,2331,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,7886.29,,,,,,,fee schedule,7886.29,7886.29, Appendectomy With Complex Principal Diagnosis,2332,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,10178.63,,,,,,,fee schedule,10178.63,10178.63, Appendectomy With Complex Principal Diagnosis,2332,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,10178.63,,,,,,,fee schedule,10178.63,10178.63, Appendectomy With Complex Principal Diagnosis,2332,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,10178.63,,,,,,,fee schedule,10178.63,10178.63, Appendectomy With Complex Principal Diagnosis,2332,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,10178.63,,,,,,,fee schedule,10178.63,10178.63, Appendectomy With Complex Principal Diagnosis,2332,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,10178.63,,,,,,,fee schedule,10178.63,10178.63, Appendectomy With Complex Principal Diagnosis,2332,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,10178.63,,,,,,,fee schedule,10178.63,10178.63, Appendectomy With Complex Principal Diagnosis,2332,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,10178.63,,,,,,,fee schedule,10178.63,10178.63, Appendectomy With Complex Principal Diagnosis,2332,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,10178.63,,,,,,,fee schedule,10178.63,10178.63, Appendectomy With Complex Principal Diagnosis,2332,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,10178.63,,,,,,,fee schedule,10178.63,10178.63, Appendectomy With Complex Principal Diagnosis,2332,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,10178.63,,,,,,,fee schedule,10178.63,10178.63, Appendectomy With Complex Principal Diagnosis,2332,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,10178.63,,,,,,,fee schedule,10178.63,10178.63, Appendectomy With Complex Principal Diagnosis,2333,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,14332.8,,,,,,,fee schedule,14332.8,14332.8, Appendectomy With Complex Principal Diagnosis,2333,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,14332.8,,,,,,,fee schedule,14332.8,14332.8, Appendectomy With Complex Principal Diagnosis,2333,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,14332.8,,,,,,,fee schedule,14332.8,14332.8, Appendectomy With Complex Principal Diagnosis,2333,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,14332.8,,,,,,,fee schedule,14332.8,14332.8, Appendectomy With Complex Principal Diagnosis,2333,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,14332.8,,,,,,,fee schedule,14332.8,14332.8, Appendectomy With Complex Principal Diagnosis,2333,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,14332.8,,,,,,,fee schedule,14332.8,14332.8, Appendectomy With Complex Principal Diagnosis,2333,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,14332.8,,,,,,,fee schedule,14332.8,14332.8, Appendectomy With Complex Principal Diagnosis,2333,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,14332.8,,,,,,,fee schedule,14332.8,14332.8, Appendectomy With Complex Principal Diagnosis,2333,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,14332.8,,,,,,,fee schedule,14332.8,14332.8, Appendectomy With Complex Principal Diagnosis,2333,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,14332.8,,,,,,,fee schedule,14332.8,14332.8, Appendectomy With Complex Principal Diagnosis,2333,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,14332.8,,,,,,,fee schedule,14332.8,14332.8, Appendectomy With Complex Principal Diagnosis,2334,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,22503.52,,,,,,,fee schedule,22503.52,22503.52, Appendectomy With Complex Principal Diagnosis,2334,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,22503.52,,,,,,,fee schedule,22503.52,22503.52, Appendectomy With Complex Principal Diagnosis,2334,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,22503.52,,,,,,,fee schedule,22503.52,22503.52, Appendectomy With Complex Principal Diagnosis,2334,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,22503.52,,,,,,,fee schedule,22503.52,22503.52, Appendectomy With Complex Principal Diagnosis,2334,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,22503.52,,,,,,,fee schedule,22503.52,22503.52, Appendectomy With Complex Principal Diagnosis,2334,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,22503.52,,,,,,,fee schedule,22503.52,22503.52, Appendectomy With Complex Principal Diagnosis,2334,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,22503.52,,,,,,,fee schedule,22503.52,22503.52, Appendectomy With Complex Principal Diagnosis,2334,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,22503.52,,,,,,,fee schedule,22503.52,22503.52, Appendectomy With Complex Principal Diagnosis,2334,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,22503.52,,,,,,,fee schedule,22503.52,22503.52, Appendectomy With Complex Principal Diagnosis,2334,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,22503.52,,,,,,,fee schedule,22503.52,22503.52, Appendectomy With Complex Principal Diagnosis,2334,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,22503.52,,,,,,,fee schedule,22503.52,22503.52, Appendectomy Without Complex Principal Diagnosis,2341,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,7371.78,,,,,,,fee schedule,7371.78,7371.78, Appendectomy Without Complex Principal Diagnosis,2341,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,7371.78,,,,,,,fee schedule,7371.78,7371.78, Appendectomy Without Complex Principal Diagnosis,2341,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,7371.78,,,,,,,fee schedule,7371.78,7371.78, Appendectomy Without Complex Principal Diagnosis,2341,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,7371.78,,,,,,,fee schedule,7371.78,7371.78, Appendectomy Without Complex Principal Diagnosis,2341,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,7371.78,,,,,,,fee schedule,7371.78,7371.78, Appendectomy Without Complex Principal Diagnosis,2341,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,7371.78,,,,,,,fee schedule,7371.78,7371.78, Appendectomy Without Complex Principal Diagnosis,2341,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,7371.78,,,,,,,fee schedule,7371.78,7371.78, Appendectomy Without Complex Principal Diagnosis,2341,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,7371.78,,,,,,,fee schedule,7371.78,7371.78, Appendectomy Without Complex Principal Diagnosis,2341,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,7371.78,,,,,,,fee schedule,7371.78,7371.78, Appendectomy Without Complex Principal Diagnosis,2341,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,7371.78,,,,,,,fee schedule,7371.78,7371.78, Appendectomy Without Complex Principal Diagnosis,2341,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,7371.78,,,,,,,fee schedule,7371.78,7371.78, Appendectomy Without Complex Principal Diagnosis,2342,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,8994.35,,,,,,,fee schedule,8994.35,8994.35, Appendectomy Without Complex Principal Diagnosis,2342,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,8994.35,,,,,,,fee schedule,8994.35,8994.35, Appendectomy Without Complex Principal Diagnosis,2342,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,8994.35,,,,,,,fee schedule,8994.35,8994.35, Appendectomy Without Complex Principal Diagnosis,2342,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,8994.35,,,,,,,fee schedule,8994.35,8994.35, Appendectomy Without Complex Principal Diagnosis,2342,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,8994.35,,,,,,,fee schedule,8994.35,8994.35, Appendectomy Without Complex Principal Diagnosis,2342,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,8994.35,,,,,,,fee schedule,8994.35,8994.35, Appendectomy Without Complex Principal Diagnosis,2342,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,8994.35,,,,,,,fee schedule,8994.35,8994.35, Appendectomy Without Complex Principal Diagnosis,2342,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,8994.35,,,,,,,fee schedule,8994.35,8994.35, Appendectomy Without Complex Principal Diagnosis,2342,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,8994.35,,,,,,,fee schedule,8994.35,8994.35, Appendectomy Without Complex Principal Diagnosis,2342,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,8994.35,,,,,,,fee schedule,8994.35,8994.35, Appendectomy Without Complex Principal Diagnosis,2342,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,8994.35,,,,,,,fee schedule,8994.35,8994.35, Appendectomy Without Complex Principal Diagnosis,2343,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,13848.64,,,,,,,fee schedule,13848.64,13848.64, Appendectomy Without Complex Principal Diagnosis,2343,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,13848.64,,,,,,,fee schedule,13848.64,13848.64, Appendectomy Without Complex Principal Diagnosis,2343,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,13848.64,,,,,,,fee schedule,13848.64,13848.64, Appendectomy Without Complex Principal Diagnosis,2343,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,13848.64,,,,,,,fee schedule,13848.64,13848.64, Appendectomy Without Complex Principal Diagnosis,2343,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,13848.64,,,,,,,fee schedule,13848.64,13848.64, Appendectomy Without Complex Principal Diagnosis,2343,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,13848.64,,,,,,,fee schedule,13848.64,13848.64, Appendectomy Without Complex Principal Diagnosis,2343,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,13848.64,,,,,,,fee schedule,13848.64,13848.64, Appendectomy Without Complex Principal Diagnosis,2343,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,13848.64,,,,,,,fee schedule,13848.64,13848.64, Appendectomy Without Complex Principal Diagnosis,2343,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,13848.64,,,,,,,fee schedule,13848.64,13848.64, Appendectomy Without Complex Principal Diagnosis,2343,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,13848.64,,,,,,,fee schedule,13848.64,13848.64, Appendectomy Without Complex Principal Diagnosis,2343,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,13848.64,,,,,,,fee schedule,13848.64,13848.64, Appendectomy Without Complex Principal Diagnosis,2344,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,19982.5,,,,,,,fee schedule,19982.5,19982.5, Appendectomy Without Complex Principal Diagnosis,2344,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,19982.5,,,,,,,fee schedule,19982.5,19982.5, Appendectomy Without Complex Principal Diagnosis,2344,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,19982.5,,,,,,,fee schedule,19982.5,19982.5, Appendectomy Without Complex Principal Diagnosis,2344,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,19982.5,,,,,,,fee schedule,19982.5,19982.5, Appendectomy Without Complex Principal Diagnosis,2344,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,19982.5,,,,,,,fee schedule,19982.5,19982.5, Appendectomy Without Complex Principal Diagnosis,2344,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,19982.5,,,,,,,fee schedule,19982.5,19982.5, Appendectomy Without Complex Principal Diagnosis,2344,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,19982.5,,,,,,,fee schedule,19982.5,19982.5, Appendectomy Without Complex Principal Diagnosis,2344,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,19982.5,,,,,,,fee schedule,19982.5,19982.5, Appendectomy Without Complex Principal Diagnosis,2344,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,19982.5,,,,,,,fee schedule,19982.5,19982.5, Appendectomy Without Complex Principal Diagnosis,2344,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,19982.5,,,,,,,fee schedule,19982.5,19982.5, Appendectomy Without Complex Principal Diagnosis,2344,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,19982.5,,,,,,,fee schedule,19982.5,19982.5, Digestive Malignancy,2401,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5904.48,,,,,,,fee schedule,5904.48,5904.48, Digestive Malignancy,2401,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5904.48,,,,,,,fee schedule,5904.48,5904.48, Digestive Malignancy,2401,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5904.48,,,,,,,fee schedule,5904.48,5904.48, Digestive Malignancy,2401,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5904.48,,,,,,,fee schedule,5904.48,5904.48, Digestive Malignancy,2401,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5904.48,,,,,,,fee schedule,5904.48,5904.48, Digestive Malignancy,2401,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5904.48,,,,,,,fee schedule,5904.48,5904.48, Digestive Malignancy,2401,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5904.48,,,,,,,fee schedule,5904.48,5904.48, Digestive Malignancy,2401,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5904.48,,,,,,,fee schedule,5904.48,5904.48, Digestive Malignancy,2401,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5904.48,,,,,,,fee schedule,5904.48,5904.48, Digestive Malignancy,2401,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5904.48,,,,,,,fee schedule,5904.48,5904.48, Digestive Malignancy,2401,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5904.48,,,,,,,fee schedule,5904.48,5904.48, Digestive Malignancy,2402,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,7347.78,,,,,,,fee schedule,7347.78,7347.78, Digestive Malignancy,2402,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,7347.78,,,,,,,fee schedule,7347.78,7347.78, Digestive Malignancy,2402,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,7347.78,,,,,,,fee schedule,7347.78,7347.78, Digestive Malignancy,2402,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,7347.78,,,,,,,fee schedule,7347.78,7347.78, Digestive Malignancy,2402,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,7347.78,,,,,,,fee schedule,7347.78,7347.78, Digestive Malignancy,2402,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,7347.78,,,,,,,fee schedule,7347.78,7347.78, Digestive Malignancy,2402,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,7347.78,,,,,,,fee schedule,7347.78,7347.78, Digestive Malignancy,2402,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,7347.78,,,,,,,fee schedule,7347.78,7347.78, Digestive Malignancy,2402,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,7347.78,,,,,,,fee schedule,7347.78,7347.78, Digestive Malignancy,2402,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,7347.78,,,,,,,fee schedule,7347.78,7347.78, Digestive Malignancy,2402,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,7347.78,,,,,,,fee schedule,7347.78,7347.78, Digestive Malignancy,2403,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,10708.67,,,,,,,fee schedule,10708.67,10708.67, Digestive Malignancy,2403,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,10708.67,,,,,,,fee schedule,10708.67,10708.67, Digestive Malignancy,2403,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,10708.67,,,,,,,fee schedule,10708.67,10708.67, Digestive Malignancy,2403,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,10708.67,,,,,,,fee schedule,10708.67,10708.67, Digestive Malignancy,2403,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,10708.67,,,,,,,fee schedule,10708.67,10708.67, Digestive Malignancy,2403,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,10708.67,,,,,,,fee schedule,10708.67,10708.67, Digestive Malignancy,2403,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,10708.67,,,,,,,fee schedule,10708.67,10708.67, Digestive Malignancy,2403,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,10708.67,,,,,,,fee schedule,10708.67,10708.67, Digestive Malignancy,2403,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,10708.67,,,,,,,fee schedule,10708.67,10708.67, Digestive Malignancy,2403,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,10708.67,,,,,,,fee schedule,10708.67,10708.67, Digestive Malignancy,2403,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,10708.67,,,,,,,fee schedule,10708.67,10708.67, Digestive Malignancy,2404,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,17084.6,,,,,,,fee schedule,17084.6,17084.6, Digestive Malignancy,2404,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,17084.6,,,,,,,fee schedule,17084.6,17084.6, Digestive Malignancy,2404,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,17084.6,,,,,,,fee schedule,17084.6,17084.6, Digestive Malignancy,2404,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,17084.6,,,,,,,fee schedule,17084.6,17084.6, Digestive Malignancy,2404,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,17084.6,,,,,,,fee schedule,17084.6,17084.6, Digestive Malignancy,2404,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,17084.6,,,,,,,fee schedule,17084.6,17084.6, Digestive Malignancy,2404,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,17084.6,,,,,,,fee schedule,17084.6,17084.6, Digestive Malignancy,2404,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,17084.6,,,,,,,fee schedule,17084.6,17084.6, Digestive Malignancy,2404,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,17084.6,,,,,,,fee schedule,17084.6,17084.6, Digestive Malignancy,2404,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,17084.6,,,,,,,fee schedule,17084.6,17084.6, Digestive Malignancy,2404,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,17084.6,,,,,,,fee schedule,17084.6,17084.6, Peptic Ulcer And Gastritis,2411,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5202.24,,,,,,,fee schedule,5202.24,5202.24, Peptic Ulcer And Gastritis,2411,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5202.24,,,,,,,fee schedule,5202.24,5202.24, Peptic Ulcer And Gastritis,2411,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5202.24,,,,,,,fee schedule,5202.24,5202.24, Peptic Ulcer And Gastritis,2411,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5202.24,,,,,,,fee schedule,5202.24,5202.24, Peptic Ulcer And Gastritis,2411,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5202.24,,,,,,,fee schedule,5202.24,5202.24, Peptic Ulcer And Gastritis,2411,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5202.24,,,,,,,fee schedule,5202.24,5202.24, Peptic Ulcer And Gastritis,2411,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5202.24,,,,,,,fee schedule,5202.24,5202.24, Peptic Ulcer And Gastritis,2411,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5202.24,,,,,,,fee schedule,5202.24,5202.24, Peptic Ulcer And Gastritis,2411,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5202.24,,,,,,,fee schedule,5202.24,5202.24, Peptic Ulcer And Gastritis,2411,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5202.24,,,,,,,fee schedule,5202.24,5202.24, Peptic Ulcer And Gastritis,2411,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5202.24,,,,,,,fee schedule,5202.24,5202.24, Peptic Ulcer And Gastritis,2412,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,6263.72,,,,,,,fee schedule,6263.72,6263.72, Peptic Ulcer And Gastritis,2412,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,6263.72,,,,,,,fee schedule,6263.72,6263.72, Peptic Ulcer And Gastritis,2412,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,6263.72,,,,,,,fee schedule,6263.72,6263.72, Peptic Ulcer And Gastritis,2412,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,6263.72,,,,,,,fee schedule,6263.72,6263.72, Peptic Ulcer And Gastritis,2412,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,6263.72,,,,,,,fee schedule,6263.72,6263.72, Peptic Ulcer And Gastritis,2412,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,6263.72,,,,,,,fee schedule,6263.72,6263.72, Peptic Ulcer And Gastritis,2412,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,6263.72,,,,,,,fee schedule,6263.72,6263.72, Peptic Ulcer And Gastritis,2412,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,6263.72,,,,,,,fee schedule,6263.72,6263.72, Peptic Ulcer And Gastritis,2412,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,6263.72,,,,,,,fee schedule,6263.72,6263.72, Peptic Ulcer And Gastritis,2412,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,6263.72,,,,,,,fee schedule,6263.72,6263.72, Peptic Ulcer And Gastritis,2412,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,6263.72,,,,,,,fee schedule,6263.72,6263.72, Peptic Ulcer And Gastritis,2413,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,9289.36,,,,,,,fee schedule,9289.36,9289.36, Peptic Ulcer And Gastritis,2413,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,9289.36,,,,,,,fee schedule,9289.36,9289.36, Peptic Ulcer And Gastritis,2413,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,9289.36,,,,,,,fee schedule,9289.36,9289.36, Peptic Ulcer And Gastritis,2413,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,9289.36,,,,,,,fee schedule,9289.36,9289.36, Peptic Ulcer And Gastritis,2413,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,9289.36,,,,,,,fee schedule,9289.36,9289.36, Peptic Ulcer And Gastritis,2413,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,9289.36,,,,,,,fee schedule,9289.36,9289.36, Peptic Ulcer And Gastritis,2413,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,9289.36,,,,,,,fee schedule,9289.36,9289.36, Peptic Ulcer And Gastritis,2413,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,9289.36,,,,,,,fee schedule,9289.36,9289.36, Peptic Ulcer And Gastritis,2413,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,9289.36,,,,,,,fee schedule,9289.36,9289.36, Peptic Ulcer And Gastritis,2413,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,9289.36,,,,,,,fee schedule,9289.36,9289.36, Peptic Ulcer And Gastritis,2413,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,9289.36,,,,,,,fee schedule,9289.36,9289.36, Peptic Ulcer And Gastritis,2414,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,17673.22,,,,,,,fee schedule,17673.22,17673.22, Peptic Ulcer And Gastritis,2414,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,17673.22,,,,,,,fee schedule,17673.22,17673.22, Peptic Ulcer And Gastritis,2414,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,17673.22,,,,,,,fee schedule,17673.22,17673.22, Peptic Ulcer And Gastritis,2414,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,17673.22,,,,,,,fee schedule,17673.22,17673.22, Peptic Ulcer And Gastritis,2414,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,17673.22,,,,,,,fee schedule,17673.22,17673.22, Peptic Ulcer And Gastritis,2414,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,17673.22,,,,,,,fee schedule,17673.22,17673.22, Peptic Ulcer And Gastritis,2414,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,17673.22,,,,,,,fee schedule,17673.22,17673.22, Peptic Ulcer And Gastritis,2414,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,17673.22,,,,,,,fee schedule,17673.22,17673.22, Peptic Ulcer And Gastritis,2414,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,17673.22,,,,,,,fee schedule,17673.22,17673.22, Peptic Ulcer And Gastritis,2414,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,17673.22,,,,,,,fee schedule,17673.22,17673.22, Peptic Ulcer And Gastritis,2414,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,17673.22,,,,,,,fee schedule,17673.22,17673.22, Major Esophageal Disorders,2421,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4884.64,,,,,,,fee schedule,4884.64,4884.64, Major Esophageal Disorders,2421,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4884.64,,,,,,,fee schedule,4884.64,4884.64, Major Esophageal Disorders,2421,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4884.64,,,,,,,fee schedule,4884.64,4884.64, Major Esophageal Disorders,2421,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4884.64,,,,,,,fee schedule,4884.64,4884.64, Major Esophageal Disorders,2421,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4884.64,,,,,,,fee schedule,4884.64,4884.64, Major Esophageal Disorders,2421,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4884.64,,,,,,,fee schedule,4884.64,4884.64, Major Esophageal Disorders,2421,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4884.64,,,,,,,fee schedule,4884.64,4884.64, Major Esophageal Disorders,2421,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4884.64,,,,,,,fee schedule,4884.64,4884.64, Major Esophageal Disorders,2421,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4884.64,,,,,,,fee schedule,4884.64,4884.64, Major Esophageal Disorders,2421,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4884.64,,,,,,,fee schedule,4884.64,4884.64, Major Esophageal Disorders,2421,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4884.64,,,,,,,fee schedule,4884.64,4884.64, Major Esophageal Disorders,2422,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,6241.84,,,,,,,fee schedule,6241.84,6241.84, Major Esophageal Disorders,2422,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,6241.84,,,,,,,fee schedule,6241.84,6241.84, Major Esophageal Disorders,2422,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,6241.84,,,,,,,fee schedule,6241.84,6241.84, Major Esophageal Disorders,2422,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,6241.84,,,,,,,fee schedule,6241.84,6241.84, Major Esophageal Disorders,2422,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,6241.84,,,,,,,fee schedule,6241.84,6241.84, Major Esophageal Disorders,2422,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,6241.84,,,,,,,fee schedule,6241.84,6241.84, Major Esophageal Disorders,2422,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,6241.84,,,,,,,fee schedule,6241.84,6241.84, Major Esophageal Disorders,2422,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,6241.84,,,,,,,fee schedule,6241.84,6241.84, Major Esophageal Disorders,2422,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,6241.84,,,,,,,fee schedule,6241.84,6241.84, Major Esophageal Disorders,2422,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,6241.84,,,,,,,fee schedule,6241.84,6241.84, Major Esophageal Disorders,2422,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,6241.84,,,,,,,fee schedule,6241.84,6241.84, Major Esophageal Disorders,2423,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,9307.71,,,,,,,fee schedule,9307.71,9307.71, Major Esophageal Disorders,2423,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,9307.71,,,,,,,fee schedule,9307.71,9307.71, Major Esophageal Disorders,2423,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,9307.71,,,,,,,fee schedule,9307.71,9307.71, Major Esophageal Disorders,2423,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,9307.71,,,,,,,fee schedule,9307.71,9307.71, Major Esophageal Disorders,2423,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,9307.71,,,,,,,fee schedule,9307.71,9307.71, Major Esophageal Disorders,2423,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,9307.71,,,,,,,fee schedule,9307.71,9307.71, Major Esophageal Disorders,2423,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,9307.71,,,,,,,fee schedule,9307.71,9307.71, Major Esophageal Disorders,2423,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,9307.71,,,,,,,fee schedule,9307.71,9307.71, Major Esophageal Disorders,2423,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,9307.71,,,,,,,fee schedule,9307.71,9307.71, Major Esophageal Disorders,2423,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,9307.71,,,,,,,fee schedule,9307.71,9307.71, Major Esophageal Disorders,2423,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,9307.71,,,,,,,fee schedule,9307.71,9307.71, Major Esophageal Disorders,2424,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,18100.21,,,,,,,fee schedule,18100.21,18100.21, Major Esophageal Disorders,2424,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,18100.21,,,,,,,fee schedule,18100.21,18100.21, Major Esophageal Disorders,2424,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,18100.21,,,,,,,fee schedule,18100.21,18100.21, Major Esophageal Disorders,2424,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,18100.21,,,,,,,fee schedule,18100.21,18100.21, Major Esophageal Disorders,2424,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,18100.21,,,,,,,fee schedule,18100.21,18100.21, Major Esophageal Disorders,2424,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,18100.21,,,,,,,fee schedule,18100.21,18100.21, Major Esophageal Disorders,2424,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,18100.21,,,,,,,fee schedule,18100.21,18100.21, Major Esophageal Disorders,2424,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,18100.21,,,,,,,fee schedule,18100.21,18100.21, Major Esophageal Disorders,2424,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,18100.21,,,,,,,fee schedule,18100.21,18100.21, Major Esophageal Disorders,2424,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,18100.21,,,,,,,fee schedule,18100.21,18100.21, Major Esophageal Disorders,2424,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,18100.21,,,,,,,fee schedule,18100.21,18100.21, Other Esophageal Disorders,2431,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4758.31,,,,,,,fee schedule,4758.31,4758.31, Other Esophageal Disorders,2431,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4758.31,,,,,,,fee schedule,4758.31,4758.31, Other Esophageal Disorders,2431,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4758.31,,,,,,,fee schedule,4758.31,4758.31, Other Esophageal Disorders,2431,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4758.31,,,,,,,fee schedule,4758.31,4758.31, Other Esophageal Disorders,2431,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4758.31,,,,,,,fee schedule,4758.31,4758.31, Other Esophageal Disorders,2431,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4758.31,,,,,,,fee schedule,4758.31,4758.31, Other Esophageal Disorders,2431,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4758.31,,,,,,,fee schedule,4758.31,4758.31, Other Esophageal Disorders,2431,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4758.31,,,,,,,fee schedule,4758.31,4758.31, Other Esophageal Disorders,2431,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4758.31,,,,,,,fee schedule,4758.31,4758.31, Other Esophageal Disorders,2431,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4758.31,,,,,,,fee schedule,4758.31,4758.31, Other Esophageal Disorders,2431,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4758.31,,,,,,,fee schedule,4758.31,4758.31, Other Esophageal Disorders,2432,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,6108.45,,,,,,,fee schedule,6108.45,6108.45, Other Esophageal Disorders,2432,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,6108.45,,,,,,,fee schedule,6108.45,6108.45, Other Esophageal Disorders,2432,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,6108.45,,,,,,,fee schedule,6108.45,6108.45, Other Esophageal Disorders,2432,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,6108.45,,,,,,,fee schedule,6108.45,6108.45, Other Esophageal Disorders,2432,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,6108.45,,,,,,,fee schedule,6108.45,6108.45, Other Esophageal Disorders,2432,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,6108.45,,,,,,,fee schedule,6108.45,6108.45, Other Esophageal Disorders,2432,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,6108.45,,,,,,,fee schedule,6108.45,6108.45, Other Esophageal Disorders,2432,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,6108.45,,,,,,,fee schedule,6108.45,6108.45, Other Esophageal Disorders,2432,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,6108.45,,,,,,,fee schedule,6108.45,6108.45, Other Esophageal Disorders,2432,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,6108.45,,,,,,,fee schedule,6108.45,6108.45, Other Esophageal Disorders,2432,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,6108.45,,,,,,,fee schedule,6108.45,6108.45, Other Esophageal Disorders,2433,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,8659.11,,,,,,,fee schedule,8659.11,8659.11, Other Esophageal Disorders,2433,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,8659.11,,,,,,,fee schedule,8659.11,8659.11, Other Esophageal Disorders,2433,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,8659.11,,,,,,,fee schedule,8659.11,8659.11, Other Esophageal Disorders,2433,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,8659.11,,,,,,,fee schedule,8659.11,8659.11, Other Esophageal Disorders,2433,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,8659.11,,,,,,,fee schedule,8659.11,8659.11, Other Esophageal Disorders,2433,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,8659.11,,,,,,,fee schedule,8659.11,8659.11, Other Esophageal Disorders,2433,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,8659.11,,,,,,,fee schedule,8659.11,8659.11, Other Esophageal Disorders,2433,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,8659.11,,,,,,,fee schedule,8659.11,8659.11, Other Esophageal Disorders,2433,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,8659.11,,,,,,,fee schedule,8659.11,8659.11, Other Esophageal Disorders,2433,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,8659.11,,,,,,,fee schedule,8659.11,8659.11, Other Esophageal Disorders,2433,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,8659.11,,,,,,,fee schedule,8659.11,8659.11, Other Esophageal Disorders,2434,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,15998.42,,,,,,,fee schedule,15998.42,15998.42, Other Esophageal Disorders,2434,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,15998.42,,,,,,,fee schedule,15998.42,15998.42, Other Esophageal Disorders,2434,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,15998.42,,,,,,,fee schedule,15998.42,15998.42, Other Esophageal Disorders,2434,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,15998.42,,,,,,,fee schedule,15998.42,15998.42, Other Esophageal Disorders,2434,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,15998.42,,,,,,,fee schedule,15998.42,15998.42, Other Esophageal Disorders,2434,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,15998.42,,,,,,,fee schedule,15998.42,15998.42, Other Esophageal Disorders,2434,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,15998.42,,,,,,,fee schedule,15998.42,15998.42, Other Esophageal Disorders,2434,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,15998.42,,,,,,,fee schedule,15998.42,15998.42, Other Esophageal Disorders,2434,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,15998.42,,,,,,,fee schedule,15998.42,15998.42, Other Esophageal Disorders,2434,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,15998.42,,,,,,,fee schedule,15998.42,15998.42, Other Esophageal Disorders,2434,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,15998.42,,,,,,,fee schedule,15998.42,15998.42, Diverticulitis And Diverticulosis,2441,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,3897.97,,,,,,,fee schedule,3897.97,3897.97, Diverticulitis And Diverticulosis,2441,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,3897.97,,,,,,,fee schedule,3897.97,3897.97, Diverticulitis And Diverticulosis,2441,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,3897.97,,,,,,,fee schedule,3897.97,3897.97, Diverticulitis And Diverticulosis,2441,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,3897.97,,,,,,,fee schedule,3897.97,3897.97, Diverticulitis And Diverticulosis,2441,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,3897.97,,,,,,,fee schedule,3897.97,3897.97, Diverticulitis And Diverticulosis,2441,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,3897.97,,,,,,,fee schedule,3897.97,3897.97, Diverticulitis And Diverticulosis,2441,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,3897.97,,,,,,,fee schedule,3897.97,3897.97, Diverticulitis And Diverticulosis,2441,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,3897.97,,,,,,,fee schedule,3897.97,3897.97, Diverticulitis And Diverticulosis,2441,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,3897.97,,,,,,,fee schedule,3897.97,3897.97, Diverticulitis And Diverticulosis,2441,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,3897.97,,,,,,,fee schedule,3897.97,3897.97, Diverticulitis And Diverticulosis,2441,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,3897.97,,,,,,,fee schedule,3897.97,3897.97, Diverticulitis And Diverticulosis,2442,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5373.04,,,,,,,fee schedule,5373.04,5373.04, Diverticulitis And Diverticulosis,2442,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5373.04,,,,,,,fee schedule,5373.04,5373.04, Diverticulitis And Diverticulosis,2442,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5373.04,,,,,,,fee schedule,5373.04,5373.04, Diverticulitis And Diverticulosis,2442,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5373.04,,,,,,,fee schedule,5373.04,5373.04, Diverticulitis And Diverticulosis,2442,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5373.04,,,,,,,fee schedule,5373.04,5373.04, Diverticulitis And Diverticulosis,2442,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5373.04,,,,,,,fee schedule,5373.04,5373.04, Diverticulitis And Diverticulosis,2442,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5373.04,,,,,,,fee schedule,5373.04,5373.04, Diverticulitis And Diverticulosis,2442,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5373.04,,,,,,,fee schedule,5373.04,5373.04, Diverticulitis And Diverticulosis,2442,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5373.04,,,,,,,fee schedule,5373.04,5373.04, Diverticulitis And Diverticulosis,2442,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5373.04,,,,,,,fee schedule,5373.04,5373.04, Diverticulitis And Diverticulosis,2442,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5373.04,,,,,,,fee schedule,5373.04,5373.04, Diverticulitis And Diverticulosis,2443,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,8429.73,,,,,,,fee schedule,8429.73,8429.73, Diverticulitis And Diverticulosis,2443,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,8429.73,,,,,,,fee schedule,8429.73,8429.73, Diverticulitis And Diverticulosis,2443,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,8429.73,,,,,,,fee schedule,8429.73,8429.73, Diverticulitis And Diverticulosis,2443,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,8429.73,,,,,,,fee schedule,8429.73,8429.73, Diverticulitis And Diverticulosis,2443,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,8429.73,,,,,,,fee schedule,8429.73,8429.73, Diverticulitis And Diverticulosis,2443,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,8429.73,,,,,,,fee schedule,8429.73,8429.73, Diverticulitis And Diverticulosis,2443,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,8429.73,,,,,,,fee schedule,8429.73,8429.73, Diverticulitis And Diverticulosis,2443,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,8429.73,,,,,,,fee schedule,8429.73,8429.73, Diverticulitis And Diverticulosis,2443,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,8429.73,,,,,,,fee schedule,8429.73,8429.73, Diverticulitis And Diverticulosis,2443,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,8429.73,,,,,,,fee schedule,8429.73,8429.73, Diverticulitis And Diverticulosis,2443,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,8429.73,,,,,,,fee schedule,8429.73,8429.73, Diverticulitis And Diverticulosis,2444,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,15501.56,,,,,,,fee schedule,15501.56,15501.56, Diverticulitis And Diverticulosis,2444,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,15501.56,,,,,,,fee schedule,15501.56,15501.56, Diverticulitis And Diverticulosis,2444,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,15501.56,,,,,,,fee schedule,15501.56,15501.56, Diverticulitis And Diverticulosis,2444,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,15501.56,,,,,,,fee schedule,15501.56,15501.56, Diverticulitis And Diverticulosis,2444,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,15501.56,,,,,,,fee schedule,15501.56,15501.56, Diverticulitis And Diverticulosis,2444,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,15501.56,,,,,,,fee schedule,15501.56,15501.56, Diverticulitis And Diverticulosis,2444,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,15501.56,,,,,,,fee schedule,15501.56,15501.56, Diverticulitis And Diverticulosis,2444,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,15501.56,,,,,,,fee schedule,15501.56,15501.56, Diverticulitis And Diverticulosis,2444,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,15501.56,,,,,,,fee schedule,15501.56,15501.56, Diverticulitis And Diverticulosis,2444,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,15501.56,,,,,,,fee schedule,15501.56,15501.56, Diverticulitis And Diverticulosis,2444,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,15501.56,,,,,,,fee schedule,15501.56,15501.56, Inflammatory Bowel Disease,2451,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4430.13,,,,,,,fee schedule,4430.13,4430.13, Inflammatory Bowel Disease,2451,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4430.13,,,,,,,fee schedule,4430.13,4430.13, Inflammatory Bowel Disease,2451,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4430.13,,,,,,,fee schedule,4430.13,4430.13, Inflammatory Bowel Disease,2451,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4430.13,,,,,,,fee schedule,4430.13,4430.13, Inflammatory Bowel Disease,2451,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4430.13,,,,,,,fee schedule,4430.13,4430.13, Inflammatory Bowel Disease,2451,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4430.13,,,,,,,fee schedule,4430.13,4430.13, Inflammatory Bowel Disease,2451,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4430.13,,,,,,,fee schedule,4430.13,4430.13, Inflammatory Bowel Disease,2451,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4430.13,,,,,,,fee schedule,4430.13,4430.13, Inflammatory Bowel Disease,2451,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4430.13,,,,,,,fee schedule,4430.13,4430.13, Inflammatory Bowel Disease,2451,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4430.13,,,,,,,fee schedule,4430.13,4430.13, Inflammatory Bowel Disease,2451,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4430.13,,,,,,,fee schedule,4430.13,4430.13, Inflammatory Bowel Disease,2452,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5982.82,,,,,,,fee schedule,5982.82,5982.82, Inflammatory Bowel Disease,2452,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5982.82,,,,,,,fee schedule,5982.82,5982.82, Inflammatory Bowel Disease,2452,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5982.82,,,,,,,fee schedule,5982.82,5982.82, Inflammatory Bowel Disease,2452,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5982.82,,,,,,,fee schedule,5982.82,5982.82, Inflammatory Bowel Disease,2452,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5982.82,,,,,,,fee schedule,5982.82,5982.82, Inflammatory Bowel Disease,2452,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5982.82,,,,,,,fee schedule,5982.82,5982.82, Inflammatory Bowel Disease,2452,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5982.82,,,,,,,fee schedule,5982.82,5982.82, Inflammatory Bowel Disease,2452,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5982.82,,,,,,,fee schedule,5982.82,5982.82, Inflammatory Bowel Disease,2452,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5982.82,,,,,,,fee schedule,5982.82,5982.82, Inflammatory Bowel Disease,2452,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5982.82,,,,,,,fee schedule,5982.82,5982.82, Inflammatory Bowel Disease,2452,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5982.82,,,,,,,fee schedule,5982.82,5982.82, Inflammatory Bowel Disease,2453,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,9234.31,,,,,,,fee schedule,9234.31,9234.31, Inflammatory Bowel Disease,2453,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,9234.31,,,,,,,fee schedule,9234.31,9234.31, Inflammatory Bowel Disease,2453,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,9234.31,,,,,,,fee schedule,9234.31,9234.31, Inflammatory Bowel Disease,2453,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,9234.31,,,,,,,fee schedule,9234.31,9234.31, Inflammatory Bowel Disease,2453,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,9234.31,,,,,,,fee schedule,9234.31,9234.31, Inflammatory Bowel Disease,2453,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,9234.31,,,,,,,fee schedule,9234.31,9234.31, Inflammatory Bowel Disease,2453,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,9234.31,,,,,,,fee schedule,9234.31,9234.31, Inflammatory Bowel Disease,2453,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,9234.31,,,,,,,fee schedule,9234.31,9234.31, Inflammatory Bowel Disease,2453,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,9234.31,,,,,,,fee schedule,9234.31,9234.31, Inflammatory Bowel Disease,2453,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,9234.31,,,,,,,fee schedule,9234.31,9234.31, Inflammatory Bowel Disease,2453,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,9234.31,,,,,,,fee schedule,9234.31,9234.31, Inflammatory Bowel Disease,2454,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,15848.09,,,,,,,fee schedule,15848.09,15848.09, Inflammatory Bowel Disease,2454,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,15848.09,,,,,,,fee schedule,15848.09,15848.09, Inflammatory Bowel Disease,2454,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,15848.09,,,,,,,fee schedule,15848.09,15848.09, Inflammatory Bowel Disease,2454,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,15848.09,,,,,,,fee schedule,15848.09,15848.09, Inflammatory Bowel Disease,2454,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,15848.09,,,,,,,fee schedule,15848.09,15848.09, Inflammatory Bowel Disease,2454,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,15848.09,,,,,,,fee schedule,15848.09,15848.09, Inflammatory Bowel Disease,2454,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,15848.09,,,,,,,fee schedule,15848.09,15848.09, Inflammatory Bowel Disease,2454,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,15848.09,,,,,,,fee schedule,15848.09,15848.09, Inflammatory Bowel Disease,2454,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,15848.09,,,,,,,fee schedule,15848.09,15848.09, Inflammatory Bowel Disease,2454,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,15848.09,,,,,,,fee schedule,15848.09,15848.09, Inflammatory Bowel Disease,2454,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,15848.09,,,,,,,fee schedule,15848.09,15848.09, Gastrointestinal Vascular Insufficiency,2461,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4580.46,,,,,,,fee schedule,4580.46,4580.46, Gastrointestinal Vascular Insufficiency,2461,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4580.46,,,,,,,fee schedule,4580.46,4580.46, Gastrointestinal Vascular Insufficiency,2461,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4580.46,,,,,,,fee schedule,4580.46,4580.46, Gastrointestinal Vascular Insufficiency,2461,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4580.46,,,,,,,fee schedule,4580.46,4580.46, Gastrointestinal Vascular Insufficiency,2461,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4580.46,,,,,,,fee schedule,4580.46,4580.46, Gastrointestinal Vascular Insufficiency,2461,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4580.46,,,,,,,fee schedule,4580.46,4580.46, Gastrointestinal Vascular Insufficiency,2461,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4580.46,,,,,,,fee schedule,4580.46,4580.46, Gastrointestinal Vascular Insufficiency,2461,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4580.46,,,,,,,fee schedule,4580.46,4580.46, Gastrointestinal Vascular Insufficiency,2461,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4580.46,,,,,,,fee schedule,4580.46,4580.46, Gastrointestinal Vascular Insufficiency,2461,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4580.46,,,,,,,fee schedule,4580.46,4580.46, Gastrointestinal Vascular Insufficiency,2461,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4580.46,,,,,,,fee schedule,4580.46,4580.46, Gastrointestinal Vascular Insufficiency,2462,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5850.14,,,,,,,fee schedule,5850.14,5850.14, Gastrointestinal Vascular Insufficiency,2462,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5850.14,,,,,,,fee schedule,5850.14,5850.14, Gastrointestinal Vascular Insufficiency,2462,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5850.14,,,,,,,fee schedule,5850.14,5850.14, Gastrointestinal Vascular Insufficiency,2462,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5850.14,,,,,,,fee schedule,5850.14,5850.14, Gastrointestinal Vascular Insufficiency,2462,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5850.14,,,,,,,fee schedule,5850.14,5850.14, Gastrointestinal Vascular Insufficiency,2462,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5850.14,,,,,,,fee schedule,5850.14,5850.14, Gastrointestinal Vascular Insufficiency,2462,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5850.14,,,,,,,fee schedule,5850.14,5850.14, Gastrointestinal Vascular Insufficiency,2462,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5850.14,,,,,,,fee schedule,5850.14,5850.14, Gastrointestinal Vascular Insufficiency,2462,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5850.14,,,,,,,fee schedule,5850.14,5850.14, Gastrointestinal Vascular Insufficiency,2462,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5850.14,,,,,,,fee schedule,5850.14,5850.14, Gastrointestinal Vascular Insufficiency,2462,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5850.14,,,,,,,fee schedule,5850.14,5850.14, Gastrointestinal Vascular Insufficiency,2463,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,8848.25,,,,,,,fee schedule,8848.25,8848.25, Gastrointestinal Vascular Insufficiency,2463,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,8848.25,,,,,,,fee schedule,8848.25,8848.25, Gastrointestinal Vascular Insufficiency,2463,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,8848.25,,,,,,,fee schedule,8848.25,8848.25, Gastrointestinal Vascular Insufficiency,2463,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,8848.25,,,,,,,fee schedule,8848.25,8848.25, Gastrointestinal Vascular Insufficiency,2463,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,8848.25,,,,,,,fee schedule,8848.25,8848.25, Gastrointestinal Vascular Insufficiency,2463,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,8848.25,,,,,,,fee schedule,8848.25,8848.25, Gastrointestinal Vascular Insufficiency,2463,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,8848.25,,,,,,,fee schedule,8848.25,8848.25, Gastrointestinal Vascular Insufficiency,2463,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,8848.25,,,,,,,fee schedule,8848.25,8848.25, Gastrointestinal Vascular Insufficiency,2463,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,8848.25,,,,,,,fee schedule,8848.25,8848.25, Gastrointestinal Vascular Insufficiency,2463,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,8848.25,,,,,,,fee schedule,8848.25,8848.25, Gastrointestinal Vascular Insufficiency,2463,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,8848.25,,,,,,,fee schedule,8848.25,8848.25, Gastrointestinal Vascular Insufficiency,2464,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,14304.57,,,,,,,fee schedule,14304.57,14304.57, Gastrointestinal Vascular Insufficiency,2464,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,14304.57,,,,,,,fee schedule,14304.57,14304.57, Gastrointestinal Vascular Insufficiency,2464,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,14304.57,,,,,,,fee schedule,14304.57,14304.57, Gastrointestinal Vascular Insufficiency,2464,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,14304.57,,,,,,,fee schedule,14304.57,14304.57, Gastrointestinal Vascular Insufficiency,2464,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,14304.57,,,,,,,fee schedule,14304.57,14304.57, Gastrointestinal Vascular Insufficiency,2464,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,14304.57,,,,,,,fee schedule,14304.57,14304.57, Gastrointestinal Vascular Insufficiency,2464,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,14304.57,,,,,,,fee schedule,14304.57,14304.57, Gastrointestinal Vascular Insufficiency,2464,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,14304.57,,,,,,,fee schedule,14304.57,14304.57, Gastrointestinal Vascular Insufficiency,2464,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,14304.57,,,,,,,fee schedule,14304.57,14304.57, Gastrointestinal Vascular Insufficiency,2464,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,14304.57,,,,,,,fee schedule,14304.57,14304.57, Gastrointestinal Vascular Insufficiency,2464,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,14304.57,,,,,,,fee schedule,14304.57,14304.57, Intestinal Obstruction,2471,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,3595.9,,,,,,,fee schedule,3595.9,3595.9, Intestinal Obstruction,2471,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,3595.9,,,,,,,fee schedule,3595.9,3595.9, Intestinal Obstruction,2471,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,3595.9,,,,,,,fee schedule,3595.9,3595.9, Intestinal Obstruction,2471,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,3595.9,,,,,,,fee schedule,3595.9,3595.9, Intestinal Obstruction,2471,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,3595.9,,,,,,,fee schedule,3595.9,3595.9, Intestinal Obstruction,2471,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,3595.9,,,,,,,fee schedule,3595.9,3595.9, Intestinal Obstruction,2471,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,3595.9,,,,,,,fee schedule,3595.9,3595.9, Intestinal Obstruction,2471,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,3595.9,,,,,,,fee schedule,3595.9,3595.9, Intestinal Obstruction,2471,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,3595.9,,,,,,,fee schedule,3595.9,3595.9, Intestinal Obstruction,2471,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,3595.9,,,,,,,fee schedule,3595.9,3595.9, Intestinal Obstruction,2471,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,3595.9,,,,,,,fee schedule,3595.9,3595.9, Intestinal Obstruction,2472,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4807.71,,,,,,,fee schedule,4807.71,4807.71, Intestinal Obstruction,2472,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4807.71,,,,,,,fee schedule,4807.71,4807.71, Intestinal Obstruction,2472,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4807.71,,,,,,,fee schedule,4807.71,4807.71, Intestinal Obstruction,2472,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4807.71,,,,,,,fee schedule,4807.71,4807.71, Intestinal Obstruction,2472,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4807.71,,,,,,,fee schedule,4807.71,4807.71, Intestinal Obstruction,2472,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4807.71,,,,,,,fee schedule,4807.71,4807.71, Intestinal Obstruction,2472,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4807.71,,,,,,,fee schedule,4807.71,4807.71, Intestinal Obstruction,2472,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4807.71,,,,,,,fee schedule,4807.71,4807.71, Intestinal Obstruction,2472,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4807.71,,,,,,,fee schedule,4807.71,4807.71, Intestinal Obstruction,2472,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4807.71,,,,,,,fee schedule,4807.71,4807.71, Intestinal Obstruction,2472,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4807.71,,,,,,,fee schedule,4807.71,4807.71, Intestinal Obstruction,2473,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,7708.43,,,,,,,fee schedule,7708.43,7708.43, Intestinal Obstruction,2473,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,7708.43,,,,,,,fee schedule,7708.43,7708.43, Intestinal Obstruction,2473,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,7708.43,,,,,,,fee schedule,7708.43,7708.43, Intestinal Obstruction,2473,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,7708.43,,,,,,,fee schedule,7708.43,7708.43, Intestinal Obstruction,2473,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,7708.43,,,,,,,fee schedule,7708.43,7708.43, Intestinal Obstruction,2473,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,7708.43,,,,,,,fee schedule,7708.43,7708.43, Intestinal Obstruction,2473,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,7708.43,,,,,,,fee schedule,7708.43,7708.43, Intestinal Obstruction,2473,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,7708.43,,,,,,,fee schedule,7708.43,7708.43, Intestinal Obstruction,2473,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,7708.43,,,,,,,fee schedule,7708.43,7708.43, Intestinal Obstruction,2473,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,7708.43,,,,,,,fee schedule,7708.43,7708.43, Intestinal Obstruction,2473,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,7708.43,,,,,,,fee schedule,7708.43,7708.43, Intestinal Obstruction,2474,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,13830.29,,,,,,,fee schedule,13830.29,13830.29, Intestinal Obstruction,2474,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,13830.29,,,,,,,fee schedule,13830.29,13830.29, Intestinal Obstruction,2474,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,13830.29,,,,,,,fee schedule,13830.29,13830.29, Intestinal Obstruction,2474,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,13830.29,,,,,,,fee schedule,13830.29,13830.29, Intestinal Obstruction,2474,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,13830.29,,,,,,,fee schedule,13830.29,13830.29, Intestinal Obstruction,2474,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,13830.29,,,,,,,fee schedule,13830.29,13830.29, Intestinal Obstruction,2474,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,13830.29,,,,,,,fee schedule,13830.29,13830.29, Intestinal Obstruction,2474,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,13830.29,,,,,,,fee schedule,13830.29,13830.29, Intestinal Obstruction,2474,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,13830.29,,,,,,,fee schedule,13830.29,13830.29, Intestinal Obstruction,2474,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,13830.29,,,,,,,fee schedule,13830.29,13830.29, Intestinal Obstruction,2474,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,13830.29,,,,,,,fee schedule,13830.29,13830.29, Major Gastrointestinal And Peritoneal Infections,2481,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4166.87,,,,,,,fee schedule,4166.87,4166.87, Major Gastrointestinal And Peritoneal Infections,2481,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4166.87,,,,,,,fee schedule,4166.87,4166.87, Major Gastrointestinal And Peritoneal Infections,2481,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4166.87,,,,,,,fee schedule,4166.87,4166.87, Major Gastrointestinal And Peritoneal Infections,2481,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4166.87,,,,,,,fee schedule,4166.87,4166.87, Major Gastrointestinal And Peritoneal Infections,2481,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4166.87,,,,,,,fee schedule,4166.87,4166.87, Major Gastrointestinal And Peritoneal Infections,2481,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4166.87,,,,,,,fee schedule,4166.87,4166.87, Major Gastrointestinal And Peritoneal Infections,2481,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4166.87,,,,,,,fee schedule,4166.87,4166.87, Major Gastrointestinal And Peritoneal Infections,2481,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4166.87,,,,,,,fee schedule,4166.87,4166.87, Major Gastrointestinal And Peritoneal Infections,2481,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4166.87,,,,,,,fee schedule,4166.87,4166.87, Major Gastrointestinal And Peritoneal Infections,2481,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4166.87,,,,,,,fee schedule,4166.87,4166.87, Major Gastrointestinal And Peritoneal Infections,2481,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4166.87,,,,,,,fee schedule,4166.87,4166.87, Major Gastrointestinal And Peritoneal Infections,2482,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5681.46,,,,,,,fee schedule,5681.46,5681.46, Major Gastrointestinal And Peritoneal Infections,2482,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5681.46,,,,,,,fee schedule,5681.46,5681.46, Major Gastrointestinal And Peritoneal Infections,2482,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5681.46,,,,,,,fee schedule,5681.46,5681.46, Major Gastrointestinal And Peritoneal Infections,2482,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5681.46,,,,,,,fee schedule,5681.46,5681.46, Major Gastrointestinal And Peritoneal Infections,2482,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5681.46,,,,,,,fee schedule,5681.46,5681.46, Major Gastrointestinal And Peritoneal Infections,2482,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5681.46,,,,,,,fee schedule,5681.46,5681.46, Major Gastrointestinal And Peritoneal Infections,2482,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5681.46,,,,,,,fee schedule,5681.46,5681.46, Major Gastrointestinal And Peritoneal Infections,2482,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5681.46,,,,,,,fee schedule,5681.46,5681.46, Major Gastrointestinal And Peritoneal Infections,2482,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5681.46,,,,,,,fee schedule,5681.46,5681.46, Major Gastrointestinal And Peritoneal Infections,2482,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5681.46,,,,,,,fee schedule,5681.46,5681.46, Major Gastrointestinal And Peritoneal Infections,2482,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5681.46,,,,,,,fee schedule,5681.46,5681.46, Major Gastrointestinal And Peritoneal Infections,2483,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,8609.7,,,,,,,fee schedule,8609.7,8609.7, Major Gastrointestinal And Peritoneal Infections,2483,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,8609.7,,,,,,,fee schedule,8609.7,8609.7, Major Gastrointestinal And Peritoneal Infections,2483,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,8609.7,,,,,,,fee schedule,8609.7,8609.7, Major Gastrointestinal And Peritoneal Infections,2483,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,8609.7,,,,,,,fee schedule,8609.7,8609.7, Major Gastrointestinal And Peritoneal Infections,2483,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,8609.7,,,,,,,fee schedule,8609.7,8609.7, Major Gastrointestinal And Peritoneal Infections,2483,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,8609.7,,,,,,,fee schedule,8609.7,8609.7, Major Gastrointestinal And Peritoneal Infections,2483,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,8609.7,,,,,,,fee schedule,8609.7,8609.7, Major Gastrointestinal And Peritoneal Infections,2483,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,8609.7,,,,,,,fee schedule,8609.7,8609.7, Major Gastrointestinal And Peritoneal Infections,2483,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,8609.7,,,,,,,fee schedule,8609.7,8609.7, Major Gastrointestinal And Peritoneal Infections,2483,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,8609.7,,,,,,,fee schedule,8609.7,8609.7, Major Gastrointestinal And Peritoneal Infections,2483,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,8609.7,,,,,,,fee schedule,8609.7,8609.7, Major Gastrointestinal And Peritoneal Infections,2484,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,15036.46,,,,,,,fee schedule,15036.46,15036.46, Major Gastrointestinal And Peritoneal Infections,2484,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,15036.46,,,,,,,fee schedule,15036.46,15036.46, Major Gastrointestinal And Peritoneal Infections,2484,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,15036.46,,,,,,,fee schedule,15036.46,15036.46, Major Gastrointestinal And Peritoneal Infections,2484,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,15036.46,,,,,,,fee schedule,15036.46,15036.46, Major Gastrointestinal And Peritoneal Infections,2484,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,15036.46,,,,,,,fee schedule,15036.46,15036.46, Major Gastrointestinal And Peritoneal Infections,2484,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,15036.46,,,,,,,fee schedule,15036.46,15036.46, Major Gastrointestinal And Peritoneal Infections,2484,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,15036.46,,,,,,,fee schedule,15036.46,15036.46, Major Gastrointestinal And Peritoneal Infections,2484,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,15036.46,,,,,,,fee schedule,15036.46,15036.46, Major Gastrointestinal And Peritoneal Infections,2484,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,15036.46,,,,,,,fee schedule,15036.46,15036.46, Major Gastrointestinal And Peritoneal Infections,2484,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,15036.46,,,,,,,fee schedule,15036.46,15036.46, Major Gastrointestinal And Peritoneal Infections,2484,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,15036.46,,,,,,,fee schedule,15036.46,15036.46, "Other Gastroenteritis, Nausea And Vomiting",2491,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,3850.69,,,,,,,fee schedule,3850.69,3850.69, "Other Gastroenteritis, Nausea And Vomiting",2491,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,3850.69,,,,,,,fee schedule,3850.69,3850.69, "Other Gastroenteritis, Nausea And Vomiting",2491,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,3850.69,,,,,,,fee schedule,3850.69,3850.69, "Other Gastroenteritis, Nausea And Vomiting",2491,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,3850.69,,,,,,,fee schedule,3850.69,3850.69, "Other Gastroenteritis, Nausea And Vomiting",2491,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,3850.69,,,,,,,fee schedule,3850.69,3850.69, "Other Gastroenteritis, Nausea And Vomiting",2491,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,3850.69,,,,,,,fee schedule,3850.69,3850.69, "Other Gastroenteritis, Nausea And Vomiting",2491,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,3850.69,,,,,,,fee schedule,3850.69,3850.69, "Other Gastroenteritis, Nausea And Vomiting",2491,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,3850.69,,,,,,,fee schedule,3850.69,3850.69, "Other Gastroenteritis, Nausea And Vomiting",2491,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,3850.69,,,,,,,fee schedule,3850.69,3850.69, "Other Gastroenteritis, Nausea And Vomiting",2491,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,3850.69,,,,,,,fee schedule,3850.69,3850.69, "Other Gastroenteritis, Nausea And Vomiting",2491,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,3850.69,,,,,,,fee schedule,3850.69,3850.69, "Other Gastroenteritis, Nausea And Vomiting",2492,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4783.01,,,,,,,fee schedule,4783.01,4783.01, "Other Gastroenteritis, Nausea And Vomiting",2492,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4783.01,,,,,,,fee schedule,4783.01,4783.01, "Other Gastroenteritis, Nausea And Vomiting",2492,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4783.01,,,,,,,fee schedule,4783.01,4783.01, "Other Gastroenteritis, Nausea And Vomiting",2492,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4783.01,,,,,,,fee schedule,4783.01,4783.01, "Other Gastroenteritis, Nausea And Vomiting",2492,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4783.01,,,,,,,fee schedule,4783.01,4783.01, "Other Gastroenteritis, Nausea And Vomiting",2492,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4783.01,,,,,,,fee schedule,4783.01,4783.01, "Other Gastroenteritis, Nausea And Vomiting",2492,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4783.01,,,,,,,fee schedule,4783.01,4783.01, "Other Gastroenteritis, Nausea And Vomiting",2492,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4783.01,,,,,,,fee schedule,4783.01,4783.01, "Other Gastroenteritis, Nausea And Vomiting",2492,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4783.01,,,,,,,fee schedule,4783.01,4783.01, "Other Gastroenteritis, Nausea And Vomiting",2492,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4783.01,,,,,,,fee schedule,4783.01,4783.01, "Other Gastroenteritis, Nausea And Vomiting",2492,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4783.01,,,,,,,fee schedule,4783.01,4783.01, "Other Gastroenteritis, Nausea And Vomiting",2493,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,7122.64,,,,,,,fee schedule,7122.64,7122.64, "Other Gastroenteritis, Nausea And Vomiting",2493,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,7122.64,,,,,,,fee schedule,7122.64,7122.64, "Other Gastroenteritis, Nausea And Vomiting",2493,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,7122.64,,,,,,,fee schedule,7122.64,7122.64, "Other Gastroenteritis, Nausea And Vomiting",2493,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,7122.64,,,,,,,fee schedule,7122.64,7122.64, "Other Gastroenteritis, Nausea And Vomiting",2493,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,7122.64,,,,,,,fee schedule,7122.64,7122.64, "Other Gastroenteritis, Nausea And Vomiting",2493,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,7122.64,,,,,,,fee schedule,7122.64,7122.64, "Other Gastroenteritis, Nausea And Vomiting",2493,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,7122.64,,,,,,,fee schedule,7122.64,7122.64, "Other Gastroenteritis, Nausea And Vomiting",2493,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,7122.64,,,,,,,fee schedule,7122.64,7122.64, "Other Gastroenteritis, Nausea And Vomiting",2493,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,7122.64,,,,,,,fee schedule,7122.64,7122.64, "Other Gastroenteritis, Nausea And Vomiting",2493,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,7122.64,,,,,,,fee schedule,7122.64,7122.64, "Other Gastroenteritis, Nausea And Vomiting",2493,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,7122.64,,,,,,,fee schedule,7122.64,7122.64, "Other Gastroenteritis, Nausea And Vomiting",2494,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,13108.29,,,,,,,fee schedule,13108.29,13108.29, "Other Gastroenteritis, Nausea And Vomiting",2494,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,13108.29,,,,,,,fee schedule,13108.29,13108.29, "Other Gastroenteritis, Nausea And Vomiting",2494,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,13108.29,,,,,,,fee schedule,13108.29,13108.29, "Other Gastroenteritis, Nausea And Vomiting",2494,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,13108.29,,,,,,,fee schedule,13108.29,13108.29, "Other Gastroenteritis, Nausea And Vomiting",2494,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,13108.29,,,,,,,fee schedule,13108.29,13108.29, "Other Gastroenteritis, Nausea And Vomiting",2494,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,13108.29,,,,,,,fee schedule,13108.29,13108.29, "Other Gastroenteritis, Nausea And Vomiting",2494,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,13108.29,,,,,,,fee schedule,13108.29,13108.29, "Other Gastroenteritis, Nausea And Vomiting",2494,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,13108.29,,,,,,,fee schedule,13108.29,13108.29, "Other Gastroenteritis, Nausea And Vomiting",2494,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,13108.29,,,,,,,fee schedule,13108.29,13108.29, "Other Gastroenteritis, Nausea And Vomiting",2494,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,13108.29,,,,,,,fee schedule,13108.29,13108.29, "Other Gastroenteritis, Nausea And Vomiting",2494,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,13108.29,,,,,,,fee schedule,13108.29,13108.29, Abdominal Pain,2511,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4240.27,,,,,,,fee schedule,4240.27,4240.27, Abdominal Pain,2511,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4240.27,,,,,,,fee schedule,4240.27,4240.27, Abdominal Pain,2511,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4240.27,,,,,,,fee schedule,4240.27,4240.27, Abdominal Pain,2511,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4240.27,,,,,,,fee schedule,4240.27,4240.27, Abdominal Pain,2511,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4240.27,,,,,,,fee schedule,4240.27,4240.27, Abdominal Pain,2511,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4240.27,,,,,,,fee schedule,4240.27,4240.27, Abdominal Pain,2511,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4240.27,,,,,,,fee schedule,4240.27,4240.27, Abdominal Pain,2511,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4240.27,,,,,,,fee schedule,4240.27,4240.27, Abdominal Pain,2511,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4240.27,,,,,,,fee schedule,4240.27,4240.27, Abdominal Pain,2511,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4240.27,,,,,,,fee schedule,4240.27,4240.27, Abdominal Pain,2511,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4240.27,,,,,,,fee schedule,4240.27,4240.27, Abdominal Pain,2512,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5303.17,,,,,,,fee schedule,5303.17,5303.17, Abdominal Pain,2512,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5303.17,,,,,,,fee schedule,5303.17,5303.17, Abdominal Pain,2512,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5303.17,,,,,,,fee schedule,5303.17,5303.17, Abdominal Pain,2512,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5303.17,,,,,,,fee schedule,5303.17,5303.17, Abdominal Pain,2512,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5303.17,,,,,,,fee schedule,5303.17,5303.17, Abdominal Pain,2512,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5303.17,,,,,,,fee schedule,5303.17,5303.17, Abdominal Pain,2512,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5303.17,,,,,,,fee schedule,5303.17,5303.17, Abdominal Pain,2512,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5303.17,,,,,,,fee schedule,5303.17,5303.17, Abdominal Pain,2512,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5303.17,,,,,,,fee schedule,5303.17,5303.17, Abdominal Pain,2512,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5303.17,,,,,,,fee schedule,5303.17,5303.17, Abdominal Pain,2512,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5303.17,,,,,,,fee schedule,5303.17,5303.17, Abdominal Pain,2513,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,6971.61,,,,,,,fee schedule,6971.61,6971.61, Abdominal Pain,2513,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,6971.61,,,,,,,fee schedule,6971.61,6971.61, Abdominal Pain,2513,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,6971.61,,,,,,,fee schedule,6971.61,6971.61, Abdominal Pain,2513,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,6971.61,,,,,,,fee schedule,6971.61,6971.61, Abdominal Pain,2513,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,6971.61,,,,,,,fee schedule,6971.61,6971.61, Abdominal Pain,2513,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,6971.61,,,,,,,fee schedule,6971.61,6971.61, Abdominal Pain,2513,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,6971.61,,,,,,,fee schedule,6971.61,6971.61, Abdominal Pain,2513,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,6971.61,,,,,,,fee schedule,6971.61,6971.61, Abdominal Pain,2513,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,6971.61,,,,,,,fee schedule,6971.61,6971.61, Abdominal Pain,2513,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,6971.61,,,,,,,fee schedule,6971.61,6971.61, Abdominal Pain,2513,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,6971.61,,,,,,,fee schedule,6971.61,6971.61, Abdominal Pain,2514,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,10947.92,,,,,,,fee schedule,10947.92,10947.92, Abdominal Pain,2514,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,10947.92,,,,,,,fee schedule,10947.92,10947.92, Abdominal Pain,2514,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,10947.92,,,,,,,fee schedule,10947.92,10947.92, Abdominal Pain,2514,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,10947.92,,,,,,,fee schedule,10947.92,10947.92, Abdominal Pain,2514,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,10947.92,,,,,,,fee schedule,10947.92,10947.92, Abdominal Pain,2514,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,10947.92,,,,,,,fee schedule,10947.92,10947.92, Abdominal Pain,2514,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,10947.92,,,,,,,fee schedule,10947.92,10947.92, Abdominal Pain,2514,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,10947.92,,,,,,,fee schedule,10947.92,10947.92, Abdominal Pain,2514,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,10947.92,,,,,,,fee schedule,10947.92,10947.92, Abdominal Pain,2514,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,10947.92,,,,,,,fee schedule,10947.92,10947.92, Abdominal Pain,2514,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,10947.92,,,,,,,fee schedule,10947.92,10947.92, "Malfunction, Reaction And Complication Of Gastrointestinal Device Or Procedure",2521,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4805.6,,,,,,,fee schedule,4805.6,4805.6, "Malfunction, Reaction And Complication Of Gastrointestinal Device Or Procedure",2521,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4805.6,,,,,,,fee schedule,4805.6,4805.6, "Malfunction, Reaction And Complication Of Gastrointestinal Device Or Procedure",2521,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4805.6,,,,,,,fee schedule,4805.6,4805.6, "Malfunction, Reaction And Complication Of Gastrointestinal Device Or Procedure",2521,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4805.6,,,,,,,fee schedule,4805.6,4805.6, "Malfunction, Reaction And Complication Of Gastrointestinal Device Or Procedure",2521,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4805.6,,,,,,,fee schedule,4805.6,4805.6, "Malfunction, Reaction And Complication Of Gastrointestinal Device Or Procedure",2521,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4805.6,,,,,,,fee schedule,4805.6,4805.6, "Malfunction, Reaction And Complication Of Gastrointestinal Device Or Procedure",2521,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4805.6,,,,,,,fee schedule,4805.6,4805.6, "Malfunction, Reaction And Complication Of Gastrointestinal Device Or Procedure",2521,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4805.6,,,,,,,fee schedule,4805.6,4805.6, "Malfunction, Reaction And Complication Of Gastrointestinal Device Or Procedure",2521,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4805.6,,,,,,,fee schedule,4805.6,4805.6, "Malfunction, Reaction And Complication Of Gastrointestinal Device Or Procedure",2521,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4805.6,,,,,,,fee schedule,4805.6,4805.6, "Malfunction, Reaction And Complication Of Gastrointestinal Device Or Procedure",2521,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4805.6,,,,,,,fee schedule,4805.6,4805.6, "Malfunction, Reaction And Complication Of Gastrointestinal Device Or Procedure",2522,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,6270.07,,,,,,,fee schedule,6270.07,6270.07, "Malfunction, Reaction And Complication Of Gastrointestinal Device Or Procedure",2522,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,6270.07,,,,,,,fee schedule,6270.07,6270.07, "Malfunction, Reaction And Complication Of Gastrointestinal Device Or Procedure",2522,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,6270.07,,,,,,,fee schedule,6270.07,6270.07, "Malfunction, Reaction And Complication Of Gastrointestinal Device Or Procedure",2522,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,6270.07,,,,,,,fee schedule,6270.07,6270.07, "Malfunction, Reaction And Complication Of Gastrointestinal Device Or Procedure",2522,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,6270.07,,,,,,,fee schedule,6270.07,6270.07, "Malfunction, Reaction And Complication Of Gastrointestinal Device Or Procedure",2522,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,6270.07,,,,,,,fee schedule,6270.07,6270.07, "Malfunction, Reaction And Complication Of Gastrointestinal Device Or Procedure",2522,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,6270.07,,,,,,,fee schedule,6270.07,6270.07, "Malfunction, Reaction And Complication Of Gastrointestinal Device Or Procedure",2522,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,6270.07,,,,,,,fee schedule,6270.07,6270.07, "Malfunction, Reaction And Complication Of Gastrointestinal Device Or Procedure",2522,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,6270.07,,,,,,,fee schedule,6270.07,6270.07, "Malfunction, Reaction And Complication Of Gastrointestinal Device Or Procedure",2522,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,6270.07,,,,,,,fee schedule,6270.07,6270.07, "Malfunction, Reaction And Complication Of Gastrointestinal Device Or Procedure",2522,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,6270.07,,,,,,,fee schedule,6270.07,6270.07, "Malfunction, Reaction And Complication Of Gastrointestinal Device Or Procedure",2523,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,9510.97,,,,,,,fee schedule,9510.97,9510.97, "Malfunction, Reaction And Complication Of Gastrointestinal Device Or Procedure",2523,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,9510.97,,,,,,,fee schedule,9510.97,9510.97, "Malfunction, Reaction And Complication Of Gastrointestinal Device Or Procedure",2523,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,9510.97,,,,,,,fee schedule,9510.97,9510.97, "Malfunction, Reaction And Complication Of Gastrointestinal Device Or Procedure",2523,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,9510.97,,,,,,,fee schedule,9510.97,9510.97, "Malfunction, Reaction And Complication Of Gastrointestinal Device Or Procedure",2523,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,9510.97,,,,,,,fee schedule,9510.97,9510.97, "Malfunction, Reaction And Complication Of Gastrointestinal Device Or Procedure",2523,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,9510.97,,,,,,,fee schedule,9510.97,9510.97, "Malfunction, Reaction And Complication Of Gastrointestinal Device Or Procedure",2523,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,9510.97,,,,,,,fee schedule,9510.97,9510.97, "Malfunction, Reaction And Complication Of Gastrointestinal Device Or Procedure",2523,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,9510.97,,,,,,,fee schedule,9510.97,9510.97, "Malfunction, Reaction And Complication Of Gastrointestinal Device Or Procedure",2523,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,9510.97,,,,,,,fee schedule,9510.97,9510.97, "Malfunction, Reaction And Complication Of Gastrointestinal Device Or Procedure",2523,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,9510.97,,,,,,,fee schedule,9510.97,9510.97, "Malfunction, Reaction And Complication Of Gastrointestinal Device Or Procedure",2523,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,9510.97,,,,,,,fee schedule,9510.97,9510.97, "Malfunction, Reaction And Complication Of Gastrointestinal Device Or Procedure",2524,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,17668.28,,,,,,,fee schedule,17668.28,17668.28, "Malfunction, Reaction And Complication Of Gastrointestinal Device Or Procedure",2524,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,17668.28,,,,,,,fee schedule,17668.28,17668.28, "Malfunction, Reaction And Complication Of Gastrointestinal Device Or Procedure",2524,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,17668.28,,,,,,,fee schedule,17668.28,17668.28, "Malfunction, Reaction And Complication Of Gastrointestinal Device Or Procedure",2524,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,17668.28,,,,,,,fee schedule,17668.28,17668.28, "Malfunction, Reaction And Complication Of Gastrointestinal Device Or Procedure",2524,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,17668.28,,,,,,,fee schedule,17668.28,17668.28, "Malfunction, Reaction And Complication Of Gastrointestinal Device Or Procedure",2524,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,17668.28,,,,,,,fee schedule,17668.28,17668.28, "Malfunction, Reaction And Complication Of Gastrointestinal Device Or Procedure",2524,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,17668.28,,,,,,,fee schedule,17668.28,17668.28, "Malfunction, Reaction And Complication Of Gastrointestinal Device Or Procedure",2524,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,17668.28,,,,,,,fee schedule,17668.28,17668.28, "Malfunction, Reaction And Complication Of Gastrointestinal Device Or Procedure",2524,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,17668.28,,,,,,,fee schedule,17668.28,17668.28, "Malfunction, Reaction And Complication Of Gastrointestinal Device Or Procedure",2524,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,17668.28,,,,,,,fee schedule,17668.28,17668.28, "Malfunction, Reaction And Complication Of Gastrointestinal Device Or Procedure",2524,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,17668.28,,,,,,,fee schedule,17668.28,17668.28, Other And Unspecified Gastrointestinal Hemorrhage,2531,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4540.23,,,,,,,fee schedule,4540.23,4540.23, Other And Unspecified Gastrointestinal Hemorrhage,2531,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4540.23,,,,,,,fee schedule,4540.23,4540.23, Other And Unspecified Gastrointestinal Hemorrhage,2531,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4540.23,,,,,,,fee schedule,4540.23,4540.23, Other And Unspecified Gastrointestinal Hemorrhage,2531,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4540.23,,,,,,,fee schedule,4540.23,4540.23, Other And Unspecified Gastrointestinal Hemorrhage,2531,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4540.23,,,,,,,fee schedule,4540.23,4540.23, Other And Unspecified Gastrointestinal Hemorrhage,2531,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4540.23,,,,,,,fee schedule,4540.23,4540.23, Other And Unspecified Gastrointestinal Hemorrhage,2531,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4540.23,,,,,,,fee schedule,4540.23,4540.23, Other And Unspecified Gastrointestinal Hemorrhage,2531,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4540.23,,,,,,,fee schedule,4540.23,4540.23, Other And Unspecified Gastrointestinal Hemorrhage,2531,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4540.23,,,,,,,fee schedule,4540.23,4540.23, Other And Unspecified Gastrointestinal Hemorrhage,2531,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4540.23,,,,,,,fee schedule,4540.23,4540.23, Other And Unspecified Gastrointestinal Hemorrhage,2531,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4540.23,,,,,,,fee schedule,4540.23,4540.23, Other And Unspecified Gastrointestinal Hemorrhage,2532,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5849.43,,,,,,,fee schedule,5849.43,5849.43, Other And Unspecified Gastrointestinal Hemorrhage,2532,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5849.43,,,,,,,fee schedule,5849.43,5849.43, Other And Unspecified Gastrointestinal Hemorrhage,2532,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5849.43,,,,,,,fee schedule,5849.43,5849.43, Other And Unspecified Gastrointestinal Hemorrhage,2532,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5849.43,,,,,,,fee schedule,5849.43,5849.43, Other And Unspecified Gastrointestinal Hemorrhage,2532,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5849.43,,,,,,,fee schedule,5849.43,5849.43, Other And Unspecified Gastrointestinal Hemorrhage,2532,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5849.43,,,,,,,fee schedule,5849.43,5849.43, Other And Unspecified Gastrointestinal Hemorrhage,2532,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5849.43,,,,,,,fee schedule,5849.43,5849.43, Other And Unspecified Gastrointestinal Hemorrhage,2532,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5849.43,,,,,,,fee schedule,5849.43,5849.43, Other And Unspecified Gastrointestinal Hemorrhage,2532,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5849.43,,,,,,,fee schedule,5849.43,5849.43, Other And Unspecified Gastrointestinal Hemorrhage,2532,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5849.43,,,,,,,fee schedule,5849.43,5849.43, Other And Unspecified Gastrointestinal Hemorrhage,2532,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5849.43,,,,,,,fee schedule,5849.43,5849.43, Other And Unspecified Gastrointestinal Hemorrhage,2533,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,8805.91,,,,,,,fee schedule,8805.91,8805.91, Other And Unspecified Gastrointestinal Hemorrhage,2533,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,8805.91,,,,,,,fee schedule,8805.91,8805.91, Other And Unspecified Gastrointestinal Hemorrhage,2533,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,8805.91,,,,,,,fee schedule,8805.91,8805.91, Other And Unspecified Gastrointestinal Hemorrhage,2533,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,8805.91,,,,,,,fee schedule,8805.91,8805.91, Other And Unspecified Gastrointestinal Hemorrhage,2533,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,8805.91,,,,,,,fee schedule,8805.91,8805.91, Other And Unspecified Gastrointestinal Hemorrhage,2533,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,8805.91,,,,,,,fee schedule,8805.91,8805.91, Other And Unspecified Gastrointestinal Hemorrhage,2533,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,8805.91,,,,,,,fee schedule,8805.91,8805.91, Other And Unspecified Gastrointestinal Hemorrhage,2533,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,8805.91,,,,,,,fee schedule,8805.91,8805.91, Other And Unspecified Gastrointestinal Hemorrhage,2533,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,8805.91,,,,,,,fee schedule,8805.91,8805.91, Other And Unspecified Gastrointestinal Hemorrhage,2533,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,8805.91,,,,,,,fee schedule,8805.91,8805.91, Other And Unspecified Gastrointestinal Hemorrhage,2533,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,8805.91,,,,,,,fee schedule,8805.91,8805.91, Other And Unspecified Gastrointestinal Hemorrhage,2534,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,15154.32,,,,,,,fee schedule,15154.32,15154.32, Other And Unspecified Gastrointestinal Hemorrhage,2534,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,15154.32,,,,,,,fee schedule,15154.32,15154.32, Other And Unspecified Gastrointestinal Hemorrhage,2534,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,15154.32,,,,,,,fee schedule,15154.32,15154.32, Other And Unspecified Gastrointestinal Hemorrhage,2534,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,15154.32,,,,,,,fee schedule,15154.32,15154.32, Other And Unspecified Gastrointestinal Hemorrhage,2534,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,15154.32,,,,,,,fee schedule,15154.32,15154.32, Other And Unspecified Gastrointestinal Hemorrhage,2534,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,15154.32,,,,,,,fee schedule,15154.32,15154.32, Other And Unspecified Gastrointestinal Hemorrhage,2534,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,15154.32,,,,,,,fee schedule,15154.32,15154.32, Other And Unspecified Gastrointestinal Hemorrhage,2534,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,15154.32,,,,,,,fee schedule,15154.32,15154.32, Other And Unspecified Gastrointestinal Hemorrhage,2534,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,15154.32,,,,,,,fee schedule,15154.32,15154.32, Other And Unspecified Gastrointestinal Hemorrhage,2534,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,15154.32,,,,,,,fee schedule,15154.32,15154.32, Other And Unspecified Gastrointestinal Hemorrhage,2534,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,15154.32,,,,,,,fee schedule,15154.32,15154.32, Other Digestive System Diagnoses,2541,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4484.47,,,,,,,fee schedule,4484.47,4484.47, Other Digestive System Diagnoses,2541,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4484.47,,,,,,,fee schedule,4484.47,4484.47, Other Digestive System Diagnoses,2541,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4484.47,,,,,,,fee schedule,4484.47,4484.47, Other Digestive System Diagnoses,2541,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4484.47,,,,,,,fee schedule,4484.47,4484.47, Other Digestive System Diagnoses,2541,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4484.47,,,,,,,fee schedule,4484.47,4484.47, Other Digestive System Diagnoses,2541,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4484.47,,,,,,,fee schedule,4484.47,4484.47, Other Digestive System Diagnoses,2541,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4484.47,,,,,,,fee schedule,4484.47,4484.47, Other Digestive System Diagnoses,2541,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4484.47,,,,,,,fee schedule,4484.47,4484.47, Other Digestive System Diagnoses,2541,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4484.47,,,,,,,fee schedule,4484.47,4484.47, Other Digestive System Diagnoses,2541,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4484.47,,,,,,,fee schedule,4484.47,4484.47, Other Digestive System Diagnoses,2541,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4484.47,,,,,,,fee schedule,4484.47,4484.47, Other Digestive System Diagnoses,2542,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5857.9,,,,,,,fee schedule,5857.9,5857.9, Other Digestive System Diagnoses,2542,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5857.9,,,,,,,fee schedule,5857.9,5857.9, Other Digestive System Diagnoses,2542,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5857.9,,,,,,,fee schedule,5857.9,5857.9, Other Digestive System Diagnoses,2542,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5857.9,,,,,,,fee schedule,5857.9,5857.9, Other Digestive System Diagnoses,2542,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5857.9,,,,,,,fee schedule,5857.9,5857.9, Other Digestive System Diagnoses,2542,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5857.9,,,,,,,fee schedule,5857.9,5857.9, Other Digestive System Diagnoses,2542,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5857.9,,,,,,,fee schedule,5857.9,5857.9, Other Digestive System Diagnoses,2542,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5857.9,,,,,,,fee schedule,5857.9,5857.9, Other Digestive System Diagnoses,2542,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5857.9,,,,,,,fee schedule,5857.9,5857.9, Other Digestive System Diagnoses,2542,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5857.9,,,,,,,fee schedule,5857.9,5857.9, Other Digestive System Diagnoses,2542,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5857.9,,,,,,,fee schedule,5857.9,5857.9, Other Digestive System Diagnoses,2543,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,8711.33,,,,,,,fee schedule,8711.33,8711.33, Other Digestive System Diagnoses,2543,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,8711.33,,,,,,,fee schedule,8711.33,8711.33, Other Digestive System Diagnoses,2543,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,8711.33,,,,,,,fee schedule,8711.33,8711.33, Other Digestive System Diagnoses,2543,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,8711.33,,,,,,,fee schedule,8711.33,8711.33, Other Digestive System Diagnoses,2543,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,8711.33,,,,,,,fee schedule,8711.33,8711.33, Other Digestive System Diagnoses,2543,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,8711.33,,,,,,,fee schedule,8711.33,8711.33, Other Digestive System Diagnoses,2543,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,8711.33,,,,,,,fee schedule,8711.33,8711.33, Other Digestive System Diagnoses,2543,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,8711.33,,,,,,,fee schedule,8711.33,8711.33, Other Digestive System Diagnoses,2543,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,8711.33,,,,,,,fee schedule,8711.33,8711.33, Other Digestive System Diagnoses,2543,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,8711.33,,,,,,,fee schedule,8711.33,8711.33, Other Digestive System Diagnoses,2543,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,8711.33,,,,,,,fee schedule,8711.33,8711.33, Other Digestive System Diagnoses,2544,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,14708.27,,,,,,,fee schedule,14708.27,14708.27, Other Digestive System Diagnoses,2544,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,14708.27,,,,,,,fee schedule,14708.27,14708.27, Other Digestive System Diagnoses,2544,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,14708.27,,,,,,,fee schedule,14708.27,14708.27, Other Digestive System Diagnoses,2544,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,14708.27,,,,,,,fee schedule,14708.27,14708.27, Other Digestive System Diagnoses,2544,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,14708.27,,,,,,,fee schedule,14708.27,14708.27, Other Digestive System Diagnoses,2544,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,14708.27,,,,,,,fee schedule,14708.27,14708.27, Other Digestive System Diagnoses,2544,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,14708.27,,,,,,,fee schedule,14708.27,14708.27, Other Digestive System Diagnoses,2544,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,14708.27,,,,,,,fee schedule,14708.27,14708.27, Other Digestive System Diagnoses,2544,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,14708.27,,,,,,,fee schedule,14708.27,14708.27, Other Digestive System Diagnoses,2544,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,14708.27,,,,,,,fee schedule,14708.27,14708.27, Other Digestive System Diagnoses,2544,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,14708.27,,,,,,,fee schedule,14708.27,14708.27, "Major Pancreas, Liver And Shunt Procedures",2601,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,13886.05,,,,,,,fee schedule,13886.05,13886.05, "Major Pancreas, Liver And Shunt Procedures",2601,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,13886.05,,,,,,,fee schedule,13886.05,13886.05, "Major Pancreas, Liver And Shunt Procedures",2601,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,13886.05,,,,,,,fee schedule,13886.05,13886.05, "Major Pancreas, Liver And Shunt Procedures",2601,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,13886.05,,,,,,,fee schedule,13886.05,13886.05, "Major Pancreas, Liver And Shunt Procedures",2601,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,13886.05,,,,,,,fee schedule,13886.05,13886.05, "Major Pancreas, Liver And Shunt Procedures",2601,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,13886.05,,,,,,,fee schedule,13886.05,13886.05, "Major Pancreas, Liver And Shunt Procedures",2601,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,13886.05,,,,,,,fee schedule,13886.05,13886.05, "Major Pancreas, Liver And Shunt Procedures",2601,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,13886.05,,,,,,,fee schedule,13886.05,13886.05, "Major Pancreas, Liver And Shunt Procedures",2601,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,13886.05,,,,,,,fee schedule,13886.05,13886.05, "Major Pancreas, Liver And Shunt Procedures",2601,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,13886.05,,,,,,,fee schedule,13886.05,13886.05, "Major Pancreas, Liver And Shunt Procedures",2601,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,13886.05,,,,,,,fee schedule,13886.05,13886.05, "Major Pancreas, Liver And Shunt Procedures",2602,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,18971.84,,,,,,,fee schedule,18971.84,18971.84, "Major Pancreas, Liver And Shunt Procedures",2602,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,18971.84,,,,,,,fee schedule,18971.84,18971.84, "Major Pancreas, Liver And Shunt Procedures",2602,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,18971.84,,,,,,,fee schedule,18971.84,18971.84, "Major Pancreas, Liver And Shunt Procedures",2602,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,18971.84,,,,,,,fee schedule,18971.84,18971.84, "Major Pancreas, Liver And Shunt Procedures",2602,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,18971.84,,,,,,,fee schedule,18971.84,18971.84, "Major Pancreas, Liver And Shunt Procedures",2602,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,18971.84,,,,,,,fee schedule,18971.84,18971.84, "Major Pancreas, Liver And Shunt Procedures",2602,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,18971.84,,,,,,,fee schedule,18971.84,18971.84, "Major Pancreas, Liver And Shunt Procedures",2602,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,18971.84,,,,,,,fee schedule,18971.84,18971.84, "Major Pancreas, Liver And Shunt Procedures",2602,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,18971.84,,,,,,,fee schedule,18971.84,18971.84, "Major Pancreas, Liver And Shunt Procedures",2602,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,18971.84,,,,,,,fee schedule,18971.84,18971.84, "Major Pancreas, Liver And Shunt Procedures",2602,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,18971.84,,,,,,,fee schedule,18971.84,18971.84, "Major Pancreas, Liver And Shunt Procedures",2603,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,25147.34,,,,,,,fee schedule,25147.34,25147.34, "Major Pancreas, Liver And Shunt Procedures",2603,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,25147.34,,,,,,,fee schedule,25147.34,25147.34, "Major Pancreas, Liver And Shunt Procedures",2603,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,25147.34,,,,,,,fee schedule,25147.34,25147.34, "Major Pancreas, Liver And Shunt Procedures",2603,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,25147.34,,,,,,,fee schedule,25147.34,25147.34, "Major Pancreas, Liver And Shunt Procedures",2603,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,25147.34,,,,,,,fee schedule,25147.34,25147.34, "Major Pancreas, Liver And Shunt Procedures",2603,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,25147.34,,,,,,,fee schedule,25147.34,25147.34, "Major Pancreas, Liver And Shunt Procedures",2603,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,25147.34,,,,,,,fee schedule,25147.34,25147.34, "Major Pancreas, Liver And Shunt Procedures",2603,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,25147.34,,,,,,,fee schedule,25147.34,25147.34, "Major Pancreas, Liver And Shunt Procedures",2603,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,25147.34,,,,,,,fee schedule,25147.34,25147.34, "Major Pancreas, Liver And Shunt Procedures",2603,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,25147.34,,,,,,,fee schedule,25147.34,25147.34, "Major Pancreas, Liver And Shunt Procedures",2603,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,25147.34,,,,,,,fee schedule,25147.34,25147.34, "Major Pancreas, Liver And Shunt Procedures",2604,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,42505.78,,,,,,,fee schedule,42505.78,42505.78, "Major Pancreas, Liver And Shunt Procedures",2604,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,42505.78,,,,,,,fee schedule,42505.78,42505.78, "Major Pancreas, Liver And Shunt Procedures",2604,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,42505.78,,,,,,,fee schedule,42505.78,42505.78, "Major Pancreas, Liver And Shunt Procedures",2604,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,42505.78,,,,,,,fee schedule,42505.78,42505.78, "Major Pancreas, Liver And Shunt Procedures",2604,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,42505.78,,,,,,,fee schedule,42505.78,42505.78, "Major Pancreas, Liver And Shunt Procedures",2604,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,42505.78,,,,,,,fee schedule,42505.78,42505.78, "Major Pancreas, Liver And Shunt Procedures",2604,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,42505.78,,,,,,,fee schedule,42505.78,42505.78, "Major Pancreas, Liver And Shunt Procedures",2604,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,42505.78,,,,,,,fee schedule,42505.78,42505.78, "Major Pancreas, Liver And Shunt Procedures",2604,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,42505.78,,,,,,,fee schedule,42505.78,42505.78, "Major Pancreas, Liver And Shunt Procedures",2604,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,42505.78,,,,,,,fee schedule,42505.78,42505.78, "Major Pancreas, Liver And Shunt Procedures",2604,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,42505.78,,,,,,,fee schedule,42505.78,42505.78, Major Biliary Tract Procedures,2611,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,12030.58,,,,,,,fee schedule,12030.58,12030.58, Major Biliary Tract Procedures,2611,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,12030.58,,,,,,,fee schedule,12030.58,12030.58, Major Biliary Tract Procedures,2611,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,12030.58,,,,,,,fee schedule,12030.58,12030.58, Major Biliary Tract Procedures,2611,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,12030.58,,,,,,,fee schedule,12030.58,12030.58, Major Biliary Tract Procedures,2611,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,12030.58,,,,,,,fee schedule,12030.58,12030.58, Major Biliary Tract Procedures,2611,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,12030.58,,,,,,,fee schedule,12030.58,12030.58, Major Biliary Tract Procedures,2611,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,12030.58,,,,,,,fee schedule,12030.58,12030.58, Major Biliary Tract Procedures,2611,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,12030.58,,,,,,,fee schedule,12030.58,12030.58, Major Biliary Tract Procedures,2611,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,12030.58,,,,,,,fee schedule,12030.58,12030.58, Major Biliary Tract Procedures,2611,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,12030.58,,,,,,,fee schedule,12030.58,12030.58, Major Biliary Tract Procedures,2611,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,12030.58,,,,,,,fee schedule,12030.58,12030.58, Major Biliary Tract Procedures,2612,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,16980.86,,,,,,,fee schedule,16980.86,16980.86, Major Biliary Tract Procedures,2612,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,16980.86,,,,,,,fee schedule,16980.86,16980.86, Major Biliary Tract Procedures,2612,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,16980.86,,,,,,,fee schedule,16980.86,16980.86, Major Biliary Tract Procedures,2612,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,16980.86,,,,,,,fee schedule,16980.86,16980.86, Major Biliary Tract Procedures,2612,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,16980.86,,,,,,,fee schedule,16980.86,16980.86, Major Biliary Tract Procedures,2612,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,16980.86,,,,,,,fee schedule,16980.86,16980.86, Major Biliary Tract Procedures,2612,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,16980.86,,,,,,,fee schedule,16980.86,16980.86, Major Biliary Tract Procedures,2612,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,16980.86,,,,,,,fee schedule,16980.86,16980.86, Major Biliary Tract Procedures,2612,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,16980.86,,,,,,,fee schedule,16980.86,16980.86, Major Biliary Tract Procedures,2612,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,16980.86,,,,,,,fee schedule,16980.86,16980.86, Major Biliary Tract Procedures,2612,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,16980.86,,,,,,,fee schedule,16980.86,16980.86, Major Biliary Tract Procedures,2613,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,20816.72,,,,,,,fee schedule,20816.72,20816.72, Major Biliary Tract Procedures,2613,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,20816.72,,,,,,,fee schedule,20816.72,20816.72, Major Biliary Tract Procedures,2613,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,20816.72,,,,,,,fee schedule,20816.72,20816.72, Major Biliary Tract Procedures,2613,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,20816.72,,,,,,,fee schedule,20816.72,20816.72, Major Biliary Tract Procedures,2613,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,20816.72,,,,,,,fee schedule,20816.72,20816.72, Major Biliary Tract Procedures,2613,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,20816.72,,,,,,,fee schedule,20816.72,20816.72, Major Biliary Tract Procedures,2613,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,20816.72,,,,,,,fee schedule,20816.72,20816.72, Major Biliary Tract Procedures,2613,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,20816.72,,,,,,,fee schedule,20816.72,20816.72, Major Biliary Tract Procedures,2613,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,20816.72,,,,,,,fee schedule,20816.72,20816.72, Major Biliary Tract Procedures,2613,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,20816.72,,,,,,,fee schedule,20816.72,20816.72, Major Biliary Tract Procedures,2613,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,20816.72,,,,,,,fee schedule,20816.72,20816.72, Major Biliary Tract Procedures,2614,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,39523.19,,,,,,,fee schedule,39523.19,39523.19, Major Biliary Tract Procedures,2614,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,39523.19,,,,,,,fee schedule,39523.19,39523.19, Major Biliary Tract Procedures,2614,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,39523.19,,,,,,,fee schedule,39523.19,39523.19, Major Biliary Tract Procedures,2614,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,39523.19,,,,,,,fee schedule,39523.19,39523.19, Major Biliary Tract Procedures,2614,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,39523.19,,,,,,,fee schedule,39523.19,39523.19, Major Biliary Tract Procedures,2614,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,39523.19,,,,,,,fee schedule,39523.19,39523.19, Major Biliary Tract Procedures,2614,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,39523.19,,,,,,,fee schedule,39523.19,39523.19, Major Biliary Tract Procedures,2614,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,39523.19,,,,,,,fee schedule,39523.19,39523.19, Major Biliary Tract Procedures,2614,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,39523.19,,,,,,,fee schedule,39523.19,39523.19, Major Biliary Tract Procedures,2614,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,39523.19,,,,,,,fee schedule,39523.19,39523.19, Major Biliary Tract Procedures,2614,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,39523.19,,,,,,,fee schedule,39523.19,39523.19, Cholecystectomy,2631,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,8923.07,,,,,,,fee schedule,8923.07,8923.07, Cholecystectomy,2631,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,8923.07,,,,,,,fee schedule,8923.07,8923.07, Cholecystectomy,2631,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,8923.07,,,,,,,fee schedule,8923.07,8923.07, Cholecystectomy,2631,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,8923.07,,,,,,,fee schedule,8923.07,8923.07, Cholecystectomy,2631,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,8923.07,,,,,,,fee schedule,8923.07,8923.07, Cholecystectomy,2631,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,8923.07,,,,,,,fee schedule,8923.07,8923.07, Cholecystectomy,2631,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,8923.07,,,,,,,fee schedule,8923.07,8923.07, Cholecystectomy,2631,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,8923.07,,,,,,,fee schedule,8923.07,8923.07, Cholecystectomy,2631,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,8923.07,,,,,,,fee schedule,8923.07,8923.07, Cholecystectomy,2631,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,8923.07,,,,,,,fee schedule,8923.07,8923.07, Cholecystectomy,2631,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,8923.07,,,,,,,fee schedule,8923.07,8923.07, Cholecystectomy,2632,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,11041.79,,,,,,,fee schedule,11041.79,11041.79, Cholecystectomy,2632,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,11041.79,,,,,,,fee schedule,11041.79,11041.79, Cholecystectomy,2632,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,11041.79,,,,,,,fee schedule,11041.79,11041.79, Cholecystectomy,2632,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,11041.79,,,,,,,fee schedule,11041.79,11041.79, Cholecystectomy,2632,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,11041.79,,,,,,,fee schedule,11041.79,11041.79, Cholecystectomy,2632,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,11041.79,,,,,,,fee schedule,11041.79,11041.79, Cholecystectomy,2632,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,11041.79,,,,,,,fee schedule,11041.79,11041.79, Cholecystectomy,2632,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,11041.79,,,,,,,fee schedule,11041.79,11041.79, Cholecystectomy,2632,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,11041.79,,,,,,,fee schedule,11041.79,11041.79, Cholecystectomy,2632,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,11041.79,,,,,,,fee schedule,11041.79,11041.79, Cholecystectomy,2632,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,11041.79,,,,,,,fee schedule,11041.79,11041.79, Cholecystectomy,2633,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,15197.37,,,,,,,fee schedule,15197.37,15197.37, Cholecystectomy,2633,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,15197.37,,,,,,,fee schedule,15197.37,15197.37, Cholecystectomy,2633,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,15197.37,,,,,,,fee schedule,15197.37,15197.37, Cholecystectomy,2633,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,15197.37,,,,,,,fee schedule,15197.37,15197.37, Cholecystectomy,2633,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,15197.37,,,,,,,fee schedule,15197.37,15197.37, Cholecystectomy,2633,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,15197.37,,,,,,,fee schedule,15197.37,15197.37, Cholecystectomy,2633,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,15197.37,,,,,,,fee schedule,15197.37,15197.37, Cholecystectomy,2633,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,15197.37,,,,,,,fee schedule,15197.37,15197.37, Cholecystectomy,2633,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,15197.37,,,,,,,fee schedule,15197.37,15197.37, Cholecystectomy,2633,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,15197.37,,,,,,,fee schedule,15197.37,15197.37, Cholecystectomy,2633,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,15197.37,,,,,,,fee schedule,15197.37,15197.37, Cholecystectomy,2634,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,25582.8,,,,,,,fee schedule,25582.8,25582.8, Cholecystectomy,2634,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,25582.8,,,,,,,fee schedule,25582.8,25582.8, Cholecystectomy,2634,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,25582.8,,,,,,,fee schedule,25582.8,25582.8, Cholecystectomy,2634,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,25582.8,,,,,,,fee schedule,25582.8,25582.8, Cholecystectomy,2634,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,25582.8,,,,,,,fee schedule,25582.8,25582.8, Cholecystectomy,2634,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,25582.8,,,,,,,fee schedule,25582.8,25582.8, Cholecystectomy,2634,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,25582.8,,,,,,,fee schedule,25582.8,25582.8, Cholecystectomy,2634,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,25582.8,,,,,,,fee schedule,25582.8,25582.8, Cholecystectomy,2634,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,25582.8,,,,,,,fee schedule,25582.8,25582.8, Cholecystectomy,2634,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,25582.8,,,,,,,fee schedule,25582.8,25582.8, Cholecystectomy,2634,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,25582.8,,,,,,,fee schedule,25582.8,25582.8, "Other Hepatobiliary, Pancreas And Abdominal Procedures",2641,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,9928.08,,,,,,,fee schedule,9928.08,9928.08, "Other Hepatobiliary, Pancreas And Abdominal Procedures",2641,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,9928.08,,,,,,,fee schedule,9928.08,9928.08, "Other Hepatobiliary, Pancreas And Abdominal Procedures",2641,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,9928.08,,,,,,,fee schedule,9928.08,9928.08, "Other Hepatobiliary, Pancreas And Abdominal Procedures",2641,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,9928.08,,,,,,,fee schedule,9928.08,9928.08, "Other Hepatobiliary, Pancreas And Abdominal Procedures",2641,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,9928.08,,,,,,,fee schedule,9928.08,9928.08, "Other Hepatobiliary, Pancreas And Abdominal Procedures",2641,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,9928.08,,,,,,,fee schedule,9928.08,9928.08, "Other Hepatobiliary, Pancreas And Abdominal Procedures",2641,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,9928.08,,,,,,,fee schedule,9928.08,9928.08, "Other Hepatobiliary, Pancreas And Abdominal Procedures",2641,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,9928.08,,,,,,,fee schedule,9928.08,9928.08, "Other Hepatobiliary, Pancreas And Abdominal Procedures",2641,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,9928.08,,,,,,,fee schedule,9928.08,9928.08, "Other Hepatobiliary, Pancreas And Abdominal Procedures",2641,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,9928.08,,,,,,,fee schedule,9928.08,9928.08, "Other Hepatobiliary, Pancreas And Abdominal Procedures",2641,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,9928.08,,,,,,,fee schedule,9928.08,9928.08, "Other Hepatobiliary, Pancreas And Abdominal Procedures",2642,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,12475.21,,,,,,,fee schedule,12475.21,12475.21, "Other Hepatobiliary, Pancreas And Abdominal Procedures",2642,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,12475.21,,,,,,,fee schedule,12475.21,12475.21, "Other Hepatobiliary, Pancreas And Abdominal Procedures",2642,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,12475.21,,,,,,,fee schedule,12475.21,12475.21, "Other Hepatobiliary, Pancreas And Abdominal Procedures",2642,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,12475.21,,,,,,,fee schedule,12475.21,12475.21, "Other Hepatobiliary, Pancreas And Abdominal Procedures",2642,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,12475.21,,,,,,,fee schedule,12475.21,12475.21, "Other Hepatobiliary, Pancreas And Abdominal Procedures",2642,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,12475.21,,,,,,,fee schedule,12475.21,12475.21, "Other Hepatobiliary, Pancreas And Abdominal Procedures",2642,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,12475.21,,,,,,,fee schedule,12475.21,12475.21, "Other Hepatobiliary, Pancreas And Abdominal Procedures",2642,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,12475.21,,,,,,,fee schedule,12475.21,12475.21, "Other Hepatobiliary, Pancreas And Abdominal Procedures",2642,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,12475.21,,,,,,,fee schedule,12475.21,12475.21, "Other Hepatobiliary, Pancreas And Abdominal Procedures",2642,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,12475.21,,,,,,,fee schedule,12475.21,12475.21, "Other Hepatobiliary, Pancreas And Abdominal Procedures",2642,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,12475.21,,,,,,,fee schedule,12475.21,12475.21, "Other Hepatobiliary, Pancreas And Abdominal Procedures",2643,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,18749.52,,,,,,,fee schedule,18749.52,18749.52, "Other Hepatobiliary, Pancreas And Abdominal Procedures",2643,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,18749.52,,,,,,,fee schedule,18749.52,18749.52, "Other Hepatobiliary, Pancreas And Abdominal Procedures",2643,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,18749.52,,,,,,,fee schedule,18749.52,18749.52, "Other Hepatobiliary, Pancreas And Abdominal Procedures",2643,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,18749.52,,,,,,,fee schedule,18749.52,18749.52, "Other Hepatobiliary, Pancreas And Abdominal Procedures",2643,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,18749.52,,,,,,,fee schedule,18749.52,18749.52, "Other Hepatobiliary, Pancreas And Abdominal Procedures",2643,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,18749.52,,,,,,,fee schedule,18749.52,18749.52, "Other Hepatobiliary, Pancreas And Abdominal Procedures",2643,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,18749.52,,,,,,,fee schedule,18749.52,18749.52, "Other Hepatobiliary, Pancreas And Abdominal Procedures",2643,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,18749.52,,,,,,,fee schedule,18749.52,18749.52, "Other Hepatobiliary, Pancreas And Abdominal Procedures",2643,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,18749.52,,,,,,,fee schedule,18749.52,18749.52, "Other Hepatobiliary, Pancreas And Abdominal Procedures",2643,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,18749.52,,,,,,,fee schedule,18749.52,18749.52, "Other Hepatobiliary, Pancreas And Abdominal Procedures",2643,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,18749.52,,,,,,,fee schedule,18749.52,18749.52, "Other Hepatobiliary, Pancreas And Abdominal Procedures",2644,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,33694.93,,,,,,,fee schedule,33694.93,33694.93, "Other Hepatobiliary, Pancreas And Abdominal Procedures",2644,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,33694.93,,,,,,,fee schedule,33694.93,33694.93, "Other Hepatobiliary, Pancreas And Abdominal Procedures",2644,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,33694.93,,,,,,,fee schedule,33694.93,33694.93, "Other Hepatobiliary, Pancreas And Abdominal Procedures",2644,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,33694.93,,,,,,,fee schedule,33694.93,33694.93, "Other Hepatobiliary, Pancreas And Abdominal Procedures",2644,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,33694.93,,,,,,,fee schedule,33694.93,33694.93, "Other Hepatobiliary, Pancreas And Abdominal Procedures",2644,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,33694.93,,,,,,,fee schedule,33694.93,33694.93, "Other Hepatobiliary, Pancreas And Abdominal Procedures",2644,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,33694.93,,,,,,,fee schedule,33694.93,33694.93, "Other Hepatobiliary, Pancreas And Abdominal Procedures",2644,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,33694.93,,,,,,,fee schedule,33694.93,33694.93, "Other Hepatobiliary, Pancreas And Abdominal Procedures",2644,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,33694.93,,,,,,,fee schedule,33694.93,33694.93, "Other Hepatobiliary, Pancreas And Abdominal Procedures",2644,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,33694.93,,,,,,,fee schedule,33694.93,33694.93, "Other Hepatobiliary, Pancreas And Abdominal Procedures",2644,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,33694.93,,,,,,,fee schedule,33694.93,33694.93, Hepatic Coma And Other Major Acute Liver Disorders,2791,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,3855.63,,,,,,,fee schedule,3855.63,3855.63, Hepatic Coma And Other Major Acute Liver Disorders,2791,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,3855.63,,,,,,,fee schedule,3855.63,3855.63, Hepatic Coma And Other Major Acute Liver Disorders,2791,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,3855.63,,,,,,,fee schedule,3855.63,3855.63, Hepatic Coma And Other Major Acute Liver Disorders,2791,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,3855.63,,,,,,,fee schedule,3855.63,3855.63, Hepatic Coma And Other Major Acute Liver Disorders,2791,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,3855.63,,,,,,,fee schedule,3855.63,3855.63, Hepatic Coma And Other Major Acute Liver Disorders,2791,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,3855.63,,,,,,,fee schedule,3855.63,3855.63, Hepatic Coma And Other Major Acute Liver Disorders,2791,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,3855.63,,,,,,,fee schedule,3855.63,3855.63, Hepatic Coma And Other Major Acute Liver Disorders,2791,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,3855.63,,,,,,,fee schedule,3855.63,3855.63, Hepatic Coma And Other Major Acute Liver Disorders,2791,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,3855.63,,,,,,,fee schedule,3855.63,3855.63, Hepatic Coma And Other Major Acute Liver Disorders,2791,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,3855.63,,,,,,,fee schedule,3855.63,3855.63, Hepatic Coma And Other Major Acute Liver Disorders,2791,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,3855.63,,,,,,,fee schedule,3855.63,3855.63, Hepatic Coma And Other Major Acute Liver Disorders,2792,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5569.95,,,,,,,fee schedule,5569.95,5569.95, Hepatic Coma And Other Major Acute Liver Disorders,2792,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5569.95,,,,,,,fee schedule,5569.95,5569.95, Hepatic Coma And Other Major Acute Liver Disorders,2792,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5569.95,,,,,,,fee schedule,5569.95,5569.95, Hepatic Coma And Other Major Acute Liver Disorders,2792,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5569.95,,,,,,,fee schedule,5569.95,5569.95, Hepatic Coma And Other Major Acute Liver Disorders,2792,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5569.95,,,,,,,fee schedule,5569.95,5569.95, Hepatic Coma And Other Major Acute Liver Disorders,2792,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5569.95,,,,,,,fee schedule,5569.95,5569.95, Hepatic Coma And Other Major Acute Liver Disorders,2792,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5569.95,,,,,,,fee schedule,5569.95,5569.95, Hepatic Coma And Other Major Acute Liver Disorders,2792,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5569.95,,,,,,,fee schedule,5569.95,5569.95, Hepatic Coma And Other Major Acute Liver Disorders,2792,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5569.95,,,,,,,fee schedule,5569.95,5569.95, Hepatic Coma And Other Major Acute Liver Disorders,2792,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5569.95,,,,,,,fee schedule,5569.95,5569.95, Hepatic Coma And Other Major Acute Liver Disorders,2792,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5569.95,,,,,,,fee schedule,5569.95,5569.95, Hepatic Coma And Other Major Acute Liver Disorders,2793,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,9565.32,,,,,,,fee schedule,9565.32,9565.32, Hepatic Coma And Other Major Acute Liver Disorders,2793,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,9565.32,,,,,,,fee schedule,9565.32,9565.32, Hepatic Coma And Other Major Acute Liver Disorders,2793,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,9565.32,,,,,,,fee schedule,9565.32,9565.32, Hepatic Coma And Other Major Acute Liver Disorders,2793,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,9565.32,,,,,,,fee schedule,9565.32,9565.32, Hepatic Coma And Other Major Acute Liver Disorders,2793,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,9565.32,,,,,,,fee schedule,9565.32,9565.32, Hepatic Coma And Other Major Acute Liver Disorders,2793,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,9565.32,,,,,,,fee schedule,9565.32,9565.32, Hepatic Coma And Other Major Acute Liver Disorders,2793,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,9565.32,,,,,,,fee schedule,9565.32,9565.32, Hepatic Coma And Other Major Acute Liver Disorders,2793,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,9565.32,,,,,,,fee schedule,9565.32,9565.32, Hepatic Coma And Other Major Acute Liver Disorders,2793,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,9565.32,,,,,,,fee schedule,9565.32,9565.32, Hepatic Coma And Other Major Acute Liver Disorders,2793,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,9565.32,,,,,,,fee schedule,9565.32,9565.32, Hepatic Coma And Other Major Acute Liver Disorders,2793,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,9565.32,,,,,,,fee schedule,9565.32,9565.32, Hepatic Coma And Other Major Acute Liver Disorders,2794,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,18177.84,,,,,,,fee schedule,18177.84,18177.84, Hepatic Coma And Other Major Acute Liver Disorders,2794,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,18177.84,,,,,,,fee schedule,18177.84,18177.84, Hepatic Coma And Other Major Acute Liver Disorders,2794,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,18177.84,,,,,,,fee schedule,18177.84,18177.84, Hepatic Coma And Other Major Acute Liver Disorders,2794,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,18177.84,,,,,,,fee schedule,18177.84,18177.84, Hepatic Coma And Other Major Acute Liver Disorders,2794,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,18177.84,,,,,,,fee schedule,18177.84,18177.84, Hepatic Coma And Other Major Acute Liver Disorders,2794,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,18177.84,,,,,,,fee schedule,18177.84,18177.84, Hepatic Coma And Other Major Acute Liver Disorders,2794,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,18177.84,,,,,,,fee schedule,18177.84,18177.84, Hepatic Coma And Other Major Acute Liver Disorders,2794,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,18177.84,,,,,,,fee schedule,18177.84,18177.84, Hepatic Coma And Other Major Acute Liver Disorders,2794,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,18177.84,,,,,,,fee schedule,18177.84,18177.84, Hepatic Coma And Other Major Acute Liver Disorders,2794,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,18177.84,,,,,,,fee schedule,18177.84,18177.84, Hepatic Coma And Other Major Acute Liver Disorders,2794,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,18177.84,,,,,,,fee schedule,18177.84,18177.84, Alcoholic Liver Disease,2801,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4658.8,,,,,,,fee schedule,4658.8,4658.8, Alcoholic Liver Disease,2801,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4658.8,,,,,,,fee schedule,4658.8,4658.8, Alcoholic Liver Disease,2801,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4658.8,,,,,,,fee schedule,4658.8,4658.8, Alcoholic Liver Disease,2801,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4658.8,,,,,,,fee schedule,4658.8,4658.8, Alcoholic Liver Disease,2801,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4658.8,,,,,,,fee schedule,4658.8,4658.8, Alcoholic Liver Disease,2801,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4658.8,,,,,,,fee schedule,4658.8,4658.8, Alcoholic Liver Disease,2801,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4658.8,,,,,,,fee schedule,4658.8,4658.8, Alcoholic Liver Disease,2801,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4658.8,,,,,,,fee schedule,4658.8,4658.8, Alcoholic Liver Disease,2801,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4658.8,,,,,,,fee schedule,4658.8,4658.8, Alcoholic Liver Disease,2801,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4658.8,,,,,,,fee schedule,4658.8,4658.8, Alcoholic Liver Disease,2801,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4658.8,,,,,,,fee schedule,4658.8,4658.8, Alcoholic Liver Disease,2802,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,6202.32,,,,,,,fee schedule,6202.32,6202.32, Alcoholic Liver Disease,2802,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,6202.32,,,,,,,fee schedule,6202.32,6202.32, Alcoholic Liver Disease,2802,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,6202.32,,,,,,,fee schedule,6202.32,6202.32, Alcoholic Liver Disease,2802,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,6202.32,,,,,,,fee schedule,6202.32,6202.32, Alcoholic Liver Disease,2802,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,6202.32,,,,,,,fee schedule,6202.32,6202.32, Alcoholic Liver Disease,2802,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,6202.32,,,,,,,fee schedule,6202.32,6202.32, Alcoholic Liver Disease,2802,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,6202.32,,,,,,,fee schedule,6202.32,6202.32, Alcoholic Liver Disease,2802,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,6202.32,,,,,,,fee schedule,6202.32,6202.32, Alcoholic Liver Disease,2802,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,6202.32,,,,,,,fee schedule,6202.32,6202.32, Alcoholic Liver Disease,2802,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,6202.32,,,,,,,fee schedule,6202.32,6202.32, Alcoholic Liver Disease,2802,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,6202.32,,,,,,,fee schedule,6202.32,6202.32, Alcoholic Liver Disease,2803,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,9755.88,,,,,,,fee schedule,9755.88,9755.88, Alcoholic Liver Disease,2803,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,9755.88,,,,,,,fee schedule,9755.88,9755.88, Alcoholic Liver Disease,2803,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,9755.88,,,,,,,fee schedule,9755.88,9755.88, Alcoholic Liver Disease,2803,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,9755.88,,,,,,,fee schedule,9755.88,9755.88, Alcoholic Liver Disease,2803,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,9755.88,,,,,,,fee schedule,9755.88,9755.88, Alcoholic Liver Disease,2803,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,9755.88,,,,,,,fee schedule,9755.88,9755.88, Alcoholic Liver Disease,2803,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,9755.88,,,,,,,fee schedule,9755.88,9755.88, Alcoholic Liver Disease,2803,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,9755.88,,,,,,,fee schedule,9755.88,9755.88, Alcoholic Liver Disease,2803,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,9755.88,,,,,,,fee schedule,9755.88,9755.88, Alcoholic Liver Disease,2803,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,9755.88,,,,,,,fee schedule,9755.88,9755.88, Alcoholic Liver Disease,2803,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,9755.88,,,,,,,fee schedule,9755.88,9755.88, Alcoholic Liver Disease,2804,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,19179.33,,,,,,,fee schedule,19179.33,19179.33, Alcoholic Liver Disease,2804,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,19179.33,,,,,,,fee schedule,19179.33,19179.33, Alcoholic Liver Disease,2804,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,19179.33,,,,,,,fee schedule,19179.33,19179.33, Alcoholic Liver Disease,2804,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,19179.33,,,,,,,fee schedule,19179.33,19179.33, Alcoholic Liver Disease,2804,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,19179.33,,,,,,,fee schedule,19179.33,19179.33, Alcoholic Liver Disease,2804,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,19179.33,,,,,,,fee schedule,19179.33,19179.33, Alcoholic Liver Disease,2804,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,19179.33,,,,,,,fee schedule,19179.33,19179.33, Alcoholic Liver Disease,2804,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,19179.33,,,,,,,fee schedule,19179.33,19179.33, Alcoholic Liver Disease,2804,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,19179.33,,,,,,,fee schedule,19179.33,19179.33, Alcoholic Liver Disease,2804,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,19179.33,,,,,,,fee schedule,19179.33,19179.33, Alcoholic Liver Disease,2804,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,19179.33,,,,,,,fee schedule,19179.33,19179.33, Malignancy Of Hepatobiliary System And Pancreas,2811,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5761.92,,,,,,,fee schedule,5761.92,5761.92, Malignancy Of Hepatobiliary System And Pancreas,2811,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5761.92,,,,,,,fee schedule,5761.92,5761.92, Malignancy Of Hepatobiliary System And Pancreas,2811,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5761.92,,,,,,,fee schedule,5761.92,5761.92, Malignancy Of Hepatobiliary System And Pancreas,2811,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5761.92,,,,,,,fee schedule,5761.92,5761.92, Malignancy Of Hepatobiliary System And Pancreas,2811,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5761.92,,,,,,,fee schedule,5761.92,5761.92, Malignancy Of Hepatobiliary System And Pancreas,2811,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5761.92,,,,,,,fee schedule,5761.92,5761.92, Malignancy Of Hepatobiliary System And Pancreas,2811,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5761.92,,,,,,,fee schedule,5761.92,5761.92, Malignancy Of Hepatobiliary System And Pancreas,2811,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5761.92,,,,,,,fee schedule,5761.92,5761.92, Malignancy Of Hepatobiliary System And Pancreas,2811,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5761.92,,,,,,,fee schedule,5761.92,5761.92, Malignancy Of Hepatobiliary System And Pancreas,2811,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5761.92,,,,,,,fee schedule,5761.92,5761.92, Malignancy Of Hepatobiliary System And Pancreas,2811,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5761.92,,,,,,,fee schedule,5761.92,5761.92, Malignancy Of Hepatobiliary System And Pancreas,2812,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,7703.49,,,,,,,fee schedule,7703.49,7703.49, Malignancy Of Hepatobiliary System And Pancreas,2812,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,7703.49,,,,,,,fee schedule,7703.49,7703.49, Malignancy Of Hepatobiliary System And Pancreas,2812,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,7703.49,,,,,,,fee schedule,7703.49,7703.49, Malignancy Of Hepatobiliary System And Pancreas,2812,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,7703.49,,,,,,,fee schedule,7703.49,7703.49, Malignancy Of Hepatobiliary System And Pancreas,2812,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,7703.49,,,,,,,fee schedule,7703.49,7703.49, Malignancy Of Hepatobiliary System And Pancreas,2812,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,7703.49,,,,,,,fee schedule,7703.49,7703.49, Malignancy Of Hepatobiliary System And Pancreas,2812,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,7703.49,,,,,,,fee schedule,7703.49,7703.49, Malignancy Of Hepatobiliary System And Pancreas,2812,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,7703.49,,,,,,,fee schedule,7703.49,7703.49, Malignancy Of Hepatobiliary System And Pancreas,2812,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,7703.49,,,,,,,fee schedule,7703.49,7703.49, Malignancy Of Hepatobiliary System And Pancreas,2812,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,7703.49,,,,,,,fee schedule,7703.49,7703.49, Malignancy Of Hepatobiliary System And Pancreas,2812,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,7703.49,,,,,,,fee schedule,7703.49,7703.49, Malignancy Of Hepatobiliary System And Pancreas,2813,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,10449.65,,,,,,,fee schedule,10449.65,10449.65, Malignancy Of Hepatobiliary System And Pancreas,2813,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,10449.65,,,,,,,fee schedule,10449.65,10449.65, Malignancy Of Hepatobiliary System And Pancreas,2813,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,10449.65,,,,,,,fee schedule,10449.65,10449.65, Malignancy Of Hepatobiliary System And Pancreas,2813,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,10449.65,,,,,,,fee schedule,10449.65,10449.65, Malignancy Of Hepatobiliary System And Pancreas,2813,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,10449.65,,,,,,,fee schedule,10449.65,10449.65, Malignancy Of Hepatobiliary System And Pancreas,2813,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,10449.65,,,,,,,fee schedule,10449.65,10449.65, Malignancy Of Hepatobiliary System And Pancreas,2813,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,10449.65,,,,,,,fee schedule,10449.65,10449.65, Malignancy Of Hepatobiliary System And Pancreas,2813,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,10449.65,,,,,,,fee schedule,10449.65,10449.65, Malignancy Of Hepatobiliary System And Pancreas,2813,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,10449.65,,,,,,,fee schedule,10449.65,10449.65, Malignancy Of Hepatobiliary System And Pancreas,2813,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,10449.65,,,,,,,fee schedule,10449.65,10449.65, Malignancy Of Hepatobiliary System And Pancreas,2813,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,10449.65,,,,,,,fee schedule,10449.65,10449.65, Malignancy Of Hepatobiliary System And Pancreas,2814,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,15896.79,,,,,,,fee schedule,15896.79,15896.79, Malignancy Of Hepatobiliary System And Pancreas,2814,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,15896.79,,,,,,,fee schedule,15896.79,15896.79, Malignancy Of Hepatobiliary System And Pancreas,2814,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,15896.79,,,,,,,fee schedule,15896.79,15896.79, Malignancy Of Hepatobiliary System And Pancreas,2814,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,15896.79,,,,,,,fee schedule,15896.79,15896.79, Malignancy Of Hepatobiliary System And Pancreas,2814,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,15896.79,,,,,,,fee schedule,15896.79,15896.79, Malignancy Of Hepatobiliary System And Pancreas,2814,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,15896.79,,,,,,,fee schedule,15896.79,15896.79, Malignancy Of Hepatobiliary System And Pancreas,2814,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,15896.79,,,,,,,fee schedule,15896.79,15896.79, Malignancy Of Hepatobiliary System And Pancreas,2814,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,15896.79,,,,,,,fee schedule,15896.79,15896.79, Malignancy Of Hepatobiliary System And Pancreas,2814,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,15896.79,,,,,,,fee schedule,15896.79,15896.79, Malignancy Of Hepatobiliary System And Pancreas,2814,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,15896.79,,,,,,,fee schedule,15896.79,15896.79, Malignancy Of Hepatobiliary System And Pancreas,2814,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,15896.79,,,,,,,fee schedule,15896.79,15896.79, Disorders Of Pancreas Except Malignancy,2821,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4040.54,,,,,,,fee schedule,4040.54,4040.54, Disorders Of Pancreas Except Malignancy,2821,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4040.54,,,,,,,fee schedule,4040.54,4040.54, Disorders Of Pancreas Except Malignancy,2821,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4040.54,,,,,,,fee schedule,4040.54,4040.54, Disorders Of Pancreas Except Malignancy,2821,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4040.54,,,,,,,fee schedule,4040.54,4040.54, Disorders Of Pancreas Except Malignancy,2821,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4040.54,,,,,,,fee schedule,4040.54,4040.54, Disorders Of Pancreas Except Malignancy,2821,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4040.54,,,,,,,fee schedule,4040.54,4040.54, Disorders Of Pancreas Except Malignancy,2821,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4040.54,,,,,,,fee schedule,4040.54,4040.54, Disorders Of Pancreas Except Malignancy,2821,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4040.54,,,,,,,fee schedule,4040.54,4040.54, Disorders Of Pancreas Except Malignancy,2821,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4040.54,,,,,,,fee schedule,4040.54,4040.54, Disorders Of Pancreas Except Malignancy,2821,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4040.54,,,,,,,fee schedule,4040.54,4040.54, Disorders Of Pancreas Except Malignancy,2821,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4040.54,,,,,,,fee schedule,4040.54,4040.54, Disorders Of Pancreas Except Malignancy,2822,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5603.12,,,,,,,fee schedule,5603.12,5603.12, Disorders Of Pancreas Except Malignancy,2822,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5603.12,,,,,,,fee schedule,5603.12,5603.12, Disorders Of Pancreas Except Malignancy,2822,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5603.12,,,,,,,fee schedule,5603.12,5603.12, Disorders Of Pancreas Except Malignancy,2822,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5603.12,,,,,,,fee schedule,5603.12,5603.12, Disorders Of Pancreas Except Malignancy,2822,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5603.12,,,,,,,fee schedule,5603.12,5603.12, Disorders Of Pancreas Except Malignancy,2822,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5603.12,,,,,,,fee schedule,5603.12,5603.12, Disorders Of Pancreas Except Malignancy,2822,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5603.12,,,,,,,fee schedule,5603.12,5603.12, Disorders Of Pancreas Except Malignancy,2822,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5603.12,,,,,,,fee schedule,5603.12,5603.12, Disorders Of Pancreas Except Malignancy,2822,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5603.12,,,,,,,fee schedule,5603.12,5603.12, Disorders Of Pancreas Except Malignancy,2822,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5603.12,,,,,,,fee schedule,5603.12,5603.12, Disorders Of Pancreas Except Malignancy,2822,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5603.12,,,,,,,fee schedule,5603.12,5603.12, Disorders Of Pancreas Except Malignancy,2823,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,9161.62,,,,,,,fee schedule,9161.62,9161.62, Disorders Of Pancreas Except Malignancy,2823,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,9161.62,,,,,,,fee schedule,9161.62,9161.62, Disorders Of Pancreas Except Malignancy,2823,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,9161.62,,,,,,,fee schedule,9161.62,9161.62, Disorders Of Pancreas Except Malignancy,2823,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,9161.62,,,,,,,fee schedule,9161.62,9161.62, Disorders Of Pancreas Except Malignancy,2823,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,9161.62,,,,,,,fee schedule,9161.62,9161.62, Disorders Of Pancreas Except Malignancy,2823,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,9161.62,,,,,,,fee schedule,9161.62,9161.62, Disorders Of Pancreas Except Malignancy,2823,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,9161.62,,,,,,,fee schedule,9161.62,9161.62, Disorders Of Pancreas Except Malignancy,2823,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,9161.62,,,,,,,fee schedule,9161.62,9161.62, Disorders Of Pancreas Except Malignancy,2823,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,9161.62,,,,,,,fee schedule,9161.62,9161.62, Disorders Of Pancreas Except Malignancy,2823,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,9161.62,,,,,,,fee schedule,9161.62,9161.62, Disorders Of Pancreas Except Malignancy,2823,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,9161.62,,,,,,,fee schedule,9161.62,9161.62, Disorders Of Pancreas Except Malignancy,2824,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,19470.11,,,,,,,fee schedule,19470.11,19470.11, Disorders Of Pancreas Except Malignancy,2824,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,19470.11,,,,,,,fee schedule,19470.11,19470.11, Disorders Of Pancreas Except Malignancy,2824,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,19470.11,,,,,,,fee schedule,19470.11,19470.11, Disorders Of Pancreas Except Malignancy,2824,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,19470.11,,,,,,,fee schedule,19470.11,19470.11, Disorders Of Pancreas Except Malignancy,2824,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,19470.11,,,,,,,fee schedule,19470.11,19470.11, Disorders Of Pancreas Except Malignancy,2824,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,19470.11,,,,,,,fee schedule,19470.11,19470.11, Disorders Of Pancreas Except Malignancy,2824,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,19470.11,,,,,,,fee schedule,19470.11,19470.11, Disorders Of Pancreas Except Malignancy,2824,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,19470.11,,,,,,,fee schedule,19470.11,19470.11, Disorders Of Pancreas Except Malignancy,2824,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,19470.11,,,,,,,fee schedule,19470.11,19470.11, Disorders Of Pancreas Except Malignancy,2824,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,19470.11,,,,,,,fee schedule,19470.11,19470.11, Disorders Of Pancreas Except Malignancy,2824,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,19470.11,,,,,,,fee schedule,19470.11,19470.11, Other Disorders Of The Liver,2831,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4344.73,,,,,,,fee schedule,4344.73,4344.73, Other Disorders Of The Liver,2831,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4344.73,,,,,,,fee schedule,4344.73,4344.73, Other Disorders Of The Liver,2831,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4344.73,,,,,,,fee schedule,4344.73,4344.73, Other Disorders Of The Liver,2831,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4344.73,,,,,,,fee schedule,4344.73,4344.73, Other Disorders Of The Liver,2831,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4344.73,,,,,,,fee schedule,4344.73,4344.73, Other Disorders Of The Liver,2831,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4344.73,,,,,,,fee schedule,4344.73,4344.73, Other Disorders Of The Liver,2831,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4344.73,,,,,,,fee schedule,4344.73,4344.73, Other Disorders Of The Liver,2831,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4344.73,,,,,,,fee schedule,4344.73,4344.73, Other Disorders Of The Liver,2831,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4344.73,,,,,,,fee schedule,4344.73,4344.73, Other Disorders Of The Liver,2831,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4344.73,,,,,,,fee schedule,4344.73,4344.73, Other Disorders Of The Liver,2831,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4344.73,,,,,,,fee schedule,4344.73,4344.73, Other Disorders Of The Liver,2832,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,6051.99,,,,,,,fee schedule,6051.99,6051.99, Other Disorders Of The Liver,2832,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,6051.99,,,,,,,fee schedule,6051.99,6051.99, Other Disorders Of The Liver,2832,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,6051.99,,,,,,,fee schedule,6051.99,6051.99, Other Disorders Of The Liver,2832,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,6051.99,,,,,,,fee schedule,6051.99,6051.99, Other Disorders Of The Liver,2832,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,6051.99,,,,,,,fee schedule,6051.99,6051.99, Other Disorders Of The Liver,2832,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,6051.99,,,,,,,fee schedule,6051.99,6051.99, Other Disorders Of The Liver,2832,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,6051.99,,,,,,,fee schedule,6051.99,6051.99, Other Disorders Of The Liver,2832,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,6051.99,,,,,,,fee schedule,6051.99,6051.99, Other Disorders Of The Liver,2832,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,6051.99,,,,,,,fee schedule,6051.99,6051.99, Other Disorders Of The Liver,2832,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,6051.99,,,,,,,fee schedule,6051.99,6051.99, Other Disorders Of The Liver,2832,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,6051.99,,,,,,,fee schedule,6051.99,6051.99, Other Disorders Of The Liver,2833,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,9225.14,,,,,,,fee schedule,9225.14,9225.14, Other Disorders Of The Liver,2833,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,9225.14,,,,,,,fee schedule,9225.14,9225.14, Other Disorders Of The Liver,2833,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,9225.14,,,,,,,fee schedule,9225.14,9225.14, Other Disorders Of The Liver,2833,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,9225.14,,,,,,,fee schedule,9225.14,9225.14, Other Disorders Of The Liver,2833,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,9225.14,,,,,,,fee schedule,9225.14,9225.14, Other Disorders Of The Liver,2833,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,9225.14,,,,,,,fee schedule,9225.14,9225.14, Other Disorders Of The Liver,2833,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,9225.14,,,,,,,fee schedule,9225.14,9225.14, Other Disorders Of The Liver,2833,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,9225.14,,,,,,,fee schedule,9225.14,9225.14, Other Disorders Of The Liver,2833,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,9225.14,,,,,,,fee schedule,9225.14,9225.14, Other Disorders Of The Liver,2833,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,9225.14,,,,,,,fee schedule,9225.14,9225.14, Other Disorders Of The Liver,2833,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,9225.14,,,,,,,fee schedule,9225.14,9225.14, Other Disorders Of The Liver,2834,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,17272.34,,,,,,,fee schedule,17272.34,17272.34, Other Disorders Of The Liver,2834,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,17272.34,,,,,,,fee schedule,17272.34,17272.34, Other Disorders Of The Liver,2834,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,17272.34,,,,,,,fee schedule,17272.34,17272.34, Other Disorders Of The Liver,2834,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,17272.34,,,,,,,fee schedule,17272.34,17272.34, Other Disorders Of The Liver,2834,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,17272.34,,,,,,,fee schedule,17272.34,17272.34, Other Disorders Of The Liver,2834,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,17272.34,,,,,,,fee schedule,17272.34,17272.34, Other Disorders Of The Liver,2834,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,17272.34,,,,,,,fee schedule,17272.34,17272.34, Other Disorders Of The Liver,2834,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,17272.34,,,,,,,fee schedule,17272.34,17272.34, Other Disorders Of The Liver,2834,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,17272.34,,,,,,,fee schedule,17272.34,17272.34, Other Disorders Of The Liver,2834,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,17272.34,,,,,,,fee schedule,17272.34,17272.34, Other Disorders Of The Liver,2834,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,17272.34,,,,,,,fee schedule,17272.34,17272.34, Disorders Of Gallbladder And Biliary Tract,2841,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5317.28,,,,,,,fee schedule,5317.28,5317.28, Disorders Of Gallbladder And Biliary Tract,2841,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5317.28,,,,,,,fee schedule,5317.28,5317.28, Disorders Of Gallbladder And Biliary Tract,2841,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5317.28,,,,,,,fee schedule,5317.28,5317.28, Disorders Of Gallbladder And Biliary Tract,2841,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5317.28,,,,,,,fee schedule,5317.28,5317.28, Disorders Of Gallbladder And Biliary Tract,2841,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5317.28,,,,,,,fee schedule,5317.28,5317.28, Disorders Of Gallbladder And Biliary Tract,2841,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5317.28,,,,,,,fee schedule,5317.28,5317.28, Disorders Of Gallbladder And Biliary Tract,2841,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5317.28,,,,,,,fee schedule,5317.28,5317.28, Disorders Of Gallbladder And Biliary Tract,2841,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5317.28,,,,,,,fee schedule,5317.28,5317.28, Disorders Of Gallbladder And Biliary Tract,2841,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5317.28,,,,,,,fee schedule,5317.28,5317.28, Disorders Of Gallbladder And Biliary Tract,2841,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5317.28,,,,,,,fee schedule,5317.28,5317.28, Disorders Of Gallbladder And Biliary Tract,2841,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5317.28,,,,,,,fee schedule,5317.28,5317.28, Disorders Of Gallbladder And Biliary Tract,2842,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,7143.11,,,,,,,fee schedule,7143.11,7143.11, Disorders Of Gallbladder And Biliary Tract,2842,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,7143.11,,,,,,,fee schedule,7143.11,7143.11, Disorders Of Gallbladder And Biliary Tract,2842,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,7143.11,,,,,,,fee schedule,7143.11,7143.11, Disorders Of Gallbladder And Biliary Tract,2842,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,7143.11,,,,,,,fee schedule,7143.11,7143.11, Disorders Of Gallbladder And Biliary Tract,2842,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,7143.11,,,,,,,fee schedule,7143.11,7143.11, Disorders Of Gallbladder And Biliary Tract,2842,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,7143.11,,,,,,,fee schedule,7143.11,7143.11, Disorders Of Gallbladder And Biliary Tract,2842,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,7143.11,,,,,,,fee schedule,7143.11,7143.11, Disorders Of Gallbladder And Biliary Tract,2842,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,7143.11,,,,,,,fee schedule,7143.11,7143.11, Disorders Of Gallbladder And Biliary Tract,2842,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,7143.11,,,,,,,fee schedule,7143.11,7143.11, Disorders Of Gallbladder And Biliary Tract,2842,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,7143.11,,,,,,,fee schedule,7143.11,7143.11, Disorders Of Gallbladder And Biliary Tract,2842,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,7143.11,,,,,,,fee schedule,7143.11,7143.11, Disorders Of Gallbladder And Biliary Tract,2843,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,9928.79,,,,,,,fee schedule,9928.79,9928.79, Disorders Of Gallbladder And Biliary Tract,2843,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,9928.79,,,,,,,fee schedule,9928.79,9928.79, Disorders Of Gallbladder And Biliary Tract,2843,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,9928.79,,,,,,,fee schedule,9928.79,9928.79, Disorders Of Gallbladder And Biliary Tract,2843,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,9928.79,,,,,,,fee schedule,9928.79,9928.79, Disorders Of Gallbladder And Biliary Tract,2843,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,9928.79,,,,,,,fee schedule,9928.79,9928.79, Disorders Of Gallbladder And Biliary Tract,2843,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,9928.79,,,,,,,fee schedule,9928.79,9928.79, Disorders Of Gallbladder And Biliary Tract,2843,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,9928.79,,,,,,,fee schedule,9928.79,9928.79, Disorders Of Gallbladder And Biliary Tract,2843,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,9928.79,,,,,,,fee schedule,9928.79,9928.79, Disorders Of Gallbladder And Biliary Tract,2843,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,9928.79,,,,,,,fee schedule,9928.79,9928.79, Disorders Of Gallbladder And Biliary Tract,2843,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,9928.79,,,,,,,fee schedule,9928.79,9928.79, Disorders Of Gallbladder And Biliary Tract,2843,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,9928.79,,,,,,,fee schedule,9928.79,9928.79, Disorders Of Gallbladder And Biliary Tract,2844,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,16662.55,,,,,,,fee schedule,16662.55,16662.55, Disorders Of Gallbladder And Biliary Tract,2844,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,16662.55,,,,,,,fee schedule,16662.55,16662.55, Disorders Of Gallbladder And Biliary Tract,2844,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,16662.55,,,,,,,fee schedule,16662.55,16662.55, Disorders Of Gallbladder And Biliary Tract,2844,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,16662.55,,,,,,,fee schedule,16662.55,16662.55, Disorders Of Gallbladder And Biliary Tract,2844,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,16662.55,,,,,,,fee schedule,16662.55,16662.55, Disorders Of Gallbladder And Biliary Tract,2844,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,16662.55,,,,,,,fee schedule,16662.55,16662.55, Disorders Of Gallbladder And Biliary Tract,2844,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,16662.55,,,,,,,fee schedule,16662.55,16662.55, Disorders Of Gallbladder And Biliary Tract,2844,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,16662.55,,,,,,,fee schedule,16662.55,16662.55, Disorders Of Gallbladder And Biliary Tract,2844,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,16662.55,,,,,,,fee schedule,16662.55,16662.55, Disorders Of Gallbladder And Biliary Tract,2844,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,16662.55,,,,,,,fee schedule,16662.55,16662.55, Disorders Of Gallbladder And Biliary Tract,2844,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,16662.55,,,,,,,fee schedule,16662.55,16662.55, Description Not Available,2991,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,27635.18,,,,,,,fee schedule,27635.18,27635.18, Description Not Available,2991,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,27635.18,,,,,,,fee schedule,27635.18,27635.18, Description Not Available,2991,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,27635.18,,,,,,,fee schedule,27635.18,27635.18, Description Not Available,2991,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,27635.18,,,,,,,fee schedule,27635.18,27635.18, Description Not Available,2991,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,27635.18,,,,,,,fee schedule,27635.18,27635.18, Description Not Available,2991,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,27635.18,,,,,,,fee schedule,27635.18,27635.18, Description Not Available,2991,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,27635.18,,,,,,,fee schedule,27635.18,27635.18, Description Not Available,2991,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,27635.18,,,,,,,fee schedule,27635.18,27635.18, Description Not Available,2991,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,27635.18,,,,,,,fee schedule,27635.18,27635.18, Description Not Available,2991,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,27635.18,,,,,,,fee schedule,27635.18,27635.18, Description Not Available,2991,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,27635.18,,,,,,,fee schedule,27635.18,27635.18, Description Not Available,2992,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,33223.48,,,,,,,fee schedule,33223.48,33223.48, Description Not Available,2992,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,33223.48,,,,,,,fee schedule,33223.48,33223.48, Description Not Available,2992,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,33223.48,,,,,,,fee schedule,33223.48,33223.48, Description Not Available,2992,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,33223.48,,,,,,,fee schedule,33223.48,33223.48, Description Not Available,2992,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,33223.48,,,,,,,fee schedule,33223.48,33223.48, Description Not Available,2992,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,33223.48,,,,,,,fee schedule,33223.48,33223.48, Description Not Available,2992,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,33223.48,,,,,,,fee schedule,33223.48,33223.48, Description Not Available,2992,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,33223.48,,,,,,,fee schedule,33223.48,33223.48, Description Not Available,2992,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,33223.48,,,,,,,fee schedule,33223.48,33223.48, Description Not Available,2992,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,33223.48,,,,,,,fee schedule,33223.48,33223.48, Description Not Available,2992,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,33223.48,,,,,,,fee schedule,33223.48,33223.48, Description Not Available,2993,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,45172.89,,,,,,,fee schedule,45172.89,45172.89, Description Not Available,2993,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,45172.89,,,,,,,fee schedule,45172.89,45172.89, Description Not Available,2993,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,45172.89,,,,,,,fee schedule,45172.89,45172.89, Description Not Available,2993,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,45172.89,,,,,,,fee schedule,45172.89,45172.89, Description Not Available,2993,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,45172.89,,,,,,,fee schedule,45172.89,45172.89, Description Not Available,2993,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,45172.89,,,,,,,fee schedule,45172.89,45172.89, Description Not Available,2993,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,45172.89,,,,,,,fee schedule,45172.89,45172.89, Description Not Available,2993,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,45172.89,,,,,,,fee schedule,45172.89,45172.89, Description Not Available,2993,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,45172.89,,,,,,,fee schedule,45172.89,45172.89, Description Not Available,2993,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,45172.89,,,,,,,fee schedule,45172.89,45172.89, Description Not Available,2993,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,45172.89,,,,,,,fee schedule,45172.89,45172.89, Description Not Available,2994,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,57768.79,,,,,,,fee schedule,57768.79,57768.79, Description Not Available,2994,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,57768.79,,,,,,,fee schedule,57768.79,57768.79, Description Not Available,2994,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,57768.79,,,,,,,fee schedule,57768.79,57768.79, Description Not Available,2994,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,57768.79,,,,,,,fee schedule,57768.79,57768.79, Description Not Available,2994,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,57768.79,,,,,,,fee schedule,57768.79,57768.79, Description Not Available,2994,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,57768.79,,,,,,,fee schedule,57768.79,57768.79, Description Not Available,2994,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,57768.79,,,,,,,fee schedule,57768.79,57768.79, Description Not Available,2994,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,57768.79,,,,,,,fee schedule,57768.79,57768.79, Description Not Available,2994,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,57768.79,,,,,,,fee schedule,57768.79,57768.79, Description Not Available,2994,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,57768.79,,,,,,,fee schedule,57768.79,57768.79, Description Not Available,2994,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,57768.79,,,,,,,fee schedule,57768.79,57768.79, Description Not Available,3001,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,20790.61,,,,,,,fee schedule,20790.61,20790.61, Description Not Available,3001,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,20790.61,,,,,,,fee schedule,20790.61,20790.61, Description Not Available,3001,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,20790.61,,,,,,,fee schedule,20790.61,20790.61, Description Not Available,3001,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,20790.61,,,,,,,fee schedule,20790.61,20790.61, Description Not Available,3001,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,20790.61,,,,,,,fee schedule,20790.61,20790.61, Description Not Available,3001,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,20790.61,,,,,,,fee schedule,20790.61,20790.61, Description Not Available,3001,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,20790.61,,,,,,,fee schedule,20790.61,20790.61, Description Not Available,3001,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,20790.61,,,,,,,fee schedule,20790.61,20790.61, Description Not Available,3001,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,20790.61,,,,,,,fee schedule,20790.61,20790.61, Description Not Available,3001,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,20790.61,,,,,,,fee schedule,20790.61,20790.61, Description Not Available,3001,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,20790.61,,,,,,,fee schedule,20790.61,20790.61, Description Not Available,3002,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,23616.52,,,,,,,fee schedule,23616.52,23616.52, Description Not Available,3002,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,23616.52,,,,,,,fee schedule,23616.52,23616.52, Description Not Available,3002,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,23616.52,,,,,,,fee schedule,23616.52,23616.52, Description Not Available,3002,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,23616.52,,,,,,,fee schedule,23616.52,23616.52, Description Not Available,3002,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,23616.52,,,,,,,fee schedule,23616.52,23616.52, Description Not Available,3002,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,23616.52,,,,,,,fee schedule,23616.52,23616.52, Description Not Available,3002,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,23616.52,,,,,,,fee schedule,23616.52,23616.52, Description Not Available,3002,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,23616.52,,,,,,,fee schedule,23616.52,23616.52, Description Not Available,3002,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,23616.52,,,,,,,fee schedule,23616.52,23616.52, Description Not Available,3002,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,23616.52,,,,,,,fee schedule,23616.52,23616.52, Description Not Available,3002,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,23616.52,,,,,,,fee schedule,23616.52,23616.52, Description Not Available,3003,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,30814.68,,,,,,,fee schedule,30814.68,30814.68, Description Not Available,3003,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,30814.68,,,,,,,fee schedule,30814.68,30814.68, Description Not Available,3003,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,30814.68,,,,,,,fee schedule,30814.68,30814.68, Description Not Available,3003,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,30814.68,,,,,,,fee schedule,30814.68,30814.68, Description Not Available,3003,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,30814.68,,,,,,,fee schedule,30814.68,30814.68, Description Not Available,3003,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,30814.68,,,,,,,fee schedule,30814.68,30814.68, Description Not Available,3003,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,30814.68,,,,,,,fee schedule,30814.68,30814.68, Description Not Available,3003,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,30814.68,,,,,,,fee schedule,30814.68,30814.68, Description Not Available,3003,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,30814.68,,,,,,,fee schedule,30814.68,30814.68, Description Not Available,3003,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,30814.68,,,,,,,fee schedule,30814.68,30814.68, Description Not Available,3003,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,30814.68,,,,,,,fee schedule,30814.68,30814.68, Description Not Available,3004,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,44071.18,,,,,,,fee schedule,44071.18,44071.18, Description Not Available,3004,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,44071.18,,,,,,,fee schedule,44071.18,44071.18, Description Not Available,3004,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,44071.18,,,,,,,fee schedule,44071.18,44071.18, Description Not Available,3004,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,44071.18,,,,,,,fee schedule,44071.18,44071.18, Description Not Available,3004,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,44071.18,,,,,,,fee schedule,44071.18,44071.18, Description Not Available,3004,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,44071.18,,,,,,,fee schedule,44071.18,44071.18, Description Not Available,3004,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,44071.18,,,,,,,fee schedule,44071.18,44071.18, Description Not Available,3004,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,44071.18,,,,,,,fee schedule,44071.18,44071.18, Description Not Available,3004,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,44071.18,,,,,,,fee schedule,44071.18,44071.18, Description Not Available,3004,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,44071.18,,,,,,,fee schedule,44071.18,44071.18, Description Not Available,3004,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,44071.18,,,,,,,fee schedule,44071.18,44071.18, Dorsal And Lumbar Fusion Procedure For Curvature Of Back,3031,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,29337.5,,,,,,,fee schedule,29337.5,29337.5, Dorsal And Lumbar Fusion Procedure For Curvature Of Back,3031,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,29337.5,,,,,,,fee schedule,29337.5,29337.5, Dorsal And Lumbar Fusion Procedure For Curvature Of Back,3031,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,29337.5,,,,,,,fee schedule,29337.5,29337.5, Dorsal And Lumbar Fusion Procedure For Curvature Of Back,3031,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,29337.5,,,,,,,fee schedule,29337.5,29337.5, Dorsal And Lumbar Fusion Procedure For Curvature Of Back,3031,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,29337.5,,,,,,,fee schedule,29337.5,29337.5, Dorsal And Lumbar Fusion Procedure For Curvature Of Back,3031,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,29337.5,,,,,,,fee schedule,29337.5,29337.5, Dorsal And Lumbar Fusion Procedure For Curvature Of Back,3031,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,29337.5,,,,,,,fee schedule,29337.5,29337.5, Dorsal And Lumbar Fusion Procedure For Curvature Of Back,3031,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,29337.5,,,,,,,fee schedule,29337.5,29337.5, Dorsal And Lumbar Fusion Procedure For Curvature Of Back,3031,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,29337.5,,,,,,,fee schedule,29337.5,29337.5, Dorsal And Lumbar Fusion Procedure For Curvature Of Back,3031,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,29337.5,,,,,,,fee schedule,29337.5,29337.5, Dorsal And Lumbar Fusion Procedure For Curvature Of Back,3031,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,29337.5,,,,,,,fee schedule,29337.5,29337.5, Dorsal And Lumbar Fusion Procedure For Curvature Of Back,3032,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,33843.85,,,,,,,fee schedule,33843.85,33843.85, Dorsal And Lumbar Fusion Procedure For Curvature Of Back,3032,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,33843.85,,,,,,,fee schedule,33843.85,33843.85, Dorsal And Lumbar Fusion Procedure For Curvature Of Back,3032,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,33843.85,,,,,,,fee schedule,33843.85,33843.85, Dorsal And Lumbar Fusion Procedure For Curvature Of Back,3032,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,33843.85,,,,,,,fee schedule,33843.85,33843.85, Dorsal And Lumbar Fusion Procedure For Curvature Of Back,3032,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,33843.85,,,,,,,fee schedule,33843.85,33843.85, Dorsal And Lumbar Fusion Procedure For Curvature Of Back,3032,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,33843.85,,,,,,,fee schedule,33843.85,33843.85, Dorsal And Lumbar Fusion Procedure For Curvature Of Back,3032,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,33843.85,,,,,,,fee schedule,33843.85,33843.85, Dorsal And Lumbar Fusion Procedure For Curvature Of Back,3032,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,33843.85,,,,,,,fee schedule,33843.85,33843.85, Dorsal And Lumbar Fusion Procedure For Curvature Of Back,3032,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,33843.85,,,,,,,fee schedule,33843.85,33843.85, Dorsal And Lumbar Fusion Procedure For Curvature Of Back,3032,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,33843.85,,,,,,,fee schedule,33843.85,33843.85, Dorsal And Lumbar Fusion Procedure For Curvature Of Back,3032,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,33843.85,,,,,,,fee schedule,33843.85,33843.85, Dorsal And Lumbar Fusion Procedure For Curvature Of Back,3033,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,46534.32,,,,,,,fee schedule,46534.32,46534.32, Dorsal And Lumbar Fusion Procedure For Curvature Of Back,3033,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,46534.32,,,,,,,fee schedule,46534.32,46534.32, Dorsal And Lumbar Fusion Procedure For Curvature Of Back,3033,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,46534.32,,,,,,,fee schedule,46534.32,46534.32, Dorsal And Lumbar Fusion Procedure For Curvature Of Back,3033,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,46534.32,,,,,,,fee schedule,46534.32,46534.32, Dorsal And Lumbar Fusion Procedure For Curvature Of Back,3033,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,46534.32,,,,,,,fee schedule,46534.32,46534.32, Dorsal And Lumbar Fusion Procedure For Curvature Of Back,3033,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,46534.32,,,,,,,fee schedule,46534.32,46534.32, Dorsal And Lumbar Fusion Procedure For Curvature Of Back,3033,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,46534.32,,,,,,,fee schedule,46534.32,46534.32, Dorsal And Lumbar Fusion Procedure For Curvature Of Back,3033,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,46534.32,,,,,,,fee schedule,46534.32,46534.32, Dorsal And Lumbar Fusion Procedure For Curvature Of Back,3033,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,46534.32,,,,,,,fee schedule,46534.32,46534.32, Dorsal And Lumbar Fusion Procedure For Curvature Of Back,3033,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,46534.32,,,,,,,fee schedule,46534.32,46534.32, Dorsal And Lumbar Fusion Procedure For Curvature Of Back,3033,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,46534.32,,,,,,,fee schedule,46534.32,46534.32, Dorsal And Lumbar Fusion Procedure For Curvature Of Back,3034,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,67052.5,,,,,,,fee schedule,67052.5,67052.5, Dorsal And Lumbar Fusion Procedure For Curvature Of Back,3034,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,67052.5,,,,,,,fee schedule,67052.5,67052.5, Dorsal And Lumbar Fusion Procedure For Curvature Of Back,3034,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,67052.5,,,,,,,fee schedule,67052.5,67052.5, Dorsal And Lumbar Fusion Procedure For Curvature Of Back,3034,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,67052.5,,,,,,,fee schedule,67052.5,67052.5, Dorsal And Lumbar Fusion Procedure For Curvature Of Back,3034,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,67052.5,,,,,,,fee schedule,67052.5,67052.5, Dorsal And Lumbar Fusion Procedure For Curvature Of Back,3034,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,67052.5,,,,,,,fee schedule,67052.5,67052.5, Dorsal And Lumbar Fusion Procedure For Curvature Of Back,3034,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,67052.5,,,,,,,fee schedule,67052.5,67052.5, Dorsal And Lumbar Fusion Procedure For Curvature Of Back,3034,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,67052.5,,,,,,,fee schedule,67052.5,67052.5, Dorsal And Lumbar Fusion Procedure For Curvature Of Back,3034,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,67052.5,,,,,,,fee schedule,67052.5,67052.5, Dorsal And Lumbar Fusion Procedure For Curvature Of Back,3034,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,67052.5,,,,,,,fee schedule,67052.5,67052.5, Dorsal And Lumbar Fusion Procedure For Curvature Of Back,3034,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,67052.5,,,,,,,fee schedule,67052.5,67052.5, Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,3041,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,18381.81,,,,,,,fee schedule,18381.81,18381.81, Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,3041,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,18381.81,,,,,,,fee schedule,18381.81,18381.81, Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,3041,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,18381.81,,,,,,,fee schedule,18381.81,18381.81, Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,3041,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,18381.81,,,,,,,fee schedule,18381.81,18381.81, Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,3041,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,18381.81,,,,,,,fee schedule,18381.81,18381.81, Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,3041,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,18381.81,,,,,,,fee schedule,18381.81,18381.81, Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,3041,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,18381.81,,,,,,,fee schedule,18381.81,18381.81, Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,3041,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,18381.81,,,,,,,fee schedule,18381.81,18381.81, Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,3041,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,18381.81,,,,,,,fee schedule,18381.81,18381.81, Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,3041,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,18381.81,,,,,,,fee schedule,18381.81,18381.81, Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,3041,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,18381.81,,,,,,,fee schedule,18381.81,18381.81, Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,3042,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,25044.29,,,,,,,fee schedule,25044.29,25044.29, Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,3042,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,25044.29,,,,,,,fee schedule,25044.29,25044.29, Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,3042,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,25044.29,,,,,,,fee schedule,25044.29,25044.29, Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,3042,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,25044.29,,,,,,,fee schedule,25044.29,25044.29, Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,3042,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,25044.29,,,,,,,fee schedule,25044.29,25044.29, Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,3042,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,25044.29,,,,,,,fee schedule,25044.29,25044.29, Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,3042,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,25044.29,,,,,,,fee schedule,25044.29,25044.29, Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,3042,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,25044.29,,,,,,,fee schedule,25044.29,25044.29, Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,3042,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,25044.29,,,,,,,fee schedule,25044.29,25044.29, Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,3042,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,25044.29,,,,,,,fee schedule,25044.29,25044.29, Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,3042,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,25044.29,,,,,,,fee schedule,25044.29,25044.29, Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,3043,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,34860.87,,,,,,,fee schedule,34860.87,34860.87, Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,3043,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,34860.87,,,,,,,fee schedule,34860.87,34860.87, Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,3043,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,34860.87,,,,,,,fee schedule,34860.87,34860.87, Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,3043,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,34860.87,,,,,,,fee schedule,34860.87,34860.87, Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,3043,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,34860.87,,,,,,,fee schedule,34860.87,34860.87, Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,3043,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,34860.87,,,,,,,fee schedule,34860.87,34860.87, Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,3043,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,34860.87,,,,,,,fee schedule,34860.87,34860.87, Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,3043,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,34860.87,,,,,,,fee schedule,34860.87,34860.87, Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,3043,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,34860.87,,,,,,,fee schedule,34860.87,34860.87, Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,3043,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,34860.87,,,,,,,fee schedule,34860.87,34860.87, Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,3043,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,34860.87,,,,,,,fee schedule,34860.87,34860.87, Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,3044,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,47288.09,,,,,,,fee schedule,47288.09,47288.09, Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,3044,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,47288.09,,,,,,,fee schedule,47288.09,47288.09, Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,3044,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,47288.09,,,,,,,fee schedule,47288.09,47288.09, Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,3044,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,47288.09,,,,,,,fee schedule,47288.09,47288.09, Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,3044,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,47288.09,,,,,,,fee schedule,47288.09,47288.09, Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,3044,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,47288.09,,,,,,,fee schedule,47288.09,47288.09, Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,3044,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,47288.09,,,,,,,fee schedule,47288.09,47288.09, Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,3044,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,47288.09,,,,,,,fee schedule,47288.09,47288.09, Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,3044,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,47288.09,,,,,,,fee schedule,47288.09,47288.09, Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,3044,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,47288.09,,,,,,,fee schedule,47288.09,47288.09, Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,3044,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,47288.09,,,,,,,fee schedule,47288.09,47288.09, Amputation Of Lower Limb Except Toes,3051,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,8225.76,,,,,,,fee schedule,8225.76,8225.76, Amputation Of Lower Limb Except Toes,3051,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,8225.76,,,,,,,fee schedule,8225.76,8225.76, Amputation Of Lower Limb Except Toes,3051,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,8225.76,,,,,,,fee schedule,8225.76,8225.76, Amputation Of Lower Limb Except Toes,3051,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,8225.76,,,,,,,fee schedule,8225.76,8225.76, Amputation Of Lower Limb Except Toes,3051,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,8225.76,,,,,,,fee schedule,8225.76,8225.76, Amputation Of Lower Limb Except Toes,3051,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,8225.76,,,,,,,fee schedule,8225.76,8225.76, Amputation Of Lower Limb Except Toes,3051,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,8225.76,,,,,,,fee schedule,8225.76,8225.76, Amputation Of Lower Limb Except Toes,3051,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,8225.76,,,,,,,fee schedule,8225.76,8225.76, Amputation Of Lower Limb Except Toes,3051,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,8225.76,,,,,,,fee schedule,8225.76,8225.76, Amputation Of Lower Limb Except Toes,3051,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,8225.76,,,,,,,fee schedule,8225.76,8225.76, Amputation Of Lower Limb Except Toes,3051,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,8225.76,,,,,,,fee schedule,8225.76,8225.76, Amputation Of Lower Limb Except Toes,3052,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,11199.18,,,,,,,fee schedule,11199.18,11199.18, Amputation Of Lower Limb Except Toes,3052,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,11199.18,,,,,,,fee schedule,11199.18,11199.18, Amputation Of Lower Limb Except Toes,3052,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,11199.18,,,,,,,fee schedule,11199.18,11199.18, Amputation Of Lower Limb Except Toes,3052,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,11199.18,,,,,,,fee schedule,11199.18,11199.18, Amputation Of Lower Limb Except Toes,3052,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,11199.18,,,,,,,fee schedule,11199.18,11199.18, Amputation Of Lower Limb Except Toes,3052,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,11199.18,,,,,,,fee schedule,11199.18,11199.18, Amputation Of Lower Limb Except Toes,3052,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,11199.18,,,,,,,fee schedule,11199.18,11199.18, Amputation Of Lower Limb Except Toes,3052,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,11199.18,,,,,,,fee schedule,11199.18,11199.18, Amputation Of Lower Limb Except Toes,3052,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,11199.18,,,,,,,fee schedule,11199.18,11199.18, Amputation Of Lower Limb Except Toes,3052,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,11199.18,,,,,,,fee schedule,11199.18,11199.18, Amputation Of Lower Limb Except Toes,3052,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,11199.18,,,,,,,fee schedule,11199.18,11199.18, Amputation Of Lower Limb Except Toes,3053,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,17142.48,,,,,,,fee schedule,17142.48,17142.48, Amputation Of Lower Limb Except Toes,3053,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,17142.48,,,,,,,fee schedule,17142.48,17142.48, Amputation Of Lower Limb Except Toes,3053,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,17142.48,,,,,,,fee schedule,17142.48,17142.48, Amputation Of Lower Limb Except Toes,3053,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,17142.48,,,,,,,fee schedule,17142.48,17142.48, Amputation Of Lower Limb Except Toes,3053,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,17142.48,,,,,,,fee schedule,17142.48,17142.48, Amputation Of Lower Limb Except Toes,3053,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,17142.48,,,,,,,fee schedule,17142.48,17142.48, Amputation Of Lower Limb Except Toes,3053,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,17142.48,,,,,,,fee schedule,17142.48,17142.48, Amputation Of Lower Limb Except Toes,3053,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,17142.48,,,,,,,fee schedule,17142.48,17142.48, Amputation Of Lower Limb Except Toes,3053,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,17142.48,,,,,,,fee schedule,17142.48,17142.48, Amputation Of Lower Limb Except Toes,3053,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,17142.48,,,,,,,fee schedule,17142.48,17142.48, Amputation Of Lower Limb Except Toes,3053,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,17142.48,,,,,,,fee schedule,17142.48,17142.48, Amputation Of Lower Limb Except Toes,3054,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,28247.79,,,,,,,fee schedule,28247.79,28247.79, Amputation Of Lower Limb Except Toes,3054,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,28247.79,,,,,,,fee schedule,28247.79,28247.79, Amputation Of Lower Limb Except Toes,3054,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,28247.79,,,,,,,fee schedule,28247.79,28247.79, Amputation Of Lower Limb Except Toes,3054,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,28247.79,,,,,,,fee schedule,28247.79,28247.79, Amputation Of Lower Limb Except Toes,3054,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,28247.79,,,,,,,fee schedule,28247.79,28247.79, Amputation Of Lower Limb Except Toes,3054,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,28247.79,,,,,,,fee schedule,28247.79,28247.79, Amputation Of Lower Limb Except Toes,3054,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,28247.79,,,,,,,fee schedule,28247.79,28247.79, Amputation Of Lower Limb Except Toes,3054,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,28247.79,,,,,,,fee schedule,28247.79,28247.79, Amputation Of Lower Limb Except Toes,3054,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,28247.79,,,,,,,fee schedule,28247.79,28247.79, Amputation Of Lower Limb Except Toes,3054,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,28247.79,,,,,,,fee schedule,28247.79,28247.79, Amputation Of Lower Limb Except Toes,3054,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,28247.79,,,,,,,fee schedule,28247.79,28247.79, Hip And Femur Fracture Repair,3081,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,9757.99,,,,,,,fee schedule,9757.99,9757.99, Hip And Femur Fracture Repair,3081,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,9757.99,,,,,,,fee schedule,9757.99,9757.99, Hip And Femur Fracture Repair,3081,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,9757.99,,,,,,,fee schedule,9757.99,9757.99, Hip And Femur Fracture Repair,3081,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,9757.99,,,,,,,fee schedule,9757.99,9757.99, Hip And Femur Fracture Repair,3081,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,9757.99,,,,,,,fee schedule,9757.99,9757.99, Hip And Femur Fracture Repair,3081,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,9757.99,,,,,,,fee schedule,9757.99,9757.99, Hip And Femur Fracture Repair,3081,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,9757.99,,,,,,,fee schedule,9757.99,9757.99, Hip And Femur Fracture Repair,3081,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,9757.99,,,,,,,fee schedule,9757.99,9757.99, Hip And Femur Fracture Repair,3081,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,9757.99,,,,,,,fee schedule,9757.99,9757.99, Hip And Femur Fracture Repair,3081,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,9757.99,,,,,,,fee schedule,9757.99,9757.99, Hip And Femur Fracture Repair,3081,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,9757.99,,,,,,,fee schedule,9757.99,9757.99, Hip And Femur Fracture Repair,3082,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,12583.2,,,,,,,fee schedule,12583.2,12583.2, Hip And Femur Fracture Repair,3082,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,12583.2,,,,,,,fee schedule,12583.2,12583.2, Hip And Femur Fracture Repair,3082,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,12583.2,,,,,,,fee schedule,12583.2,12583.2, Hip And Femur Fracture Repair,3082,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,12583.2,,,,,,,fee schedule,12583.2,12583.2, Hip And Femur Fracture Repair,3082,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,12583.2,,,,,,,fee schedule,12583.2,12583.2, Hip And Femur Fracture Repair,3082,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,12583.2,,,,,,,fee schedule,12583.2,12583.2, Hip And Femur Fracture Repair,3082,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,12583.2,,,,,,,fee schedule,12583.2,12583.2, Hip And Femur Fracture Repair,3082,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,12583.2,,,,,,,fee schedule,12583.2,12583.2, Hip And Femur Fracture Repair,3082,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,12583.2,,,,,,,fee schedule,12583.2,12583.2, Hip And Femur Fracture Repair,3082,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,12583.2,,,,,,,fee schedule,12583.2,12583.2, Hip And Femur Fracture Repair,3082,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,12583.2,,,,,,,fee schedule,12583.2,12583.2, Hip And Femur Fracture Repair,3083,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,15975.84,,,,,,,fee schedule,15975.84,15975.84, Hip And Femur Fracture Repair,3083,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,15975.84,,,,,,,fee schedule,15975.84,15975.84, Hip And Femur Fracture Repair,3083,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,15975.84,,,,,,,fee schedule,15975.84,15975.84, Hip And Femur Fracture Repair,3083,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,15975.84,,,,,,,fee schedule,15975.84,15975.84, Hip And Femur Fracture Repair,3083,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,15975.84,,,,,,,fee schedule,15975.84,15975.84, Hip And Femur Fracture Repair,3083,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,15975.84,,,,,,,fee schedule,15975.84,15975.84, Hip And Femur Fracture Repair,3083,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,15975.84,,,,,,,fee schedule,15975.84,15975.84, Hip And Femur Fracture Repair,3083,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,15975.84,,,,,,,fee schedule,15975.84,15975.84, Hip And Femur Fracture Repair,3083,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,15975.84,,,,,,,fee schedule,15975.84,15975.84, Hip And Femur Fracture Repair,3083,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,15975.84,,,,,,,fee schedule,15975.84,15975.84, Hip And Femur Fracture Repair,3083,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,15975.84,,,,,,,fee schedule,15975.84,15975.84, Hip And Femur Fracture Repair,3084,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,23020.14,,,,,,,fee schedule,23020.14,23020.14, Hip And Femur Fracture Repair,3084,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,23020.14,,,,,,,fee schedule,23020.14,23020.14, Hip And Femur Fracture Repair,3084,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,23020.14,,,,,,,fee schedule,23020.14,23020.14, Hip And Femur Fracture Repair,3084,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,23020.14,,,,,,,fee schedule,23020.14,23020.14, Hip And Femur Fracture Repair,3084,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,23020.14,,,,,,,fee schedule,23020.14,23020.14, Hip And Femur Fracture Repair,3084,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,23020.14,,,,,,,fee schedule,23020.14,23020.14, Hip And Femur Fracture Repair,3084,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,23020.14,,,,,,,fee schedule,23020.14,23020.14, Hip And Femur Fracture Repair,3084,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,23020.14,,,,,,,fee schedule,23020.14,23020.14, Hip And Femur Fracture Repair,3084,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,23020.14,,,,,,,fee schedule,23020.14,23020.14, Hip And Femur Fracture Repair,3084,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,23020.14,,,,,,,fee schedule,23020.14,23020.14, Hip And Femur Fracture Repair,3084,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,23020.14,,,,,,,fee schedule,23020.14,23020.14, Other Significant Hip And Femur Surgery,3091,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,11397.5,,,,,,,fee schedule,11397.5,11397.5, Other Significant Hip And Femur Surgery,3091,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,11397.5,,,,,,,fee schedule,11397.5,11397.5, Other Significant Hip And Femur Surgery,3091,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,11397.5,,,,,,,fee schedule,11397.5,11397.5, Other Significant Hip And Femur Surgery,3091,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,11397.5,,,,,,,fee schedule,11397.5,11397.5, Other Significant Hip And Femur Surgery,3091,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,11397.5,,,,,,,fee schedule,11397.5,11397.5, Other Significant Hip And Femur Surgery,3091,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,11397.5,,,,,,,fee schedule,11397.5,11397.5, Other Significant Hip And Femur Surgery,3091,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,11397.5,,,,,,,fee schedule,11397.5,11397.5, Other Significant Hip And Femur Surgery,3091,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,11397.5,,,,,,,fee schedule,11397.5,11397.5, Other Significant Hip And Femur Surgery,3091,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,11397.5,,,,,,,fee schedule,11397.5,11397.5, Other Significant Hip And Femur Surgery,3091,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,11397.5,,,,,,,fee schedule,11397.5,11397.5, Other Significant Hip And Femur Surgery,3091,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,11397.5,,,,,,,fee schedule,11397.5,11397.5, Other Significant Hip And Femur Surgery,3092,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,14931.3,,,,,,,fee schedule,14931.3,14931.3, Other Significant Hip And Femur Surgery,3092,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,14931.3,,,,,,,fee schedule,14931.3,14931.3, Other Significant Hip And Femur Surgery,3092,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,14931.3,,,,,,,fee schedule,14931.3,14931.3, Other Significant Hip And Femur Surgery,3092,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,14931.3,,,,,,,fee schedule,14931.3,14931.3, Other Significant Hip And Femur Surgery,3092,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,14931.3,,,,,,,fee schedule,14931.3,14931.3, Other Significant Hip And Femur Surgery,3092,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,14931.3,,,,,,,fee schedule,14931.3,14931.3, Other Significant Hip And Femur Surgery,3092,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,14931.3,,,,,,,fee schedule,14931.3,14931.3, Other Significant Hip And Femur Surgery,3092,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,14931.3,,,,,,,fee schedule,14931.3,14931.3, Other Significant Hip And Femur Surgery,3092,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,14931.3,,,,,,,fee schedule,14931.3,14931.3, Other Significant Hip And Femur Surgery,3092,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,14931.3,,,,,,,fee schedule,14931.3,14931.3, Other Significant Hip And Femur Surgery,3092,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,14931.3,,,,,,,fee schedule,14931.3,14931.3, Other Significant Hip And Femur Surgery,3093,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,20364.32,,,,,,,fee schedule,20364.32,20364.32, Other Significant Hip And Femur Surgery,3093,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,20364.32,,,,,,,fee schedule,20364.32,20364.32, Other Significant Hip And Femur Surgery,3093,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,20364.32,,,,,,,fee schedule,20364.32,20364.32, Other Significant Hip And Femur Surgery,3093,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,20364.32,,,,,,,fee schedule,20364.32,20364.32, Other Significant Hip And Femur Surgery,3093,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,20364.32,,,,,,,fee schedule,20364.32,20364.32, Other Significant Hip And Femur Surgery,3093,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,20364.32,,,,,,,fee schedule,20364.32,20364.32, Other Significant Hip And Femur Surgery,3093,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,20364.32,,,,,,,fee schedule,20364.32,20364.32, Other Significant Hip And Femur Surgery,3093,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,20364.32,,,,,,,fee schedule,20364.32,20364.32, Other Significant Hip And Femur Surgery,3093,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,20364.32,,,,,,,fee schedule,20364.32,20364.32, Other Significant Hip And Femur Surgery,3093,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,20364.32,,,,,,,fee schedule,20364.32,20364.32, Other Significant Hip And Femur Surgery,3093,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,20364.32,,,,,,,fee schedule,20364.32,20364.32, Other Significant Hip And Femur Surgery,3094,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,29272.57,,,,,,,fee schedule,29272.57,29272.57, Other Significant Hip And Femur Surgery,3094,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,29272.57,,,,,,,fee schedule,29272.57,29272.57, Other Significant Hip And Femur Surgery,3094,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,29272.57,,,,,,,fee schedule,29272.57,29272.57, Other Significant Hip And Femur Surgery,3094,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,29272.57,,,,,,,fee schedule,29272.57,29272.57, Other Significant Hip And Femur Surgery,3094,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,29272.57,,,,,,,fee schedule,29272.57,29272.57, Other Significant Hip And Femur Surgery,3094,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,29272.57,,,,,,,fee schedule,29272.57,29272.57, Other Significant Hip And Femur Surgery,3094,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,29272.57,,,,,,,fee schedule,29272.57,29272.57, Other Significant Hip And Femur Surgery,3094,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,29272.57,,,,,,,fee schedule,29272.57,29272.57, Other Significant Hip And Femur Surgery,3094,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,29272.57,,,,,,,fee schedule,29272.57,29272.57, Other Significant Hip And Femur Surgery,3094,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,29272.57,,,,,,,fee schedule,29272.57,29272.57, Other Significant Hip And Femur Surgery,3094,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,29272.57,,,,,,,fee schedule,29272.57,29272.57, Intervertebral Disc Excision And Decompression,3101,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,9476.39,,,,,,,fee schedule,9476.39,9476.39, Intervertebral Disc Excision And Decompression,3101,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,9476.39,,,,,,,fee schedule,9476.39,9476.39, Intervertebral Disc Excision And Decompression,3101,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,9476.39,,,,,,,fee schedule,9476.39,9476.39, Intervertebral Disc Excision And Decompression,3101,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,9476.39,,,,,,,fee schedule,9476.39,9476.39, Intervertebral Disc Excision And Decompression,3101,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,9476.39,,,,,,,fee schedule,9476.39,9476.39, Intervertebral Disc Excision And Decompression,3101,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,9476.39,,,,,,,fee schedule,9476.39,9476.39, Intervertebral Disc Excision And Decompression,3101,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,9476.39,,,,,,,fee schedule,9476.39,9476.39, Intervertebral Disc Excision And Decompression,3101,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,9476.39,,,,,,,fee schedule,9476.39,9476.39, Intervertebral Disc Excision And Decompression,3101,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,9476.39,,,,,,,fee schedule,9476.39,9476.39, Intervertebral Disc Excision And Decompression,3101,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,9476.39,,,,,,,fee schedule,9476.39,9476.39, Intervertebral Disc Excision And Decompression,3101,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,9476.39,,,,,,,fee schedule,9476.39,9476.39, Intervertebral Disc Excision And Decompression,3102,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,12996.78,,,,,,,fee schedule,12996.78,12996.78, Intervertebral Disc Excision And Decompression,3102,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,12996.78,,,,,,,fee schedule,12996.78,12996.78, Intervertebral Disc Excision And Decompression,3102,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,12996.78,,,,,,,fee schedule,12996.78,12996.78, Intervertebral Disc Excision And Decompression,3102,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,12996.78,,,,,,,fee schedule,12996.78,12996.78, Intervertebral Disc Excision And Decompression,3102,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,12996.78,,,,,,,fee schedule,12996.78,12996.78, Intervertebral Disc Excision And Decompression,3102,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,12996.78,,,,,,,fee schedule,12996.78,12996.78, Intervertebral Disc Excision And Decompression,3102,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,12996.78,,,,,,,fee schedule,12996.78,12996.78, Intervertebral Disc Excision And Decompression,3102,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,12996.78,,,,,,,fee schedule,12996.78,12996.78, Intervertebral Disc Excision And Decompression,3102,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,12996.78,,,,,,,fee schedule,12996.78,12996.78, Intervertebral Disc Excision And Decompression,3102,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,12996.78,,,,,,,fee schedule,12996.78,12996.78, Intervertebral Disc Excision And Decompression,3102,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,12996.78,,,,,,,fee schedule,12996.78,12996.78, Intervertebral Disc Excision And Decompression,3103,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,18731.17,,,,,,,fee schedule,18731.17,18731.17, Intervertebral Disc Excision And Decompression,3103,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,18731.17,,,,,,,fee schedule,18731.17,18731.17, Intervertebral Disc Excision And Decompression,3103,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,18731.17,,,,,,,fee schedule,18731.17,18731.17, Intervertebral Disc Excision And Decompression,3103,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,18731.17,,,,,,,fee schedule,18731.17,18731.17, Intervertebral Disc Excision And Decompression,3103,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,18731.17,,,,,,,fee schedule,18731.17,18731.17, Intervertebral Disc Excision And Decompression,3103,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,18731.17,,,,,,,fee schedule,18731.17,18731.17, Intervertebral Disc Excision And Decompression,3103,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,18731.17,,,,,,,fee schedule,18731.17,18731.17, Intervertebral Disc Excision And Decompression,3103,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,18731.17,,,,,,,fee schedule,18731.17,18731.17, Intervertebral Disc Excision And Decompression,3103,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,18731.17,,,,,,,fee schedule,18731.17,18731.17, Intervertebral Disc Excision And Decompression,3103,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,18731.17,,,,,,,fee schedule,18731.17,18731.17, Intervertebral Disc Excision And Decompression,3103,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,18731.17,,,,,,,fee schedule,18731.17,18731.17, Intervertebral Disc Excision And Decompression,3104,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,27322.52,,,,,,,fee schedule,27322.52,27322.52, Intervertebral Disc Excision And Decompression,3104,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,27322.52,,,,,,,fee schedule,27322.52,27322.52, Intervertebral Disc Excision And Decompression,3104,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,27322.52,,,,,,,fee schedule,27322.52,27322.52, Intervertebral Disc Excision And Decompression,3104,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,27322.52,,,,,,,fee schedule,27322.52,27322.52, Intervertebral Disc Excision And Decompression,3104,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,27322.52,,,,,,,fee schedule,27322.52,27322.52, Intervertebral Disc Excision And Decompression,3104,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,27322.52,,,,,,,fee schedule,27322.52,27322.52, Intervertebral Disc Excision And Decompression,3104,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,27322.52,,,,,,,fee schedule,27322.52,27322.52, Intervertebral Disc Excision And Decompression,3104,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,27322.52,,,,,,,fee schedule,27322.52,27322.52, Intervertebral Disc Excision And Decompression,3104,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,27322.52,,,,,,,fee schedule,27322.52,27322.52, Intervertebral Disc Excision And Decompression,3104,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,27322.52,,,,,,,fee schedule,27322.52,27322.52, Intervertebral Disc Excision And Decompression,3104,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,27322.52,,,,,,,fee schedule,27322.52,27322.52, "Skin Graft, Except Hand, For Musculoskeletal And Connective Tissue Diagnoses",3121,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,11362.21,,,,,,,fee schedule,11362.21,11362.21, "Skin Graft, Except Hand, For Musculoskeletal And Connective Tissue Diagnoses",3121,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,11362.21,,,,,,,fee schedule,11362.21,11362.21, "Skin Graft, Except Hand, For Musculoskeletal And Connective Tissue Diagnoses",3121,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,11362.21,,,,,,,fee schedule,11362.21,11362.21, "Skin Graft, Except Hand, For Musculoskeletal And Connective Tissue Diagnoses",3121,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,11362.21,,,,,,,fee schedule,11362.21,11362.21, "Skin Graft, Except Hand, For Musculoskeletal And Connective Tissue Diagnoses",3121,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,11362.21,,,,,,,fee schedule,11362.21,11362.21, "Skin Graft, Except Hand, For Musculoskeletal And Connective Tissue Diagnoses",3121,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,11362.21,,,,,,,fee schedule,11362.21,11362.21, "Skin Graft, Except Hand, For Musculoskeletal And Connective Tissue Diagnoses",3121,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,11362.21,,,,,,,fee schedule,11362.21,11362.21, "Skin Graft, Except Hand, For Musculoskeletal And Connective Tissue Diagnoses",3121,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,11362.21,,,,,,,fee schedule,11362.21,11362.21, "Skin Graft, Except Hand, For Musculoskeletal And Connective Tissue Diagnoses",3121,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,11362.21,,,,,,,fee schedule,11362.21,11362.21, "Skin Graft, Except Hand, For Musculoskeletal And Connective Tissue Diagnoses",3121,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,11362.21,,,,,,,fee schedule,11362.21,11362.21, "Skin Graft, Except Hand, For Musculoskeletal And Connective Tissue Diagnoses",3121,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,11362.21,,,,,,,fee schedule,11362.21,11362.21, "Skin Graft, Except Hand, For Musculoskeletal And Connective Tissue Diagnoses",3122,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,16383.77,,,,,,,fee schedule,16383.77,16383.77, "Skin Graft, Except Hand, For Musculoskeletal And Connective Tissue Diagnoses",3122,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,16383.77,,,,,,,fee schedule,16383.77,16383.77, "Skin Graft, Except Hand, For Musculoskeletal And Connective Tissue Diagnoses",3122,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,16383.77,,,,,,,fee schedule,16383.77,16383.77, "Skin Graft, Except Hand, For Musculoskeletal And Connective Tissue Diagnoses",3122,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,16383.77,,,,,,,fee schedule,16383.77,16383.77, "Skin Graft, Except Hand, For Musculoskeletal And Connective Tissue Diagnoses",3122,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,16383.77,,,,,,,fee schedule,16383.77,16383.77, "Skin Graft, Except Hand, For Musculoskeletal And Connective Tissue Diagnoses",3122,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,16383.77,,,,,,,fee schedule,16383.77,16383.77, "Skin Graft, Except Hand, For Musculoskeletal And Connective Tissue Diagnoses",3122,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,16383.77,,,,,,,fee schedule,16383.77,16383.77, "Skin Graft, Except Hand, For Musculoskeletal And Connective Tissue Diagnoses",3122,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,16383.77,,,,,,,fee schedule,16383.77,16383.77, "Skin Graft, Except Hand, For Musculoskeletal And Connective Tissue Diagnoses",3122,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,16383.77,,,,,,,fee schedule,16383.77,16383.77, "Skin Graft, Except Hand, For Musculoskeletal And Connective Tissue Diagnoses",3122,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,16383.77,,,,,,,fee schedule,16383.77,16383.77, "Skin Graft, Except Hand, For Musculoskeletal And Connective Tissue Diagnoses",3122,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,16383.77,,,,,,,fee schedule,16383.77,16383.77, "Skin Graft, Except Hand, For Musculoskeletal And Connective Tissue Diagnoses",3123,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,25075.35,,,,,,,fee schedule,25075.35,25075.35, "Skin Graft, Except Hand, For Musculoskeletal And Connective Tissue Diagnoses",3123,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,25075.35,,,,,,,fee schedule,25075.35,25075.35, "Skin Graft, Except Hand, For Musculoskeletal And Connective Tissue Diagnoses",3123,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,25075.35,,,,,,,fee schedule,25075.35,25075.35, "Skin Graft, Except Hand, For Musculoskeletal And Connective Tissue Diagnoses",3123,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,25075.35,,,,,,,fee schedule,25075.35,25075.35, "Skin Graft, Except Hand, For Musculoskeletal And Connective Tissue Diagnoses",3123,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,25075.35,,,,,,,fee schedule,25075.35,25075.35, "Skin Graft, Except Hand, For Musculoskeletal And Connective Tissue Diagnoses",3123,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,25075.35,,,,,,,fee schedule,25075.35,25075.35, "Skin Graft, Except Hand, For Musculoskeletal And Connective Tissue Diagnoses",3123,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,25075.35,,,,,,,fee schedule,25075.35,25075.35, "Skin Graft, Except Hand, For Musculoskeletal And Connective Tissue Diagnoses",3123,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,25075.35,,,,,,,fee schedule,25075.35,25075.35, "Skin Graft, Except Hand, For Musculoskeletal And Connective Tissue Diagnoses",3123,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,25075.35,,,,,,,fee schedule,25075.35,25075.35, "Skin Graft, Except Hand, For Musculoskeletal And Connective Tissue Diagnoses",3123,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,25075.35,,,,,,,fee schedule,25075.35,25075.35, "Skin Graft, Except Hand, For Musculoskeletal And Connective Tissue Diagnoses",3123,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,25075.35,,,,,,,fee schedule,25075.35,25075.35, "Skin Graft, Except Hand, For Musculoskeletal And Connective Tissue Diagnoses",3124,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,40835.22,,,,,,,fee schedule,40835.22,40835.22, "Skin Graft, Except Hand, For Musculoskeletal And Connective Tissue Diagnoses",3124,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,40835.22,,,,,,,fee schedule,40835.22,40835.22, "Skin Graft, Except Hand, For Musculoskeletal And Connective Tissue Diagnoses",3124,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,40835.22,,,,,,,fee schedule,40835.22,40835.22, "Skin Graft, Except Hand, For Musculoskeletal And Connective Tissue Diagnoses",3124,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,40835.22,,,,,,,fee schedule,40835.22,40835.22, "Skin Graft, Except Hand, For Musculoskeletal And Connective Tissue Diagnoses",3124,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,40835.22,,,,,,,fee schedule,40835.22,40835.22, "Skin Graft, Except Hand, For Musculoskeletal And Connective Tissue Diagnoses",3124,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,40835.22,,,,,,,fee schedule,40835.22,40835.22, "Skin Graft, Except Hand, For Musculoskeletal And Connective Tissue Diagnoses",3124,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,40835.22,,,,,,,fee schedule,40835.22,40835.22, "Skin Graft, Except Hand, For Musculoskeletal And Connective Tissue Diagnoses",3124,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,40835.22,,,,,,,fee schedule,40835.22,40835.22, "Skin Graft, Except Hand, For Musculoskeletal And Connective Tissue Diagnoses",3124,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,40835.22,,,,,,,fee schedule,40835.22,40835.22, "Skin Graft, Except Hand, For Musculoskeletal And Connective Tissue Diagnoses",3124,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,40835.22,,,,,,,fee schedule,40835.22,40835.22, "Skin Graft, Except Hand, For Musculoskeletal And Connective Tissue Diagnoses",3124,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,40835.22,,,,,,,fee schedule,40835.22,40835.22, Knee And Lower Leg Procedures Except Foot,3131,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,10484.23,,,,,,,fee schedule,10484.23,10484.23, Knee And Lower Leg Procedures Except Foot,3131,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,10484.23,,,,,,,fee schedule,10484.23,10484.23, Knee And Lower Leg Procedures Except Foot,3131,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,10484.23,,,,,,,fee schedule,10484.23,10484.23, Knee And Lower Leg Procedures Except Foot,3131,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,10484.23,,,,,,,fee schedule,10484.23,10484.23, Knee And Lower Leg Procedures Except Foot,3131,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,10484.23,,,,,,,fee schedule,10484.23,10484.23, Knee And Lower Leg Procedures Except Foot,3131,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,10484.23,,,,,,,fee schedule,10484.23,10484.23, Knee And Lower Leg Procedures Except Foot,3131,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,10484.23,,,,,,,fee schedule,10484.23,10484.23, Knee And Lower Leg Procedures Except Foot,3131,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,10484.23,,,,,,,fee schedule,10484.23,10484.23, Knee And Lower Leg Procedures Except Foot,3131,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,10484.23,,,,,,,fee schedule,10484.23,10484.23, Knee And Lower Leg Procedures Except Foot,3131,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,10484.23,,,,,,,fee schedule,10484.23,10484.23, Knee And Lower Leg Procedures Except Foot,3131,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,10484.23,,,,,,,fee schedule,10484.23,10484.23, Knee And Lower Leg Procedures Except Foot,3132,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,13967.92,,,,,,,fee schedule,13967.92,13967.92, Knee And Lower Leg Procedures Except Foot,3132,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,13967.92,,,,,,,fee schedule,13967.92,13967.92, Knee And Lower Leg Procedures Except Foot,3132,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,13967.92,,,,,,,fee schedule,13967.92,13967.92, Knee And Lower Leg Procedures Except Foot,3132,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,13967.92,,,,,,,fee schedule,13967.92,13967.92, Knee And Lower Leg Procedures Except Foot,3132,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,13967.92,,,,,,,fee schedule,13967.92,13967.92, Knee And Lower Leg Procedures Except Foot,3132,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,13967.92,,,,,,,fee schedule,13967.92,13967.92, Knee And Lower Leg Procedures Except Foot,3132,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,13967.92,,,,,,,fee schedule,13967.92,13967.92, Knee And Lower Leg Procedures Except Foot,3132,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,13967.92,,,,,,,fee schedule,13967.92,13967.92, Knee And Lower Leg Procedures Except Foot,3132,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,13967.92,,,,,,,fee schedule,13967.92,13967.92, Knee And Lower Leg Procedures Except Foot,3132,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,13967.92,,,,,,,fee schedule,13967.92,13967.92, Knee And Lower Leg Procedures Except Foot,3132,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,13967.92,,,,,,,fee schedule,13967.92,13967.92, Knee And Lower Leg Procedures Except Foot,3133,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,19839.23,,,,,,,fee schedule,19839.23,19839.23, Knee And Lower Leg Procedures Except Foot,3133,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,19839.23,,,,,,,fee schedule,19839.23,19839.23, Knee And Lower Leg Procedures Except Foot,3133,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,19839.23,,,,,,,fee schedule,19839.23,19839.23, Knee And Lower Leg Procedures Except Foot,3133,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,19839.23,,,,,,,fee schedule,19839.23,19839.23, Knee And Lower Leg Procedures Except Foot,3133,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,19839.23,,,,,,,fee schedule,19839.23,19839.23, Knee And Lower Leg Procedures Except Foot,3133,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,19839.23,,,,,,,fee schedule,19839.23,19839.23, Knee And Lower Leg Procedures Except Foot,3133,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,19839.23,,,,,,,fee schedule,19839.23,19839.23, Knee And Lower Leg Procedures Except Foot,3133,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,19839.23,,,,,,,fee schedule,19839.23,19839.23, Knee And Lower Leg Procedures Except Foot,3133,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,19839.23,,,,,,,fee schedule,19839.23,19839.23, Knee And Lower Leg Procedures Except Foot,3133,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,19839.23,,,,,,,fee schedule,19839.23,19839.23, Knee And Lower Leg Procedures Except Foot,3133,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,19839.23,,,,,,,fee schedule,19839.23,19839.23, Knee And Lower Leg Procedures Except Foot,3134,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,29347.38,,,,,,,fee schedule,29347.38,29347.38, Knee And Lower Leg Procedures Except Foot,3134,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,29347.38,,,,,,,fee schedule,29347.38,29347.38, Knee And Lower Leg Procedures Except Foot,3134,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,29347.38,,,,,,,fee schedule,29347.38,29347.38, Knee And Lower Leg Procedures Except Foot,3134,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,29347.38,,,,,,,fee schedule,29347.38,29347.38, Knee And Lower Leg Procedures Except Foot,3134,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,29347.38,,,,,,,fee schedule,29347.38,29347.38, Knee And Lower Leg Procedures Except Foot,3134,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,29347.38,,,,,,,fee schedule,29347.38,29347.38, Knee And Lower Leg Procedures Except Foot,3134,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,29347.38,,,,,,,fee schedule,29347.38,29347.38, Knee And Lower Leg Procedures Except Foot,3134,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,29347.38,,,,,,,fee schedule,29347.38,29347.38, Knee And Lower Leg Procedures Except Foot,3134,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,29347.38,,,,,,,fee schedule,29347.38,29347.38, Knee And Lower Leg Procedures Except Foot,3134,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,29347.38,,,,,,,fee schedule,29347.38,29347.38, Knee And Lower Leg Procedures Except Foot,3134,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,29347.38,,,,,,,fee schedule,29347.38,29347.38, Foot And Toe Procedures,3141,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,7287.09,,,,,,,fee schedule,7287.09,7287.09, Foot And Toe Procedures,3141,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,7287.09,,,,,,,fee schedule,7287.09,7287.09, Foot And Toe Procedures,3141,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,7287.09,,,,,,,fee schedule,7287.09,7287.09, Foot And Toe Procedures,3141,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,7287.09,,,,,,,fee schedule,7287.09,7287.09, Foot And Toe Procedures,3141,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,7287.09,,,,,,,fee schedule,7287.09,7287.09, Foot And Toe Procedures,3141,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,7287.09,,,,,,,fee schedule,7287.09,7287.09, Foot And Toe Procedures,3141,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,7287.09,,,,,,,fee schedule,7287.09,7287.09, Foot And Toe Procedures,3141,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,7287.09,,,,,,,fee schedule,7287.09,7287.09, Foot And Toe Procedures,3141,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,7287.09,,,,,,,fee schedule,7287.09,7287.09, Foot And Toe Procedures,3141,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,7287.09,,,,,,,fee schedule,7287.09,7287.09, Foot And Toe Procedures,3141,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,7287.09,,,,,,,fee schedule,7287.09,7287.09, Foot And Toe Procedures,3142,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,9605.55,,,,,,,fee schedule,9605.55,9605.55, Foot And Toe Procedures,3142,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,9605.55,,,,,,,fee schedule,9605.55,9605.55, Foot And Toe Procedures,3142,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,9605.55,,,,,,,fee schedule,9605.55,9605.55, Foot And Toe Procedures,3142,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,9605.55,,,,,,,fee schedule,9605.55,9605.55, Foot And Toe Procedures,3142,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,9605.55,,,,,,,fee schedule,9605.55,9605.55, Foot And Toe Procedures,3142,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,9605.55,,,,,,,fee schedule,9605.55,9605.55, Foot And Toe Procedures,3142,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,9605.55,,,,,,,fee schedule,9605.55,9605.55, Foot And Toe Procedures,3142,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,9605.55,,,,,,,fee schedule,9605.55,9605.55, Foot And Toe Procedures,3142,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,9605.55,,,,,,,fee schedule,9605.55,9605.55, Foot And Toe Procedures,3142,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,9605.55,,,,,,,fee schedule,9605.55,9605.55, Foot And Toe Procedures,3142,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,9605.55,,,,,,,fee schedule,9605.55,9605.55, Foot And Toe Procedures,3143,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,14452.78,,,,,,,fee schedule,14452.78,14452.78, Foot And Toe Procedures,3143,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,14452.78,,,,,,,fee schedule,14452.78,14452.78, Foot And Toe Procedures,3143,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,14452.78,,,,,,,fee schedule,14452.78,14452.78, Foot And Toe Procedures,3143,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,14452.78,,,,,,,fee schedule,14452.78,14452.78, Foot And Toe Procedures,3143,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,14452.78,,,,,,,fee schedule,14452.78,14452.78, Foot And Toe Procedures,3143,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,14452.78,,,,,,,fee schedule,14452.78,14452.78, Foot And Toe Procedures,3143,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,14452.78,,,,,,,fee schedule,14452.78,14452.78, Foot And Toe Procedures,3143,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,14452.78,,,,,,,fee schedule,14452.78,14452.78, Foot And Toe Procedures,3143,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,14452.78,,,,,,,fee schedule,14452.78,14452.78, Foot And Toe Procedures,3143,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,14452.78,,,,,,,fee schedule,14452.78,14452.78, Foot And Toe Procedures,3143,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,14452.78,,,,,,,fee schedule,14452.78,14452.78, Foot And Toe Procedures,3144,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,23183.88,,,,,,,fee schedule,23183.88,23183.88, Foot And Toe Procedures,3144,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,23183.88,,,,,,,fee schedule,23183.88,23183.88, Foot And Toe Procedures,3144,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,23183.88,,,,,,,fee schedule,23183.88,23183.88, Foot And Toe Procedures,3144,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,23183.88,,,,,,,fee schedule,23183.88,23183.88, Foot And Toe Procedures,3144,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,23183.88,,,,,,,fee schedule,23183.88,23183.88, Foot And Toe Procedures,3144,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,23183.88,,,,,,,fee schedule,23183.88,23183.88, Foot And Toe Procedures,3144,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,23183.88,,,,,,,fee schedule,23183.88,23183.88, Foot And Toe Procedures,3144,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,23183.88,,,,,,,fee schedule,23183.88,23183.88, Foot And Toe Procedures,3144,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,23183.88,,,,,,,fee schedule,23183.88,23183.88, Foot And Toe Procedures,3144,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,23183.88,,,,,,,fee schedule,23183.88,23183.88, Foot And Toe Procedures,3144,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,23183.88,,,,,,,fee schedule,23183.88,23183.88, "Shoulder, Upper Arm And Forearm Procedures Except Joint Replacement",3151,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,9361.35,,,,,,,fee schedule,9361.35,9361.35, "Shoulder, Upper Arm And Forearm Procedures Except Joint Replacement",3151,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,9361.35,,,,,,,fee schedule,9361.35,9361.35, "Shoulder, Upper Arm And Forearm Procedures Except Joint Replacement",3151,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,9361.35,,,,,,,fee schedule,9361.35,9361.35, "Shoulder, Upper Arm And Forearm Procedures Except Joint Replacement",3151,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,9361.35,,,,,,,fee schedule,9361.35,9361.35, "Shoulder, Upper Arm And Forearm Procedures Except Joint Replacement",3151,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,9361.35,,,,,,,fee schedule,9361.35,9361.35, "Shoulder, Upper Arm And Forearm Procedures Except Joint Replacement",3151,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,9361.35,,,,,,,fee schedule,9361.35,9361.35, "Shoulder, Upper Arm And Forearm Procedures Except Joint Replacement",3151,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,9361.35,,,,,,,fee schedule,9361.35,9361.35, "Shoulder, Upper Arm And Forearm Procedures Except Joint Replacement",3151,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,9361.35,,,,,,,fee schedule,9361.35,9361.35, "Shoulder, Upper Arm And Forearm Procedures Except Joint Replacement",3151,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,9361.35,,,,,,,fee schedule,9361.35,9361.35, "Shoulder, Upper Arm And Forearm Procedures Except Joint Replacement",3151,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,9361.35,,,,,,,fee schedule,9361.35,9361.35, "Shoulder, Upper Arm And Forearm Procedures Except Joint Replacement",3151,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,9361.35,,,,,,,fee schedule,9361.35,9361.35, "Shoulder, Upper Arm And Forearm Procedures Except Joint Replacement",3152,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,13601.62,,,,,,,fee schedule,13601.62,13601.62, "Shoulder, Upper Arm And Forearm Procedures Except Joint Replacement",3152,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,13601.62,,,,,,,fee schedule,13601.62,13601.62, "Shoulder, Upper Arm And Forearm Procedures Except Joint Replacement",3152,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,13601.62,,,,,,,fee schedule,13601.62,13601.62, "Shoulder, Upper Arm And Forearm Procedures Except Joint Replacement",3152,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,13601.62,,,,,,,fee schedule,13601.62,13601.62, "Shoulder, Upper Arm And Forearm Procedures Except Joint Replacement",3152,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,13601.62,,,,,,,fee schedule,13601.62,13601.62, "Shoulder, Upper Arm And Forearm Procedures Except Joint Replacement",3152,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,13601.62,,,,,,,fee schedule,13601.62,13601.62, "Shoulder, Upper Arm And Forearm Procedures Except Joint Replacement",3152,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,13601.62,,,,,,,fee schedule,13601.62,13601.62, "Shoulder, Upper Arm And Forearm Procedures Except Joint Replacement",3152,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,13601.62,,,,,,,fee schedule,13601.62,13601.62, "Shoulder, Upper Arm And Forearm Procedures Except Joint Replacement",3152,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,13601.62,,,,,,,fee schedule,13601.62,13601.62, "Shoulder, Upper Arm And Forearm Procedures Except Joint Replacement",3152,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,13601.62,,,,,,,fee schedule,13601.62,13601.62, "Shoulder, Upper Arm And Forearm Procedures Except Joint Replacement",3152,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,13601.62,,,,,,,fee schedule,13601.62,13601.62, "Shoulder, Upper Arm And Forearm Procedures Except Joint Replacement",3153,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,18404.4,,,,,,,fee schedule,18404.4,18404.4, "Shoulder, Upper Arm And Forearm Procedures Except Joint Replacement",3153,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,18404.4,,,,,,,fee schedule,18404.4,18404.4, "Shoulder, Upper Arm And Forearm Procedures Except Joint Replacement",3153,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,18404.4,,,,,,,fee schedule,18404.4,18404.4, "Shoulder, Upper Arm And Forearm Procedures Except Joint Replacement",3153,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,18404.4,,,,,,,fee schedule,18404.4,18404.4, "Shoulder, Upper Arm And Forearm Procedures Except Joint Replacement",3153,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,18404.4,,,,,,,fee schedule,18404.4,18404.4, "Shoulder, Upper Arm And Forearm Procedures Except Joint Replacement",3153,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,18404.4,,,,,,,fee schedule,18404.4,18404.4, "Shoulder, Upper Arm And Forearm Procedures Except Joint Replacement",3153,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,18404.4,,,,,,,fee schedule,18404.4,18404.4, "Shoulder, Upper Arm And Forearm Procedures Except Joint Replacement",3153,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,18404.4,,,,,,,fee schedule,18404.4,18404.4, "Shoulder, Upper Arm And Forearm Procedures Except Joint Replacement",3153,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,18404.4,,,,,,,fee schedule,18404.4,18404.4, "Shoulder, Upper Arm And Forearm Procedures Except Joint Replacement",3153,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,18404.4,,,,,,,fee schedule,18404.4,18404.4, "Shoulder, Upper Arm And Forearm Procedures Except Joint Replacement",3153,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,18404.4,,,,,,,fee schedule,18404.4,18404.4, "Shoulder, Upper Arm And Forearm Procedures Except Joint Replacement",3154,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,28825.82,,,,,,,fee schedule,28825.82,28825.82, "Shoulder, Upper Arm And Forearm Procedures Except Joint Replacement",3154,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,28825.82,,,,,,,fee schedule,28825.82,28825.82, "Shoulder, Upper Arm And Forearm Procedures Except Joint Replacement",3154,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,28825.82,,,,,,,fee schedule,28825.82,28825.82, "Shoulder, Upper Arm And Forearm Procedures Except Joint Replacement",3154,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,28825.82,,,,,,,fee schedule,28825.82,28825.82, "Shoulder, Upper Arm And Forearm Procedures Except Joint Replacement",3154,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,28825.82,,,,,,,fee schedule,28825.82,28825.82, "Shoulder, Upper Arm And Forearm Procedures Except Joint Replacement",3154,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,28825.82,,,,,,,fee schedule,28825.82,28825.82, "Shoulder, Upper Arm And Forearm Procedures Except Joint Replacement",3154,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,28825.82,,,,,,,fee schedule,28825.82,28825.82, "Shoulder, Upper Arm And Forearm Procedures Except Joint Replacement",3154,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,28825.82,,,,,,,fee schedule,28825.82,28825.82, "Shoulder, Upper Arm And Forearm Procedures Except Joint Replacement",3154,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,28825.82,,,,,,,fee schedule,28825.82,28825.82, "Shoulder, Upper Arm And Forearm Procedures Except Joint Replacement",3154,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,28825.82,,,,,,,fee schedule,28825.82,28825.82, "Shoulder, Upper Arm And Forearm Procedures Except Joint Replacement",3154,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,28825.82,,,,,,,fee schedule,28825.82,28825.82, Hand And Wrist Procedures,3161,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,7354.84,,,,,,,fee schedule,7354.84,7354.84, Hand And Wrist Procedures,3161,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,7354.84,,,,,,,fee schedule,7354.84,7354.84, Hand And Wrist Procedures,3161,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,7354.84,,,,,,,fee schedule,7354.84,7354.84, Hand And Wrist Procedures,3161,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,7354.84,,,,,,,fee schedule,7354.84,7354.84, Hand And Wrist Procedures,3161,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,7354.84,,,,,,,fee schedule,7354.84,7354.84, Hand And Wrist Procedures,3161,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,7354.84,,,,,,,fee schedule,7354.84,7354.84, Hand And Wrist Procedures,3161,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,7354.84,,,,,,,fee schedule,7354.84,7354.84, Hand And Wrist Procedures,3161,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,7354.84,,,,,,,fee schedule,7354.84,7354.84, Hand And Wrist Procedures,3161,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,7354.84,,,,,,,fee schedule,7354.84,7354.84, Hand And Wrist Procedures,3161,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,7354.84,,,,,,,fee schedule,7354.84,7354.84, Hand And Wrist Procedures,3161,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,7354.84,,,,,,,fee schedule,7354.84,7354.84, Hand And Wrist Procedures,3162,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,9837.75,,,,,,,fee schedule,9837.75,9837.75, Hand And Wrist Procedures,3162,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,9837.75,,,,,,,fee schedule,9837.75,9837.75, Hand And Wrist Procedures,3162,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,9837.75,,,,,,,fee schedule,9837.75,9837.75, Hand And Wrist Procedures,3162,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,9837.75,,,,,,,fee schedule,9837.75,9837.75, Hand And Wrist Procedures,3162,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,9837.75,,,,,,,fee schedule,9837.75,9837.75, Hand And Wrist Procedures,3162,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,9837.75,,,,,,,fee schedule,9837.75,9837.75, Hand And Wrist Procedures,3162,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,9837.75,,,,,,,fee schedule,9837.75,9837.75, Hand And Wrist Procedures,3162,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,9837.75,,,,,,,fee schedule,9837.75,9837.75, Hand And Wrist Procedures,3162,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,9837.75,,,,,,,fee schedule,9837.75,9837.75, Hand And Wrist Procedures,3162,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,9837.75,,,,,,,fee schedule,9837.75,9837.75, Hand And Wrist Procedures,3162,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,9837.75,,,,,,,fee schedule,9837.75,9837.75, Hand And Wrist Procedures,3163,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,14704.04,,,,,,,fee schedule,14704.04,14704.04, Hand And Wrist Procedures,3163,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,14704.04,,,,,,,fee schedule,14704.04,14704.04, Hand And Wrist Procedures,3163,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,14704.04,,,,,,,fee schedule,14704.04,14704.04, Hand And Wrist Procedures,3163,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,14704.04,,,,,,,fee schedule,14704.04,14704.04, Hand And Wrist Procedures,3163,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,14704.04,,,,,,,fee schedule,14704.04,14704.04, Hand And Wrist Procedures,3163,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,14704.04,,,,,,,fee schedule,14704.04,14704.04, Hand And Wrist Procedures,3163,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,14704.04,,,,,,,fee schedule,14704.04,14704.04, Hand And Wrist Procedures,3163,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,14704.04,,,,,,,fee schedule,14704.04,14704.04, Hand And Wrist Procedures,3163,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,14704.04,,,,,,,fee schedule,14704.04,14704.04, Hand And Wrist Procedures,3163,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,14704.04,,,,,,,fee schedule,14704.04,14704.04, Hand And Wrist Procedures,3163,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,14704.04,,,,,,,fee schedule,14704.04,14704.04, Hand And Wrist Procedures,3164,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,23361.73,,,,,,,fee schedule,23361.73,23361.73, Hand And Wrist Procedures,3164,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,23361.73,,,,,,,fee schedule,23361.73,23361.73, Hand And Wrist Procedures,3164,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,23361.73,,,,,,,fee schedule,23361.73,23361.73, Hand And Wrist Procedures,3164,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,23361.73,,,,,,,fee schedule,23361.73,23361.73, Hand And Wrist Procedures,3164,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,23361.73,,,,,,,fee schedule,23361.73,23361.73, Hand And Wrist Procedures,3164,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,23361.73,,,,,,,fee schedule,23361.73,23361.73, Hand And Wrist Procedures,3164,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,23361.73,,,,,,,fee schedule,23361.73,23361.73, Hand And Wrist Procedures,3164,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,23361.73,,,,,,,fee schedule,23361.73,23361.73, Hand And Wrist Procedures,3164,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,23361.73,,,,,,,fee schedule,23361.73,23361.73, Hand And Wrist Procedures,3164,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,23361.73,,,,,,,fee schedule,23361.73,23361.73, Hand And Wrist Procedures,3164,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,23361.73,,,,,,,fee schedule,23361.73,23361.73, "Tendon, Muscle And Other Soft Tissue Procedures",3171,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,8051.44,,,,,,,fee schedule,8051.44,8051.44, "Tendon, Muscle And Other Soft Tissue Procedures",3171,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,8051.44,,,,,,,fee schedule,8051.44,8051.44, "Tendon, Muscle And Other Soft Tissue Procedures",3171,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,8051.44,,,,,,,fee schedule,8051.44,8051.44, "Tendon, Muscle And Other Soft Tissue Procedures",3171,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,8051.44,,,,,,,fee schedule,8051.44,8051.44, "Tendon, Muscle And Other Soft Tissue Procedures",3171,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,8051.44,,,,,,,fee schedule,8051.44,8051.44, "Tendon, Muscle And Other Soft Tissue Procedures",3171,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,8051.44,,,,,,,fee schedule,8051.44,8051.44, "Tendon, Muscle And Other Soft Tissue Procedures",3171,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,8051.44,,,,,,,fee schedule,8051.44,8051.44, "Tendon, Muscle And Other Soft Tissue Procedures",3171,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,8051.44,,,,,,,fee schedule,8051.44,8051.44, "Tendon, Muscle And Other Soft Tissue Procedures",3171,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,8051.44,,,,,,,fee schedule,8051.44,8051.44, "Tendon, Muscle And Other Soft Tissue Procedures",3171,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,8051.44,,,,,,,fee schedule,8051.44,8051.44, "Tendon, Muscle And Other Soft Tissue Procedures",3171,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,8051.44,,,,,,,fee schedule,8051.44,8051.44, "Tendon, Muscle And Other Soft Tissue Procedures",3172,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,10726.31,,,,,,,fee schedule,10726.31,10726.31, "Tendon, Muscle And Other Soft Tissue Procedures",3172,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,10726.31,,,,,,,fee schedule,10726.31,10726.31, "Tendon, Muscle And Other Soft Tissue Procedures",3172,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,10726.31,,,,,,,fee schedule,10726.31,10726.31, "Tendon, Muscle And Other Soft Tissue Procedures",3172,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,10726.31,,,,,,,fee schedule,10726.31,10726.31, "Tendon, Muscle And Other Soft Tissue Procedures",3172,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,10726.31,,,,,,,fee schedule,10726.31,10726.31, "Tendon, Muscle And Other Soft Tissue Procedures",3172,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,10726.31,,,,,,,fee schedule,10726.31,10726.31, "Tendon, Muscle And Other Soft Tissue Procedures",3172,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,10726.31,,,,,,,fee schedule,10726.31,10726.31, "Tendon, Muscle And Other Soft Tissue Procedures",3172,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,10726.31,,,,,,,fee schedule,10726.31,10726.31, "Tendon, Muscle And Other Soft Tissue Procedures",3172,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,10726.31,,,,,,,fee schedule,10726.31,10726.31, "Tendon, Muscle And Other Soft Tissue Procedures",3172,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,10726.31,,,,,,,fee schedule,10726.31,10726.31, "Tendon, Muscle And Other Soft Tissue Procedures",3172,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,10726.31,,,,,,,fee schedule,10726.31,10726.31, "Tendon, Muscle And Other Soft Tissue Procedures",3173,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,15303.94,,,,,,,fee schedule,15303.94,15303.94, "Tendon, Muscle And Other Soft Tissue Procedures",3173,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,15303.94,,,,,,,fee schedule,15303.94,15303.94, "Tendon, Muscle And Other Soft Tissue Procedures",3173,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,15303.94,,,,,,,fee schedule,15303.94,15303.94, "Tendon, Muscle And Other Soft Tissue Procedures",3173,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,15303.94,,,,,,,fee schedule,15303.94,15303.94, "Tendon, Muscle And Other Soft Tissue Procedures",3173,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,15303.94,,,,,,,fee schedule,15303.94,15303.94, "Tendon, Muscle And Other Soft Tissue Procedures",3173,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,15303.94,,,,,,,fee schedule,15303.94,15303.94, "Tendon, Muscle And Other Soft Tissue Procedures",3173,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,15303.94,,,,,,,fee schedule,15303.94,15303.94, "Tendon, Muscle And Other Soft Tissue Procedures",3173,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,15303.94,,,,,,,fee schedule,15303.94,15303.94, "Tendon, Muscle And Other Soft Tissue Procedures",3173,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,15303.94,,,,,,,fee schedule,15303.94,15303.94, "Tendon, Muscle And Other Soft Tissue Procedures",3173,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,15303.94,,,,,,,fee schedule,15303.94,15303.94, "Tendon, Muscle And Other Soft Tissue Procedures",3173,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,15303.94,,,,,,,fee schedule,15303.94,15303.94, "Tendon, Muscle And Other Soft Tissue Procedures",3174,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,26141.77,,,,,,,fee schedule,26141.77,26141.77, "Tendon, Muscle And Other Soft Tissue Procedures",3174,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,26141.77,,,,,,,fee schedule,26141.77,26141.77, "Tendon, Muscle And Other Soft Tissue Procedures",3174,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,26141.77,,,,,,,fee schedule,26141.77,26141.77, "Tendon, Muscle And Other Soft Tissue Procedures",3174,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,26141.77,,,,,,,fee schedule,26141.77,26141.77, "Tendon, Muscle And Other Soft Tissue Procedures",3174,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,26141.77,,,,,,,fee schedule,26141.77,26141.77, "Tendon, Muscle And Other Soft Tissue Procedures",3174,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,26141.77,,,,,,,fee schedule,26141.77,26141.77, "Tendon, Muscle And Other Soft Tissue Procedures",3174,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,26141.77,,,,,,,fee schedule,26141.77,26141.77, "Tendon, Muscle And Other Soft Tissue Procedures",3174,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,26141.77,,,,,,,fee schedule,26141.77,26141.77, "Tendon, Muscle And Other Soft Tissue Procedures",3174,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,26141.77,,,,,,,fee schedule,26141.77,26141.77, "Tendon, Muscle And Other Soft Tissue Procedures",3174,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,26141.77,,,,,,,fee schedule,26141.77,26141.77, "Tendon, Muscle And Other Soft Tissue Procedures",3174,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,26141.77,,,,,,,fee schedule,26141.77,26141.77, Other Musculoskeletal System And Connective Tissue Procedures,3201,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,8899.07,,,,,,,fee schedule,8899.07,8899.07, Other Musculoskeletal System And Connective Tissue Procedures,3201,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,8899.07,,,,,,,fee schedule,8899.07,8899.07, Other Musculoskeletal System And Connective Tissue Procedures,3201,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,8899.07,,,,,,,fee schedule,8899.07,8899.07, Other Musculoskeletal System And Connective Tissue Procedures,3201,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,8899.07,,,,,,,fee schedule,8899.07,8899.07, Other Musculoskeletal System And Connective Tissue Procedures,3201,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,8899.07,,,,,,,fee schedule,8899.07,8899.07, Other Musculoskeletal System And Connective Tissue Procedures,3201,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,8899.07,,,,,,,fee schedule,8899.07,8899.07, Other Musculoskeletal System And Connective Tissue Procedures,3201,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,8899.07,,,,,,,fee schedule,8899.07,8899.07, Other Musculoskeletal System And Connective Tissue Procedures,3201,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,8899.07,,,,,,,fee schedule,8899.07,8899.07, Other Musculoskeletal System And Connective Tissue Procedures,3201,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,8899.07,,,,,,,fee schedule,8899.07,8899.07, Other Musculoskeletal System And Connective Tissue Procedures,3201,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,8899.07,,,,,,,fee schedule,8899.07,8899.07, Other Musculoskeletal System And Connective Tissue Procedures,3201,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,8899.07,,,,,,,fee schedule,8899.07,8899.07, Other Musculoskeletal System And Connective Tissue Procedures,3202,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,12431.45,,,,,,,fee schedule,12431.45,12431.45, Other Musculoskeletal System And Connective Tissue Procedures,3202,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,12431.45,,,,,,,fee schedule,12431.45,12431.45, Other Musculoskeletal System And Connective Tissue Procedures,3202,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,12431.45,,,,,,,fee schedule,12431.45,12431.45, Other Musculoskeletal System And Connective Tissue Procedures,3202,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,12431.45,,,,,,,fee schedule,12431.45,12431.45, Other Musculoskeletal System And Connective Tissue Procedures,3202,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,12431.45,,,,,,,fee schedule,12431.45,12431.45, Other Musculoskeletal System And Connective Tissue Procedures,3202,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,12431.45,,,,,,,fee schedule,12431.45,12431.45, Other Musculoskeletal System And Connective Tissue Procedures,3202,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,12431.45,,,,,,,fee schedule,12431.45,12431.45, Other Musculoskeletal System And Connective Tissue Procedures,3202,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,12431.45,,,,,,,fee schedule,12431.45,12431.45, Other Musculoskeletal System And Connective Tissue Procedures,3202,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,12431.45,,,,,,,fee schedule,12431.45,12431.45, Other Musculoskeletal System And Connective Tissue Procedures,3202,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,12431.45,,,,,,,fee schedule,12431.45,12431.45, Other Musculoskeletal System And Connective Tissue Procedures,3202,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,12431.45,,,,,,,fee schedule,12431.45,12431.45, Other Musculoskeletal System And Connective Tissue Procedures,3203,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,17884.95,,,,,,,fee schedule,17884.95,17884.95, Other Musculoskeletal System And Connective Tissue Procedures,3203,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,17884.95,,,,,,,fee schedule,17884.95,17884.95, Other Musculoskeletal System And Connective Tissue Procedures,3203,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,17884.95,,,,,,,fee schedule,17884.95,17884.95, Other Musculoskeletal System And Connective Tissue Procedures,3203,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,17884.95,,,,,,,fee schedule,17884.95,17884.95, Other Musculoskeletal System And Connective Tissue Procedures,3203,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,17884.95,,,,,,,fee schedule,17884.95,17884.95, Other Musculoskeletal System And Connective Tissue Procedures,3203,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,17884.95,,,,,,,fee schedule,17884.95,17884.95, Other Musculoskeletal System And Connective Tissue Procedures,3203,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,17884.95,,,,,,,fee schedule,17884.95,17884.95, Other Musculoskeletal System And Connective Tissue Procedures,3203,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,17884.95,,,,,,,fee schedule,17884.95,17884.95, Other Musculoskeletal System And Connective Tissue Procedures,3203,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,17884.95,,,,,,,fee schedule,17884.95,17884.95, Other Musculoskeletal System And Connective Tissue Procedures,3203,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,17884.95,,,,,,,fee schedule,17884.95,17884.95, Other Musculoskeletal System And Connective Tissue Procedures,3203,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,17884.95,,,,,,,fee schedule,17884.95,17884.95, Other Musculoskeletal System And Connective Tissue Procedures,3204,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,27309.11,,,,,,,fee schedule,27309.11,27309.11, Other Musculoskeletal System And Connective Tissue Procedures,3204,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,27309.11,,,,,,,fee schedule,27309.11,27309.11, Other Musculoskeletal System And Connective Tissue Procedures,3204,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,27309.11,,,,,,,fee schedule,27309.11,27309.11, Other Musculoskeletal System And Connective Tissue Procedures,3204,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,27309.11,,,,,,,fee schedule,27309.11,27309.11, Other Musculoskeletal System And Connective Tissue Procedures,3204,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,27309.11,,,,,,,fee schedule,27309.11,27309.11, Other Musculoskeletal System And Connective Tissue Procedures,3204,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,27309.11,,,,,,,fee schedule,27309.11,27309.11, Other Musculoskeletal System And Connective Tissue Procedures,3204,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,27309.11,,,,,,,fee schedule,27309.11,27309.11, Other Musculoskeletal System And Connective Tissue Procedures,3204,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,27309.11,,,,,,,fee schedule,27309.11,27309.11, Other Musculoskeletal System And Connective Tissue Procedures,3204,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,27309.11,,,,,,,fee schedule,27309.11,27309.11, Other Musculoskeletal System And Connective Tissue Procedures,3204,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,27309.11,,,,,,,fee schedule,27309.11,27309.11, Other Musculoskeletal System And Connective Tissue Procedures,3204,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,27309.11,,,,,,,fee schedule,27309.11,27309.11, Decompression,3211,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,12531.67,,,,,,,fee schedule,12531.67,12531.67, Decompression,3211,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,12531.67,,,,,,,fee schedule,12531.67,12531.67, Decompression,3211,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,12531.67,,,,,,,fee schedule,12531.67,12531.67, Decompression,3211,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,12531.67,,,,,,,fee schedule,12531.67,12531.67, Decompression,3211,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,12531.67,,,,,,,fee schedule,12531.67,12531.67, Decompression,3211,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,12531.67,,,,,,,fee schedule,12531.67,12531.67, Decompression,3211,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,12531.67,,,,,,,fee schedule,12531.67,12531.67, Decompression,3211,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,12531.67,,,,,,,fee schedule,12531.67,12531.67, Decompression,3211,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,12531.67,,,,,,,fee schedule,12531.67,12531.67, Decompression,3211,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,12531.67,,,,,,,fee schedule,12531.67,12531.67, Decompression,3211,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,12531.67,,,,,,,fee schedule,12531.67,12531.67, Decompression,3212,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,17039.44,,,,,,,fee schedule,17039.44,17039.44, Decompression,3212,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,17039.44,,,,,,,fee schedule,17039.44,17039.44, Decompression,3212,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,17039.44,,,,,,,fee schedule,17039.44,17039.44, Decompression,3212,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,17039.44,,,,,,,fee schedule,17039.44,17039.44, Decompression,3212,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,17039.44,,,,,,,fee schedule,17039.44,17039.44, Decompression,3212,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,17039.44,,,,,,,fee schedule,17039.44,17039.44, Decompression,3212,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,17039.44,,,,,,,fee schedule,17039.44,17039.44, Decompression,3212,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,17039.44,,,,,,,fee schedule,17039.44,17039.44, Decompression,3212,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,17039.44,,,,,,,fee schedule,17039.44,17039.44, Decompression,3212,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,17039.44,,,,,,,fee schedule,17039.44,17039.44, Decompression,3212,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,17039.44,,,,,,,fee schedule,17039.44,17039.44, Decompression,3213,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,26692.97,,,,,,,fee schedule,26692.97,26692.97, Decompression,3213,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,26692.97,,,,,,,fee schedule,26692.97,26692.97, Decompression,3213,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,26692.97,,,,,,,fee schedule,26692.97,26692.97, Decompression,3213,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,26692.97,,,,,,,fee schedule,26692.97,26692.97, Decompression,3213,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,26692.97,,,,,,,fee schedule,26692.97,26692.97, Decompression,3213,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,26692.97,,,,,,,fee schedule,26692.97,26692.97, Decompression,3213,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,26692.97,,,,,,,fee schedule,26692.97,26692.97, Decompression,3213,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,26692.97,,,,,,,fee schedule,26692.97,26692.97, Decompression,3213,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,26692.97,,,,,,,fee schedule,26692.97,26692.97, Decompression,3213,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,26692.97,,,,,,,fee schedule,26692.97,26692.97, Decompression,3213,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,26692.97,,,,,,,fee schedule,26692.97,26692.97, Decompression,3214,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,35622.39,,,,,,,fee schedule,35622.39,35622.39, Decompression,3214,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,35622.39,,,,,,,fee schedule,35622.39,35622.39, Decompression,3214,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,35622.39,,,,,,,fee schedule,35622.39,35622.39, Decompression,3214,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,35622.39,,,,,,,fee schedule,35622.39,35622.39, Decompression,3214,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,35622.39,,,,,,,fee schedule,35622.39,35622.39, Decompression,3214,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,35622.39,,,,,,,fee schedule,35622.39,35622.39, Decompression,3214,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,35622.39,,,,,,,fee schedule,35622.39,35622.39, Decompression,3214,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,35622.39,,,,,,,fee schedule,35622.39,35622.39, Decompression,3214,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,35622.39,,,,,,,fee schedule,35622.39,35622.39, Decompression,3214,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,35622.39,,,,,,,fee schedule,35622.39,35622.39, Decompression,3214,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,35622.39,,,,,,,fee schedule,35622.39,35622.39, Shoulder And Elbow Joint Replacement,3221,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,11789.2,,,,,,,fee schedule,11789.2,11789.2, Shoulder And Elbow Joint Replacement,3221,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,11789.2,,,,,,,fee schedule,11789.2,11789.2, Shoulder And Elbow Joint Replacement,3221,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,11789.2,,,,,,,fee schedule,11789.2,11789.2, Shoulder And Elbow Joint Replacement,3221,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,11789.2,,,,,,,fee schedule,11789.2,11789.2, Shoulder And Elbow Joint Replacement,3221,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,11789.2,,,,,,,fee schedule,11789.2,11789.2, Shoulder And Elbow Joint Replacement,3221,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,11789.2,,,,,,,fee schedule,11789.2,11789.2, Shoulder And Elbow Joint Replacement,3221,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,11789.2,,,,,,,fee schedule,11789.2,11789.2, Shoulder And Elbow Joint Replacement,3221,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,11789.2,,,,,,,fee schedule,11789.2,11789.2, Shoulder And Elbow Joint Replacement,3221,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,11789.2,,,,,,,fee schedule,11789.2,11789.2, Shoulder And Elbow Joint Replacement,3221,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,11789.2,,,,,,,fee schedule,11789.2,11789.2, Shoulder And Elbow Joint Replacement,3221,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,11789.2,,,,,,,fee schedule,11789.2,11789.2, Shoulder And Elbow Joint Replacement,3222,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,14250.93,,,,,,,fee schedule,14250.93,14250.93, Shoulder And Elbow Joint Replacement,3222,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,14250.93,,,,,,,fee schedule,14250.93,14250.93, Shoulder And Elbow Joint Replacement,3222,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,14250.93,,,,,,,fee schedule,14250.93,14250.93, Shoulder And Elbow Joint Replacement,3222,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,14250.93,,,,,,,fee schedule,14250.93,14250.93, Shoulder And Elbow Joint Replacement,3222,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,14250.93,,,,,,,fee schedule,14250.93,14250.93, Shoulder And Elbow Joint Replacement,3222,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,14250.93,,,,,,,fee schedule,14250.93,14250.93, Shoulder And Elbow Joint Replacement,3222,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,14250.93,,,,,,,fee schedule,14250.93,14250.93, Shoulder And Elbow Joint Replacement,3222,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,14250.93,,,,,,,fee schedule,14250.93,14250.93, Shoulder And Elbow Joint Replacement,3222,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,14250.93,,,,,,,fee schedule,14250.93,14250.93, Shoulder And Elbow Joint Replacement,3222,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,14250.93,,,,,,,fee schedule,14250.93,14250.93, Shoulder And Elbow Joint Replacement,3222,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,14250.93,,,,,,,fee schedule,14250.93,14250.93, Shoulder And Elbow Joint Replacement,3223,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,19461.64,,,,,,,fee schedule,19461.64,19461.64, Shoulder And Elbow Joint Replacement,3223,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,19461.64,,,,,,,fee schedule,19461.64,19461.64, Shoulder And Elbow Joint Replacement,3223,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,19461.64,,,,,,,fee schedule,19461.64,19461.64, Shoulder And Elbow Joint Replacement,3223,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,19461.64,,,,,,,fee schedule,19461.64,19461.64, Shoulder And Elbow Joint Replacement,3223,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,19461.64,,,,,,,fee schedule,19461.64,19461.64, Shoulder And Elbow Joint Replacement,3223,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,19461.64,,,,,,,fee schedule,19461.64,19461.64, Shoulder And Elbow Joint Replacement,3223,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,19461.64,,,,,,,fee schedule,19461.64,19461.64, Shoulder And Elbow Joint Replacement,3223,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,19461.64,,,,,,,fee schedule,19461.64,19461.64, Shoulder And Elbow Joint Replacement,3223,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,19461.64,,,,,,,fee schedule,19461.64,19461.64, Shoulder And Elbow Joint Replacement,3223,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,19461.64,,,,,,,fee schedule,19461.64,19461.64, Shoulder And Elbow Joint Replacement,3223,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,19461.64,,,,,,,fee schedule,19461.64,19461.64, Shoulder And Elbow Joint Replacement,3224,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,24960.31,,,,,,,fee schedule,24960.31,24960.31, Shoulder And Elbow Joint Replacement,3224,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,24960.31,,,,,,,fee schedule,24960.31,24960.31, Shoulder And Elbow Joint Replacement,3224,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,24960.31,,,,,,,fee schedule,24960.31,24960.31, Shoulder And Elbow Joint Replacement,3224,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,24960.31,,,,,,,fee schedule,24960.31,24960.31, Shoulder And Elbow Joint Replacement,3224,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,24960.31,,,,,,,fee schedule,24960.31,24960.31, Shoulder And Elbow Joint Replacement,3224,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,24960.31,,,,,,,fee schedule,24960.31,24960.31, Shoulder And Elbow Joint Replacement,3224,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,24960.31,,,,,,,fee schedule,24960.31,24960.31, Shoulder And Elbow Joint Replacement,3224,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,24960.31,,,,,,,fee schedule,24960.31,24960.31, Shoulder And Elbow Joint Replacement,3224,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,24960.31,,,,,,,fee schedule,24960.31,24960.31, Shoulder And Elbow Joint Replacement,3224,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,24960.31,,,,,,,fee schedule,24960.31,24960.31, Shoulder And Elbow Joint Replacement,3224,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,24960.31,,,,,,,fee schedule,24960.31,24960.31, Non-Elective Or Complex Hip Joint Replacement,3231,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,11620.52,,,,,,,fee schedule,11620.52,11620.52, Non-Elective Or Complex Hip Joint Replacement,3231,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,11620.52,,,,,,,fee schedule,11620.52,11620.52, Non-Elective Or Complex Hip Joint Replacement,3231,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,11620.52,,,,,,,fee schedule,11620.52,11620.52, Non-Elective Or Complex Hip Joint Replacement,3231,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,11620.52,,,,,,,fee schedule,11620.52,11620.52, Non-Elective Or Complex Hip Joint Replacement,3231,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,11620.52,,,,,,,fee schedule,11620.52,11620.52, Non-Elective Or Complex Hip Joint Replacement,3231,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,11620.52,,,,,,,fee schedule,11620.52,11620.52, Non-Elective Or Complex Hip Joint Replacement,3231,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,11620.52,,,,,,,fee schedule,11620.52,11620.52, Non-Elective Or Complex Hip Joint Replacement,3231,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,11620.52,,,,,,,fee schedule,11620.52,11620.52, Non-Elective Or Complex Hip Joint Replacement,3231,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,11620.52,,,,,,,fee schedule,11620.52,11620.52, Non-Elective Or Complex Hip Joint Replacement,3231,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,11620.52,,,,,,,fee schedule,11620.52,11620.52, Non-Elective Or Complex Hip Joint Replacement,3231,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,11620.52,,,,,,,fee schedule,11620.52,11620.52, Non-Elective Or Complex Hip Joint Replacement,3232,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,14033.56,,,,,,,fee schedule,14033.56,14033.56, Non-Elective Or Complex Hip Joint Replacement,3232,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,14033.56,,,,,,,fee schedule,14033.56,14033.56, Non-Elective Or Complex Hip Joint Replacement,3232,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,14033.56,,,,,,,fee schedule,14033.56,14033.56, Non-Elective Or Complex Hip Joint Replacement,3232,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,14033.56,,,,,,,fee schedule,14033.56,14033.56, Non-Elective Or Complex Hip Joint Replacement,3232,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,14033.56,,,,,,,fee schedule,14033.56,14033.56, Non-Elective Or Complex Hip Joint Replacement,3232,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,14033.56,,,,,,,fee schedule,14033.56,14033.56, Non-Elective Or Complex Hip Joint Replacement,3232,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,14033.56,,,,,,,fee schedule,14033.56,14033.56, Non-Elective Or Complex Hip Joint Replacement,3232,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,14033.56,,,,,,,fee schedule,14033.56,14033.56, Non-Elective Or Complex Hip Joint Replacement,3232,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,14033.56,,,,,,,fee schedule,14033.56,14033.56, Non-Elective Or Complex Hip Joint Replacement,3232,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,14033.56,,,,,,,fee schedule,14033.56,14033.56, Non-Elective Or Complex Hip Joint Replacement,3232,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,14033.56,,,,,,,fee schedule,14033.56,14033.56, Non-Elective Or Complex Hip Joint Replacement,3233,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,18873.03,,,,,,,fee schedule,18873.03,18873.03, Non-Elective Or Complex Hip Joint Replacement,3233,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,18873.03,,,,,,,fee schedule,18873.03,18873.03, Non-Elective Or Complex Hip Joint Replacement,3233,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,18873.03,,,,,,,fee schedule,18873.03,18873.03, Non-Elective Or Complex Hip Joint Replacement,3233,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,18873.03,,,,,,,fee schedule,18873.03,18873.03, Non-Elective Or Complex Hip Joint Replacement,3233,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,18873.03,,,,,,,fee schedule,18873.03,18873.03, Non-Elective Or Complex Hip Joint Replacement,3233,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,18873.03,,,,,,,fee schedule,18873.03,18873.03, Non-Elective Or Complex Hip Joint Replacement,3233,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,18873.03,,,,,,,fee schedule,18873.03,18873.03, Non-Elective Or Complex Hip Joint Replacement,3233,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,18873.03,,,,,,,fee schedule,18873.03,18873.03, Non-Elective Or Complex Hip Joint Replacement,3233,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,18873.03,,,,,,,fee schedule,18873.03,18873.03, Non-Elective Or Complex Hip Joint Replacement,3233,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,18873.03,,,,,,,fee schedule,18873.03,18873.03, Non-Elective Or Complex Hip Joint Replacement,3233,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,18873.03,,,,,,,fee schedule,18873.03,18873.03, Non-Elective Or Complex Hip Joint Replacement,3234,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,26391.61,,,,,,,fee schedule,26391.61,26391.61, Non-Elective Or Complex Hip Joint Replacement,3234,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,26391.61,,,,,,,fee schedule,26391.61,26391.61, Non-Elective Or Complex Hip Joint Replacement,3234,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,26391.61,,,,,,,fee schedule,26391.61,26391.61, Non-Elective Or Complex Hip Joint Replacement,3234,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,26391.61,,,,,,,fee schedule,26391.61,26391.61, Non-Elective Or Complex Hip Joint Replacement,3234,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,26391.61,,,,,,,fee schedule,26391.61,26391.61, Non-Elective Or Complex Hip Joint Replacement,3234,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,26391.61,,,,,,,fee schedule,26391.61,26391.61, Non-Elective Or Complex Hip Joint Replacement,3234,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,26391.61,,,,,,,fee schedule,26391.61,26391.61, Non-Elective Or Complex Hip Joint Replacement,3234,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,26391.61,,,,,,,fee schedule,26391.61,26391.61, Non-Elective Or Complex Hip Joint Replacement,3234,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,26391.61,,,,,,,fee schedule,26391.61,26391.61, Non-Elective Or Complex Hip Joint Replacement,3234,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,26391.61,,,,,,,fee schedule,26391.61,26391.61, Non-Elective Or Complex Hip Joint Replacement,3234,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,26391.61,,,,,,,fee schedule,26391.61,26391.61, Elective Hip Joint Replacement,3241,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,9949.96,,,,,,,fee schedule,9949.96,9949.96, Elective Hip Joint Replacement,3241,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,9949.96,,,,,,,fee schedule,9949.96,9949.96, Elective Hip Joint Replacement,3241,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,9949.96,,,,,,,fee schedule,9949.96,9949.96, Elective Hip Joint Replacement,3241,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,9949.96,,,,,,,fee schedule,9949.96,9949.96, Elective Hip Joint Replacement,3241,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,9949.96,,,,,,,fee schedule,9949.96,9949.96, Elective Hip Joint Replacement,3241,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,9949.96,,,,,,,fee schedule,9949.96,9949.96, Elective Hip Joint Replacement,3241,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,9949.96,,,,,,,fee schedule,9949.96,9949.96, Elective Hip Joint Replacement,3241,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,9949.96,,,,,,,fee schedule,9949.96,9949.96, Elective Hip Joint Replacement,3241,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,9949.96,,,,,,,fee schedule,9949.96,9949.96, Elective Hip Joint Replacement,3241,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,9949.96,,,,,,,fee schedule,9949.96,9949.96, Elective Hip Joint Replacement,3241,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,9949.96,,,,,,,fee schedule,9949.96,9949.96, Elective Hip Joint Replacement,3242,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,12123.74,,,,,,,fee schedule,12123.74,12123.74, Elective Hip Joint Replacement,3242,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,12123.74,,,,,,,fee schedule,12123.74,12123.74, Elective Hip Joint Replacement,3242,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,12123.74,,,,,,,fee schedule,12123.74,12123.74, Elective Hip Joint Replacement,3242,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,12123.74,,,,,,,fee schedule,12123.74,12123.74, Elective Hip Joint Replacement,3242,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,12123.74,,,,,,,fee schedule,12123.74,12123.74, Elective Hip Joint Replacement,3242,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,12123.74,,,,,,,fee schedule,12123.74,12123.74, Elective Hip Joint Replacement,3242,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,12123.74,,,,,,,fee schedule,12123.74,12123.74, Elective Hip Joint Replacement,3242,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,12123.74,,,,,,,fee schedule,12123.74,12123.74, Elective Hip Joint Replacement,3242,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,12123.74,,,,,,,fee schedule,12123.74,12123.74, Elective Hip Joint Replacement,3242,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,12123.74,,,,,,,fee schedule,12123.74,12123.74, Elective Hip Joint Replacement,3242,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,12123.74,,,,,,,fee schedule,12123.74,12123.74, Elective Hip Joint Replacement,3243,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,18071.27,,,,,,,fee schedule,18071.27,18071.27, Elective Hip Joint Replacement,3243,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,18071.27,,,,,,,fee schedule,18071.27,18071.27, Elective Hip Joint Replacement,3243,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,18071.27,,,,,,,fee schedule,18071.27,18071.27, Elective Hip Joint Replacement,3243,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,18071.27,,,,,,,fee schedule,18071.27,18071.27, Elective Hip Joint Replacement,3243,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,18071.27,,,,,,,fee schedule,18071.27,18071.27, Elective Hip Joint Replacement,3243,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,18071.27,,,,,,,fee schedule,18071.27,18071.27, Elective Hip Joint Replacement,3243,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,18071.27,,,,,,,fee schedule,18071.27,18071.27, Elective Hip Joint Replacement,3243,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,18071.27,,,,,,,fee schedule,18071.27,18071.27, Elective Hip Joint Replacement,3243,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,18071.27,,,,,,,fee schedule,18071.27,18071.27, Elective Hip Joint Replacement,3243,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,18071.27,,,,,,,fee schedule,18071.27,18071.27, Elective Hip Joint Replacement,3243,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,18071.27,,,,,,,fee schedule,18071.27,18071.27, Elective Hip Joint Replacement,3244,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,25244.03,,,,,,,fee schedule,25244.03,25244.03, Elective Hip Joint Replacement,3244,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,25244.03,,,,,,,fee schedule,25244.03,25244.03, Elective Hip Joint Replacement,3244,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,25244.03,,,,,,,fee schedule,25244.03,25244.03, Elective Hip Joint Replacement,3244,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,25244.03,,,,,,,fee schedule,25244.03,25244.03, Elective Hip Joint Replacement,3244,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,25244.03,,,,,,,fee schedule,25244.03,25244.03, Elective Hip Joint Replacement,3244,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,25244.03,,,,,,,fee schedule,25244.03,25244.03, Elective Hip Joint Replacement,3244,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,25244.03,,,,,,,fee schedule,25244.03,25244.03, Elective Hip Joint Replacement,3244,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,25244.03,,,,,,,fee schedule,25244.03,25244.03, Elective Hip Joint Replacement,3244,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,25244.03,,,,,,,fee schedule,25244.03,25244.03, Elective Hip Joint Replacement,3244,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,25244.03,,,,,,,fee schedule,25244.03,25244.03, Elective Hip Joint Replacement,3244,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,25244.03,,,,,,,fee schedule,25244.03,25244.03, Non-Elective Or Complex Knee Joint Replacement,3251,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,15342.06,,,,,,,fee schedule,15342.06,15342.06, Non-Elective Or Complex Knee Joint Replacement,3251,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,15342.06,,,,,,,fee schedule,15342.06,15342.06, Non-Elective Or Complex Knee Joint Replacement,3251,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,15342.06,,,,,,,fee schedule,15342.06,15342.06, Non-Elective Or Complex Knee Joint Replacement,3251,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,15342.06,,,,,,,fee schedule,15342.06,15342.06, Non-Elective Or Complex Knee Joint Replacement,3251,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,15342.06,,,,,,,fee schedule,15342.06,15342.06, Non-Elective Or Complex Knee Joint Replacement,3251,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,15342.06,,,,,,,fee schedule,15342.06,15342.06, Non-Elective Or Complex Knee Joint Replacement,3251,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,15342.06,,,,,,,fee schedule,15342.06,15342.06, Non-Elective Or Complex Knee Joint Replacement,3251,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,15342.06,,,,,,,fee schedule,15342.06,15342.06, Non-Elective Or Complex Knee Joint Replacement,3251,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,15342.06,,,,,,,fee schedule,15342.06,15342.06, Non-Elective Or Complex Knee Joint Replacement,3251,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,15342.06,,,,,,,fee schedule,15342.06,15342.06, Non-Elective Or Complex Knee Joint Replacement,3251,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,15342.06,,,,,,,fee schedule,15342.06,15342.06, Non-Elective Or Complex Knee Joint Replacement,3252,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,19001.48,,,,,,,fee schedule,19001.48,19001.48, Non-Elective Or Complex Knee Joint Replacement,3252,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,19001.48,,,,,,,fee schedule,19001.48,19001.48, Non-Elective Or Complex Knee Joint Replacement,3252,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,19001.48,,,,,,,fee schedule,19001.48,19001.48, Non-Elective Or Complex Knee Joint Replacement,3252,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,19001.48,,,,,,,fee schedule,19001.48,19001.48, Non-Elective Or Complex Knee Joint Replacement,3252,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,19001.48,,,,,,,fee schedule,19001.48,19001.48, Non-Elective Or Complex Knee Joint Replacement,3252,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,19001.48,,,,,,,fee schedule,19001.48,19001.48, Non-Elective Or Complex Knee Joint Replacement,3252,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,19001.48,,,,,,,fee schedule,19001.48,19001.48, Non-Elective Or Complex Knee Joint Replacement,3252,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,19001.48,,,,,,,fee schedule,19001.48,19001.48, Non-Elective Or Complex Knee Joint Replacement,3252,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,19001.48,,,,,,,fee schedule,19001.48,19001.48, Non-Elective Or Complex Knee Joint Replacement,3252,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,19001.48,,,,,,,fee schedule,19001.48,19001.48, Non-Elective Or Complex Knee Joint Replacement,3252,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,19001.48,,,,,,,fee schedule,19001.48,19001.48, Non-Elective Or Complex Knee Joint Replacement,3253,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,23018.73,,,,,,,fee schedule,23018.73,23018.73, Non-Elective Or Complex Knee Joint Replacement,3253,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,23018.73,,,,,,,fee schedule,23018.73,23018.73, Non-Elective Or Complex Knee Joint Replacement,3253,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,23018.73,,,,,,,fee schedule,23018.73,23018.73, Non-Elective Or Complex Knee Joint Replacement,3253,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,23018.73,,,,,,,fee schedule,23018.73,23018.73, Non-Elective Or Complex Knee Joint Replacement,3253,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,23018.73,,,,,,,fee schedule,23018.73,23018.73, Non-Elective Or Complex Knee Joint Replacement,3253,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,23018.73,,,,,,,fee schedule,23018.73,23018.73, Non-Elective Or Complex Knee Joint Replacement,3253,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,23018.73,,,,,,,fee schedule,23018.73,23018.73, Non-Elective Or Complex Knee Joint Replacement,3253,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,23018.73,,,,,,,fee schedule,23018.73,23018.73, Non-Elective Or Complex Knee Joint Replacement,3253,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,23018.73,,,,,,,fee schedule,23018.73,23018.73, Non-Elective Or Complex Knee Joint Replacement,3253,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,23018.73,,,,,,,fee schedule,23018.73,23018.73, Non-Elective Or Complex Knee Joint Replacement,3253,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,23018.73,,,,,,,fee schedule,23018.73,23018.73, Non-Elective Or Complex Knee Joint Replacement,3254,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,28785.59,,,,,,,fee schedule,28785.59,28785.59, Non-Elective Or Complex Knee Joint Replacement,3254,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,28785.59,,,,,,,fee schedule,28785.59,28785.59, Non-Elective Or Complex Knee Joint Replacement,3254,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,28785.59,,,,,,,fee schedule,28785.59,28785.59, Non-Elective Or Complex Knee Joint Replacement,3254,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,28785.59,,,,,,,fee schedule,28785.59,28785.59, Non-Elective Or Complex Knee Joint Replacement,3254,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,28785.59,,,,,,,fee schedule,28785.59,28785.59, Non-Elective Or Complex Knee Joint Replacement,3254,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,28785.59,,,,,,,fee schedule,28785.59,28785.59, Non-Elective Or Complex Knee Joint Replacement,3254,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,28785.59,,,,,,,fee schedule,28785.59,28785.59, Non-Elective Or Complex Knee Joint Replacement,3254,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,28785.59,,,,,,,fee schedule,28785.59,28785.59, Non-Elective Or Complex Knee Joint Replacement,3254,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,28785.59,,,,,,,fee schedule,28785.59,28785.59, Non-Elective Or Complex Knee Joint Replacement,3254,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,28785.59,,,,,,,fee schedule,28785.59,28785.59, Non-Elective Or Complex Knee Joint Replacement,3254,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,28785.59,,,,,,,fee schedule,28785.59,28785.59, Elective Knee Joint Replacement,3261,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,9808.81,,,,,,,fee schedule,9808.81,9808.81, Elective Knee Joint Replacement,3261,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,9808.81,,,,,,,fee schedule,9808.81,9808.81, Elective Knee Joint Replacement,3261,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,9808.81,,,,,,,fee schedule,9808.81,9808.81, Elective Knee Joint Replacement,3261,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,9808.81,,,,,,,fee schedule,9808.81,9808.81, Elective Knee Joint Replacement,3261,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,9808.81,,,,,,,fee schedule,9808.81,9808.81, Elective Knee Joint Replacement,3261,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,9808.81,,,,,,,fee schedule,9808.81,9808.81, Elective Knee Joint Replacement,3261,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,9808.81,,,,,,,fee schedule,9808.81,9808.81, Elective Knee Joint Replacement,3261,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,9808.81,,,,,,,fee schedule,9808.81,9808.81, Elective Knee Joint Replacement,3261,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,9808.81,,,,,,,fee schedule,9808.81,9808.81, Elective Knee Joint Replacement,3261,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,9808.81,,,,,,,fee schedule,9808.81,9808.81, Elective Knee Joint Replacement,3261,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,9808.81,,,,,,,fee schedule,9808.81,9808.81, Elective Knee Joint Replacement,3262,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,11082.73,,,,,,,fee schedule,11082.73,11082.73, Elective Knee Joint Replacement,3262,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,11082.73,,,,,,,fee schedule,11082.73,11082.73, Elective Knee Joint Replacement,3262,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,11082.73,,,,,,,fee schedule,11082.73,11082.73, Elective Knee Joint Replacement,3262,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,11082.73,,,,,,,fee schedule,11082.73,11082.73, Elective Knee Joint Replacement,3262,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,11082.73,,,,,,,fee schedule,11082.73,11082.73, Elective Knee Joint Replacement,3262,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,11082.73,,,,,,,fee schedule,11082.73,11082.73, Elective Knee Joint Replacement,3262,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,11082.73,,,,,,,fee schedule,11082.73,11082.73, Elective Knee Joint Replacement,3262,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,11082.73,,,,,,,fee schedule,11082.73,11082.73, Elective Knee Joint Replacement,3262,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,11082.73,,,,,,,fee schedule,11082.73,11082.73, Elective Knee Joint Replacement,3262,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,11082.73,,,,,,,fee schedule,11082.73,11082.73, Elective Knee Joint Replacement,3262,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,11082.73,,,,,,,fee schedule,11082.73,11082.73, Elective Knee Joint Replacement,3263,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,15227.01,,,,,,,fee schedule,15227.01,15227.01, Elective Knee Joint Replacement,3263,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,15227.01,,,,,,,fee schedule,15227.01,15227.01, Elective Knee Joint Replacement,3263,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,15227.01,,,,,,,fee schedule,15227.01,15227.01, Elective Knee Joint Replacement,3263,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,15227.01,,,,,,,fee schedule,15227.01,15227.01, Elective Knee Joint Replacement,3263,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,15227.01,,,,,,,fee schedule,15227.01,15227.01, Elective Knee Joint Replacement,3263,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,15227.01,,,,,,,fee schedule,15227.01,15227.01, Elective Knee Joint Replacement,3263,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,15227.01,,,,,,,fee schedule,15227.01,15227.01, Elective Knee Joint Replacement,3263,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,15227.01,,,,,,,fee schedule,15227.01,15227.01, Elective Knee Joint Replacement,3263,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,15227.01,,,,,,,fee schedule,15227.01,15227.01, Elective Knee Joint Replacement,3263,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,15227.01,,,,,,,fee schedule,15227.01,15227.01, Elective Knee Joint Replacement,3263,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,15227.01,,,,,,,fee schedule,15227.01,15227.01, Elective Knee Joint Replacement,3264,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,23974.34,,,,,,,fee schedule,23974.34,23974.34, Elective Knee Joint Replacement,3264,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,23974.34,,,,,,,fee schedule,23974.34,23974.34, Elective Knee Joint Replacement,3264,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,23974.34,,,,,,,fee schedule,23974.34,23974.34, Elective Knee Joint Replacement,3264,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,23974.34,,,,,,,fee schedule,23974.34,23974.34, Elective Knee Joint Replacement,3264,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,23974.34,,,,,,,fee schedule,23974.34,23974.34, Elective Knee Joint Replacement,3264,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,23974.34,,,,,,,fee schedule,23974.34,23974.34, Elective Knee Joint Replacement,3264,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,23974.34,,,,,,,fee schedule,23974.34,23974.34, Elective Knee Joint Replacement,3264,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,23974.34,,,,,,,fee schedule,23974.34,23974.34, Elective Knee Joint Replacement,3264,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,23974.34,,,,,,,fee schedule,23974.34,23974.34, Elective Knee Joint Replacement,3264,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,23974.34,,,,,,,fee schedule,23974.34,23974.34, Elective Knee Joint Replacement,3264,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,23974.34,,,,,,,fee schedule,23974.34,23974.34, Fracture Of Femur,3401,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,3835.87,,,,,,,fee schedule,3835.87,3835.87, Fracture Of Femur,3401,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,3835.87,,,,,,,fee schedule,3835.87,3835.87, Fracture Of Femur,3401,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,3835.87,,,,,,,fee schedule,3835.87,3835.87, Fracture Of Femur,3401,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,3835.87,,,,,,,fee schedule,3835.87,3835.87, Fracture Of Femur,3401,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,3835.87,,,,,,,fee schedule,3835.87,3835.87, Fracture Of Femur,3401,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,3835.87,,,,,,,fee schedule,3835.87,3835.87, Fracture Of Femur,3401,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,3835.87,,,,,,,fee schedule,3835.87,3835.87, Fracture Of Femur,3401,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,3835.87,,,,,,,fee schedule,3835.87,3835.87, Fracture Of Femur,3401,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,3835.87,,,,,,,fee schedule,3835.87,3835.87, Fracture Of Femur,3401,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,3835.87,,,,,,,fee schedule,3835.87,3835.87, Fracture Of Femur,3401,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,3835.87,,,,,,,fee schedule,3835.87,3835.87, Fracture Of Femur,3402,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4848.65,,,,,,,fee schedule,4848.65,4848.65, Fracture Of Femur,3402,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4848.65,,,,,,,fee schedule,4848.65,4848.65, Fracture Of Femur,3402,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4848.65,,,,,,,fee schedule,4848.65,4848.65, Fracture Of Femur,3402,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4848.65,,,,,,,fee schedule,4848.65,4848.65, Fracture Of Femur,3402,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4848.65,,,,,,,fee schedule,4848.65,4848.65, Fracture Of Femur,3402,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4848.65,,,,,,,fee schedule,4848.65,4848.65, Fracture Of Femur,3402,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4848.65,,,,,,,fee schedule,4848.65,4848.65, Fracture Of Femur,3402,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4848.65,,,,,,,fee schedule,4848.65,4848.65, Fracture Of Femur,3402,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4848.65,,,,,,,fee schedule,4848.65,4848.65, Fracture Of Femur,3402,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4848.65,,,,,,,fee schedule,4848.65,4848.65, Fracture Of Femur,3402,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4848.65,,,,,,,fee schedule,4848.65,4848.65, Fracture Of Femur,3403,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,7337.2,,,,,,,fee schedule,7337.2,7337.2, Fracture Of Femur,3403,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,7337.2,,,,,,,fee schedule,7337.2,7337.2, Fracture Of Femur,3403,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,7337.2,,,,,,,fee schedule,7337.2,7337.2, Fracture Of Femur,3403,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,7337.2,,,,,,,fee schedule,7337.2,7337.2, Fracture Of Femur,3403,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,7337.2,,,,,,,fee schedule,7337.2,7337.2, Fracture Of Femur,3403,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,7337.2,,,,,,,fee schedule,7337.2,7337.2, Fracture Of Femur,3403,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,7337.2,,,,,,,fee schedule,7337.2,7337.2, Fracture Of Femur,3403,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,7337.2,,,,,,,fee schedule,7337.2,7337.2, Fracture Of Femur,3403,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,7337.2,,,,,,,fee schedule,7337.2,7337.2, Fracture Of Femur,3403,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,7337.2,,,,,,,fee schedule,7337.2,7337.2, Fracture Of Femur,3403,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,7337.2,,,,,,,fee schedule,7337.2,7337.2, Fracture Of Femur,3404,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,11312.81,,,,,,,fee schedule,11312.81,11312.81, Fracture Of Femur,3404,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,11312.81,,,,,,,fee schedule,11312.81,11312.81, Fracture Of Femur,3404,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,11312.81,,,,,,,fee schedule,11312.81,11312.81, Fracture Of Femur,3404,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,11312.81,,,,,,,fee schedule,11312.81,11312.81, Fracture Of Femur,3404,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,11312.81,,,,,,,fee schedule,11312.81,11312.81, Fracture Of Femur,3404,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,11312.81,,,,,,,fee schedule,11312.81,11312.81, Fracture Of Femur,3404,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,11312.81,,,,,,,fee schedule,11312.81,11312.81, Fracture Of Femur,3404,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,11312.81,,,,,,,fee schedule,11312.81,11312.81, Fracture Of Femur,3404,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,11312.81,,,,,,,fee schedule,11312.81,11312.81, Fracture Of Femur,3404,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,11312.81,,,,,,,fee schedule,11312.81,11312.81, Fracture Of Femur,3404,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,11312.81,,,,,,,fee schedule,11312.81,11312.81, Fracture Of Pelvis Or Dislocation Of Hip,3411,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4156.99,,,,,,,fee schedule,4156.99,4156.99, Fracture Of Pelvis Or Dislocation Of Hip,3411,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4156.99,,,,,,,fee schedule,4156.99,4156.99, Fracture Of Pelvis Or Dislocation Of Hip,3411,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4156.99,,,,,,,fee schedule,4156.99,4156.99, Fracture Of Pelvis Or Dislocation Of Hip,3411,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4156.99,,,,,,,fee schedule,4156.99,4156.99, Fracture Of Pelvis Or Dislocation Of Hip,3411,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4156.99,,,,,,,fee schedule,4156.99,4156.99, Fracture Of Pelvis Or Dislocation Of Hip,3411,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4156.99,,,,,,,fee schedule,4156.99,4156.99, Fracture Of Pelvis Or Dislocation Of Hip,3411,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4156.99,,,,,,,fee schedule,4156.99,4156.99, Fracture Of Pelvis Or Dislocation Of Hip,3411,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4156.99,,,,,,,fee schedule,4156.99,4156.99, Fracture Of Pelvis Or Dislocation Of Hip,3411,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4156.99,,,,,,,fee schedule,4156.99,4156.99, Fracture Of Pelvis Or Dislocation Of Hip,3411,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4156.99,,,,,,,fee schedule,4156.99,4156.99, Fracture Of Pelvis Or Dislocation Of Hip,3411,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4156.99,,,,,,,fee schedule,4156.99,4156.99, Fracture Of Pelvis Or Dislocation Of Hip,3412,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5232.59,,,,,,,fee schedule,5232.59,5232.59, Fracture Of Pelvis Or Dislocation Of Hip,3412,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5232.59,,,,,,,fee schedule,5232.59,5232.59, Fracture Of Pelvis Or Dislocation Of Hip,3412,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5232.59,,,,,,,fee schedule,5232.59,5232.59, Fracture Of Pelvis Or Dislocation Of Hip,3412,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5232.59,,,,,,,fee schedule,5232.59,5232.59, Fracture Of Pelvis Or Dislocation Of Hip,3412,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5232.59,,,,,,,fee schedule,5232.59,5232.59, Fracture Of Pelvis Or Dislocation Of Hip,3412,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5232.59,,,,,,,fee schedule,5232.59,5232.59, Fracture Of Pelvis Or Dislocation Of Hip,3412,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5232.59,,,,,,,fee schedule,5232.59,5232.59, Fracture Of Pelvis Or Dislocation Of Hip,3412,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5232.59,,,,,,,fee schedule,5232.59,5232.59, Fracture Of Pelvis Or Dislocation Of Hip,3412,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5232.59,,,,,,,fee schedule,5232.59,5232.59, Fracture Of Pelvis Or Dislocation Of Hip,3412,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5232.59,,,,,,,fee schedule,5232.59,5232.59, Fracture Of Pelvis Or Dislocation Of Hip,3412,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5232.59,,,,,,,fee schedule,5232.59,5232.59, Fracture Of Pelvis Or Dislocation Of Hip,3413,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,7777.6,,,,,,,fee schedule,7777.6,7777.6, Fracture Of Pelvis Or Dislocation Of Hip,3413,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,7777.6,,,,,,,fee schedule,7777.6,7777.6, Fracture Of Pelvis Or Dislocation Of Hip,3413,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,7777.6,,,,,,,fee schedule,7777.6,7777.6, Fracture Of Pelvis Or Dislocation Of Hip,3413,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,7777.6,,,,,,,fee schedule,7777.6,7777.6, Fracture Of Pelvis Or Dislocation Of Hip,3413,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,7777.6,,,,,,,fee schedule,7777.6,7777.6, Fracture Of Pelvis Or Dislocation Of Hip,3413,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,7777.6,,,,,,,fee schedule,7777.6,7777.6, Fracture Of Pelvis Or Dislocation Of Hip,3413,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,7777.6,,,,,,,fee schedule,7777.6,7777.6, Fracture Of Pelvis Or Dislocation Of Hip,3413,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,7777.6,,,,,,,fee schedule,7777.6,7777.6, Fracture Of Pelvis Or Dislocation Of Hip,3413,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,7777.6,,,,,,,fee schedule,7777.6,7777.6, Fracture Of Pelvis Or Dislocation Of Hip,3413,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,7777.6,,,,,,,fee schedule,7777.6,7777.6, Fracture Of Pelvis Or Dislocation Of Hip,3413,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,7777.6,,,,,,,fee schedule,7777.6,7777.6, Fracture Of Pelvis Or Dislocation Of Hip,3414,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,14221.29,,,,,,,fee schedule,14221.29,14221.29, Fracture Of Pelvis Or Dislocation Of Hip,3414,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,14221.29,,,,,,,fee schedule,14221.29,14221.29, Fracture Of Pelvis Or Dislocation Of Hip,3414,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,14221.29,,,,,,,fee schedule,14221.29,14221.29, Fracture Of Pelvis Or Dislocation Of Hip,3414,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,14221.29,,,,,,,fee schedule,14221.29,14221.29, Fracture Of Pelvis Or Dislocation Of Hip,3414,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,14221.29,,,,,,,fee schedule,14221.29,14221.29, Fracture Of Pelvis Or Dislocation Of Hip,3414,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,14221.29,,,,,,,fee schedule,14221.29,14221.29, Fracture Of Pelvis Or Dislocation Of Hip,3414,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,14221.29,,,,,,,fee schedule,14221.29,14221.29, Fracture Of Pelvis Or Dislocation Of Hip,3414,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,14221.29,,,,,,,fee schedule,14221.29,14221.29, Fracture Of Pelvis Or Dislocation Of Hip,3414,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,14221.29,,,,,,,fee schedule,14221.29,14221.29, Fracture Of Pelvis Or Dislocation Of Hip,3414,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,14221.29,,,,,,,fee schedule,14221.29,14221.29, Fracture Of Pelvis Or Dislocation Of Hip,3414,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,14221.29,,,,,,,fee schedule,14221.29,14221.29, "Fractures And Dislocations Except Femur, Pelvis And Back",3421,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4533.17,,,,,,,fee schedule,4533.17,4533.17, "Fractures And Dislocations Except Femur, Pelvis And Back",3421,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4533.17,,,,,,,fee schedule,4533.17,4533.17, "Fractures And Dislocations Except Femur, Pelvis And Back",3421,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4533.17,,,,,,,fee schedule,4533.17,4533.17, "Fractures And Dislocations Except Femur, Pelvis And Back",3421,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4533.17,,,,,,,fee schedule,4533.17,4533.17, "Fractures And Dislocations Except Femur, Pelvis And Back",3421,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4533.17,,,,,,,fee schedule,4533.17,4533.17, "Fractures And Dislocations Except Femur, Pelvis And Back",3421,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4533.17,,,,,,,fee schedule,4533.17,4533.17, "Fractures And Dislocations Except Femur, Pelvis And Back",3421,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4533.17,,,,,,,fee schedule,4533.17,4533.17, "Fractures And Dislocations Except Femur, Pelvis And Back",3421,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4533.17,,,,,,,fee schedule,4533.17,4533.17, "Fractures And Dislocations Except Femur, Pelvis And Back",3421,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4533.17,,,,,,,fee schedule,4533.17,4533.17, "Fractures And Dislocations Except Femur, Pelvis And Back",3421,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4533.17,,,,,,,fee schedule,4533.17,4533.17, "Fractures And Dislocations Except Femur, Pelvis And Back",3421,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4533.17,,,,,,,fee schedule,4533.17,4533.17, "Fractures And Dislocations Except Femur, Pelvis And Back",3422,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5815.56,,,,,,,fee schedule,5815.56,5815.56, "Fractures And Dislocations Except Femur, Pelvis And Back",3422,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5815.56,,,,,,,fee schedule,5815.56,5815.56, "Fractures And Dislocations Except Femur, Pelvis And Back",3422,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5815.56,,,,,,,fee schedule,5815.56,5815.56, "Fractures And Dislocations Except Femur, Pelvis And Back",3422,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5815.56,,,,,,,fee schedule,5815.56,5815.56, "Fractures And Dislocations Except Femur, Pelvis And Back",3422,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5815.56,,,,,,,fee schedule,5815.56,5815.56, "Fractures And Dislocations Except Femur, Pelvis And Back",3422,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5815.56,,,,,,,fee schedule,5815.56,5815.56, "Fractures And Dislocations Except Femur, Pelvis And Back",3422,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5815.56,,,,,,,fee schedule,5815.56,5815.56, "Fractures And Dislocations Except Femur, Pelvis And Back",3422,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5815.56,,,,,,,fee schedule,5815.56,5815.56, "Fractures And Dislocations Except Femur, Pelvis And Back",3422,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5815.56,,,,,,,fee schedule,5815.56,5815.56, "Fractures And Dislocations Except Femur, Pelvis And Back",3422,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5815.56,,,,,,,fee schedule,5815.56,5815.56, "Fractures And Dislocations Except Femur, Pelvis And Back",3422,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5815.56,,,,,,,fee schedule,5815.56,5815.56, "Fractures And Dislocations Except Femur, Pelvis And Back",3423,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,8321.75,,,,,,,fee schedule,8321.75,8321.75, "Fractures And Dislocations Except Femur, Pelvis And Back",3423,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,8321.75,,,,,,,fee schedule,8321.75,8321.75, "Fractures And Dislocations Except Femur, Pelvis And Back",3423,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,8321.75,,,,,,,fee schedule,8321.75,8321.75, "Fractures And Dislocations Except Femur, Pelvis And Back",3423,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,8321.75,,,,,,,fee schedule,8321.75,8321.75, "Fractures And Dislocations Except Femur, Pelvis And Back",3423,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,8321.75,,,,,,,fee schedule,8321.75,8321.75, "Fractures And Dislocations Except Femur, Pelvis And Back",3423,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,8321.75,,,,,,,fee schedule,8321.75,8321.75, "Fractures And Dislocations Except Femur, Pelvis And Back",3423,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,8321.75,,,,,,,fee schedule,8321.75,8321.75, "Fractures And Dislocations Except Femur, Pelvis And Back",3423,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,8321.75,,,,,,,fee schedule,8321.75,8321.75, "Fractures And Dislocations Except Femur, Pelvis And Back",3423,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,8321.75,,,,,,,fee schedule,8321.75,8321.75, "Fractures And Dislocations Except Femur, Pelvis And Back",3423,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,8321.75,,,,,,,fee schedule,8321.75,8321.75, "Fractures And Dislocations Except Femur, Pelvis And Back",3423,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,8321.75,,,,,,,fee schedule,8321.75,8321.75, "Fractures And Dislocations Except Femur, Pelvis And Back",3424,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,15089.39,,,,,,,fee schedule,15089.39,15089.39, "Fractures And Dislocations Except Femur, Pelvis And Back",3424,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,15089.39,,,,,,,fee schedule,15089.39,15089.39, "Fractures And Dislocations Except Femur, Pelvis And Back",3424,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,15089.39,,,,,,,fee schedule,15089.39,15089.39, "Fractures And Dislocations Except Femur, Pelvis And Back",3424,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,15089.39,,,,,,,fee schedule,15089.39,15089.39, "Fractures And Dislocations Except Femur, Pelvis And Back",3424,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,15089.39,,,,,,,fee schedule,15089.39,15089.39, "Fractures And Dislocations Except Femur, Pelvis And Back",3424,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,15089.39,,,,,,,fee schedule,15089.39,15089.39, "Fractures And Dislocations Except Femur, Pelvis And Back",3424,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,15089.39,,,,,,,fee schedule,15089.39,15089.39, "Fractures And Dislocations Except Femur, Pelvis And Back",3424,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,15089.39,,,,,,,fee schedule,15089.39,15089.39, "Fractures And Dislocations Except Femur, Pelvis And Back",3424,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,15089.39,,,,,,,fee schedule,15089.39,15089.39, "Fractures And Dislocations Except Femur, Pelvis And Back",3424,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,15089.39,,,,,,,fee schedule,15089.39,15089.39, "Fractures And Dislocations Except Femur, Pelvis And Back",3424,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,15089.39,,,,,,,fee schedule,15089.39,15089.39, Musculoskeletal Malignancy And Pathological Fracture Due To Musculoskeletal Malignancy,3431,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,6823.4,,,,,,,fee schedule,6823.4,6823.4, Musculoskeletal Malignancy And Pathological Fracture Due To Musculoskeletal Malignancy,3431,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,6823.4,,,,,,,fee schedule,6823.4,6823.4, Musculoskeletal Malignancy And Pathological Fracture Due To Musculoskeletal Malignancy,3431,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,6823.4,,,,,,,fee schedule,6823.4,6823.4, Musculoskeletal Malignancy And Pathological Fracture Due To Musculoskeletal Malignancy,3431,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,6823.4,,,,,,,fee schedule,6823.4,6823.4, Musculoskeletal Malignancy And Pathological Fracture Due To Musculoskeletal Malignancy,3431,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,6823.4,,,,,,,fee schedule,6823.4,6823.4, Musculoskeletal Malignancy And Pathological Fracture Due To Musculoskeletal Malignancy,3431,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,6823.4,,,,,,,fee schedule,6823.4,6823.4, Musculoskeletal Malignancy And Pathological Fracture Due To Musculoskeletal Malignancy,3431,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,6823.4,,,,,,,fee schedule,6823.4,6823.4, Musculoskeletal Malignancy And Pathological Fracture Due To Musculoskeletal Malignancy,3431,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,6823.4,,,,,,,fee schedule,6823.4,6823.4, Musculoskeletal Malignancy And Pathological Fracture Due To Musculoskeletal Malignancy,3431,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,6823.4,,,,,,,fee schedule,6823.4,6823.4, Musculoskeletal Malignancy And Pathological Fracture Due To Musculoskeletal Malignancy,3431,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,6823.4,,,,,,,fee schedule,6823.4,6823.4, Musculoskeletal Malignancy And Pathological Fracture Due To Musculoskeletal Malignancy,3431,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,6823.4,,,,,,,fee schedule,6823.4,6823.4, Musculoskeletal Malignancy And Pathological Fracture Due To Musculoskeletal Malignancy,3432,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,8084.61,,,,,,,fee schedule,8084.61,8084.61, Musculoskeletal Malignancy And Pathological Fracture Due To Musculoskeletal Malignancy,3432,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,8084.61,,,,,,,fee schedule,8084.61,8084.61, Musculoskeletal Malignancy And Pathological Fracture Due To Musculoskeletal Malignancy,3432,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,8084.61,,,,,,,fee schedule,8084.61,8084.61, Musculoskeletal Malignancy And Pathological Fracture Due To Musculoskeletal Malignancy,3432,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,8084.61,,,,,,,fee schedule,8084.61,8084.61, Musculoskeletal Malignancy And Pathological Fracture Due To Musculoskeletal Malignancy,3432,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,8084.61,,,,,,,fee schedule,8084.61,8084.61, Musculoskeletal Malignancy And Pathological Fracture Due To Musculoskeletal Malignancy,3432,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,8084.61,,,,,,,fee schedule,8084.61,8084.61, Musculoskeletal Malignancy And Pathological Fracture Due To Musculoskeletal Malignancy,3432,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,8084.61,,,,,,,fee schedule,8084.61,8084.61, Musculoskeletal Malignancy And Pathological Fracture Due To Musculoskeletal Malignancy,3432,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,8084.61,,,,,,,fee schedule,8084.61,8084.61, Musculoskeletal Malignancy And Pathological Fracture Due To Musculoskeletal Malignancy,3432,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,8084.61,,,,,,,fee schedule,8084.61,8084.61, Musculoskeletal Malignancy And Pathological Fracture Due To Musculoskeletal Malignancy,3432,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,8084.61,,,,,,,fee schedule,8084.61,8084.61, Musculoskeletal Malignancy And Pathological Fracture Due To Musculoskeletal Malignancy,3432,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,8084.61,,,,,,,fee schedule,8084.61,8084.61, Musculoskeletal Malignancy And Pathological Fracture Due To Musculoskeletal Malignancy,3433,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,12211.25,,,,,,,fee schedule,12211.25,12211.25, Musculoskeletal Malignancy And Pathological Fracture Due To Musculoskeletal Malignancy,3433,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,12211.25,,,,,,,fee schedule,12211.25,12211.25, Musculoskeletal Malignancy And Pathological Fracture Due To Musculoskeletal Malignancy,3433,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,12211.25,,,,,,,fee schedule,12211.25,12211.25, Musculoskeletal Malignancy And Pathological Fracture Due To Musculoskeletal Malignancy,3433,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,12211.25,,,,,,,fee schedule,12211.25,12211.25, Musculoskeletal Malignancy And Pathological Fracture Due To Musculoskeletal Malignancy,3433,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,12211.25,,,,,,,fee schedule,12211.25,12211.25, Musculoskeletal Malignancy And Pathological Fracture Due To Musculoskeletal Malignancy,3433,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,12211.25,,,,,,,fee schedule,12211.25,12211.25, Musculoskeletal Malignancy And Pathological Fracture Due To Musculoskeletal Malignancy,3433,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,12211.25,,,,,,,fee schedule,12211.25,12211.25, Musculoskeletal Malignancy And Pathological Fracture Due To Musculoskeletal Malignancy,3433,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,12211.25,,,,,,,fee schedule,12211.25,12211.25, Musculoskeletal Malignancy And Pathological Fracture Due To Musculoskeletal Malignancy,3433,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,12211.25,,,,,,,fee schedule,12211.25,12211.25, Musculoskeletal Malignancy And Pathological Fracture Due To Musculoskeletal Malignancy,3433,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,12211.25,,,,,,,fee schedule,12211.25,12211.25, Musculoskeletal Malignancy And Pathological Fracture Due To Musculoskeletal Malignancy,3433,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,12211.25,,,,,,,fee schedule,12211.25,12211.25, Musculoskeletal Malignancy And Pathological Fracture Due To Musculoskeletal Malignancy,3434,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,19022.65,,,,,,,fee schedule,19022.65,19022.65, Musculoskeletal Malignancy And Pathological Fracture Due To Musculoskeletal Malignancy,3434,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,19022.65,,,,,,,fee schedule,19022.65,19022.65, Musculoskeletal Malignancy And Pathological Fracture Due To Musculoskeletal Malignancy,3434,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,19022.65,,,,,,,fee schedule,19022.65,19022.65, Musculoskeletal Malignancy And Pathological Fracture Due To Musculoskeletal Malignancy,3434,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,19022.65,,,,,,,fee schedule,19022.65,19022.65, Musculoskeletal Malignancy And Pathological Fracture Due To Musculoskeletal Malignancy,3434,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,19022.65,,,,,,,fee schedule,19022.65,19022.65, Musculoskeletal Malignancy And Pathological Fracture Due To Musculoskeletal Malignancy,3434,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,19022.65,,,,,,,fee schedule,19022.65,19022.65, Musculoskeletal Malignancy And Pathological Fracture Due To Musculoskeletal Malignancy,3434,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,19022.65,,,,,,,fee schedule,19022.65,19022.65, Musculoskeletal Malignancy And Pathological Fracture Due To Musculoskeletal Malignancy,3434,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,19022.65,,,,,,,fee schedule,19022.65,19022.65, Musculoskeletal Malignancy And Pathological Fracture Due To Musculoskeletal Malignancy,3434,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,19022.65,,,,,,,fee schedule,19022.65,19022.65, Musculoskeletal Malignancy And Pathological Fracture Due To Musculoskeletal Malignancy,3434,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,19022.65,,,,,,,fee schedule,19022.65,19022.65, Musculoskeletal Malignancy And Pathological Fracture Due To Musculoskeletal Malignancy,3434,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,19022.65,,,,,,,fee schedule,19022.65,19022.65, "Osteomyelitis, Septic Arthritis And Other Musculoskeletal Infections",3441,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5446.44,,,,,,,fee schedule,5446.44,5446.44, "Osteomyelitis, Septic Arthritis And Other Musculoskeletal Infections",3441,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5446.44,,,,,,,fee schedule,5446.44,5446.44, "Osteomyelitis, Septic Arthritis And Other Musculoskeletal Infections",3441,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5446.44,,,,,,,fee schedule,5446.44,5446.44, "Osteomyelitis, Septic Arthritis And Other Musculoskeletal Infections",3441,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5446.44,,,,,,,fee schedule,5446.44,5446.44, "Osteomyelitis, Septic Arthritis And Other Musculoskeletal Infections",3441,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5446.44,,,,,,,fee schedule,5446.44,5446.44, "Osteomyelitis, Septic Arthritis And Other Musculoskeletal Infections",3441,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5446.44,,,,,,,fee schedule,5446.44,5446.44, "Osteomyelitis, Septic Arthritis And Other Musculoskeletal Infections",3441,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5446.44,,,,,,,fee schedule,5446.44,5446.44, "Osteomyelitis, Septic Arthritis And Other Musculoskeletal Infections",3441,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5446.44,,,,,,,fee schedule,5446.44,5446.44, "Osteomyelitis, Septic Arthritis And Other Musculoskeletal Infections",3441,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5446.44,,,,,,,fee schedule,5446.44,5446.44, "Osteomyelitis, Septic Arthritis And Other Musculoskeletal Infections",3441,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5446.44,,,,,,,fee schedule,5446.44,5446.44, "Osteomyelitis, Septic Arthritis And Other Musculoskeletal Infections",3441,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5446.44,,,,,,,fee schedule,5446.44,5446.44, "Osteomyelitis, Septic Arthritis And Other Musculoskeletal Infections",3442,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,7352.02,,,,,,,fee schedule,7352.02,7352.02, "Osteomyelitis, Septic Arthritis And Other Musculoskeletal Infections",3442,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,7352.02,,,,,,,fee schedule,7352.02,7352.02, "Osteomyelitis, Septic Arthritis And Other Musculoskeletal Infections",3442,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,7352.02,,,,,,,fee schedule,7352.02,7352.02, "Osteomyelitis, Septic Arthritis And Other Musculoskeletal Infections",3442,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,7352.02,,,,,,,fee schedule,7352.02,7352.02, "Osteomyelitis, Septic Arthritis And Other Musculoskeletal Infections",3442,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,7352.02,,,,,,,fee schedule,7352.02,7352.02, "Osteomyelitis, Septic Arthritis And Other Musculoskeletal Infections",3442,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,7352.02,,,,,,,fee schedule,7352.02,7352.02, "Osteomyelitis, Septic Arthritis And Other Musculoskeletal Infections",3442,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,7352.02,,,,,,,fee schedule,7352.02,7352.02, "Osteomyelitis, Septic Arthritis And Other Musculoskeletal Infections",3442,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,7352.02,,,,,,,fee schedule,7352.02,7352.02, "Osteomyelitis, Septic Arthritis And Other Musculoskeletal Infections",3442,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,7352.02,,,,,,,fee schedule,7352.02,7352.02, "Osteomyelitis, Septic Arthritis And Other Musculoskeletal Infections",3442,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,7352.02,,,,,,,fee schedule,7352.02,7352.02, "Osteomyelitis, Septic Arthritis And Other Musculoskeletal Infections",3442,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,7352.02,,,,,,,fee schedule,7352.02,7352.02, "Osteomyelitis, Septic Arthritis And Other Musculoskeletal Infections",3443,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,10864.64,,,,,,,fee schedule,10864.64,10864.64, "Osteomyelitis, Septic Arthritis And Other Musculoskeletal Infections",3443,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,10864.64,,,,,,,fee schedule,10864.64,10864.64, "Osteomyelitis, Septic Arthritis And Other Musculoskeletal Infections",3443,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,10864.64,,,,,,,fee schedule,10864.64,10864.64, "Osteomyelitis, Septic Arthritis And Other Musculoskeletal Infections",3443,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,10864.64,,,,,,,fee schedule,10864.64,10864.64, "Osteomyelitis, Septic Arthritis And Other Musculoskeletal Infections",3443,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,10864.64,,,,,,,fee schedule,10864.64,10864.64, "Osteomyelitis, Septic Arthritis And Other Musculoskeletal Infections",3443,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,10864.64,,,,,,,fee schedule,10864.64,10864.64, "Osteomyelitis, Septic Arthritis And Other Musculoskeletal Infections",3443,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,10864.64,,,,,,,fee schedule,10864.64,10864.64, "Osteomyelitis, Septic Arthritis And Other Musculoskeletal Infections",3443,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,10864.64,,,,,,,fee schedule,10864.64,10864.64, "Osteomyelitis, Septic Arthritis And Other Musculoskeletal Infections",3443,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,10864.64,,,,,,,fee schedule,10864.64,10864.64, "Osteomyelitis, Septic Arthritis And Other Musculoskeletal Infections",3443,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,10864.64,,,,,,,fee schedule,10864.64,10864.64, "Osteomyelitis, Septic Arthritis And Other Musculoskeletal Infections",3443,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,10864.64,,,,,,,fee schedule,10864.64,10864.64, "Osteomyelitis, Septic Arthritis And Other Musculoskeletal Infections",3444,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,17306.22,,,,,,,fee schedule,17306.22,17306.22, "Osteomyelitis, Septic Arthritis And Other Musculoskeletal Infections",3444,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,17306.22,,,,,,,fee schedule,17306.22,17306.22, "Osteomyelitis, Septic Arthritis And Other Musculoskeletal Infections",3444,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,17306.22,,,,,,,fee schedule,17306.22,17306.22, "Osteomyelitis, Septic Arthritis And Other Musculoskeletal Infections",3444,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,17306.22,,,,,,,fee schedule,17306.22,17306.22, "Osteomyelitis, Septic Arthritis And Other Musculoskeletal Infections",3444,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,17306.22,,,,,,,fee schedule,17306.22,17306.22, "Osteomyelitis, Septic Arthritis And Other Musculoskeletal Infections",3444,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,17306.22,,,,,,,fee schedule,17306.22,17306.22, "Osteomyelitis, Septic Arthritis And Other Musculoskeletal Infections",3444,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,17306.22,,,,,,,fee schedule,17306.22,17306.22, "Osteomyelitis, Septic Arthritis And Other Musculoskeletal Infections",3444,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,17306.22,,,,,,,fee schedule,17306.22,17306.22, "Osteomyelitis, Septic Arthritis And Other Musculoskeletal Infections",3444,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,17306.22,,,,,,,fee schedule,17306.22,17306.22, "Osteomyelitis, Septic Arthritis And Other Musculoskeletal Infections",3444,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,17306.22,,,,,,,fee schedule,17306.22,17306.22, "Osteomyelitis, Septic Arthritis And Other Musculoskeletal Infections",3444,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,17306.22,,,,,,,fee schedule,17306.22,17306.22, Connective Tissue Disorders,3461,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5855.08,,,,,,,fee schedule,5855.08,5855.08, Connective Tissue Disorders,3461,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5855.08,,,,,,,fee schedule,5855.08,5855.08, Connective Tissue Disorders,3461,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5855.08,,,,,,,fee schedule,5855.08,5855.08, Connective Tissue Disorders,3461,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5855.08,,,,,,,fee schedule,5855.08,5855.08, Connective Tissue Disorders,3461,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5855.08,,,,,,,fee schedule,5855.08,5855.08, Connective Tissue Disorders,3461,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5855.08,,,,,,,fee schedule,5855.08,5855.08, Connective Tissue Disorders,3461,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5855.08,,,,,,,fee schedule,5855.08,5855.08, Connective Tissue Disorders,3461,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5855.08,,,,,,,fee schedule,5855.08,5855.08, Connective Tissue Disorders,3461,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5855.08,,,,,,,fee schedule,5855.08,5855.08, Connective Tissue Disorders,3461,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5855.08,,,,,,,fee schedule,5855.08,5855.08, Connective Tissue Disorders,3461,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5855.08,,,,,,,fee schedule,5855.08,5855.08, Connective Tissue Disorders,3462,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,8225.76,,,,,,,fee schedule,8225.76,8225.76, Connective Tissue Disorders,3462,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,8225.76,,,,,,,fee schedule,8225.76,8225.76, Connective Tissue Disorders,3462,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,8225.76,,,,,,,fee schedule,8225.76,8225.76, Connective Tissue Disorders,3462,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,8225.76,,,,,,,fee schedule,8225.76,8225.76, Connective Tissue Disorders,3462,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,8225.76,,,,,,,fee schedule,8225.76,8225.76, Connective Tissue Disorders,3462,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,8225.76,,,,,,,fee schedule,8225.76,8225.76, Connective Tissue Disorders,3462,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,8225.76,,,,,,,fee schedule,8225.76,8225.76, Connective Tissue Disorders,3462,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,8225.76,,,,,,,fee schedule,8225.76,8225.76, Connective Tissue Disorders,3462,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,8225.76,,,,,,,fee schedule,8225.76,8225.76, Connective Tissue Disorders,3462,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,8225.76,,,,,,,fee schedule,8225.76,8225.76, Connective Tissue Disorders,3462,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,8225.76,,,,,,,fee schedule,8225.76,8225.76, Connective Tissue Disorders,3463,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,12271.95,,,,,,,fee schedule,12271.95,12271.95, Connective Tissue Disorders,3463,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,12271.95,,,,,,,fee schedule,12271.95,12271.95, Connective Tissue Disorders,3463,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,12271.95,,,,,,,fee schedule,12271.95,12271.95, Connective Tissue Disorders,3463,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,12271.95,,,,,,,fee schedule,12271.95,12271.95, Connective Tissue Disorders,3463,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,12271.95,,,,,,,fee schedule,12271.95,12271.95, Connective Tissue Disorders,3463,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,12271.95,,,,,,,fee schedule,12271.95,12271.95, Connective Tissue Disorders,3463,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,12271.95,,,,,,,fee schedule,12271.95,12271.95, Connective Tissue Disorders,3463,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,12271.95,,,,,,,fee schedule,12271.95,12271.95, Connective Tissue Disorders,3463,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,12271.95,,,,,,,fee schedule,12271.95,12271.95, Connective Tissue Disorders,3463,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,12271.95,,,,,,,fee schedule,12271.95,12271.95, Connective Tissue Disorders,3463,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,12271.95,,,,,,,fee schedule,12271.95,12271.95, Connective Tissue Disorders,3464,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,22472.46,,,,,,,fee schedule,22472.46,22472.46, Connective Tissue Disorders,3464,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,22472.46,,,,,,,fee schedule,22472.46,22472.46, Connective Tissue Disorders,3464,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,22472.46,,,,,,,fee schedule,22472.46,22472.46, Connective Tissue Disorders,3464,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,22472.46,,,,,,,fee schedule,22472.46,22472.46, Connective Tissue Disorders,3464,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,22472.46,,,,,,,fee schedule,22472.46,22472.46, Connective Tissue Disorders,3464,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,22472.46,,,,,,,fee schedule,22472.46,22472.46, Connective Tissue Disorders,3464,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,22472.46,,,,,,,fee schedule,22472.46,22472.46, Connective Tissue Disorders,3464,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,22472.46,,,,,,,fee schedule,22472.46,22472.46, Connective Tissue Disorders,3464,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,22472.46,,,,,,,fee schedule,22472.46,22472.46, Connective Tissue Disorders,3464,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,22472.46,,,,,,,fee schedule,22472.46,22472.46, Connective Tissue Disorders,3464,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,22472.46,,,,,,,fee schedule,22472.46,22472.46, "Other Back And Neck Disorders, Fractures And Injuries",3471,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5340.57,,,,,,,fee schedule,5340.57,5340.57, "Other Back And Neck Disorders, Fractures And Injuries",3471,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5340.57,,,,,,,fee schedule,5340.57,5340.57, "Other Back And Neck Disorders, Fractures And Injuries",3471,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5340.57,,,,,,,fee schedule,5340.57,5340.57, "Other Back And Neck Disorders, Fractures And Injuries",3471,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5340.57,,,,,,,fee schedule,5340.57,5340.57, "Other Back And Neck Disorders, Fractures And Injuries",3471,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5340.57,,,,,,,fee schedule,5340.57,5340.57, "Other Back And Neck Disorders, Fractures And Injuries",3471,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5340.57,,,,,,,fee schedule,5340.57,5340.57, "Other Back And Neck Disorders, Fractures And Injuries",3471,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5340.57,,,,,,,fee schedule,5340.57,5340.57, "Other Back And Neck Disorders, Fractures And Injuries",3471,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5340.57,,,,,,,fee schedule,5340.57,5340.57, "Other Back And Neck Disorders, Fractures And Injuries",3471,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5340.57,,,,,,,fee schedule,5340.57,5340.57, "Other Back And Neck Disorders, Fractures And Injuries",3471,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5340.57,,,,,,,fee schedule,5340.57,5340.57, "Other Back And Neck Disorders, Fractures And Injuries",3471,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5340.57,,,,,,,fee schedule,5340.57,5340.57, "Other Back And Neck Disorders, Fractures And Injuries",3472,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,6795.17,,,,,,,fee schedule,6795.17,6795.17, "Other Back And Neck Disorders, Fractures And Injuries",3472,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,6795.17,,,,,,,fee schedule,6795.17,6795.17, "Other Back And Neck Disorders, Fractures And Injuries",3472,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,6795.17,,,,,,,fee schedule,6795.17,6795.17, "Other Back And Neck Disorders, Fractures And Injuries",3472,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,6795.17,,,,,,,fee schedule,6795.17,6795.17, "Other Back And Neck Disorders, Fractures And Injuries",3472,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,6795.17,,,,,,,fee schedule,6795.17,6795.17, "Other Back And Neck Disorders, Fractures And Injuries",3472,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,6795.17,,,,,,,fee schedule,6795.17,6795.17, "Other Back And Neck Disorders, Fractures And Injuries",3472,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,6795.17,,,,,,,fee schedule,6795.17,6795.17, "Other Back And Neck Disorders, Fractures And Injuries",3472,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,6795.17,,,,,,,fee schedule,6795.17,6795.17, "Other Back And Neck Disorders, Fractures And Injuries",3472,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,6795.17,,,,,,,fee schedule,6795.17,6795.17, "Other Back And Neck Disorders, Fractures And Injuries",3472,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,6795.17,,,,,,,fee schedule,6795.17,6795.17, "Other Back And Neck Disorders, Fractures And Injuries",3472,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,6795.17,,,,,,,fee schedule,6795.17,6795.17, "Other Back And Neck Disorders, Fractures And Injuries",3473,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,9636.6,,,,,,,fee schedule,9636.6,9636.6, "Other Back And Neck Disorders, Fractures And Injuries",3473,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,9636.6,,,,,,,fee schedule,9636.6,9636.6, "Other Back And Neck Disorders, Fractures And Injuries",3473,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,9636.6,,,,,,,fee schedule,9636.6,9636.6, "Other Back And Neck Disorders, Fractures And Injuries",3473,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,9636.6,,,,,,,fee schedule,9636.6,9636.6, "Other Back And Neck Disorders, Fractures And Injuries",3473,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,9636.6,,,,,,,fee schedule,9636.6,9636.6, "Other Back And Neck Disorders, Fractures And Injuries",3473,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,9636.6,,,,,,,fee schedule,9636.6,9636.6, "Other Back And Neck Disorders, Fractures And Injuries",3473,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,9636.6,,,,,,,fee schedule,9636.6,9636.6, "Other Back And Neck Disorders, Fractures And Injuries",3473,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,9636.6,,,,,,,fee schedule,9636.6,9636.6, "Other Back And Neck Disorders, Fractures And Injuries",3473,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,9636.6,,,,,,,fee schedule,9636.6,9636.6, "Other Back And Neck Disorders, Fractures And Injuries",3473,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,9636.6,,,,,,,fee schedule,9636.6,9636.6, "Other Back And Neck Disorders, Fractures And Injuries",3473,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,9636.6,,,,,,,fee schedule,9636.6,9636.6, "Other Back And Neck Disorders, Fractures And Injuries",3474,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,15910.2,,,,,,,fee schedule,15910.2,15910.2, "Other Back And Neck Disorders, Fractures And Injuries",3474,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,15910.2,,,,,,,fee schedule,15910.2,15910.2, "Other Back And Neck Disorders, Fractures And Injuries",3474,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,15910.2,,,,,,,fee schedule,15910.2,15910.2, "Other Back And Neck Disorders, Fractures And Injuries",3474,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,15910.2,,,,,,,fee schedule,15910.2,15910.2, "Other Back And Neck Disorders, Fractures And Injuries",3474,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,15910.2,,,,,,,fee schedule,15910.2,15910.2, "Other Back And Neck Disorders, Fractures And Injuries",3474,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,15910.2,,,,,,,fee schedule,15910.2,15910.2, "Other Back And Neck Disorders, Fractures And Injuries",3474,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,15910.2,,,,,,,fee schedule,15910.2,15910.2, "Other Back And Neck Disorders, Fractures And Injuries",3474,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,15910.2,,,,,,,fee schedule,15910.2,15910.2, "Other Back And Neck Disorders, Fractures And Injuries",3474,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,15910.2,,,,,,,fee schedule,15910.2,15910.2, "Other Back And Neck Disorders, Fractures And Injuries",3474,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,15910.2,,,,,,,fee schedule,15910.2,15910.2, "Other Back And Neck Disorders, Fractures And Injuries",3474,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,15910.2,,,,,,,fee schedule,15910.2,15910.2, "Malfunction, Reaction, Complication Of Orthopedic Device Or Procedure",3491,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4827.48,,,,,,,fee schedule,4827.48,4827.48, "Malfunction, Reaction, Complication Of Orthopedic Device Or Procedure",3491,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4827.48,,,,,,,fee schedule,4827.48,4827.48, "Malfunction, Reaction, Complication Of Orthopedic Device Or Procedure",3491,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4827.48,,,,,,,fee schedule,4827.48,4827.48, "Malfunction, Reaction, Complication Of Orthopedic Device Or Procedure",3491,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4827.48,,,,,,,fee schedule,4827.48,4827.48, "Malfunction, Reaction, Complication Of Orthopedic Device Or Procedure",3491,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4827.48,,,,,,,fee schedule,4827.48,4827.48, "Malfunction, Reaction, Complication Of Orthopedic Device Or Procedure",3491,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4827.48,,,,,,,fee schedule,4827.48,4827.48, "Malfunction, Reaction, Complication Of Orthopedic Device Or Procedure",3491,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4827.48,,,,,,,fee schedule,4827.48,4827.48, "Malfunction, Reaction, Complication Of Orthopedic Device Or Procedure",3491,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4827.48,,,,,,,fee schedule,4827.48,4827.48, "Malfunction, Reaction, Complication Of Orthopedic Device Or Procedure",3491,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4827.48,,,,,,,fee schedule,4827.48,4827.48, "Malfunction, Reaction, Complication Of Orthopedic Device Or Procedure",3491,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4827.48,,,,,,,fee schedule,4827.48,4827.48, "Malfunction, Reaction, Complication Of Orthopedic Device Or Procedure",3491,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4827.48,,,,,,,fee schedule,4827.48,4827.48, "Malfunction, Reaction, Complication Of Orthopedic Device Or Procedure",3492,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,6596.14,,,,,,,fee schedule,6596.14,6596.14, "Malfunction, Reaction, Complication Of Orthopedic Device Or Procedure",3492,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,6596.14,,,,,,,fee schedule,6596.14,6596.14, "Malfunction, Reaction, Complication Of Orthopedic Device Or Procedure",3492,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,6596.14,,,,,,,fee schedule,6596.14,6596.14, "Malfunction, Reaction, Complication Of Orthopedic Device Or Procedure",3492,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,6596.14,,,,,,,fee schedule,6596.14,6596.14, "Malfunction, Reaction, Complication Of Orthopedic Device Or Procedure",3492,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,6596.14,,,,,,,fee schedule,6596.14,6596.14, "Malfunction, Reaction, Complication Of Orthopedic Device Or Procedure",3492,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,6596.14,,,,,,,fee schedule,6596.14,6596.14, "Malfunction, Reaction, Complication Of Orthopedic Device Or Procedure",3492,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,6596.14,,,,,,,fee schedule,6596.14,6596.14, "Malfunction, Reaction, Complication Of Orthopedic Device Or Procedure",3492,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,6596.14,,,,,,,fee schedule,6596.14,6596.14, "Malfunction, Reaction, Complication Of Orthopedic Device Or Procedure",3492,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,6596.14,,,,,,,fee schedule,6596.14,6596.14, "Malfunction, Reaction, Complication Of Orthopedic Device Or Procedure",3492,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,6596.14,,,,,,,fee schedule,6596.14,6596.14, "Malfunction, Reaction, Complication Of Orthopedic Device Or Procedure",3492,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,6596.14,,,,,,,fee schedule,6596.14,6596.14, "Malfunction, Reaction, Complication Of Orthopedic Device Or Procedure",3493,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,9497.56,,,,,,,fee schedule,9497.56,9497.56, "Malfunction, Reaction, Complication Of Orthopedic Device Or Procedure",3493,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,9497.56,,,,,,,fee schedule,9497.56,9497.56, "Malfunction, Reaction, Complication Of Orthopedic Device Or Procedure",3493,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,9497.56,,,,,,,fee schedule,9497.56,9497.56, "Malfunction, Reaction, Complication Of Orthopedic Device Or Procedure",3493,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,9497.56,,,,,,,fee schedule,9497.56,9497.56, "Malfunction, Reaction, Complication Of Orthopedic Device Or Procedure",3493,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,9497.56,,,,,,,fee schedule,9497.56,9497.56, "Malfunction, Reaction, Complication Of Orthopedic Device Or Procedure",3493,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,9497.56,,,,,,,fee schedule,9497.56,9497.56, "Malfunction, Reaction, Complication Of Orthopedic Device Or Procedure",3493,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,9497.56,,,,,,,fee schedule,9497.56,9497.56, "Malfunction, Reaction, Complication Of Orthopedic Device Or Procedure",3493,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,9497.56,,,,,,,fee schedule,9497.56,9497.56, "Malfunction, Reaction, Complication Of Orthopedic Device Or Procedure",3493,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,9497.56,,,,,,,fee schedule,9497.56,9497.56, "Malfunction, Reaction, Complication Of Orthopedic Device Or Procedure",3493,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,9497.56,,,,,,,fee schedule,9497.56,9497.56, "Malfunction, Reaction, Complication Of Orthopedic Device Or Procedure",3493,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,9497.56,,,,,,,fee schedule,9497.56,9497.56, "Malfunction, Reaction, Complication Of Orthopedic Device Or Procedure",3494,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,15687.18,,,,,,,fee schedule,15687.18,15687.18, "Malfunction, Reaction, Complication Of Orthopedic Device Or Procedure",3494,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,15687.18,,,,,,,fee schedule,15687.18,15687.18, "Malfunction, Reaction, Complication Of Orthopedic Device Or Procedure",3494,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,15687.18,,,,,,,fee schedule,15687.18,15687.18, "Malfunction, Reaction, Complication Of Orthopedic Device Or Procedure",3494,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,15687.18,,,,,,,fee schedule,15687.18,15687.18, "Malfunction, Reaction, Complication Of Orthopedic Device Or Procedure",3494,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,15687.18,,,,,,,fee schedule,15687.18,15687.18, "Malfunction, Reaction, Complication Of Orthopedic Device Or Procedure",3494,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,15687.18,,,,,,,fee schedule,15687.18,15687.18, "Malfunction, Reaction, Complication Of Orthopedic Device Or Procedure",3494,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,15687.18,,,,,,,fee schedule,15687.18,15687.18, "Malfunction, Reaction, Complication Of Orthopedic Device Or Procedure",3494,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,15687.18,,,,,,,fee schedule,15687.18,15687.18, "Malfunction, Reaction, Complication Of Orthopedic Device Or Procedure",3494,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,15687.18,,,,,,,fee schedule,15687.18,15687.18, "Malfunction, Reaction, Complication Of Orthopedic Device Or Procedure",3494,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,15687.18,,,,,,,fee schedule,15687.18,15687.18, "Malfunction, Reaction, Complication Of Orthopedic Device Or Procedure",3494,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,15687.18,,,,,,,fee schedule,15687.18,15687.18, Other Musculoskeletal System And Connective Tissue Diagnoses,3511,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4360.25,,,,,,,fee schedule,4360.25,4360.25, Other Musculoskeletal System And Connective Tissue Diagnoses,3511,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4360.25,,,,,,,fee schedule,4360.25,4360.25, Other Musculoskeletal System And Connective Tissue Diagnoses,3511,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4360.25,,,,,,,fee schedule,4360.25,4360.25, Other Musculoskeletal System And Connective Tissue Diagnoses,3511,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4360.25,,,,,,,fee schedule,4360.25,4360.25, Other Musculoskeletal System And Connective Tissue Diagnoses,3511,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4360.25,,,,,,,fee schedule,4360.25,4360.25, Other Musculoskeletal System And Connective Tissue Diagnoses,3511,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4360.25,,,,,,,fee schedule,4360.25,4360.25, Other Musculoskeletal System And Connective Tissue Diagnoses,3511,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4360.25,,,,,,,fee schedule,4360.25,4360.25, Other Musculoskeletal System And Connective Tissue Diagnoses,3511,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4360.25,,,,,,,fee schedule,4360.25,4360.25, Other Musculoskeletal System And Connective Tissue Diagnoses,3511,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4360.25,,,,,,,fee schedule,4360.25,4360.25, Other Musculoskeletal System And Connective Tissue Diagnoses,3511,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4360.25,,,,,,,fee schedule,4360.25,4360.25, Other Musculoskeletal System And Connective Tissue Diagnoses,3511,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4360.25,,,,,,,fee schedule,4360.25,4360.25, Other Musculoskeletal System And Connective Tissue Diagnoses,3512,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5461.26,,,,,,,fee schedule,5461.26,5461.26, Other Musculoskeletal System And Connective Tissue Diagnoses,3512,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5461.26,,,,,,,fee schedule,5461.26,5461.26, Other Musculoskeletal System And Connective Tissue Diagnoses,3512,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5461.26,,,,,,,fee schedule,5461.26,5461.26, Other Musculoskeletal System And Connective Tissue Diagnoses,3512,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5461.26,,,,,,,fee schedule,5461.26,5461.26, Other Musculoskeletal System And Connective Tissue Diagnoses,3512,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5461.26,,,,,,,fee schedule,5461.26,5461.26, Other Musculoskeletal System And Connective Tissue Diagnoses,3512,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5461.26,,,,,,,fee schedule,5461.26,5461.26, Other Musculoskeletal System And Connective Tissue Diagnoses,3512,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5461.26,,,,,,,fee schedule,5461.26,5461.26, Other Musculoskeletal System And Connective Tissue Diagnoses,3512,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5461.26,,,,,,,fee schedule,5461.26,5461.26, Other Musculoskeletal System And Connective Tissue Diagnoses,3512,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5461.26,,,,,,,fee schedule,5461.26,5461.26, Other Musculoskeletal System And Connective Tissue Diagnoses,3512,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5461.26,,,,,,,fee schedule,5461.26,5461.26, Other Musculoskeletal System And Connective Tissue Diagnoses,3512,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5461.26,,,,,,,fee schedule,5461.26,5461.26, Other Musculoskeletal System And Connective Tissue Diagnoses,3513,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,8035.21,,,,,,,fee schedule,8035.21,8035.21, Other Musculoskeletal System And Connective Tissue Diagnoses,3513,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,8035.21,,,,,,,fee schedule,8035.21,8035.21, Other Musculoskeletal System And Connective Tissue Diagnoses,3513,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,8035.21,,,,,,,fee schedule,8035.21,8035.21, Other Musculoskeletal System And Connective Tissue Diagnoses,3513,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,8035.21,,,,,,,fee schedule,8035.21,8035.21, Other Musculoskeletal System And Connective Tissue Diagnoses,3513,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,8035.21,,,,,,,fee schedule,8035.21,8035.21, Other Musculoskeletal System And Connective Tissue Diagnoses,3513,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,8035.21,,,,,,,fee schedule,8035.21,8035.21, Other Musculoskeletal System And Connective Tissue Diagnoses,3513,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,8035.21,,,,,,,fee schedule,8035.21,8035.21, Other Musculoskeletal System And Connective Tissue Diagnoses,3513,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,8035.21,,,,,,,fee schedule,8035.21,8035.21, Other Musculoskeletal System And Connective Tissue Diagnoses,3513,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,8035.21,,,,,,,fee schedule,8035.21,8035.21, Other Musculoskeletal System And Connective Tissue Diagnoses,3513,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,8035.21,,,,,,,fee schedule,8035.21,8035.21, Other Musculoskeletal System And Connective Tissue Diagnoses,3513,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,8035.21,,,,,,,fee schedule,8035.21,8035.21, Other Musculoskeletal System And Connective Tissue Diagnoses,3514,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,14181.77,,,,,,,fee schedule,14181.77,14181.77, Other Musculoskeletal System And Connective Tissue Diagnoses,3514,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,14181.77,,,,,,,fee schedule,14181.77,14181.77, Other Musculoskeletal System And Connective Tissue Diagnoses,3514,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,14181.77,,,,,,,fee schedule,14181.77,14181.77, Other Musculoskeletal System And Connective Tissue Diagnoses,3514,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,14181.77,,,,,,,fee schedule,14181.77,14181.77, Other Musculoskeletal System And Connective Tissue Diagnoses,3514,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,14181.77,,,,,,,fee schedule,14181.77,14181.77, Other Musculoskeletal System And Connective Tissue Diagnoses,3514,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,14181.77,,,,,,,fee schedule,14181.77,14181.77, Other Musculoskeletal System And Connective Tissue Diagnoses,3514,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,14181.77,,,,,,,fee schedule,14181.77,14181.77, Other Musculoskeletal System And Connective Tissue Diagnoses,3514,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,14181.77,,,,,,,fee schedule,14181.77,14181.77, Other Musculoskeletal System And Connective Tissue Diagnoses,3514,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,14181.77,,,,,,,fee schedule,14181.77,14181.77, Other Musculoskeletal System And Connective Tissue Diagnoses,3514,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,14181.77,,,,,,,fee schedule,14181.77,14181.77, Other Musculoskeletal System And Connective Tissue Diagnoses,3514,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,14181.77,,,,,,,fee schedule,14181.77,14181.77, Skin Graft For Skin And Subcutaneous Tissue Diagnoses,3611,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,12175.97,,,,,,,fee schedule,12175.97,12175.97, Skin Graft For Skin And Subcutaneous Tissue Diagnoses,3611,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,12175.97,,,,,,,fee schedule,12175.97,12175.97, Skin Graft For Skin And Subcutaneous Tissue Diagnoses,3611,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,12175.97,,,,,,,fee schedule,12175.97,12175.97, Skin Graft For Skin And Subcutaneous Tissue Diagnoses,3611,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,12175.97,,,,,,,fee schedule,12175.97,12175.97, Skin Graft For Skin And Subcutaneous Tissue Diagnoses,3611,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,12175.97,,,,,,,fee schedule,12175.97,12175.97, Skin Graft For Skin And Subcutaneous Tissue Diagnoses,3611,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,12175.97,,,,,,,fee schedule,12175.97,12175.97, Skin Graft For Skin And Subcutaneous Tissue Diagnoses,3611,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,12175.97,,,,,,,fee schedule,12175.97,12175.97, Skin Graft For Skin And Subcutaneous Tissue Diagnoses,3611,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,12175.97,,,,,,,fee schedule,12175.97,12175.97, Skin Graft For Skin And Subcutaneous Tissue Diagnoses,3611,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,12175.97,,,,,,,fee schedule,12175.97,12175.97, Skin Graft For Skin And Subcutaneous Tissue Diagnoses,3611,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,12175.97,,,,,,,fee schedule,12175.97,12175.97, Skin Graft For Skin And Subcutaneous Tissue Diagnoses,3611,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,12175.97,,,,,,,fee schedule,12175.97,12175.97, Skin Graft For Skin And Subcutaneous Tissue Diagnoses,3612,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,16236.97,,,,,,,fee schedule,16236.97,16236.97, Skin Graft For Skin And Subcutaneous Tissue Diagnoses,3612,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,16236.97,,,,,,,fee schedule,16236.97,16236.97, Skin Graft For Skin And Subcutaneous Tissue Diagnoses,3612,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,16236.97,,,,,,,fee schedule,16236.97,16236.97, Skin Graft For Skin And Subcutaneous Tissue Diagnoses,3612,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,16236.97,,,,,,,fee schedule,16236.97,16236.97, Skin Graft For Skin And Subcutaneous Tissue Diagnoses,3612,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,16236.97,,,,,,,fee schedule,16236.97,16236.97, Skin Graft For Skin And Subcutaneous Tissue Diagnoses,3612,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,16236.97,,,,,,,fee schedule,16236.97,16236.97, Skin Graft For Skin And Subcutaneous Tissue Diagnoses,3612,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,16236.97,,,,,,,fee schedule,16236.97,16236.97, Skin Graft For Skin And Subcutaneous Tissue Diagnoses,3612,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,16236.97,,,,,,,fee schedule,16236.97,16236.97, Skin Graft For Skin And Subcutaneous Tissue Diagnoses,3612,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,16236.97,,,,,,,fee schedule,16236.97,16236.97, Skin Graft For Skin And Subcutaneous Tissue Diagnoses,3612,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,16236.97,,,,,,,fee schedule,16236.97,16236.97, Skin Graft For Skin And Subcutaneous Tissue Diagnoses,3612,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,16236.97,,,,,,,fee schedule,16236.97,16236.97, Skin Graft For Skin And Subcutaneous Tissue Diagnoses,3613,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,22370.13,,,,,,,fee schedule,22370.13,22370.13, Skin Graft For Skin And Subcutaneous Tissue Diagnoses,3613,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,22370.13,,,,,,,fee schedule,22370.13,22370.13, Skin Graft For Skin And Subcutaneous Tissue Diagnoses,3613,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,22370.13,,,,,,,fee schedule,22370.13,22370.13, Skin Graft For Skin And Subcutaneous Tissue Diagnoses,3613,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,22370.13,,,,,,,fee schedule,22370.13,22370.13, Skin Graft For Skin And Subcutaneous Tissue Diagnoses,3613,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,22370.13,,,,,,,fee schedule,22370.13,22370.13, Skin Graft For Skin And Subcutaneous Tissue Diagnoses,3613,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,22370.13,,,,,,,fee schedule,22370.13,22370.13, Skin Graft For Skin And Subcutaneous Tissue Diagnoses,3613,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,22370.13,,,,,,,fee schedule,22370.13,22370.13, Skin Graft For Skin And Subcutaneous Tissue Diagnoses,3613,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,22370.13,,,,,,,fee schedule,22370.13,22370.13, Skin Graft For Skin And Subcutaneous Tissue Diagnoses,3613,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,22370.13,,,,,,,fee schedule,22370.13,22370.13, Skin Graft For Skin And Subcutaneous Tissue Diagnoses,3613,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,22370.13,,,,,,,fee schedule,22370.13,22370.13, Skin Graft For Skin And Subcutaneous Tissue Diagnoses,3613,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,22370.13,,,,,,,fee schedule,22370.13,22370.13, Skin Graft For Skin And Subcutaneous Tissue Diagnoses,3614,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,39730.69,,,,,,,fee schedule,39730.69,39730.69, Skin Graft For Skin And Subcutaneous Tissue Diagnoses,3614,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,39730.69,,,,,,,fee schedule,39730.69,39730.69, Skin Graft For Skin And Subcutaneous Tissue Diagnoses,3614,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,39730.69,,,,,,,fee schedule,39730.69,39730.69, Skin Graft For Skin And Subcutaneous Tissue Diagnoses,3614,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,39730.69,,,,,,,fee schedule,39730.69,39730.69, Skin Graft For Skin And Subcutaneous Tissue Diagnoses,3614,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,39730.69,,,,,,,fee schedule,39730.69,39730.69, Skin Graft For Skin And Subcutaneous Tissue Diagnoses,3614,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,39730.69,,,,,,,fee schedule,39730.69,39730.69, Skin Graft For Skin And Subcutaneous Tissue Diagnoses,3614,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,39730.69,,,,,,,fee schedule,39730.69,39730.69, Skin Graft For Skin And Subcutaneous Tissue Diagnoses,3614,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,39730.69,,,,,,,fee schedule,39730.69,39730.69, Skin Graft For Skin And Subcutaneous Tissue Diagnoses,3614,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,39730.69,,,,,,,fee schedule,39730.69,39730.69, Skin Graft For Skin And Subcutaneous Tissue Diagnoses,3614,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,39730.69,,,,,,,fee schedule,39730.69,39730.69, Skin Graft For Skin And Subcutaneous Tissue Diagnoses,3614,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,39730.69,,,,,,,fee schedule,39730.69,39730.69, Mastectomy Procedures,3621,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,11664.99,,,,,,,fee schedule,11664.99,11664.99, Mastectomy Procedures,3621,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,11664.99,,,,,,,fee schedule,11664.99,11664.99, Mastectomy Procedures,3621,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,11664.99,,,,,,,fee schedule,11664.99,11664.99, Mastectomy Procedures,3621,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,11664.99,,,,,,,fee schedule,11664.99,11664.99, Mastectomy Procedures,3621,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,11664.99,,,,,,,fee schedule,11664.99,11664.99, Mastectomy Procedures,3621,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,11664.99,,,,,,,fee schedule,11664.99,11664.99, Mastectomy Procedures,3621,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,11664.99,,,,,,,fee schedule,11664.99,11664.99, Mastectomy Procedures,3621,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,11664.99,,,,,,,fee schedule,11664.99,11664.99, Mastectomy Procedures,3621,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,11664.99,,,,,,,fee schedule,11664.99,11664.99, Mastectomy Procedures,3621,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,11664.99,,,,,,,fee schedule,11664.99,11664.99, Mastectomy Procedures,3621,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,11664.99,,,,,,,fee schedule,11664.99,11664.99, Mastectomy Procedures,3622,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,17546.88,,,,,,,fee schedule,17546.88,17546.88, Mastectomy Procedures,3622,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,17546.88,,,,,,,fee schedule,17546.88,17546.88, Mastectomy Procedures,3622,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,17546.88,,,,,,,fee schedule,17546.88,17546.88, Mastectomy Procedures,3622,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,17546.88,,,,,,,fee schedule,17546.88,17546.88, Mastectomy Procedures,3622,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,17546.88,,,,,,,fee schedule,17546.88,17546.88, Mastectomy Procedures,3622,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,17546.88,,,,,,,fee schedule,17546.88,17546.88, Mastectomy Procedures,3622,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,17546.88,,,,,,,fee schedule,17546.88,17546.88, Mastectomy Procedures,3622,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,17546.88,,,,,,,fee schedule,17546.88,17546.88, Mastectomy Procedures,3622,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,17546.88,,,,,,,fee schedule,17546.88,17546.88, Mastectomy Procedures,3622,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,17546.88,,,,,,,fee schedule,17546.88,17546.88, Mastectomy Procedures,3622,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,17546.88,,,,,,,fee schedule,17546.88,17546.88, Mastectomy Procedures,3623,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,18172.9,,,,,,,fee schedule,18172.9,18172.9, Mastectomy Procedures,3623,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,18172.9,,,,,,,fee schedule,18172.9,18172.9, Mastectomy Procedures,3623,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,18172.9,,,,,,,fee schedule,18172.9,18172.9, Mastectomy Procedures,3623,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,18172.9,,,,,,,fee schedule,18172.9,18172.9, Mastectomy Procedures,3623,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,18172.9,,,,,,,fee schedule,18172.9,18172.9, Mastectomy Procedures,3623,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,18172.9,,,,,,,fee schedule,18172.9,18172.9, Mastectomy Procedures,3623,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,18172.9,,,,,,,fee schedule,18172.9,18172.9, Mastectomy Procedures,3623,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,18172.9,,,,,,,fee schedule,18172.9,18172.9, Mastectomy Procedures,3623,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,18172.9,,,,,,,fee schedule,18172.9,18172.9, Mastectomy Procedures,3623,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,18172.9,,,,,,,fee schedule,18172.9,18172.9, Mastectomy Procedures,3623,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,18172.9,,,,,,,fee schedule,18172.9,18172.9, Mastectomy Procedures,3624,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,22758.3,,,,,,,fee schedule,22758.3,22758.3, Mastectomy Procedures,3624,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,22758.3,,,,,,,fee schedule,22758.3,22758.3, Mastectomy Procedures,3624,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,22758.3,,,,,,,fee schedule,22758.3,22758.3, Mastectomy Procedures,3624,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,22758.3,,,,,,,fee schedule,22758.3,22758.3, Mastectomy Procedures,3624,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,22758.3,,,,,,,fee schedule,22758.3,22758.3, Mastectomy Procedures,3624,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,22758.3,,,,,,,fee schedule,22758.3,22758.3, Mastectomy Procedures,3624,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,22758.3,,,,,,,fee schedule,22758.3,22758.3, Mastectomy Procedures,3624,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,22758.3,,,,,,,fee schedule,22758.3,22758.3, Mastectomy Procedures,3624,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,22758.3,,,,,,,fee schedule,22758.3,22758.3, Mastectomy Procedures,3624,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,22758.3,,,,,,,fee schedule,22758.3,22758.3, Mastectomy Procedures,3624,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,22758.3,,,,,,,fee schedule,22758.3,22758.3, Breast Procedures Except Mastectomy,3631,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,9911.85,,,,,,,fee schedule,9911.85,9911.85, Breast Procedures Except Mastectomy,3631,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,9911.85,,,,,,,fee schedule,9911.85,9911.85, Breast Procedures Except Mastectomy,3631,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,9911.85,,,,,,,fee schedule,9911.85,9911.85, Breast Procedures Except Mastectomy,3631,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,9911.85,,,,,,,fee schedule,9911.85,9911.85, Breast Procedures Except Mastectomy,3631,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,9911.85,,,,,,,fee schedule,9911.85,9911.85, Breast Procedures Except Mastectomy,3631,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,9911.85,,,,,,,fee schedule,9911.85,9911.85, Breast Procedures Except Mastectomy,3631,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,9911.85,,,,,,,fee schedule,9911.85,9911.85, Breast Procedures Except Mastectomy,3631,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,9911.85,,,,,,,fee schedule,9911.85,9911.85, Breast Procedures Except Mastectomy,3631,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,9911.85,,,,,,,fee schedule,9911.85,9911.85, Breast Procedures Except Mastectomy,3631,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,9911.85,,,,,,,fee schedule,9911.85,9911.85, Breast Procedures Except Mastectomy,3631,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,9911.85,,,,,,,fee schedule,9911.85,9911.85, Breast Procedures Except Mastectomy,3632,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,15807.16,,,,,,,fee schedule,15807.16,15807.16, Breast Procedures Except Mastectomy,3632,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,15807.16,,,,,,,fee schedule,15807.16,15807.16, Breast Procedures Except Mastectomy,3632,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,15807.16,,,,,,,fee schedule,15807.16,15807.16, Breast Procedures Except Mastectomy,3632,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,15807.16,,,,,,,fee schedule,15807.16,15807.16, Breast Procedures Except Mastectomy,3632,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,15807.16,,,,,,,fee schedule,15807.16,15807.16, Breast Procedures Except Mastectomy,3632,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,15807.16,,,,,,,fee schedule,15807.16,15807.16, Breast Procedures Except Mastectomy,3632,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,15807.16,,,,,,,fee schedule,15807.16,15807.16, Breast Procedures Except Mastectomy,3632,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,15807.16,,,,,,,fee schedule,15807.16,15807.16, Breast Procedures Except Mastectomy,3632,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,15807.16,,,,,,,fee schedule,15807.16,15807.16, Breast Procedures Except Mastectomy,3632,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,15807.16,,,,,,,fee schedule,15807.16,15807.16, Breast Procedures Except Mastectomy,3632,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,15807.16,,,,,,,fee schedule,15807.16,15807.16, Breast Procedures Except Mastectomy,3633,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,21601.54,,,,,,,fee schedule,21601.54,21601.54, Breast Procedures Except Mastectomy,3633,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,21601.54,,,,,,,fee schedule,21601.54,21601.54, Breast Procedures Except Mastectomy,3633,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,21601.54,,,,,,,fee schedule,21601.54,21601.54, Breast Procedures Except Mastectomy,3633,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,21601.54,,,,,,,fee schedule,21601.54,21601.54, Breast Procedures Except Mastectomy,3633,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,21601.54,,,,,,,fee schedule,21601.54,21601.54, Breast Procedures Except Mastectomy,3633,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,21601.54,,,,,,,fee schedule,21601.54,21601.54, Breast Procedures Except Mastectomy,3633,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,21601.54,,,,,,,fee schedule,21601.54,21601.54, Breast Procedures Except Mastectomy,3633,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,21601.54,,,,,,,fee schedule,21601.54,21601.54, Breast Procedures Except Mastectomy,3633,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,21601.54,,,,,,,fee schedule,21601.54,21601.54, Breast Procedures Except Mastectomy,3633,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,21601.54,,,,,,,fee schedule,21601.54,21601.54, Breast Procedures Except Mastectomy,3633,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,21601.54,,,,,,,fee schedule,21601.54,21601.54, Breast Procedures Except Mastectomy,3634,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,23448.54,,,,,,,fee schedule,23448.54,23448.54, Breast Procedures Except Mastectomy,3634,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,23448.54,,,,,,,fee schedule,23448.54,23448.54, Breast Procedures Except Mastectomy,3634,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,23448.54,,,,,,,fee schedule,23448.54,23448.54, Breast Procedures Except Mastectomy,3634,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,23448.54,,,,,,,fee schedule,23448.54,23448.54, Breast Procedures Except Mastectomy,3634,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,23448.54,,,,,,,fee schedule,23448.54,23448.54, Breast Procedures Except Mastectomy,3634,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,23448.54,,,,,,,fee schedule,23448.54,23448.54, Breast Procedures Except Mastectomy,3634,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,23448.54,,,,,,,fee schedule,23448.54,23448.54, Breast Procedures Except Mastectomy,3634,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,23448.54,,,,,,,fee schedule,23448.54,23448.54, Breast Procedures Except Mastectomy,3634,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,23448.54,,,,,,,fee schedule,23448.54,23448.54, Breast Procedures Except Mastectomy,3634,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,23448.54,,,,,,,fee schedule,23448.54,23448.54, Breast Procedures Except Mastectomy,3634,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,23448.54,,,,,,,fee schedule,23448.54,23448.54, "Other Skin, Subcutaneous Tissue And Related Procedures",3641,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,6231.96,,,,,,,fee schedule,6231.96,6231.96, "Other Skin, Subcutaneous Tissue And Related Procedures",3641,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,6231.96,,,,,,,fee schedule,6231.96,6231.96, "Other Skin, Subcutaneous Tissue And Related Procedures",3641,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,6231.96,,,,,,,fee schedule,6231.96,6231.96, "Other Skin, Subcutaneous Tissue And Related Procedures",3641,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,6231.96,,,,,,,fee schedule,6231.96,6231.96, "Other Skin, Subcutaneous Tissue And Related Procedures",3641,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,6231.96,,,,,,,fee schedule,6231.96,6231.96, "Other Skin, Subcutaneous Tissue And Related Procedures",3641,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,6231.96,,,,,,,fee schedule,6231.96,6231.96, "Other Skin, Subcutaneous Tissue And Related Procedures",3641,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,6231.96,,,,,,,fee schedule,6231.96,6231.96, "Other Skin, Subcutaneous Tissue And Related Procedures",3641,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,6231.96,,,,,,,fee schedule,6231.96,6231.96, "Other Skin, Subcutaneous Tissue And Related Procedures",3641,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,6231.96,,,,,,,fee schedule,6231.96,6231.96, "Other Skin, Subcutaneous Tissue And Related Procedures",3641,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,6231.96,,,,,,,fee schedule,6231.96,6231.96, "Other Skin, Subcutaneous Tissue And Related Procedures",3641,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,6231.96,,,,,,,fee schedule,6231.96,6231.96, "Other Skin, Subcutaneous Tissue And Related Procedures",3642,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,8225.06,,,,,,,fee schedule,8225.06,8225.06, "Other Skin, Subcutaneous Tissue And Related Procedures",3642,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,8225.06,,,,,,,fee schedule,8225.06,8225.06, "Other Skin, Subcutaneous Tissue And Related Procedures",3642,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,8225.06,,,,,,,fee schedule,8225.06,8225.06, "Other Skin, Subcutaneous Tissue And Related Procedures",3642,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,8225.06,,,,,,,fee schedule,8225.06,8225.06, "Other Skin, Subcutaneous Tissue And Related Procedures",3642,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,8225.06,,,,,,,fee schedule,8225.06,8225.06, "Other Skin, Subcutaneous Tissue And Related Procedures",3642,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,8225.06,,,,,,,fee schedule,8225.06,8225.06, "Other Skin, Subcutaneous Tissue And Related Procedures",3642,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,8225.06,,,,,,,fee schedule,8225.06,8225.06, "Other Skin, Subcutaneous Tissue And Related Procedures",3642,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,8225.06,,,,,,,fee schedule,8225.06,8225.06, "Other Skin, Subcutaneous Tissue And Related Procedures",3642,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,8225.06,,,,,,,fee schedule,8225.06,8225.06, "Other Skin, Subcutaneous Tissue And Related Procedures",3642,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,8225.06,,,,,,,fee schedule,8225.06,8225.06, "Other Skin, Subcutaneous Tissue And Related Procedures",3642,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,8225.06,,,,,,,fee schedule,8225.06,8225.06, "Other Skin, Subcutaneous Tissue And Related Procedures",3643,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,13578.33,,,,,,,fee schedule,13578.33,13578.33, "Other Skin, Subcutaneous Tissue And Related Procedures",3643,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,13578.33,,,,,,,fee schedule,13578.33,13578.33, "Other Skin, Subcutaneous Tissue And Related Procedures",3643,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,13578.33,,,,,,,fee schedule,13578.33,13578.33, "Other Skin, Subcutaneous Tissue And Related Procedures",3643,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,13578.33,,,,,,,fee schedule,13578.33,13578.33, "Other Skin, Subcutaneous Tissue And Related Procedures",3643,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,13578.33,,,,,,,fee schedule,13578.33,13578.33, "Other Skin, Subcutaneous Tissue And Related Procedures",3643,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,13578.33,,,,,,,fee schedule,13578.33,13578.33, "Other Skin, Subcutaneous Tissue And Related Procedures",3643,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,13578.33,,,,,,,fee schedule,13578.33,13578.33, "Other Skin, Subcutaneous Tissue And Related Procedures",3643,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,13578.33,,,,,,,fee schedule,13578.33,13578.33, "Other Skin, Subcutaneous Tissue And Related Procedures",3643,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,13578.33,,,,,,,fee schedule,13578.33,13578.33, "Other Skin, Subcutaneous Tissue And Related Procedures",3643,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,13578.33,,,,,,,fee schedule,13578.33,13578.33, "Other Skin, Subcutaneous Tissue And Related Procedures",3643,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,13578.33,,,,,,,fee schedule,13578.33,13578.33, "Other Skin, Subcutaneous Tissue And Related Procedures",3644,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,22792.18,,,,,,,fee schedule,22792.18,22792.18, "Other Skin, Subcutaneous Tissue And Related Procedures",3644,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,22792.18,,,,,,,fee schedule,22792.18,22792.18, "Other Skin, Subcutaneous Tissue And Related Procedures",3644,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,22792.18,,,,,,,fee schedule,22792.18,22792.18, "Other Skin, Subcutaneous Tissue And Related Procedures",3644,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,22792.18,,,,,,,fee schedule,22792.18,22792.18, "Other Skin, Subcutaneous Tissue And Related Procedures",3644,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,22792.18,,,,,,,fee schedule,22792.18,22792.18, "Other Skin, Subcutaneous Tissue And Related Procedures",3644,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,22792.18,,,,,,,fee schedule,22792.18,22792.18, "Other Skin, Subcutaneous Tissue And Related Procedures",3644,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,22792.18,,,,,,,fee schedule,22792.18,22792.18, "Other Skin, Subcutaneous Tissue And Related Procedures",3644,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,22792.18,,,,,,,fee schedule,22792.18,22792.18, "Other Skin, Subcutaneous Tissue And Related Procedures",3644,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,22792.18,,,,,,,fee schedule,22792.18,22792.18, "Other Skin, Subcutaneous Tissue And Related Procedures",3644,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,22792.18,,,,,,,fee schedule,22792.18,22792.18, "Other Skin, Subcutaneous Tissue And Related Procedures",3644,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,22792.18,,,,,,,fee schedule,22792.18,22792.18, Skin Ulcers,3801,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4304.5,,,,,,,fee schedule,4304.5,4304.5, Skin Ulcers,3801,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4304.5,,,,,,,fee schedule,4304.5,4304.5, Skin Ulcers,3801,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4304.5,,,,,,,fee schedule,4304.5,4304.5, Skin Ulcers,3801,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4304.5,,,,,,,fee schedule,4304.5,4304.5, Skin Ulcers,3801,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4304.5,,,,,,,fee schedule,4304.5,4304.5, Skin Ulcers,3801,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4304.5,,,,,,,fee schedule,4304.5,4304.5, Skin Ulcers,3801,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4304.5,,,,,,,fee schedule,4304.5,4304.5, Skin Ulcers,3801,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4304.5,,,,,,,fee schedule,4304.5,4304.5, Skin Ulcers,3801,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4304.5,,,,,,,fee schedule,4304.5,4304.5, Skin Ulcers,3801,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4304.5,,,,,,,fee schedule,4304.5,4304.5, Skin Ulcers,3801,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4304.5,,,,,,,fee schedule,4304.5,4304.5, Skin Ulcers,3802,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5514.19,,,,,,,fee schedule,5514.19,5514.19, Skin Ulcers,3802,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5514.19,,,,,,,fee schedule,5514.19,5514.19, Skin Ulcers,3802,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5514.19,,,,,,,fee schedule,5514.19,5514.19, Skin Ulcers,3802,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5514.19,,,,,,,fee schedule,5514.19,5514.19, Skin Ulcers,3802,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5514.19,,,,,,,fee schedule,5514.19,5514.19, Skin Ulcers,3802,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5514.19,,,,,,,fee schedule,5514.19,5514.19, Skin Ulcers,3802,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5514.19,,,,,,,fee schedule,5514.19,5514.19, Skin Ulcers,3802,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5514.19,,,,,,,fee schedule,5514.19,5514.19, Skin Ulcers,3802,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5514.19,,,,,,,fee schedule,5514.19,5514.19, Skin Ulcers,3802,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5514.19,,,,,,,fee schedule,5514.19,5514.19, Skin Ulcers,3802,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5514.19,,,,,,,fee schedule,5514.19,5514.19, Skin Ulcers,3803,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,8488.31,,,,,,,fee schedule,8488.31,8488.31, Skin Ulcers,3803,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,8488.31,,,,,,,fee schedule,8488.31,8488.31, Skin Ulcers,3803,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,8488.31,,,,,,,fee schedule,8488.31,8488.31, Skin Ulcers,3803,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,8488.31,,,,,,,fee schedule,8488.31,8488.31, Skin Ulcers,3803,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,8488.31,,,,,,,fee schedule,8488.31,8488.31, Skin Ulcers,3803,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,8488.31,,,,,,,fee schedule,8488.31,8488.31, Skin Ulcers,3803,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,8488.31,,,,,,,fee schedule,8488.31,8488.31, Skin Ulcers,3803,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,8488.31,,,,,,,fee schedule,8488.31,8488.31, Skin Ulcers,3803,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,8488.31,,,,,,,fee schedule,8488.31,8488.31, Skin Ulcers,3803,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,8488.31,,,,,,,fee schedule,8488.31,8488.31, Skin Ulcers,3803,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,8488.31,,,,,,,fee schedule,8488.31,8488.31, Skin Ulcers,3804,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,14804.96,,,,,,,fee schedule,14804.96,14804.96, Skin Ulcers,3804,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,14804.96,,,,,,,fee schedule,14804.96,14804.96, Skin Ulcers,3804,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,14804.96,,,,,,,fee schedule,14804.96,14804.96, Skin Ulcers,3804,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,14804.96,,,,,,,fee schedule,14804.96,14804.96, Skin Ulcers,3804,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,14804.96,,,,,,,fee schedule,14804.96,14804.96, Skin Ulcers,3804,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,14804.96,,,,,,,fee schedule,14804.96,14804.96, Skin Ulcers,3804,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,14804.96,,,,,,,fee schedule,14804.96,14804.96, Skin Ulcers,3804,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,14804.96,,,,,,,fee schedule,14804.96,14804.96, Skin Ulcers,3804,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,14804.96,,,,,,,fee schedule,14804.96,14804.96, Skin Ulcers,3804,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,14804.96,,,,,,,fee schedule,14804.96,14804.96, Skin Ulcers,3804,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,14804.96,,,,,,,fee schedule,14804.96,14804.96, Major Skin Disorders,3811,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,3521.09,,,,,,,fee schedule,3521.09,3521.09, Major Skin Disorders,3811,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,3521.09,,,,,,,fee schedule,3521.09,3521.09, Major Skin Disorders,3811,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,3521.09,,,,,,,fee schedule,3521.09,3521.09, Major Skin Disorders,3811,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,3521.09,,,,,,,fee schedule,3521.09,3521.09, Major Skin Disorders,3811,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,3521.09,,,,,,,fee schedule,3521.09,3521.09, Major Skin Disorders,3811,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,3521.09,,,,,,,fee schedule,3521.09,3521.09, Major Skin Disorders,3811,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,3521.09,,,,,,,fee schedule,3521.09,3521.09, Major Skin Disorders,3811,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,3521.09,,,,,,,fee schedule,3521.09,3521.09, Major Skin Disorders,3811,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,3521.09,,,,,,,fee schedule,3521.09,3521.09, Major Skin Disorders,3811,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,3521.09,,,,,,,fee schedule,3521.09,3521.09, Major Skin Disorders,3811,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,3521.09,,,,,,,fee schedule,3521.09,3521.09, Major Skin Disorders,3812,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,6289.13,,,,,,,fee schedule,6289.13,6289.13, Major Skin Disorders,3812,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,6289.13,,,,,,,fee schedule,6289.13,6289.13, Major Skin Disorders,3812,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,6289.13,,,,,,,fee schedule,6289.13,6289.13, Major Skin Disorders,3812,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,6289.13,,,,,,,fee schedule,6289.13,6289.13, Major Skin Disorders,3812,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,6289.13,,,,,,,fee schedule,6289.13,6289.13, Major Skin Disorders,3812,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,6289.13,,,,,,,fee schedule,6289.13,6289.13, Major Skin Disorders,3812,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,6289.13,,,,,,,fee schedule,6289.13,6289.13, Major Skin Disorders,3812,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,6289.13,,,,,,,fee schedule,6289.13,6289.13, Major Skin Disorders,3812,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,6289.13,,,,,,,fee schedule,6289.13,6289.13, Major Skin Disorders,3812,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,6289.13,,,,,,,fee schedule,6289.13,6289.13, Major Skin Disorders,3812,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,6289.13,,,,,,,fee schedule,6289.13,6289.13, Major Skin Disorders,3813,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,10429.89,,,,,,,fee schedule,10429.89,10429.89, Major Skin Disorders,3813,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,10429.89,,,,,,,fee schedule,10429.89,10429.89, Major Skin Disorders,3813,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,10429.89,,,,,,,fee schedule,10429.89,10429.89, Major Skin Disorders,3813,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,10429.89,,,,,,,fee schedule,10429.89,10429.89, Major Skin Disorders,3813,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,10429.89,,,,,,,fee schedule,10429.89,10429.89, Major Skin Disorders,3813,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,10429.89,,,,,,,fee schedule,10429.89,10429.89, Major Skin Disorders,3813,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,10429.89,,,,,,,fee schedule,10429.89,10429.89, Major Skin Disorders,3813,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,10429.89,,,,,,,fee schedule,10429.89,10429.89, Major Skin Disorders,3813,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,10429.89,,,,,,,fee schedule,10429.89,10429.89, Major Skin Disorders,3813,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,10429.89,,,,,,,fee schedule,10429.89,10429.89, Major Skin Disorders,3813,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,10429.89,,,,,,,fee schedule,10429.89,10429.89, Major Skin Disorders,3814,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,21633.3,,,,,,,fee schedule,21633.3,21633.3, Major Skin Disorders,3814,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,21633.3,,,,,,,fee schedule,21633.3,21633.3, Major Skin Disorders,3814,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,21633.3,,,,,,,fee schedule,21633.3,21633.3, Major Skin Disorders,3814,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,21633.3,,,,,,,fee schedule,21633.3,21633.3, Major Skin Disorders,3814,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,21633.3,,,,,,,fee schedule,21633.3,21633.3, Major Skin Disorders,3814,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,21633.3,,,,,,,fee schedule,21633.3,21633.3, Major Skin Disorders,3814,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,21633.3,,,,,,,fee schedule,21633.3,21633.3, Major Skin Disorders,3814,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,21633.3,,,,,,,fee schedule,21633.3,21633.3, Major Skin Disorders,3814,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,21633.3,,,,,,,fee schedule,21633.3,21633.3, Major Skin Disorders,3814,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,21633.3,,,,,,,fee schedule,21633.3,21633.3, Major Skin Disorders,3814,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,21633.3,,,,,,,fee schedule,21633.3,21633.3, Malignant Breast Disorders,3821,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5356.1,,,,,,,fee schedule,5356.1,5356.1, Malignant Breast Disorders,3821,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5356.1,,,,,,,fee schedule,5356.1,5356.1, Malignant Breast Disorders,3821,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5356.1,,,,,,,fee schedule,5356.1,5356.1, Malignant Breast Disorders,3821,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5356.1,,,,,,,fee schedule,5356.1,5356.1, Malignant Breast Disorders,3821,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5356.1,,,,,,,fee schedule,5356.1,5356.1, Malignant Breast Disorders,3821,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5356.1,,,,,,,fee schedule,5356.1,5356.1, Malignant Breast Disorders,3821,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5356.1,,,,,,,fee schedule,5356.1,5356.1, Malignant Breast Disorders,3821,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5356.1,,,,,,,fee schedule,5356.1,5356.1, Malignant Breast Disorders,3821,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5356.1,,,,,,,fee schedule,5356.1,5356.1, Malignant Breast Disorders,3821,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5356.1,,,,,,,fee schedule,5356.1,5356.1, Malignant Breast Disorders,3821,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5356.1,,,,,,,fee schedule,5356.1,5356.1, Malignant Breast Disorders,3822,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,6855.16,,,,,,,fee schedule,6855.16,6855.16, Malignant Breast Disorders,3822,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,6855.16,,,,,,,fee schedule,6855.16,6855.16, Malignant Breast Disorders,3822,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,6855.16,,,,,,,fee schedule,6855.16,6855.16, Malignant Breast Disorders,3822,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,6855.16,,,,,,,fee schedule,6855.16,6855.16, Malignant Breast Disorders,3822,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,6855.16,,,,,,,fee schedule,6855.16,6855.16, Malignant Breast Disorders,3822,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,6855.16,,,,,,,fee schedule,6855.16,6855.16, Malignant Breast Disorders,3822,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,6855.16,,,,,,,fee schedule,6855.16,6855.16, Malignant Breast Disorders,3822,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,6855.16,,,,,,,fee schedule,6855.16,6855.16, Malignant Breast Disorders,3822,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,6855.16,,,,,,,fee schedule,6855.16,6855.16, Malignant Breast Disorders,3822,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,6855.16,,,,,,,fee schedule,6855.16,6855.16, Malignant Breast Disorders,3822,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,6855.16,,,,,,,fee schedule,6855.16,6855.16, Malignant Breast Disorders,3823,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,9232.19,,,,,,,fee schedule,9232.19,9232.19, Malignant Breast Disorders,3823,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,9232.19,,,,,,,fee schedule,9232.19,9232.19, Malignant Breast Disorders,3823,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,9232.19,,,,,,,fee schedule,9232.19,9232.19, Malignant Breast Disorders,3823,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,9232.19,,,,,,,fee schedule,9232.19,9232.19, Malignant Breast Disorders,3823,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,9232.19,,,,,,,fee schedule,9232.19,9232.19, Malignant Breast Disorders,3823,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,9232.19,,,,,,,fee schedule,9232.19,9232.19, Malignant Breast Disorders,3823,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,9232.19,,,,,,,fee schedule,9232.19,9232.19, Malignant Breast Disorders,3823,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,9232.19,,,,,,,fee schedule,9232.19,9232.19, Malignant Breast Disorders,3823,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,9232.19,,,,,,,fee schedule,9232.19,9232.19, Malignant Breast Disorders,3823,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,9232.19,,,,,,,fee schedule,9232.19,9232.19, Malignant Breast Disorders,3823,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,9232.19,,,,,,,fee schedule,9232.19,9232.19, Malignant Breast Disorders,3824,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,15379.46,,,,,,,fee schedule,15379.46,15379.46, Malignant Breast Disorders,3824,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,15379.46,,,,,,,fee schedule,15379.46,15379.46, Malignant Breast Disorders,3824,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,15379.46,,,,,,,fee schedule,15379.46,15379.46, Malignant Breast Disorders,3824,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,15379.46,,,,,,,fee schedule,15379.46,15379.46, Malignant Breast Disorders,3824,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,15379.46,,,,,,,fee schedule,15379.46,15379.46, Malignant Breast Disorders,3824,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,15379.46,,,,,,,fee schedule,15379.46,15379.46, Malignant Breast Disorders,3824,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,15379.46,,,,,,,fee schedule,15379.46,15379.46, Malignant Breast Disorders,3824,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,15379.46,,,,,,,fee schedule,15379.46,15379.46, Malignant Breast Disorders,3824,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,15379.46,,,,,,,fee schedule,15379.46,15379.46, Malignant Breast Disorders,3824,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,15379.46,,,,,,,fee schedule,15379.46,15379.46, Malignant Breast Disorders,3824,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,15379.46,,,,,,,fee schedule,15379.46,15379.46, Cellulitis And Other Skin Infections,3831,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,3541.56,,,,,,,fee schedule,3541.56,3541.56, Cellulitis And Other Skin Infections,3831,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,3541.56,,,,,,,fee schedule,3541.56,3541.56, Cellulitis And Other Skin Infections,3831,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,3541.56,,,,,,,fee schedule,3541.56,3541.56, Cellulitis And Other Skin Infections,3831,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,3541.56,,,,,,,fee schedule,3541.56,3541.56, Cellulitis And Other Skin Infections,3831,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,3541.56,,,,,,,fee schedule,3541.56,3541.56, Cellulitis And Other Skin Infections,3831,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,3541.56,,,,,,,fee schedule,3541.56,3541.56, Cellulitis And Other Skin Infections,3831,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,3541.56,,,,,,,fee schedule,3541.56,3541.56, Cellulitis And Other Skin Infections,3831,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,3541.56,,,,,,,fee schedule,3541.56,3541.56, Cellulitis And Other Skin Infections,3831,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,3541.56,,,,,,,fee schedule,3541.56,3541.56, Cellulitis And Other Skin Infections,3831,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,3541.56,,,,,,,fee schedule,3541.56,3541.56, Cellulitis And Other Skin Infections,3831,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,3541.56,,,,,,,fee schedule,3541.56,3541.56, Cellulitis And Other Skin Infections,3832,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4763.96,,,,,,,fee schedule,4763.96,4763.96, Cellulitis And Other Skin Infections,3832,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4763.96,,,,,,,fee schedule,4763.96,4763.96, Cellulitis And Other Skin Infections,3832,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4763.96,,,,,,,fee schedule,4763.96,4763.96, Cellulitis And Other Skin Infections,3832,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4763.96,,,,,,,fee schedule,4763.96,4763.96, Cellulitis And Other Skin Infections,3832,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4763.96,,,,,,,fee schedule,4763.96,4763.96, Cellulitis And Other Skin Infections,3832,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4763.96,,,,,,,fee schedule,4763.96,4763.96, Cellulitis And Other Skin Infections,3832,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4763.96,,,,,,,fee schedule,4763.96,4763.96, Cellulitis And Other Skin Infections,3832,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4763.96,,,,,,,fee schedule,4763.96,4763.96, Cellulitis And Other Skin Infections,3832,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4763.96,,,,,,,fee schedule,4763.96,4763.96, Cellulitis And Other Skin Infections,3832,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4763.96,,,,,,,fee schedule,4763.96,4763.96, Cellulitis And Other Skin Infections,3832,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4763.96,,,,,,,fee schedule,4763.96,4763.96, Cellulitis And Other Skin Infections,3833,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,7388.01,,,,,,,fee schedule,7388.01,7388.01, Cellulitis And Other Skin Infections,3833,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,7388.01,,,,,,,fee schedule,7388.01,7388.01, Cellulitis And Other Skin Infections,3833,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,7388.01,,,,,,,fee schedule,7388.01,7388.01, Cellulitis And Other Skin Infections,3833,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,7388.01,,,,,,,fee schedule,7388.01,7388.01, Cellulitis And Other Skin Infections,3833,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,7388.01,,,,,,,fee schedule,7388.01,7388.01, Cellulitis And Other Skin Infections,3833,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,7388.01,,,,,,,fee schedule,7388.01,7388.01, Cellulitis And Other Skin Infections,3833,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,7388.01,,,,,,,fee schedule,7388.01,7388.01, Cellulitis And Other Skin Infections,3833,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,7388.01,,,,,,,fee schedule,7388.01,7388.01, Cellulitis And Other Skin Infections,3833,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,7388.01,,,,,,,fee schedule,7388.01,7388.01, Cellulitis And Other Skin Infections,3833,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,7388.01,,,,,,,fee schedule,7388.01,7388.01, Cellulitis And Other Skin Infections,3833,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,7388.01,,,,,,,fee schedule,7388.01,7388.01, Cellulitis And Other Skin Infections,3834,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,14146.48,,,,,,,fee schedule,14146.48,14146.48, Cellulitis And Other Skin Infections,3834,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,14146.48,,,,,,,fee schedule,14146.48,14146.48, Cellulitis And Other Skin Infections,3834,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,14146.48,,,,,,,fee schedule,14146.48,14146.48, Cellulitis And Other Skin Infections,3834,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,14146.48,,,,,,,fee schedule,14146.48,14146.48, Cellulitis And Other Skin Infections,3834,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,14146.48,,,,,,,fee schedule,14146.48,14146.48, Cellulitis And Other Skin Infections,3834,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,14146.48,,,,,,,fee schedule,14146.48,14146.48, Cellulitis And Other Skin Infections,3834,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,14146.48,,,,,,,fee schedule,14146.48,14146.48, Cellulitis And Other Skin Infections,3834,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,14146.48,,,,,,,fee schedule,14146.48,14146.48, Cellulitis And Other Skin Infections,3834,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,14146.48,,,,,,,fee schedule,14146.48,14146.48, Cellulitis And Other Skin Infections,3834,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,14146.48,,,,,,,fee schedule,14146.48,14146.48, Cellulitis And Other Skin Infections,3834,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,14146.48,,,,,,,fee schedule,14146.48,14146.48, "Contusion, Open Wound And Other Trauma To Skin And Subcutaneous Tissue",3841,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5230.47,,,,,,,fee schedule,5230.47,5230.47, "Contusion, Open Wound And Other Trauma To Skin And Subcutaneous Tissue",3841,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5230.47,,,,,,,fee schedule,5230.47,5230.47, "Contusion, Open Wound And Other Trauma To Skin And Subcutaneous Tissue",3841,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5230.47,,,,,,,fee schedule,5230.47,5230.47, "Contusion, Open Wound And Other Trauma To Skin And Subcutaneous Tissue",3841,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5230.47,,,,,,,fee schedule,5230.47,5230.47, "Contusion, Open Wound And Other Trauma To Skin And Subcutaneous Tissue",3841,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5230.47,,,,,,,fee schedule,5230.47,5230.47, "Contusion, Open Wound And Other Trauma To Skin And Subcutaneous Tissue",3841,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5230.47,,,,,,,fee schedule,5230.47,5230.47, "Contusion, Open Wound And Other Trauma To Skin And Subcutaneous Tissue",3841,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5230.47,,,,,,,fee schedule,5230.47,5230.47, "Contusion, Open Wound And Other Trauma To Skin And Subcutaneous Tissue",3841,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5230.47,,,,,,,fee schedule,5230.47,5230.47, "Contusion, Open Wound And Other Trauma To Skin And Subcutaneous Tissue",3841,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5230.47,,,,,,,fee schedule,5230.47,5230.47, "Contusion, Open Wound And Other Trauma To Skin And Subcutaneous Tissue",3841,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5230.47,,,,,,,fee schedule,5230.47,5230.47, "Contusion, Open Wound And Other Trauma To Skin And Subcutaneous Tissue",3841,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5230.47,,,,,,,fee schedule,5230.47,5230.47, "Contusion, Open Wound And Other Trauma To Skin And Subcutaneous Tissue",3842,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,6430.28,,,,,,,fee schedule,6430.28,6430.28, "Contusion, Open Wound And Other Trauma To Skin And Subcutaneous Tissue",3842,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,6430.28,,,,,,,fee schedule,6430.28,6430.28, "Contusion, Open Wound And Other Trauma To Skin And Subcutaneous Tissue",3842,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,6430.28,,,,,,,fee schedule,6430.28,6430.28, "Contusion, Open Wound And Other Trauma To Skin And Subcutaneous Tissue",3842,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,6430.28,,,,,,,fee schedule,6430.28,6430.28, "Contusion, Open Wound And Other Trauma To Skin And Subcutaneous Tissue",3842,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,6430.28,,,,,,,fee schedule,6430.28,6430.28, "Contusion, Open Wound And Other Trauma To Skin And Subcutaneous Tissue",3842,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,6430.28,,,,,,,fee schedule,6430.28,6430.28, "Contusion, Open Wound And Other Trauma To Skin And Subcutaneous Tissue",3842,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,6430.28,,,,,,,fee schedule,6430.28,6430.28, "Contusion, Open Wound And Other Trauma To Skin And Subcutaneous Tissue",3842,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,6430.28,,,,,,,fee schedule,6430.28,6430.28, "Contusion, Open Wound And Other Trauma To Skin And Subcutaneous Tissue",3842,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,6430.28,,,,,,,fee schedule,6430.28,6430.28, "Contusion, Open Wound And Other Trauma To Skin And Subcutaneous Tissue",3842,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,6430.28,,,,,,,fee schedule,6430.28,6430.28, "Contusion, Open Wound And Other Trauma To Skin And Subcutaneous Tissue",3842,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,6430.28,,,,,,,fee schedule,6430.28,6430.28, "Contusion, Open Wound And Other Trauma To Skin And Subcutaneous Tissue",3843,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,9146.8,,,,,,,fee schedule,9146.8,9146.8, "Contusion, Open Wound And Other Trauma To Skin And Subcutaneous Tissue",3843,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,9146.8,,,,,,,fee schedule,9146.8,9146.8, "Contusion, Open Wound And Other Trauma To Skin And Subcutaneous Tissue",3843,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,9146.8,,,,,,,fee schedule,9146.8,9146.8, "Contusion, Open Wound And Other Trauma To Skin And Subcutaneous Tissue",3843,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,9146.8,,,,,,,fee schedule,9146.8,9146.8, "Contusion, Open Wound And Other Trauma To Skin And Subcutaneous Tissue",3843,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,9146.8,,,,,,,fee schedule,9146.8,9146.8, "Contusion, Open Wound And Other Trauma To Skin And Subcutaneous Tissue",3843,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,9146.8,,,,,,,fee schedule,9146.8,9146.8, "Contusion, Open Wound And Other Trauma To Skin And Subcutaneous Tissue",3843,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,9146.8,,,,,,,fee schedule,9146.8,9146.8, "Contusion, Open Wound And Other Trauma To Skin And Subcutaneous Tissue",3843,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,9146.8,,,,,,,fee schedule,9146.8,9146.8, "Contusion, Open Wound And Other Trauma To Skin And Subcutaneous Tissue",3843,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,9146.8,,,,,,,fee schedule,9146.8,9146.8, "Contusion, Open Wound And Other Trauma To Skin And Subcutaneous Tissue",3843,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,9146.8,,,,,,,fee schedule,9146.8,9146.8, "Contusion, Open Wound And Other Trauma To Skin And Subcutaneous Tissue",3843,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,9146.8,,,,,,,fee schedule,9146.8,9146.8, "Contusion, Open Wound And Other Trauma To Skin And Subcutaneous Tissue",3844,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,14730.86,,,,,,,fee schedule,14730.86,14730.86, "Contusion, Open Wound And Other Trauma To Skin And Subcutaneous Tissue",3844,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,14730.86,,,,,,,fee schedule,14730.86,14730.86, "Contusion, Open Wound And Other Trauma To Skin And Subcutaneous Tissue",3844,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,14730.86,,,,,,,fee schedule,14730.86,14730.86, "Contusion, Open Wound And Other Trauma To Skin And Subcutaneous Tissue",3844,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,14730.86,,,,,,,fee schedule,14730.86,14730.86, "Contusion, Open Wound And Other Trauma To Skin And Subcutaneous Tissue",3844,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,14730.86,,,,,,,fee schedule,14730.86,14730.86, "Contusion, Open Wound And Other Trauma To Skin And Subcutaneous Tissue",3844,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,14730.86,,,,,,,fee schedule,14730.86,14730.86, "Contusion, Open Wound And Other Trauma To Skin And Subcutaneous Tissue",3844,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,14730.86,,,,,,,fee schedule,14730.86,14730.86, "Contusion, Open Wound And Other Trauma To Skin And Subcutaneous Tissue",3844,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,14730.86,,,,,,,fee schedule,14730.86,14730.86, "Contusion, Open Wound And Other Trauma To Skin And Subcutaneous Tissue",3844,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,14730.86,,,,,,,fee schedule,14730.86,14730.86, "Contusion, Open Wound And Other Trauma To Skin And Subcutaneous Tissue",3844,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,14730.86,,,,,,,fee schedule,14730.86,14730.86, "Contusion, Open Wound And Other Trauma To Skin And Subcutaneous Tissue",3844,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,14730.86,,,,,,,fee schedule,14730.86,14730.86, "Other Skin, Subcutaneous Tissue And Breast Disorders",3851,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,3993.96,,,,,,,fee schedule,3993.96,3993.96, "Other Skin, Subcutaneous Tissue And Breast Disorders",3851,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,3993.96,,,,,,,fee schedule,3993.96,3993.96, "Other Skin, Subcutaneous Tissue And Breast Disorders",3851,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,3993.96,,,,,,,fee schedule,3993.96,3993.96, "Other Skin, Subcutaneous Tissue And Breast Disorders",3851,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,3993.96,,,,,,,fee schedule,3993.96,3993.96, "Other Skin, Subcutaneous Tissue And Breast Disorders",3851,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,3993.96,,,,,,,fee schedule,3993.96,3993.96, "Other Skin, Subcutaneous Tissue And Breast Disorders",3851,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,3993.96,,,,,,,fee schedule,3993.96,3993.96, "Other Skin, Subcutaneous Tissue And Breast Disorders",3851,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,3993.96,,,,,,,fee schedule,3993.96,3993.96, "Other Skin, Subcutaneous Tissue And Breast Disorders",3851,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,3993.96,,,,,,,fee schedule,3993.96,3993.96, "Other Skin, Subcutaneous Tissue And Breast Disorders",3851,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,3993.96,,,,,,,fee schedule,3993.96,3993.96, "Other Skin, Subcutaneous Tissue And Breast Disorders",3851,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,3993.96,,,,,,,fee schedule,3993.96,3993.96, "Other Skin, Subcutaneous Tissue And Breast Disorders",3851,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,3993.96,,,,,,,fee schedule,3993.96,3993.96, "Other Skin, Subcutaneous Tissue And Breast Disorders",3852,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5176.13,,,,,,,fee schedule,5176.13,5176.13, "Other Skin, Subcutaneous Tissue And Breast Disorders",3852,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5176.13,,,,,,,fee schedule,5176.13,5176.13, "Other Skin, Subcutaneous Tissue And Breast Disorders",3852,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5176.13,,,,,,,fee schedule,5176.13,5176.13, "Other Skin, Subcutaneous Tissue And Breast Disorders",3852,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5176.13,,,,,,,fee schedule,5176.13,5176.13, "Other Skin, Subcutaneous Tissue And Breast Disorders",3852,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5176.13,,,,,,,fee schedule,5176.13,5176.13, "Other Skin, Subcutaneous Tissue And Breast Disorders",3852,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5176.13,,,,,,,fee schedule,5176.13,5176.13, "Other Skin, Subcutaneous Tissue And Breast Disorders",3852,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5176.13,,,,,,,fee schedule,5176.13,5176.13, "Other Skin, Subcutaneous Tissue And Breast Disorders",3852,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5176.13,,,,,,,fee schedule,5176.13,5176.13, "Other Skin, Subcutaneous Tissue And Breast Disorders",3852,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5176.13,,,,,,,fee schedule,5176.13,5176.13, "Other Skin, Subcutaneous Tissue And Breast Disorders",3852,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5176.13,,,,,,,fee schedule,5176.13,5176.13, "Other Skin, Subcutaneous Tissue And Breast Disorders",3852,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5176.13,,,,,,,fee schedule,5176.13,5176.13, "Other Skin, Subcutaneous Tissue And Breast Disorders",3853,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,8419.15,,,,,,,fee schedule,8419.15,8419.15, "Other Skin, Subcutaneous Tissue And Breast Disorders",3853,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,8419.15,,,,,,,fee schedule,8419.15,8419.15, "Other Skin, Subcutaneous Tissue And Breast Disorders",3853,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,8419.15,,,,,,,fee schedule,8419.15,8419.15, "Other Skin, Subcutaneous Tissue And Breast Disorders",3853,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,8419.15,,,,,,,fee schedule,8419.15,8419.15, "Other Skin, Subcutaneous Tissue And Breast Disorders",3853,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,8419.15,,,,,,,fee schedule,8419.15,8419.15, "Other Skin, Subcutaneous Tissue And Breast Disorders",3853,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,8419.15,,,,,,,fee schedule,8419.15,8419.15, "Other Skin, Subcutaneous Tissue And Breast Disorders",3853,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,8419.15,,,,,,,fee schedule,8419.15,8419.15, "Other Skin, Subcutaneous Tissue And Breast Disorders",3853,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,8419.15,,,,,,,fee schedule,8419.15,8419.15, "Other Skin, Subcutaneous Tissue And Breast Disorders",3853,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,8419.15,,,,,,,fee schedule,8419.15,8419.15, "Other Skin, Subcutaneous Tissue And Breast Disorders",3853,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,8419.15,,,,,,,fee schedule,8419.15,8419.15, "Other Skin, Subcutaneous Tissue And Breast Disorders",3853,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,8419.15,,,,,,,fee schedule,8419.15,8419.15, "Other Skin, Subcutaneous Tissue And Breast Disorders",3854,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,14061.79,,,,,,,fee schedule,14061.79,14061.79, "Other Skin, Subcutaneous Tissue And Breast Disorders",3854,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,14061.79,,,,,,,fee schedule,14061.79,14061.79, "Other Skin, Subcutaneous Tissue And Breast Disorders",3854,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,14061.79,,,,,,,fee schedule,14061.79,14061.79, "Other Skin, Subcutaneous Tissue And Breast Disorders",3854,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,14061.79,,,,,,,fee schedule,14061.79,14061.79, "Other Skin, Subcutaneous Tissue And Breast Disorders",3854,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,14061.79,,,,,,,fee schedule,14061.79,14061.79, "Other Skin, Subcutaneous Tissue And Breast Disorders",3854,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,14061.79,,,,,,,fee schedule,14061.79,14061.79, "Other Skin, Subcutaneous Tissue And Breast Disorders",3854,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,14061.79,,,,,,,fee schedule,14061.79,14061.79, "Other Skin, Subcutaneous Tissue And Breast Disorders",3854,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,14061.79,,,,,,,fee schedule,14061.79,14061.79, "Other Skin, Subcutaneous Tissue And Breast Disorders",3854,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,14061.79,,,,,,,fee schedule,14061.79,14061.79, "Other Skin, Subcutaneous Tissue And Breast Disorders",3854,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,14061.79,,,,,,,fee schedule,14061.79,14061.79, "Other Skin, Subcutaneous Tissue And Breast Disorders",3854,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,14061.79,,,,,,,fee schedule,14061.79,14061.79, Adrenal Procedures,4011,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,9269.6,,,,,,,fee schedule,9269.6,9269.6, Adrenal Procedures,4011,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,9269.6,,,,,,,fee schedule,9269.6,9269.6, Adrenal Procedures,4011,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,9269.6,,,,,,,fee schedule,9269.6,9269.6, Adrenal Procedures,4011,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,9269.6,,,,,,,fee schedule,9269.6,9269.6, Adrenal Procedures,4011,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,9269.6,,,,,,,fee schedule,9269.6,9269.6, Adrenal Procedures,4011,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,9269.6,,,,,,,fee schedule,9269.6,9269.6, Adrenal Procedures,4011,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,9269.6,,,,,,,fee schedule,9269.6,9269.6, Adrenal Procedures,4011,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,9269.6,,,,,,,fee schedule,9269.6,9269.6, Adrenal Procedures,4011,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,9269.6,,,,,,,fee schedule,9269.6,9269.6, Adrenal Procedures,4011,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,9269.6,,,,,,,fee schedule,9269.6,9269.6, Adrenal Procedures,4011,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,9269.6,,,,,,,fee schedule,9269.6,9269.6, Adrenal Procedures,4012,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,12668.59,,,,,,,fee schedule,12668.59,12668.59, Adrenal Procedures,4012,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,12668.59,,,,,,,fee schedule,12668.59,12668.59, Adrenal Procedures,4012,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,12668.59,,,,,,,fee schedule,12668.59,12668.59, Adrenal Procedures,4012,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,12668.59,,,,,,,fee schedule,12668.59,12668.59, Adrenal Procedures,4012,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,12668.59,,,,,,,fee schedule,12668.59,12668.59, Adrenal Procedures,4012,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,12668.59,,,,,,,fee schedule,12668.59,12668.59, Adrenal Procedures,4012,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,12668.59,,,,,,,fee schedule,12668.59,12668.59, Adrenal Procedures,4012,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,12668.59,,,,,,,fee schedule,12668.59,12668.59, Adrenal Procedures,4012,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,12668.59,,,,,,,fee schedule,12668.59,12668.59, Adrenal Procedures,4012,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,12668.59,,,,,,,fee schedule,12668.59,12668.59, Adrenal Procedures,4012,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,12668.59,,,,,,,fee schedule,12668.59,12668.59, Adrenal Procedures,4013,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,23529,,,,,,,fee schedule,23529,23529, Adrenal Procedures,4013,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,23529,,,,,,,fee schedule,23529,23529, Adrenal Procedures,4013,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,23529,,,,,,,fee schedule,23529,23529, Adrenal Procedures,4013,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,23529,,,,,,,fee schedule,23529,23529, Adrenal Procedures,4013,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,23529,,,,,,,fee schedule,23529,23529, Adrenal Procedures,4013,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,23529,,,,,,,fee schedule,23529,23529, Adrenal Procedures,4013,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,23529,,,,,,,fee schedule,23529,23529, Adrenal Procedures,4013,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,23529,,,,,,,fee schedule,23529,23529, Adrenal Procedures,4013,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,23529,,,,,,,fee schedule,23529,23529, Adrenal Procedures,4013,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,23529,,,,,,,fee schedule,23529,23529, Adrenal Procedures,4013,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,23529,,,,,,,fee schedule,23529,23529, Adrenal Procedures,4014,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,37606.32,,,,,,,fee schedule,37606.32,37606.32, Adrenal Procedures,4014,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,37606.32,,,,,,,fee schedule,37606.32,37606.32, Adrenal Procedures,4014,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,37606.32,,,,,,,fee schedule,37606.32,37606.32, Adrenal Procedures,4014,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,37606.32,,,,,,,fee schedule,37606.32,37606.32, Adrenal Procedures,4014,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,37606.32,,,,,,,fee schedule,37606.32,37606.32, Adrenal Procedures,4014,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,37606.32,,,,,,,fee schedule,37606.32,37606.32, Adrenal Procedures,4014,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,37606.32,,,,,,,fee schedule,37606.32,37606.32, Adrenal Procedures,4014,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,37606.32,,,,,,,fee schedule,37606.32,37606.32, Adrenal Procedures,4014,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,37606.32,,,,,,,fee schedule,37606.32,37606.32, Adrenal Procedures,4014,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,37606.32,,,,,,,fee schedule,37606.32,37606.32, Adrenal Procedures,4014,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,37606.32,,,,,,,fee schedule,37606.32,37606.32, Procedures For Obesity,4031,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,8214.47,,,,,,,fee schedule,8214.47,8214.47, Procedures For Obesity,4031,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,8214.47,,,,,,,fee schedule,8214.47,8214.47, Procedures For Obesity,4031,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,8214.47,,,,,,,fee schedule,8214.47,8214.47, Procedures For Obesity,4031,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,8214.47,,,,,,,fee schedule,8214.47,8214.47, Procedures For Obesity,4031,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,8214.47,,,,,,,fee schedule,8214.47,8214.47, Procedures For Obesity,4031,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,8214.47,,,,,,,fee schedule,8214.47,8214.47, Procedures For Obesity,4031,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,8214.47,,,,,,,fee schedule,8214.47,8214.47, Procedures For Obesity,4031,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,8214.47,,,,,,,fee schedule,8214.47,8214.47, Procedures For Obesity,4031,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,8214.47,,,,,,,fee schedule,8214.47,8214.47, Procedures For Obesity,4031,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,8214.47,,,,,,,fee schedule,8214.47,8214.47, Procedures For Obesity,4031,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,8214.47,,,,,,,fee schedule,8214.47,8214.47, Procedures For Obesity,4032,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,10156.05,,,,,,,fee schedule,10156.05,10156.05, Procedures For Obesity,4032,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,10156.05,,,,,,,fee schedule,10156.05,10156.05, Procedures For Obesity,4032,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,10156.05,,,,,,,fee schedule,10156.05,10156.05, Procedures For Obesity,4032,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,10156.05,,,,,,,fee schedule,10156.05,10156.05, Procedures For Obesity,4032,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,10156.05,,,,,,,fee schedule,10156.05,10156.05, Procedures For Obesity,4032,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,10156.05,,,,,,,fee schedule,10156.05,10156.05, Procedures For Obesity,4032,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,10156.05,,,,,,,fee schedule,10156.05,10156.05, Procedures For Obesity,4032,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,10156.05,,,,,,,fee schedule,10156.05,10156.05, Procedures For Obesity,4032,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,10156.05,,,,,,,fee schedule,10156.05,10156.05, Procedures For Obesity,4032,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,10156.05,,,,,,,fee schedule,10156.05,10156.05, Procedures For Obesity,4032,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,10156.05,,,,,,,fee schedule,10156.05,10156.05, Procedures For Obesity,4033,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,16751.48,,,,,,,fee schedule,16751.48,16751.48, Procedures For Obesity,4033,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,16751.48,,,,,,,fee schedule,16751.48,16751.48, Procedures For Obesity,4033,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,16751.48,,,,,,,fee schedule,16751.48,16751.48, Procedures For Obesity,4033,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,16751.48,,,,,,,fee schedule,16751.48,16751.48, Procedures For Obesity,4033,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,16751.48,,,,,,,fee schedule,16751.48,16751.48, Procedures For Obesity,4033,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,16751.48,,,,,,,fee schedule,16751.48,16751.48, Procedures For Obesity,4033,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,16751.48,,,,,,,fee schedule,16751.48,16751.48, Procedures For Obesity,4033,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,16751.48,,,,,,,fee schedule,16751.48,16751.48, Procedures For Obesity,4033,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,16751.48,,,,,,,fee schedule,16751.48,16751.48, Procedures For Obesity,4033,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,16751.48,,,,,,,fee schedule,16751.48,16751.48, Procedures For Obesity,4033,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,16751.48,,,,,,,fee schedule,16751.48,16751.48, Procedures For Obesity,4034,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,33263.71,,,,,,,fee schedule,33263.71,33263.71, Procedures For Obesity,4034,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,33263.71,,,,,,,fee schedule,33263.71,33263.71, Procedures For Obesity,4034,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,33263.71,,,,,,,fee schedule,33263.71,33263.71, Procedures For Obesity,4034,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,33263.71,,,,,,,fee schedule,33263.71,33263.71, Procedures For Obesity,4034,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,33263.71,,,,,,,fee schedule,33263.71,33263.71, Procedures For Obesity,4034,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,33263.71,,,,,,,fee schedule,33263.71,33263.71, Procedures For Obesity,4034,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,33263.71,,,,,,,fee schedule,33263.71,33263.71, Procedures For Obesity,4034,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,33263.71,,,,,,,fee schedule,33263.71,33263.71, Procedures For Obesity,4034,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,33263.71,,,,,,,fee schedule,33263.71,33263.71, Procedures For Obesity,4034,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,33263.71,,,,,,,fee schedule,33263.71,33263.71, Procedures For Obesity,4034,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,33263.71,,,,,,,fee schedule,33263.71,33263.71, "Thyroid, Parathyroid And Thyroglossal Procedures",4041,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,8275.87,,,,,,,fee schedule,8275.87,8275.87, "Thyroid, Parathyroid And Thyroglossal Procedures",4041,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,8275.87,,,,,,,fee schedule,8275.87,8275.87, "Thyroid, Parathyroid And Thyroglossal Procedures",4041,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,8275.87,,,,,,,fee schedule,8275.87,8275.87, "Thyroid, Parathyroid And Thyroglossal Procedures",4041,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,8275.87,,,,,,,fee schedule,8275.87,8275.87, "Thyroid, Parathyroid And Thyroglossal Procedures",4041,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,8275.87,,,,,,,fee schedule,8275.87,8275.87, "Thyroid, Parathyroid And Thyroglossal Procedures",4041,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,8275.87,,,,,,,fee schedule,8275.87,8275.87, "Thyroid, Parathyroid And Thyroglossal Procedures",4041,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,8275.87,,,,,,,fee schedule,8275.87,8275.87, "Thyroid, Parathyroid And Thyroglossal Procedures",4041,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,8275.87,,,,,,,fee schedule,8275.87,8275.87, "Thyroid, Parathyroid And Thyroglossal Procedures",4041,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,8275.87,,,,,,,fee schedule,8275.87,8275.87, "Thyroid, Parathyroid And Thyroglossal Procedures",4041,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,8275.87,,,,,,,fee schedule,8275.87,8275.87, "Thyroid, Parathyroid And Thyroglossal Procedures",4041,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,8275.87,,,,,,,fee schedule,8275.87,8275.87, "Thyroid, Parathyroid And Thyroglossal Procedures",4042,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,11658.64,,,,,,,fee schedule,11658.64,11658.64, "Thyroid, Parathyroid And Thyroglossal Procedures",4042,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,11658.64,,,,,,,fee schedule,11658.64,11658.64, "Thyroid, Parathyroid And Thyroglossal Procedures",4042,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,11658.64,,,,,,,fee schedule,11658.64,11658.64, "Thyroid, Parathyroid And Thyroglossal Procedures",4042,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,11658.64,,,,,,,fee schedule,11658.64,11658.64, "Thyroid, Parathyroid And Thyroglossal Procedures",4042,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,11658.64,,,,,,,fee schedule,11658.64,11658.64, "Thyroid, Parathyroid And Thyroglossal Procedures",4042,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,11658.64,,,,,,,fee schedule,11658.64,11658.64, "Thyroid, Parathyroid And Thyroglossal Procedures",4042,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,11658.64,,,,,,,fee schedule,11658.64,11658.64, "Thyroid, Parathyroid And Thyroglossal Procedures",4042,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,11658.64,,,,,,,fee schedule,11658.64,11658.64, "Thyroid, Parathyroid And Thyroglossal Procedures",4042,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,11658.64,,,,,,,fee schedule,11658.64,11658.64, "Thyroid, Parathyroid And Thyroglossal Procedures",4042,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,11658.64,,,,,,,fee schedule,11658.64,11658.64, "Thyroid, Parathyroid And Thyroglossal Procedures",4042,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,11658.64,,,,,,,fee schedule,11658.64,11658.64, "Thyroid, Parathyroid And Thyroglossal Procedures",4043,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,19317.67,,,,,,,fee schedule,19317.67,19317.67, "Thyroid, Parathyroid And Thyroglossal Procedures",4043,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,19317.67,,,,,,,fee schedule,19317.67,19317.67, "Thyroid, Parathyroid And Thyroglossal Procedures",4043,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,19317.67,,,,,,,fee schedule,19317.67,19317.67, "Thyroid, Parathyroid And Thyroglossal Procedures",4043,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,19317.67,,,,,,,fee schedule,19317.67,19317.67, "Thyroid, Parathyroid And Thyroglossal Procedures",4043,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,19317.67,,,,,,,fee schedule,19317.67,19317.67, "Thyroid, Parathyroid And Thyroglossal Procedures",4043,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,19317.67,,,,,,,fee schedule,19317.67,19317.67, "Thyroid, Parathyroid And Thyroglossal Procedures",4043,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,19317.67,,,,,,,fee schedule,19317.67,19317.67, "Thyroid, Parathyroid And Thyroglossal Procedures",4043,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,19317.67,,,,,,,fee schedule,19317.67,19317.67, "Thyroid, Parathyroid And Thyroglossal Procedures",4043,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,19317.67,,,,,,,fee schedule,19317.67,19317.67, "Thyroid, Parathyroid And Thyroglossal Procedures",4043,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,19317.67,,,,,,,fee schedule,19317.67,19317.67, "Thyroid, Parathyroid And Thyroglossal Procedures",4043,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,19317.67,,,,,,,fee schedule,19317.67,19317.67, "Thyroid, Parathyroid And Thyroglossal Procedures",4044,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,33356.87,,,,,,,fee schedule,33356.87,33356.87, "Thyroid, Parathyroid And Thyroglossal Procedures",4044,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,33356.87,,,,,,,fee schedule,33356.87,33356.87, "Thyroid, Parathyroid And Thyroglossal Procedures",4044,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,33356.87,,,,,,,fee schedule,33356.87,33356.87, "Thyroid, Parathyroid And Thyroglossal Procedures",4044,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,33356.87,,,,,,,fee schedule,33356.87,33356.87, "Thyroid, Parathyroid And Thyroglossal Procedures",4044,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,33356.87,,,,,,,fee schedule,33356.87,33356.87, "Thyroid, Parathyroid And Thyroglossal Procedures",4044,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,33356.87,,,,,,,fee schedule,33356.87,33356.87, "Thyroid, Parathyroid And Thyroglossal Procedures",4044,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,33356.87,,,,,,,fee schedule,33356.87,33356.87, "Thyroid, Parathyroid And Thyroglossal Procedures",4044,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,33356.87,,,,,,,fee schedule,33356.87,33356.87, "Thyroid, Parathyroid And Thyroglossal Procedures",4044,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,33356.87,,,,,,,fee schedule,33356.87,33356.87, "Thyroid, Parathyroid And Thyroglossal Procedures",4044,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,33356.87,,,,,,,fee schedule,33356.87,33356.87, "Thyroid, Parathyroid And Thyroglossal Procedures",4044,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,33356.87,,,,,,,fee schedule,33356.87,33356.87, "Other Procedures For Endocrine, Nutritional And Metabolic Disorders",4051,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,9779.17,,,,,,,fee schedule,9779.17,9779.17, "Other Procedures For Endocrine, Nutritional And Metabolic Disorders",4051,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,9779.17,,,,,,,fee schedule,9779.17,9779.17, "Other Procedures For Endocrine, Nutritional And Metabolic Disorders",4051,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,9779.17,,,,,,,fee schedule,9779.17,9779.17, "Other Procedures For Endocrine, Nutritional And Metabolic Disorders",4051,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,9779.17,,,,,,,fee schedule,9779.17,9779.17, "Other Procedures For Endocrine, Nutritional And Metabolic Disorders",4051,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,9779.17,,,,,,,fee schedule,9779.17,9779.17, "Other Procedures For Endocrine, Nutritional And Metabolic Disorders",4051,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,9779.17,,,,,,,fee schedule,9779.17,9779.17, "Other Procedures For Endocrine, Nutritional And Metabolic Disorders",4051,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,9779.17,,,,,,,fee schedule,9779.17,9779.17, "Other Procedures For Endocrine, Nutritional And Metabolic Disorders",4051,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,9779.17,,,,,,,fee schedule,9779.17,9779.17, "Other Procedures For Endocrine, Nutritional And Metabolic Disorders",4051,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,9779.17,,,,,,,fee schedule,9779.17,9779.17, "Other Procedures For Endocrine, Nutritional And Metabolic Disorders",4051,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,9779.17,,,,,,,fee schedule,9779.17,9779.17, "Other Procedures For Endocrine, Nutritional And Metabolic Disorders",4051,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,9779.17,,,,,,,fee schedule,9779.17,9779.17, "Other Procedures For Endocrine, Nutritional And Metabolic Disorders",4052,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,11878.84,,,,,,,fee schedule,11878.84,11878.84, "Other Procedures For Endocrine, Nutritional And Metabolic Disorders",4052,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,11878.84,,,,,,,fee schedule,11878.84,11878.84, "Other Procedures For Endocrine, Nutritional And Metabolic Disorders",4052,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,11878.84,,,,,,,fee schedule,11878.84,11878.84, "Other Procedures For Endocrine, Nutritional And Metabolic Disorders",4052,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,11878.84,,,,,,,fee schedule,11878.84,11878.84, "Other Procedures For Endocrine, Nutritional And Metabolic Disorders",4052,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,11878.84,,,,,,,fee schedule,11878.84,11878.84, "Other Procedures For Endocrine, Nutritional And Metabolic Disorders",4052,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,11878.84,,,,,,,fee schedule,11878.84,11878.84, "Other Procedures For Endocrine, Nutritional And Metabolic Disorders",4052,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,11878.84,,,,,,,fee schedule,11878.84,11878.84, "Other Procedures For Endocrine, Nutritional And Metabolic Disorders",4052,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,11878.84,,,,,,,fee schedule,11878.84,11878.84, "Other Procedures For Endocrine, Nutritional And Metabolic Disorders",4052,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,11878.84,,,,,,,fee schedule,11878.84,11878.84, "Other Procedures For Endocrine, Nutritional And Metabolic Disorders",4052,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,11878.84,,,,,,,fee schedule,11878.84,11878.84, "Other Procedures For Endocrine, Nutritional And Metabolic Disorders",4052,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,11878.84,,,,,,,fee schedule,11878.84,11878.84, "Other Procedures For Endocrine, Nutritional And Metabolic Disorders",4053,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,17687.33,,,,,,,fee schedule,17687.33,17687.33, "Other Procedures For Endocrine, Nutritional And Metabolic Disorders",4053,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,17687.33,,,,,,,fee schedule,17687.33,17687.33, "Other Procedures For Endocrine, Nutritional And Metabolic Disorders",4053,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,17687.33,,,,,,,fee schedule,17687.33,17687.33, "Other Procedures For Endocrine, Nutritional And Metabolic Disorders",4053,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,17687.33,,,,,,,fee schedule,17687.33,17687.33, "Other Procedures For Endocrine, Nutritional And Metabolic Disorders",4053,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,17687.33,,,,,,,fee schedule,17687.33,17687.33, "Other Procedures For Endocrine, Nutritional And Metabolic Disorders",4053,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,17687.33,,,,,,,fee schedule,17687.33,17687.33, "Other Procedures For Endocrine, Nutritional And Metabolic Disorders",4053,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,17687.33,,,,,,,fee schedule,17687.33,17687.33, "Other Procedures For Endocrine, Nutritional And Metabolic Disorders",4053,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,17687.33,,,,,,,fee schedule,17687.33,17687.33, "Other Procedures For Endocrine, Nutritional And Metabolic Disorders",4053,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,17687.33,,,,,,,fee schedule,17687.33,17687.33, "Other Procedures For Endocrine, Nutritional And Metabolic Disorders",4053,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,17687.33,,,,,,,fee schedule,17687.33,17687.33, "Other Procedures For Endocrine, Nutritional And Metabolic Disorders",4053,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,17687.33,,,,,,,fee schedule,17687.33,17687.33, "Other Procedures For Endocrine, Nutritional And Metabolic Disorders",4054,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,33760.57,,,,,,,fee schedule,33760.57,33760.57, "Other Procedures For Endocrine, Nutritional And Metabolic Disorders",4054,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,33760.57,,,,,,,fee schedule,33760.57,33760.57, "Other Procedures For Endocrine, Nutritional And Metabolic Disorders",4054,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,33760.57,,,,,,,fee schedule,33760.57,33760.57, "Other Procedures For Endocrine, Nutritional And Metabolic Disorders",4054,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,33760.57,,,,,,,fee schedule,33760.57,33760.57, "Other Procedures For Endocrine, Nutritional And Metabolic Disorders",4054,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,33760.57,,,,,,,fee schedule,33760.57,33760.57, "Other Procedures For Endocrine, Nutritional And Metabolic Disorders",4054,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,33760.57,,,,,,,fee schedule,33760.57,33760.57, "Other Procedures For Endocrine, Nutritional And Metabolic Disorders",4054,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,33760.57,,,,,,,fee schedule,33760.57,33760.57, "Other Procedures For Endocrine, Nutritional And Metabolic Disorders",4054,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,33760.57,,,,,,,fee schedule,33760.57,33760.57, "Other Procedures For Endocrine, Nutritional And Metabolic Disorders",4054,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,33760.57,,,,,,,fee schedule,33760.57,33760.57, "Other Procedures For Endocrine, Nutritional And Metabolic Disorders",4054,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,33760.57,,,,,,,fee schedule,33760.57,33760.57, "Other Procedures For Endocrine, Nutritional And Metabolic Disorders",4054,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,33760.57,,,,,,,fee schedule,33760.57,33760.57, Diabetes,4201,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,3797.76,,,,,,,fee schedule,3797.76,3797.76, Diabetes,4201,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,3797.76,,,,,,,fee schedule,3797.76,3797.76, Diabetes,4201,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,3797.76,,,,,,,fee schedule,3797.76,3797.76, Diabetes,4201,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,3797.76,,,,,,,fee schedule,3797.76,3797.76, Diabetes,4201,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,3797.76,,,,,,,fee schedule,3797.76,3797.76, Diabetes,4201,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,3797.76,,,,,,,fee schedule,3797.76,3797.76, Diabetes,4201,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,3797.76,,,,,,,fee schedule,3797.76,3797.76, Diabetes,4201,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,3797.76,,,,,,,fee schedule,3797.76,3797.76, Diabetes,4201,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,3797.76,,,,,,,fee schedule,3797.76,3797.76, Diabetes,4201,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,3797.76,,,,,,,fee schedule,3797.76,3797.76, Diabetes,4201,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,3797.76,,,,,,,fee schedule,3797.76,3797.76, Diabetes,4202,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4971.45,,,,,,,fee schedule,4971.45,4971.45, Diabetes,4202,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4971.45,,,,,,,fee schedule,4971.45,4971.45, Diabetes,4202,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4971.45,,,,,,,fee schedule,4971.45,4971.45, Diabetes,4202,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4971.45,,,,,,,fee schedule,4971.45,4971.45, Diabetes,4202,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4971.45,,,,,,,fee schedule,4971.45,4971.45, Diabetes,4202,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4971.45,,,,,,,fee schedule,4971.45,4971.45, Diabetes,4202,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4971.45,,,,,,,fee schedule,4971.45,4971.45, Diabetes,4202,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4971.45,,,,,,,fee schedule,4971.45,4971.45, Diabetes,4202,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4971.45,,,,,,,fee schedule,4971.45,4971.45, Diabetes,4202,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4971.45,,,,,,,fee schedule,4971.45,4971.45, Diabetes,4202,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4971.45,,,,,,,fee schedule,4971.45,4971.45, Diabetes,4203,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,7524.23,,,,,,,fee schedule,7524.23,7524.23, Diabetes,4203,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,7524.23,,,,,,,fee schedule,7524.23,7524.23, Diabetes,4203,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,7524.23,,,,,,,fee schedule,7524.23,7524.23, Diabetes,4203,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,7524.23,,,,,,,fee schedule,7524.23,7524.23, Diabetes,4203,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,7524.23,,,,,,,fee schedule,7524.23,7524.23, Diabetes,4203,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,7524.23,,,,,,,fee schedule,7524.23,7524.23, Diabetes,4203,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,7524.23,,,,,,,fee schedule,7524.23,7524.23, Diabetes,4203,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,7524.23,,,,,,,fee schedule,7524.23,7524.23, Diabetes,4203,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,7524.23,,,,,,,fee schedule,7524.23,7524.23, Diabetes,4203,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,7524.23,,,,,,,fee schedule,7524.23,7524.23, Diabetes,4203,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,7524.23,,,,,,,fee schedule,7524.23,7524.23, Diabetes,4204,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,14130.25,,,,,,,fee schedule,14130.25,14130.25, Diabetes,4204,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,14130.25,,,,,,,fee schedule,14130.25,14130.25, Diabetes,4204,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,14130.25,,,,,,,fee schedule,14130.25,14130.25, Diabetes,4204,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,14130.25,,,,,,,fee schedule,14130.25,14130.25, Diabetes,4204,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,14130.25,,,,,,,fee schedule,14130.25,14130.25, Diabetes,4204,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,14130.25,,,,,,,fee schedule,14130.25,14130.25, Diabetes,4204,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,14130.25,,,,,,,fee schedule,14130.25,14130.25, Diabetes,4204,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,14130.25,,,,,,,fee schedule,14130.25,14130.25, Diabetes,4204,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,14130.25,,,,,,,fee schedule,14130.25,14130.25, Diabetes,4204,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,14130.25,,,,,,,fee schedule,14130.25,14130.25, Diabetes,4204,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,14130.25,,,,,,,fee schedule,14130.25,14130.25, "Malnutrition, Failure To Thrive And Other Nutritional Disorders",4211,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,3834.46,,,,,,,fee schedule,3834.46,3834.46, "Malnutrition, Failure To Thrive And Other Nutritional Disorders",4211,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,3834.46,,,,,,,fee schedule,3834.46,3834.46, "Malnutrition, Failure To Thrive And Other Nutritional Disorders",4211,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,3834.46,,,,,,,fee schedule,3834.46,3834.46, "Malnutrition, Failure To Thrive And Other Nutritional Disorders",4211,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,3834.46,,,,,,,fee schedule,3834.46,3834.46, "Malnutrition, Failure To Thrive And Other Nutritional Disorders",4211,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,3834.46,,,,,,,fee schedule,3834.46,3834.46, "Malnutrition, Failure To Thrive And Other Nutritional Disorders",4211,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,3834.46,,,,,,,fee schedule,3834.46,3834.46, "Malnutrition, Failure To Thrive And Other Nutritional Disorders",4211,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,3834.46,,,,,,,fee schedule,3834.46,3834.46, "Malnutrition, Failure To Thrive And Other Nutritional Disorders",4211,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,3834.46,,,,,,,fee schedule,3834.46,3834.46, "Malnutrition, Failure To Thrive And Other Nutritional Disorders",4211,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,3834.46,,,,,,,fee schedule,3834.46,3834.46, "Malnutrition, Failure To Thrive And Other Nutritional Disorders",4211,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,3834.46,,,,,,,fee schedule,3834.46,3834.46, "Malnutrition, Failure To Thrive And Other Nutritional Disorders",4211,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,3834.46,,,,,,,fee schedule,3834.46,3834.46, "Malnutrition, Failure To Thrive And Other Nutritional Disorders",4212,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5637.7,,,,,,,fee schedule,5637.7,5637.7, "Malnutrition, Failure To Thrive And Other Nutritional Disorders",4212,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5637.7,,,,,,,fee schedule,5637.7,5637.7, "Malnutrition, Failure To Thrive And Other Nutritional Disorders",4212,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5637.7,,,,,,,fee schedule,5637.7,5637.7, "Malnutrition, Failure To Thrive And Other Nutritional Disorders",4212,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5637.7,,,,,,,fee schedule,5637.7,5637.7, "Malnutrition, Failure To Thrive And Other Nutritional Disorders",4212,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5637.7,,,,,,,fee schedule,5637.7,5637.7, "Malnutrition, Failure To Thrive And Other Nutritional Disorders",4212,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5637.7,,,,,,,fee schedule,5637.7,5637.7, "Malnutrition, Failure To Thrive And Other Nutritional Disorders",4212,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5637.7,,,,,,,fee schedule,5637.7,5637.7, "Malnutrition, Failure To Thrive And Other Nutritional Disorders",4212,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5637.7,,,,,,,fee schedule,5637.7,5637.7, "Malnutrition, Failure To Thrive And Other Nutritional Disorders",4212,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5637.7,,,,,,,fee schedule,5637.7,5637.7, "Malnutrition, Failure To Thrive And Other Nutritional Disorders",4212,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5637.7,,,,,,,fee schedule,5637.7,5637.7, "Malnutrition, Failure To Thrive And Other Nutritional Disorders",4212,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5637.7,,,,,,,fee schedule,5637.7,5637.7, "Malnutrition, Failure To Thrive And Other Nutritional Disorders",4213,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,8784.73,,,,,,,fee schedule,8784.73,8784.73, "Malnutrition, Failure To Thrive And Other Nutritional Disorders",4213,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,8784.73,,,,,,,fee schedule,8784.73,8784.73, "Malnutrition, Failure To Thrive And Other Nutritional Disorders",4213,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,8784.73,,,,,,,fee schedule,8784.73,8784.73, "Malnutrition, Failure To Thrive And Other Nutritional Disorders",4213,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,8784.73,,,,,,,fee schedule,8784.73,8784.73, "Malnutrition, Failure To Thrive And Other Nutritional Disorders",4213,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,8784.73,,,,,,,fee schedule,8784.73,8784.73, "Malnutrition, Failure To Thrive And Other Nutritional Disorders",4213,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,8784.73,,,,,,,fee schedule,8784.73,8784.73, "Malnutrition, Failure To Thrive And Other Nutritional Disorders",4213,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,8784.73,,,,,,,fee schedule,8784.73,8784.73, "Malnutrition, Failure To Thrive And Other Nutritional Disorders",4213,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,8784.73,,,,,,,fee schedule,8784.73,8784.73, "Malnutrition, Failure To Thrive And Other Nutritional Disorders",4213,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,8784.73,,,,,,,fee schedule,8784.73,8784.73, "Malnutrition, Failure To Thrive And Other Nutritional Disorders",4213,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,8784.73,,,,,,,fee schedule,8784.73,8784.73, "Malnutrition, Failure To Thrive And Other Nutritional Disorders",4213,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,8784.73,,,,,,,fee schedule,8784.73,8784.73, "Malnutrition, Failure To Thrive And Other Nutritional Disorders",4214,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,15061.16,,,,,,,fee schedule,15061.16,15061.16, "Malnutrition, Failure To Thrive And Other Nutritional Disorders",4214,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,15061.16,,,,,,,fee schedule,15061.16,15061.16, "Malnutrition, Failure To Thrive And Other Nutritional Disorders",4214,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,15061.16,,,,,,,fee schedule,15061.16,15061.16, "Malnutrition, Failure To Thrive And Other Nutritional Disorders",4214,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,15061.16,,,,,,,fee schedule,15061.16,15061.16, "Malnutrition, Failure To Thrive And Other Nutritional Disorders",4214,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,15061.16,,,,,,,fee schedule,15061.16,15061.16, "Malnutrition, Failure To Thrive And Other Nutritional Disorders",4214,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,15061.16,,,,,,,fee schedule,15061.16,15061.16, "Malnutrition, Failure To Thrive And Other Nutritional Disorders",4214,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,15061.16,,,,,,,fee schedule,15061.16,15061.16, "Malnutrition, Failure To Thrive And Other Nutritional Disorders",4214,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,15061.16,,,,,,,fee schedule,15061.16,15061.16, "Malnutrition, Failure To Thrive And Other Nutritional Disorders",4214,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,15061.16,,,,,,,fee schedule,15061.16,15061.16, "Malnutrition, Failure To Thrive And Other Nutritional Disorders",4214,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,15061.16,,,,,,,fee schedule,15061.16,15061.16, "Malnutrition, Failure To Thrive And Other Nutritional Disorders",4214,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,15061.16,,,,,,,fee schedule,15061.16,15061.16, Hypovolemia And Related Electrolyte Disorders,4221,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,3223.96,,,,,,,fee schedule,3223.96,3223.96, Hypovolemia And Related Electrolyte Disorders,4221,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,3223.96,,,,,,,fee schedule,3223.96,3223.96, Hypovolemia And Related Electrolyte Disorders,4221,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,3223.96,,,,,,,fee schedule,3223.96,3223.96, Hypovolemia And Related Electrolyte Disorders,4221,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,3223.96,,,,,,,fee schedule,3223.96,3223.96, Hypovolemia And Related Electrolyte Disorders,4221,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,3223.96,,,,,,,fee schedule,3223.96,3223.96, Hypovolemia And Related Electrolyte Disorders,4221,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,3223.96,,,,,,,fee schedule,3223.96,3223.96, Hypovolemia And Related Electrolyte Disorders,4221,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,3223.96,,,,,,,fee schedule,3223.96,3223.96, Hypovolemia And Related Electrolyte Disorders,4221,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,3223.96,,,,,,,fee schedule,3223.96,3223.96, Hypovolemia And Related Electrolyte Disorders,4221,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,3223.96,,,,,,,fee schedule,3223.96,3223.96, Hypovolemia And Related Electrolyte Disorders,4221,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,3223.96,,,,,,,fee schedule,3223.96,3223.96, Hypovolemia And Related Electrolyte Disorders,4221,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,3223.96,,,,,,,fee schedule,3223.96,3223.96, Hypovolemia And Related Electrolyte Disorders,4222,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4348.96,,,,,,,fee schedule,4348.96,4348.96, Hypovolemia And Related Electrolyte Disorders,4222,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4348.96,,,,,,,fee schedule,4348.96,4348.96, Hypovolemia And Related Electrolyte Disorders,4222,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4348.96,,,,,,,fee schedule,4348.96,4348.96, Hypovolemia And Related Electrolyte Disorders,4222,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4348.96,,,,,,,fee schedule,4348.96,4348.96, Hypovolemia And Related Electrolyte Disorders,4222,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4348.96,,,,,,,fee schedule,4348.96,4348.96, Hypovolemia And Related Electrolyte Disorders,4222,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4348.96,,,,,,,fee schedule,4348.96,4348.96, Hypovolemia And Related Electrolyte Disorders,4222,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4348.96,,,,,,,fee schedule,4348.96,4348.96, Hypovolemia And Related Electrolyte Disorders,4222,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4348.96,,,,,,,fee schedule,4348.96,4348.96, Hypovolemia And Related Electrolyte Disorders,4222,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4348.96,,,,,,,fee schedule,4348.96,4348.96, Hypovolemia And Related Electrolyte Disorders,4222,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4348.96,,,,,,,fee schedule,4348.96,4348.96, Hypovolemia And Related Electrolyte Disorders,4222,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4348.96,,,,,,,fee schedule,4348.96,4348.96, Hypovolemia And Related Electrolyte Disorders,4223,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,6345.59,,,,,,,fee schedule,6345.59,6345.59, Hypovolemia And Related Electrolyte Disorders,4223,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,6345.59,,,,,,,fee schedule,6345.59,6345.59, Hypovolemia And Related Electrolyte Disorders,4223,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,6345.59,,,,,,,fee schedule,6345.59,6345.59, Hypovolemia And Related Electrolyte Disorders,4223,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,6345.59,,,,,,,fee schedule,6345.59,6345.59, Hypovolemia And Related Electrolyte Disorders,4223,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,6345.59,,,,,,,fee schedule,6345.59,6345.59, Hypovolemia And Related Electrolyte Disorders,4223,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,6345.59,,,,,,,fee schedule,6345.59,6345.59, Hypovolemia And Related Electrolyte Disorders,4223,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,6345.59,,,,,,,fee schedule,6345.59,6345.59, Hypovolemia And Related Electrolyte Disorders,4223,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,6345.59,,,,,,,fee schedule,6345.59,6345.59, Hypovolemia And Related Electrolyte Disorders,4223,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,6345.59,,,,,,,fee schedule,6345.59,6345.59, Hypovolemia And Related Electrolyte Disorders,4223,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,6345.59,,,,,,,fee schedule,6345.59,6345.59, Hypovolemia And Related Electrolyte Disorders,4223,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,6345.59,,,,,,,fee schedule,6345.59,6345.59, Hypovolemia And Related Electrolyte Disorders,4224,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,10371.31,,,,,,,fee schedule,10371.31,10371.31, Hypovolemia And Related Electrolyte Disorders,4224,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,10371.31,,,,,,,fee schedule,10371.31,10371.31, Hypovolemia And Related Electrolyte Disorders,4224,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,10371.31,,,,,,,fee schedule,10371.31,10371.31, Hypovolemia And Related Electrolyte Disorders,4224,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,10371.31,,,,,,,fee schedule,10371.31,10371.31, Hypovolemia And Related Electrolyte Disorders,4224,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,10371.31,,,,,,,fee schedule,10371.31,10371.31, Hypovolemia And Related Electrolyte Disorders,4224,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,10371.31,,,,,,,fee schedule,10371.31,10371.31, Hypovolemia And Related Electrolyte Disorders,4224,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,10371.31,,,,,,,fee schedule,10371.31,10371.31, Hypovolemia And Related Electrolyte Disorders,4224,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,10371.31,,,,,,,fee schedule,10371.31,10371.31, Hypovolemia And Related Electrolyte Disorders,4224,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,10371.31,,,,,,,fee schedule,10371.31,10371.31, Hypovolemia And Related Electrolyte Disorders,4224,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,10371.31,,,,,,,fee schedule,10371.31,10371.31, Hypovolemia And Related Electrolyte Disorders,4224,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,10371.31,,,,,,,fee schedule,10371.31,10371.31, Inborn Errors Of Metabolism,4231,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5091.43,,,,,,,fee schedule,5091.43,5091.43, Inborn Errors Of Metabolism,4231,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5091.43,,,,,,,fee schedule,5091.43,5091.43, Inborn Errors Of Metabolism,4231,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5091.43,,,,,,,fee schedule,5091.43,5091.43, Inborn Errors Of Metabolism,4231,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5091.43,,,,,,,fee schedule,5091.43,5091.43, Inborn Errors Of Metabolism,4231,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5091.43,,,,,,,fee schedule,5091.43,5091.43, Inborn Errors Of Metabolism,4231,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5091.43,,,,,,,fee schedule,5091.43,5091.43, Inborn Errors Of Metabolism,4231,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5091.43,,,,,,,fee schedule,5091.43,5091.43, Inborn Errors Of Metabolism,4231,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5091.43,,,,,,,fee schedule,5091.43,5091.43, Inborn Errors Of Metabolism,4231,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5091.43,,,,,,,fee schedule,5091.43,5091.43, Inborn Errors Of Metabolism,4231,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5091.43,,,,,,,fee schedule,5091.43,5091.43, Inborn Errors Of Metabolism,4231,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5091.43,,,,,,,fee schedule,5091.43,5091.43, Inborn Errors Of Metabolism,4232,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,7157.93,,,,,,,fee schedule,7157.93,7157.93, Inborn Errors Of Metabolism,4232,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,7157.93,,,,,,,fee schedule,7157.93,7157.93, Inborn Errors Of Metabolism,4232,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,7157.93,,,,,,,fee schedule,7157.93,7157.93, Inborn Errors Of Metabolism,4232,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,7157.93,,,,,,,fee schedule,7157.93,7157.93, Inborn Errors Of Metabolism,4232,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,7157.93,,,,,,,fee schedule,7157.93,7157.93, Inborn Errors Of Metabolism,4232,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,7157.93,,,,,,,fee schedule,7157.93,7157.93, Inborn Errors Of Metabolism,4232,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,7157.93,,,,,,,fee schedule,7157.93,7157.93, Inborn Errors Of Metabolism,4232,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,7157.93,,,,,,,fee schedule,7157.93,7157.93, Inborn Errors Of Metabolism,4232,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,7157.93,,,,,,,fee schedule,7157.93,7157.93, Inborn Errors Of Metabolism,4232,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,7157.93,,,,,,,fee schedule,7157.93,7157.93, Inborn Errors Of Metabolism,4232,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,7157.93,,,,,,,fee schedule,7157.93,7157.93, Inborn Errors Of Metabolism,4233,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,10953.57,,,,,,,fee schedule,10953.57,10953.57, Inborn Errors Of Metabolism,4233,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,10953.57,,,,,,,fee schedule,10953.57,10953.57, Inborn Errors Of Metabolism,4233,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,10953.57,,,,,,,fee schedule,10953.57,10953.57, Inborn Errors Of Metabolism,4233,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,10953.57,,,,,,,fee schedule,10953.57,10953.57, Inborn Errors Of Metabolism,4233,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,10953.57,,,,,,,fee schedule,10953.57,10953.57, Inborn Errors Of Metabolism,4233,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,10953.57,,,,,,,fee schedule,10953.57,10953.57, Inborn Errors Of Metabolism,4233,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,10953.57,,,,,,,fee schedule,10953.57,10953.57, Inborn Errors Of Metabolism,4233,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,10953.57,,,,,,,fee schedule,10953.57,10953.57, Inborn Errors Of Metabolism,4233,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,10953.57,,,,,,,fee schedule,10953.57,10953.57, Inborn Errors Of Metabolism,4233,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,10953.57,,,,,,,fee schedule,10953.57,10953.57, Inborn Errors Of Metabolism,4233,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,10953.57,,,,,,,fee schedule,10953.57,10953.57, Inborn Errors Of Metabolism,4234,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,28088.99,,,,,,,fee schedule,28088.99,28088.99, Inborn Errors Of Metabolism,4234,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,28088.99,,,,,,,fee schedule,28088.99,28088.99, Inborn Errors Of Metabolism,4234,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,28088.99,,,,,,,fee schedule,28088.99,28088.99, Inborn Errors Of Metabolism,4234,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,28088.99,,,,,,,fee schedule,28088.99,28088.99, Inborn Errors Of Metabolism,4234,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,28088.99,,,,,,,fee schedule,28088.99,28088.99, Inborn Errors Of Metabolism,4234,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,28088.99,,,,,,,fee schedule,28088.99,28088.99, Inborn Errors Of Metabolism,4234,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,28088.99,,,,,,,fee schedule,28088.99,28088.99, Inborn Errors Of Metabolism,4234,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,28088.99,,,,,,,fee schedule,28088.99,28088.99, Inborn Errors Of Metabolism,4234,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,28088.99,,,,,,,fee schedule,28088.99,28088.99, Inborn Errors Of Metabolism,4234,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,28088.99,,,,,,,fee schedule,28088.99,28088.99, Inborn Errors Of Metabolism,4234,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,28088.99,,,,,,,fee schedule,28088.99,28088.99, Other Endocrine Disorders,4241,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4437.18,,,,,,,fee schedule,4437.18,4437.18, Other Endocrine Disorders,4241,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4437.18,,,,,,,fee schedule,4437.18,4437.18, Other Endocrine Disorders,4241,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4437.18,,,,,,,fee schedule,4437.18,4437.18, Other Endocrine Disorders,4241,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4437.18,,,,,,,fee schedule,4437.18,4437.18, Other Endocrine Disorders,4241,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4437.18,,,,,,,fee schedule,4437.18,4437.18, Other Endocrine Disorders,4241,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4437.18,,,,,,,fee schedule,4437.18,4437.18, Other Endocrine Disorders,4241,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4437.18,,,,,,,fee schedule,4437.18,4437.18, Other Endocrine Disorders,4241,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4437.18,,,,,,,fee schedule,4437.18,4437.18, Other Endocrine Disorders,4241,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4437.18,,,,,,,fee schedule,4437.18,4437.18, Other Endocrine Disorders,4241,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4437.18,,,,,,,fee schedule,4437.18,4437.18, Other Endocrine Disorders,4241,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4437.18,,,,,,,fee schedule,4437.18,4437.18, Other Endocrine Disorders,4242,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,6428.16,,,,,,,fee schedule,6428.16,6428.16, Other Endocrine Disorders,4242,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,6428.16,,,,,,,fee schedule,6428.16,6428.16, Other Endocrine Disorders,4242,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,6428.16,,,,,,,fee schedule,6428.16,6428.16, Other Endocrine Disorders,4242,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,6428.16,,,,,,,fee schedule,6428.16,6428.16, Other Endocrine Disorders,4242,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,6428.16,,,,,,,fee schedule,6428.16,6428.16, Other Endocrine Disorders,4242,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,6428.16,,,,,,,fee schedule,6428.16,6428.16, Other Endocrine Disorders,4242,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,6428.16,,,,,,,fee schedule,6428.16,6428.16, Other Endocrine Disorders,4242,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,6428.16,,,,,,,fee schedule,6428.16,6428.16, Other Endocrine Disorders,4242,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,6428.16,,,,,,,fee schedule,6428.16,6428.16, Other Endocrine Disorders,4242,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,6428.16,,,,,,,fee schedule,6428.16,6428.16, Other Endocrine Disorders,4242,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,6428.16,,,,,,,fee schedule,6428.16,6428.16, Other Endocrine Disorders,4243,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,9664.83,,,,,,,fee schedule,9664.83,9664.83, Other Endocrine Disorders,4243,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,9664.83,,,,,,,fee schedule,9664.83,9664.83, Other Endocrine Disorders,4243,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,9664.83,,,,,,,fee schedule,9664.83,9664.83, Other Endocrine Disorders,4243,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,9664.83,,,,,,,fee schedule,9664.83,9664.83, Other Endocrine Disorders,4243,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,9664.83,,,,,,,fee schedule,9664.83,9664.83, Other Endocrine Disorders,4243,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,9664.83,,,,,,,fee schedule,9664.83,9664.83, Other Endocrine Disorders,4243,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,9664.83,,,,,,,fee schedule,9664.83,9664.83, Other Endocrine Disorders,4243,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,9664.83,,,,,,,fee schedule,9664.83,9664.83, Other Endocrine Disorders,4243,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,9664.83,,,,,,,fee schedule,9664.83,9664.83, Other Endocrine Disorders,4243,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,9664.83,,,,,,,fee schedule,9664.83,9664.83, Other Endocrine Disorders,4243,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,9664.83,,,,,,,fee schedule,9664.83,9664.83, Other Endocrine Disorders,4244,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,15679.41,,,,,,,fee schedule,15679.41,15679.41, Other Endocrine Disorders,4244,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,15679.41,,,,,,,fee schedule,15679.41,15679.41, Other Endocrine Disorders,4244,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,15679.41,,,,,,,fee schedule,15679.41,15679.41, Other Endocrine Disorders,4244,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,15679.41,,,,,,,fee schedule,15679.41,15679.41, Other Endocrine Disorders,4244,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,15679.41,,,,,,,fee schedule,15679.41,15679.41, Other Endocrine Disorders,4244,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,15679.41,,,,,,,fee schedule,15679.41,15679.41, Other Endocrine Disorders,4244,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,15679.41,,,,,,,fee schedule,15679.41,15679.41, Other Endocrine Disorders,4244,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,15679.41,,,,,,,fee schedule,15679.41,15679.41, Other Endocrine Disorders,4244,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,15679.41,,,,,,,fee schedule,15679.41,15679.41, Other Endocrine Disorders,4244,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,15679.41,,,,,,,fee schedule,15679.41,15679.41, Other Endocrine Disorders,4244,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,15679.41,,,,,,,fee schedule,15679.41,15679.41, Other Non-Hypovolemic Electrolyte Disorders,4251,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,3530.97,,,,,,,fee schedule,3530.97,3530.97, Other Non-Hypovolemic Electrolyte Disorders,4251,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,3530.97,,,,,,,fee schedule,3530.97,3530.97, Other Non-Hypovolemic Electrolyte Disorders,4251,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,3530.97,,,,,,,fee schedule,3530.97,3530.97, Other Non-Hypovolemic Electrolyte Disorders,4251,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,3530.97,,,,,,,fee schedule,3530.97,3530.97, Other Non-Hypovolemic Electrolyte Disorders,4251,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,3530.97,,,,,,,fee schedule,3530.97,3530.97, Other Non-Hypovolemic Electrolyte Disorders,4251,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,3530.97,,,,,,,fee schedule,3530.97,3530.97, Other Non-Hypovolemic Electrolyte Disorders,4251,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,3530.97,,,,,,,fee schedule,3530.97,3530.97, Other Non-Hypovolemic Electrolyte Disorders,4251,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,3530.97,,,,,,,fee schedule,3530.97,3530.97, Other Non-Hypovolemic Electrolyte Disorders,4251,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,3530.97,,,,,,,fee schedule,3530.97,3530.97, Other Non-Hypovolemic Electrolyte Disorders,4251,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,3530.97,,,,,,,fee schedule,3530.97,3530.97, Other Non-Hypovolemic Electrolyte Disorders,4251,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,3530.97,,,,,,,fee schedule,3530.97,3530.97, Other Non-Hypovolemic Electrolyte Disorders,4252,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4713.85,,,,,,,fee schedule,4713.85,4713.85, Other Non-Hypovolemic Electrolyte Disorders,4252,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4713.85,,,,,,,fee schedule,4713.85,4713.85, Other Non-Hypovolemic Electrolyte Disorders,4252,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4713.85,,,,,,,fee schedule,4713.85,4713.85, Other Non-Hypovolemic Electrolyte Disorders,4252,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4713.85,,,,,,,fee schedule,4713.85,4713.85, Other Non-Hypovolemic Electrolyte Disorders,4252,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4713.85,,,,,,,fee schedule,4713.85,4713.85, Other Non-Hypovolemic Electrolyte Disorders,4252,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4713.85,,,,,,,fee schedule,4713.85,4713.85, Other Non-Hypovolemic Electrolyte Disorders,4252,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4713.85,,,,,,,fee schedule,4713.85,4713.85, Other Non-Hypovolemic Electrolyte Disorders,4252,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4713.85,,,,,,,fee schedule,4713.85,4713.85, Other Non-Hypovolemic Electrolyte Disorders,4252,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4713.85,,,,,,,fee schedule,4713.85,4713.85, Other Non-Hypovolemic Electrolyte Disorders,4252,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4713.85,,,,,,,fee schedule,4713.85,4713.85, Other Non-Hypovolemic Electrolyte Disorders,4252,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4713.85,,,,,,,fee schedule,4713.85,4713.85, Other Non-Hypovolemic Electrolyte Disorders,4253,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,6977.25,,,,,,,fee schedule,6977.25,6977.25, Other Non-Hypovolemic Electrolyte Disorders,4253,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,6977.25,,,,,,,fee schedule,6977.25,6977.25, Other Non-Hypovolemic Electrolyte Disorders,4253,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,6977.25,,,,,,,fee schedule,6977.25,6977.25, Other Non-Hypovolemic Electrolyte Disorders,4253,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,6977.25,,,,,,,fee schedule,6977.25,6977.25, Other Non-Hypovolemic Electrolyte Disorders,4253,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,6977.25,,,,,,,fee schedule,6977.25,6977.25, Other Non-Hypovolemic Electrolyte Disorders,4253,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,6977.25,,,,,,,fee schedule,6977.25,6977.25, Other Non-Hypovolemic Electrolyte Disorders,4253,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,6977.25,,,,,,,fee schedule,6977.25,6977.25, Other Non-Hypovolemic Electrolyte Disorders,4253,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,6977.25,,,,,,,fee schedule,6977.25,6977.25, Other Non-Hypovolemic Electrolyte Disorders,4253,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,6977.25,,,,,,,fee schedule,6977.25,6977.25, Other Non-Hypovolemic Electrolyte Disorders,4253,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,6977.25,,,,,,,fee schedule,6977.25,6977.25, Other Non-Hypovolemic Electrolyte Disorders,4253,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,6977.25,,,,,,,fee schedule,6977.25,6977.25, Other Non-Hypovolemic Electrolyte Disorders,4254,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,13655.97,,,,,,,fee schedule,13655.97,13655.97, Other Non-Hypovolemic Electrolyte Disorders,4254,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,13655.97,,,,,,,fee schedule,13655.97,13655.97, Other Non-Hypovolemic Electrolyte Disorders,4254,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,13655.97,,,,,,,fee schedule,13655.97,13655.97, Other Non-Hypovolemic Electrolyte Disorders,4254,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,13655.97,,,,,,,fee schedule,13655.97,13655.97, Other Non-Hypovolemic Electrolyte Disorders,4254,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,13655.97,,,,,,,fee schedule,13655.97,13655.97, Other Non-Hypovolemic Electrolyte Disorders,4254,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,13655.97,,,,,,,fee schedule,13655.97,13655.97, Other Non-Hypovolemic Electrolyte Disorders,4254,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,13655.97,,,,,,,fee schedule,13655.97,13655.97, Other Non-Hypovolemic Electrolyte Disorders,4254,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,13655.97,,,,,,,fee schedule,13655.97,13655.97, Other Non-Hypovolemic Electrolyte Disorders,4254,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,13655.97,,,,,,,fee schedule,13655.97,13655.97, Other Non-Hypovolemic Electrolyte Disorders,4254,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,13655.97,,,,,,,fee schedule,13655.97,13655.97, Other Non-Hypovolemic Electrolyte Disorders,4254,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,13655.97,,,,,,,fee schedule,13655.97,13655.97, Non-Hypovolemic Sodium Disorders,4261,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,3683.42,,,,,,,fee schedule,3683.42,3683.42, Non-Hypovolemic Sodium Disorders,4261,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,3683.42,,,,,,,fee schedule,3683.42,3683.42, Non-Hypovolemic Sodium Disorders,4261,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,3683.42,,,,,,,fee schedule,3683.42,3683.42, Non-Hypovolemic Sodium Disorders,4261,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,3683.42,,,,,,,fee schedule,3683.42,3683.42, Non-Hypovolemic Sodium Disorders,4261,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,3683.42,,,,,,,fee schedule,3683.42,3683.42, Non-Hypovolemic Sodium Disorders,4261,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,3683.42,,,,,,,fee schedule,3683.42,3683.42, Non-Hypovolemic Sodium Disorders,4261,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,3683.42,,,,,,,fee schedule,3683.42,3683.42, Non-Hypovolemic Sodium Disorders,4261,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,3683.42,,,,,,,fee schedule,3683.42,3683.42, Non-Hypovolemic Sodium Disorders,4261,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,3683.42,,,,,,,fee schedule,3683.42,3683.42, Non-Hypovolemic Sodium Disorders,4261,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,3683.42,,,,,,,fee schedule,3683.42,3683.42, Non-Hypovolemic Sodium Disorders,4261,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,3683.42,,,,,,,fee schedule,3683.42,3683.42, Non-Hypovolemic Sodium Disorders,4262,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4982.04,,,,,,,fee schedule,4982.04,4982.04, Non-Hypovolemic Sodium Disorders,4262,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4982.04,,,,,,,fee schedule,4982.04,4982.04, Non-Hypovolemic Sodium Disorders,4262,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4982.04,,,,,,,fee schedule,4982.04,4982.04, Non-Hypovolemic Sodium Disorders,4262,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4982.04,,,,,,,fee schedule,4982.04,4982.04, Non-Hypovolemic Sodium Disorders,4262,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4982.04,,,,,,,fee schedule,4982.04,4982.04, Non-Hypovolemic Sodium Disorders,4262,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4982.04,,,,,,,fee schedule,4982.04,4982.04, Non-Hypovolemic Sodium Disorders,4262,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4982.04,,,,,,,fee schedule,4982.04,4982.04, Non-Hypovolemic Sodium Disorders,4262,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4982.04,,,,,,,fee schedule,4982.04,4982.04, Non-Hypovolemic Sodium Disorders,4262,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4982.04,,,,,,,fee schedule,4982.04,4982.04, Non-Hypovolemic Sodium Disorders,4262,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4982.04,,,,,,,fee schedule,4982.04,4982.04, Non-Hypovolemic Sodium Disorders,4262,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4982.04,,,,,,,fee schedule,4982.04,4982.04, Non-Hypovolemic Sodium Disorders,4263,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,7636.44,,,,,,,fee schedule,7636.44,7636.44, Non-Hypovolemic Sodium Disorders,4263,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,7636.44,,,,,,,fee schedule,7636.44,7636.44, Non-Hypovolemic Sodium Disorders,4263,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,7636.44,,,,,,,fee schedule,7636.44,7636.44, Non-Hypovolemic Sodium Disorders,4263,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,7636.44,,,,,,,fee schedule,7636.44,7636.44, Non-Hypovolemic Sodium Disorders,4263,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,7636.44,,,,,,,fee schedule,7636.44,7636.44, Non-Hypovolemic Sodium Disorders,4263,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,7636.44,,,,,,,fee schedule,7636.44,7636.44, Non-Hypovolemic Sodium Disorders,4263,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,7636.44,,,,,,,fee schedule,7636.44,7636.44, Non-Hypovolemic Sodium Disorders,4263,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,7636.44,,,,,,,fee schedule,7636.44,7636.44, Non-Hypovolemic Sodium Disorders,4263,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,7636.44,,,,,,,fee schedule,7636.44,7636.44, Non-Hypovolemic Sodium Disorders,4263,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,7636.44,,,,,,,fee schedule,7636.44,7636.44, Non-Hypovolemic Sodium Disorders,4263,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,7636.44,,,,,,,fee schedule,7636.44,7636.44, Non-Hypovolemic Sodium Disorders,4264,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,13485.17,,,,,,,fee schedule,13485.17,13485.17, Non-Hypovolemic Sodium Disorders,4264,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,13485.17,,,,,,,fee schedule,13485.17,13485.17, Non-Hypovolemic Sodium Disorders,4264,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,13485.17,,,,,,,fee schedule,13485.17,13485.17, Non-Hypovolemic Sodium Disorders,4264,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,13485.17,,,,,,,fee schedule,13485.17,13485.17, Non-Hypovolemic Sodium Disorders,4264,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,13485.17,,,,,,,fee schedule,13485.17,13485.17, Non-Hypovolemic Sodium Disorders,4264,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,13485.17,,,,,,,fee schedule,13485.17,13485.17, Non-Hypovolemic Sodium Disorders,4264,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,13485.17,,,,,,,fee schedule,13485.17,13485.17, Non-Hypovolemic Sodium Disorders,4264,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,13485.17,,,,,,,fee schedule,13485.17,13485.17, Non-Hypovolemic Sodium Disorders,4264,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,13485.17,,,,,,,fee schedule,13485.17,13485.17, Non-Hypovolemic Sodium Disorders,4264,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,13485.17,,,,,,,fee schedule,13485.17,13485.17, Non-Hypovolemic Sodium Disorders,4264,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,13485.17,,,,,,,fee schedule,13485.17,13485.17, Thyroid Disorders,4271,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4049.01,,,,,,,fee schedule,4049.01,4049.01, Thyroid Disorders,4271,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4049.01,,,,,,,fee schedule,4049.01,4049.01, Thyroid Disorders,4271,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4049.01,,,,,,,fee schedule,4049.01,4049.01, Thyroid Disorders,4271,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4049.01,,,,,,,fee schedule,4049.01,4049.01, Thyroid Disorders,4271,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4049.01,,,,,,,fee schedule,4049.01,4049.01, Thyroid Disorders,4271,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4049.01,,,,,,,fee schedule,4049.01,4049.01, Thyroid Disorders,4271,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4049.01,,,,,,,fee schedule,4049.01,4049.01, Thyroid Disorders,4271,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4049.01,,,,,,,fee schedule,4049.01,4049.01, Thyroid Disorders,4271,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4049.01,,,,,,,fee schedule,4049.01,4049.01, Thyroid Disorders,4271,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4049.01,,,,,,,fee schedule,4049.01,4049.01, Thyroid Disorders,4271,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4049.01,,,,,,,fee schedule,4049.01,4049.01, Thyroid Disorders,4272,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5478.2,,,,,,,fee schedule,5478.2,5478.2, Thyroid Disorders,4272,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5478.2,,,,,,,fee schedule,5478.2,5478.2, Thyroid Disorders,4272,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5478.2,,,,,,,fee schedule,5478.2,5478.2, Thyroid Disorders,4272,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5478.2,,,,,,,fee schedule,5478.2,5478.2, Thyroid Disorders,4272,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5478.2,,,,,,,fee schedule,5478.2,5478.2, Thyroid Disorders,4272,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5478.2,,,,,,,fee schedule,5478.2,5478.2, Thyroid Disorders,4272,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5478.2,,,,,,,fee schedule,5478.2,5478.2, Thyroid Disorders,4272,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5478.2,,,,,,,fee schedule,5478.2,5478.2, Thyroid Disorders,4272,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5478.2,,,,,,,fee schedule,5478.2,5478.2, Thyroid Disorders,4272,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5478.2,,,,,,,fee schedule,5478.2,5478.2, Thyroid Disorders,4272,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5478.2,,,,,,,fee schedule,5478.2,5478.2, Thyroid Disorders,4273,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,8920.24,,,,,,,fee schedule,8920.24,8920.24, Thyroid Disorders,4273,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,8920.24,,,,,,,fee schedule,8920.24,8920.24, Thyroid Disorders,4273,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,8920.24,,,,,,,fee schedule,8920.24,8920.24, Thyroid Disorders,4273,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,8920.24,,,,,,,fee schedule,8920.24,8920.24, Thyroid Disorders,4273,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,8920.24,,,,,,,fee schedule,8920.24,8920.24, Thyroid Disorders,4273,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,8920.24,,,,,,,fee schedule,8920.24,8920.24, Thyroid Disorders,4273,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,8920.24,,,,,,,fee schedule,8920.24,8920.24, Thyroid Disorders,4273,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,8920.24,,,,,,,fee schedule,8920.24,8920.24, Thyroid Disorders,4273,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,8920.24,,,,,,,fee schedule,8920.24,8920.24, Thyroid Disorders,4273,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,8920.24,,,,,,,fee schedule,8920.24,8920.24, Thyroid Disorders,4273,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,8920.24,,,,,,,fee schedule,8920.24,8920.24, Thyroid Disorders,4274,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,16122.64,,,,,,,fee schedule,16122.64,16122.64, Thyroid Disorders,4274,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,16122.64,,,,,,,fee schedule,16122.64,16122.64, Thyroid Disorders,4274,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,16122.64,,,,,,,fee schedule,16122.64,16122.64, Thyroid Disorders,4274,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,16122.64,,,,,,,fee schedule,16122.64,16122.64, Thyroid Disorders,4274,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,16122.64,,,,,,,fee schedule,16122.64,16122.64, Thyroid Disorders,4274,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,16122.64,,,,,,,fee schedule,16122.64,16122.64, Thyroid Disorders,4274,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,16122.64,,,,,,,fee schedule,16122.64,16122.64, Thyroid Disorders,4274,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,16122.64,,,,,,,fee schedule,16122.64,16122.64, Thyroid Disorders,4274,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,16122.64,,,,,,,fee schedule,16122.64,16122.64, Thyroid Disorders,4274,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,16122.64,,,,,,,fee schedule,16122.64,16122.64, Thyroid Disorders,4274,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,16122.64,,,,,,,fee schedule,16122.64,16122.64, Description Not Available,4281,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5464.79,,,,,,,fee schedule,5464.79,5464.79, Description Not Available,4281,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5464.79,,,,,,,fee schedule,5464.79,5464.79, Description Not Available,4281,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5464.79,,,,,,,fee schedule,5464.79,5464.79, Description Not Available,4281,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5464.79,,,,,,,fee schedule,5464.79,5464.79, Description Not Available,4281,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5464.79,,,,,,,fee schedule,5464.79,5464.79, Description Not Available,4281,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5464.79,,,,,,,fee schedule,5464.79,5464.79, Description Not Available,4281,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5464.79,,,,,,,fee schedule,5464.79,5464.79, Description Not Available,4281,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5464.79,,,,,,,fee schedule,5464.79,5464.79, Description Not Available,4281,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5464.79,,,,,,,fee schedule,5464.79,5464.79, Description Not Available,4281,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5464.79,,,,,,,fee schedule,5464.79,5464.79, Description Not Available,4281,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5464.79,,,,,,,fee schedule,5464.79,5464.79, Description Not Available,4282,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,8499.6,,,,,,,fee schedule,8499.6,8499.6, Description Not Available,4282,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,8499.6,,,,,,,fee schedule,8499.6,8499.6, Description Not Available,4282,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,8499.6,,,,,,,fee schedule,8499.6,8499.6, Description Not Available,4282,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,8499.6,,,,,,,fee schedule,8499.6,8499.6, Description Not Available,4282,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,8499.6,,,,,,,fee schedule,8499.6,8499.6, Description Not Available,4282,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,8499.6,,,,,,,fee schedule,8499.6,8499.6, Description Not Available,4282,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,8499.6,,,,,,,fee schedule,8499.6,8499.6, Description Not Available,4282,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,8499.6,,,,,,,fee schedule,8499.6,8499.6, Description Not Available,4282,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,8499.6,,,,,,,fee schedule,8499.6,8499.6, Description Not Available,4282,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,8499.6,,,,,,,fee schedule,8499.6,8499.6, Description Not Available,4282,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,8499.6,,,,,,,fee schedule,8499.6,8499.6, Description Not Available,4283,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,23398.43,,,,,,,fee schedule,23398.43,23398.43, Description Not Available,4283,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,23398.43,,,,,,,fee schedule,23398.43,23398.43, Description Not Available,4283,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,23398.43,,,,,,,fee schedule,23398.43,23398.43, Description Not Available,4283,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,23398.43,,,,,,,fee schedule,23398.43,23398.43, Description Not Available,4283,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,23398.43,,,,,,,fee schedule,23398.43,23398.43, Description Not Available,4283,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,23398.43,,,,,,,fee schedule,23398.43,23398.43, Description Not Available,4283,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,23398.43,,,,,,,fee schedule,23398.43,23398.43, Description Not Available,4283,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,23398.43,,,,,,,fee schedule,23398.43,23398.43, Description Not Available,4283,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,23398.43,,,,,,,fee schedule,23398.43,23398.43, Description Not Available,4283,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,23398.43,,,,,,,fee schedule,23398.43,23398.43, Description Not Available,4283,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,23398.43,,,,,,,fee schedule,23398.43,23398.43, Description Not Available,4284,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,39683.4,,,,,,,fee schedule,39683.4,39683.4, Description Not Available,4284,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,39683.4,,,,,,,fee schedule,39683.4,39683.4, Description Not Available,4284,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,39683.4,,,,,,,fee schedule,39683.4,39683.4, Description Not Available,4284,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,39683.4,,,,,,,fee schedule,39683.4,39683.4, Description Not Available,4284,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,39683.4,,,,,,,fee schedule,39683.4,39683.4, Description Not Available,4284,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,39683.4,,,,,,,fee schedule,39683.4,39683.4, Description Not Available,4284,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,39683.4,,,,,,,fee schedule,39683.4,39683.4, Description Not Available,4284,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,39683.4,,,,,,,fee schedule,39683.4,39683.4, Description Not Available,4284,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,39683.4,,,,,,,fee schedule,39683.4,39683.4, Description Not Available,4284,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,39683.4,,,,,,,fee schedule,39683.4,39683.4, Description Not Available,4284,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,39683.4,,,,,,,fee schedule,39683.4,39683.4, Kidney Transplant,4401,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,35773.43,,,,,,,fee schedule,35773.43,35773.43, Kidney Transplant,4401,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,35773.43,,,,,,,fee schedule,35773.43,35773.43, Kidney Transplant,4401,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,35773.43,,,,,,,fee schedule,35773.43,35773.43, Kidney Transplant,4401,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,35773.43,,,,,,,fee schedule,35773.43,35773.43, Kidney Transplant,4401,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,35773.43,,,,,,,fee schedule,35773.43,35773.43, Kidney Transplant,4401,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,35773.43,,,,,,,fee schedule,35773.43,35773.43, Kidney Transplant,4401,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,35773.43,,,,,,,fee schedule,35773.43,35773.43, Kidney Transplant,4401,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,35773.43,,,,,,,fee schedule,35773.43,35773.43, Kidney Transplant,4401,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,35773.43,,,,,,,fee schedule,35773.43,35773.43, Kidney Transplant,4401,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,35773.43,,,,,,,fee schedule,35773.43,35773.43, Kidney Transplant,4401,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,35773.43,,,,,,,fee schedule,35773.43,35773.43, Kidney Transplant,4402,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,38226.69,,,,,,,fee schedule,38226.69,38226.69, Kidney Transplant,4402,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,38226.69,,,,,,,fee schedule,38226.69,38226.69, Kidney Transplant,4402,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,38226.69,,,,,,,fee schedule,38226.69,38226.69, Kidney Transplant,4402,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,38226.69,,,,,,,fee schedule,38226.69,38226.69, Kidney Transplant,4402,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,38226.69,,,,,,,fee schedule,38226.69,38226.69, Kidney Transplant,4402,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,38226.69,,,,,,,fee schedule,38226.69,38226.69, Kidney Transplant,4402,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,38226.69,,,,,,,fee schedule,38226.69,38226.69, Kidney Transplant,4402,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,38226.69,,,,,,,fee schedule,38226.69,38226.69, Kidney Transplant,4402,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,38226.69,,,,,,,fee schedule,38226.69,38226.69, Kidney Transplant,4402,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,38226.69,,,,,,,fee schedule,38226.69,38226.69, Kidney Transplant,4402,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,38226.69,,,,,,,fee schedule,38226.69,38226.69, Kidney Transplant,4403,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,44856,,,,,,,fee schedule,44856,44856, Kidney Transplant,4403,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,44856,,,,,,,fee schedule,44856,44856, Kidney Transplant,4403,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,44856,,,,,,,fee schedule,44856,44856, Kidney Transplant,4403,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,44856,,,,,,,fee schedule,44856,44856, Kidney Transplant,4403,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,44856,,,,,,,fee schedule,44856,44856, Kidney Transplant,4403,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,44856,,,,,,,fee schedule,44856,44856, Kidney Transplant,4403,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,44856,,,,,,,fee schedule,44856,44856, Kidney Transplant,4403,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,44856,,,,,,,fee schedule,44856,44856, Kidney Transplant,4403,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,44856,,,,,,,fee schedule,44856,44856, Kidney Transplant,4403,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,44856,,,,,,,fee schedule,44856,44856, Kidney Transplant,4403,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,44856,,,,,,,fee schedule,44856,44856, Kidney Transplant,4404,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,65976.2,,,,,,,fee schedule,65976.2,65976.2, Kidney Transplant,4404,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,65976.2,,,,,,,fee schedule,65976.2,65976.2, Kidney Transplant,4404,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,65976.2,,,,,,,fee schedule,65976.2,65976.2, Kidney Transplant,4404,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,65976.2,,,,,,,fee schedule,65976.2,65976.2, Kidney Transplant,4404,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,65976.2,,,,,,,fee schedule,65976.2,65976.2, Kidney Transplant,4404,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,65976.2,,,,,,,fee schedule,65976.2,65976.2, Kidney Transplant,4404,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,65976.2,,,,,,,fee schedule,65976.2,65976.2, Kidney Transplant,4404,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,65976.2,,,,,,,fee schedule,65976.2,65976.2, Kidney Transplant,4404,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,65976.2,,,,,,,fee schedule,65976.2,65976.2, Kidney Transplant,4404,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,65976.2,,,,,,,fee schedule,65976.2,65976.2, Kidney Transplant,4404,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,65976.2,,,,,,,fee schedule,65976.2,65976.2, Major Bladder Procedures,4411,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,15821.27,,,,,,,fee schedule,15821.27,15821.27, Major Bladder Procedures,4411,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,15821.27,,,,,,,fee schedule,15821.27,15821.27, Major Bladder Procedures,4411,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,15821.27,,,,,,,fee schedule,15821.27,15821.27, Major Bladder Procedures,4411,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,15821.27,,,,,,,fee schedule,15821.27,15821.27, Major Bladder Procedures,4411,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,15821.27,,,,,,,fee schedule,15821.27,15821.27, Major Bladder Procedures,4411,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,15821.27,,,,,,,fee schedule,15821.27,15821.27, Major Bladder Procedures,4411,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,15821.27,,,,,,,fee schedule,15821.27,15821.27, Major Bladder Procedures,4411,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,15821.27,,,,,,,fee schedule,15821.27,15821.27, Major Bladder Procedures,4411,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,15821.27,,,,,,,fee schedule,15821.27,15821.27, Major Bladder Procedures,4411,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,15821.27,,,,,,,fee schedule,15821.27,15821.27, Major Bladder Procedures,4411,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,15821.27,,,,,,,fee schedule,15821.27,15821.27, Major Bladder Procedures,4412,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,19712.9,,,,,,,fee schedule,19712.9,19712.9, Major Bladder Procedures,4412,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,19712.9,,,,,,,fee schedule,19712.9,19712.9, Major Bladder Procedures,4412,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,19712.9,,,,,,,fee schedule,19712.9,19712.9, Major Bladder Procedures,4412,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,19712.9,,,,,,,fee schedule,19712.9,19712.9, Major Bladder Procedures,4412,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,19712.9,,,,,,,fee schedule,19712.9,19712.9, Major Bladder Procedures,4412,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,19712.9,,,,,,,fee schedule,19712.9,19712.9, Major Bladder Procedures,4412,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,19712.9,,,,,,,fee schedule,19712.9,19712.9, Major Bladder Procedures,4412,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,19712.9,,,,,,,fee schedule,19712.9,19712.9, Major Bladder Procedures,4412,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,19712.9,,,,,,,fee schedule,19712.9,19712.9, Major Bladder Procedures,4412,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,19712.9,,,,,,,fee schedule,19712.9,19712.9, Major Bladder Procedures,4412,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,19712.9,,,,,,,fee schedule,19712.9,19712.9, Major Bladder Procedures,4413,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,25466.34,,,,,,,fee schedule,25466.34,25466.34, Major Bladder Procedures,4413,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,25466.34,,,,,,,fee schedule,25466.34,25466.34, Major Bladder Procedures,4413,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,25466.34,,,,,,,fee schedule,25466.34,25466.34, Major Bladder Procedures,4413,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,25466.34,,,,,,,fee schedule,25466.34,25466.34, Major Bladder Procedures,4413,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,25466.34,,,,,,,fee schedule,25466.34,25466.34, Major Bladder Procedures,4413,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,25466.34,,,,,,,fee schedule,25466.34,25466.34, Major Bladder Procedures,4413,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,25466.34,,,,,,,fee schedule,25466.34,25466.34, Major Bladder Procedures,4413,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,25466.34,,,,,,,fee schedule,25466.34,25466.34, Major Bladder Procedures,4413,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,25466.34,,,,,,,fee schedule,25466.34,25466.34, Major Bladder Procedures,4413,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,25466.34,,,,,,,fee schedule,25466.34,25466.34, Major Bladder Procedures,4413,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,25466.34,,,,,,,fee schedule,25466.34,25466.34, Major Bladder Procedures,4414,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,37089.69,,,,,,,fee schedule,37089.69,37089.69, Major Bladder Procedures,4414,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,37089.69,,,,,,,fee schedule,37089.69,37089.69, Major Bladder Procedures,4414,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,37089.69,,,,,,,fee schedule,37089.69,37089.69, Major Bladder Procedures,4414,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,37089.69,,,,,,,fee schedule,37089.69,37089.69, Major Bladder Procedures,4414,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,37089.69,,,,,,,fee schedule,37089.69,37089.69, Major Bladder Procedures,4414,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,37089.69,,,,,,,fee schedule,37089.69,37089.69, Major Bladder Procedures,4414,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,37089.69,,,,,,,fee schedule,37089.69,37089.69, Major Bladder Procedures,4414,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,37089.69,,,,,,,fee schedule,37089.69,37089.69, Major Bladder Procedures,4414,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,37089.69,,,,,,,fee schedule,37089.69,37089.69, Major Bladder Procedures,4414,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,37089.69,,,,,,,fee schedule,37089.69,37089.69, Major Bladder Procedures,4414,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,37089.69,,,,,,,fee schedule,37089.69,37089.69, Kidney And Urinary Tract Procedures For Malignancy,4421,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,10521.64,,,,,,,fee schedule,10521.64,10521.64, Kidney And Urinary Tract Procedures For Malignancy,4421,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,10521.64,,,,,,,fee schedule,10521.64,10521.64, Kidney And Urinary Tract Procedures For Malignancy,4421,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,10521.64,,,,,,,fee schedule,10521.64,10521.64, Kidney And Urinary Tract Procedures For Malignancy,4421,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,10521.64,,,,,,,fee schedule,10521.64,10521.64, Kidney And Urinary Tract Procedures For Malignancy,4421,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,10521.64,,,,,,,fee schedule,10521.64,10521.64, Kidney And Urinary Tract Procedures For Malignancy,4421,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,10521.64,,,,,,,fee schedule,10521.64,10521.64, Kidney And Urinary Tract Procedures For Malignancy,4421,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,10521.64,,,,,,,fee schedule,10521.64,10521.64, Kidney And Urinary Tract Procedures For Malignancy,4421,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,10521.64,,,,,,,fee schedule,10521.64,10521.64, Kidney And Urinary Tract Procedures For Malignancy,4421,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,10521.64,,,,,,,fee schedule,10521.64,10521.64, Kidney And Urinary Tract Procedures For Malignancy,4421,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,10521.64,,,,,,,fee schedule,10521.64,10521.64, Kidney And Urinary Tract Procedures For Malignancy,4421,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,10521.64,,,,,,,fee schedule,10521.64,10521.64, Kidney And Urinary Tract Procedures For Malignancy,4422,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,12335.47,,,,,,,fee schedule,12335.47,12335.47, Kidney And Urinary Tract Procedures For Malignancy,4422,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,12335.47,,,,,,,fee schedule,12335.47,12335.47, Kidney And Urinary Tract Procedures For Malignancy,4422,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,12335.47,,,,,,,fee schedule,12335.47,12335.47, Kidney And Urinary Tract Procedures For Malignancy,4422,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,12335.47,,,,,,,fee schedule,12335.47,12335.47, Kidney And Urinary Tract Procedures For Malignancy,4422,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,12335.47,,,,,,,fee schedule,12335.47,12335.47, Kidney And Urinary Tract Procedures For Malignancy,4422,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,12335.47,,,,,,,fee schedule,12335.47,12335.47, Kidney And Urinary Tract Procedures For Malignancy,4422,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,12335.47,,,,,,,fee schedule,12335.47,12335.47, Kidney And Urinary Tract Procedures For Malignancy,4422,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,12335.47,,,,,,,fee schedule,12335.47,12335.47, Kidney And Urinary Tract Procedures For Malignancy,4422,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,12335.47,,,,,,,fee schedule,12335.47,12335.47, Kidney And Urinary Tract Procedures For Malignancy,4422,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,12335.47,,,,,,,fee schedule,12335.47,12335.47, Kidney And Urinary Tract Procedures For Malignancy,4422,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,12335.47,,,,,,,fee schedule,12335.47,12335.47, Kidney And Urinary Tract Procedures For Malignancy,4423,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,18966.9,,,,,,,fee schedule,18966.9,18966.9, Kidney And Urinary Tract Procedures For Malignancy,4423,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,18966.9,,,,,,,fee schedule,18966.9,18966.9, Kidney And Urinary Tract Procedures For Malignancy,4423,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,18966.9,,,,,,,fee schedule,18966.9,18966.9, Kidney And Urinary Tract Procedures For Malignancy,4423,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,18966.9,,,,,,,fee schedule,18966.9,18966.9, Kidney And Urinary Tract Procedures For Malignancy,4423,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,18966.9,,,,,,,fee schedule,18966.9,18966.9, Kidney And Urinary Tract Procedures For Malignancy,4423,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,18966.9,,,,,,,fee schedule,18966.9,18966.9, Kidney And Urinary Tract Procedures For Malignancy,4423,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,18966.9,,,,,,,fee schedule,18966.9,18966.9, Kidney And Urinary Tract Procedures For Malignancy,4423,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,18966.9,,,,,,,fee schedule,18966.9,18966.9, Kidney And Urinary Tract Procedures For Malignancy,4423,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,18966.9,,,,,,,fee schedule,18966.9,18966.9, Kidney And Urinary Tract Procedures For Malignancy,4423,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,18966.9,,,,,,,fee schedule,18966.9,18966.9, Kidney And Urinary Tract Procedures For Malignancy,4423,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,18966.9,,,,,,,fee schedule,18966.9,18966.9, Kidney And Urinary Tract Procedures For Malignancy,4424,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,31559.27,,,,,,,fee schedule,31559.27,31559.27, Kidney And Urinary Tract Procedures For Malignancy,4424,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,31559.27,,,,,,,fee schedule,31559.27,31559.27, Kidney And Urinary Tract Procedures For Malignancy,4424,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,31559.27,,,,,,,fee schedule,31559.27,31559.27, Kidney And Urinary Tract Procedures For Malignancy,4424,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,31559.27,,,,,,,fee schedule,31559.27,31559.27, Kidney And Urinary Tract Procedures For Malignancy,4424,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,31559.27,,,,,,,fee schedule,31559.27,31559.27, Kidney And Urinary Tract Procedures For Malignancy,4424,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,31559.27,,,,,,,fee schedule,31559.27,31559.27, Kidney And Urinary Tract Procedures For Malignancy,4424,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,31559.27,,,,,,,fee schedule,31559.27,31559.27, Kidney And Urinary Tract Procedures For Malignancy,4424,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,31559.27,,,,,,,fee schedule,31559.27,31559.27, Kidney And Urinary Tract Procedures For Malignancy,4424,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,31559.27,,,,,,,fee schedule,31559.27,31559.27, Kidney And Urinary Tract Procedures For Malignancy,4424,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,31559.27,,,,,,,fee schedule,31559.27,31559.27, Kidney And Urinary Tract Procedures For Malignancy,4424,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,31559.27,,,,,,,fee schedule,31559.27,31559.27, Kidney And Urinary Tract Procedures For Non-Malignancy,4431,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,9982.43,,,,,,,fee schedule,9982.43,9982.43, Kidney And Urinary Tract Procedures For Non-Malignancy,4431,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,9982.43,,,,,,,fee schedule,9982.43,9982.43, Kidney And Urinary Tract Procedures For Non-Malignancy,4431,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,9982.43,,,,,,,fee schedule,9982.43,9982.43, Kidney And Urinary Tract Procedures For Non-Malignancy,4431,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,9982.43,,,,,,,fee schedule,9982.43,9982.43, Kidney And Urinary Tract Procedures For Non-Malignancy,4431,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,9982.43,,,,,,,fee schedule,9982.43,9982.43, Kidney And Urinary Tract Procedures For Non-Malignancy,4431,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,9982.43,,,,,,,fee schedule,9982.43,9982.43, Kidney And Urinary Tract Procedures For Non-Malignancy,4431,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,9982.43,,,,,,,fee schedule,9982.43,9982.43, Kidney And Urinary Tract Procedures For Non-Malignancy,4431,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,9982.43,,,,,,,fee schedule,9982.43,9982.43, Kidney And Urinary Tract Procedures For Non-Malignancy,4431,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,9982.43,,,,,,,fee schedule,9982.43,9982.43, Kidney And Urinary Tract Procedures For Non-Malignancy,4431,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,9982.43,,,,,,,fee schedule,9982.43,9982.43, Kidney And Urinary Tract Procedures For Non-Malignancy,4431,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,9982.43,,,,,,,fee schedule,9982.43,9982.43, Kidney And Urinary Tract Procedures For Non-Malignancy,4432,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,11992.47,,,,,,,fee schedule,11992.47,11992.47, Kidney And Urinary Tract Procedures For Non-Malignancy,4432,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,11992.47,,,,,,,fee schedule,11992.47,11992.47, Kidney And Urinary Tract Procedures For Non-Malignancy,4432,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,11992.47,,,,,,,fee schedule,11992.47,11992.47, Kidney And Urinary Tract Procedures For Non-Malignancy,4432,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,11992.47,,,,,,,fee schedule,11992.47,11992.47, Kidney And Urinary Tract Procedures For Non-Malignancy,4432,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,11992.47,,,,,,,fee schedule,11992.47,11992.47, Kidney And Urinary Tract Procedures For Non-Malignancy,4432,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,11992.47,,,,,,,fee schedule,11992.47,11992.47, Kidney And Urinary Tract Procedures For Non-Malignancy,4432,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,11992.47,,,,,,,fee schedule,11992.47,11992.47, Kidney And Urinary Tract Procedures For Non-Malignancy,4432,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,11992.47,,,,,,,fee schedule,11992.47,11992.47, Kidney And Urinary Tract Procedures For Non-Malignancy,4432,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,11992.47,,,,,,,fee schedule,11992.47,11992.47, Kidney And Urinary Tract Procedures For Non-Malignancy,4432,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,11992.47,,,,,,,fee schedule,11992.47,11992.47, Kidney And Urinary Tract Procedures For Non-Malignancy,4432,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,11992.47,,,,,,,fee schedule,11992.47,11992.47, Kidney And Urinary Tract Procedures For Non-Malignancy,4433,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,16359.78,,,,,,,fee schedule,16359.78,16359.78, Kidney And Urinary Tract Procedures For Non-Malignancy,4433,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,16359.78,,,,,,,fee schedule,16359.78,16359.78, Kidney And Urinary Tract Procedures For Non-Malignancy,4433,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,16359.78,,,,,,,fee schedule,16359.78,16359.78, Kidney And Urinary Tract Procedures For Non-Malignancy,4433,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,16359.78,,,,,,,fee schedule,16359.78,16359.78, Kidney And Urinary Tract Procedures For Non-Malignancy,4433,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,16359.78,,,,,,,fee schedule,16359.78,16359.78, Kidney And Urinary Tract Procedures For Non-Malignancy,4433,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,16359.78,,,,,,,fee schedule,16359.78,16359.78, Kidney And Urinary Tract Procedures For Non-Malignancy,4433,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,16359.78,,,,,,,fee schedule,16359.78,16359.78, Kidney And Urinary Tract Procedures For Non-Malignancy,4433,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,16359.78,,,,,,,fee schedule,16359.78,16359.78, Kidney And Urinary Tract Procedures For Non-Malignancy,4433,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,16359.78,,,,,,,fee schedule,16359.78,16359.78, Kidney And Urinary Tract Procedures For Non-Malignancy,4433,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,16359.78,,,,,,,fee schedule,16359.78,16359.78, Kidney And Urinary Tract Procedures For Non-Malignancy,4433,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,16359.78,,,,,,,fee schedule,16359.78,16359.78, Kidney And Urinary Tract Procedures For Non-Malignancy,4434,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,26931.53,,,,,,,fee schedule,26931.53,26931.53, Kidney And Urinary Tract Procedures For Non-Malignancy,4434,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,26931.53,,,,,,,fee schedule,26931.53,26931.53, Kidney And Urinary Tract Procedures For Non-Malignancy,4434,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,26931.53,,,,,,,fee schedule,26931.53,26931.53, Kidney And Urinary Tract Procedures For Non-Malignancy,4434,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,26931.53,,,,,,,fee schedule,26931.53,26931.53, Kidney And Urinary Tract Procedures For Non-Malignancy,4434,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,26931.53,,,,,,,fee schedule,26931.53,26931.53, Kidney And Urinary Tract Procedures For Non-Malignancy,4434,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,26931.53,,,,,,,fee schedule,26931.53,26931.53, Kidney And Urinary Tract Procedures For Non-Malignancy,4434,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,26931.53,,,,,,,fee schedule,26931.53,26931.53, Kidney And Urinary Tract Procedures For Non-Malignancy,4434,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,26931.53,,,,,,,fee schedule,26931.53,26931.53, Kidney And Urinary Tract Procedures For Non-Malignancy,4434,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,26931.53,,,,,,,fee schedule,26931.53,26931.53, Kidney And Urinary Tract Procedures For Non-Malignancy,4434,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,26931.53,,,,,,,fee schedule,26931.53,26931.53, Kidney And Urinary Tract Procedures For Non-Malignancy,4434,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,26931.53,,,,,,,fee schedule,26931.53,26931.53, Renal Dialysis Access Device Procedures And Vessel Repair,4441,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,9497.56,,,,,,,fee schedule,9497.56,9497.56, Renal Dialysis Access Device Procedures And Vessel Repair,4441,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,9497.56,,,,,,,fee schedule,9497.56,9497.56, Renal Dialysis Access Device Procedures And Vessel Repair,4441,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,9497.56,,,,,,,fee schedule,9497.56,9497.56, Renal Dialysis Access Device Procedures And Vessel Repair,4441,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,9497.56,,,,,,,fee schedule,9497.56,9497.56, Renal Dialysis Access Device Procedures And Vessel Repair,4441,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,9497.56,,,,,,,fee schedule,9497.56,9497.56, Renal Dialysis Access Device Procedures And Vessel Repair,4441,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,9497.56,,,,,,,fee schedule,9497.56,9497.56, Renal Dialysis Access Device Procedures And Vessel Repair,4441,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,9497.56,,,,,,,fee schedule,9497.56,9497.56, Renal Dialysis Access Device Procedures And Vessel Repair,4441,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,9497.56,,,,,,,fee schedule,9497.56,9497.56, Renal Dialysis Access Device Procedures And Vessel Repair,4441,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,9497.56,,,,,,,fee schedule,9497.56,9497.56, Renal Dialysis Access Device Procedures And Vessel Repair,4441,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,9497.56,,,,,,,fee schedule,9497.56,9497.56, Renal Dialysis Access Device Procedures And Vessel Repair,4441,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,9497.56,,,,,,,fee schedule,9497.56,9497.56, Renal Dialysis Access Device Procedures And Vessel Repair,4442,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,13087.82,,,,,,,fee schedule,13087.82,13087.82, Renal Dialysis Access Device Procedures And Vessel Repair,4442,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,13087.82,,,,,,,fee schedule,13087.82,13087.82, Renal Dialysis Access Device Procedures And Vessel Repair,4442,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,13087.82,,,,,,,fee schedule,13087.82,13087.82, Renal Dialysis Access Device Procedures And Vessel Repair,4442,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,13087.82,,,,,,,fee schedule,13087.82,13087.82, Renal Dialysis Access Device Procedures And Vessel Repair,4442,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,13087.82,,,,,,,fee schedule,13087.82,13087.82, Renal Dialysis Access Device Procedures And Vessel Repair,4442,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,13087.82,,,,,,,fee schedule,13087.82,13087.82, Renal Dialysis Access Device Procedures And Vessel Repair,4442,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,13087.82,,,,,,,fee schedule,13087.82,13087.82, Renal Dialysis Access Device Procedures And Vessel Repair,4442,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,13087.82,,,,,,,fee schedule,13087.82,13087.82, Renal Dialysis Access Device Procedures And Vessel Repair,4442,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,13087.82,,,,,,,fee schedule,13087.82,13087.82, Renal Dialysis Access Device Procedures And Vessel Repair,4442,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,13087.82,,,,,,,fee schedule,13087.82,13087.82, Renal Dialysis Access Device Procedures And Vessel Repair,4442,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,13087.82,,,,,,,fee schedule,13087.82,13087.82, Renal Dialysis Access Device Procedures And Vessel Repair,4443,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,18599.9,,,,,,,fee schedule,18599.9,18599.9, Renal Dialysis Access Device Procedures And Vessel Repair,4443,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,18599.9,,,,,,,fee schedule,18599.9,18599.9, Renal Dialysis Access Device Procedures And Vessel Repair,4443,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,18599.9,,,,,,,fee schedule,18599.9,18599.9, Renal Dialysis Access Device Procedures And Vessel Repair,4443,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,18599.9,,,,,,,fee schedule,18599.9,18599.9, Renal Dialysis Access Device Procedures And Vessel Repair,4443,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,18599.9,,,,,,,fee schedule,18599.9,18599.9, Renal Dialysis Access Device Procedures And Vessel Repair,4443,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,18599.9,,,,,,,fee schedule,18599.9,18599.9, Renal Dialysis Access Device Procedures And Vessel Repair,4443,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,18599.9,,,,,,,fee schedule,18599.9,18599.9, Renal Dialysis Access Device Procedures And Vessel Repair,4443,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,18599.9,,,,,,,fee schedule,18599.9,18599.9, Renal Dialysis Access Device Procedures And Vessel Repair,4443,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,18599.9,,,,,,,fee schedule,18599.9,18599.9, Renal Dialysis Access Device Procedures And Vessel Repair,4443,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,18599.9,,,,,,,fee schedule,18599.9,18599.9, Renal Dialysis Access Device Procedures And Vessel Repair,4443,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,18599.9,,,,,,,fee schedule,18599.9,18599.9, Renal Dialysis Access Device Procedures And Vessel Repair,4444,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,29646.63,,,,,,,fee schedule,29646.63,29646.63, Renal Dialysis Access Device Procedures And Vessel Repair,4444,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,29646.63,,,,,,,fee schedule,29646.63,29646.63, Renal Dialysis Access Device Procedures And Vessel Repair,4444,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,29646.63,,,,,,,fee schedule,29646.63,29646.63, Renal Dialysis Access Device Procedures And Vessel Repair,4444,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,29646.63,,,,,,,fee schedule,29646.63,29646.63, Renal Dialysis Access Device Procedures And Vessel Repair,4444,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,29646.63,,,,,,,fee schedule,29646.63,29646.63, Renal Dialysis Access Device Procedures And Vessel Repair,4444,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,29646.63,,,,,,,fee schedule,29646.63,29646.63, Renal Dialysis Access Device Procedures And Vessel Repair,4444,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,29646.63,,,,,,,fee schedule,29646.63,29646.63, Renal Dialysis Access Device Procedures And Vessel Repair,4444,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,29646.63,,,,,,,fee schedule,29646.63,29646.63, Renal Dialysis Access Device Procedures And Vessel Repair,4444,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,29646.63,,,,,,,fee schedule,29646.63,29646.63, Renal Dialysis Access Device Procedures And Vessel Repair,4444,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,29646.63,,,,,,,fee schedule,29646.63,29646.63, Renal Dialysis Access Device Procedures And Vessel Repair,4444,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,29646.63,,,,,,,fee schedule,29646.63,29646.63, Other Bladder Procedures,4451,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,8163.66,,,,,,,fee schedule,8163.66,8163.66, Other Bladder Procedures,4451,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,8163.66,,,,,,,fee schedule,8163.66,8163.66, Other Bladder Procedures,4451,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,8163.66,,,,,,,fee schedule,8163.66,8163.66, Other Bladder Procedures,4451,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,8163.66,,,,,,,fee schedule,8163.66,8163.66, Other Bladder Procedures,4451,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,8163.66,,,,,,,fee schedule,8163.66,8163.66, Other Bladder Procedures,4451,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,8163.66,,,,,,,fee schedule,8163.66,8163.66, Other Bladder Procedures,4451,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,8163.66,,,,,,,fee schedule,8163.66,8163.66, Other Bladder Procedures,4451,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,8163.66,,,,,,,fee schedule,8163.66,8163.66, Other Bladder Procedures,4451,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,8163.66,,,,,,,fee schedule,8163.66,8163.66, Other Bladder Procedures,4451,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,8163.66,,,,,,,fee schedule,8163.66,8163.66, Other Bladder Procedures,4451,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,8163.66,,,,,,,fee schedule,8163.66,8163.66, Other Bladder Procedures,4452,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,11266.23,,,,,,,fee schedule,11266.23,11266.23, Other Bladder Procedures,4452,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,11266.23,,,,,,,fee schedule,11266.23,11266.23, Other Bladder Procedures,4452,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,11266.23,,,,,,,fee schedule,11266.23,11266.23, Other Bladder Procedures,4452,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,11266.23,,,,,,,fee schedule,11266.23,11266.23, Other Bladder Procedures,4452,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,11266.23,,,,,,,fee schedule,11266.23,11266.23, Other Bladder Procedures,4452,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,11266.23,,,,,,,fee schedule,11266.23,11266.23, Other Bladder Procedures,4452,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,11266.23,,,,,,,fee schedule,11266.23,11266.23, Other Bladder Procedures,4452,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,11266.23,,,,,,,fee schedule,11266.23,11266.23, Other Bladder Procedures,4452,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,11266.23,,,,,,,fee schedule,11266.23,11266.23, Other Bladder Procedures,4452,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,11266.23,,,,,,,fee schedule,11266.23,11266.23, Other Bladder Procedures,4452,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,11266.23,,,,,,,fee schedule,11266.23,11266.23, Other Bladder Procedures,4453,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,15293.36,,,,,,,fee schedule,15293.36,15293.36, Other Bladder Procedures,4453,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,15293.36,,,,,,,fee schedule,15293.36,15293.36, Other Bladder Procedures,4453,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,15293.36,,,,,,,fee schedule,15293.36,15293.36, Other Bladder Procedures,4453,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,15293.36,,,,,,,fee schedule,15293.36,15293.36, Other Bladder Procedures,4453,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,15293.36,,,,,,,fee schedule,15293.36,15293.36, Other Bladder Procedures,4453,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,15293.36,,,,,,,fee schedule,15293.36,15293.36, Other Bladder Procedures,4453,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,15293.36,,,,,,,fee schedule,15293.36,15293.36, Other Bladder Procedures,4453,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,15293.36,,,,,,,fee schedule,15293.36,15293.36, Other Bladder Procedures,4453,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,15293.36,,,,,,,fee schedule,15293.36,15293.36, Other Bladder Procedures,4453,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,15293.36,,,,,,,fee schedule,15293.36,15293.36, Other Bladder Procedures,4453,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,15293.36,,,,,,,fee schedule,15293.36,15293.36, Other Bladder Procedures,4454,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,22938.98,,,,,,,fee schedule,22938.98,22938.98, Other Bladder Procedures,4454,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,22938.98,,,,,,,fee schedule,22938.98,22938.98, Other Bladder Procedures,4454,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,22938.98,,,,,,,fee schedule,22938.98,22938.98, Other Bladder Procedures,4454,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,22938.98,,,,,,,fee schedule,22938.98,22938.98, Other Bladder Procedures,4454,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,22938.98,,,,,,,fee schedule,22938.98,22938.98, Other Bladder Procedures,4454,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,22938.98,,,,,,,fee schedule,22938.98,22938.98, Other Bladder Procedures,4454,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,22938.98,,,,,,,fee schedule,22938.98,22938.98, Other Bladder Procedures,4454,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,22938.98,,,,,,,fee schedule,22938.98,22938.98, Other Bladder Procedures,4454,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,22938.98,,,,,,,fee schedule,22938.98,22938.98, Other Bladder Procedures,4454,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,22938.98,,,,,,,fee schedule,22938.98,22938.98, Other Bladder Procedures,4454,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,22938.98,,,,,,,fee schedule,22938.98,22938.98, Urethral And Transurethral Procedures,4461,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,7067.59,,,,,,,fee schedule,7067.59,7067.59, Urethral And Transurethral Procedures,4461,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,7067.59,,,,,,,fee schedule,7067.59,7067.59, Urethral And Transurethral Procedures,4461,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,7067.59,,,,,,,fee schedule,7067.59,7067.59, Urethral And Transurethral Procedures,4461,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,7067.59,,,,,,,fee schedule,7067.59,7067.59, Urethral And Transurethral Procedures,4461,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,7067.59,,,,,,,fee schedule,7067.59,7067.59, Urethral And Transurethral Procedures,4461,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,7067.59,,,,,,,fee schedule,7067.59,7067.59, Urethral And Transurethral Procedures,4461,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,7067.59,,,,,,,fee schedule,7067.59,7067.59, Urethral And Transurethral Procedures,4461,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,7067.59,,,,,,,fee schedule,7067.59,7067.59, Urethral And Transurethral Procedures,4461,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,7067.59,,,,,,,fee schedule,7067.59,7067.59, Urethral And Transurethral Procedures,4461,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,7067.59,,,,,,,fee schedule,7067.59,7067.59, Urethral And Transurethral Procedures,4461,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,7067.59,,,,,,,fee schedule,7067.59,7067.59, Urethral And Transurethral Procedures,4462,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,9187.73,,,,,,,fee schedule,9187.73,9187.73, Urethral And Transurethral Procedures,4462,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,9187.73,,,,,,,fee schedule,9187.73,9187.73, Urethral And Transurethral Procedures,4462,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,9187.73,,,,,,,fee schedule,9187.73,9187.73, Urethral And Transurethral Procedures,4462,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,9187.73,,,,,,,fee schedule,9187.73,9187.73, Urethral And Transurethral Procedures,4462,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,9187.73,,,,,,,fee schedule,9187.73,9187.73, Urethral And Transurethral Procedures,4462,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,9187.73,,,,,,,fee schedule,9187.73,9187.73, Urethral And Transurethral Procedures,4462,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,9187.73,,,,,,,fee schedule,9187.73,9187.73, Urethral And Transurethral Procedures,4462,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,9187.73,,,,,,,fee schedule,9187.73,9187.73, Urethral And Transurethral Procedures,4462,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,9187.73,,,,,,,fee schedule,9187.73,9187.73, Urethral And Transurethral Procedures,4462,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,9187.73,,,,,,,fee schedule,9187.73,9187.73, Urethral And Transurethral Procedures,4462,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,9187.73,,,,,,,fee schedule,9187.73,9187.73, Urethral And Transurethral Procedures,4463,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,13785.12,,,,,,,fee schedule,13785.12,13785.12, Urethral And Transurethral Procedures,4463,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,13785.12,,,,,,,fee schedule,13785.12,13785.12, Urethral And Transurethral Procedures,4463,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,13785.12,,,,,,,fee schedule,13785.12,13785.12, Urethral And Transurethral Procedures,4463,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,13785.12,,,,,,,fee schedule,13785.12,13785.12, Urethral And Transurethral Procedures,4463,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,13785.12,,,,,,,fee schedule,13785.12,13785.12, Urethral And Transurethral Procedures,4463,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,13785.12,,,,,,,fee schedule,13785.12,13785.12, Urethral And Transurethral Procedures,4463,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,13785.12,,,,,,,fee schedule,13785.12,13785.12, Urethral And Transurethral Procedures,4463,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,13785.12,,,,,,,fee schedule,13785.12,13785.12, Urethral And Transurethral Procedures,4463,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,13785.12,,,,,,,fee schedule,13785.12,13785.12, Urethral And Transurethral Procedures,4463,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,13785.12,,,,,,,fee schedule,13785.12,13785.12, Urethral And Transurethral Procedures,4463,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,13785.12,,,,,,,fee schedule,13785.12,13785.12, Urethral And Transurethral Procedures,4464,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,22000.3,,,,,,,fee schedule,22000.3,22000.3, Urethral And Transurethral Procedures,4464,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,22000.3,,,,,,,fee schedule,22000.3,22000.3, Urethral And Transurethral Procedures,4464,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,22000.3,,,,,,,fee schedule,22000.3,22000.3, Urethral And Transurethral Procedures,4464,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,22000.3,,,,,,,fee schedule,22000.3,22000.3, Urethral And Transurethral Procedures,4464,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,22000.3,,,,,,,fee schedule,22000.3,22000.3, Urethral And Transurethral Procedures,4464,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,22000.3,,,,,,,fee schedule,22000.3,22000.3, Urethral And Transurethral Procedures,4464,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,22000.3,,,,,,,fee schedule,22000.3,22000.3, Urethral And Transurethral Procedures,4464,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,22000.3,,,,,,,fee schedule,22000.3,22000.3, Urethral And Transurethral Procedures,4464,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,22000.3,,,,,,,fee schedule,22000.3,22000.3, Urethral And Transurethral Procedures,4464,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,22000.3,,,,,,,fee schedule,22000.3,22000.3, Urethral And Transurethral Procedures,4464,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,22000.3,,,,,,,fee schedule,22000.3,22000.3, "Other Kidney, Urinary Tract And Related Procedures",4471,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,9811.63,,,,,,,fee schedule,9811.63,9811.63, "Other Kidney, Urinary Tract And Related Procedures",4471,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,9811.63,,,,,,,fee schedule,9811.63,9811.63, "Other Kidney, Urinary Tract And Related Procedures",4471,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,9811.63,,,,,,,fee schedule,9811.63,9811.63, "Other Kidney, Urinary Tract And Related Procedures",4471,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,9811.63,,,,,,,fee schedule,9811.63,9811.63, "Other Kidney, Urinary Tract And Related Procedures",4471,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,9811.63,,,,,,,fee schedule,9811.63,9811.63, "Other Kidney, Urinary Tract And Related Procedures",4471,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,9811.63,,,,,,,fee schedule,9811.63,9811.63, "Other Kidney, Urinary Tract And Related Procedures",4471,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,9811.63,,,,,,,fee schedule,9811.63,9811.63, "Other Kidney, Urinary Tract And Related Procedures",4471,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,9811.63,,,,,,,fee schedule,9811.63,9811.63, "Other Kidney, Urinary Tract And Related Procedures",4471,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,9811.63,,,,,,,fee schedule,9811.63,9811.63, "Other Kidney, Urinary Tract And Related Procedures",4471,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,9811.63,,,,,,,fee schedule,9811.63,9811.63, "Other Kidney, Urinary Tract And Related Procedures",4471,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,9811.63,,,,,,,fee schedule,9811.63,9811.63, "Other Kidney, Urinary Tract And Related Procedures",4472,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,12172.44,,,,,,,fee schedule,12172.44,12172.44, "Other Kidney, Urinary Tract And Related Procedures",4472,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,12172.44,,,,,,,fee schedule,12172.44,12172.44, "Other Kidney, Urinary Tract And Related Procedures",4472,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,12172.44,,,,,,,fee schedule,12172.44,12172.44, "Other Kidney, Urinary Tract And Related Procedures",4472,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,12172.44,,,,,,,fee schedule,12172.44,12172.44, "Other Kidney, Urinary Tract And Related Procedures",4472,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,12172.44,,,,,,,fee schedule,12172.44,12172.44, "Other Kidney, Urinary Tract And Related Procedures",4472,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,12172.44,,,,,,,fee schedule,12172.44,12172.44, "Other Kidney, Urinary Tract And Related Procedures",4472,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,12172.44,,,,,,,fee schedule,12172.44,12172.44, "Other Kidney, Urinary Tract And Related Procedures",4472,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,12172.44,,,,,,,fee schedule,12172.44,12172.44, "Other Kidney, Urinary Tract And Related Procedures",4472,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,12172.44,,,,,,,fee schedule,12172.44,12172.44, "Other Kidney, Urinary Tract And Related Procedures",4472,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,12172.44,,,,,,,fee schedule,12172.44,12172.44, "Other Kidney, Urinary Tract And Related Procedures",4472,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,12172.44,,,,,,,fee schedule,12172.44,12172.44, "Other Kidney, Urinary Tract And Related Procedures",4473,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,18107.27,,,,,,,fee schedule,18107.27,18107.27, "Other Kidney, Urinary Tract And Related Procedures",4473,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,18107.27,,,,,,,fee schedule,18107.27,18107.27, "Other Kidney, Urinary Tract And Related Procedures",4473,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,18107.27,,,,,,,fee schedule,18107.27,18107.27, "Other Kidney, Urinary Tract And Related Procedures",4473,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,18107.27,,,,,,,fee schedule,18107.27,18107.27, "Other Kidney, Urinary Tract And Related Procedures",4473,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,18107.27,,,,,,,fee schedule,18107.27,18107.27, "Other Kidney, Urinary Tract And Related Procedures",4473,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,18107.27,,,,,,,fee schedule,18107.27,18107.27, "Other Kidney, Urinary Tract And Related Procedures",4473,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,18107.27,,,,,,,fee schedule,18107.27,18107.27, "Other Kidney, Urinary Tract And Related Procedures",4473,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,18107.27,,,,,,,fee schedule,18107.27,18107.27, "Other Kidney, Urinary Tract And Related Procedures",4473,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,18107.27,,,,,,,fee schedule,18107.27,18107.27, "Other Kidney, Urinary Tract And Related Procedures",4473,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,18107.27,,,,,,,fee schedule,18107.27,18107.27, "Other Kidney, Urinary Tract And Related Procedures",4473,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,18107.27,,,,,,,fee schedule,18107.27,18107.27, "Other Kidney, Urinary Tract And Related Procedures",4474,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,31658.08,,,,,,,fee schedule,31658.08,31658.08, "Other Kidney, Urinary Tract And Related Procedures",4474,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,31658.08,,,,,,,fee schedule,31658.08,31658.08, "Other Kidney, Urinary Tract And Related Procedures",4474,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,31658.08,,,,,,,fee schedule,31658.08,31658.08, "Other Kidney, Urinary Tract And Related Procedures",4474,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,31658.08,,,,,,,fee schedule,31658.08,31658.08, "Other Kidney, Urinary Tract And Related Procedures",4474,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,31658.08,,,,,,,fee schedule,31658.08,31658.08, "Other Kidney, Urinary Tract And Related Procedures",4474,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,31658.08,,,,,,,fee schedule,31658.08,31658.08, "Other Kidney, Urinary Tract And Related Procedures",4474,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,31658.08,,,,,,,fee schedule,31658.08,31658.08, "Other Kidney, Urinary Tract And Related Procedures",4474,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,31658.08,,,,,,,fee schedule,31658.08,31658.08, "Other Kidney, Urinary Tract And Related Procedures",4474,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,31658.08,,,,,,,fee schedule,31658.08,31658.08, "Other Kidney, Urinary Tract And Related Procedures",4474,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,31658.08,,,,,,,fee schedule,31658.08,31658.08, "Other Kidney, Urinary Tract And Related Procedures",4474,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,31658.08,,,,,,,fee schedule,31658.08,31658.08, Description Not Available,4481,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,10314.85,,,,,,,fee schedule,10314.85,10314.85, Description Not Available,4481,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,10314.85,,,,,,,fee schedule,10314.85,10314.85, Description Not Available,4481,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,10314.85,,,,,,,fee schedule,10314.85,10314.85, Description Not Available,4481,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,10314.85,,,,,,,fee schedule,10314.85,10314.85, Description Not Available,4481,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,10314.85,,,,,,,fee schedule,10314.85,10314.85, Description Not Available,4481,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,10314.85,,,,,,,fee schedule,10314.85,10314.85, Description Not Available,4481,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,10314.85,,,,,,,fee schedule,10314.85,10314.85, Description Not Available,4481,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,10314.85,,,,,,,fee schedule,10314.85,10314.85, Description Not Available,4481,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,10314.85,,,,,,,fee schedule,10314.85,10314.85, Description Not Available,4481,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,10314.85,,,,,,,fee schedule,10314.85,10314.85, Description Not Available,4481,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,10314.85,,,,,,,fee schedule,10314.85,10314.85, Description Not Available,4482,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,15392.17,,,,,,,fee schedule,15392.17,15392.17, Description Not Available,4482,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,15392.17,,,,,,,fee schedule,15392.17,15392.17, Description Not Available,4482,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,15392.17,,,,,,,fee schedule,15392.17,15392.17, Description Not Available,4482,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,15392.17,,,,,,,fee schedule,15392.17,15392.17, Description Not Available,4482,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,15392.17,,,,,,,fee schedule,15392.17,15392.17, Description Not Available,4482,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,15392.17,,,,,,,fee schedule,15392.17,15392.17, Description Not Available,4482,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,15392.17,,,,,,,fee schedule,15392.17,15392.17, Description Not Available,4482,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,15392.17,,,,,,,fee schedule,15392.17,15392.17, Description Not Available,4482,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,15392.17,,,,,,,fee schedule,15392.17,15392.17, Description Not Available,4482,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,15392.17,,,,,,,fee schedule,15392.17,15392.17, Description Not Available,4482,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,15392.17,,,,,,,fee schedule,15392.17,15392.17, Description Not Available,4483,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,18609.78,,,,,,,fee schedule,18609.78,18609.78, Description Not Available,4483,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,18609.78,,,,,,,fee schedule,18609.78,18609.78, Description Not Available,4483,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,18609.78,,,,,,,fee schedule,18609.78,18609.78, Description Not Available,4483,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,18609.78,,,,,,,fee schedule,18609.78,18609.78, Description Not Available,4483,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,18609.78,,,,,,,fee schedule,18609.78,18609.78, Description Not Available,4483,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,18609.78,,,,,,,fee schedule,18609.78,18609.78, Description Not Available,4483,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,18609.78,,,,,,,fee schedule,18609.78,18609.78, Description Not Available,4483,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,18609.78,,,,,,,fee schedule,18609.78,18609.78, Description Not Available,4483,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,18609.78,,,,,,,fee schedule,18609.78,18609.78, Description Not Available,4483,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,18609.78,,,,,,,fee schedule,18609.78,18609.78, Description Not Available,4483,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,18609.78,,,,,,,fee schedule,18609.78,18609.78, Description Not Available,4484,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,31392.71,,,,,,,fee schedule,31392.71,31392.71, Description Not Available,4484,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,31392.71,,,,,,,fee schedule,31392.71,31392.71, Description Not Available,4484,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,31392.71,,,,,,,fee schedule,31392.71,31392.71, Description Not Available,4484,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,31392.71,,,,,,,fee schedule,31392.71,31392.71, Description Not Available,4484,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,31392.71,,,,,,,fee schedule,31392.71,31392.71, Description Not Available,4484,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,31392.71,,,,,,,fee schedule,31392.71,31392.71, Description Not Available,4484,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,31392.71,,,,,,,fee schedule,31392.71,31392.71, Description Not Available,4484,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,31392.71,,,,,,,fee schedule,31392.71,31392.71, Description Not Available,4484,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,31392.71,,,,,,,fee schedule,31392.71,31392.71, Description Not Available,4484,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,31392.71,,,,,,,fee schedule,31392.71,31392.71, Description Not Available,4484,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,31392.71,,,,,,,fee schedule,31392.71,31392.71, Kidney And Urinary Tract Malignancy,4611,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5627.11,,,,,,,fee schedule,5627.11,5627.11, Kidney And Urinary Tract Malignancy,4611,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5627.11,,,,,,,fee schedule,5627.11,5627.11, Kidney And Urinary Tract Malignancy,4611,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5627.11,,,,,,,fee schedule,5627.11,5627.11, Kidney And Urinary Tract Malignancy,4611,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5627.11,,,,,,,fee schedule,5627.11,5627.11, Kidney And Urinary Tract Malignancy,4611,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5627.11,,,,,,,fee schedule,5627.11,5627.11, Kidney And Urinary Tract Malignancy,4611,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5627.11,,,,,,,fee schedule,5627.11,5627.11, Kidney And Urinary Tract Malignancy,4611,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5627.11,,,,,,,fee schedule,5627.11,5627.11, Kidney And Urinary Tract Malignancy,4611,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5627.11,,,,,,,fee schedule,5627.11,5627.11, Kidney And Urinary Tract Malignancy,4611,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5627.11,,,,,,,fee schedule,5627.11,5627.11, Kidney And Urinary Tract Malignancy,4611,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5627.11,,,,,,,fee schedule,5627.11,5627.11, Kidney And Urinary Tract Malignancy,4611,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5627.11,,,,,,,fee schedule,5627.11,5627.11, Kidney And Urinary Tract Malignancy,4612,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,6719.65,,,,,,,fee schedule,6719.65,6719.65, Kidney And Urinary Tract Malignancy,4612,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,6719.65,,,,,,,fee schedule,6719.65,6719.65, Kidney And Urinary Tract Malignancy,4612,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,6719.65,,,,,,,fee schedule,6719.65,6719.65, Kidney And Urinary Tract Malignancy,4612,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,6719.65,,,,,,,fee schedule,6719.65,6719.65, Kidney And Urinary Tract Malignancy,4612,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,6719.65,,,,,,,fee schedule,6719.65,6719.65, Kidney And Urinary Tract Malignancy,4612,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,6719.65,,,,,,,fee schedule,6719.65,6719.65, Kidney And Urinary Tract Malignancy,4612,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,6719.65,,,,,,,fee schedule,6719.65,6719.65, Kidney And Urinary Tract Malignancy,4612,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,6719.65,,,,,,,fee schedule,6719.65,6719.65, Kidney And Urinary Tract Malignancy,4612,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,6719.65,,,,,,,fee schedule,6719.65,6719.65, Kidney And Urinary Tract Malignancy,4612,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,6719.65,,,,,,,fee schedule,6719.65,6719.65, Kidney And Urinary Tract Malignancy,4612,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,6719.65,,,,,,,fee schedule,6719.65,6719.65, Kidney And Urinary Tract Malignancy,4613,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,10216.04,,,,,,,fee schedule,10216.04,10216.04, Kidney And Urinary Tract Malignancy,4613,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,10216.04,,,,,,,fee schedule,10216.04,10216.04, Kidney And Urinary Tract Malignancy,4613,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,10216.04,,,,,,,fee schedule,10216.04,10216.04, Kidney And Urinary Tract Malignancy,4613,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,10216.04,,,,,,,fee schedule,10216.04,10216.04, Kidney And Urinary Tract Malignancy,4613,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,10216.04,,,,,,,fee schedule,10216.04,10216.04, Kidney And Urinary Tract Malignancy,4613,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,10216.04,,,,,,,fee schedule,10216.04,10216.04, Kidney And Urinary Tract Malignancy,4613,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,10216.04,,,,,,,fee schedule,10216.04,10216.04, Kidney And Urinary Tract Malignancy,4613,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,10216.04,,,,,,,fee schedule,10216.04,10216.04, Kidney And Urinary Tract Malignancy,4613,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,10216.04,,,,,,,fee schedule,10216.04,10216.04, Kidney And Urinary Tract Malignancy,4613,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,10216.04,,,,,,,fee schedule,10216.04,10216.04, Kidney And Urinary Tract Malignancy,4613,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,10216.04,,,,,,,fee schedule,10216.04,10216.04, Kidney And Urinary Tract Malignancy,4614,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,17573,,,,,,,fee schedule,17573,17573, Kidney And Urinary Tract Malignancy,4614,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,17573,,,,,,,fee schedule,17573,17573, Kidney And Urinary Tract Malignancy,4614,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,17573,,,,,,,fee schedule,17573,17573, Kidney And Urinary Tract Malignancy,4614,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,17573,,,,,,,fee schedule,17573,17573, Kidney And Urinary Tract Malignancy,4614,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,17573,,,,,,,fee schedule,17573,17573, Kidney And Urinary Tract Malignancy,4614,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,17573,,,,,,,fee schedule,17573,17573, Kidney And Urinary Tract Malignancy,4614,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,17573,,,,,,,fee schedule,17573,17573, Kidney And Urinary Tract Malignancy,4614,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,17573,,,,,,,fee schedule,17573,17573, Kidney And Urinary Tract Malignancy,4614,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,17573,,,,,,,fee schedule,17573,17573, Kidney And Urinary Tract Malignancy,4614,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,17573,,,,,,,fee schedule,17573,17573, Kidney And Urinary Tract Malignancy,4614,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,17573,,,,,,,fee schedule,17573,17573, Nephritis And Nephrosis,4621,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4294.62,,,,,,,fee schedule,4294.62,4294.62, Nephritis And Nephrosis,4621,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4294.62,,,,,,,fee schedule,4294.62,4294.62, Nephritis And Nephrosis,4621,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4294.62,,,,,,,fee schedule,4294.62,4294.62, Nephritis And Nephrosis,4621,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4294.62,,,,,,,fee schedule,4294.62,4294.62, Nephritis And Nephrosis,4621,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4294.62,,,,,,,fee schedule,4294.62,4294.62, Nephritis And Nephrosis,4621,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4294.62,,,,,,,fee schedule,4294.62,4294.62, Nephritis And Nephrosis,4621,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4294.62,,,,,,,fee schedule,4294.62,4294.62, Nephritis And Nephrosis,4621,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4294.62,,,,,,,fee schedule,4294.62,4294.62, Nephritis And Nephrosis,4621,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4294.62,,,,,,,fee schedule,4294.62,4294.62, Nephritis And Nephrosis,4621,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4294.62,,,,,,,fee schedule,4294.62,4294.62, Nephritis And Nephrosis,4621,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4294.62,,,,,,,fee schedule,4294.62,4294.62, Nephritis And Nephrosis,4622,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,6098.57,,,,,,,fee schedule,6098.57,6098.57, Nephritis And Nephrosis,4622,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,6098.57,,,,,,,fee schedule,6098.57,6098.57, Nephritis And Nephrosis,4622,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,6098.57,,,,,,,fee schedule,6098.57,6098.57, Nephritis And Nephrosis,4622,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,6098.57,,,,,,,fee schedule,6098.57,6098.57, Nephritis And Nephrosis,4622,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,6098.57,,,,,,,fee schedule,6098.57,6098.57, Nephritis And Nephrosis,4622,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,6098.57,,,,,,,fee schedule,6098.57,6098.57, Nephritis And Nephrosis,4622,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,6098.57,,,,,,,fee schedule,6098.57,6098.57, Nephritis And Nephrosis,4622,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,6098.57,,,,,,,fee schedule,6098.57,6098.57, Nephritis And Nephrosis,4622,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,6098.57,,,,,,,fee schedule,6098.57,6098.57, Nephritis And Nephrosis,4622,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,6098.57,,,,,,,fee schedule,6098.57,6098.57, Nephritis And Nephrosis,4622,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,6098.57,,,,,,,fee schedule,6098.57,6098.57, Nephritis And Nephrosis,4623,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,11409.5,,,,,,,fee schedule,11409.5,11409.5, Nephritis And Nephrosis,4623,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,11409.5,,,,,,,fee schedule,11409.5,11409.5, Nephritis And Nephrosis,4623,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,11409.5,,,,,,,fee schedule,11409.5,11409.5, Nephritis And Nephrosis,4623,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,11409.5,,,,,,,fee schedule,11409.5,11409.5, Nephritis And Nephrosis,4623,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,11409.5,,,,,,,fee schedule,11409.5,11409.5, Nephritis And Nephrosis,4623,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,11409.5,,,,,,,fee schedule,11409.5,11409.5, Nephritis And Nephrosis,4623,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,11409.5,,,,,,,fee schedule,11409.5,11409.5, Nephritis And Nephrosis,4623,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,11409.5,,,,,,,fee schedule,11409.5,11409.5, Nephritis And Nephrosis,4623,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,11409.5,,,,,,,fee schedule,11409.5,11409.5, Nephritis And Nephrosis,4623,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,11409.5,,,,,,,fee schedule,11409.5,11409.5, Nephritis And Nephrosis,4623,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,11409.5,,,,,,,fee schedule,11409.5,11409.5, Nephritis And Nephrosis,4624,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,20350.91,,,,,,,fee schedule,20350.91,20350.91, Nephritis And Nephrosis,4624,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,20350.91,,,,,,,fee schedule,20350.91,20350.91, Nephritis And Nephrosis,4624,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,20350.91,,,,,,,fee schedule,20350.91,20350.91, Nephritis And Nephrosis,4624,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,20350.91,,,,,,,fee schedule,20350.91,20350.91, Nephritis And Nephrosis,4624,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,20350.91,,,,,,,fee schedule,20350.91,20350.91, Nephritis And Nephrosis,4624,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,20350.91,,,,,,,fee schedule,20350.91,20350.91, Nephritis And Nephrosis,4624,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,20350.91,,,,,,,fee schedule,20350.91,20350.91, Nephritis And Nephrosis,4624,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,20350.91,,,,,,,fee schedule,20350.91,20350.91, Nephritis And Nephrosis,4624,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,20350.91,,,,,,,fee schedule,20350.91,20350.91, Nephritis And Nephrosis,4624,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,20350.91,,,,,,,fee schedule,20350.91,20350.91, Nephritis And Nephrosis,4624,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,20350.91,,,,,,,fee schedule,20350.91,20350.91, Kidney And Urinary Tract Infections,4631,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,3832.34,,,,,,,fee schedule,3832.34,3832.34, Kidney And Urinary Tract Infections,4631,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,3832.34,,,,,,,fee schedule,3832.34,3832.34, Kidney And Urinary Tract Infections,4631,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,3832.34,,,,,,,fee schedule,3832.34,3832.34, Kidney And Urinary Tract Infections,4631,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,3832.34,,,,,,,fee schedule,3832.34,3832.34, Kidney And Urinary Tract Infections,4631,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,3832.34,,,,,,,fee schedule,3832.34,3832.34, Kidney And Urinary Tract Infections,4631,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,3832.34,,,,,,,fee schedule,3832.34,3832.34, Kidney And Urinary Tract Infections,4631,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,3832.34,,,,,,,fee schedule,3832.34,3832.34, Kidney And Urinary Tract Infections,4631,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,3832.34,,,,,,,fee schedule,3832.34,3832.34, Kidney And Urinary Tract Infections,4631,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,3832.34,,,,,,,fee schedule,3832.34,3832.34, Kidney And Urinary Tract Infections,4631,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,3832.34,,,,,,,fee schedule,3832.34,3832.34, Kidney And Urinary Tract Infections,4631,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,3832.34,,,,,,,fee schedule,3832.34,3832.34, Kidney And Urinary Tract Infections,4632,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4919.93,,,,,,,fee schedule,4919.93,4919.93, Kidney And Urinary Tract Infections,4632,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4919.93,,,,,,,fee schedule,4919.93,4919.93, Kidney And Urinary Tract Infections,4632,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4919.93,,,,,,,fee schedule,4919.93,4919.93, Kidney And Urinary Tract Infections,4632,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4919.93,,,,,,,fee schedule,4919.93,4919.93, Kidney And Urinary Tract Infections,4632,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4919.93,,,,,,,fee schedule,4919.93,4919.93, Kidney And Urinary Tract Infections,4632,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4919.93,,,,,,,fee schedule,4919.93,4919.93, Kidney And Urinary Tract Infections,4632,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4919.93,,,,,,,fee schedule,4919.93,4919.93, Kidney And Urinary Tract Infections,4632,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4919.93,,,,,,,fee schedule,4919.93,4919.93, Kidney And Urinary Tract Infections,4632,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4919.93,,,,,,,fee schedule,4919.93,4919.93, Kidney And Urinary Tract Infections,4632,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4919.93,,,,,,,fee schedule,4919.93,4919.93, Kidney And Urinary Tract Infections,4632,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4919.93,,,,,,,fee schedule,4919.93,4919.93, Kidney And Urinary Tract Infections,4633,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,6717.53,,,,,,,fee schedule,6717.53,6717.53, Kidney And Urinary Tract Infections,4633,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,6717.53,,,,,,,fee schedule,6717.53,6717.53, Kidney And Urinary Tract Infections,4633,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,6717.53,,,,,,,fee schedule,6717.53,6717.53, Kidney And Urinary Tract Infections,4633,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,6717.53,,,,,,,fee schedule,6717.53,6717.53, Kidney And Urinary Tract Infections,4633,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,6717.53,,,,,,,fee schedule,6717.53,6717.53, Kidney And Urinary Tract Infections,4633,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,6717.53,,,,,,,fee schedule,6717.53,6717.53, Kidney And Urinary Tract Infections,4633,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,6717.53,,,,,,,fee schedule,6717.53,6717.53, Kidney And Urinary Tract Infections,4633,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,6717.53,,,,,,,fee schedule,6717.53,6717.53, Kidney And Urinary Tract Infections,4633,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,6717.53,,,,,,,fee schedule,6717.53,6717.53, Kidney And Urinary Tract Infections,4633,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,6717.53,,,,,,,fee schedule,6717.53,6717.53, Kidney And Urinary Tract Infections,4633,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,6717.53,,,,,,,fee schedule,6717.53,6717.53, Kidney And Urinary Tract Infections,4634,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,11184.36,,,,,,,fee schedule,11184.36,11184.36, Kidney And Urinary Tract Infections,4634,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,11184.36,,,,,,,fee schedule,11184.36,11184.36, Kidney And Urinary Tract Infections,4634,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,11184.36,,,,,,,fee schedule,11184.36,11184.36, Kidney And Urinary Tract Infections,4634,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,11184.36,,,,,,,fee schedule,11184.36,11184.36, Kidney And Urinary Tract Infections,4634,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,11184.36,,,,,,,fee schedule,11184.36,11184.36, Kidney And Urinary Tract Infections,4634,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,11184.36,,,,,,,fee schedule,11184.36,11184.36, Kidney And Urinary Tract Infections,4634,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,11184.36,,,,,,,fee schedule,11184.36,11184.36, Kidney And Urinary Tract Infections,4634,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,11184.36,,,,,,,fee schedule,11184.36,11184.36, Kidney And Urinary Tract Infections,4634,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,11184.36,,,,,,,fee schedule,11184.36,11184.36, Kidney And Urinary Tract Infections,4634,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,11184.36,,,,,,,fee schedule,11184.36,11184.36, Kidney And Urinary Tract Infections,4634,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,11184.36,,,,,,,fee schedule,11184.36,11184.36, Urinary Stones And Acquired Upper Urinary Tract Obstruction,4651,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4761.13,,,,,,,fee schedule,4761.13,4761.13, Urinary Stones And Acquired Upper Urinary Tract Obstruction,4651,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4761.13,,,,,,,fee schedule,4761.13,4761.13, Urinary Stones And Acquired Upper Urinary Tract Obstruction,4651,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4761.13,,,,,,,fee schedule,4761.13,4761.13, Urinary Stones And Acquired Upper Urinary Tract Obstruction,4651,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4761.13,,,,,,,fee schedule,4761.13,4761.13, Urinary Stones And Acquired Upper Urinary Tract Obstruction,4651,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4761.13,,,,,,,fee schedule,4761.13,4761.13, Urinary Stones And Acquired Upper Urinary Tract Obstruction,4651,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4761.13,,,,,,,fee schedule,4761.13,4761.13, Urinary Stones And Acquired Upper Urinary Tract Obstruction,4651,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4761.13,,,,,,,fee schedule,4761.13,4761.13, Urinary Stones And Acquired Upper Urinary Tract Obstruction,4651,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4761.13,,,,,,,fee schedule,4761.13,4761.13, Urinary Stones And Acquired Upper Urinary Tract Obstruction,4651,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4761.13,,,,,,,fee schedule,4761.13,4761.13, Urinary Stones And Acquired Upper Urinary Tract Obstruction,4651,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4761.13,,,,,,,fee schedule,4761.13,4761.13, Urinary Stones And Acquired Upper Urinary Tract Obstruction,4651,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4761.13,,,,,,,fee schedule,4761.13,4761.13, Urinary Stones And Acquired Upper Urinary Tract Obstruction,4652,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5833.91,,,,,,,fee schedule,5833.91,5833.91, Urinary Stones And Acquired Upper Urinary Tract Obstruction,4652,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5833.91,,,,,,,fee schedule,5833.91,5833.91, Urinary Stones And Acquired Upper Urinary Tract Obstruction,4652,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5833.91,,,,,,,fee schedule,5833.91,5833.91, Urinary Stones And Acquired Upper Urinary Tract Obstruction,4652,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5833.91,,,,,,,fee schedule,5833.91,5833.91, Urinary Stones And Acquired Upper Urinary Tract Obstruction,4652,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5833.91,,,,,,,fee schedule,5833.91,5833.91, Urinary Stones And Acquired Upper Urinary Tract Obstruction,4652,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5833.91,,,,,,,fee schedule,5833.91,5833.91, Urinary Stones And Acquired Upper Urinary Tract Obstruction,4652,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5833.91,,,,,,,fee schedule,5833.91,5833.91, Urinary Stones And Acquired Upper Urinary Tract Obstruction,4652,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5833.91,,,,,,,fee schedule,5833.91,5833.91, Urinary Stones And Acquired Upper Urinary Tract Obstruction,4652,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5833.91,,,,,,,fee schedule,5833.91,5833.91, Urinary Stones And Acquired Upper Urinary Tract Obstruction,4652,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5833.91,,,,,,,fee schedule,5833.91,5833.91, Urinary Stones And Acquired Upper Urinary Tract Obstruction,4652,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5833.91,,,,,,,fee schedule,5833.91,5833.91, Urinary Stones And Acquired Upper Urinary Tract Obstruction,4653,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,8532.07,,,,,,,fee schedule,8532.07,8532.07, Urinary Stones And Acquired Upper Urinary Tract Obstruction,4653,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,8532.07,,,,,,,fee schedule,8532.07,8532.07, Urinary Stones And Acquired Upper Urinary Tract Obstruction,4653,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,8532.07,,,,,,,fee schedule,8532.07,8532.07, Urinary Stones And Acquired Upper Urinary Tract Obstruction,4653,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,8532.07,,,,,,,fee schedule,8532.07,8532.07, Urinary Stones And Acquired Upper Urinary Tract Obstruction,4653,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,8532.07,,,,,,,fee schedule,8532.07,8532.07, Urinary Stones And Acquired Upper Urinary Tract Obstruction,4653,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,8532.07,,,,,,,fee schedule,8532.07,8532.07, Urinary Stones And Acquired Upper Urinary Tract Obstruction,4653,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,8532.07,,,,,,,fee schedule,8532.07,8532.07, Urinary Stones And Acquired Upper Urinary Tract Obstruction,4653,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,8532.07,,,,,,,fee schedule,8532.07,8532.07, Urinary Stones And Acquired Upper Urinary Tract Obstruction,4653,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,8532.07,,,,,,,fee schedule,8532.07,8532.07, Urinary Stones And Acquired Upper Urinary Tract Obstruction,4653,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,8532.07,,,,,,,fee schedule,8532.07,8532.07, Urinary Stones And Acquired Upper Urinary Tract Obstruction,4653,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,8532.07,,,,,,,fee schedule,8532.07,8532.07, Urinary Stones And Acquired Upper Urinary Tract Obstruction,4654,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,15366.05,,,,,,,fee schedule,15366.05,15366.05, Urinary Stones And Acquired Upper Urinary Tract Obstruction,4654,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,15366.05,,,,,,,fee schedule,15366.05,15366.05, Urinary Stones And Acquired Upper Urinary Tract Obstruction,4654,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,15366.05,,,,,,,fee schedule,15366.05,15366.05, Urinary Stones And Acquired Upper Urinary Tract Obstruction,4654,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,15366.05,,,,,,,fee schedule,15366.05,15366.05, Urinary Stones And Acquired Upper Urinary Tract Obstruction,4654,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,15366.05,,,,,,,fee schedule,15366.05,15366.05, Urinary Stones And Acquired Upper Urinary Tract Obstruction,4654,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,15366.05,,,,,,,fee schedule,15366.05,15366.05, Urinary Stones And Acquired Upper Urinary Tract Obstruction,4654,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,15366.05,,,,,,,fee schedule,15366.05,15366.05, Urinary Stones And Acquired Upper Urinary Tract Obstruction,4654,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,15366.05,,,,,,,fee schedule,15366.05,15366.05, Urinary Stones And Acquired Upper Urinary Tract Obstruction,4654,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,15366.05,,,,,,,fee schedule,15366.05,15366.05, Urinary Stones And Acquired Upper Urinary Tract Obstruction,4654,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,15366.05,,,,,,,fee schedule,15366.05,15366.05, Urinary Stones And Acquired Upper Urinary Tract Obstruction,4654,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,15366.05,,,,,,,fee schedule,15366.05,15366.05, "Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure",4661,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4278.39,,,,,,,fee schedule,4278.39,4278.39, "Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure",4661,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4278.39,,,,,,,fee schedule,4278.39,4278.39, "Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure",4661,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4278.39,,,,,,,fee schedule,4278.39,4278.39, "Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure",4661,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4278.39,,,,,,,fee schedule,4278.39,4278.39, "Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure",4661,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4278.39,,,,,,,fee schedule,4278.39,4278.39, "Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure",4661,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4278.39,,,,,,,fee schedule,4278.39,4278.39, "Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure",4661,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4278.39,,,,,,,fee schedule,4278.39,4278.39, "Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure",4661,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4278.39,,,,,,,fee schedule,4278.39,4278.39, "Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure",4661,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4278.39,,,,,,,fee schedule,4278.39,4278.39, "Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure",4661,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4278.39,,,,,,,fee schedule,4278.39,4278.39, "Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure",4661,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4278.39,,,,,,,fee schedule,4278.39,4278.39, "Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure",4662,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5506.43,,,,,,,fee schedule,5506.43,5506.43, "Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure",4662,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5506.43,,,,,,,fee schedule,5506.43,5506.43, "Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure",4662,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5506.43,,,,,,,fee schedule,5506.43,5506.43, "Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure",4662,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5506.43,,,,,,,fee schedule,5506.43,5506.43, "Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure",4662,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5506.43,,,,,,,fee schedule,5506.43,5506.43, "Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure",4662,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5506.43,,,,,,,fee schedule,5506.43,5506.43, "Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure",4662,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5506.43,,,,,,,fee schedule,5506.43,5506.43, "Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure",4662,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5506.43,,,,,,,fee schedule,5506.43,5506.43, "Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure",4662,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5506.43,,,,,,,fee schedule,5506.43,5506.43, "Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure",4662,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5506.43,,,,,,,fee schedule,5506.43,5506.43, "Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure",4662,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5506.43,,,,,,,fee schedule,5506.43,5506.43, "Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure",4663,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,8633.7,,,,,,,fee schedule,8633.7,8633.7, "Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure",4663,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,8633.7,,,,,,,fee schedule,8633.7,8633.7, "Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure",4663,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,8633.7,,,,,,,fee schedule,8633.7,8633.7, "Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure",4663,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,8633.7,,,,,,,fee schedule,8633.7,8633.7, "Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure",4663,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,8633.7,,,,,,,fee schedule,8633.7,8633.7, "Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure",4663,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,8633.7,,,,,,,fee schedule,8633.7,8633.7, "Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure",4663,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,8633.7,,,,,,,fee schedule,8633.7,8633.7, "Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure",4663,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,8633.7,,,,,,,fee schedule,8633.7,8633.7, "Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure",4663,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,8633.7,,,,,,,fee schedule,8633.7,8633.7, "Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure",4663,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,8633.7,,,,,,,fee schedule,8633.7,8633.7, "Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure",4663,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,8633.7,,,,,,,fee schedule,8633.7,8633.7, "Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure",4664,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,14565,,,,,,,fee schedule,14565,14565, "Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure",4664,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,14565,,,,,,,fee schedule,14565,14565, "Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure",4664,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,14565,,,,,,,fee schedule,14565,14565, "Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure",4664,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,14565,,,,,,,fee schedule,14565,14565, "Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure",4664,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,14565,,,,,,,fee schedule,14565,14565, "Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure",4664,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,14565,,,,,,,fee schedule,14565,14565, "Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure",4664,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,14565,,,,,,,fee schedule,14565,14565, "Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure",4664,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,14565,,,,,,,fee schedule,14565,14565, "Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure",4664,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,14565,,,,,,,fee schedule,14565,14565, "Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure",4664,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,14565,,,,,,,fee schedule,14565,14565, "Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure",4664,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,14565,,,,,,,fee schedule,14565,14565, "Other Kidney And Urinary Tract Diagnoses, Signs And Symptoms",4681,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4123.12,,,,,,,fee schedule,4123.12,4123.12, "Other Kidney And Urinary Tract Diagnoses, Signs And Symptoms",4681,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4123.12,,,,,,,fee schedule,4123.12,4123.12, "Other Kidney And Urinary Tract Diagnoses, Signs And Symptoms",4681,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4123.12,,,,,,,fee schedule,4123.12,4123.12, "Other Kidney And Urinary Tract Diagnoses, Signs And Symptoms",4681,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4123.12,,,,,,,fee schedule,4123.12,4123.12, "Other Kidney And Urinary Tract Diagnoses, Signs And Symptoms",4681,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4123.12,,,,,,,fee schedule,4123.12,4123.12, "Other Kidney And Urinary Tract Diagnoses, Signs And Symptoms",4681,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4123.12,,,,,,,fee schedule,4123.12,4123.12, "Other Kidney And Urinary Tract Diagnoses, Signs And Symptoms",4681,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4123.12,,,,,,,fee schedule,4123.12,4123.12, "Other Kidney And Urinary Tract Diagnoses, Signs And Symptoms",4681,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4123.12,,,,,,,fee schedule,4123.12,4123.12, "Other Kidney And Urinary Tract Diagnoses, Signs And Symptoms",4681,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4123.12,,,,,,,fee schedule,4123.12,4123.12, "Other Kidney And Urinary Tract Diagnoses, Signs And Symptoms",4681,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4123.12,,,,,,,fee schedule,4123.12,4123.12, "Other Kidney And Urinary Tract Diagnoses, Signs And Symptoms",4681,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4123.12,,,,,,,fee schedule,4123.12,4123.12, "Other Kidney And Urinary Tract Diagnoses, Signs And Symptoms",4682,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5361.04,,,,,,,fee schedule,5361.04,5361.04, "Other Kidney And Urinary Tract Diagnoses, Signs And Symptoms",4682,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5361.04,,,,,,,fee schedule,5361.04,5361.04, "Other Kidney And Urinary Tract Diagnoses, Signs And Symptoms",4682,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5361.04,,,,,,,fee schedule,5361.04,5361.04, "Other Kidney And Urinary Tract Diagnoses, Signs And Symptoms",4682,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5361.04,,,,,,,fee schedule,5361.04,5361.04, "Other Kidney And Urinary Tract Diagnoses, Signs And Symptoms",4682,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5361.04,,,,,,,fee schedule,5361.04,5361.04, "Other Kidney And Urinary Tract Diagnoses, Signs And Symptoms",4682,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5361.04,,,,,,,fee schedule,5361.04,5361.04, "Other Kidney And Urinary Tract Diagnoses, Signs And Symptoms",4682,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5361.04,,,,,,,fee schedule,5361.04,5361.04, "Other Kidney And Urinary Tract Diagnoses, Signs And Symptoms",4682,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5361.04,,,,,,,fee schedule,5361.04,5361.04, "Other Kidney And Urinary Tract Diagnoses, Signs And Symptoms",4682,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5361.04,,,,,,,fee schedule,5361.04,5361.04, "Other Kidney And Urinary Tract Diagnoses, Signs And Symptoms",4682,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5361.04,,,,,,,fee schedule,5361.04,5361.04, "Other Kidney And Urinary Tract Diagnoses, Signs And Symptoms",4682,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5361.04,,,,,,,fee schedule,5361.04,5361.04, "Other Kidney And Urinary Tract Diagnoses, Signs And Symptoms",4683,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,8302.69,,,,,,,fee schedule,8302.69,8302.69, "Other Kidney And Urinary Tract Diagnoses, Signs And Symptoms",4683,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,8302.69,,,,,,,fee schedule,8302.69,8302.69, "Other Kidney And Urinary Tract Diagnoses, Signs And Symptoms",4683,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,8302.69,,,,,,,fee schedule,8302.69,8302.69, "Other Kidney And Urinary Tract Diagnoses, Signs And Symptoms",4683,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,8302.69,,,,,,,fee schedule,8302.69,8302.69, "Other Kidney And Urinary Tract Diagnoses, Signs And Symptoms",4683,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,8302.69,,,,,,,fee schedule,8302.69,8302.69, "Other Kidney And Urinary Tract Diagnoses, Signs And Symptoms",4683,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,8302.69,,,,,,,fee schedule,8302.69,8302.69, "Other Kidney And Urinary Tract Diagnoses, Signs And Symptoms",4683,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,8302.69,,,,,,,fee schedule,8302.69,8302.69, "Other Kidney And Urinary Tract Diagnoses, Signs And Symptoms",4683,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,8302.69,,,,,,,fee schedule,8302.69,8302.69, "Other Kidney And Urinary Tract Diagnoses, Signs And Symptoms",4683,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,8302.69,,,,,,,fee schedule,8302.69,8302.69, "Other Kidney And Urinary Tract Diagnoses, Signs And Symptoms",4683,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,8302.69,,,,,,,fee schedule,8302.69,8302.69, "Other Kidney And Urinary Tract Diagnoses, Signs And Symptoms",4683,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,8302.69,,,,,,,fee schedule,8302.69,8302.69, "Other Kidney And Urinary Tract Diagnoses, Signs And Symptoms",4684,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,14649.69,,,,,,,fee schedule,14649.69,14649.69, "Other Kidney And Urinary Tract Diagnoses, Signs And Symptoms",4684,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,14649.69,,,,,,,fee schedule,14649.69,14649.69, "Other Kidney And Urinary Tract Diagnoses, Signs And Symptoms",4684,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,14649.69,,,,,,,fee schedule,14649.69,14649.69, "Other Kidney And Urinary Tract Diagnoses, Signs And Symptoms",4684,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,14649.69,,,,,,,fee schedule,14649.69,14649.69, "Other Kidney And Urinary Tract Diagnoses, Signs And Symptoms",4684,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,14649.69,,,,,,,fee schedule,14649.69,14649.69, "Other Kidney And Urinary Tract Diagnoses, Signs And Symptoms",4684,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,14649.69,,,,,,,fee schedule,14649.69,14649.69, "Other Kidney And Urinary Tract Diagnoses, Signs And Symptoms",4684,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,14649.69,,,,,,,fee schedule,14649.69,14649.69, "Other Kidney And Urinary Tract Diagnoses, Signs And Symptoms",4684,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,14649.69,,,,,,,fee schedule,14649.69,14649.69, "Other Kidney And Urinary Tract Diagnoses, Signs And Symptoms",4684,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,14649.69,,,,,,,fee schedule,14649.69,14649.69, "Other Kidney And Urinary Tract Diagnoses, Signs And Symptoms",4684,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,14649.69,,,,,,,fee schedule,14649.69,14649.69, "Other Kidney And Urinary Tract Diagnoses, Signs And Symptoms",4684,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,14649.69,,,,,,,fee schedule,14649.69,14649.69, Acute Kidney Injury,4691,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,3680.6,,,,,,,fee schedule,3680.6,3680.6, Acute Kidney Injury,4691,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,3680.6,,,,,,,fee schedule,3680.6,3680.6, Acute Kidney Injury,4691,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,3680.6,,,,,,,fee schedule,3680.6,3680.6, Acute Kidney Injury,4691,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,3680.6,,,,,,,fee schedule,3680.6,3680.6, Acute Kidney Injury,4691,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,3680.6,,,,,,,fee schedule,3680.6,3680.6, Acute Kidney Injury,4691,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,3680.6,,,,,,,fee schedule,3680.6,3680.6, Acute Kidney Injury,4691,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,3680.6,,,,,,,fee schedule,3680.6,3680.6, Acute Kidney Injury,4691,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,3680.6,,,,,,,fee schedule,3680.6,3680.6, Acute Kidney Injury,4691,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,3680.6,,,,,,,fee schedule,3680.6,3680.6, Acute Kidney Injury,4691,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,3680.6,,,,,,,fee schedule,3680.6,3680.6, Acute Kidney Injury,4691,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,3680.6,,,,,,,fee schedule,3680.6,3680.6, Acute Kidney Injury,4692,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5205.77,,,,,,,fee schedule,5205.77,5205.77, Acute Kidney Injury,4692,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5205.77,,,,,,,fee schedule,5205.77,5205.77, Acute Kidney Injury,4692,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5205.77,,,,,,,fee schedule,5205.77,5205.77, Acute Kidney Injury,4692,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5205.77,,,,,,,fee schedule,5205.77,5205.77, Acute Kidney Injury,4692,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5205.77,,,,,,,fee schedule,5205.77,5205.77, Acute Kidney Injury,4692,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5205.77,,,,,,,fee schedule,5205.77,5205.77, Acute Kidney Injury,4692,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5205.77,,,,,,,fee schedule,5205.77,5205.77, Acute Kidney Injury,4692,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5205.77,,,,,,,fee schedule,5205.77,5205.77, Acute Kidney Injury,4692,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5205.77,,,,,,,fee schedule,5205.77,5205.77, Acute Kidney Injury,4692,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5205.77,,,,,,,fee schedule,5205.77,5205.77, Acute Kidney Injury,4692,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5205.77,,,,,,,fee schedule,5205.77,5205.77, Acute Kidney Injury,4693,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,8923.07,,,,,,,fee schedule,8923.07,8923.07, Acute Kidney Injury,4693,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,8923.07,,,,,,,fee schedule,8923.07,8923.07, Acute Kidney Injury,4693,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,8923.07,,,,,,,fee schedule,8923.07,8923.07, Acute Kidney Injury,4693,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,8923.07,,,,,,,fee schedule,8923.07,8923.07, Acute Kidney Injury,4693,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,8923.07,,,,,,,fee schedule,8923.07,8923.07, Acute Kidney Injury,4693,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,8923.07,,,,,,,fee schedule,8923.07,8923.07, Acute Kidney Injury,4693,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,8923.07,,,,,,,fee schedule,8923.07,8923.07, Acute Kidney Injury,4693,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,8923.07,,,,,,,fee schedule,8923.07,8923.07, Acute Kidney Injury,4693,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,8923.07,,,,,,,fee schedule,8923.07,8923.07, Acute Kidney Injury,4693,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,8923.07,,,,,,,fee schedule,8923.07,8923.07, Acute Kidney Injury,4693,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,8923.07,,,,,,,fee schedule,8923.07,8923.07, Acute Kidney Injury,4694,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,17169.3,,,,,,,fee schedule,17169.3,17169.3, Acute Kidney Injury,4694,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,17169.3,,,,,,,fee schedule,17169.3,17169.3, Acute Kidney Injury,4694,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,17169.3,,,,,,,fee schedule,17169.3,17169.3, Acute Kidney Injury,4694,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,17169.3,,,,,,,fee schedule,17169.3,17169.3, Acute Kidney Injury,4694,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,17169.3,,,,,,,fee schedule,17169.3,17169.3, Acute Kidney Injury,4694,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,17169.3,,,,,,,fee schedule,17169.3,17169.3, Acute Kidney Injury,4694,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,17169.3,,,,,,,fee schedule,17169.3,17169.3, Acute Kidney Injury,4694,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,17169.3,,,,,,,fee schedule,17169.3,17169.3, Acute Kidney Injury,4694,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,17169.3,,,,,,,fee schedule,17169.3,17169.3, Acute Kidney Injury,4694,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,17169.3,,,,,,,fee schedule,17169.3,17169.3, Acute Kidney Injury,4694,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,17169.3,,,,,,,fee schedule,17169.3,17169.3, Chronic Kidney Disease,4701,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,3990.43,,,,,,,fee schedule,3990.43,3990.43, Chronic Kidney Disease,4701,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,3990.43,,,,,,,fee schedule,3990.43,3990.43, Chronic Kidney Disease,4701,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,3990.43,,,,,,,fee schedule,3990.43,3990.43, Chronic Kidney Disease,4701,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,3990.43,,,,,,,fee schedule,3990.43,3990.43, Chronic Kidney Disease,4701,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,3990.43,,,,,,,fee schedule,3990.43,3990.43, Chronic Kidney Disease,4701,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,3990.43,,,,,,,fee schedule,3990.43,3990.43, Chronic Kidney Disease,4701,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,3990.43,,,,,,,fee schedule,3990.43,3990.43, Chronic Kidney Disease,4701,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,3990.43,,,,,,,fee schedule,3990.43,3990.43, Chronic Kidney Disease,4701,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,3990.43,,,,,,,fee schedule,3990.43,3990.43, Chronic Kidney Disease,4701,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,3990.43,,,,,,,fee schedule,3990.43,3990.43, Chronic Kidney Disease,4701,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,3990.43,,,,,,,fee schedule,3990.43,3990.43, Chronic Kidney Disease,4702,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5495.84,,,,,,,fee schedule,5495.84,5495.84, Chronic Kidney Disease,4702,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5495.84,,,,,,,fee schedule,5495.84,5495.84, Chronic Kidney Disease,4702,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5495.84,,,,,,,fee schedule,5495.84,5495.84, Chronic Kidney Disease,4702,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5495.84,,,,,,,fee schedule,5495.84,5495.84, Chronic Kidney Disease,4702,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5495.84,,,,,,,fee schedule,5495.84,5495.84, Chronic Kidney Disease,4702,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5495.84,,,,,,,fee schedule,5495.84,5495.84, Chronic Kidney Disease,4702,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5495.84,,,,,,,fee schedule,5495.84,5495.84, Chronic Kidney Disease,4702,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5495.84,,,,,,,fee schedule,5495.84,5495.84, Chronic Kidney Disease,4702,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5495.84,,,,,,,fee schedule,5495.84,5495.84, Chronic Kidney Disease,4702,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5495.84,,,,,,,fee schedule,5495.84,5495.84, Chronic Kidney Disease,4702,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5495.84,,,,,,,fee schedule,5495.84,5495.84, Chronic Kidney Disease,4703,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,8652.05,,,,,,,fee schedule,8652.05,8652.05, Chronic Kidney Disease,4703,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,8652.05,,,,,,,fee schedule,8652.05,8652.05, Chronic Kidney Disease,4703,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,8652.05,,,,,,,fee schedule,8652.05,8652.05, Chronic Kidney Disease,4703,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,8652.05,,,,,,,fee schedule,8652.05,8652.05, Chronic Kidney Disease,4703,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,8652.05,,,,,,,fee schedule,8652.05,8652.05, Chronic Kidney Disease,4703,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,8652.05,,,,,,,fee schedule,8652.05,8652.05, Chronic Kidney Disease,4703,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,8652.05,,,,,,,fee schedule,8652.05,8652.05, Chronic Kidney Disease,4703,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,8652.05,,,,,,,fee schedule,8652.05,8652.05, Chronic Kidney Disease,4703,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,8652.05,,,,,,,fee schedule,8652.05,8652.05, Chronic Kidney Disease,4703,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,8652.05,,,,,,,fee schedule,8652.05,8652.05, Chronic Kidney Disease,4703,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,8652.05,,,,,,,fee schedule,8652.05,8652.05, Chronic Kidney Disease,4704,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,15744.35,,,,,,,fee schedule,15744.35,15744.35, Chronic Kidney Disease,4704,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,15744.35,,,,,,,fee schedule,15744.35,15744.35, Chronic Kidney Disease,4704,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,15744.35,,,,,,,fee schedule,15744.35,15744.35, Chronic Kidney Disease,4704,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,15744.35,,,,,,,fee schedule,15744.35,15744.35, Chronic Kidney Disease,4704,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,15744.35,,,,,,,fee schedule,15744.35,15744.35, Chronic Kidney Disease,4704,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,15744.35,,,,,,,fee schedule,15744.35,15744.35, Chronic Kidney Disease,4704,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,15744.35,,,,,,,fee schedule,15744.35,15744.35, Chronic Kidney Disease,4704,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,15744.35,,,,,,,fee schedule,15744.35,15744.35, Chronic Kidney Disease,4704,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,15744.35,,,,,,,fee schedule,15744.35,15744.35, Chronic Kidney Disease,4704,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,15744.35,,,,,,,fee schedule,15744.35,15744.35, Chronic Kidney Disease,4704,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,15744.35,,,,,,,fee schedule,15744.35,15744.35, Transurethral Prostatectomy,4821,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,6153.62,,,,,,,fee schedule,6153.62,6153.62, Transurethral Prostatectomy,4821,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,6153.62,,,,,,,fee schedule,6153.62,6153.62, Transurethral Prostatectomy,4821,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,6153.62,,,,,,,fee schedule,6153.62,6153.62, Transurethral Prostatectomy,4821,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,6153.62,,,,,,,fee schedule,6153.62,6153.62, Transurethral Prostatectomy,4821,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,6153.62,,,,,,,fee schedule,6153.62,6153.62, Transurethral Prostatectomy,4821,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,6153.62,,,,,,,fee schedule,6153.62,6153.62, Transurethral Prostatectomy,4821,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,6153.62,,,,,,,fee schedule,6153.62,6153.62, Transurethral Prostatectomy,4821,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,6153.62,,,,,,,fee schedule,6153.62,6153.62, Transurethral Prostatectomy,4821,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,6153.62,,,,,,,fee schedule,6153.62,6153.62, Transurethral Prostatectomy,4821,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,6153.62,,,,,,,fee schedule,6153.62,6153.62, Transurethral Prostatectomy,4821,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,6153.62,,,,,,,fee schedule,6153.62,6153.62, Transurethral Prostatectomy,4822,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,8704.28,,,,,,,fee schedule,8704.28,8704.28, Transurethral Prostatectomy,4822,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,8704.28,,,,,,,fee schedule,8704.28,8704.28, Transurethral Prostatectomy,4822,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,8704.28,,,,,,,fee schedule,8704.28,8704.28, Transurethral Prostatectomy,4822,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,8704.28,,,,,,,fee schedule,8704.28,8704.28, Transurethral Prostatectomy,4822,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,8704.28,,,,,,,fee schedule,8704.28,8704.28, Transurethral Prostatectomy,4822,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,8704.28,,,,,,,fee schedule,8704.28,8704.28, Transurethral Prostatectomy,4822,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,8704.28,,,,,,,fee schedule,8704.28,8704.28, Transurethral Prostatectomy,4822,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,8704.28,,,,,,,fee schedule,8704.28,8704.28, Transurethral Prostatectomy,4822,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,8704.28,,,,,,,fee schedule,8704.28,8704.28, Transurethral Prostatectomy,4822,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,8704.28,,,,,,,fee schedule,8704.28,8704.28, Transurethral Prostatectomy,4822,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,8704.28,,,,,,,fee schedule,8704.28,8704.28, Transurethral Prostatectomy,4823,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,14162.71,,,,,,,fee schedule,14162.71,14162.71, Transurethral Prostatectomy,4823,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,14162.71,,,,,,,fee schedule,14162.71,14162.71, Transurethral Prostatectomy,4823,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,14162.71,,,,,,,fee schedule,14162.71,14162.71, Transurethral Prostatectomy,4823,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,14162.71,,,,,,,fee schedule,14162.71,14162.71, Transurethral Prostatectomy,4823,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,14162.71,,,,,,,fee schedule,14162.71,14162.71, Transurethral Prostatectomy,4823,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,14162.71,,,,,,,fee schedule,14162.71,14162.71, Transurethral Prostatectomy,4823,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,14162.71,,,,,,,fee schedule,14162.71,14162.71, Transurethral Prostatectomy,4823,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,14162.71,,,,,,,fee schedule,14162.71,14162.71, Transurethral Prostatectomy,4823,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,14162.71,,,,,,,fee schedule,14162.71,14162.71, Transurethral Prostatectomy,4823,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,14162.71,,,,,,,fee schedule,14162.71,14162.71, Transurethral Prostatectomy,4823,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,14162.71,,,,,,,fee schedule,14162.71,14162.71, Transurethral Prostatectomy,4824,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,19408,,,,,,,fee schedule,19408,19408, Transurethral Prostatectomy,4824,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,19408,,,,,,,fee schedule,19408,19408, Transurethral Prostatectomy,4824,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,19408,,,,,,,fee schedule,19408,19408, Transurethral Prostatectomy,4824,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,19408,,,,,,,fee schedule,19408,19408, Transurethral Prostatectomy,4824,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,19408,,,,,,,fee schedule,19408,19408, Transurethral Prostatectomy,4824,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,19408,,,,,,,fee schedule,19408,19408, Transurethral Prostatectomy,4824,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,19408,,,,,,,fee schedule,19408,19408, Transurethral Prostatectomy,4824,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,19408,,,,,,,fee schedule,19408,19408, Transurethral Prostatectomy,4824,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,19408,,,,,,,fee schedule,19408,19408, Transurethral Prostatectomy,4824,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,19408,,,,,,,fee schedule,19408,19408, Transurethral Prostatectomy,4824,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,19408,,,,,,,fee schedule,19408,19408, "Penis, Testes And Scrotal Procedures",4831,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,7340.73,,,,,,,fee schedule,7340.73,7340.73, "Penis, Testes And Scrotal Procedures",4831,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,7340.73,,,,,,,fee schedule,7340.73,7340.73, "Penis, Testes And Scrotal Procedures",4831,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,7340.73,,,,,,,fee schedule,7340.73,7340.73, "Penis, Testes And Scrotal Procedures",4831,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,7340.73,,,,,,,fee schedule,7340.73,7340.73, "Penis, Testes And Scrotal Procedures",4831,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,7340.73,,,,,,,fee schedule,7340.73,7340.73, "Penis, Testes And Scrotal Procedures",4831,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,7340.73,,,,,,,fee schedule,7340.73,7340.73, "Penis, Testes And Scrotal Procedures",4831,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,7340.73,,,,,,,fee schedule,7340.73,7340.73, "Penis, Testes And Scrotal Procedures",4831,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,7340.73,,,,,,,fee schedule,7340.73,7340.73, "Penis, Testes And Scrotal Procedures",4831,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,7340.73,,,,,,,fee schedule,7340.73,7340.73, "Penis, Testes And Scrotal Procedures",4831,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,7340.73,,,,,,,fee schedule,7340.73,7340.73, "Penis, Testes And Scrotal Procedures",4831,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,7340.73,,,,,,,fee schedule,7340.73,7340.73, "Penis, Testes And Scrotal Procedures",4832,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,11199.18,,,,,,,fee schedule,11199.18,11199.18, "Penis, Testes And Scrotal Procedures",4832,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,11199.18,,,,,,,fee schedule,11199.18,11199.18, "Penis, Testes And Scrotal Procedures",4832,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,11199.18,,,,,,,fee schedule,11199.18,11199.18, "Penis, Testes And Scrotal Procedures",4832,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,11199.18,,,,,,,fee schedule,11199.18,11199.18, "Penis, Testes And Scrotal Procedures",4832,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,11199.18,,,,,,,fee schedule,11199.18,11199.18, "Penis, Testes And Scrotal Procedures",4832,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,11199.18,,,,,,,fee schedule,11199.18,11199.18, "Penis, Testes And Scrotal Procedures",4832,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,11199.18,,,,,,,fee schedule,11199.18,11199.18, "Penis, Testes And Scrotal Procedures",4832,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,11199.18,,,,,,,fee schedule,11199.18,11199.18, "Penis, Testes And Scrotal Procedures",4832,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,11199.18,,,,,,,fee schedule,11199.18,11199.18, "Penis, Testes And Scrotal Procedures",4832,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,11199.18,,,,,,,fee schedule,11199.18,11199.18, "Penis, Testes And Scrotal Procedures",4832,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,11199.18,,,,,,,fee schedule,11199.18,11199.18, "Penis, Testes And Scrotal Procedures",4833,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,16898.28,,,,,,,fee schedule,16898.28,16898.28, "Penis, Testes And Scrotal Procedures",4833,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,16898.28,,,,,,,fee schedule,16898.28,16898.28, "Penis, Testes And Scrotal Procedures",4833,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,16898.28,,,,,,,fee schedule,16898.28,16898.28, "Penis, Testes And Scrotal Procedures",4833,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,16898.28,,,,,,,fee schedule,16898.28,16898.28, "Penis, Testes And Scrotal Procedures",4833,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,16898.28,,,,,,,fee schedule,16898.28,16898.28, "Penis, Testes And Scrotal Procedures",4833,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,16898.28,,,,,,,fee schedule,16898.28,16898.28, "Penis, Testes And Scrotal Procedures",4833,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,16898.28,,,,,,,fee schedule,16898.28,16898.28, "Penis, Testes And Scrotal Procedures",4833,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,16898.28,,,,,,,fee schedule,16898.28,16898.28, "Penis, Testes And Scrotal Procedures",4833,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,16898.28,,,,,,,fee schedule,16898.28,16898.28, "Penis, Testes And Scrotal Procedures",4833,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,16898.28,,,,,,,fee schedule,16898.28,16898.28, "Penis, Testes And Scrotal Procedures",4833,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,16898.28,,,,,,,fee schedule,16898.28,16898.28, "Penis, Testes And Scrotal Procedures",4834,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,29511.83,,,,,,,fee schedule,29511.83,29511.83, "Penis, Testes And Scrotal Procedures",4834,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,29511.83,,,,,,,fee schedule,29511.83,29511.83, "Penis, Testes And Scrotal Procedures",4834,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,29511.83,,,,,,,fee schedule,29511.83,29511.83, "Penis, Testes And Scrotal Procedures",4834,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,29511.83,,,,,,,fee schedule,29511.83,29511.83, "Penis, Testes And Scrotal Procedures",4834,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,29511.83,,,,,,,fee schedule,29511.83,29511.83, "Penis, Testes And Scrotal Procedures",4834,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,29511.83,,,,,,,fee schedule,29511.83,29511.83, "Penis, Testes And Scrotal Procedures",4834,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,29511.83,,,,,,,fee schedule,29511.83,29511.83, "Penis, Testes And Scrotal Procedures",4834,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,29511.83,,,,,,,fee schedule,29511.83,29511.83, "Penis, Testes And Scrotal Procedures",4834,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,29511.83,,,,,,,fee schedule,29511.83,29511.83, "Penis, Testes And Scrotal Procedures",4834,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,29511.83,,,,,,,fee schedule,29511.83,29511.83, "Penis, Testes And Scrotal Procedures",4834,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,29511.83,,,,,,,fee schedule,29511.83,29511.83, Other Male Reproductive System And Related Procedures,4841,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,9001.41,,,,,,,fee schedule,9001.41,9001.41, Other Male Reproductive System And Related Procedures,4841,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,9001.41,,,,,,,fee schedule,9001.41,9001.41, Other Male Reproductive System And Related Procedures,4841,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,9001.41,,,,,,,fee schedule,9001.41,9001.41, Other Male Reproductive System And Related Procedures,4841,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,9001.41,,,,,,,fee schedule,9001.41,9001.41, Other Male Reproductive System And Related Procedures,4841,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,9001.41,,,,,,,fee schedule,9001.41,9001.41, Other Male Reproductive System And Related Procedures,4841,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,9001.41,,,,,,,fee schedule,9001.41,9001.41, Other Male Reproductive System And Related Procedures,4841,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,9001.41,,,,,,,fee schedule,9001.41,9001.41, Other Male Reproductive System And Related Procedures,4841,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,9001.41,,,,,,,fee schedule,9001.41,9001.41, Other Male Reproductive System And Related Procedures,4841,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,9001.41,,,,,,,fee schedule,9001.41,9001.41, Other Male Reproductive System And Related Procedures,4841,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,9001.41,,,,,,,fee schedule,9001.41,9001.41, Other Male Reproductive System And Related Procedures,4841,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,9001.41,,,,,,,fee schedule,9001.41,9001.41, Other Male Reproductive System And Related Procedures,4842,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,11072.85,,,,,,,fee schedule,11072.85,11072.85, Other Male Reproductive System And Related Procedures,4842,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,11072.85,,,,,,,fee schedule,11072.85,11072.85, Other Male Reproductive System And Related Procedures,4842,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,11072.85,,,,,,,fee schedule,11072.85,11072.85, Other Male Reproductive System And Related Procedures,4842,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,11072.85,,,,,,,fee schedule,11072.85,11072.85, Other Male Reproductive System And Related Procedures,4842,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,11072.85,,,,,,,fee schedule,11072.85,11072.85, Other Male Reproductive System And Related Procedures,4842,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,11072.85,,,,,,,fee schedule,11072.85,11072.85, Other Male Reproductive System And Related Procedures,4842,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,11072.85,,,,,,,fee schedule,11072.85,11072.85, Other Male Reproductive System And Related Procedures,4842,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,11072.85,,,,,,,fee schedule,11072.85,11072.85, Other Male Reproductive System And Related Procedures,4842,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,11072.85,,,,,,,fee schedule,11072.85,11072.85, Other Male Reproductive System And Related Procedures,4842,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,11072.85,,,,,,,fee schedule,11072.85,11072.85, Other Male Reproductive System And Related Procedures,4842,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,11072.85,,,,,,,fee schedule,11072.85,11072.85, Other Male Reproductive System And Related Procedures,4843,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,17745.91,,,,,,,fee schedule,17745.91,17745.91, Other Male Reproductive System And Related Procedures,4843,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,17745.91,,,,,,,fee schedule,17745.91,17745.91, Other Male Reproductive System And Related Procedures,4843,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,17745.91,,,,,,,fee schedule,17745.91,17745.91, Other Male Reproductive System And Related Procedures,4843,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,17745.91,,,,,,,fee schedule,17745.91,17745.91, Other Male Reproductive System And Related Procedures,4843,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,17745.91,,,,,,,fee schedule,17745.91,17745.91, Other Male Reproductive System And Related Procedures,4843,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,17745.91,,,,,,,fee schedule,17745.91,17745.91, Other Male Reproductive System And Related Procedures,4843,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,17745.91,,,,,,,fee schedule,17745.91,17745.91, Other Male Reproductive System And Related Procedures,4843,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,17745.91,,,,,,,fee schedule,17745.91,17745.91, Other Male Reproductive System And Related Procedures,4843,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,17745.91,,,,,,,fee schedule,17745.91,17745.91, Other Male Reproductive System And Related Procedures,4843,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,17745.91,,,,,,,fee schedule,17745.91,17745.91, Other Male Reproductive System And Related Procedures,4843,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,17745.91,,,,,,,fee schedule,17745.91,17745.91, Other Male Reproductive System And Related Procedures,4844,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,32509.94,,,,,,,fee schedule,32509.94,32509.94, Other Male Reproductive System And Related Procedures,4844,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,32509.94,,,,,,,fee schedule,32509.94,32509.94, Other Male Reproductive System And Related Procedures,4844,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,32509.94,,,,,,,fee schedule,32509.94,32509.94, Other Male Reproductive System And Related Procedures,4844,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,32509.94,,,,,,,fee schedule,32509.94,32509.94, Other Male Reproductive System And Related Procedures,4844,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,32509.94,,,,,,,fee schedule,32509.94,32509.94, Other Male Reproductive System And Related Procedures,4844,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,32509.94,,,,,,,fee schedule,32509.94,32509.94, Other Male Reproductive System And Related Procedures,4844,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,32509.94,,,,,,,fee schedule,32509.94,32509.94, Other Male Reproductive System And Related Procedures,4844,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,32509.94,,,,,,,fee schedule,32509.94,32509.94, Other Male Reproductive System And Related Procedures,4844,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,32509.94,,,,,,,fee schedule,32509.94,32509.94, Other Male Reproductive System And Related Procedures,4844,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,32509.94,,,,,,,fee schedule,32509.94,32509.94, Other Male Reproductive System And Related Procedures,4844,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,32509.94,,,,,,,fee schedule,32509.94,32509.94, Description Not Available,4851,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,10674.79,,,,,,,fee schedule,10674.79,10674.79, Description Not Available,4851,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,10674.79,,,,,,,fee schedule,10674.79,10674.79, Description Not Available,4851,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,10674.79,,,,,,,fee schedule,10674.79,10674.79, Description Not Available,4851,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,10674.79,,,,,,,fee schedule,10674.79,10674.79, Description Not Available,4851,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,10674.79,,,,,,,fee schedule,10674.79,10674.79, Description Not Available,4851,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,10674.79,,,,,,,fee schedule,10674.79,10674.79, Description Not Available,4851,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,10674.79,,,,,,,fee schedule,10674.79,10674.79, Description Not Available,4851,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,10674.79,,,,,,,fee schedule,10674.79,10674.79, Description Not Available,4851,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,10674.79,,,,,,,fee schedule,10674.79,10674.79, Description Not Available,4851,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,10674.79,,,,,,,fee schedule,10674.79,10674.79, Description Not Available,4851,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,10674.79,,,,,,,fee schedule,10674.79,10674.79, Description Not Available,4852,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,12288.18,,,,,,,fee schedule,12288.18,12288.18, Description Not Available,4852,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,12288.18,,,,,,,fee schedule,12288.18,12288.18, Description Not Available,4852,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,12288.18,,,,,,,fee schedule,12288.18,12288.18, Description Not Available,4852,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,12288.18,,,,,,,fee schedule,12288.18,12288.18, Description Not Available,4852,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,12288.18,,,,,,,fee schedule,12288.18,12288.18, Description Not Available,4852,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,12288.18,,,,,,,fee schedule,12288.18,12288.18, Description Not Available,4852,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,12288.18,,,,,,,fee schedule,12288.18,12288.18, Description Not Available,4852,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,12288.18,,,,,,,fee schedule,12288.18,12288.18, Description Not Available,4852,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,12288.18,,,,,,,fee schedule,12288.18,12288.18, Description Not Available,4852,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,12288.18,,,,,,,fee schedule,12288.18,12288.18, Description Not Available,4852,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,12288.18,,,,,,,fee schedule,12288.18,12288.18, Description Not Available,4853,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,19667.02,,,,,,,fee schedule,19667.02,19667.02, Description Not Available,4853,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,19667.02,,,,,,,fee schedule,19667.02,19667.02, Description Not Available,4853,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,19667.02,,,,,,,fee schedule,19667.02,19667.02, Description Not Available,4853,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,19667.02,,,,,,,fee schedule,19667.02,19667.02, Description Not Available,4853,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,19667.02,,,,,,,fee schedule,19667.02,19667.02, Description Not Available,4853,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,19667.02,,,,,,,fee schedule,19667.02,19667.02, Description Not Available,4853,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,19667.02,,,,,,,fee schedule,19667.02,19667.02, Description Not Available,4853,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,19667.02,,,,,,,fee schedule,19667.02,19667.02, Description Not Available,4853,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,19667.02,,,,,,,fee schedule,19667.02,19667.02, Description Not Available,4853,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,19667.02,,,,,,,fee schedule,19667.02,19667.02, Description Not Available,4853,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,19667.02,,,,,,,fee schedule,19667.02,19667.02, Description Not Available,4854,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,32433.72,,,,,,,fee schedule,32433.72,32433.72, Description Not Available,4854,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,32433.72,,,,,,,fee schedule,32433.72,32433.72, Description Not Available,4854,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,32433.72,,,,,,,fee schedule,32433.72,32433.72, Description Not Available,4854,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,32433.72,,,,,,,fee schedule,32433.72,32433.72, Description Not Available,4854,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,32433.72,,,,,,,fee schedule,32433.72,32433.72, Description Not Available,4854,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,32433.72,,,,,,,fee schedule,32433.72,32433.72, Description Not Available,4854,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,32433.72,,,,,,,fee schedule,32433.72,32433.72, Description Not Available,4854,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,32433.72,,,,,,,fee schedule,32433.72,32433.72, Description Not Available,4854,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,32433.72,,,,,,,fee schedule,32433.72,32433.72, Description Not Available,4854,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,32433.72,,,,,,,fee schedule,32433.72,32433.72, Description Not Available,4854,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,32433.72,,,,,,,fee schedule,32433.72,32433.72, "Malignancy, Male Reproductive System",5001,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5380.8,,,,,,,fee schedule,5380.8,5380.8, "Malignancy, Male Reproductive System",5001,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5380.8,,,,,,,fee schedule,5380.8,5380.8, "Malignancy, Male Reproductive System",5001,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5380.8,,,,,,,fee schedule,5380.8,5380.8, "Malignancy, Male Reproductive System",5001,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5380.8,,,,,,,fee schedule,5380.8,5380.8, "Malignancy, Male Reproductive System",5001,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5380.8,,,,,,,fee schedule,5380.8,5380.8, "Malignancy, Male Reproductive System",5001,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5380.8,,,,,,,fee schedule,5380.8,5380.8, "Malignancy, Male Reproductive System",5001,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5380.8,,,,,,,fee schedule,5380.8,5380.8, "Malignancy, Male Reproductive System",5001,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5380.8,,,,,,,fee schedule,5380.8,5380.8, "Malignancy, Male Reproductive System",5001,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5380.8,,,,,,,fee schedule,5380.8,5380.8, "Malignancy, Male Reproductive System",5001,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5380.8,,,,,,,fee schedule,5380.8,5380.8, "Malignancy, Male Reproductive System",5001,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5380.8,,,,,,,fee schedule,5380.8,5380.8, "Malignancy, Male Reproductive System",5002,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,6371.7,,,,,,,fee schedule,6371.7,6371.7, "Malignancy, Male Reproductive System",5002,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,6371.7,,,,,,,fee schedule,6371.7,6371.7, "Malignancy, Male Reproductive System",5002,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,6371.7,,,,,,,fee schedule,6371.7,6371.7, "Malignancy, Male Reproductive System",5002,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,6371.7,,,,,,,fee schedule,6371.7,6371.7, "Malignancy, Male Reproductive System",5002,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,6371.7,,,,,,,fee schedule,6371.7,6371.7, "Malignancy, Male Reproductive System",5002,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,6371.7,,,,,,,fee schedule,6371.7,6371.7, "Malignancy, Male Reproductive System",5002,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,6371.7,,,,,,,fee schedule,6371.7,6371.7, "Malignancy, Male Reproductive System",5002,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,6371.7,,,,,,,fee schedule,6371.7,6371.7, "Malignancy, Male Reproductive System",5002,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,6371.7,,,,,,,fee schedule,6371.7,6371.7, "Malignancy, Male Reproductive System",5002,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,6371.7,,,,,,,fee schedule,6371.7,6371.7, "Malignancy, Male Reproductive System",5002,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,6371.7,,,,,,,fee schedule,6371.7,6371.7, "Malignancy, Male Reproductive System",5003,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,9629.54,,,,,,,fee schedule,9629.54,9629.54, "Malignancy, Male Reproductive System",5003,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,9629.54,,,,,,,fee schedule,9629.54,9629.54, "Malignancy, Male Reproductive System",5003,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,9629.54,,,,,,,fee schedule,9629.54,9629.54, "Malignancy, Male Reproductive System",5003,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,9629.54,,,,,,,fee schedule,9629.54,9629.54, "Malignancy, Male Reproductive System",5003,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,9629.54,,,,,,,fee schedule,9629.54,9629.54, "Malignancy, Male Reproductive System",5003,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,9629.54,,,,,,,fee schedule,9629.54,9629.54, "Malignancy, Male Reproductive System",5003,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,9629.54,,,,,,,fee schedule,9629.54,9629.54, "Malignancy, Male Reproductive System",5003,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,9629.54,,,,,,,fee schedule,9629.54,9629.54, "Malignancy, Male Reproductive System",5003,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,9629.54,,,,,,,fee schedule,9629.54,9629.54, "Malignancy, Male Reproductive System",5003,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,9629.54,,,,,,,fee schedule,9629.54,9629.54, "Malignancy, Male Reproductive System",5003,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,9629.54,,,,,,,fee schedule,9629.54,9629.54, "Malignancy, Male Reproductive System",5004,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,15080.92,,,,,,,fee schedule,15080.92,15080.92, "Malignancy, Male Reproductive System",5004,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,15080.92,,,,,,,fee schedule,15080.92,15080.92, "Malignancy, Male Reproductive System",5004,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,15080.92,,,,,,,fee schedule,15080.92,15080.92, "Malignancy, Male Reproductive System",5004,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,15080.92,,,,,,,fee schedule,15080.92,15080.92, "Malignancy, Male Reproductive System",5004,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,15080.92,,,,,,,fee schedule,15080.92,15080.92, "Malignancy, Male Reproductive System",5004,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,15080.92,,,,,,,fee schedule,15080.92,15080.92, "Malignancy, Male Reproductive System",5004,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,15080.92,,,,,,,fee schedule,15080.92,15080.92, "Malignancy, Male Reproductive System",5004,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,15080.92,,,,,,,fee schedule,15080.92,15080.92, "Malignancy, Male Reproductive System",5004,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,15080.92,,,,,,,fee schedule,15080.92,15080.92, "Malignancy, Male Reproductive System",5004,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,15080.92,,,,,,,fee schedule,15080.92,15080.92, "Malignancy, Male Reproductive System",5004,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,15080.92,,,,,,,fee schedule,15080.92,15080.92, Male Reproductive System Diagnoses Except Malignancy,5011,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4055.36,,,,,,,fee schedule,4055.36,4055.36, Male Reproductive System Diagnoses Except Malignancy,5011,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4055.36,,,,,,,fee schedule,4055.36,4055.36, Male Reproductive System Diagnoses Except Malignancy,5011,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4055.36,,,,,,,fee schedule,4055.36,4055.36, Male Reproductive System Diagnoses Except Malignancy,5011,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4055.36,,,,,,,fee schedule,4055.36,4055.36, Male Reproductive System Diagnoses Except Malignancy,5011,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4055.36,,,,,,,fee schedule,4055.36,4055.36, Male Reproductive System Diagnoses Except Malignancy,5011,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4055.36,,,,,,,fee schedule,4055.36,4055.36, Male Reproductive System Diagnoses Except Malignancy,5011,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4055.36,,,,,,,fee schedule,4055.36,4055.36, Male Reproductive System Diagnoses Except Malignancy,5011,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4055.36,,,,,,,fee schedule,4055.36,4055.36, Male Reproductive System Diagnoses Except Malignancy,5011,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4055.36,,,,,,,fee schedule,4055.36,4055.36, Male Reproductive System Diagnoses Except Malignancy,5011,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4055.36,,,,,,,fee schedule,4055.36,4055.36, Male Reproductive System Diagnoses Except Malignancy,5011,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4055.36,,,,,,,fee schedule,4055.36,4055.36, Male Reproductive System Diagnoses Except Malignancy,5012,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5183.18,,,,,,,fee schedule,5183.18,5183.18, Male Reproductive System Diagnoses Except Malignancy,5012,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5183.18,,,,,,,fee schedule,5183.18,5183.18, Male Reproductive System Diagnoses Except Malignancy,5012,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5183.18,,,,,,,fee schedule,5183.18,5183.18, Male Reproductive System Diagnoses Except Malignancy,5012,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5183.18,,,,,,,fee schedule,5183.18,5183.18, Male Reproductive System Diagnoses Except Malignancy,5012,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5183.18,,,,,,,fee schedule,5183.18,5183.18, Male Reproductive System Diagnoses Except Malignancy,5012,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5183.18,,,,,,,fee schedule,5183.18,5183.18, Male Reproductive System Diagnoses Except Malignancy,5012,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5183.18,,,,,,,fee schedule,5183.18,5183.18, Male Reproductive System Diagnoses Except Malignancy,5012,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5183.18,,,,,,,fee schedule,5183.18,5183.18, Male Reproductive System Diagnoses Except Malignancy,5012,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5183.18,,,,,,,fee schedule,5183.18,5183.18, Male Reproductive System Diagnoses Except Malignancy,5012,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5183.18,,,,,,,fee schedule,5183.18,5183.18, Male Reproductive System Diagnoses Except Malignancy,5012,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5183.18,,,,,,,fee schedule,5183.18,5183.18, Male Reproductive System Diagnoses Except Malignancy,5013,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,7687.26,,,,,,,fee schedule,7687.26,7687.26, Male Reproductive System Diagnoses Except Malignancy,5013,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,7687.26,,,,,,,fee schedule,7687.26,7687.26, Male Reproductive System Diagnoses Except Malignancy,5013,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,7687.26,,,,,,,fee schedule,7687.26,7687.26, Male Reproductive System Diagnoses Except Malignancy,5013,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,7687.26,,,,,,,fee schedule,7687.26,7687.26, Male Reproductive System Diagnoses Except Malignancy,5013,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,7687.26,,,,,,,fee schedule,7687.26,7687.26, Male Reproductive System Diagnoses Except Malignancy,5013,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,7687.26,,,,,,,fee schedule,7687.26,7687.26, Male Reproductive System Diagnoses Except Malignancy,5013,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,7687.26,,,,,,,fee schedule,7687.26,7687.26, Male Reproductive System Diagnoses Except Malignancy,5013,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,7687.26,,,,,,,fee schedule,7687.26,7687.26, Male Reproductive System Diagnoses Except Malignancy,5013,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,7687.26,,,,,,,fee schedule,7687.26,7687.26, Male Reproductive System Diagnoses Except Malignancy,5013,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,7687.26,,,,,,,fee schedule,7687.26,7687.26, Male Reproductive System Diagnoses Except Malignancy,5013,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,7687.26,,,,,,,fee schedule,7687.26,7687.26, Male Reproductive System Diagnoses Except Malignancy,5014,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,15829.04,,,,,,,fee schedule,15829.04,15829.04, Male Reproductive System Diagnoses Except Malignancy,5014,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,15829.04,,,,,,,fee schedule,15829.04,15829.04, Male Reproductive System Diagnoses Except Malignancy,5014,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,15829.04,,,,,,,fee schedule,15829.04,15829.04, Male Reproductive System Diagnoses Except Malignancy,5014,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,15829.04,,,,,,,fee schedule,15829.04,15829.04, Male Reproductive System Diagnoses Except Malignancy,5014,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,15829.04,,,,,,,fee schedule,15829.04,15829.04, Male Reproductive System Diagnoses Except Malignancy,5014,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,15829.04,,,,,,,fee schedule,15829.04,15829.04, Male Reproductive System Diagnoses Except Malignancy,5014,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,15829.04,,,,,,,fee schedule,15829.04,15829.04, Male Reproductive System Diagnoses Except Malignancy,5014,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,15829.04,,,,,,,fee schedule,15829.04,15829.04, Male Reproductive System Diagnoses Except Malignancy,5014,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,15829.04,,,,,,,fee schedule,15829.04,15829.04, Male Reproductive System Diagnoses Except Malignancy,5014,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,15829.04,,,,,,,fee schedule,15829.04,15829.04, Male Reproductive System Diagnoses Except Malignancy,5014,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,15829.04,,,,,,,fee schedule,15829.04,15829.04, Uterine And Adnexa Procedures For Ovarian And Adnexal Malignancy,5111,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,10620.45,,,,,,,fee schedule,10620.45,10620.45, Uterine And Adnexa Procedures For Ovarian And Adnexal Malignancy,5111,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,10620.45,,,,,,,fee schedule,10620.45,10620.45, Uterine And Adnexa Procedures For Ovarian And Adnexal Malignancy,5111,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,10620.45,,,,,,,fee schedule,10620.45,10620.45, Uterine And Adnexa Procedures For Ovarian And Adnexal Malignancy,5111,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,10620.45,,,,,,,fee schedule,10620.45,10620.45, Uterine And Adnexa Procedures For Ovarian And Adnexal Malignancy,5111,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,10620.45,,,,,,,fee schedule,10620.45,10620.45, Uterine And Adnexa Procedures For Ovarian And Adnexal Malignancy,5111,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,10620.45,,,,,,,fee schedule,10620.45,10620.45, Uterine And Adnexa Procedures For Ovarian And Adnexal Malignancy,5111,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,10620.45,,,,,,,fee schedule,10620.45,10620.45, Uterine And Adnexa Procedures For Ovarian And Adnexal Malignancy,5111,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,10620.45,,,,,,,fee schedule,10620.45,10620.45, Uterine And Adnexa Procedures For Ovarian And Adnexal Malignancy,5111,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,10620.45,,,,,,,fee schedule,10620.45,10620.45, Uterine And Adnexa Procedures For Ovarian And Adnexal Malignancy,5111,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,10620.45,,,,,,,fee schedule,10620.45,10620.45, Uterine And Adnexa Procedures For Ovarian And Adnexal Malignancy,5111,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,10620.45,,,,,,,fee schedule,10620.45,10620.45, Uterine And Adnexa Procedures For Ovarian And Adnexal Malignancy,5112,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,12829.51,,,,,,,fee schedule,12829.51,12829.51, Uterine And Adnexa Procedures For Ovarian And Adnexal Malignancy,5112,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,12829.51,,,,,,,fee schedule,12829.51,12829.51, Uterine And Adnexa Procedures For Ovarian And Adnexal Malignancy,5112,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,12829.51,,,,,,,fee schedule,12829.51,12829.51, Uterine And Adnexa Procedures For Ovarian And Adnexal Malignancy,5112,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,12829.51,,,,,,,fee schedule,12829.51,12829.51, Uterine And Adnexa Procedures For Ovarian And Adnexal Malignancy,5112,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,12829.51,,,,,,,fee schedule,12829.51,12829.51, Uterine And Adnexa Procedures For Ovarian And Adnexal Malignancy,5112,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,12829.51,,,,,,,fee schedule,12829.51,12829.51, Uterine And Adnexa Procedures For Ovarian And Adnexal Malignancy,5112,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,12829.51,,,,,,,fee schedule,12829.51,12829.51, Uterine And Adnexa Procedures For Ovarian And Adnexal Malignancy,5112,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,12829.51,,,,,,,fee schedule,12829.51,12829.51, Uterine And Adnexa Procedures For Ovarian And Adnexal Malignancy,5112,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,12829.51,,,,,,,fee schedule,12829.51,12829.51, Uterine And Adnexa Procedures For Ovarian And Adnexal Malignancy,5112,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,12829.51,,,,,,,fee schedule,12829.51,12829.51, Uterine And Adnexa Procedures For Ovarian And Adnexal Malignancy,5112,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,12829.51,,,,,,,fee schedule,12829.51,12829.51, Uterine And Adnexa Procedures For Ovarian And Adnexal Malignancy,5113,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,19631.03,,,,,,,fee schedule,19631.03,19631.03, Uterine And Adnexa Procedures For Ovarian And Adnexal Malignancy,5113,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,19631.03,,,,,,,fee schedule,19631.03,19631.03, Uterine And Adnexa Procedures For Ovarian And Adnexal Malignancy,5113,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,19631.03,,,,,,,fee schedule,19631.03,19631.03, Uterine And Adnexa Procedures For Ovarian And Adnexal Malignancy,5113,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,19631.03,,,,,,,fee schedule,19631.03,19631.03, Uterine And Adnexa Procedures For Ovarian And Adnexal Malignancy,5113,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,19631.03,,,,,,,fee schedule,19631.03,19631.03, Uterine And Adnexa Procedures For Ovarian And Adnexal Malignancy,5113,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,19631.03,,,,,,,fee schedule,19631.03,19631.03, Uterine And Adnexa Procedures For Ovarian And Adnexal Malignancy,5113,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,19631.03,,,,,,,fee schedule,19631.03,19631.03, Uterine And Adnexa Procedures For Ovarian And Adnexal Malignancy,5113,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,19631.03,,,,,,,fee schedule,19631.03,19631.03, Uterine And Adnexa Procedures For Ovarian And Adnexal Malignancy,5113,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,19631.03,,,,,,,fee schedule,19631.03,19631.03, Uterine And Adnexa Procedures For Ovarian And Adnexal Malignancy,5113,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,19631.03,,,,,,,fee schedule,19631.03,19631.03, Uterine And Adnexa Procedures For Ovarian And Adnexal Malignancy,5113,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,19631.03,,,,,,,fee schedule,19631.03,19631.03, Uterine And Adnexa Procedures For Ovarian And Adnexal Malignancy,5114,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,35890.59,,,,,,,fee schedule,35890.59,35890.59, Uterine And Adnexa Procedures For Ovarian And Adnexal Malignancy,5114,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,35890.59,,,,,,,fee schedule,35890.59,35890.59, Uterine And Adnexa Procedures For Ovarian And Adnexal Malignancy,5114,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,35890.59,,,,,,,fee schedule,35890.59,35890.59, Uterine And Adnexa Procedures For Ovarian And Adnexal Malignancy,5114,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,35890.59,,,,,,,fee schedule,35890.59,35890.59, Uterine And Adnexa Procedures For Ovarian And Adnexal Malignancy,5114,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,35890.59,,,,,,,fee schedule,35890.59,35890.59, Uterine And Adnexa Procedures For Ovarian And Adnexal Malignancy,5114,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,35890.59,,,,,,,fee schedule,35890.59,35890.59, Uterine And Adnexa Procedures For Ovarian And Adnexal Malignancy,5114,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,35890.59,,,,,,,fee schedule,35890.59,35890.59, Uterine And Adnexa Procedures For Ovarian And Adnexal Malignancy,5114,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,35890.59,,,,,,,fee schedule,35890.59,35890.59, Uterine And Adnexa Procedures For Ovarian And Adnexal Malignancy,5114,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,35890.59,,,,,,,fee schedule,35890.59,35890.59, Uterine And Adnexa Procedures For Ovarian And Adnexal Malignancy,5114,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,35890.59,,,,,,,fee schedule,35890.59,35890.59, Uterine And Adnexa Procedures For Ovarian And Adnexal Malignancy,5114,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,35890.59,,,,,,,fee schedule,35890.59,35890.59, Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy,5121,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,10551.99,,,,,,,fee schedule,10551.99,10551.99, Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy,5121,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,10551.99,,,,,,,fee schedule,10551.99,10551.99, Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy,5121,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,10551.99,,,,,,,fee schedule,10551.99,10551.99, Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy,5121,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,10551.99,,,,,,,fee schedule,10551.99,10551.99, Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy,5121,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,10551.99,,,,,,,fee schedule,10551.99,10551.99, Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy,5121,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,10551.99,,,,,,,fee schedule,10551.99,10551.99, Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy,5121,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,10551.99,,,,,,,fee schedule,10551.99,10551.99, Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy,5121,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,10551.99,,,,,,,fee schedule,10551.99,10551.99, Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy,5121,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,10551.99,,,,,,,fee schedule,10551.99,10551.99, Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy,5121,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,10551.99,,,,,,,fee schedule,10551.99,10551.99, Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy,5121,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,10551.99,,,,,,,fee schedule,10551.99,10551.99, Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy,5122,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,12119.5,,,,,,,fee schedule,12119.5,12119.5, Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy,5122,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,12119.5,,,,,,,fee schedule,12119.5,12119.5, Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy,5122,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,12119.5,,,,,,,fee schedule,12119.5,12119.5, Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy,5122,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,12119.5,,,,,,,fee schedule,12119.5,12119.5, Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy,5122,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,12119.5,,,,,,,fee schedule,12119.5,12119.5, Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy,5122,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,12119.5,,,,,,,fee schedule,12119.5,12119.5, Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy,5122,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,12119.5,,,,,,,fee schedule,12119.5,12119.5, Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy,5122,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,12119.5,,,,,,,fee schedule,12119.5,12119.5, Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy,5122,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,12119.5,,,,,,,fee schedule,12119.5,12119.5, Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy,5122,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,12119.5,,,,,,,fee schedule,12119.5,12119.5, Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy,5122,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,12119.5,,,,,,,fee schedule,12119.5,12119.5, Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy,5123,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,20024.14,,,,,,,fee schedule,20024.14,20024.14, Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy,5123,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,20024.14,,,,,,,fee schedule,20024.14,20024.14, Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy,5123,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,20024.14,,,,,,,fee schedule,20024.14,20024.14, Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy,5123,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,20024.14,,,,,,,fee schedule,20024.14,20024.14, Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy,5123,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,20024.14,,,,,,,fee schedule,20024.14,20024.14, Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy,5123,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,20024.14,,,,,,,fee schedule,20024.14,20024.14, Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy,5123,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,20024.14,,,,,,,fee schedule,20024.14,20024.14, Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy,5123,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,20024.14,,,,,,,fee schedule,20024.14,20024.14, Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy,5123,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,20024.14,,,,,,,fee schedule,20024.14,20024.14, Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy,5123,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,20024.14,,,,,,,fee schedule,20024.14,20024.14, Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy,5123,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,20024.14,,,,,,,fee schedule,20024.14,20024.14, Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy,5124,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,34335.77,,,,,,,fee schedule,34335.77,34335.77, Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy,5124,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,34335.77,,,,,,,fee schedule,34335.77,34335.77, Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy,5124,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,34335.77,,,,,,,fee schedule,34335.77,34335.77, Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy,5124,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,34335.77,,,,,,,fee schedule,34335.77,34335.77, Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy,5124,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,34335.77,,,,,,,fee schedule,34335.77,34335.77, Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy,5124,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,34335.77,,,,,,,fee schedule,34335.77,34335.77, Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy,5124,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,34335.77,,,,,,,fee schedule,34335.77,34335.77, Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy,5124,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,34335.77,,,,,,,fee schedule,34335.77,34335.77, Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy,5124,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,34335.77,,,,,,,fee schedule,34335.77,34335.77, Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy,5124,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,34335.77,,,,,,,fee schedule,34335.77,34335.77, Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy,5124,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,34335.77,,,,,,,fee schedule,34335.77,34335.77, Uterine And Adnexa Procedures For Non-Malignancy Except Leiomyoma,5131,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,7906.05,,,,,,,fee schedule,7906.05,7906.05, Uterine And Adnexa Procedures For Non-Malignancy Except Leiomyoma,5131,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,7906.05,,,,,,,fee schedule,7906.05,7906.05, Uterine And Adnexa Procedures For Non-Malignancy Except Leiomyoma,5131,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,7906.05,,,,,,,fee schedule,7906.05,7906.05, Uterine And Adnexa Procedures For Non-Malignancy Except Leiomyoma,5131,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,7906.05,,,,,,,fee schedule,7906.05,7906.05, Uterine And Adnexa Procedures For Non-Malignancy Except Leiomyoma,5131,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,7906.05,,,,,,,fee schedule,7906.05,7906.05, Uterine And Adnexa Procedures For Non-Malignancy Except Leiomyoma,5131,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,7906.05,,,,,,,fee schedule,7906.05,7906.05, Uterine And Adnexa Procedures For Non-Malignancy Except Leiomyoma,5131,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,7906.05,,,,,,,fee schedule,7906.05,7906.05, Uterine And Adnexa Procedures For Non-Malignancy Except Leiomyoma,5131,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,7906.05,,,,,,,fee schedule,7906.05,7906.05, Uterine And Adnexa Procedures For Non-Malignancy Except Leiomyoma,5131,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,7906.05,,,,,,,fee schedule,7906.05,7906.05, Uterine And Adnexa Procedures For Non-Malignancy Except Leiomyoma,5131,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,7906.05,,,,,,,fee schedule,7906.05,7906.05, Uterine And Adnexa Procedures For Non-Malignancy Except Leiomyoma,5131,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,7906.05,,,,,,,fee schedule,7906.05,7906.05, Uterine And Adnexa Procedures For Non-Malignancy Except Leiomyoma,5132,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,9735.41,,,,,,,fee schedule,9735.41,9735.41, Uterine And Adnexa Procedures For Non-Malignancy Except Leiomyoma,5132,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,9735.41,,,,,,,fee schedule,9735.41,9735.41, Uterine And Adnexa Procedures For Non-Malignancy Except Leiomyoma,5132,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,9735.41,,,,,,,fee schedule,9735.41,9735.41, Uterine And Adnexa Procedures For Non-Malignancy Except Leiomyoma,5132,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,9735.41,,,,,,,fee schedule,9735.41,9735.41, Uterine And Adnexa Procedures For Non-Malignancy Except Leiomyoma,5132,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,9735.41,,,,,,,fee schedule,9735.41,9735.41, Uterine And Adnexa Procedures For Non-Malignancy Except Leiomyoma,5132,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,9735.41,,,,,,,fee schedule,9735.41,9735.41, Uterine And Adnexa Procedures For Non-Malignancy Except Leiomyoma,5132,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,9735.41,,,,,,,fee schedule,9735.41,9735.41, Uterine And Adnexa Procedures For Non-Malignancy Except Leiomyoma,5132,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,9735.41,,,,,,,fee schedule,9735.41,9735.41, Uterine And Adnexa Procedures For Non-Malignancy Except Leiomyoma,5132,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,9735.41,,,,,,,fee schedule,9735.41,9735.41, Uterine And Adnexa Procedures For Non-Malignancy Except Leiomyoma,5132,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,9735.41,,,,,,,fee schedule,9735.41,9735.41, Uterine And Adnexa Procedures For Non-Malignancy Except Leiomyoma,5132,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,9735.41,,,,,,,fee schedule,9735.41,9735.41, Uterine And Adnexa Procedures For Non-Malignancy Except Leiomyoma,5133,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,16057.71,,,,,,,fee schedule,16057.71,16057.71, Uterine And Adnexa Procedures For Non-Malignancy Except Leiomyoma,5133,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,16057.71,,,,,,,fee schedule,16057.71,16057.71, Uterine And Adnexa Procedures For Non-Malignancy Except Leiomyoma,5133,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,16057.71,,,,,,,fee schedule,16057.71,16057.71, Uterine And Adnexa Procedures For Non-Malignancy Except Leiomyoma,5133,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,16057.71,,,,,,,fee schedule,16057.71,16057.71, Uterine And Adnexa Procedures For Non-Malignancy Except Leiomyoma,5133,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,16057.71,,,,,,,fee schedule,16057.71,16057.71, Uterine And Adnexa Procedures For Non-Malignancy Except Leiomyoma,5133,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,16057.71,,,,,,,fee schedule,16057.71,16057.71, Uterine And Adnexa Procedures For Non-Malignancy Except Leiomyoma,5133,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,16057.71,,,,,,,fee schedule,16057.71,16057.71, Uterine And Adnexa Procedures For Non-Malignancy Except Leiomyoma,5133,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,16057.71,,,,,,,fee schedule,16057.71,16057.71, Uterine And Adnexa Procedures For Non-Malignancy Except Leiomyoma,5133,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,16057.71,,,,,,,fee schedule,16057.71,16057.71, Uterine And Adnexa Procedures For Non-Malignancy Except Leiomyoma,5133,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,16057.71,,,,,,,fee schedule,16057.71,16057.71, Uterine And Adnexa Procedures For Non-Malignancy Except Leiomyoma,5133,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,16057.71,,,,,,,fee schedule,16057.71,16057.71, Uterine And Adnexa Procedures For Non-Malignancy Except Leiomyoma,5134,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,28955.68,,,,,,,fee schedule,28955.68,28955.68, Uterine And Adnexa Procedures For Non-Malignancy Except Leiomyoma,5134,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,28955.68,,,,,,,fee schedule,28955.68,28955.68, Uterine And Adnexa Procedures For Non-Malignancy Except Leiomyoma,5134,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,28955.68,,,,,,,fee schedule,28955.68,28955.68, Uterine And Adnexa Procedures For Non-Malignancy Except Leiomyoma,5134,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,28955.68,,,,,,,fee schedule,28955.68,28955.68, Uterine And Adnexa Procedures For Non-Malignancy Except Leiomyoma,5134,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,28955.68,,,,,,,fee schedule,28955.68,28955.68, Uterine And Adnexa Procedures For Non-Malignancy Except Leiomyoma,5134,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,28955.68,,,,,,,fee schedule,28955.68,28955.68, Uterine And Adnexa Procedures For Non-Malignancy Except Leiomyoma,5134,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,28955.68,,,,,,,fee schedule,28955.68,28955.68, Uterine And Adnexa Procedures For Non-Malignancy Except Leiomyoma,5134,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,28955.68,,,,,,,fee schedule,28955.68,28955.68, Uterine And Adnexa Procedures For Non-Malignancy Except Leiomyoma,5134,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,28955.68,,,,,,,fee schedule,28955.68,28955.68, Uterine And Adnexa Procedures For Non-Malignancy Except Leiomyoma,5134,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,28955.68,,,,,,,fee schedule,28955.68,28955.68, Uterine And Adnexa Procedures For Non-Malignancy Except Leiomyoma,5134,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,28955.68,,,,,,,fee schedule,28955.68,28955.68, Female Reproductive System Reconstructive Procedures,5141,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,7826.3,,,,,,,fee schedule,7826.3,7826.3, Female Reproductive System Reconstructive Procedures,5141,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,7826.3,,,,,,,fee schedule,7826.3,7826.3, Female Reproductive System Reconstructive Procedures,5141,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,7826.3,,,,,,,fee schedule,7826.3,7826.3, Female Reproductive System Reconstructive Procedures,5141,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,7826.3,,,,,,,fee schedule,7826.3,7826.3, Female Reproductive System Reconstructive Procedures,5141,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,7826.3,,,,,,,fee schedule,7826.3,7826.3, Female Reproductive System Reconstructive Procedures,5141,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,7826.3,,,,,,,fee schedule,7826.3,7826.3, Female Reproductive System Reconstructive Procedures,5141,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,7826.3,,,,,,,fee schedule,7826.3,7826.3, Female Reproductive System Reconstructive Procedures,5141,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,7826.3,,,,,,,fee schedule,7826.3,7826.3, Female Reproductive System Reconstructive Procedures,5141,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,7826.3,,,,,,,fee schedule,7826.3,7826.3, Female Reproductive System Reconstructive Procedures,5141,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,7826.3,,,,,,,fee schedule,7826.3,7826.3, Female Reproductive System Reconstructive Procedures,5141,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,7826.3,,,,,,,fee schedule,7826.3,7826.3, Female Reproductive System Reconstructive Procedures,5142,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,11718.63,,,,,,,fee schedule,11718.63,11718.63, Female Reproductive System Reconstructive Procedures,5142,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,11718.63,,,,,,,fee schedule,11718.63,11718.63, Female Reproductive System Reconstructive Procedures,5142,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,11718.63,,,,,,,fee schedule,11718.63,11718.63, Female Reproductive System Reconstructive Procedures,5142,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,11718.63,,,,,,,fee schedule,11718.63,11718.63, Female Reproductive System Reconstructive Procedures,5142,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,11718.63,,,,,,,fee schedule,11718.63,11718.63, Female Reproductive System Reconstructive Procedures,5142,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,11718.63,,,,,,,fee schedule,11718.63,11718.63, Female Reproductive System Reconstructive Procedures,5142,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,11718.63,,,,,,,fee schedule,11718.63,11718.63, Female Reproductive System Reconstructive Procedures,5142,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,11718.63,,,,,,,fee schedule,11718.63,11718.63, Female Reproductive System Reconstructive Procedures,5142,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,11718.63,,,,,,,fee schedule,11718.63,11718.63, Female Reproductive System Reconstructive Procedures,5142,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,11718.63,,,,,,,fee schedule,11718.63,11718.63, Female Reproductive System Reconstructive Procedures,5142,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,11718.63,,,,,,,fee schedule,11718.63,11718.63, Female Reproductive System Reconstructive Procedures,5143,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,14625.7,,,,,,,fee schedule,14625.7,14625.7, Female Reproductive System Reconstructive Procedures,5143,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,14625.7,,,,,,,fee schedule,14625.7,14625.7, Female Reproductive System Reconstructive Procedures,5143,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,14625.7,,,,,,,fee schedule,14625.7,14625.7, Female Reproductive System Reconstructive Procedures,5143,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,14625.7,,,,,,,fee schedule,14625.7,14625.7, Female Reproductive System Reconstructive Procedures,5143,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,14625.7,,,,,,,fee schedule,14625.7,14625.7, Female Reproductive System Reconstructive Procedures,5143,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,14625.7,,,,,,,fee schedule,14625.7,14625.7, Female Reproductive System Reconstructive Procedures,5143,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,14625.7,,,,,,,fee schedule,14625.7,14625.7, Female Reproductive System Reconstructive Procedures,5143,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,14625.7,,,,,,,fee schedule,14625.7,14625.7, Female Reproductive System Reconstructive Procedures,5143,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,14625.7,,,,,,,fee schedule,14625.7,14625.7, Female Reproductive System Reconstructive Procedures,5143,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,14625.7,,,,,,,fee schedule,14625.7,14625.7, Female Reproductive System Reconstructive Procedures,5143,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,14625.7,,,,,,,fee schedule,14625.7,14625.7, Female Reproductive System Reconstructive Procedures,5144,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,30354.52,,,,,,,fee schedule,30354.52,30354.52, Female Reproductive System Reconstructive Procedures,5144,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,30354.52,,,,,,,fee schedule,30354.52,30354.52, Female Reproductive System Reconstructive Procedures,5144,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,30354.52,,,,,,,fee schedule,30354.52,30354.52, Female Reproductive System Reconstructive Procedures,5144,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,30354.52,,,,,,,fee schedule,30354.52,30354.52, Female Reproductive System Reconstructive Procedures,5144,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,30354.52,,,,,,,fee schedule,30354.52,30354.52, Female Reproductive System Reconstructive Procedures,5144,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,30354.52,,,,,,,fee schedule,30354.52,30354.52, Female Reproductive System Reconstructive Procedures,5144,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,30354.52,,,,,,,fee schedule,30354.52,30354.52, Female Reproductive System Reconstructive Procedures,5144,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,30354.52,,,,,,,fee schedule,30354.52,30354.52, Female Reproductive System Reconstructive Procedures,5144,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,30354.52,,,,,,,fee schedule,30354.52,30354.52, Female Reproductive System Reconstructive Procedures,5144,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,30354.52,,,,,,,fee schedule,30354.52,30354.52, Female Reproductive System Reconstructive Procedures,5144,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,30354.52,,,,,,,fee schedule,30354.52,30354.52, Dilation And Curettage For Non-Obstetric Diagnoses,5171,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,6140.92,,,,,,,fee schedule,6140.92,6140.92, Dilation And Curettage For Non-Obstetric Diagnoses,5171,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,6140.92,,,,,,,fee schedule,6140.92,6140.92, Dilation And Curettage For Non-Obstetric Diagnoses,5171,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,6140.92,,,,,,,fee schedule,6140.92,6140.92, Dilation And Curettage For Non-Obstetric Diagnoses,5171,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,6140.92,,,,,,,fee schedule,6140.92,6140.92, Dilation And Curettage For Non-Obstetric Diagnoses,5171,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,6140.92,,,,,,,fee schedule,6140.92,6140.92, Dilation And Curettage For Non-Obstetric Diagnoses,5171,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,6140.92,,,,,,,fee schedule,6140.92,6140.92, Dilation And Curettage For Non-Obstetric Diagnoses,5171,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,6140.92,,,,,,,fee schedule,6140.92,6140.92, Dilation And Curettage For Non-Obstetric Diagnoses,5171,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,6140.92,,,,,,,fee schedule,6140.92,6140.92, Dilation And Curettage For Non-Obstetric Diagnoses,5171,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,6140.92,,,,,,,fee schedule,6140.92,6140.92, Dilation And Curettage For Non-Obstetric Diagnoses,5171,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,6140.92,,,,,,,fee schedule,6140.92,6140.92, Dilation And Curettage For Non-Obstetric Diagnoses,5171,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,6140.92,,,,,,,fee schedule,6140.92,6140.92, Dilation And Curettage For Non-Obstetric Diagnoses,5172,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,8340.1,,,,,,,fee schedule,8340.1,8340.1, Dilation And Curettage For Non-Obstetric Diagnoses,5172,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,8340.1,,,,,,,fee schedule,8340.1,8340.1, Dilation And Curettage For Non-Obstetric Diagnoses,5172,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,8340.1,,,,,,,fee schedule,8340.1,8340.1, Dilation And Curettage For Non-Obstetric Diagnoses,5172,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,8340.1,,,,,,,fee schedule,8340.1,8340.1, Dilation And Curettage For Non-Obstetric Diagnoses,5172,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,8340.1,,,,,,,fee schedule,8340.1,8340.1, Dilation And Curettage For Non-Obstetric Diagnoses,5172,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,8340.1,,,,,,,fee schedule,8340.1,8340.1, Dilation And Curettage For Non-Obstetric Diagnoses,5172,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,8340.1,,,,,,,fee schedule,8340.1,8340.1, Dilation And Curettage For Non-Obstetric Diagnoses,5172,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,8340.1,,,,,,,fee schedule,8340.1,8340.1, Dilation And Curettage For Non-Obstetric Diagnoses,5172,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,8340.1,,,,,,,fee schedule,8340.1,8340.1, Dilation And Curettage For Non-Obstetric Diagnoses,5172,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,8340.1,,,,,,,fee schedule,8340.1,8340.1, Dilation And Curettage For Non-Obstetric Diagnoses,5172,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,8340.1,,,,,,,fee schedule,8340.1,8340.1, Dilation And Curettage For Non-Obstetric Diagnoses,5173,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,12542.26,,,,,,,fee schedule,12542.26,12542.26, Dilation And Curettage For Non-Obstetric Diagnoses,5173,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,12542.26,,,,,,,fee schedule,12542.26,12542.26, Dilation And Curettage For Non-Obstetric Diagnoses,5173,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,12542.26,,,,,,,fee schedule,12542.26,12542.26, Dilation And Curettage For Non-Obstetric Diagnoses,5173,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,12542.26,,,,,,,fee schedule,12542.26,12542.26, Dilation And Curettage For Non-Obstetric Diagnoses,5173,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,12542.26,,,,,,,fee schedule,12542.26,12542.26, Dilation And Curettage For Non-Obstetric Diagnoses,5173,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,12542.26,,,,,,,fee schedule,12542.26,12542.26, Dilation And Curettage For Non-Obstetric Diagnoses,5173,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,12542.26,,,,,,,fee schedule,12542.26,12542.26, Dilation And Curettage For Non-Obstetric Diagnoses,5173,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,12542.26,,,,,,,fee schedule,12542.26,12542.26, Dilation And Curettage For Non-Obstetric Diagnoses,5173,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,12542.26,,,,,,,fee schedule,12542.26,12542.26, Dilation And Curettage For Non-Obstetric Diagnoses,5173,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,12542.26,,,,,,,fee schedule,12542.26,12542.26, Dilation And Curettage For Non-Obstetric Diagnoses,5173,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,12542.26,,,,,,,fee schedule,12542.26,12542.26, Dilation And Curettage For Non-Obstetric Diagnoses,5174,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,19150.4,,,,,,,fee schedule,19150.4,19150.4, Dilation And Curettage For Non-Obstetric Diagnoses,5174,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,19150.4,,,,,,,fee schedule,19150.4,19150.4, Dilation And Curettage For Non-Obstetric Diagnoses,5174,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,19150.4,,,,,,,fee schedule,19150.4,19150.4, Dilation And Curettage For Non-Obstetric Diagnoses,5174,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,19150.4,,,,,,,fee schedule,19150.4,19150.4, Dilation And Curettage For Non-Obstetric Diagnoses,5174,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,19150.4,,,,,,,fee schedule,19150.4,19150.4, Dilation And Curettage For Non-Obstetric Diagnoses,5174,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,19150.4,,,,,,,fee schedule,19150.4,19150.4, Dilation And Curettage For Non-Obstetric Diagnoses,5174,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,19150.4,,,,,,,fee schedule,19150.4,19150.4, Dilation And Curettage For Non-Obstetric Diagnoses,5174,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,19150.4,,,,,,,fee schedule,19150.4,19150.4, Dilation And Curettage For Non-Obstetric Diagnoses,5174,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,19150.4,,,,,,,fee schedule,19150.4,19150.4, Dilation And Curettage For Non-Obstetric Diagnoses,5174,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,19150.4,,,,,,,fee schedule,19150.4,19150.4, Dilation And Curettage For Non-Obstetric Diagnoses,5174,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,19150.4,,,,,,,fee schedule,19150.4,19150.4, Other Female Reproductive System And Related Procedures,5181,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,6774.7,,,,,,,fee schedule,6774.7,6774.7, Other Female Reproductive System And Related Procedures,5181,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,6774.7,,,,,,,fee schedule,6774.7,6774.7, Other Female Reproductive System And Related Procedures,5181,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,6774.7,,,,,,,fee schedule,6774.7,6774.7, Other Female Reproductive System And Related Procedures,5181,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,6774.7,,,,,,,fee schedule,6774.7,6774.7, Other Female Reproductive System And Related Procedures,5181,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,6774.7,,,,,,,fee schedule,6774.7,6774.7, Other Female Reproductive System And Related Procedures,5181,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,6774.7,,,,,,,fee schedule,6774.7,6774.7, Other Female Reproductive System And Related Procedures,5181,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,6774.7,,,,,,,fee schedule,6774.7,6774.7, Other Female Reproductive System And Related Procedures,5181,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,6774.7,,,,,,,fee schedule,6774.7,6774.7, Other Female Reproductive System And Related Procedures,5181,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,6774.7,,,,,,,fee schedule,6774.7,6774.7, Other Female Reproductive System And Related Procedures,5181,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,6774.7,,,,,,,fee schedule,6774.7,6774.7, Other Female Reproductive System And Related Procedures,5181,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,6774.7,,,,,,,fee schedule,6774.7,6774.7, Other Female Reproductive System And Related Procedures,5182,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,11356.57,,,,,,,fee schedule,11356.57,11356.57, Other Female Reproductive System And Related Procedures,5182,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,11356.57,,,,,,,fee schedule,11356.57,11356.57, Other Female Reproductive System And Related Procedures,5182,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,11356.57,,,,,,,fee schedule,11356.57,11356.57, Other Female Reproductive System And Related Procedures,5182,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,11356.57,,,,,,,fee schedule,11356.57,11356.57, Other Female Reproductive System And Related Procedures,5182,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,11356.57,,,,,,,fee schedule,11356.57,11356.57, Other Female Reproductive System And Related Procedures,5182,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,11356.57,,,,,,,fee schedule,11356.57,11356.57, Other Female Reproductive System And Related Procedures,5182,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,11356.57,,,,,,,fee schedule,11356.57,11356.57, Other Female Reproductive System And Related Procedures,5182,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,11356.57,,,,,,,fee schedule,11356.57,11356.57, Other Female Reproductive System And Related Procedures,5182,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,11356.57,,,,,,,fee schedule,11356.57,11356.57, Other Female Reproductive System And Related Procedures,5182,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,11356.57,,,,,,,fee schedule,11356.57,11356.57, Other Female Reproductive System And Related Procedures,5182,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,11356.57,,,,,,,fee schedule,11356.57,11356.57, Other Female Reproductive System And Related Procedures,5183,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,17896.95,,,,,,,fee schedule,17896.95,17896.95, Other Female Reproductive System And Related Procedures,5183,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,17896.95,,,,,,,fee schedule,17896.95,17896.95, Other Female Reproductive System And Related Procedures,5183,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,17896.95,,,,,,,fee schedule,17896.95,17896.95, Other Female Reproductive System And Related Procedures,5183,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,17896.95,,,,,,,fee schedule,17896.95,17896.95, Other Female Reproductive System And Related Procedures,5183,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,17896.95,,,,,,,fee schedule,17896.95,17896.95, Other Female Reproductive System And Related Procedures,5183,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,17896.95,,,,,,,fee schedule,17896.95,17896.95, Other Female Reproductive System And Related Procedures,5183,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,17896.95,,,,,,,fee schedule,17896.95,17896.95, Other Female Reproductive System And Related Procedures,5183,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,17896.95,,,,,,,fee schedule,17896.95,17896.95, Other Female Reproductive System And Related Procedures,5183,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,17896.95,,,,,,,fee schedule,17896.95,17896.95, Other Female Reproductive System And Related Procedures,5183,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,17896.95,,,,,,,fee schedule,17896.95,17896.95, Other Female Reproductive System And Related Procedures,5183,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,17896.95,,,,,,,fee schedule,17896.95,17896.95, Other Female Reproductive System And Related Procedures,5184,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,29673.45,,,,,,,fee schedule,29673.45,29673.45, Other Female Reproductive System And Related Procedures,5184,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,29673.45,,,,,,,fee schedule,29673.45,29673.45, Other Female Reproductive System And Related Procedures,5184,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,29673.45,,,,,,,fee schedule,29673.45,29673.45, Other Female Reproductive System And Related Procedures,5184,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,29673.45,,,,,,,fee schedule,29673.45,29673.45, Other Female Reproductive System And Related Procedures,5184,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,29673.45,,,,,,,fee schedule,29673.45,29673.45, Other Female Reproductive System And Related Procedures,5184,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,29673.45,,,,,,,fee schedule,29673.45,29673.45, Other Female Reproductive System And Related Procedures,5184,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,29673.45,,,,,,,fee schedule,29673.45,29673.45, Other Female Reproductive System And Related Procedures,5184,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,29673.45,,,,,,,fee schedule,29673.45,29673.45, Other Female Reproductive System And Related Procedures,5184,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,29673.45,,,,,,,fee schedule,29673.45,29673.45, Other Female Reproductive System And Related Procedures,5184,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,29673.45,,,,,,,fee schedule,29673.45,29673.45, Other Female Reproductive System And Related Procedures,5184,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,29673.45,,,,,,,fee schedule,29673.45,29673.45, Uterine And Adnexa Procedures For Leiomyoma,5191,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,7346.37,,,,,,,fee schedule,7346.37,7346.37, Uterine And Adnexa Procedures For Leiomyoma,5191,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,7346.37,,,,,,,fee schedule,7346.37,7346.37, Uterine And Adnexa Procedures For Leiomyoma,5191,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,7346.37,,,,,,,fee schedule,7346.37,7346.37, Uterine And Adnexa Procedures For Leiomyoma,5191,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,7346.37,,,,,,,fee schedule,7346.37,7346.37, Uterine And Adnexa Procedures For Leiomyoma,5191,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,7346.37,,,,,,,fee schedule,7346.37,7346.37, Uterine And Adnexa Procedures For Leiomyoma,5191,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,7346.37,,,,,,,fee schedule,7346.37,7346.37, Uterine And Adnexa Procedures For Leiomyoma,5191,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,7346.37,,,,,,,fee schedule,7346.37,7346.37, Uterine And Adnexa Procedures For Leiomyoma,5191,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,7346.37,,,,,,,fee schedule,7346.37,7346.37, Uterine And Adnexa Procedures For Leiomyoma,5191,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,7346.37,,,,,,,fee schedule,7346.37,7346.37, Uterine And Adnexa Procedures For Leiomyoma,5191,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,7346.37,,,,,,,fee schedule,7346.37,7346.37, Uterine And Adnexa Procedures For Leiomyoma,5191,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,7346.37,,,,,,,fee schedule,7346.37,7346.37, Uterine And Adnexa Procedures For Leiomyoma,5192,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,9662.71,,,,,,,fee schedule,9662.71,9662.71, Uterine And Adnexa Procedures For Leiomyoma,5192,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,9662.71,,,,,,,fee schedule,9662.71,9662.71, Uterine And Adnexa Procedures For Leiomyoma,5192,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,9662.71,,,,,,,fee schedule,9662.71,9662.71, Uterine And Adnexa Procedures For Leiomyoma,5192,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,9662.71,,,,,,,fee schedule,9662.71,9662.71, Uterine And Adnexa Procedures For Leiomyoma,5192,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,9662.71,,,,,,,fee schedule,9662.71,9662.71, Uterine And Adnexa Procedures For Leiomyoma,5192,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,9662.71,,,,,,,fee schedule,9662.71,9662.71, Uterine And Adnexa Procedures For Leiomyoma,5192,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,9662.71,,,,,,,fee schedule,9662.71,9662.71, Uterine And Adnexa Procedures For Leiomyoma,5192,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,9662.71,,,,,,,fee schedule,9662.71,9662.71, Uterine And Adnexa Procedures For Leiomyoma,5192,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,9662.71,,,,,,,fee schedule,9662.71,9662.71, Uterine And Adnexa Procedures For Leiomyoma,5192,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,9662.71,,,,,,,fee schedule,9662.71,9662.71, Uterine And Adnexa Procedures For Leiomyoma,5192,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,9662.71,,,,,,,fee schedule,9662.71,9662.71, Uterine And Adnexa Procedures For Leiomyoma,5193,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,17561.71,,,,,,,fee schedule,17561.71,17561.71, Uterine And Adnexa Procedures For Leiomyoma,5193,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,17561.71,,,,,,,fee schedule,17561.71,17561.71, Uterine And Adnexa Procedures For Leiomyoma,5193,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,17561.71,,,,,,,fee schedule,17561.71,17561.71, Uterine And Adnexa Procedures For Leiomyoma,5193,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,17561.71,,,,,,,fee schedule,17561.71,17561.71, Uterine And Adnexa Procedures For Leiomyoma,5193,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,17561.71,,,,,,,fee schedule,17561.71,17561.71, Uterine And Adnexa Procedures For Leiomyoma,5193,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,17561.71,,,,,,,fee schedule,17561.71,17561.71, Uterine And Adnexa Procedures For Leiomyoma,5193,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,17561.71,,,,,,,fee schedule,17561.71,17561.71, Uterine And Adnexa Procedures For Leiomyoma,5193,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,17561.71,,,,,,,fee schedule,17561.71,17561.71, Uterine And Adnexa Procedures For Leiomyoma,5193,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,17561.71,,,,,,,fee schedule,17561.71,17561.71, Uterine And Adnexa Procedures For Leiomyoma,5193,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,17561.71,,,,,,,fee schedule,17561.71,17561.71, Uterine And Adnexa Procedures For Leiomyoma,5193,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,17561.71,,,,,,,fee schedule,17561.71,17561.71, Uterine And Adnexa Procedures For Leiomyoma,5194,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,29060.84,,,,,,,fee schedule,29060.84,29060.84, Uterine And Adnexa Procedures For Leiomyoma,5194,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,29060.84,,,,,,,fee schedule,29060.84,29060.84, Uterine And Adnexa Procedures For Leiomyoma,5194,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,29060.84,,,,,,,fee schedule,29060.84,29060.84, Uterine And Adnexa Procedures For Leiomyoma,5194,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,29060.84,,,,,,,fee schedule,29060.84,29060.84, Uterine And Adnexa Procedures For Leiomyoma,5194,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,29060.84,,,,,,,fee schedule,29060.84,29060.84, Uterine And Adnexa Procedures For Leiomyoma,5194,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,29060.84,,,,,,,fee schedule,29060.84,29060.84, Uterine And Adnexa Procedures For Leiomyoma,5194,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,29060.84,,,,,,,fee schedule,29060.84,29060.84, Uterine And Adnexa Procedures For Leiomyoma,5194,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,29060.84,,,,,,,fee schedule,29060.84,29060.84, Uterine And Adnexa Procedures For Leiomyoma,5194,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,29060.84,,,,,,,fee schedule,29060.84,29060.84, Uterine And Adnexa Procedures For Leiomyoma,5194,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,29060.84,,,,,,,fee schedule,29060.84,29060.84, Uterine And Adnexa Procedures For Leiomyoma,5194,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,29060.84,,,,,,,fee schedule,29060.84,29060.84, Description Not Available,5201,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,10157.46,,,,,,,fee schedule,10157.46,10157.46, Description Not Available,5201,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,10157.46,,,,,,,fee schedule,10157.46,10157.46, Description Not Available,5201,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,10157.46,,,,,,,fee schedule,10157.46,10157.46, Description Not Available,5201,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,10157.46,,,,,,,fee schedule,10157.46,10157.46, Description Not Available,5201,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,10157.46,,,,,,,fee schedule,10157.46,10157.46, Description Not Available,5201,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,10157.46,,,,,,,fee schedule,10157.46,10157.46, Description Not Available,5201,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,10157.46,,,,,,,fee schedule,10157.46,10157.46, Description Not Available,5201,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,10157.46,,,,,,,fee schedule,10157.46,10157.46, Description Not Available,5201,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,10157.46,,,,,,,fee schedule,10157.46,10157.46, Description Not Available,5201,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,10157.46,,,,,,,fee schedule,10157.46,10157.46, Description Not Available,5201,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,10157.46,,,,,,,fee schedule,10157.46,10157.46, Description Not Available,5202,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,12948.79,,,,,,,fee schedule,12948.79,12948.79, Description Not Available,5202,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,12948.79,,,,,,,fee schedule,12948.79,12948.79, Description Not Available,5202,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,12948.79,,,,,,,fee schedule,12948.79,12948.79, Description Not Available,5202,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,12948.79,,,,,,,fee schedule,12948.79,12948.79, Description Not Available,5202,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,12948.79,,,,,,,fee schedule,12948.79,12948.79, Description Not Available,5202,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,12948.79,,,,,,,fee schedule,12948.79,12948.79, Description Not Available,5202,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,12948.79,,,,,,,fee schedule,12948.79,12948.79, Description Not Available,5202,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,12948.79,,,,,,,fee schedule,12948.79,12948.79, Description Not Available,5202,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,12948.79,,,,,,,fee schedule,12948.79,12948.79, Description Not Available,5202,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,12948.79,,,,,,,fee schedule,12948.79,12948.79, Description Not Available,5202,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,12948.79,,,,,,,fee schedule,12948.79,12948.79, Description Not Available,5203,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,19919.69,,,,,,,fee schedule,19919.69,19919.69, Description Not Available,5203,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,19919.69,,,,,,,fee schedule,19919.69,19919.69, Description Not Available,5203,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,19919.69,,,,,,,fee schedule,19919.69,19919.69, Description Not Available,5203,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,19919.69,,,,,,,fee schedule,19919.69,19919.69, Description Not Available,5203,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,19919.69,,,,,,,fee schedule,19919.69,19919.69, Description Not Available,5203,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,19919.69,,,,,,,fee schedule,19919.69,19919.69, Description Not Available,5203,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,19919.69,,,,,,,fee schedule,19919.69,19919.69, Description Not Available,5203,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,19919.69,,,,,,,fee schedule,19919.69,19919.69, Description Not Available,5203,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,19919.69,,,,,,,fee schedule,19919.69,19919.69, Description Not Available,5203,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,19919.69,,,,,,,fee schedule,19919.69,19919.69, Description Not Available,5203,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,19919.69,,,,,,,fee schedule,19919.69,19919.69, Description Not Available,5204,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,37467.98,,,,,,,fee schedule,37467.98,37467.98, Description Not Available,5204,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,37467.98,,,,,,,fee schedule,37467.98,37467.98, Description Not Available,5204,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,37467.98,,,,,,,fee schedule,37467.98,37467.98, Description Not Available,5204,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,37467.98,,,,,,,fee schedule,37467.98,37467.98, Description Not Available,5204,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,37467.98,,,,,,,fee schedule,37467.98,37467.98, Description Not Available,5204,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,37467.98,,,,,,,fee schedule,37467.98,37467.98, Description Not Available,5204,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,37467.98,,,,,,,fee schedule,37467.98,37467.98, Description Not Available,5204,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,37467.98,,,,,,,fee schedule,37467.98,37467.98, Description Not Available,5204,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,37467.98,,,,,,,fee schedule,37467.98,37467.98, Description Not Available,5204,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,37467.98,,,,,,,fee schedule,37467.98,37467.98, Description Not Available,5204,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,37467.98,,,,,,,fee schedule,37467.98,37467.98, Female Reproductive System Malignancy,5301,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5337.04,,,,,,,fee schedule,5337.04,5337.04, Female Reproductive System Malignancy,5301,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5337.04,,,,,,,fee schedule,5337.04,5337.04, Female Reproductive System Malignancy,5301,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5337.04,,,,,,,fee schedule,5337.04,5337.04, Female Reproductive System Malignancy,5301,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5337.04,,,,,,,fee schedule,5337.04,5337.04, Female Reproductive System Malignancy,5301,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5337.04,,,,,,,fee schedule,5337.04,5337.04, Female Reproductive System Malignancy,5301,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5337.04,,,,,,,fee schedule,5337.04,5337.04, Female Reproductive System Malignancy,5301,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5337.04,,,,,,,fee schedule,5337.04,5337.04, Female Reproductive System Malignancy,5301,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5337.04,,,,,,,fee schedule,5337.04,5337.04, Female Reproductive System Malignancy,5301,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5337.04,,,,,,,fee schedule,5337.04,5337.04, Female Reproductive System Malignancy,5301,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5337.04,,,,,,,fee schedule,5337.04,5337.04, Female Reproductive System Malignancy,5301,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5337.04,,,,,,,fee schedule,5337.04,5337.04, Female Reproductive System Malignancy,5302,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,6709.77,,,,,,,fee schedule,6709.77,6709.77, Female Reproductive System Malignancy,5302,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,6709.77,,,,,,,fee schedule,6709.77,6709.77, Female Reproductive System Malignancy,5302,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,6709.77,,,,,,,fee schedule,6709.77,6709.77, Female Reproductive System Malignancy,5302,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,6709.77,,,,,,,fee schedule,6709.77,6709.77, Female Reproductive System Malignancy,5302,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,6709.77,,,,,,,fee schedule,6709.77,6709.77, Female Reproductive System Malignancy,5302,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,6709.77,,,,,,,fee schedule,6709.77,6709.77, Female Reproductive System Malignancy,5302,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,6709.77,,,,,,,fee schedule,6709.77,6709.77, Female Reproductive System Malignancy,5302,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,6709.77,,,,,,,fee schedule,6709.77,6709.77, Female Reproductive System Malignancy,5302,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,6709.77,,,,,,,fee schedule,6709.77,6709.77, Female Reproductive System Malignancy,5302,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,6709.77,,,,,,,fee schedule,6709.77,6709.77, Female Reproductive System Malignancy,5302,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,6709.77,,,,,,,fee schedule,6709.77,6709.77, Female Reproductive System Malignancy,5303,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,10292.26,,,,,,,fee schedule,10292.26,10292.26, Female Reproductive System Malignancy,5303,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,10292.26,,,,,,,fee schedule,10292.26,10292.26, Female Reproductive System Malignancy,5303,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,10292.26,,,,,,,fee schedule,10292.26,10292.26, Female Reproductive System Malignancy,5303,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,10292.26,,,,,,,fee schedule,10292.26,10292.26, Female Reproductive System Malignancy,5303,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,10292.26,,,,,,,fee schedule,10292.26,10292.26, Female Reproductive System Malignancy,5303,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,10292.26,,,,,,,fee schedule,10292.26,10292.26, Female Reproductive System Malignancy,5303,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,10292.26,,,,,,,fee schedule,10292.26,10292.26, Female Reproductive System Malignancy,5303,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,10292.26,,,,,,,fee schedule,10292.26,10292.26, Female Reproductive System Malignancy,5303,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,10292.26,,,,,,,fee schedule,10292.26,10292.26, Female Reproductive System Malignancy,5303,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,10292.26,,,,,,,fee schedule,10292.26,10292.26, Female Reproductive System Malignancy,5303,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,10292.26,,,,,,,fee schedule,10292.26,10292.26, Female Reproductive System Malignancy,5304,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,16282.14,,,,,,,fee schedule,16282.14,16282.14, Female Reproductive System Malignancy,5304,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,16282.14,,,,,,,fee schedule,16282.14,16282.14, Female Reproductive System Malignancy,5304,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,16282.14,,,,,,,fee schedule,16282.14,16282.14, Female Reproductive System Malignancy,5304,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,16282.14,,,,,,,fee schedule,16282.14,16282.14, Female Reproductive System Malignancy,5304,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,16282.14,,,,,,,fee schedule,16282.14,16282.14, Female Reproductive System Malignancy,5304,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,16282.14,,,,,,,fee schedule,16282.14,16282.14, Female Reproductive System Malignancy,5304,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,16282.14,,,,,,,fee schedule,16282.14,16282.14, Female Reproductive System Malignancy,5304,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,16282.14,,,,,,,fee schedule,16282.14,16282.14, Female Reproductive System Malignancy,5304,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,16282.14,,,,,,,fee schedule,16282.14,16282.14, Female Reproductive System Malignancy,5304,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,16282.14,,,,,,,fee schedule,16282.14,16282.14, Female Reproductive System Malignancy,5304,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,16282.14,,,,,,,fee schedule,16282.14,16282.14, Female Reproductive System Infections,5311,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,3945.97,,,,,,,fee schedule,3945.97,3945.97, Female Reproductive System Infections,5311,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,3945.97,,,,,,,fee schedule,3945.97,3945.97, Female Reproductive System Infections,5311,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,3945.97,,,,,,,fee schedule,3945.97,3945.97, Female Reproductive System Infections,5311,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,3945.97,,,,,,,fee schedule,3945.97,3945.97, Female Reproductive System Infections,5311,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,3945.97,,,,,,,fee schedule,3945.97,3945.97, Female Reproductive System Infections,5311,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,3945.97,,,,,,,fee schedule,3945.97,3945.97, Female Reproductive System Infections,5311,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,3945.97,,,,,,,fee schedule,3945.97,3945.97, Female Reproductive System Infections,5311,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,3945.97,,,,,,,fee schedule,3945.97,3945.97, Female Reproductive System Infections,5311,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,3945.97,,,,,,,fee schedule,3945.97,3945.97, Female Reproductive System Infections,5311,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,3945.97,,,,,,,fee schedule,3945.97,3945.97, Female Reproductive System Infections,5311,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,3945.97,,,,,,,fee schedule,3945.97,3945.97, Female Reproductive System Infections,5312,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5206.47,,,,,,,fee schedule,5206.47,5206.47, Female Reproductive System Infections,5312,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5206.47,,,,,,,fee schedule,5206.47,5206.47, Female Reproductive System Infections,5312,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5206.47,,,,,,,fee schedule,5206.47,5206.47, Female Reproductive System Infections,5312,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5206.47,,,,,,,fee schedule,5206.47,5206.47, Female Reproductive System Infections,5312,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5206.47,,,,,,,fee schedule,5206.47,5206.47, Female Reproductive System Infections,5312,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5206.47,,,,,,,fee schedule,5206.47,5206.47, Female Reproductive System Infections,5312,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5206.47,,,,,,,fee schedule,5206.47,5206.47, Female Reproductive System Infections,5312,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5206.47,,,,,,,fee schedule,5206.47,5206.47, Female Reproductive System Infections,5312,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5206.47,,,,,,,fee schedule,5206.47,5206.47, Female Reproductive System Infections,5312,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5206.47,,,,,,,fee schedule,5206.47,5206.47, Female Reproductive System Infections,5312,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5206.47,,,,,,,fee schedule,5206.47,5206.47, Female Reproductive System Infections,5313,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,8736.04,,,,,,,fee schedule,8736.04,8736.04, Female Reproductive System Infections,5313,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,8736.04,,,,,,,fee schedule,8736.04,8736.04, Female Reproductive System Infections,5313,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,8736.04,,,,,,,fee schedule,8736.04,8736.04, Female Reproductive System Infections,5313,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,8736.04,,,,,,,fee schedule,8736.04,8736.04, Female Reproductive System Infections,5313,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,8736.04,,,,,,,fee schedule,8736.04,8736.04, Female Reproductive System Infections,5313,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,8736.04,,,,,,,fee schedule,8736.04,8736.04, Female Reproductive System Infections,5313,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,8736.04,,,,,,,fee schedule,8736.04,8736.04, Female Reproductive System Infections,5313,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,8736.04,,,,,,,fee schedule,8736.04,8736.04, Female Reproductive System Infections,5313,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,8736.04,,,,,,,fee schedule,8736.04,8736.04, Female Reproductive System Infections,5313,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,8736.04,,,,,,,fee schedule,8736.04,8736.04, Female Reproductive System Infections,5313,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,8736.04,,,,,,,fee schedule,8736.04,8736.04, Female Reproductive System Infections,5314,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,16197.45,,,,,,,fee schedule,16197.45,16197.45, Female Reproductive System Infections,5314,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,16197.45,,,,,,,fee schedule,16197.45,16197.45, Female Reproductive System Infections,5314,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,16197.45,,,,,,,fee schedule,16197.45,16197.45, Female Reproductive System Infections,5314,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,16197.45,,,,,,,fee schedule,16197.45,16197.45, Female Reproductive System Infections,5314,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,16197.45,,,,,,,fee schedule,16197.45,16197.45, Female Reproductive System Infections,5314,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,16197.45,,,,,,,fee schedule,16197.45,16197.45, Female Reproductive System Infections,5314,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,16197.45,,,,,,,fee schedule,16197.45,16197.45, Female Reproductive System Infections,5314,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,16197.45,,,,,,,fee schedule,16197.45,16197.45, Female Reproductive System Infections,5314,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,16197.45,,,,,,,fee schedule,16197.45,16197.45, Female Reproductive System Infections,5314,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,16197.45,,,,,,,fee schedule,16197.45,16197.45, Female Reproductive System Infections,5314,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,16197.45,,,,,,,fee schedule,16197.45,16197.45, Menstrual And Other Female Reproductive System Disorders,5321,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,3876.1,,,,,,,fee schedule,3876.1,3876.1, Menstrual And Other Female Reproductive System Disorders,5321,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,3876.1,,,,,,,fee schedule,3876.1,3876.1, Menstrual And Other Female Reproductive System Disorders,5321,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,3876.1,,,,,,,fee schedule,3876.1,3876.1, Menstrual And Other Female Reproductive System Disorders,5321,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,3876.1,,,,,,,fee schedule,3876.1,3876.1, Menstrual And Other Female Reproductive System Disorders,5321,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,3876.1,,,,,,,fee schedule,3876.1,3876.1, Menstrual And Other Female Reproductive System Disorders,5321,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,3876.1,,,,,,,fee schedule,3876.1,3876.1, Menstrual And Other Female Reproductive System Disorders,5321,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,3876.1,,,,,,,fee schedule,3876.1,3876.1, Menstrual And Other Female Reproductive System Disorders,5321,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,3876.1,,,,,,,fee schedule,3876.1,3876.1, Menstrual And Other Female Reproductive System Disorders,5321,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,3876.1,,,,,,,fee schedule,3876.1,3876.1, Menstrual And Other Female Reproductive System Disorders,5321,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,3876.1,,,,,,,fee schedule,3876.1,3876.1, Menstrual And Other Female Reproductive System Disorders,5321,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,3876.1,,,,,,,fee schedule,3876.1,3876.1, Menstrual And Other Female Reproductive System Disorders,5322,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5142.25,,,,,,,fee schedule,5142.25,5142.25, Menstrual And Other Female Reproductive System Disorders,5322,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5142.25,,,,,,,fee schedule,5142.25,5142.25, Menstrual And Other Female Reproductive System Disorders,5322,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5142.25,,,,,,,fee schedule,5142.25,5142.25, Menstrual And Other Female Reproductive System Disorders,5322,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5142.25,,,,,,,fee schedule,5142.25,5142.25, Menstrual And Other Female Reproductive System Disorders,5322,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5142.25,,,,,,,fee schedule,5142.25,5142.25, Menstrual And Other Female Reproductive System Disorders,5322,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5142.25,,,,,,,fee schedule,5142.25,5142.25, Menstrual And Other Female Reproductive System Disorders,5322,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5142.25,,,,,,,fee schedule,5142.25,5142.25, Menstrual And Other Female Reproductive System Disorders,5322,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5142.25,,,,,,,fee schedule,5142.25,5142.25, Menstrual And Other Female Reproductive System Disorders,5322,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5142.25,,,,,,,fee schedule,5142.25,5142.25, Menstrual And Other Female Reproductive System Disorders,5322,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5142.25,,,,,,,fee schedule,5142.25,5142.25, Menstrual And Other Female Reproductive System Disorders,5322,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5142.25,,,,,,,fee schedule,5142.25,5142.25, Menstrual And Other Female Reproductive System Disorders,5323,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,7215.1,,,,,,,fee schedule,7215.1,7215.1, Menstrual And Other Female Reproductive System Disorders,5323,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,7215.1,,,,,,,fee schedule,7215.1,7215.1, Menstrual And Other Female Reproductive System Disorders,5323,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,7215.1,,,,,,,fee schedule,7215.1,7215.1, Menstrual And Other Female Reproductive System Disorders,5323,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,7215.1,,,,,,,fee schedule,7215.1,7215.1, Menstrual And Other Female Reproductive System Disorders,5323,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,7215.1,,,,,,,fee schedule,7215.1,7215.1, Menstrual And Other Female Reproductive System Disorders,5323,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,7215.1,,,,,,,fee schedule,7215.1,7215.1, Menstrual And Other Female Reproductive System Disorders,5323,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,7215.1,,,,,,,fee schedule,7215.1,7215.1, Menstrual And Other Female Reproductive System Disorders,5323,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,7215.1,,,,,,,fee schedule,7215.1,7215.1, Menstrual And Other Female Reproductive System Disorders,5323,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,7215.1,,,,,,,fee schedule,7215.1,7215.1, Menstrual And Other Female Reproductive System Disorders,5323,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,7215.1,,,,,,,fee schedule,7215.1,7215.1, Menstrual And Other Female Reproductive System Disorders,5323,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,7215.1,,,,,,,fee schedule,7215.1,7215.1, Menstrual And Other Female Reproductive System Disorders,5324,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,11588.76,,,,,,,fee schedule,11588.76,11588.76, Menstrual And Other Female Reproductive System Disorders,5324,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,11588.76,,,,,,,fee schedule,11588.76,11588.76, Menstrual And Other Female Reproductive System Disorders,5324,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,11588.76,,,,,,,fee schedule,11588.76,11588.76, Menstrual And Other Female Reproductive System Disorders,5324,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,11588.76,,,,,,,fee schedule,11588.76,11588.76, Menstrual And Other Female Reproductive System Disorders,5324,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,11588.76,,,,,,,fee schedule,11588.76,11588.76, Menstrual And Other Female Reproductive System Disorders,5324,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,11588.76,,,,,,,fee schedule,11588.76,11588.76, Menstrual And Other Female Reproductive System Disorders,5324,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,11588.76,,,,,,,fee schedule,11588.76,11588.76, Menstrual And Other Female Reproductive System Disorders,5324,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,11588.76,,,,,,,fee schedule,11588.76,11588.76, Menstrual And Other Female Reproductive System Disorders,5324,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,11588.76,,,,,,,fee schedule,11588.76,11588.76, Menstrual And Other Female Reproductive System Disorders,5324,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,11588.76,,,,,,,fee schedule,11588.76,11588.76, Menstrual And Other Female Reproductive System Disorders,5324,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,11588.76,,,,,,,fee schedule,11588.76,11588.76, Cesarean Section With Sterilization,5391,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4291.8,,,,,,,fee schedule,4291.8,4291.8, Cesarean Section With Sterilization,5391,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4291.8,,,,,,,fee schedule,4291.8,4291.8, Cesarean Section With Sterilization,5391,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4291.8,,,,,,,fee schedule,4291.8,4291.8, Cesarean Section With Sterilization,5391,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4291.8,,,,,,,fee schedule,4291.8,4291.8, Cesarean Section With Sterilization,5391,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4291.8,,,,,,,fee schedule,4291.8,4291.8, Cesarean Section With Sterilization,5391,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4291.8,,,,,,,fee schedule,4291.8,4291.8, Cesarean Section With Sterilization,5391,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4291.8,,,,,,,fee schedule,4291.8,4291.8, Cesarean Section With Sterilization,5391,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4291.8,,,,,,,fee schedule,4291.8,4291.8, Cesarean Section With Sterilization,5391,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4291.8,,,,,,,fee schedule,4291.8,4291.8, Cesarean Section With Sterilization,5391,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4291.8,,,,,,,fee schedule,4291.8,4291.8, Cesarean Section With Sterilization,5391,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4291.8,,,,,,,fee schedule,4291.8,4291.8, Cesarean Section With Sterilization,5392,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5601,,,,,,,fee schedule,5601,5601, Cesarean Section With Sterilization,5392,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5601,,,,,,,fee schedule,5601,5601, Cesarean Section With Sterilization,5392,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5601,,,,,,,fee schedule,5601,5601, Cesarean Section With Sterilization,5392,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5601,,,,,,,fee schedule,5601,5601, Cesarean Section With Sterilization,5392,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5601,,,,,,,fee schedule,5601,5601, Cesarean Section With Sterilization,5392,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5601,,,,,,,fee schedule,5601,5601, Cesarean Section With Sterilization,5392,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5601,,,,,,,fee schedule,5601,5601, Cesarean Section With Sterilization,5392,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5601,,,,,,,fee schedule,5601,5601, Cesarean Section With Sterilization,5392,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5601,,,,,,,fee schedule,5601,5601, Cesarean Section With Sterilization,5392,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5601,,,,,,,fee schedule,5601,5601, Cesarean Section With Sterilization,5392,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5601,,,,,,,fee schedule,5601,5601, Cesarean Section With Sterilization,5393,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,11398.18,,,,,,,fee schedule,11398.18,11398.18, Cesarean Section With Sterilization,5393,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,11398.18,,,,,,,fee schedule,11398.18,11398.18, Cesarean Section With Sterilization,5393,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,11398.18,,,,,,,fee schedule,11398.18,11398.18, Cesarean Section With Sterilization,5393,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,11398.18,,,,,,,fee schedule,11398.18,11398.18, Cesarean Section With Sterilization,5393,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,11398.18,,,,,,,fee schedule,11398.18,11398.18, Cesarean Section With Sterilization,5393,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,11398.18,,,,,,,fee schedule,11398.18,11398.18, Cesarean Section With Sterilization,5393,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,11398.18,,,,,,,fee schedule,11398.18,11398.18, Cesarean Section With Sterilization,5393,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,11398.18,,,,,,,fee schedule,11398.18,11398.18, Cesarean Section With Sterilization,5393,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,11398.18,,,,,,,fee schedule,11398.18,11398.18, Cesarean Section With Sterilization,5393,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,11398.18,,,,,,,fee schedule,11398.18,11398.18, Cesarean Section With Sterilization,5393,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,11398.18,,,,,,,fee schedule,11398.18,11398.18, Cesarean Section With Sterilization,5394,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,25339.59,,,,,,,fee schedule,25339.59,25339.59, Cesarean Section With Sterilization,5394,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,25339.59,,,,,,,fee schedule,25339.59,25339.59, Cesarean Section With Sterilization,5394,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,25339.59,,,,,,,fee schedule,25339.59,25339.59, Cesarean Section With Sterilization,5394,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,25339.59,,,,,,,fee schedule,25339.59,25339.59, Cesarean Section With Sterilization,5394,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,25339.59,,,,,,,fee schedule,25339.59,25339.59, Cesarean Section With Sterilization,5394,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,25339.59,,,,,,,fee schedule,25339.59,25339.59, Cesarean Section With Sterilization,5394,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,25339.59,,,,,,,fee schedule,25339.59,25339.59, Cesarean Section With Sterilization,5394,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,25339.59,,,,,,,fee schedule,25339.59,25339.59, Cesarean Section With Sterilization,5394,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,25339.59,,,,,,,fee schedule,25339.59,25339.59, Cesarean Section With Sterilization,5394,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,25339.59,,,,,,,fee schedule,25339.59,25339.59, Cesarean Section With Sterilization,5394,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,25339.59,,,,,,,fee schedule,25339.59,25339.59, Cesarean Section Without Sterilization,5401,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4276.97,,,,,,,fee schedule,4276.97,4276.97, Cesarean Section Without Sterilization,5401,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4276.97,,,,,,,fee schedule,4276.97,4276.97, Cesarean Section Without Sterilization,5401,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4276.97,,,,,,,fee schedule,4276.97,4276.97, Cesarean Section Without Sterilization,5401,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4276.97,,,,,,,fee schedule,4276.97,4276.97, Cesarean Section Without Sterilization,5401,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4276.97,,,,,,,fee schedule,4276.97,4276.97, Cesarean Section Without Sterilization,5401,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4276.97,,,,,,,fee schedule,4276.97,4276.97, Cesarean Section Without Sterilization,5401,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4276.97,,,,,,,fee schedule,4276.97,4276.97, Cesarean Section Without Sterilization,5401,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4276.97,,,,,,,fee schedule,4276.97,4276.97, Cesarean Section Without Sterilization,5401,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4276.97,,,,,,,fee schedule,4276.97,4276.97, Cesarean Section Without Sterilization,5401,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4276.97,,,,,,,fee schedule,4276.97,4276.97, Cesarean Section Without Sterilization,5401,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4276.97,,,,,,,fee schedule,4276.97,4276.97, Cesarean Section Without Sterilization,5402,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5465.49,,,,,,,fee schedule,5465.49,5465.49, Cesarean Section Without Sterilization,5402,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5465.49,,,,,,,fee schedule,5465.49,5465.49, Cesarean Section Without Sterilization,5402,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5465.49,,,,,,,fee schedule,5465.49,5465.49, Cesarean Section Without Sterilization,5402,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5465.49,,,,,,,fee schedule,5465.49,5465.49, Cesarean Section Without Sterilization,5402,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5465.49,,,,,,,fee schedule,5465.49,5465.49, Cesarean Section Without Sterilization,5402,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5465.49,,,,,,,fee schedule,5465.49,5465.49, Cesarean Section Without Sterilization,5402,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5465.49,,,,,,,fee schedule,5465.49,5465.49, Cesarean Section Without Sterilization,5402,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5465.49,,,,,,,fee schedule,5465.49,5465.49, Cesarean Section Without Sterilization,5402,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5465.49,,,,,,,fee schedule,5465.49,5465.49, Cesarean Section Without Sterilization,5402,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5465.49,,,,,,,fee schedule,5465.49,5465.49, Cesarean Section Without Sterilization,5402,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5465.49,,,,,,,fee schedule,5465.49,5465.49, Cesarean Section Without Sterilization,5403,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,8620.79,,,,,,,fee schedule,8620.79,8620.79, Cesarean Section Without Sterilization,5403,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,8620.79,,,,,,,fee schedule,8620.79,8620.79, Cesarean Section Without Sterilization,5403,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,8620.79,,,,,,,fee schedule,8620.79,8620.79, Cesarean Section Without Sterilization,5403,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,8620.79,,,,,,,fee schedule,8620.79,8620.79, Cesarean Section Without Sterilization,5403,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,8620.79,,,,,,,fee schedule,8620.79,8620.79, Cesarean Section Without Sterilization,5403,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,8620.79,,,,,,,fee schedule,8620.79,8620.79, Cesarean Section Without Sterilization,5403,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,8620.79,,,,,,,fee schedule,8620.79,8620.79, Cesarean Section Without Sterilization,5403,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,8620.79,,,,,,,fee schedule,8620.79,8620.79, Cesarean Section Without Sterilization,5403,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,8620.79,,,,,,,fee schedule,8620.79,8620.79, Cesarean Section Without Sterilization,5403,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,8620.79,,,,,,,fee schedule,8620.79,8620.79, Cesarean Section Without Sterilization,5403,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,8620.79,,,,,,,fee schedule,8620.79,8620.79, Cesarean Section Without Sterilization,5404,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,22010.06,,,,,,,fee schedule,22010.06,22010.06, Cesarean Section Without Sterilization,5404,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,22010.06,,,,,,,fee schedule,22010.06,22010.06, Cesarean Section Without Sterilization,5404,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,22010.06,,,,,,,fee schedule,22010.06,22010.06, Cesarean Section Without Sterilization,5404,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,22010.06,,,,,,,fee schedule,22010.06,22010.06, Cesarean Section Without Sterilization,5404,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,22010.06,,,,,,,fee schedule,22010.06,22010.06, Cesarean Section Without Sterilization,5404,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,22010.06,,,,,,,fee schedule,22010.06,22010.06, Cesarean Section Without Sterilization,5404,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,22010.06,,,,,,,fee schedule,22010.06,22010.06, Cesarean Section Without Sterilization,5404,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,22010.06,,,,,,,fee schedule,22010.06,22010.06, Cesarean Section Without Sterilization,5404,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,22010.06,,,,,,,fee schedule,22010.06,22010.06, Cesarean Section Without Sterilization,5404,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,22010.06,,,,,,,fee schedule,22010.06,22010.06, Cesarean Section Without Sterilization,5404,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,22010.06,,,,,,,fee schedule,22010.06,22010.06, Vaginal Delivery With Sterilization And/Or D&C,5411,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4247.33,,,,,,,fee schedule,4247.33,4247.33, Vaginal Delivery With Sterilization And/Or D&C,5411,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4247.33,,,,,,,fee schedule,4247.33,4247.33, Vaginal Delivery With Sterilization And/Or D&C,5411,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4247.33,,,,,,,fee schedule,4247.33,4247.33, Vaginal Delivery With Sterilization And/Or D&C,5411,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4247.33,,,,,,,fee schedule,4247.33,4247.33, Vaginal Delivery With Sterilization And/Or D&C,5411,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4247.33,,,,,,,fee schedule,4247.33,4247.33, Vaginal Delivery With Sterilization And/Or D&C,5411,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4247.33,,,,,,,fee schedule,4247.33,4247.33, Vaginal Delivery With Sterilization And/Or D&C,5411,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4247.33,,,,,,,fee schedule,4247.33,4247.33, Vaginal Delivery With Sterilization And/Or D&C,5411,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4247.33,,,,,,,fee schedule,4247.33,4247.33, Vaginal Delivery With Sterilization And/Or D&C,5411,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4247.33,,,,,,,fee schedule,4247.33,4247.33, Vaginal Delivery With Sterilization And/Or D&C,5411,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4247.33,,,,,,,fee schedule,4247.33,4247.33, Vaginal Delivery With Sterilization And/Or D&C,5411,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4247.33,,,,,,,fee schedule,4247.33,4247.33, Vaginal Delivery With Sterilization And/Or D&C,5412,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4722.32,,,,,,,fee schedule,4722.32,4722.32, Vaginal Delivery With Sterilization And/Or D&C,5412,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4722.32,,,,,,,fee schedule,4722.32,4722.32, Vaginal Delivery With Sterilization And/Or D&C,5412,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4722.32,,,,,,,fee schedule,4722.32,4722.32, Vaginal Delivery With Sterilization And/Or D&C,5412,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4722.32,,,,,,,fee schedule,4722.32,4722.32, Vaginal Delivery With Sterilization And/Or D&C,5412,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4722.32,,,,,,,fee schedule,4722.32,4722.32, Vaginal Delivery With Sterilization And/Or D&C,5412,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4722.32,,,,,,,fee schedule,4722.32,4722.32, Vaginal Delivery With Sterilization And/Or D&C,5412,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4722.32,,,,,,,fee schedule,4722.32,4722.32, Vaginal Delivery With Sterilization And/Or D&C,5412,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4722.32,,,,,,,fee schedule,4722.32,4722.32, Vaginal Delivery With Sterilization And/Or D&C,5412,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4722.32,,,,,,,fee schedule,4722.32,4722.32, Vaginal Delivery With Sterilization And/Or D&C,5412,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4722.32,,,,,,,fee schedule,4722.32,4722.32, Vaginal Delivery With Sterilization And/Or D&C,5412,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4722.32,,,,,,,fee schedule,4722.32,4722.32, Vaginal Delivery With Sterilization And/Or D&C,5413,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,7259.34,,,,,,,fee schedule,7259.34,7259.34, Vaginal Delivery With Sterilization And/Or D&C,5413,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,7259.34,,,,,,,fee schedule,7259.34,7259.34, Vaginal Delivery With Sterilization And/Or D&C,5413,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,7259.34,,,,,,,fee schedule,7259.34,7259.34, Vaginal Delivery With Sterilization And/Or D&C,5413,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,7259.34,,,,,,,fee schedule,7259.34,7259.34, Vaginal Delivery With Sterilization And/Or D&C,5413,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,7259.34,,,,,,,fee schedule,7259.34,7259.34, Vaginal Delivery With Sterilization And/Or D&C,5413,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,7259.34,,,,,,,fee schedule,7259.34,7259.34, Vaginal Delivery With Sterilization And/Or D&C,5413,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,7259.34,,,,,,,fee schedule,7259.34,7259.34, Vaginal Delivery With Sterilization And/Or D&C,5413,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,7259.34,,,,,,,fee schedule,7259.34,7259.34, Vaginal Delivery With Sterilization And/Or D&C,5413,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,7259.34,,,,,,,fee schedule,7259.34,7259.34, Vaginal Delivery With Sterilization And/Or D&C,5413,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,7259.34,,,,,,,fee schedule,7259.34,7259.34, Vaginal Delivery With Sterilization And/Or D&C,5413,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,7259.34,,,,,,,fee schedule,7259.34,7259.34, Vaginal Delivery With Sterilization And/Or D&C,5414,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,17214.04,,,,,,,fee schedule,17214.04,17214.04, Vaginal Delivery With Sterilization And/Or D&C,5414,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,17214.04,,,,,,,fee schedule,17214.04,17214.04, Vaginal Delivery With Sterilization And/Or D&C,5414,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,17214.04,,,,,,,fee schedule,17214.04,17214.04, Vaginal Delivery With Sterilization And/Or D&C,5414,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,17214.04,,,,,,,fee schedule,17214.04,17214.04, Vaginal Delivery With Sterilization And/Or D&C,5414,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,17214.04,,,,,,,fee schedule,17214.04,17214.04, Vaginal Delivery With Sterilization And/Or D&C,5414,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,17214.04,,,,,,,fee schedule,17214.04,17214.04, Vaginal Delivery With Sterilization And/Or D&C,5414,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,17214.04,,,,,,,fee schedule,17214.04,17214.04, Vaginal Delivery With Sterilization And/Or D&C,5414,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,17214.04,,,,,,,fee schedule,17214.04,17214.04, Vaginal Delivery With Sterilization And/Or D&C,5414,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,17214.04,,,,,,,fee schedule,17214.04,17214.04, Vaginal Delivery With Sterilization And/Or D&C,5414,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,17214.04,,,,,,,fee schedule,17214.04,17214.04, Vaginal Delivery With Sterilization And/Or D&C,5414,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,17214.04,,,,,,,fee schedule,17214.04,17214.04, Vaginal Delivery With O.R. Procedure Except Sterilization And/Or D&C,5421,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,2900.01,,,,,,,fee schedule,2900.01,2900.01, Vaginal Delivery With O.R. Procedure Except Sterilization And/Or D&C,5421,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,2900.01,,,,,,,fee schedule,2900.01,2900.01, Vaginal Delivery With O.R. Procedure Except Sterilization And/Or D&C,5421,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,2900.01,,,,,,,fee schedule,2900.01,2900.01, Vaginal Delivery With O.R. Procedure Except Sterilization And/Or D&C,5421,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,2900.01,,,,,,,fee schedule,2900.01,2900.01, Vaginal Delivery With O.R. Procedure Except Sterilization And/Or D&C,5421,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,2900.01,,,,,,,fee schedule,2900.01,2900.01, Vaginal Delivery With O.R. Procedure Except Sterilization And/Or D&C,5421,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,2900.01,,,,,,,fee schedule,2900.01,2900.01, Vaginal Delivery With O.R. Procedure Except Sterilization And/Or D&C,5421,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,2900.01,,,,,,,fee schedule,2900.01,2900.01, Vaginal Delivery With O.R. Procedure Except Sterilization And/Or D&C,5421,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,2900.01,,,,,,,fee schedule,2900.01,2900.01, Vaginal Delivery With O.R. Procedure Except Sterilization And/Or D&C,5421,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,2900.01,,,,,,,fee schedule,2900.01,2900.01, Vaginal Delivery With O.R. Procedure Except Sterilization And/Or D&C,5421,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,2900.01,,,,,,,fee schedule,2900.01,2900.01, Vaginal Delivery With O.R. Procedure Except Sterilization And/Or D&C,5421,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,2900.01,,,,,,,fee schedule,2900.01,2900.01, Vaginal Delivery With O.R. Procedure Except Sterilization And/Or D&C,5422,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,3541.56,,,,,,,fee schedule,3541.56,3541.56, Vaginal Delivery With O.R. Procedure Except Sterilization And/Or D&C,5422,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,3541.56,,,,,,,fee schedule,3541.56,3541.56, Vaginal Delivery With O.R. Procedure Except Sterilization And/Or D&C,5422,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,3541.56,,,,,,,fee schedule,3541.56,3541.56, Vaginal Delivery With O.R. Procedure Except Sterilization And/Or D&C,5422,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,3541.56,,,,,,,fee schedule,3541.56,3541.56, Vaginal Delivery With O.R. Procedure Except Sterilization And/Or D&C,5422,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,3541.56,,,,,,,fee schedule,3541.56,3541.56, Vaginal Delivery With O.R. Procedure Except Sterilization And/Or D&C,5422,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,3541.56,,,,,,,fee schedule,3541.56,3541.56, Vaginal Delivery With O.R. Procedure Except Sterilization And/Or D&C,5422,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,3541.56,,,,,,,fee schedule,3541.56,3541.56, Vaginal Delivery With O.R. Procedure Except Sterilization And/Or D&C,5422,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,3541.56,,,,,,,fee schedule,3541.56,3541.56, Vaginal Delivery With O.R. Procedure Except Sterilization And/Or D&C,5422,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,3541.56,,,,,,,fee schedule,3541.56,3541.56, Vaginal Delivery With O.R. Procedure Except Sterilization And/Or D&C,5422,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,3541.56,,,,,,,fee schedule,3541.56,3541.56, Vaginal Delivery With O.R. Procedure Except Sterilization And/Or D&C,5422,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,3541.56,,,,,,,fee schedule,3541.56,3541.56, Vaginal Delivery With O.R. Procedure Except Sterilization And/Or D&C,5423,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,6947.14,,,,,,,fee schedule,6947.14,6947.14, Vaginal Delivery With O.R. Procedure Except Sterilization And/Or D&C,5423,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,6947.14,,,,,,,fee schedule,6947.14,6947.14, Vaginal Delivery With O.R. Procedure Except Sterilization And/Or D&C,5423,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,6947.14,,,,,,,fee schedule,6947.14,6947.14, Vaginal Delivery With O.R. Procedure Except Sterilization And/Or D&C,5423,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,6947.14,,,,,,,fee schedule,6947.14,6947.14, Vaginal Delivery With O.R. Procedure Except Sterilization And/Or D&C,5423,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,6947.14,,,,,,,fee schedule,6947.14,6947.14, Vaginal Delivery With O.R. Procedure Except Sterilization And/Or D&C,5423,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,6947.14,,,,,,,fee schedule,6947.14,6947.14, Vaginal Delivery With O.R. Procedure Except Sterilization And/Or D&C,5423,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,6947.14,,,,,,,fee schedule,6947.14,6947.14, Vaginal Delivery With O.R. Procedure Except Sterilization And/Or D&C,5423,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,6947.14,,,,,,,fee schedule,6947.14,6947.14, Vaginal Delivery With O.R. Procedure Except Sterilization And/Or D&C,5423,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,6947.14,,,,,,,fee schedule,6947.14,6947.14, Vaginal Delivery With O.R. Procedure Except Sterilization And/Or D&C,5423,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,6947.14,,,,,,,fee schedule,6947.14,6947.14, Vaginal Delivery With O.R. Procedure Except Sterilization And/Or D&C,5423,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,6947.14,,,,,,,fee schedule,6947.14,6947.14, Vaginal Delivery With O.R. Procedure Except Sterilization And/Or D&C,5424,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,22014.3,,,,,,,fee schedule,22014.3,22014.3, Vaginal Delivery With O.R. Procedure Except Sterilization And/Or D&C,5424,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,22014.3,,,,,,,fee schedule,22014.3,22014.3, Vaginal Delivery With O.R. Procedure Except Sterilization And/Or D&C,5424,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,22014.3,,,,,,,fee schedule,22014.3,22014.3, Vaginal Delivery With O.R. Procedure Except Sterilization And/Or D&C,5424,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,22014.3,,,,,,,fee schedule,22014.3,22014.3, Vaginal Delivery With O.R. Procedure Except Sterilization And/Or D&C,5424,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,22014.3,,,,,,,fee schedule,22014.3,22014.3, Vaginal Delivery With O.R. Procedure Except Sterilization And/Or D&C,5424,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,22014.3,,,,,,,fee schedule,22014.3,22014.3, Vaginal Delivery With O.R. Procedure Except Sterilization And/Or D&C,5424,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,22014.3,,,,,,,fee schedule,22014.3,22014.3, Vaginal Delivery With O.R. Procedure Except Sterilization And/Or D&C,5424,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,22014.3,,,,,,,fee schedule,22014.3,22014.3, Vaginal Delivery With O.R. Procedure Except Sterilization And/Or D&C,5424,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,22014.3,,,,,,,fee schedule,22014.3,22014.3, Vaginal Delivery With O.R. Procedure Except Sterilization And/Or D&C,5424,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,22014.3,,,,,,,fee schedule,22014.3,22014.3, Vaginal Delivery With O.R. Procedure Except Sterilization And/Or D&C,5424,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,22014.3,,,,,,,fee schedule,22014.3,22014.3, "Abortion With D&C, Aspiration Curettage Or Hysterotomy",5431,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4206.4,,,,,,,fee schedule,4206.4,4206.4, "Abortion With D&C, Aspiration Curettage Or Hysterotomy",5431,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4206.4,,,,,,,fee schedule,4206.4,4206.4, "Abortion With D&C, Aspiration Curettage Or Hysterotomy",5431,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4206.4,,,,,,,fee schedule,4206.4,4206.4, "Abortion With D&C, Aspiration Curettage Or Hysterotomy",5431,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4206.4,,,,,,,fee schedule,4206.4,4206.4, "Abortion With D&C, Aspiration Curettage Or Hysterotomy",5431,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4206.4,,,,,,,fee schedule,4206.4,4206.4, "Abortion With D&C, Aspiration Curettage Or Hysterotomy",5431,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4206.4,,,,,,,fee schedule,4206.4,4206.4, "Abortion With D&C, Aspiration Curettage Or Hysterotomy",5431,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4206.4,,,,,,,fee schedule,4206.4,4206.4, "Abortion With D&C, Aspiration Curettage Or Hysterotomy",5431,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4206.4,,,,,,,fee schedule,4206.4,4206.4, "Abortion With D&C, Aspiration Curettage Or Hysterotomy",5431,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4206.4,,,,,,,fee schedule,4206.4,4206.4, "Abortion With D&C, Aspiration Curettage Or Hysterotomy",5431,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4206.4,,,,,,,fee schedule,4206.4,4206.4, "Abortion With D&C, Aspiration Curettage Or Hysterotomy",5431,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4206.4,,,,,,,fee schedule,4206.4,4206.4, "Abortion With D&C, Aspiration Curettage Or Hysterotomy",5432,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5344.81,,,,,,,fee schedule,5344.81,5344.81, "Abortion With D&C, Aspiration Curettage Or Hysterotomy",5432,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5344.81,,,,,,,fee schedule,5344.81,5344.81, "Abortion With D&C, Aspiration Curettage Or Hysterotomy",5432,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5344.81,,,,,,,fee schedule,5344.81,5344.81, "Abortion With D&C, Aspiration Curettage Or Hysterotomy",5432,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5344.81,,,,,,,fee schedule,5344.81,5344.81, "Abortion With D&C, Aspiration Curettage Or Hysterotomy",5432,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5344.81,,,,,,,fee schedule,5344.81,5344.81, "Abortion With D&C, Aspiration Curettage Or Hysterotomy",5432,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5344.81,,,,,,,fee schedule,5344.81,5344.81, "Abortion With D&C, Aspiration Curettage Or Hysterotomy",5432,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5344.81,,,,,,,fee schedule,5344.81,5344.81, "Abortion With D&C, Aspiration Curettage Or Hysterotomy",5432,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5344.81,,,,,,,fee schedule,5344.81,5344.81, "Abortion With D&C, Aspiration Curettage Or Hysterotomy",5432,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5344.81,,,,,,,fee schedule,5344.81,5344.81, "Abortion With D&C, Aspiration Curettage Or Hysterotomy",5432,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5344.81,,,,,,,fee schedule,5344.81,5344.81, "Abortion With D&C, Aspiration Curettage Or Hysterotomy",5432,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5344.81,,,,,,,fee schedule,5344.81,5344.81, "Abortion With D&C, Aspiration Curettage Or Hysterotomy",5433,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,9070.68,,,,,,,fee schedule,9070.68,9070.68, "Abortion With D&C, Aspiration Curettage Or Hysterotomy",5433,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,9070.68,,,,,,,fee schedule,9070.68,9070.68, "Abortion With D&C, Aspiration Curettage Or Hysterotomy",5433,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,9070.68,,,,,,,fee schedule,9070.68,9070.68, "Abortion With D&C, Aspiration Curettage Or Hysterotomy",5433,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,9070.68,,,,,,,fee schedule,9070.68,9070.68, "Abortion With D&C, Aspiration Curettage Or Hysterotomy",5433,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,9070.68,,,,,,,fee schedule,9070.68,9070.68, "Abortion With D&C, Aspiration Curettage Or Hysterotomy",5433,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,9070.68,,,,,,,fee schedule,9070.68,9070.68, "Abortion With D&C, Aspiration Curettage Or Hysterotomy",5433,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,9070.68,,,,,,,fee schedule,9070.68,9070.68, "Abortion With D&C, Aspiration Curettage Or Hysterotomy",5433,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,9070.68,,,,,,,fee schedule,9070.68,9070.68, "Abortion With D&C, Aspiration Curettage Or Hysterotomy",5433,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,9070.68,,,,,,,fee schedule,9070.68,9070.68, "Abortion With D&C, Aspiration Curettage Or Hysterotomy",5433,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,9070.68,,,,,,,fee schedule,9070.68,9070.68, "Abortion With D&C, Aspiration Curettage Or Hysterotomy",5433,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,9070.68,,,,,,,fee schedule,9070.68,9070.68, "Abortion With D&C, Aspiration Curettage Or Hysterotomy",5434,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,20121.54,,,,,,,fee schedule,20121.54,20121.54, "Abortion With D&C, Aspiration Curettage Or Hysterotomy",5434,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,20121.54,,,,,,,fee schedule,20121.54,20121.54, "Abortion With D&C, Aspiration Curettage Or Hysterotomy",5434,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,20121.54,,,,,,,fee schedule,20121.54,20121.54, "Abortion With D&C, Aspiration Curettage Or Hysterotomy",5434,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,20121.54,,,,,,,fee schedule,20121.54,20121.54, "Abortion With D&C, Aspiration Curettage Or Hysterotomy",5434,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,20121.54,,,,,,,fee schedule,20121.54,20121.54, "Abortion With D&C, Aspiration Curettage Or Hysterotomy",5434,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,20121.54,,,,,,,fee schedule,20121.54,20121.54, "Abortion With D&C, Aspiration Curettage Or Hysterotomy",5434,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,20121.54,,,,,,,fee schedule,20121.54,20121.54, "Abortion With D&C, Aspiration Curettage Or Hysterotomy",5434,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,20121.54,,,,,,,fee schedule,20121.54,20121.54, "Abortion With D&C, Aspiration Curettage Or Hysterotomy",5434,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,20121.54,,,,,,,fee schedule,20121.54,20121.54, "Abortion With D&C, Aspiration Curettage Or Hysterotomy",5434,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,20121.54,,,,,,,fee schedule,20121.54,20121.54, "Abortion With D&C, Aspiration Curettage Or Hysterotomy",5434,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,20121.54,,,,,,,fee schedule,20121.54,20121.54, Antepartum With O.R. Procedure,5471,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4303.79,,,,,,,fee schedule,4303.79,4303.79, Antepartum With O.R. Procedure,5471,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4303.79,,,,,,,fee schedule,4303.79,4303.79, Antepartum With O.R. Procedure,5471,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4303.79,,,,,,,fee schedule,4303.79,4303.79, Antepartum With O.R. Procedure,5471,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4303.79,,,,,,,fee schedule,4303.79,4303.79, Antepartum With O.R. Procedure,5471,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4303.79,,,,,,,fee schedule,4303.79,4303.79, Antepartum With O.R. Procedure,5471,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4303.79,,,,,,,fee schedule,4303.79,4303.79, Antepartum With O.R. Procedure,5471,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4303.79,,,,,,,fee schedule,4303.79,4303.79, Antepartum With O.R. Procedure,5471,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4303.79,,,,,,,fee schedule,4303.79,4303.79, Antepartum With O.R. Procedure,5471,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4303.79,,,,,,,fee schedule,4303.79,4303.79, Antepartum With O.R. Procedure,5471,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4303.79,,,,,,,fee schedule,4303.79,4303.79, Antepartum With O.R. Procedure,5471,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4303.79,,,,,,,fee schedule,4303.79,4303.79, Antepartum With O.R. Procedure,5472,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,7876.41,,,,,,,fee schedule,7876.41,7876.41, Antepartum With O.R. Procedure,5472,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,7876.41,,,,,,,fee schedule,7876.41,7876.41, Antepartum With O.R. Procedure,5472,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,7876.41,,,,,,,fee schedule,7876.41,7876.41, Antepartum With O.R. Procedure,5472,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,7876.41,,,,,,,fee schedule,7876.41,7876.41, Antepartum With O.R. Procedure,5472,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,7876.41,,,,,,,fee schedule,7876.41,7876.41, Antepartum With O.R. Procedure,5472,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,7876.41,,,,,,,fee schedule,7876.41,7876.41, Antepartum With O.R. Procedure,5472,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,7876.41,,,,,,,fee schedule,7876.41,7876.41, Antepartum With O.R. Procedure,5472,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,7876.41,,,,,,,fee schedule,7876.41,7876.41, Antepartum With O.R. Procedure,5472,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,7876.41,,,,,,,fee schedule,7876.41,7876.41, Antepartum With O.R. Procedure,5472,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,7876.41,,,,,,,fee schedule,7876.41,7876.41, Antepartum With O.R. Procedure,5472,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,7876.41,,,,,,,fee schedule,7876.41,7876.41, Antepartum With O.R. Procedure,5473,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,12858.29,,,,,,,fee schedule,12858.29,12858.29, Antepartum With O.R. Procedure,5473,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,12858.29,,,,,,,fee schedule,12858.29,12858.29, Antepartum With O.R. Procedure,5473,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,12858.29,,,,,,,fee schedule,12858.29,12858.29, Antepartum With O.R. Procedure,5473,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,12858.29,,,,,,,fee schedule,12858.29,12858.29, Antepartum With O.R. Procedure,5473,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,12858.29,,,,,,,fee schedule,12858.29,12858.29, Antepartum With O.R. Procedure,5473,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,12858.29,,,,,,,fee schedule,12858.29,12858.29, Antepartum With O.R. Procedure,5473,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,12858.29,,,,,,,fee schedule,12858.29,12858.29, Antepartum With O.R. Procedure,5473,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,12858.29,,,,,,,fee schedule,12858.29,12858.29, Antepartum With O.R. Procedure,5473,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,12858.29,,,,,,,fee schedule,12858.29,12858.29, Antepartum With O.R. Procedure,5473,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,12858.29,,,,,,,fee schedule,12858.29,12858.29, Antepartum With O.R. Procedure,5473,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,12858.29,,,,,,,fee schedule,12858.29,12858.29, Antepartum With O.R. Procedure,5474,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,28489.95,,,,,,,fee schedule,28489.95,28489.95, Antepartum With O.R. Procedure,5474,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,28489.95,,,,,,,fee schedule,28489.95,28489.95, Antepartum With O.R. Procedure,5474,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,28489.95,,,,,,,fee schedule,28489.95,28489.95, Antepartum With O.R. Procedure,5474,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,28489.95,,,,,,,fee schedule,28489.95,28489.95, Antepartum With O.R. Procedure,5474,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,28489.95,,,,,,,fee schedule,28489.95,28489.95, Antepartum With O.R. Procedure,5474,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,28489.95,,,,,,,fee schedule,28489.95,28489.95, Antepartum With O.R. Procedure,5474,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,28489.95,,,,,,,fee schedule,28489.95,28489.95, Antepartum With O.R. Procedure,5474,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,28489.95,,,,,,,fee schedule,28489.95,28489.95, Antepartum With O.R. Procedure,5474,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,28489.95,,,,,,,fee schedule,28489.95,28489.95, Antepartum With O.R. Procedure,5474,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,28489.95,,,,,,,fee schedule,28489.95,28489.95, Antepartum With O.R. Procedure,5474,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,28489.95,,,,,,,fee schedule,28489.95,28489.95, Postpartum And Post Abortion Diagnosis With O.R. Procedure,5481,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,3332.65,,,,,,,fee schedule,3332.65,3332.65, Postpartum And Post Abortion Diagnosis With O.R. Procedure,5481,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,3332.65,,,,,,,fee schedule,3332.65,3332.65, Postpartum And Post Abortion Diagnosis With O.R. Procedure,5481,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,3332.65,,,,,,,fee schedule,3332.65,3332.65, Postpartum And Post Abortion Diagnosis With O.R. Procedure,5481,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,3332.65,,,,,,,fee schedule,3332.65,3332.65, Postpartum And Post Abortion Diagnosis With O.R. Procedure,5481,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,3332.65,,,,,,,fee schedule,3332.65,3332.65, Postpartum And Post Abortion Diagnosis With O.R. Procedure,5481,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,3332.65,,,,,,,fee schedule,3332.65,3332.65, Postpartum And Post Abortion Diagnosis With O.R. Procedure,5481,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,3332.65,,,,,,,fee schedule,3332.65,3332.65, Postpartum And Post Abortion Diagnosis With O.R. Procedure,5481,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,3332.65,,,,,,,fee schedule,3332.65,3332.65, Postpartum And Post Abortion Diagnosis With O.R. Procedure,5481,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,3332.65,,,,,,,fee schedule,3332.65,3332.65, Postpartum And Post Abortion Diagnosis With O.R. Procedure,5481,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,3332.65,,,,,,,fee schedule,3332.65,3332.65, Postpartum And Post Abortion Diagnosis With O.R. Procedure,5481,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,3332.65,,,,,,,fee schedule,3332.65,3332.65, Postpartum And Post Abortion Diagnosis With O.R. Procedure,5482,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,8144.6,,,,,,,fee schedule,8144.6,8144.6, Postpartum And Post Abortion Diagnosis With O.R. Procedure,5482,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,8144.6,,,,,,,fee schedule,8144.6,8144.6, Postpartum And Post Abortion Diagnosis With O.R. Procedure,5482,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,8144.6,,,,,,,fee schedule,8144.6,8144.6, Postpartum And Post Abortion Diagnosis With O.R. Procedure,5482,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,8144.6,,,,,,,fee schedule,8144.6,8144.6, Postpartum And Post Abortion Diagnosis With O.R. Procedure,5482,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,8144.6,,,,,,,fee schedule,8144.6,8144.6, Postpartum And Post Abortion Diagnosis With O.R. Procedure,5482,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,8144.6,,,,,,,fee schedule,8144.6,8144.6, Postpartum And Post Abortion Diagnosis With O.R. Procedure,5482,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,8144.6,,,,,,,fee schedule,8144.6,8144.6, Postpartum And Post Abortion Diagnosis With O.R. Procedure,5482,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,8144.6,,,,,,,fee schedule,8144.6,8144.6, Postpartum And Post Abortion Diagnosis With O.R. Procedure,5482,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,8144.6,,,,,,,fee schedule,8144.6,8144.6, Postpartum And Post Abortion Diagnosis With O.R. Procedure,5482,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,8144.6,,,,,,,fee schedule,8144.6,8144.6, Postpartum And Post Abortion Diagnosis With O.R. Procedure,5482,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,8144.6,,,,,,,fee schedule,8144.6,8144.6, Postpartum And Post Abortion Diagnosis With O.R. Procedure,5483,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,13364.88,,,,,,,fee schedule,13364.88,13364.88, Postpartum And Post Abortion Diagnosis With O.R. Procedure,5483,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,13364.88,,,,,,,fee schedule,13364.88,13364.88, Postpartum And Post Abortion Diagnosis With O.R. Procedure,5483,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,13364.88,,,,,,,fee schedule,13364.88,13364.88, Postpartum And Post Abortion Diagnosis With O.R. Procedure,5483,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,13364.88,,,,,,,fee schedule,13364.88,13364.88, Postpartum And Post Abortion Diagnosis With O.R. Procedure,5483,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,13364.88,,,,,,,fee schedule,13364.88,13364.88, Postpartum And Post Abortion Diagnosis With O.R. Procedure,5483,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,13364.88,,,,,,,fee schedule,13364.88,13364.88, Postpartum And Post Abortion Diagnosis With O.R. Procedure,5483,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,13364.88,,,,,,,fee schedule,13364.88,13364.88, Postpartum And Post Abortion Diagnosis With O.R. Procedure,5483,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,13364.88,,,,,,,fee schedule,13364.88,13364.88, Postpartum And Post Abortion Diagnosis With O.R. Procedure,5483,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,13364.88,,,,,,,fee schedule,13364.88,13364.88, Postpartum And Post Abortion Diagnosis With O.R. Procedure,5483,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,13364.88,,,,,,,fee schedule,13364.88,13364.88, Postpartum And Post Abortion Diagnosis With O.R. Procedure,5483,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,13364.88,,,,,,,fee schedule,13364.88,13364.88, Postpartum And Post Abortion Diagnosis With O.R. Procedure,5484,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,29263.53,,,,,,,fee schedule,29263.53,29263.53, Postpartum And Post Abortion Diagnosis With O.R. Procedure,5484,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,29263.53,,,,,,,fee schedule,29263.53,29263.53, Postpartum And Post Abortion Diagnosis With O.R. Procedure,5484,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,29263.53,,,,,,,fee schedule,29263.53,29263.53, Postpartum And Post Abortion Diagnosis With O.R. Procedure,5484,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,29263.53,,,,,,,fee schedule,29263.53,29263.53, Postpartum And Post Abortion Diagnosis With O.R. Procedure,5484,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,29263.53,,,,,,,fee schedule,29263.53,29263.53, Postpartum And Post Abortion Diagnosis With O.R. Procedure,5484,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,29263.53,,,,,,,fee schedule,29263.53,29263.53, Postpartum And Post Abortion Diagnosis With O.R. Procedure,5484,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,29263.53,,,,,,,fee schedule,29263.53,29263.53, Postpartum And Post Abortion Diagnosis With O.R. Procedure,5484,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,29263.53,,,,,,,fee schedule,29263.53,29263.53, Postpartum And Post Abortion Diagnosis With O.R. Procedure,5484,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,29263.53,,,,,,,fee schedule,29263.53,29263.53, Postpartum And Post Abortion Diagnosis With O.R. Procedure,5484,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,29263.53,,,,,,,fee schedule,29263.53,29263.53, Postpartum And Post Abortion Diagnosis With O.R. Procedure,5484,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,29263.53,,,,,,,fee schedule,29263.53,29263.53, Vaginal Delivery,5601,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,2548.54,,,,,,,fee schedule,2548.54,2548.54, Vaginal Delivery,5601,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,2548.54,,,,,,,fee schedule,2548.54,2548.54, Vaginal Delivery,5601,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,2548.54,,,,,,,fee schedule,2548.54,2548.54, Vaginal Delivery,5601,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,2548.54,,,,,,,fee schedule,2548.54,2548.54, Vaginal Delivery,5601,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,2548.54,,,,,,,fee schedule,2548.54,2548.54, Vaginal Delivery,5601,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,2548.54,,,,,,,fee schedule,2548.54,2548.54, Vaginal Delivery,5601,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,2548.54,,,,,,,fee schedule,2548.54,2548.54, Vaginal Delivery,5601,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,2548.54,,,,,,,fee schedule,2548.54,2548.54, Vaginal Delivery,5601,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,2548.54,,,,,,,fee schedule,2548.54,2548.54, Vaginal Delivery,5601,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,2548.54,,,,,,,fee schedule,2548.54,2548.54, Vaginal Delivery,5601,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,2548.54,,,,,,,fee schedule,2548.54,2548.54, Vaginal Delivery,5602,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,2952.24,,,,,,,fee schedule,2952.24,2952.24, Vaginal Delivery,5602,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,2952.24,,,,,,,fee schedule,2952.24,2952.24, Vaginal Delivery,5602,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,2952.24,,,,,,,fee schedule,2952.24,2952.24, Vaginal Delivery,5602,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,2952.24,,,,,,,fee schedule,2952.24,2952.24, Vaginal Delivery,5602,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,2952.24,,,,,,,fee schedule,2952.24,2952.24, Vaginal Delivery,5602,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,2952.24,,,,,,,fee schedule,2952.24,2952.24, Vaginal Delivery,5602,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,2952.24,,,,,,,fee schedule,2952.24,2952.24, Vaginal Delivery,5602,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,2952.24,,,,,,,fee schedule,2952.24,2952.24, Vaginal Delivery,5602,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,2952.24,,,,,,,fee schedule,2952.24,2952.24, Vaginal Delivery,5602,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,2952.24,,,,,,,fee schedule,2952.24,2952.24, Vaginal Delivery,5602,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,2952.24,,,,,,,fee schedule,2952.24,2952.24, Vaginal Delivery,5603,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4655.73,,,,,,,fee schedule,4655.73,4655.73, Vaginal Delivery,5603,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4655.73,,,,,,,fee schedule,4655.73,4655.73, Vaginal Delivery,5603,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4655.73,,,,,,,fee schedule,4655.73,4655.73, Vaginal Delivery,5603,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4655.73,,,,,,,fee schedule,4655.73,4655.73, Vaginal Delivery,5603,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4655.73,,,,,,,fee schedule,4655.73,4655.73, Vaginal Delivery,5603,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4655.73,,,,,,,fee schedule,4655.73,4655.73, Vaginal Delivery,5603,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4655.73,,,,,,,fee schedule,4655.73,4655.73, Vaginal Delivery,5603,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4655.73,,,,,,,fee schedule,4655.73,4655.73, Vaginal Delivery,5603,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4655.73,,,,,,,fee schedule,4655.73,4655.73, Vaginal Delivery,5603,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4655.73,,,,,,,fee schedule,4655.73,4655.73, Vaginal Delivery,5603,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4655.73,,,,,,,fee schedule,4655.73,4655.73, Vaginal Delivery,5604,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,10715.47,,,,,,,fee schedule,10715.47,10715.47, Vaginal Delivery,5604,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,10715.47,,,,,,,fee schedule,10715.47,10715.47, Vaginal Delivery,5604,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,10715.47,,,,,,,fee schedule,10715.47,10715.47, Vaginal Delivery,5604,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,10715.47,,,,,,,fee schedule,10715.47,10715.47, Vaginal Delivery,5604,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,10715.47,,,,,,,fee schedule,10715.47,10715.47, Vaginal Delivery,5604,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,10715.47,,,,,,,fee schedule,10715.47,10715.47, Vaginal Delivery,5604,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,10715.47,,,,,,,fee schedule,10715.47,10715.47, Vaginal Delivery,5604,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,10715.47,,,,,,,fee schedule,10715.47,10715.47, Vaginal Delivery,5604,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,10715.47,,,,,,,fee schedule,10715.47,10715.47, Vaginal Delivery,5604,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,10715.47,,,,,,,fee schedule,10715.47,10715.47, Vaginal Delivery,5604,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,10715.47,,,,,,,fee schedule,10715.47,10715.47, Postpartum And Post Abortion Diagnoses Without Procedure,5611,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,2042.5,,,,,,,fee schedule,2042.5,2042.5, Postpartum And Post Abortion Diagnoses Without Procedure,5611,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,2042.5,,,,,,,fee schedule,2042.5,2042.5, Postpartum And Post Abortion Diagnoses Without Procedure,5611,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,2042.5,,,,,,,fee schedule,2042.5,2042.5, Postpartum And Post Abortion Diagnoses Without Procedure,5611,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,2042.5,,,,,,,fee schedule,2042.5,2042.5, Postpartum And Post Abortion Diagnoses Without Procedure,5611,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,2042.5,,,,,,,fee schedule,2042.5,2042.5, Postpartum And Post Abortion Diagnoses Without Procedure,5611,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,2042.5,,,,,,,fee schedule,2042.5,2042.5, Postpartum And Post Abortion Diagnoses Without Procedure,5611,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,2042.5,,,,,,,fee schedule,2042.5,2042.5, Postpartum And Post Abortion Diagnoses Without Procedure,5611,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,2042.5,,,,,,,fee schedule,2042.5,2042.5, Postpartum And Post Abortion Diagnoses Without Procedure,5611,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,2042.5,,,,,,,fee schedule,2042.5,2042.5, Postpartum And Post Abortion Diagnoses Without Procedure,5611,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,2042.5,,,,,,,fee schedule,2042.5,2042.5, Postpartum And Post Abortion Diagnoses Without Procedure,5611,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,2042.5,,,,,,,fee schedule,2042.5,2042.5, Postpartum And Post Abortion Diagnoses Without Procedure,5612,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,3353.83,,,,,,,fee schedule,3353.83,3353.83, Postpartum And Post Abortion Diagnoses Without Procedure,5612,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,3353.83,,,,,,,fee schedule,3353.83,3353.83, Postpartum And Post Abortion Diagnoses Without Procedure,5612,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,3353.83,,,,,,,fee schedule,3353.83,3353.83, Postpartum And Post Abortion Diagnoses Without Procedure,5612,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,3353.83,,,,,,,fee schedule,3353.83,3353.83, Postpartum And Post Abortion Diagnoses Without Procedure,5612,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,3353.83,,,,,,,fee schedule,3353.83,3353.83, Postpartum And Post Abortion Diagnoses Without Procedure,5612,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,3353.83,,,,,,,fee schedule,3353.83,3353.83, Postpartum And Post Abortion Diagnoses Without Procedure,5612,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,3353.83,,,,,,,fee schedule,3353.83,3353.83, Postpartum And Post Abortion Diagnoses Without Procedure,5612,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,3353.83,,,,,,,fee schedule,3353.83,3353.83, Postpartum And Post Abortion Diagnoses Without Procedure,5612,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,3353.83,,,,,,,fee schedule,3353.83,3353.83, Postpartum And Post Abortion Diagnoses Without Procedure,5612,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,3353.83,,,,,,,fee schedule,3353.83,3353.83, Postpartum And Post Abortion Diagnoses Without Procedure,5612,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,3353.83,,,,,,,fee schedule,3353.83,3353.83, Postpartum And Post Abortion Diagnoses Without Procedure,5613,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,6289.61,,,,,,,fee schedule,6289.61,6289.61, Postpartum And Post Abortion Diagnoses Without Procedure,5613,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,6289.61,,,,,,,fee schedule,6289.61,6289.61, Postpartum And Post Abortion Diagnoses Without Procedure,5613,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,6289.61,,,,,,,fee schedule,6289.61,6289.61, Postpartum And Post Abortion Diagnoses Without Procedure,5613,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,6289.61,,,,,,,fee schedule,6289.61,6289.61, Postpartum And Post Abortion Diagnoses Without Procedure,5613,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,6289.61,,,,,,,fee schedule,6289.61,6289.61, Postpartum And Post Abortion Diagnoses Without Procedure,5613,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,6289.61,,,,,,,fee schedule,6289.61,6289.61, Postpartum And Post Abortion Diagnoses Without Procedure,5613,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,6289.61,,,,,,,fee schedule,6289.61,6289.61, Postpartum And Post Abortion Diagnoses Without Procedure,5613,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,6289.61,,,,,,,fee schedule,6289.61,6289.61, Postpartum And Post Abortion Diagnoses Without Procedure,5613,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,6289.61,,,,,,,fee schedule,6289.61,6289.61, Postpartum And Post Abortion Diagnoses Without Procedure,5613,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,6289.61,,,,,,,fee schedule,6289.61,6289.61, Postpartum And Post Abortion Diagnoses Without Procedure,5613,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,6289.61,,,,,,,fee schedule,6289.61,6289.61, Postpartum And Post Abortion Diagnoses Without Procedure,5614,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,15169.28,,,,,,,fee schedule,15169.28,15169.28, Postpartum And Post Abortion Diagnoses Without Procedure,5614,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,15169.28,,,,,,,fee schedule,15169.28,15169.28, Postpartum And Post Abortion Diagnoses Without Procedure,5614,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,15169.28,,,,,,,fee schedule,15169.28,15169.28, Postpartum And Post Abortion Diagnoses Without Procedure,5614,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,15169.28,,,,,,,fee schedule,15169.28,15169.28, Postpartum And Post Abortion Diagnoses Without Procedure,5614,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,15169.28,,,,,,,fee schedule,15169.28,15169.28, Postpartum And Post Abortion Diagnoses Without Procedure,5614,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,15169.28,,,,,,,fee schedule,15169.28,15169.28, Postpartum And Post Abortion Diagnoses Without Procedure,5614,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,15169.28,,,,,,,fee schedule,15169.28,15169.28, Postpartum And Post Abortion Diagnoses Without Procedure,5614,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,15169.28,,,,,,,fee schedule,15169.28,15169.28, Postpartum And Post Abortion Diagnoses Without Procedure,5614,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,15169.28,,,,,,,fee schedule,15169.28,15169.28, Postpartum And Post Abortion Diagnoses Without Procedure,5614,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,15169.28,,,,,,,fee schedule,15169.28,15169.28, Postpartum And Post Abortion Diagnoses Without Procedure,5614,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,15169.28,,,,,,,fee schedule,15169.28,15169.28, "Abortion Without D&C, Aspiration Curettage Or Hysterotomy",5641,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,2570.42,,,,,,,fee schedule,2570.42,2570.42, "Abortion Without D&C, Aspiration Curettage Or Hysterotomy",5641,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,2570.42,,,,,,,fee schedule,2570.42,2570.42, "Abortion Without D&C, Aspiration Curettage Or Hysterotomy",5641,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,2570.42,,,,,,,fee schedule,2570.42,2570.42, "Abortion Without D&C, Aspiration Curettage Or Hysterotomy",5641,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,2570.42,,,,,,,fee schedule,2570.42,2570.42, "Abortion Without D&C, Aspiration Curettage Or Hysterotomy",5641,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,2570.42,,,,,,,fee schedule,2570.42,2570.42, "Abortion Without D&C, Aspiration Curettage Or Hysterotomy",5641,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,2570.42,,,,,,,fee schedule,2570.42,2570.42, "Abortion Without D&C, Aspiration Curettage Or Hysterotomy",5641,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,2570.42,,,,,,,fee schedule,2570.42,2570.42, "Abortion Without D&C, Aspiration Curettage Or Hysterotomy",5641,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,2570.42,,,,,,,fee schedule,2570.42,2570.42, "Abortion Without D&C, Aspiration Curettage Or Hysterotomy",5641,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,2570.42,,,,,,,fee schedule,2570.42,2570.42, "Abortion Without D&C, Aspiration Curettage Or Hysterotomy",5641,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,2570.42,,,,,,,fee schedule,2570.42,2570.42, "Abortion Without D&C, Aspiration Curettage Or Hysterotomy",5641,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,2570.42,,,,,,,fee schedule,2570.42,2570.42, "Abortion Without D&C, Aspiration Curettage Or Hysterotomy",5642,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,3601.55,,,,,,,fee schedule,3601.55,3601.55, "Abortion Without D&C, Aspiration Curettage Or Hysterotomy",5642,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,3601.55,,,,,,,fee schedule,3601.55,3601.55, "Abortion Without D&C, Aspiration Curettage Or Hysterotomy",5642,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,3601.55,,,,,,,fee schedule,3601.55,3601.55, "Abortion Without D&C, Aspiration Curettage Or Hysterotomy",5642,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,3601.55,,,,,,,fee schedule,3601.55,3601.55, "Abortion Without D&C, Aspiration Curettage Or Hysterotomy",5642,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,3601.55,,,,,,,fee schedule,3601.55,3601.55, "Abortion Without D&C, Aspiration Curettage Or Hysterotomy",5642,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,3601.55,,,,,,,fee schedule,3601.55,3601.55, "Abortion Without D&C, Aspiration Curettage Or Hysterotomy",5642,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,3601.55,,,,,,,fee schedule,3601.55,3601.55, "Abortion Without D&C, Aspiration Curettage Or Hysterotomy",5642,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,3601.55,,,,,,,fee schedule,3601.55,3601.55, "Abortion Without D&C, Aspiration Curettage Or Hysterotomy",5642,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,3601.55,,,,,,,fee schedule,3601.55,3601.55, "Abortion Without D&C, Aspiration Curettage Or Hysterotomy",5642,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,3601.55,,,,,,,fee schedule,3601.55,3601.55, "Abortion Without D&C, Aspiration Curettage Or Hysterotomy",5642,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,3601.55,,,,,,,fee schedule,3601.55,3601.55, "Abortion Without D&C, Aspiration Curettage Or Hysterotomy",5643,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,6326.43,,,,,,,fee schedule,6326.43,6326.43, "Abortion Without D&C, Aspiration Curettage Or Hysterotomy",5643,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,6326.43,,,,,,,fee schedule,6326.43,6326.43, "Abortion Without D&C, Aspiration Curettage Or Hysterotomy",5643,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,6326.43,,,,,,,fee schedule,6326.43,6326.43, "Abortion Without D&C, Aspiration Curettage Or Hysterotomy",5643,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,6326.43,,,,,,,fee schedule,6326.43,6326.43, "Abortion Without D&C, Aspiration Curettage Or Hysterotomy",5643,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,6326.43,,,,,,,fee schedule,6326.43,6326.43, "Abortion Without D&C, Aspiration Curettage Or Hysterotomy",5643,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,6326.43,,,,,,,fee schedule,6326.43,6326.43, "Abortion Without D&C, Aspiration Curettage Or Hysterotomy",5643,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,6326.43,,,,,,,fee schedule,6326.43,6326.43, "Abortion Without D&C, Aspiration Curettage Or Hysterotomy",5643,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,6326.43,,,,,,,fee schedule,6326.43,6326.43, "Abortion Without D&C, Aspiration Curettage Or Hysterotomy",5643,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,6326.43,,,,,,,fee schedule,6326.43,6326.43, "Abortion Without D&C, Aspiration Curettage Or Hysterotomy",5643,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,6326.43,,,,,,,fee schedule,6326.43,6326.43, "Abortion Without D&C, Aspiration Curettage Or Hysterotomy",5643,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,6326.43,,,,,,,fee schedule,6326.43,6326.43, "Abortion Without D&C, Aspiration Curettage Or Hysterotomy",5644,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,15808.69,,,,,,,fee schedule,15808.69,15808.69, "Abortion Without D&C, Aspiration Curettage Or Hysterotomy",5644,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,15808.69,,,,,,,fee schedule,15808.69,15808.69, "Abortion Without D&C, Aspiration Curettage Or Hysterotomy",5644,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,15808.69,,,,,,,fee schedule,15808.69,15808.69, "Abortion Without D&C, Aspiration Curettage Or Hysterotomy",5644,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,15808.69,,,,,,,fee schedule,15808.69,15808.69, "Abortion Without D&C, Aspiration Curettage Or Hysterotomy",5644,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,15808.69,,,,,,,fee schedule,15808.69,15808.69, "Abortion Without D&C, Aspiration Curettage Or Hysterotomy",5644,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,15808.69,,,,,,,fee schedule,15808.69,15808.69, "Abortion Without D&C, Aspiration Curettage Or Hysterotomy",5644,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,15808.69,,,,,,,fee schedule,15808.69,15808.69, "Abortion Without D&C, Aspiration Curettage Or Hysterotomy",5644,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,15808.69,,,,,,,fee schedule,15808.69,15808.69, "Abortion Without D&C, Aspiration Curettage Or Hysterotomy",5644,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,15808.69,,,,,,,fee schedule,15808.69,15808.69, "Abortion Without D&C, Aspiration Curettage Or Hysterotomy",5644,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,15808.69,,,,,,,fee schedule,15808.69,15808.69, "Abortion Without D&C, Aspiration Curettage Or Hysterotomy",5644,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,15808.69,,,,,,,fee schedule,15808.69,15808.69, Antepartum Without O.R. Procedure,5661,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,2233.06,,,,,,,fee schedule,2233.06,2233.06, Antepartum Without O.R. Procedure,5661,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,2233.06,,,,,,,fee schedule,2233.06,2233.06, Antepartum Without O.R. Procedure,5661,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,2233.06,,,,,,,fee schedule,2233.06,2233.06, Antepartum Without O.R. Procedure,5661,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,2233.06,,,,,,,fee schedule,2233.06,2233.06, Antepartum Without O.R. Procedure,5661,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,2233.06,,,,,,,fee schedule,2233.06,2233.06, Antepartum Without O.R. Procedure,5661,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,2233.06,,,,,,,fee schedule,2233.06,2233.06, Antepartum Without O.R. Procedure,5661,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,2233.06,,,,,,,fee schedule,2233.06,2233.06, Antepartum Without O.R. Procedure,5661,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,2233.06,,,,,,,fee schedule,2233.06,2233.06, Antepartum Without O.R. Procedure,5661,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,2233.06,,,,,,,fee schedule,2233.06,2233.06, Antepartum Without O.R. Procedure,5661,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,2233.06,,,,,,,fee schedule,2233.06,2233.06, Antepartum Without O.R. Procedure,5661,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,2233.06,,,,,,,fee schedule,2233.06,2233.06, Antepartum Without O.R. Procedure,5662,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,3238.08,,,,,,,fee schedule,3238.08,3238.08, Antepartum Without O.R. Procedure,5662,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,3238.08,,,,,,,fee schedule,3238.08,3238.08, Antepartum Without O.R. Procedure,5662,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,3238.08,,,,,,,fee schedule,3238.08,3238.08, Antepartum Without O.R. Procedure,5662,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,3238.08,,,,,,,fee schedule,3238.08,3238.08, Antepartum Without O.R. Procedure,5662,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,3238.08,,,,,,,fee schedule,3238.08,3238.08, Antepartum Without O.R. Procedure,5662,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,3238.08,,,,,,,fee schedule,3238.08,3238.08, Antepartum Without O.R. Procedure,5662,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,3238.08,,,,,,,fee schedule,3238.08,3238.08, Antepartum Without O.R. Procedure,5662,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,3238.08,,,,,,,fee schedule,3238.08,3238.08, Antepartum Without O.R. Procedure,5662,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,3238.08,,,,,,,fee schedule,3238.08,3238.08, Antepartum Without O.R. Procedure,5662,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,3238.08,,,,,,,fee schedule,3238.08,3238.08, Antepartum Without O.R. Procedure,5662,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,3238.08,,,,,,,fee schedule,3238.08,3238.08, Antepartum Without O.R. Procedure,5663,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,6231.45,,,,,,,fee schedule,6231.45,6231.45, Antepartum Without O.R. Procedure,5663,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,6231.45,,,,,,,fee schedule,6231.45,6231.45, Antepartum Without O.R. Procedure,5663,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,6231.45,,,,,,,fee schedule,6231.45,6231.45, Antepartum Without O.R. Procedure,5663,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,6231.45,,,,,,,fee schedule,6231.45,6231.45, Antepartum Without O.R. Procedure,5663,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,6231.45,,,,,,,fee schedule,6231.45,6231.45, Antepartum Without O.R. Procedure,5663,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,6231.45,,,,,,,fee schedule,6231.45,6231.45, Antepartum Without O.R. Procedure,5663,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,6231.45,,,,,,,fee schedule,6231.45,6231.45, Antepartum Without O.R. Procedure,5663,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,6231.45,,,,,,,fee schedule,6231.45,6231.45, Antepartum Without O.R. Procedure,5663,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,6231.45,,,,,,,fee schedule,6231.45,6231.45, Antepartum Without O.R. Procedure,5663,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,6231.45,,,,,,,fee schedule,6231.45,6231.45, Antepartum Without O.R. Procedure,5663,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,6231.45,,,,,,,fee schedule,6231.45,6231.45, Antepartum Without O.R. Procedure,5664,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,15086.06,,,,,,,fee schedule,15086.06,15086.06, Antepartum Without O.R. Procedure,5664,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,15086.06,,,,,,,fee schedule,15086.06,15086.06, Antepartum Without O.R. Procedure,5664,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,15086.06,,,,,,,fee schedule,15086.06,15086.06, Antepartum Without O.R. Procedure,5664,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,15086.06,,,,,,,fee schedule,15086.06,15086.06, Antepartum Without O.R. Procedure,5664,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,15086.06,,,,,,,fee schedule,15086.06,15086.06, Antepartum Without O.R. Procedure,5664,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,15086.06,,,,,,,fee schedule,15086.06,15086.06, Antepartum Without O.R. Procedure,5664,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,15086.06,,,,,,,fee schedule,15086.06,15086.06, Antepartum Without O.R. Procedure,5664,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,15086.06,,,,,,,fee schedule,15086.06,15086.06, Antepartum Without O.R. Procedure,5664,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,15086.06,,,,,,,fee schedule,15086.06,15086.06, Antepartum Without O.R. Procedure,5664,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,15086.06,,,,,,,fee schedule,15086.06,15086.06, Antepartum Without O.R. Procedure,5664,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,15086.06,,,,,,,fee schedule,15086.06,15086.06, "Neonate, Transferred < 5 Days Old, Not Born Here",5801,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,2205.54,,,,,,,fee schedule,2205.54,2205.54, "Neonate, Transferred < 5 Days Old, Not Born Here",5801,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,2205.54,,,,,,,fee schedule,2205.54,2205.54, "Neonate, Transferred < 5 Days Old, Not Born Here",5801,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,2205.54,,,,,,,fee schedule,2205.54,2205.54, "Neonate, Transferred < 5 Days Old, Not Born Here",5801,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,2205.54,,,,,,,fee schedule,2205.54,2205.54, "Neonate, Transferred < 5 Days Old, Not Born Here",5801,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,2205.54,,,,,,,fee schedule,2205.54,2205.54, "Neonate, Transferred < 5 Days Old, Not Born Here",5801,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,2205.54,,,,,,,fee schedule,2205.54,2205.54, "Neonate, Transferred < 5 Days Old, Not Born Here",5801,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,2205.54,,,,,,,fee schedule,2205.54,2205.54, "Neonate, Transferred < 5 Days Old, Not Born Here",5801,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,2205.54,,,,,,,fee schedule,2205.54,2205.54, "Neonate, Transferred < 5 Days Old, Not Born Here",5801,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,2205.54,,,,,,,fee schedule,2205.54,2205.54, "Neonate, Transferred < 5 Days Old, Not Born Here",5801,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,2205.54,,,,,,,fee schedule,2205.54,2205.54, "Neonate, Transferred < 5 Days Old, Not Born Here",5801,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,2205.54,,,,,,,fee schedule,2205.54,2205.54, "Neonate, Transferred < 5 Days Old, Not Born Here",5802,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,3463.93,,,,,,,fee schedule,3463.93,3463.93, "Neonate, Transferred < 5 Days Old, Not Born Here",5802,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,3463.93,,,,,,,fee schedule,3463.93,3463.93, "Neonate, Transferred < 5 Days Old, Not Born Here",5802,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,3463.93,,,,,,,fee schedule,3463.93,3463.93, "Neonate, Transferred < 5 Days Old, Not Born Here",5802,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,3463.93,,,,,,,fee schedule,3463.93,3463.93, "Neonate, Transferred < 5 Days Old, Not Born Here",5802,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,3463.93,,,,,,,fee schedule,3463.93,3463.93, "Neonate, Transferred < 5 Days Old, Not Born Here",5802,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,3463.93,,,,,,,fee schedule,3463.93,3463.93, "Neonate, Transferred < 5 Days Old, Not Born Here",5802,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,3463.93,,,,,,,fee schedule,3463.93,3463.93, "Neonate, Transferred < 5 Days Old, Not Born Here",5802,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,3463.93,,,,,,,fee schedule,3463.93,3463.93, "Neonate, Transferred < 5 Days Old, Not Born Here",5802,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,3463.93,,,,,,,fee schedule,3463.93,3463.93, "Neonate, Transferred < 5 Days Old, Not Born Here",5802,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,3463.93,,,,,,,fee schedule,3463.93,3463.93, "Neonate, Transferred < 5 Days Old, Not Born Here",5802,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,3463.93,,,,,,,fee schedule,3463.93,3463.93, "Neonate, Transferred < 5 Days Old, Not Born Here",5803,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,6836.81,,,,,,,fee schedule,6836.81,6836.81, "Neonate, Transferred < 5 Days Old, Not Born Here",5803,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,6836.81,,,,,,,fee schedule,6836.81,6836.81, "Neonate, Transferred < 5 Days Old, Not Born Here",5803,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,6836.81,,,,,,,fee schedule,6836.81,6836.81, "Neonate, Transferred < 5 Days Old, Not Born Here",5803,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,6836.81,,,,,,,fee schedule,6836.81,6836.81, "Neonate, Transferred < 5 Days Old, Not Born Here",5803,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,6836.81,,,,,,,fee schedule,6836.81,6836.81, "Neonate, Transferred < 5 Days Old, Not Born Here",5803,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,6836.81,,,,,,,fee schedule,6836.81,6836.81, "Neonate, Transferred < 5 Days Old, Not Born Here",5803,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,6836.81,,,,,,,fee schedule,6836.81,6836.81, "Neonate, Transferred < 5 Days Old, Not Born Here",5803,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,6836.81,,,,,,,fee schedule,6836.81,6836.81, "Neonate, Transferred < 5 Days Old, Not Born Here",5803,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,6836.81,,,,,,,fee schedule,6836.81,6836.81, "Neonate, Transferred < 5 Days Old, Not Born Here",5803,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,6836.81,,,,,,,fee schedule,6836.81,6836.81, "Neonate, Transferred < 5 Days Old, Not Born Here",5803,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,6836.81,,,,,,,fee schedule,6836.81,6836.81, "Neonate, Transferred < 5 Days Old, Not Born Here",5804,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,8736.04,,,,,,,fee schedule,8736.04,8736.04, "Neonate, Transferred < 5 Days Old, Not Born Here",5804,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,8736.04,,,,,,,fee schedule,8736.04,8736.04, "Neonate, Transferred < 5 Days Old, Not Born Here",5804,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,8736.04,,,,,,,fee schedule,8736.04,8736.04, "Neonate, Transferred < 5 Days Old, Not Born Here",5804,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,8736.04,,,,,,,fee schedule,8736.04,8736.04, "Neonate, Transferred < 5 Days Old, Not Born Here",5804,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,8736.04,,,,,,,fee schedule,8736.04,8736.04, "Neonate, Transferred < 5 Days Old, Not Born Here",5804,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,8736.04,,,,,,,fee schedule,8736.04,8736.04, "Neonate, Transferred < 5 Days Old, Not Born Here",5804,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,8736.04,,,,,,,fee schedule,8736.04,8736.04, "Neonate, Transferred < 5 Days Old, Not Born Here",5804,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,8736.04,,,,,,,fee schedule,8736.04,8736.04, "Neonate, Transferred < 5 Days Old, Not Born Here",5804,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,8736.04,,,,,,,fee schedule,8736.04,8736.04, "Neonate, Transferred < 5 Days Old, Not Born Here",5804,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,8736.04,,,,,,,fee schedule,8736.04,8736.04, "Neonate, Transferred < 5 Days Old, Not Born Here",5804,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,8736.04,,,,,,,fee schedule,8736.04,8736.04, "Neonate, Transferred < 5 Days Old, Born Here",5811,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,765.76,,,,,,,fee schedule,765.76,765.76, "Neonate, Transferred < 5 Days Old, Born Here",5811,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,765.76,,,,,,,fee schedule,765.76,765.76, "Neonate, Transferred < 5 Days Old, Born Here",5811,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,765.76,,,,,,,fee schedule,765.76,765.76, "Neonate, Transferred < 5 Days Old, Born Here",5811,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,765.76,,,,,,,fee schedule,765.76,765.76, "Neonate, Transferred < 5 Days Old, Born Here",5811,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,765.76,,,,,,,fee schedule,765.76,765.76, "Neonate, Transferred < 5 Days Old, Born Here",5811,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,765.76,,,,,,,fee schedule,765.76,765.76, "Neonate, Transferred < 5 Days Old, Born Here",5811,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,765.76,,,,,,,fee schedule,765.76,765.76, "Neonate, Transferred < 5 Days Old, Born Here",5811,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,765.76,,,,,,,fee schedule,765.76,765.76, "Neonate, Transferred < 5 Days Old, Born Here",5811,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,765.76,,,,,,,fee schedule,765.76,765.76, "Neonate, Transferred < 5 Days Old, Born Here",5811,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,765.76,,,,,,,fee schedule,765.76,765.76, "Neonate, Transferred < 5 Days Old, Born Here",5811,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,765.76,,,,,,,fee schedule,765.76,765.76, "Neonate, Transferred < 5 Days Old, Born Here",5812,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,1196.99,,,,,,,fee schedule,1196.99,1196.99, "Neonate, Transferred < 5 Days Old, Born Here",5812,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,1196.99,,,,,,,fee schedule,1196.99,1196.99, "Neonate, Transferred < 5 Days Old, Born Here",5812,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,1196.99,,,,,,,fee schedule,1196.99,1196.99, "Neonate, Transferred < 5 Days Old, Born Here",5812,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,1196.99,,,,,,,fee schedule,1196.99,1196.99, "Neonate, Transferred < 5 Days Old, Born Here",5812,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,1196.99,,,,,,,fee schedule,1196.99,1196.99, "Neonate, Transferred < 5 Days Old, Born Here",5812,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,1196.99,,,,,,,fee schedule,1196.99,1196.99, "Neonate, Transferred < 5 Days Old, Born Here",5812,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,1196.99,,,,,,,fee schedule,1196.99,1196.99, "Neonate, Transferred < 5 Days Old, Born Here",5812,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,1196.99,,,,,,,fee schedule,1196.99,1196.99, "Neonate, Transferred < 5 Days Old, Born Here",5812,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,1196.99,,,,,,,fee schedule,1196.99,1196.99, "Neonate, Transferred < 5 Days Old, Born Here",5812,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,1196.99,,,,,,,fee schedule,1196.99,1196.99, "Neonate, Transferred < 5 Days Old, Born Here",5812,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,1196.99,,,,,,,fee schedule,1196.99,1196.99, "Neonate, Transferred < 5 Days Old, Born Here",5813,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,2266.94,,,,,,,fee schedule,2266.94,2266.94, "Neonate, Transferred < 5 Days Old, Born Here",5813,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,2266.94,,,,,,,fee schedule,2266.94,2266.94, "Neonate, Transferred < 5 Days Old, Born Here",5813,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,2266.94,,,,,,,fee schedule,2266.94,2266.94, "Neonate, Transferred < 5 Days Old, Born Here",5813,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,2266.94,,,,,,,fee schedule,2266.94,2266.94, "Neonate, Transferred < 5 Days Old, Born Here",5813,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,2266.94,,,,,,,fee schedule,2266.94,2266.94, "Neonate, Transferred < 5 Days Old, Born Here",5813,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,2266.94,,,,,,,fee schedule,2266.94,2266.94, "Neonate, Transferred < 5 Days Old, Born Here",5813,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,2266.94,,,,,,,fee schedule,2266.94,2266.94, "Neonate, Transferred < 5 Days Old, Born Here",5813,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,2266.94,,,,,,,fee schedule,2266.94,2266.94, "Neonate, Transferred < 5 Days Old, Born Here",5813,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,2266.94,,,,,,,fee schedule,2266.94,2266.94, "Neonate, Transferred < 5 Days Old, Born Here",5813,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,2266.94,,,,,,,fee schedule,2266.94,2266.94, "Neonate, Transferred < 5 Days Old, Born Here",5813,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,2266.94,,,,,,,fee schedule,2266.94,2266.94, "Neonate, Transferred < 5 Days Old, Born Here",5814,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4152.05,,,,,,,fee schedule,4152.05,4152.05, "Neonate, Transferred < 5 Days Old, Born Here",5814,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4152.05,,,,,,,fee schedule,4152.05,4152.05, "Neonate, Transferred < 5 Days Old, Born Here",5814,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4152.05,,,,,,,fee schedule,4152.05,4152.05, "Neonate, Transferred < 5 Days Old, Born Here",5814,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4152.05,,,,,,,fee schedule,4152.05,4152.05, "Neonate, Transferred < 5 Days Old, Born Here",5814,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4152.05,,,,,,,fee schedule,4152.05,4152.05, "Neonate, Transferred < 5 Days Old, Born Here",5814,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4152.05,,,,,,,fee schedule,4152.05,4152.05, "Neonate, Transferred < 5 Days Old, Born Here",5814,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4152.05,,,,,,,fee schedule,4152.05,4152.05, "Neonate, Transferred < 5 Days Old, Born Here",5814,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4152.05,,,,,,,fee schedule,4152.05,4152.05, "Neonate, Transferred < 5 Days Old, Born Here",5814,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4152.05,,,,,,,fee schedule,4152.05,4152.05, "Neonate, Transferred < 5 Days Old, Born Here",5814,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4152.05,,,,,,,fee schedule,4152.05,4152.05, "Neonate, Transferred < 5 Days Old, Born Here",5814,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4152.05,,,,,,,fee schedule,4152.05,4152.05, Neonate With Ecmo,5831,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,160553.08,,,,,,,fee schedule,160553.08,160553.08, Neonate With Ecmo,5831,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,160553.08,,,,,,,fee schedule,160553.08,160553.08, Neonate With Ecmo,5831,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,160553.08,,,,,,,fee schedule,160553.08,160553.08, Neonate With Ecmo,5831,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,160553.08,,,,,,,fee schedule,160553.08,160553.08, Neonate With Ecmo,5831,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,160553.08,,,,,,,fee schedule,160553.08,160553.08, Neonate With Ecmo,5831,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,160553.08,,,,,,,fee schedule,160553.08,160553.08, Neonate With Ecmo,5831,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,160553.08,,,,,,,fee schedule,160553.08,160553.08, Neonate With Ecmo,5831,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,160553.08,,,,,,,fee schedule,160553.08,160553.08, Neonate With Ecmo,5831,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,160553.08,,,,,,,fee schedule,160553.08,160553.08, Neonate With Ecmo,5831,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,160553.08,,,,,,,fee schedule,160553.08,160553.08, Neonate With Ecmo,5831,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,160553.08,,,,,,,fee schedule,160553.08,160553.08, Neonate With Ecmo,5832,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,178865.02,,,,,,,fee schedule,178865.02,178865.02, Neonate With Ecmo,5832,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,178865.02,,,,,,,fee schedule,178865.02,178865.02, Neonate With Ecmo,5832,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,178865.02,,,,,,,fee schedule,178865.02,178865.02, Neonate With Ecmo,5832,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,178865.02,,,,,,,fee schedule,178865.02,178865.02, Neonate With Ecmo,5832,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,178865.02,,,,,,,fee schedule,178865.02,178865.02, Neonate With Ecmo,5832,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,178865.02,,,,,,,fee schedule,178865.02,178865.02, Neonate With Ecmo,5832,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,178865.02,,,,,,,fee schedule,178865.02,178865.02, Neonate With Ecmo,5832,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,178865.02,,,,,,,fee schedule,178865.02,178865.02, Neonate With Ecmo,5832,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,178865.02,,,,,,,fee schedule,178865.02,178865.02, Neonate With Ecmo,5832,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,178865.02,,,,,,,fee schedule,178865.02,178865.02, Neonate With Ecmo,5832,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,178865.02,,,,,,,fee schedule,178865.02,178865.02, Neonate With Ecmo,5833,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,232953.21,,,,,,,fee schedule,232953.21,232953.21, Neonate With Ecmo,5833,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,232953.21,,,,,,,fee schedule,232953.21,232953.21, Neonate With Ecmo,5833,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,232953.21,,,,,,,fee schedule,232953.21,232953.21, Neonate With Ecmo,5833,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,232953.21,,,,,,,fee schedule,232953.21,232953.21, Neonate With Ecmo,5833,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,232953.21,,,,,,,fee schedule,232953.21,232953.21, Neonate With Ecmo,5833,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,232953.21,,,,,,,fee schedule,232953.21,232953.21, Neonate With Ecmo,5833,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,232953.21,,,,,,,fee schedule,232953.21,232953.21, Neonate With Ecmo,5833,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,232953.21,,,,,,,fee schedule,232953.21,232953.21, Neonate With Ecmo,5833,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,232953.21,,,,,,,fee schedule,232953.21,232953.21, Neonate With Ecmo,5833,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,232953.21,,,,,,,fee schedule,232953.21,232953.21, Neonate With Ecmo,5833,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,232953.21,,,,,,,fee schedule,232953.21,232953.21, Neonate With Ecmo,5834,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,409024.79,,,,,,,fee schedule,409024.79,409024.79, Neonate With Ecmo,5834,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,409024.79,,,,,,,fee schedule,409024.79,409024.79, Neonate With Ecmo,5834,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,409024.79,,,,,,,fee schedule,409024.79,409024.79, Neonate With Ecmo,5834,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,409024.79,,,,,,,fee schedule,409024.79,409024.79, Neonate With Ecmo,5834,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,409024.79,,,,,,,fee schedule,409024.79,409024.79, Neonate With Ecmo,5834,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,409024.79,,,,,,,fee schedule,409024.79,409024.79, Neonate With Ecmo,5834,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,409024.79,,,,,,,fee schedule,409024.79,409024.79, Neonate With Ecmo,5834,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,409024.79,,,,,,,fee schedule,409024.79,409024.79, Neonate With Ecmo,5834,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,409024.79,,,,,,,fee schedule,409024.79,409024.79, Neonate With Ecmo,5834,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,409024.79,,,,,,,fee schedule,409024.79,409024.79, Neonate With Ecmo,5834,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,409024.79,,,,,,,fee schedule,409024.79,409024.79, Neonate Birth Weight < 1500 Grams With Major Procedure,5881,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,122545.18,,,,,,,fee schedule,122545.18,122545.18, Neonate Birth Weight < 1500 Grams With Major Procedure,5881,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,122545.18,,,,,,,fee schedule,122545.18,122545.18, Neonate Birth Weight < 1500 Grams With Major Procedure,5881,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,122545.18,,,,,,,fee schedule,122545.18,122545.18, Neonate Birth Weight < 1500 Grams With Major Procedure,5881,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,122545.18,,,,,,,fee schedule,122545.18,122545.18, Neonate Birth Weight < 1500 Grams With Major Procedure,5881,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,122545.18,,,,,,,fee schedule,122545.18,122545.18, Neonate Birth Weight < 1500 Grams With Major Procedure,5881,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,122545.18,,,,,,,fee schedule,122545.18,122545.18, Neonate Birth Weight < 1500 Grams With Major Procedure,5881,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,122545.18,,,,,,,fee schedule,122545.18,122545.18, Neonate Birth Weight < 1500 Grams With Major Procedure,5881,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,122545.18,,,,,,,fee schedule,122545.18,122545.18, Neonate Birth Weight < 1500 Grams With Major Procedure,5881,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,122545.18,,,,,,,fee schedule,122545.18,122545.18, Neonate Birth Weight < 1500 Grams With Major Procedure,5881,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,122545.18,,,,,,,fee schedule,122545.18,122545.18, Neonate Birth Weight < 1500 Grams With Major Procedure,5881,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,122545.18,,,,,,,fee schedule,122545.18,122545.18, Neonate Birth Weight < 1500 Grams With Major Procedure,5882,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,142968.79,,,,,,,fee schedule,142968.79,142968.79, Neonate Birth Weight < 1500 Grams With Major Procedure,5882,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,142968.79,,,,,,,fee schedule,142968.79,142968.79, Neonate Birth Weight < 1500 Grams With Major Procedure,5882,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,142968.79,,,,,,,fee schedule,142968.79,142968.79, Neonate Birth Weight < 1500 Grams With Major Procedure,5882,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,142968.79,,,,,,,fee schedule,142968.79,142968.79, Neonate Birth Weight < 1500 Grams With Major Procedure,5882,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,142968.79,,,,,,,fee schedule,142968.79,142968.79, Neonate Birth Weight < 1500 Grams With Major Procedure,5882,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,142968.79,,,,,,,fee schedule,142968.79,142968.79, Neonate Birth Weight < 1500 Grams With Major Procedure,5882,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,142968.79,,,,,,,fee schedule,142968.79,142968.79, Neonate Birth Weight < 1500 Grams With Major Procedure,5882,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,142968.79,,,,,,,fee schedule,142968.79,142968.79, Neonate Birth Weight < 1500 Grams With Major Procedure,5882,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,142968.79,,,,,,,fee schedule,142968.79,142968.79, Neonate Birth Weight < 1500 Grams With Major Procedure,5882,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,142968.79,,,,,,,fee schedule,142968.79,142968.79, Neonate Birth Weight < 1500 Grams With Major Procedure,5882,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,142968.79,,,,,,,fee schedule,142968.79,142968.79, Neonate Birth Weight < 1500 Grams With Major Procedure,5883,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,166845.74,,,,,,,fee schedule,166845.74,166845.74, Neonate Birth Weight < 1500 Grams With Major Procedure,5883,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,166845.74,,,,,,,fee schedule,166845.74,166845.74, Neonate Birth Weight < 1500 Grams With Major Procedure,5883,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,166845.74,,,,,,,fee schedule,166845.74,166845.74, Neonate Birth Weight < 1500 Grams With Major Procedure,5883,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,166845.74,,,,,,,fee schedule,166845.74,166845.74, Neonate Birth Weight < 1500 Grams With Major Procedure,5883,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,166845.74,,,,,,,fee schedule,166845.74,166845.74, Neonate Birth Weight < 1500 Grams With Major Procedure,5883,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,166845.74,,,,,,,fee schedule,166845.74,166845.74, Neonate Birth Weight < 1500 Grams With Major Procedure,5883,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,166845.74,,,,,,,fee schedule,166845.74,166845.74, Neonate Birth Weight < 1500 Grams With Major Procedure,5883,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,166845.74,,,,,,,fee schedule,166845.74,166845.74, Neonate Birth Weight < 1500 Grams With Major Procedure,5883,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,166845.74,,,,,,,fee schedule,166845.74,166845.74, Neonate Birth Weight < 1500 Grams With Major Procedure,5883,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,166845.74,,,,,,,fee schedule,166845.74,166845.74, Neonate Birth Weight < 1500 Grams With Major Procedure,5883,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,166845.74,,,,,,,fee schedule,166845.74,166845.74, Neonate Birth Weight < 1500 Grams With Major Procedure,5884,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,250519.86,,,,,,,fee schedule,250519.86,250519.86, Neonate Birth Weight < 1500 Grams With Major Procedure,5884,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,250519.86,,,,,,,fee schedule,250519.86,250519.86, Neonate Birth Weight < 1500 Grams With Major Procedure,5884,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,250519.86,,,,,,,fee schedule,250519.86,250519.86, Neonate Birth Weight < 1500 Grams With Major Procedure,5884,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,250519.86,,,,,,,fee schedule,250519.86,250519.86, Neonate Birth Weight < 1500 Grams With Major Procedure,5884,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,250519.86,,,,,,,fee schedule,250519.86,250519.86, Neonate Birth Weight < 1500 Grams With Major Procedure,5884,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,250519.86,,,,,,,fee schedule,250519.86,250519.86, Neonate Birth Weight < 1500 Grams With Major Procedure,5884,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,250519.86,,,,,,,fee schedule,250519.86,250519.86, Neonate Birth Weight < 1500 Grams With Major Procedure,5884,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,250519.86,,,,,,,fee schedule,250519.86,250519.86, Neonate Birth Weight < 1500 Grams With Major Procedure,5884,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,250519.86,,,,,,,fee schedule,250519.86,250519.86, Neonate Birth Weight < 1500 Grams With Major Procedure,5884,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,250519.86,,,,,,,fee schedule,250519.86,250519.86, Neonate Birth Weight < 1500 Grams With Major Procedure,5884,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,250519.86,,,,,,,fee schedule,250519.86,250519.86, "Weeks, Or Birth Weight 500-749 Grams With Major Anomaly Or Without Life Sustaining",5891,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,116776.91,,,,,,,fee schedule,116776.91,116776.91, "Weeks, Or Birth Weight 500-749 Grams With Major Anomaly Or Without Life Sustaining",5891,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,116776.91,,,,,,,fee schedule,116776.91,116776.91, "Weeks, Or Birth Weight 500-749 Grams With Major Anomaly Or Without Life Sustaining",5891,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,116776.91,,,,,,,fee schedule,116776.91,116776.91, "Weeks, Or Birth Weight 500-749 Grams With Major Anomaly Or Without Life Sustaining",5891,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,116776.91,,,,,,,fee schedule,116776.91,116776.91, "Weeks, Or Birth Weight 500-749 Grams With Major Anomaly Or Without Life Sustaining",5891,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,116776.91,,,,,,,fee schedule,116776.91,116776.91, "Weeks, Or Birth Weight 500-749 Grams With Major Anomaly Or Without Life Sustaining",5891,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,116776.91,,,,,,,fee schedule,116776.91,116776.91, "Weeks, Or Birth Weight 500-749 Grams With Major Anomaly Or Without Life Sustaining",5891,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,116776.91,,,,,,,fee schedule,116776.91,116776.91, "Weeks, Or Birth Weight 500-749 Grams With Major Anomaly Or Without Life Sustaining",5891,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,116776.91,,,,,,,fee schedule,116776.91,116776.91, "Weeks, Or Birth Weight 500-749 Grams With Major Anomaly Or Without Life Sustaining",5891,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,116776.91,,,,,,,fee schedule,116776.91,116776.91, "Weeks, Or Birth Weight 500-749 Grams With Major Anomaly Or Without Life Sustaining",5891,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,116776.91,,,,,,,fee schedule,116776.91,116776.91, "Weeks, Or Birth Weight 500-749 Grams With Major Anomaly Or Without Life Sustaining",5891,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,116776.91,,,,,,,fee schedule,116776.91,116776.91, "Weeks, Or Birth Weight 500-749 Grams With Major Anomaly Or Without Life Sustaining",5892,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,116776.91,,,,,,,fee schedule,116776.91,116776.91, "Weeks, Or Birth Weight 500-749 Grams With Major Anomaly Or Without Life Sustaining",5892,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,116776.91,,,,,,,fee schedule,116776.91,116776.91, "Weeks, Or Birth Weight 500-749 Grams With Major Anomaly Or Without Life Sustaining",5892,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,116776.91,,,,,,,fee schedule,116776.91,116776.91, "Weeks, Or Birth Weight 500-749 Grams With Major Anomaly Or Without Life Sustaining",5892,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,116776.91,,,,,,,fee schedule,116776.91,116776.91, "Weeks, Or Birth Weight 500-749 Grams With Major Anomaly Or Without Life Sustaining",5892,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,116776.91,,,,,,,fee schedule,116776.91,116776.91, "Weeks, Or Birth Weight 500-749 Grams With Major Anomaly Or Without Life Sustaining",5892,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,116776.91,,,,,,,fee schedule,116776.91,116776.91, "Weeks, Or Birth Weight 500-749 Grams With Major Anomaly Or Without Life Sustaining",5892,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,116776.91,,,,,,,fee schedule,116776.91,116776.91, "Weeks, Or Birth Weight 500-749 Grams With Major Anomaly Or Without Life Sustaining",5892,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,116776.91,,,,,,,fee schedule,116776.91,116776.91, "Weeks, Or Birth Weight 500-749 Grams With Major Anomaly Or Without Life Sustaining",5892,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,116776.91,,,,,,,fee schedule,116776.91,116776.91, "Weeks, Or Birth Weight 500-749 Grams With Major Anomaly Or Without Life Sustaining",5892,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,116776.91,,,,,,,fee schedule,116776.91,116776.91, "Weeks, Or Birth Weight 500-749 Grams With Major Anomaly Or Without Life Sustaining",5892,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,116776.91,,,,,,,fee schedule,116776.91,116776.91, "Weeks, Or Birth Weight 500-749 Grams With Major Anomaly Or Without Life Sustaining",5893,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,116776.91,,,,,,,fee schedule,116776.91,116776.91, "Weeks, Or Birth Weight 500-749 Grams With Major Anomaly Or Without Life Sustaining",5893,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,116776.91,,,,,,,fee schedule,116776.91,116776.91, "Weeks, Or Birth Weight 500-749 Grams With Major Anomaly Or Without Life Sustaining",5893,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,116776.91,,,,,,,fee schedule,116776.91,116776.91, "Weeks, Or Birth Weight 500-749 Grams With Major Anomaly Or Without Life Sustaining",5893,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,116776.91,,,,,,,fee schedule,116776.91,116776.91, "Weeks, Or Birth Weight 500-749 Grams With Major Anomaly Or Without Life Sustaining",5893,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,116776.91,,,,,,,fee schedule,116776.91,116776.91, "Weeks, Or Birth Weight 500-749 Grams With Major Anomaly Or Without Life Sustaining",5893,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,116776.91,,,,,,,fee schedule,116776.91,116776.91, "Weeks, Or Birth Weight 500-749 Grams With Major Anomaly Or Without Life Sustaining",5893,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,116776.91,,,,,,,fee schedule,116776.91,116776.91, "Weeks, Or Birth Weight 500-749 Grams With Major Anomaly Or Without Life Sustaining",5893,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,116776.91,,,,,,,fee schedule,116776.91,116776.91, "Weeks, Or Birth Weight 500-749 Grams With Major Anomaly Or Without Life Sustaining",5893,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,116776.91,,,,,,,fee schedule,116776.91,116776.91, "Weeks, Or Birth Weight 500-749 Grams With Major Anomaly Or Without Life Sustaining",5893,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,116776.91,,,,,,,fee schedule,116776.91,116776.91, "Weeks, Or Birth Weight 500-749 Grams With Major Anomaly Or Without Life Sustaining",5893,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,116776.91,,,,,,,fee schedule,116776.91,116776.91, "Weeks, Or Birth Weight 500-749 Grams With Major Anomaly Or Without Life Sustaining",5894,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,2420.09,,,,,,,fee schedule,2420.09,2420.09, "Weeks, Or Birth Weight 500-749 Grams With Major Anomaly Or Without Life Sustaining",5894,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,2420.09,,,,,,,fee schedule,2420.09,2420.09, "Weeks, Or Birth Weight 500-749 Grams With Major Anomaly Or Without Life Sustaining",5894,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,2420.09,,,,,,,fee schedule,2420.09,2420.09, "Weeks, Or Birth Weight 500-749 Grams With Major Anomaly Or Without Life Sustaining",5894,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,2420.09,,,,,,,fee schedule,2420.09,2420.09, "Weeks, Or Birth Weight 500-749 Grams With Major Anomaly Or Without Life Sustaining",5894,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,2420.09,,,,,,,fee schedule,2420.09,2420.09, "Weeks, Or Birth Weight 500-749 Grams With Major Anomaly Or Without Life Sustaining",5894,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,2420.09,,,,,,,fee schedule,2420.09,2420.09, "Weeks, Or Birth Weight 500-749 Grams With Major Anomaly Or Without Life Sustaining",5894,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,2420.09,,,,,,,fee schedule,2420.09,2420.09, "Weeks, Or Birth Weight 500-749 Grams With Major Anomaly Or Without Life Sustaining",5894,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,2420.09,,,,,,,fee schedule,2420.09,2420.09, "Weeks, Or Birth Weight 500-749 Grams With Major Anomaly Or Without Life Sustaining",5894,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,2420.09,,,,,,,fee schedule,2420.09,2420.09, "Weeks, Or Birth Weight 500-749 Grams With Major Anomaly Or Without Life Sustaining",5894,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,2420.09,,,,,,,fee schedule,2420.09,2420.09, "Weeks, Or Birth Weight 500-749 Grams With Major Anomaly Or Without Life Sustaining",5894,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,2420.09,,,,,,,fee schedule,2420.09,2420.09, Neonate Birth Weight 500-749 Grams Without Major Procedure,5911,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,22567.04,,,,,,,fee schedule,22567.04,22567.04, Neonate Birth Weight 500-749 Grams Without Major Procedure,5911,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,22567.04,,,,,,,fee schedule,22567.04,22567.04, Neonate Birth Weight 500-749 Grams Without Major Procedure,5911,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,22567.04,,,,,,,fee schedule,22567.04,22567.04, Neonate Birth Weight 500-749 Grams Without Major Procedure,5911,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,22567.04,,,,,,,fee schedule,22567.04,22567.04, Neonate Birth Weight 500-749 Grams Without Major Procedure,5911,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,22567.04,,,,,,,fee schedule,22567.04,22567.04, Neonate Birth Weight 500-749 Grams Without Major Procedure,5911,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,22567.04,,,,,,,fee schedule,22567.04,22567.04, Neonate Birth Weight 500-749 Grams Without Major Procedure,5911,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,22567.04,,,,,,,fee schedule,22567.04,22567.04, Neonate Birth Weight 500-749 Grams Without Major Procedure,5911,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,22567.04,,,,,,,fee schedule,22567.04,22567.04, Neonate Birth Weight 500-749 Grams Without Major Procedure,5911,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,22567.04,,,,,,,fee schedule,22567.04,22567.04, Neonate Birth Weight 500-749 Grams Without Major Procedure,5911,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,22567.04,,,,,,,fee schedule,22567.04,22567.04, Neonate Birth Weight 500-749 Grams Without Major Procedure,5911,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,22567.04,,,,,,,fee schedule,22567.04,22567.04, Neonate Birth Weight 500-749 Grams Without Major Procedure,5912,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,106265.86,,,,,,,fee schedule,106265.86,106265.86, Neonate Birth Weight 500-749 Grams Without Major Procedure,5912,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,106265.86,,,,,,,fee schedule,106265.86,106265.86, Neonate Birth Weight 500-749 Grams Without Major Procedure,5912,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,106265.86,,,,,,,fee schedule,106265.86,106265.86, Neonate Birth Weight 500-749 Grams Without Major Procedure,5912,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,106265.86,,,,,,,fee schedule,106265.86,106265.86, Neonate Birth Weight 500-749 Grams Without Major Procedure,5912,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,106265.86,,,,,,,fee schedule,106265.86,106265.86, Neonate Birth Weight 500-749 Grams Without Major Procedure,5912,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,106265.86,,,,,,,fee schedule,106265.86,106265.86, Neonate Birth Weight 500-749 Grams Without Major Procedure,5912,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,106265.86,,,,,,,fee schedule,106265.86,106265.86, Neonate Birth Weight 500-749 Grams Without Major Procedure,5912,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,106265.86,,,,,,,fee schedule,106265.86,106265.86, Neonate Birth Weight 500-749 Grams Without Major Procedure,5912,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,106265.86,,,,,,,fee schedule,106265.86,106265.86, Neonate Birth Weight 500-749 Grams Without Major Procedure,5912,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,106265.86,,,,,,,fee schedule,106265.86,106265.86, Neonate Birth Weight 500-749 Grams Without Major Procedure,5912,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,106265.86,,,,,,,fee schedule,106265.86,106265.86, Neonate Birth Weight 500-749 Grams Without Major Procedure,5913,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,123894.62,,,,,,,fee schedule,123894.62,123894.62, Neonate Birth Weight 500-749 Grams Without Major Procedure,5913,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,123894.62,,,,,,,fee schedule,123894.62,123894.62, Neonate Birth Weight 500-749 Grams Without Major Procedure,5913,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,123894.62,,,,,,,fee schedule,123894.62,123894.62, Neonate Birth Weight 500-749 Grams Without Major Procedure,5913,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,123894.62,,,,,,,fee schedule,123894.62,123894.62, Neonate Birth Weight 500-749 Grams Without Major Procedure,5913,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,123894.62,,,,,,,fee schedule,123894.62,123894.62, Neonate Birth Weight 500-749 Grams Without Major Procedure,5913,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,123894.62,,,,,,,fee schedule,123894.62,123894.62, Neonate Birth Weight 500-749 Grams Without Major Procedure,5913,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,123894.62,,,,,,,fee schedule,123894.62,123894.62, Neonate Birth Weight 500-749 Grams Without Major Procedure,5913,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,123894.62,,,,,,,fee schedule,123894.62,123894.62, Neonate Birth Weight 500-749 Grams Without Major Procedure,5913,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,123894.62,,,,,,,fee schedule,123894.62,123894.62, Neonate Birth Weight 500-749 Grams Without Major Procedure,5913,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,123894.62,,,,,,,fee schedule,123894.62,123894.62, Neonate Birth Weight 500-749 Grams Without Major Procedure,5913,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,123894.62,,,,,,,fee schedule,123894.62,123894.62, Neonate Birth Weight 500-749 Grams Without Major Procedure,5914,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,164278.85,,,,,,,fee schedule,164278.85,164278.85, Neonate Birth Weight 500-749 Grams Without Major Procedure,5914,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,164278.85,,,,,,,fee schedule,164278.85,164278.85, Neonate Birth Weight 500-749 Grams Without Major Procedure,5914,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,164278.85,,,,,,,fee schedule,164278.85,164278.85, Neonate Birth Weight 500-749 Grams Without Major Procedure,5914,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,164278.85,,,,,,,fee schedule,164278.85,164278.85, Neonate Birth Weight 500-749 Grams Without Major Procedure,5914,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,164278.85,,,,,,,fee schedule,164278.85,164278.85, Neonate Birth Weight 500-749 Grams Without Major Procedure,5914,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,164278.85,,,,,,,fee schedule,164278.85,164278.85, Neonate Birth Weight 500-749 Grams Without Major Procedure,5914,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,164278.85,,,,,,,fee schedule,164278.85,164278.85, Neonate Birth Weight 500-749 Grams Without Major Procedure,5914,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,164278.85,,,,,,,fee schedule,164278.85,164278.85, Neonate Birth Weight 500-749 Grams Without Major Procedure,5914,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,164278.85,,,,,,,fee schedule,164278.85,164278.85, Neonate Birth Weight 500-749 Grams Without Major Procedure,5914,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,164278.85,,,,,,,fee schedule,164278.85,164278.85, Neonate Birth Weight 500-749 Grams Without Major Procedure,5914,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,164278.85,,,,,,,fee schedule,164278.85,164278.85, Neonate Birth Weight 750-999 Grams Without Major Procedure,5931,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,64674.76,,,,,,,fee schedule,64674.76,64674.76, Neonate Birth Weight 750-999 Grams Without Major Procedure,5931,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,64674.76,,,,,,,fee schedule,64674.76,64674.76, Neonate Birth Weight 750-999 Grams Without Major Procedure,5931,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,64674.76,,,,,,,fee schedule,64674.76,64674.76, Neonate Birth Weight 750-999 Grams Without Major Procedure,5931,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,64674.76,,,,,,,fee schedule,64674.76,64674.76, Neonate Birth Weight 750-999 Grams Without Major Procedure,5931,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,64674.76,,,,,,,fee schedule,64674.76,64674.76, Neonate Birth Weight 750-999 Grams Without Major Procedure,5931,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,64674.76,,,,,,,fee schedule,64674.76,64674.76, Neonate Birth Weight 750-999 Grams Without Major Procedure,5931,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,64674.76,,,,,,,fee schedule,64674.76,64674.76, Neonate Birth Weight 750-999 Grams Without Major Procedure,5931,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,64674.76,,,,,,,fee schedule,64674.76,64674.76, Neonate Birth Weight 750-999 Grams Without Major Procedure,5931,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,64674.76,,,,,,,fee schedule,64674.76,64674.76, Neonate Birth Weight 750-999 Grams Without Major Procedure,5931,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,64674.76,,,,,,,fee schedule,64674.76,64674.76, Neonate Birth Weight 750-999 Grams Without Major Procedure,5931,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,64674.76,,,,,,,fee schedule,64674.76,64674.76, Neonate Birth Weight 750-999 Grams Without Major Procedure,5932,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,84982.62,,,,,,,fee schedule,84982.62,84982.62, Neonate Birth Weight 750-999 Grams Without Major Procedure,5932,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,84982.62,,,,,,,fee schedule,84982.62,84982.62, Neonate Birth Weight 750-999 Grams Without Major Procedure,5932,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,84982.62,,,,,,,fee schedule,84982.62,84982.62, Neonate Birth Weight 750-999 Grams Without Major Procedure,5932,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,84982.62,,,,,,,fee schedule,84982.62,84982.62, Neonate Birth Weight 750-999 Grams Without Major Procedure,5932,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,84982.62,,,,,,,fee schedule,84982.62,84982.62, Neonate Birth Weight 750-999 Grams Without Major Procedure,5932,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,84982.62,,,,,,,fee schedule,84982.62,84982.62, Neonate Birth Weight 750-999 Grams Without Major Procedure,5932,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,84982.62,,,,,,,fee schedule,84982.62,84982.62, Neonate Birth Weight 750-999 Grams Without Major Procedure,5932,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,84982.62,,,,,,,fee schedule,84982.62,84982.62, Neonate Birth Weight 750-999 Grams Without Major Procedure,5932,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,84982.62,,,,,,,fee schedule,84982.62,84982.62, Neonate Birth Weight 750-999 Grams Without Major Procedure,5932,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,84982.62,,,,,,,fee schedule,84982.62,84982.62, Neonate Birth Weight 750-999 Grams Without Major Procedure,5932,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,84982.62,,,,,,,fee schedule,84982.62,84982.62, Neonate Birth Weight 750-999 Grams Without Major Procedure,5933,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,105656.78,,,,,,,fee schedule,105656.78,105656.78, Neonate Birth Weight 750-999 Grams Without Major Procedure,5933,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,105656.78,,,,,,,fee schedule,105656.78,105656.78, Neonate Birth Weight 750-999 Grams Without Major Procedure,5933,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,105656.78,,,,,,,fee schedule,105656.78,105656.78, Neonate Birth Weight 750-999 Grams Without Major Procedure,5933,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,105656.78,,,,,,,fee schedule,105656.78,105656.78, Neonate Birth Weight 750-999 Grams Without Major Procedure,5933,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,105656.78,,,,,,,fee schedule,105656.78,105656.78, Neonate Birth Weight 750-999 Grams Without Major Procedure,5933,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,105656.78,,,,,,,fee schedule,105656.78,105656.78, Neonate Birth Weight 750-999 Grams Without Major Procedure,5933,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,105656.78,,,,,,,fee schedule,105656.78,105656.78, Neonate Birth Weight 750-999 Grams Without Major Procedure,5933,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,105656.78,,,,,,,fee schedule,105656.78,105656.78, Neonate Birth Weight 750-999 Grams Without Major Procedure,5933,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,105656.78,,,,,,,fee schedule,105656.78,105656.78, Neonate Birth Weight 750-999 Grams Without Major Procedure,5933,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,105656.78,,,,,,,fee schedule,105656.78,105656.78, Neonate Birth Weight 750-999 Grams Without Major Procedure,5933,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,105656.78,,,,,,,fee schedule,105656.78,105656.78, Neonate Birth Weight 750-999 Grams Without Major Procedure,5934,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,144432.56,,,,,,,fee schedule,144432.56,144432.56, Neonate Birth Weight 750-999 Grams Without Major Procedure,5934,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,144432.56,,,,,,,fee schedule,144432.56,144432.56, Neonate Birth Weight 750-999 Grams Without Major Procedure,5934,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,144432.56,,,,,,,fee schedule,144432.56,144432.56, Neonate Birth Weight 750-999 Grams Without Major Procedure,5934,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,144432.56,,,,,,,fee schedule,144432.56,144432.56, Neonate Birth Weight 750-999 Grams Without Major Procedure,5934,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,144432.56,,,,,,,fee schedule,144432.56,144432.56, Neonate Birth Weight 750-999 Grams Without Major Procedure,5934,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,144432.56,,,,,,,fee schedule,144432.56,144432.56, Neonate Birth Weight 750-999 Grams Without Major Procedure,5934,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,144432.56,,,,,,,fee schedule,144432.56,144432.56, Neonate Birth Weight 750-999 Grams Without Major Procedure,5934,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,144432.56,,,,,,,fee schedule,144432.56,144432.56, Neonate Birth Weight 750-999 Grams Without Major Procedure,5934,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,144432.56,,,,,,,fee schedule,144432.56,144432.56, Neonate Birth Weight 750-999 Grams Without Major Procedure,5934,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,144432.56,,,,,,,fee schedule,144432.56,144432.56, Neonate Birth Weight 750-999 Grams Without Major Procedure,5934,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,144432.56,,,,,,,fee schedule,144432.56,144432.56, Respiratory Condition Or Major Anomaly,6021,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,44968.22,,,,,,,fee schedule,44968.22,44968.22, Respiratory Condition Or Major Anomaly,6021,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,44968.22,,,,,,,fee schedule,44968.22,44968.22, Respiratory Condition Or Major Anomaly,6021,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,44968.22,,,,,,,fee schedule,44968.22,44968.22, Respiratory Condition Or Major Anomaly,6021,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,44968.22,,,,,,,fee schedule,44968.22,44968.22, Respiratory Condition Or Major Anomaly,6021,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,44968.22,,,,,,,fee schedule,44968.22,44968.22, Respiratory Condition Or Major Anomaly,6021,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,44968.22,,,,,,,fee schedule,44968.22,44968.22, Respiratory Condition Or Major Anomaly,6021,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,44968.22,,,,,,,fee schedule,44968.22,44968.22, Respiratory Condition Or Major Anomaly,6021,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,44968.22,,,,,,,fee schedule,44968.22,44968.22, Respiratory Condition Or Major Anomaly,6021,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,44968.22,,,,,,,fee schedule,44968.22,44968.22, Respiratory Condition Or Major Anomaly,6021,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,44968.22,,,,,,,fee schedule,44968.22,44968.22, Respiratory Condition Or Major Anomaly,6021,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,44968.22,,,,,,,fee schedule,44968.22,44968.22, Respiratory Condition Or Major Anomaly,6022,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,60365.32,,,,,,,fee schedule,60365.32,60365.32, Respiratory Condition Or Major Anomaly,6022,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,60365.32,,,,,,,fee schedule,60365.32,60365.32, Respiratory Condition Or Major Anomaly,6022,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,60365.32,,,,,,,fee schedule,60365.32,60365.32, Respiratory Condition Or Major Anomaly,6022,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,60365.32,,,,,,,fee schedule,60365.32,60365.32, Respiratory Condition Or Major Anomaly,6022,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,60365.32,,,,,,,fee schedule,60365.32,60365.32, Respiratory Condition Or Major Anomaly,6022,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,60365.32,,,,,,,fee schedule,60365.32,60365.32, Respiratory Condition Or Major Anomaly,6022,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,60365.32,,,,,,,fee schedule,60365.32,60365.32, Respiratory Condition Or Major Anomaly,6022,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,60365.32,,,,,,,fee schedule,60365.32,60365.32, Respiratory Condition Or Major Anomaly,6022,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,60365.32,,,,,,,fee schedule,60365.32,60365.32, Respiratory Condition Or Major Anomaly,6022,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,60365.32,,,,,,,fee schedule,60365.32,60365.32, Respiratory Condition Or Major Anomaly,6022,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,60365.32,,,,,,,fee schedule,60365.32,60365.32, Respiratory Condition Or Major Anomaly,6023,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,75545.76,,,,,,,fee schedule,75545.76,75545.76, Respiratory Condition Or Major Anomaly,6023,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,75545.76,,,,,,,fee schedule,75545.76,75545.76, Respiratory Condition Or Major Anomaly,6023,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,75545.76,,,,,,,fee schedule,75545.76,75545.76, Respiratory Condition Or Major Anomaly,6023,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,75545.76,,,,,,,fee schedule,75545.76,75545.76, Respiratory Condition Or Major Anomaly,6023,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,75545.76,,,,,,,fee schedule,75545.76,75545.76, Respiratory Condition Or Major Anomaly,6023,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,75545.76,,,,,,,fee schedule,75545.76,75545.76, Respiratory Condition Or Major Anomaly,6023,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,75545.76,,,,,,,fee schedule,75545.76,75545.76, Respiratory Condition Or Major Anomaly,6023,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,75545.76,,,,,,,fee schedule,75545.76,75545.76, Respiratory Condition Or Major Anomaly,6023,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,75545.76,,,,,,,fee schedule,75545.76,75545.76, Respiratory Condition Or Major Anomaly,6023,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,75545.76,,,,,,,fee schedule,75545.76,75545.76, Respiratory Condition Or Major Anomaly,6023,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,75545.76,,,,,,,fee schedule,75545.76,75545.76, Respiratory Condition Or Major Anomaly,6024,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,108805.93,,,,,,,fee schedule,108805.93,108805.93, Respiratory Condition Or Major Anomaly,6024,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,108805.93,,,,,,,fee schedule,108805.93,108805.93, Respiratory Condition Or Major Anomaly,6024,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,108805.93,,,,,,,fee schedule,108805.93,108805.93, Respiratory Condition Or Major Anomaly,6024,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,108805.93,,,,,,,fee schedule,108805.93,108805.93, Respiratory Condition Or Major Anomaly,6024,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,108805.93,,,,,,,fee schedule,108805.93,108805.93, Respiratory Condition Or Major Anomaly,6024,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,108805.93,,,,,,,fee schedule,108805.93,108805.93, Respiratory Condition Or Major Anomaly,6024,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,108805.93,,,,,,,fee schedule,108805.93,108805.93, Respiratory Condition Or Major Anomaly,6024,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,108805.93,,,,,,,fee schedule,108805.93,108805.93, Respiratory Condition Or Major Anomaly,6024,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,108805.93,,,,,,,fee schedule,108805.93,108805.93, Respiratory Condition Or Major Anomaly,6024,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,108805.93,,,,,,,fee schedule,108805.93,108805.93, Respiratory Condition Or Major Anomaly,6024,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,108805.93,,,,,,,fee schedule,108805.93,108805.93, Neonate Birth Weight 1000-1249 Grams With Or Without Significant Condition,6031,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,6011.76,,,,,,,fee schedule,6011.76,6011.76, Neonate Birth Weight 1000-1249 Grams With Or Without Significant Condition,6031,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,6011.76,,,,,,,fee schedule,6011.76,6011.76, Neonate Birth Weight 1000-1249 Grams With Or Without Significant Condition,6031,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,6011.76,,,,,,,fee schedule,6011.76,6011.76, Neonate Birth Weight 1000-1249 Grams With Or Without Significant Condition,6031,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,6011.76,,,,,,,fee schedule,6011.76,6011.76, Neonate Birth Weight 1000-1249 Grams With Or Without Significant Condition,6031,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,6011.76,,,,,,,fee schedule,6011.76,6011.76, Neonate Birth Weight 1000-1249 Grams With Or Without Significant Condition,6031,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,6011.76,,,,,,,fee schedule,6011.76,6011.76, Neonate Birth Weight 1000-1249 Grams With Or Without Significant Condition,6031,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,6011.76,,,,,,,fee schedule,6011.76,6011.76, Neonate Birth Weight 1000-1249 Grams With Or Without Significant Condition,6031,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,6011.76,,,,,,,fee schedule,6011.76,6011.76, Neonate Birth Weight 1000-1249 Grams With Or Without Significant Condition,6031,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,6011.76,,,,,,,fee schedule,6011.76,6011.76, Neonate Birth Weight 1000-1249 Grams With Or Without Significant Condition,6031,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,6011.76,,,,,,,fee schedule,6011.76,6011.76, Neonate Birth Weight 1000-1249 Grams With Or Without Significant Condition,6031,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,6011.76,,,,,,,fee schedule,6011.76,6011.76, Neonate Birth Weight 1000-1249 Grams With Or Without Significant Condition,6032,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,36768.57,,,,,,,fee schedule,36768.57,36768.57, Neonate Birth Weight 1000-1249 Grams With Or Without Significant Condition,6032,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,36768.57,,,,,,,fee schedule,36768.57,36768.57, Neonate Birth Weight 1000-1249 Grams With Or Without Significant Condition,6032,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,36768.57,,,,,,,fee schedule,36768.57,36768.57, Neonate Birth Weight 1000-1249 Grams With Or Without Significant Condition,6032,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,36768.57,,,,,,,fee schedule,36768.57,36768.57, Neonate Birth Weight 1000-1249 Grams With Or Without Significant Condition,6032,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,36768.57,,,,,,,fee schedule,36768.57,36768.57, Neonate Birth Weight 1000-1249 Grams With Or Without Significant Condition,6032,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,36768.57,,,,,,,fee schedule,36768.57,36768.57, Neonate Birth Weight 1000-1249 Grams With Or Without Significant Condition,6032,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,36768.57,,,,,,,fee schedule,36768.57,36768.57, Neonate Birth Weight 1000-1249 Grams With Or Without Significant Condition,6032,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,36768.57,,,,,,,fee schedule,36768.57,36768.57, Neonate Birth Weight 1000-1249 Grams With Or Without Significant Condition,6032,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,36768.57,,,,,,,fee schedule,36768.57,36768.57, Neonate Birth Weight 1000-1249 Grams With Or Without Significant Condition,6032,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,36768.57,,,,,,,fee schedule,36768.57,36768.57, Neonate Birth Weight 1000-1249 Grams With Or Without Significant Condition,6032,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,36768.57,,,,,,,fee schedule,36768.57,36768.57, Neonate Birth Weight 1000-1249 Grams With Or Without Significant Condition,6033,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,45063.49,,,,,,,fee schedule,45063.49,45063.49, Neonate Birth Weight 1000-1249 Grams With Or Without Significant Condition,6033,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,45063.49,,,,,,,fee schedule,45063.49,45063.49, Neonate Birth Weight 1000-1249 Grams With Or Without Significant Condition,6033,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,45063.49,,,,,,,fee schedule,45063.49,45063.49, Neonate Birth Weight 1000-1249 Grams With Or Without Significant Condition,6033,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,45063.49,,,,,,,fee schedule,45063.49,45063.49, Neonate Birth Weight 1000-1249 Grams With Or Without Significant Condition,6033,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,45063.49,,,,,,,fee schedule,45063.49,45063.49, Neonate Birth Weight 1000-1249 Grams With Or Without Significant Condition,6033,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,45063.49,,,,,,,fee schedule,45063.49,45063.49, Neonate Birth Weight 1000-1249 Grams With Or Without Significant Condition,6033,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,45063.49,,,,,,,fee schedule,45063.49,45063.49, Neonate Birth Weight 1000-1249 Grams With Or Without Significant Condition,6033,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,45063.49,,,,,,,fee schedule,45063.49,45063.49, Neonate Birth Weight 1000-1249 Grams With Or Without Significant Condition,6033,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,45063.49,,,,,,,fee schedule,45063.49,45063.49, Neonate Birth Weight 1000-1249 Grams With Or Without Significant Condition,6033,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,45063.49,,,,,,,fee schedule,45063.49,45063.49, Neonate Birth Weight 1000-1249 Grams With Or Without Significant Condition,6033,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,45063.49,,,,,,,fee schedule,45063.49,45063.49, Neonate Birth Weight 1000-1249 Grams With Or Without Significant Condition,6034,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,79581.36,,,,,,,fee schedule,79581.36,79581.36, Neonate Birth Weight 1000-1249 Grams With Or Without Significant Condition,6034,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,79581.36,,,,,,,fee schedule,79581.36,79581.36, Neonate Birth Weight 1000-1249 Grams With Or Without Significant Condition,6034,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,79581.36,,,,,,,fee schedule,79581.36,79581.36, Neonate Birth Weight 1000-1249 Grams With Or Without Significant Condition,6034,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,79581.36,,,,,,,fee schedule,79581.36,79581.36, Neonate Birth Weight 1000-1249 Grams With Or Without Significant Condition,6034,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,79581.36,,,,,,,fee schedule,79581.36,79581.36, Neonate Birth Weight 1000-1249 Grams With Or Without Significant Condition,6034,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,79581.36,,,,,,,fee schedule,79581.36,79581.36, Neonate Birth Weight 1000-1249 Grams With Or Without Significant Condition,6034,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,79581.36,,,,,,,fee schedule,79581.36,79581.36, Neonate Birth Weight 1000-1249 Grams With Or Without Significant Condition,6034,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,79581.36,,,,,,,fee schedule,79581.36,79581.36, Neonate Birth Weight 1000-1249 Grams With Or Without Significant Condition,6034,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,79581.36,,,,,,,fee schedule,79581.36,79581.36, Neonate Birth Weight 1000-1249 Grams With Or Without Significant Condition,6034,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,79581.36,,,,,,,fee schedule,79581.36,79581.36, Neonate Birth Weight 1000-1249 Grams With Or Without Significant Condition,6034,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,79581.36,,,,,,,fee schedule,79581.36,79581.36, Respiratory Condition Or Major Anomaly,6071,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,30789.98,,,,,,,fee schedule,30789.98,30789.98, Respiratory Condition Or Major Anomaly,6071,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,30789.98,,,,,,,fee schedule,30789.98,30789.98, Respiratory Condition Or Major Anomaly,6071,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,30789.98,,,,,,,fee schedule,30789.98,30789.98, Respiratory Condition Or Major Anomaly,6071,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,30789.98,,,,,,,fee schedule,30789.98,30789.98, Respiratory Condition Or Major Anomaly,6071,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,30789.98,,,,,,,fee schedule,30789.98,30789.98, Respiratory Condition Or Major Anomaly,6071,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,30789.98,,,,,,,fee schedule,30789.98,30789.98, Respiratory Condition Or Major Anomaly,6071,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,30789.98,,,,,,,fee schedule,30789.98,30789.98, Respiratory Condition Or Major Anomaly,6071,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,30789.98,,,,,,,fee schedule,30789.98,30789.98, Respiratory Condition Or Major Anomaly,6071,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,30789.98,,,,,,,fee schedule,30789.98,30789.98, Respiratory Condition Or Major Anomaly,6071,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,30789.98,,,,,,,fee schedule,30789.98,30789.98, Respiratory Condition Or Major Anomaly,6071,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,30789.98,,,,,,,fee schedule,30789.98,30789.98, Respiratory Condition Or Major Anomaly,6072,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,43070.4,,,,,,,fee schedule,43070.4,43070.4, Respiratory Condition Or Major Anomaly,6072,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,43070.4,,,,,,,fee schedule,43070.4,43070.4, Respiratory Condition Or Major Anomaly,6072,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,43070.4,,,,,,,fee schedule,43070.4,43070.4, Respiratory Condition Or Major Anomaly,6072,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,43070.4,,,,,,,fee schedule,43070.4,43070.4, Respiratory Condition Or Major Anomaly,6072,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,43070.4,,,,,,,fee schedule,43070.4,43070.4, Respiratory Condition Or Major Anomaly,6072,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,43070.4,,,,,,,fee schedule,43070.4,43070.4, Respiratory Condition Or Major Anomaly,6072,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,43070.4,,,,,,,fee schedule,43070.4,43070.4, Respiratory Condition Or Major Anomaly,6072,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,43070.4,,,,,,,fee schedule,43070.4,43070.4, Respiratory Condition Or Major Anomaly,6072,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,43070.4,,,,,,,fee schedule,43070.4,43070.4, Respiratory Condition Or Major Anomaly,6072,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,43070.4,,,,,,,fee schedule,43070.4,43070.4, Respiratory Condition Or Major Anomaly,6072,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,43070.4,,,,,,,fee schedule,43070.4,43070.4, Respiratory Condition Or Major Anomaly,6073,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,57665.75,,,,,,,fee schedule,57665.75,57665.75, Respiratory Condition Or Major Anomaly,6073,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,57665.75,,,,,,,fee schedule,57665.75,57665.75, Respiratory Condition Or Major Anomaly,6073,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,57665.75,,,,,,,fee schedule,57665.75,57665.75, Respiratory Condition Or Major Anomaly,6073,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,57665.75,,,,,,,fee schedule,57665.75,57665.75, Respiratory Condition Or Major Anomaly,6073,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,57665.75,,,,,,,fee schedule,57665.75,57665.75, Respiratory Condition Or Major Anomaly,6073,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,57665.75,,,,,,,fee schedule,57665.75,57665.75, Respiratory Condition Or Major Anomaly,6073,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,57665.75,,,,,,,fee schedule,57665.75,57665.75, Respiratory Condition Or Major Anomaly,6073,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,57665.75,,,,,,,fee schedule,57665.75,57665.75, Respiratory Condition Or Major Anomaly,6073,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,57665.75,,,,,,,fee schedule,57665.75,57665.75, Respiratory Condition Or Major Anomaly,6073,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,57665.75,,,,,,,fee schedule,57665.75,57665.75, Respiratory Condition Or Major Anomaly,6073,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,57665.75,,,,,,,fee schedule,57665.75,57665.75, Respiratory Condition Or Major Anomaly,6074,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,84107.47,,,,,,,fee schedule,84107.47,84107.47, Respiratory Condition Or Major Anomaly,6074,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,84107.47,,,,,,,fee schedule,84107.47,84107.47, Respiratory Condition Or Major Anomaly,6074,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,84107.47,,,,,,,fee schedule,84107.47,84107.47, Respiratory Condition Or Major Anomaly,6074,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,84107.47,,,,,,,fee schedule,84107.47,84107.47, Respiratory Condition Or Major Anomaly,6074,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,84107.47,,,,,,,fee schedule,84107.47,84107.47, Respiratory Condition Or Major Anomaly,6074,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,84107.47,,,,,,,fee schedule,84107.47,84107.47, Respiratory Condition Or Major Anomaly,6074,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,84107.47,,,,,,,fee schedule,84107.47,84107.47, Respiratory Condition Or Major Anomaly,6074,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,84107.47,,,,,,,fee schedule,84107.47,84107.47, Respiratory Condition Or Major Anomaly,6074,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,84107.47,,,,,,,fee schedule,84107.47,84107.47, Respiratory Condition Or Major Anomaly,6074,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,84107.47,,,,,,,fee schedule,84107.47,84107.47, Respiratory Condition Or Major Anomaly,6074,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,84107.47,,,,,,,fee schedule,84107.47,84107.47, Neonate Birth Weight 1250-1499 Grams With Or Without Significant Condition,6081,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,16495.29,,,,,,,fee schedule,16495.29,16495.29, Neonate Birth Weight 1250-1499 Grams With Or Without Significant Condition,6081,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,16495.29,,,,,,,fee schedule,16495.29,16495.29, Neonate Birth Weight 1250-1499 Grams With Or Without Significant Condition,6081,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,16495.29,,,,,,,fee schedule,16495.29,16495.29, Neonate Birth Weight 1250-1499 Grams With Or Without Significant Condition,6081,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,16495.29,,,,,,,fee schedule,16495.29,16495.29, Neonate Birth Weight 1250-1499 Grams With Or Without Significant Condition,6081,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,16495.29,,,,,,,fee schedule,16495.29,16495.29, Neonate Birth Weight 1250-1499 Grams With Or Without Significant Condition,6081,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,16495.29,,,,,,,fee schedule,16495.29,16495.29, Neonate Birth Weight 1250-1499 Grams With Or Without Significant Condition,6081,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,16495.29,,,,,,,fee schedule,16495.29,16495.29, Neonate Birth Weight 1250-1499 Grams With Or Without Significant Condition,6081,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,16495.29,,,,,,,fee schedule,16495.29,16495.29, Neonate Birth Weight 1250-1499 Grams With Or Without Significant Condition,6081,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,16495.29,,,,,,,fee schedule,16495.29,16495.29, Neonate Birth Weight 1250-1499 Grams With Or Without Significant Condition,6081,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,16495.29,,,,,,,fee schedule,16495.29,16495.29, Neonate Birth Weight 1250-1499 Grams With Or Without Significant Condition,6081,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,16495.29,,,,,,,fee schedule,16495.29,16495.29, Neonate Birth Weight 1250-1499 Grams With Or Without Significant Condition,6082,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,28607.73,,,,,,,fee schedule,28607.73,28607.73, Neonate Birth Weight 1250-1499 Grams With Or Without Significant Condition,6082,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,28607.73,,,,,,,fee schedule,28607.73,28607.73, Neonate Birth Weight 1250-1499 Grams With Or Without Significant Condition,6082,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,28607.73,,,,,,,fee schedule,28607.73,28607.73, Neonate Birth Weight 1250-1499 Grams With Or Without Significant Condition,6082,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,28607.73,,,,,,,fee schedule,28607.73,28607.73, Neonate Birth Weight 1250-1499 Grams With Or Without Significant Condition,6082,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,28607.73,,,,,,,fee schedule,28607.73,28607.73, Neonate Birth Weight 1250-1499 Grams With Or Without Significant Condition,6082,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,28607.73,,,,,,,fee schedule,28607.73,28607.73, Neonate Birth Weight 1250-1499 Grams With Or Without Significant Condition,6082,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,28607.73,,,,,,,fee schedule,28607.73,28607.73, Neonate Birth Weight 1250-1499 Grams With Or Without Significant Condition,6082,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,28607.73,,,,,,,fee schedule,28607.73,28607.73, Neonate Birth Weight 1250-1499 Grams With Or Without Significant Condition,6082,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,28607.73,,,,,,,fee schedule,28607.73,28607.73, Neonate Birth Weight 1250-1499 Grams With Or Without Significant Condition,6082,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,28607.73,,,,,,,fee schedule,28607.73,28607.73, Neonate Birth Weight 1250-1499 Grams With Or Without Significant Condition,6082,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,28607.73,,,,,,,fee schedule,28607.73,28607.73, Neonate Birth Weight 1250-1499 Grams With Or Without Significant Condition,6083,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,41409.72,,,,,,,fee schedule,41409.72,41409.72, Neonate Birth Weight 1250-1499 Grams With Or Without Significant Condition,6083,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,41409.72,,,,,,,fee schedule,41409.72,41409.72, Neonate Birth Weight 1250-1499 Grams With Or Without Significant Condition,6083,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,41409.72,,,,,,,fee schedule,41409.72,41409.72, Neonate Birth Weight 1250-1499 Grams With Or Without Significant Condition,6083,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,41409.72,,,,,,,fee schedule,41409.72,41409.72, Neonate Birth Weight 1250-1499 Grams With Or Without Significant Condition,6083,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,41409.72,,,,,,,fee schedule,41409.72,41409.72, Neonate Birth Weight 1250-1499 Grams With Or Without Significant Condition,6083,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,41409.72,,,,,,,fee schedule,41409.72,41409.72, Neonate Birth Weight 1250-1499 Grams With Or Without Significant Condition,6083,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,41409.72,,,,,,,fee schedule,41409.72,41409.72, Neonate Birth Weight 1250-1499 Grams With Or Without Significant Condition,6083,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,41409.72,,,,,,,fee schedule,41409.72,41409.72, Neonate Birth Weight 1250-1499 Grams With Or Without Significant Condition,6083,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,41409.72,,,,,,,fee schedule,41409.72,41409.72, Neonate Birth Weight 1250-1499 Grams With Or Without Significant Condition,6083,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,41409.72,,,,,,,fee schedule,41409.72,41409.72, Neonate Birth Weight 1250-1499 Grams With Or Without Significant Condition,6083,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,41409.72,,,,,,,fee schedule,41409.72,41409.72, Neonate Birth Weight 1250-1499 Grams With Or Without Significant Condition,6084,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,47971.98,,,,,,,fee schedule,47971.98,47971.98, Neonate Birth Weight 1250-1499 Grams With Or Without Significant Condition,6084,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,47971.98,,,,,,,fee schedule,47971.98,47971.98, Neonate Birth Weight 1250-1499 Grams With Or Without Significant Condition,6084,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,47971.98,,,,,,,fee schedule,47971.98,47971.98, Neonate Birth Weight 1250-1499 Grams With Or Without Significant Condition,6084,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,47971.98,,,,,,,fee schedule,47971.98,47971.98, Neonate Birth Weight 1250-1499 Grams With Or Without Significant Condition,6084,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,47971.98,,,,,,,fee schedule,47971.98,47971.98, Neonate Birth Weight 1250-1499 Grams With Or Without Significant Condition,6084,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,47971.98,,,,,,,fee schedule,47971.98,47971.98, Neonate Birth Weight 1250-1499 Grams With Or Without Significant Condition,6084,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,47971.98,,,,,,,fee schedule,47971.98,47971.98, Neonate Birth Weight 1250-1499 Grams With Or Without Significant Condition,6084,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,47971.98,,,,,,,fee schedule,47971.98,47971.98, Neonate Birth Weight 1250-1499 Grams With Or Without Significant Condition,6084,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,47971.98,,,,,,,fee schedule,47971.98,47971.98, Neonate Birth Weight 1250-1499 Grams With Or Without Significant Condition,6084,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,47971.98,,,,,,,fee schedule,47971.98,47971.98, Neonate Birth Weight 1250-1499 Grams With Or Without Significant Condition,6084,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,47971.98,,,,,,,fee schedule,47971.98,47971.98, Neonate Birth Weight 1500-2499 Grams With Major Procedure,6091,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,31735,,,,,,,fee schedule,31735,31735, Neonate Birth Weight 1500-2499 Grams With Major Procedure,6091,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,31735,,,,,,,fee schedule,31735,31735, Neonate Birth Weight 1500-2499 Grams With Major Procedure,6091,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,31735,,,,,,,fee schedule,31735,31735, Neonate Birth Weight 1500-2499 Grams With Major Procedure,6091,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,31735,,,,,,,fee schedule,31735,31735, Neonate Birth Weight 1500-2499 Grams With Major Procedure,6091,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,31735,,,,,,,fee schedule,31735,31735, Neonate Birth Weight 1500-2499 Grams With Major Procedure,6091,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,31735,,,,,,,fee schedule,31735,31735, Neonate Birth Weight 1500-2499 Grams With Major Procedure,6091,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,31735,,,,,,,fee schedule,31735,31735, Neonate Birth Weight 1500-2499 Grams With Major Procedure,6091,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,31735,,,,,,,fee schedule,31735,31735, Neonate Birth Weight 1500-2499 Grams With Major Procedure,6091,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,31735,,,,,,,fee schedule,31735,31735, Neonate Birth Weight 1500-2499 Grams With Major Procedure,6091,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,31735,,,,,,,fee schedule,31735,31735, Neonate Birth Weight 1500-2499 Grams With Major Procedure,6091,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,31735,,,,,,,fee schedule,31735,31735, Neonate Birth Weight 1500-2499 Grams With Major Procedure,6092,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,39507.66,,,,,,,fee schedule,39507.66,39507.66, Neonate Birth Weight 1500-2499 Grams With Major Procedure,6092,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,39507.66,,,,,,,fee schedule,39507.66,39507.66, Neonate Birth Weight 1500-2499 Grams With Major Procedure,6092,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,39507.66,,,,,,,fee schedule,39507.66,39507.66, Neonate Birth Weight 1500-2499 Grams With Major Procedure,6092,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,39507.66,,,,,,,fee schedule,39507.66,39507.66, Neonate Birth Weight 1500-2499 Grams With Major Procedure,6092,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,39507.66,,,,,,,fee schedule,39507.66,39507.66, Neonate Birth Weight 1500-2499 Grams With Major Procedure,6092,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,39507.66,,,,,,,fee schedule,39507.66,39507.66, Neonate Birth Weight 1500-2499 Grams With Major Procedure,6092,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,39507.66,,,,,,,fee schedule,39507.66,39507.66, Neonate Birth Weight 1500-2499 Grams With Major Procedure,6092,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,39507.66,,,,,,,fee schedule,39507.66,39507.66, Neonate Birth Weight 1500-2499 Grams With Major Procedure,6092,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,39507.66,,,,,,,fee schedule,39507.66,39507.66, Neonate Birth Weight 1500-2499 Grams With Major Procedure,6092,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,39507.66,,,,,,,fee schedule,39507.66,39507.66, Neonate Birth Weight 1500-2499 Grams With Major Procedure,6092,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,39507.66,,,,,,,fee schedule,39507.66,39507.66, Neonate Birth Weight 1500-2499 Grams With Major Procedure,6093,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,60547.41,,,,,,,fee schedule,60547.41,60547.41, Neonate Birth Weight 1500-2499 Grams With Major Procedure,6093,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,60547.41,,,,,,,fee schedule,60547.41,60547.41, Neonate Birth Weight 1500-2499 Grams With Major Procedure,6093,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,60547.41,,,,,,,fee schedule,60547.41,60547.41, Neonate Birth Weight 1500-2499 Grams With Major Procedure,6093,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,60547.41,,,,,,,fee schedule,60547.41,60547.41, Neonate Birth Weight 1500-2499 Grams With Major Procedure,6093,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,60547.41,,,,,,,fee schedule,60547.41,60547.41, Neonate Birth Weight 1500-2499 Grams With Major Procedure,6093,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,60547.41,,,,,,,fee schedule,60547.41,60547.41, Neonate Birth Weight 1500-2499 Grams With Major Procedure,6093,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,60547.41,,,,,,,fee schedule,60547.41,60547.41, Neonate Birth Weight 1500-2499 Grams With Major Procedure,6093,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,60547.41,,,,,,,fee schedule,60547.41,60547.41, Neonate Birth Weight 1500-2499 Grams With Major Procedure,6093,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,60547.41,,,,,,,fee schedule,60547.41,60547.41, Neonate Birth Weight 1500-2499 Grams With Major Procedure,6093,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,60547.41,,,,,,,fee schedule,60547.41,60547.41, Neonate Birth Weight 1500-2499 Grams With Major Procedure,6093,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,60547.41,,,,,,,fee schedule,60547.41,60547.41, Neonate Birth Weight 1500-2499 Grams With Major Procedure,6094,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,174543.58,,,,,,,fee schedule,174543.58,174543.58, Neonate Birth Weight 1500-2499 Grams With Major Procedure,6094,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,174543.58,,,,,,,fee schedule,174543.58,174543.58, Neonate Birth Weight 1500-2499 Grams With Major Procedure,6094,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,174543.58,,,,,,,fee schedule,174543.58,174543.58, Neonate Birth Weight 1500-2499 Grams With Major Procedure,6094,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,174543.58,,,,,,,fee schedule,174543.58,174543.58, Neonate Birth Weight 1500-2499 Grams With Major Procedure,6094,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,174543.58,,,,,,,fee schedule,174543.58,174543.58, Neonate Birth Weight 1500-2499 Grams With Major Procedure,6094,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,174543.58,,,,,,,fee schedule,174543.58,174543.58, Neonate Birth Weight 1500-2499 Grams With Major Procedure,6094,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,174543.58,,,,,,,fee schedule,174543.58,174543.58, Neonate Birth Weight 1500-2499 Grams With Major Procedure,6094,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,174543.58,,,,,,,fee schedule,174543.58,174543.58, Neonate Birth Weight 1500-2499 Grams With Major Procedure,6094,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,174543.58,,,,,,,fee schedule,174543.58,174543.58, Neonate Birth Weight 1500-2499 Grams With Major Procedure,6094,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,174543.58,,,,,,,fee schedule,174543.58,174543.58, Neonate Birth Weight 1500-2499 Grams With Major Procedure,6094,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,174543.58,,,,,,,fee schedule,174543.58,174543.58, Neonate Birth Weight 1500-1999 Grams With Major Anomaly,6111,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,12022.11,,,,,,,fee schedule,12022.11,12022.11, Neonate Birth Weight 1500-1999 Grams With Major Anomaly,6111,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,12022.11,,,,,,,fee schedule,12022.11,12022.11, Neonate Birth Weight 1500-1999 Grams With Major Anomaly,6111,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,12022.11,,,,,,,fee schedule,12022.11,12022.11, Neonate Birth Weight 1500-1999 Grams With Major Anomaly,6111,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,12022.11,,,,,,,fee schedule,12022.11,12022.11, Neonate Birth Weight 1500-1999 Grams With Major Anomaly,6111,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,12022.11,,,,,,,fee schedule,12022.11,12022.11, Neonate Birth Weight 1500-1999 Grams With Major Anomaly,6111,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,12022.11,,,,,,,fee schedule,12022.11,12022.11, Neonate Birth Weight 1500-1999 Grams With Major Anomaly,6111,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,12022.11,,,,,,,fee schedule,12022.11,12022.11, Neonate Birth Weight 1500-1999 Grams With Major Anomaly,6111,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,12022.11,,,,,,,fee schedule,12022.11,12022.11, Neonate Birth Weight 1500-1999 Grams With Major Anomaly,6111,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,12022.11,,,,,,,fee schedule,12022.11,12022.11, Neonate Birth Weight 1500-1999 Grams With Major Anomaly,6111,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,12022.11,,,,,,,fee schedule,12022.11,12022.11, Neonate Birth Weight 1500-1999 Grams With Major Anomaly,6111,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,12022.11,,,,,,,fee schedule,12022.11,12022.11, Neonate Birth Weight 1500-1999 Grams With Major Anomaly,6112,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,22917.8,,,,,,,fee schedule,22917.8,22917.8, Neonate Birth Weight 1500-1999 Grams With Major Anomaly,6112,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,22917.8,,,,,,,fee schedule,22917.8,22917.8, Neonate Birth Weight 1500-1999 Grams With Major Anomaly,6112,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,22917.8,,,,,,,fee schedule,22917.8,22917.8, Neonate Birth Weight 1500-1999 Grams With Major Anomaly,6112,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,22917.8,,,,,,,fee schedule,22917.8,22917.8, Neonate Birth Weight 1500-1999 Grams With Major Anomaly,6112,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,22917.8,,,,,,,fee schedule,22917.8,22917.8, Neonate Birth Weight 1500-1999 Grams With Major Anomaly,6112,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,22917.8,,,,,,,fee schedule,22917.8,22917.8, Neonate Birth Weight 1500-1999 Grams With Major Anomaly,6112,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,22917.8,,,,,,,fee schedule,22917.8,22917.8, Neonate Birth Weight 1500-1999 Grams With Major Anomaly,6112,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,22917.8,,,,,,,fee schedule,22917.8,22917.8, Neonate Birth Weight 1500-1999 Grams With Major Anomaly,6112,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,22917.8,,,,,,,fee schedule,22917.8,22917.8, Neonate Birth Weight 1500-1999 Grams With Major Anomaly,6112,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,22917.8,,,,,,,fee schedule,22917.8,22917.8, Neonate Birth Weight 1500-1999 Grams With Major Anomaly,6112,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,22917.8,,,,,,,fee schedule,22917.8,22917.8, Neonate Birth Weight 1500-1999 Grams With Major Anomaly,6113,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,37306.36,,,,,,,fee schedule,37306.36,37306.36, Neonate Birth Weight 1500-1999 Grams With Major Anomaly,6113,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,37306.36,,,,,,,fee schedule,37306.36,37306.36, Neonate Birth Weight 1500-1999 Grams With Major Anomaly,6113,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,37306.36,,,,,,,fee schedule,37306.36,37306.36, Neonate Birth Weight 1500-1999 Grams With Major Anomaly,6113,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,37306.36,,,,,,,fee schedule,37306.36,37306.36, Neonate Birth Weight 1500-1999 Grams With Major Anomaly,6113,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,37306.36,,,,,,,fee schedule,37306.36,37306.36, Neonate Birth Weight 1500-1999 Grams With Major Anomaly,6113,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,37306.36,,,,,,,fee schedule,37306.36,37306.36, Neonate Birth Weight 1500-1999 Grams With Major Anomaly,6113,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,37306.36,,,,,,,fee schedule,37306.36,37306.36, Neonate Birth Weight 1500-1999 Grams With Major Anomaly,6113,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,37306.36,,,,,,,fee schedule,37306.36,37306.36, Neonate Birth Weight 1500-1999 Grams With Major Anomaly,6113,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,37306.36,,,,,,,fee schedule,37306.36,37306.36, Neonate Birth Weight 1500-1999 Grams With Major Anomaly,6113,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,37306.36,,,,,,,fee schedule,37306.36,37306.36, Neonate Birth Weight 1500-1999 Grams With Major Anomaly,6113,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,37306.36,,,,,,,fee schedule,37306.36,37306.36, Neonate Birth Weight 1500-1999 Grams With Major Anomaly,6114,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,69953.22,,,,,,,fee schedule,69953.22,69953.22, Neonate Birth Weight 1500-1999 Grams With Major Anomaly,6114,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,69953.22,,,,,,,fee schedule,69953.22,69953.22, Neonate Birth Weight 1500-1999 Grams With Major Anomaly,6114,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,69953.22,,,,,,,fee schedule,69953.22,69953.22, Neonate Birth Weight 1500-1999 Grams With Major Anomaly,6114,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,69953.22,,,,,,,fee schedule,69953.22,69953.22, Neonate Birth Weight 1500-1999 Grams With Major Anomaly,6114,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,69953.22,,,,,,,fee schedule,69953.22,69953.22, Neonate Birth Weight 1500-1999 Grams With Major Anomaly,6114,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,69953.22,,,,,,,fee schedule,69953.22,69953.22, Neonate Birth Weight 1500-1999 Grams With Major Anomaly,6114,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,69953.22,,,,,,,fee schedule,69953.22,69953.22, Neonate Birth Weight 1500-1999 Grams With Major Anomaly,6114,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,69953.22,,,,,,,fee schedule,69953.22,69953.22, Neonate Birth Weight 1500-1999 Grams With Major Anomaly,6114,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,69953.22,,,,,,,fee schedule,69953.22,69953.22, Neonate Birth Weight 1500-1999 Grams With Major Anomaly,6114,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,69953.22,,,,,,,fee schedule,69953.22,69953.22, Neonate Birth Weight 1500-1999 Grams With Major Anomaly,6114,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,69953.22,,,,,,,fee schedule,69953.22,69953.22, Respiratory Condition,6121,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,18443.92,,,,,,,fee schedule,18443.92,18443.92, Respiratory Condition,6121,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,18443.92,,,,,,,fee schedule,18443.92,18443.92, Respiratory Condition,6121,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,18443.92,,,,,,,fee schedule,18443.92,18443.92, Respiratory Condition,6121,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,18443.92,,,,,,,fee schedule,18443.92,18443.92, Respiratory Condition,6121,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,18443.92,,,,,,,fee schedule,18443.92,18443.92, Respiratory Condition,6121,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,18443.92,,,,,,,fee schedule,18443.92,18443.92, Respiratory Condition,6121,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,18443.92,,,,,,,fee schedule,18443.92,18443.92, Respiratory Condition,6121,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,18443.92,,,,,,,fee schedule,18443.92,18443.92, Respiratory Condition,6121,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,18443.92,,,,,,,fee schedule,18443.92,18443.92, Respiratory Condition,6121,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,18443.92,,,,,,,fee schedule,18443.92,18443.92, Respiratory Condition,6121,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,18443.92,,,,,,,fee schedule,18443.92,18443.92, Respiratory Condition,6122,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,26722.62,,,,,,,fee schedule,26722.62,26722.62, Respiratory Condition,6122,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,26722.62,,,,,,,fee schedule,26722.62,26722.62, Respiratory Condition,6122,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,26722.62,,,,,,,fee schedule,26722.62,26722.62, Respiratory Condition,6122,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,26722.62,,,,,,,fee schedule,26722.62,26722.62, Respiratory Condition,6122,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,26722.62,,,,,,,fee schedule,26722.62,26722.62, Respiratory Condition,6122,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,26722.62,,,,,,,fee schedule,26722.62,26722.62, Respiratory Condition,6122,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,26722.62,,,,,,,fee schedule,26722.62,26722.62, Respiratory Condition,6122,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,26722.62,,,,,,,fee schedule,26722.62,26722.62, Respiratory Condition,6122,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,26722.62,,,,,,,fee schedule,26722.62,26722.62, Respiratory Condition,6122,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,26722.62,,,,,,,fee schedule,26722.62,26722.62, Respiratory Condition,6122,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,26722.62,,,,,,,fee schedule,26722.62,26722.62, Respiratory Condition,6123,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,38159.64,,,,,,,fee schedule,38159.64,38159.64, Respiratory Condition,6123,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,38159.64,,,,,,,fee schedule,38159.64,38159.64, Respiratory Condition,6123,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,38159.64,,,,,,,fee schedule,38159.64,38159.64, Respiratory Condition,6123,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,38159.64,,,,,,,fee schedule,38159.64,38159.64, Respiratory Condition,6123,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,38159.64,,,,,,,fee schedule,38159.64,38159.64, Respiratory Condition,6123,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,38159.64,,,,,,,fee schedule,38159.64,38159.64, Respiratory Condition,6123,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,38159.64,,,,,,,fee schedule,38159.64,38159.64, Respiratory Condition,6123,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,38159.64,,,,,,,fee schedule,38159.64,38159.64, Respiratory Condition,6123,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,38159.64,,,,,,,fee schedule,38159.64,38159.64, Respiratory Condition,6123,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,38159.64,,,,,,,fee schedule,38159.64,38159.64, Respiratory Condition,6123,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,38159.64,,,,,,,fee schedule,38159.64,38159.64, Respiratory Condition,6124,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,55104.5,,,,,,,fee schedule,55104.5,55104.5, Respiratory Condition,6124,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,55104.5,,,,,,,fee schedule,55104.5,55104.5, Respiratory Condition,6124,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,55104.5,,,,,,,fee schedule,55104.5,55104.5, Respiratory Condition,6124,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,55104.5,,,,,,,fee schedule,55104.5,55104.5, Respiratory Condition,6124,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,55104.5,,,,,,,fee schedule,55104.5,55104.5, Respiratory Condition,6124,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,55104.5,,,,,,,fee schedule,55104.5,55104.5, Respiratory Condition,6124,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,55104.5,,,,,,,fee schedule,55104.5,55104.5, Respiratory Condition,6124,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,55104.5,,,,,,,fee schedule,55104.5,55104.5, Respiratory Condition,6124,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,55104.5,,,,,,,fee schedule,55104.5,55104.5, Respiratory Condition,6124,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,55104.5,,,,,,,fee schedule,55104.5,55104.5, Respiratory Condition,6124,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,55104.5,,,,,,,fee schedule,55104.5,55104.5, Neonate Birth Weight 1500-1999 Grams With Congenital Or Perinatal Infection,6131,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,14138.72,,,,,,,fee schedule,14138.72,14138.72, Neonate Birth Weight 1500-1999 Grams With Congenital Or Perinatal Infection,6131,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,14138.72,,,,,,,fee schedule,14138.72,14138.72, Neonate Birth Weight 1500-1999 Grams With Congenital Or Perinatal Infection,6131,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,14138.72,,,,,,,fee schedule,14138.72,14138.72, Neonate Birth Weight 1500-1999 Grams With Congenital Or Perinatal Infection,6131,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,14138.72,,,,,,,fee schedule,14138.72,14138.72, Neonate Birth Weight 1500-1999 Grams With Congenital Or Perinatal Infection,6131,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,14138.72,,,,,,,fee schedule,14138.72,14138.72, Neonate Birth Weight 1500-1999 Grams With Congenital Or Perinatal Infection,6131,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,14138.72,,,,,,,fee schedule,14138.72,14138.72, Neonate Birth Weight 1500-1999 Grams With Congenital Or Perinatal Infection,6131,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,14138.72,,,,,,,fee schedule,14138.72,14138.72, Neonate Birth Weight 1500-1999 Grams With Congenital Or Perinatal Infection,6131,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,14138.72,,,,,,,fee schedule,14138.72,14138.72, Neonate Birth Weight 1500-1999 Grams With Congenital Or Perinatal Infection,6131,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,14138.72,,,,,,,fee schedule,14138.72,14138.72, Neonate Birth Weight 1500-1999 Grams With Congenital Or Perinatal Infection,6131,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,14138.72,,,,,,,fee schedule,14138.72,14138.72, Neonate Birth Weight 1500-1999 Grams With Congenital Or Perinatal Infection,6131,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,14138.72,,,,,,,fee schedule,14138.72,14138.72, Neonate Birth Weight 1500-1999 Grams With Congenital Or Perinatal Infection,6132,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,22046.18,,,,,,,fee schedule,22046.18,22046.18, Neonate Birth Weight 1500-1999 Grams With Congenital Or Perinatal Infection,6132,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,22046.18,,,,,,,fee schedule,22046.18,22046.18, Neonate Birth Weight 1500-1999 Grams With Congenital Or Perinatal Infection,6132,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,22046.18,,,,,,,fee schedule,22046.18,22046.18, Neonate Birth Weight 1500-1999 Grams With Congenital Or Perinatal Infection,6132,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,22046.18,,,,,,,fee schedule,22046.18,22046.18, Neonate Birth Weight 1500-1999 Grams With Congenital Or Perinatal Infection,6132,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,22046.18,,,,,,,fee schedule,22046.18,22046.18, Neonate Birth Weight 1500-1999 Grams With Congenital Or Perinatal Infection,6132,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,22046.18,,,,,,,fee schedule,22046.18,22046.18, Neonate Birth Weight 1500-1999 Grams With Congenital Or Perinatal Infection,6132,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,22046.18,,,,,,,fee schedule,22046.18,22046.18, Neonate Birth Weight 1500-1999 Grams With Congenital Or Perinatal Infection,6132,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,22046.18,,,,,,,fee schedule,22046.18,22046.18, Neonate Birth Weight 1500-1999 Grams With Congenital Or Perinatal Infection,6132,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,22046.18,,,,,,,fee schedule,22046.18,22046.18, Neonate Birth Weight 1500-1999 Grams With Congenital Or Perinatal Infection,6132,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,22046.18,,,,,,,fee schedule,22046.18,22046.18, Neonate Birth Weight 1500-1999 Grams With Congenital Or Perinatal Infection,6132,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,22046.18,,,,,,,fee schedule,22046.18,22046.18, Neonate Birth Weight 1500-1999 Grams With Congenital Or Perinatal Infection,6133,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,37453.87,,,,,,,fee schedule,37453.87,37453.87, Neonate Birth Weight 1500-1999 Grams With Congenital Or Perinatal Infection,6133,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,37453.87,,,,,,,fee schedule,37453.87,37453.87, Neonate Birth Weight 1500-1999 Grams With Congenital Or Perinatal Infection,6133,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,37453.87,,,,,,,fee schedule,37453.87,37453.87, Neonate Birth Weight 1500-1999 Grams With Congenital Or Perinatal Infection,6133,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,37453.87,,,,,,,fee schedule,37453.87,37453.87, Neonate Birth Weight 1500-1999 Grams With Congenital Or Perinatal Infection,6133,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,37453.87,,,,,,,fee schedule,37453.87,37453.87, Neonate Birth Weight 1500-1999 Grams With Congenital Or Perinatal Infection,6133,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,37453.87,,,,,,,fee schedule,37453.87,37453.87, Neonate Birth Weight 1500-1999 Grams With Congenital Or Perinatal Infection,6133,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,37453.87,,,,,,,fee schedule,37453.87,37453.87, Neonate Birth Weight 1500-1999 Grams With Congenital Or Perinatal Infection,6133,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,37453.87,,,,,,,fee schedule,37453.87,37453.87, Neonate Birth Weight 1500-1999 Grams With Congenital Or Perinatal Infection,6133,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,37453.87,,,,,,,fee schedule,37453.87,37453.87, Neonate Birth Weight 1500-1999 Grams With Congenital Or Perinatal Infection,6133,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,37453.87,,,,,,,fee schedule,37453.87,37453.87, Neonate Birth Weight 1500-1999 Grams With Congenital Or Perinatal Infection,6133,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,37453.87,,,,,,,fee schedule,37453.87,37453.87, Neonate Birth Weight 1500-1999 Grams With Congenital Or Perinatal Infection,6134,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,69310.27,,,,,,,fee schedule,69310.27,69310.27, Neonate Birth Weight 1500-1999 Grams With Congenital Or Perinatal Infection,6134,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,69310.27,,,,,,,fee schedule,69310.27,69310.27, Neonate Birth Weight 1500-1999 Grams With Congenital Or Perinatal Infection,6134,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,69310.27,,,,,,,fee schedule,69310.27,69310.27, Neonate Birth Weight 1500-1999 Grams With Congenital Or Perinatal Infection,6134,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,69310.27,,,,,,,fee schedule,69310.27,69310.27, Neonate Birth Weight 1500-1999 Grams With Congenital Or Perinatal Infection,6134,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,69310.27,,,,,,,fee schedule,69310.27,69310.27, Neonate Birth Weight 1500-1999 Grams With Congenital Or Perinatal Infection,6134,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,69310.27,,,,,,,fee schedule,69310.27,69310.27, Neonate Birth Weight 1500-1999 Grams With Congenital Or Perinatal Infection,6134,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,69310.27,,,,,,,fee schedule,69310.27,69310.27, Neonate Birth Weight 1500-1999 Grams With Congenital Or Perinatal Infection,6134,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,69310.27,,,,,,,fee schedule,69310.27,69310.27, Neonate Birth Weight 1500-1999 Grams With Congenital Or Perinatal Infection,6134,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,69310.27,,,,,,,fee schedule,69310.27,69310.27, Neonate Birth Weight 1500-1999 Grams With Congenital Or Perinatal Infection,6134,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,69310.27,,,,,,,fee schedule,69310.27,69310.27, Neonate Birth Weight 1500-1999 Grams With Congenital Or Perinatal Infection,6134,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,69310.27,,,,,,,fee schedule,69310.27,69310.27, Neonate Birth Weight 1500-1999 Grams With Or Without Other Significant Condition,6141,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,9307.71,,,,,,,fee schedule,9307.71,9307.71, Neonate Birth Weight 1500-1999 Grams With Or Without Other Significant Condition,6141,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,9307.71,,,,,,,fee schedule,9307.71,9307.71, Neonate Birth Weight 1500-1999 Grams With Or Without Other Significant Condition,6141,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,9307.71,,,,,,,fee schedule,9307.71,9307.71, Neonate Birth Weight 1500-1999 Grams With Or Without Other Significant Condition,6141,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,9307.71,,,,,,,fee schedule,9307.71,9307.71, Neonate Birth Weight 1500-1999 Grams With Or Without Other Significant Condition,6141,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,9307.71,,,,,,,fee schedule,9307.71,9307.71, Neonate Birth Weight 1500-1999 Grams With Or Without Other Significant Condition,6141,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,9307.71,,,,,,,fee schedule,9307.71,9307.71, Neonate Birth Weight 1500-1999 Grams With Or Without Other Significant Condition,6141,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,9307.71,,,,,,,fee schedule,9307.71,9307.71, Neonate Birth Weight 1500-1999 Grams With Or Without Other Significant Condition,6141,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,9307.71,,,,,,,fee schedule,9307.71,9307.71, Neonate Birth Weight 1500-1999 Grams With Or Without Other Significant Condition,6141,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,9307.71,,,,,,,fee schedule,9307.71,9307.71, Neonate Birth Weight 1500-1999 Grams With Or Without Other Significant Condition,6141,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,9307.71,,,,,,,fee schedule,9307.71,9307.71, Neonate Birth Weight 1500-1999 Grams With Or Without Other Significant Condition,6141,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,9307.71,,,,,,,fee schedule,9307.71,9307.71, Neonate Birth Weight 1500-1999 Grams With Or Without Other Significant Condition,6142,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,18040.92,,,,,,,fee schedule,18040.92,18040.92, Neonate Birth Weight 1500-1999 Grams With Or Without Other Significant Condition,6142,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,18040.92,,,,,,,fee schedule,18040.92,18040.92, Neonate Birth Weight 1500-1999 Grams With Or Without Other Significant Condition,6142,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,18040.92,,,,,,,fee schedule,18040.92,18040.92, Neonate Birth Weight 1500-1999 Grams With Or Without Other Significant Condition,6142,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,18040.92,,,,,,,fee schedule,18040.92,18040.92, Neonate Birth Weight 1500-1999 Grams With Or Without Other Significant Condition,6142,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,18040.92,,,,,,,fee schedule,18040.92,18040.92, Neonate Birth Weight 1500-1999 Grams With Or Without Other Significant Condition,6142,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,18040.92,,,,,,,fee schedule,18040.92,18040.92, Neonate Birth Weight 1500-1999 Grams With Or Without Other Significant Condition,6142,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,18040.92,,,,,,,fee schedule,18040.92,18040.92, Neonate Birth Weight 1500-1999 Grams With Or Without Other Significant Condition,6142,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,18040.92,,,,,,,fee schedule,18040.92,18040.92, Neonate Birth Weight 1500-1999 Grams With Or Without Other Significant Condition,6142,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,18040.92,,,,,,,fee schedule,18040.92,18040.92, Neonate Birth Weight 1500-1999 Grams With Or Without Other Significant Condition,6142,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,18040.92,,,,,,,fee schedule,18040.92,18040.92, Neonate Birth Weight 1500-1999 Grams With Or Without Other Significant Condition,6142,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,18040.92,,,,,,,fee schedule,18040.92,18040.92, Neonate Birth Weight 1500-1999 Grams With Or Without Other Significant Condition,6143,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,31233.91,,,,,,,fee schedule,31233.91,31233.91, Neonate Birth Weight 1500-1999 Grams With Or Without Other Significant Condition,6143,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,31233.91,,,,,,,fee schedule,31233.91,31233.91, Neonate Birth Weight 1500-1999 Grams With Or Without Other Significant Condition,6143,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,31233.91,,,,,,,fee schedule,31233.91,31233.91, Neonate Birth Weight 1500-1999 Grams With Or Without Other Significant Condition,6143,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,31233.91,,,,,,,fee schedule,31233.91,31233.91, Neonate Birth Weight 1500-1999 Grams With Or Without Other Significant Condition,6143,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,31233.91,,,,,,,fee schedule,31233.91,31233.91, Neonate Birth Weight 1500-1999 Grams With Or Without Other Significant Condition,6143,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,31233.91,,,,,,,fee schedule,31233.91,31233.91, Neonate Birth Weight 1500-1999 Grams With Or Without Other Significant Condition,6143,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,31233.91,,,,,,,fee schedule,31233.91,31233.91, Neonate Birth Weight 1500-1999 Grams With Or Without Other Significant Condition,6143,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,31233.91,,,,,,,fee schedule,31233.91,31233.91, Neonate Birth Weight 1500-1999 Grams With Or Without Other Significant Condition,6143,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,31233.91,,,,,,,fee schedule,31233.91,31233.91, Neonate Birth Weight 1500-1999 Grams With Or Without Other Significant Condition,6143,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,31233.91,,,,,,,fee schedule,31233.91,31233.91, Neonate Birth Weight 1500-1999 Grams With Or Without Other Significant Condition,6143,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,31233.91,,,,,,,fee schedule,31233.91,31233.91, Neonate Birth Weight 1500-1999 Grams With Or Without Other Significant Condition,6144,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,46246.37,,,,,,,fee schedule,46246.37,46246.37, Neonate Birth Weight 1500-1999 Grams With Or Without Other Significant Condition,6144,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,46246.37,,,,,,,fee schedule,46246.37,46246.37, Neonate Birth Weight 1500-1999 Grams With Or Without Other Significant Condition,6144,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,46246.37,,,,,,,fee schedule,46246.37,46246.37, Neonate Birth Weight 1500-1999 Grams With Or Without Other Significant Condition,6144,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,46246.37,,,,,,,fee schedule,46246.37,46246.37, Neonate Birth Weight 1500-1999 Grams With Or Without Other Significant Condition,6144,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,46246.37,,,,,,,fee schedule,46246.37,46246.37, Neonate Birth Weight 1500-1999 Grams With Or Without Other Significant Condition,6144,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,46246.37,,,,,,,fee schedule,46246.37,46246.37, Neonate Birth Weight 1500-1999 Grams With Or Without Other Significant Condition,6144,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,46246.37,,,,,,,fee schedule,46246.37,46246.37, Neonate Birth Weight 1500-1999 Grams With Or Without Other Significant Condition,6144,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,46246.37,,,,,,,fee schedule,46246.37,46246.37, Neonate Birth Weight 1500-1999 Grams With Or Without Other Significant Condition,6144,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,46246.37,,,,,,,fee schedule,46246.37,46246.37, Neonate Birth Weight 1500-1999 Grams With Or Without Other Significant Condition,6144,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,46246.37,,,,,,,fee schedule,46246.37,46246.37, Neonate Birth Weight 1500-1999 Grams With Or Without Other Significant Condition,6144,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,46246.37,,,,,,,fee schedule,46246.37,46246.37, Neonate Birth Weight 2000-2499 Grams With Major Anomaly,6211,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4502.82,,,,,,,fee schedule,4502.82,4502.82, Neonate Birth Weight 2000-2499 Grams With Major Anomaly,6211,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4502.82,,,,,,,fee schedule,4502.82,4502.82, Neonate Birth Weight 2000-2499 Grams With Major Anomaly,6211,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4502.82,,,,,,,fee schedule,4502.82,4502.82, Neonate Birth Weight 2000-2499 Grams With Major Anomaly,6211,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4502.82,,,,,,,fee schedule,4502.82,4502.82, Neonate Birth Weight 2000-2499 Grams With Major Anomaly,6211,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4502.82,,,,,,,fee schedule,4502.82,4502.82, Neonate Birth Weight 2000-2499 Grams With Major Anomaly,6211,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4502.82,,,,,,,fee schedule,4502.82,4502.82, Neonate Birth Weight 2000-2499 Grams With Major Anomaly,6211,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4502.82,,,,,,,fee schedule,4502.82,4502.82, Neonate Birth Weight 2000-2499 Grams With Major Anomaly,6211,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4502.82,,,,,,,fee schedule,4502.82,4502.82, Neonate Birth Weight 2000-2499 Grams With Major Anomaly,6211,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4502.82,,,,,,,fee schedule,4502.82,4502.82, Neonate Birth Weight 2000-2499 Grams With Major Anomaly,6211,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4502.82,,,,,,,fee schedule,4502.82,4502.82, Neonate Birth Weight 2000-2499 Grams With Major Anomaly,6211,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4502.82,,,,,,,fee schedule,4502.82,4502.82, Neonate Birth Weight 2000-2499 Grams With Major Anomaly,6212,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,13622.8,,,,,,,fee schedule,13622.8,13622.8, Neonate Birth Weight 2000-2499 Grams With Major Anomaly,6212,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,13622.8,,,,,,,fee schedule,13622.8,13622.8, Neonate Birth Weight 2000-2499 Grams With Major Anomaly,6212,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,13622.8,,,,,,,fee schedule,13622.8,13622.8, Neonate Birth Weight 2000-2499 Grams With Major Anomaly,6212,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,13622.8,,,,,,,fee schedule,13622.8,13622.8, Neonate Birth Weight 2000-2499 Grams With Major Anomaly,6212,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,13622.8,,,,,,,fee schedule,13622.8,13622.8, Neonate Birth Weight 2000-2499 Grams With Major Anomaly,6212,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,13622.8,,,,,,,fee schedule,13622.8,13622.8, Neonate Birth Weight 2000-2499 Grams With Major Anomaly,6212,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,13622.8,,,,,,,fee schedule,13622.8,13622.8, Neonate Birth Weight 2000-2499 Grams With Major Anomaly,6212,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,13622.8,,,,,,,fee schedule,13622.8,13622.8, Neonate Birth Weight 2000-2499 Grams With Major Anomaly,6212,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,13622.8,,,,,,,fee schedule,13622.8,13622.8, Neonate Birth Weight 2000-2499 Grams With Major Anomaly,6212,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,13622.8,,,,,,,fee schedule,13622.8,13622.8, Neonate Birth Weight 2000-2499 Grams With Major Anomaly,6212,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,13622.8,,,,,,,fee schedule,13622.8,13622.8, Neonate Birth Weight 2000-2499 Grams With Major Anomaly,6213,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,27196.9,,,,,,,fee schedule,27196.9,27196.9, Neonate Birth Weight 2000-2499 Grams With Major Anomaly,6213,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,27196.9,,,,,,,fee schedule,27196.9,27196.9, Neonate Birth Weight 2000-2499 Grams With Major Anomaly,6213,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,27196.9,,,,,,,fee schedule,27196.9,27196.9, Neonate Birth Weight 2000-2499 Grams With Major Anomaly,6213,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,27196.9,,,,,,,fee schedule,27196.9,27196.9, Neonate Birth Weight 2000-2499 Grams With Major Anomaly,6213,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,27196.9,,,,,,,fee schedule,27196.9,27196.9, Neonate Birth Weight 2000-2499 Grams With Major Anomaly,6213,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,27196.9,,,,,,,fee schedule,27196.9,27196.9, Neonate Birth Weight 2000-2499 Grams With Major Anomaly,6213,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,27196.9,,,,,,,fee schedule,27196.9,27196.9, Neonate Birth Weight 2000-2499 Grams With Major Anomaly,6213,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,27196.9,,,,,,,fee schedule,27196.9,27196.9, Neonate Birth Weight 2000-2499 Grams With Major Anomaly,6213,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,27196.9,,,,,,,fee schedule,27196.9,27196.9, Neonate Birth Weight 2000-2499 Grams With Major Anomaly,6213,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,27196.9,,,,,,,fee schedule,27196.9,27196.9, Neonate Birth Weight 2000-2499 Grams With Major Anomaly,6213,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,27196.9,,,,,,,fee schedule,27196.9,27196.9, Neonate Birth Weight 2000-2499 Grams With Major Anomaly,6214,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,54040.2,,,,,,,fee schedule,54040.2,54040.2, Neonate Birth Weight 2000-2499 Grams With Major Anomaly,6214,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,54040.2,,,,,,,fee schedule,54040.2,54040.2, Neonate Birth Weight 2000-2499 Grams With Major Anomaly,6214,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,54040.2,,,,,,,fee schedule,54040.2,54040.2, Neonate Birth Weight 2000-2499 Grams With Major Anomaly,6214,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,54040.2,,,,,,,fee schedule,54040.2,54040.2, Neonate Birth Weight 2000-2499 Grams With Major Anomaly,6214,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,54040.2,,,,,,,fee schedule,54040.2,54040.2, Neonate Birth Weight 2000-2499 Grams With Major Anomaly,6214,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,54040.2,,,,,,,fee schedule,54040.2,54040.2, Neonate Birth Weight 2000-2499 Grams With Major Anomaly,6214,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,54040.2,,,,,,,fee schedule,54040.2,54040.2, Neonate Birth Weight 2000-2499 Grams With Major Anomaly,6214,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,54040.2,,,,,,,fee schedule,54040.2,54040.2, Neonate Birth Weight 2000-2499 Grams With Major Anomaly,6214,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,54040.2,,,,,,,fee schedule,54040.2,54040.2, Neonate Birth Weight 2000-2499 Grams With Major Anomaly,6214,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,54040.2,,,,,,,fee schedule,54040.2,54040.2, Neonate Birth Weight 2000-2499 Grams With Major Anomaly,6214,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,54040.2,,,,,,,fee schedule,54040.2,54040.2, Respiratory Condition,6221,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,11631.11,,,,,,,fee schedule,11631.11,11631.11, Respiratory Condition,6221,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,11631.11,,,,,,,fee schedule,11631.11,11631.11, Respiratory Condition,6221,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,11631.11,,,,,,,fee schedule,11631.11,11631.11, Respiratory Condition,6221,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,11631.11,,,,,,,fee schedule,11631.11,11631.11, Respiratory Condition,6221,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,11631.11,,,,,,,fee schedule,11631.11,11631.11, Respiratory Condition,6221,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,11631.11,,,,,,,fee schedule,11631.11,11631.11, Respiratory Condition,6221,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,11631.11,,,,,,,fee schedule,11631.11,11631.11, Respiratory Condition,6221,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,11631.11,,,,,,,fee schedule,11631.11,11631.11, Respiratory Condition,6221,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,11631.11,,,,,,,fee schedule,11631.11,11631.11, Respiratory Condition,6221,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,11631.11,,,,,,,fee schedule,11631.11,11631.11, Respiratory Condition,6221,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,11631.11,,,,,,,fee schedule,11631.11,11631.11, Respiratory Condition,6222,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,16769.83,,,,,,,fee schedule,16769.83,16769.83, Respiratory Condition,6222,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,16769.83,,,,,,,fee schedule,16769.83,16769.83, Respiratory Condition,6222,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,16769.83,,,,,,,fee schedule,16769.83,16769.83, Respiratory Condition,6222,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,16769.83,,,,,,,fee schedule,16769.83,16769.83, Respiratory Condition,6222,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,16769.83,,,,,,,fee schedule,16769.83,16769.83, Respiratory Condition,6222,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,16769.83,,,,,,,fee schedule,16769.83,16769.83, Respiratory Condition,6222,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,16769.83,,,,,,,fee schedule,16769.83,16769.83, Respiratory Condition,6222,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,16769.83,,,,,,,fee schedule,16769.83,16769.83, Respiratory Condition,6222,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,16769.83,,,,,,,fee schedule,16769.83,16769.83, Respiratory Condition,6222,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,16769.83,,,,,,,fee schedule,16769.83,16769.83, Respiratory Condition,6222,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,16769.83,,,,,,,fee schedule,16769.83,16769.83, Respiratory Condition,6223,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,23965.87,,,,,,,fee schedule,23965.87,23965.87, Respiratory Condition,6223,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,23965.87,,,,,,,fee schedule,23965.87,23965.87, Respiratory Condition,6223,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,23965.87,,,,,,,fee schedule,23965.87,23965.87, Respiratory Condition,6223,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,23965.87,,,,,,,fee schedule,23965.87,23965.87, Respiratory Condition,6223,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,23965.87,,,,,,,fee schedule,23965.87,23965.87, Respiratory Condition,6223,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,23965.87,,,,,,,fee schedule,23965.87,23965.87, Respiratory Condition,6223,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,23965.87,,,,,,,fee schedule,23965.87,23965.87, Respiratory Condition,6223,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,23965.87,,,,,,,fee schedule,23965.87,23965.87, Respiratory Condition,6223,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,23965.87,,,,,,,fee schedule,23965.87,23965.87, Respiratory Condition,6223,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,23965.87,,,,,,,fee schedule,23965.87,23965.87, Respiratory Condition,6223,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,23965.87,,,,,,,fee schedule,23965.87,23965.87, Respiratory Condition,6224,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,35734.61,,,,,,,fee schedule,35734.61,35734.61, Respiratory Condition,6224,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,35734.61,,,,,,,fee schedule,35734.61,35734.61, Respiratory Condition,6224,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,35734.61,,,,,,,fee schedule,35734.61,35734.61, Respiratory Condition,6224,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,35734.61,,,,,,,fee schedule,35734.61,35734.61, Respiratory Condition,6224,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,35734.61,,,,,,,fee schedule,35734.61,35734.61, Respiratory Condition,6224,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,35734.61,,,,,,,fee schedule,35734.61,35734.61, Respiratory Condition,6224,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,35734.61,,,,,,,fee schedule,35734.61,35734.61, Respiratory Condition,6224,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,35734.61,,,,,,,fee schedule,35734.61,35734.61, Respiratory Condition,6224,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,35734.61,,,,,,,fee schedule,35734.61,35734.61, Respiratory Condition,6224,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,35734.61,,,,,,,fee schedule,35734.61,35734.61, Respiratory Condition,6224,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,35734.61,,,,,,,fee schedule,35734.61,35734.61, Neonate Birth Weight 2000-2499 Grams With Congenital Or Perinatal Infection,6231,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,8404.32,,,,,,,fee schedule,8404.32,8404.32, Neonate Birth Weight 2000-2499 Grams With Congenital Or Perinatal Infection,6231,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,8404.32,,,,,,,fee schedule,8404.32,8404.32, Neonate Birth Weight 2000-2499 Grams With Congenital Or Perinatal Infection,6231,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,8404.32,,,,,,,fee schedule,8404.32,8404.32, Neonate Birth Weight 2000-2499 Grams With Congenital Or Perinatal Infection,6231,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,8404.32,,,,,,,fee schedule,8404.32,8404.32, Neonate Birth Weight 2000-2499 Grams With Congenital Or Perinatal Infection,6231,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,8404.32,,,,,,,fee schedule,8404.32,8404.32, Neonate Birth Weight 2000-2499 Grams With Congenital Or Perinatal Infection,6231,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,8404.32,,,,,,,fee schedule,8404.32,8404.32, Neonate Birth Weight 2000-2499 Grams With Congenital Or Perinatal Infection,6231,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,8404.32,,,,,,,fee schedule,8404.32,8404.32, Neonate Birth Weight 2000-2499 Grams With Congenital Or Perinatal Infection,6231,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,8404.32,,,,,,,fee schedule,8404.32,8404.32, Neonate Birth Weight 2000-2499 Grams With Congenital Or Perinatal Infection,6231,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,8404.32,,,,,,,fee schedule,8404.32,8404.32, Neonate Birth Weight 2000-2499 Grams With Congenital Or Perinatal Infection,6231,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,8404.32,,,,,,,fee schedule,8404.32,8404.32, Neonate Birth Weight 2000-2499 Grams With Congenital Or Perinatal Infection,6231,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,8404.32,,,,,,,fee schedule,8404.32,8404.32, Neonate Birth Weight 2000-2499 Grams With Congenital Or Perinatal Infection,6232,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,14571.35,,,,,,,fee schedule,14571.35,14571.35, Neonate Birth Weight 2000-2499 Grams With Congenital Or Perinatal Infection,6232,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,14571.35,,,,,,,fee schedule,14571.35,14571.35, Neonate Birth Weight 2000-2499 Grams With Congenital Or Perinatal Infection,6232,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,14571.35,,,,,,,fee schedule,14571.35,14571.35, Neonate Birth Weight 2000-2499 Grams With Congenital Or Perinatal Infection,6232,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,14571.35,,,,,,,fee schedule,14571.35,14571.35, Neonate Birth Weight 2000-2499 Grams With Congenital Or Perinatal Infection,6232,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,14571.35,,,,,,,fee schedule,14571.35,14571.35, Neonate Birth Weight 2000-2499 Grams With Congenital Or Perinatal Infection,6232,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,14571.35,,,,,,,fee schedule,14571.35,14571.35, Neonate Birth Weight 2000-2499 Grams With Congenital Or Perinatal Infection,6232,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,14571.35,,,,,,,fee schedule,14571.35,14571.35, Neonate Birth Weight 2000-2499 Grams With Congenital Or Perinatal Infection,6232,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,14571.35,,,,,,,fee schedule,14571.35,14571.35, Neonate Birth Weight 2000-2499 Grams With Congenital Or Perinatal Infection,6232,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,14571.35,,,,,,,fee schedule,14571.35,14571.35, Neonate Birth Weight 2000-2499 Grams With Congenital Or Perinatal Infection,6232,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,14571.35,,,,,,,fee schedule,14571.35,14571.35, Neonate Birth Weight 2000-2499 Grams With Congenital Or Perinatal Infection,6232,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,14571.35,,,,,,,fee schedule,14571.35,14571.35, Neonate Birth Weight 2000-2499 Grams With Congenital Or Perinatal Infection,6233,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,29034.02,,,,,,,fee schedule,29034.02,29034.02, Neonate Birth Weight 2000-2499 Grams With Congenital Or Perinatal Infection,6233,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,29034.02,,,,,,,fee schedule,29034.02,29034.02, Neonate Birth Weight 2000-2499 Grams With Congenital Or Perinatal Infection,6233,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,29034.02,,,,,,,fee schedule,29034.02,29034.02, Neonate Birth Weight 2000-2499 Grams With Congenital Or Perinatal Infection,6233,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,29034.02,,,,,,,fee schedule,29034.02,29034.02, Neonate Birth Weight 2000-2499 Grams With Congenital Or Perinatal Infection,6233,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,29034.02,,,,,,,fee schedule,29034.02,29034.02, Neonate Birth Weight 2000-2499 Grams With Congenital Or Perinatal Infection,6233,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,29034.02,,,,,,,fee schedule,29034.02,29034.02, Neonate Birth Weight 2000-2499 Grams With Congenital Or Perinatal Infection,6233,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,29034.02,,,,,,,fee schedule,29034.02,29034.02, Neonate Birth Weight 2000-2499 Grams With Congenital Or Perinatal Infection,6233,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,29034.02,,,,,,,fee schedule,29034.02,29034.02, Neonate Birth Weight 2000-2499 Grams With Congenital Or Perinatal Infection,6233,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,29034.02,,,,,,,fee schedule,29034.02,29034.02, Neonate Birth Weight 2000-2499 Grams With Congenital Or Perinatal Infection,6233,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,29034.02,,,,,,,fee schedule,29034.02,29034.02, Neonate Birth Weight 2000-2499 Grams With Congenital Or Perinatal Infection,6233,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,29034.02,,,,,,,fee schedule,29034.02,29034.02, Neonate Birth Weight 2000-2499 Grams With Congenital Or Perinatal Infection,6234,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,38603.57,,,,,,,fee schedule,38603.57,38603.57, Neonate Birth Weight 2000-2499 Grams With Congenital Or Perinatal Infection,6234,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,38603.57,,,,,,,fee schedule,38603.57,38603.57, Neonate Birth Weight 2000-2499 Grams With Congenital Or Perinatal Infection,6234,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,38603.57,,,,,,,fee schedule,38603.57,38603.57, Neonate Birth Weight 2000-2499 Grams With Congenital Or Perinatal Infection,6234,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,38603.57,,,,,,,fee schedule,38603.57,38603.57, Neonate Birth Weight 2000-2499 Grams With Congenital Or Perinatal Infection,6234,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,38603.57,,,,,,,fee schedule,38603.57,38603.57, Neonate Birth Weight 2000-2499 Grams With Congenital Or Perinatal Infection,6234,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,38603.57,,,,,,,fee schedule,38603.57,38603.57, Neonate Birth Weight 2000-2499 Grams With Congenital Or Perinatal Infection,6234,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,38603.57,,,,,,,fee schedule,38603.57,38603.57, Neonate Birth Weight 2000-2499 Grams With Congenital Or Perinatal Infection,6234,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,38603.57,,,,,,,fee schedule,38603.57,38603.57, Neonate Birth Weight 2000-2499 Grams With Congenital Or Perinatal Infection,6234,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,38603.57,,,,,,,fee schedule,38603.57,38603.57, Neonate Birth Weight 2000-2499 Grams With Congenital Or Perinatal Infection,6234,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,38603.57,,,,,,,fee schedule,38603.57,38603.57, Neonate Birth Weight 2000-2499 Grams With Congenital Or Perinatal Infection,6234,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,38603.57,,,,,,,fee schedule,38603.57,38603.57, Neonate Birth Weight 2000-2499 Grams With Other Significant Condition,6251,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,9071.28,,,,,,,fee schedule,9071.28,9071.28, Neonate Birth Weight 2000-2499 Grams With Other Significant Condition,6251,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,9071.28,,,,,,,fee schedule,9071.28,9071.28, Neonate Birth Weight 2000-2499 Grams With Other Significant Condition,6251,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,9071.28,,,,,,,fee schedule,9071.28,9071.28, Neonate Birth Weight 2000-2499 Grams With Other Significant Condition,6251,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,9071.28,,,,,,,fee schedule,9071.28,9071.28, Neonate Birth Weight 2000-2499 Grams With Other Significant Condition,6251,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,9071.28,,,,,,,fee schedule,9071.28,9071.28, Neonate Birth Weight 2000-2499 Grams With Other Significant Condition,6251,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,9071.28,,,,,,,fee schedule,9071.28,9071.28, Neonate Birth Weight 2000-2499 Grams With Other Significant Condition,6251,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,9071.28,,,,,,,fee schedule,9071.28,9071.28, Neonate Birth Weight 2000-2499 Grams With Other Significant Condition,6251,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,9071.28,,,,,,,fee schedule,9071.28,9071.28, Neonate Birth Weight 2000-2499 Grams With Other Significant Condition,6251,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,9071.28,,,,,,,fee schedule,9071.28,9071.28, Neonate Birth Weight 2000-2499 Grams With Other Significant Condition,6251,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,9071.28,,,,,,,fee schedule,9071.28,9071.28, Neonate Birth Weight 2000-2499 Grams With Other Significant Condition,6251,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,9071.28,,,,,,,fee schedule,9071.28,9071.28, Neonate Birth Weight 2000-2499 Grams With Other Significant Condition,6252,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,13219.8,,,,,,,fee schedule,13219.8,13219.8, Neonate Birth Weight 2000-2499 Grams With Other Significant Condition,6252,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,13219.8,,,,,,,fee schedule,13219.8,13219.8, Neonate Birth Weight 2000-2499 Grams With Other Significant Condition,6252,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,13219.8,,,,,,,fee schedule,13219.8,13219.8, Neonate Birth Weight 2000-2499 Grams With Other Significant Condition,6252,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,13219.8,,,,,,,fee schedule,13219.8,13219.8, Neonate Birth Weight 2000-2499 Grams With Other Significant Condition,6252,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,13219.8,,,,,,,fee schedule,13219.8,13219.8, Neonate Birth Weight 2000-2499 Grams With Other Significant Condition,6252,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,13219.8,,,,,,,fee schedule,13219.8,13219.8, Neonate Birth Weight 2000-2499 Grams With Other Significant Condition,6252,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,13219.8,,,,,,,fee schedule,13219.8,13219.8, Neonate Birth Weight 2000-2499 Grams With Other Significant Condition,6252,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,13219.8,,,,,,,fee schedule,13219.8,13219.8, Neonate Birth Weight 2000-2499 Grams With Other Significant Condition,6252,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,13219.8,,,,,,,fee schedule,13219.8,13219.8, Neonate Birth Weight 2000-2499 Grams With Other Significant Condition,6252,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,13219.8,,,,,,,fee schedule,13219.8,13219.8, Neonate Birth Weight 2000-2499 Grams With Other Significant Condition,6252,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,13219.8,,,,,,,fee schedule,13219.8,13219.8, Neonate Birth Weight 2000-2499 Grams With Other Significant Condition,6253,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,22003.12,,,,,,,fee schedule,22003.12,22003.12, Neonate Birth Weight 2000-2499 Grams With Other Significant Condition,6253,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,22003.12,,,,,,,fee schedule,22003.12,22003.12, Neonate Birth Weight 2000-2499 Grams With Other Significant Condition,6253,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,22003.12,,,,,,,fee schedule,22003.12,22003.12, Neonate Birth Weight 2000-2499 Grams With Other Significant Condition,6253,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,22003.12,,,,,,,fee schedule,22003.12,22003.12, Neonate Birth Weight 2000-2499 Grams With Other Significant Condition,6253,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,22003.12,,,,,,,fee schedule,22003.12,22003.12, Neonate Birth Weight 2000-2499 Grams With Other Significant Condition,6253,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,22003.12,,,,,,,fee schedule,22003.12,22003.12, Neonate Birth Weight 2000-2499 Grams With Other Significant Condition,6253,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,22003.12,,,,,,,fee schedule,22003.12,22003.12, Neonate Birth Weight 2000-2499 Grams With Other Significant Condition,6253,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,22003.12,,,,,,,fee schedule,22003.12,22003.12, Neonate Birth Weight 2000-2499 Grams With Other Significant Condition,6253,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,22003.12,,,,,,,fee schedule,22003.12,22003.12, Neonate Birth Weight 2000-2499 Grams With Other Significant Condition,6253,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,22003.12,,,,,,,fee schedule,22003.12,22003.12, Neonate Birth Weight 2000-2499 Grams With Other Significant Condition,6253,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,22003.12,,,,,,,fee schedule,22003.12,22003.12, Neonate Birth Weight 2000-2499 Grams With Other Significant Condition,6254,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,47902.11,,,,,,,fee schedule,47902.11,47902.11, Neonate Birth Weight 2000-2499 Grams With Other Significant Condition,6254,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,47902.11,,,,,,,fee schedule,47902.11,47902.11, Neonate Birth Weight 2000-2499 Grams With Other Significant Condition,6254,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,47902.11,,,,,,,fee schedule,47902.11,47902.11, Neonate Birth Weight 2000-2499 Grams With Other Significant Condition,6254,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,47902.11,,,,,,,fee schedule,47902.11,47902.11, Neonate Birth Weight 2000-2499 Grams With Other Significant Condition,6254,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,47902.11,,,,,,,fee schedule,47902.11,47902.11, Neonate Birth Weight 2000-2499 Grams With Other Significant Condition,6254,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,47902.11,,,,,,,fee schedule,47902.11,47902.11, Neonate Birth Weight 2000-2499 Grams With Other Significant Condition,6254,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,47902.11,,,,,,,fee schedule,47902.11,47902.11, Neonate Birth Weight 2000-2499 Grams With Other Significant Condition,6254,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,47902.11,,,,,,,fee schedule,47902.11,47902.11, Neonate Birth Weight 2000-2499 Grams With Other Significant Condition,6254,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,47902.11,,,,,,,fee schedule,47902.11,47902.11, Neonate Birth Weight 2000-2499 Grams With Other Significant Condition,6254,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,47902.11,,,,,,,fee schedule,47902.11,47902.11, Neonate Birth Weight 2000-2499 Grams With Other Significant Condition,6254,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,47902.11,,,,,,,fee schedule,47902.11,47902.11, "Neonate Birth Weight 2000-2499 Grams, Normal Newborn Or Neonate With Other Problem",6261,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,1144.06,,,,,,,fee schedule,1144.06,1144.06, "Neonate Birth Weight 2000-2499 Grams, Normal Newborn Or Neonate With Other Problem",6261,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,1144.06,,,,,,,fee schedule,1144.06,1144.06, "Neonate Birth Weight 2000-2499 Grams, Normal Newborn Or Neonate With Other Problem",6261,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,1144.06,,,,,,,fee schedule,1144.06,1144.06, "Neonate Birth Weight 2000-2499 Grams, Normal Newborn Or Neonate With Other Problem",6261,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,1144.06,,,,,,,fee schedule,1144.06,1144.06, "Neonate Birth Weight 2000-2499 Grams, Normal Newborn Or Neonate With Other Problem",6261,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,1144.06,,,,,,,fee schedule,1144.06,1144.06, "Neonate Birth Weight 2000-2499 Grams, Normal Newborn Or Neonate With Other Problem",6261,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,1144.06,,,,,,,fee schedule,1144.06,1144.06, "Neonate Birth Weight 2000-2499 Grams, Normal Newborn Or Neonate With Other Problem",6261,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,1144.06,,,,,,,fee schedule,1144.06,1144.06, "Neonate Birth Weight 2000-2499 Grams, Normal Newborn Or Neonate With Other Problem",6261,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,1144.06,,,,,,,fee schedule,1144.06,1144.06, "Neonate Birth Weight 2000-2499 Grams, Normal Newborn Or Neonate With Other Problem",6261,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,1144.06,,,,,,,fee schedule,1144.06,1144.06, "Neonate Birth Weight 2000-2499 Grams, Normal Newborn Or Neonate With Other Problem",6261,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,1144.06,,,,,,,fee schedule,1144.06,1144.06, "Neonate Birth Weight 2000-2499 Grams, Normal Newborn Or Neonate With Other Problem",6261,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,1144.06,,,,,,,fee schedule,1144.06,1144.06, "Neonate Birth Weight 2000-2499 Grams, Normal Newborn Or Neonate With Other Problem",6262,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,2443.38,,,,,,,fee schedule,2443.38,2443.38, "Neonate Birth Weight 2000-2499 Grams, Normal Newborn Or Neonate With Other Problem",6262,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,2443.38,,,,,,,fee schedule,2443.38,2443.38, "Neonate Birth Weight 2000-2499 Grams, Normal Newborn Or Neonate With Other Problem",6262,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,2443.38,,,,,,,fee schedule,2443.38,2443.38, "Neonate Birth Weight 2000-2499 Grams, Normal Newborn Or Neonate With Other Problem",6262,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,2443.38,,,,,,,fee schedule,2443.38,2443.38, "Neonate Birth Weight 2000-2499 Grams, Normal Newborn Or Neonate With Other Problem",6262,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,2443.38,,,,,,,fee schedule,2443.38,2443.38, "Neonate Birth Weight 2000-2499 Grams, Normal Newborn Or Neonate With Other Problem",6262,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,2443.38,,,,,,,fee schedule,2443.38,2443.38, "Neonate Birth Weight 2000-2499 Grams, Normal Newborn Or Neonate With Other Problem",6262,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,2443.38,,,,,,,fee schedule,2443.38,2443.38, "Neonate Birth Weight 2000-2499 Grams, Normal Newborn Or Neonate With Other Problem",6262,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,2443.38,,,,,,,fee schedule,2443.38,2443.38, "Neonate Birth Weight 2000-2499 Grams, Normal Newborn Or Neonate With Other Problem",6262,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,2443.38,,,,,,,fee schedule,2443.38,2443.38, "Neonate Birth Weight 2000-2499 Grams, Normal Newborn Or Neonate With Other Problem",6262,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,2443.38,,,,,,,fee schedule,2443.38,2443.38, "Neonate Birth Weight 2000-2499 Grams, Normal Newborn Or Neonate With Other Problem",6262,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,2443.38,,,,,,,fee schedule,2443.38,2443.38, "Neonate Birth Weight 2000-2499 Grams, Normal Newborn Or Neonate With Other Problem",6263,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,7361.69,,,,,,,fee schedule,7361.69,7361.69, "Neonate Birth Weight 2000-2499 Grams, Normal Newborn Or Neonate With Other Problem",6263,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,7361.69,,,,,,,fee schedule,7361.69,7361.69, "Neonate Birth Weight 2000-2499 Grams, Normal Newborn Or Neonate With Other Problem",6263,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,7361.69,,,,,,,fee schedule,7361.69,7361.69, "Neonate Birth Weight 2000-2499 Grams, Normal Newborn Or Neonate With Other Problem",6263,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,7361.69,,,,,,,fee schedule,7361.69,7361.69, "Neonate Birth Weight 2000-2499 Grams, Normal Newborn Or Neonate With Other Problem",6263,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,7361.69,,,,,,,fee schedule,7361.69,7361.69, "Neonate Birth Weight 2000-2499 Grams, Normal Newborn Or Neonate With Other Problem",6263,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,7361.69,,,,,,,fee schedule,7361.69,7361.69, "Neonate Birth Weight 2000-2499 Grams, Normal Newborn Or Neonate With Other Problem",6263,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,7361.69,,,,,,,fee schedule,7361.69,7361.69, "Neonate Birth Weight 2000-2499 Grams, Normal Newborn Or Neonate With Other Problem",6263,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,7361.69,,,,,,,fee schedule,7361.69,7361.69, "Neonate Birth Weight 2000-2499 Grams, Normal Newborn Or Neonate With Other Problem",6263,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,7361.69,,,,,,,fee schedule,7361.69,7361.69, "Neonate Birth Weight 2000-2499 Grams, Normal Newborn Or Neonate With Other Problem",6263,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,7361.69,,,,,,,fee schedule,7361.69,7361.69, "Neonate Birth Weight 2000-2499 Grams, Normal Newborn Or Neonate With Other Problem",6263,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,7361.69,,,,,,,fee schedule,7361.69,7361.69, "Neonate Birth Weight 2000-2499 Grams, Normal Newborn Or Neonate With Other Problem",6264,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,17010.24,,,,,,,fee schedule,17010.24,17010.24, "Neonate Birth Weight 2000-2499 Grams, Normal Newborn Or Neonate With Other Problem",6264,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,17010.24,,,,,,,fee schedule,17010.24,17010.24, "Neonate Birth Weight 2000-2499 Grams, Normal Newborn Or Neonate With Other Problem",6264,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,17010.24,,,,,,,fee schedule,17010.24,17010.24, "Neonate Birth Weight 2000-2499 Grams, Normal Newborn Or Neonate With Other Problem",6264,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,17010.24,,,,,,,fee schedule,17010.24,17010.24, "Neonate Birth Weight 2000-2499 Grams, Normal Newborn Or Neonate With Other Problem",6264,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,17010.24,,,,,,,fee schedule,17010.24,17010.24, "Neonate Birth Weight 2000-2499 Grams, Normal Newborn Or Neonate With Other Problem",6264,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,17010.24,,,,,,,fee schedule,17010.24,17010.24, "Neonate Birth Weight 2000-2499 Grams, Normal Newborn Or Neonate With Other Problem",6264,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,17010.24,,,,,,,fee schedule,17010.24,17010.24, "Neonate Birth Weight 2000-2499 Grams, Normal Newborn Or Neonate With Other Problem",6264,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,17010.24,,,,,,,fee schedule,17010.24,17010.24, "Neonate Birth Weight 2000-2499 Grams, Normal Newborn Or Neonate With Other Problem",6264,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,17010.24,,,,,,,fee schedule,17010.24,17010.24, "Neonate Birth Weight 2000-2499 Grams, Normal Newborn Or Neonate With Other Problem",6264,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,17010.24,,,,,,,fee schedule,17010.24,17010.24, "Neonate Birth Weight 2000-2499 Grams, Normal Newborn Or Neonate With Other Problem",6264,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,17010.24,,,,,,,fee schedule,17010.24,17010.24, Neonate Birth Weight > 2499 Grams With Major Cardiovascular Procedure,6301,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,19850.52,,,,,,,fee schedule,19850.52,19850.52, Neonate Birth Weight > 2499 Grams With Major Cardiovascular Procedure,6301,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,19850.52,,,,,,,fee schedule,19850.52,19850.52, Neonate Birth Weight > 2499 Grams With Major Cardiovascular Procedure,6301,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,19850.52,,,,,,,fee schedule,19850.52,19850.52, Neonate Birth Weight > 2499 Grams With Major Cardiovascular Procedure,6301,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,19850.52,,,,,,,fee schedule,19850.52,19850.52, Neonate Birth Weight > 2499 Grams With Major Cardiovascular Procedure,6301,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,19850.52,,,,,,,fee schedule,19850.52,19850.52, Neonate Birth Weight > 2499 Grams With Major Cardiovascular Procedure,6301,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,19850.52,,,,,,,fee schedule,19850.52,19850.52, Neonate Birth Weight > 2499 Grams With Major Cardiovascular Procedure,6301,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,19850.52,,,,,,,fee schedule,19850.52,19850.52, Neonate Birth Weight > 2499 Grams With Major Cardiovascular Procedure,6301,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,19850.52,,,,,,,fee schedule,19850.52,19850.52, Neonate Birth Weight > 2499 Grams With Major Cardiovascular Procedure,6301,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,19850.52,,,,,,,fee schedule,19850.52,19850.52, Neonate Birth Weight > 2499 Grams With Major Cardiovascular Procedure,6301,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,19850.52,,,,,,,fee schedule,19850.52,19850.52, Neonate Birth Weight > 2499 Grams With Major Cardiovascular Procedure,6301,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,19850.52,,,,,,,fee schedule,19850.52,19850.52, Neonate Birth Weight > 2499 Grams With Major Cardiovascular Procedure,6302,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,38247.86,,,,,,,fee schedule,38247.86,38247.86, Neonate Birth Weight > 2499 Grams With Major Cardiovascular Procedure,6302,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,38247.86,,,,,,,fee schedule,38247.86,38247.86, Neonate Birth Weight > 2499 Grams With Major Cardiovascular Procedure,6302,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,38247.86,,,,,,,fee schedule,38247.86,38247.86, Neonate Birth Weight > 2499 Grams With Major Cardiovascular Procedure,6302,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,38247.86,,,,,,,fee schedule,38247.86,38247.86, Neonate Birth Weight > 2499 Grams With Major Cardiovascular Procedure,6302,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,38247.86,,,,,,,fee schedule,38247.86,38247.86, Neonate Birth Weight > 2499 Grams With Major Cardiovascular Procedure,6302,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,38247.86,,,,,,,fee schedule,38247.86,38247.86, Neonate Birth Weight > 2499 Grams With Major Cardiovascular Procedure,6302,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,38247.86,,,,,,,fee schedule,38247.86,38247.86, Neonate Birth Weight > 2499 Grams With Major Cardiovascular Procedure,6302,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,38247.86,,,,,,,fee schedule,38247.86,38247.86, Neonate Birth Weight > 2499 Grams With Major Cardiovascular Procedure,6302,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,38247.86,,,,,,,fee schedule,38247.86,38247.86, Neonate Birth Weight > 2499 Grams With Major Cardiovascular Procedure,6302,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,38247.86,,,,,,,fee schedule,38247.86,38247.86, Neonate Birth Weight > 2499 Grams With Major Cardiovascular Procedure,6302,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,38247.86,,,,,,,fee schedule,38247.86,38247.86, Neonate Birth Weight > 2499 Grams With Major Cardiovascular Procedure,6303,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,83923.26,,,,,,,fee schedule,83923.26,83923.26, Neonate Birth Weight > 2499 Grams With Major Cardiovascular Procedure,6303,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,83923.26,,,,,,,fee schedule,83923.26,83923.26, Neonate Birth Weight > 2499 Grams With Major Cardiovascular Procedure,6303,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,83923.26,,,,,,,fee schedule,83923.26,83923.26, Neonate Birth Weight > 2499 Grams With Major Cardiovascular Procedure,6303,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,83923.26,,,,,,,fee schedule,83923.26,83923.26, Neonate Birth Weight > 2499 Grams With Major Cardiovascular Procedure,6303,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,83923.26,,,,,,,fee schedule,83923.26,83923.26, Neonate Birth Weight > 2499 Grams With Major Cardiovascular Procedure,6303,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,83923.26,,,,,,,fee schedule,83923.26,83923.26, Neonate Birth Weight > 2499 Grams With Major Cardiovascular Procedure,6303,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,83923.26,,,,,,,fee schedule,83923.26,83923.26, Neonate Birth Weight > 2499 Grams With Major Cardiovascular Procedure,6303,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,83923.26,,,,,,,fee schedule,83923.26,83923.26, Neonate Birth Weight > 2499 Grams With Major Cardiovascular Procedure,6303,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,83923.26,,,,,,,fee schedule,83923.26,83923.26, Neonate Birth Weight > 2499 Grams With Major Cardiovascular Procedure,6303,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,83923.26,,,,,,,fee schedule,83923.26,83923.26, Neonate Birth Weight > 2499 Grams With Major Cardiovascular Procedure,6303,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,83923.26,,,,,,,fee schedule,83923.26,83923.26, Neonate Birth Weight > 2499 Grams With Major Cardiovascular Procedure,6304,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,152249.68,,,,,,,fee schedule,152249.68,152249.68, Neonate Birth Weight > 2499 Grams With Major Cardiovascular Procedure,6304,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,152249.68,,,,,,,fee schedule,152249.68,152249.68, Neonate Birth Weight > 2499 Grams With Major Cardiovascular Procedure,6304,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,152249.68,,,,,,,fee schedule,152249.68,152249.68, Neonate Birth Weight > 2499 Grams With Major Cardiovascular Procedure,6304,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,152249.68,,,,,,,fee schedule,152249.68,152249.68, Neonate Birth Weight > 2499 Grams With Major Cardiovascular Procedure,6304,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,152249.68,,,,,,,fee schedule,152249.68,152249.68, Neonate Birth Weight > 2499 Grams With Major Cardiovascular Procedure,6304,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,152249.68,,,,,,,fee schedule,152249.68,152249.68, Neonate Birth Weight > 2499 Grams With Major Cardiovascular Procedure,6304,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,152249.68,,,,,,,fee schedule,152249.68,152249.68, Neonate Birth Weight > 2499 Grams With Major Cardiovascular Procedure,6304,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,152249.68,,,,,,,fee schedule,152249.68,152249.68, Neonate Birth Weight > 2499 Grams With Major Cardiovascular Procedure,6304,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,152249.68,,,,,,,fee schedule,152249.68,152249.68, Neonate Birth Weight > 2499 Grams With Major Cardiovascular Procedure,6304,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,152249.68,,,,,,,fee schedule,152249.68,152249.68, Neonate Birth Weight > 2499 Grams With Major Cardiovascular Procedure,6304,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,152249.68,,,,,,,fee schedule,152249.68,152249.68, Neonate Birth Weight > 2499 Grams With Other Major Procedure,6311,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5695.57,,,,,,,fee schedule,5695.57,5695.57, Neonate Birth Weight > 2499 Grams With Other Major Procedure,6311,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5695.57,,,,,,,fee schedule,5695.57,5695.57, Neonate Birth Weight > 2499 Grams With Other Major Procedure,6311,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5695.57,,,,,,,fee schedule,5695.57,5695.57, Neonate Birth Weight > 2499 Grams With Other Major Procedure,6311,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5695.57,,,,,,,fee schedule,5695.57,5695.57, Neonate Birth Weight > 2499 Grams With Other Major Procedure,6311,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5695.57,,,,,,,fee schedule,5695.57,5695.57, Neonate Birth Weight > 2499 Grams With Other Major Procedure,6311,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5695.57,,,,,,,fee schedule,5695.57,5695.57, Neonate Birth Weight > 2499 Grams With Other Major Procedure,6311,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5695.57,,,,,,,fee schedule,5695.57,5695.57, Neonate Birth Weight > 2499 Grams With Other Major Procedure,6311,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5695.57,,,,,,,fee schedule,5695.57,5695.57, Neonate Birth Weight > 2499 Grams With Other Major Procedure,6311,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5695.57,,,,,,,fee schedule,5695.57,5695.57, Neonate Birth Weight > 2499 Grams With Other Major Procedure,6311,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5695.57,,,,,,,fee schedule,5695.57,5695.57, Neonate Birth Weight > 2499 Grams With Other Major Procedure,6311,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5695.57,,,,,,,fee schedule,5695.57,5695.57, Neonate Birth Weight > 2499 Grams With Other Major Procedure,6312,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,28422.82,,,,,,,fee schedule,28422.82,28422.82, Neonate Birth Weight > 2499 Grams With Other Major Procedure,6312,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,28422.82,,,,,,,fee schedule,28422.82,28422.82, Neonate Birth Weight > 2499 Grams With Other Major Procedure,6312,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,28422.82,,,,,,,fee schedule,28422.82,28422.82, Neonate Birth Weight > 2499 Grams With Other Major Procedure,6312,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,28422.82,,,,,,,fee schedule,28422.82,28422.82, Neonate Birth Weight > 2499 Grams With Other Major Procedure,6312,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,28422.82,,,,,,,fee schedule,28422.82,28422.82, Neonate Birth Weight > 2499 Grams With Other Major Procedure,6312,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,28422.82,,,,,,,fee schedule,28422.82,28422.82, Neonate Birth Weight > 2499 Grams With Other Major Procedure,6312,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,28422.82,,,,,,,fee schedule,28422.82,28422.82, Neonate Birth Weight > 2499 Grams With Other Major Procedure,6312,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,28422.82,,,,,,,fee schedule,28422.82,28422.82, Neonate Birth Weight > 2499 Grams With Other Major Procedure,6312,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,28422.82,,,,,,,fee schedule,28422.82,28422.82, Neonate Birth Weight > 2499 Grams With Other Major Procedure,6312,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,28422.82,,,,,,,fee schedule,28422.82,28422.82, Neonate Birth Weight > 2499 Grams With Other Major Procedure,6312,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,28422.82,,,,,,,fee schedule,28422.82,28422.82, Neonate Birth Weight > 2499 Grams With Other Major Procedure,6313,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,49342.59,,,,,,,fee schedule,49342.59,49342.59, Neonate Birth Weight > 2499 Grams With Other Major Procedure,6313,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,49342.59,,,,,,,fee schedule,49342.59,49342.59, Neonate Birth Weight > 2499 Grams With Other Major Procedure,6313,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,49342.59,,,,,,,fee schedule,49342.59,49342.59, Neonate Birth Weight > 2499 Grams With Other Major Procedure,6313,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,49342.59,,,,,,,fee schedule,49342.59,49342.59, Neonate Birth Weight > 2499 Grams With Other Major Procedure,6313,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,49342.59,,,,,,,fee schedule,49342.59,49342.59, Neonate Birth Weight > 2499 Grams With Other Major Procedure,6313,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,49342.59,,,,,,,fee schedule,49342.59,49342.59, Neonate Birth Weight > 2499 Grams With Other Major Procedure,6313,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,49342.59,,,,,,,fee schedule,49342.59,49342.59, Neonate Birth Weight > 2499 Grams With Other Major Procedure,6313,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,49342.59,,,,,,,fee schedule,49342.59,49342.59, Neonate Birth Weight > 2499 Grams With Other Major Procedure,6313,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,49342.59,,,,,,,fee schedule,49342.59,49342.59, Neonate Birth Weight > 2499 Grams With Other Major Procedure,6313,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,49342.59,,,,,,,fee schedule,49342.59,49342.59, Neonate Birth Weight > 2499 Grams With Other Major Procedure,6313,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,49342.59,,,,,,,fee schedule,49342.59,49342.59, Neonate Birth Weight > 2499 Grams With Other Major Procedure,6314,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,167879.69,,,,,,,fee schedule,167879.69,167879.69, Neonate Birth Weight > 2499 Grams With Other Major Procedure,6314,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,167879.69,,,,,,,fee schedule,167879.69,167879.69, Neonate Birth Weight > 2499 Grams With Other Major Procedure,6314,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,167879.69,,,,,,,fee schedule,167879.69,167879.69, Neonate Birth Weight > 2499 Grams With Other Major Procedure,6314,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,167879.69,,,,,,,fee schedule,167879.69,167879.69, Neonate Birth Weight > 2499 Grams With Other Major Procedure,6314,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,167879.69,,,,,,,fee schedule,167879.69,167879.69, Neonate Birth Weight > 2499 Grams With Other Major Procedure,6314,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,167879.69,,,,,,,fee schedule,167879.69,167879.69, Neonate Birth Weight > 2499 Grams With Other Major Procedure,6314,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,167879.69,,,,,,,fee schedule,167879.69,167879.69, Neonate Birth Weight > 2499 Grams With Other Major Procedure,6314,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,167879.69,,,,,,,fee schedule,167879.69,167879.69, Neonate Birth Weight > 2499 Grams With Other Major Procedure,6314,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,167879.69,,,,,,,fee schedule,167879.69,167879.69, Neonate Birth Weight > 2499 Grams With Other Major Procedure,6314,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,167879.69,,,,,,,fee schedule,167879.69,167879.69, Neonate Birth Weight > 2499 Grams With Other Major Procedure,6314,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,167879.69,,,,,,,fee schedule,167879.69,167879.69, Neonate Birth Weight > 2499 Grams With Major Anomaly,6331,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,1839.95,,,,,,,fee schedule,1839.95,1839.95, Neonate Birth Weight > 2499 Grams With Major Anomaly,6331,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,1839.95,,,,,,,fee schedule,1839.95,1839.95, Neonate Birth Weight > 2499 Grams With Major Anomaly,6331,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,1839.95,,,,,,,fee schedule,1839.95,1839.95, Neonate Birth Weight > 2499 Grams With Major Anomaly,6331,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,1839.95,,,,,,,fee schedule,1839.95,1839.95, Neonate Birth Weight > 2499 Grams With Major Anomaly,6331,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,1839.95,,,,,,,fee schedule,1839.95,1839.95, Neonate Birth Weight > 2499 Grams With Major Anomaly,6331,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,1839.95,,,,,,,fee schedule,1839.95,1839.95, Neonate Birth Weight > 2499 Grams With Major Anomaly,6331,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,1839.95,,,,,,,fee schedule,1839.95,1839.95, Neonate Birth Weight > 2499 Grams With Major Anomaly,6331,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,1839.95,,,,,,,fee schedule,1839.95,1839.95, Neonate Birth Weight > 2499 Grams With Major Anomaly,6331,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,1839.95,,,,,,,fee schedule,1839.95,1839.95, Neonate Birth Weight > 2499 Grams With Major Anomaly,6331,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,1839.95,,,,,,,fee schedule,1839.95,1839.95, Neonate Birth Weight > 2499 Grams With Major Anomaly,6331,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,1839.95,,,,,,,fee schedule,1839.95,1839.95, Neonate Birth Weight > 2499 Grams With Major Anomaly,6332,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,8061.32,,,,,,,fee schedule,8061.32,8061.32, Neonate Birth Weight > 2499 Grams With Major Anomaly,6332,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,8061.32,,,,,,,fee schedule,8061.32,8061.32, Neonate Birth Weight > 2499 Grams With Major Anomaly,6332,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,8061.32,,,,,,,fee schedule,8061.32,8061.32, Neonate Birth Weight > 2499 Grams With Major Anomaly,6332,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,8061.32,,,,,,,fee schedule,8061.32,8061.32, Neonate Birth Weight > 2499 Grams With Major Anomaly,6332,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,8061.32,,,,,,,fee schedule,8061.32,8061.32, Neonate Birth Weight > 2499 Grams With Major Anomaly,6332,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,8061.32,,,,,,,fee schedule,8061.32,8061.32, Neonate Birth Weight > 2499 Grams With Major Anomaly,6332,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,8061.32,,,,,,,fee schedule,8061.32,8061.32, Neonate Birth Weight > 2499 Grams With Major Anomaly,6332,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,8061.32,,,,,,,fee schedule,8061.32,8061.32, Neonate Birth Weight > 2499 Grams With Major Anomaly,6332,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,8061.32,,,,,,,fee schedule,8061.32,8061.32, Neonate Birth Weight > 2499 Grams With Major Anomaly,6332,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,8061.32,,,,,,,fee schedule,8061.32,8061.32, Neonate Birth Weight > 2499 Grams With Major Anomaly,6332,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,8061.32,,,,,,,fee schedule,8061.32,8061.32, Neonate Birth Weight > 2499 Grams With Major Anomaly,6333,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,20906.36,,,,,,,fee schedule,20906.36,20906.36, Neonate Birth Weight > 2499 Grams With Major Anomaly,6333,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,20906.36,,,,,,,fee schedule,20906.36,20906.36, Neonate Birth Weight > 2499 Grams With Major Anomaly,6333,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,20906.36,,,,,,,fee schedule,20906.36,20906.36, Neonate Birth Weight > 2499 Grams With Major Anomaly,6333,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,20906.36,,,,,,,fee schedule,20906.36,20906.36, Neonate Birth Weight > 2499 Grams With Major Anomaly,6333,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,20906.36,,,,,,,fee schedule,20906.36,20906.36, Neonate Birth Weight > 2499 Grams With Major Anomaly,6333,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,20906.36,,,,,,,fee schedule,20906.36,20906.36, Neonate Birth Weight > 2499 Grams With Major Anomaly,6333,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,20906.36,,,,,,,fee schedule,20906.36,20906.36, Neonate Birth Weight > 2499 Grams With Major Anomaly,6333,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,20906.36,,,,,,,fee schedule,20906.36,20906.36, Neonate Birth Weight > 2499 Grams With Major Anomaly,6333,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,20906.36,,,,,,,fee schedule,20906.36,20906.36, Neonate Birth Weight > 2499 Grams With Major Anomaly,6333,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,20906.36,,,,,,,fee schedule,20906.36,20906.36, Neonate Birth Weight > 2499 Grams With Major Anomaly,6333,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,20906.36,,,,,,,fee schedule,20906.36,20906.36, Neonate Birth Weight > 2499 Grams With Major Anomaly,6334,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,54959.82,,,,,,,fee schedule,54959.82,54959.82, Neonate Birth Weight > 2499 Grams With Major Anomaly,6334,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,54959.82,,,,,,,fee schedule,54959.82,54959.82, Neonate Birth Weight > 2499 Grams With Major Anomaly,6334,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,54959.82,,,,,,,fee schedule,54959.82,54959.82, Neonate Birth Weight > 2499 Grams With Major Anomaly,6334,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,54959.82,,,,,,,fee schedule,54959.82,54959.82, Neonate Birth Weight > 2499 Grams With Major Anomaly,6334,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,54959.82,,,,,,,fee schedule,54959.82,54959.82, Neonate Birth Weight > 2499 Grams With Major Anomaly,6334,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,54959.82,,,,,,,fee schedule,54959.82,54959.82, Neonate Birth Weight > 2499 Grams With Major Anomaly,6334,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,54959.82,,,,,,,fee schedule,54959.82,54959.82, Neonate Birth Weight > 2499 Grams With Major Anomaly,6334,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,54959.82,,,,,,,fee schedule,54959.82,54959.82, Neonate Birth Weight > 2499 Grams With Major Anomaly,6334,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,54959.82,,,,,,,fee schedule,54959.82,54959.82, Neonate Birth Weight > 2499 Grams With Major Anomaly,6334,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,54959.82,,,,,,,fee schedule,54959.82,54959.82, Neonate Birth Weight > 2499 Grams With Major Anomaly,6334,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,54959.82,,,,,,,fee schedule,54959.82,54959.82, Respiratory Condition,6341,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5338.45,,,,,,,fee schedule,5338.45,5338.45, Respiratory Condition,6341,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5338.45,,,,,,,fee schedule,5338.45,5338.45, Respiratory Condition,6341,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5338.45,,,,,,,fee schedule,5338.45,5338.45, Respiratory Condition,6341,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5338.45,,,,,,,fee schedule,5338.45,5338.45, Respiratory Condition,6341,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5338.45,,,,,,,fee schedule,5338.45,5338.45, Respiratory Condition,6341,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5338.45,,,,,,,fee schedule,5338.45,5338.45, Respiratory Condition,6341,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5338.45,,,,,,,fee schedule,5338.45,5338.45, Respiratory Condition,6341,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5338.45,,,,,,,fee schedule,5338.45,5338.45, Respiratory Condition,6341,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5338.45,,,,,,,fee schedule,5338.45,5338.45, Respiratory Condition,6341,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5338.45,,,,,,,fee schedule,5338.45,5338.45, Respiratory Condition,6341,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5338.45,,,,,,,fee schedule,5338.45,5338.45, Respiratory Condition,6342,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,8716.28,,,,,,,fee schedule,8716.28,8716.28, Respiratory Condition,6342,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,8716.28,,,,,,,fee schedule,8716.28,8716.28, Respiratory Condition,6342,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,8716.28,,,,,,,fee schedule,8716.28,8716.28, Respiratory Condition,6342,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,8716.28,,,,,,,fee schedule,8716.28,8716.28, Respiratory Condition,6342,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,8716.28,,,,,,,fee schedule,8716.28,8716.28, Respiratory Condition,6342,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,8716.28,,,,,,,fee schedule,8716.28,8716.28, Respiratory Condition,6342,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,8716.28,,,,,,,fee schedule,8716.28,8716.28, Respiratory Condition,6342,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,8716.28,,,,,,,fee schedule,8716.28,8716.28, Respiratory Condition,6342,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,8716.28,,,,,,,fee schedule,8716.28,8716.28, Respiratory Condition,6342,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,8716.28,,,,,,,fee schedule,8716.28,8716.28, Respiratory Condition,6342,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,8716.28,,,,,,,fee schedule,8716.28,8716.28, Respiratory Condition,6343,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,17412.08,,,,,,,fee schedule,17412.08,17412.08, Respiratory Condition,6343,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,17412.08,,,,,,,fee schedule,17412.08,17412.08, Respiratory Condition,6343,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,17412.08,,,,,,,fee schedule,17412.08,17412.08, Respiratory Condition,6343,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,17412.08,,,,,,,fee schedule,17412.08,17412.08, Respiratory Condition,6343,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,17412.08,,,,,,,fee schedule,17412.08,17412.08, Respiratory Condition,6343,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,17412.08,,,,,,,fee schedule,17412.08,17412.08, Respiratory Condition,6343,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,17412.08,,,,,,,fee schedule,17412.08,17412.08, Respiratory Condition,6343,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,17412.08,,,,,,,fee schedule,17412.08,17412.08, Respiratory Condition,6343,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,17412.08,,,,,,,fee schedule,17412.08,17412.08, Respiratory Condition,6343,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,17412.08,,,,,,,fee schedule,17412.08,17412.08, Respiratory Condition,6343,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,17412.08,,,,,,,fee schedule,17412.08,17412.08, Respiratory Condition,6344,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,33337.11,,,,,,,fee schedule,33337.11,33337.11, Respiratory Condition,6344,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,33337.11,,,,,,,fee schedule,33337.11,33337.11, Respiratory Condition,6344,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,33337.11,,,,,,,fee schedule,33337.11,33337.11, Respiratory Condition,6344,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,33337.11,,,,,,,fee schedule,33337.11,33337.11, Respiratory Condition,6344,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,33337.11,,,,,,,fee schedule,33337.11,33337.11, Respiratory Condition,6344,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,33337.11,,,,,,,fee schedule,33337.11,33337.11, Respiratory Condition,6344,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,33337.11,,,,,,,fee schedule,33337.11,33337.11, Respiratory Condition,6344,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,33337.11,,,,,,,fee schedule,33337.11,33337.11, Respiratory Condition,6344,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,33337.11,,,,,,,fee schedule,33337.11,33337.11, Respiratory Condition,6344,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,33337.11,,,,,,,fee schedule,33337.11,33337.11, Respiratory Condition,6344,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,33337.11,,,,,,,fee schedule,33337.11,33337.11, Neonate Birth Weight > 2499 Grams With Congenital Or Perinatal Infection,6361,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5795.09,,,,,,,fee schedule,5795.09,5795.09, Neonate Birth Weight > 2499 Grams With Congenital Or Perinatal Infection,6361,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5795.09,,,,,,,fee schedule,5795.09,5795.09, Neonate Birth Weight > 2499 Grams With Congenital Or Perinatal Infection,6361,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5795.09,,,,,,,fee schedule,5795.09,5795.09, Neonate Birth Weight > 2499 Grams With Congenital Or Perinatal Infection,6361,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5795.09,,,,,,,fee schedule,5795.09,5795.09, Neonate Birth Weight > 2499 Grams With Congenital Or Perinatal Infection,6361,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5795.09,,,,,,,fee schedule,5795.09,5795.09, Neonate Birth Weight > 2499 Grams With Congenital Or Perinatal Infection,6361,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5795.09,,,,,,,fee schedule,5795.09,5795.09, Neonate Birth Weight > 2499 Grams With Congenital Or Perinatal Infection,6361,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5795.09,,,,,,,fee schedule,5795.09,5795.09, Neonate Birth Weight > 2499 Grams With Congenital Or Perinatal Infection,6361,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5795.09,,,,,,,fee schedule,5795.09,5795.09, Neonate Birth Weight > 2499 Grams With Congenital Or Perinatal Infection,6361,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5795.09,,,,,,,fee schedule,5795.09,5795.09, Neonate Birth Weight > 2499 Grams With Congenital Or Perinatal Infection,6361,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5795.09,,,,,,,fee schedule,5795.09,5795.09, Neonate Birth Weight > 2499 Grams With Congenital Or Perinatal Infection,6361,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5795.09,,,,,,,fee schedule,5795.09,5795.09, Neonate Birth Weight > 2499 Grams With Congenital Or Perinatal Infection,6362,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,9381.82,,,,,,,fee schedule,9381.82,9381.82, Neonate Birth Weight > 2499 Grams With Congenital Or Perinatal Infection,6362,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,9381.82,,,,,,,fee schedule,9381.82,9381.82, Neonate Birth Weight > 2499 Grams With Congenital Or Perinatal Infection,6362,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,9381.82,,,,,,,fee schedule,9381.82,9381.82, Neonate Birth Weight > 2499 Grams With Congenital Or Perinatal Infection,6362,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,9381.82,,,,,,,fee schedule,9381.82,9381.82, Neonate Birth Weight > 2499 Grams With Congenital Or Perinatal Infection,6362,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,9381.82,,,,,,,fee schedule,9381.82,9381.82, Neonate Birth Weight > 2499 Grams With Congenital Or Perinatal Infection,6362,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,9381.82,,,,,,,fee schedule,9381.82,9381.82, Neonate Birth Weight > 2499 Grams With Congenital Or Perinatal Infection,6362,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,9381.82,,,,,,,fee schedule,9381.82,9381.82, Neonate Birth Weight > 2499 Grams With Congenital Or Perinatal Infection,6362,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,9381.82,,,,,,,fee schedule,9381.82,9381.82, Neonate Birth Weight > 2499 Grams With Congenital Or Perinatal Infection,6362,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,9381.82,,,,,,,fee schedule,9381.82,9381.82, Neonate Birth Weight > 2499 Grams With Congenital Or Perinatal Infection,6362,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,9381.82,,,,,,,fee schedule,9381.82,9381.82, Neonate Birth Weight > 2499 Grams With Congenital Or Perinatal Infection,6362,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,9381.82,,,,,,,fee schedule,9381.82,9381.82, Neonate Birth Weight > 2499 Grams With Congenital Or Perinatal Infection,6363,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,19527.28,,,,,,,fee schedule,19527.28,19527.28, Neonate Birth Weight > 2499 Grams With Congenital Or Perinatal Infection,6363,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,19527.28,,,,,,,fee schedule,19527.28,19527.28, Neonate Birth Weight > 2499 Grams With Congenital Or Perinatal Infection,6363,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,19527.28,,,,,,,fee schedule,19527.28,19527.28, Neonate Birth Weight > 2499 Grams With Congenital Or Perinatal Infection,6363,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,19527.28,,,,,,,fee schedule,19527.28,19527.28, Neonate Birth Weight > 2499 Grams With Congenital Or Perinatal Infection,6363,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,19527.28,,,,,,,fee schedule,19527.28,19527.28, Neonate Birth Weight > 2499 Grams With Congenital Or Perinatal Infection,6363,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,19527.28,,,,,,,fee schedule,19527.28,19527.28, Neonate Birth Weight > 2499 Grams With Congenital Or Perinatal Infection,6363,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,19527.28,,,,,,,fee schedule,19527.28,19527.28, Neonate Birth Weight > 2499 Grams With Congenital Or Perinatal Infection,6363,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,19527.28,,,,,,,fee schedule,19527.28,19527.28, Neonate Birth Weight > 2499 Grams With Congenital Or Perinatal Infection,6363,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,19527.28,,,,,,,fee schedule,19527.28,19527.28, Neonate Birth Weight > 2499 Grams With Congenital Or Perinatal Infection,6363,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,19527.28,,,,,,,fee schedule,19527.28,19527.28, Neonate Birth Weight > 2499 Grams With Congenital Or Perinatal Infection,6363,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,19527.28,,,,,,,fee schedule,19527.28,19527.28, Neonate Birth Weight > 2499 Grams With Congenital Or Perinatal Infection,6364,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,19527.28,,,,,,,fee schedule,19527.28,19527.28, Neonate Birth Weight > 2499 Grams With Congenital Or Perinatal Infection,6364,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,19527.28,,,,,,,fee schedule,19527.28,19527.28, Neonate Birth Weight > 2499 Grams With Congenital Or Perinatal Infection,6364,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,19527.28,,,,,,,fee schedule,19527.28,19527.28, Neonate Birth Weight > 2499 Grams With Congenital Or Perinatal Infection,6364,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,19527.28,,,,,,,fee schedule,19527.28,19527.28, Neonate Birth Weight > 2499 Grams With Congenital Or Perinatal Infection,6364,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,19527.28,,,,,,,fee schedule,19527.28,19527.28, Neonate Birth Weight > 2499 Grams With Congenital Or Perinatal Infection,6364,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,19527.28,,,,,,,fee schedule,19527.28,19527.28, Neonate Birth Weight > 2499 Grams With Congenital Or Perinatal Infection,6364,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,19527.28,,,,,,,fee schedule,19527.28,19527.28, Neonate Birth Weight > 2499 Grams With Congenital Or Perinatal Infection,6364,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,19527.28,,,,,,,fee schedule,19527.28,19527.28, Neonate Birth Weight > 2499 Grams With Congenital Or Perinatal Infection,6364,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,19527.28,,,,,,,fee schedule,19527.28,19527.28, Neonate Birth Weight > 2499 Grams With Congenital Or Perinatal Infection,6364,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,19527.28,,,,,,,fee schedule,19527.28,19527.28, Neonate Birth Weight > 2499 Grams With Congenital Or Perinatal Infection,6364,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,19527.28,,,,,,,fee schedule,19527.28,19527.28, Neonate Birth Weight > 2499 Grams With Other Significant Condition,6391,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,2723.57,,,,,,,fee schedule,2723.57,2723.57, Neonate Birth Weight > 2499 Grams With Other Significant Condition,6391,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,2723.57,,,,,,,fee schedule,2723.57,2723.57, Neonate Birth Weight > 2499 Grams With Other Significant Condition,6391,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,2723.57,,,,,,,fee schedule,2723.57,2723.57, Neonate Birth Weight > 2499 Grams With Other Significant Condition,6391,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,2723.57,,,,,,,fee schedule,2723.57,2723.57, Neonate Birth Weight > 2499 Grams With Other Significant Condition,6391,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,2723.57,,,,,,,fee schedule,2723.57,2723.57, Neonate Birth Weight > 2499 Grams With Other Significant Condition,6391,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,2723.57,,,,,,,fee schedule,2723.57,2723.57, Neonate Birth Weight > 2499 Grams With Other Significant Condition,6391,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,2723.57,,,,,,,fee schedule,2723.57,2723.57, Neonate Birth Weight > 2499 Grams With Other Significant Condition,6391,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,2723.57,,,,,,,fee schedule,2723.57,2723.57, Neonate Birth Weight > 2499 Grams With Other Significant Condition,6391,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,2723.57,,,,,,,fee schedule,2723.57,2723.57, Neonate Birth Weight > 2499 Grams With Other Significant Condition,6391,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,2723.57,,,,,,,fee schedule,2723.57,2723.57, Neonate Birth Weight > 2499 Grams With Other Significant Condition,6391,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,2723.57,,,,,,,fee schedule,2723.57,2723.57, Neonate Birth Weight > 2499 Grams With Other Significant Condition,6392,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5238.94,,,,,,,fee schedule,5238.94,5238.94, Neonate Birth Weight > 2499 Grams With Other Significant Condition,6392,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5238.94,,,,,,,fee schedule,5238.94,5238.94, Neonate Birth Weight > 2499 Grams With Other Significant Condition,6392,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5238.94,,,,,,,fee schedule,5238.94,5238.94, Neonate Birth Weight > 2499 Grams With Other Significant Condition,6392,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5238.94,,,,,,,fee schedule,5238.94,5238.94, Neonate Birth Weight > 2499 Grams With Other Significant Condition,6392,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5238.94,,,,,,,fee schedule,5238.94,5238.94, Neonate Birth Weight > 2499 Grams With Other Significant Condition,6392,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5238.94,,,,,,,fee schedule,5238.94,5238.94, Neonate Birth Weight > 2499 Grams With Other Significant Condition,6392,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5238.94,,,,,,,fee schedule,5238.94,5238.94, Neonate Birth Weight > 2499 Grams With Other Significant Condition,6392,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5238.94,,,,,,,fee schedule,5238.94,5238.94, Neonate Birth Weight > 2499 Grams With Other Significant Condition,6392,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5238.94,,,,,,,fee schedule,5238.94,5238.94, Neonate Birth Weight > 2499 Grams With Other Significant Condition,6392,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5238.94,,,,,,,fee schedule,5238.94,5238.94, Neonate Birth Weight > 2499 Grams With Other Significant Condition,6392,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5238.94,,,,,,,fee schedule,5238.94,5238.94, Neonate Birth Weight > 2499 Grams With Other Significant Condition,6393,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,15468.39,,,,,,,fee schedule,15468.39,15468.39, Neonate Birth Weight > 2499 Grams With Other Significant Condition,6393,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,15468.39,,,,,,,fee schedule,15468.39,15468.39, Neonate Birth Weight > 2499 Grams With Other Significant Condition,6393,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,15468.39,,,,,,,fee schedule,15468.39,15468.39, Neonate Birth Weight > 2499 Grams With Other Significant Condition,6393,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,15468.39,,,,,,,fee schedule,15468.39,15468.39, Neonate Birth Weight > 2499 Grams With Other Significant Condition,6393,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,15468.39,,,,,,,fee schedule,15468.39,15468.39, Neonate Birth Weight > 2499 Grams With Other Significant Condition,6393,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,15468.39,,,,,,,fee schedule,15468.39,15468.39, Neonate Birth Weight > 2499 Grams With Other Significant Condition,6393,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,15468.39,,,,,,,fee schedule,15468.39,15468.39, Neonate Birth Weight > 2499 Grams With Other Significant Condition,6393,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,15468.39,,,,,,,fee schedule,15468.39,15468.39, Neonate Birth Weight > 2499 Grams With Other Significant Condition,6393,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,15468.39,,,,,,,fee schedule,15468.39,15468.39, Neonate Birth Weight > 2499 Grams With Other Significant Condition,6393,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,15468.39,,,,,,,fee schedule,15468.39,15468.39, Neonate Birth Weight > 2499 Grams With Other Significant Condition,6393,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,15468.39,,,,,,,fee schedule,15468.39,15468.39, Neonate Birth Weight > 2499 Grams With Other Significant Condition,6394,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,23211.41,,,,,,,fee schedule,23211.41,23211.41, Neonate Birth Weight > 2499 Grams With Other Significant Condition,6394,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,23211.41,,,,,,,fee schedule,23211.41,23211.41, Neonate Birth Weight > 2499 Grams With Other Significant Condition,6394,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,23211.41,,,,,,,fee schedule,23211.41,23211.41, Neonate Birth Weight > 2499 Grams With Other Significant Condition,6394,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,23211.41,,,,,,,fee schedule,23211.41,23211.41, Neonate Birth Weight > 2499 Grams With Other Significant Condition,6394,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,23211.41,,,,,,,fee schedule,23211.41,23211.41, Neonate Birth Weight > 2499 Grams With Other Significant Condition,6394,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,23211.41,,,,,,,fee schedule,23211.41,23211.41, Neonate Birth Weight > 2499 Grams With Other Significant Condition,6394,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,23211.41,,,,,,,fee schedule,23211.41,23211.41, Neonate Birth Weight > 2499 Grams With Other Significant Condition,6394,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,23211.41,,,,,,,fee schedule,23211.41,23211.41, Neonate Birth Weight > 2499 Grams With Other Significant Condition,6394,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,23211.41,,,,,,,fee schedule,23211.41,23211.41, Neonate Birth Weight > 2499 Grams With Other Significant Condition,6394,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,23211.41,,,,,,,fee schedule,23211.41,23211.41, Neonate Birth Weight > 2499 Grams With Other Significant Condition,6394,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,23211.41,,,,,,,fee schedule,23211.41,23211.41, "Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem",6401,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,821.52,,,,,,,fee schedule,821.52,821.52, "Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem",6401,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,821.52,,,,,,,fee schedule,821.52,821.52, "Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem",6401,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,821.52,,,,,,,fee schedule,821.52,821.52, "Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem",6401,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,821.52,,,,,,,fee schedule,821.52,821.52, "Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem",6401,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,821.52,,,,,,,fee schedule,821.52,821.52, "Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem",6401,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,821.52,,,,,,,fee schedule,821.52,821.52, "Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem",6401,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,821.52,,,,,,,fee schedule,821.52,821.52, "Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem",6401,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,821.52,,,,,,,fee schedule,821.52,821.52, "Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem",6401,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,821.52,,,,,,,fee schedule,821.52,821.52, "Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem",6401,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,821.52,,,,,,,fee schedule,821.52,821.52, "Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem",6401,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,821.52,,,,,,,fee schedule,821.52,821.52, "Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem",6402,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,1221.69,,,,,,,fee schedule,1221.69,1221.69, "Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem",6402,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,1221.69,,,,,,,fee schedule,1221.69,1221.69, "Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem",6402,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,1221.69,,,,,,,fee schedule,1221.69,1221.69, "Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem",6402,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,1221.69,,,,,,,fee schedule,1221.69,1221.69, "Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem",6402,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,1221.69,,,,,,,fee schedule,1221.69,1221.69, "Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem",6402,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,1221.69,,,,,,,fee schedule,1221.69,1221.69, "Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem",6402,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,1221.69,,,,,,,fee schedule,1221.69,1221.69, "Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem",6402,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,1221.69,,,,,,,fee schedule,1221.69,1221.69, "Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem",6402,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,1221.69,,,,,,,fee schedule,1221.69,1221.69, "Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem",6402,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,1221.69,,,,,,,fee schedule,1221.69,1221.69, "Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem",6402,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,1221.69,,,,,,,fee schedule,1221.69,1221.69, "Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem",6403,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,2877.52,,,,,,,fee schedule,2877.52,2877.52, "Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem",6403,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,2877.52,,,,,,,fee schedule,2877.52,2877.52, "Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem",6403,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,2877.52,,,,,,,fee schedule,2877.52,2877.52, "Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem",6403,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,2877.52,,,,,,,fee schedule,2877.52,2877.52, "Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem",6403,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,2877.52,,,,,,,fee schedule,2877.52,2877.52, "Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem",6403,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,2877.52,,,,,,,fee schedule,2877.52,2877.52, "Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem",6403,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,2877.52,,,,,,,fee schedule,2877.52,2877.52, "Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem",6403,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,2877.52,,,,,,,fee schedule,2877.52,2877.52, "Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem",6403,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,2877.52,,,,,,,fee schedule,2877.52,2877.52, "Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem",6403,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,2877.52,,,,,,,fee schedule,2877.52,2877.52, "Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem",6403,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,2877.52,,,,,,,fee schedule,2877.52,2877.52, "Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem",6404,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,18368.04,,,,,,,fee schedule,18368.04,18368.04, "Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem",6404,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,18368.04,,,,,,,fee schedule,18368.04,18368.04, "Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem",6404,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,18368.04,,,,,,,fee schedule,18368.04,18368.04, "Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem",6404,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,18368.04,,,,,,,fee schedule,18368.04,18368.04, "Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem",6404,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,18368.04,,,,,,,fee schedule,18368.04,18368.04, "Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem",6404,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,18368.04,,,,,,,fee schedule,18368.04,18368.04, "Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem",6404,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,18368.04,,,,,,,fee schedule,18368.04,18368.04, "Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem",6404,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,18368.04,,,,,,,fee schedule,18368.04,18368.04, "Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem",6404,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,18368.04,,,,,,,fee schedule,18368.04,18368.04, "Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem",6404,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,18368.04,,,,,,,fee schedule,18368.04,18368.04, "Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem",6404,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,18368.04,,,,,,,fee schedule,18368.04,18368.04, Splenectomy,6501,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,10896.4,,,,,,,fee schedule,10896.4,10896.4, Splenectomy,6501,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,10896.4,,,,,,,fee schedule,10896.4,10896.4, Splenectomy,6501,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,10896.4,,,,,,,fee schedule,10896.4,10896.4, Splenectomy,6501,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,10896.4,,,,,,,fee schedule,10896.4,10896.4, Splenectomy,6501,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,10896.4,,,,,,,fee schedule,10896.4,10896.4, Splenectomy,6501,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,10896.4,,,,,,,fee schedule,10896.4,10896.4, Splenectomy,6501,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,10896.4,,,,,,,fee schedule,10896.4,10896.4, Splenectomy,6501,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,10896.4,,,,,,,fee schedule,10896.4,10896.4, Splenectomy,6501,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,10896.4,,,,,,,fee schedule,10896.4,10896.4, Splenectomy,6501,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,10896.4,,,,,,,fee schedule,10896.4,10896.4, Splenectomy,6501,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,10896.4,,,,,,,fee schedule,10896.4,10896.4, Splenectomy,6502,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,15875.62,,,,,,,fee schedule,15875.62,15875.62, Splenectomy,6502,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,15875.62,,,,,,,fee schedule,15875.62,15875.62, Splenectomy,6502,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,15875.62,,,,,,,fee schedule,15875.62,15875.62, Splenectomy,6502,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,15875.62,,,,,,,fee schedule,15875.62,15875.62, Splenectomy,6502,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,15875.62,,,,,,,fee schedule,15875.62,15875.62, Splenectomy,6502,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,15875.62,,,,,,,fee schedule,15875.62,15875.62, Splenectomy,6502,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,15875.62,,,,,,,fee schedule,15875.62,15875.62, Splenectomy,6502,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,15875.62,,,,,,,fee schedule,15875.62,15875.62, Splenectomy,6502,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,15875.62,,,,,,,fee schedule,15875.62,15875.62, Splenectomy,6502,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,15875.62,,,,,,,fee schedule,15875.62,15875.62, Splenectomy,6502,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,15875.62,,,,,,,fee schedule,15875.62,15875.62, Splenectomy,6503,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,19704.43,,,,,,,fee schedule,19704.43,19704.43, Splenectomy,6503,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,19704.43,,,,,,,fee schedule,19704.43,19704.43, Splenectomy,6503,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,19704.43,,,,,,,fee schedule,19704.43,19704.43, Splenectomy,6503,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,19704.43,,,,,,,fee schedule,19704.43,19704.43, Splenectomy,6503,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,19704.43,,,,,,,fee schedule,19704.43,19704.43, Splenectomy,6503,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,19704.43,,,,,,,fee schedule,19704.43,19704.43, Splenectomy,6503,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,19704.43,,,,,,,fee schedule,19704.43,19704.43, Splenectomy,6503,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,19704.43,,,,,,,fee schedule,19704.43,19704.43, Splenectomy,6503,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,19704.43,,,,,,,fee schedule,19704.43,19704.43, Splenectomy,6503,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,19704.43,,,,,,,fee schedule,19704.43,19704.43, Splenectomy,6503,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,19704.43,,,,,,,fee schedule,19704.43,19704.43, Splenectomy,6504,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,31267.78,,,,,,,fee schedule,31267.78,31267.78, Splenectomy,6504,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,31267.78,,,,,,,fee schedule,31267.78,31267.78, Splenectomy,6504,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,31267.78,,,,,,,fee schedule,31267.78,31267.78, Splenectomy,6504,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,31267.78,,,,,,,fee schedule,31267.78,31267.78, Splenectomy,6504,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,31267.78,,,,,,,fee schedule,31267.78,31267.78, Splenectomy,6504,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,31267.78,,,,,,,fee schedule,31267.78,31267.78, Splenectomy,6504,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,31267.78,,,,,,,fee schedule,31267.78,31267.78, Splenectomy,6504,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,31267.78,,,,,,,fee schedule,31267.78,31267.78, Splenectomy,6504,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,31267.78,,,,,,,fee schedule,31267.78,31267.78, Splenectomy,6504,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,31267.78,,,,,,,fee schedule,31267.78,31267.78, Splenectomy,6504,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,31267.78,,,,,,,fee schedule,31267.78,31267.78, Other Procedures Of Blood And Blood-Forming Organs,6511,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,9444.63,,,,,,,fee schedule,9444.63,9444.63, Other Procedures Of Blood And Blood-Forming Organs,6511,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,9444.63,,,,,,,fee schedule,9444.63,9444.63, Other Procedures Of Blood And Blood-Forming Organs,6511,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,9444.63,,,,,,,fee schedule,9444.63,9444.63, Other Procedures Of Blood And Blood-Forming Organs,6511,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,9444.63,,,,,,,fee schedule,9444.63,9444.63, Other Procedures Of Blood And Blood-Forming Organs,6511,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,9444.63,,,,,,,fee schedule,9444.63,9444.63, Other Procedures Of Blood And Blood-Forming Organs,6511,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,9444.63,,,,,,,fee schedule,9444.63,9444.63, Other Procedures Of Blood And Blood-Forming Organs,6511,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,9444.63,,,,,,,fee schedule,9444.63,9444.63, Other Procedures Of Blood And Blood-Forming Organs,6511,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,9444.63,,,,,,,fee schedule,9444.63,9444.63, Other Procedures Of Blood And Blood-Forming Organs,6511,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,9444.63,,,,,,,fee schedule,9444.63,9444.63, Other Procedures Of Blood And Blood-Forming Organs,6511,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,9444.63,,,,,,,fee schedule,9444.63,9444.63, Other Procedures Of Blood And Blood-Forming Organs,6511,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,9444.63,,,,,,,fee schedule,9444.63,9444.63, Other Procedures Of Blood And Blood-Forming Organs,6512,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,13421.65,,,,,,,fee schedule,13421.65,13421.65, Other Procedures Of Blood And Blood-Forming Organs,6512,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,13421.65,,,,,,,fee schedule,13421.65,13421.65, Other Procedures Of Blood And Blood-Forming Organs,6512,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,13421.65,,,,,,,fee schedule,13421.65,13421.65, Other Procedures Of Blood And Blood-Forming Organs,6512,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,13421.65,,,,,,,fee schedule,13421.65,13421.65, Other Procedures Of Blood And Blood-Forming Organs,6512,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,13421.65,,,,,,,fee schedule,13421.65,13421.65, Other Procedures Of Blood And Blood-Forming Organs,6512,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,13421.65,,,,,,,fee schedule,13421.65,13421.65, Other Procedures Of Blood And Blood-Forming Organs,6512,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,13421.65,,,,,,,fee schedule,13421.65,13421.65, Other Procedures Of Blood And Blood-Forming Organs,6512,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,13421.65,,,,,,,fee schedule,13421.65,13421.65, Other Procedures Of Blood And Blood-Forming Organs,6512,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,13421.65,,,,,,,fee schedule,13421.65,13421.65, Other Procedures Of Blood And Blood-Forming Organs,6512,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,13421.65,,,,,,,fee schedule,13421.65,13421.65, Other Procedures Of Blood And Blood-Forming Organs,6512,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,13421.65,,,,,,,fee schedule,13421.65,13421.65, Other Procedures Of Blood And Blood-Forming Organs,6513,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,18196.19,,,,,,,fee schedule,18196.19,18196.19, Other Procedures Of Blood And Blood-Forming Organs,6513,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,18196.19,,,,,,,fee schedule,18196.19,18196.19, Other Procedures Of Blood And Blood-Forming Organs,6513,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,18196.19,,,,,,,fee schedule,18196.19,18196.19, Other Procedures Of Blood And Blood-Forming Organs,6513,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,18196.19,,,,,,,fee schedule,18196.19,18196.19, Other Procedures Of Blood And Blood-Forming Organs,6513,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,18196.19,,,,,,,fee schedule,18196.19,18196.19, Other Procedures Of Blood And Blood-Forming Organs,6513,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,18196.19,,,,,,,fee schedule,18196.19,18196.19, Other Procedures Of Blood And Blood-Forming Organs,6513,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,18196.19,,,,,,,fee schedule,18196.19,18196.19, Other Procedures Of Blood And Blood-Forming Organs,6513,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,18196.19,,,,,,,fee schedule,18196.19,18196.19, Other Procedures Of Blood And Blood-Forming Organs,6513,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,18196.19,,,,,,,fee schedule,18196.19,18196.19, Other Procedures Of Blood And Blood-Forming Organs,6513,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,18196.19,,,,,,,fee schedule,18196.19,18196.19, Other Procedures Of Blood And Blood-Forming Organs,6513,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,18196.19,,,,,,,fee schedule,18196.19,18196.19, Other Procedures Of Blood And Blood-Forming Organs,6514,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,35126.24,,,,,,,fee schedule,35126.24,35126.24, Other Procedures Of Blood And Blood-Forming Organs,6514,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,35126.24,,,,,,,fee schedule,35126.24,35126.24, Other Procedures Of Blood And Blood-Forming Organs,6514,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,35126.24,,,,,,,fee schedule,35126.24,35126.24, Other Procedures Of Blood And Blood-Forming Organs,6514,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,35126.24,,,,,,,fee schedule,35126.24,35126.24, Other Procedures Of Blood And Blood-Forming Organs,6514,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,35126.24,,,,,,,fee schedule,35126.24,35126.24, Other Procedures Of Blood And Blood-Forming Organs,6514,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,35126.24,,,,,,,fee schedule,35126.24,35126.24, Other Procedures Of Blood And Blood-Forming Organs,6514,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,35126.24,,,,,,,fee schedule,35126.24,35126.24, Other Procedures Of Blood And Blood-Forming Organs,6514,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,35126.24,,,,,,,fee schedule,35126.24,35126.24, Other Procedures Of Blood And Blood-Forming Organs,6514,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,35126.24,,,,,,,fee schedule,35126.24,35126.24, Other Procedures Of Blood And Blood-Forming Organs,6514,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,35126.24,,,,,,,fee schedule,35126.24,35126.24, Other Procedures Of Blood And Blood-Forming Organs,6514,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,35126.24,,,,,,,fee schedule,35126.24,35126.24, Major Hematologic Or Immunologic Diagnoses Except Sickle Cell Crisis And Coagulation,6601,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5151.42,,,,,,,fee schedule,5151.42,5151.42, Major Hematologic Or Immunologic Diagnoses Except Sickle Cell Crisis And Coagulation,6601,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5151.42,,,,,,,fee schedule,5151.42,5151.42, Major Hematologic Or Immunologic Diagnoses Except Sickle Cell Crisis And Coagulation,6601,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5151.42,,,,,,,fee schedule,5151.42,5151.42, Major Hematologic Or Immunologic Diagnoses Except Sickle Cell Crisis And Coagulation,6601,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5151.42,,,,,,,fee schedule,5151.42,5151.42, Major Hematologic Or Immunologic Diagnoses Except Sickle Cell Crisis And Coagulation,6601,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5151.42,,,,,,,fee schedule,5151.42,5151.42, Major Hematologic Or Immunologic Diagnoses Except Sickle Cell Crisis And Coagulation,6601,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5151.42,,,,,,,fee schedule,5151.42,5151.42, Major Hematologic Or Immunologic Diagnoses Except Sickle Cell Crisis And Coagulation,6601,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5151.42,,,,,,,fee schedule,5151.42,5151.42, Major Hematologic Or Immunologic Diagnoses Except Sickle Cell Crisis And Coagulation,6601,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5151.42,,,,,,,fee schedule,5151.42,5151.42, Major Hematologic Or Immunologic Diagnoses Except Sickle Cell Crisis And Coagulation,6601,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5151.42,,,,,,,fee schedule,5151.42,5151.42, Major Hematologic Or Immunologic Diagnoses Except Sickle Cell Crisis And Coagulation,6601,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5151.42,,,,,,,fee schedule,5151.42,5151.42, Major Hematologic Or Immunologic Diagnoses Except Sickle Cell Crisis And Coagulation,6601,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5151.42,,,,,,,fee schedule,5151.42,5151.42, Major Hematologic Or Immunologic Diagnoses Except Sickle Cell Crisis And Coagulation,6602,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,6570.73,,,,,,,fee schedule,6570.73,6570.73, Major Hematologic Or Immunologic Diagnoses Except Sickle Cell Crisis And Coagulation,6602,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,6570.73,,,,,,,fee schedule,6570.73,6570.73, Major Hematologic Or Immunologic Diagnoses Except Sickle Cell Crisis And Coagulation,6602,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,6570.73,,,,,,,fee schedule,6570.73,6570.73, Major Hematologic Or Immunologic Diagnoses Except Sickle Cell Crisis And Coagulation,6602,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,6570.73,,,,,,,fee schedule,6570.73,6570.73, Major Hematologic Or Immunologic Diagnoses Except Sickle Cell Crisis And Coagulation,6602,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,6570.73,,,,,,,fee schedule,6570.73,6570.73, Major Hematologic Or Immunologic Diagnoses Except Sickle Cell Crisis And Coagulation,6602,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,6570.73,,,,,,,fee schedule,6570.73,6570.73, Major Hematologic Or Immunologic Diagnoses Except Sickle Cell Crisis And Coagulation,6602,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,6570.73,,,,,,,fee schedule,6570.73,6570.73, Major Hematologic Or Immunologic Diagnoses Except Sickle Cell Crisis And Coagulation,6602,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,6570.73,,,,,,,fee schedule,6570.73,6570.73, Major Hematologic Or Immunologic Diagnoses Except Sickle Cell Crisis And Coagulation,6602,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,6570.73,,,,,,,fee schedule,6570.73,6570.73, Major Hematologic Or Immunologic Diagnoses Except Sickle Cell Crisis And Coagulation,6602,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,6570.73,,,,,,,fee schedule,6570.73,6570.73, Major Hematologic Or Immunologic Diagnoses Except Sickle Cell Crisis And Coagulation,6602,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,6570.73,,,,,,,fee schedule,6570.73,6570.73, Major Hematologic Or Immunologic Diagnoses Except Sickle Cell Crisis And Coagulation,6603,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,10393.89,,,,,,,fee schedule,10393.89,10393.89, Major Hematologic Or Immunologic Diagnoses Except Sickle Cell Crisis And Coagulation,6603,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,10393.89,,,,,,,fee schedule,10393.89,10393.89, Major Hematologic Or Immunologic Diagnoses Except Sickle Cell Crisis And Coagulation,6603,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,10393.89,,,,,,,fee schedule,10393.89,10393.89, Major Hematologic Or Immunologic Diagnoses Except Sickle Cell Crisis And Coagulation,6603,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,10393.89,,,,,,,fee schedule,10393.89,10393.89, Major Hematologic Or Immunologic Diagnoses Except Sickle Cell Crisis And Coagulation,6603,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,10393.89,,,,,,,fee schedule,10393.89,10393.89, Major Hematologic Or Immunologic Diagnoses Except Sickle Cell Crisis And Coagulation,6603,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,10393.89,,,,,,,fee schedule,10393.89,10393.89, Major Hematologic Or Immunologic Diagnoses Except Sickle Cell Crisis And Coagulation,6603,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,10393.89,,,,,,,fee schedule,10393.89,10393.89, Major Hematologic Or Immunologic Diagnoses Except Sickle Cell Crisis And Coagulation,6603,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,10393.89,,,,,,,fee schedule,10393.89,10393.89, Major Hematologic Or Immunologic Diagnoses Except Sickle Cell Crisis And Coagulation,6603,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,10393.89,,,,,,,fee schedule,10393.89,10393.89, Major Hematologic Or Immunologic Diagnoses Except Sickle Cell Crisis And Coagulation,6603,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,10393.89,,,,,,,fee schedule,10393.89,10393.89, Major Hematologic Or Immunologic Diagnoses Except Sickle Cell Crisis And Coagulation,6603,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,10393.89,,,,,,,fee schedule,10393.89,10393.89, Major Hematologic Or Immunologic Diagnoses Except Sickle Cell Crisis And Coagulation,6604,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,19683.96,,,,,,,fee schedule,19683.96,19683.96, Major Hematologic Or Immunologic Diagnoses Except Sickle Cell Crisis And Coagulation,6604,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,19683.96,,,,,,,fee schedule,19683.96,19683.96, Major Hematologic Or Immunologic Diagnoses Except Sickle Cell Crisis And Coagulation,6604,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,19683.96,,,,,,,fee schedule,19683.96,19683.96, Major Hematologic Or Immunologic Diagnoses Except Sickle Cell Crisis And Coagulation,6604,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,19683.96,,,,,,,fee schedule,19683.96,19683.96, Major Hematologic Or Immunologic Diagnoses Except Sickle Cell Crisis And Coagulation,6604,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,19683.96,,,,,,,fee schedule,19683.96,19683.96, Major Hematologic Or Immunologic Diagnoses Except Sickle Cell Crisis And Coagulation,6604,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,19683.96,,,,,,,fee schedule,19683.96,19683.96, Major Hematologic Or Immunologic Diagnoses Except Sickle Cell Crisis And Coagulation,6604,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,19683.96,,,,,,,fee schedule,19683.96,19683.96, Major Hematologic Or Immunologic Diagnoses Except Sickle Cell Crisis And Coagulation,6604,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,19683.96,,,,,,,fee schedule,19683.96,19683.96, Major Hematologic Or Immunologic Diagnoses Except Sickle Cell Crisis And Coagulation,6604,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,19683.96,,,,,,,fee schedule,19683.96,19683.96, Major Hematologic Or Immunologic Diagnoses Except Sickle Cell Crisis And Coagulation,6604,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,19683.96,,,,,,,fee schedule,19683.96,19683.96, Major Hematologic Or Immunologic Diagnoses Except Sickle Cell Crisis And Coagulation,6604,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,19683.96,,,,,,,fee schedule,19683.96,19683.96, Coagulation And Platelet Disorders,6611,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,6100.69,,,,,,,fee schedule,6100.69,6100.69, Coagulation And Platelet Disorders,6611,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,6100.69,,,,,,,fee schedule,6100.69,6100.69, Coagulation And Platelet Disorders,6611,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,6100.69,,,,,,,fee schedule,6100.69,6100.69, Coagulation And Platelet Disorders,6611,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,6100.69,,,,,,,fee schedule,6100.69,6100.69, Coagulation And Platelet Disorders,6611,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,6100.69,,,,,,,fee schedule,6100.69,6100.69, Coagulation And Platelet Disorders,6611,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,6100.69,,,,,,,fee schedule,6100.69,6100.69, Coagulation And Platelet Disorders,6611,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,6100.69,,,,,,,fee schedule,6100.69,6100.69, Coagulation And Platelet Disorders,6611,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,6100.69,,,,,,,fee schedule,6100.69,6100.69, Coagulation And Platelet Disorders,6611,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,6100.69,,,,,,,fee schedule,6100.69,6100.69, Coagulation And Platelet Disorders,6611,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,6100.69,,,,,,,fee schedule,6100.69,6100.69, Coagulation And Platelet Disorders,6611,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,6100.69,,,,,,,fee schedule,6100.69,6100.69, Coagulation And Platelet Disorders,6612,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,8326.69,,,,,,,fee schedule,8326.69,8326.69, Coagulation And Platelet Disorders,6612,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,8326.69,,,,,,,fee schedule,8326.69,8326.69, Coagulation And Platelet Disorders,6612,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,8326.69,,,,,,,fee schedule,8326.69,8326.69, Coagulation And Platelet Disorders,6612,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,8326.69,,,,,,,fee schedule,8326.69,8326.69, Coagulation And Platelet Disorders,6612,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,8326.69,,,,,,,fee schedule,8326.69,8326.69, Coagulation And Platelet Disorders,6612,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,8326.69,,,,,,,fee schedule,8326.69,8326.69, Coagulation And Platelet Disorders,6612,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,8326.69,,,,,,,fee schedule,8326.69,8326.69, Coagulation And Platelet Disorders,6612,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,8326.69,,,,,,,fee schedule,8326.69,8326.69, Coagulation And Platelet Disorders,6612,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,8326.69,,,,,,,fee schedule,8326.69,8326.69, Coagulation And Platelet Disorders,6612,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,8326.69,,,,,,,fee schedule,8326.69,8326.69, Coagulation And Platelet Disorders,6612,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,8326.69,,,,,,,fee schedule,8326.69,8326.69, Coagulation And Platelet Disorders,6613,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,12069.39,,,,,,,fee schedule,12069.39,12069.39, Coagulation And Platelet Disorders,6613,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,12069.39,,,,,,,fee schedule,12069.39,12069.39, Coagulation And Platelet Disorders,6613,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,12069.39,,,,,,,fee schedule,12069.39,12069.39, Coagulation And Platelet Disorders,6613,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,12069.39,,,,,,,fee schedule,12069.39,12069.39, Coagulation And Platelet Disorders,6613,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,12069.39,,,,,,,fee schedule,12069.39,12069.39, Coagulation And Platelet Disorders,6613,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,12069.39,,,,,,,fee schedule,12069.39,12069.39, Coagulation And Platelet Disorders,6613,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,12069.39,,,,,,,fee schedule,12069.39,12069.39, Coagulation And Platelet Disorders,6613,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,12069.39,,,,,,,fee schedule,12069.39,12069.39, Coagulation And Platelet Disorders,6613,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,12069.39,,,,,,,fee schedule,12069.39,12069.39, Coagulation And Platelet Disorders,6613,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,12069.39,,,,,,,fee schedule,12069.39,12069.39, Coagulation And Platelet Disorders,6613,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,12069.39,,,,,,,fee schedule,12069.39,12069.39, Coagulation And Platelet Disorders,6614,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,19220.27,,,,,,,fee schedule,19220.27,19220.27, Coagulation And Platelet Disorders,6614,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,19220.27,,,,,,,fee schedule,19220.27,19220.27, Coagulation And Platelet Disorders,6614,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,19220.27,,,,,,,fee schedule,19220.27,19220.27, Coagulation And Platelet Disorders,6614,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,19220.27,,,,,,,fee schedule,19220.27,19220.27, Coagulation And Platelet Disorders,6614,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,19220.27,,,,,,,fee schedule,19220.27,19220.27, Coagulation And Platelet Disorders,6614,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,19220.27,,,,,,,fee schedule,19220.27,19220.27, Coagulation And Platelet Disorders,6614,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,19220.27,,,,,,,fee schedule,19220.27,19220.27, Coagulation And Platelet Disorders,6614,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,19220.27,,,,,,,fee schedule,19220.27,19220.27, Coagulation And Platelet Disorders,6614,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,19220.27,,,,,,,fee schedule,19220.27,19220.27, Coagulation And Platelet Disorders,6614,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,19220.27,,,,,,,fee schedule,19220.27,19220.27, Coagulation And Platelet Disorders,6614,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,19220.27,,,,,,,fee schedule,19220.27,19220.27, Sickle Cell Anemia Crisis,6621,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4524.7,,,,,,,fee schedule,4524.7,4524.7, Sickle Cell Anemia Crisis,6621,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4524.7,,,,,,,fee schedule,4524.7,4524.7, Sickle Cell Anemia Crisis,6621,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4524.7,,,,,,,fee schedule,4524.7,4524.7, Sickle Cell Anemia Crisis,6621,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4524.7,,,,,,,fee schedule,4524.7,4524.7, Sickle Cell Anemia Crisis,6621,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4524.7,,,,,,,fee schedule,4524.7,4524.7, Sickle Cell Anemia Crisis,6621,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4524.7,,,,,,,fee schedule,4524.7,4524.7, Sickle Cell Anemia Crisis,6621,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4524.7,,,,,,,fee schedule,4524.7,4524.7, Sickle Cell Anemia Crisis,6621,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4524.7,,,,,,,fee schedule,4524.7,4524.7, Sickle Cell Anemia Crisis,6621,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4524.7,,,,,,,fee schedule,4524.7,4524.7, Sickle Cell Anemia Crisis,6621,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4524.7,,,,,,,fee schedule,4524.7,4524.7, Sickle Cell Anemia Crisis,6621,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4524.7,,,,,,,fee schedule,4524.7,4524.7, Sickle Cell Anemia Crisis,6622,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,6205.85,,,,,,,fee schedule,6205.85,6205.85, Sickle Cell Anemia Crisis,6622,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,6205.85,,,,,,,fee schedule,6205.85,6205.85, Sickle Cell Anemia Crisis,6622,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,6205.85,,,,,,,fee schedule,6205.85,6205.85, Sickle Cell Anemia Crisis,6622,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,6205.85,,,,,,,fee schedule,6205.85,6205.85, Sickle Cell Anemia Crisis,6622,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,6205.85,,,,,,,fee schedule,6205.85,6205.85, Sickle Cell Anemia Crisis,6622,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,6205.85,,,,,,,fee schedule,6205.85,6205.85, Sickle Cell Anemia Crisis,6622,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,6205.85,,,,,,,fee schedule,6205.85,6205.85, Sickle Cell Anemia Crisis,6622,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,6205.85,,,,,,,fee schedule,6205.85,6205.85, Sickle Cell Anemia Crisis,6622,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,6205.85,,,,,,,fee schedule,6205.85,6205.85, Sickle Cell Anemia Crisis,6622,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,6205.85,,,,,,,fee schedule,6205.85,6205.85, Sickle Cell Anemia Crisis,6622,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,6205.85,,,,,,,fee schedule,6205.85,6205.85, Sickle Cell Anemia Crisis,6623,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,9926.67,,,,,,,fee schedule,9926.67,9926.67, Sickle Cell Anemia Crisis,6623,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,9926.67,,,,,,,fee schedule,9926.67,9926.67, Sickle Cell Anemia Crisis,6623,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,9926.67,,,,,,,fee schedule,9926.67,9926.67, Sickle Cell Anemia Crisis,6623,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,9926.67,,,,,,,fee schedule,9926.67,9926.67, Sickle Cell Anemia Crisis,6623,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,9926.67,,,,,,,fee schedule,9926.67,9926.67, Sickle Cell Anemia Crisis,6623,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,9926.67,,,,,,,fee schedule,9926.67,9926.67, Sickle Cell Anemia Crisis,6623,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,9926.67,,,,,,,fee schedule,9926.67,9926.67, Sickle Cell Anemia Crisis,6623,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,9926.67,,,,,,,fee schedule,9926.67,9926.67, Sickle Cell Anemia Crisis,6623,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,9926.67,,,,,,,fee schedule,9926.67,9926.67, Sickle Cell Anemia Crisis,6623,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,9926.67,,,,,,,fee schedule,9926.67,9926.67, Sickle Cell Anemia Crisis,6623,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,9926.67,,,,,,,fee schedule,9926.67,9926.67, Sickle Cell Anemia Crisis,6624,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,17993.64,,,,,,,fee schedule,17993.64,17993.64, Sickle Cell Anemia Crisis,6624,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,17993.64,,,,,,,fee schedule,17993.64,17993.64, Sickle Cell Anemia Crisis,6624,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,17993.64,,,,,,,fee schedule,17993.64,17993.64, Sickle Cell Anemia Crisis,6624,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,17993.64,,,,,,,fee schedule,17993.64,17993.64, Sickle Cell Anemia Crisis,6624,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,17993.64,,,,,,,fee schedule,17993.64,17993.64, Sickle Cell Anemia Crisis,6624,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,17993.64,,,,,,,fee schedule,17993.64,17993.64, Sickle Cell Anemia Crisis,6624,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,17993.64,,,,,,,fee schedule,17993.64,17993.64, Sickle Cell Anemia Crisis,6624,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,17993.64,,,,,,,fee schedule,17993.64,17993.64, Sickle Cell Anemia Crisis,6624,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,17993.64,,,,,,,fee schedule,17993.64,17993.64, Sickle Cell Anemia Crisis,6624,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,17993.64,,,,,,,fee schedule,17993.64,17993.64, Sickle Cell Anemia Crisis,6624,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,17993.64,,,,,,,fee schedule,17993.64,17993.64, Other Anemia And Disorders Of Blood And Blood-Forming Organs,6631,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4162.64,,,,,,,fee schedule,4162.64,4162.64, Other Anemia And Disorders Of Blood And Blood-Forming Organs,6631,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4162.64,,,,,,,fee schedule,4162.64,4162.64, Other Anemia And Disorders Of Blood And Blood-Forming Organs,6631,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4162.64,,,,,,,fee schedule,4162.64,4162.64, Other Anemia And Disorders Of Blood And Blood-Forming Organs,6631,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4162.64,,,,,,,fee schedule,4162.64,4162.64, Other Anemia And Disorders Of Blood And Blood-Forming Organs,6631,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4162.64,,,,,,,fee schedule,4162.64,4162.64, Other Anemia And Disorders Of Blood And Blood-Forming Organs,6631,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4162.64,,,,,,,fee schedule,4162.64,4162.64, Other Anemia And Disorders Of Blood And Blood-Forming Organs,6631,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4162.64,,,,,,,fee schedule,4162.64,4162.64, Other Anemia And Disorders Of Blood And Blood-Forming Organs,6631,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4162.64,,,,,,,fee schedule,4162.64,4162.64, Other Anemia And Disorders Of Blood And Blood-Forming Organs,6631,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4162.64,,,,,,,fee schedule,4162.64,4162.64, Other Anemia And Disorders Of Blood And Blood-Forming Organs,6631,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4162.64,,,,,,,fee schedule,4162.64,4162.64, Other Anemia And Disorders Of Blood And Blood-Forming Organs,6631,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4162.64,,,,,,,fee schedule,4162.64,4162.64, Other Anemia And Disorders Of Blood And Blood-Forming Organs,6632,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5783.09,,,,,,,fee schedule,5783.09,5783.09, Other Anemia And Disorders Of Blood And Blood-Forming Organs,6632,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5783.09,,,,,,,fee schedule,5783.09,5783.09, Other Anemia And Disorders Of Blood And Blood-Forming Organs,6632,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5783.09,,,,,,,fee schedule,5783.09,5783.09, Other Anemia And Disorders Of Blood And Blood-Forming Organs,6632,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5783.09,,,,,,,fee schedule,5783.09,5783.09, Other Anemia And Disorders Of Blood And Blood-Forming Organs,6632,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5783.09,,,,,,,fee schedule,5783.09,5783.09, Other Anemia And Disorders Of Blood And Blood-Forming Organs,6632,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5783.09,,,,,,,fee schedule,5783.09,5783.09, Other Anemia And Disorders Of Blood And Blood-Forming Organs,6632,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5783.09,,,,,,,fee schedule,5783.09,5783.09, Other Anemia And Disorders Of Blood And Blood-Forming Organs,6632,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5783.09,,,,,,,fee schedule,5783.09,5783.09, Other Anemia And Disorders Of Blood And Blood-Forming Organs,6632,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5783.09,,,,,,,fee schedule,5783.09,5783.09, Other Anemia And Disorders Of Blood And Blood-Forming Organs,6632,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5783.09,,,,,,,fee schedule,5783.09,5783.09, Other Anemia And Disorders Of Blood And Blood-Forming Organs,6632,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5783.09,,,,,,,fee schedule,5783.09,5783.09, Other Anemia And Disorders Of Blood And Blood-Forming Organs,6633,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,8116.37,,,,,,,fee schedule,8116.37,8116.37, Other Anemia And Disorders Of Blood And Blood-Forming Organs,6633,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,8116.37,,,,,,,fee schedule,8116.37,8116.37, Other Anemia And Disorders Of Blood And Blood-Forming Organs,6633,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,8116.37,,,,,,,fee schedule,8116.37,8116.37, Other Anemia And Disorders Of Blood And Blood-Forming Organs,6633,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,8116.37,,,,,,,fee schedule,8116.37,8116.37, Other Anemia And Disorders Of Blood And Blood-Forming Organs,6633,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,8116.37,,,,,,,fee schedule,8116.37,8116.37, Other Anemia And Disorders Of Blood And Blood-Forming Organs,6633,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,8116.37,,,,,,,fee schedule,8116.37,8116.37, Other Anemia And Disorders Of Blood And Blood-Forming Organs,6633,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,8116.37,,,,,,,fee schedule,8116.37,8116.37, Other Anemia And Disorders Of Blood And Blood-Forming Organs,6633,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,8116.37,,,,,,,fee schedule,8116.37,8116.37, Other Anemia And Disorders Of Blood And Blood-Forming Organs,6633,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,8116.37,,,,,,,fee schedule,8116.37,8116.37, Other Anemia And Disorders Of Blood And Blood-Forming Organs,6633,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,8116.37,,,,,,,fee schedule,8116.37,8116.37, Other Anemia And Disorders Of Blood And Blood-Forming Organs,6633,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,8116.37,,,,,,,fee schedule,8116.37,8116.37, Other Anemia And Disorders Of Blood And Blood-Forming Organs,6634,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,14281.99,,,,,,,fee schedule,14281.99,14281.99, Other Anemia And Disorders Of Blood And Blood-Forming Organs,6634,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,14281.99,,,,,,,fee schedule,14281.99,14281.99, Other Anemia And Disorders Of Blood And Blood-Forming Organs,6634,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,14281.99,,,,,,,fee schedule,14281.99,14281.99, Other Anemia And Disorders Of Blood And Blood-Forming Organs,6634,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,14281.99,,,,,,,fee schedule,14281.99,14281.99, Other Anemia And Disorders Of Blood And Blood-Forming Organs,6634,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,14281.99,,,,,,,fee schedule,14281.99,14281.99, Other Anemia And Disorders Of Blood And Blood-Forming Organs,6634,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,14281.99,,,,,,,fee schedule,14281.99,14281.99, Other Anemia And Disorders Of Blood And Blood-Forming Organs,6634,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,14281.99,,,,,,,fee schedule,14281.99,14281.99, Other Anemia And Disorders Of Blood And Blood-Forming Organs,6634,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,14281.99,,,,,,,fee schedule,14281.99,14281.99, Other Anemia And Disorders Of Blood And Blood-Forming Organs,6634,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,14281.99,,,,,,,fee schedule,14281.99,14281.99, Other Anemia And Disorders Of Blood And Blood-Forming Organs,6634,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,14281.99,,,,,,,fee schedule,14281.99,14281.99, Other Anemia And Disorders Of Blood And Blood-Forming Organs,6634,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,14281.99,,,,,,,fee schedule,14281.99,14281.99, "Major O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6801,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,12203.49,,,,,,,fee schedule,12203.49,12203.49, "Major O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6801,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,12203.49,,,,,,,fee schedule,12203.49,12203.49, "Major O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6801,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,12203.49,,,,,,,fee schedule,12203.49,12203.49, "Major O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6801,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,12203.49,,,,,,,fee schedule,12203.49,12203.49, "Major O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6801,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,12203.49,,,,,,,fee schedule,12203.49,12203.49, "Major O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6801,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,12203.49,,,,,,,fee schedule,12203.49,12203.49, "Major O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6801,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,12203.49,,,,,,,fee schedule,12203.49,12203.49, "Major O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6801,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,12203.49,,,,,,,fee schedule,12203.49,12203.49, "Major O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6801,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,12203.49,,,,,,,fee schedule,12203.49,12203.49, "Major O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6801,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,12203.49,,,,,,,fee schedule,12203.49,12203.49, "Major O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6801,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,12203.49,,,,,,,fee schedule,12203.49,12203.49, "Major O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6802,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,16796.65,,,,,,,fee schedule,16796.65,16796.65, "Major O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6802,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,16796.65,,,,,,,fee schedule,16796.65,16796.65, "Major O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6802,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,16796.65,,,,,,,fee schedule,16796.65,16796.65, "Major O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6802,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,16796.65,,,,,,,fee schedule,16796.65,16796.65, "Major O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6802,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,16796.65,,,,,,,fee schedule,16796.65,16796.65, "Major O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6802,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,16796.65,,,,,,,fee schedule,16796.65,16796.65, "Major O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6802,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,16796.65,,,,,,,fee schedule,16796.65,16796.65, "Major O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6802,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,16796.65,,,,,,,fee schedule,16796.65,16796.65, "Major O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6802,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,16796.65,,,,,,,fee schedule,16796.65,16796.65, "Major O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6802,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,16796.65,,,,,,,fee schedule,16796.65,16796.65, "Major O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6802,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,16796.65,,,,,,,fee schedule,16796.65,16796.65, "Major O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6803,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,26636.51,,,,,,,fee schedule,26636.51,26636.51, "Major O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6803,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,26636.51,,,,,,,fee schedule,26636.51,26636.51, "Major O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6803,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,26636.51,,,,,,,fee schedule,26636.51,26636.51, "Major O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6803,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,26636.51,,,,,,,fee schedule,26636.51,26636.51, "Major O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6803,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,26636.51,,,,,,,fee schedule,26636.51,26636.51, "Major O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6803,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,26636.51,,,,,,,fee schedule,26636.51,26636.51, "Major O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6803,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,26636.51,,,,,,,fee schedule,26636.51,26636.51, "Major O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6803,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,26636.51,,,,,,,fee schedule,26636.51,26636.51, "Major O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6803,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,26636.51,,,,,,,fee schedule,26636.51,26636.51, "Major O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6803,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,26636.51,,,,,,,fee schedule,26636.51,26636.51, "Major O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6803,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,26636.51,,,,,,,fee schedule,26636.51,26636.51, "Major O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6804,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,48902.18,,,,,,,fee schedule,48902.18,48902.18, "Major O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6804,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,48902.18,,,,,,,fee schedule,48902.18,48902.18, "Major O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6804,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,48902.18,,,,,,,fee schedule,48902.18,48902.18, "Major O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6804,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,48902.18,,,,,,,fee schedule,48902.18,48902.18, "Major O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6804,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,48902.18,,,,,,,fee schedule,48902.18,48902.18, "Major O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6804,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,48902.18,,,,,,,fee schedule,48902.18,48902.18, "Major O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6804,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,48902.18,,,,,,,fee schedule,48902.18,48902.18, "Major O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6804,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,48902.18,,,,,,,fee schedule,48902.18,48902.18, "Major O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6804,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,48902.18,,,,,,,fee schedule,48902.18,48902.18, "Major O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6804,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,48902.18,,,,,,,fee schedule,48902.18,48902.18, "Major O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6804,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,48902.18,,,,,,,fee schedule,48902.18,48902.18, "Other O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6811,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,9723.41,,,,,,,fee schedule,9723.41,9723.41, "Other O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6811,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,9723.41,,,,,,,fee schedule,9723.41,9723.41, "Other O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6811,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,9723.41,,,,,,,fee schedule,9723.41,9723.41, "Other O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6811,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,9723.41,,,,,,,fee schedule,9723.41,9723.41, "Other O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6811,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,9723.41,,,,,,,fee schedule,9723.41,9723.41, "Other O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6811,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,9723.41,,,,,,,fee schedule,9723.41,9723.41, "Other O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6811,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,9723.41,,,,,,,fee schedule,9723.41,9723.41, "Other O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6811,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,9723.41,,,,,,,fee schedule,9723.41,9723.41, "Other O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6811,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,9723.41,,,,,,,fee schedule,9723.41,9723.41, "Other O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6811,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,9723.41,,,,,,,fee schedule,9723.41,9723.41, "Other O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6811,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,9723.41,,,,,,,fee schedule,9723.41,9723.41, "Other O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6812,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,13051.83,,,,,,,fee schedule,13051.83,13051.83, "Other O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6812,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,13051.83,,,,,,,fee schedule,13051.83,13051.83, "Other O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6812,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,13051.83,,,,,,,fee schedule,13051.83,13051.83, "Other O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6812,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,13051.83,,,,,,,fee schedule,13051.83,13051.83, "Other O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6812,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,13051.83,,,,,,,fee schedule,13051.83,13051.83, "Other O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6812,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,13051.83,,,,,,,fee schedule,13051.83,13051.83, "Other O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6812,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,13051.83,,,,,,,fee schedule,13051.83,13051.83, "Other O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6812,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,13051.83,,,,,,,fee schedule,13051.83,13051.83, "Other O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6812,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,13051.83,,,,,,,fee schedule,13051.83,13051.83, "Other O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6812,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,13051.83,,,,,,,fee schedule,13051.83,13051.83, "Other O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6812,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,13051.83,,,,,,,fee schedule,13051.83,13051.83, "Other O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6813,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,20513.95,,,,,,,fee schedule,20513.95,20513.95, "Other O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6813,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,20513.95,,,,,,,fee schedule,20513.95,20513.95, "Other O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6813,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,20513.95,,,,,,,fee schedule,20513.95,20513.95, "Other O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6813,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,20513.95,,,,,,,fee schedule,20513.95,20513.95, "Other O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6813,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,20513.95,,,,,,,fee schedule,20513.95,20513.95, "Other O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6813,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,20513.95,,,,,,,fee schedule,20513.95,20513.95, "Other O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6813,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,20513.95,,,,,,,fee schedule,20513.95,20513.95, "Other O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6813,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,20513.95,,,,,,,fee schedule,20513.95,20513.95, "Other O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6813,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,20513.95,,,,,,,fee schedule,20513.95,20513.95, "Other O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6813,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,20513.95,,,,,,,fee schedule,20513.95,20513.95, "Other O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6813,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,20513.95,,,,,,,fee schedule,20513.95,20513.95, "Other O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6814,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,40912.15,,,,,,,fee schedule,40912.15,40912.15, "Other O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6814,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,40912.15,,,,,,,fee schedule,40912.15,40912.15, "Other O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6814,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,40912.15,,,,,,,fee schedule,40912.15,40912.15, "Other O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6814,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,40912.15,,,,,,,fee schedule,40912.15,40912.15, "Other O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6814,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,40912.15,,,,,,,fee schedule,40912.15,40912.15, "Other O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6814,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,40912.15,,,,,,,fee schedule,40912.15,40912.15, "Other O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6814,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,40912.15,,,,,,,fee schedule,40912.15,40912.15, "Other O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6814,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,40912.15,,,,,,,fee schedule,40912.15,40912.15, "Other O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6814,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,40912.15,,,,,,,fee schedule,40912.15,40912.15, "Other O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6814,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,40912.15,,,,,,,fee schedule,40912.15,40912.15, "Other O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms",6814,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,40912.15,,,,,,,fee schedule,40912.15,40912.15, Acute Leukemia,6901,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,10573.86,,,,,,,fee schedule,10573.86,10573.86, Acute Leukemia,6901,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,10573.86,,,,,,,fee schedule,10573.86,10573.86, Acute Leukemia,6901,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,10573.86,,,,,,,fee schedule,10573.86,10573.86, Acute Leukemia,6901,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,10573.86,,,,,,,fee schedule,10573.86,10573.86, Acute Leukemia,6901,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,10573.86,,,,,,,fee schedule,10573.86,10573.86, Acute Leukemia,6901,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,10573.86,,,,,,,fee schedule,10573.86,10573.86, Acute Leukemia,6901,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,10573.86,,,,,,,fee schedule,10573.86,10573.86, Acute Leukemia,6901,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,10573.86,,,,,,,fee schedule,10573.86,10573.86, Acute Leukemia,6901,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,10573.86,,,,,,,fee schedule,10573.86,10573.86, Acute Leukemia,6901,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,10573.86,,,,,,,fee schedule,10573.86,10573.86, Acute Leukemia,6901,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,10573.86,,,,,,,fee schedule,10573.86,10573.86, Acute Leukemia,6902,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,19050.18,,,,,,,fee schedule,19050.18,19050.18, Acute Leukemia,6902,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,19050.18,,,,,,,fee schedule,19050.18,19050.18, Acute Leukemia,6902,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,19050.18,,,,,,,fee schedule,19050.18,19050.18, Acute Leukemia,6902,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,19050.18,,,,,,,fee schedule,19050.18,19050.18, Acute Leukemia,6902,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,19050.18,,,,,,,fee schedule,19050.18,19050.18, Acute Leukemia,6902,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,19050.18,,,,,,,fee schedule,19050.18,19050.18, Acute Leukemia,6902,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,19050.18,,,,,,,fee schedule,19050.18,19050.18, Acute Leukemia,6902,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,19050.18,,,,,,,fee schedule,19050.18,19050.18, Acute Leukemia,6902,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,19050.18,,,,,,,fee schedule,19050.18,19050.18, Acute Leukemia,6902,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,19050.18,,,,,,,fee schedule,19050.18,19050.18, Acute Leukemia,6902,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,19050.18,,,,,,,fee schedule,19050.18,19050.18, Acute Leukemia,6903,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,29528.06,,,,,,,fee schedule,29528.06,29528.06, Acute Leukemia,6903,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,29528.06,,,,,,,fee schedule,29528.06,29528.06, Acute Leukemia,6903,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,29528.06,,,,,,,fee schedule,29528.06,29528.06, Acute Leukemia,6903,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,29528.06,,,,,,,fee schedule,29528.06,29528.06, Acute Leukemia,6903,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,29528.06,,,,,,,fee schedule,29528.06,29528.06, Acute Leukemia,6903,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,29528.06,,,,,,,fee schedule,29528.06,29528.06, Acute Leukemia,6903,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,29528.06,,,,,,,fee schedule,29528.06,29528.06, Acute Leukemia,6903,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,29528.06,,,,,,,fee schedule,29528.06,29528.06, Acute Leukemia,6903,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,29528.06,,,,,,,fee schedule,29528.06,29528.06, Acute Leukemia,6903,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,29528.06,,,,,,,fee schedule,29528.06,29528.06, Acute Leukemia,6903,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,29528.06,,,,,,,fee schedule,29528.06,29528.06, Acute Leukemia,6904,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,43711.94,,,,,,,fee schedule,43711.94,43711.94, Acute Leukemia,6904,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,43711.94,,,,,,,fee schedule,43711.94,43711.94, Acute Leukemia,6904,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,43711.94,,,,,,,fee schedule,43711.94,43711.94, Acute Leukemia,6904,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,43711.94,,,,,,,fee schedule,43711.94,43711.94, Acute Leukemia,6904,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,43711.94,,,,,,,fee schedule,43711.94,43711.94, Acute Leukemia,6904,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,43711.94,,,,,,,fee schedule,43711.94,43711.94, Acute Leukemia,6904,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,43711.94,,,,,,,fee schedule,43711.94,43711.94, Acute Leukemia,6904,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,43711.94,,,,,,,fee schedule,43711.94,43711.94, Acute Leukemia,6904,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,43711.94,,,,,,,fee schedule,43711.94,43711.94, Acute Leukemia,6904,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,43711.94,,,,,,,fee schedule,43711.94,43711.94, Acute Leukemia,6904,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,43711.94,,,,,,,fee schedule,43711.94,43711.94, "Lymphoma, Myeloma And Non-Acute Leukemia",6911,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,7942.75,,,,,,,fee schedule,7942.75,7942.75, "Lymphoma, Myeloma And Non-Acute Leukemia",6911,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,7942.75,,,,,,,fee schedule,7942.75,7942.75, "Lymphoma, Myeloma And Non-Acute Leukemia",6911,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,7942.75,,,,,,,fee schedule,7942.75,7942.75, "Lymphoma, Myeloma And Non-Acute Leukemia",6911,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,7942.75,,,,,,,fee schedule,7942.75,7942.75, "Lymphoma, Myeloma And Non-Acute Leukemia",6911,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,7942.75,,,,,,,fee schedule,7942.75,7942.75, "Lymphoma, Myeloma And Non-Acute Leukemia",6911,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,7942.75,,,,,,,fee schedule,7942.75,7942.75, "Lymphoma, Myeloma And Non-Acute Leukemia",6911,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,7942.75,,,,,,,fee schedule,7942.75,7942.75, "Lymphoma, Myeloma And Non-Acute Leukemia",6911,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,7942.75,,,,,,,fee schedule,7942.75,7942.75, "Lymphoma, Myeloma And Non-Acute Leukemia",6911,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,7942.75,,,,,,,fee schedule,7942.75,7942.75, "Lymphoma, Myeloma And Non-Acute Leukemia",6911,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,7942.75,,,,,,,fee schedule,7942.75,7942.75, "Lymphoma, Myeloma And Non-Acute Leukemia",6911,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,7942.75,,,,,,,fee schedule,7942.75,7942.75, "Lymphoma, Myeloma And Non-Acute Leukemia",6912,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,10904.17,,,,,,,fee schedule,10904.17,10904.17, "Lymphoma, Myeloma And Non-Acute Leukemia",6912,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,10904.17,,,,,,,fee schedule,10904.17,10904.17, "Lymphoma, Myeloma And Non-Acute Leukemia",6912,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,10904.17,,,,,,,fee schedule,10904.17,10904.17, "Lymphoma, Myeloma And Non-Acute Leukemia",6912,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,10904.17,,,,,,,fee schedule,10904.17,10904.17, "Lymphoma, Myeloma And Non-Acute Leukemia",6912,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,10904.17,,,,,,,fee schedule,10904.17,10904.17, "Lymphoma, Myeloma And Non-Acute Leukemia",6912,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,10904.17,,,,,,,fee schedule,10904.17,10904.17, "Lymphoma, Myeloma And Non-Acute Leukemia",6912,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,10904.17,,,,,,,fee schedule,10904.17,10904.17, "Lymphoma, Myeloma And Non-Acute Leukemia",6912,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,10904.17,,,,,,,fee schedule,10904.17,10904.17, "Lymphoma, Myeloma And Non-Acute Leukemia",6912,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,10904.17,,,,,,,fee schedule,10904.17,10904.17, "Lymphoma, Myeloma And Non-Acute Leukemia",6912,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,10904.17,,,,,,,fee schedule,10904.17,10904.17, "Lymphoma, Myeloma And Non-Acute Leukemia",6912,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,10904.17,,,,,,,fee schedule,10904.17,10904.17, "Lymphoma, Myeloma And Non-Acute Leukemia",6913,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,16225.68,,,,,,,fee schedule,16225.68,16225.68, "Lymphoma, Myeloma And Non-Acute Leukemia",6913,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,16225.68,,,,,,,fee schedule,16225.68,16225.68, "Lymphoma, Myeloma And Non-Acute Leukemia",6913,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,16225.68,,,,,,,fee schedule,16225.68,16225.68, "Lymphoma, Myeloma And Non-Acute Leukemia",6913,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,16225.68,,,,,,,fee schedule,16225.68,16225.68, "Lymphoma, Myeloma And Non-Acute Leukemia",6913,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,16225.68,,,,,,,fee schedule,16225.68,16225.68, "Lymphoma, Myeloma And Non-Acute Leukemia",6913,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,16225.68,,,,,,,fee schedule,16225.68,16225.68, "Lymphoma, Myeloma And Non-Acute Leukemia",6913,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,16225.68,,,,,,,fee schedule,16225.68,16225.68, "Lymphoma, Myeloma And Non-Acute Leukemia",6913,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,16225.68,,,,,,,fee schedule,16225.68,16225.68, "Lymphoma, Myeloma And Non-Acute Leukemia",6913,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,16225.68,,,,,,,fee schedule,16225.68,16225.68, "Lymphoma, Myeloma And Non-Acute Leukemia",6913,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,16225.68,,,,,,,fee schedule,16225.68,16225.68, "Lymphoma, Myeloma And Non-Acute Leukemia",6913,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,16225.68,,,,,,,fee schedule,16225.68,16225.68, "Lymphoma, Myeloma And Non-Acute Leukemia",6914,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,27522.26,,,,,,,fee schedule,27522.26,27522.26, "Lymphoma, Myeloma And Non-Acute Leukemia",6914,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,27522.26,,,,,,,fee schedule,27522.26,27522.26, "Lymphoma, Myeloma And Non-Acute Leukemia",6914,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,27522.26,,,,,,,fee schedule,27522.26,27522.26, "Lymphoma, Myeloma And Non-Acute Leukemia",6914,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,27522.26,,,,,,,fee schedule,27522.26,27522.26, "Lymphoma, Myeloma And Non-Acute Leukemia",6914,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,27522.26,,,,,,,fee schedule,27522.26,27522.26, "Lymphoma, Myeloma And Non-Acute Leukemia",6914,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,27522.26,,,,,,,fee schedule,27522.26,27522.26, "Lymphoma, Myeloma And Non-Acute Leukemia",6914,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,27522.26,,,,,,,fee schedule,27522.26,27522.26, "Lymphoma, Myeloma And Non-Acute Leukemia",6914,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,27522.26,,,,,,,fee schedule,27522.26,27522.26, "Lymphoma, Myeloma And Non-Acute Leukemia",6914,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,27522.26,,,,,,,fee schedule,27522.26,27522.26, "Lymphoma, Myeloma And Non-Acute Leukemia",6914,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,27522.26,,,,,,,fee schedule,27522.26,27522.26, "Lymphoma, Myeloma And Non-Acute Leukemia",6914,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,27522.26,,,,,,,fee schedule,27522.26,27522.26, Radiotherapy,6921,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,8751.56,,,,,,,fee schedule,8751.56,8751.56, Radiotherapy,6921,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,8751.56,,,,,,,fee schedule,8751.56,8751.56, Radiotherapy,6921,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,8751.56,,,,,,,fee schedule,8751.56,8751.56, Radiotherapy,6921,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,8751.56,,,,,,,fee schedule,8751.56,8751.56, Radiotherapy,6921,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,8751.56,,,,,,,fee schedule,8751.56,8751.56, Radiotherapy,6921,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,8751.56,,,,,,,fee schedule,8751.56,8751.56, Radiotherapy,6921,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,8751.56,,,,,,,fee schedule,8751.56,8751.56, Radiotherapy,6921,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,8751.56,,,,,,,fee schedule,8751.56,8751.56, Radiotherapy,6921,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,8751.56,,,,,,,fee schedule,8751.56,8751.56, Radiotherapy,6921,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,8751.56,,,,,,,fee schedule,8751.56,8751.56, Radiotherapy,6921,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,8751.56,,,,,,,fee schedule,8751.56,8751.56, Radiotherapy,6922,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,13320.02,,,,,,,fee schedule,13320.02,13320.02, Radiotherapy,6922,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,13320.02,,,,,,,fee schedule,13320.02,13320.02, Radiotherapy,6922,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,13320.02,,,,,,,fee schedule,13320.02,13320.02, Radiotherapy,6922,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,13320.02,,,,,,,fee schedule,13320.02,13320.02, Radiotherapy,6922,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,13320.02,,,,,,,fee schedule,13320.02,13320.02, Radiotherapy,6922,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,13320.02,,,,,,,fee schedule,13320.02,13320.02, Radiotherapy,6922,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,13320.02,,,,,,,fee schedule,13320.02,13320.02, Radiotherapy,6922,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,13320.02,,,,,,,fee schedule,13320.02,13320.02, Radiotherapy,6922,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,13320.02,,,,,,,fee schedule,13320.02,13320.02, Radiotherapy,6922,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,13320.02,,,,,,,fee schedule,13320.02,13320.02, Radiotherapy,6922,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,13320.02,,,,,,,fee schedule,13320.02,13320.02, Radiotherapy,6923,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,19230.86,,,,,,,fee schedule,19230.86,19230.86, Radiotherapy,6923,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,19230.86,,,,,,,fee schedule,19230.86,19230.86, Radiotherapy,6923,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,19230.86,,,,,,,fee schedule,19230.86,19230.86, Radiotherapy,6923,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,19230.86,,,,,,,fee schedule,19230.86,19230.86, Radiotherapy,6923,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,19230.86,,,,,,,fee schedule,19230.86,19230.86, Radiotherapy,6923,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,19230.86,,,,,,,fee schedule,19230.86,19230.86, Radiotherapy,6923,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,19230.86,,,,,,,fee schedule,19230.86,19230.86, Radiotherapy,6923,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,19230.86,,,,,,,fee schedule,19230.86,19230.86, Radiotherapy,6923,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,19230.86,,,,,,,fee schedule,19230.86,19230.86, Radiotherapy,6923,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,19230.86,,,,,,,fee schedule,19230.86,19230.86, Radiotherapy,6923,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,19230.86,,,,,,,fee schedule,19230.86,19230.86, Radiotherapy,6924,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,24150.08,,,,,,,fee schedule,24150.08,24150.08, Radiotherapy,6924,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,24150.08,,,,,,,fee schedule,24150.08,24150.08, Radiotherapy,6924,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,24150.08,,,,,,,fee schedule,24150.08,24150.08, Radiotherapy,6924,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,24150.08,,,,,,,fee schedule,24150.08,24150.08, Radiotherapy,6924,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,24150.08,,,,,,,fee schedule,24150.08,24150.08, Radiotherapy,6924,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,24150.08,,,,,,,fee schedule,24150.08,24150.08, Radiotherapy,6924,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,24150.08,,,,,,,fee schedule,24150.08,24150.08, Radiotherapy,6924,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,24150.08,,,,,,,fee schedule,24150.08,24150.08, Radiotherapy,6924,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,24150.08,,,,,,,fee schedule,24150.08,24150.08, Radiotherapy,6924,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,24150.08,,,,,,,fee schedule,24150.08,24150.08, Radiotherapy,6924,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,24150.08,,,,,,,fee schedule,24150.08,24150.08, Lymphatic And Other Malignancies And Neoplasms Of Uncertain Behavior,6941,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5377.27,,,,,,,fee schedule,5377.27,5377.27, Lymphatic And Other Malignancies And Neoplasms Of Uncertain Behavior,6941,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5377.27,,,,,,,fee schedule,5377.27,5377.27, Lymphatic And Other Malignancies And Neoplasms Of Uncertain Behavior,6941,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5377.27,,,,,,,fee schedule,5377.27,5377.27, Lymphatic And Other Malignancies And Neoplasms Of Uncertain Behavior,6941,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5377.27,,,,,,,fee schedule,5377.27,5377.27, Lymphatic And Other Malignancies And Neoplasms Of Uncertain Behavior,6941,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5377.27,,,,,,,fee schedule,5377.27,5377.27, Lymphatic And Other Malignancies And Neoplasms Of Uncertain Behavior,6941,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5377.27,,,,,,,fee schedule,5377.27,5377.27, Lymphatic And Other Malignancies And Neoplasms Of Uncertain Behavior,6941,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5377.27,,,,,,,fee schedule,5377.27,5377.27, Lymphatic And Other Malignancies And Neoplasms Of Uncertain Behavior,6941,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5377.27,,,,,,,fee schedule,5377.27,5377.27, Lymphatic And Other Malignancies And Neoplasms Of Uncertain Behavior,6941,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5377.27,,,,,,,fee schedule,5377.27,5377.27, Lymphatic And Other Malignancies And Neoplasms Of Uncertain Behavior,6941,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5377.27,,,,,,,fee schedule,5377.27,5377.27, Lymphatic And Other Malignancies And Neoplasms Of Uncertain Behavior,6941,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5377.27,,,,,,,fee schedule,5377.27,5377.27, Lymphatic And Other Malignancies And Neoplasms Of Uncertain Behavior,6942,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,7009.01,,,,,,,fee schedule,7009.01,7009.01, Lymphatic And Other Malignancies And Neoplasms Of Uncertain Behavior,6942,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,7009.01,,,,,,,fee schedule,7009.01,7009.01, Lymphatic And Other Malignancies And Neoplasms Of Uncertain Behavior,6942,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,7009.01,,,,,,,fee schedule,7009.01,7009.01, Lymphatic And Other Malignancies And Neoplasms Of Uncertain Behavior,6942,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,7009.01,,,,,,,fee schedule,7009.01,7009.01, Lymphatic And Other Malignancies And Neoplasms Of Uncertain Behavior,6942,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,7009.01,,,,,,,fee schedule,7009.01,7009.01, Lymphatic And Other Malignancies And Neoplasms Of Uncertain Behavior,6942,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,7009.01,,,,,,,fee schedule,7009.01,7009.01, Lymphatic And Other Malignancies And Neoplasms Of Uncertain Behavior,6942,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,7009.01,,,,,,,fee schedule,7009.01,7009.01, Lymphatic And Other Malignancies And Neoplasms Of Uncertain Behavior,6942,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,7009.01,,,,,,,fee schedule,7009.01,7009.01, Lymphatic And Other Malignancies And Neoplasms Of Uncertain Behavior,6942,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,7009.01,,,,,,,fee schedule,7009.01,7009.01, Lymphatic And Other Malignancies And Neoplasms Of Uncertain Behavior,6942,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,7009.01,,,,,,,fee schedule,7009.01,7009.01, Lymphatic And Other Malignancies And Neoplasms Of Uncertain Behavior,6942,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,7009.01,,,,,,,fee schedule,7009.01,7009.01, Lymphatic And Other Malignancies And Neoplasms Of Uncertain Behavior,6943,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,10659.26,,,,,,,fee schedule,10659.26,10659.26, Lymphatic And Other Malignancies And Neoplasms Of Uncertain Behavior,6943,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,10659.26,,,,,,,fee schedule,10659.26,10659.26, Lymphatic And Other Malignancies And Neoplasms Of Uncertain Behavior,6943,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,10659.26,,,,,,,fee schedule,10659.26,10659.26, Lymphatic And Other Malignancies And Neoplasms Of Uncertain Behavior,6943,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,10659.26,,,,,,,fee schedule,10659.26,10659.26, Lymphatic And Other Malignancies And Neoplasms Of Uncertain Behavior,6943,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,10659.26,,,,,,,fee schedule,10659.26,10659.26, Lymphatic And Other Malignancies And Neoplasms Of Uncertain Behavior,6943,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,10659.26,,,,,,,fee schedule,10659.26,10659.26, Lymphatic And Other Malignancies And Neoplasms Of Uncertain Behavior,6943,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,10659.26,,,,,,,fee schedule,10659.26,10659.26, Lymphatic And Other Malignancies And Neoplasms Of Uncertain Behavior,6943,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,10659.26,,,,,,,fee schedule,10659.26,10659.26, Lymphatic And Other Malignancies And Neoplasms Of Uncertain Behavior,6943,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,10659.26,,,,,,,fee schedule,10659.26,10659.26, Lymphatic And Other Malignancies And Neoplasms Of Uncertain Behavior,6943,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,10659.26,,,,,,,fee schedule,10659.26,10659.26, Lymphatic And Other Malignancies And Neoplasms Of Uncertain Behavior,6943,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,10659.26,,,,,,,fee schedule,10659.26,10659.26, Lymphatic And Other Malignancies And Neoplasms Of Uncertain Behavior,6944,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,17593.47,,,,,,,fee schedule,17593.47,17593.47, Lymphatic And Other Malignancies And Neoplasms Of Uncertain Behavior,6944,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,17593.47,,,,,,,fee schedule,17593.47,17593.47, Lymphatic And Other Malignancies And Neoplasms Of Uncertain Behavior,6944,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,17593.47,,,,,,,fee schedule,17593.47,17593.47, Lymphatic And Other Malignancies And Neoplasms Of Uncertain Behavior,6944,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,17593.47,,,,,,,fee schedule,17593.47,17593.47, Lymphatic And Other Malignancies And Neoplasms Of Uncertain Behavior,6944,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,17593.47,,,,,,,fee schedule,17593.47,17593.47, Lymphatic And Other Malignancies And Neoplasms Of Uncertain Behavior,6944,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,17593.47,,,,,,,fee schedule,17593.47,17593.47, Lymphatic And Other Malignancies And Neoplasms Of Uncertain Behavior,6944,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,17593.47,,,,,,,fee schedule,17593.47,17593.47, Lymphatic And Other Malignancies And Neoplasms Of Uncertain Behavior,6944,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,17593.47,,,,,,,fee schedule,17593.47,17593.47, Lymphatic And Other Malignancies And Neoplasms Of Uncertain Behavior,6944,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,17593.47,,,,,,,fee schedule,17593.47,17593.47, Lymphatic And Other Malignancies And Neoplasms Of Uncertain Behavior,6944,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,17593.47,,,,,,,fee schedule,17593.47,17593.47, Lymphatic And Other Malignancies And Neoplasms Of Uncertain Behavior,6944,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,17593.47,,,,,,,fee schedule,17593.47,17593.47, Chemotherapy For Acute Leukemia,6951,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,6397.82,,,,,,,fee schedule,6397.82,6397.82, Chemotherapy For Acute Leukemia,6951,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,6397.82,,,,,,,fee schedule,6397.82,6397.82, Chemotherapy For Acute Leukemia,6951,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,6397.82,,,,,,,fee schedule,6397.82,6397.82, Chemotherapy For Acute Leukemia,6951,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,6397.82,,,,,,,fee schedule,6397.82,6397.82, Chemotherapy For Acute Leukemia,6951,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,6397.82,,,,,,,fee schedule,6397.82,6397.82, Chemotherapy For Acute Leukemia,6951,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,6397.82,,,,,,,fee schedule,6397.82,6397.82, Chemotherapy For Acute Leukemia,6951,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,6397.82,,,,,,,fee schedule,6397.82,6397.82, Chemotherapy For Acute Leukemia,6951,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,6397.82,,,,,,,fee schedule,6397.82,6397.82, Chemotherapy For Acute Leukemia,6951,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,6397.82,,,,,,,fee schedule,6397.82,6397.82, Chemotherapy For Acute Leukemia,6951,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,6397.82,,,,,,,fee schedule,6397.82,6397.82, Chemotherapy For Acute Leukemia,6951,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,6397.82,,,,,,,fee schedule,6397.82,6397.82, Chemotherapy For Acute Leukemia,6952,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,10197.69,,,,,,,fee schedule,10197.69,10197.69, Chemotherapy For Acute Leukemia,6952,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,10197.69,,,,,,,fee schedule,10197.69,10197.69, Chemotherapy For Acute Leukemia,6952,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,10197.69,,,,,,,fee schedule,10197.69,10197.69, Chemotherapy For Acute Leukemia,6952,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,10197.69,,,,,,,fee schedule,10197.69,10197.69, Chemotherapy For Acute Leukemia,6952,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,10197.69,,,,,,,fee schedule,10197.69,10197.69, Chemotherapy For Acute Leukemia,6952,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,10197.69,,,,,,,fee schedule,10197.69,10197.69, Chemotherapy For Acute Leukemia,6952,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,10197.69,,,,,,,fee schedule,10197.69,10197.69, Chemotherapy For Acute Leukemia,6952,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,10197.69,,,,,,,fee schedule,10197.69,10197.69, Chemotherapy For Acute Leukemia,6952,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,10197.69,,,,,,,fee schedule,10197.69,10197.69, Chemotherapy For Acute Leukemia,6952,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,10197.69,,,,,,,fee schedule,10197.69,10197.69, Chemotherapy For Acute Leukemia,6952,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,10197.69,,,,,,,fee schedule,10197.69,10197.69, Chemotherapy For Acute Leukemia,6953,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,20369.26,,,,,,,fee schedule,20369.26,20369.26, Chemotherapy For Acute Leukemia,6953,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,20369.26,,,,,,,fee schedule,20369.26,20369.26, Chemotherapy For Acute Leukemia,6953,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,20369.26,,,,,,,fee schedule,20369.26,20369.26, Chemotherapy For Acute Leukemia,6953,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,20369.26,,,,,,,fee schedule,20369.26,20369.26, Chemotherapy For Acute Leukemia,6953,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,20369.26,,,,,,,fee schedule,20369.26,20369.26, Chemotherapy For Acute Leukemia,6953,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,20369.26,,,,,,,fee schedule,20369.26,20369.26, Chemotherapy For Acute Leukemia,6953,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,20369.26,,,,,,,fee schedule,20369.26,20369.26, Chemotherapy For Acute Leukemia,6953,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,20369.26,,,,,,,fee schedule,20369.26,20369.26, Chemotherapy For Acute Leukemia,6953,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,20369.26,,,,,,,fee schedule,20369.26,20369.26, Chemotherapy For Acute Leukemia,6953,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,20369.26,,,,,,,fee schedule,20369.26,20369.26, Chemotherapy For Acute Leukemia,6953,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,20369.26,,,,,,,fee schedule,20369.26,20369.26, Chemotherapy For Acute Leukemia,6954,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,40231.78,,,,,,,fee schedule,40231.78,40231.78, Chemotherapy For Acute Leukemia,6954,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,40231.78,,,,,,,fee schedule,40231.78,40231.78, Chemotherapy For Acute Leukemia,6954,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,40231.78,,,,,,,fee schedule,40231.78,40231.78, Chemotherapy For Acute Leukemia,6954,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,40231.78,,,,,,,fee schedule,40231.78,40231.78, Chemotherapy For Acute Leukemia,6954,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,40231.78,,,,,,,fee schedule,40231.78,40231.78, Chemotherapy For Acute Leukemia,6954,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,40231.78,,,,,,,fee schedule,40231.78,40231.78, Chemotherapy For Acute Leukemia,6954,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,40231.78,,,,,,,fee schedule,40231.78,40231.78, Chemotherapy For Acute Leukemia,6954,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,40231.78,,,,,,,fee schedule,40231.78,40231.78, Chemotherapy For Acute Leukemia,6954,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,40231.78,,,,,,,fee schedule,40231.78,40231.78, Chemotherapy For Acute Leukemia,6954,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,40231.78,,,,,,,fee schedule,40231.78,40231.78, Chemotherapy For Acute Leukemia,6954,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,40231.78,,,,,,,fee schedule,40231.78,40231.78, Other Chemotherapy,6961,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5798.62,,,,,,,fee schedule,5798.62,5798.62, Other Chemotherapy,6961,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5798.62,,,,,,,fee schedule,5798.62,5798.62, Other Chemotherapy,6961,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5798.62,,,,,,,fee schedule,5798.62,5798.62, Other Chemotherapy,6961,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5798.62,,,,,,,fee schedule,5798.62,5798.62, Other Chemotherapy,6961,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5798.62,,,,,,,fee schedule,5798.62,5798.62, Other Chemotherapy,6961,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5798.62,,,,,,,fee schedule,5798.62,5798.62, Other Chemotherapy,6961,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5798.62,,,,,,,fee schedule,5798.62,5798.62, Other Chemotherapy,6961,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5798.62,,,,,,,fee schedule,5798.62,5798.62, Other Chemotherapy,6961,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5798.62,,,,,,,fee schedule,5798.62,5798.62, Other Chemotherapy,6961,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5798.62,,,,,,,fee schedule,5798.62,5798.62, Other Chemotherapy,6961,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5798.62,,,,,,,fee schedule,5798.62,5798.62, Other Chemotherapy,6962,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,7241.92,,,,,,,fee schedule,7241.92,7241.92, Other Chemotherapy,6962,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,7241.92,,,,,,,fee schedule,7241.92,7241.92, Other Chemotherapy,6962,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,7241.92,,,,,,,fee schedule,7241.92,7241.92, Other Chemotherapy,6962,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,7241.92,,,,,,,fee schedule,7241.92,7241.92, Other Chemotherapy,6962,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,7241.92,,,,,,,fee schedule,7241.92,7241.92, Other Chemotherapy,6962,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,7241.92,,,,,,,fee schedule,7241.92,7241.92, Other Chemotherapy,6962,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,7241.92,,,,,,,fee schedule,7241.92,7241.92, Other Chemotherapy,6962,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,7241.92,,,,,,,fee schedule,7241.92,7241.92, Other Chemotherapy,6962,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,7241.92,,,,,,,fee schedule,7241.92,7241.92, Other Chemotherapy,6962,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,7241.92,,,,,,,fee schedule,7241.92,7241.92, Other Chemotherapy,6962,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,7241.92,,,,,,,fee schedule,7241.92,7241.92, Other Chemotherapy,6963,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,11738.39,,,,,,,fee schedule,11738.39,11738.39, Other Chemotherapy,6963,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,11738.39,,,,,,,fee schedule,11738.39,11738.39, Other Chemotherapy,6963,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,11738.39,,,,,,,fee schedule,11738.39,11738.39, Other Chemotherapy,6963,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,11738.39,,,,,,,fee schedule,11738.39,11738.39, Other Chemotherapy,6963,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,11738.39,,,,,,,fee schedule,11738.39,11738.39, Other Chemotherapy,6963,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,11738.39,,,,,,,fee schedule,11738.39,11738.39, Other Chemotherapy,6963,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,11738.39,,,,,,,fee schedule,11738.39,11738.39, Other Chemotherapy,6963,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,11738.39,,,,,,,fee schedule,11738.39,11738.39, Other Chemotherapy,6963,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,11738.39,,,,,,,fee schedule,11738.39,11738.39, Other Chemotherapy,6963,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,11738.39,,,,,,,fee schedule,11738.39,11738.39, Other Chemotherapy,6963,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,11738.39,,,,,,,fee schedule,11738.39,11738.39, Other Chemotherapy,6964,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,21646.71,,,,,,,fee schedule,21646.71,21646.71, Other Chemotherapy,6964,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,21646.71,,,,,,,fee schedule,21646.71,21646.71, Other Chemotherapy,6964,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,21646.71,,,,,,,fee schedule,21646.71,21646.71, Other Chemotherapy,6964,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,21646.71,,,,,,,fee schedule,21646.71,21646.71, Other Chemotherapy,6964,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,21646.71,,,,,,,fee schedule,21646.71,21646.71, Other Chemotherapy,6964,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,21646.71,,,,,,,fee schedule,21646.71,21646.71, Other Chemotherapy,6964,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,21646.71,,,,,,,fee schedule,21646.71,21646.71, Other Chemotherapy,6964,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,21646.71,,,,,,,fee schedule,21646.71,21646.71, Other Chemotherapy,6964,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,21646.71,,,,,,,fee schedule,21646.71,21646.71, Other Chemotherapy,6964,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,21646.71,,,,,,,fee schedule,21646.71,21646.71, Other Chemotherapy,6964,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,21646.71,,,,,,,fee schedule,21646.71,21646.71, Infectious And Parasitic Diseases Including Hiv With O.R. Procedure,7101,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,9986.66,,,,,,,fee schedule,9986.66,9986.66, Infectious And Parasitic Diseases Including Hiv With O.R. Procedure,7101,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,9986.66,,,,,,,fee schedule,9986.66,9986.66, Infectious And Parasitic Diseases Including Hiv With O.R. Procedure,7101,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,9986.66,,,,,,,fee schedule,9986.66,9986.66, Infectious And Parasitic Diseases Including Hiv With O.R. Procedure,7101,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,9986.66,,,,,,,fee schedule,9986.66,9986.66, Infectious And Parasitic Diseases Including Hiv With O.R. Procedure,7101,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,9986.66,,,,,,,fee schedule,9986.66,9986.66, Infectious And Parasitic Diseases Including Hiv With O.R. Procedure,7101,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,9986.66,,,,,,,fee schedule,9986.66,9986.66, Infectious And Parasitic Diseases Including Hiv With O.R. Procedure,7101,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,9986.66,,,,,,,fee schedule,9986.66,9986.66, Infectious And Parasitic Diseases Including Hiv With O.R. Procedure,7101,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,9986.66,,,,,,,fee schedule,9986.66,9986.66, Infectious And Parasitic Diseases Including Hiv With O.R. Procedure,7101,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,9986.66,,,,,,,fee schedule,9986.66,9986.66, Infectious And Parasitic Diseases Including Hiv With O.R. Procedure,7101,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,9986.66,,,,,,,fee schedule,9986.66,9986.66, Infectious And Parasitic Diseases Including Hiv With O.R. Procedure,7101,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,9986.66,,,,,,,fee schedule,9986.66,9986.66, Infectious And Parasitic Diseases Including Hiv With O.R. Procedure,7102,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,14729.45,,,,,,,fee schedule,14729.45,14729.45, Infectious And Parasitic Diseases Including Hiv With O.R. Procedure,7102,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,14729.45,,,,,,,fee schedule,14729.45,14729.45, Infectious And Parasitic Diseases Including Hiv With O.R. Procedure,7102,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,14729.45,,,,,,,fee schedule,14729.45,14729.45, Infectious And Parasitic Diseases Including Hiv With O.R. Procedure,7102,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,14729.45,,,,,,,fee schedule,14729.45,14729.45, Infectious And Parasitic Diseases Including Hiv With O.R. Procedure,7102,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,14729.45,,,,,,,fee schedule,14729.45,14729.45, Infectious And Parasitic Diseases Including Hiv With O.R. Procedure,7102,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,14729.45,,,,,,,fee schedule,14729.45,14729.45, Infectious And Parasitic Diseases Including Hiv With O.R. Procedure,7102,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,14729.45,,,,,,,fee schedule,14729.45,14729.45, Infectious And Parasitic Diseases Including Hiv With O.R. Procedure,7102,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,14729.45,,,,,,,fee schedule,14729.45,14729.45, Infectious And Parasitic Diseases Including Hiv With O.R. Procedure,7102,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,14729.45,,,,,,,fee schedule,14729.45,14729.45, Infectious And Parasitic Diseases Including Hiv With O.R. Procedure,7102,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,14729.45,,,,,,,fee schedule,14729.45,14729.45, Infectious And Parasitic Diseases Including Hiv With O.R. Procedure,7102,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,14729.45,,,,,,,fee schedule,14729.45,14729.45, Infectious And Parasitic Diseases Including Hiv With O.R. Procedure,7103,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,21837.97,,,,,,,fee schedule,21837.97,21837.97, Infectious And Parasitic Diseases Including Hiv With O.R. Procedure,7103,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,21837.97,,,,,,,fee schedule,21837.97,21837.97, Infectious And Parasitic Diseases Including Hiv With O.R. Procedure,7103,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,21837.97,,,,,,,fee schedule,21837.97,21837.97, Infectious And Parasitic Diseases Including Hiv With O.R. Procedure,7103,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,21837.97,,,,,,,fee schedule,21837.97,21837.97, Infectious And Parasitic Diseases Including Hiv With O.R. Procedure,7103,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,21837.97,,,,,,,fee schedule,21837.97,21837.97, Infectious And Parasitic Diseases Including Hiv With O.R. Procedure,7103,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,21837.97,,,,,,,fee schedule,21837.97,21837.97, Infectious And Parasitic Diseases Including Hiv With O.R. Procedure,7103,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,21837.97,,,,,,,fee schedule,21837.97,21837.97, Infectious And Parasitic Diseases Including Hiv With O.R. Procedure,7103,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,21837.97,,,,,,,fee schedule,21837.97,21837.97, Infectious And Parasitic Diseases Including Hiv With O.R. Procedure,7103,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,21837.97,,,,,,,fee schedule,21837.97,21837.97, Infectious And Parasitic Diseases Including Hiv With O.R. Procedure,7103,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,21837.97,,,,,,,fee schedule,21837.97,21837.97, Infectious And Parasitic Diseases Including Hiv With O.R. Procedure,7103,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,21837.97,,,,,,,fee schedule,21837.97,21837.97, Infectious And Parasitic Diseases Including Hiv With O.R. Procedure,7104,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,33573.54,,,,,,,fee schedule,33573.54,33573.54, Infectious And Parasitic Diseases Including Hiv With O.R. Procedure,7104,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,33573.54,,,,,,,fee schedule,33573.54,33573.54, Infectious And Parasitic Diseases Including Hiv With O.R. Procedure,7104,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,33573.54,,,,,,,fee schedule,33573.54,33573.54, Infectious And Parasitic Diseases Including Hiv With O.R. Procedure,7104,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,33573.54,,,,,,,fee schedule,33573.54,33573.54, Infectious And Parasitic Diseases Including Hiv With O.R. Procedure,7104,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,33573.54,,,,,,,fee schedule,33573.54,33573.54, Infectious And Parasitic Diseases Including Hiv With O.R. Procedure,7104,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,33573.54,,,,,,,fee schedule,33573.54,33573.54, Infectious And Parasitic Diseases Including Hiv With O.R. Procedure,7104,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,33573.54,,,,,,,fee schedule,33573.54,33573.54, Infectious And Parasitic Diseases Including Hiv With O.R. Procedure,7104,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,33573.54,,,,,,,fee schedule,33573.54,33573.54, Infectious And Parasitic Diseases Including Hiv With O.R. Procedure,7104,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,33573.54,,,,,,,fee schedule,33573.54,33573.54, Infectious And Parasitic Diseases Including Hiv With O.R. Procedure,7104,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,33573.54,,,,,,,fee schedule,33573.54,33573.54, Infectious And Parasitic Diseases Including Hiv With O.R. Procedure,7104,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,33573.54,,,,,,,fee schedule,33573.54,33573.54, "Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure",7111,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,8472.78,,,,,,,fee schedule,8472.78,8472.78, "Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure",7111,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,8472.78,,,,,,,fee schedule,8472.78,8472.78, "Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure",7111,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,8472.78,,,,,,,fee schedule,8472.78,8472.78, "Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure",7111,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,8472.78,,,,,,,fee schedule,8472.78,8472.78, "Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure",7111,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,8472.78,,,,,,,fee schedule,8472.78,8472.78, "Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure",7111,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,8472.78,,,,,,,fee schedule,8472.78,8472.78, "Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure",7111,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,8472.78,,,,,,,fee schedule,8472.78,8472.78, "Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure",7111,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,8472.78,,,,,,,fee schedule,8472.78,8472.78, "Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure",7111,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,8472.78,,,,,,,fee schedule,8472.78,8472.78, "Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure",7111,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,8472.78,,,,,,,fee schedule,8472.78,8472.78, "Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure",7111,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,8472.78,,,,,,,fee schedule,8472.78,8472.78, "Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure",7112,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,12036.93,,,,,,,fee schedule,12036.93,12036.93, "Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure",7112,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,12036.93,,,,,,,fee schedule,12036.93,12036.93, "Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure",7112,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,12036.93,,,,,,,fee schedule,12036.93,12036.93, "Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure",7112,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,12036.93,,,,,,,fee schedule,12036.93,12036.93, "Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure",7112,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,12036.93,,,,,,,fee schedule,12036.93,12036.93, "Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure",7112,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,12036.93,,,,,,,fee schedule,12036.93,12036.93, "Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure",7112,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,12036.93,,,,,,,fee schedule,12036.93,12036.93, "Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure",7112,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,12036.93,,,,,,,fee schedule,12036.93,12036.93, "Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure",7112,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,12036.93,,,,,,,fee schedule,12036.93,12036.93, "Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure",7112,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,12036.93,,,,,,,fee schedule,12036.93,12036.93, "Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure",7112,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,12036.93,,,,,,,fee schedule,12036.93,12036.93, "Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure",7113,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,19446.12,,,,,,,fee schedule,19446.12,19446.12, "Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure",7113,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,19446.12,,,,,,,fee schedule,19446.12,19446.12, "Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure",7113,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,19446.12,,,,,,,fee schedule,19446.12,19446.12, "Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure",7113,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,19446.12,,,,,,,fee schedule,19446.12,19446.12, "Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure",7113,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,19446.12,,,,,,,fee schedule,19446.12,19446.12, "Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure",7113,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,19446.12,,,,,,,fee schedule,19446.12,19446.12, "Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure",7113,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,19446.12,,,,,,,fee schedule,19446.12,19446.12, "Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure",7113,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,19446.12,,,,,,,fee schedule,19446.12,19446.12, "Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure",7113,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,19446.12,,,,,,,fee schedule,19446.12,19446.12, "Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure",7113,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,19446.12,,,,,,,fee schedule,19446.12,19446.12, "Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure",7113,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,19446.12,,,,,,,fee schedule,19446.12,19446.12, "Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure",7114,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,32732.26,,,,,,,fee schedule,32732.26,32732.26, "Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure",7114,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,32732.26,,,,,,,fee schedule,32732.26,32732.26, "Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure",7114,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,32732.26,,,,,,,fee schedule,32732.26,32732.26, "Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure",7114,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,32732.26,,,,,,,fee schedule,32732.26,32732.26, "Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure",7114,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,32732.26,,,,,,,fee schedule,32732.26,32732.26, "Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure",7114,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,32732.26,,,,,,,fee schedule,32732.26,32732.26, "Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure",7114,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,32732.26,,,,,,,fee schedule,32732.26,32732.26, "Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure",7114,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,32732.26,,,,,,,fee schedule,32732.26,32732.26, "Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure",7114,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,32732.26,,,,,,,fee schedule,32732.26,32732.26, "Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure",7114,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,32732.26,,,,,,,fee schedule,32732.26,32732.26, "Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure",7114,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,32732.26,,,,,,,fee schedule,32732.26,32732.26, Septicemia And Disseminated Infections,7201,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4855.71,,,,,,,fee schedule,4855.71,4855.71, Septicemia And Disseminated Infections,7201,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4855.71,,,,,,,fee schedule,4855.71,4855.71, Septicemia And Disseminated Infections,7201,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4855.71,,,,,,,fee schedule,4855.71,4855.71, Septicemia And Disseminated Infections,7201,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4855.71,,,,,,,fee schedule,4855.71,4855.71, Septicemia And Disseminated Infections,7201,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4855.71,,,,,,,fee schedule,4855.71,4855.71, Septicemia And Disseminated Infections,7201,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4855.71,,,,,,,fee schedule,4855.71,4855.71, Septicemia And Disseminated Infections,7201,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4855.71,,,,,,,fee schedule,4855.71,4855.71, Septicemia And Disseminated Infections,7201,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4855.71,,,,,,,fee schedule,4855.71,4855.71, Septicemia And Disseminated Infections,7201,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4855.71,,,,,,,fee schedule,4855.71,4855.71, Septicemia And Disseminated Infections,7201,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4855.71,,,,,,,fee schedule,4855.71,4855.71, Septicemia And Disseminated Infections,7201,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4855.71,,,,,,,fee schedule,4855.71,4855.71, Septicemia And Disseminated Infections,7202,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,6817.75,,,,,,,fee schedule,6817.75,6817.75, Septicemia And Disseminated Infections,7202,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,6817.75,,,,,,,fee schedule,6817.75,6817.75, Septicemia And Disseminated Infections,7202,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,6817.75,,,,,,,fee schedule,6817.75,6817.75, Septicemia And Disseminated Infections,7202,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,6817.75,,,,,,,fee schedule,6817.75,6817.75, Septicemia And Disseminated Infections,7202,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,6817.75,,,,,,,fee schedule,6817.75,6817.75, Septicemia And Disseminated Infections,7202,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,6817.75,,,,,,,fee schedule,6817.75,6817.75, Septicemia And Disseminated Infections,7202,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,6817.75,,,,,,,fee schedule,6817.75,6817.75, Septicemia And Disseminated Infections,7202,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,6817.75,,,,,,,fee schedule,6817.75,6817.75, Septicemia And Disseminated Infections,7202,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,6817.75,,,,,,,fee schedule,6817.75,6817.75, Septicemia And Disseminated Infections,7202,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,6817.75,,,,,,,fee schedule,6817.75,6817.75, Septicemia And Disseminated Infections,7202,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,6817.75,,,,,,,fee schedule,6817.75,6817.75, Septicemia And Disseminated Infections,7203,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,10839.23,,,,,,,fee schedule,10839.23,10839.23, Septicemia And Disseminated Infections,7203,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,10839.23,,,,,,,fee schedule,10839.23,10839.23, Septicemia And Disseminated Infections,7203,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,10839.23,,,,,,,fee schedule,10839.23,10839.23, Septicemia And Disseminated Infections,7203,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,10839.23,,,,,,,fee schedule,10839.23,10839.23, Septicemia And Disseminated Infections,7203,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,10839.23,,,,,,,fee schedule,10839.23,10839.23, Septicemia And Disseminated Infections,7203,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,10839.23,,,,,,,fee schedule,10839.23,10839.23, Septicemia And Disseminated Infections,7203,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,10839.23,,,,,,,fee schedule,10839.23,10839.23, Septicemia And Disseminated Infections,7203,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,10839.23,,,,,,,fee schedule,10839.23,10839.23, Septicemia And Disseminated Infections,7203,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,10839.23,,,,,,,fee schedule,10839.23,10839.23, Septicemia And Disseminated Infections,7203,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,10839.23,,,,,,,fee schedule,10839.23,10839.23, Septicemia And Disseminated Infections,7203,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,10839.23,,,,,,,fee schedule,10839.23,10839.23, Septicemia And Disseminated Infections,7204,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,19988.15,,,,,,,fee schedule,19988.15,19988.15, Septicemia And Disseminated Infections,7204,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,19988.15,,,,,,,fee schedule,19988.15,19988.15, Septicemia And Disseminated Infections,7204,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,19988.15,,,,,,,fee schedule,19988.15,19988.15, Septicemia And Disseminated Infections,7204,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,19988.15,,,,,,,fee schedule,19988.15,19988.15, Septicemia And Disseminated Infections,7204,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,19988.15,,,,,,,fee schedule,19988.15,19988.15, Septicemia And Disseminated Infections,7204,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,19988.15,,,,,,,fee schedule,19988.15,19988.15, Septicemia And Disseminated Infections,7204,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,19988.15,,,,,,,fee schedule,19988.15,19988.15, Septicemia And Disseminated Infections,7204,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,19988.15,,,,,,,fee schedule,19988.15,19988.15, Septicemia And Disseminated Infections,7204,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,19988.15,,,,,,,fee schedule,19988.15,19988.15, Septicemia And Disseminated Infections,7204,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,19988.15,,,,,,,fee schedule,19988.15,19988.15, Septicemia And Disseminated Infections,7204,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,19988.15,,,,,,,fee schedule,19988.15,19988.15, "Post-Operative, Post-Traumatic, Other Device Infections",7211,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4821.83,,,,,,,fee schedule,4821.83,4821.83, "Post-Operative, Post-Traumatic, Other Device Infections",7211,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4821.83,,,,,,,fee schedule,4821.83,4821.83, "Post-Operative, Post-Traumatic, Other Device Infections",7211,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4821.83,,,,,,,fee schedule,4821.83,4821.83, "Post-Operative, Post-Traumatic, Other Device Infections",7211,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4821.83,,,,,,,fee schedule,4821.83,4821.83, "Post-Operative, Post-Traumatic, Other Device Infections",7211,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4821.83,,,,,,,fee schedule,4821.83,4821.83, "Post-Operative, Post-Traumatic, Other Device Infections",7211,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4821.83,,,,,,,fee schedule,4821.83,4821.83, "Post-Operative, Post-Traumatic, Other Device Infections",7211,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4821.83,,,,,,,fee schedule,4821.83,4821.83, "Post-Operative, Post-Traumatic, Other Device Infections",7211,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4821.83,,,,,,,fee schedule,4821.83,4821.83, "Post-Operative, Post-Traumatic, Other Device Infections",7211,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4821.83,,,,,,,fee schedule,4821.83,4821.83, "Post-Operative, Post-Traumatic, Other Device Infections",7211,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4821.83,,,,,,,fee schedule,4821.83,4821.83, "Post-Operative, Post-Traumatic, Other Device Infections",7211,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4821.83,,,,,,,fee schedule,4821.83,4821.83, "Post-Operative, Post-Traumatic, Other Device Infections",7212,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,6735.88,,,,,,,fee schedule,6735.88,6735.88, "Post-Operative, Post-Traumatic, Other Device Infections",7212,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,6735.88,,,,,,,fee schedule,6735.88,6735.88, "Post-Operative, Post-Traumatic, Other Device Infections",7212,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,6735.88,,,,,,,fee schedule,6735.88,6735.88, "Post-Operative, Post-Traumatic, Other Device Infections",7212,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,6735.88,,,,,,,fee schedule,6735.88,6735.88, "Post-Operative, Post-Traumatic, Other Device Infections",7212,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,6735.88,,,,,,,fee schedule,6735.88,6735.88, "Post-Operative, Post-Traumatic, Other Device Infections",7212,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,6735.88,,,,,,,fee schedule,6735.88,6735.88, "Post-Operative, Post-Traumatic, Other Device Infections",7212,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,6735.88,,,,,,,fee schedule,6735.88,6735.88, "Post-Operative, Post-Traumatic, Other Device Infections",7212,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,6735.88,,,,,,,fee schedule,6735.88,6735.88, "Post-Operative, Post-Traumatic, Other Device Infections",7212,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,6735.88,,,,,,,fee schedule,6735.88,6735.88, "Post-Operative, Post-Traumatic, Other Device Infections",7212,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,6735.88,,,,,,,fee schedule,6735.88,6735.88, "Post-Operative, Post-Traumatic, Other Device Infections",7212,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,6735.88,,,,,,,fee schedule,6735.88,6735.88, "Post-Operative, Post-Traumatic, Other Device Infections",7213,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,11089.08,,,,,,,fee schedule,11089.08,11089.08, "Post-Operative, Post-Traumatic, Other Device Infections",7213,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,11089.08,,,,,,,fee schedule,11089.08,11089.08, "Post-Operative, Post-Traumatic, Other Device Infections",7213,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,11089.08,,,,,,,fee schedule,11089.08,11089.08, "Post-Operative, Post-Traumatic, Other Device Infections",7213,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,11089.08,,,,,,,fee schedule,11089.08,11089.08, "Post-Operative, Post-Traumatic, Other Device Infections",7213,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,11089.08,,,,,,,fee schedule,11089.08,11089.08, "Post-Operative, Post-Traumatic, Other Device Infections",7213,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,11089.08,,,,,,,fee schedule,11089.08,11089.08, "Post-Operative, Post-Traumatic, Other Device Infections",7213,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,11089.08,,,,,,,fee schedule,11089.08,11089.08, "Post-Operative, Post-Traumatic, Other Device Infections",7213,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,11089.08,,,,,,,fee schedule,11089.08,11089.08, "Post-Operative, Post-Traumatic, Other Device Infections",7213,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,11089.08,,,,,,,fee schedule,11089.08,11089.08, "Post-Operative, Post-Traumatic, Other Device Infections",7213,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,11089.08,,,,,,,fee schedule,11089.08,11089.08, "Post-Operative, Post-Traumatic, Other Device Infections",7213,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,11089.08,,,,,,,fee schedule,11089.08,11089.08, "Post-Operative, Post-Traumatic, Other Device Infections",7214,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,18916.79,,,,,,,fee schedule,18916.79,18916.79, "Post-Operative, Post-Traumatic, Other Device Infections",7214,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,18916.79,,,,,,,fee schedule,18916.79,18916.79, "Post-Operative, Post-Traumatic, Other Device Infections",7214,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,18916.79,,,,,,,fee schedule,18916.79,18916.79, "Post-Operative, Post-Traumatic, Other Device Infections",7214,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,18916.79,,,,,,,fee schedule,18916.79,18916.79, "Post-Operative, Post-Traumatic, Other Device Infections",7214,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,18916.79,,,,,,,fee schedule,18916.79,18916.79, "Post-Operative, Post-Traumatic, Other Device Infections",7214,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,18916.79,,,,,,,fee schedule,18916.79,18916.79, "Post-Operative, Post-Traumatic, Other Device Infections",7214,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,18916.79,,,,,,,fee schedule,18916.79,18916.79, "Post-Operative, Post-Traumatic, Other Device Infections",7214,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,18916.79,,,,,,,fee schedule,18916.79,18916.79, "Post-Operative, Post-Traumatic, Other Device Infections",7214,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,18916.79,,,,,,,fee schedule,18916.79,18916.79, "Post-Operative, Post-Traumatic, Other Device Infections",7214,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,18916.79,,,,,,,fee schedule,18916.79,18916.79, "Post-Operative, Post-Traumatic, Other Device Infections",7214,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,18916.79,,,,,,,fee schedule,18916.79,18916.79, Fever And Inflammatory Conditions,7221,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,3442.05,,,,,,,fee schedule,3442.05,3442.05, Fever And Inflammatory Conditions,7221,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,3442.05,,,,,,,fee schedule,3442.05,3442.05, Fever And Inflammatory Conditions,7221,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,3442.05,,,,,,,fee schedule,3442.05,3442.05, Fever And Inflammatory Conditions,7221,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,3442.05,,,,,,,fee schedule,3442.05,3442.05, Fever And Inflammatory Conditions,7221,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,3442.05,,,,,,,fee schedule,3442.05,3442.05, Fever And Inflammatory Conditions,7221,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,3442.05,,,,,,,fee schedule,3442.05,3442.05, Fever And Inflammatory Conditions,7221,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,3442.05,,,,,,,fee schedule,3442.05,3442.05, Fever And Inflammatory Conditions,7221,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,3442.05,,,,,,,fee schedule,3442.05,3442.05, Fever And Inflammatory Conditions,7221,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,3442.05,,,,,,,fee schedule,3442.05,3442.05, Fever And Inflammatory Conditions,7221,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,3442.05,,,,,,,fee schedule,3442.05,3442.05, Fever And Inflammatory Conditions,7221,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,3442.05,,,,,,,fee schedule,3442.05,3442.05, Fever And Inflammatory Conditions,7222,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4731.49,,,,,,,fee schedule,4731.49,4731.49, Fever And Inflammatory Conditions,7222,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4731.49,,,,,,,fee schedule,4731.49,4731.49, Fever And Inflammatory Conditions,7222,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4731.49,,,,,,,fee schedule,4731.49,4731.49, Fever And Inflammatory Conditions,7222,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4731.49,,,,,,,fee schedule,4731.49,4731.49, Fever And Inflammatory Conditions,7222,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4731.49,,,,,,,fee schedule,4731.49,4731.49, Fever And Inflammatory Conditions,7222,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4731.49,,,,,,,fee schedule,4731.49,4731.49, Fever And Inflammatory Conditions,7222,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4731.49,,,,,,,fee schedule,4731.49,4731.49, Fever And Inflammatory Conditions,7222,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4731.49,,,,,,,fee schedule,4731.49,4731.49, Fever And Inflammatory Conditions,7222,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4731.49,,,,,,,fee schedule,4731.49,4731.49, Fever And Inflammatory Conditions,7222,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4731.49,,,,,,,fee schedule,4731.49,4731.49, Fever And Inflammatory Conditions,7222,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4731.49,,,,,,,fee schedule,4731.49,4731.49, Fever And Inflammatory Conditions,7223,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,6482.51,,,,,,,fee schedule,6482.51,6482.51, Fever And Inflammatory Conditions,7223,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,6482.51,,,,,,,fee schedule,6482.51,6482.51, Fever And Inflammatory Conditions,7223,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,6482.51,,,,,,,fee schedule,6482.51,6482.51, Fever And Inflammatory Conditions,7223,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,6482.51,,,,,,,fee schedule,6482.51,6482.51, Fever And Inflammatory Conditions,7223,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,6482.51,,,,,,,fee schedule,6482.51,6482.51, Fever And Inflammatory Conditions,7223,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,6482.51,,,,,,,fee schedule,6482.51,6482.51, Fever And Inflammatory Conditions,7223,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,6482.51,,,,,,,fee schedule,6482.51,6482.51, Fever And Inflammatory Conditions,7223,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,6482.51,,,,,,,fee schedule,6482.51,6482.51, Fever And Inflammatory Conditions,7223,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,6482.51,,,,,,,fee schedule,6482.51,6482.51, Fever And Inflammatory Conditions,7223,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,6482.51,,,,,,,fee schedule,6482.51,6482.51, Fever And Inflammatory Conditions,7223,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,6482.51,,,,,,,fee schedule,6482.51,6482.51, Fever And Inflammatory Conditions,7224,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,10107.35,,,,,,,fee schedule,10107.35,10107.35, Fever And Inflammatory Conditions,7224,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,10107.35,,,,,,,fee schedule,10107.35,10107.35, Fever And Inflammatory Conditions,7224,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,10107.35,,,,,,,fee schedule,10107.35,10107.35, Fever And Inflammatory Conditions,7224,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,10107.35,,,,,,,fee schedule,10107.35,10107.35, Fever And Inflammatory Conditions,7224,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,10107.35,,,,,,,fee schedule,10107.35,10107.35, Fever And Inflammatory Conditions,7224,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,10107.35,,,,,,,fee schedule,10107.35,10107.35, Fever And Inflammatory Conditions,7224,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,10107.35,,,,,,,fee schedule,10107.35,10107.35, Fever And Inflammatory Conditions,7224,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,10107.35,,,,,,,fee schedule,10107.35,10107.35, Fever And Inflammatory Conditions,7224,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,10107.35,,,,,,,fee schedule,10107.35,10107.35, Fever And Inflammatory Conditions,7224,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,10107.35,,,,,,,fee schedule,10107.35,10107.35, Fever And Inflammatory Conditions,7224,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,10107.35,,,,,,,fee schedule,10107.35,10107.35, Viral Illness,7231,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,3231.73,,,,,,,fee schedule,3231.73,3231.73, Viral Illness,7231,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,3231.73,,,,,,,fee schedule,3231.73,3231.73, Viral Illness,7231,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,3231.73,,,,,,,fee schedule,3231.73,3231.73, Viral Illness,7231,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,3231.73,,,,,,,fee schedule,3231.73,3231.73, Viral Illness,7231,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,3231.73,,,,,,,fee schedule,3231.73,3231.73, Viral Illness,7231,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,3231.73,,,,,,,fee schedule,3231.73,3231.73, Viral Illness,7231,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,3231.73,,,,,,,fee schedule,3231.73,3231.73, Viral Illness,7231,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,3231.73,,,,,,,fee schedule,3231.73,3231.73, Viral Illness,7231,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,3231.73,,,,,,,fee schedule,3231.73,3231.73, Viral Illness,7231,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,3231.73,,,,,,,fee schedule,3231.73,3231.73, Viral Illness,7231,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,3231.73,,,,,,,fee schedule,3231.73,3231.73, Viral Illness,7232,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4653.86,,,,,,,fee schedule,4653.86,4653.86, Viral Illness,7232,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4653.86,,,,,,,fee schedule,4653.86,4653.86, Viral Illness,7232,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4653.86,,,,,,,fee schedule,4653.86,4653.86, Viral Illness,7232,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4653.86,,,,,,,fee schedule,4653.86,4653.86, Viral Illness,7232,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4653.86,,,,,,,fee schedule,4653.86,4653.86, Viral Illness,7232,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4653.86,,,,,,,fee schedule,4653.86,4653.86, Viral Illness,7232,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4653.86,,,,,,,fee schedule,4653.86,4653.86, Viral Illness,7232,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4653.86,,,,,,,fee schedule,4653.86,4653.86, Viral Illness,7232,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4653.86,,,,,,,fee schedule,4653.86,4653.86, Viral Illness,7232,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4653.86,,,,,,,fee schedule,4653.86,4653.86, Viral Illness,7232,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4653.86,,,,,,,fee schedule,4653.86,4653.86, Viral Illness,7233,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,7683.03,,,,,,,fee schedule,7683.03,7683.03, Viral Illness,7233,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,7683.03,,,,,,,fee schedule,7683.03,7683.03, Viral Illness,7233,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,7683.03,,,,,,,fee schedule,7683.03,7683.03, Viral Illness,7233,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,7683.03,,,,,,,fee schedule,7683.03,7683.03, Viral Illness,7233,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,7683.03,,,,,,,fee schedule,7683.03,7683.03, Viral Illness,7233,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,7683.03,,,,,,,fee schedule,7683.03,7683.03, Viral Illness,7233,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,7683.03,,,,,,,fee schedule,7683.03,7683.03, Viral Illness,7233,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,7683.03,,,,,,,fee schedule,7683.03,7683.03, Viral Illness,7233,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,7683.03,,,,,,,fee schedule,7683.03,7683.03, Viral Illness,7233,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,7683.03,,,,,,,fee schedule,7683.03,7683.03, Viral Illness,7233,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,7683.03,,,,,,,fee schedule,7683.03,7683.03, Viral Illness,7234,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,14826.14,,,,,,,fee schedule,14826.14,14826.14, Viral Illness,7234,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,14826.14,,,,,,,fee schedule,14826.14,14826.14, Viral Illness,7234,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,14826.14,,,,,,,fee schedule,14826.14,14826.14, Viral Illness,7234,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,14826.14,,,,,,,fee schedule,14826.14,14826.14, Viral Illness,7234,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,14826.14,,,,,,,fee schedule,14826.14,14826.14, Viral Illness,7234,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,14826.14,,,,,,,fee schedule,14826.14,14826.14, Viral Illness,7234,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,14826.14,,,,,,,fee schedule,14826.14,14826.14, Viral Illness,7234,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,14826.14,,,,,,,fee schedule,14826.14,14826.14, Viral Illness,7234,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,14826.14,,,,,,,fee schedule,14826.14,14826.14, Viral Illness,7234,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,14826.14,,,,,,,fee schedule,14826.14,14826.14, Viral Illness,7234,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,14826.14,,,,,,,fee schedule,14826.14,14826.14, Other Infectious And Parasitic Diseases,7241,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4063.83,,,,,,,fee schedule,4063.83,4063.83, Other Infectious And Parasitic Diseases,7241,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4063.83,,,,,,,fee schedule,4063.83,4063.83, Other Infectious And Parasitic Diseases,7241,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4063.83,,,,,,,fee schedule,4063.83,4063.83, Other Infectious And Parasitic Diseases,7241,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4063.83,,,,,,,fee schedule,4063.83,4063.83, Other Infectious And Parasitic Diseases,7241,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4063.83,,,,,,,fee schedule,4063.83,4063.83, Other Infectious And Parasitic Diseases,7241,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4063.83,,,,,,,fee schedule,4063.83,4063.83, Other Infectious And Parasitic Diseases,7241,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4063.83,,,,,,,fee schedule,4063.83,4063.83, Other Infectious And Parasitic Diseases,7241,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4063.83,,,,,,,fee schedule,4063.83,4063.83, Other Infectious And Parasitic Diseases,7241,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4063.83,,,,,,,fee schedule,4063.83,4063.83, Other Infectious And Parasitic Diseases,7241,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4063.83,,,,,,,fee schedule,4063.83,4063.83, Other Infectious And Parasitic Diseases,7241,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4063.83,,,,,,,fee schedule,4063.83,4063.83, Other Infectious And Parasitic Diseases,7242,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5845.9,,,,,,,fee schedule,5845.9,5845.9, Other Infectious And Parasitic Diseases,7242,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5845.9,,,,,,,fee schedule,5845.9,5845.9, Other Infectious And Parasitic Diseases,7242,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5845.9,,,,,,,fee schedule,5845.9,5845.9, Other Infectious And Parasitic Diseases,7242,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5845.9,,,,,,,fee schedule,5845.9,5845.9, Other Infectious And Parasitic Diseases,7242,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5845.9,,,,,,,fee schedule,5845.9,5845.9, Other Infectious And Parasitic Diseases,7242,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5845.9,,,,,,,fee schedule,5845.9,5845.9, Other Infectious And Parasitic Diseases,7242,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5845.9,,,,,,,fee schedule,5845.9,5845.9, Other Infectious And Parasitic Diseases,7242,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5845.9,,,,,,,fee schedule,5845.9,5845.9, Other Infectious And Parasitic Diseases,7242,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5845.9,,,,,,,fee schedule,5845.9,5845.9, Other Infectious And Parasitic Diseases,7242,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5845.9,,,,,,,fee schedule,5845.9,5845.9, Other Infectious And Parasitic Diseases,7242,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5845.9,,,,,,,fee schedule,5845.9,5845.9, Other Infectious And Parasitic Diseases,7243,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,9213.14,,,,,,,fee schedule,9213.14,9213.14, Other Infectious And Parasitic Diseases,7243,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,9213.14,,,,,,,fee schedule,9213.14,9213.14, Other Infectious And Parasitic Diseases,7243,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,9213.14,,,,,,,fee schedule,9213.14,9213.14, Other Infectious And Parasitic Diseases,7243,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,9213.14,,,,,,,fee schedule,9213.14,9213.14, Other Infectious And Parasitic Diseases,7243,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,9213.14,,,,,,,fee schedule,9213.14,9213.14, Other Infectious And Parasitic Diseases,7243,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,9213.14,,,,,,,fee schedule,9213.14,9213.14, Other Infectious And Parasitic Diseases,7243,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,9213.14,,,,,,,fee schedule,9213.14,9213.14, Other Infectious And Parasitic Diseases,7243,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,9213.14,,,,,,,fee schedule,9213.14,9213.14, Other Infectious And Parasitic Diseases,7243,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,9213.14,,,,,,,fee schedule,9213.14,9213.14, Other Infectious And Parasitic Diseases,7243,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,9213.14,,,,,,,fee schedule,9213.14,9213.14, Other Infectious And Parasitic Diseases,7243,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,9213.14,,,,,,,fee schedule,9213.14,9213.14, Other Infectious And Parasitic Diseases,7244,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,18083.98,,,,,,,fee schedule,18083.98,18083.98, Other Infectious And Parasitic Diseases,7244,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,18083.98,,,,,,,fee schedule,18083.98,18083.98, Other Infectious And Parasitic Diseases,7244,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,18083.98,,,,,,,fee schedule,18083.98,18083.98, Other Infectious And Parasitic Diseases,7244,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,18083.98,,,,,,,fee schedule,18083.98,18083.98, Other Infectious And Parasitic Diseases,7244,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,18083.98,,,,,,,fee schedule,18083.98,18083.98, Other Infectious And Parasitic Diseases,7244,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,18083.98,,,,,,,fee schedule,18083.98,18083.98, Other Infectious And Parasitic Diseases,7244,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,18083.98,,,,,,,fee schedule,18083.98,18083.98, Other Infectious And Parasitic Diseases,7244,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,18083.98,,,,,,,fee schedule,18083.98,18083.98, Other Infectious And Parasitic Diseases,7244,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,18083.98,,,,,,,fee schedule,18083.98,18083.98, Other Infectious And Parasitic Diseases,7244,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,18083.98,,,,,,,fee schedule,18083.98,18083.98, Other Infectious And Parasitic Diseases,7244,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,18083.98,,,,,,,fee schedule,18083.98,18083.98, Mental Illness Diagnosis With O.R. Procedure,7401,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,6490.98,,,,,,,fee schedule,6490.98,6490.98, Mental Illness Diagnosis With O.R. Procedure,7401,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,6490.98,,,,,,,fee schedule,6490.98,6490.98, Mental Illness Diagnosis With O.R. Procedure,7401,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,6490.98,,,,,,,fee schedule,6490.98,6490.98, Mental Illness Diagnosis With O.R. Procedure,7401,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,6490.98,,,,,,,fee schedule,6490.98,6490.98, Mental Illness Diagnosis With O.R. Procedure,7401,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,6490.98,,,,,,,fee schedule,6490.98,6490.98, Mental Illness Diagnosis With O.R. Procedure,7401,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,6490.98,,,,,,,fee schedule,6490.98,6490.98, Mental Illness Diagnosis With O.R. Procedure,7401,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,6490.98,,,,,,,fee schedule,6490.98,6490.98, Mental Illness Diagnosis With O.R. Procedure,7401,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,6490.98,,,,,,,fee schedule,6490.98,6490.98, Mental Illness Diagnosis With O.R. Procedure,7401,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,6490.98,,,,,,,fee schedule,6490.98,6490.98, Mental Illness Diagnosis With O.R. Procedure,7401,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,6490.98,,,,,,,fee schedule,6490.98,6490.98, Mental Illness Diagnosis With O.R. Procedure,7401,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,6490.98,,,,,,,fee schedule,6490.98,6490.98, Mental Illness Diagnosis With O.R. Procedure,7402,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,10889.34,,,,,,,fee schedule,10889.34,10889.34, Mental Illness Diagnosis With O.R. Procedure,7402,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,10889.34,,,,,,,fee schedule,10889.34,10889.34, Mental Illness Diagnosis With O.R. Procedure,7402,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,10889.34,,,,,,,fee schedule,10889.34,10889.34, Mental Illness Diagnosis With O.R. Procedure,7402,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,10889.34,,,,,,,fee schedule,10889.34,10889.34, Mental Illness Diagnosis With O.R. Procedure,7402,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,10889.34,,,,,,,fee schedule,10889.34,10889.34, Mental Illness Diagnosis With O.R. Procedure,7402,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,10889.34,,,,,,,fee schedule,10889.34,10889.34, Mental Illness Diagnosis With O.R. Procedure,7402,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,10889.34,,,,,,,fee schedule,10889.34,10889.34, Mental Illness Diagnosis With O.R. Procedure,7402,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,10889.34,,,,,,,fee schedule,10889.34,10889.34, Mental Illness Diagnosis With O.R. Procedure,7402,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,10889.34,,,,,,,fee schedule,10889.34,10889.34, Mental Illness Diagnosis With O.R. Procedure,7402,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,10889.34,,,,,,,fee schedule,10889.34,10889.34, Mental Illness Diagnosis With O.R. Procedure,7402,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,10889.34,,,,,,,fee schedule,10889.34,10889.34, Mental Illness Diagnosis With O.R. Procedure,7403,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,19073.47,,,,,,,fee schedule,19073.47,19073.47, Mental Illness Diagnosis With O.R. Procedure,7403,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,19073.47,,,,,,,fee schedule,19073.47,19073.47, Mental Illness Diagnosis With O.R. Procedure,7403,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,19073.47,,,,,,,fee schedule,19073.47,19073.47, Mental Illness Diagnosis With O.R. Procedure,7403,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,19073.47,,,,,,,fee schedule,19073.47,19073.47, Mental Illness Diagnosis With O.R. Procedure,7403,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,19073.47,,,,,,,fee schedule,19073.47,19073.47, Mental Illness Diagnosis With O.R. Procedure,7403,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,19073.47,,,,,,,fee schedule,19073.47,19073.47, Mental Illness Diagnosis With O.R. Procedure,7403,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,19073.47,,,,,,,fee schedule,19073.47,19073.47, Mental Illness Diagnosis With O.R. Procedure,7403,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,19073.47,,,,,,,fee schedule,19073.47,19073.47, Mental Illness Diagnosis With O.R. Procedure,7403,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,19073.47,,,,,,,fee schedule,19073.47,19073.47, Mental Illness Diagnosis With O.R. Procedure,7403,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,19073.47,,,,,,,fee schedule,19073.47,19073.47, Mental Illness Diagnosis With O.R. Procedure,7403,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,19073.47,,,,,,,fee schedule,19073.47,19073.47, Mental Illness Diagnosis With O.R. Procedure,7404,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,41425.24,,,,,,,fee schedule,41425.24,41425.24, Mental Illness Diagnosis With O.R. Procedure,7404,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,41425.24,,,,,,,fee schedule,41425.24,41425.24, Mental Illness Diagnosis With O.R. Procedure,7404,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,41425.24,,,,,,,fee schedule,41425.24,41425.24, Mental Illness Diagnosis With O.R. Procedure,7404,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,41425.24,,,,,,,fee schedule,41425.24,41425.24, Mental Illness Diagnosis With O.R. Procedure,7404,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,41425.24,,,,,,,fee schedule,41425.24,41425.24, Mental Illness Diagnosis With O.R. Procedure,7404,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,41425.24,,,,,,,fee schedule,41425.24,41425.24, Mental Illness Diagnosis With O.R. Procedure,7404,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,41425.24,,,,,,,fee schedule,41425.24,41425.24, Mental Illness Diagnosis With O.R. Procedure,7404,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,41425.24,,,,,,,fee schedule,41425.24,41425.24, Mental Illness Diagnosis With O.R. Procedure,7404,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,41425.24,,,,,,,fee schedule,41425.24,41425.24, Mental Illness Diagnosis With O.R. Procedure,7404,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,41425.24,,,,,,,fee schedule,41425.24,41425.24, Mental Illness Diagnosis With O.R. Procedure,7404,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,41425.24,,,,,,,fee schedule,41425.24,41425.24, Schizophrenia,7501,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4414.6,,,,,,,fee schedule,4414.6,4414.6, Schizophrenia,7501,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4414.6,,,,,,,fee schedule,4414.6,4414.6, Schizophrenia,7501,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4414.6,,,,,,,fee schedule,4414.6,4414.6, Schizophrenia,7501,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4414.6,,,,,,,fee schedule,4414.6,4414.6, Schizophrenia,7501,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4414.6,,,,,,,fee schedule,4414.6,4414.6, Schizophrenia,7501,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4414.6,,,,,,,fee schedule,4414.6,4414.6, Schizophrenia,7501,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4414.6,,,,,,,fee schedule,4414.6,4414.6, Schizophrenia,7501,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4414.6,,,,,,,fee schedule,4414.6,4414.6, Schizophrenia,7501,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4414.6,,,,,,,fee schedule,4414.6,4414.6, Schizophrenia,7501,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4414.6,,,,,,,fee schedule,4414.6,4414.6, Schizophrenia,7501,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4414.6,,,,,,,fee schedule,4414.6,4414.6, Schizophrenia,7502,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,6105.63,,,,,,,fee schedule,6105.63,6105.63, Schizophrenia,7502,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,6105.63,,,,,,,fee schedule,6105.63,6105.63, Schizophrenia,7502,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,6105.63,,,,,,,fee schedule,6105.63,6105.63, Schizophrenia,7502,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,6105.63,,,,,,,fee schedule,6105.63,6105.63, Schizophrenia,7502,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,6105.63,,,,,,,fee schedule,6105.63,6105.63, Schizophrenia,7502,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,6105.63,,,,,,,fee schedule,6105.63,6105.63, Schizophrenia,7502,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,6105.63,,,,,,,fee schedule,6105.63,6105.63, Schizophrenia,7502,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,6105.63,,,,,,,fee schedule,6105.63,6105.63, Schizophrenia,7502,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,6105.63,,,,,,,fee schedule,6105.63,6105.63, Schizophrenia,7502,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,6105.63,,,,,,,fee schedule,6105.63,6105.63, Schizophrenia,7502,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,6105.63,,,,,,,fee schedule,6105.63,6105.63, Schizophrenia,7503,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,9151.74,,,,,,,fee schedule,9151.74,9151.74, Schizophrenia,7503,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,9151.74,,,,,,,fee schedule,9151.74,9151.74, Schizophrenia,7503,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,9151.74,,,,,,,fee schedule,9151.74,9151.74, Schizophrenia,7503,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,9151.74,,,,,,,fee schedule,9151.74,9151.74, Schizophrenia,7503,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,9151.74,,,,,,,fee schedule,9151.74,9151.74, Schizophrenia,7503,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,9151.74,,,,,,,fee schedule,9151.74,9151.74, Schizophrenia,7503,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,9151.74,,,,,,,fee schedule,9151.74,9151.74, Schizophrenia,7503,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,9151.74,,,,,,,fee schedule,9151.74,9151.74, Schizophrenia,7503,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,9151.74,,,,,,,fee schedule,9151.74,9151.74, Schizophrenia,7503,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,9151.74,,,,,,,fee schedule,9151.74,9151.74, Schizophrenia,7503,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,9151.74,,,,,,,fee schedule,9151.74,9151.74, Schizophrenia,7504,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,17685.22,,,,,,,fee schedule,17685.22,17685.22, Schizophrenia,7504,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,17685.22,,,,,,,fee schedule,17685.22,17685.22, Schizophrenia,7504,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,17685.22,,,,,,,fee schedule,17685.22,17685.22, Schizophrenia,7504,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,17685.22,,,,,,,fee schedule,17685.22,17685.22, Schizophrenia,7504,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,17685.22,,,,,,,fee schedule,17685.22,17685.22, Schizophrenia,7504,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,17685.22,,,,,,,fee schedule,17685.22,17685.22, Schizophrenia,7504,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,17685.22,,,,,,,fee schedule,17685.22,17685.22, Schizophrenia,7504,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,17685.22,,,,,,,fee schedule,17685.22,17685.22, Schizophrenia,7504,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,17685.22,,,,,,,fee schedule,17685.22,17685.22, Schizophrenia,7504,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,17685.22,,,,,,,fee schedule,17685.22,17685.22, Schizophrenia,7504,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,17685.22,,,,,,,fee schedule,17685.22,17685.22, Major Depressive Disorders And Other Or Unspecified Psychoses,7511,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,2739.8,,,,,,,fee schedule,2739.8,2739.8, Major Depressive Disorders And Other Or Unspecified Psychoses,7511,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,2739.8,,,,,,,fee schedule,2739.8,2739.8, Major Depressive Disorders And Other Or Unspecified Psychoses,7511,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,2739.8,,,,,,,fee schedule,2739.8,2739.8, Major Depressive Disorders And Other Or Unspecified Psychoses,7511,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,2739.8,,,,,,,fee schedule,2739.8,2739.8, Major Depressive Disorders And Other Or Unspecified Psychoses,7511,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,2739.8,,,,,,,fee schedule,2739.8,2739.8, Major Depressive Disorders And Other Or Unspecified Psychoses,7511,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,2739.8,,,,,,,fee schedule,2739.8,2739.8, Major Depressive Disorders And Other Or Unspecified Psychoses,7511,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,2739.8,,,,,,,fee schedule,2739.8,2739.8, Major Depressive Disorders And Other Or Unspecified Psychoses,7511,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,2739.8,,,,,,,fee schedule,2739.8,2739.8, Major Depressive Disorders And Other Or Unspecified Psychoses,7511,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,2739.8,,,,,,,fee schedule,2739.8,2739.8, Major Depressive Disorders And Other Or Unspecified Psychoses,7511,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,2739.8,,,,,,,fee schedule,2739.8,2739.8, Major Depressive Disorders And Other Or Unspecified Psychoses,7511,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,2739.8,,,,,,,fee schedule,2739.8,2739.8, Major Depressive Disorders And Other Or Unspecified Psychoses,7512,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,3680.6,,,,,,,fee schedule,3680.6,3680.6, Major Depressive Disorders And Other Or Unspecified Psychoses,7512,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,3680.6,,,,,,,fee schedule,3680.6,3680.6, Major Depressive Disorders And Other Or Unspecified Psychoses,7512,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,3680.6,,,,,,,fee schedule,3680.6,3680.6, Major Depressive Disorders And Other Or Unspecified Psychoses,7512,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,3680.6,,,,,,,fee schedule,3680.6,3680.6, Major Depressive Disorders And Other Or Unspecified Psychoses,7512,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,3680.6,,,,,,,fee schedule,3680.6,3680.6, Major Depressive Disorders And Other Or Unspecified Psychoses,7512,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,3680.6,,,,,,,fee schedule,3680.6,3680.6, Major Depressive Disorders And Other Or Unspecified Psychoses,7512,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,3680.6,,,,,,,fee schedule,3680.6,3680.6, Major Depressive Disorders And Other Or Unspecified Psychoses,7512,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,3680.6,,,,,,,fee schedule,3680.6,3680.6, Major Depressive Disorders And Other Or Unspecified Psychoses,7512,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,3680.6,,,,,,,fee schedule,3680.6,3680.6, Major Depressive Disorders And Other Or Unspecified Psychoses,7512,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,3680.6,,,,,,,fee schedule,3680.6,3680.6, Major Depressive Disorders And Other Or Unspecified Psychoses,7512,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,3680.6,,,,,,,fee schedule,3680.6,3680.6, Major Depressive Disorders And Other Or Unspecified Psychoses,7513,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,7473.41,,,,,,,fee schedule,7473.41,7473.41, Major Depressive Disorders And Other Or Unspecified Psychoses,7513,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,7473.41,,,,,,,fee schedule,7473.41,7473.41, Major Depressive Disorders And Other Or Unspecified Psychoses,7513,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,7473.41,,,,,,,fee schedule,7473.41,7473.41, Major Depressive Disorders And Other Or Unspecified Psychoses,7513,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,7473.41,,,,,,,fee schedule,7473.41,7473.41, Major Depressive Disorders And Other Or Unspecified Psychoses,7513,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,7473.41,,,,,,,fee schedule,7473.41,7473.41, Major Depressive Disorders And Other Or Unspecified Psychoses,7513,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,7473.41,,,,,,,fee schedule,7473.41,7473.41, Major Depressive Disorders And Other Or Unspecified Psychoses,7513,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,7473.41,,,,,,,fee schedule,7473.41,7473.41, Major Depressive Disorders And Other Or Unspecified Psychoses,7513,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,7473.41,,,,,,,fee schedule,7473.41,7473.41, Major Depressive Disorders And Other Or Unspecified Psychoses,7513,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,7473.41,,,,,,,fee schedule,7473.41,7473.41, Major Depressive Disorders And Other Or Unspecified Psychoses,7513,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,7473.41,,,,,,,fee schedule,7473.41,7473.41, Major Depressive Disorders And Other Or Unspecified Psychoses,7513,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,7473.41,,,,,,,fee schedule,7473.41,7473.41, Major Depressive Disorders And Other Or Unspecified Psychoses,7514,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,14308.81,,,,,,,fee schedule,14308.81,14308.81, Major Depressive Disorders And Other Or Unspecified Psychoses,7514,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,14308.81,,,,,,,fee schedule,14308.81,14308.81, Major Depressive Disorders And Other Or Unspecified Psychoses,7514,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,14308.81,,,,,,,fee schedule,14308.81,14308.81, Major Depressive Disorders And Other Or Unspecified Psychoses,7514,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,14308.81,,,,,,,fee schedule,14308.81,14308.81, Major Depressive Disorders And Other Or Unspecified Psychoses,7514,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,14308.81,,,,,,,fee schedule,14308.81,14308.81, Major Depressive Disorders And Other Or Unspecified Psychoses,7514,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,14308.81,,,,,,,fee schedule,14308.81,14308.81, Major Depressive Disorders And Other Or Unspecified Psychoses,7514,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,14308.81,,,,,,,fee schedule,14308.81,14308.81, Major Depressive Disorders And Other Or Unspecified Psychoses,7514,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,14308.81,,,,,,,fee schedule,14308.81,14308.81, Major Depressive Disorders And Other Or Unspecified Psychoses,7514,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,14308.81,,,,,,,fee schedule,14308.81,14308.81, Major Depressive Disorders And Other Or Unspecified Psychoses,7514,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,14308.81,,,,,,,fee schedule,14308.81,14308.81, Major Depressive Disorders And Other Or Unspecified Psychoses,7514,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,14308.81,,,,,,,fee schedule,14308.81,14308.81, Disorders Of Personality And Impulse Control,7521,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,2869.67,,,,,,,fee schedule,2869.67,2869.67, Disorders Of Personality And Impulse Control,7521,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,2869.67,,,,,,,fee schedule,2869.67,2869.67, Disorders Of Personality And Impulse Control,7521,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,2869.67,,,,,,,fee schedule,2869.67,2869.67, Disorders Of Personality And Impulse Control,7521,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,2869.67,,,,,,,fee schedule,2869.67,2869.67, Disorders Of Personality And Impulse Control,7521,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,2869.67,,,,,,,fee schedule,2869.67,2869.67, Disorders Of Personality And Impulse Control,7521,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,2869.67,,,,,,,fee schedule,2869.67,2869.67, Disorders Of Personality And Impulse Control,7521,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,2869.67,,,,,,,fee schedule,2869.67,2869.67, Disorders Of Personality And Impulse Control,7521,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,2869.67,,,,,,,fee schedule,2869.67,2869.67, Disorders Of Personality And Impulse Control,7521,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,2869.67,,,,,,,fee schedule,2869.67,2869.67, Disorders Of Personality And Impulse Control,7521,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,2869.67,,,,,,,fee schedule,2869.67,2869.67, Disorders Of Personality And Impulse Control,7521,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,2869.67,,,,,,,fee schedule,2869.67,2869.67, Disorders Of Personality And Impulse Control,7522,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,3779.41,,,,,,,fee schedule,3779.41,3779.41, Disorders Of Personality And Impulse Control,7522,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,3779.41,,,,,,,fee schedule,3779.41,3779.41, Disorders Of Personality And Impulse Control,7522,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,3779.41,,,,,,,fee schedule,3779.41,3779.41, Disorders Of Personality And Impulse Control,7522,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,3779.41,,,,,,,fee schedule,3779.41,3779.41, Disorders Of Personality And Impulse Control,7522,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,3779.41,,,,,,,fee schedule,3779.41,3779.41, Disorders Of Personality And Impulse Control,7522,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,3779.41,,,,,,,fee schedule,3779.41,3779.41, Disorders Of Personality And Impulse Control,7522,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,3779.41,,,,,,,fee schedule,3779.41,3779.41, Disorders Of Personality And Impulse Control,7522,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,3779.41,,,,,,,fee schedule,3779.41,3779.41, Disorders Of Personality And Impulse Control,7522,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,3779.41,,,,,,,fee schedule,3779.41,3779.41, Disorders Of Personality And Impulse Control,7522,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,3779.41,,,,,,,fee schedule,3779.41,3779.41, Disorders Of Personality And Impulse Control,7522,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,3779.41,,,,,,,fee schedule,3779.41,3779.41, Disorders Of Personality And Impulse Control,7523,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,8419.85,,,,,,,fee schedule,8419.85,8419.85, Disorders Of Personality And Impulse Control,7523,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,8419.85,,,,,,,fee schedule,8419.85,8419.85, Disorders Of Personality And Impulse Control,7523,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,8419.85,,,,,,,fee schedule,8419.85,8419.85, Disorders Of Personality And Impulse Control,7523,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,8419.85,,,,,,,fee schedule,8419.85,8419.85, Disorders Of Personality And Impulse Control,7523,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,8419.85,,,,,,,fee schedule,8419.85,8419.85, Disorders Of Personality And Impulse Control,7523,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,8419.85,,,,,,,fee schedule,8419.85,8419.85, Disorders Of Personality And Impulse Control,7523,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,8419.85,,,,,,,fee schedule,8419.85,8419.85, Disorders Of Personality And Impulse Control,7523,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,8419.85,,,,,,,fee schedule,8419.85,8419.85, Disorders Of Personality And Impulse Control,7523,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,8419.85,,,,,,,fee schedule,8419.85,8419.85, Disorders Of Personality And Impulse Control,7523,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,8419.85,,,,,,,fee schedule,8419.85,8419.85, Disorders Of Personality And Impulse Control,7523,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,8419.85,,,,,,,fee schedule,8419.85,8419.85, Disorders Of Personality And Impulse Control,7524,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,20043.9,,,,,,,fee schedule,20043.9,20043.9, Disorders Of Personality And Impulse Control,7524,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,20043.9,,,,,,,fee schedule,20043.9,20043.9, Disorders Of Personality And Impulse Control,7524,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,20043.9,,,,,,,fee schedule,20043.9,20043.9, Disorders Of Personality And Impulse Control,7524,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,20043.9,,,,,,,fee schedule,20043.9,20043.9, Disorders Of Personality And Impulse Control,7524,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,20043.9,,,,,,,fee schedule,20043.9,20043.9, Disorders Of Personality And Impulse Control,7524,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,20043.9,,,,,,,fee schedule,20043.9,20043.9, Disorders Of Personality And Impulse Control,7524,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,20043.9,,,,,,,fee schedule,20043.9,20043.9, Disorders Of Personality And Impulse Control,7524,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,20043.9,,,,,,,fee schedule,20043.9,20043.9, Disorders Of Personality And Impulse Control,7524,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,20043.9,,,,,,,fee schedule,20043.9,20043.9, Disorders Of Personality And Impulse Control,7524,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,20043.9,,,,,,,fee schedule,20043.9,20043.9, Disorders Of Personality And Impulse Control,7524,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,20043.9,,,,,,,fee schedule,20043.9,20043.9, Bipolar Disorders,7531,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,3157.62,,,,,,,fee schedule,3157.62,3157.62, Bipolar Disorders,7531,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,3157.62,,,,,,,fee schedule,3157.62,3157.62, Bipolar Disorders,7531,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,3157.62,,,,,,,fee schedule,3157.62,3157.62, Bipolar Disorders,7531,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,3157.62,,,,,,,fee schedule,3157.62,3157.62, Bipolar Disorders,7531,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,3157.62,,,,,,,fee schedule,3157.62,3157.62, Bipolar Disorders,7531,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,3157.62,,,,,,,fee schedule,3157.62,3157.62, Bipolar Disorders,7531,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,3157.62,,,,,,,fee schedule,3157.62,3157.62, Bipolar Disorders,7531,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,3157.62,,,,,,,fee schedule,3157.62,3157.62, Bipolar Disorders,7531,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,3157.62,,,,,,,fee schedule,3157.62,3157.62, Bipolar Disorders,7531,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,3157.62,,,,,,,fee schedule,3157.62,3157.62, Bipolar Disorders,7531,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,3157.62,,,,,,,fee schedule,3157.62,3157.62, Bipolar Disorders,7532,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4204.28,,,,,,,fee schedule,4204.28,4204.28, Bipolar Disorders,7532,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4204.28,,,,,,,fee schedule,4204.28,4204.28, Bipolar Disorders,7532,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4204.28,,,,,,,fee schedule,4204.28,4204.28, Bipolar Disorders,7532,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4204.28,,,,,,,fee schedule,4204.28,4204.28, Bipolar Disorders,7532,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4204.28,,,,,,,fee schedule,4204.28,4204.28, Bipolar Disorders,7532,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4204.28,,,,,,,fee schedule,4204.28,4204.28, Bipolar Disorders,7532,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4204.28,,,,,,,fee schedule,4204.28,4204.28, Bipolar Disorders,7532,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4204.28,,,,,,,fee schedule,4204.28,4204.28, Bipolar Disorders,7532,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4204.28,,,,,,,fee schedule,4204.28,4204.28, Bipolar Disorders,7532,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4204.28,,,,,,,fee schedule,4204.28,4204.28, Bipolar Disorders,7532,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4204.28,,,,,,,fee schedule,4204.28,4204.28, Bipolar Disorders,7533,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,7722.55,,,,,,,fee schedule,7722.55,7722.55, Bipolar Disorders,7533,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,7722.55,,,,,,,fee schedule,7722.55,7722.55, Bipolar Disorders,7533,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,7722.55,,,,,,,fee schedule,7722.55,7722.55, Bipolar Disorders,7533,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,7722.55,,,,,,,fee schedule,7722.55,7722.55, Bipolar Disorders,7533,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,7722.55,,,,,,,fee schedule,7722.55,7722.55, Bipolar Disorders,7533,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,7722.55,,,,,,,fee schedule,7722.55,7722.55, Bipolar Disorders,7533,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,7722.55,,,,,,,fee schedule,7722.55,7722.55, Bipolar Disorders,7533,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,7722.55,,,,,,,fee schedule,7722.55,7722.55, Bipolar Disorders,7533,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,7722.55,,,,,,,fee schedule,7722.55,7722.55, Bipolar Disorders,7533,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,7722.55,,,,,,,fee schedule,7722.55,7722.55, Bipolar Disorders,7533,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,7722.55,,,,,,,fee schedule,7722.55,7722.55, Bipolar Disorders,7534,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,13387.77,,,,,,,fee schedule,13387.77,13387.77, Bipolar Disorders,7534,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,13387.77,,,,,,,fee schedule,13387.77,13387.77, Bipolar Disorders,7534,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,13387.77,,,,,,,fee schedule,13387.77,13387.77, Bipolar Disorders,7534,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,13387.77,,,,,,,fee schedule,13387.77,13387.77, Bipolar Disorders,7534,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,13387.77,,,,,,,fee schedule,13387.77,13387.77, Bipolar Disorders,7534,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,13387.77,,,,,,,fee schedule,13387.77,13387.77, Bipolar Disorders,7534,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,13387.77,,,,,,,fee schedule,13387.77,13387.77, Bipolar Disorders,7534,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,13387.77,,,,,,,fee schedule,13387.77,13387.77, Bipolar Disorders,7534,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,13387.77,,,,,,,fee schedule,13387.77,13387.77, Bipolar Disorders,7534,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,13387.77,,,,,,,fee schedule,13387.77,13387.77, Bipolar Disorders,7534,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,13387.77,,,,,,,fee schedule,13387.77,13387.77, Adjustment Disorders And Neuroses Except Depressive Diagnoses,7551,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,2034.74,,,,,,,fee schedule,2034.74,2034.74, Adjustment Disorders And Neuroses Except Depressive Diagnoses,7551,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,2034.74,,,,,,,fee schedule,2034.74,2034.74, Adjustment Disorders And Neuroses Except Depressive Diagnoses,7551,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,2034.74,,,,,,,fee schedule,2034.74,2034.74, Adjustment Disorders And Neuroses Except Depressive Diagnoses,7551,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,2034.74,,,,,,,fee schedule,2034.74,2034.74, Adjustment Disorders And Neuroses Except Depressive Diagnoses,7551,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,2034.74,,,,,,,fee schedule,2034.74,2034.74, Adjustment Disorders And Neuroses Except Depressive Diagnoses,7551,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,2034.74,,,,,,,fee schedule,2034.74,2034.74, Adjustment Disorders And Neuroses Except Depressive Diagnoses,7551,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,2034.74,,,,,,,fee schedule,2034.74,2034.74, Adjustment Disorders And Neuroses Except Depressive Diagnoses,7551,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,2034.74,,,,,,,fee schedule,2034.74,2034.74, Adjustment Disorders And Neuroses Except Depressive Diagnoses,7551,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,2034.74,,,,,,,fee schedule,2034.74,2034.74, Adjustment Disorders And Neuroses Except Depressive Diagnoses,7551,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,2034.74,,,,,,,fee schedule,2034.74,2034.74, Adjustment Disorders And Neuroses Except Depressive Diagnoses,7551,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,2034.74,,,,,,,fee schedule,2034.74,2034.74, Adjustment Disorders And Neuroses Except Depressive Diagnoses,7552,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,2835.08,,,,,,,fee schedule,2835.08,2835.08, Adjustment Disorders And Neuroses Except Depressive Diagnoses,7552,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,2835.08,,,,,,,fee schedule,2835.08,2835.08, Adjustment Disorders And Neuroses Except Depressive Diagnoses,7552,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,2835.08,,,,,,,fee schedule,2835.08,2835.08, Adjustment Disorders And Neuroses Except Depressive Diagnoses,7552,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,2835.08,,,,,,,fee schedule,2835.08,2835.08, Adjustment Disorders And Neuroses Except Depressive Diagnoses,7552,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,2835.08,,,,,,,fee schedule,2835.08,2835.08, Adjustment Disorders And Neuroses Except Depressive Diagnoses,7552,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,2835.08,,,,,,,fee schedule,2835.08,2835.08, Adjustment Disorders And Neuroses Except Depressive Diagnoses,7552,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,2835.08,,,,,,,fee schedule,2835.08,2835.08, Adjustment Disorders And Neuroses Except Depressive Diagnoses,7552,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,2835.08,,,,,,,fee schedule,2835.08,2835.08, Adjustment Disorders And Neuroses Except Depressive Diagnoses,7552,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,2835.08,,,,,,,fee schedule,2835.08,2835.08, Adjustment Disorders And Neuroses Except Depressive Diagnoses,7552,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,2835.08,,,,,,,fee schedule,2835.08,2835.08, Adjustment Disorders And Neuroses Except Depressive Diagnoses,7552,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,2835.08,,,,,,,fee schedule,2835.08,2835.08, Adjustment Disorders And Neuroses Except Depressive Diagnoses,7553,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5627.11,,,,,,,fee schedule,5627.11,5627.11, Adjustment Disorders And Neuroses Except Depressive Diagnoses,7553,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5627.11,,,,,,,fee schedule,5627.11,5627.11, Adjustment Disorders And Neuroses Except Depressive Diagnoses,7553,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5627.11,,,,,,,fee schedule,5627.11,5627.11, Adjustment Disorders And Neuroses Except Depressive Diagnoses,7553,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5627.11,,,,,,,fee schedule,5627.11,5627.11, Adjustment Disorders And Neuroses Except Depressive Diagnoses,7553,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5627.11,,,,,,,fee schedule,5627.11,5627.11, Adjustment Disorders And Neuroses Except Depressive Diagnoses,7553,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5627.11,,,,,,,fee schedule,5627.11,5627.11, Adjustment Disorders And Neuroses Except Depressive Diagnoses,7553,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5627.11,,,,,,,fee schedule,5627.11,5627.11, Adjustment Disorders And Neuroses Except Depressive Diagnoses,7553,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5627.11,,,,,,,fee schedule,5627.11,5627.11, Adjustment Disorders And Neuroses Except Depressive Diagnoses,7553,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5627.11,,,,,,,fee schedule,5627.11,5627.11, Adjustment Disorders And Neuroses Except Depressive Diagnoses,7553,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5627.11,,,,,,,fee schedule,5627.11,5627.11, Adjustment Disorders And Neuroses Except Depressive Diagnoses,7553,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5627.11,,,,,,,fee schedule,5627.11,5627.11, Adjustment Disorders And Neuroses Except Depressive Diagnoses,7554,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,7756.43,,,,,,,fee schedule,7756.43,7756.43, Adjustment Disorders And Neuroses Except Depressive Diagnoses,7554,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,7756.43,,,,,,,fee schedule,7756.43,7756.43, Adjustment Disorders And Neuroses Except Depressive Diagnoses,7554,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,7756.43,,,,,,,fee schedule,7756.43,7756.43, Adjustment Disorders And Neuroses Except Depressive Diagnoses,7554,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,7756.43,,,,,,,fee schedule,7756.43,7756.43, Adjustment Disorders And Neuroses Except Depressive Diagnoses,7554,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,7756.43,,,,,,,fee schedule,7756.43,7756.43, Adjustment Disorders And Neuroses Except Depressive Diagnoses,7554,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,7756.43,,,,,,,fee schedule,7756.43,7756.43, Adjustment Disorders And Neuroses Except Depressive Diagnoses,7554,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,7756.43,,,,,,,fee schedule,7756.43,7756.43, Adjustment Disorders And Neuroses Except Depressive Diagnoses,7554,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,7756.43,,,,,,,fee schedule,7756.43,7756.43, Adjustment Disorders And Neuroses Except Depressive Diagnoses,7554,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,7756.43,,,,,,,fee schedule,7756.43,7756.43, Adjustment Disorders And Neuroses Except Depressive Diagnoses,7554,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,7756.43,,,,,,,fee schedule,7756.43,7756.43, Adjustment Disorders And Neuroses Except Depressive Diagnoses,7554,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,7756.43,,,,,,,fee schedule,7756.43,7756.43, Acute Anxiety And Delirium States,7561,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,3381.35,,,,,,,fee schedule,3381.35,3381.35, Acute Anxiety And Delirium States,7561,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,3381.35,,,,,,,fee schedule,3381.35,3381.35, Acute Anxiety And Delirium States,7561,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,3381.35,,,,,,,fee schedule,3381.35,3381.35, Acute Anxiety And Delirium States,7561,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,3381.35,,,,,,,fee schedule,3381.35,3381.35, Acute Anxiety And Delirium States,7561,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,3381.35,,,,,,,fee schedule,3381.35,3381.35, Acute Anxiety And Delirium States,7561,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,3381.35,,,,,,,fee schedule,3381.35,3381.35, Acute Anxiety And Delirium States,7561,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,3381.35,,,,,,,fee schedule,3381.35,3381.35, Acute Anxiety And Delirium States,7561,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,3381.35,,,,,,,fee schedule,3381.35,3381.35, Acute Anxiety And Delirium States,7561,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,3381.35,,,,,,,fee schedule,3381.35,3381.35, Acute Anxiety And Delirium States,7561,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,3381.35,,,,,,,fee schedule,3381.35,3381.35, Acute Anxiety And Delirium States,7561,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,3381.35,,,,,,,fee schedule,3381.35,3381.35, Acute Anxiety And Delirium States,7562,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5184.6,,,,,,,fee schedule,5184.6,5184.6, Acute Anxiety And Delirium States,7562,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5184.6,,,,,,,fee schedule,5184.6,5184.6, Acute Anxiety And Delirium States,7562,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5184.6,,,,,,,fee schedule,5184.6,5184.6, Acute Anxiety And Delirium States,7562,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5184.6,,,,,,,fee schedule,5184.6,5184.6, Acute Anxiety And Delirium States,7562,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5184.6,,,,,,,fee schedule,5184.6,5184.6, Acute Anxiety And Delirium States,7562,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5184.6,,,,,,,fee schedule,5184.6,5184.6, Acute Anxiety And Delirium States,7562,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5184.6,,,,,,,fee schedule,5184.6,5184.6, Acute Anxiety And Delirium States,7562,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5184.6,,,,,,,fee schedule,5184.6,5184.6, Acute Anxiety And Delirium States,7562,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5184.6,,,,,,,fee schedule,5184.6,5184.6, Acute Anxiety And Delirium States,7562,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5184.6,,,,,,,fee schedule,5184.6,5184.6, Acute Anxiety And Delirium States,7562,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5184.6,,,,,,,fee schedule,5184.6,5184.6, Acute Anxiety And Delirium States,7563,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,7257.45,,,,,,,fee schedule,7257.45,7257.45, Acute Anxiety And Delirium States,7563,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,7257.45,,,,,,,fee schedule,7257.45,7257.45, Acute Anxiety And Delirium States,7563,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,7257.45,,,,,,,fee schedule,7257.45,7257.45, Acute Anxiety And Delirium States,7563,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,7257.45,,,,,,,fee schedule,7257.45,7257.45, Acute Anxiety And Delirium States,7563,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,7257.45,,,,,,,fee schedule,7257.45,7257.45, Acute Anxiety And Delirium States,7563,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,7257.45,,,,,,,fee schedule,7257.45,7257.45, Acute Anxiety And Delirium States,7563,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,7257.45,,,,,,,fee schedule,7257.45,7257.45, Acute Anxiety And Delirium States,7563,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,7257.45,,,,,,,fee schedule,7257.45,7257.45, Acute Anxiety And Delirium States,7563,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,7257.45,,,,,,,fee schedule,7257.45,7257.45, Acute Anxiety And Delirium States,7563,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,7257.45,,,,,,,fee schedule,7257.45,7257.45, Acute Anxiety And Delirium States,7563,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,7257.45,,,,,,,fee schedule,7257.45,7257.45, Acute Anxiety And Delirium States,7564,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,12883.15,,,,,,,fee schedule,12883.15,12883.15, Acute Anxiety And Delirium States,7564,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,12883.15,,,,,,,fee schedule,12883.15,12883.15, Acute Anxiety And Delirium States,7564,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,12883.15,,,,,,,fee schedule,12883.15,12883.15, Acute Anxiety And Delirium States,7564,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,12883.15,,,,,,,fee schedule,12883.15,12883.15, Acute Anxiety And Delirium States,7564,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,12883.15,,,,,,,fee schedule,12883.15,12883.15, Acute Anxiety And Delirium States,7564,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,12883.15,,,,,,,fee schedule,12883.15,12883.15, Acute Anxiety And Delirium States,7564,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,12883.15,,,,,,,fee schedule,12883.15,12883.15, Acute Anxiety And Delirium States,7564,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,12883.15,,,,,,,fee schedule,12883.15,12883.15, Acute Anxiety And Delirium States,7564,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,12883.15,,,,,,,fee schedule,12883.15,12883.15, Acute Anxiety And Delirium States,7564,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,12883.15,,,,,,,fee schedule,12883.15,12883.15, Acute Anxiety And Delirium States,7564,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,12883.15,,,,,,,fee schedule,12883.15,12883.15, Organic Mental Health Disturbances,7571,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4063.83,,,,,,,fee schedule,4063.83,4063.83, Organic Mental Health Disturbances,7571,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4063.83,,,,,,,fee schedule,4063.83,4063.83, Organic Mental Health Disturbances,7571,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4063.83,,,,,,,fee schedule,4063.83,4063.83, Organic Mental Health Disturbances,7571,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4063.83,,,,,,,fee schedule,4063.83,4063.83, Organic Mental Health Disturbances,7571,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4063.83,,,,,,,fee schedule,4063.83,4063.83, Organic Mental Health Disturbances,7571,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4063.83,,,,,,,fee schedule,4063.83,4063.83, Organic Mental Health Disturbances,7571,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4063.83,,,,,,,fee schedule,4063.83,4063.83, Organic Mental Health Disturbances,7571,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4063.83,,,,,,,fee schedule,4063.83,4063.83, Organic Mental Health Disturbances,7571,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4063.83,,,,,,,fee schedule,4063.83,4063.83, Organic Mental Health Disturbances,7571,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4063.83,,,,,,,fee schedule,4063.83,4063.83, Organic Mental Health Disturbances,7571,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4063.83,,,,,,,fee schedule,4063.83,4063.83, Organic Mental Health Disturbances,7572,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,6102.8,,,,,,,fee schedule,6102.8,6102.8, Organic Mental Health Disturbances,7572,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,6102.8,,,,,,,fee schedule,6102.8,6102.8, Organic Mental Health Disturbances,7572,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,6102.8,,,,,,,fee schedule,6102.8,6102.8, Organic Mental Health Disturbances,7572,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,6102.8,,,,,,,fee schedule,6102.8,6102.8, Organic Mental Health Disturbances,7572,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,6102.8,,,,,,,fee schedule,6102.8,6102.8, Organic Mental Health Disturbances,7572,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,6102.8,,,,,,,fee schedule,6102.8,6102.8, Organic Mental Health Disturbances,7572,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,6102.8,,,,,,,fee schedule,6102.8,6102.8, Organic Mental Health Disturbances,7572,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,6102.8,,,,,,,fee schedule,6102.8,6102.8, Organic Mental Health Disturbances,7572,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,6102.8,,,,,,,fee schedule,6102.8,6102.8, Organic Mental Health Disturbances,7572,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,6102.8,,,,,,,fee schedule,6102.8,6102.8, Organic Mental Health Disturbances,7572,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,6102.8,,,,,,,fee schedule,6102.8,6102.8, Organic Mental Health Disturbances,7573,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,8720.51,,,,,,,fee schedule,8720.51,8720.51, Organic Mental Health Disturbances,7573,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,8720.51,,,,,,,fee schedule,8720.51,8720.51, Organic Mental Health Disturbances,7573,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,8720.51,,,,,,,fee schedule,8720.51,8720.51, Organic Mental Health Disturbances,7573,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,8720.51,,,,,,,fee schedule,8720.51,8720.51, Organic Mental Health Disturbances,7573,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,8720.51,,,,,,,fee schedule,8720.51,8720.51, Organic Mental Health Disturbances,7573,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,8720.51,,,,,,,fee schedule,8720.51,8720.51, Organic Mental Health Disturbances,7573,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,8720.51,,,,,,,fee schedule,8720.51,8720.51, Organic Mental Health Disturbances,7573,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,8720.51,,,,,,,fee schedule,8720.51,8720.51, Organic Mental Health Disturbances,7573,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,8720.51,,,,,,,fee schedule,8720.51,8720.51, Organic Mental Health Disturbances,7573,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,8720.51,,,,,,,fee schedule,8720.51,8720.51, Organic Mental Health Disturbances,7573,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,8720.51,,,,,,,fee schedule,8720.51,8720.51, Organic Mental Health Disturbances,7574,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,21451.21,,,,,,,fee schedule,21451.21,21451.21, Organic Mental Health Disturbances,7574,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,21451.21,,,,,,,fee schedule,21451.21,21451.21, Organic Mental Health Disturbances,7574,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,21451.21,,,,,,,fee schedule,21451.21,21451.21, Organic Mental Health Disturbances,7574,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,21451.21,,,,,,,fee schedule,21451.21,21451.21, Organic Mental Health Disturbances,7574,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,21451.21,,,,,,,fee schedule,21451.21,21451.21, Organic Mental Health Disturbances,7574,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,21451.21,,,,,,,fee schedule,21451.21,21451.21, Organic Mental Health Disturbances,7574,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,21451.21,,,,,,,fee schedule,21451.21,21451.21, Organic Mental Health Disturbances,7574,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,21451.21,,,,,,,fee schedule,21451.21,21451.21, Organic Mental Health Disturbances,7574,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,21451.21,,,,,,,fee schedule,21451.21,21451.21, Organic Mental Health Disturbances,7574,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,21451.21,,,,,,,fee schedule,21451.21,21451.21, Organic Mental Health Disturbances,7574,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,21451.21,,,,,,,fee schedule,21451.21,21451.21, Behavioral Disorders,7581,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,3367.23,,,,,,,fee schedule,3367.23,3367.23, Behavioral Disorders,7581,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,3367.23,,,,,,,fee schedule,3367.23,3367.23, Behavioral Disorders,7581,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,3367.23,,,,,,,fee schedule,3367.23,3367.23, Behavioral Disorders,7581,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,3367.23,,,,,,,fee schedule,3367.23,3367.23, Behavioral Disorders,7581,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,3367.23,,,,,,,fee schedule,3367.23,3367.23, Behavioral Disorders,7581,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,3367.23,,,,,,,fee schedule,3367.23,3367.23, Behavioral Disorders,7581,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,3367.23,,,,,,,fee schedule,3367.23,3367.23, Behavioral Disorders,7581,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,3367.23,,,,,,,fee schedule,3367.23,3367.23, Behavioral Disorders,7581,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,3367.23,,,,,,,fee schedule,3367.23,3367.23, Behavioral Disorders,7581,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,3367.23,,,,,,,fee schedule,3367.23,3367.23, Behavioral Disorders,7581,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,3367.23,,,,,,,fee schedule,3367.23,3367.23, Behavioral Disorders,7582,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4308.03,,,,,,,fee schedule,4308.03,4308.03, Behavioral Disorders,7582,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4308.03,,,,,,,fee schedule,4308.03,4308.03, Behavioral Disorders,7582,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4308.03,,,,,,,fee schedule,4308.03,4308.03, Behavioral Disorders,7582,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4308.03,,,,,,,fee schedule,4308.03,4308.03, Behavioral Disorders,7582,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4308.03,,,,,,,fee schedule,4308.03,4308.03, Behavioral Disorders,7582,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4308.03,,,,,,,fee schedule,4308.03,4308.03, Behavioral Disorders,7582,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4308.03,,,,,,,fee schedule,4308.03,4308.03, Behavioral Disorders,7582,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4308.03,,,,,,,fee schedule,4308.03,4308.03, Behavioral Disorders,7582,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4308.03,,,,,,,fee schedule,4308.03,4308.03, Behavioral Disorders,7582,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4308.03,,,,,,,fee schedule,4308.03,4308.03, Behavioral Disorders,7582,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4308.03,,,,,,,fee schedule,4308.03,4308.03, Behavioral Disorders,7583,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,7047.83,,,,,,,fee schedule,7047.83,7047.83, Behavioral Disorders,7583,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,7047.83,,,,,,,fee schedule,7047.83,7047.83, Behavioral Disorders,7583,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,7047.83,,,,,,,fee schedule,7047.83,7047.83, Behavioral Disorders,7583,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,7047.83,,,,,,,fee schedule,7047.83,7047.83, Behavioral Disorders,7583,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,7047.83,,,,,,,fee schedule,7047.83,7047.83, Behavioral Disorders,7583,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,7047.83,,,,,,,fee schedule,7047.83,7047.83, Behavioral Disorders,7583,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,7047.83,,,,,,,fee schedule,7047.83,7047.83, Behavioral Disorders,7583,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,7047.83,,,,,,,fee schedule,7047.83,7047.83, Behavioral Disorders,7583,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,7047.83,,,,,,,fee schedule,7047.83,7047.83, Behavioral Disorders,7583,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,7047.83,,,,,,,fee schedule,7047.83,7047.83, Behavioral Disorders,7583,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,7047.83,,,,,,,fee schedule,7047.83,7047.83, Behavioral Disorders,7584,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,23752.03,,,,,,,fee schedule,23752.03,23752.03, Behavioral Disorders,7584,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,23752.03,,,,,,,fee schedule,23752.03,23752.03, Behavioral Disorders,7584,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,23752.03,,,,,,,fee schedule,23752.03,23752.03, Behavioral Disorders,7584,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,23752.03,,,,,,,fee schedule,23752.03,23752.03, Behavioral Disorders,7584,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,23752.03,,,,,,,fee schedule,23752.03,23752.03, Behavioral Disorders,7584,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,23752.03,,,,,,,fee schedule,23752.03,23752.03, Behavioral Disorders,7584,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,23752.03,,,,,,,fee schedule,23752.03,23752.03, Behavioral Disorders,7584,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,23752.03,,,,,,,fee schedule,23752.03,23752.03, Behavioral Disorders,7584,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,23752.03,,,,,,,fee schedule,23752.03,23752.03, Behavioral Disorders,7584,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,23752.03,,,,,,,fee schedule,23752.03,23752.03, Behavioral Disorders,7584,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,23752.03,,,,,,,fee schedule,23752.03,23752.03, Eating Disorders,7591,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,7919.46,,,,,,,fee schedule,7919.46,7919.46, Eating Disorders,7591,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,7919.46,,,,,,,fee schedule,7919.46,7919.46, Eating Disorders,7591,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,7919.46,,,,,,,fee schedule,7919.46,7919.46, Eating Disorders,7591,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,7919.46,,,,,,,fee schedule,7919.46,7919.46, Eating Disorders,7591,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,7919.46,,,,,,,fee schedule,7919.46,7919.46, Eating Disorders,7591,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,7919.46,,,,,,,fee schedule,7919.46,7919.46, Eating Disorders,7591,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,7919.46,,,,,,,fee schedule,7919.46,7919.46, Eating Disorders,7591,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,7919.46,,,,,,,fee schedule,7919.46,7919.46, Eating Disorders,7591,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,7919.46,,,,,,,fee schedule,7919.46,7919.46, Eating Disorders,7591,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,7919.46,,,,,,,fee schedule,7919.46,7919.46, Eating Disorders,7591,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,7919.46,,,,,,,fee schedule,7919.46,7919.46, Eating Disorders,7592,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,10573.16,,,,,,,fee schedule,10573.16,10573.16, Eating Disorders,7592,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,10573.16,,,,,,,fee schedule,10573.16,10573.16, Eating Disorders,7592,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,10573.16,,,,,,,fee schedule,10573.16,10573.16, Eating Disorders,7592,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,10573.16,,,,,,,fee schedule,10573.16,10573.16, Eating Disorders,7592,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,10573.16,,,,,,,fee schedule,10573.16,10573.16, Eating Disorders,7592,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,10573.16,,,,,,,fee schedule,10573.16,10573.16, Eating Disorders,7592,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,10573.16,,,,,,,fee schedule,10573.16,10573.16, Eating Disorders,7592,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,10573.16,,,,,,,fee schedule,10573.16,10573.16, Eating Disorders,7592,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,10573.16,,,,,,,fee schedule,10573.16,10573.16, Eating Disorders,7592,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,10573.16,,,,,,,fee schedule,10573.16,10573.16, Eating Disorders,7592,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,10573.16,,,,,,,fee schedule,10573.16,10573.16, Eating Disorders,7593,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,14951.76,,,,,,,fee schedule,14951.76,14951.76, Eating Disorders,7593,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,14951.76,,,,,,,fee schedule,14951.76,14951.76, Eating Disorders,7593,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,14951.76,,,,,,,fee schedule,14951.76,14951.76, Eating Disorders,7593,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,14951.76,,,,,,,fee schedule,14951.76,14951.76, Eating Disorders,7593,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,14951.76,,,,,,,fee schedule,14951.76,14951.76, Eating Disorders,7593,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,14951.76,,,,,,,fee schedule,14951.76,14951.76, Eating Disorders,7593,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,14951.76,,,,,,,fee schedule,14951.76,14951.76, Eating Disorders,7593,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,14951.76,,,,,,,fee schedule,14951.76,14951.76, Eating Disorders,7593,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,14951.76,,,,,,,fee schedule,14951.76,14951.76, Eating Disorders,7593,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,14951.76,,,,,,,fee schedule,14951.76,14951.76, Eating Disorders,7593,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,14951.76,,,,,,,fee schedule,14951.76,14951.76, Eating Disorders,7594,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,25065.47,,,,,,,fee schedule,25065.47,25065.47, Eating Disorders,7594,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,25065.47,,,,,,,fee schedule,25065.47,25065.47, Eating Disorders,7594,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,25065.47,,,,,,,fee schedule,25065.47,25065.47, Eating Disorders,7594,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,25065.47,,,,,,,fee schedule,25065.47,25065.47, Eating Disorders,7594,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,25065.47,,,,,,,fee schedule,25065.47,25065.47, Eating Disorders,7594,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,25065.47,,,,,,,fee schedule,25065.47,25065.47, Eating Disorders,7594,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,25065.47,,,,,,,fee schedule,25065.47,25065.47, Eating Disorders,7594,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,25065.47,,,,,,,fee schedule,25065.47,25065.47, Eating Disorders,7594,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,25065.47,,,,,,,fee schedule,25065.47,25065.47, Eating Disorders,7594,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,25065.47,,,,,,,fee schedule,25065.47,25065.47, Eating Disorders,7594,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,25065.47,,,,,,,fee schedule,25065.47,25065.47, Other Mental Health Disorders,7601,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4037.01,,,,,,,fee schedule,4037.01,4037.01, Other Mental Health Disorders,7601,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4037.01,,,,,,,fee schedule,4037.01,4037.01, Other Mental Health Disorders,7601,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4037.01,,,,,,,fee schedule,4037.01,4037.01, Other Mental Health Disorders,7601,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4037.01,,,,,,,fee schedule,4037.01,4037.01, Other Mental Health Disorders,7601,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4037.01,,,,,,,fee schedule,4037.01,4037.01, Other Mental Health Disorders,7601,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4037.01,,,,,,,fee schedule,4037.01,4037.01, Other Mental Health Disorders,7601,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4037.01,,,,,,,fee schedule,4037.01,4037.01, Other Mental Health Disorders,7601,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4037.01,,,,,,,fee schedule,4037.01,4037.01, Other Mental Health Disorders,7601,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4037.01,,,,,,,fee schedule,4037.01,4037.01, Other Mental Health Disorders,7601,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4037.01,,,,,,,fee schedule,4037.01,4037.01, Other Mental Health Disorders,7601,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4037.01,,,,,,,fee schedule,4037.01,4037.01, Other Mental Health Disorders,7602,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4847.94,,,,,,,fee schedule,4847.94,4847.94, Other Mental Health Disorders,7602,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4847.94,,,,,,,fee schedule,4847.94,4847.94, Other Mental Health Disorders,7602,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4847.94,,,,,,,fee schedule,4847.94,4847.94, Other Mental Health Disorders,7602,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4847.94,,,,,,,fee schedule,4847.94,4847.94, Other Mental Health Disorders,7602,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4847.94,,,,,,,fee schedule,4847.94,4847.94, Other Mental Health Disorders,7602,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4847.94,,,,,,,fee schedule,4847.94,4847.94, Other Mental Health Disorders,7602,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4847.94,,,,,,,fee schedule,4847.94,4847.94, Other Mental Health Disorders,7602,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4847.94,,,,,,,fee schedule,4847.94,4847.94, Other Mental Health Disorders,7602,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4847.94,,,,,,,fee schedule,4847.94,4847.94, Other Mental Health Disorders,7602,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4847.94,,,,,,,fee schedule,4847.94,4847.94, Other Mental Health Disorders,7602,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4847.94,,,,,,,fee schedule,4847.94,4847.94, Other Mental Health Disorders,7603,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,7613.86,,,,,,,fee schedule,7613.86,7613.86, Other Mental Health Disorders,7603,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,7613.86,,,,,,,fee schedule,7613.86,7613.86, Other Mental Health Disorders,7603,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,7613.86,,,,,,,fee schedule,7613.86,7613.86, Other Mental Health Disorders,7603,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,7613.86,,,,,,,fee schedule,7613.86,7613.86, Other Mental Health Disorders,7603,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,7613.86,,,,,,,fee schedule,7613.86,7613.86, Other Mental Health Disorders,7603,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,7613.86,,,,,,,fee schedule,7613.86,7613.86, Other Mental Health Disorders,7603,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,7613.86,,,,,,,fee schedule,7613.86,7613.86, Other Mental Health Disorders,7603,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,7613.86,,,,,,,fee schedule,7613.86,7613.86, Other Mental Health Disorders,7603,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,7613.86,,,,,,,fee schedule,7613.86,7613.86, Other Mental Health Disorders,7603,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,7613.86,,,,,,,fee schedule,7613.86,7613.86, Other Mental Health Disorders,7603,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,7613.86,,,,,,,fee schedule,7613.86,7613.86, Other Mental Health Disorders,7604,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,15579.19,,,,,,,fee schedule,15579.19,15579.19, Other Mental Health Disorders,7604,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,15579.19,,,,,,,fee schedule,15579.19,15579.19, Other Mental Health Disorders,7604,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,15579.19,,,,,,,fee schedule,15579.19,15579.19, Other Mental Health Disorders,7604,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,15579.19,,,,,,,fee schedule,15579.19,15579.19, Other Mental Health Disorders,7604,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,15579.19,,,,,,,fee schedule,15579.19,15579.19, Other Mental Health Disorders,7604,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,15579.19,,,,,,,fee schedule,15579.19,15579.19, Other Mental Health Disorders,7604,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,15579.19,,,,,,,fee schedule,15579.19,15579.19, Other Mental Health Disorders,7604,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,15579.19,,,,,,,fee schedule,15579.19,15579.19, Other Mental Health Disorders,7604,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,15579.19,,,,,,,fee schedule,15579.19,15579.19, Other Mental Health Disorders,7604,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,15579.19,,,,,,,fee schedule,15579.19,15579.19, Other Mental Health Disorders,7604,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,15579.19,,,,,,,fee schedule,15579.19,15579.19, Description Not Available,7611,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5697.69,,,,,,,fee schedule,5697.69,5697.69, Description Not Available,7611,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5697.69,,,,,,,fee schedule,5697.69,5697.69, Description Not Available,7611,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5697.69,,,,,,,fee schedule,5697.69,5697.69, Description Not Available,7611,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5697.69,,,,,,,fee schedule,5697.69,5697.69, Description Not Available,7611,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5697.69,,,,,,,fee schedule,5697.69,5697.69, Description Not Available,7611,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5697.69,,,,,,,fee schedule,5697.69,5697.69, Description Not Available,7611,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5697.69,,,,,,,fee schedule,5697.69,5697.69, Description Not Available,7611,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5697.69,,,,,,,fee schedule,5697.69,5697.69, Description Not Available,7611,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5697.69,,,,,,,fee schedule,5697.69,5697.69, Description Not Available,7611,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5697.69,,,,,,,fee schedule,5697.69,5697.69, Description Not Available,7611,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5697.69,,,,,,,fee schedule,5697.69,5697.69, Description Not Available,7612,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,6027.99,,,,,,,fee schedule,6027.99,6027.99, Description Not Available,7612,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,6027.99,,,,,,,fee schedule,6027.99,6027.99, Description Not Available,7612,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,6027.99,,,,,,,fee schedule,6027.99,6027.99, Description Not Available,7612,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,6027.99,,,,,,,fee schedule,6027.99,6027.99, Description Not Available,7612,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,6027.99,,,,,,,fee schedule,6027.99,6027.99, Description Not Available,7612,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,6027.99,,,,,,,fee schedule,6027.99,6027.99, Description Not Available,7612,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,6027.99,,,,,,,fee schedule,6027.99,6027.99, Description Not Available,7612,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,6027.99,,,,,,,fee schedule,6027.99,6027.99, Description Not Available,7612,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,6027.99,,,,,,,fee schedule,6027.99,6027.99, Description Not Available,7612,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,6027.99,,,,,,,fee schedule,6027.99,6027.99, Description Not Available,7612,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,6027.99,,,,,,,fee schedule,6027.99,6027.99, Description Not Available,7613,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,11063.67,,,,,,,fee schedule,11063.67,11063.67, Description Not Available,7613,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,11063.67,,,,,,,fee schedule,11063.67,11063.67, Description Not Available,7613,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,11063.67,,,,,,,fee schedule,11063.67,11063.67, Description Not Available,7613,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,11063.67,,,,,,,fee schedule,11063.67,11063.67, Description Not Available,7613,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,11063.67,,,,,,,fee schedule,11063.67,11063.67, Description Not Available,7613,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,11063.67,,,,,,,fee schedule,11063.67,11063.67, Description Not Available,7613,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,11063.67,,,,,,,fee schedule,11063.67,11063.67, Description Not Available,7613,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,11063.67,,,,,,,fee schedule,11063.67,11063.67, Description Not Available,7613,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,11063.67,,,,,,,fee schedule,11063.67,11063.67, Description Not Available,7613,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,11063.67,,,,,,,fee schedule,11063.67,11063.67, Description Not Available,7613,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,11063.67,,,,,,,fee schedule,11063.67,11063.67, Description Not Available,7614,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,18997.24,,,,,,,fee schedule,18997.24,18997.24, Description Not Available,7614,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,18997.24,,,,,,,fee schedule,18997.24,18997.24, Description Not Available,7614,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,18997.24,,,,,,,fee schedule,18997.24,18997.24, Description Not Available,7614,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,18997.24,,,,,,,fee schedule,18997.24,18997.24, Description Not Available,7614,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,18997.24,,,,,,,fee schedule,18997.24,18997.24, Description Not Available,7614,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,18997.24,,,,,,,fee schedule,18997.24,18997.24, Description Not Available,7614,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,18997.24,,,,,,,fee schedule,18997.24,18997.24, Description Not Available,7614,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,18997.24,,,,,,,fee schedule,18997.24,18997.24, Description Not Available,7614,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,18997.24,,,,,,,fee schedule,18997.24,18997.24, Description Not Available,7614,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,18997.24,,,,,,,fee schedule,18997.24,18997.24, Description Not Available,7614,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,18997.24,,,,,,,fee schedule,18997.24,18997.24, Description Not Available,7621,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4483.76,,,,,,,fee schedule,4483.76,4483.76, Description Not Available,7621,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4483.76,,,,,,,fee schedule,4483.76,4483.76, Description Not Available,7621,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4483.76,,,,,,,fee schedule,4483.76,4483.76, Description Not Available,7621,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4483.76,,,,,,,fee schedule,4483.76,4483.76, Description Not Available,7621,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4483.76,,,,,,,fee schedule,4483.76,4483.76, Description Not Available,7621,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4483.76,,,,,,,fee schedule,4483.76,4483.76, Description Not Available,7621,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4483.76,,,,,,,fee schedule,4483.76,4483.76, Description Not Available,7621,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4483.76,,,,,,,fee schedule,4483.76,4483.76, Description Not Available,7621,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4483.76,,,,,,,fee schedule,4483.76,4483.76, Description Not Available,7621,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4483.76,,,,,,,fee schedule,4483.76,4483.76, Description Not Available,7621,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4483.76,,,,,,,fee schedule,4483.76,4483.76, Description Not Available,7622,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5348.33,,,,,,,fee schedule,5348.33,5348.33, Description Not Available,7622,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5348.33,,,,,,,fee schedule,5348.33,5348.33, Description Not Available,7622,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5348.33,,,,,,,fee schedule,5348.33,5348.33, Description Not Available,7622,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5348.33,,,,,,,fee schedule,5348.33,5348.33, Description Not Available,7622,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5348.33,,,,,,,fee schedule,5348.33,5348.33, Description Not Available,7622,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5348.33,,,,,,,fee schedule,5348.33,5348.33, Description Not Available,7622,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5348.33,,,,,,,fee schedule,5348.33,5348.33, Description Not Available,7622,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5348.33,,,,,,,fee schedule,5348.33,5348.33, Description Not Available,7622,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5348.33,,,,,,,fee schedule,5348.33,5348.33, Description Not Available,7622,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5348.33,,,,,,,fee schedule,5348.33,5348.33, Description Not Available,7622,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5348.33,,,,,,,fee schedule,5348.33,5348.33, Description Not Available,7623,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,8532.07,,,,,,,fee schedule,8532.07,8532.07, Description Not Available,7623,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,8532.07,,,,,,,fee schedule,8532.07,8532.07, Description Not Available,7623,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,8532.07,,,,,,,fee schedule,8532.07,8532.07, Description Not Available,7623,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,8532.07,,,,,,,fee schedule,8532.07,8532.07, Description Not Available,7623,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,8532.07,,,,,,,fee schedule,8532.07,8532.07, Description Not Available,7623,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,8532.07,,,,,,,fee schedule,8532.07,8532.07, Description Not Available,7623,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,8532.07,,,,,,,fee schedule,8532.07,8532.07, Description Not Available,7623,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,8532.07,,,,,,,fee schedule,8532.07,8532.07, Description Not Available,7623,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,8532.07,,,,,,,fee schedule,8532.07,8532.07, Description Not Available,7623,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,8532.07,,,,,,,fee schedule,8532.07,8532.07, Description Not Available,7623,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,8532.07,,,,,,,fee schedule,8532.07,8532.07, Description Not Available,7624,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,9839.16,,,,,,,fee schedule,9839.16,9839.16, Description Not Available,7624,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,9839.16,,,,,,,fee schedule,9839.16,9839.16, Description Not Available,7624,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,9839.16,,,,,,,fee schedule,9839.16,9839.16, Description Not Available,7624,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,9839.16,,,,,,,fee schedule,9839.16,9839.16, Description Not Available,7624,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,9839.16,,,,,,,fee schedule,9839.16,9839.16, Description Not Available,7624,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,9839.16,,,,,,,fee schedule,9839.16,9839.16, Description Not Available,7624,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,9839.16,,,,,,,fee schedule,9839.16,9839.16, Description Not Available,7624,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,9839.16,,,,,,,fee schedule,9839.16,9839.16, Description Not Available,7624,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,9839.16,,,,,,,fee schedule,9839.16,9839.16, Description Not Available,7624,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,9839.16,,,,,,,fee schedule,9839.16,9839.16, Description Not Available,7624,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,9839.16,,,,,,,fee schedule,9839.16,9839.16, "Drug And Alcohol Abuse Or Dependence, Left Against Medical Advice",7701,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,2053.79,,,,,,,fee schedule,2053.79,2053.79, "Drug And Alcohol Abuse Or Dependence, Left Against Medical Advice",7701,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,2053.79,,,,,,,fee schedule,2053.79,2053.79, "Drug And Alcohol Abuse Or Dependence, Left Against Medical Advice",7701,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,2053.79,,,,,,,fee schedule,2053.79,2053.79, "Drug And Alcohol Abuse Or Dependence, Left Against Medical Advice",7701,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,2053.79,,,,,,,fee schedule,2053.79,2053.79, "Drug And Alcohol Abuse Or Dependence, Left Against Medical Advice",7701,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,2053.79,,,,,,,fee schedule,2053.79,2053.79, "Drug And Alcohol Abuse Or Dependence, Left Against Medical Advice",7701,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,2053.79,,,,,,,fee schedule,2053.79,2053.79, "Drug And Alcohol Abuse Or Dependence, Left Against Medical Advice",7701,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,2053.79,,,,,,,fee schedule,2053.79,2053.79, "Drug And Alcohol Abuse Or Dependence, Left Against Medical Advice",7701,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,2053.79,,,,,,,fee schedule,2053.79,2053.79, "Drug And Alcohol Abuse Or Dependence, Left Against Medical Advice",7701,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,2053.79,,,,,,,fee schedule,2053.79,2053.79, "Drug And Alcohol Abuse Or Dependence, Left Against Medical Advice",7701,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,2053.79,,,,,,,fee schedule,2053.79,2053.79, "Drug And Alcohol Abuse Or Dependence, Left Against Medical Advice",7701,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,2053.79,,,,,,,fee schedule,2053.79,2053.79, "Drug And Alcohol Abuse Or Dependence, Left Against Medical Advice",7702,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,3219.73,,,,,,,fee schedule,3219.73,3219.73, "Drug And Alcohol Abuse Or Dependence, Left Against Medical Advice",7702,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,3219.73,,,,,,,fee schedule,3219.73,3219.73, "Drug And Alcohol Abuse Or Dependence, Left Against Medical Advice",7702,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,3219.73,,,,,,,fee schedule,3219.73,3219.73, "Drug And Alcohol Abuse Or Dependence, Left Against Medical Advice",7702,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,3219.73,,,,,,,fee schedule,3219.73,3219.73, "Drug And Alcohol Abuse Or Dependence, Left Against Medical Advice",7702,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,3219.73,,,,,,,fee schedule,3219.73,3219.73, "Drug And Alcohol Abuse Or Dependence, Left Against Medical Advice",7702,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,3219.73,,,,,,,fee schedule,3219.73,3219.73, "Drug And Alcohol Abuse Or Dependence, Left Against Medical Advice",7702,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,3219.73,,,,,,,fee schedule,3219.73,3219.73, "Drug And Alcohol Abuse Or Dependence, Left Against Medical Advice",7702,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,3219.73,,,,,,,fee schedule,3219.73,3219.73, "Drug And Alcohol Abuse Or Dependence, Left Against Medical Advice",7702,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,3219.73,,,,,,,fee schedule,3219.73,3219.73, "Drug And Alcohol Abuse Or Dependence, Left Against Medical Advice",7702,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,3219.73,,,,,,,fee schedule,3219.73,3219.73, "Drug And Alcohol Abuse Or Dependence, Left Against Medical Advice",7702,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,3219.73,,,,,,,fee schedule,3219.73,3219.73, "Drug And Alcohol Abuse Or Dependence, Left Against Medical Advice",7703,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5552.3,,,,,,,fee schedule,5552.3,5552.3, "Drug And Alcohol Abuse Or Dependence, Left Against Medical Advice",7703,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5552.3,,,,,,,fee schedule,5552.3,5552.3, "Drug And Alcohol Abuse Or Dependence, Left Against Medical Advice",7703,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5552.3,,,,,,,fee schedule,5552.3,5552.3, "Drug And Alcohol Abuse Or Dependence, Left Against Medical Advice",7703,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5552.3,,,,,,,fee schedule,5552.3,5552.3, "Drug And Alcohol Abuse Or Dependence, Left Against Medical Advice",7703,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5552.3,,,,,,,fee schedule,5552.3,5552.3, "Drug And Alcohol Abuse Or Dependence, Left Against Medical Advice",7703,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5552.3,,,,,,,fee schedule,5552.3,5552.3, "Drug And Alcohol Abuse Or Dependence, Left Against Medical Advice",7703,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5552.3,,,,,,,fee schedule,5552.3,5552.3, "Drug And Alcohol Abuse Or Dependence, Left Against Medical Advice",7703,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5552.3,,,,,,,fee schedule,5552.3,5552.3, "Drug And Alcohol Abuse Or Dependence, Left Against Medical Advice",7703,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5552.3,,,,,,,fee schedule,5552.3,5552.3, "Drug And Alcohol Abuse Or Dependence, Left Against Medical Advice",7703,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5552.3,,,,,,,fee schedule,5552.3,5552.3, "Drug And Alcohol Abuse Or Dependence, Left Against Medical Advice",7703,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5552.3,,,,,,,fee schedule,5552.3,5552.3, "Drug And Alcohol Abuse Or Dependence, Left Against Medical Advice",7704,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,11891.54,,,,,,,fee schedule,11891.54,11891.54, "Drug And Alcohol Abuse Or Dependence, Left Against Medical Advice",7704,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,11891.54,,,,,,,fee schedule,11891.54,11891.54, "Drug And Alcohol Abuse Or Dependence, Left Against Medical Advice",7704,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,11891.54,,,,,,,fee schedule,11891.54,11891.54, "Drug And Alcohol Abuse Or Dependence, Left Against Medical Advice",7704,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,11891.54,,,,,,,fee schedule,11891.54,11891.54, "Drug And Alcohol Abuse Or Dependence, Left Against Medical Advice",7704,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,11891.54,,,,,,,fee schedule,11891.54,11891.54, "Drug And Alcohol Abuse Or Dependence, Left Against Medical Advice",7704,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,11891.54,,,,,,,fee schedule,11891.54,11891.54, "Drug And Alcohol Abuse Or Dependence, Left Against Medical Advice",7704,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,11891.54,,,,,,,fee schedule,11891.54,11891.54, "Drug And Alcohol Abuse Or Dependence, Left Against Medical Advice",7704,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,11891.54,,,,,,,fee schedule,11891.54,11891.54, "Drug And Alcohol Abuse Or Dependence, Left Against Medical Advice",7704,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,11891.54,,,,,,,fee schedule,11891.54,11891.54, "Drug And Alcohol Abuse Or Dependence, Left Against Medical Advice",7704,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,11891.54,,,,,,,fee schedule,11891.54,11891.54, "Drug And Alcohol Abuse Or Dependence, Left Against Medical Advice",7704,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,11891.54,,,,,,,fee schedule,11891.54,11891.54, Alcohol And Drug Dependence With Rehabilitation And/Or Detoxification Therapy,7721,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,3873.27,,,,,,,fee schedule,3873.27,3873.27, Alcohol And Drug Dependence With Rehabilitation And/Or Detoxification Therapy,7721,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,3873.27,,,,,,,fee schedule,3873.27,3873.27, Alcohol And Drug Dependence With Rehabilitation And/Or Detoxification Therapy,7721,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,3873.27,,,,,,,fee schedule,3873.27,3873.27, Alcohol And Drug Dependence With Rehabilitation And/Or Detoxification Therapy,7721,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,3873.27,,,,,,,fee schedule,3873.27,3873.27, Alcohol And Drug Dependence With Rehabilitation And/Or Detoxification Therapy,7721,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,3873.27,,,,,,,fee schedule,3873.27,3873.27, Alcohol And Drug Dependence With Rehabilitation And/Or Detoxification Therapy,7721,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,3873.27,,,,,,,fee schedule,3873.27,3873.27, Alcohol And Drug Dependence With Rehabilitation And/Or Detoxification Therapy,7721,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,3873.27,,,,,,,fee schedule,3873.27,3873.27, Alcohol And Drug Dependence With Rehabilitation And/Or Detoxification Therapy,7721,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,3873.27,,,,,,,fee schedule,3873.27,3873.27, Alcohol And Drug Dependence With Rehabilitation And/Or Detoxification Therapy,7721,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,3873.27,,,,,,,fee schedule,3873.27,3873.27, Alcohol And Drug Dependence With Rehabilitation And/Or Detoxification Therapy,7721,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,3873.27,,,,,,,fee schedule,3873.27,3873.27, Alcohol And Drug Dependence With Rehabilitation And/Or Detoxification Therapy,7721,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,3873.27,,,,,,,fee schedule,3873.27,3873.27, Alcohol And Drug Dependence With Rehabilitation And/Or Detoxification Therapy,7722,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5097.79,,,,,,,fee schedule,5097.79,5097.79, Alcohol And Drug Dependence With Rehabilitation And/Or Detoxification Therapy,7722,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5097.79,,,,,,,fee schedule,5097.79,5097.79, Alcohol And Drug Dependence With Rehabilitation And/Or Detoxification Therapy,7722,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5097.79,,,,,,,fee schedule,5097.79,5097.79, Alcohol And Drug Dependence With Rehabilitation And/Or Detoxification Therapy,7722,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5097.79,,,,,,,fee schedule,5097.79,5097.79, Alcohol And Drug Dependence With Rehabilitation And/Or Detoxification Therapy,7722,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5097.79,,,,,,,fee schedule,5097.79,5097.79, Alcohol And Drug Dependence With Rehabilitation And/Or Detoxification Therapy,7722,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5097.79,,,,,,,fee schedule,5097.79,5097.79, Alcohol And Drug Dependence With Rehabilitation And/Or Detoxification Therapy,7722,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5097.79,,,,,,,fee schedule,5097.79,5097.79, Alcohol And Drug Dependence With Rehabilitation And/Or Detoxification Therapy,7722,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5097.79,,,,,,,fee schedule,5097.79,5097.79, Alcohol And Drug Dependence With Rehabilitation And/Or Detoxification Therapy,7722,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5097.79,,,,,,,fee schedule,5097.79,5097.79, Alcohol And Drug Dependence With Rehabilitation And/Or Detoxification Therapy,7722,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5097.79,,,,,,,fee schedule,5097.79,5097.79, Alcohol And Drug Dependence With Rehabilitation And/Or Detoxification Therapy,7722,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5097.79,,,,,,,fee schedule,5097.79,5097.79, Alcohol And Drug Dependence With Rehabilitation And/Or Detoxification Therapy,7723,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,7891.23,,,,,,,fee schedule,7891.23,7891.23, Alcohol And Drug Dependence With Rehabilitation And/Or Detoxification Therapy,7723,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,7891.23,,,,,,,fee schedule,7891.23,7891.23, Alcohol And Drug Dependence With Rehabilitation And/Or Detoxification Therapy,7723,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,7891.23,,,,,,,fee schedule,7891.23,7891.23, Alcohol And Drug Dependence With Rehabilitation And/Or Detoxification Therapy,7723,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,7891.23,,,,,,,fee schedule,7891.23,7891.23, Alcohol And Drug Dependence With Rehabilitation And/Or Detoxification Therapy,7723,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,7891.23,,,,,,,fee schedule,7891.23,7891.23, Alcohol And Drug Dependence With Rehabilitation And/Or Detoxification Therapy,7723,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,7891.23,,,,,,,fee schedule,7891.23,7891.23, Alcohol And Drug Dependence With Rehabilitation And/Or Detoxification Therapy,7723,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,7891.23,,,,,,,fee schedule,7891.23,7891.23, Alcohol And Drug Dependence With Rehabilitation And/Or Detoxification Therapy,7723,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,7891.23,,,,,,,fee schedule,7891.23,7891.23, Alcohol And Drug Dependence With Rehabilitation And/Or Detoxification Therapy,7723,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,7891.23,,,,,,,fee schedule,7891.23,7891.23, Alcohol And Drug Dependence With Rehabilitation And/Or Detoxification Therapy,7723,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,7891.23,,,,,,,fee schedule,7891.23,7891.23, Alcohol And Drug Dependence With Rehabilitation And/Or Detoxification Therapy,7723,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,7891.23,,,,,,,fee schedule,7891.23,7891.23, Alcohol And Drug Dependence With Rehabilitation And/Or Detoxification Therapy,7724,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,16238.39,,,,,,,fee schedule,16238.39,16238.39, Alcohol And Drug Dependence With Rehabilitation And/Or Detoxification Therapy,7724,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,16238.39,,,,,,,fee schedule,16238.39,16238.39, Alcohol And Drug Dependence With Rehabilitation And/Or Detoxification Therapy,7724,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,16238.39,,,,,,,fee schedule,16238.39,16238.39, Alcohol And Drug Dependence With Rehabilitation And/Or Detoxification Therapy,7724,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,16238.39,,,,,,,fee schedule,16238.39,16238.39, Alcohol And Drug Dependence With Rehabilitation And/Or Detoxification Therapy,7724,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,16238.39,,,,,,,fee schedule,16238.39,16238.39, Alcohol And Drug Dependence With Rehabilitation And/Or Detoxification Therapy,7724,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,16238.39,,,,,,,fee schedule,16238.39,16238.39, Alcohol And Drug Dependence With Rehabilitation And/Or Detoxification Therapy,7724,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,16238.39,,,,,,,fee schedule,16238.39,16238.39, Alcohol And Drug Dependence With Rehabilitation And/Or Detoxification Therapy,7724,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,16238.39,,,,,,,fee schedule,16238.39,16238.39, Alcohol And Drug Dependence With Rehabilitation And/Or Detoxification Therapy,7724,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,16238.39,,,,,,,fee schedule,16238.39,16238.39, Alcohol And Drug Dependence With Rehabilitation And/Or Detoxification Therapy,7724,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,16238.39,,,,,,,fee schedule,16238.39,16238.39, Alcohol And Drug Dependence With Rehabilitation And/Or Detoxification Therapy,7724,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,16238.39,,,,,,,fee schedule,16238.39,16238.39, Opioid Abuse And Dependence,7731,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,2333.99,,,,,,,fee schedule,2333.99,2333.99, Opioid Abuse And Dependence,7731,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,2333.99,,,,,,,fee schedule,2333.99,2333.99, Opioid Abuse And Dependence,7731,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,2333.99,,,,,,,fee schedule,2333.99,2333.99, Opioid Abuse And Dependence,7731,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,2333.99,,,,,,,fee schedule,2333.99,2333.99, Opioid Abuse And Dependence,7731,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,2333.99,,,,,,,fee schedule,2333.99,2333.99, Opioid Abuse And Dependence,7731,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,2333.99,,,,,,,fee schedule,2333.99,2333.99, Opioid Abuse And Dependence,7731,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,2333.99,,,,,,,fee schedule,2333.99,2333.99, Opioid Abuse And Dependence,7731,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,2333.99,,,,,,,fee schedule,2333.99,2333.99, Opioid Abuse And Dependence,7731,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,2333.99,,,,,,,fee schedule,2333.99,2333.99, Opioid Abuse And Dependence,7731,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,2333.99,,,,,,,fee schedule,2333.99,2333.99, Opioid Abuse And Dependence,7731,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,2333.99,,,,,,,fee schedule,2333.99,2333.99, Opioid Abuse And Dependence,7732,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,3462.51,,,,,,,fee schedule,3462.51,3462.51, Opioid Abuse And Dependence,7732,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,3462.51,,,,,,,fee schedule,3462.51,3462.51, Opioid Abuse And Dependence,7732,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,3462.51,,,,,,,fee schedule,3462.51,3462.51, Opioid Abuse And Dependence,7732,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,3462.51,,,,,,,fee schedule,3462.51,3462.51, Opioid Abuse And Dependence,7732,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,3462.51,,,,,,,fee schedule,3462.51,3462.51, Opioid Abuse And Dependence,7732,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,3462.51,,,,,,,fee schedule,3462.51,3462.51, Opioid Abuse And Dependence,7732,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,3462.51,,,,,,,fee schedule,3462.51,3462.51, Opioid Abuse And Dependence,7732,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,3462.51,,,,,,,fee schedule,3462.51,3462.51, Opioid Abuse And Dependence,7732,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,3462.51,,,,,,,fee schedule,3462.51,3462.51, Opioid Abuse And Dependence,7732,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,3462.51,,,,,,,fee schedule,3462.51,3462.51, Opioid Abuse And Dependence,7732,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,3462.51,,,,,,,fee schedule,3462.51,3462.51, Opioid Abuse And Dependence,7733,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,6717.53,,,,,,,fee schedule,6717.53,6717.53, Opioid Abuse And Dependence,7733,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,6717.53,,,,,,,fee schedule,6717.53,6717.53, Opioid Abuse And Dependence,7733,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,6717.53,,,,,,,fee schedule,6717.53,6717.53, Opioid Abuse And Dependence,7733,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,6717.53,,,,,,,fee schedule,6717.53,6717.53, Opioid Abuse And Dependence,7733,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,6717.53,,,,,,,fee schedule,6717.53,6717.53, Opioid Abuse And Dependence,7733,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,6717.53,,,,,,,fee schedule,6717.53,6717.53, Opioid Abuse And Dependence,7733,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,6717.53,,,,,,,fee schedule,6717.53,6717.53, Opioid Abuse And Dependence,7733,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,6717.53,,,,,,,fee schedule,6717.53,6717.53, Opioid Abuse And Dependence,7733,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,6717.53,,,,,,,fee schedule,6717.53,6717.53, Opioid Abuse And Dependence,7733,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,6717.53,,,,,,,fee schedule,6717.53,6717.53, Opioid Abuse And Dependence,7733,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,6717.53,,,,,,,fee schedule,6717.53,6717.53, Opioid Abuse And Dependence,7734,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,14389.26,,,,,,,fee schedule,14389.26,14389.26, Opioid Abuse And Dependence,7734,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,14389.26,,,,,,,fee schedule,14389.26,14389.26, Opioid Abuse And Dependence,7734,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,14389.26,,,,,,,fee schedule,14389.26,14389.26, Opioid Abuse And Dependence,7734,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,14389.26,,,,,,,fee schedule,14389.26,14389.26, Opioid Abuse And Dependence,7734,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,14389.26,,,,,,,fee schedule,14389.26,14389.26, Opioid Abuse And Dependence,7734,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,14389.26,,,,,,,fee schedule,14389.26,14389.26, Opioid Abuse And Dependence,7734,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,14389.26,,,,,,,fee schedule,14389.26,14389.26, Opioid Abuse And Dependence,7734,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,14389.26,,,,,,,fee schedule,14389.26,14389.26, Opioid Abuse And Dependence,7734,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,14389.26,,,,,,,fee schedule,14389.26,14389.26, Opioid Abuse And Dependence,7734,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,14389.26,,,,,,,fee schedule,14389.26,14389.26, Opioid Abuse And Dependence,7734,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,14389.26,,,,,,,fee schedule,14389.26,14389.26, Cocaine Abuse And Dependence,7741,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,2593.71,,,,,,,fee schedule,2593.71,2593.71, Cocaine Abuse And Dependence,7741,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,2593.71,,,,,,,fee schedule,2593.71,2593.71, Cocaine Abuse And Dependence,7741,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,2593.71,,,,,,,fee schedule,2593.71,2593.71, Cocaine Abuse And Dependence,7741,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,2593.71,,,,,,,fee schedule,2593.71,2593.71, Cocaine Abuse And Dependence,7741,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,2593.71,,,,,,,fee schedule,2593.71,2593.71, Cocaine Abuse And Dependence,7741,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,2593.71,,,,,,,fee schedule,2593.71,2593.71, Cocaine Abuse And Dependence,7741,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,2593.71,,,,,,,fee schedule,2593.71,2593.71, Cocaine Abuse And Dependence,7741,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,2593.71,,,,,,,fee schedule,2593.71,2593.71, Cocaine Abuse And Dependence,7741,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,2593.71,,,,,,,fee schedule,2593.71,2593.71, Cocaine Abuse And Dependence,7741,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,2593.71,,,,,,,fee schedule,2593.71,2593.71, Cocaine Abuse And Dependence,7741,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,2593.71,,,,,,,fee schedule,2593.71,2593.71, Cocaine Abuse And Dependence,7742,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,3466.75,,,,,,,fee schedule,3466.75,3466.75, Cocaine Abuse And Dependence,7742,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,3466.75,,,,,,,fee schedule,3466.75,3466.75, Cocaine Abuse And Dependence,7742,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,3466.75,,,,,,,fee schedule,3466.75,3466.75, Cocaine Abuse And Dependence,7742,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,3466.75,,,,,,,fee schedule,3466.75,3466.75, Cocaine Abuse And Dependence,7742,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,3466.75,,,,,,,fee schedule,3466.75,3466.75, Cocaine Abuse And Dependence,7742,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,3466.75,,,,,,,fee schedule,3466.75,3466.75, Cocaine Abuse And Dependence,7742,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,3466.75,,,,,,,fee schedule,3466.75,3466.75, Cocaine Abuse And Dependence,7742,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,3466.75,,,,,,,fee schedule,3466.75,3466.75, Cocaine Abuse And Dependence,7742,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,3466.75,,,,,,,fee schedule,3466.75,3466.75, Cocaine Abuse And Dependence,7742,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,3466.75,,,,,,,fee schedule,3466.75,3466.75, Cocaine Abuse And Dependence,7742,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,3466.75,,,,,,,fee schedule,3466.75,3466.75, Cocaine Abuse And Dependence,7743,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,6066.81,,,,,,,fee schedule,6066.81,6066.81, Cocaine Abuse And Dependence,7743,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,6066.81,,,,,,,fee schedule,6066.81,6066.81, Cocaine Abuse And Dependence,7743,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,6066.81,,,,,,,fee schedule,6066.81,6066.81, Cocaine Abuse And Dependence,7743,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,6066.81,,,,,,,fee schedule,6066.81,6066.81, Cocaine Abuse And Dependence,7743,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,6066.81,,,,,,,fee schedule,6066.81,6066.81, Cocaine Abuse And Dependence,7743,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,6066.81,,,,,,,fee schedule,6066.81,6066.81, Cocaine Abuse And Dependence,7743,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,6066.81,,,,,,,fee schedule,6066.81,6066.81, Cocaine Abuse And Dependence,7743,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,6066.81,,,,,,,fee schedule,6066.81,6066.81, Cocaine Abuse And Dependence,7743,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,6066.81,,,,,,,fee schedule,6066.81,6066.81, Cocaine Abuse And Dependence,7743,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,6066.81,,,,,,,fee schedule,6066.81,6066.81, Cocaine Abuse And Dependence,7743,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,6066.81,,,,,,,fee schedule,6066.81,6066.81, Cocaine Abuse And Dependence,7744,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,15084.45,,,,,,,fee schedule,15084.45,15084.45, Cocaine Abuse And Dependence,7744,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,15084.45,,,,,,,fee schedule,15084.45,15084.45, Cocaine Abuse And Dependence,7744,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,15084.45,,,,,,,fee schedule,15084.45,15084.45, Cocaine Abuse And Dependence,7744,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,15084.45,,,,,,,fee schedule,15084.45,15084.45, Cocaine Abuse And Dependence,7744,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,15084.45,,,,,,,fee schedule,15084.45,15084.45, Cocaine Abuse And Dependence,7744,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,15084.45,,,,,,,fee schedule,15084.45,15084.45, Cocaine Abuse And Dependence,7744,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,15084.45,,,,,,,fee schedule,15084.45,15084.45, Cocaine Abuse And Dependence,7744,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,15084.45,,,,,,,fee schedule,15084.45,15084.45, Cocaine Abuse And Dependence,7744,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,15084.45,,,,,,,fee schedule,15084.45,15084.45, Cocaine Abuse And Dependence,7744,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,15084.45,,,,,,,fee schedule,15084.45,15084.45, Cocaine Abuse And Dependence,7744,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,15084.45,,,,,,,fee schedule,15084.45,15084.45, Alcohol Abuse And Dependence,7751,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,2987.53,,,,,,,fee schedule,2987.53,2987.53, Alcohol Abuse And Dependence,7751,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,2987.53,,,,,,,fee schedule,2987.53,2987.53, Alcohol Abuse And Dependence,7751,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,2987.53,,,,,,,fee schedule,2987.53,2987.53, Alcohol Abuse And Dependence,7751,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,2987.53,,,,,,,fee schedule,2987.53,2987.53, Alcohol Abuse And Dependence,7751,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,2987.53,,,,,,,fee schedule,2987.53,2987.53, Alcohol Abuse And Dependence,7751,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,2987.53,,,,,,,fee schedule,2987.53,2987.53, Alcohol Abuse And Dependence,7751,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,2987.53,,,,,,,fee schedule,2987.53,2987.53, Alcohol Abuse And Dependence,7751,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,2987.53,,,,,,,fee schedule,2987.53,2987.53, Alcohol Abuse And Dependence,7751,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,2987.53,,,,,,,fee schedule,2987.53,2987.53, Alcohol Abuse And Dependence,7751,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,2987.53,,,,,,,fee schedule,2987.53,2987.53, Alcohol Abuse And Dependence,7751,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,2987.53,,,,,,,fee schedule,2987.53,2987.53, Alcohol Abuse And Dependence,7752,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4542.34,,,,,,,fee schedule,4542.34,4542.34, Alcohol Abuse And Dependence,7752,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4542.34,,,,,,,fee schedule,4542.34,4542.34, Alcohol Abuse And Dependence,7752,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4542.34,,,,,,,fee schedule,4542.34,4542.34, Alcohol Abuse And Dependence,7752,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4542.34,,,,,,,fee schedule,4542.34,4542.34, Alcohol Abuse And Dependence,7752,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4542.34,,,,,,,fee schedule,4542.34,4542.34, Alcohol Abuse And Dependence,7752,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4542.34,,,,,,,fee schedule,4542.34,4542.34, Alcohol Abuse And Dependence,7752,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4542.34,,,,,,,fee schedule,4542.34,4542.34, Alcohol Abuse And Dependence,7752,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4542.34,,,,,,,fee schedule,4542.34,4542.34, Alcohol Abuse And Dependence,7752,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4542.34,,,,,,,fee schedule,4542.34,4542.34, Alcohol Abuse And Dependence,7752,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4542.34,,,,,,,fee schedule,4542.34,4542.34, Alcohol Abuse And Dependence,7752,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4542.34,,,,,,,fee schedule,4542.34,4542.34, Alcohol Abuse And Dependence,7753,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,8237.76,,,,,,,fee schedule,8237.76,8237.76, Alcohol Abuse And Dependence,7753,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,8237.76,,,,,,,fee schedule,8237.76,8237.76, Alcohol Abuse And Dependence,7753,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,8237.76,,,,,,,fee schedule,8237.76,8237.76, Alcohol Abuse And Dependence,7753,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,8237.76,,,,,,,fee schedule,8237.76,8237.76, Alcohol Abuse And Dependence,7753,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,8237.76,,,,,,,fee schedule,8237.76,8237.76, Alcohol Abuse And Dependence,7753,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,8237.76,,,,,,,fee schedule,8237.76,8237.76, Alcohol Abuse And Dependence,7753,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,8237.76,,,,,,,fee schedule,8237.76,8237.76, Alcohol Abuse And Dependence,7753,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,8237.76,,,,,,,fee schedule,8237.76,8237.76, Alcohol Abuse And Dependence,7753,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,8237.76,,,,,,,fee schedule,8237.76,8237.76, Alcohol Abuse And Dependence,7753,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,8237.76,,,,,,,fee schedule,8237.76,8237.76, Alcohol Abuse And Dependence,7753,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,8237.76,,,,,,,fee schedule,8237.76,8237.76, Alcohol Abuse And Dependence,7754,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,18599.9,,,,,,,fee schedule,18599.9,18599.9, Alcohol Abuse And Dependence,7754,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,18599.9,,,,,,,fee schedule,18599.9,18599.9, Alcohol Abuse And Dependence,7754,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,18599.9,,,,,,,fee schedule,18599.9,18599.9, Alcohol Abuse And Dependence,7754,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,18599.9,,,,,,,fee schedule,18599.9,18599.9, Alcohol Abuse And Dependence,7754,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,18599.9,,,,,,,fee schedule,18599.9,18599.9, Alcohol Abuse And Dependence,7754,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,18599.9,,,,,,,fee schedule,18599.9,18599.9, Alcohol Abuse And Dependence,7754,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,18599.9,,,,,,,fee schedule,18599.9,18599.9, Alcohol Abuse And Dependence,7754,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,18599.9,,,,,,,fee schedule,18599.9,18599.9, Alcohol Abuse And Dependence,7754,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,18599.9,,,,,,,fee schedule,18599.9,18599.9, Alcohol Abuse And Dependence,7754,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,18599.9,,,,,,,fee schedule,18599.9,18599.9, Alcohol Abuse And Dependence,7754,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,18599.9,,,,,,,fee schedule,18599.9,18599.9, Other Drug Abuse And Dependence,7761,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,2705.93,,,,,,,fee schedule,2705.93,2705.93, Other Drug Abuse And Dependence,7761,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,2705.93,,,,,,,fee schedule,2705.93,2705.93, Other Drug Abuse And Dependence,7761,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,2705.93,,,,,,,fee schedule,2705.93,2705.93, Other Drug Abuse And Dependence,7761,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,2705.93,,,,,,,fee schedule,2705.93,2705.93, Other Drug Abuse And Dependence,7761,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,2705.93,,,,,,,fee schedule,2705.93,2705.93, Other Drug Abuse And Dependence,7761,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,2705.93,,,,,,,fee schedule,2705.93,2705.93, Other Drug Abuse And Dependence,7761,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,2705.93,,,,,,,fee schedule,2705.93,2705.93, Other Drug Abuse And Dependence,7761,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,2705.93,,,,,,,fee schedule,2705.93,2705.93, Other Drug Abuse And Dependence,7761,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,2705.93,,,,,,,fee schedule,2705.93,2705.93, Other Drug Abuse And Dependence,7761,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,2705.93,,,,,,,fee schedule,2705.93,2705.93, Other Drug Abuse And Dependence,7761,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,2705.93,,,,,,,fee schedule,2705.93,2705.93, Other Drug Abuse And Dependence,7762,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,3723.65,,,,,,,fee schedule,3723.65,3723.65, Other Drug Abuse And Dependence,7762,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,3723.65,,,,,,,fee schedule,3723.65,3723.65, Other Drug Abuse And Dependence,7762,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,3723.65,,,,,,,fee schedule,3723.65,3723.65, Other Drug Abuse And Dependence,7762,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,3723.65,,,,,,,fee schedule,3723.65,3723.65, Other Drug Abuse And Dependence,7762,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,3723.65,,,,,,,fee schedule,3723.65,3723.65, Other Drug Abuse And Dependence,7762,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,3723.65,,,,,,,fee schedule,3723.65,3723.65, Other Drug Abuse And Dependence,7762,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,3723.65,,,,,,,fee schedule,3723.65,3723.65, Other Drug Abuse And Dependence,7762,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,3723.65,,,,,,,fee schedule,3723.65,3723.65, Other Drug Abuse And Dependence,7762,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,3723.65,,,,,,,fee schedule,3723.65,3723.65, Other Drug Abuse And Dependence,7762,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,3723.65,,,,,,,fee schedule,3723.65,3723.65, Other Drug Abuse And Dependence,7762,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,3723.65,,,,,,,fee schedule,3723.65,3723.65, Other Drug Abuse And Dependence,7763,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,7043.6,,,,,,,fee schedule,7043.6,7043.6, Other Drug Abuse And Dependence,7763,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,7043.6,,,,,,,fee schedule,7043.6,7043.6, Other Drug Abuse And Dependence,7763,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,7043.6,,,,,,,fee schedule,7043.6,7043.6, Other Drug Abuse And Dependence,7763,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,7043.6,,,,,,,fee schedule,7043.6,7043.6, Other Drug Abuse And Dependence,7763,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,7043.6,,,,,,,fee schedule,7043.6,7043.6, Other Drug Abuse And Dependence,7763,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,7043.6,,,,,,,fee schedule,7043.6,7043.6, Other Drug Abuse And Dependence,7763,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,7043.6,,,,,,,fee schedule,7043.6,7043.6, Other Drug Abuse And Dependence,7763,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,7043.6,,,,,,,fee schedule,7043.6,7043.6, Other Drug Abuse And Dependence,7763,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,7043.6,,,,,,,fee schedule,7043.6,7043.6, Other Drug Abuse And Dependence,7763,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,7043.6,,,,,,,fee schedule,7043.6,7043.6, Other Drug Abuse And Dependence,7763,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,7043.6,,,,,,,fee schedule,7043.6,7043.6, Other Drug Abuse And Dependence,7764,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,13371.54,,,,,,,fee schedule,13371.54,13371.54, Other Drug Abuse And Dependence,7764,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,13371.54,,,,,,,fee schedule,13371.54,13371.54, Other Drug Abuse And Dependence,7764,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,13371.54,,,,,,,fee schedule,13371.54,13371.54, Other Drug Abuse And Dependence,7764,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,13371.54,,,,,,,fee schedule,13371.54,13371.54, Other Drug Abuse And Dependence,7764,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,13371.54,,,,,,,fee schedule,13371.54,13371.54, Other Drug Abuse And Dependence,7764,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,13371.54,,,,,,,fee schedule,13371.54,13371.54, Other Drug Abuse And Dependence,7764,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,13371.54,,,,,,,fee schedule,13371.54,13371.54, Other Drug Abuse And Dependence,7764,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,13371.54,,,,,,,fee schedule,13371.54,13371.54, Other Drug Abuse And Dependence,7764,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,13371.54,,,,,,,fee schedule,13371.54,13371.54, Other Drug Abuse And Dependence,7764,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,13371.54,,,,,,,fee schedule,13371.54,13371.54, Other Drug Abuse And Dependence,7764,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,13371.54,,,,,,,fee schedule,13371.54,13371.54, Extensive O.R. Procedures For Other Complications Of Treatment,7921,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,11241.52,,,,,,,fee schedule,11241.52,11241.52, Extensive O.R. Procedures For Other Complications Of Treatment,7921,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,11241.52,,,,,,,fee schedule,11241.52,11241.52, Extensive O.R. Procedures For Other Complications Of Treatment,7921,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,11241.52,,,,,,,fee schedule,11241.52,11241.52, Extensive O.R. Procedures For Other Complications Of Treatment,7921,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,11241.52,,,,,,,fee schedule,11241.52,11241.52, Extensive O.R. Procedures For Other Complications Of Treatment,7921,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,11241.52,,,,,,,fee schedule,11241.52,11241.52, Extensive O.R. Procedures For Other Complications Of Treatment,7921,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,11241.52,,,,,,,fee schedule,11241.52,11241.52, Extensive O.R. Procedures For Other Complications Of Treatment,7921,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,11241.52,,,,,,,fee schedule,11241.52,11241.52, Extensive O.R. Procedures For Other Complications Of Treatment,7921,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,11241.52,,,,,,,fee schedule,11241.52,11241.52, Extensive O.R. Procedures For Other Complications Of Treatment,7921,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,11241.52,,,,,,,fee schedule,11241.52,11241.52, Extensive O.R. Procedures For Other Complications Of Treatment,7921,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,11241.52,,,,,,,fee schedule,11241.52,11241.52, Extensive O.R. Procedures For Other Complications Of Treatment,7921,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,11241.52,,,,,,,fee schedule,11241.52,11241.52, Extensive O.R. Procedures For Other Complications Of Treatment,7922,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,14253.05,,,,,,,fee schedule,14253.05,14253.05, Extensive O.R. Procedures For Other Complications Of Treatment,7922,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,14253.05,,,,,,,fee schedule,14253.05,14253.05, Extensive O.R. Procedures For Other Complications Of Treatment,7922,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,14253.05,,,,,,,fee schedule,14253.05,14253.05, Extensive O.R. Procedures For Other Complications Of Treatment,7922,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,14253.05,,,,,,,fee schedule,14253.05,14253.05, Extensive O.R. Procedures For Other Complications Of Treatment,7922,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,14253.05,,,,,,,fee schedule,14253.05,14253.05, Extensive O.R. Procedures For Other Complications Of Treatment,7922,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,14253.05,,,,,,,fee schedule,14253.05,14253.05, Extensive O.R. Procedures For Other Complications Of Treatment,7922,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,14253.05,,,,,,,fee schedule,14253.05,14253.05, Extensive O.R. Procedures For Other Complications Of Treatment,7922,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,14253.05,,,,,,,fee schedule,14253.05,14253.05, Extensive O.R. Procedures For Other Complications Of Treatment,7922,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,14253.05,,,,,,,fee schedule,14253.05,14253.05, Extensive O.R. Procedures For Other Complications Of Treatment,7922,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,14253.05,,,,,,,fee schedule,14253.05,14253.05, Extensive O.R. Procedures For Other Complications Of Treatment,7922,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,14253.05,,,,,,,fee schedule,14253.05,14253.05, Extensive O.R. Procedures For Other Complications Of Treatment,7923,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,20912,,,,,,,fee schedule,20912,20912, Extensive O.R. Procedures For Other Complications Of Treatment,7923,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,20912,,,,,,,fee schedule,20912,20912, Extensive O.R. Procedures For Other Complications Of Treatment,7923,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,20912,,,,,,,fee schedule,20912,20912, Extensive O.R. Procedures For Other Complications Of Treatment,7923,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,20912,,,,,,,fee schedule,20912,20912, Extensive O.R. Procedures For Other Complications Of Treatment,7923,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,20912,,,,,,,fee schedule,20912,20912, Extensive O.R. Procedures For Other Complications Of Treatment,7923,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,20912,,,,,,,fee schedule,20912,20912, Extensive O.R. Procedures For Other Complications Of Treatment,7923,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,20912,,,,,,,fee schedule,20912,20912, Extensive O.R. Procedures For Other Complications Of Treatment,7923,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,20912,,,,,,,fee schedule,20912,20912, Extensive O.R. Procedures For Other Complications Of Treatment,7923,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,20912,,,,,,,fee schedule,20912,20912, Extensive O.R. Procedures For Other Complications Of Treatment,7923,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,20912,,,,,,,fee schedule,20912,20912, Extensive O.R. Procedures For Other Complications Of Treatment,7923,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,20912,,,,,,,fee schedule,20912,20912, Extensive O.R. Procedures For Other Complications Of Treatment,7924,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,35493.24,,,,,,,fee schedule,35493.24,35493.24, Extensive O.R. Procedures For Other Complications Of Treatment,7924,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,35493.24,,,,,,,fee schedule,35493.24,35493.24, Extensive O.R. Procedures For Other Complications Of Treatment,7924,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,35493.24,,,,,,,fee schedule,35493.24,35493.24, Extensive O.R. Procedures For Other Complications Of Treatment,7924,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,35493.24,,,,,,,fee schedule,35493.24,35493.24, Extensive O.R. Procedures For Other Complications Of Treatment,7924,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,35493.24,,,,,,,fee schedule,35493.24,35493.24, Extensive O.R. Procedures For Other Complications Of Treatment,7924,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,35493.24,,,,,,,fee schedule,35493.24,35493.24, Extensive O.R. Procedures For Other Complications Of Treatment,7924,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,35493.24,,,,,,,fee schedule,35493.24,35493.24, Extensive O.R. Procedures For Other Complications Of Treatment,7924,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,35493.24,,,,,,,fee schedule,35493.24,35493.24, Extensive O.R. Procedures For Other Complications Of Treatment,7924,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,35493.24,,,,,,,fee schedule,35493.24,35493.24, Extensive O.R. Procedures For Other Complications Of Treatment,7924,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,35493.24,,,,,,,fee schedule,35493.24,35493.24, Extensive O.R. Procedures For Other Complications Of Treatment,7924,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,35493.24,,,,,,,fee schedule,35493.24,35493.24, Moderately Extensive O.R. Procedures For Other Complications Of Treatment,7931,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,8424.09,,,,,,,fee schedule,8424.09,8424.09, Moderately Extensive O.R. Procedures For Other Complications Of Treatment,7931,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,8424.09,,,,,,,fee schedule,8424.09,8424.09, Moderately Extensive O.R. Procedures For Other Complications Of Treatment,7931,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,8424.09,,,,,,,fee schedule,8424.09,8424.09, Moderately Extensive O.R. Procedures For Other Complications Of Treatment,7931,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,8424.09,,,,,,,fee schedule,8424.09,8424.09, Moderately Extensive O.R. Procedures For Other Complications Of Treatment,7931,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,8424.09,,,,,,,fee schedule,8424.09,8424.09, Moderately Extensive O.R. Procedures For Other Complications Of Treatment,7931,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,8424.09,,,,,,,fee schedule,8424.09,8424.09, Moderately Extensive O.R. Procedures For Other Complications Of Treatment,7931,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,8424.09,,,,,,,fee schedule,8424.09,8424.09, Moderately Extensive O.R. Procedures For Other Complications Of Treatment,7931,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,8424.09,,,,,,,fee schedule,8424.09,8424.09, Moderately Extensive O.R. Procedures For Other Complications Of Treatment,7931,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,8424.09,,,,,,,fee schedule,8424.09,8424.09, Moderately Extensive O.R. Procedures For Other Complications Of Treatment,7931,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,8424.09,,,,,,,fee schedule,8424.09,8424.09, Moderately Extensive O.R. Procedures For Other Complications Of Treatment,7931,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,8424.09,,,,,,,fee schedule,8424.09,8424.09, Moderately Extensive O.R. Procedures For Other Complications Of Treatment,7932,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,11259.17,,,,,,,fee schedule,11259.17,11259.17, Moderately Extensive O.R. Procedures For Other Complications Of Treatment,7932,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,11259.17,,,,,,,fee schedule,11259.17,11259.17, Moderately Extensive O.R. Procedures For Other Complications Of Treatment,7932,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,11259.17,,,,,,,fee schedule,11259.17,11259.17, Moderately Extensive O.R. Procedures For Other Complications Of Treatment,7932,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,11259.17,,,,,,,fee schedule,11259.17,11259.17, Moderately Extensive O.R. Procedures For Other Complications Of Treatment,7932,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,11259.17,,,,,,,fee schedule,11259.17,11259.17, Moderately Extensive O.R. Procedures For Other Complications Of Treatment,7932,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,11259.17,,,,,,,fee schedule,11259.17,11259.17, Moderately Extensive O.R. Procedures For Other Complications Of Treatment,7932,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,11259.17,,,,,,,fee schedule,11259.17,11259.17, Moderately Extensive O.R. Procedures For Other Complications Of Treatment,7932,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,11259.17,,,,,,,fee schedule,11259.17,11259.17, Moderately Extensive O.R. Procedures For Other Complications Of Treatment,7932,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,11259.17,,,,,,,fee schedule,11259.17,11259.17, Moderately Extensive O.R. Procedures For Other Complications Of Treatment,7932,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,11259.17,,,,,,,fee schedule,11259.17,11259.17, Moderately Extensive O.R. Procedures For Other Complications Of Treatment,7932,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,11259.17,,,,,,,fee schedule,11259.17,11259.17, Moderately Extensive O.R. Procedures For Other Complications Of Treatment,7933,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,16068.29,,,,,,,fee schedule,16068.29,16068.29, Moderately Extensive O.R. Procedures For Other Complications Of Treatment,7933,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,16068.29,,,,,,,fee schedule,16068.29,16068.29, Moderately Extensive O.R. Procedures For Other Complications Of Treatment,7933,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,16068.29,,,,,,,fee schedule,16068.29,16068.29, Moderately Extensive O.R. Procedures For Other Complications Of Treatment,7933,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,16068.29,,,,,,,fee schedule,16068.29,16068.29, Moderately Extensive O.R. Procedures For Other Complications Of Treatment,7933,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,16068.29,,,,,,,fee schedule,16068.29,16068.29, Moderately Extensive O.R. Procedures For Other Complications Of Treatment,7933,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,16068.29,,,,,,,fee schedule,16068.29,16068.29, Moderately Extensive O.R. Procedures For Other Complications Of Treatment,7933,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,16068.29,,,,,,,fee schedule,16068.29,16068.29, Moderately Extensive O.R. Procedures For Other Complications Of Treatment,7933,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,16068.29,,,,,,,fee schedule,16068.29,16068.29, Moderately Extensive O.R. Procedures For Other Complications Of Treatment,7933,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,16068.29,,,,,,,fee schedule,16068.29,16068.29, Moderately Extensive O.R. Procedures For Other Complications Of Treatment,7933,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,16068.29,,,,,,,fee schedule,16068.29,16068.29, Moderately Extensive O.R. Procedures For Other Complications Of Treatment,7933,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,16068.29,,,,,,,fee schedule,16068.29,16068.29, Moderately Extensive O.R. Procedures For Other Complications Of Treatment,7934,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,28010.65,,,,,,,fee schedule,28010.65,28010.65, Moderately Extensive O.R. Procedures For Other Complications Of Treatment,7934,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,28010.65,,,,,,,fee schedule,28010.65,28010.65, Moderately Extensive O.R. Procedures For Other Complications Of Treatment,7934,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,28010.65,,,,,,,fee schedule,28010.65,28010.65, Moderately Extensive O.R. Procedures For Other Complications Of Treatment,7934,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,28010.65,,,,,,,fee schedule,28010.65,28010.65, Moderately Extensive O.R. Procedures For Other Complications Of Treatment,7934,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,28010.65,,,,,,,fee schedule,28010.65,28010.65, Moderately Extensive O.R. Procedures For Other Complications Of Treatment,7934,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,28010.65,,,,,,,fee schedule,28010.65,28010.65, Moderately Extensive O.R. Procedures For Other Complications Of Treatment,7934,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,28010.65,,,,,,,fee schedule,28010.65,28010.65, Moderately Extensive O.R. Procedures For Other Complications Of Treatment,7934,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,28010.65,,,,,,,fee schedule,28010.65,28010.65, Moderately Extensive O.R. Procedures For Other Complications Of Treatment,7934,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,28010.65,,,,,,,fee schedule,28010.65,28010.65, Moderately Extensive O.R. Procedures For Other Complications Of Treatment,7934,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,28010.65,,,,,,,fee schedule,28010.65,28010.65, Moderately Extensive O.R. Procedures For Other Complications Of Treatment,7934,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,28010.65,,,,,,,fee schedule,28010.65,28010.65, Non-Extensive O.R. Procedures For Other Complications Of Treatment,7941,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,6741.53,,,,,,,fee schedule,6741.53,6741.53, Non-Extensive O.R. Procedures For Other Complications Of Treatment,7941,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,6741.53,,,,,,,fee schedule,6741.53,6741.53, Non-Extensive O.R. Procedures For Other Complications Of Treatment,7941,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,6741.53,,,,,,,fee schedule,6741.53,6741.53, Non-Extensive O.R. Procedures For Other Complications Of Treatment,7941,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,6741.53,,,,,,,fee schedule,6741.53,6741.53, Non-Extensive O.R. Procedures For Other Complications Of Treatment,7941,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,6741.53,,,,,,,fee schedule,6741.53,6741.53, Non-Extensive O.R. Procedures For Other Complications Of Treatment,7941,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,6741.53,,,,,,,fee schedule,6741.53,6741.53, Non-Extensive O.R. Procedures For Other Complications Of Treatment,7941,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,6741.53,,,,,,,fee schedule,6741.53,6741.53, Non-Extensive O.R. Procedures For Other Complications Of Treatment,7941,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,6741.53,,,,,,,fee schedule,6741.53,6741.53, Non-Extensive O.R. Procedures For Other Complications Of Treatment,7941,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,6741.53,,,,,,,fee schedule,6741.53,6741.53, Non-Extensive O.R. Procedures For Other Complications Of Treatment,7941,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,6741.53,,,,,,,fee schedule,6741.53,6741.53, Non-Extensive O.R. Procedures For Other Complications Of Treatment,7941,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,6741.53,,,,,,,fee schedule,6741.53,6741.53, Non-Extensive O.R. Procedures For Other Complications Of Treatment,7942,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,9127.03,,,,,,,fee schedule,9127.03,9127.03, Non-Extensive O.R. Procedures For Other Complications Of Treatment,7942,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,9127.03,,,,,,,fee schedule,9127.03,9127.03, Non-Extensive O.R. Procedures For Other Complications Of Treatment,7942,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,9127.03,,,,,,,fee schedule,9127.03,9127.03, Non-Extensive O.R. Procedures For Other Complications Of Treatment,7942,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,9127.03,,,,,,,fee schedule,9127.03,9127.03, Non-Extensive O.R. Procedures For Other Complications Of Treatment,7942,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,9127.03,,,,,,,fee schedule,9127.03,9127.03, Non-Extensive O.R. Procedures For Other Complications Of Treatment,7942,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,9127.03,,,,,,,fee schedule,9127.03,9127.03, Non-Extensive O.R. Procedures For Other Complications Of Treatment,7942,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,9127.03,,,,,,,fee schedule,9127.03,9127.03, Non-Extensive O.R. Procedures For Other Complications Of Treatment,7942,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,9127.03,,,,,,,fee schedule,9127.03,9127.03, Non-Extensive O.R. Procedures For Other Complications Of Treatment,7942,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,9127.03,,,,,,,fee schedule,9127.03,9127.03, Non-Extensive O.R. Procedures For Other Complications Of Treatment,7942,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,9127.03,,,,,,,fee schedule,9127.03,9127.03, Non-Extensive O.R. Procedures For Other Complications Of Treatment,7942,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,9127.03,,,,,,,fee schedule,9127.03,9127.03, Non-Extensive O.R. Procedures For Other Complications Of Treatment,7943,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,13111.11,,,,,,,fee schedule,13111.11,13111.11, Non-Extensive O.R. Procedures For Other Complications Of Treatment,7943,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,13111.11,,,,,,,fee schedule,13111.11,13111.11, Non-Extensive O.R. Procedures For Other Complications Of Treatment,7943,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,13111.11,,,,,,,fee schedule,13111.11,13111.11, Non-Extensive O.R. Procedures For Other Complications Of Treatment,7943,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,13111.11,,,,,,,fee schedule,13111.11,13111.11, Non-Extensive O.R. Procedures For Other Complications Of Treatment,7943,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,13111.11,,,,,,,fee schedule,13111.11,13111.11, Non-Extensive O.R. Procedures For Other Complications Of Treatment,7943,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,13111.11,,,,,,,fee schedule,13111.11,13111.11, Non-Extensive O.R. Procedures For Other Complications Of Treatment,7943,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,13111.11,,,,,,,fee schedule,13111.11,13111.11, Non-Extensive O.R. Procedures For Other Complications Of Treatment,7943,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,13111.11,,,,,,,fee schedule,13111.11,13111.11, Non-Extensive O.R. Procedures For Other Complications Of Treatment,7943,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,13111.11,,,,,,,fee schedule,13111.11,13111.11, Non-Extensive O.R. Procedures For Other Complications Of Treatment,7943,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,13111.11,,,,,,,fee schedule,13111.11,13111.11, Non-Extensive O.R. Procedures For Other Complications Of Treatment,7943,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,13111.11,,,,,,,fee schedule,13111.11,13111.11, Non-Extensive O.R. Procedures For Other Complications Of Treatment,7944,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,27201.13,,,,,,,fee schedule,27201.13,27201.13, Non-Extensive O.R. Procedures For Other Complications Of Treatment,7944,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,27201.13,,,,,,,fee schedule,27201.13,27201.13, Non-Extensive O.R. Procedures For Other Complications Of Treatment,7944,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,27201.13,,,,,,,fee schedule,27201.13,27201.13, Non-Extensive O.R. Procedures For Other Complications Of Treatment,7944,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,27201.13,,,,,,,fee schedule,27201.13,27201.13, Non-Extensive O.R. Procedures For Other Complications Of Treatment,7944,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,27201.13,,,,,,,fee schedule,27201.13,27201.13, Non-Extensive O.R. Procedures For Other Complications Of Treatment,7944,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,27201.13,,,,,,,fee schedule,27201.13,27201.13, Non-Extensive O.R. Procedures For Other Complications Of Treatment,7944,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,27201.13,,,,,,,fee schedule,27201.13,27201.13, Non-Extensive O.R. Procedures For Other Complications Of Treatment,7944,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,27201.13,,,,,,,fee schedule,27201.13,27201.13, Non-Extensive O.R. Procedures For Other Complications Of Treatment,7944,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,27201.13,,,,,,,fee schedule,27201.13,27201.13, Non-Extensive O.R. Procedures For Other Complications Of Treatment,7944,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,27201.13,,,,,,,fee schedule,27201.13,27201.13, Non-Extensive O.R. Procedures For Other Complications Of Treatment,7944,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,27201.13,,,,,,,fee schedule,27201.13,27201.13, Hemorrhage Or Hematoma Due To Complication,8101,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,3997.49,,,,,,,fee schedule,3997.49,3997.49, Hemorrhage Or Hematoma Due To Complication,8101,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,3997.49,,,,,,,fee schedule,3997.49,3997.49, Hemorrhage Or Hematoma Due To Complication,8101,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,3997.49,,,,,,,fee schedule,3997.49,3997.49, Hemorrhage Or Hematoma Due To Complication,8101,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,3997.49,,,,,,,fee schedule,3997.49,3997.49, Hemorrhage Or Hematoma Due To Complication,8101,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,3997.49,,,,,,,fee schedule,3997.49,3997.49, Hemorrhage Or Hematoma Due To Complication,8101,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,3997.49,,,,,,,fee schedule,3997.49,3997.49, Hemorrhage Or Hematoma Due To Complication,8101,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,3997.49,,,,,,,fee schedule,3997.49,3997.49, Hemorrhage Or Hematoma Due To Complication,8101,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,3997.49,,,,,,,fee schedule,3997.49,3997.49, Hemorrhage Or Hematoma Due To Complication,8101,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,3997.49,,,,,,,fee schedule,3997.49,3997.49, Hemorrhage Or Hematoma Due To Complication,8101,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,3997.49,,,,,,,fee schedule,3997.49,3997.49, Hemorrhage Or Hematoma Due To Complication,8101,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,3997.49,,,,,,,fee schedule,3997.49,3997.49, Hemorrhage Or Hematoma Due To Complication,8102,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5559.36,,,,,,,fee schedule,5559.36,5559.36, Hemorrhage Or Hematoma Due To Complication,8102,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5559.36,,,,,,,fee schedule,5559.36,5559.36, Hemorrhage Or Hematoma Due To Complication,8102,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5559.36,,,,,,,fee schedule,5559.36,5559.36, Hemorrhage Or Hematoma Due To Complication,8102,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5559.36,,,,,,,fee schedule,5559.36,5559.36, Hemorrhage Or Hematoma Due To Complication,8102,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5559.36,,,,,,,fee schedule,5559.36,5559.36, Hemorrhage Or Hematoma Due To Complication,8102,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5559.36,,,,,,,fee schedule,5559.36,5559.36, Hemorrhage Or Hematoma Due To Complication,8102,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5559.36,,,,,,,fee schedule,5559.36,5559.36, Hemorrhage Or Hematoma Due To Complication,8102,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5559.36,,,,,,,fee schedule,5559.36,5559.36, Hemorrhage Or Hematoma Due To Complication,8102,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5559.36,,,,,,,fee schedule,5559.36,5559.36, Hemorrhage Or Hematoma Due To Complication,8102,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5559.36,,,,,,,fee schedule,5559.36,5559.36, Hemorrhage Or Hematoma Due To Complication,8102,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5559.36,,,,,,,fee schedule,5559.36,5559.36, Hemorrhage Or Hematoma Due To Complication,8103,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,8839.78,,,,,,,fee schedule,8839.78,8839.78, Hemorrhage Or Hematoma Due To Complication,8103,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,8839.78,,,,,,,fee schedule,8839.78,8839.78, Hemorrhage Or Hematoma Due To Complication,8103,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,8839.78,,,,,,,fee schedule,8839.78,8839.78, Hemorrhage Or Hematoma Due To Complication,8103,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,8839.78,,,,,,,fee schedule,8839.78,8839.78, Hemorrhage Or Hematoma Due To Complication,8103,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,8839.78,,,,,,,fee schedule,8839.78,8839.78, Hemorrhage Or Hematoma Due To Complication,8103,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,8839.78,,,,,,,fee schedule,8839.78,8839.78, Hemorrhage Or Hematoma Due To Complication,8103,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,8839.78,,,,,,,fee schedule,8839.78,8839.78, Hemorrhage Or Hematoma Due To Complication,8103,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,8839.78,,,,,,,fee schedule,8839.78,8839.78, Hemorrhage Or Hematoma Due To Complication,8103,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,8839.78,,,,,,,fee schedule,8839.78,8839.78, Hemorrhage Or Hematoma Due To Complication,8103,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,8839.78,,,,,,,fee schedule,8839.78,8839.78, Hemorrhage Or Hematoma Due To Complication,8103,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,8839.78,,,,,,,fee schedule,8839.78,8839.78, Hemorrhage Or Hematoma Due To Complication,8104,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,16926.51,,,,,,,fee schedule,16926.51,16926.51, Hemorrhage Or Hematoma Due To Complication,8104,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,16926.51,,,,,,,fee schedule,16926.51,16926.51, Hemorrhage Or Hematoma Due To Complication,8104,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,16926.51,,,,,,,fee schedule,16926.51,16926.51, Hemorrhage Or Hematoma Due To Complication,8104,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,16926.51,,,,,,,fee schedule,16926.51,16926.51, Hemorrhage Or Hematoma Due To Complication,8104,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,16926.51,,,,,,,fee schedule,16926.51,16926.51, Hemorrhage Or Hematoma Due To Complication,8104,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,16926.51,,,,,,,fee schedule,16926.51,16926.51, Hemorrhage Or Hematoma Due To Complication,8104,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,16926.51,,,,,,,fee schedule,16926.51,16926.51, Hemorrhage Or Hematoma Due To Complication,8104,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,16926.51,,,,,,,fee schedule,16926.51,16926.51, Hemorrhage Or Hematoma Due To Complication,8104,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,16926.51,,,,,,,fee schedule,16926.51,16926.51, Hemorrhage Or Hematoma Due To Complication,8104,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,16926.51,,,,,,,fee schedule,16926.51,16926.51, Hemorrhage Or Hematoma Due To Complication,8104,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,16926.51,,,,,,,fee schedule,16926.51,16926.51, Allergic Reactions,8111,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,2877.43,,,,,,,fee schedule,2877.43,2877.43, Allergic Reactions,8111,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,2877.43,,,,,,,fee schedule,2877.43,2877.43, Allergic Reactions,8111,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,2877.43,,,,,,,fee schedule,2877.43,2877.43, Allergic Reactions,8111,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,2877.43,,,,,,,fee schedule,2877.43,2877.43, Allergic Reactions,8111,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,2877.43,,,,,,,fee schedule,2877.43,2877.43, Allergic Reactions,8111,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,2877.43,,,,,,,fee schedule,2877.43,2877.43, Allergic Reactions,8111,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,2877.43,,,,,,,fee schedule,2877.43,2877.43, Allergic Reactions,8111,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,2877.43,,,,,,,fee schedule,2877.43,2877.43, Allergic Reactions,8111,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,2877.43,,,,,,,fee schedule,2877.43,2877.43, Allergic Reactions,8111,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,2877.43,,,,,,,fee schedule,2877.43,2877.43, Allergic Reactions,8111,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,2877.43,,,,,,,fee schedule,2877.43,2877.43, Allergic Reactions,8112,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4180.99,,,,,,,fee schedule,4180.99,4180.99, Allergic Reactions,8112,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4180.99,,,,,,,fee schedule,4180.99,4180.99, Allergic Reactions,8112,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4180.99,,,,,,,fee schedule,4180.99,4180.99, Allergic Reactions,8112,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4180.99,,,,,,,fee schedule,4180.99,4180.99, Allergic Reactions,8112,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4180.99,,,,,,,fee schedule,4180.99,4180.99, Allergic Reactions,8112,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4180.99,,,,,,,fee schedule,4180.99,4180.99, Allergic Reactions,8112,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4180.99,,,,,,,fee schedule,4180.99,4180.99, Allergic Reactions,8112,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4180.99,,,,,,,fee schedule,4180.99,4180.99, Allergic Reactions,8112,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4180.99,,,,,,,fee schedule,4180.99,4180.99, Allergic Reactions,8112,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4180.99,,,,,,,fee schedule,4180.99,4180.99, Allergic Reactions,8112,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4180.99,,,,,,,fee schedule,4180.99,4180.99, Allergic Reactions,8113,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,8072.61,,,,,,,fee schedule,8072.61,8072.61, Allergic Reactions,8113,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,8072.61,,,,,,,fee schedule,8072.61,8072.61, Allergic Reactions,8113,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,8072.61,,,,,,,fee schedule,8072.61,8072.61, Allergic Reactions,8113,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,8072.61,,,,,,,fee schedule,8072.61,8072.61, Allergic Reactions,8113,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,8072.61,,,,,,,fee schedule,8072.61,8072.61, Allergic Reactions,8113,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,8072.61,,,,,,,fee schedule,8072.61,8072.61, Allergic Reactions,8113,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,8072.61,,,,,,,fee schedule,8072.61,8072.61, Allergic Reactions,8113,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,8072.61,,,,,,,fee schedule,8072.61,8072.61, Allergic Reactions,8113,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,8072.61,,,,,,,fee schedule,8072.61,8072.61, Allergic Reactions,8113,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,8072.61,,,,,,,fee schedule,8072.61,8072.61, Allergic Reactions,8113,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,8072.61,,,,,,,fee schedule,8072.61,8072.61, Allergic Reactions,8114,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,15710.47,,,,,,,fee schedule,15710.47,15710.47, Allergic Reactions,8114,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,15710.47,,,,,,,fee schedule,15710.47,15710.47, Allergic Reactions,8114,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,15710.47,,,,,,,fee schedule,15710.47,15710.47, Allergic Reactions,8114,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,15710.47,,,,,,,fee schedule,15710.47,15710.47, Allergic Reactions,8114,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,15710.47,,,,,,,fee schedule,15710.47,15710.47, Allergic Reactions,8114,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,15710.47,,,,,,,fee schedule,15710.47,15710.47, Allergic Reactions,8114,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,15710.47,,,,,,,fee schedule,15710.47,15710.47, Allergic Reactions,8114,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,15710.47,,,,,,,fee schedule,15710.47,15710.47, Allergic Reactions,8114,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,15710.47,,,,,,,fee schedule,15710.47,15710.47, Allergic Reactions,8114,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,15710.47,,,,,,,fee schedule,15710.47,15710.47, Allergic Reactions,8114,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,15710.47,,,,,,,fee schedule,15710.47,15710.47, Poisoning Of Medicinal Agents,8121,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,3075.75,,,,,,,fee schedule,3075.75,3075.75, Poisoning Of Medicinal Agents,8121,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,3075.75,,,,,,,fee schedule,3075.75,3075.75, Poisoning Of Medicinal Agents,8121,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,3075.75,,,,,,,fee schedule,3075.75,3075.75, Poisoning Of Medicinal Agents,8121,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,3075.75,,,,,,,fee schedule,3075.75,3075.75, Poisoning Of Medicinal Agents,8121,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,3075.75,,,,,,,fee schedule,3075.75,3075.75, Poisoning Of Medicinal Agents,8121,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,3075.75,,,,,,,fee schedule,3075.75,3075.75, Poisoning Of Medicinal Agents,8121,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,3075.75,,,,,,,fee schedule,3075.75,3075.75, Poisoning Of Medicinal Agents,8121,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,3075.75,,,,,,,fee schedule,3075.75,3075.75, Poisoning Of Medicinal Agents,8121,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,3075.75,,,,,,,fee schedule,3075.75,3075.75, Poisoning Of Medicinal Agents,8121,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,3075.75,,,,,,,fee schedule,3075.75,3075.75, Poisoning Of Medicinal Agents,8121,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,3075.75,,,,,,,fee schedule,3075.75,3075.75, Poisoning Of Medicinal Agents,8122,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4595.28,,,,,,,fee schedule,4595.28,4595.28, Poisoning Of Medicinal Agents,8122,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4595.28,,,,,,,fee schedule,4595.28,4595.28, Poisoning Of Medicinal Agents,8122,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4595.28,,,,,,,fee schedule,4595.28,4595.28, Poisoning Of Medicinal Agents,8122,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4595.28,,,,,,,fee schedule,4595.28,4595.28, Poisoning Of Medicinal Agents,8122,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4595.28,,,,,,,fee schedule,4595.28,4595.28, Poisoning Of Medicinal Agents,8122,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4595.28,,,,,,,fee schedule,4595.28,4595.28, Poisoning Of Medicinal Agents,8122,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4595.28,,,,,,,fee schedule,4595.28,4595.28, Poisoning Of Medicinal Agents,8122,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4595.28,,,,,,,fee schedule,4595.28,4595.28, Poisoning Of Medicinal Agents,8122,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4595.28,,,,,,,fee schedule,4595.28,4595.28, Poisoning Of Medicinal Agents,8122,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4595.28,,,,,,,fee schedule,4595.28,4595.28, Poisoning Of Medicinal Agents,8122,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4595.28,,,,,,,fee schedule,4595.28,4595.28, Poisoning Of Medicinal Agents,8123,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,7318.14,,,,,,,fee schedule,7318.14,7318.14, Poisoning Of Medicinal Agents,8123,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,7318.14,,,,,,,fee schedule,7318.14,7318.14, Poisoning Of Medicinal Agents,8123,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,7318.14,,,,,,,fee schedule,7318.14,7318.14, Poisoning Of Medicinal Agents,8123,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,7318.14,,,,,,,fee schedule,7318.14,7318.14, Poisoning Of Medicinal Agents,8123,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,7318.14,,,,,,,fee schedule,7318.14,7318.14, Poisoning Of Medicinal Agents,8123,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,7318.14,,,,,,,fee schedule,7318.14,7318.14, Poisoning Of Medicinal Agents,8123,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,7318.14,,,,,,,fee schedule,7318.14,7318.14, Poisoning Of Medicinal Agents,8123,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,7318.14,,,,,,,fee schedule,7318.14,7318.14, Poisoning Of Medicinal Agents,8123,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,7318.14,,,,,,,fee schedule,7318.14,7318.14, Poisoning Of Medicinal Agents,8123,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,7318.14,,,,,,,fee schedule,7318.14,7318.14, Poisoning Of Medicinal Agents,8123,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,7318.14,,,,,,,fee schedule,7318.14,7318.14, Poisoning Of Medicinal Agents,8124,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,14359.62,,,,,,,fee schedule,14359.62,14359.62, Poisoning Of Medicinal Agents,8124,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,14359.62,,,,,,,fee schedule,14359.62,14359.62, Poisoning Of Medicinal Agents,8124,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,14359.62,,,,,,,fee schedule,14359.62,14359.62, Poisoning Of Medicinal Agents,8124,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,14359.62,,,,,,,fee schedule,14359.62,14359.62, Poisoning Of Medicinal Agents,8124,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,14359.62,,,,,,,fee schedule,14359.62,14359.62, Poisoning Of Medicinal Agents,8124,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,14359.62,,,,,,,fee schedule,14359.62,14359.62, Poisoning Of Medicinal Agents,8124,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,14359.62,,,,,,,fee schedule,14359.62,14359.62, Poisoning Of Medicinal Agents,8124,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,14359.62,,,,,,,fee schedule,14359.62,14359.62, Poisoning Of Medicinal Agents,8124,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,14359.62,,,,,,,fee schedule,14359.62,14359.62, Poisoning Of Medicinal Agents,8124,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,14359.62,,,,,,,fee schedule,14359.62,14359.62, Poisoning Of Medicinal Agents,8124,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,14359.62,,,,,,,fee schedule,14359.62,14359.62, Other Complications Of Treatment,8131,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4494.35,,,,,,,fee schedule,4494.35,4494.35, Other Complications Of Treatment,8131,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4494.35,,,,,,,fee schedule,4494.35,4494.35, Other Complications Of Treatment,8131,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4494.35,,,,,,,fee schedule,4494.35,4494.35, Other Complications Of Treatment,8131,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4494.35,,,,,,,fee schedule,4494.35,4494.35, Other Complications Of Treatment,8131,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4494.35,,,,,,,fee schedule,4494.35,4494.35, Other Complications Of Treatment,8131,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4494.35,,,,,,,fee schedule,4494.35,4494.35, Other Complications Of Treatment,8131,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4494.35,,,,,,,fee schedule,4494.35,4494.35, Other Complications Of Treatment,8131,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4494.35,,,,,,,fee schedule,4494.35,4494.35, Other Complications Of Treatment,8131,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4494.35,,,,,,,fee schedule,4494.35,4494.35, Other Complications Of Treatment,8131,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4494.35,,,,,,,fee schedule,4494.35,4494.35, Other Complications Of Treatment,8131,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4494.35,,,,,,,fee schedule,4494.35,4494.35, Other Complications Of Treatment,8132,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,6125.39,,,,,,,fee schedule,6125.39,6125.39, Other Complications Of Treatment,8132,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,6125.39,,,,,,,fee schedule,6125.39,6125.39, Other Complications Of Treatment,8132,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,6125.39,,,,,,,fee schedule,6125.39,6125.39, Other Complications Of Treatment,8132,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,6125.39,,,,,,,fee schedule,6125.39,6125.39, Other Complications Of Treatment,8132,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,6125.39,,,,,,,fee schedule,6125.39,6125.39, Other Complications Of Treatment,8132,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,6125.39,,,,,,,fee schedule,6125.39,6125.39, Other Complications Of Treatment,8132,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,6125.39,,,,,,,fee schedule,6125.39,6125.39, Other Complications Of Treatment,8132,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,6125.39,,,,,,,fee schedule,6125.39,6125.39, Other Complications Of Treatment,8132,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,6125.39,,,,,,,fee schedule,6125.39,6125.39, Other Complications Of Treatment,8132,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,6125.39,,,,,,,fee schedule,6125.39,6125.39, Other Complications Of Treatment,8132,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,6125.39,,,,,,,fee schedule,6125.39,6125.39, Other Complications Of Treatment,8133,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,8976,,,,,,,fee schedule,8976,8976, Other Complications Of Treatment,8133,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,8976,,,,,,,fee schedule,8976,8976, Other Complications Of Treatment,8133,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,8976,,,,,,,fee schedule,8976,8976, Other Complications Of Treatment,8133,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,8976,,,,,,,fee schedule,8976,8976, Other Complications Of Treatment,8133,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,8976,,,,,,,fee schedule,8976,8976, Other Complications Of Treatment,8133,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,8976,,,,,,,fee schedule,8976,8976, Other Complications Of Treatment,8133,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,8976,,,,,,,fee schedule,8976,8976, Other Complications Of Treatment,8133,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,8976,,,,,,,fee schedule,8976,8976, Other Complications Of Treatment,8133,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,8976,,,,,,,fee schedule,8976,8976, Other Complications Of Treatment,8133,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,8976,,,,,,,fee schedule,8976,8976, Other Complications Of Treatment,8133,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,8976,,,,,,,fee schedule,8976,8976, Other Complications Of Treatment,8134,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,15805.04,,,,,,,fee schedule,15805.04,15805.04, Other Complications Of Treatment,8134,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,15805.04,,,,,,,fee schedule,15805.04,15805.04, Other Complications Of Treatment,8134,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,15805.04,,,,,,,fee schedule,15805.04,15805.04, Other Complications Of Treatment,8134,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,15805.04,,,,,,,fee schedule,15805.04,15805.04, Other Complications Of Treatment,8134,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,15805.04,,,,,,,fee schedule,15805.04,15805.04, Other Complications Of Treatment,8134,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,15805.04,,,,,,,fee schedule,15805.04,15805.04, Other Complications Of Treatment,8134,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,15805.04,,,,,,,fee schedule,15805.04,15805.04, Other Complications Of Treatment,8134,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,15805.04,,,,,,,fee schedule,15805.04,15805.04, Other Complications Of Treatment,8134,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,15805.04,,,,,,,fee schedule,15805.04,15805.04, Other Complications Of Treatment,8134,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,15805.04,,,,,,,fee schedule,15805.04,15805.04, Other Complications Of Treatment,8134,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,15805.04,,,,,,,fee schedule,15805.04,15805.04, "Other Injury, Poisoning And Toxic Effect Diagnoses",8151,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,3391.23,,,,,,,fee schedule,3391.23,3391.23, "Other Injury, Poisoning And Toxic Effect Diagnoses",8151,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,3391.23,,,,,,,fee schedule,3391.23,3391.23, "Other Injury, Poisoning And Toxic Effect Diagnoses",8151,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,3391.23,,,,,,,fee schedule,3391.23,3391.23, "Other Injury, Poisoning And Toxic Effect Diagnoses",8151,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,3391.23,,,,,,,fee schedule,3391.23,3391.23, "Other Injury, Poisoning And Toxic Effect Diagnoses",8151,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,3391.23,,,,,,,fee schedule,3391.23,3391.23, "Other Injury, Poisoning And Toxic Effect Diagnoses",8151,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,3391.23,,,,,,,fee schedule,3391.23,3391.23, "Other Injury, Poisoning And Toxic Effect Diagnoses",8151,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,3391.23,,,,,,,fee schedule,3391.23,3391.23, "Other Injury, Poisoning And Toxic Effect Diagnoses",8151,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,3391.23,,,,,,,fee schedule,3391.23,3391.23, "Other Injury, Poisoning And Toxic Effect Diagnoses",8151,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,3391.23,,,,,,,fee schedule,3391.23,3391.23, "Other Injury, Poisoning And Toxic Effect Diagnoses",8151,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,3391.23,,,,,,,fee schedule,3391.23,3391.23, "Other Injury, Poisoning And Toxic Effect Diagnoses",8151,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,3391.23,,,,,,,fee schedule,3391.23,3391.23, "Other Injury, Poisoning And Toxic Effect Diagnoses",8152,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5172.6,,,,,,,fee schedule,5172.6,5172.6, "Other Injury, Poisoning And Toxic Effect Diagnoses",8152,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5172.6,,,,,,,fee schedule,5172.6,5172.6, "Other Injury, Poisoning And Toxic Effect Diagnoses",8152,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5172.6,,,,,,,fee schedule,5172.6,5172.6, "Other Injury, Poisoning And Toxic Effect Diagnoses",8152,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5172.6,,,,,,,fee schedule,5172.6,5172.6, "Other Injury, Poisoning And Toxic Effect Diagnoses",8152,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5172.6,,,,,,,fee schedule,5172.6,5172.6, "Other Injury, Poisoning And Toxic Effect Diagnoses",8152,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5172.6,,,,,,,fee schedule,5172.6,5172.6, "Other Injury, Poisoning And Toxic Effect Diagnoses",8152,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5172.6,,,,,,,fee schedule,5172.6,5172.6, "Other Injury, Poisoning And Toxic Effect Diagnoses",8152,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5172.6,,,,,,,fee schedule,5172.6,5172.6, "Other Injury, Poisoning And Toxic Effect Diagnoses",8152,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5172.6,,,,,,,fee schedule,5172.6,5172.6, "Other Injury, Poisoning And Toxic Effect Diagnoses",8152,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5172.6,,,,,,,fee schedule,5172.6,5172.6, "Other Injury, Poisoning And Toxic Effect Diagnoses",8152,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5172.6,,,,,,,fee schedule,5172.6,5172.6, "Other Injury, Poisoning And Toxic Effect Diagnoses",8153,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,8647.11,,,,,,,fee schedule,8647.11,8647.11, "Other Injury, Poisoning And Toxic Effect Diagnoses",8153,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,8647.11,,,,,,,fee schedule,8647.11,8647.11, "Other Injury, Poisoning And Toxic Effect Diagnoses",8153,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,8647.11,,,,,,,fee schedule,8647.11,8647.11, "Other Injury, Poisoning And Toxic Effect Diagnoses",8153,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,8647.11,,,,,,,fee schedule,8647.11,8647.11, "Other Injury, Poisoning And Toxic Effect Diagnoses",8153,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,8647.11,,,,,,,fee schedule,8647.11,8647.11, "Other Injury, Poisoning And Toxic Effect Diagnoses",8153,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,8647.11,,,,,,,fee schedule,8647.11,8647.11, "Other Injury, Poisoning And Toxic Effect Diagnoses",8153,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,8647.11,,,,,,,fee schedule,8647.11,8647.11, "Other Injury, Poisoning And Toxic Effect Diagnoses",8153,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,8647.11,,,,,,,fee schedule,8647.11,8647.11, "Other Injury, Poisoning And Toxic Effect Diagnoses",8153,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,8647.11,,,,,,,fee schedule,8647.11,8647.11, "Other Injury, Poisoning And Toxic Effect Diagnoses",8153,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,8647.11,,,,,,,fee schedule,8647.11,8647.11, "Other Injury, Poisoning And Toxic Effect Diagnoses",8153,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,8647.11,,,,,,,fee schedule,8647.11,8647.11, "Other Injury, Poisoning And Toxic Effect Diagnoses",8154,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,18386.05,,,,,,,fee schedule,18386.05,18386.05, "Other Injury, Poisoning And Toxic Effect Diagnoses",8154,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,18386.05,,,,,,,fee schedule,18386.05,18386.05, "Other Injury, Poisoning And Toxic Effect Diagnoses",8154,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,18386.05,,,,,,,fee schedule,18386.05,18386.05, "Other Injury, Poisoning And Toxic Effect Diagnoses",8154,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,18386.05,,,,,,,fee schedule,18386.05,18386.05, "Other Injury, Poisoning And Toxic Effect Diagnoses",8154,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,18386.05,,,,,,,fee schedule,18386.05,18386.05, "Other Injury, Poisoning And Toxic Effect Diagnoses",8154,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,18386.05,,,,,,,fee schedule,18386.05,18386.05, "Other Injury, Poisoning And Toxic Effect Diagnoses",8154,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,18386.05,,,,,,,fee schedule,18386.05,18386.05, "Other Injury, Poisoning And Toxic Effect Diagnoses",8154,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,18386.05,,,,,,,fee schedule,18386.05,18386.05, "Other Injury, Poisoning And Toxic Effect Diagnoses",8154,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,18386.05,,,,,,,fee schedule,18386.05,18386.05, "Other Injury, Poisoning And Toxic Effect Diagnoses",8154,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,18386.05,,,,,,,fee schedule,18386.05,18386.05, "Other Injury, Poisoning And Toxic Effect Diagnoses",8154,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,18386.05,,,,,,,fee schedule,18386.05,18386.05, Toxic Effects Of Non-Medicinal Substances,8161,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,3610.73,,,,,,,fee schedule,3610.73,3610.73, Toxic Effects Of Non-Medicinal Substances,8161,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,3610.73,,,,,,,fee schedule,3610.73,3610.73, Toxic Effects Of Non-Medicinal Substances,8161,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,3610.73,,,,,,,fee schedule,3610.73,3610.73, Toxic Effects Of Non-Medicinal Substances,8161,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,3610.73,,,,,,,fee schedule,3610.73,3610.73, Toxic Effects Of Non-Medicinal Substances,8161,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,3610.73,,,,,,,fee schedule,3610.73,3610.73, Toxic Effects Of Non-Medicinal Substances,8161,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,3610.73,,,,,,,fee schedule,3610.73,3610.73, Toxic Effects Of Non-Medicinal Substances,8161,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,3610.73,,,,,,,fee schedule,3610.73,3610.73, Toxic Effects Of Non-Medicinal Substances,8161,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,3610.73,,,,,,,fee schedule,3610.73,3610.73, Toxic Effects Of Non-Medicinal Substances,8161,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,3610.73,,,,,,,fee schedule,3610.73,3610.73, Toxic Effects Of Non-Medicinal Substances,8161,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,3610.73,,,,,,,fee schedule,3610.73,3610.73, Toxic Effects Of Non-Medicinal Substances,8161,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,3610.73,,,,,,,fee schedule,3610.73,3610.73, Toxic Effects Of Non-Medicinal Substances,8162,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4986.27,,,,,,,fee schedule,4986.27,4986.27, Toxic Effects Of Non-Medicinal Substances,8162,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4986.27,,,,,,,fee schedule,4986.27,4986.27, Toxic Effects Of Non-Medicinal Substances,8162,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4986.27,,,,,,,fee schedule,4986.27,4986.27, Toxic Effects Of Non-Medicinal Substances,8162,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4986.27,,,,,,,fee schedule,4986.27,4986.27, Toxic Effects Of Non-Medicinal Substances,8162,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4986.27,,,,,,,fee schedule,4986.27,4986.27, Toxic Effects Of Non-Medicinal Substances,8162,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4986.27,,,,,,,fee schedule,4986.27,4986.27, Toxic Effects Of Non-Medicinal Substances,8162,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4986.27,,,,,,,fee schedule,4986.27,4986.27, Toxic Effects Of Non-Medicinal Substances,8162,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4986.27,,,,,,,fee schedule,4986.27,4986.27, Toxic Effects Of Non-Medicinal Substances,8162,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4986.27,,,,,,,fee schedule,4986.27,4986.27, Toxic Effects Of Non-Medicinal Substances,8162,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4986.27,,,,,,,fee schedule,4986.27,4986.27, Toxic Effects Of Non-Medicinal Substances,8162,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4986.27,,,,,,,fee schedule,4986.27,4986.27, Toxic Effects Of Non-Medicinal Substances,8163,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,9405.81,,,,,,,fee schedule,9405.81,9405.81, Toxic Effects Of Non-Medicinal Substances,8163,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,9405.81,,,,,,,fee schedule,9405.81,9405.81, Toxic Effects Of Non-Medicinal Substances,8163,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,9405.81,,,,,,,fee schedule,9405.81,9405.81, Toxic Effects Of Non-Medicinal Substances,8163,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,9405.81,,,,,,,fee schedule,9405.81,9405.81, Toxic Effects Of Non-Medicinal Substances,8163,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,9405.81,,,,,,,fee schedule,9405.81,9405.81, Toxic Effects Of Non-Medicinal Substances,8163,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,9405.81,,,,,,,fee schedule,9405.81,9405.81, Toxic Effects Of Non-Medicinal Substances,8163,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,9405.81,,,,,,,fee schedule,9405.81,9405.81, Toxic Effects Of Non-Medicinal Substances,8163,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,9405.81,,,,,,,fee schedule,9405.81,9405.81, Toxic Effects Of Non-Medicinal Substances,8163,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,9405.81,,,,,,,fee schedule,9405.81,9405.81, Toxic Effects Of Non-Medicinal Substances,8163,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,9405.81,,,,,,,fee schedule,9405.81,9405.81, Toxic Effects Of Non-Medicinal Substances,8163,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,9405.81,,,,,,,fee schedule,9405.81,9405.81, Toxic Effects Of Non-Medicinal Substances,8164,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,18011.99,,,,,,,fee schedule,18011.99,18011.99, Toxic Effects Of Non-Medicinal Substances,8164,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,18011.99,,,,,,,fee schedule,18011.99,18011.99, Toxic Effects Of Non-Medicinal Substances,8164,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,18011.99,,,,,,,fee schedule,18011.99,18011.99, Toxic Effects Of Non-Medicinal Substances,8164,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,18011.99,,,,,,,fee schedule,18011.99,18011.99, Toxic Effects Of Non-Medicinal Substances,8164,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,18011.99,,,,,,,fee schedule,18011.99,18011.99, Toxic Effects Of Non-Medicinal Substances,8164,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,18011.99,,,,,,,fee schedule,18011.99,18011.99, Toxic Effects Of Non-Medicinal Substances,8164,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,18011.99,,,,,,,fee schedule,18011.99,18011.99, Toxic Effects Of Non-Medicinal Substances,8164,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,18011.99,,,,,,,fee schedule,18011.99,18011.99, Toxic Effects Of Non-Medicinal Substances,8164,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,18011.99,,,,,,,fee schedule,18011.99,18011.99, Toxic Effects Of Non-Medicinal Substances,8164,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,18011.99,,,,,,,fee schedule,18011.99,18011.99, Toxic Effects Of Non-Medicinal Substances,8164,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,18011.99,,,,,,,fee schedule,18011.99,18011.99, Intentional Self-Harm And Attempted Suicide,8171,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,3063.05,,,,,,,fee schedule,3063.05,3063.05, Intentional Self-Harm And Attempted Suicide,8171,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,3063.05,,,,,,,fee schedule,3063.05,3063.05, Intentional Self-Harm And Attempted Suicide,8171,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,3063.05,,,,,,,fee schedule,3063.05,3063.05, Intentional Self-Harm And Attempted Suicide,8171,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,3063.05,,,,,,,fee schedule,3063.05,3063.05, Intentional Self-Harm And Attempted Suicide,8171,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,3063.05,,,,,,,fee schedule,3063.05,3063.05, Intentional Self-Harm And Attempted Suicide,8171,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,3063.05,,,,,,,fee schedule,3063.05,3063.05, Intentional Self-Harm And Attempted Suicide,8171,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,3063.05,,,,,,,fee schedule,3063.05,3063.05, Intentional Self-Harm And Attempted Suicide,8171,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,3063.05,,,,,,,fee schedule,3063.05,3063.05, Intentional Self-Harm And Attempted Suicide,8171,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,3063.05,,,,,,,fee schedule,3063.05,3063.05, Intentional Self-Harm And Attempted Suicide,8171,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,3063.05,,,,,,,fee schedule,3063.05,3063.05, Intentional Self-Harm And Attempted Suicide,8171,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,3063.05,,,,,,,fee schedule,3063.05,3063.05, Intentional Self-Harm And Attempted Suicide,8172,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4471.06,,,,,,,fee schedule,4471.06,4471.06, Intentional Self-Harm And Attempted Suicide,8172,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4471.06,,,,,,,fee schedule,4471.06,4471.06, Intentional Self-Harm And Attempted Suicide,8172,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4471.06,,,,,,,fee schedule,4471.06,4471.06, Intentional Self-Harm And Attempted Suicide,8172,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4471.06,,,,,,,fee schedule,4471.06,4471.06, Intentional Self-Harm And Attempted Suicide,8172,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4471.06,,,,,,,fee schedule,4471.06,4471.06, Intentional Self-Harm And Attempted Suicide,8172,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4471.06,,,,,,,fee schedule,4471.06,4471.06, Intentional Self-Harm And Attempted Suicide,8172,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4471.06,,,,,,,fee schedule,4471.06,4471.06, Intentional Self-Harm And Attempted Suicide,8172,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4471.06,,,,,,,fee schedule,4471.06,4471.06, Intentional Self-Harm And Attempted Suicide,8172,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4471.06,,,,,,,fee schedule,4471.06,4471.06, Intentional Self-Harm And Attempted Suicide,8172,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4471.06,,,,,,,fee schedule,4471.06,4471.06, Intentional Self-Harm And Attempted Suicide,8172,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4471.06,,,,,,,fee schedule,4471.06,4471.06, Intentional Self-Harm And Attempted Suicide,8173,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,8369.04,,,,,,,fee schedule,8369.04,8369.04, Intentional Self-Harm And Attempted Suicide,8173,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,8369.04,,,,,,,fee schedule,8369.04,8369.04, Intentional Self-Harm And Attempted Suicide,8173,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,8369.04,,,,,,,fee schedule,8369.04,8369.04, Intentional Self-Harm And Attempted Suicide,8173,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,8369.04,,,,,,,fee schedule,8369.04,8369.04, Intentional Self-Harm And Attempted Suicide,8173,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,8369.04,,,,,,,fee schedule,8369.04,8369.04, Intentional Self-Harm And Attempted Suicide,8173,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,8369.04,,,,,,,fee schedule,8369.04,8369.04, Intentional Self-Harm And Attempted Suicide,8173,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,8369.04,,,,,,,fee schedule,8369.04,8369.04, Intentional Self-Harm And Attempted Suicide,8173,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,8369.04,,,,,,,fee schedule,8369.04,8369.04, Intentional Self-Harm And Attempted Suicide,8173,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,8369.04,,,,,,,fee schedule,8369.04,8369.04, Intentional Self-Harm And Attempted Suicide,8173,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,8369.04,,,,,,,fee schedule,8369.04,8369.04, Intentional Self-Harm And Attempted Suicide,8173,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,8369.04,,,,,,,fee schedule,8369.04,8369.04, Intentional Self-Harm And Attempted Suicide,8174,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,17042.26,,,,,,,fee schedule,17042.26,17042.26, Intentional Self-Harm And Attempted Suicide,8174,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,17042.26,,,,,,,fee schedule,17042.26,17042.26, Intentional Self-Harm And Attempted Suicide,8174,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,17042.26,,,,,,,fee schedule,17042.26,17042.26, Intentional Self-Harm And Attempted Suicide,8174,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,17042.26,,,,,,,fee schedule,17042.26,17042.26, Intentional Self-Harm And Attempted Suicide,8174,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,17042.26,,,,,,,fee schedule,17042.26,17042.26, Intentional Self-Harm And Attempted Suicide,8174,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,17042.26,,,,,,,fee schedule,17042.26,17042.26, Intentional Self-Harm And Attempted Suicide,8174,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,17042.26,,,,,,,fee schedule,17042.26,17042.26, Intentional Self-Harm And Attempted Suicide,8174,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,17042.26,,,,,,,fee schedule,17042.26,17042.26, Intentional Self-Harm And Attempted Suicide,8174,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,17042.26,,,,,,,fee schedule,17042.26,17042.26, Intentional Self-Harm And Attempted Suicide,8174,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,17042.26,,,,,,,fee schedule,17042.26,17042.26, Intentional Self-Harm And Attempted Suicide,8174,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,17042.26,,,,,,,fee schedule,17042.26,17042.26, Extensive Third Degree Burns With Skin Graft,8411,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,33104.91,,,,,,,fee schedule,33104.91,33104.91, Extensive Third Degree Burns With Skin Graft,8411,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,33104.91,,,,,,,fee schedule,33104.91,33104.91, Extensive Third Degree Burns With Skin Graft,8411,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,33104.91,,,,,,,fee schedule,33104.91,33104.91, Extensive Third Degree Burns With Skin Graft,8411,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,33104.91,,,,,,,fee schedule,33104.91,33104.91, Extensive Third Degree Burns With Skin Graft,8411,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,33104.91,,,,,,,fee schedule,33104.91,33104.91, Extensive Third Degree Burns With Skin Graft,8411,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,33104.91,,,,,,,fee schedule,33104.91,33104.91, Extensive Third Degree Burns With Skin Graft,8411,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,33104.91,,,,,,,fee schedule,33104.91,33104.91, Extensive Third Degree Burns With Skin Graft,8411,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,33104.91,,,,,,,fee schedule,33104.91,33104.91, Extensive Third Degree Burns With Skin Graft,8411,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,33104.91,,,,,,,fee schedule,33104.91,33104.91, Extensive Third Degree Burns With Skin Graft,8411,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,33104.91,,,,,,,fee schedule,33104.91,33104.91, Extensive Third Degree Burns With Skin Graft,8411,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,33104.91,,,,,,,fee schedule,33104.91,33104.91, Extensive Third Degree Burns With Skin Graft,8412,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,33104.91,,,,,,,fee schedule,33104.91,33104.91, Extensive Third Degree Burns With Skin Graft,8412,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,33104.91,,,,,,,fee schedule,33104.91,33104.91, Extensive Third Degree Burns With Skin Graft,8412,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,33104.91,,,,,,,fee schedule,33104.91,33104.91, Extensive Third Degree Burns With Skin Graft,8412,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,33104.91,,,,,,,fee schedule,33104.91,33104.91, Extensive Third Degree Burns With Skin Graft,8412,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,33104.91,,,,,,,fee schedule,33104.91,33104.91, Extensive Third Degree Burns With Skin Graft,8412,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,33104.91,,,,,,,fee schedule,33104.91,33104.91, Extensive Third Degree Burns With Skin Graft,8412,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,33104.91,,,,,,,fee schedule,33104.91,33104.91, Extensive Third Degree Burns With Skin Graft,8412,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,33104.91,,,,,,,fee schedule,33104.91,33104.91, Extensive Third Degree Burns With Skin Graft,8412,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,33104.91,,,,,,,fee schedule,33104.91,33104.91, Extensive Third Degree Burns With Skin Graft,8412,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,33104.91,,,,,,,fee schedule,33104.91,33104.91, Extensive Third Degree Burns With Skin Graft,8412,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,33104.91,,,,,,,fee schedule,33104.91,33104.91, Extensive Third Degree Burns With Skin Graft,8413,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,50524.05,,,,,,,fee schedule,50524.05,50524.05, Extensive Third Degree Burns With Skin Graft,8413,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,50524.05,,,,,,,fee schedule,50524.05,50524.05, Extensive Third Degree Burns With Skin Graft,8413,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,50524.05,,,,,,,fee schedule,50524.05,50524.05, Extensive Third Degree Burns With Skin Graft,8413,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,50524.05,,,,,,,fee schedule,50524.05,50524.05, Extensive Third Degree Burns With Skin Graft,8413,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,50524.05,,,,,,,fee schedule,50524.05,50524.05, Extensive Third Degree Burns With Skin Graft,8413,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,50524.05,,,,,,,fee schedule,50524.05,50524.05, Extensive Third Degree Burns With Skin Graft,8413,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,50524.05,,,,,,,fee schedule,50524.05,50524.05, Extensive Third Degree Burns With Skin Graft,8413,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,50524.05,,,,,,,fee schedule,50524.05,50524.05, Extensive Third Degree Burns With Skin Graft,8413,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,50524.05,,,,,,,fee schedule,50524.05,50524.05, Extensive Third Degree Burns With Skin Graft,8413,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,50524.05,,,,,,,fee schedule,50524.05,50524.05, Extensive Third Degree Burns With Skin Graft,8413,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,50524.05,,,,,,,fee schedule,50524.05,50524.05, Extensive Third Degree Burns With Skin Graft,8414,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,155356.49,,,,,,,fee schedule,155356.49,155356.49, Extensive Third Degree Burns With Skin Graft,8414,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,155356.49,,,,,,,fee schedule,155356.49,155356.49, Extensive Third Degree Burns With Skin Graft,8414,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,155356.49,,,,,,,fee schedule,155356.49,155356.49, Extensive Third Degree Burns With Skin Graft,8414,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,155356.49,,,,,,,fee schedule,155356.49,155356.49, Extensive Third Degree Burns With Skin Graft,8414,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,155356.49,,,,,,,fee schedule,155356.49,155356.49, Extensive Third Degree Burns With Skin Graft,8414,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,155356.49,,,,,,,fee schedule,155356.49,155356.49, Extensive Third Degree Burns With Skin Graft,8414,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,155356.49,,,,,,,fee schedule,155356.49,155356.49, Extensive Third Degree Burns With Skin Graft,8414,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,155356.49,,,,,,,fee schedule,155356.49,155356.49, Extensive Third Degree Burns With Skin Graft,8414,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,155356.49,,,,,,,fee schedule,155356.49,155356.49, Extensive Third Degree Burns With Skin Graft,8414,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,155356.49,,,,,,,fee schedule,155356.49,155356.49, Extensive Third Degree Burns With Skin Graft,8414,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,155356.49,,,,,,,fee schedule,155356.49,155356.49, Burns With Skin Graft Except Extensive Third Degree Burns,8421,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,12523.91,,,,,,,fee schedule,12523.91,12523.91, Burns With Skin Graft Except Extensive Third Degree Burns,8421,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,12523.91,,,,,,,fee schedule,12523.91,12523.91, Burns With Skin Graft Except Extensive Third Degree Burns,8421,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,12523.91,,,,,,,fee schedule,12523.91,12523.91, Burns With Skin Graft Except Extensive Third Degree Burns,8421,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,12523.91,,,,,,,fee schedule,12523.91,12523.91, Burns With Skin Graft Except Extensive Third Degree Burns,8421,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,12523.91,,,,,,,fee schedule,12523.91,12523.91, Burns With Skin Graft Except Extensive Third Degree Burns,8421,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,12523.91,,,,,,,fee schedule,12523.91,12523.91, Burns With Skin Graft Except Extensive Third Degree Burns,8421,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,12523.91,,,,,,,fee schedule,12523.91,12523.91, Burns With Skin Graft Except Extensive Third Degree Burns,8421,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,12523.91,,,,,,,fee schedule,12523.91,12523.91, Burns With Skin Graft Except Extensive Third Degree Burns,8421,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,12523.91,,,,,,,fee schedule,12523.91,12523.91, Burns With Skin Graft Except Extensive Third Degree Burns,8421,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,12523.91,,,,,,,fee schedule,12523.91,12523.91, Burns With Skin Graft Except Extensive Third Degree Burns,8421,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,12523.91,,,,,,,fee schedule,12523.91,12523.91, Burns With Skin Graft Except Extensive Third Degree Burns,8422,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,18875.85,,,,,,,fee schedule,18875.85,18875.85, Burns With Skin Graft Except Extensive Third Degree Burns,8422,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,18875.85,,,,,,,fee schedule,18875.85,18875.85, Burns With Skin Graft Except Extensive Third Degree Burns,8422,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,18875.85,,,,,,,fee schedule,18875.85,18875.85, Burns With Skin Graft Except Extensive Third Degree Burns,8422,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,18875.85,,,,,,,fee schedule,18875.85,18875.85, Burns With Skin Graft Except Extensive Third Degree Burns,8422,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,18875.85,,,,,,,fee schedule,18875.85,18875.85, Burns With Skin Graft Except Extensive Third Degree Burns,8422,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,18875.85,,,,,,,fee schedule,18875.85,18875.85, Burns With Skin Graft Except Extensive Third Degree Burns,8422,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,18875.85,,,,,,,fee schedule,18875.85,18875.85, Burns With Skin Graft Except Extensive Third Degree Burns,8422,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,18875.85,,,,,,,fee schedule,18875.85,18875.85, Burns With Skin Graft Except Extensive Third Degree Burns,8422,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,18875.85,,,,,,,fee schedule,18875.85,18875.85, Burns With Skin Graft Except Extensive Third Degree Burns,8422,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,18875.85,,,,,,,fee schedule,18875.85,18875.85, Burns With Skin Graft Except Extensive Third Degree Burns,8422,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,18875.85,,,,,,,fee schedule,18875.85,18875.85, Burns With Skin Graft Except Extensive Third Degree Burns,8423,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,35132.59,,,,,,,fee schedule,35132.59,35132.59, Burns With Skin Graft Except Extensive Third Degree Burns,8423,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,35132.59,,,,,,,fee schedule,35132.59,35132.59, Burns With Skin Graft Except Extensive Third Degree Burns,8423,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,35132.59,,,,,,,fee schedule,35132.59,35132.59, Burns With Skin Graft Except Extensive Third Degree Burns,8423,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,35132.59,,,,,,,fee schedule,35132.59,35132.59, Burns With Skin Graft Except Extensive Third Degree Burns,8423,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,35132.59,,,,,,,fee schedule,35132.59,35132.59, Burns With Skin Graft Except Extensive Third Degree Burns,8423,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,35132.59,,,,,,,fee schedule,35132.59,35132.59, Burns With Skin Graft Except Extensive Third Degree Burns,8423,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,35132.59,,,,,,,fee schedule,35132.59,35132.59, Burns With Skin Graft Except Extensive Third Degree Burns,8423,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,35132.59,,,,,,,fee schedule,35132.59,35132.59, Burns With Skin Graft Except Extensive Third Degree Burns,8423,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,35132.59,,,,,,,fee schedule,35132.59,35132.59, Burns With Skin Graft Except Extensive Third Degree Burns,8423,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,35132.59,,,,,,,fee schedule,35132.59,35132.59, Burns With Skin Graft Except Extensive Third Degree Burns,8423,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,35132.59,,,,,,,fee schedule,35132.59,35132.59, Burns With Skin Graft Except Extensive Third Degree Burns,8424,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,86977.13,,,,,,,fee schedule,86977.13,86977.13, Burns With Skin Graft Except Extensive Third Degree Burns,8424,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,86977.13,,,,,,,fee schedule,86977.13,86977.13, Burns With Skin Graft Except Extensive Third Degree Burns,8424,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,86977.13,,,,,,,fee schedule,86977.13,86977.13, Burns With Skin Graft Except Extensive Third Degree Burns,8424,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,86977.13,,,,,,,fee schedule,86977.13,86977.13, Burns With Skin Graft Except Extensive Third Degree Burns,8424,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,86977.13,,,,,,,fee schedule,86977.13,86977.13, Burns With Skin Graft Except Extensive Third Degree Burns,8424,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,86977.13,,,,,,,fee schedule,86977.13,86977.13, Burns With Skin Graft Except Extensive Third Degree Burns,8424,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,86977.13,,,,,,,fee schedule,86977.13,86977.13, Burns With Skin Graft Except Extensive Third Degree Burns,8424,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,86977.13,,,,,,,fee schedule,86977.13,86977.13, Burns With Skin Graft Except Extensive Third Degree Burns,8424,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,86977.13,,,,,,,fee schedule,86977.13,86977.13, Burns With Skin Graft Except Extensive Third Degree Burns,8424,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,86977.13,,,,,,,fee schedule,86977.13,86977.13, Burns With Skin Graft Except Extensive Third Degree Burns,8424,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,86977.13,,,,,,,fee schedule,86977.13,86977.13, Extensive Third Degree Burns Without Skin Graft,8431,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5394.92,,,,,,,fee schedule,5394.92,5394.92, Extensive Third Degree Burns Without Skin Graft,8431,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5394.92,,,,,,,fee schedule,5394.92,5394.92, Extensive Third Degree Burns Without Skin Graft,8431,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5394.92,,,,,,,fee schedule,5394.92,5394.92, Extensive Third Degree Burns Without Skin Graft,8431,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5394.92,,,,,,,fee schedule,5394.92,5394.92, Extensive Third Degree Burns Without Skin Graft,8431,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5394.92,,,,,,,fee schedule,5394.92,5394.92, Extensive Third Degree Burns Without Skin Graft,8431,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5394.92,,,,,,,fee schedule,5394.92,5394.92, Extensive Third Degree Burns Without Skin Graft,8431,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5394.92,,,,,,,fee schedule,5394.92,5394.92, Extensive Third Degree Burns Without Skin Graft,8431,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5394.92,,,,,,,fee schedule,5394.92,5394.92, Extensive Third Degree Burns Without Skin Graft,8431,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5394.92,,,,,,,fee schedule,5394.92,5394.92, Extensive Third Degree Burns Without Skin Graft,8431,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5394.92,,,,,,,fee schedule,5394.92,5394.92, Extensive Third Degree Burns Without Skin Graft,8431,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5394.92,,,,,,,fee schedule,5394.92,5394.92, Extensive Third Degree Burns Without Skin Graft,8432,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,7666.09,,,,,,,fee schedule,7666.09,7666.09, Extensive Third Degree Burns Without Skin Graft,8432,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,7666.09,,,,,,,fee schedule,7666.09,7666.09, Extensive Third Degree Burns Without Skin Graft,8432,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,7666.09,,,,,,,fee schedule,7666.09,7666.09, Extensive Third Degree Burns Without Skin Graft,8432,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,7666.09,,,,,,,fee schedule,7666.09,7666.09, Extensive Third Degree Burns Without Skin Graft,8432,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,7666.09,,,,,,,fee schedule,7666.09,7666.09, Extensive Third Degree Burns Without Skin Graft,8432,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,7666.09,,,,,,,fee schedule,7666.09,7666.09, Extensive Third Degree Burns Without Skin Graft,8432,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,7666.09,,,,,,,fee schedule,7666.09,7666.09, Extensive Third Degree Burns Without Skin Graft,8432,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,7666.09,,,,,,,fee schedule,7666.09,7666.09, Extensive Third Degree Burns Without Skin Graft,8432,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,7666.09,,,,,,,fee schedule,7666.09,7666.09, Extensive Third Degree Burns Without Skin Graft,8432,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,7666.09,,,,,,,fee schedule,7666.09,7666.09, Extensive Third Degree Burns Without Skin Graft,8432,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,7666.09,,,,,,,fee schedule,7666.09,7666.09, Extensive Third Degree Burns Without Skin Graft,8433,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,13793.59,,,,,,,fee schedule,13793.59,13793.59, Extensive Third Degree Burns Without Skin Graft,8433,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,13793.59,,,,,,,fee schedule,13793.59,13793.59, Extensive Third Degree Burns Without Skin Graft,8433,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,13793.59,,,,,,,fee schedule,13793.59,13793.59, Extensive Third Degree Burns Without Skin Graft,8433,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,13793.59,,,,,,,fee schedule,13793.59,13793.59, Extensive Third Degree Burns Without Skin Graft,8433,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,13793.59,,,,,,,fee schedule,13793.59,13793.59, Extensive Third Degree Burns Without Skin Graft,8433,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,13793.59,,,,,,,fee schedule,13793.59,13793.59, Extensive Third Degree Burns Without Skin Graft,8433,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,13793.59,,,,,,,fee schedule,13793.59,13793.59, Extensive Third Degree Burns Without Skin Graft,8433,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,13793.59,,,,,,,fee schedule,13793.59,13793.59, Extensive Third Degree Burns Without Skin Graft,8433,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,13793.59,,,,,,,fee schedule,13793.59,13793.59, Extensive Third Degree Burns Without Skin Graft,8433,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,13793.59,,,,,,,fee schedule,13793.59,13793.59, Extensive Third Degree Burns Without Skin Graft,8433,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,13793.59,,,,,,,fee schedule,13793.59,13793.59, Extensive Third Degree Burns Without Skin Graft,8434,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,19882.28,,,,,,,fee schedule,19882.28,19882.28, Extensive Third Degree Burns Without Skin Graft,8434,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,19882.28,,,,,,,fee schedule,19882.28,19882.28, Extensive Third Degree Burns Without Skin Graft,8434,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,19882.28,,,,,,,fee schedule,19882.28,19882.28, Extensive Third Degree Burns Without Skin Graft,8434,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,19882.28,,,,,,,fee schedule,19882.28,19882.28, Extensive Third Degree Burns Without Skin Graft,8434,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,19882.28,,,,,,,fee schedule,19882.28,19882.28, Extensive Third Degree Burns Without Skin Graft,8434,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,19882.28,,,,,,,fee schedule,19882.28,19882.28, Extensive Third Degree Burns Without Skin Graft,8434,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,19882.28,,,,,,,fee schedule,19882.28,19882.28, Extensive Third Degree Burns Without Skin Graft,8434,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,19882.28,,,,,,,fee schedule,19882.28,19882.28, Extensive Third Degree Burns Without Skin Graft,8434,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,19882.28,,,,,,,fee schedule,19882.28,19882.28, Extensive Third Degree Burns Without Skin Graft,8434,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,19882.28,,,,,,,fee schedule,19882.28,19882.28, Extensive Third Degree Burns Without Skin Graft,8434,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,19882.28,,,,,,,fee schedule,19882.28,19882.28, Partial Thickness Burns Without Skin Graft,8441,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4002.43,,,,,,,fee schedule,4002.43,4002.43, Partial Thickness Burns Without Skin Graft,8441,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4002.43,,,,,,,fee schedule,4002.43,4002.43, Partial Thickness Burns Without Skin Graft,8441,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4002.43,,,,,,,fee schedule,4002.43,4002.43, Partial Thickness Burns Without Skin Graft,8441,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4002.43,,,,,,,fee schedule,4002.43,4002.43, Partial Thickness Burns Without Skin Graft,8441,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4002.43,,,,,,,fee schedule,4002.43,4002.43, Partial Thickness Burns Without Skin Graft,8441,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4002.43,,,,,,,fee schedule,4002.43,4002.43, Partial Thickness Burns Without Skin Graft,8441,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4002.43,,,,,,,fee schedule,4002.43,4002.43, Partial Thickness Burns Without Skin Graft,8441,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4002.43,,,,,,,fee schedule,4002.43,4002.43, Partial Thickness Burns Without Skin Graft,8441,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4002.43,,,,,,,fee schedule,4002.43,4002.43, Partial Thickness Burns Without Skin Graft,8441,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4002.43,,,,,,,fee schedule,4002.43,4002.43, Partial Thickness Burns Without Skin Graft,8441,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4002.43,,,,,,,fee schedule,4002.43,4002.43, Partial Thickness Burns Without Skin Graft,8442,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,6714,,,,,,,fee schedule,6714,6714, Partial Thickness Burns Without Skin Graft,8442,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,6714,,,,,,,fee schedule,6714,6714, Partial Thickness Burns Without Skin Graft,8442,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,6714,,,,,,,fee schedule,6714,6714, Partial Thickness Burns Without Skin Graft,8442,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,6714,,,,,,,fee schedule,6714,6714, Partial Thickness Burns Without Skin Graft,8442,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,6714,,,,,,,fee schedule,6714,6714, Partial Thickness Burns Without Skin Graft,8442,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,6714,,,,,,,fee schedule,6714,6714, Partial Thickness Burns Without Skin Graft,8442,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,6714,,,,,,,fee schedule,6714,6714, Partial Thickness Burns Without Skin Graft,8442,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,6714,,,,,,,fee schedule,6714,6714, Partial Thickness Burns Without Skin Graft,8442,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,6714,,,,,,,fee schedule,6714,6714, Partial Thickness Burns Without Skin Graft,8442,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,6714,,,,,,,fee schedule,6714,6714, Partial Thickness Burns Without Skin Graft,8442,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,6714,,,,,,,fee schedule,6714,6714, Partial Thickness Burns Without Skin Graft,8443,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,10533.64,,,,,,,fee schedule,10533.64,10533.64, Partial Thickness Burns Without Skin Graft,8443,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,10533.64,,,,,,,fee schedule,10533.64,10533.64, Partial Thickness Burns Without Skin Graft,8443,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,10533.64,,,,,,,fee schedule,10533.64,10533.64, Partial Thickness Burns Without Skin Graft,8443,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,10533.64,,,,,,,fee schedule,10533.64,10533.64, Partial Thickness Burns Without Skin Graft,8443,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,10533.64,,,,,,,fee schedule,10533.64,10533.64, Partial Thickness Burns Without Skin Graft,8443,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,10533.64,,,,,,,fee schedule,10533.64,10533.64, Partial Thickness Burns Without Skin Graft,8443,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,10533.64,,,,,,,fee schedule,10533.64,10533.64, Partial Thickness Burns Without Skin Graft,8443,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,10533.64,,,,,,,fee schedule,10533.64,10533.64, Partial Thickness Burns Without Skin Graft,8443,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,10533.64,,,,,,,fee schedule,10533.64,10533.64, Partial Thickness Burns Without Skin Graft,8443,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,10533.64,,,,,,,fee schedule,10533.64,10533.64, Partial Thickness Burns Without Skin Graft,8443,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,10533.64,,,,,,,fee schedule,10533.64,10533.64, Partial Thickness Burns Without Skin Graft,8444,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,18765.05,,,,,,,fee schedule,18765.05,18765.05, Partial Thickness Burns Without Skin Graft,8444,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,18765.05,,,,,,,fee schedule,18765.05,18765.05, Partial Thickness Burns Without Skin Graft,8444,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,18765.05,,,,,,,fee schedule,18765.05,18765.05, Partial Thickness Burns Without Skin Graft,8444,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,18765.05,,,,,,,fee schedule,18765.05,18765.05, Partial Thickness Burns Without Skin Graft,8444,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,18765.05,,,,,,,fee schedule,18765.05,18765.05, Partial Thickness Burns Without Skin Graft,8444,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,18765.05,,,,,,,fee schedule,18765.05,18765.05, Partial Thickness Burns Without Skin Graft,8444,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,18765.05,,,,,,,fee schedule,18765.05,18765.05, Partial Thickness Burns Without Skin Graft,8444,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,18765.05,,,,,,,fee schedule,18765.05,18765.05, Partial Thickness Burns Without Skin Graft,8444,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,18765.05,,,,,,,fee schedule,18765.05,18765.05, Partial Thickness Burns Without Skin Graft,8444,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,18765.05,,,,,,,fee schedule,18765.05,18765.05, Partial Thickness Burns Without Skin Graft,8444,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,18765.05,,,,,,,fee schedule,18765.05,18765.05, Services,8501,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,10928.16,,,,,,,fee schedule,10928.16,10928.16, Services,8501,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,10928.16,,,,,,,fee schedule,10928.16,10928.16, Services,8501,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,10928.16,,,,,,,fee schedule,10928.16,10928.16, Services,8501,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,10928.16,,,,,,,fee schedule,10928.16,10928.16, Services,8501,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,10928.16,,,,,,,fee schedule,10928.16,10928.16, Services,8501,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,10928.16,,,,,,,fee schedule,10928.16,10928.16, Services,8501,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,10928.16,,,,,,,fee schedule,10928.16,10928.16, Services,8501,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,10928.16,,,,,,,fee schedule,10928.16,10928.16, Services,8501,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,10928.16,,,,,,,fee schedule,10928.16,10928.16, Services,8501,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,10928.16,,,,,,,fee schedule,10928.16,10928.16, Services,8501,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,10928.16,,,,,,,fee schedule,10928.16,10928.16, Services,8502,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,17191.18,,,,,,,fee schedule,17191.18,17191.18, Services,8502,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,17191.18,,,,,,,fee schedule,17191.18,17191.18, Services,8502,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,17191.18,,,,,,,fee schedule,17191.18,17191.18, Services,8502,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,17191.18,,,,,,,fee schedule,17191.18,17191.18, Services,8502,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,17191.18,,,,,,,fee schedule,17191.18,17191.18, Services,8502,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,17191.18,,,,,,,fee schedule,17191.18,17191.18, Services,8502,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,17191.18,,,,,,,fee schedule,17191.18,17191.18, Services,8502,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,17191.18,,,,,,,fee schedule,17191.18,17191.18, Services,8502,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,17191.18,,,,,,,fee schedule,17191.18,17191.18, Services,8502,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,17191.18,,,,,,,fee schedule,17191.18,17191.18, Services,8502,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,17191.18,,,,,,,fee schedule,17191.18,17191.18, Services,8503,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,25717.6,,,,,,,fee schedule,25717.6,25717.6, Services,8503,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,25717.6,,,,,,,fee schedule,25717.6,25717.6, Services,8503,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,25717.6,,,,,,,fee schedule,25717.6,25717.6, Services,8503,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,25717.6,,,,,,,fee schedule,25717.6,25717.6, Services,8503,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,25717.6,,,,,,,fee schedule,25717.6,25717.6, Services,8503,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,25717.6,,,,,,,fee schedule,25717.6,25717.6, Services,8503,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,25717.6,,,,,,,fee schedule,25717.6,25717.6, Services,8503,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,25717.6,,,,,,,fee schedule,25717.6,25717.6, Services,8503,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,25717.6,,,,,,,fee schedule,25717.6,25717.6, Services,8503,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,25717.6,,,,,,,fee schedule,25717.6,25717.6, Services,8503,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,25717.6,,,,,,,fee schedule,25717.6,25717.6, Services,8504,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,45621.05,,,,,,,fee schedule,45621.05,45621.05, Services,8504,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,45621.05,,,,,,,fee schedule,45621.05,45621.05, Services,8504,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,45621.05,,,,,,,fee schedule,45621.05,45621.05, Services,8504,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,45621.05,,,,,,,fee schedule,45621.05,45621.05, Services,8504,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,45621.05,,,,,,,fee schedule,45621.05,45621.05, Services,8504,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,45621.05,,,,,,,fee schedule,45621.05,45621.05, Services,8504,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,45621.05,,,,,,,fee schedule,45621.05,45621.05, Services,8504,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,45621.05,,,,,,,fee schedule,45621.05,45621.05, Services,8504,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,45621.05,,,,,,,fee schedule,45621.05,45621.05, Services,8504,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,45621.05,,,,,,,fee schedule,45621.05,45621.05, Services,8504,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,45621.05,,,,,,,fee schedule,45621.05,45621.05, Gender Related Procedures,8511,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,14533.95,,,,,,,fee schedule,14533.95,14533.95, Gender Related Procedures,8511,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,14533.95,,,,,,,fee schedule,14533.95,14533.95, Gender Related Procedures,8511,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,14533.95,,,,,,,fee schedule,14533.95,14533.95, Gender Related Procedures,8511,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,14533.95,,,,,,,fee schedule,14533.95,14533.95, Gender Related Procedures,8511,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,14533.95,,,,,,,fee schedule,14533.95,14533.95, Gender Related Procedures,8511,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,14533.95,,,,,,,fee schedule,14533.95,14533.95, Gender Related Procedures,8511,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,14533.95,,,,,,,fee schedule,14533.95,14533.95, Gender Related Procedures,8511,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,14533.95,,,,,,,fee schedule,14533.95,14533.95, Gender Related Procedures,8511,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,14533.95,,,,,,,fee schedule,14533.95,14533.95, Gender Related Procedures,8511,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,14533.95,,,,,,,fee schedule,14533.95,14533.95, Gender Related Procedures,8511,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,14533.95,,,,,,,fee schedule,14533.95,14533.95, Gender Related Procedures,8512,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,24816.33,,,,,,,fee schedule,24816.33,24816.33, Gender Related Procedures,8512,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,24816.33,,,,,,,fee schedule,24816.33,24816.33, Gender Related Procedures,8512,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,24816.33,,,,,,,fee schedule,24816.33,24816.33, Gender Related Procedures,8512,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,24816.33,,,,,,,fee schedule,24816.33,24816.33, Gender Related Procedures,8512,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,24816.33,,,,,,,fee schedule,24816.33,24816.33, Gender Related Procedures,8512,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,24816.33,,,,,,,fee schedule,24816.33,24816.33, Gender Related Procedures,8512,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,24816.33,,,,,,,fee schedule,24816.33,24816.33, Gender Related Procedures,8512,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,24816.33,,,,,,,fee schedule,24816.33,24816.33, Gender Related Procedures,8512,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,24816.33,,,,,,,fee schedule,24816.33,24816.33, Gender Related Procedures,8512,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,24816.33,,,,,,,fee schedule,24816.33,24816.33, Gender Related Procedures,8512,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,24816.33,,,,,,,fee schedule,24816.33,24816.33, Gender Related Procedures,8513,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,80258.9,,,,,,,fee schedule,80258.9,80258.9, Gender Related Procedures,8513,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,80258.9,,,,,,,fee schedule,80258.9,80258.9, Gender Related Procedures,8513,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,80258.9,,,,,,,fee schedule,80258.9,80258.9, Gender Related Procedures,8513,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,80258.9,,,,,,,fee schedule,80258.9,80258.9, Gender Related Procedures,8513,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,80258.9,,,,,,,fee schedule,80258.9,80258.9, Gender Related Procedures,8513,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,80258.9,,,,,,,fee schedule,80258.9,80258.9, Gender Related Procedures,8513,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,80258.9,,,,,,,fee schedule,80258.9,80258.9, Gender Related Procedures,8513,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,80258.9,,,,,,,fee schedule,80258.9,80258.9, Gender Related Procedures,8513,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,80258.9,,,,,,,fee schedule,80258.9,80258.9, Gender Related Procedures,8513,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,80258.9,,,,,,,fee schedule,80258.9,80258.9, Gender Related Procedures,8513,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,80258.9,,,,,,,fee schedule,80258.9,80258.9, Gender Related Procedures,8514,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,80258.9,,,,,,,fee schedule,80258.9,80258.9, Gender Related Procedures,8514,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,80258.9,,,,,,,fee schedule,80258.9,80258.9, Gender Related Procedures,8514,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,80258.9,,,,,,,fee schedule,80258.9,80258.9, Gender Related Procedures,8514,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,80258.9,,,,,,,fee schedule,80258.9,80258.9, Gender Related Procedures,8514,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,80258.9,,,,,,,fee schedule,80258.9,80258.9, Gender Related Procedures,8514,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,80258.9,,,,,,,fee schedule,80258.9,80258.9, Gender Related Procedures,8514,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,80258.9,,,,,,,fee schedule,80258.9,80258.9, Gender Related Procedures,8514,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,80258.9,,,,,,,fee schedule,80258.9,80258.9, Gender Related Procedures,8514,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,80258.9,,,,,,,fee schedule,80258.9,80258.9, Gender Related Procedures,8514,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,80258.9,,,,,,,fee schedule,80258.9,80258.9, Gender Related Procedures,8514,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,80258.9,,,,,,,fee schedule,80258.9,80258.9, Rehabilitation,8601,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,8378.92,,,,,,,fee schedule,8378.92,8378.92, Rehabilitation,8601,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,8378.92,,,,,,,fee schedule,8378.92,8378.92, Rehabilitation,8601,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,8378.92,,,,,,,fee schedule,8378.92,8378.92, Rehabilitation,8601,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,8378.92,,,,,,,fee schedule,8378.92,8378.92, Rehabilitation,8601,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,8378.92,,,,,,,fee schedule,8378.92,8378.92, Rehabilitation,8601,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,8378.92,,,,,,,fee schedule,8378.92,8378.92, Rehabilitation,8601,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,8378.92,,,,,,,fee schedule,8378.92,8378.92, Rehabilitation,8601,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,8378.92,,,,,,,fee schedule,8378.92,8378.92, Rehabilitation,8601,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,8378.92,,,,,,,fee schedule,8378.92,8378.92, Rehabilitation,8601,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,8378.92,,,,,,,fee schedule,8378.92,8378.92, Rehabilitation,8601,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,8378.92,,,,,,,fee schedule,8378.92,8378.92, Rehabilitation,8602,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,10846.29,,,,,,,fee schedule,10846.29,10846.29, Rehabilitation,8602,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,10846.29,,,,,,,fee schedule,10846.29,10846.29, Rehabilitation,8602,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,10846.29,,,,,,,fee schedule,10846.29,10846.29, Rehabilitation,8602,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,10846.29,,,,,,,fee schedule,10846.29,10846.29, Rehabilitation,8602,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,10846.29,,,,,,,fee schedule,10846.29,10846.29, Rehabilitation,8602,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,10846.29,,,,,,,fee schedule,10846.29,10846.29, Rehabilitation,8602,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,10846.29,,,,,,,fee schedule,10846.29,10846.29, Rehabilitation,8602,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,10846.29,,,,,,,fee schedule,10846.29,10846.29, Rehabilitation,8602,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,10846.29,,,,,,,fee schedule,10846.29,10846.29, Rehabilitation,8602,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,10846.29,,,,,,,fee schedule,10846.29,10846.29, Rehabilitation,8602,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,10846.29,,,,,,,fee schedule,10846.29,10846.29, Rehabilitation,8603,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,14394.91,,,,,,,fee schedule,14394.91,14394.91, Rehabilitation,8603,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,14394.91,,,,,,,fee schedule,14394.91,14394.91, Rehabilitation,8603,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,14394.91,,,,,,,fee schedule,14394.91,14394.91, Rehabilitation,8603,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,14394.91,,,,,,,fee schedule,14394.91,14394.91, Rehabilitation,8603,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,14394.91,,,,,,,fee schedule,14394.91,14394.91, Rehabilitation,8603,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,14394.91,,,,,,,fee schedule,14394.91,14394.91, Rehabilitation,8603,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,14394.91,,,,,,,fee schedule,14394.91,14394.91, Rehabilitation,8603,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,14394.91,,,,,,,fee schedule,14394.91,14394.91, Rehabilitation,8603,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,14394.91,,,,,,,fee schedule,14394.91,14394.91, Rehabilitation,8603,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,14394.91,,,,,,,fee schedule,14394.91,14394.91, Rehabilitation,8603,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,14394.91,,,,,,,fee schedule,14394.91,14394.91, Rehabilitation,8604,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,17820.72,,,,,,,fee schedule,17820.72,17820.72, Rehabilitation,8604,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,17820.72,,,,,,,fee schedule,17820.72,17820.72, Rehabilitation,8604,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,17820.72,,,,,,,fee schedule,17820.72,17820.72, Rehabilitation,8604,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,17820.72,,,,,,,fee schedule,17820.72,17820.72, Rehabilitation,8604,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,17820.72,,,,,,,fee schedule,17820.72,17820.72, Rehabilitation,8604,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,17820.72,,,,,,,fee schedule,17820.72,17820.72, Rehabilitation,8604,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,17820.72,,,,,,,fee schedule,17820.72,17820.72, Rehabilitation,8604,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,17820.72,,,,,,,fee schedule,17820.72,17820.72, Rehabilitation,8604,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,17820.72,,,,,,,fee schedule,17820.72,17820.72, Rehabilitation,8604,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,17820.72,,,,,,,fee schedule,17820.72,17820.72, Rehabilitation,8604,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,17820.72,,,,,,,fee schedule,17820.72,17820.72, "Signs, Symptoms And Other Factors Influencing Health Status",8611,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,3943.85,,,,,,,fee schedule,3943.85,3943.85, "Signs, Symptoms And Other Factors Influencing Health Status",8611,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,3943.85,,,,,,,fee schedule,3943.85,3943.85, "Signs, Symptoms And Other Factors Influencing Health Status",8611,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,3943.85,,,,,,,fee schedule,3943.85,3943.85, "Signs, Symptoms And Other Factors Influencing Health Status",8611,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,3943.85,,,,,,,fee schedule,3943.85,3943.85, "Signs, Symptoms And Other Factors Influencing Health Status",8611,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,3943.85,,,,,,,fee schedule,3943.85,3943.85, "Signs, Symptoms And Other Factors Influencing Health Status",8611,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,3943.85,,,,,,,fee schedule,3943.85,3943.85, "Signs, Symptoms And Other Factors Influencing Health Status",8611,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,3943.85,,,,,,,fee schedule,3943.85,3943.85, "Signs, Symptoms And Other Factors Influencing Health Status",8611,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,3943.85,,,,,,,fee schedule,3943.85,3943.85, "Signs, Symptoms And Other Factors Influencing Health Status",8611,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,3943.85,,,,,,,fee schedule,3943.85,3943.85, "Signs, Symptoms And Other Factors Influencing Health Status",8611,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,3943.85,,,,,,,fee schedule,3943.85,3943.85, "Signs, Symptoms And Other Factors Influencing Health Status",8611,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,3943.85,,,,,,,fee schedule,3943.85,3943.85, "Signs, Symptoms And Other Factors Influencing Health Status",8612,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5162.72,,,,,,,fee schedule,5162.72,5162.72, "Signs, Symptoms And Other Factors Influencing Health Status",8612,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5162.72,,,,,,,fee schedule,5162.72,5162.72, "Signs, Symptoms And Other Factors Influencing Health Status",8612,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5162.72,,,,,,,fee schedule,5162.72,5162.72, "Signs, Symptoms And Other Factors Influencing Health Status",8612,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5162.72,,,,,,,fee schedule,5162.72,5162.72, "Signs, Symptoms And Other Factors Influencing Health Status",8612,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5162.72,,,,,,,fee schedule,5162.72,5162.72, "Signs, Symptoms And Other Factors Influencing Health Status",8612,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5162.72,,,,,,,fee schedule,5162.72,5162.72, "Signs, Symptoms And Other Factors Influencing Health Status",8612,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5162.72,,,,,,,fee schedule,5162.72,5162.72, "Signs, Symptoms And Other Factors Influencing Health Status",8612,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5162.72,,,,,,,fee schedule,5162.72,5162.72, "Signs, Symptoms And Other Factors Influencing Health Status",8612,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5162.72,,,,,,,fee schedule,5162.72,5162.72, "Signs, Symptoms And Other Factors Influencing Health Status",8612,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5162.72,,,,,,,fee schedule,5162.72,5162.72, "Signs, Symptoms And Other Factors Influencing Health Status",8612,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5162.72,,,,,,,fee schedule,5162.72,5162.72, "Signs, Symptoms And Other Factors Influencing Health Status",8613,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,7559.52,,,,,,,fee schedule,7559.52,7559.52, "Signs, Symptoms And Other Factors Influencing Health Status",8613,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,7559.52,,,,,,,fee schedule,7559.52,7559.52, "Signs, Symptoms And Other Factors Influencing Health Status",8613,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,7559.52,,,,,,,fee schedule,7559.52,7559.52, "Signs, Symptoms And Other Factors Influencing Health Status",8613,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,7559.52,,,,,,,fee schedule,7559.52,7559.52, "Signs, Symptoms And Other Factors Influencing Health Status",8613,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,7559.52,,,,,,,fee schedule,7559.52,7559.52, "Signs, Symptoms And Other Factors Influencing Health Status",8613,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,7559.52,,,,,,,fee schedule,7559.52,7559.52, "Signs, Symptoms And Other Factors Influencing Health Status",8613,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,7559.52,,,,,,,fee schedule,7559.52,7559.52, "Signs, Symptoms And Other Factors Influencing Health Status",8613,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,7559.52,,,,,,,fee schedule,7559.52,7559.52, "Signs, Symptoms And Other Factors Influencing Health Status",8613,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,7559.52,,,,,,,fee schedule,7559.52,7559.52, "Signs, Symptoms And Other Factors Influencing Health Status",8613,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,7559.52,,,,,,,fee schedule,7559.52,7559.52, "Signs, Symptoms And Other Factors Influencing Health Status",8613,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,7559.52,,,,,,,fee schedule,7559.52,7559.52, "Signs, Symptoms And Other Factors Influencing Health Status",8614,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,12336.88,,,,,,,fee schedule,12336.88,12336.88, "Signs, Symptoms And Other Factors Influencing Health Status",8614,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,12336.88,,,,,,,fee schedule,12336.88,12336.88, "Signs, Symptoms And Other Factors Influencing Health Status",8614,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,12336.88,,,,,,,fee schedule,12336.88,12336.88, "Signs, Symptoms And Other Factors Influencing Health Status",8614,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,12336.88,,,,,,,fee schedule,12336.88,12336.88, "Signs, Symptoms And Other Factors Influencing Health Status",8614,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,12336.88,,,,,,,fee schedule,12336.88,12336.88, "Signs, Symptoms And Other Factors Influencing Health Status",8614,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,12336.88,,,,,,,fee schedule,12336.88,12336.88, "Signs, Symptoms And Other Factors Influencing Health Status",8614,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,12336.88,,,,,,,fee schedule,12336.88,12336.88, "Signs, Symptoms And Other Factors Influencing Health Status",8614,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,12336.88,,,,,,,fee schedule,12336.88,12336.88, "Signs, Symptoms And Other Factors Influencing Health Status",8614,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,12336.88,,,,,,,fee schedule,12336.88,12336.88, "Signs, Symptoms And Other Factors Influencing Health Status",8614,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,12336.88,,,,,,,fee schedule,12336.88,12336.88, "Signs, Symptoms And Other Factors Influencing Health Status",8614,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,12336.88,,,,,,,fee schedule,12336.88,12336.88, Other Aftercare And Convalescence,8621,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,2868.96,,,,,,,fee schedule,2868.96,2868.96, Other Aftercare And Convalescence,8621,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,2868.96,,,,,,,fee schedule,2868.96,2868.96, Other Aftercare And Convalescence,8621,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,2868.96,,,,,,,fee schedule,2868.96,2868.96, Other Aftercare And Convalescence,8621,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,2868.96,,,,,,,fee schedule,2868.96,2868.96, Other Aftercare And Convalescence,8621,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,2868.96,,,,,,,fee schedule,2868.96,2868.96, Other Aftercare And Convalescence,8621,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,2868.96,,,,,,,fee schedule,2868.96,2868.96, Other Aftercare And Convalescence,8621,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,2868.96,,,,,,,fee schedule,2868.96,2868.96, Other Aftercare And Convalescence,8621,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,2868.96,,,,,,,fee schedule,2868.96,2868.96, Other Aftercare And Convalescence,8621,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,2868.96,,,,,,,fee schedule,2868.96,2868.96, Other Aftercare And Convalescence,8621,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,2868.96,,,,,,,fee schedule,2868.96,2868.96, Other Aftercare And Convalescence,8621,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,2868.96,,,,,,,fee schedule,2868.96,2868.96, Other Aftercare And Convalescence,8622,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,6558.73,,,,,,,fee schedule,6558.73,6558.73, Other Aftercare And Convalescence,8622,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,6558.73,,,,,,,fee schedule,6558.73,6558.73, Other Aftercare And Convalescence,8622,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,6558.73,,,,,,,fee schedule,6558.73,6558.73, Other Aftercare And Convalescence,8622,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,6558.73,,,,,,,fee schedule,6558.73,6558.73, Other Aftercare And Convalescence,8622,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,6558.73,,,,,,,fee schedule,6558.73,6558.73, Other Aftercare And Convalescence,8622,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,6558.73,,,,,,,fee schedule,6558.73,6558.73, Other Aftercare And Convalescence,8622,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,6558.73,,,,,,,fee schedule,6558.73,6558.73, Other Aftercare And Convalescence,8622,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,6558.73,,,,,,,fee schedule,6558.73,6558.73, Other Aftercare And Convalescence,8622,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,6558.73,,,,,,,fee schedule,6558.73,6558.73, Other Aftercare And Convalescence,8622,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,6558.73,,,,,,,fee schedule,6558.73,6558.73, Other Aftercare And Convalescence,8622,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,6558.73,,,,,,,fee schedule,6558.73,6558.73, Other Aftercare And Convalescence,8623,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,8350.69,,,,,,,fee schedule,8350.69,8350.69, Other Aftercare And Convalescence,8623,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,8350.69,,,,,,,fee schedule,8350.69,8350.69, Other Aftercare And Convalescence,8623,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,8350.69,,,,,,,fee schedule,8350.69,8350.69, Other Aftercare And Convalescence,8623,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,8350.69,,,,,,,fee schedule,8350.69,8350.69, Other Aftercare And Convalescence,8623,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,8350.69,,,,,,,fee schedule,8350.69,8350.69, Other Aftercare And Convalescence,8623,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,8350.69,,,,,,,fee schedule,8350.69,8350.69, Other Aftercare And Convalescence,8623,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,8350.69,,,,,,,fee schedule,8350.69,8350.69, Other Aftercare And Convalescence,8623,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,8350.69,,,,,,,fee schedule,8350.69,8350.69, Other Aftercare And Convalescence,8623,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,8350.69,,,,,,,fee schedule,8350.69,8350.69, Other Aftercare And Convalescence,8623,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,8350.69,,,,,,,fee schedule,8350.69,8350.69, Other Aftercare And Convalescence,8623,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,8350.69,,,,,,,fee schedule,8350.69,8350.69, Other Aftercare And Convalescence,8624,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,8350.69,,,,,,,fee schedule,8350.69,8350.69, Other Aftercare And Convalescence,8624,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,8350.69,,,,,,,fee schedule,8350.69,8350.69, Other Aftercare And Convalescence,8624,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,8350.69,,,,,,,fee schedule,8350.69,8350.69, Other Aftercare And Convalescence,8624,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,8350.69,,,,,,,fee schedule,8350.69,8350.69, Other Aftercare And Convalescence,8624,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,8350.69,,,,,,,fee schedule,8350.69,8350.69, Other Aftercare And Convalescence,8624,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,8350.69,,,,,,,fee schedule,8350.69,8350.69, Other Aftercare And Convalescence,8624,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,8350.69,,,,,,,fee schedule,8350.69,8350.69, Other Aftercare And Convalescence,8624,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,8350.69,,,,,,,fee schedule,8350.69,8350.69, Other Aftercare And Convalescence,8624,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,8350.69,,,,,,,fee schedule,8350.69,8350.69, Other Aftercare And Convalescence,8624,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,8350.69,,,,,,,fee schedule,8350.69,8350.69, Other Aftercare And Convalescence,8624,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,8350.69,,,,,,,fee schedule,8350.69,8350.69, Neonatal Aftercare,8631,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,9887.86,,,,,,,fee schedule,9887.86,9887.86, Neonatal Aftercare,8631,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,9887.86,,,,,,,fee schedule,9887.86,9887.86, Neonatal Aftercare,8631,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,9887.86,,,,,,,fee schedule,9887.86,9887.86, Neonatal Aftercare,8631,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,9887.86,,,,,,,fee schedule,9887.86,9887.86, Neonatal Aftercare,8631,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,9887.86,,,,,,,fee schedule,9887.86,9887.86, Neonatal Aftercare,8631,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,9887.86,,,,,,,fee schedule,9887.86,9887.86, Neonatal Aftercare,8631,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,9887.86,,,,,,,fee schedule,9887.86,9887.86, Neonatal Aftercare,8631,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,9887.86,,,,,,,fee schedule,9887.86,9887.86, Neonatal Aftercare,8631,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,9887.86,,,,,,,fee schedule,9887.86,9887.86, Neonatal Aftercare,8631,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,9887.86,,,,,,,fee schedule,9887.86,9887.86, Neonatal Aftercare,8631,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,9887.86,,,,,,,fee schedule,9887.86,9887.86, Neonatal Aftercare,8632,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,18055.04,,,,,,,fee schedule,18055.04,18055.04, Neonatal Aftercare,8632,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,18055.04,,,,,,,fee schedule,18055.04,18055.04, Neonatal Aftercare,8632,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,18055.04,,,,,,,fee schedule,18055.04,18055.04, Neonatal Aftercare,8632,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,18055.04,,,,,,,fee schedule,18055.04,18055.04, Neonatal Aftercare,8632,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,18055.04,,,,,,,fee schedule,18055.04,18055.04, Neonatal Aftercare,8632,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,18055.04,,,,,,,fee schedule,18055.04,18055.04, Neonatal Aftercare,8632,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,18055.04,,,,,,,fee schedule,18055.04,18055.04, Neonatal Aftercare,8632,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,18055.04,,,,,,,fee schedule,18055.04,18055.04, Neonatal Aftercare,8632,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,18055.04,,,,,,,fee schedule,18055.04,18055.04, Neonatal Aftercare,8632,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,18055.04,,,,,,,fee schedule,18055.04,18055.04, Neonatal Aftercare,8632,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,18055.04,,,,,,,fee schedule,18055.04,18055.04, Neonatal Aftercare,8633,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,34999.2,,,,,,,fee schedule,34999.2,34999.2, Neonatal Aftercare,8633,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,34999.2,,,,,,,fee schedule,34999.2,34999.2, Neonatal Aftercare,8633,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,34999.2,,,,,,,fee schedule,34999.2,34999.2, Neonatal Aftercare,8633,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,34999.2,,,,,,,fee schedule,34999.2,34999.2, Neonatal Aftercare,8633,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,34999.2,,,,,,,fee schedule,34999.2,34999.2, Neonatal Aftercare,8633,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,34999.2,,,,,,,fee schedule,34999.2,34999.2, Neonatal Aftercare,8633,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,34999.2,,,,,,,fee schedule,34999.2,34999.2, Neonatal Aftercare,8633,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,34999.2,,,,,,,fee schedule,34999.2,34999.2, Neonatal Aftercare,8633,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,34999.2,,,,,,,fee schedule,34999.2,34999.2, Neonatal Aftercare,8633,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,34999.2,,,,,,,fee schedule,34999.2,34999.2, Neonatal Aftercare,8633,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,34999.2,,,,,,,fee schedule,34999.2,34999.2, Neonatal Aftercare,8634,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,68416.76,,,,,,,fee schedule,68416.76,68416.76, Neonatal Aftercare,8634,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,68416.76,,,,,,,fee schedule,68416.76,68416.76, Neonatal Aftercare,8634,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,68416.76,,,,,,,fee schedule,68416.76,68416.76, Neonatal Aftercare,8634,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,68416.76,,,,,,,fee schedule,68416.76,68416.76, Neonatal Aftercare,8634,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,68416.76,,,,,,,fee schedule,68416.76,68416.76, Neonatal Aftercare,8634,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,68416.76,,,,,,,fee schedule,68416.76,68416.76, Neonatal Aftercare,8634,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,68416.76,,,,,,,fee schedule,68416.76,68416.76, Neonatal Aftercare,8634,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,68416.76,,,,,,,fee schedule,68416.76,68416.76, Neonatal Aftercare,8634,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,68416.76,,,,,,,fee schedule,68416.76,68416.76, Neonatal Aftercare,8634,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,68416.76,,,,,,,fee schedule,68416.76,68416.76, Neonatal Aftercare,8634,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,68416.76,,,,,,,fee schedule,68416.76,68416.76, HIV With Multiple Major HIV Related Conditions,8901,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5848.02,,,,,,,fee schedule,5848.02,5848.02, HIV With Multiple Major HIV Related Conditions,8901,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5848.02,,,,,,,fee schedule,5848.02,5848.02, HIV With Multiple Major HIV Related Conditions,8901,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5848.02,,,,,,,fee schedule,5848.02,5848.02, HIV With Multiple Major HIV Related Conditions,8901,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5848.02,,,,,,,fee schedule,5848.02,5848.02, HIV With Multiple Major HIV Related Conditions,8901,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5848.02,,,,,,,fee schedule,5848.02,5848.02, HIV With Multiple Major HIV Related Conditions,8901,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5848.02,,,,,,,fee schedule,5848.02,5848.02, HIV With Multiple Major HIV Related Conditions,8901,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5848.02,,,,,,,fee schedule,5848.02,5848.02, HIV With Multiple Major HIV Related Conditions,8901,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5848.02,,,,,,,fee schedule,5848.02,5848.02, HIV With Multiple Major HIV Related Conditions,8901,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5848.02,,,,,,,fee schedule,5848.02,5848.02, HIV With Multiple Major HIV Related Conditions,8901,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5848.02,,,,,,,fee schedule,5848.02,5848.02, HIV With Multiple Major HIV Related Conditions,8901,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5848.02,,,,,,,fee schedule,5848.02,5848.02, HIV With Multiple Major HIV Related Conditions,8902,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,8242.7,,,,,,,fee schedule,8242.7,8242.7, HIV With Multiple Major HIV Related Conditions,8902,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,8242.7,,,,,,,fee schedule,8242.7,8242.7, HIV With Multiple Major HIV Related Conditions,8902,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,8242.7,,,,,,,fee schedule,8242.7,8242.7, HIV With Multiple Major HIV Related Conditions,8902,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,8242.7,,,,,,,fee schedule,8242.7,8242.7, HIV With Multiple Major HIV Related Conditions,8902,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,8242.7,,,,,,,fee schedule,8242.7,8242.7, HIV With Multiple Major HIV Related Conditions,8902,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,8242.7,,,,,,,fee schedule,8242.7,8242.7, HIV With Multiple Major HIV Related Conditions,8902,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,8242.7,,,,,,,fee schedule,8242.7,8242.7, HIV With Multiple Major HIV Related Conditions,8902,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,8242.7,,,,,,,fee schedule,8242.7,8242.7, HIV With Multiple Major HIV Related Conditions,8902,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,8242.7,,,,,,,fee schedule,8242.7,8242.7, HIV With Multiple Major HIV Related Conditions,8902,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,8242.7,,,,,,,fee schedule,8242.7,8242.7, HIV With Multiple Major HIV Related Conditions,8902,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,8242.7,,,,,,,fee schedule,8242.7,8242.7, HIV With Multiple Major HIV Related Conditions,8903,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,14213.53,,,,,,,fee schedule,14213.53,14213.53, HIV With Multiple Major HIV Related Conditions,8903,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,14213.53,,,,,,,fee schedule,14213.53,14213.53, HIV With Multiple Major HIV Related Conditions,8903,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,14213.53,,,,,,,fee schedule,14213.53,14213.53, HIV With Multiple Major HIV Related Conditions,8903,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,14213.53,,,,,,,fee schedule,14213.53,14213.53, HIV With Multiple Major HIV Related Conditions,8903,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,14213.53,,,,,,,fee schedule,14213.53,14213.53, HIV With Multiple Major HIV Related Conditions,8903,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,14213.53,,,,,,,fee schedule,14213.53,14213.53, HIV With Multiple Major HIV Related Conditions,8903,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,14213.53,,,,,,,fee schedule,14213.53,14213.53, HIV With Multiple Major HIV Related Conditions,8903,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,14213.53,,,,,,,fee schedule,14213.53,14213.53, HIV With Multiple Major HIV Related Conditions,8903,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,14213.53,,,,,,,fee schedule,14213.53,14213.53, HIV With Multiple Major HIV Related Conditions,8903,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,14213.53,,,,,,,fee schedule,14213.53,14213.53, HIV With Multiple Major HIV Related Conditions,8903,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,14213.53,,,,,,,fee schedule,14213.53,14213.53, HIV With Multiple Major HIV Related Conditions,8904,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,25328.01,,,,,,,fee schedule,25328.01,25328.01, HIV With Multiple Major HIV Related Conditions,8904,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,25328.01,,,,,,,fee schedule,25328.01,25328.01, HIV With Multiple Major HIV Related Conditions,8904,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,25328.01,,,,,,,fee schedule,25328.01,25328.01, HIV With Multiple Major HIV Related Conditions,8904,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,25328.01,,,,,,,fee schedule,25328.01,25328.01, HIV With Multiple Major HIV Related Conditions,8904,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,25328.01,,,,,,,fee schedule,25328.01,25328.01, HIV With Multiple Major HIV Related Conditions,8904,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,25328.01,,,,,,,fee schedule,25328.01,25328.01, HIV With Multiple Major HIV Related Conditions,8904,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,25328.01,,,,,,,fee schedule,25328.01,25328.01, HIV With Multiple Major HIV Related Conditions,8904,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,25328.01,,,,,,,fee schedule,25328.01,25328.01, HIV With Multiple Major HIV Related Conditions,8904,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,25328.01,,,,,,,fee schedule,25328.01,25328.01, HIV With Multiple Major HIV Related Conditions,8904,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,25328.01,,,,,,,fee schedule,25328.01,25328.01, HIV With Multiple Major HIV Related Conditions,8904,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,25328.01,,,,,,,fee schedule,25328.01,25328.01, HIV With Major HIV Related Condition,8921,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5776.74,,,,,,,fee schedule,5776.74,5776.74, HIV With Major HIV Related Condition,8921,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5776.74,,,,,,,fee schedule,5776.74,5776.74, HIV With Major HIV Related Condition,8921,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5776.74,,,,,,,fee schedule,5776.74,5776.74, HIV With Major HIV Related Condition,8921,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5776.74,,,,,,,fee schedule,5776.74,5776.74, HIV With Major HIV Related Condition,8921,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5776.74,,,,,,,fee schedule,5776.74,5776.74, HIV With Major HIV Related Condition,8921,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5776.74,,,,,,,fee schedule,5776.74,5776.74, HIV With Major HIV Related Condition,8921,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5776.74,,,,,,,fee schedule,5776.74,5776.74, HIV With Major HIV Related Condition,8921,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5776.74,,,,,,,fee schedule,5776.74,5776.74, HIV With Major HIV Related Condition,8921,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5776.74,,,,,,,fee schedule,5776.74,5776.74, HIV With Major HIV Related Condition,8921,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5776.74,,,,,,,fee schedule,5776.74,5776.74, HIV With Major HIV Related Condition,8921,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5776.74,,,,,,,fee schedule,5776.74,5776.74, HIV With Major HIV Related Condition,8922,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,7104.29,,,,,,,fee schedule,7104.29,7104.29, HIV With Major HIV Related Condition,8922,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,7104.29,,,,,,,fee schedule,7104.29,7104.29, HIV With Major HIV Related Condition,8922,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,7104.29,,,,,,,fee schedule,7104.29,7104.29, HIV With Major HIV Related Condition,8922,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,7104.29,,,,,,,fee schedule,7104.29,7104.29, HIV With Major HIV Related Condition,8922,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,7104.29,,,,,,,fee schedule,7104.29,7104.29, HIV With Major HIV Related Condition,8922,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,7104.29,,,,,,,fee schedule,7104.29,7104.29, HIV With Major HIV Related Condition,8922,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,7104.29,,,,,,,fee schedule,7104.29,7104.29, HIV With Major HIV Related Condition,8922,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,7104.29,,,,,,,fee schedule,7104.29,7104.29, HIV With Major HIV Related Condition,8922,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,7104.29,,,,,,,fee schedule,7104.29,7104.29, HIV With Major HIV Related Condition,8922,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,7104.29,,,,,,,fee schedule,7104.29,7104.29, HIV With Major HIV Related Condition,8922,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,7104.29,,,,,,,fee schedule,7104.29,7104.29, HIV With Major HIV Related Condition,8923,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,10170.87,,,,,,,fee schedule,10170.87,10170.87, HIV With Major HIV Related Condition,8923,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,10170.87,,,,,,,fee schedule,10170.87,10170.87, HIV With Major HIV Related Condition,8923,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,10170.87,,,,,,,fee schedule,10170.87,10170.87, HIV With Major HIV Related Condition,8923,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,10170.87,,,,,,,fee schedule,10170.87,10170.87, HIV With Major HIV Related Condition,8923,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,10170.87,,,,,,,fee schedule,10170.87,10170.87, HIV With Major HIV Related Condition,8923,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,10170.87,,,,,,,fee schedule,10170.87,10170.87, HIV With Major HIV Related Condition,8923,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,10170.87,,,,,,,fee schedule,10170.87,10170.87, HIV With Major HIV Related Condition,8923,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,10170.87,,,,,,,fee schedule,10170.87,10170.87, HIV With Major HIV Related Condition,8923,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,10170.87,,,,,,,fee schedule,10170.87,10170.87, HIV With Major HIV Related Condition,8923,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,10170.87,,,,,,,fee schedule,10170.87,10170.87, HIV With Major HIV Related Condition,8923,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,10170.87,,,,,,,fee schedule,10170.87,10170.87, HIV With Major HIV Related Condition,8924,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,16642.79,,,,,,,fee schedule,16642.79,16642.79, HIV With Major HIV Related Condition,8924,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,16642.79,,,,,,,fee schedule,16642.79,16642.79, HIV With Major HIV Related Condition,8924,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,16642.79,,,,,,,fee schedule,16642.79,16642.79, HIV With Major HIV Related Condition,8924,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,16642.79,,,,,,,fee schedule,16642.79,16642.79, HIV With Major HIV Related Condition,8924,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,16642.79,,,,,,,fee schedule,16642.79,16642.79, HIV With Major HIV Related Condition,8924,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,16642.79,,,,,,,fee schedule,16642.79,16642.79, HIV With Major HIV Related Condition,8924,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,16642.79,,,,,,,fee schedule,16642.79,16642.79, HIV With Major HIV Related Condition,8924,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,16642.79,,,,,,,fee schedule,16642.79,16642.79, HIV With Major HIV Related Condition,8924,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,16642.79,,,,,,,fee schedule,16642.79,16642.79, HIV With Major HIV Related Condition,8924,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,16642.79,,,,,,,fee schedule,16642.79,16642.79, HIV With Major HIV Related Condition,8924,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,16642.79,,,,,,,fee schedule,16642.79,16642.79, HIV With Multiple Significant HIV Related Conditions,8931,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,5426.68,,,,,,,fee schedule,5426.68,5426.68, HIV With Multiple Significant HIV Related Conditions,8931,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,5426.68,,,,,,,fee schedule,5426.68,5426.68, HIV With Multiple Significant HIV Related Conditions,8931,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,5426.68,,,,,,,fee schedule,5426.68,5426.68, HIV With Multiple Significant HIV Related Conditions,8931,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,5426.68,,,,,,,fee schedule,5426.68,5426.68, HIV With Multiple Significant HIV Related Conditions,8931,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,5426.68,,,,,,,fee schedule,5426.68,5426.68, HIV With Multiple Significant HIV Related Conditions,8931,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,5426.68,,,,,,,fee schedule,5426.68,5426.68, HIV With Multiple Significant HIV Related Conditions,8931,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,5426.68,,,,,,,fee schedule,5426.68,5426.68, HIV With Multiple Significant HIV Related Conditions,8931,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,5426.68,,,,,,,fee schedule,5426.68,5426.68, HIV With Multiple Significant HIV Related Conditions,8931,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,5426.68,,,,,,,fee schedule,5426.68,5426.68, HIV With Multiple Significant HIV Related Conditions,8931,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,5426.68,,,,,,,fee schedule,5426.68,5426.68, HIV With Multiple Significant HIV Related Conditions,8931,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,5426.68,,,,,,,fee schedule,5426.68,5426.68, HIV With Multiple Significant HIV Related Conditions,8932,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,7666.79,,,,,,,fee schedule,7666.79,7666.79, HIV With Multiple Significant HIV Related Conditions,8932,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,7666.79,,,,,,,fee schedule,7666.79,7666.79, HIV With Multiple Significant HIV Related Conditions,8932,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,7666.79,,,,,,,fee schedule,7666.79,7666.79, HIV With Multiple Significant HIV Related Conditions,8932,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,7666.79,,,,,,,fee schedule,7666.79,7666.79, HIV With Multiple Significant HIV Related Conditions,8932,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,7666.79,,,,,,,fee schedule,7666.79,7666.79, HIV With Multiple Significant HIV Related Conditions,8932,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,7666.79,,,,,,,fee schedule,7666.79,7666.79, HIV With Multiple Significant HIV Related Conditions,8932,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,7666.79,,,,,,,fee schedule,7666.79,7666.79, HIV With Multiple Significant HIV Related Conditions,8932,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,7666.79,,,,,,,fee schedule,7666.79,7666.79, HIV With Multiple Significant HIV Related Conditions,8932,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,7666.79,,,,,,,fee schedule,7666.79,7666.79, HIV With Multiple Significant HIV Related Conditions,8932,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,7666.79,,,,,,,fee schedule,7666.79,7666.79, HIV With Multiple Significant HIV Related Conditions,8932,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,7666.79,,,,,,,fee schedule,7666.79,7666.79, HIV With Multiple Significant HIV Related Conditions,8933,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,9289.36,,,,,,,fee schedule,9289.36,9289.36, HIV With Multiple Significant HIV Related Conditions,8933,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,9289.36,,,,,,,fee schedule,9289.36,9289.36, HIV With Multiple Significant HIV Related Conditions,8933,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,9289.36,,,,,,,fee schedule,9289.36,9289.36, HIV With Multiple Significant HIV Related Conditions,8933,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,9289.36,,,,,,,fee schedule,9289.36,9289.36, HIV With Multiple Significant HIV Related Conditions,8933,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,9289.36,,,,,,,fee schedule,9289.36,9289.36, HIV With Multiple Significant HIV Related Conditions,8933,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,9289.36,,,,,,,fee schedule,9289.36,9289.36, HIV With Multiple Significant HIV Related Conditions,8933,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,9289.36,,,,,,,fee schedule,9289.36,9289.36, HIV With Multiple Significant HIV Related Conditions,8933,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,9289.36,,,,,,,fee schedule,9289.36,9289.36, HIV With Multiple Significant HIV Related Conditions,8933,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,9289.36,,,,,,,fee schedule,9289.36,9289.36, HIV With Multiple Significant HIV Related Conditions,8933,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,9289.36,,,,,,,fee schedule,9289.36,9289.36, HIV With Multiple Significant HIV Related Conditions,8933,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,9289.36,,,,,,,fee schedule,9289.36,9289.36, HIV With Multiple Significant HIV Related Conditions,8934,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,15891.85,,,,,,,fee schedule,15891.85,15891.85, HIV With Multiple Significant HIV Related Conditions,8934,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,15891.85,,,,,,,fee schedule,15891.85,15891.85, HIV With Multiple Significant HIV Related Conditions,8934,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,15891.85,,,,,,,fee schedule,15891.85,15891.85, HIV With Multiple Significant HIV Related Conditions,8934,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,15891.85,,,,,,,fee schedule,15891.85,15891.85, HIV With Multiple Significant HIV Related Conditions,8934,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,15891.85,,,,,,,fee schedule,15891.85,15891.85, HIV With Multiple Significant HIV Related Conditions,8934,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,15891.85,,,,,,,fee schedule,15891.85,15891.85, HIV With Multiple Significant HIV Related Conditions,8934,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,15891.85,,,,,,,fee schedule,15891.85,15891.85, HIV With Multiple Significant HIV Related Conditions,8934,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,15891.85,,,,,,,fee schedule,15891.85,15891.85, HIV With Multiple Significant HIV Related Conditions,8934,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,15891.85,,,,,,,fee schedule,15891.85,15891.85, HIV With Multiple Significant HIV Related Conditions,8934,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,15891.85,,,,,,,fee schedule,15891.85,15891.85, HIV With Multiple Significant HIV Related Conditions,8934,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,15891.85,,,,,,,fee schedule,15891.85,15891.85, HIV With One Significant HIV Condition Or Without Significant Related Conditions,8941,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,4967.92,,,,,,,fee schedule,4967.92,4967.92, HIV With One Significant HIV Condition Or Without Significant Related Conditions,8941,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,4967.92,,,,,,,fee schedule,4967.92,4967.92, HIV With One Significant HIV Condition Or Without Significant Related Conditions,8941,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,4967.92,,,,,,,fee schedule,4967.92,4967.92, HIV With One Significant HIV Condition Or Without Significant Related Conditions,8941,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,4967.92,,,,,,,fee schedule,4967.92,4967.92, HIV With One Significant HIV Condition Or Without Significant Related Conditions,8941,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,4967.92,,,,,,,fee schedule,4967.92,4967.92, HIV With One Significant HIV Condition Or Without Significant Related Conditions,8941,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,4967.92,,,,,,,fee schedule,4967.92,4967.92, HIV With One Significant HIV Condition Or Without Significant Related Conditions,8941,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,4967.92,,,,,,,fee schedule,4967.92,4967.92, HIV With One Significant HIV Condition Or Without Significant Related Conditions,8941,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,4967.92,,,,,,,fee schedule,4967.92,4967.92, HIV With One Significant HIV Condition Or Without Significant Related Conditions,8941,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,4967.92,,,,,,,fee schedule,4967.92,4967.92, HIV With One Significant HIV Condition Or Without Significant Related Conditions,8941,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,4967.92,,,,,,,fee schedule,4967.92,4967.92, HIV With One Significant HIV Condition Or Without Significant Related Conditions,8941,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,4967.92,,,,,,,fee schedule,4967.92,4967.92, HIV With One Significant HIV Condition Or Without Significant Related Conditions,8942,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,6262.31,,,,,,,fee schedule,6262.31,6262.31, HIV With One Significant HIV Condition Or Without Significant Related Conditions,8942,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,6262.31,,,,,,,fee schedule,6262.31,6262.31, HIV With One Significant HIV Condition Or Without Significant Related Conditions,8942,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,6262.31,,,,,,,fee schedule,6262.31,6262.31, HIV With One Significant HIV Condition Or Without Significant Related Conditions,8942,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,6262.31,,,,,,,fee schedule,6262.31,6262.31, HIV With One Significant HIV Condition Or Without Significant Related Conditions,8942,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,6262.31,,,,,,,fee schedule,6262.31,6262.31, HIV With One Significant HIV Condition Or Without Significant Related Conditions,8942,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,6262.31,,,,,,,fee schedule,6262.31,6262.31, HIV With One Significant HIV Condition Or Without Significant Related Conditions,8942,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,6262.31,,,,,,,fee schedule,6262.31,6262.31, HIV With One Significant HIV Condition Or Without Significant Related Conditions,8942,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,6262.31,,,,,,,fee schedule,6262.31,6262.31, HIV With One Significant HIV Condition Or Without Significant Related Conditions,8942,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,6262.31,,,,,,,fee schedule,6262.31,6262.31, HIV With One Significant HIV Condition Or Without Significant Related Conditions,8942,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,6262.31,,,,,,,fee schedule,6262.31,6262.31, HIV With One Significant HIV Condition Or Without Significant Related Conditions,8942,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,6262.31,,,,,,,fee schedule,6262.31,6262.31, HIV With One Significant HIV Condition Or Without Significant Related Conditions,8943,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,8287.17,,,,,,,fee schedule,8287.17,8287.17, HIV With One Significant HIV Condition Or Without Significant Related Conditions,8943,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,8287.17,,,,,,,fee schedule,8287.17,8287.17, HIV With One Significant HIV Condition Or Without Significant Related Conditions,8943,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,8287.17,,,,,,,fee schedule,8287.17,8287.17, HIV With One Significant HIV Condition Or Without Significant Related Conditions,8943,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,8287.17,,,,,,,fee schedule,8287.17,8287.17, HIV With One Significant HIV Condition Or Without Significant Related Conditions,8943,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,8287.17,,,,,,,fee schedule,8287.17,8287.17, HIV With One Significant HIV Condition Or Without Significant Related Conditions,8943,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,8287.17,,,,,,,fee schedule,8287.17,8287.17, HIV With One Significant HIV Condition Or Without Significant Related Conditions,8943,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,8287.17,,,,,,,fee schedule,8287.17,8287.17, HIV With One Significant HIV Condition Or Without Significant Related Conditions,8943,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,8287.17,,,,,,,fee schedule,8287.17,8287.17, HIV With One Significant HIV Condition Or Without Significant Related Conditions,8943,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,8287.17,,,,,,,fee schedule,8287.17,8287.17, HIV With One Significant HIV Condition Or Without Significant Related Conditions,8943,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,8287.17,,,,,,,fee schedule,8287.17,8287.17, HIV With One Significant HIV Condition Or Without Significant Related Conditions,8943,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,8287.17,,,,,,,fee schedule,8287.17,8287.17, HIV With One Significant HIV Condition Or Without Significant Related Conditions,8944,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,13752.66,,,,,,,fee schedule,13752.66,13752.66, HIV With One Significant HIV Condition Or Without Significant Related Conditions,8944,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,13752.66,,,,,,,fee schedule,13752.66,13752.66, HIV With One Significant HIV Condition Or Without Significant Related Conditions,8944,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,13752.66,,,,,,,fee schedule,13752.66,13752.66, HIV With One Significant HIV Condition Or Without Significant Related Conditions,8944,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,13752.66,,,,,,,fee schedule,13752.66,13752.66, HIV With One Significant HIV Condition Or Without Significant Related Conditions,8944,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,13752.66,,,,,,,fee schedule,13752.66,13752.66, HIV With One Significant HIV Condition Or Without Significant Related Conditions,8944,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,13752.66,,,,,,,fee schedule,13752.66,13752.66, HIV With One Significant HIV Condition Or Without Significant Related Conditions,8944,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,13752.66,,,,,,,fee schedule,13752.66,13752.66, HIV With One Significant HIV Condition Or Without Significant Related Conditions,8944,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,13752.66,,,,,,,fee schedule,13752.66,13752.66, HIV With One Significant HIV Condition Or Without Significant Related Conditions,8944,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,13752.66,,,,,,,fee schedule,13752.66,13752.66, HIV With One Significant HIV Condition Or Without Significant Related Conditions,8944,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,13752.66,,,,,,,fee schedule,13752.66,13752.66, HIV With One Significant HIV Condition Or Without Significant Related Conditions,8944,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,13752.66,,,,,,,fee schedule,13752.66,13752.66, Craniotomy For Multiple Significant Trauma,9101,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,18404.4,,,,,,,fee schedule,18404.4,18404.4, Craniotomy For Multiple Significant Trauma,9101,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,18404.4,,,,,,,fee schedule,18404.4,18404.4, Craniotomy For Multiple Significant Trauma,9101,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,18404.4,,,,,,,fee schedule,18404.4,18404.4, Craniotomy For Multiple Significant Trauma,9101,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,18404.4,,,,,,,fee schedule,18404.4,18404.4, Craniotomy For Multiple Significant Trauma,9101,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,18404.4,,,,,,,fee schedule,18404.4,18404.4, Craniotomy For Multiple Significant Trauma,9101,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,18404.4,,,,,,,fee schedule,18404.4,18404.4, Craniotomy For Multiple Significant Trauma,9101,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,18404.4,,,,,,,fee schedule,18404.4,18404.4, Craniotomy For Multiple Significant Trauma,9101,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,18404.4,,,,,,,fee schedule,18404.4,18404.4, Craniotomy For Multiple Significant Trauma,9101,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,18404.4,,,,,,,fee schedule,18404.4,18404.4, Craniotomy For Multiple Significant Trauma,9101,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,18404.4,,,,,,,fee schedule,18404.4,18404.4, Craniotomy For Multiple Significant Trauma,9101,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,18404.4,,,,,,,fee schedule,18404.4,18404.4, Craniotomy For Multiple Significant Trauma,9102,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,19740.42,,,,,,,fee schedule,19740.42,19740.42, Craniotomy For Multiple Significant Trauma,9102,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,19740.42,,,,,,,fee schedule,19740.42,19740.42, Craniotomy For Multiple Significant Trauma,9102,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,19740.42,,,,,,,fee schedule,19740.42,19740.42, Craniotomy For Multiple Significant Trauma,9102,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,19740.42,,,,,,,fee schedule,19740.42,19740.42, Craniotomy For Multiple Significant Trauma,9102,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,19740.42,,,,,,,fee schedule,19740.42,19740.42, Craniotomy For Multiple Significant Trauma,9102,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,19740.42,,,,,,,fee schedule,19740.42,19740.42, Craniotomy For Multiple Significant Trauma,9102,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,19740.42,,,,,,,fee schedule,19740.42,19740.42, Craniotomy For Multiple Significant Trauma,9102,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,19740.42,,,,,,,fee schedule,19740.42,19740.42, Craniotomy For Multiple Significant Trauma,9102,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,19740.42,,,,,,,fee schedule,19740.42,19740.42, Craniotomy For Multiple Significant Trauma,9102,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,19740.42,,,,,,,fee schedule,19740.42,19740.42, Craniotomy For Multiple Significant Trauma,9102,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,19740.42,,,,,,,fee schedule,19740.42,19740.42, Craniotomy For Multiple Significant Trauma,9103,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,32476.06,,,,,,,fee schedule,32476.06,32476.06, Craniotomy For Multiple Significant Trauma,9103,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,32476.06,,,,,,,fee schedule,32476.06,32476.06, Craniotomy For Multiple Significant Trauma,9103,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,32476.06,,,,,,,fee schedule,32476.06,32476.06, Craniotomy For Multiple Significant Trauma,9103,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,32476.06,,,,,,,fee schedule,32476.06,32476.06, Craniotomy For Multiple Significant Trauma,9103,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,32476.06,,,,,,,fee schedule,32476.06,32476.06, Craniotomy For Multiple Significant Trauma,9103,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,32476.06,,,,,,,fee schedule,32476.06,32476.06, Craniotomy For Multiple Significant Trauma,9103,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,32476.06,,,,,,,fee schedule,32476.06,32476.06, Craniotomy For Multiple Significant Trauma,9103,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,32476.06,,,,,,,fee schedule,32476.06,32476.06, Craniotomy For Multiple Significant Trauma,9103,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,32476.06,,,,,,,fee schedule,32476.06,32476.06, Craniotomy For Multiple Significant Trauma,9103,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,32476.06,,,,,,,fee schedule,32476.06,32476.06, Craniotomy For Multiple Significant Trauma,9103,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,32476.06,,,,,,,fee schedule,32476.06,32476.06, Craniotomy For Multiple Significant Trauma,9104,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,50310.2,,,,,,,fee schedule,50310.2,50310.2, Craniotomy For Multiple Significant Trauma,9104,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,50310.2,,,,,,,fee schedule,50310.2,50310.2, Craniotomy For Multiple Significant Trauma,9104,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,50310.2,,,,,,,fee schedule,50310.2,50310.2, Craniotomy For Multiple Significant Trauma,9104,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,50310.2,,,,,,,fee schedule,50310.2,50310.2, Craniotomy For Multiple Significant Trauma,9104,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,50310.2,,,,,,,fee schedule,50310.2,50310.2, Craniotomy For Multiple Significant Trauma,9104,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,50310.2,,,,,,,fee schedule,50310.2,50310.2, Craniotomy For Multiple Significant Trauma,9104,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,50310.2,,,,,,,fee schedule,50310.2,50310.2, Craniotomy For Multiple Significant Trauma,9104,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,50310.2,,,,,,,fee schedule,50310.2,50310.2, Craniotomy For Multiple Significant Trauma,9104,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,50310.2,,,,,,,fee schedule,50310.2,50310.2, Craniotomy For Multiple Significant Trauma,9104,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,50310.2,,,,,,,fee schedule,50310.2,50310.2, Craniotomy For Multiple Significant Trauma,9104,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,50310.2,,,,,,,fee schedule,50310.2,50310.2, Extensive Abdominal Or Thoracic Procedures For Multiple Significant Trauma,9111,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,13830.29,,,,,,,fee schedule,13830.29,13830.29, Extensive Abdominal Or Thoracic Procedures For Multiple Significant Trauma,9111,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,13830.29,,,,,,,fee schedule,13830.29,13830.29, Extensive Abdominal Or Thoracic Procedures For Multiple Significant Trauma,9111,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,13830.29,,,,,,,fee schedule,13830.29,13830.29, Extensive Abdominal Or Thoracic Procedures For Multiple Significant Trauma,9111,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,13830.29,,,,,,,fee schedule,13830.29,13830.29, Extensive Abdominal Or Thoracic Procedures For Multiple Significant Trauma,9111,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,13830.29,,,,,,,fee schedule,13830.29,13830.29, Extensive Abdominal Or Thoracic Procedures For Multiple Significant Trauma,9111,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,13830.29,,,,,,,fee schedule,13830.29,13830.29, Extensive Abdominal Or Thoracic Procedures For Multiple Significant Trauma,9111,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,13830.29,,,,,,,fee schedule,13830.29,13830.29, Extensive Abdominal Or Thoracic Procedures For Multiple Significant Trauma,9111,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,13830.29,,,,,,,fee schedule,13830.29,13830.29, Extensive Abdominal Or Thoracic Procedures For Multiple Significant Trauma,9111,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,13830.29,,,,,,,fee schedule,13830.29,13830.29, Extensive Abdominal Or Thoracic Procedures For Multiple Significant Trauma,9111,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,13830.29,,,,,,,fee schedule,13830.29,13830.29, Extensive Abdominal Or Thoracic Procedures For Multiple Significant Trauma,9111,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,13830.29,,,,,,,fee schedule,13830.29,13830.29, Extensive Abdominal Or Thoracic Procedures For Multiple Significant Trauma,9112,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,18066.33,,,,,,,fee schedule,18066.33,18066.33, Extensive Abdominal Or Thoracic Procedures For Multiple Significant Trauma,9112,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,18066.33,,,,,,,fee schedule,18066.33,18066.33, Extensive Abdominal Or Thoracic Procedures For Multiple Significant Trauma,9112,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,18066.33,,,,,,,fee schedule,18066.33,18066.33, Extensive Abdominal Or Thoracic Procedures For Multiple Significant Trauma,9112,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,18066.33,,,,,,,fee schedule,18066.33,18066.33, Extensive Abdominal Or Thoracic Procedures For Multiple Significant Trauma,9112,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,18066.33,,,,,,,fee schedule,18066.33,18066.33, Extensive Abdominal Or Thoracic Procedures For Multiple Significant Trauma,9112,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,18066.33,,,,,,,fee schedule,18066.33,18066.33, Extensive Abdominal Or Thoracic Procedures For Multiple Significant Trauma,9112,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,18066.33,,,,,,,fee schedule,18066.33,18066.33, Extensive Abdominal Or Thoracic Procedures For Multiple Significant Trauma,9112,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,18066.33,,,,,,,fee schedule,18066.33,18066.33, Extensive Abdominal Or Thoracic Procedures For Multiple Significant Trauma,9112,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,18066.33,,,,,,,fee schedule,18066.33,18066.33, Extensive Abdominal Or Thoracic Procedures For Multiple Significant Trauma,9112,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,18066.33,,,,,,,fee schedule,18066.33,18066.33, Extensive Abdominal Or Thoracic Procedures For Multiple Significant Trauma,9112,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,18066.33,,,,,,,fee schedule,18066.33,18066.33, Extensive Abdominal Or Thoracic Procedures For Multiple Significant Trauma,9113,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,27690.94,,,,,,,fee schedule,27690.94,27690.94, Extensive Abdominal Or Thoracic Procedures For Multiple Significant Trauma,9113,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,27690.94,,,,,,,fee schedule,27690.94,27690.94, Extensive Abdominal Or Thoracic Procedures For Multiple Significant Trauma,9113,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,27690.94,,,,,,,fee schedule,27690.94,27690.94, Extensive Abdominal Or Thoracic Procedures For Multiple Significant Trauma,9113,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,27690.94,,,,,,,fee schedule,27690.94,27690.94, Extensive Abdominal Or Thoracic Procedures For Multiple Significant Trauma,9113,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,27690.94,,,,,,,fee schedule,27690.94,27690.94, Extensive Abdominal Or Thoracic Procedures For Multiple Significant Trauma,9113,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,27690.94,,,,,,,fee schedule,27690.94,27690.94, Extensive Abdominal Or Thoracic Procedures For Multiple Significant Trauma,9113,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,27690.94,,,,,,,fee schedule,27690.94,27690.94, Extensive Abdominal Or Thoracic Procedures For Multiple Significant Trauma,9113,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,27690.94,,,,,,,fee schedule,27690.94,27690.94, Extensive Abdominal Or Thoracic Procedures For Multiple Significant Trauma,9113,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,27690.94,,,,,,,fee schedule,27690.94,27690.94, Extensive Abdominal Or Thoracic Procedures For Multiple Significant Trauma,9113,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,27690.94,,,,,,,fee schedule,27690.94,27690.94, Extensive Abdominal Or Thoracic Procedures For Multiple Significant Trauma,9113,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,27690.94,,,,,,,fee schedule,27690.94,27690.94, Extensive Abdominal Or Thoracic Procedures For Multiple Significant Trauma,9114,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,47852.7,,,,,,,fee schedule,47852.7,47852.7, Extensive Abdominal Or Thoracic Procedures For Multiple Significant Trauma,9114,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,47852.7,,,,,,,fee schedule,47852.7,47852.7, Extensive Abdominal Or Thoracic Procedures For Multiple Significant Trauma,9114,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,47852.7,,,,,,,fee schedule,47852.7,47852.7, Extensive Abdominal Or Thoracic Procedures For Multiple Significant Trauma,9114,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,47852.7,,,,,,,fee schedule,47852.7,47852.7, Extensive Abdominal Or Thoracic Procedures For Multiple Significant Trauma,9114,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,47852.7,,,,,,,fee schedule,47852.7,47852.7, Extensive Abdominal Or Thoracic Procedures For Multiple Significant Trauma,9114,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,47852.7,,,,,,,fee schedule,47852.7,47852.7, Extensive Abdominal Or Thoracic Procedures For Multiple Significant Trauma,9114,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,47852.7,,,,,,,fee schedule,47852.7,47852.7, Extensive Abdominal Or Thoracic Procedures For Multiple Significant Trauma,9114,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,47852.7,,,,,,,fee schedule,47852.7,47852.7, Extensive Abdominal Or Thoracic Procedures For Multiple Significant Trauma,9114,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,47852.7,,,,,,,fee schedule,47852.7,47852.7, Extensive Abdominal Or Thoracic Procedures For Multiple Significant Trauma,9114,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,47852.7,,,,,,,fee schedule,47852.7,47852.7, Extensive Abdominal Or Thoracic Procedures For Multiple Significant Trauma,9114,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,47852.7,,,,,,,fee schedule,47852.7,47852.7, Musculoskeletal And Other Procedures For Multiple Significant Trauma,9121,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,14941.18,,,,,,,fee schedule,14941.18,14941.18, Musculoskeletal And Other Procedures For Multiple Significant Trauma,9121,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,14941.18,,,,,,,fee schedule,14941.18,14941.18, Musculoskeletal And Other Procedures For Multiple Significant Trauma,9121,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,14941.18,,,,,,,fee schedule,14941.18,14941.18, Musculoskeletal And Other Procedures For Multiple Significant Trauma,9121,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,14941.18,,,,,,,fee schedule,14941.18,14941.18, Musculoskeletal And Other Procedures For Multiple Significant Trauma,9121,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,14941.18,,,,,,,fee schedule,14941.18,14941.18, Musculoskeletal And Other Procedures For Multiple Significant Trauma,9121,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,14941.18,,,,,,,fee schedule,14941.18,14941.18, Musculoskeletal And Other Procedures For Multiple Significant Trauma,9121,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,14941.18,,,,,,,fee schedule,14941.18,14941.18, Musculoskeletal And Other Procedures For Multiple Significant Trauma,9121,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,14941.18,,,,,,,fee schedule,14941.18,14941.18, Musculoskeletal And Other Procedures For Multiple Significant Trauma,9121,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,14941.18,,,,,,,fee schedule,14941.18,14941.18, Musculoskeletal And Other Procedures For Multiple Significant Trauma,9121,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,14941.18,,,,,,,fee schedule,14941.18,14941.18, Musculoskeletal And Other Procedures For Multiple Significant Trauma,9121,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,14941.18,,,,,,,fee schedule,14941.18,14941.18, Musculoskeletal And Other Procedures For Multiple Significant Trauma,9122,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,20137.77,,,,,,,fee schedule,20137.77,20137.77, Musculoskeletal And Other Procedures For Multiple Significant Trauma,9122,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,20137.77,,,,,,,fee schedule,20137.77,20137.77, Musculoskeletal And Other Procedures For Multiple Significant Trauma,9122,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,20137.77,,,,,,,fee schedule,20137.77,20137.77, Musculoskeletal And Other Procedures For Multiple Significant Trauma,9122,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,20137.77,,,,,,,fee schedule,20137.77,20137.77, Musculoskeletal And Other Procedures For Multiple Significant Trauma,9122,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,20137.77,,,,,,,fee schedule,20137.77,20137.77, Musculoskeletal And Other Procedures For Multiple Significant Trauma,9122,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,20137.77,,,,,,,fee schedule,20137.77,20137.77, Musculoskeletal And Other Procedures For Multiple Significant Trauma,9122,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,20137.77,,,,,,,fee schedule,20137.77,20137.77, Musculoskeletal And Other Procedures For Multiple Significant Trauma,9122,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,20137.77,,,,,,,fee schedule,20137.77,20137.77, Musculoskeletal And Other Procedures For Multiple Significant Trauma,9122,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,20137.77,,,,,,,fee schedule,20137.77,20137.77, Musculoskeletal And Other Procedures For Multiple Significant Trauma,9122,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,20137.77,,,,,,,fee schedule,20137.77,20137.77, Musculoskeletal And Other Procedures For Multiple Significant Trauma,9122,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,20137.77,,,,,,,fee schedule,20137.77,20137.77, Musculoskeletal And Other Procedures For Multiple Significant Trauma,9123,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,28221.68,,,,,,,fee schedule,28221.68,28221.68, Musculoskeletal And Other Procedures For Multiple Significant Trauma,9123,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,28221.68,,,,,,,fee schedule,28221.68,28221.68, Musculoskeletal And Other Procedures For Multiple Significant Trauma,9123,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,28221.68,,,,,,,fee schedule,28221.68,28221.68, Musculoskeletal And Other Procedures For Multiple Significant Trauma,9123,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,28221.68,,,,,,,fee schedule,28221.68,28221.68, Musculoskeletal And Other Procedures For Multiple Significant Trauma,9123,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,28221.68,,,,,,,fee schedule,28221.68,28221.68, Musculoskeletal And Other Procedures For Multiple Significant Trauma,9123,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,28221.68,,,,,,,fee schedule,28221.68,28221.68, Musculoskeletal And Other Procedures For Multiple Significant Trauma,9123,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,28221.68,,,,,,,fee schedule,28221.68,28221.68, Musculoskeletal And Other Procedures For Multiple Significant Trauma,9123,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,28221.68,,,,,,,fee schedule,28221.68,28221.68, Musculoskeletal And Other Procedures For Multiple Significant Trauma,9123,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,28221.68,,,,,,,fee schedule,28221.68,28221.68, Musculoskeletal And Other Procedures For Multiple Significant Trauma,9123,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,28221.68,,,,,,,fee schedule,28221.68,28221.68, Musculoskeletal And Other Procedures For Multiple Significant Trauma,9123,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,28221.68,,,,,,,fee schedule,28221.68,28221.68, Musculoskeletal And Other Procedures For Multiple Significant Trauma,9124,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,44492.53,,,,,,,fee schedule,44492.53,44492.53, Musculoskeletal And Other Procedures For Multiple Significant Trauma,9124,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,44492.53,,,,,,,fee schedule,44492.53,44492.53, Musculoskeletal And Other Procedures For Multiple Significant Trauma,9124,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,44492.53,,,,,,,fee schedule,44492.53,44492.53, Musculoskeletal And Other Procedures For Multiple Significant Trauma,9124,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,44492.53,,,,,,,fee schedule,44492.53,44492.53, Musculoskeletal And Other Procedures For Multiple Significant Trauma,9124,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,44492.53,,,,,,,fee schedule,44492.53,44492.53, Musculoskeletal And Other Procedures For Multiple Significant Trauma,9124,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,44492.53,,,,,,,fee schedule,44492.53,44492.53, Musculoskeletal And Other Procedures For Multiple Significant Trauma,9124,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,44492.53,,,,,,,fee schedule,44492.53,44492.53, Musculoskeletal And Other Procedures For Multiple Significant Trauma,9124,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,44492.53,,,,,,,fee schedule,44492.53,44492.53, Musculoskeletal And Other Procedures For Multiple Significant Trauma,9124,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,44492.53,,,,,,,fee schedule,44492.53,44492.53, Musculoskeletal And Other Procedures For Multiple Significant Trauma,9124,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,44492.53,,,,,,,fee schedule,44492.53,44492.53, Musculoskeletal And Other Procedures For Multiple Significant Trauma,9124,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,44492.53,,,,,,,fee schedule,44492.53,44492.53, Multiple Significant Trauma Without O.R. Procedure,9301,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,6680.12,,,,,,,fee schedule,6680.12,6680.12, Multiple Significant Trauma Without O.R. Procedure,9301,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,6680.12,,,,,,,fee schedule,6680.12,6680.12, Multiple Significant Trauma Without O.R. Procedure,9301,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,6680.12,,,,,,,fee schedule,6680.12,6680.12, Multiple Significant Trauma Without O.R. Procedure,9301,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,6680.12,,,,,,,fee schedule,6680.12,6680.12, Multiple Significant Trauma Without O.R. Procedure,9301,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,6680.12,,,,,,,fee schedule,6680.12,6680.12, Multiple Significant Trauma Without O.R. Procedure,9301,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,6680.12,,,,,,,fee schedule,6680.12,6680.12, Multiple Significant Trauma Without O.R. Procedure,9301,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,6680.12,,,,,,,fee schedule,6680.12,6680.12, Multiple Significant Trauma Without O.R. Procedure,9301,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,6680.12,,,,,,,fee schedule,6680.12,6680.12, Multiple Significant Trauma Without O.R. Procedure,9301,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,6680.12,,,,,,,fee schedule,6680.12,6680.12, Multiple Significant Trauma Without O.R. Procedure,9301,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,6680.12,,,,,,,fee schedule,6680.12,6680.12, Multiple Significant Trauma Without O.R. Procedure,9301,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,6680.12,,,,,,,fee schedule,6680.12,6680.12, Multiple Significant Trauma Without O.R. Procedure,9302,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,8413.5,,,,,,,fee schedule,8413.5,8413.5, Multiple Significant Trauma Without O.R. Procedure,9302,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,8413.5,,,,,,,fee schedule,8413.5,8413.5, Multiple Significant Trauma Without O.R. Procedure,9302,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,8413.5,,,,,,,fee schedule,8413.5,8413.5, Multiple Significant Trauma Without O.R. Procedure,9302,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,8413.5,,,,,,,fee schedule,8413.5,8413.5, Multiple Significant Trauma Without O.R. Procedure,9302,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,8413.5,,,,,,,fee schedule,8413.5,8413.5, Multiple Significant Trauma Without O.R. Procedure,9302,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,8413.5,,,,,,,fee schedule,8413.5,8413.5, Multiple Significant Trauma Without O.R. Procedure,9302,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,8413.5,,,,,,,fee schedule,8413.5,8413.5, Multiple Significant Trauma Without O.R. Procedure,9302,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,8413.5,,,,,,,fee schedule,8413.5,8413.5, Multiple Significant Trauma Without O.R. Procedure,9302,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,8413.5,,,,,,,fee schedule,8413.5,8413.5, Multiple Significant Trauma Without O.R. Procedure,9302,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,8413.5,,,,,,,fee schedule,8413.5,8413.5, Multiple Significant Trauma Without O.R. Procedure,9302,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,8413.5,,,,,,,fee schedule,8413.5,8413.5, Multiple Significant Trauma Without O.R. Procedure,9303,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,13020.07,,,,,,,fee schedule,13020.07,13020.07, Multiple Significant Trauma Without O.R. Procedure,9303,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,13020.07,,,,,,,fee schedule,13020.07,13020.07, Multiple Significant Trauma Without O.R. Procedure,9303,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,13020.07,,,,,,,fee schedule,13020.07,13020.07, Multiple Significant Trauma Without O.R. Procedure,9303,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,13020.07,,,,,,,fee schedule,13020.07,13020.07, Multiple Significant Trauma Without O.R. Procedure,9303,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,13020.07,,,,,,,fee schedule,13020.07,13020.07, Multiple Significant Trauma Without O.R. Procedure,9303,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,13020.07,,,,,,,fee schedule,13020.07,13020.07, Multiple Significant Trauma Without O.R. Procedure,9303,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,13020.07,,,,,,,fee schedule,13020.07,13020.07, Multiple Significant Trauma Without O.R. Procedure,9303,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,13020.07,,,,,,,fee schedule,13020.07,13020.07, Multiple Significant Trauma Without O.R. Procedure,9303,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,13020.07,,,,,,,fee schedule,13020.07,13020.07, Multiple Significant Trauma Without O.R. Procedure,9303,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,13020.07,,,,,,,fee schedule,13020.07,13020.07, Multiple Significant Trauma Without O.R. Procedure,9303,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,13020.07,,,,,,,fee schedule,13020.07,13020.07, Multiple Significant Trauma Without O.R. Procedure,9304,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,23097.07,,,,,,,fee schedule,23097.07,23097.07, Multiple Significant Trauma Without O.R. Procedure,9304,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,23097.07,,,,,,,fee schedule,23097.07,23097.07, Multiple Significant Trauma Without O.R. Procedure,9304,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,23097.07,,,,,,,fee schedule,23097.07,23097.07, Multiple Significant Trauma Without O.R. Procedure,9304,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,23097.07,,,,,,,fee schedule,23097.07,23097.07, Multiple Significant Trauma Without O.R. Procedure,9304,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,23097.07,,,,,,,fee schedule,23097.07,23097.07, Multiple Significant Trauma Without O.R. Procedure,9304,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,23097.07,,,,,,,fee schedule,23097.07,23097.07, Multiple Significant Trauma Without O.R. Procedure,9304,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,23097.07,,,,,,,fee schedule,23097.07,23097.07, Multiple Significant Trauma Without O.R. Procedure,9304,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,23097.07,,,,,,,fee schedule,23097.07,23097.07, Multiple Significant Trauma Without O.R. Procedure,9304,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,23097.07,,,,,,,fee schedule,23097.07,23097.07, Multiple Significant Trauma Without O.R. Procedure,9304,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,23097.07,,,,,,,fee schedule,23097.07,23097.07, Multiple Significant Trauma Without O.R. Procedure,9304,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,23097.07,,,,,,,fee schedule,23097.07,23097.07, Extensive O.R. Procedure Unrelated To Principal Diagnosis,9501,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,11770.85,,,,,,,fee schedule,11770.85,11770.85, Extensive O.R. Procedure Unrelated To Principal Diagnosis,9501,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,11770.85,,,,,,,fee schedule,11770.85,11770.85, Extensive O.R. Procedure Unrelated To Principal Diagnosis,9501,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,11770.85,,,,,,,fee schedule,11770.85,11770.85, Extensive O.R. Procedure Unrelated To Principal Diagnosis,9501,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,11770.85,,,,,,,fee schedule,11770.85,11770.85, Extensive O.R. Procedure Unrelated To Principal Diagnosis,9501,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,11770.85,,,,,,,fee schedule,11770.85,11770.85, Extensive O.R. Procedure Unrelated To Principal Diagnosis,9501,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,11770.85,,,,,,,fee schedule,11770.85,11770.85, Extensive O.R. Procedure Unrelated To Principal Diagnosis,9501,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,11770.85,,,,,,,fee schedule,11770.85,11770.85, Extensive O.R. Procedure Unrelated To Principal Diagnosis,9501,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,11770.85,,,,,,,fee schedule,11770.85,11770.85, Extensive O.R. Procedure Unrelated To Principal Diagnosis,9501,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,11770.85,,,,,,,fee schedule,11770.85,11770.85, Extensive O.R. Procedure Unrelated To Principal Diagnosis,9501,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,11770.85,,,,,,,fee schedule,11770.85,11770.85, Extensive O.R. Procedure Unrelated To Principal Diagnosis,9501,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,11770.85,,,,,,,fee schedule,11770.85,11770.85, Extensive O.R. Procedure Unrelated To Principal Diagnosis,9502,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,15319.47,,,,,,,fee schedule,15319.47,15319.47, Extensive O.R. Procedure Unrelated To Principal Diagnosis,9502,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,15319.47,,,,,,,fee schedule,15319.47,15319.47, Extensive O.R. Procedure Unrelated To Principal Diagnosis,9502,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,15319.47,,,,,,,fee schedule,15319.47,15319.47, Extensive O.R. Procedure Unrelated To Principal Diagnosis,9502,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,15319.47,,,,,,,fee schedule,15319.47,15319.47, Extensive O.R. Procedure Unrelated To Principal Diagnosis,9502,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,15319.47,,,,,,,fee schedule,15319.47,15319.47, Extensive O.R. Procedure Unrelated To Principal Diagnosis,9502,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,15319.47,,,,,,,fee schedule,15319.47,15319.47, Extensive O.R. Procedure Unrelated To Principal Diagnosis,9502,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,15319.47,,,,,,,fee schedule,15319.47,15319.47, Extensive O.R. Procedure Unrelated To Principal Diagnosis,9502,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,15319.47,,,,,,,fee schedule,15319.47,15319.47, Extensive O.R. Procedure Unrelated To Principal Diagnosis,9502,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,15319.47,,,,,,,fee schedule,15319.47,15319.47, Extensive O.R. Procedure Unrelated To Principal Diagnosis,9502,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,15319.47,,,,,,,fee schedule,15319.47,15319.47, Extensive O.R. Procedure Unrelated To Principal Diagnosis,9502,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,15319.47,,,,,,,fee schedule,15319.47,15319.47, Extensive O.R. Procedure Unrelated To Principal Diagnosis,9503,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,23740.03,,,,,,,fee schedule,23740.03,23740.03, Extensive O.R. Procedure Unrelated To Principal Diagnosis,9503,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,23740.03,,,,,,,fee schedule,23740.03,23740.03, Extensive O.R. Procedure Unrelated To Principal Diagnosis,9503,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,23740.03,,,,,,,fee schedule,23740.03,23740.03, Extensive O.R. Procedure Unrelated To Principal Diagnosis,9503,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,23740.03,,,,,,,fee schedule,23740.03,23740.03, Extensive O.R. Procedure Unrelated To Principal Diagnosis,9503,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,23740.03,,,,,,,fee schedule,23740.03,23740.03, Extensive O.R. Procedure Unrelated To Principal Diagnosis,9503,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,23740.03,,,,,,,fee schedule,23740.03,23740.03, Extensive O.R. Procedure Unrelated To Principal Diagnosis,9503,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,23740.03,,,,,,,fee schedule,23740.03,23740.03, Extensive O.R. Procedure Unrelated To Principal Diagnosis,9503,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,23740.03,,,,,,,fee schedule,23740.03,23740.03, Extensive O.R. Procedure Unrelated To Principal Diagnosis,9503,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,23740.03,,,,,,,fee schedule,23740.03,23740.03, Extensive O.R. Procedure Unrelated To Principal Diagnosis,9503,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,23740.03,,,,,,,fee schedule,23740.03,23740.03, Extensive O.R. Procedure Unrelated To Principal Diagnosis,9503,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,23740.03,,,,,,,fee schedule,23740.03,23740.03, Extensive O.R. Procedure Unrelated To Principal Diagnosis,9504,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,39517.54,,,,,,,fee schedule,39517.54,39517.54, Extensive O.R. Procedure Unrelated To Principal Diagnosis,9504,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,39517.54,,,,,,,fee schedule,39517.54,39517.54, Extensive O.R. Procedure Unrelated To Principal Diagnosis,9504,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,39517.54,,,,,,,fee schedule,39517.54,39517.54, Extensive O.R. Procedure Unrelated To Principal Diagnosis,9504,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,39517.54,,,,,,,fee schedule,39517.54,39517.54, Extensive O.R. Procedure Unrelated To Principal Diagnosis,9504,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,39517.54,,,,,,,fee schedule,39517.54,39517.54, Extensive O.R. Procedure Unrelated To Principal Diagnosis,9504,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,39517.54,,,,,,,fee schedule,39517.54,39517.54, Extensive O.R. Procedure Unrelated To Principal Diagnosis,9504,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,39517.54,,,,,,,fee schedule,39517.54,39517.54, Extensive O.R. Procedure Unrelated To Principal Diagnosis,9504,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,39517.54,,,,,,,fee schedule,39517.54,39517.54, Extensive O.R. Procedure Unrelated To Principal Diagnosis,9504,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,39517.54,,,,,,,fee schedule,39517.54,39517.54, Extensive O.R. Procedure Unrelated To Principal Diagnosis,9504,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,39517.54,,,,,,,fee schedule,39517.54,39517.54, Extensive O.R. Procedure Unrelated To Principal Diagnosis,9504,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,39517.54,,,,,,,fee schedule,39517.54,39517.54, Moderately Extensive O.R. Procedure Unrelated To Principal Diagnosis,9511,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,8784.73,,,,,,,fee schedule,8784.73,8784.73, Moderately Extensive O.R. Procedure Unrelated To Principal Diagnosis,9511,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,8784.73,,,,,,,fee schedule,8784.73,8784.73, Moderately Extensive O.R. Procedure Unrelated To Principal Diagnosis,9511,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,8784.73,,,,,,,fee schedule,8784.73,8784.73, Moderately Extensive O.R. Procedure Unrelated To Principal Diagnosis,9511,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,8784.73,,,,,,,fee schedule,8784.73,8784.73, Moderately Extensive O.R. Procedure Unrelated To Principal Diagnosis,9511,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,8784.73,,,,,,,fee schedule,8784.73,8784.73, Moderately Extensive O.R. Procedure Unrelated To Principal Diagnosis,9511,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,8784.73,,,,,,,fee schedule,8784.73,8784.73, Moderately Extensive O.R. Procedure Unrelated To Principal Diagnosis,9511,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,8784.73,,,,,,,fee schedule,8784.73,8784.73, Moderately Extensive O.R. Procedure Unrelated To Principal Diagnosis,9511,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,8784.73,,,,,,,fee schedule,8784.73,8784.73, Moderately Extensive O.R. Procedure Unrelated To Principal Diagnosis,9511,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,8784.73,,,,,,,fee schedule,8784.73,8784.73, Moderately Extensive O.R. Procedure Unrelated To Principal Diagnosis,9511,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,8784.73,,,,,,,fee schedule,8784.73,8784.73, Moderately Extensive O.R. Procedure Unrelated To Principal Diagnosis,9511,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,8784.73,,,,,,,fee schedule,8784.73,8784.73, Moderately Extensive O.R. Procedure Unrelated To Principal Diagnosis,9512,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,12730.7,,,,,,,fee schedule,12730.7,12730.7, Moderately Extensive O.R. Procedure Unrelated To Principal Diagnosis,9512,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,12730.7,,,,,,,fee schedule,12730.7,12730.7, Moderately Extensive O.R. Procedure Unrelated To Principal Diagnosis,9512,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,12730.7,,,,,,,fee schedule,12730.7,12730.7, Moderately Extensive O.R. Procedure Unrelated To Principal Diagnosis,9512,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,12730.7,,,,,,,fee schedule,12730.7,12730.7, Moderately Extensive O.R. Procedure Unrelated To Principal Diagnosis,9512,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,12730.7,,,,,,,fee schedule,12730.7,12730.7, Moderately Extensive O.R. Procedure Unrelated To Principal Diagnosis,9512,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,12730.7,,,,,,,fee schedule,12730.7,12730.7, Moderately Extensive O.R. Procedure Unrelated To Principal Diagnosis,9512,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,12730.7,,,,,,,fee schedule,12730.7,12730.7, Moderately Extensive O.R. Procedure Unrelated To Principal Diagnosis,9512,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,12730.7,,,,,,,fee schedule,12730.7,12730.7, Moderately Extensive O.R. Procedure Unrelated To Principal Diagnosis,9512,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,12730.7,,,,,,,fee schedule,12730.7,12730.7, Moderately Extensive O.R. Procedure Unrelated To Principal Diagnosis,9512,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,12730.7,,,,,,,fee schedule,12730.7,12730.7, Moderately Extensive O.R. Procedure Unrelated To Principal Diagnosis,9512,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,12730.7,,,,,,,fee schedule,12730.7,12730.7, Moderately Extensive O.R. Procedure Unrelated To Principal Diagnosis,9513,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,18690.23,,,,,,,fee schedule,18690.23,18690.23, Moderately Extensive O.R. Procedure Unrelated To Principal Diagnosis,9513,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,18690.23,,,,,,,fee schedule,18690.23,18690.23, Moderately Extensive O.R. Procedure Unrelated To Principal Diagnosis,9513,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,18690.23,,,,,,,fee schedule,18690.23,18690.23, Moderately Extensive O.R. Procedure Unrelated To Principal Diagnosis,9513,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,18690.23,,,,,,,fee schedule,18690.23,18690.23, Moderately Extensive O.R. Procedure Unrelated To Principal Diagnosis,9513,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,18690.23,,,,,,,fee schedule,18690.23,18690.23, Moderately Extensive O.R. Procedure Unrelated To Principal Diagnosis,9513,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,18690.23,,,,,,,fee schedule,18690.23,18690.23, Moderately Extensive O.R. Procedure Unrelated To Principal Diagnosis,9513,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,18690.23,,,,,,,fee schedule,18690.23,18690.23, Moderately Extensive O.R. Procedure Unrelated To Principal Diagnosis,9513,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,18690.23,,,,,,,fee schedule,18690.23,18690.23, Moderately Extensive O.R. Procedure Unrelated To Principal Diagnosis,9513,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,18690.23,,,,,,,fee schedule,18690.23,18690.23, Moderately Extensive O.R. Procedure Unrelated To Principal Diagnosis,9513,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,18690.23,,,,,,,fee schedule,18690.23,18690.23, Moderately Extensive O.R. Procedure Unrelated To Principal Diagnosis,9513,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,18690.23,,,,,,,fee schedule,18690.23,18690.23, Moderately Extensive O.R. Procedure Unrelated To Principal Diagnosis,9514,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,30985.48,,,,,,,fee schedule,30985.48,30985.48, Moderately Extensive O.R. Procedure Unrelated To Principal Diagnosis,9514,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,30985.48,,,,,,,fee schedule,30985.48,30985.48, Moderately Extensive O.R. Procedure Unrelated To Principal Diagnosis,9514,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,30985.48,,,,,,,fee schedule,30985.48,30985.48, Moderately Extensive O.R. Procedure Unrelated To Principal Diagnosis,9514,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,30985.48,,,,,,,fee schedule,30985.48,30985.48, Moderately Extensive O.R. Procedure Unrelated To Principal Diagnosis,9514,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,30985.48,,,,,,,fee schedule,30985.48,30985.48, Moderately Extensive O.R. Procedure Unrelated To Principal Diagnosis,9514,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,30985.48,,,,,,,fee schedule,30985.48,30985.48, Moderately Extensive O.R. Procedure Unrelated To Principal Diagnosis,9514,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,30985.48,,,,,,,fee schedule,30985.48,30985.48, Moderately Extensive O.R. Procedure Unrelated To Principal Diagnosis,9514,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,30985.48,,,,,,,fee schedule,30985.48,30985.48, Moderately Extensive O.R. Procedure Unrelated To Principal Diagnosis,9514,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,30985.48,,,,,,,fee schedule,30985.48,30985.48, Moderately Extensive O.R. Procedure Unrelated To Principal Diagnosis,9514,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,30985.48,,,,,,,fee schedule,30985.48,30985.48, Moderately Extensive O.R. Procedure Unrelated To Principal Diagnosis,9514,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,30985.48,,,,,,,fee schedule,30985.48,30985.48, Non-Extensive O.R. Procedure Unrelated To Principal Diagnosis,9521,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,7567.99,,,,,,,fee schedule,7567.99,7567.99, Non-Extensive O.R. Procedure Unrelated To Principal Diagnosis,9521,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,7567.99,,,,,,,fee schedule,7567.99,7567.99, Non-Extensive O.R. Procedure Unrelated To Principal Diagnosis,9521,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,7567.99,,,,,,,fee schedule,7567.99,7567.99, Non-Extensive O.R. Procedure Unrelated To Principal Diagnosis,9521,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,7567.99,,,,,,,fee schedule,7567.99,7567.99, Non-Extensive O.R. Procedure Unrelated To Principal Diagnosis,9521,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,7567.99,,,,,,,fee schedule,7567.99,7567.99, Non-Extensive O.R. Procedure Unrelated To Principal Diagnosis,9521,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,7567.99,,,,,,,fee schedule,7567.99,7567.99, Non-Extensive O.R. Procedure Unrelated To Principal Diagnosis,9521,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,7567.99,,,,,,,fee schedule,7567.99,7567.99, Non-Extensive O.R. Procedure Unrelated To Principal Diagnosis,9521,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,7567.99,,,,,,,fee schedule,7567.99,7567.99, Non-Extensive O.R. Procedure Unrelated To Principal Diagnosis,9521,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,7567.99,,,,,,,fee schedule,7567.99,7567.99, Non-Extensive O.R. Procedure Unrelated To Principal Diagnosis,9521,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,7567.99,,,,,,,fee schedule,7567.99,7567.99, Non-Extensive O.R. Procedure Unrelated To Principal Diagnosis,9521,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,7567.99,,,,,,,fee schedule,7567.99,7567.99, Non-Extensive O.R. Procedure Unrelated To Principal Diagnosis,9522,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,10667.03,,,,,,,fee schedule,10667.03,10667.03, Non-Extensive O.R. Procedure Unrelated To Principal Diagnosis,9522,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,10667.03,,,,,,,fee schedule,10667.03,10667.03, Non-Extensive O.R. Procedure Unrelated To Principal Diagnosis,9522,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,10667.03,,,,,,,fee schedule,10667.03,10667.03, Non-Extensive O.R. Procedure Unrelated To Principal Diagnosis,9522,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,10667.03,,,,,,,fee schedule,10667.03,10667.03, Non-Extensive O.R. Procedure Unrelated To Principal Diagnosis,9522,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,10667.03,,,,,,,fee schedule,10667.03,10667.03, Non-Extensive O.R. Procedure Unrelated To Principal Diagnosis,9522,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,10667.03,,,,,,,fee schedule,10667.03,10667.03, Non-Extensive O.R. Procedure Unrelated To Principal Diagnosis,9522,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,10667.03,,,,,,,fee schedule,10667.03,10667.03, Non-Extensive O.R. Procedure Unrelated To Principal Diagnosis,9522,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,10667.03,,,,,,,fee schedule,10667.03,10667.03, Non-Extensive O.R. Procedure Unrelated To Principal Diagnosis,9522,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,10667.03,,,,,,,fee schedule,10667.03,10667.03, Non-Extensive O.R. Procedure Unrelated To Principal Diagnosis,9522,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,10667.03,,,,,,,fee schedule,10667.03,10667.03, Non-Extensive O.R. Procedure Unrelated To Principal Diagnosis,9522,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,10667.03,,,,,,,fee schedule,10667.03,10667.03, Non-Extensive O.R. Procedure Unrelated To Principal Diagnosis,9523,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,16224.27,,,,,,,fee schedule,16224.27,16224.27, Non-Extensive O.R. Procedure Unrelated To Principal Diagnosis,9523,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,16224.27,,,,,,,fee schedule,16224.27,16224.27, Non-Extensive O.R. Procedure Unrelated To Principal Diagnosis,9523,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,16224.27,,,,,,,fee schedule,16224.27,16224.27, Non-Extensive O.R. Procedure Unrelated To Principal Diagnosis,9523,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,16224.27,,,,,,,fee schedule,16224.27,16224.27, Non-Extensive O.R. Procedure Unrelated To Principal Diagnosis,9523,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,16224.27,,,,,,,fee schedule,16224.27,16224.27, Non-Extensive O.R. Procedure Unrelated To Principal Diagnosis,9523,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,16224.27,,,,,,,fee schedule,16224.27,16224.27, Non-Extensive O.R. Procedure Unrelated To Principal Diagnosis,9523,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,16224.27,,,,,,,fee schedule,16224.27,16224.27, Non-Extensive O.R. Procedure Unrelated To Principal Diagnosis,9523,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,16224.27,,,,,,,fee schedule,16224.27,16224.27, Non-Extensive O.R. Procedure Unrelated To Principal Diagnosis,9523,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,16224.27,,,,,,,fee schedule,16224.27,16224.27, Non-Extensive O.R. Procedure Unrelated To Principal Diagnosis,9523,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,16224.27,,,,,,,fee schedule,16224.27,16224.27, Non-Extensive O.R. Procedure Unrelated To Principal Diagnosis,9523,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,16224.27,,,,,,,fee schedule,16224.27,16224.27, Non-Extensive O.R. Procedure Unrelated To Principal Diagnosis,9524,APR-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,28222.38,,,,,,,fee schedule,28222.38,28222.38, Non-Extensive O.R. Procedure Unrelated To Principal Diagnosis,9524,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,28222.38,,,,,,,fee schedule,28222.38,28222.38, Non-Extensive O.R. Procedure Unrelated To Principal Diagnosis,9524,APR-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Healthy Kids Medicaid Managed Care Plan,28222.38,,,,,,,fee schedule,28222.38,28222.38, Non-Extensive O.R. Procedure Unrelated To Principal Diagnosis,9524,APR-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,28222.38,,,,,,,fee schedule,28222.38,28222.38, Non-Extensive O.R. Procedure Unrelated To Principal Diagnosis,9524,APR-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,28222.38,,,,,,,fee schedule,28222.38,28222.38, Non-Extensive O.R. Procedure Unrelated To Principal Diagnosis,9524,APR-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,28222.38,,,,,,,fee schedule,28222.38,28222.38, Non-Extensive O.R. Procedure Unrelated To Principal Diagnosis,9524,APR-DRG,,,,,facility,inpatient,,,,,,Prestige,Medicaid Managed Care Plan,28222.38,,,,,,,fee schedule,28222.38,28222.38, Non-Extensive O.R. Procedure Unrelated To Principal Diagnosis,9524,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,28222.38,,,,,,,fee schedule,28222.38,28222.38, Non-Extensive O.R. Procedure Unrelated To Principal Diagnosis,9524,APR-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,28222.38,,,,,,,fee schedule,28222.38,28222.38, Non-Extensive O.R. Procedure Unrelated To Principal Diagnosis,9524,APR-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,28222.38,,,,,,,fee schedule,28222.38,28222.38, Non-Extensive O.R. Procedure Unrelated To Principal Diagnosis,9524,APR-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,28222.38,,,,,,,fee schedule,28222.38,28222.38, GENERAL PEDS ROOM DAILY,1230001,CDM,123,RC,,,facility,both,,,,4528.16,4528.16,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC NEWBORN 2 ROOM DAILY,1720001,CDM,172,RC,,,facility,both,,,,12596,12596,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC NEWBORN 3 ROOM DAILY,1730001,CDM,173,RC,,,facility,both,,,,14968,14968,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC NEWBORN 4 ROOM DAILY,1740001,CDM,174,RC,,,facility,both,,,,17813,17813,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MUSCLE BIOPSY PERCUTANEOUS NEEDLE,2030001,CDM,203,RC,,,facility,both,,,,13735,13735,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC EVAL CENTRAL AUDITORY FUNC W/REP, INIT 60 MIN",20600001,CDM,206,RC,,,facility,both,,,,11076,11076,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HEARING AID CHECK MONAURAL,20800001,CDM,208,RC,,,facility,both,,,,18895,18895,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MT-DNA GENOME LG DELETION ANALYSIS,22000001,CDM,220,RC,,,facility,both,,,,221,221,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PROSTAGLANDIN EACH,22000002,CDM,220,RC,,,facility,both,,,,221,221,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC SUGARS; SINGLE QUAL EA SPECIMEN,22000003,CDM,220,RC,,,facility,both,,,,221,221,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC SUGARS; SINGLE QUAN EA SPECIMEN,22000004,CDM,220,RC,,,facility,both,,,,276,276,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC UREA NITROGEN CLEARANCE,22000005,CDM,220,RC,,,facility,both,,,,221,221,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC LAB IMMUNOLOGY,22000006,CDM,220,RC,,,facility,both,,,,243,243,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AB ID; LEUKOCYTE AB,22000007,CDM,220,RC,,,facility,both,,,,243,243,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC TOTAL VOL,UR,STONE RISK PROFIL",22200001,CDM,222,RC,,,facility,both,,,,5384.28,5384.28,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC CK ISOENZY, MB FRACT QST",22200002,CDM,222,RC,,,facility,both,,,,2848.56,2848.56,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC HA DIGITAL, ADVANCED, MONAURAL, ITE",22200003,CDM,222,RC,,,facility,both,,,,3800,3800,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC INFUSION DRUG THERAPY EA ADDL HOUR,26000001,CDM,260,RC,96360,HCPCS,facility,both,,,,708,708,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC IV INFUSION, ADDL SEQ UP TO 1 HOUR",26000002,CDM,260,RC,96361,HCPCS,facility,both,,,,213,213,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC IV INFUSION, CONCURRENT",26000003,CDM,260,RC,96365,HCPCS,facility,both,,,,923,923,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC THER/PROPH/DIAG INJ, SC/IM",26000004,CDM,260,RC,96366,HCPCS,facility,both,,,,213,213,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC THER/PROPH/DIAG INJ, IV PUSH",26000005,CDM,260,RC,96367,HCPCS,facility,both,,,,351,351,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC TX/PRO/DX INJ EA ADDL SEQ, NEW",26000006,CDM,260,RC,96368,HCPCS,facility,both,,,,684,684,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC TX/PRO/DX INJ EA ADDL SEQ, SAME",26000007,CDM,260,RC,96372,HCPCS,facility,both,,,,294,294,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC CHEMOTHERAPY ADMIN, IM/SQ, NON-HORMONAL",26000008,CDM,260,RC,96374,HCPCS,facility,both,,,,424,424,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC CHEMOTHERAPY ADMIN, IM/SQ, HORMONAL",26000009,CDM,260,RC,96375,HCPCS,facility,both,,,,213,213,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC CHEMOTHERAPY ADMIN, IVP, SINGLE/INITIAL",26000010,CDM,260,RC,96376,HCPCS,facility,both,,,,286,286,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC IONTOPHORESIS THERAPY EA 15 MINS,26000012,CDM,260,RC,96523,HCPCS,facility,both,,,,402,402,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DESSICANT BLOCK - EACH,26000054,CDM,771,RC,,,facility,both,,,,923,923,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE DEAC 10/3/2022 HC MINI WAX BRUSH,26000055,CDM,771,RC,,,facility,both,,,,923,923,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE DEAC 10/3/2022 HC SUPER SEAL (REFILLS),26000056,CDM,771,RC,,,facility,both,,,,1484,1484,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PERQ DEV BREAST ADD STEREOTACTIC GUIDANCE,27000060,CDM,270,RC,,,facility,both,,,,3150,3150,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PERQ DEV BREAST 1ST US IMAG,27000061,CDM,270,RC,,,facility,both,,,,6300,6300,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PERQ DEV BREAST ADD US IMAG,27000062,CDM,270,RC,,,facility,both,,,,3150,3150,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PERQ DEV BREAST 1ST MR GUIDE,27000063,CDM,270,RC,,,facility,both,,,,3064.29,3064.29,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PERQ DEV BREAST ADD MR GUIDE,27000064,CDM,270,RC,,,facility,both,,,,3500,3500,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC OPEN/PERQ PLACE STENT SAME INITIAL ARTERY,27000065,CDM,270,RC,,,facility,both,,,,3500,3500,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC GENOMIC SEQ ANALYSIS, SOLID ORGAN NEOPLASM, 5-50 GENES",27000066,CDM,270,RC,,,facility,both,,,,7000,7000,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC VASC EMBOLIZE/OCCLUDE ARTERY,27000067,CDM,270,RC,,,facility,both,,,,4500,4500,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC VASC EMBOLIZE/OCCLUDE ORGAN,27000068,CDM,270,RC,,,facility,both,,,,4500,4500,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC STREP PNEUMONIAE IGG AB, 14 SEROTYPES, MULTI IA, QUANT",27000071,CDM,270,RC,,,facility,both,,,,6300,6300,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC UNLISTED PROC, DENTOALVEOLAR STRUCTURES",27000073,CDM,270,RC,,,facility,both,,,,5816.16,5816.16,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC UNLISTED PROC, TONGUE OR FLOOR OF MOUTH",27000074,CDM,270,RC,,,facility,both,,,,6000,6000,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CLONOSEQ MRD ASSAY - PCR & NGS,27000079,CDM,270,RC,,,facility,both,,,,6037.5,6037.5,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC EVALUATION OF SPEECH SOUND PRODUCTION W/LANGUAGE COMPREHENSION,27000155,CDM,270,RC,,,facility,both,,,,2100,2100,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC BEHAVIORAL & QUALIT ANALYSIS VOICE/RESONANCE,27000156,CDM,270,RC,,,facility,both,,,,2100,2100,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AUTOLOG BLOOD OP SALVAGE,27000157,CDM,270,RC,,,facility,both,,,,2100,2100,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CYP2C19 GENE COM VARIANTS,27000158,CDM,270,RC,,,facility,both,,,,2100,2100,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ALPHA-1-ANTITRYPSIN; PHENOTYPE (40),27000159,CDM,270,RC,,,facility,both,,,,2100,2100,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CHOLINESTERASE; SERUM,27000160,CDM,270,RC,,,facility,both,,,,4200,4200,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DIBUCAINE NUMBER,27000161,CDM,270,RC,,,facility,both,,,,4200,4200,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC GLUCOSE; BLD BY MONITOR DEVICE,27000162,CDM,270,RC,,,facility,both,,,,4200,4200,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC FREE INSULIN,27000163,CDM,270,RC,,,facility,both,,,,4200,4200,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC SUGARS; MULTI QUAL EA SPECIMEN,27000164,CDM,270,RC,,,facility,both,,,,4000,4000,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MITOCHONDRIAL GENOME ANALYSIS,27061002,CDM,271,RC,,,facility,both,,,,6192,6192,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC BLOOD OCCULT,QLT FECES",27061003,CDM,271,RC,,,facility,both,,,,1573,1573,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC URINE STONE ANALYSIS,27061004,CDM,271,RC,,,facility,both,,,,2084,2084,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CREATINE(UR) MAYO,27061005,CDM,271,RC,,,facility,both,,,,4109,4109,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC CREATINE, PLASMA",27061006,CDM,271,RC,,,facility,both,,,,1688,1688,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DEOXYCORTICOSTERONE ENDO,27061007,CDM,271,RC,,,facility,both,,,,1238,1238,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC GALACTOSYLCERAMIDE B-GAL MAYO,27061008,CDM,271,RC,,,facility,both,,,,150,150,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC HA, DIGITAL, PREMIUM, BINAURAL, CIC",27080021,CDM,270,RC,,,facility,both,,,,3500,3500,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC HA, DIGITAL, ADVANCED, BINAURAL, ITC",27080022,CDM,270,RC,,,facility,both,,,,4500,4500,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC HA, DIGITAL, PREMIUM, BINAURAL, ITC",27080023,CDM,270,RC,,,facility,both,,,,3150,3150,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC HA, DIGITAL, ADVANCED, BINAURAL, ITE",27080024,CDM,270,RC,,,facility,both,,,,3000,3000,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC HA, DIGITAL, PREMIUM, BINAURAL, ITE",27080026,CDM,270,RC,,,facility,both,,,,3500,3500,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC HA, DIGITAL, STANDARD BINAURAL, ITE",27080027,CDM,270,RC,,,facility,both,,,,4500,4500,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC HA, DIGITAL, STANDARD BINAURAL, BTE",27080028,CDM,270,RC,,,facility,both,,,,3040.68,3040.68,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC HA, DIGITAL, STANDARD BINAURAL, BTE, RITE (RECEIVER IN THE EAR)",27080030,CDM,270,RC,,,facility,both,,,,6300,6300,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC HA, DIGITAL, ADVANCED, BINAURAL, BTE",27080031,CDM,270,RC,,,facility,both,,,,9000,9000,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC HA, DIGITAL, ADVANCED, BINAURAL, BTE, RITE",27080032,CDM,270,RC,,,facility,both,,,,7000,7000,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC HA, DIGITAL, PREMIUM, BINAURAL, BTE",27080033,CDM,270,RC,,,facility,both,,,,9000,9000,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC HA, DIGITAL, PREMIUM, BINAURAL, BTE, RITE",27080034,CDM,270,RC,,,facility,both,,,,7000,7000,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC EAR MOLD/INSERT NON DISP, EA",27080035,CDM,270,RC,,,facility,both,,,,9000,9000,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC BATTERY FOR HEARING DEVICE, EA",27080036,CDM,270,RC,,,facility,both,,,,6300,6300,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC HEARING SERVICE, MISC",27080037,CDM,270,RC,,,facility,both,,,,6300,6300,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC IONM IN OPERATNG ROOM 15 MIN,27080039,CDM,270,RC,,,facility,both,,,,6300,6300,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC IONM REMOTE/>1 PT OR PER HR,27080040,CDM,270,RC,,,facility,both,,,,6333.33,6333.33,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC TRAUMA ALERT CONSULT W/CC,27080042,CDM,270,RC,,,facility,both,,,,6500,6500,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MISCELLANEOUS DIALYSIS-ULTRAFILTRATION,27080044,CDM,270,RC,,,facility,both,,,,7000,7000,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC O/P HEMODIALYSIS URR,27080045,CDM,270,RC,,,facility,both,,,,9000,9000,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE DEAC 6/1/2020 HC O/P HEMODIALYSIS URR 75%>,27080046,CDM,270,RC,,,facility,both,,,,160,160,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC TRAUMA ALERT 2 W/CRITICAL CARE,27080047,CDM,270,RC,,,facility,both,,,,2,2,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC STRESS TTE COMPLETE,27080050,CDM,270,RC,,,facility,both,,,,4050,4050,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DONOR HUMAN MILK (PREP/STORE/DISTRIBUTION),27080051,CDM,270,RC,,,facility,both,,,,1655,1655,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PTEN GENE FULL SEQUENCE,27080052,CDM,270,RC,,,facility,both,,,,4500,4500,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC FORTIFIED EBM (PREP/STORE/DISTRIBUTION),27160009,CDM,271,RC,,,facility,both,,,,442.05,442.05,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC FORTIFIED DHM (PREP/STORE/DISTRIBUTION),27160010,CDM,271,RC,,,facility,both,,,,254.89,254.89,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ORAL CARE (PREP/STORE/DISTRIBUTION),27160011,CDM,271,RC,,,facility,both,,,,134,134,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CUSTOM FORMULA (PREP/STORE/DISTRIBUTION),27160012,CDM,271,RC,,,facility,both,,,,141,141,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC UNIT DOSE FORMULA (PREP/STORE/DISTRIBUTION),27160013,CDM,271,RC,,,facility,both,,,,147,147,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DRUG SCREENING FENTANYL (38),27160014,CDM,271,RC,,,facility,both,,,,12.6,12.6,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PRT PLATELETS,27290081,CDM,272,RC,,,facility,both,,,,73.66,73.66,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PRETREAT RBC; CHEM OR DRUGS,27490009,CDM,274,RC,,,facility,both,,,,421,421,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC WASHED RED BLOOD CELLS EA UNIT,27490081,CDM,274,RC,,,facility,both,,,,367.57,367.57,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE DEAC 11/01/2023 HC ADM SARSCOV2 30MCG/0.3ML; BOOSTER DOSE,30000000,CDM,300,RC,,,facility,both,,,,594,594,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC COMPREHENSIVE METABOLIC PANEL,30000001,CDM,300,RC,36415,HCPCS,facility,both,,,,61.82,61.82,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC LIPID PANEL,30000001,CDM,300,RC,36415,HCPCS,facility,both,,,,32.5,32.5,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC RENAL FUNCTION PANEL,30000004,CDM,301,RC,80048,HCPCS,facility,both,,,,420,420,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HEPATIC FUNCTION PANEL,30000005,CDM,301,RC,80053,HCPCS,facility,both,,,,525,525,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC BENZODIAZEPINES, 1-12",30000006,CDM,301,RC,80069,HCPCS,facility,both,,,,179,179,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CARBAMAZEPINE; FREE,30000007,CDM,301,RC,80076,HCPCS,facility,both,,,,255,255,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CHLORIDE; BLOOD,30000009,CDM,301,RC,82379,HCPCS,facility,both,,,,120,120,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC CERULOPLASMIN,30000009,CDM,301,RC,82379,HCPCS,facility,both,,,,541,541,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC COLLAGEN CROSS LINKS,30000010,CDM,301,RC,82438,HCPCS,facility,both,,,,128,128,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC GALACTOKINASE RBC,30000011,CDM,301,RC,82726,HCPCS,facility,both,,,,855,855,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HEMOGLOBIN-OXYGEN AFFINITY,30000012,CDM,301,RC,82785,HCPCS,facility,both,,,,330,330,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC LDH; ISOENZYMES,30000013,CDM,301,RC,83525,HCPCS,facility,both,,,,211,211,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC FREE THYROXINE,30000014,CDM,301,RC,84403,HCPCS,facility,both,,,,410,410,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC URIC ACID; NOT BLOOD,30000015,CDM,301,RC,84482,HCPCS,facility,both,,,,302,302,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ALLERG SP IGE; QUAN OR SEMIQUAN,30000017,CDM,305,RC,85660,HCPCS,facility,both,,,,123,123,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ANTINUCLEAR AB (ANA); TITER,30000018,CDM,302,RC,86003,HCPCS,facility,both,,,,84,84,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC C-REACTIVE PROTEIN,30000018,CDM,302,RC,86003,HCPCS,facility,both,,,,15,15,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC CCP ANTIBODY,30000020,CDM,302,RC,86156,HCPCS,facility,both,,,,27,27,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DNA AB,30000021,CDM,300,RC,86157,HCPCS,facility,both,,,,115,115,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC INSULIN AB,30000022,CDM,302,RC,86331,HCPCS,facility,both,,,,177,177,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC T CELLS; ABSOL CD4 AND CD8,30000023,CDM,302,RC,86353,HCPCS,facility,both,,,,601,601,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AB; HIV-1,30000025,CDM,302,RC,86684,HCPCS,facility,both,,,,251,251,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AB; HAAB - TOTAL,30000026,CDM,302,RC,86702,HCPCS,facility,both,,,,190,190,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC BLOOD TYPING; ABO,30000027,CDM,300,RC,86860,HCPCS,facility,both,,,,487,487,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC BLOOD TYPING; RH D,30000028,CDM,300,RC,86870,HCPCS,facility,both,,,,665,665,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC BLOOD TYPE ANTIGEN DONOR EA,30000029,CDM,300,RC,86880,HCPCS,facility,both,,,,402,402,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC BLD TYPE; RH PHENOTYPE,30000030,CDM,300,RC,86886,HCPCS,facility,both,,,,822,822,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC COMPATIBILITY TEST SPIN,30000031,CDM,300,RC,86900,HCPCS,facility,both,,,,244,244,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC COMPATIBILITY TEST ANTIGLOB,30000032,CDM,300,RC,86901,HCPCS,facility,both,,,,244,244,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC COMPATIBILITY TEST ELECTRIC,30000033,CDM,300,RC,86902,HCPCS,facility,both,,,,665,665,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC FFP THAWING EA UNIT,30000034,CDM,300,RC,86905,HCPCS,facility,both,,,,664,664,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC IRRADIATE BLD PRODUCT EA UNIT,30000035,CDM,300,RC,86906,HCPCS,facility,both,,,,496,496,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC POOL PLATELETS OR BLD PRODUCT,30000036,CDM,300,RC,86922,HCPCS,facility,both,,,,558,558,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PRETREAT RBC; ENZYMES,30000037,CDM,300,RC,86923,HCPCS,facility,both,,,,508,508,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CONCENTRATION FOR INFECT AGNT,30000038,CDM,300,RC,86945,HCPCS,facility,both,,,,340,340,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AEROB BACTERIAL BLOOD CULTURE,30000039,CDM,300,RC,86960,HCPCS,facility,both,,,,708,708,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AEROB BACTERIA CULTURE STOOL,30000040,CDM,300,RC,86965,HCPCS,facility,both,,,,708,708,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AEROBIC STOOL CULTR ADDTL PATHOG EA PLATE,30000041,CDM,300,RC,86971,HCPCS,facility,both,,,,105,105,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC BACTERIAL CULTURE - OTHR SOURCE,30000042,CDM,300,RC,86985,HCPCS,facility,both,,,,614,614,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PLASMA 1 DONOR FRZ W/IN 8 HR,30000045,CDM,300,RC,89051,HCPCS,facility,both,,,,150,150,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ECHOCARDIO FETAL CARDIOVASCULAR F/U STUDY,30000047,CDM,300,RC,86999,HCPCS,facility,both,,,,418,418,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DOPPLER ECHOCARDIOLOGY FETAL COMPLETE,30000048,CDM,306,RC,87661,HCPCS,facility,both,,,,211,211,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MICROALBUMIN; URINE SEMIQUAN,30000101,CDM,300,RC,86921,HCPCS,facility,both,,,,633,633,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC BILE ACIDS; TOTAL,30000102,CDM,300,RC,86970,HCPCS,facility,both,,,,106,106,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CHEMILUMINESCENT ASSAY,30000103,CDM,300,RC,86978,HCPCS,facility,both,,,,374,374,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CHOLINESTERASE; RBC,30000105,CDM,300,RC,89055,HCPCS,facility,both,,,,20,20,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CPK: ISOENZYMES,30000106,CDM,300,RC,89060,HCPCS,facility,both,,,,38,38,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CYTOGEN M ARRAY COPY NO&SNP,30000108,CDM,300,RC,86891,HCPCS,facility,both,,,,881,881,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC FFP (FROZ WITH 8 HRS) (AUTOLOGOUS/DIRECTED),30000160,CDM,300,RC,99001,HCPCS,facility,both,,,,47,47,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC QUANTITATIVE ASSAY DRUG (30),30000165,CDM,300,RC,83520,HCPCS,facility,both,,,,349,349,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC QUANTITATIVE ASSAY DRUG (35),30000166,CDM,300,RC,83520,HCPCS,facility,both,,,,93,93,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC QUANTITATIVE ASSAY DRUG (55),30000167,CDM,300,RC,83520,HCPCS,facility,both,,,,93,93,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC QUANTITATIVE ASSAY DRUG (75),30000168,CDM,300,RC,83520,HCPCS,facility,both,,,,93,93,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC QUANTITATIVE ASSAY DRUG (80),30000169,CDM,300,RC,83520,HCPCS,facility,both,,,,93,93,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DRUG SCREENING COCAINE,30000170,CDM,300,RC,83520,HCPCS,facility,both,,,,93,93,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC OPIOID &OPIATE ANALOG 5/MORE,30000171,CDM,300,RC,83520,HCPCS,facility,both,,,,349,349,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CHARGING BASE,30000174,CDM,300,RC,83520,HCPCS,facility,both,,,,93,93,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MUSC TEST DONE W/NERVE TEST NON EXTREMITY,30000179,CDM,300,RC,83520,HCPCS,facility,both,,,,93,93,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PREGABALIN,30000180,CDM,300,RC,83520,HCPCS,facility,both,,,,93,93,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC PERQ PLMT BILE DUCT STENT, NEW ACCESS, W/ SEPAR CATH",30000182,CDM,300,RC,80325,HCPCS,facility,both,,,,1369,1369,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC INFECT AGENT DET,GI 3-5 TARGET",30000183,CDM,300,RC,83520,HCPCS,facility,both,,,,1235,1235,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC US ABDOMINAL AORTA SCREEN AAA,30000184,CDM,300,RC,83520,HCPCS,facility,both,,,,805,805,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC MONONUCLEAR CELL ANTIGEN, QUANTITATIVE, NOS, EA AG",30000185,CDM,300,RC,83020,HCPCS,facility,both,,,,53,53,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC COMBINED CARDIAC  PANEL ANALYSIS AT LEAST 2 GENES (148),30001856,CDM,300,RC,87478,HCPCS,facility,both,,,,233,233,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC WHOLE MITO GENOME SEQUENCING & DELETION TESTING (148),30001857,CDM,300,RC,80305,HCPCS,facility,both,,,,50,50,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC IMMUNOASSAY QUANT NOS NONAB (184),30001860,CDM,300,RC,83520,HCPCS,facility,both,,,,510,510,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC GASES,BLD,W/SAT O2, MEASURED",30060001,CDM,300,RC,80326,HCPCS,facility,both,,,,1307,1307,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC RBC ENZYME GLUTATHIONE MAYO,30060002,CDM,300,RC,80361,HCPCS,facility,both,,,,346,346,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC GLUTATHIONE,BLOOD",30060003,CDM,300,RC,81050,HCPCS,facility,both,,,,56,56,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC UR 17 OH CORTICOSTEROIDS NIC,30060004,CDM,300,RC,82552,HCPCS,facility,both,,,,245,245,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC SOLUBLE IL-2R LEVEL CINCH,30060005,CDM,300,RC,83520,HCPCS,facility,both,,,,482,482,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC INHIBIN-B QUEST,30060006,CDM,300,RC,84392,HCPCS,facility,both,,,,96,96,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC STRIATED MUSCLE AB,30060007,CDM,300,RC,85290,HCPCS,facility,both,,,,357,357,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ASCA IGA IMMUNOASSAY PROM,30060008,CDM,300,RC,85557,HCPCS,facility,both,,,,302,302,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ASCA IGG IMMUNOASSAY PROM,30060009,CDM,300,RC,86277,HCPCS,facility,both,,,,212,212,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC OMPC IGG IMMUNOASSAY PROM,30060010,CDM,300,RC,87265,HCPCS,facility,both,,,,64,64,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CBIR1 IGG IMMUNOASSAY PROM,30060011,CDM,300,RC,87476,HCPCS,facility,both,,,,506,506,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC FLA2 IGG IMMUNOASSAY PROM,30060012,CDM,300,RC,87532,HCPCS,facility,both,,,,464,464,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC FLAX IGG IMMUNOASSAY PROM,30060013,CDM,300,RC,99001,HCPCS,facility,both,,,,47,47,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC SOLUBLE LIVER ANTIGEN QUEST,30060014,CDM,300,RC,,,facility,both,,,,30,30,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC MAGNETIC RESONANCE ELASTOGRAPHY,30070004,CDM,307,RC,81025,HCPCS,facility,both,,,,151,151,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MRI GUIDANCE & MONITORING FOR PARENCHYMAL TISSUE ABLATION,30070007,CDM,301,RC,82948,HCPCS,facility,both,,,,27,27,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HA DISPENSING FEE UNSPECIFIED,30070009,CDM,300,RC,88720,HCPCS,facility,both,,,,28,28,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC PLASMA, CRYOPRECIPITATE REDUCED, EA UNIT",30100000,CDM,301,RC,,,facility,both,,,,159,159,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ACUTE HEPATITIS PANEL,30100001,CDM,301,RC,80051,HCPCS,facility,both,,,,157,157,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AMIKACIN,30100002,CDM,301,RC,80061,HCPCS,facility,both,,,,264,264,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CYCLOSPORINE,30100003,CDM,301,RC,80150,HCPCS,facility,both,,,,314,314,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DIGOXIN QUANTITATIVE,30100005,CDM,301,RC,80346,HCPCS,facility,both,,,,325,325,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DIPROPYLACETIC ACID,30100006,CDM,301,RC,80156,HCPCS,facility,both,,,,342,342,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ETHOSUXIMIDE,30100007,CDM,301,RC,80157,HCPCS,facility,both,,,,59,59,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC GENTAMICIN,30100008,CDM,301,RC,80158,HCPCS,facility,both,,,,313,313,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HALOPERIDOL ASSAY,30100010,CDM,301,RC,80162,HCPCS,facility,both,,,,193,193,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC LIDOCAINE,30100011,CDM,301,RC,80164,HCPCS,facility,both,,,,326,326,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PHENOBARBITAL,30100012,CDM,301,RC,80170,HCPCS,facility,both,,,,323,323,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PHENYTOIN; TOTAL,30100013,CDM,301,RC,80173,HCPCS,facility,both,,,,70,70,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PHENYTOIN; FREE,30100015,CDM,301,RC,80176,HCPCS,facility,both,,,,199,199,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PRIMIDONE,30100016,CDM,301,RC,80178,HCPCS,facility,both,,,,138,138,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PROCAINAMIDE W METABOLITES,30100018,CDM,301,RC,80184,HCPCS,facility,both,,,,273,273,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ASSAY OF SIROLIMUS,30100019,CDM,301,RC,80185,HCPCS,facility,both,,,,297,297,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC TACROLIMUS,30100020,CDM,301,RC,80186,HCPCS,facility,both,,,,194,194,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC THEOPHYLLINE,30100021,CDM,301,RC,80188,HCPCS,facility,both,,,,266,266,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC TOBRAMYCIN,30100022,CDM,301,RC,80192,HCPCS,facility,both,,,,193,193,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC TOPIRAMATE,30100024,CDM,301,RC,80195,HCPCS,facility,both,,,,156,156,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC VANCOMYCIN,30100026,CDM,301,RC,80197,HCPCS,facility,both,,,,177,177,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC QUANTITATION OF DRUG NES,30100027,CDM,301,RC,80198,HCPCS,facility,both,,,,271,271,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AUTOM URINE DIP W MICRO,30100028,CDM,301,RC,80200,HCPCS,facility,both,,,,337,337,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AUTOM URINALYSIS WO MICRO,30100029,CDM,301,RC,80201,HCPCS,facility,both,,,,102,102,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC URINALYSIS; QUAL NOT IA,30100030,CDM,301,RC,80202,HCPCS,facility,both,,,,309,309,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC QUANT SERUM ACETONES/KETONES,30100038,CDM,301,RC,80299,HCPCS,facility,both,,,,407,407,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ACYLCARNITINES; QUAN,30100039,CDM,307,RC,81001,HCPCS,facility,both,,,,90,90,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ACTH,30100041,CDM,307,RC,81003,HCPCS,facility,both,,,,60,60,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ASSAY OF SERUM ALBUMIN,30100042,CDM,307,RC,81005,HCPCS,facility,both,,,,48,48,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ALBUMIN; QUAN,30100045,CDM,301,RC,82010,HCPCS,facility,both,,,,222,222,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ALBUMIN; URINE QUANT,30100047,CDM,301,RC,82017,HCPCS,facility,both,,,,930,930,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ALDOLASE,30100048,CDM,301,RC,82024,HCPCS,facility,both,,,,561,561,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ALDOSTERONE,30100049,CDM,301,RC,82040,HCPCS,facility,both,,,,114,114,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ALPHA-1-ANTITRYPSIN; TOTAL,30100050,CDM,301,RC,82042,HCPCS,facility,both,,,,45,45,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ALPHA-FETOPROTEIN SERUM,30100051,CDM,301,RC,82043,HCPCS,facility,both,,,,53,53,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AMINO ACIDS; MULTI QUAL EA,30100053,CDM,301,RC,82088,HCPCS,facility,both,,,,592,592,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AMINO ACIDS; SGL QUAN EA,30100054,CDM,301,RC,82105,HCPCS,facility,both,,,,254,254,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AMINO ACIDS 6/> QUAN EA,30100056,CDM,301,RC,82128,HCPCS,facility,both,,,,170,170,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC ANDROSTENEDIONE,30100057,CDM,301,RC,82139,HCPCS,facility,both,,,,168,168,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ANGIOTENSIN II,30100057,CDM,301,RC,82139,HCPCS,facility,both,,,,210,210,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC ANGIOTENSIN I - CONVERTING ENZYME,30100058,CDM,301,RC,82140,HCPCS,facility,both,,,,392,392,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC APOLIPOPROTEIN EACH,30100059,CDM,301,RC,82150,HCPCS,facility,both,,,,192,192,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DIRECT BILIRUBIN,30100060,CDM,301,RC,82180,HCPCS,facility,both,,,,203,203,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC BIOTINIDASE EA SPECIMEN,30100061,CDM,301,RC,80345,HCPCS,facility,both,,,,308,308,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC OCCULT BLOOD FECES,30100062,CDM,301,RC,82232,HCPCS,facility,both,,,,235,235,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC OCCULT BLOOD OTHER SOURCES,30100063,CDM,301,RC,82247,HCPCS,facility,both,,,,143,143,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CADMIUM,30100064,CDM,301,RC,82248,HCPCS,facility,both,,,,131,131,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CALCITONIN,30100065,CDM,301,RC,82270,HCPCS,facility,both,,,,62,62,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CALCIUM; IONIZED,30100067,CDM,301,RC,82300,HCPCS,facility,both,,,,139,139,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CALCIUM; URINE QUAN TIMED,30100068,CDM,301,RC,82306,HCPCS,facility,both,,,,689,689,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC STONE; IR SPECTROSCOPY,30100069,CDM,301,RC,82308,HCPCS,facility,both,,,,339,339,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CARBON DIOXIDE (CO2),30100070,CDM,301,RC,82310,HCPCS,facility,both,,,,130,130,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ASSAY CARBOXYHB QUANT,30100071,CDM,301,RC,82330,HCPCS,facility,both,,,,320,320,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CEA,30100072,CDM,301,RC,82340,HCPCS,facility,both,,,,162,162,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CARNITINE QUAN EA,30100073,CDM,301,RC,82365,HCPCS,facility,both,,,,102,102,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CARNITINE QUAN EA,30100074,CDM,301,RC,82374,HCPCS,facility,both,,,,125,125,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CAROTENE,30100075,CDM,301,RC,82375,HCPCS,facility,both,,,,276,276,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CATECHOLAMINES FRACTIONATED,30100076,CDM,301,RC,82378,HCPCS,facility,both,,,,318,318,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CHROMIUM,30100077,CDM,301,RC,82435,HCPCS,facility,both,,,,123,123,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CITRATE,30100078,CDM,301,RC,82436,HCPCS,facility,both,,,,96,96,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC COPPER,30100079,CDM,301,RC,82465,HCPCS,facility,both,,,,100,100,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CORTICOSTERONE,30100085,CDM,301,RC,82495,HCPCS,facility,both,,,,410,410,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CORTISOL; TOTAL,30100086,CDM,301,RC,82523,HCPCS,facility,both,,,,237,237,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CC/MS; QUAN SS & MP,30100087,CDM,301,RC,82525,HCPCS,facility,both,,,,198,198,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CPK; TOTAL,30100088,CDM,301,RC,82528,HCPCS,facility,both,,,,106,106,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CPK: MB FRACTION ONLY,30100089,CDM,301,RC,82530,HCPCS,facility,both,,,,353,353,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CREATININE; BLOOD,30100090,CDM,301,RC,82533,HCPCS,facility,both,,,,381,381,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CREATININE; NOT BLOOD,30100091,CDM,301,RC,82542,HCPCS,facility,both,,,,592,592,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CREATININE; CLEARANCE,30100094,CDM,301,RC,82550,HCPCS,facility,both,,,,192,192,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CRYOGLOBULIN - QUAL/SEMI QUAN,30100095,CDM,301,RC,82553,HCPCS,facility,both,,,,270,270,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CYANIDE,30100096,CDM,301,RC,82565,HCPCS,facility,both,,,,119,119,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC VITAMIN B-12 LEVEL,30100097,CDM,301,RC,82570,HCPCS,facility,both,,,,150,150,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC VIT B-12; UNSATURATED BC,30100098,CDM,301,RC,82575,HCPCS,facility,both,,,,240,240,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CYSTATIN C,30100100,CDM,301,RC,82595,HCPCS,facility,both,,,,83,83,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DHEA-S,30100101,CDM,301,RC,82607,HCPCS,facility,both,,,,388,388,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC VIT D 1 25-DIHYDROXY,30100102,CDM,301,RC,82610,HCPCS,facility,both,,,,174,174,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ESTRADIOL; TOTAL,30100103,CDM,301,RC,82652,HCPCS,facility,both,,,,560,560,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ESTROGENS; FRACTIONATED,30100104,CDM,301,RC,82656,HCPCS,facility,both,,,,292,292,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ESTRIOL UNCONJUGATED,30100105,CDM,301,RC,82657,HCPCS,facility,both,,,,513,513,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ETHYLENE GLYCOL,30100106,CDM,301,RC,82670,HCPCS,facility,both,,,,407,407,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC FAT/LIPIDS FECES; QUAN,30100107,CDM,301,RC,82677,HCPCS,facility,both,,,,480,480,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC FOLIC ACID; SERUM,30100108,CDM,301,RC,82710,HCPCS,facility,both,,,,324,324,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC GALACTOSEMIA; QUAN,30100109,CDM,301,RC,82728,HCPCS,facility,both,,,,365,365,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ASSAY IGA/IGD/IGG/IGM EACH,30100111,CDM,301,RC,82746,HCPCS,facility,both,,,,396,396,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ASSAY OF IGE,30100112,CDM,301,RC,82747,HCPCS,facility,both,,,,60,60,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC BLOOD GASES O2 SAT ONLY,30100114,CDM,301,RC,82784,HCPCS,facility,both,,,,250,250,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC GASTRIN,30100115,CDM,301,RC,82787,HCPCS,facility,both,,,,246,246,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC GLUCAGON,30100116,CDM,301,RC,82803,HCPCS,facility,both,,,,520,520,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC GLUCOSE BODY FLUID NOT BLOOD,30100118,CDM,301,RC,82810,HCPCS,facility,both,,,,139,139,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC GLUCOSE; QUAN BLOOD,30100119,CDM,301,RC,82820,HCPCS,facility,both,,,,91,91,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC GTT-ADDED SAMPLES,30100120,CDM,301,RC,82945,HCPCS,facility,both,,,,56,56,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC G6PD; QUAN,30100121,CDM,301,RC,82947,HCPCS,facility,both,,,,114,114,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC GLUTAMYLTRANSFERASE GAMMA,30100122,CDM,301,RC,82950,HCPCS,facility,both,,,,97,97,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC GLYCATED PROTEIN,30100123,CDM,301,RC,82951,HCPCS,facility,both,,,,227,227,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC GONADOTROPIN; FSH,30100124,CDM,301,RC,82952,HCPCS,facility,both,,,,66,66,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC GROWTH HORMONE HUMAN,30100126,CDM,301,RC,82977,HCPCS,facility,both,,,,192,192,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HGB CHROMATOGRAPHY,30100127,CDM,301,RC,83003,HCPCS,facility,both,,,,320,320,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HGB; FETAL QUAL,30100128,CDM,301,RC,83010,HCPCS,facility,both,,,,243,243,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC GLYCOSYLATED HEMOGLOBIN TEST,30100129,CDM,301,RC,83018,HCPCS,facility,both,,,,397,397,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HBG; METHEMOGLOBIN QUAN,30100130,CDM,301,RC,83020,HCPCS,facility,both,,,,345,345,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HGB; PLASMA,30100131,CDM,301,RC,83021,HCPCS,facility,both,,,,300,300,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HEMOGLOBIN; UNSTABLE SCREEN,30100133,CDM,301,RC,83033,HCPCS,facility,both,,,,100,100,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HEMOSIDERIN; QUAL,30100134,CDM,301,RC,83036,HCPCS,facility,both,,,,230,230,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC B-HEXOSAMINIDASE EA ASSAY,30100135,CDM,301,RC,83050,HCPCS,facility,both,,,,100,100,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ASSAY OF HOMOCYSTINE,30100136,CDM,301,RC,83068,HCPCS,facility,both,,,,157,157,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HOMOVANILLIC ACID,30100137,CDM,301,RC,83070,HCPCS,facility,both,,,,23,23,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC 5-HIAA,30100138,CDM,301,RC,83080,HCPCS,facility,both,,,,91,91,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC IMMUNOASSAY NONANTIBODY,30100139,CDM,301,RC,83090,HCPCS,facility,both,,,,216,216,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC IMMUNOASSAY QUANT NOS NONAB (20),30100140,CDM,301,RC,83497,HCPCS,facility,both,,,,284,284,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC GROWTH HORMONE BINDING PROTEIN,30100141,CDM,301,RC,83516,HCPCS,facility,both,,,,308,308,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC SUBSTANCE P,30100142,CDM,301,RC,83519,HCPCS,facility,both,,,,330,330,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PROTHROMBIN FRAGMENT 1.2,30100143,CDM,301,RC,83520,HCPCS,facility,both,,,,93,93,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC RNA POLYMERASE I-III IGG,30100144,CDM,301,RC,83520,HCPCS,facility,both,,,,349,349,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC SMALL FIBER AXONAL PROFILE,30100146,CDM,301,RC,83520,HCPCS,facility,both,,,,349,349,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC ANTI IGA, TRANSFUSION MED",30100147,CDM,301,RC,83520,HCPCS,facility,both,,,,93,93,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC IMMUNOASSAY QUANT NOS NONAB,30100149,CDM,301,RC,83520,HCPCS,facility,both,,,,93,93,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC INSULIN; TOTAL,30100155,CDM,301,RC,83520,HCPCS,facility,both,,,,93,93,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC IRON,30100157,CDM,301,RC,83520,HCPCS,facility,both,,,,93,93,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC LACTATE,30100162,CDM,301,RC,83520,HCPCS,facility,both,,,,93,93,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC LACTATE DEHYDROGENASE,30100174,CDM,301,RC,83520,HCPCS,facility,both,,,,722,722,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC LACTOFERRIN FECAL (QUAL),30100175,CDM,301,RC,83540,HCPCS,facility,both,,,,174,174,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC LEAD,30100176,CDM,301,RC,83605,HCPCS,facility,both,,,,366,366,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC LIPASE,30100177,CDM,301,RC,83615,HCPCS,facility,both,,,,162,162,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC LIPOPROTEIN; HDL,30100178,CDM,301,RC,83630,HCPCS,facility,both,,,,93,93,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ASSAY OF BLOOD LIPOPROTEIN LDL,30100179,CDM,301,RC,83655,HCPCS,facility,both,,,,180,180,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MAGNESIUM,30100182,CDM,301,RC,83690,HCPCS,facility,both,,,,187,187,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MANGANESE,30100183,CDM,301,RC,83695,HCPCS,facility,both,,,,124,124,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MERCURY QUAN,30100186,CDM,301,RC,83718,HCPCS,facility,both,,,,157,157,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC METANEPHRINES,30100187,CDM,301,RC,83721,HCPCS,facility,both,,,,143,143,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MUCOPOLYSACCH ACID; QUAN,30100188,CDM,301,RC,83735,HCPCS,facility,both,,,,196,196,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MYOGLOBIN,30100190,CDM,301,RC,83789,HCPCS,facility,both,,,,358,358,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC NEPHELOMETRY EA ANALYTE NES,30100191,CDM,301,RC,83835,HCPCS,facility,both,,,,244,244,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ASSAY OF NUCLEOTIDASE,30100193,CDM,301,RC,83864,HCPCS,facility,both,,,,393,393,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC QUANTITATIVE ORGANIC ACIDS EA SPECIMEN,30100195,CDM,301,RC,83874,HCPCS,facility,both,,,,253,253,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ORGANIC ACID SINGLE QUANTITATIVE,30100196,CDM,301,RC,83880,HCPCS,facility,both,,,,436,436,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC BLOOD OSMOLALITY,30100412,CDM,301,RC,83915,HCPCS,facility,both,,,,102,102,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC OSMOLALITY; URINE,30100413,CDM,301,RC,83916,HCPCS,facility,both,,,,388,388,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC OSTEOCALCIN,30100414,CDM,301,RC,83918,HCPCS,facility,both,,,,692,692,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC OXALATE,30100415,CDM,301,RC,83921,HCPCS,facility,both,,,,315,315,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PARATHORMONE,30100416,CDM,301,RC,80361,HCPCS,facility,both,,,,96,96,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ASSAY PH BODY FLUID NOS,30100417,CDM,301,RC,83930,HCPCS,facility,both,,,,174,174,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ASSAY FOR CALPROTECTIN FECAL,30100418,CDM,301,RC,83935,HCPCS,facility,both,,,,185,185,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PHENYLALANINE BLOOD,30100419,CDM,301,RC,83970,HCPCS,facility,both,,,,664,664,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ALKALINE PHOSPHATASE,30100420,CDM,301,RC,83993,HCPCS,facility,both,,,,250,250,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ALKALINE PHOSPHATASE ISOENZYM,30100421,CDM,301,RC,80342,HCPCS,facility,both,,,,73,73,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PHOSPHATE,30100422,CDM,301,RC,84030,HCPCS,facility,both,,,,121,121,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC URINE PHOSPHATE,30100422,CDM,301,RC,84030,HCPCS,facility,both,,,,47,47,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC PORPHOBILINOGEN URINE; QUAN,30100423,CDM,301,RC,84066,HCPCS,facility,both,,,,91,91,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC QUAN URINE PORPHYRINS,30100424,CDM,301,RC,84075,HCPCS,facility,both,,,,138,138,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC URINE POTASSIUM,30100426,CDM,301,RC,84100,HCPCS,facility,both,,,,140,140,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PREALBUMIN,30100427,CDM,301,RC,84105,HCPCS,facility,both,,,,87,87,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PROGESTERONE ASSAY,30100429,CDM,301,RC,84132,HCPCS,facility,both,,,,137,137,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PROLACTIN ASSAY,30100430,CDM,301,RC,84133,HCPCS,facility,both,,,,109,109,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PSA; TOTAL,30100431,CDM,301,RC,84134,HCPCS,facility,both,,,,354,354,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC TOTAL PROTEIN OTHER SPECIMEN,30100432,CDM,301,RC,84146,HCPCS,facility,both,,,,506,506,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PROTEIN; EP FRACT & QUAN,30100433,CDM,301,RC,84153,HCPCS,facility,both,,,,297,297,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PROTEIN E-PHORESIS/URINE/CSF,30100434,CDM,301,RC,84154,HCPCS,facility,both,,,,233,233,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PROTEIN WESTERN BLOT,30100435,CDM,301,RC,84155,HCPCS,facility,both,,,,74,74,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PROTEIN WB; IM ID FOR BANDS,30100436,CDM,301,RC,84156,HCPCS,facility,both,,,,54,54,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PROTOPORPHYRIN RBC; QUAN,30100437,CDM,301,RC,84157,HCPCS,facility,both,,,,67,67,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PROINSULIN,30100438,CDM,301,RC,84165,HCPCS,facility,both,,,,187,187,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC VITAMIN B6,30100439,CDM,301,RC,84166,HCPCS,facility,both,,,,149,149,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PYRUVATE,30100440,CDM,301,RC,84181,HCPCS,facility,both,,,,254,254,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ASSAY NONENDOCRINE RECEPTOR,30100441,CDM,301,RC,84182,HCPCS,facility,both,,,,438,438,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ASSAY OF SERUM SODIUM,30100442,CDM,301,RC,84244,HCPCS,facility,both,,,,383,383,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC SODIUM; URINE,30100443,CDM,301,RC,84252,HCPCS,facility,both,,,,307,307,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC SODIUM OTHER SOURCE,30100444,CDM,301,RC,84255,HCPCS,facility,both,,,,489,489,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC TESTOSTERONE; FREE,30100445,CDM,301,RC,84295,HCPCS,facility,both,,,,140,140,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC TESTOSTERONE; TOTAL,30100446,CDM,301,RC,84300,HCPCS,facility,both,,,,130,130,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ASSAY OF THIAMINE (VITAMIN B-1),30100447,CDM,301,RC,84302,HCPCS,facility,both,,,,47,47,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC THROMBOXANE URINE,30100448,CDM,301,RC,84305,HCPCS,facility,both,,,,374,374,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC THYROGLOBULIN,30100449,CDM,301,RC,84311,HCPCS,facility,both,,,,226,226,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC THYROXINE; TOTAL,30100452,CDM,301,RC,84402,HCPCS,facility,both,,,,397,397,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC THYROID STIMULATING HORMONE,30100454,CDM,301,RC,84431,HCPCS,facility,both,,,,168,168,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC TOCOPHEROL ALPHA (VIT E),30100455,CDM,301,RC,84432,HCPCS,facility,both,,,,234,234,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AST OR SGOT,30100456,CDM,301,RC,84436,HCPCS,facility,both,,,,187,187,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC TRANSFERASE; ALANINE AMINO,30100457,CDM,301,RC,84439,HCPCS,facility,both,,,,239,239,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC TRANSFERRIN,30100458,CDM,301,RC,84442,HCPCS,facility,both,,,,324,324,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC TRIGLYCERIDES,30100460,CDM,301,RC,84443,HCPCS,facility,both,,,,452,452,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC T3; FREE,30100461,CDM,301,RC,84450,HCPCS,facility,both,,,,150,150,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC T3; REVERSE,30100462,CDM,301,RC,84460,HCPCS,facility,both,,,,153,153,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC TROPONIN QUAN,30100463,CDM,301,RC,84466,HCPCS,facility,both,,,,188,188,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC UREA NITROGEN; QUAN,30100464,CDM,301,RC,84478,HCPCS,facility,both,,,,136,136,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC UREA NITROGEN URINE,30100466,CDM,301,RC,84480,HCPCS,facility,both,,,,377,377,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC VMA URINE,30100467,CDM,301,RC,84484,HCPCS,facility,both,,,,143,143,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC VIP - VASOACTIVE INTESTINAL PEPTIDE,30100468,CDM,301,RC,84520,HCPCS,facility,both,,,,104,104,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC VASOPRESSIN,30100469,CDM,301,RC,84540,HCPCS,facility,both,,,,101,101,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC VITAMIN A,30100470,CDM,301,RC,84550,HCPCS,facility,both,,,,134,134,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC VITAMIN NOS,30100471,CDM,301,RC,84560,HCPCS,facility,both,,,,105,105,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC VITAMIN K,30100473,CDM,301,RC,84585,HCPCS,facility,both,,,,332,332,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC C-PEPTIDE,30100474,CDM,301,RC,84591,HCPCS,facility,both,,,,222,222,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HCG; QUAN,30100475,CDM,301,RC,84597,HCPCS,facility,both,,,,306,306,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HCG; QUAL,30100476,CDM,301,RC,84600,HCPCS,facility,both,,,,343,343,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC UNLISTED CHEMISTRY TEST,30100477,CDM,301,RC,84620,HCPCS,facility,both,,,,91,91,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC BL SMEAR W/DIFF WBC COUNT,30100478,CDM,301,RC,84630,HCPCS,facility,both,,,,226,226,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HEMATOCRIT,30100479,CDM,301,RC,84681,HCPCS,facility,both,,,,273,273,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HEMOGLOBIN,30100480,CDM,301,RC,84702,HCPCS,facility,both,,,,404,404,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC COMPL AUTOM CBC W PLT,30100483,CDM,301,RC,84999,HCPCS,facility,both,,,,102,102,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC LYMPHOCYTE MITOGEN RESPONSE,30100485,CDM,302,RC,86336,HCPCS,facility,both,,,,63,63,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PTEN GENE DUP/DELET VARIANT,30100494,CDM,301,RC,80155,HCPCS,facility,both,,,,126,126,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PTEN GENE DUP/DELET VARIANT,30100496,CDM,301,RC,80169,HCPCS,facility,both,,,,369,369,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC SMPD1 GENE COMMON VARIANTS,30100497,CDM,301,RC,80171,HCPCS,facility,both,,,,103,103,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC SNRPN/UBE3A GENE,30100498,CDM,301,RC,80175,HCPCS,facility,both,,,,103,103,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC SNRPN/UBE3A GENE,30100499,CDM,301,RC,80177,HCPCS,facility,both,,,,61,61,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC SERPINA1 GENE,30100500,CDM,301,RC,80180,HCPCS,facility,both,,,,153,153,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC VKORC1 GENE,30100501,CDM,301,RC,80183,HCPCS,facility,both,,,,80,80,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HLA I TYPING COMPLETE LR (150),30100503,CDM,301,RC,80203,HCPCS,facility,both,,,,142,142,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HLA I TYPING COMPLETE LR (150),30100507,CDM,310,RC,81200,HCPCS,facility,both,,,,155,155,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HLA I TYPING 1 ANTIGEN LR (150),30100512,CDM,310,RC,81209,HCPCS,facility,both,,,,307,307,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HLA II TYPING AG EQUIV LR (170),30100515,CDM,310,RC,81221,HCPCS,facility,both,,,,400,400,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC HLA II TYPING 1 LOCUS LR (40),30100519,CDM,310,RC,81226,HCPCS,facility,both,,,,1471,1471,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HLA I TYPING COMPLETE HR (290),30100520,CDM,310,RC,81227,HCPCS,facility,both,,,,571,571,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HLA II TYPING 1 LOCUS HR (40),30100522,CDM,310,RC,81229,HCPCS,facility,both,,,,1397,1397,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC HLA I TYPING 1 ALLELE HR,30100522,CDM,310,RC,81229,HCPCS,facility,both,,,,3537,3537,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MOPATH PROCEDURE LEVEL 5,30100525,CDM,310,RC,81243,HCPCS,facility,both,,,,260,260,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MOPATH PROCEDURE LEVEL 4,30100525,CDM,310,RC,81243,HCPCS,facility,both,,,,500,500,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC UNLISTED MOLECULAR PATHOLOGY,30100532,CDM,310,RC,81256,HCPCS,facility,both,,,,600,600,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC MOPATH PROCEDURE LEVEL 6,30100532,CDM,310,RC,81256,HCPCS,facility,both,,,,381,381,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC AUDITORY EVOKED POTENTIALS; SCRN AUDIT POTENT W/STIMULI, AUTO ANALYS",30100534,CDM,310,RC,81260,HCPCS,facility,both,,,,334,334,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC AUDITORY EVOKED POTENTIALS; HEARING STATUS DETER, BBAND STIMULI, I&R",30100536,CDM,310,RC,81263,HCPCS,facility,both,,,,961,961,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC AUDITORY EVOKED POTENTIALS; THRESHOLD ESTIM AT MULTI FREQ, I & R",30100542,CDM,310,RC,81275,HCPCS,facility,both,,,,631,631,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE DEAC 7/1/25 HC SARSCOV2 &INF A&B & RSV,30100546,CDM,310,RC,81290,HCPCS,facility,both,,,,128,128,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ELECTROPHORESIS NES,30100553,CDM,301,RC,82044,HCPCS,facility,both,,,,148,148,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ESTROGENS; TOTAL,30100555,CDM,301,RC,82239,HCPCS,facility,both,,,,389,389,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC VENTILATOR MGT, SUBSEQ DAY - ADULT",30100558,CDM,301,RC,82397,HCPCS,facility,both,,,,338,338,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC THYROID STIMULATING IMMUNOGLOBULINS,30100559,CDM,301,RC,82482,HCPCS,facility,both,,,,90,90,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC POS AIRWAY PRESSURE CPAP, PER DAY",30100560,CDM,301,RC,82552,HCPCS,facility,both,,,,102,102,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PA; SCREEN EA AB,30100562,CDM,301,RC,82664,HCPCS,facility,both,,,,159,159,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC CHEST PT, SUBSEQ TX",30100563,CDM,301,RC,82672,HCPCS,facility,both,,,,149,149,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CO2 EXPIRED GAS BY IR / PER DAY,30100573,CDM,301,RC,83992,HCPCS,facility,both,,,,313,313,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AB; EB EARLY AG VIRUS,30100576,CDM,301,RC,84445,HCPCS,facility,both,,,,353,353,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC FMR1 GENE DETECTION,30100581,CDM,310,RC,81225,HCPCS,facility,both,,,,637,637,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC FMR1 GENE DETECTION,30100585,CDM,301,RC,82104,HCPCS,facility,both,,,,243,243,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HFE GENE,30100592,CDM,301,RC,82480,HCPCS,facility,both,,,,95,95,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HFE GENE,30100594,CDM,301,RC,82638,HCPCS,facility,both,,,,178,178,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC IKBKAP GENE,30100595,CDM,301,RC,82962,HCPCS,facility,both,,,,85,85,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC IGH VARI REGIONAL MUTATION,30100598,CDM,301,RC,83527,HCPCS,facility,both,,,,267,267,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE DEAC 11/01/2023 HC ADM SARSCOV2 30MCG/0.3ML 1ST DOSE,30100601,CDM,301,RC,83013,HCPCS,facility,both,,,,1243,1243,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC KRAS GENE,30100603,CDM,301,RC,84377,HCPCS,facility,both,,,,418,418,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE DEAC 11/01/2023 HC ADM SARSCOV2 30MCG/0.3ML 2ND DOSE,30100610,CDM,301,RC,80339,HCPCS,facility,both,,,,223,223,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE DEAC 11/01/2023 HC ADM SARSCOV2 100MCG/0.5ML 1ST DOSE,30100612,CDM,301,RC,83951,HCPCS,facility,both,,,,534,534,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE DEAC 11/01/2023 HC IMMUN ADM SARSCOV2 100MCG/0.5ML 2ND DOSE,30100613,CDM,301,RC,84060,HCPCS,facility,both,,,,446,446,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ABLATE BONE TUMOR PERQ,30100619,CDM,301,RC,84145,HCPCS,facility,both,,,,404,404,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ACETOMINOPHEN,30100620,CDM,301,RC,84150,HCPCS,facility,both,,,,607,607,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AMIODARONE,30100624,CDM,301,RC,84376,HCPCS,facility,both,,,,30,30,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC CARBAMAZEPINE;10,11-EPOXIDE",30100625,CDM,301,RC,84378,HCPCS,facility,both,,,,1114,1114,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC FELBAMATE,30100631,CDM,301,RC,84545,HCPCS,facility,both,,,,163,163,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC EL-1 FECAL QUANTITATIVE,30100655,CDM,310,RC,81321,HCPCS,facility,both,,,,1957,1957,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ASSAY OF INTERLEUKIN-6 (IL-6),30100657,CDM,310,RC,81323,HCPCS,facility,both,,,,428,428,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ACTIN ANTIBODY EACH,30100657,CDM,310,RC,81323,HCPCS,facility,both,,,,500,500,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC ANCA SCREEN EACH ANTIBODY,30100661,CDM,310,RC,81330,HCPCS,facility,both,,,,154,154,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC EMA EACH IG CLASS,30100662,CDM,310,RC,81331,HCPCS,facility,both,,,,1347,1347,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DGP ANTIBODY EACH IG CLASS,30100662,CDM,310,RC,81331,HCPCS,facility,both,,,,500,500,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC TISS TRNSGL TMNASE EA IG CLASS,30100663,CDM,310,RC,81332,HCPCS,facility,both,,,,336,336,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MITOCHONDRIAL ANTIBODY EACH,30100665,CDM,310,RC,81355,HCPCS,facility,both,,,,571,571,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CUL TYP D BLD PTHGN 6+TRGT,30100666,CDM,310,RC,81372,HCPCS,facility,both,,,,1427,1427,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MOG-IGG1 ANTB CBA EACH,30100666,CDM,310,RC,81372,HCPCS,facility,both,,,,233,233,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE DEAC 11/01/2023 HC ADM SARSCOV2 30MCG/0.3 ML; TRIS-SUCROSE FORM; 1ST DOSE,30100667,CDM,310,RC,81374,HCPCS,facility,both,,,,317,317,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE DEAC 11/01/2023 HC ADM SARSCOV2 30MCG/0.3 ML; TRIS-SUCROSE FORM; 2ND DOSE,30100668,CDM,310,RC,81375,HCPCS,facility,both,,,,964,964,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE DEAC 11/01/2023 HC ADM SARSCOV2 30MCG/0.3 ML; TRIS-SUCROSE FORM; 3RD DOSE,30100669,CDM,310,RC,81376,HCPCS,facility,both,,,,534,534,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE DEAC 11/01/2023 HC ADM SARSCOV2 30MCG/0.3 ML; TRIS-SUCROSE FORM; BOOSTER,30100670,CDM,310,RC,81379,HCPCS,facility,both,,,,1094,1094,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CLOTTING ASSAY WHOLE BLOOD PER DAY,30100671,CDM,310,RC,81381,HCPCS,facility,both,,,,601,601,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "DEAC 4/1/2025 HC IV INFUSION SOTROVIMAB, INCL INFUSION & POST ADMIN MONITORING",30100672,CDM,310,RC,81382,HCPCS,facility,both,,,,403,403,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ACTIN ANTIBODY EACH,30100677,CDM,310,RC,81403,HCPCS,facility,both,,,,604,604,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC ANCA SCREEN EACH ANTIBODY,TITER",30100678,CDM,310,RC,81404,HCPCS,facility,both,,,,825,825,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AQAPRN-4 ANTB FLO CYTMTRY EA,30100679,CDM,310,RC,81405,HCPCS,facility,both,,,,969,969,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC VOLTAGE-GTD CA CHNL ANTB EA,30100683,CDM,310,RC,81479,HCPCS,facility,both,,,,445,445,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PERCUT TRANSHEPATIC PORTOGRAM W/HDM,30100684,CDM,301,RC,80299,HCPCS,facility,both,,,,94,94,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HEPATIC VENOGRAPHY W/O HDM,30100687,CDM,301,RC,80332,HCPCS,facility,both,,,,73,73,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC VENOUS SAMPLING THRU CATH W/W/O ANGIO,30100688,CDM,301,RC,80299,HCPCS,facility,both,,,,287,287,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ALCOHOL,30100692,CDM,301,RC,80165,HCPCS,facility,both,,,,60,60,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DNA/RNA; MULTI ORG - AMP PR,30100693,CDM,301,RC,80320,HCPCS,facility,both,,,,180,180,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC BUPRENORPHINE,30100694,CDM,301,RC,80335,HCPCS,facility,both,,,,219,219,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ALKALOIDS NOS,30100695,CDM,301,RC,80367,HCPCS,facility,both,,,,72,72,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CYTOPATH FL NONGYN SMEARS,30100696,CDM,301,RC,80348,HCPCS,facility,both,,,,15,15,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CP CONCENTR TECH SMEAR,30100697,CDM,301,RC,80323,HCPCS,facility,both,,,,334,334,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CP CONCENTR TECH SMEAR,30100698,CDM,301,RC,80358,HCPCS,facility,both,,,,210,210,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CYTP DX EVAL FNA 1ST EA SITE,30100700,CDM,301,RC,80329,HCPCS,facility,both,,,,491,491,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC F2 GENE (40),30100702,CDM,301,RC,80349,HCPCS,facility,both,,,,516,516,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC F5 GENE (40),30100703,CDM,301,RC,80366,HCPCS,facility,both,,,,15,15,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC IMMUMOASSAY QUANT NOS NONAB (100),30100707,CDM,301,RC,83520,HCPCS,facility,both,,,,93,93,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC QUANTITATIVE ASSAY DRUG (85),30100709,CDM,301,RC,80299,HCPCS,facility,both,,,,287,287,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC RESP VIRUS 3-5 TARGETS,30100710,CDM,301,RC,80299,HCPCS,facility,both,,,,94,94,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CFTR GENE COM VARIAN (300),30100711,CDM,301,RC,80299,HCPCS,facility,both,,,,287,287,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CFTR DEL/DUP PART OF PANEL,30100712,CDM,301,RC,80299,HCPCS,facility,both,,,,94,94,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CFTR DEL/DUP PART OF PANEL,30100714,CDM,301,RC,80299,HCPCS,facility,both,,,,94,94,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CFTR GENE FULL SEQUENCE (1630),30100715,CDM,301,RC,80299,HCPCS,facility,both,,,,295,295,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC FANCC GENE (70),30100719,CDM,301,RC,80353,HCPCS,facility,both,,,,308,308,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC STR MARKERS SPECIMEN ANAL (200),30100720,CDM,301,RC,80364,HCPCS,facility,both,,,,131,131,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PTEN GENE PART OF PANEL,30100721,CDM,301,RC,80299,HCPCS,facility,both,,,,94,94,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CUSTOM SWIM PLUG SINGLE,30100723,CDM,301,RC,84999,HCPCS,facility,both,,,,102,102,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC INJECTION FOR CHOLANGIOGRAM, NEW ACCESS",30100724,CDM,301,RC,82373,HCPCS,facility,both,,,,102,102,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC PLACEMENT BILIARY DRAINAGE CATH, EXTERNAL",30100726,CDM,301,RC,80332,HCPCS,facility,both,,,,73,73,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC PLACEMENT BILIARY DRAINAGE CATH, INTERNAL-EXTERNAL",30100727,CDM,301,RC,80332,HCPCS,facility,both,,,,73,73,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CONVERSION EXTERNAL BILIARY DRAINAGE CATH,30100731,CDM,301,RC,80342,HCPCS,facility,both,,,,73,73,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC EXCHANGE BILIARY DRAINAGE CATH,30100735,CDM,301,RC,80338,HCPCS,facility,both,,,,15,15,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC REMOVAL BILIARY DRAINAGE CATH,30100736,CDM,301,RC,80375,HCPCS,facility,both,,,,73,73,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC SYNTHETIC GLUCOCORTICOID SCREEN, SERUM(91)",30100738,CDM,301,RC,80375,HCPCS,facility,both,,,,73,73,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE DEAC 10/1/2025 HC INFCT DS BCT/VIR RESPIR DNA/RNA 22 TRGT SAVSCOV2,30100740,CDM,301,RC,80365,HCPCS,facility,both,,,,15,15,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CELL DONOR SEARCH MANAGEMENT,30100741,CDM,301,RC,84163,HCPCS,facility,both,,,,91,91,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HARVEST ALLOGENEIC STEM CELL,30100742,CDM,301,RC,84704,HCPCS,facility,both,,,,91,91,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC MICROSOMAL ANTIBODIES, EACH",30100747,CDM,301,RC,82373,HCPCS,facility,both,,,,762,762,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC DRUG SCREEN, INSTRUMENT SINGLE DRUG",30100748,CDM,301,RC,80307,HCPCS,facility,both,,,,370,370,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC DRUG SCREEN, INSTRUMENT 5 DRUG",30100752,CDM,301,RC,80307,HCPCS,facility,both,,,,234,234,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CFTR GENE COM VARIANTS (70),30100757,CDM,301,RC,83520,HCPCS,facility,both,,,,93,93,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC METABOLIC PANEL TOTAL CA,30100761,CDM,301,RC,80377,HCPCS,facility,both,,,,67,67,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ELECTROLYTE PANEL,30100763,CDM,301,RC,80377,HCPCS,facility,both,,,,73,73,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC LUMEN MECH REM OBSTR CVAD,30100764,CDM,301,RC,80356,HCPCS,facility,both,,,,73,73,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DRAIN/INJ INTERMEDIATE JOINT/BURSA W/US,30100766,CDM,301,RC,80362,HCPCS,facility,both,,,,96,96,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC REVSC, ENDOVSC, OPEN/PERQ, TIB/PERON ARTERY, UNI, INITIAL; W/TLA",30100767,CDM,301,RC,80373,HCPCS,facility,both,,,,73,73,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC ENZYME EVAL; ALPHA GALA, EACH SPECIMEN",30100768,CDM,310,RC,81219,HCPCS,facility,both,,,,537,537,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC MRI, FETAL, INCL PLACENTL MATERNL PELVIC IMG, SINGLE/1ST GESTATION",30100771,CDM,301,RC,82642,HCPCS,facility,both,,,,176,176,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC SARSCOV2 &INF A&B & RSV (39),30100773,CDM,301,RC,80359,HCPCS,facility,both,,,,16,16,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC SUGARS; MULTIPLE QUANTITATIVE, EACH SPECIMEN",30100781,CDM,301,RC,80353,HCPCS,facility,both,,,,15,15,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC RESP VIRUS 12-25 TARGETS,30100785,CDM,301,RC,80145,HCPCS,facility,both,,,,125,125,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC RESP VIRUS 12-25 TARGETS,30100786,CDM,301,RC,80187,HCPCS,facility,both,,,,222,222,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC RADIOPHARM LOCALIZE TUMOR, SPECT, W/CT 1 AREA 1 DAY IMAGE",30100787,CDM,301,RC,80230,HCPCS,facility,both,,,,145,145,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC RADIOPHARM LOCAL TUMOR, SPECT, MIN 2 AREA 1 DAY IMG /1 AREA OR IMG 2+ DAYS",30100788,CDM,301,RC,80235,HCPCS,facility,both,,,,222,222,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC NFCT DS CHRNC HCV 6 ASSAYS (55),30100789,CDM,301,RC,80285,HCPCS,facility,both,,,,222,222,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE DEAC 7/1/25 HC SARS-COV-2 (120),30100790,CDM,310,RC,81596,HCPCS,facility,both,,,,349,349,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC SKIN TEST; TB ID,30100793,CDM,301,RC,80354,HCPCS,facility,both,,,,52,52,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DETERGENT TX FROZEN PLASMA EA UNIT,30100794,CDM,301,RC,80347,HCPCS,facility,both,,,,131,131,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC ANTI-PSYCHOTIC ,NOS 1-3 (70)",30100795,CDM,301,RC,80143,HCPCS,facility,both,,,,491,491,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC ANTI-DEPRESS, NOS (60)",30100796,CDM,301,RC,80151,HCPCS,facility,both,,,,222,222,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC DRUG/SUBS, DEFIN,NOS, 1-3 (95)",30100797,CDM,301,RC,80161,HCPCS,facility,both,,,,264,264,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC BCR/ABL MJR BP (275),30100798,CDM,301,RC,80167,HCPCS,facility,both,,,,94,94,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HLA II LOW RESOLUTION ONE ANTIGEN EQUIVALENT EA,30100799,CDM,301,RC,80179,HCPCS,facility,both,,,,491,491,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DRUG SCREEN QUANT AMPHETAMINES 3 OR 4,30100800,CDM,301,RC,80181,HCPCS,facility,both,,,,94,94,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC VON WILLEBRAND FACTOR TYPE 2N FACTOR VIII PLASMA,30100801,CDM,301,RC,80189,HCPCS,facility,both,,,,266,266,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HEM VW DS VW FACTOR & COLLAGEN III BINDING ELISA,30100802,CDM,301,RC,80193,HCPCS,facility,both,,,,409,409,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC VON WILLEBRAND FACTOR TYPE 2B PLASMA,30100803,CDM,301,RC,80204,HCPCS,facility,both,,,,289,289,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HEM VW DS VW PROPEPTIDE ELISA AG LEVEL,30100804,CDM,301,RC,80210,HCPCS,facility,both,,,,223,223,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ACTIVAIR BATTERY TESTER,30100805,CDM,301,RC,82077,HCPCS,facility,both,,,,233,233,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE DEAC 10/3/2022 HC SUPER SEAL (STARTER SET),30100810,CDM,301,RC,82127,HCPCS,facility,both,,,,366,366,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE DEAC 11/01/2023 HC ADM SARSCOV2 3MCG TRS-SUCR-1ST DOSE,30100812,CDM,301,RC,82653,HCPCS,facility,both,,,,309,309,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE DEAC 11/01/2023 HC ADM SARSCOV2 3MCG TRS-SUCR-2 DOSE,30100814,CDM,301,RC,83529,HCPCS,facility,both,,,,362,362,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MOD SED OTHER PHYS/QHP <5 YRS; INITL 15 MIN,30100817,CDM,301,RC,80145,HCPCS,facility,both,,,,503,503,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC INTR CATH DIALYS CIRCT W/TRLUML BAL ANGIOPLASTY,30100818,CDM,301,RC,80354,HCPCS,facility,both,,,,212,212,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC INTR CATH DIAL CIRC W/TRCATH PLC INTRVSC STENT(S),30100819,CDM,301,RC,80348,HCPCS,facility,both,,,,212,212,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC GENOMEXPRESS (1109),30100820,CDM,301,RC,80299,HCPCS,facility,both,,,,577,577,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PROCEDURE ENDO LEVEL 1 EA ADDL 15 MINUTE,30100821,CDM,301,RC,83520,HCPCS,facility,both,,,,1044,1044,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ANTI-MULLERIAN HORMONE (AMH),30100823,CDM,301,RC,82166,HCPCS,facility,both,,,,138,138,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC PROGRAM DEVICE EVAL, W/ ITERATIVE ADJ, IMPLANT SUBQ LEAD DEFIB SYS",30100831,CDM,301,RC,82657,HCPCS,facility,both,,,,505,505,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC X-RAY EXAM SACROILIAC JOINTS <3 VIEWS,30100834,CDM,301,RC,82784,HCPCS,facility,both,,,,102,102,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC AMINO ACID, MSUD PANEL, BLOOD SPOT, EACH SPECIMEN",30100843,CDM,301,RC,84379,HCPCS,facility,both,,,,66.32,66.32,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC AMINO ACIDS, MSUD PANEL, PLASMA, SERUM, EACH SPECIMEN",30100844,CDM,301,RC,84146,HCPCS,facility,both,,,,7,7,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC AMINO ACIDS, MSUD PANEL, PLASMA, SERUM, EACH SPECIMEN",30100845,CDM,301,RC,82542,HCPCS,facility,both,,,,471,471,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC AMINO ACIDS, 6 OR MORE AMINO ACIDS, QNT, BLD SPOT, EACH SPECIMEN",30100846,CDM,301,RC,82017,HCPCS,facility,both,,,,236,236,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE "HC AMINO ACIDS, 6 OR MORE AMINO ACIDS, QNT,  SERUM, EACH SPECIMEN",30100846,CDM,301,RC,82017,HCPCS,facility,both,,,,365,365,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC AMINO ACIDS, 6 OR MORE AMINO ACIDS, QNT, BLD SPOT, EACH SPECIMEN",30100847,CDM,301,RC,82136,HCPCS,facility,both,,,,317,317,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE "HC AMINO ACIDS, 6 OR MORE AMINO ACIDS, QNT, URINE, EACH SPECIMEN",30100847,CDM,301,RC,82136,HCPCS,facility,both,,,,442,442,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC AMINO ACIDS, 6 OR MORE AMINO ACIDS, QNT, CSF, EACH SPECIMEN",30100848,CDM,301,RC,82136,HCPCS,facility,both,,,,140,140,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE "HC AMINO ACIDS, 6 OR MORE AMINO ACIDS, QNT, URINE, EACH SPECIMEN",30100848,CDM,301,RC,82136,HCPCS,facility,both,,,,218,218,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC CARNITINE PLASMA SERUM, EACH SPECIMEN",30100849,CDM,301,RC,82139,HCPCS,facility,both,,,,233,233,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC AMINO ACIDS, 6 OR MORE AMINO ACIDS, QNT, CSF, EACH SPECIMEN",30100849,CDM,301,RC,82139,HCPCS,facility,both,,,,167,167,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE "HC CARNITINE PLASMA SERUM, EACH SPECIMEN",30100850,CDM,301,RC,82139,HCPCS,facility,both,,,,58,58,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC CARNITINE (TOTAL AND FREE), QNT, EACH SPECIMEN",30100850,CDM,301,RC,82139,HCPCS,facility,both,,,,37,37,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE "HC CARNITINE (TOTAL AND FREE), QNT, EACH SPECIMEN",30100851,CDM,301,RC,82139,HCPCS,facility,both,,,,167,167,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE "HC FATTY ACIDS COMPREHENSIVE, PLASMA/SERUM",30100851,CDM,301,RC,82139,HCPCS,facility,both,,,,233,233,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC FATTY ACIDS PROFILE, ESSENTIAL, PLASMA/SERUM",30100852,CDM,301,RC,82139,HCPCS,facility,both,,,,253,253,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE "HC FATTY ACIDS COMPREHENSIVE, PLASMA/SERUM",30100852,CDM,301,RC,82139,HCPCS,facility,both,,,,353,353,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC FATTY ACIDS PROFILE, ESSENTIAL, PLASMA/SERUM",30100853,CDM,301,RC,82379,HCPCS,facility,both,,,,126,126,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE "HC FATTY ACID, MITOCHONDRIAL, PLASMA/SERUM",30100853,CDM,301,RC,82379,HCPCS,facility,both,,,,195,195,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC FATTY ACID, MITOCHONDRIAL, PLASMA/SERUM",30100854,CDM,301,RC,82379,HCPCS,facility,both,,,,275,275,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC VERY LONG CHAIN FATTY ACIDS,30100854,CDM,301,RC,82379,HCPCS,facility,both,,,,177,177,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC VERY LONG CHAIN FATTY ACIDS,30100855,CDM,301,RC,82725,HCPCS,facility,both,,,,158,158,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE "HC ORGANIC ACIDS; TOTAL, QUANTITATIVE, EACH SPECIMEN",30100855,CDM,301,RC,82725,HCPCS,facility,both,,,,220,220,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC ORGANIC ACIDS; TOTAL, QUANTITATIVE, EACH SPECIMEN",30100856,CDM,301,RC,82725,HCPCS,facility,both,,,,209,209,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC ORGANIC ACID, SINGLE, QUANTITATIVE, PLASMA/SERUM",30100856,CDM,301,RC,82725,HCPCS,facility,both,,,,150,150,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE "HC ORGANIC ACID, SINGLE, QUANTITATIVE, PLASMA/SERUM",30100857,CDM,301,RC,82725,HCPCS,facility,both,,,,257,257,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE "HC ORGANIC ACID, SINGLE, QUANTITATIVE, URINE",30100857,CDM,301,RC,82725,HCPCS,facility,both,,,,317,317,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC PHENYLALANINE (PKU), BLOOD",30100858,CDM,301,RC,82726,HCPCS,facility,both,,,,241,241,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE "HC ORGANIC ACID, SINGLE, QUANTITATIVE, URINE",30100858,CDM,301,RC,82726,HCPCS,facility,both,,,,374,374,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC PHENYLALANINE (PKU), BLOOD",30100859,CDM,301,RC,83918,HCPCS,facility,both,,,,275,275,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC TYROSINE,30100859,CDM,301,RC,83918,HCPCS,facility,both,,,,426,426,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC TYROSINE,30100860,CDM,301,RC,83921,HCPCS,facility,both,,,,147,147,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC RBC AG DNA GT 10 BLD GRPS W/PHEN PREDICT 37 RBC AG,30100860,CDM,301,RC,83921,HCPCS,facility,both,,,,95,95,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC AIRWAY RESISTANCE BY OSCILLOMETRY,30100861,CDM,301,RC,83921,HCPCS,facility,both,,,,135,135,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC RADIOLOGIC SMALL INTESTINE FOLLOW-THROUGH STUDY,30100861,CDM,301,RC,83921,HCPCS,facility,both,,,,210,210,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PERICARDIOCENTESIS W/IMG GUIDANCE WHEN PERFORMED,30100862,CDM,301,RC,84030,HCPCS,facility,both,,,,62,62,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PERQ PRCRD DRAIN 6YR+ W/O CONGENITAL CARD ANOMALY,30100862,CDM,301,RC,84030,HCPCS,facility,both,,,,40,40,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC PERQ PRCRD DRAIN 0-5YR/ANY AGE W/CGEN CARD ANOMALY,30100863,CDM,301,RC,84510,HCPCS,facility,both,,,,77,77,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC HEALTH BEHAVIOR ASSESSMENT/RE-ASSESSMENT,30100863,CDM,301,RC,84510,HCPCS,facility,both,,,,119,119,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MANGANESE SUPEROXIDE DISMUTASE,30160001,CDM,301,RC,80299,HCPCS,facility,both,,,,227,227,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC REG-3-ALPHA BIOMARKER,QNT VCOR",30160002,CDM,301,RC,80299,HCPCS,facility,both,,,,287,287,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC ELAFIN, SERUM, QNT VCOR",30160003,CDM,301,RC,80299,HCPCS,facility,both,,,,287,287,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC COLLAGEN BINDING FACTOR,30160004,CDM,301,RC,80299,HCPCS,facility,both,,,,287,287,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC VW PROPEPTIDE AG,30160005,CDM,301,RC,80299,HCPCS,facility,both,,,,287,287,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC THROMBIN-ANTITHROMBIN COMPLEX,30160006,CDM,301,RC,80306,HCPCS,facility,both,,,,279,279,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC IMMUNOASSAY,QNT,TLRF",30160007,CDM,301,RC,80307,HCPCS,facility,both,,,,234,234,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC IGE AB (IGE: IGG AB),30160008,CDM,301,RC,84703,HCPCS,facility,both,,,,185,185,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC INTERLEUKIN-6,HIGHLY SENSITIVE",30160009,CDM,307,RC,81050,HCPCS,facility,both,,,,56,56,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC FIBROBLAST GROWTH FACTOR-23,30160011,CDM,301,RC,81304,HCPCS,facility,both,,,,500,500,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC THROMBOPOIETIN (TPO),30160012,CDM,310,RC,81340,HCPCS,facility,both,,,,1735,1735,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC INTERLEUKIN-10 (IL10), SERUM",30160013,CDM,310,RC,81370,HCPCS,facility,both,,,,2816,2816,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC TRYPTASE, SERUM",30160014,CDM,310,RC,81370,HCPCS,facility,both,,,,1843,1843,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC CYTOKINE,GM-CSF",30160015,CDM,310,RC,81378,HCPCS,facility,both,,,,2662,2662,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC CYTOKINE,INTERLEUKIN-2 (IL-2)",30160016,CDM,310,RC,81383,HCPCS,facility,both,,,,433,433,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC CYTOKINE,INTERLEUKIN-4 (IL-4)",30160017,CDM,301,RC,81460,HCPCS,facility,both,,,,3713,3713,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC CYTOKINE,INTERLEUKIN-8 (IL-8)",30160018,CDM,301,RC,82272,HCPCS,facility,both,,,,39,39,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC CYTOKINE,INTERLEUKIN-10(IL-10)",30160019,CDM,301,RC,82360,HCPCS,facility,both,,,,196,196,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC CYTOKINE,IFN-Y",30160020,CDM,301,RC,82540,HCPCS,facility,both,,,,113,113,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC CYTOKINE,TNF-ALPHA",30160021,CDM,301,RC,82540,HCPCS,facility,both,,,,291,291,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC GANGLIOSIDE GM-1 AB,IGG",30160022,CDM,301,RC,82633,HCPCS,facility,both,,,,401,401,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC GANGLIOSIDE GM-1 AB,IGM",30160023,CDM,301,RC,82658,HCPCS,facility,both,,,,500,500,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC GANGLIOSIDE ASIALO-GM-1 AB,IGG",30160024,CDM,301,RC,82805,HCPCS,facility,both,,,,760,760,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC GANGLIOSIDE ASIALO-GM-1 AB,IGM",30160025,CDM,301,RC,82978,HCPCS,facility,both,,,,393,393,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC HEPCIDIN IDX ASSAY, SERUM",30160026,CDM,301,RC,82978,HCPCS,facility,both,,,,262,262,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC LACTOFERRIN,QNT,STOOL",30160027,CDM,301,RC,83491,HCPCS,facility,both,,,,288,288,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC ORGANIC ACID SCREEN, URINE",30160028,CDM,301,RC,83520,HCPCS,facility,both,,,,1099,1099,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC ORGANIC ACID SCREEN, URINE",30160029,CDM,301,RC,83520,HCPCS,facility,both,,,,449,449,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PIVKA-2 (AKA DCP),30160030,CDM,301,RC,83520,HCPCS,facility,both,,,,349,349,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC RBC ENZYME, GLU-PHOS-ISO MAYO",30160031,CDM,301,RC,83520,HCPCS,facility,both,,,,349,349,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC RBC ENZYME, PY KINASE MAYO",30160032,CDM,301,RC,83520,HCPCS,facility,both,,,,349,349,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC PYRUVATE KINASE, RBCS MAYO",30160033,CDM,301,RC,83520,HCPCS,facility,both,,,,349,349,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC REDUCING SUBSTANCES, FECAL",30160034,CDM,301,RC,83520,HCPCS,facility,both,,,,349,349,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC TESTOSTERONE,BIOAVAILABLE",30160035,CDM,301,RC,83520,HCPCS,facility,both,,,,349,349,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CBG(CORTICOSTER BIND GLOB) NIC,30160036,CDM,301,RC,83520,HCPCS,facility,both,,,,349,349,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC THYROID UPTAKE (T4 UPTAKE),30160037,CDM,301,RC,83520,HCPCS,facility,both,,,,349,349,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC TYROSINE,FILTER CARD",30160038,CDM,301,RC,83520,HCPCS,facility,both,,,,349,349,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC TYROSINE,FILTER CARD",30160039,CDM,301,RC,83520,HCPCS,facility,both,,,,711,711,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC INTRACELLULAR CYSTINE UCA@SD,30160040,CDM,301,RC,83520,HCPCS,facility,both,,,,711,711,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CHITOTRIOSIDASE ASSAY GENZYME,30160041,CDM,301,RC,83520,HCPCS,facility,both,,,,591,591,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC POTASSIUM,BODY FLUID",30160042,CDM,301,RC,83520,HCPCS,facility,both,,,,591,591,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ASPERGILLUS IGG SPECIFIC AB,30160043,CDM,301,RC,83520,HCPCS,facility,both,,,,349,349,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HISTAMINE RELEASE,30160044,CDM,301,RC,83520,HCPCS,facility,both,,,,349,349,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HISTAMINE RELEASE(C.URTICARIA),30160045,CDM,301,RC,83520,HCPCS,facility,both,,,,349,349,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC RHEUMATOID FACTOR,30160046,CDM,301,RC,83520,HCPCS,facility,both,,,,349,349,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HTLV 1 & 2 AB SLI,30160047,CDM,301,RC,83520,HCPCS,facility,both,,,,449,449,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HERPES SIMPLEX AB IGM 1/2,30160048,CDM,301,RC,83520,HCPCS,facility,both,,,,349,349,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC T. CRUZI (CONFIRMATION),30160049,CDM,301,RC,83520,HCPCS,facility,both,,,,349,349,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC STOOL/ROTOVIRUS,30160050,CDM,301,RC,83520,HCPCS,facility,both,,,,349,349,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC CROSSMATCH,FINAL(DONOR/REC)",30160051,CDM,301,RC,83520,HCPCS,facility,both,,,,349,349,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC SERUM STORAGE,30160052,CDM,301,RC,83520,HCPCS,facility,both,,,,349,349,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC PT, PLASMA FRACTION #2",30160053,CDM,301,RC,83520,HCPCS,facility,both,,,,349,349,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PTT (1:1 DILUTION),30160054,CDM,301,RC,83520,HCPCS,facility,both,,,,349,349,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC PTT, PLASMA FRACTION #2",30160055,CDM,301,RC,83520,HCPCS,facility,both,,,,349,349,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ADAMTS-13 ANTIBODY BCW,30160056,CDM,301,RC,83520,HCPCS,facility,both,,,,349,349,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC PERIPHERAL SMEAR,MORPHOLOGY",30160057,CDM,301,RC,83520,HCPCS,facility,both,,,,349,349,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PT (1:1 DILUTION),30160058,CDM,301,RC,83520,HCPCS,facility,both,,,,349,349,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC CULTURE STOOL/RECTAL, EACH",30160059,CDM,301,RC,83520,HCPCS,facility,both,,,,349,349,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC MYCOBACTERIUM ID,ADD,MOLECULAR",30160060,CDM,301,RC,83520,HCPCS,facility,both,,,,349,349,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC PAM,WET-PREP IDENT,CSF",30160061,CDM,301,RC,83520,HCPCS,facility,both,,,,349,349,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CLOSTRIDIUM DIFFICILE TOXIN/ST,30160062,CDM,301,RC,83520,HCPCS,facility,both,,,,376,376,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CHLAMYDIA DETECTION DFA QUEST,30160063,CDM,301,RC,83631,HCPCS,facility,both,,,,304,304,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC RSV, RAPID TEST ONLY",30160064,CDM,301,RC,83919,HCPCS,facility,both,,,,170,170,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE DEAC 1/1/2025 HC C.DIFFICILE TOXIN A/B ASSAY,30160064,CDM,301,RC,83919,HCPCS,facility,both,,,,363,363,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC B-D-GLUCANS(FUNGITELL) VIRACOR,30160065,CDM,301,RC,83951,HCPCS,facility,both,,,,796,796,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC BARTONELLA, DNA PROBE UWASH",30160066,CDM,301,RC,84087,HCPCS,facility,both,,,,431,431,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC BARTONELLA HENSELAE/PCR/TISSUE,30160067,CDM,301,RC,84220,HCPCS,facility,both,,,,476,476,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC BARTONELLA HENSELEA,BLOOD PCR",30160068,CDM,301,RC,84220,HCPCS,facility,both,,,,476,476,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC BARTONELLA QUINTANA, BLOOD PCR",30160069,CDM,301,RC,84376,HCPCS,facility,both,,,,136,136,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MENINIGITIS-ENCEPH CSF BY PCR,30160070,CDM,301,RC,84410,HCPCS,facility,both,,,,350,350,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC GARDNERELLA VAGINALIS,30160071,CDM,301,RC,84449,HCPCS,facility,both,,,,189,189,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC MYCOBACTERIUM SP,DNA PROBE",30160072,CDM,301,RC,84479,HCPCS,facility,both,,,,133,133,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC WEST NILE VIRUS (NAT),30160073,CDM,301,RC,84510,HCPCS,facility,both,,,,47,47,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE "HC M.AVIUM,INTRACELL DNA PROBETGH",30160073,CDM,301,RC,84510,HCPCS,facility,both,,,,188,188,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC RALTEGRAVIR RESISITANCE, HIV-1",30160074,CDM,301,RC,84999,HCPCS,facility,both,,,,2488,2488,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CMV ANTIVIRAL RESISTANCE SEQ,30160075,CDM,301,RC,84999,HCPCS,facility,both,,,,1534,1534,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE DEAC 1/1/2022 HC RBC ENZYME PATH INTERP MAYO,30160076,CDM,301,RC,84999,HCPCS,facility,both,,,,29,29,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MANUAL CELL COUNT EACH,30160077,CDM,301,RC,82657,HCPCS,facility,both,,,,1896,1896,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC RETICYTE/HGB CONCENTRATE,30160078,CDM,301,RC,83789,HCPCS,facility,both,,,,2229,2229,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC EUGLOBULIN LYSIS,30160079,CDM,301,RC,80299,HCPCS,facility,both,,,,407,407,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC NERVE TEASING PREP,30160080,CDM,301,RC,82379,HCPCS,facility,both,,,,216,216,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC NERVE TEASING PREP,30160080,CDM,301,RC,82379,HCPCS,facility,both,,,,120,120,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC HUGGIE AIDS - PAIR,30160081,CDM,301,RC,80307,HCPCS,facility,both,,,,234,234,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC SALICYLATE,30200000,CDM,302,RC,,,facility,both,,,,161,161,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CARBAMAZEPINE; TOTAL,30200001,CDM,301,RC,80074,HCPCS,facility,both,,,,923,923,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC LITHIUM,30200003,CDM,301,RC,80168,HCPCS,facility,both,,,,81,81,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ALUMINUM ASSAY,30200004,CDM,301,RC,82085,HCPCS,facility,both,,,,142,142,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AMINO ACIDS; SGL QUAN EA,30200005,CDM,301,RC,82103,HCPCS,facility,both,,,,203,203,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DELTA ALA,30200006,CDM,301,RC,82108,HCPCS,facility,both,,,,508,508,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AMINO ACIDS 6/> QUAN EA,30200007,CDM,301,RC,82131,HCPCS,facility,both,,,,69,69,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC AMMONIA,30200007,CDM,301,RC,82131,HCPCS,facility,both,,,,122,122,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AMYLASE,30200008,CDM,301,RC,82135,HCPCS,facility,both,,,,316,316,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ARSENIC,30200009,CDM,301,RC,82157,HCPCS,facility,both,,,,543,543,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ASCORBIC ACID BLOOD,30200010,CDM,301,RC,82163,HCPCS,facility,both,,,,98,98,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC BARBITURATES,30200011,CDM,301,RC,82164,HCPCS,facility,both,,,,338,338,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC BETA-2 MICROGLOBULIN,30200012,CDM,301,RC,82172,HCPCS,facility,both,,,,101,101,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC TOTAL BILIRUBIN,30200013,CDM,301,RC,82175,HCPCS,facility,both,,,,384,384,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC VITAMIN D 25 HYDROXY,30200014,CDM,301,RC,82261,HCPCS,facility,both,,,,342,342,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CHLORIDE; URINE,30200016,CDM,301,RC,82380,HCPCS,facility,both,,,,155,155,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CHLORIDE; OTHER,30200017,CDM,301,RC,82384,HCPCS,facility,both,,,,372,372,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC SERUM/WB TOT CHOLEST,30200018,CDM,301,RC,82390,HCPCS,facility,both,,,,180,180,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CORTISOL; FREE,30200019,CDM,301,RC,82507,HCPCS,facility,both,,,,427,427,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DHEA,30200020,CDM,301,RC,82600,HCPCS,facility,both,,,,93,93,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DEOXYCORTISOL 11,30200021,CDM,301,RC,82608,HCPCS,facility,both,,,,91,91,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PANCREATIC ELASTASE FECAL,30200022,CDM,301,RC,82626,HCPCS,facility,both,,,,564,564,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC ENZYME ACTIVITY BC; NOT RA, EACH SPECIMEN",30200023,CDM,301,RC,82627,HCPCS,facility,both,,,,372,372,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ERYTHROPOIETIN,30200024,CDM,301,RC,82634,HCPCS,facility,both,,,,739,739,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ESTRONE,30200026,CDM,301,RC,82668,HCPCS,facility,both,,,,273,273,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC FAT/LIPIDS FECES; QUAL,30200027,CDM,301,RC,82671,HCPCS,facility,both,,,,148,148,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC FATTY ACIDS NONESTERIFIED,30200028,CDM,301,RC,82679,HCPCS,facility,both,,,,329,329,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC VERY LONG FATTY ACID CHAINS,30200029,CDM,301,RC,82693,HCPCS,facility,both,,,,151,151,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC FERRITIN,30200030,CDM,301,RC,82705,HCPCS,facility,both,,,,114,114,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC FOLIC ACID; RBC,30200031,CDM,301,RC,82725,HCPCS,facility,both,,,,123,123,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC IGG 1 2 3 OR 4 EACH,30200032,CDM,301,RC,82759,HCPCS,facility,both,,,,774,774,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC BLOOD GAS MIXED WO O2 SAT,30200033,CDM,301,RC,82775,HCPCS,facility,both,,,,685,685,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC GLUCOSE; POST GLUCOSE DOSE,30200034,CDM,301,RC,82941,HCPCS,facility,both,,,,372,372,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC GLUCOSE TOLERANCE TEST (GTT) 3 SPECM,30200035,CDM,301,RC,82943,HCPCS,facility,both,,,,69,69,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC GONADOTROPIN; LUTEINIZING HORMONE,30200036,CDM,301,RC,82955,HCPCS,facility,both,,,,292,292,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HAPTOGLOBIN; QUAN,30200037,CDM,301,RC,82985,HCPCS,facility,both,,,,262,262,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HYDROXYPROGESTERONE 17-D,30200038,CDM,301,RC,83088,HCPCS,facility,both,,,,656,656,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC RIA NONANTIBODY,30200039,CDM,301,RC,83150,HCPCS,facility,both,,,,267,267,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC IMMUNOASSAY QUANT NOS NONAB (25),30200041,CDM,301,RC,83498,HCPCS,facility,both,,,,520,520,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ASSAY OF LIPOPROTEIN(A),30200042,CDM,301,RC,83625,HCPCS,facility,both,,,,203,203,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MYELIN BASIC PROTEIN CSF,30200043,CDM,301,RC,83785,HCPCS,facility,both,,,,342,342,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC NATRIURETIC PEPTIDE,30200044,CDM,301,RC,83825,HCPCS,facility,both,,,,337,337,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC OLIGOCLONAL BANDS,30200046,CDM,301,RC,83873,HCPCS,facility,both,,,,347,347,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC OPIATES 1 OR MORE,30200047,CDM,301,RC,83883,HCPCS,facility,both,,,,299,299,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC ANTIPSYCHOTIC, NOS 1-3",30200049,CDM,301,RC,83937,HCPCS,facility,both,,,,446,446,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PHENYLALANINE BLOOD,30200050,CDM,301,RC,83945,HCPCS,facility,both,,,,251,251,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ASSAY OF SERUM POTASSIUM,30200051,CDM,301,RC,84080,HCPCS,facility,both,,,,315,315,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PREGNENOLONE,30200052,CDM,301,RC,84110,HCPCS,facility,both,,,,102,102,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC 17-HYDROXYPREGNENOLONE,30200053,CDM,301,RC,84120,HCPCS,facility,both,,,,330,330,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PSA; FREE,30200054,CDM,301,RC,84140,HCPCS,facility,both,,,,298,298,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ASSAY OF PROTEIN SERUM,30200055,CDM,301,RC,84143,HCPCS,facility,both,,,,422,422,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC RENIN,30200056,CDM,301,RC,84202,HCPCS,facility,both,,,,128,128,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ASSAY OF RIBOFLAVIN (VITAMIN B-2),30200057,CDM,301,RC,84206,HCPCS,facility,both,,,,260,260,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC SELENIUM,30200058,CDM,301,RC,84207,HCPCS,facility,both,,,,262,262,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC SEROTONIN,30200059,CDM,301,RC,84210,HCPCS,facility,both,,,,244,244,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC SEX HORMONE BINDING GLOBULIN,30200060,CDM,301,RC,84238,HCPCS,facility,both,,,,480,480,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC SOMATOMEDIN,30200061,CDM,301,RC,84260,HCPCS,facility,both,,,,311,311,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC SPECTROPHOTOMETRY ANALYTE NES,30200062,CDM,301,RC,84270,HCPCS,facility,both,,,,150,150,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC THYROXINE BINDING GLOBULIN,30200063,CDM,301,RC,84425,HCPCS,facility,both,,,,149,149,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC T3; TOTAL,30200064,CDM,301,RC,84446,HCPCS,facility,both,,,,254,254,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC URIC ACID; BLOOD,30200065,CDM,301,RC,84481,HCPCS,facility,both,,,,222,222,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC VOLATILES,30200066,CDM,301,RC,84586,HCPCS,facility,both,,,,418,418,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC XYLOSE ABSORPTION BLOOD &/OR URINE,30200067,CDM,301,RC,84588,HCPCS,facility,both,,,,399,399,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ZINC,30200068,CDM,301,RC,84590,HCPCS,facility,both,,,,232,232,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC NONAUTO ERYTHROCYTE SED RATE,30200069,CDM,305,RC,85549,HCPCS,facility,both,,,,446,446,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ANTINUCLEAR AB (ANA);,30200070,CDM,302,RC,86000,HCPCS,facility,both,,,,108,108,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC C-REACTIVE PROTEIN HS,30200073,CDM,302,RC,86022,HCPCS,facility,both,,,,354,354,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CARDIOLIPIN AB EA IG CLASS,30200074,CDM,302,RC,86038,HCPCS,facility,both,,,,189,189,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC COLD AGGLUTININ; SCREEN,30200075,CDM,302,RC,86039,HCPCS,facility,both,,,,132,132,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC COLD AGGLUTININ; TITER,30200076,CDM,302,RC,86140,HCPCS,facility,both,,,,87,87,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC COMPLEMENT; AG EA,30200077,CDM,302,RC,86141,HCPCS,facility,both,,,,107,107,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC COMPLEMENT; FCN ACTIVITY EA,30200078,CDM,302,RC,86146,HCPCS,facility,both,,,,136,136,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC COMPLEMENT; TOT HEMOLYTIC (CH50),30200079,CDM,302,RC,86147,HCPCS,facility,both,,,,238,238,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DNA AB; NATIVE OR DS,30200080,CDM,302,RC,86160,HCPCS,facility,both,,,,54,54,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ENA ANY METHOD,30200081,CDM,302,RC,86161,HCPCS,facility,both,,,,54,54,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC FLUORESCENT AB; SCRN EA AB,30200082,CDM,302,RC,86162,HCPCS,facility,both,,,,199,199,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC FLUORESCENT AB; TITER EA AB,30200083,CDM,302,RC,86200,HCPCS,facility,both,,,,104,104,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC IA QUANT; CA 19-9,30200084,CDM,302,RC,86215,HCPCS,facility,both,,,,185,185,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC IA QUANT; CA 125,30200085,CDM,302,RC,86225,HCPCS,facility,both,,,,169,169,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC QUAL HETEROPHILE AB,30200086,CDM,302,RC,86235,HCPCS,facility,both,,,,165,165,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC IA; OTHER TUMOR AG QUAN EA,30200087,CDM,302,RC,86255,HCPCS,facility,both,,,,233,233,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC IA INFECTIOUS AGENT AB QUAN,30200088,CDM,302,RC,86256,HCPCS,facility,both,,,,152,152,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ID; GEL QUAL; EA AB/AG,30200089,CDM,302,RC,86301,HCPCS,facility,both,,,,144,144,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC IMMUNE COMPLEX ASSAY;,30200090,CDM,302,RC,86304,HCPCS,facility,both,,,,166,166,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC SERUM IMMUNOFIXATION ELECTROPHORES,30200091,CDM,302,RC,86308,HCPCS,facility,both,,,,104,104,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC IMMUNFIX E-PHORSIS/URINE/CSF,30200092,CDM,302,RC,86316,HCPCS,facility,both,,,,193,193,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC INHIBIN A,30200093,CDM,302,RC,86317,HCPCS,facility,both,,,,138,138,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC INTRINSIC FACTOR AB,30200095,CDM,302,RC,86332,HCPCS,facility,both,,,,326,326,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ISLET CELL AB,30200096,CDM,302,RC,86334,HCPCS,facility,both,,,,282,282,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CELL FUNCTION ASSAY W/STIM,30200097,CDM,302,RC,86335,HCPCS,facility,both,,,,469,469,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC B CELLS TOTAL COUNT,30200098,CDM,302,RC,86337,HCPCS,facility,both,,,,274,274,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MONONUCLEAR CELL ANTIGEN,30200099,CDM,302,RC,86340,HCPCS,facility,both,,,,166,166,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC NK CELLS TOTAL COUNT,30200100,CDM,302,RC,86341,HCPCS,facility,both,,,,240,240,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC T CELLS; TOTAL COUNT,30200101,CDM,302,RC,86352,HCPCS,facility,both,,,,827,827,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MICROSOMAL AB EACH,30200102,CDM,302,RC,86356,HCPCS,facility,both,,,,55,55,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PA; TITER EA AB,30200103,CDM,302,RC,86359,HCPCS,facility,both,,,,265,265,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC QUAL RHEUM FACTOR,30200104,CDM,302,RC,86360,HCPCS,facility,both,,,,117,117,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC TB TEST CELL IMMUN MEASURE,30200105,CDM,302,RC,86361,HCPCS,facility,both,,,,302,302,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC SYPHILIS TEST NON-TREP QUAL,30200106,CDM,302,RC,86376,HCPCS,facility,both,,,,213,213,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC SYPHILIS TEST NON-TREP QUANT,30200107,CDM,302,RC,86382,HCPCS,facility,both,,,,161,161,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AB; ADENOVIRUS,30200108,CDM,302,RC,86406,HCPCS,facility,both,,,,185,185,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AB; ASPERGILLUS,30200109,CDM,302,RC,86430,HCPCS,facility,both,,,,91,91,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AB; BARTONELLA,30200110,CDM,302,RC,86480,HCPCS,facility,both,,,,319,319,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AB; BLASTOMYCES,30200111,CDM,302,RC,86592,HCPCS,facility,both,,,,96,96,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AB; BORDETELLA,30200112,CDM,302,RC,86593,HCPCS,facility,both,,,,61,61,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AB; LYME'S (WB) CONFIRM,30200113,CDM,302,RC,86603,HCPCS,facility,both,,,,42,42,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AB; LYME'S DISEASE,30200114,CDM,302,RC,86606,HCPCS,facility,both,,,,185,185,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AB; BRUCELLA,30200116,CDM,302,RC,86611,HCPCS,facility,both,,,,42,42,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AB; CANDIDA,30200117,CDM,302,RC,86612,HCPCS,facility,both,,,,42,42,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AB; CHLAMYDIA,30200118,CDM,302,RC,86615,HCPCS,facility,both,,,,185,185,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AB; CHLAMYDIA IGM,30200119,CDM,302,RC,86617,HCPCS,facility,both,,,,219,219,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AB; COCCIDIOIDES,30200120,CDM,302,RC,86618,HCPCS,facility,both,,,,55,55,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AB; CMV,30200121,CDM,302,RC,86622,HCPCS,facility,both,,,,104,104,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AB; CMV IGM,30200122,CDM,302,RC,86628,HCPCS,facility,both,,,,95,95,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AB; DIPHTHERIA,30200123,CDM,302,RC,86631,HCPCS,facility,both,,,,165,165,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AB; ENCEPHALITIS CALIF,30200124,CDM,302,RC,86632,HCPCS,facility,both,,,,179,179,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AB; ENCEPHALITIS E EQUINE,30200125,CDM,302,RC,86635,HCPCS,facility,both,,,,128,128,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AB; ENCEPHALITIS ST. LOUIS,30200127,CDM,302,RC,86644,HCPCS,facility,both,,,,245,245,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AB; ENCEPHALITIS W EQUINE,30200128,CDM,302,RC,86645,HCPCS,facility,both,,,,274,274,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AB; ENTEROVIRUS,30200129,CDM,302,RC,86648,HCPCS,facility,both,,,,169,169,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AB; EPSTEIN BARR VCA,30200130,CDM,302,RC,86651,HCPCS,facility,both,,,,128,128,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AB; ERLICHIA,30200131,CDM,302,RC,86652,HCPCS,facility,both,,,,153,153,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AB; HELICOBACTER PYLORI,30200132,CDM,302,RC,86653,HCPCS,facility,both,,,,153,153,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AB; HELMINTH NES,30200133,CDM,302,RC,86654,HCPCS,facility,both,,,,128,128,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AB; HEMOPHILUS INFLUENZA,30200134,CDM,302,RC,86658,HCPCS,facility,both,,,,125,125,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AB; HTLV OR HIV WB,30200135,CDM,302,RC,86665,HCPCS,facility,both,,,,199,199,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AB; HEPATITIS D,30200136,CDM,302,RC,86666,HCPCS,facility,both,,,,51,51,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AB; HSV 1,30200138,CDM,302,RC,86677,HCPCS,facility,both,,,,149,149,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AB; HSV TYPE 2,30200139,CDM,302,RC,86682,HCPCS,facility,both,,,,169,169,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AB; HIV-2,30200142,CDM,302,RC,86689,HCPCS,facility,both,,,,287,287,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AB; HBCAB - TOTAL,30200143,CDM,302,RC,86692,HCPCS,facility,both,,,,56,56,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AB: HBCAB - IGM AB,30200144,CDM,302,RC,86695,HCPCS,facility,both,,,,131,131,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AB: HBSAB,30200145,CDM,302,RC,86696,HCPCS,facility,both,,,,98,98,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AB; HBEAB,30200146,CDM,302,RC,86701,HCPCS,facility,both,,,,107,107,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AB: HAAB - IGM,30200147,CDM,302,RC,86704,HCPCS,facility,both,,,,199,199,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AB; INFLUENZA VIRUS,30200148,CDM,302,RC,86705,HCPCS,facility,both,,,,146,146,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AB; LEISHMANIA,30200149,CDM,302,RC,86706,HCPCS,facility,both,,,,177,177,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AB; LEPTOSPIRA,30200150,CDM,302,RC,86707,HCPCS,facility,both,,,,125,125,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AB; LCM,30200151,CDM,302,RC,86708,HCPCS,facility,both,,,,139,139,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AB; MUMPS,30200152,CDM,302,RC,86709,HCPCS,facility,both,,,,136,136,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AB; MYCOPLASMA,30200153,CDM,302,RC,86710,HCPCS,facility,both,,,,192,192,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AB; NEISSERIA MENINGITIDIS,30200155,CDM,302,RC,86717,HCPCS,facility,both,,,,40,40,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AB; PARVOVIRUS,30200156,CDM,302,RC,86720,HCPCS,facility,both,,,,153,153,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC TRYPANOSOMA CRUZI IGG,30200157,CDM,302,RC,86727,HCPCS,facility,both,,,,42,42,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AB; RICKETTSIA,30200158,CDM,302,RC,86735,HCPCS,facility,both,,,,138,138,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AB; RUBELLA,30200159,CDM,302,RC,86738,HCPCS,facility,both,,,,146,146,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AB; RUBEOLA,30200160,CDM,302,RC,86741,HCPCS,facility,both,,,,43,43,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AB; SALMONELLA,30200161,CDM,302,RC,86747,HCPCS,facility,both,,,,183,183,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AB; TETANUS,30200163,CDM,302,RC,86753,HCPCS,facility,both,,,,177,177,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AB; TOXOPLASMA,30200166,CDM,302,RC,86757,HCPCS,facility,both,,,,90,90,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AB; TOXOPLASMA IGM,30200167,CDM,302,RC,86762,HCPCS,facility,both,,,,162,162,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC TREPONEMA PALLIDUM,30200168,CDM,302,RC,86765,HCPCS,facility,both,,,,158,158,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AB; TRICHINELLA,30200169,CDM,302,RC,86768,HCPCS,facility,both,,,,43,43,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AB; VARICELLA-ZOSTER,30200170,CDM,302,RC,86774,HCPCS,facility,both,,,,144,144,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC WEST NILE VIRUS AB IGM,30200171,CDM,302,RC,86777,HCPCS,facility,both,,,,213,213,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC WEST NILE VIRUS ANTIBODY,30200172,CDM,302,RC,86778,HCPCS,facility,both,,,,209,209,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC DENGUE FEVER ANTIBODY, IGG",30200173,CDM,302,RC,86780,HCPCS,facility,both,,,,121,121,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HEPATITIS E ANTIBODY IGG,30200174,CDM,302,RC,86784,HCPCS,facility,both,,,,41,41,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HEPATITIS E ANTIBODY IGM,30200175,CDM,302,RC,86787,HCPCS,facility,both,,,,190,190,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC HERPES 8 IGG AB, IFA",30200176,CDM,302,RC,86788,HCPCS,facility,both,,,,107,107,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AB: THYROGLOBULIN,30200177,CDM,302,RC,86789,HCPCS,facility,both,,,,92,92,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HEPATITIS C AB,30200178,CDM,302,RC,86790,HCPCS,facility,both,,,,156,156,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HEPATITIS C CONFIRMATION,30200179,CDM,302,RC,86790,HCPCS,facility,both,,,,42,42,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC LYMPHOCYTOTOX VC; W TITRATE,30200180,CDM,302,RC,86790,HCPCS,facility,both,,,,42,42,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HLA TYPE; A B C SGL AG,30200183,CDM,302,RC,86790,HCPCS,facility,both,,,,42,42,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HLA X-MATCH NON-CYTOTOXIC,30200186,CDM,302,RC,86800,HCPCS,facility,both,,,,175,175,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC RBC AB SCRN EA TECHIQ,30200187,CDM,302,RC,86803,HCPCS,facility,both,,,,215,215,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC RBC AB ELUTION EA,30200188,CDM,302,RC,86804,HCPCS,facility,both,,,,281,281,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC COOMBS; DIRECT,30200189,CDM,302,RC,86812,HCPCS,facility,both,,,,85,85,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC BLD TYPE; RBC AG NOT ABO/RHD,30200191,CDM,300,RC,86885,HCPCS,facility,both,,,,495,495,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC SPLIT BLD PRODUCT EA UNIT,30200192,CDM,300,RC,86927,HCPCS,facility,both,,,,418,418,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC LEGIONELLA AMPLIF NA PROBE,30200196,CDM,306,RC,87522,HCPCS,facility,both,,,,425,425,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC NEISSERIA AMPLIF NA PROBE,30200198,CDM,306,RC,87536,HCPCS,facility,both,,,,612,612,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC IHC ADD SINGLE AB STN,EACH",30200199,CDM,306,RC,87581,HCPCS,facility,both,,,,53,53,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE "HC IHC ADD SINGLE AB STN,EACH",30200199,CDM,306,RC,87581,HCPCS,facility,both,,,,234,234,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AB; FRANCISELLA TULARENSIS,30200258,CDM,302,RC,86403,HCPCS,facility,both,,,,92,92,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HIV-1/HIV-2 SINGLE RESULT,30200260,CDM,302,RC,86641,HCPCS,facility,both,,,,47,47,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC FIBRIN DEGRADATION PRODUCTS,30200261,CDM,302,RC,86663,HCPCS,facility,both,,,,146,146,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC HEAT HF NASAL CANNULA, PER DAY",30200262,CDM,302,RC,86664,HCPCS,facility,both,,,,173,173,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC INHALED NITRIC OXIDE THERAPY, PER DAY",30200263,CDM,302,RC,86668,HCPCS,facility,both,,,,507,507,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CRYPTOSPOR AG BY IFA,30200265,CDM,302,RC,86698,HCPCS,facility,both,,,,177,177,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CLOSTRIDIUM AG EIA,30200266,CDM,302,RC,86703,HCPCS,facility,both,,,,179,179,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MCOLN1 GENE,30200268,CDM,302,RC,86060,HCPCS,facility,both,,,,103,103,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC FLECAINIDE,30200275,CDM,302,RC,86021,HCPCS,facility,both,,,,255,255,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ITRACONAZOLE,30200280,CDM,302,RC,86580,HCPCS,facility,both,,,,145,145,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC LEFLUNOMIDE,30200286,CDM,310,RC,86808,HCPCS,facility,both,,,,682,682,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC TRANSCATHETER THERAPY EMBOLIZATION,30200289,CDM,302,RC,86671,HCPCS,facility,both,,,,174,174,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC ANGIO F/U TRANSCATH TX, EMBOLIZ/INFUSION",30200290,CDM,302,RC,86753,HCPCS,facility,both,,,,177,177,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC EXTENDED WARRANTY FROM FACTORY,30200292,CDM,302,RC,86790,HCPCS,facility,both,,,,156,156,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DUPLEX UE ART/BPG; BILAT,30200300,CDM,302,RC,86790,HCPCS,facility,both,,,,156,156,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC IMMUMOASSAY QUANT NOS NONAB (50),30200302,CDM,302,RC,86790,HCPCS,facility,both,,,,156,156,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC GJB2 GENE FULL SEQUENCE (470),30200304,CDM,302,RC,86753,HCPCS,facility,both,,,,177,177,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC ANTIBODY; ZIKA VIRUS, IGM",30200305,CDM,302,RC,86008,HCPCS,facility,both,,,,61,61,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC RENAL BIOPSY PERCUTANEOUS,30200306,CDM,302,RC,86794,HCPCS,facility,both,,,,40,40,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC HA DIGITAL, ADVANCED, BINAURAL CIC",30200307,CDM,302,RC,86769,HCPCS,facility,both,,,,116,116,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE DEAC 11/01/2023 HC ADM SARSCOV2 25MCG/0.25ML 1ST DOSE,30200308,CDM,302,RC,86015,HCPCS,facility,both,,,,211,211,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE DEAC 11/01/2023 HC ADM SARSCOV2 25MCG/0.25ML 2ND DOSE,30200309,CDM,302,RC,86036,HCPCS,facility,both,,,,257,257,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE DEAC 11/01/2023 HC ADM SARSCOV2 3MCG TRS-SUCR-3 DOSE,30200311,CDM,302,RC,86231,HCPCS,facility,both,,,,235,235,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC IADNA CNS PTHGN NEXT GEN SEQ(780),30200312,CDM,302,RC,86258,HCPCS,facility,both,,,,215,215,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC INFECTIOUS AGENT DETECTION BY NUCLEIC ACID; ORTHOPOXVIRUS, AMPLIFIED PROBE TECHNIQUE, EA",30200313,CDM,302,RC,86362,HCPCS,facility,both,,,,40,40,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE DEAC 11/01/2023 HC ADM SARSCOV2 50 MCG/0.5 ML 1ST DOSE 6-11,30200314,CDM,302,RC,86364,HCPCS,facility,both,,,,196,196,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE DEAC 11/01/2023 HC ADM SARSCOV2 50 MCG/0.5 ML 2ND DOSE 6-11,30200315,CDM,302,RC,86381,HCPCS,facility,both,,,,235,235,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AIR BLOWER,30200316,CDM,302,RC,86015,HCPCS,facility,both,,,,165,165,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC EAR BANDITS,30200317,CDM,302,RC,86037,HCPCS,facility,both,,,,257,257,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC OTOEASE BOTTLE,30200318,CDM,302,RC,86053,HCPCS,facility,both,,,,235,235,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CRITTER CLIPS,30200320,CDM,302,RC,86596,HCPCS,facility,both,,,,210,210,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC FMR1 GENE ANALYSIS; CHARACTERIZATION OF ALLELES,30200322,CDM,302,RC,86160,HCPCS,facility,both,,,,245,245,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MOD SEDATION SAME PHYS/QHP 5/>YRS; INITL 15 MIN,30200323,CDM,302,RC,86363,HCPCS,facility,both,,,,514,514,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC DXA BONE DENSITY STDY, 1+ SITES; AXIAL SKEL, INCL VERTEB FRACTURE ASSESS",30200324,CDM,302,RC,86376,HCPCS,facility,both,,,,34,34,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PROCEDURE ENDO LEVEL 2 EA ADDL 15 MINUTE,30200325,CDM,302,RC,86356,HCPCS,facility,both,,,,258,258,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC FLUORESCENT NONINFECT AB; SCRN EA AB,30200326,CDM,302,RC,86255,HCPCS,facility,both,,,,840,840,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ACETYLCHOLINE RECEPTOR (ACHR); BINDING ANTIBODY,30200333,CDM,302,RC,86041,HCPCS,facility,both,,,,65,65,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ACETYLCHOLINE RECEPTOR (ACHR); BLOCKING ANTIBODY,30200334,CDM,302,RC,86042,HCPCS,facility,both,,,,208,208,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ACETYLCHOLINE RECEPTOR (ACHR); MODULATING ANTIBODY,30200335,CDM,302,RC,86043,HCPCS,facility,both,,,,208,208,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MUSCLE-SPECIFIC KINASE (MUSK) ANTIBODY,30200336,CDM,302,RC,86366,HCPCS,facility,both,,,,1088,1088,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC RADIOLOGIC EXAM, SPINE, LUMBOSACRAL; BENDING VIEWS ONLY, 2 OR 3 VIEWS",30200341,CDM,302,RC,86364,HCPCS,facility,both,,,,123,123,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MRA PELVIS,30200342,CDM,302,RC,86258,HCPCS,facility,both,,,,153,153,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC X-RAY EXAM OF FOOT; 2 VIEWS,30200343,CDM,302,RC,86231,HCPCS,facility,both,,,,198,198,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC HEARING AID, MONAURAL,BEHIND THE EAR (BTE)",30200344,CDM,302,RC,86581,HCPCS,facility,both,,,,104,104,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PROLACTIN,30200346,CDM,302,RC,86581,HCPCS,facility,both,,,,100,100,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE DEAC 1/1/2022 HC PATH INTERP PERF GRANZ-B CCH,30260001,CDM,302,RC,86001,HCPCS,facility,both,,,,41,41,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "DEAC 1/1/2022 HC PATH INTERP, HB CASCADE MAYO",30260002,CDM,302,RC,86343,HCPCS,facility,both,,,,133,133,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE DEAC 1/1/2022 HC PATH INTERPRETATION,30260003,CDM,302,RC,86343,HCPCS,facility,both,,,,133,133,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DUCHENNE/DMD MUSCULAR DYSTROPH,30260004,CDM,302,RC,86431,HCPCS,facility,both,,,,85,85,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ANDROGEN INSENSITIVITY SYNDROM,30260005,CDM,302,RC,86687,HCPCS,facility,both,,,,118,118,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CFTR FULL GENE SEQUENCE,30260006,CDM,302,RC,86694,HCPCS,facility,both,,,,148,148,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CFTR FULL GENE SEQUENCE,30260007,CDM,302,RC,86753,HCPCS,facility,both,,,,177,177,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC CFTR GENE SEQ,PANCREATITIS",30260008,CDM,302,RC,86759,HCPCS,facility,both,,,,245,245,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC CYSTIC FIBROSIS,INTRON-8,POLYT",30260009,CDM,302,RC,86825,HCPCS,facility,both,,,,1347,1347,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC CYSTIC FIBROSIS,INTRON-8,POLYT",30260010,CDM,302,RC,86849,HCPCS,facility,both,,,,73,73,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC EVALUATION OF SPEECH FLUENCY,30260011,CDM,302,RC,86790,HCPCS,facility,both,,,,156,156,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC RESP VIRUS 6-11 TARGETS,30260013,CDM,302,RC,86790,HCPCS,facility,both,,,,156,156,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC INTR CATH DIAL CIRC W/INTRAPROC PHARM THRMB INJ,30260014,CDM,302,RC,86160,HCPCS,facility,both,,,,319,319,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC METHOTREXATE,30500000,CDM,305,RC,,,facility,both,,,,222,222,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CALCIUM; TOTAL,30500001,CDM,301,RC,82271,HCPCS,facility,both,,,,69,69,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HEAVY METAL; QUAN,30500002,CDM,301,RC,83001,HCPCS,facility,both,,,,407,407,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HGB FRACT & QUAN; EP,30500003,CDM,301,RC,83002,HCPCS,facility,both,,,,362,362,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HISTAMINE,30500004,CDM,301,RC,83051,HCPCS,facility,both,,,,162,162,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PROSTATIC ACID PHOSPHATASE,30500005,CDM,301,RC,83986,HCPCS,facility,both,,,,82,82,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC URINE TOTAL PROTEIN,30500006,CDM,301,RC,84144,HCPCS,facility,both,,,,401,401,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC COMPL CBC W PLT W AUTOM DIFF,30500007,CDM,301,RC,84703,HCPCS,facility,both,,,,40,40,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AUTOMATED RETICULOCYTE COUNT,30500009,CDM,305,RC,85007,HCPCS,facility,both,,,,86,86,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AUTOMATED WBC,30500012,CDM,305,RC,85014,HCPCS,facility,both,,,,62,62,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AUTOMATED PLATELET COUNT,30500013,CDM,305,RC,85018,HCPCS,facility,both,,,,62,62,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC RETICULATED PLATELET ASSAY,30500014,CDM,305,RC,85025,HCPCS,facility,both,,,,320,320,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC BM SMR INTERP,30500015,CDM,305,RC,85027,HCPCS,facility,both,,,,300,300,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CHROMOGENIC SUBSTRATE ASSAY,30500016,CDM,305,RC,85045,HCPCS,facility,both,,,,91,91,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC INFEC AGENT DET,GI 6-11 TARGETS",30500017,CDM,305,RC,85048,HCPCS,facility,both,,,,49,49,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CLOTTING; FACTOR II PROTHROMBIN SPECIF,30500018,CDM,305,RC,85049,HCPCS,facility,both,,,,58,58,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CLOTTING; FACTOR V,30500019,CDM,305,RC,85055,HCPCS,facility,both,,,,152,152,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC INFEC AGENT DET,GI 12-25 TARGETS",30500020,CDM,305,RC,85097,HCPCS,facility,both,,,,1733,1733,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC INFEC AGENT DET,GI 12-25 TARGETS",30500021,CDM,305,RC,85130,HCPCS,facility,both,,,,234,234,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC BLOOD CLOT FACTOR VIII TEST,30500022,CDM,305,RC,85210,HCPCS,facility,both,,,,115,115,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CLOTTING; FACTOR VIII RISTOCETIN COFACT,30500023,CDM,305,RC,85220,HCPCS,facility,both,,,,381,381,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CLOTTING; FACTOR IX,30500024,CDM,305,RC,85230,HCPCS,facility,both,,,,392,392,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CLOTTING; FACTOR X,30500025,CDM,305,RC,85240,HCPCS,facility,both,,,,430,430,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CLOTTING; FACTOR XI,30500026,CDM,305,RC,85245,HCPCS,facility,both,,,,110,110,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CLOTTING; FACTOR XII,30500027,CDM,305,RC,85246,HCPCS,facility,both,,,,516,516,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CLOTTING; FACTOR XIII SCREEN SOLUBLE,30500028,CDM,305,RC,85247,HCPCS,facility,both,,,,376,376,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ANTITHROMBIN III ACTIVITY ASSAY,30500029,CDM,305,RC,85250,HCPCS,facility,both,,,,456,456,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ANTITHROMBIN III ANTIGEN ASSAY,30500030,CDM,305,RC,85260,HCPCS,facility,both,,,,354,354,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CLOTTING INHIBITOR; PROTEIN C AG,30500031,CDM,305,RC,85270,HCPCS,facility,both,,,,376,376,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CLOTTING INHIBITOR; PROTEIN C ACTIVITY,30500032,CDM,305,RC,85280,HCPCS,facility,both,,,,421,421,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CLOTTING INHIBITOR; PROTEIN S TOTAL,30500033,CDM,305,RC,85291,HCPCS,facility,both,,,,306,306,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CLOTTING INHIBITOR PROTEIN S FREE,30500035,CDM,305,RC,85300,HCPCS,facility,both,,,,153,153,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ACTIVATED PROTEIN C RESISTANCE,30500036,CDM,305,RC,85301,HCPCS,facility,both,,,,47,47,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC FACTOR INHIBITOR TEST,30500037,CDM,305,RC,85302,HCPCS,facility,both,,,,221,221,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC D-DIMER - QUAN,30500038,CDM,305,RC,85303,HCPCS,facility,both,,,,335,335,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC FIBRINOGEN; ACTIVITY,30500039,CDM,305,RC,85305,HCPCS,facility,both,,,,239,239,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC FIBRINOGEN; ANTIGEN,30500040,CDM,305,RC,85306,HCPCS,facility,both,,,,316,316,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC FIBRINOLYSINS OR COAG SCREEN,30500041,CDM,305,RC,85307,HCPCS,facility,both,,,,92,92,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CLOTTING FUNCT ACTIVITY,30500042,CDM,305,RC,85335,HCPCS,facility,both,,,,383,383,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ALPHA-2-ANTIPLASMIN,30500043,CDM,305,RC,85379,HCPCS,facility,both,,,,268,268,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PLASMINOGEN ACTIVATOR,30500044,CDM,305,RC,85384,HCPCS,facility,both,,,,206,206,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC FUNCTIONAL PLASMINOGEN,30500045,CDM,305,RC,85385,HCPCS,facility,both,,,,184,184,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PLASMINOGEN ANTIGEN LEVEL,30500046,CDM,305,RC,85390,HCPCS,facility,both,,,,94,94,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC K-B STAIN FOR FETAL HGB,30500047,CDM,305,RC,85397,HCPCS,facility,both,,,,379,379,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HEPARIN ASSAY,30500048,CDM,305,RC,85410,HCPCS,facility,both,,,,180,180,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HEPARIN NEUTRALIZATION,30500049,CDM,305,RC,85415,HCPCS,facility,both,,,,246,246,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MURAMIDASE,30500050,CDM,305,RC,85420,HCPCS,facility,both,,,,130,130,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PLT AGGREGATION (IN VITRO) EA AGENT,30500051,CDM,305,RC,85421,HCPCS,facility,both,,,,44,44,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PROTHROMBIN TIME;,30500053,CDM,305,RC,85460,HCPCS,facility,both,,,,42,42,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC RUSSELL VIPER VENOM TIME; DILUTED,30500055,CDM,305,RC,85520,HCPCS,facility,both,,,,255,255,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC REPTILASE TEST,30500056,CDM,305,RC,85525,HCPCS,facility,both,,,,177,177,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AUTOM ERYTHROCYTE SED RATE,30500060,CDM,305,RC,85576,HCPCS,facility,both,,,,367,367,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC SICKLING OF RBC REDUCTION,30500062,CDM,305,RC,85610,HCPCS,facility,both,,,,102,102,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC THROMBIN TIME; PLASMA,30500064,CDM,305,RC,85613,HCPCS,facility,both,,,,175,175,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PTT; PLASMA OR WHOLE BLOOD,30500065,CDM,305,RC,85635,HCPCS,facility,both,,,,196,196,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AGGLUTININS FEBRILE,30500066,CDM,305,RC,85651,HCPCS,facility,both,,,,17,17,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ALLERG SP IGE; QUAN OR SEMIQUAN,30500067,CDM,305,RC,85652,HCPCS,facility,both,,,,40,40,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AB ID; PLATELET AB,30500068,CDM,305,RC,85670,HCPCS,facility,both,,,,143,143,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AB ID; PLATELET IG ASSAY,30500069,CDM,305,RC,85730,HCPCS,facility,both,,,,159,159,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC BETA 2 GLYCOPROTEIN I AB EA,30500075,CDM,302,RC,86023,HCPCS,facility,both,,,,41,41,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC T CELLS; ABSOL CD4 COUNT,30500076,CDM,302,RC,86355,HCPCS,facility,both,,,,265,265,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC VIRAL NEUTRALIZATION,30500077,CDM,302,RC,86357,HCPCS,facility,both,,,,250,250,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC COOMBS TEST INDIRECT TITER,30500079,CDM,300,RC,86850,HCPCS,facility,both,,,,244,244,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC BACT CULT; QUAN AEROBIC,30500080,CDM,306,RC,87015,HCPCS,facility,both,,,,26,26,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC INFLUENZA A/B AG EIA,30500153,CDM,305,RC,85362,HCPCS,facility,both,,,,147,147,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC OXYGEN THERAPY, PER DAY",30500155,CDM,305,RC,85598,HCPCS,facility,both,,,,168,168,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC RUFINAMIDE,30500161,CDM,305,RC,85032,HCPCS,facility,both,,,,26,26,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ASSAY SPEC XCP UR&BREATH IA,30500163,CDM,305,RC,85046,HCPCS,facility,both,,,,28,28,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC EXTERNAL ECG REC > 48 HR UP TO 7 DAYS RECORD; INCL CONNECT & INITIAL REC,30500165,CDM,305,RC,85244,HCPCS,facility,both,,,,88,88,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC EXTERNAL ECG REC > 7 DAYS UP TO 15 DAYS RECORDING; INCL CONNECT & INITIAL REC,30500168,CDM,305,RC,85347,HCPCS,facility,both,,,,112,112,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE DEAC 05/12/2023 HC COV-19 AMP PRB HGH THRUPUT WITHIN 2 DAYS COLLECT,30500169,CDM,305,RC,85360,HCPCS,facility,both,,,,239,239,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "DEAC 4/1/2025 HC IV INFUSION, CASIRIVIMAB & IMDEVIMAB, INCL INFUSION & POST ADM MONITOR",30500172,CDM,305,RC,85555,HCPCS,facility,both,,,,42,42,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE DEAC 11/01/2023 HC IMM ADMN SARSCOV2 BIVALENT 25 MCG/0.25 ML BOOSTER,30500174,CDM,305,RC,85396,HCPCS,facility,both,,,,758,758,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CYTOGENOMIC NEOPLASIA MICROARRAY ANALYSIS,30506003,CDM,305,RC,85611,HCPCS,facility,both,,,,86,86,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CYTOGENOMIC NEOPLASIA MICROARRAY ANALYSIS,30506004,CDM,305,RC,85732,HCPCS,facility,both,,,,153,153,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PROTHROMBIN GENE ANALYSIS,30506005,CDM,305,RC,85732,HCPCS,facility,both,,,,153,153,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC FLT3 GENE (TKD) VARIANT,30506006,CDM,305,RC,85999,HCPCS,facility,both,,,,605,605,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC BONE MARROW TRANSPLANT,STR",30560001,CDM,305,RC,85060,HCPCS,facility,both,,,,147,147,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC BONE MARROW TRANSPLANT,STR",30560002,CDM,305,RC,85611,HCPCS,facility,both,,,,86,86,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "DEAC 11/01/2023 HC ADM SARSCOV2 5X1010VP/.5ML, 1ST DOSE",30600000,CDM,306,RC,,,facility,both,,,,178,178,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ANAEROB BACT CULTURE W ID,30600002,CDM,306,RC,87040,HCPCS,facility,both,,,,245,245,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC BC - ANAEROBE - ADDTL ID,30600003,CDM,306,RC,87045,HCPCS,facility,both,,,,199,199,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC BC - AEROBIC - ADDTL ID,30600004,CDM,306,RC,87046,HCPCS,facility,both,,,,107,107,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CULTURE P PATHOG - SCREEN,30600005,CDM,306,RC,87070,HCPCS,facility,both,,,,206,206,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC BACT CULTURE - URINE; QUAN COUNT,30600006,CDM,306,RC,87071,HCPCS,facility,both,,,,40,40,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC URINE BACTERIA CULTURE,30600007,CDM,306,RC,87075,HCPCS,facility,both,,,,225,225,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CULT FUNGUS W P ID; SKIN HR NL,30600008,CDM,306,RC,87076,HCPCS,facility,both,,,,33,33,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC FUNGUS CULTURE NOT BLOOD,30600009,CDM,306,RC,87077,HCPCS,facility,both,,,,141,141,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC FUNGUS CULTURE BLOOD,30600010,CDM,306,RC,87081,HCPCS,facility,both,,,,161,161,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC FUNGUS CULTURE DEF I.D YEAST,30600011,CDM,306,RC,87086,HCPCS,facility,both,,,,193,193,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC FUNGUS CULTURE DEF ID MOLD,30600012,CDM,306,RC,87088,HCPCS,facility,both,,,,34,34,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CULTURE MYCOPLASMA,30600013,CDM,306,RC,87101,HCPCS,facility,both,,,,146,146,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CHLAMYDIA CULTURE,30600014,CDM,306,RC,87102,HCPCS,facility,both,,,,172,172,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CULTURE AFB - ISOL & ID,30600015,CDM,306,RC,87103,HCPCS,facility,both,,,,194,194,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CULT MYCOBACTERIA DEFIN ID EA,30600016,CDM,306,RC,87106,HCPCS,facility,both,,,,43,43,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PINWORM EXAM,30600017,CDM,306,RC,87107,HCPCS,facility,both,,,,43,43,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC OVA & PARASITES DIR SMR W ID,30600018,CDM,306,RC,87109,HCPCS,facility,both,,,,250,250,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC SENSITIVITY - AGAR DILUTION/AGENT,30600019,CDM,306,RC,87110,HCPCS,facility,both,,,,164,164,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC SENSITIVITY - DISK PER PLATE,30600020,CDM,306,RC,87116,HCPCS,facility,both,,,,222,222,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC SENSTITIVITY - ENZYME DETECT,30600021,CDM,306,RC,87118,HCPCS,facility,both,,,,60,60,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MICROBE SUSCEPTIBILITIES MIC,30600029,CDM,306,RC,87172,HCPCS,facility,both,,,,25,25,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC SMEAR - GRAM OR GIEMSA,30600030,CDM,306,RC,87177,HCPCS,facility,both,,,,151,151,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC SMEAR; FLUORESCENT OR AFB STAIN,30600031,CDM,306,RC,87181,HCPCS,facility,both,,,,79,79,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC SMEAR SPECIAL STAIN,30600032,CDM,306,RC,87184,HCPCS,facility,both,,,,144,144,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC SMEAR - INFECTIOUS WET MOUNT,30600033,CDM,306,RC,87185,HCPCS,facility,both,,,,19,19,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC KOH FOR FUNGI/PARASITES/MITES,30600034,CDM,306,RC,87186,HCPCS,facility,both,,,,311,311,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC VIRUS ISOLATE; TISSUE CULT INOC,30600037,CDM,306,RC,87205,HCPCS,facility,both,,,,87,87,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ASPERGILLUS AG EIA,30600038,CDM,306,RC,87206,HCPCS,facility,both,,,,111,111,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC GIARDIA AG EIA,30600039,CDM,306,RC,87207,HCPCS,facility,both,,,,121,121,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HPYLORI STOOL EIA,30600040,CDM,306,RC,87210,HCPCS,facility,both,,,,23,23,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HEPATITIS B SURFACE AG EIA,30600041,CDM,306,RC,87220,HCPCS,facility,both,,,,72,72,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HEPATITIS B SURFACE AG EIA NEUTRALIZATION,30600042,CDM,306,RC,87252,HCPCS,facility,both,,,,344,344,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HEPATITIS BE AG EIA,30600059,CDM,306,RC,87305,HCPCS,facility,both,,,,139,139,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HISTOPLASMA CAPSUL AG EIA,30600061,CDM,306,RC,87329,HCPCS,facility,both,,,,114,114,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ROTAVIRUS AG EIA,30600063,CDM,306,RC,87338,HCPCS,facility,both,,,,121,121,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC STREP A AG EIA,30600064,CDM,306,RC,87340,HCPCS,facility,both,,,,206,206,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CHLAMYDIA T AMPLIF NA PROBE,30600065,CDM,306,RC,87341,HCPCS,facility,both,,,,108,108,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC C DIFF AMPLIFIED PROBE,30600066,CDM,306,RC,87350,HCPCS,facility,both,,,,132,132,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CYTOMEGALOV AMPLIF NA PROBE,30600067,CDM,306,RC,87385,HCPCS,facility,both,,,,260,260,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CYTOMEGALOVIRUS NA QUAN,30600068,CDM,306,RC,87425,HCPCS,facility,both,,,,49,49,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ENTEROVIRUS DNA AMP PROBE,30600069,CDM,306,RC,87430,HCPCS,facility,both,,,,68,68,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HEP-B NA QUAN,30600071,CDM,306,RC,87491,HCPCS,facility,both,,,,232,232,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HEP-C AMPLIF NA PROBE,30600072,CDM,306,RC,87493,HCPCS,facility,both,,,,294,294,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HEP-C NA QUAN,30600073,CDM,306,RC,87496,HCPCS,facility,both,,,,243,243,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HERPES S AMPLIF NA PROBE,30600074,CDM,306,RC,87497,HCPCS,facility,both,,,,425,425,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HERPES S AMPLIF NA PROBE,30600075,CDM,306,RC,87498,HCPCS,facility,both,,,,268,268,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HIV-1 AMPLIF NA PROBE,30600076,CDM,306,RC,87517,HCPCS,facility,both,,,,378,378,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HIV-1 NA QUAN,30600077,CDM,306,RC,87521,HCPCS,facility,both,,,,366,366,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MYCOBACTERIA T AMPLIF NA PROBE,30600078,CDM,306,RC,87529,HCPCS,facility,both,,,,260,260,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MYCOPLASMA AMPLIF NA PROBE,30600078,CDM,306,RC,87529,HCPCS,facility,both,,,,115,115,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC MYCOPLASMA AMPLIF NA PROBE,30600079,CDM,306,RC,87535,HCPCS,facility,both,,,,288,288,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC VALPROIC ACID FREE,30600080,CDM,306,RC,87541,HCPCS,facility,both,,,,184,184,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MR-STAPH DNA AMP PROBE,30600082,CDM,306,RC,87556,HCPCS,facility,both,,,,258,258,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MULTIPLEX AB STN EACH,30600083,CDM,306,RC,87591,HCPCS,facility,both,,,,233,233,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AMPLIF NA PROBE NOS AGENT,30600084,CDM,306,RC,87641,HCPCS,facility,both,,,,294,294,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AGENT NOS ASSAY W/OPTIC,30600087,CDM,306,RC,87798,HCPCS,facility,both,,,,53,53,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC PROPOXYPHENE,30600087,CDM,306,RC,87798,HCPCS,facility,both,,,,549,549,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC GENOTYPE DNA HIV REVERSE T,30600088,CDM,306,RC,87799,HCPCS,facility,both,,,,532,532,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HEPATITIS C - DNA OR RNA,30600089,CDM,306,RC,87801,HCPCS,facility,both,,,,616,616,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC METHADONE,30600090,CDM,306,RC,87899,HCPCS,facility,both,,,,160,160,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CYTOPATH FL NONGYN SMEARS,30600091,CDM,306,RC,87901,HCPCS,facility,both,,,,1373,1373,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC ANALGESICS,NON-OPIOD 1 OR 2",30600092,CDM,306,RC,87902,HCPCS,facility,both,,,,1593,1593,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC REMOVE OBSTRUCT FROM CENTRAL VENOUS DEV,30600095,CDM,306,RC,87153,HCPCS,facility,both,,,,468,468,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC REMOVE INTRALUMIN OBSTRUCT FROM CVD,30600097,CDM,306,RC,87449,HCPCS,facility,both,,,,243,243,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CHG PERC TUBE/ DRAIN CATH W/CON MONITOR,30600098,CDM,306,RC,87449,HCPCS,facility,both,,,,49,49,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ECHOCARDIO FETAL CARDIOVASCULAR W/2-D,30600099,CDM,306,RC,87449,HCPCS,facility,both,,,,243,243,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CHLAMYDIA P AMPLIF NA PROBE,30600151,CDM,306,RC,87272,HCPCS,facility,both,,,,44,44,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC GENERAL PROCEDURAL ASSIST,30600152,CDM,306,RC,87324,HCPCS,facility,both,,,,49,49,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MYCOBACTERIA A AMPLIF NA PROBE,30600153,CDM,306,RC,87328,HCPCS,facility,both,,,,104,104,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC INFLUENZA IA W DO,30600155,CDM,306,RC,87400,HCPCS,facility,both,,,,239,239,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC UNLISTED MICROBIOLOGY PROCEDURE,30600156,CDM,306,RC,87420,HCPCS,facility,both,,,,53,53,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC INJECTION OF SINUS TRACT; THERAPEUTIC,30600157,CDM,306,RC,87486,HCPCS,facility,both,,,,53,53,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC INSERT CATHETER RENAL ARTERY 1ST BILATERAL,30600157,CDM,306,RC,87486,HCPCS,facility,both,,,,166,166,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC ARTHROCENTESIS, INTERMEDIATE JOINT OR BURSA",30600159,CDM,306,RC,87561,HCPCS,facility,both,,,,282,282,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC INJECTION FOR SHOULDER X-RAY,30600160,CDM,306,RC,87804,HCPCS,facility,both,,,,124,124,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC INJECTION FOR ELBOW ARTHROGRAPHY,30600162,CDM,306,RC,87999,HCPCS,facility,both,,,,44,44,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC H PYLORI (C-13) BREATH TEST,30600171,CDM,306,RC,87471,HCPCS,facility,both,,,,274,274,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC ANTIEPILEPTICS, NOS 1-3",30600172,CDM,306,RC,87516,HCPCS,facility,both,,,,245,245,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ONCOPROTEIN DCP,30600173,CDM,306,RC,87530,HCPCS,facility,both,,,,475,475,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC TOTAL ACID PHOSPHATASE,30600173,CDM,306,RC,87530,HCPCS,facility,both,,,,225,225,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE "DEAC 11/01/2023 HC ADM SARSCOV2 5X1010VP/.5ML, 2ND DOSE",30600182,CDM,306,RC,87389,HCPCS,facility,both,,,,169,169,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "DEAC 11/01/2023 HC ADM SARSCOV2 VAC AD26 /.5ML, SINGLE DOSE",30600185,CDM,306,RC,87533,HCPCS,facility,both,,,,342,342,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DRUG TEST PRSMV CHEM ANLYZR,30600189,CDM,306,RC,87632,HCPCS,facility,both,,,,448,448,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC PLATELETS, EACH UNIT",30600196,CDM,306,RC,87880,HCPCS,facility,both,,,,120,120,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PTEN GENE PART OF PANEL,30600202,CDM,306,RC,87631,HCPCS,facility,both,,,,557,557,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ADM RSV MONOCLONAL ANTB SEASONAL DOSE IM NJX,30600211,CDM,306,RC,87505,HCPCS,facility,both,,,,96,96,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ROUTINE VENIPUNCTURE,30600213,CDM,306,RC,87209,HCPCS,facility,both,,,,78,78,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CLOTTING; FACTOR VII,30600214,CDM,306,RC,87506,HCPCS,facility,both,,,,1048,1048,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC FACTOR 8 VWF MULTIMRIC,30600215,CDM,306,RC,87507,HCPCS,facility,both,,,,951,951,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC CLOTTING: FACTOR VIII VW FACTOR AG,30600215,CDM,306,RC,87507,HCPCS,facility,both,,,,3207,3207,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC ABLATION 1 OR MORE RENAL TUMORS PERCUTANEOUS, UNIL, RADIOFREQ",30600218,CDM,306,RC,87651,HCPCS,facility,both,,,,310,310,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CHANGE OF CYSTOSTOMY TUBE; SIMPLE,30600219,CDM,306,RC,87481,HCPCS,facility,both,,,,220,220,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC STENGER TEST, PURE TONE",30600225,CDM,306,RC,87150,HCPCS,facility,both,,,,272,272,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MRA W/O CONTRAST SPINAL CANAL,30600227,CDM,306,RC,87633,HCPCS,facility,both,,,,2382,2382,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MRA UPPER EXTREMITY WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST,30600227,CDM,306,RC,87633,HCPCS,facility,both,,,,792,792,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC UNLISTED FLUOROSCOPIC PROCEDURE,30600230,CDM,306,RC,87635,HCPCS,facility,both,,,,292,292,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC LR IRRAD WHOLE BLD EA UNIT,30600232,CDM,306,RC,87502,HCPCS,facility,both,,,,169,169,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC IMMUMOASSAY QUANT NOS NONAB (170),30600234,CDM,306,RC,87637,HCPCS,facility,both,,,,640,640,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE DEAC 10/3/2022 HC HA CARE KIT (PED),30600236,CDM,306,RC,,,facility,both,,,,52,52,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE DEAC 11/01/2023 HC ADM SARSCOV2 50 MCG/0.5 ML 3RD DOSE 6-11,30600238,CDM,306,RC,87154,HCPCS,facility,both,,,,455,455,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ENDO LEVEL 3 INIT MIN,30600239,CDM,306,RC,87593,HCPCS,facility,both,,,,527,527,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC INFEC AGENT DET,GI 12-25 TARGETS",30600241,CDM,306,RC,87900,HCPCS,facility,both,,,,171,171,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC FFP HIGH TITER COVID-19 CONVALESCENT, FROZEN - 8 HR COLLECT, EA UNIT (439)",30600242,CDM,306,RC,87901,HCPCS,facility,both,,,,174,174,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC HBB (HEMOGLOBIN, SUBUNIT BETA); FULL GENE SEQ",30600243,CDM,306,RC,87906,HCPCS,facility,both,,,,174,174,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC INFEC AGENT DET,GI 12-25 TARGETS",30600244,CDM,306,RC,87507,HCPCS,facility,both,,,,1821,1821,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MENNIGITIS-ENCEPH CSF BY PCR,30600245,CDM,306,RC,87483,HCPCS,facility,both,,,,1792,1792,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CARDIAC MRI FOR VELOCITY FLOW MAPPING (ADD-ON),30600246,CDM,306,RC,87798,HCPCS,facility,both,,,,172,172,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC HEARING AID, MONAURAL, IN THE EAR (ITE)",30600247,CDM,306,RC,87594,HCPCS,facility,both,,,,442,442,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC ACYLCARNITINES; QUANTITATIVE, EACH SPECIMEN",30600248,CDM,306,RC,87635,HCPCS,facility,both,,,,292,292,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC AMINO ACID, MSUD PANEL, BLOOD SPOT, EACH SPECIMEN",30600249,CDM,306,RC,87637,HCPCS,facility,both,,,,640,640,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CYTOGENOMIC NEO MICRORA ALYS (715),30660001,CDM,306,RC,87045,HCPCS,facility,both,,,,225,225,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CYTOGENOMIC NEO MICRORA ALYS (715),30660002,CDM,306,RC,87153,HCPCS,facility,both,,,,864,864,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC AUTISM PANEL,MECP2,SEQ",30660003,CDM,306,RC,87210,HCPCS,facility,both,,,,66,66,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC AUTISM PANEL,MECP2,SEQ",30660004,CDM,306,RC,87230,HCPCS,facility,both,,,,334,334,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CHARCOT-MARIE-TOOTH TYPE 1E,30660005,CDM,306,RC,87270,HCPCS,facility,both,,,,101,101,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC SPINAL MUSCULAR ATROPHY,30660006,CDM,306,RC,87324,HCPCS,facility,both,,,,63,63,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC T-CELL GENE REARRANGEMENT TG,30660007,CDM,306,RC,87420,HCPCS,facility,both,,,,94,94,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC UGT1A1 GENE MUTATION MAYO,30660008,CDM,306,RC,87449,HCPCS,facility,both,,,,243,243,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC HEMOGLOBIN B, FULL GENE SEQ",30660009,CDM,306,RC,87471,HCPCS,facility,both,,,,274,274,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PLATELET ANTIGEN 1 GENOTYPE,30660010,CDM,306,RC,87471,HCPCS,facility,both,,,,274,274,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PLATELET ANTIGEN 1 GENOTYPE,30660011,CDM,306,RC,87471,HCPCS,facility,both,,,,274,274,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC GALACTOSEMIA GENE SEQUENCE,30660012,CDM,306,RC,87471,HCPCS,facility,both,,,,274,274,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MITO-DNA POINT MUTATIONS,30660013,CDM,306,RC,87483,HCPCS,facility,both,,,,2848,2848,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC MOL PATH,PANCREATITIS,LEVEL-2",30660014,CDM,306,RC,87512,HCPCS,facility,both,,,,240,240,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC MOL PATH,LEVEL-2,ABCC8,DEL-DUP",30660015,CDM,306,RC,87551,HCPCS,facility,both,,,,294,294,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC 21-OH(CAH) GENE SEQUENCING QST,30660016,CDM,306,RC,87561,HCPCS,facility,both,,,,282,282,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CKIT (TARGET) GENE MUTATION,30660017,CDM,306,RC,87797,HCPCS,facility,both,,,,218,218,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC DUAL GENOME,TIS,MOL PATH,L4 AD",30660018,CDM,306,RC,87906,HCPCS,facility,both,,,,731,731,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC DUAL GENOME,TIS,MOL PATH,LVL 4",30660019,CDM,306,RC,87910,HCPCS,facility,both,,,,2104,2104,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MOD SED OTHER PHYS/QHP 5/>YRS; INITL 15 MIN,30660055,CDM,306,RC,,,facility,both,,,,847,847,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CARDIOMYOPATHY  PANEL (296),30900000,CDM,309,RC,,,facility,both,,,,1342,1342,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AB ID RBC EA PANEL EA TECHN,30900001,CDM,310,RC,86805,HCPCS,facility,both,,,,620,620,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC COOMBS TEST INDIRECT QUAL,30900004,CDM,302,RC,86825,HCPCS,facility,both,,,,743,743,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC TISSUE CULTURE; BM BLD CELLS,30900006,CDM,311,RC,88230,HCPCS,facility,both,,,,155,155,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC TISSUE CULTURE; BM BLD CELLS,30900006,CDM,311,RC,88230,HCPCS,facility,both,,,,2312,2312,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MCG; IP SITU 25-99 CELLS,30900009,CDM,311,RC,88271,HCPCS,facility,both,,,,60,60,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC MCG; SITU HYBRID 10-30 CELLS,30900009,CDM,311,RC,88271,HCPCS,facility,both,,,,96,96,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC IMMUMOASSAY QUANT NOS NONAB (130),30900010,CDM,300,RC,89230,HCPCS,facility,both,,,,456,456,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MOPATH PROCEDUR LEVEL 2 (400),30900032,CDM,310,RC,81220,HCPCS,facility,both,,,,1815,1815,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MOPATH PROCEDUR LEVEL 4 (115),30900033,CDM,310,RC,81222,HCPCS,facility,both,,,,500,500,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC MOPATH PROCEDUR LEVEL 3 (95),30900033,CDM,310,RC,81222,HCPCS,facility,both,,,,892,892,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MOPATH PROCEDUR LEVEL 4 (220),30900035,CDM,310,RC,81223,HCPCS,facility,both,,,,2521,2521,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MOPATH PROCEDUR LEVEL 6 (140),30900041,CDM,310,RC,81242,HCPCS,facility,both,,,,1124,1124,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MOPATH PROCEDUR LEVEL 6 (240),30900050,CDM,310,RC,81265,HCPCS,facility,both,,,,761,761,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MOPATH PROCEDUR LEVEL 8 (165),30900061,CDM,310,RC,81321,HCPCS,facility,both,,,,3393,3393,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC UNLISTED MOL PATH (205),30900061,CDM,310,RC,81321,HCPCS,facility,both,,,,800,800,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC UNLISTED MOL PATH (220),30900087,CDM,310,RC,81401,HCPCS,facility,both,,,,403,403,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC UNLISTED MOL PATH (500),30900090,CDM,310,RC,81402,HCPCS,facility,both,,,,483,483,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC UNLISTED MOL PATH (825),30900092,CDM,310,RC,81403,HCPCS,facility,both,,,,604,604,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC NERVE CONDUCT STUDIES 1-2,30900100,CDM,310,RC,81403,HCPCS,facility,both,,,,596,596,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC NERVE CONDUCT STUDIES 3-4,30900138,CDM,310,RC,81405,HCPCS,facility,both,,,,969,969,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC NERVE CONDUCT STUDIES 5-6,30900142,CDM,310,RC,81405,HCPCS,facility,both,,,,1332,1332,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC NERVE CONDUCT STUDIES 7-8,30900195,CDM,310,RC,81407,HCPCS,facility,both,,,,2761,2761,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC NERVE CONDUCT STUDIES 9-10,30900227,CDM,310,RC,81479,HCPCS,facility,both,,,,445,445,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC NERVE CONDUCT STUDIES 11-12,30900229,CDM,310,RC,81479,HCPCS,facility,both,,,,445,445,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC NERVE CONDUCT STUDIES 13 OR MORE,30900252,CDM,310,RC,81479,HCPCS,facility,both,,,,1472,1472,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PROCEDURE ENDO LEVEL 3 INIT 15 MIN,30900273,CDM,310,RC,81479,HCPCS,facility,both,,,,445,445,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC COMPLEMENT; ANTIGEN, EACH COMPONENT",30900315,CDM,310,RC,81455,HCPCS,facility,both,,,,9386,9386,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC PERQ PLMT BILE DUCT STENT(S), EXISTING ACCESS",30900320,CDM,310,RC,81206,HCPCS,facility,both,,,,1262,1262,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ENDO LEVEL 3 EA ADDL MIN,30900327,CDM,310,RC,81270,HCPCS,facility,both,,,,556,556,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ILIAC REVASC ARTERY; ANGIOPLASTY INIT VESSEL,30900342,CDM,310,RC,81251,HCPCS,facility,both,,,,155,155,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC PERCUT MECH THROMBECTOMY, VENOUS",30900344,CDM,310,RC,81322,HCPCS,facility,both,,,,1015,1015,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC THRMB/INFUS DIAL CIRC&INTRPRC PHAR INJ W/STENT(S),30900349,CDM,310,RC,81376,HCPCS,facility,both,,,,398,398,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC BALLOON ANGIOPLASTY CTR DIALYSIS SEGMENT,30900350,CDM,310,RC,81382,HCPCS,facility,both,,,,493,493,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC TRLUML BALLOON ANGIOPLASTY; INITIAL ARTERY,30900351,CDM,302,RC,86830,HCPCS,facility,both,,,,406,406,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC TRLUML BALLOON ANGIOPLASTY; ADDL ART,30900352,CDM,302,RC,86831,HCPCS,facility,both,,,,347,347,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC TRLUML BALLOON ANGIOPLASTY; INITIAL VEIN,30900353,CDM,310,RC,81373,HCPCS,facility,both,,,,415,415,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC TRLUML BALLOON ANGIOPLASTY; ADDL VEIN,30900354,CDM,302,RC,86828,HCPCS,facility,both,,,,369,369,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC TPMT, NUDT15 GENE ANALYSIS, COMMON VARIANTS",30900355,CDM,310,RC,81324,HCPCS,facility,both,,,,1555,1555,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC INJECT INTERLAMINAR LMBR/SAC; W/IMG,30900355,CDM,310,RC,81324,HCPCS,facility,both,,,,500,500,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE "HC PERQ ABLATION 1 + LIVER TUMOR(S), RADIOFREQ",30900364,CDM,310,RC,81254,HCPCS,facility,both,,,,799,799,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE DEAC 11/01/2023 HC ADM SARSCV2 BVL 30MCG/0.3ML 1ST DOSE,30900364,CDM,310,RC,81254,HCPCS,facility,both,,,,500,500,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC BRAF GENE (205),30900373,CDM,310,RC,81210,HCPCS,facility,both,,,,1001,1001,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC IGH GENE REARRANGE AMP METH (180),30900377,CDM,310,RC,81261,HCPCS,facility,both,,,,866,866,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CHIMERISM ANAL NO CELL SELEC (170),30900380,CDM,310,RC,81267,HCPCS,facility,both,,,,1316,1316,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CHIMERISM ANAL WI/CELL SELECT (245),30900382,CDM,310,RC,81268,HCPCS,facility,both,,,,650,650,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC CHIMERISM ANAL WI/CELL SELECT (245),30900382,CDM,310,RC,81268,HCPCS,facility,both,,,,2010,2010,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC TRG GENE REARRANGEMENT ANAL (230),30900388,CDM,310,RC,81342,HCPCS,facility,both,,,,758,758,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CAR ION CHNNLPATH INC 2 GN (2675),30900394,CDM,310,RC,81413,HCPCS,facility,both,,,,3291,3291,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HPA-6 GENOTYPING (35),30900395,CDM,310,RC,81414,HCPCS,facility,both,,,,2979,2979,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC TTE CONG ABN; COMPLETE,30900395,CDM,310,RC,81414,HCPCS,facility,both,,,,900,900,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC 2D TTE W OR W/O FOL W/CON FU,30900396,CDM,310,RC,81245,HCPCS,facility,both,,,,533,533,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HLA I & II TYPE VERIFY LR (150),30900399,CDM,302,RC,86832,HCPCS,facility,both,,,,931,931,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HEART TRANSPLANT ORGAN ACQUISITION,30900400,CDM,302,RC,86833,HCPCS,facility,both,,,,989,989,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC NEONATAL RESUSCITATION,30900404,CDM,310,RC,81371,HCPCS,facility,both,,,,1431,1431,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MTHFR GENE (85),30900410,CDM,310,RC,81479,HCPCS,facility,both,,,,2315,2315,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MTHFR GENE (85),30900417,CDM,310,RC,,,facility,both,,,,3479,3479,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ACTIONABLE PHARMACOGENOMICS PANEL (284),30900432,CDM,310,RC,81291,HCPCS,facility,both,,,,215,215,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC STERILE ONE-TIME SUPPLY,30900432,CDM,310,RC,81291,HCPCS,facility,both,,,,600,600,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE "HC IMMUNIZATION ADMIN, NASAL/ORAL, EA ADDL",30900434,CDM,310,RC,81455,HCPCS,facility,both,,,,9386,9386,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC LYMPHANGIOGRAPHY, EXTREMITY ONLY, BILATERAL",30900436,CDM,310,RC,81220,HCPCS,facility,both,,,,1142,1142,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MECHANICAL CHEST WALL OSCILLATION,30900440,CDM,310,RC,81252,HCPCS,facility,both,,,,1087,1087,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC SURFACTANT ADMIN THRU TUBE,30900440,CDM,310,RC,81252,HCPCS,facility,both,,,,400,400,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC GUIDE NERVE DESTRUCTION ELECTRICAL STIM,30900442,CDM,310,RC,81401,HCPCS,facility,both,,,,403,403,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DRAIN CEREBRO SPINAL FLUID; W/O IMG,30900446,CDM,310,RC,81335,HCPCS,facility,both,,,,562,562,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HPA-2 GENOTYPING (35),30900447,CDM,310,RC,81105,HCPCS,facility,both,,,,399,399,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ECG UP TO 48 HRS SCANNING ANALYSIS REPORT,30900448,CDM,310,RC,81106,HCPCS,facility,both,,,,399,399,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC PM DEVICE PROGR EVAL, SNGL",30900449,CDM,310,RC,81107,HCPCS,facility,both,,,,399,399,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CAR ION CHNNLPATH INC 10 GNS ADDON,30900450,CDM,310,RC,81108,HCPCS,facility,both,,,,399,399,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ICD DEVICE INTERROGATE,30900451,CDM,310,RC,81109,HCPCS,facility,both,,,,399,399,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC TTE F-UP OR LMTD,30900452,CDM,310,RC,81110,HCPCS,facility,both,,,,399,399,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DUPLEX FLOW PENILE V; COMPL,30900453,CDM,310,RC,81111,HCPCS,facility,both,,,,399,399,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC MNT, INDIV, EA 15 MIN, RE-ASSESS, 2ND REF",30900454,CDM,310,RC,81112,HCPCS,facility,both,,,,399,399,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC BONE MARROW ACQUISITION FEE,30900457,CDM,310,RC,81240,HCPCS,facility,both,,,,213,213,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC INF AGENT NA PROBE NOS AGENT; EA ORG,30900458,CDM,310,RC,81241,HCPCS,facility,both,,,,466,466,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CRITICAL CARE ADDL 30 MIN,30900460,CDM,310,RC,81406,HCPCS,facility,both,,,,923,923,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CONTINUOUS PULSE OX,30900462,CDM,310,RC,81412,HCPCS,facility,both,,,,7986,7986,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE DEAC 01/01/2025 HC CAR-T; INFUSION CELL ADMINISTRATION; AUTOLOGOUS,30900464,CDM,310,RC,81271,HCPCS,facility,both,,,,205,205,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE "HC STREP PNEUMONIAE IGG AB, 23 SEROTYPES, MULTI IA, QUANT",30900464,CDM,310,RC,81271,HCPCS,facility,both,,,,484,484,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MRA W/O CONTRAST UPPER EXTREMITY,30900469,CDM,310,RC,81277,HCPCS,facility,both,,,,1497,1497,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC MRA W/CONTRAST UPPER EXTREMITY,30900469,CDM,310,RC,81277,HCPCS,facility,both,,,,3537,3537,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DEAC 01/01/2021 HC US STUDY FOLLOW UP,30900475,CDM,310,RC,81455,HCPCS,facility,both,,,,5986,5986,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC OT EVAL LOW COMPLEXITY,30900485,CDM,309,RC,,,facility,both,,,,573,573,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DRUG SCREEN QUANT CAFFEINE,30960002,CDM,310,RC,81445,HCPCS,facility,both,,,,9386,9386,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC LAB GENERAL,31000000,CDM,310,RC,,,facility,both,,,,323,323,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CP CERV/VAG; ATL; MANUAL SCRN,31000001,CDM,311,RC,88104,HCPCS,facility,both,,,,76,76,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CYTP DX EVAL FNA 1ST EA SITE,31000001,CDM,311,RC,88104,HCPCS,facility,both,,,,93,93,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC TISSUE CULTURE; SKIN OR SOLID BX,31000003,CDM,311,RC,88185,HCPCS,facility,both,,,,20,20,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC TISSUE CULTURE; AMNIOTIC FLUID,31000003,CDM,311,RC,88185,HCPCS,facility,both,,,,205,205,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CRYOPRESERVATION EA CELL LINE,31000004,CDM,310,RC,88237,HCPCS,facility,both,,,,1606,1606,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CHROM ANALY; 15-20 CELLS,31000004,CDM,310,RC,88237,HCPCS,facility,both,,,,232,232,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC CHROM ANALY; 15-20 CELLS,31000005,CDM,319,RC,88239,HCPCS,facility,both,,,,270,270,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC CHROM ANALY; 20-25 CELLS,31000005,CDM,319,RC,88239,HCPCS,facility,both,,,,2616,2616,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MCG; IP SITU 100-300 CELLS,31000007,CDM,310,RC,88272,HCPCS,facility,both,,,,92,92,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MCG; IP SITU 25-99 CELLS,31000007,CDM,310,RC,88272,HCPCS,facility,both,,,,77,77,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC CHROM ANALY; ADDTL KARYOT EA STUDY,31000008,CDM,310,RC,88273,HCPCS,facility,both,,,,97,97,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC MCG; IP SITU 100-300 CELLS,31000008,CDM,310,RC,88273,HCPCS,facility,both,,,,137,137,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CHROM ANALY; ADDTL CELL COUNTS,31000009,CDM,310,RC,88274,HCPCS,facility,both,,,,156,156,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CHROM ANALY; ADDTL KARYOT EA STUDY,31000009,CDM,310,RC,88274,HCPCS,facility,both,,,,97,97,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC SURG PATH LVL 2,31000011,CDM,310,RC,88285,HCPCS,facility,both,,,,57,57,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC SURG PATH LVL 2,31000011,CDM,310,RC,88285,HCPCS,facility,both,,,,103,103,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DECALCIFICATION,31000012,CDM,310,RC,88305,HCPCS,facility,both,,,,799,799,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC TISSUE EXAM BY PATHOLOGIST LVL 6,31000012,CDM,310,RC,88305,HCPCS,facility,both,,,,208,208,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC PATH CONSULT INTRAOP ADDL,31000013,CDM,310,RC,88319,HCPCS,facility,both,,,,1592,1592,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC INTRAOP CYTO PATH CONSULT 1,31000013,CDM,310,RC,88319,HCPCS,facility,both,,,,153,153,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC ELECTRON MICRO; DX,31000015,CDM,311,RC,88333,HCPCS,facility,both,,,,1973,1973,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ISH SINGLE PROBE 1ST,31000016,CDM,311,RC,88334,HCPCS,facility,both,,,,140,140,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC INSITU HYBRIDIZATION MANUAL,31000017,CDM,310,RC,88342,HCPCS,facility,both,,,,167,167,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC ISH SINGLE PROBE 1ST,31000017,CDM,310,RC,88342,HCPCS,facility,both,,,,524,524,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC UNLISTED SURG PATH,31000018,CDM,310,RC,88346,HCPCS,facility,both,,,,709,709,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC UNLISTED SURG PATH,31000018,CDM,310,RC,88346,HCPCS,facility,both,,,,167,167,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC CRYOPRECIPITATE EA UNIT,31000040,CDM,310,RC,88399,HCPCS,facility,both,,,,175,175,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC LEUKOCYTE POOR BLOOD EA UNIT,31000040,CDM,310,RC,88399,HCPCS,facility,both,,,,89,89,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC ISH PROBE ADDITIONAL,31000041,CDM,300,RC,89050,HCPCS,facility,both,,,,56,56,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC IAD BY NUCLEIC ACID (DNA OR RNA); BORRELIA MIYAMOTOI, APT (41)",31000043,CDM,310,RC,88350,HCPCS,facility,both,,,,171,171,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC EPILEPSY GENOMIC SEQUENCE ANALYSIS PANEL,31000112,CDM,310,RC,88362,HCPCS,facility,both,,,,1592,1592,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "DEAC 4/1/2025 HC IV INFUSION, BAMLANIVIMAB AND ETESEVIMAB, INCLUDES INFUSION AND POST ADMIN MONITORING",31000112,CDM,310,RC,88362,HCPCS,facility,both,,,,157,157,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC ANTIDEPRESSANT 1 OR 2,31000114,CDM,310,RC,88341,HCPCS,facility,both,,,,150,150,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC AMPLIF NA PROBE NOS AGENT,31000114,CDM,310,RC,88341,HCPCS,facility,both,,,,390,390,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC NA QUAN NOS AGENT,31000115,CDM,310,RC,88344,HCPCS,facility,both,,,,167,167,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE "HC INJECTION FOR CHOLANGIOGRAM, EXISTING ACCESS",31000116,CDM,310,RC,88120,HCPCS,facility,both,,,,469,469,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC STETHOSET,31000124,CDM,310,RC,81279,HCPCS,facility,both,,,,556,556,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC PERQ PLMT BILE DUCT STENT(S), NEW ACCESS, W/O SEPAR CATH",31000126,CDM,310,RC,81377,HCPCS,facility,both,,,,364,364,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC REMOVAL DUCT GALLBLADDER CALCULI,31000127,CDM,310,RC,,,facility,both,,,,631,631,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC INJ PROC NEPHROSTOGRM &/ URETEROGRM, NEW ACCESS",31000128,CDM,310,RC,,,facility,both,,,,497,497,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC INJ PROC NEPHROSTOGRM &/ URETEROGRM, EXIST ACCESS",31000129,CDM,310,RC,,,facility,both,,,,703,703,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC PLACEMENT NEPHROURETERAL CATHETER, NEW ACCESS",31000130,CDM,310,RC,,,facility,both,,,,557,557,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DRUG/SUBST DEFINITIVE QUAL/QUANT,31000136,CDM,310,RC,81306,HCPCS,facility,both,,,,945,945,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC LAB OTHER,31000139,CDM,310,RC,,,facility,both,,,,7739,7739,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MOD SED OTHER PHYS/QHP; EA ADDL 15 MIN,31000141,CDM,310,RC,81455,HCPCS,facility,both,,,,2468,2468,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE DEAC 11/01/2023 HC ADM SRSCV2 BVL 25MCG/0.25ML 1ST DOSE,31000142,CDM,310,RC,81456,HCPCS,facility,both,,,,1092,1092,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE DEAC 11/01/2023 HC ADM SRSCV2 BVL 25 MCG/0.25ML 2ND DOSE,31000143,CDM,310,RC,,,facility,both,,,,965,965,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC CYTOKINE, INTERLEUKIN-18 (IL-18 - IL-18BPA)",31000144,CDM,310,RC,81350,HCPCS,facility,both,,,,760,760,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC GENOMEXPRESS SEQUENCE ANALYSIS, EA COMPARATOR GENOME (554)",31000145,CDM,310,RC,,,facility,both,,,,222,222,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CHROMOSOMAL MICROARRAY (MICROARRAYDX) (296),31000146,CDM,310,RC,,,facility,both,,,,4659,4659,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MOPATH PROCEDURE LEVEL 7 (49),31000147,CDM,310,RC,81335,HCPCS,facility,both,,,,248,248,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CHIMERISM ANAL WI/CELL SELECT (245),31000148,CDM,310,RC,,,facility,both,,,,592,592,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PROCEDURE ENDO LEVEL 1 INIT 15 MIN,31000149,CDM,310,RC,81241,HCPCS,facility,both,,,,95,95,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC INFCT DS BCT/VIR RESPIR DNA/RNA 22 TRGT SARSCOV2,31000150,CDM,310,RC,,,facility,both,,,,680,680,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC HBB (HEMOGLOBIN, SUBUNIT BETA); FULL GENE SEQ",31000151,CDM,310,RC,81364,HCPCS,facility,both,,,,383,383,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC FLT3 GENE (795),31000152,CDM,310,RC,81245,HCPCS,facility,both,,,,2275,2275,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CARDIOMYOPATHY  PANEL (296),31000153,CDM,310,RC,81439,HCPCS,facility,both,,,,600,600,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC COMBINED CARDIAC  PANEL SEQUENCING AT LEAST 10 GENES (148),31000154,CDM,310,RC,81413,HCPCS,facility,both,,,,300,300,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC COMBINED CARDIAC  PANEL ANALYSIS AT LEAST 2 GENES (148),31000155,CDM,310,RC,81414,HCPCS,facility,both,,,,300,300,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC GENOMEXPRESS (1109),31000156,CDM,310,RC,81425,HCPCS,facility,both,,,,2250,2250,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC GENOMEXPRESS SEQUENCE ANALYSIS, EA COMPARATOR GENOME (554)",31000157,CDM,310,RC,81426,HCPCS,facility,both,,,,1125,1125,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC WHOLE MITO GENOME SEQUENCING & DELETION TESTING (148),31000158,CDM,310,RC,81460,HCPCS,facility,both,,,,300,300,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC MITO GENOME SEQUENCING HETEROPLASMY DETECTION, IF PERFRMD (148)",31000159,CDM,310,RC,81465,HCPCS,facility,both,,,,300,300,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC NOONAN AND COMPREHENSIVE RASOPATHIES  PANEL (296),31000160,CDM,310,RC,81442,HCPCS,facility,both,,,,600,600,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ONE KNOWN FAMILIAL VARIANT (136),31000161,CDM,310,RC,81455,HCPCS,facility,both,,,,276,276,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PRENATAL KNOWN FAMILIAL MUTATION (INCLUDES MCC) (370),31000162,CDM,310,RC,81265,HCPCS,facility,both,,,,750,750,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC UNLISTED MOLECULAR PATHOLOGY PROCEDURE (370),31000163,CDM,310,RC,81479,HCPCS,facility,both,,,,750,750,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC TWO KNOWN FAMILIAL VARIANTS IN A NUCLEAR GENE (98),31000164,CDM,310,RC,81455,HCPCS,facility,both,,,,198,198,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CHROMOSOMAL MICROARRAY (MICROARRAYDX) (296),31000165,CDM,310,RC,81229,HCPCS,facility,both,,,,600,600,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC XOMEDXXPRESS (739),31000166,CDM,310,RC,81415,HCPCS,facility,both,,,,1500,1500,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC XOMEDXXPRESS SEQ ANALYSIS, EA COMPARATOR EXOME (370)",31000167,CDM,310,RC,81416,HCPCS,facility,both,,,,750,750,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CYTOKINE 13 PANEL (13),31000168,CDM,310,RC,83520,HCPCS,facility,both,,,,29,29,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC MOLECULAR PATH PROC, LEVEL 4  (71)",31000169,CDM,310,RC,81403,HCPCS,facility,both,,,,1625,1625,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MOPATH PROCEDURE LEVEL 5 (246),31000172,CDM,310,RC,81404,HCPCS,facility,both,,,,500,500,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MOPATH PROCEDURE LEVEL 6 (123),31000173,CDM,310,RC,81405,HCPCS,facility,both,,,,250,250,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MOPATH PROCEDURE LEVEL 7 (83),31000174,CDM,310,RC,81406,HCPCS,facility,both,,,,167,167,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC COMPARATOR EXOME (247),31000175,CDM,310,RC,81416,HCPCS,facility,both,,,,500,500,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC COMPARATOR EXOME (493),31000176,CDM,310,RC,81416,HCPCS,facility,both,,,,1000,1000,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC EXOME SEQUENCE ANALYSIS (1232),31000177,CDM,310,RC,81415,HCPCS,facility,both,,,,2500,2500,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC EXOME RE-EVALUATION (493),31000178,CDM,310,RC,81417,HCPCS,facility,both,,,,1000,1000,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC GENOME SEQUENCE ANALYSIS (1970),31000179,CDM,310,RC,81425,HCPCS,facility,both,,,,4000,4000,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC GENOME SEQUENCE ANALYSIS (985),31000180,CDM,310,RC,81425,HCPCS,facility,both,,,,2000,2000,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC GENOME SEQ ANALYSIS, EA CMPRTR (493)",31000181,CDM,310,RC,81426,HCPCS,facility,both,,,,1000,1000,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC GENOME SEQ ANALYSIS, EA CMPRTR (985)",31000182,CDM,310,RC,81426,HCPCS,facility,both,,,,2000,2000,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MOPATH PROCEDURE LEVEL 6 (99),31000183,CDM,310,RC,81405,HCPCS,facility,both,,,,200,200,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MOPATH PROCEDURE LEVEL 7 (49),31000184,CDM,310,RC,81406,HCPCS,facility,both,,,,100,100,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MOPATH PROCEDURE LEVEL 2 (99),31000185,CDM,310,RC,81401,HCPCS,facility,both,,,,200,200,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MOPATH PROCEDURE LEVEL 2 (49),31000186,CDM,310,RC,81401,HCPCS,facility,both,,,,100,100,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CHEMICAL CAUTERIZATION OF GRANULATION TISSUE,31000187,CDM,310,RC,81418,HCPCS,facility,both,,,,1544,1544,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC ACYLCARNITINES; QUANTITATIVE, EACH SPECIMEN",31000194,CDM,310,RC,,,facility,both,,,,2315,2315,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HEALTH BEHAVIOR INTERV INDIV FACE TO FACE; 1ST 30 MIN,31000196,CDM,310,RC,,,facility,both,,,,797,797,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC EPILEPSY,ARX GENE,DEL-DUP",31060001,CDM,310,RC,80500,HCPCS,facility,both,,,,989,989,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC FACTOR VIII INVERSION/DNA,31060002,CDM,310,RC,80500,HCPCS,facility,both,,,,989,989,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC MOL PATH,LEVEL-4,KCNJ11 GENE",31060003,CDM,310,RC,80500,HCPCS,facility,both,,,,989,989,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC MOL PATH,LEVEL-4,CEL,SEQ",31060004,CDM,310,RC,80500,HCPCS,facility,both,,,,989,989,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC MOL PATH,LEVEL-4,KCNJ11,SEQ",31060005,CDM,310,RC,81161,HCPCS,facility,both,,,,500,500,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE "HC AUTISM PANEL,MOL PATH,LEVEL-4",31060006,CDM,310,RC,81173,HCPCS,facility,both,,,,1000,1000,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE "HC BM FAILURE,MPL GENE SEQ",31060008,CDM,310,RC,81223,HCPCS,facility,both,,,,1500,1500,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE "HC EPILEPSY PANEL,NHRLC1 GENE SEQ",31060008,CDM,310,RC,81223,HCPCS,facility,both,,,,2183,2183,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC DUAL GENOME,TIS,MOL PATH,LVL 5",31060009,CDM,310,RC,81223,HCPCS,facility,both,,,,1023,1023,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC EPILEPSY,PLP1 GENE,DEL-DUP",31060010,CDM,310,RC,81224,HCPCS,facility,both,,,,400,400,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE "HC EPILEPSY,ZEB2 GENE,DEL-DUP",31060010,CDM,310,RC,81224,HCPCS,facility,both,,,,1067,1067,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AQP2 GENE SEQUENCING,31060011,CDM,310,RC,81229,HCPCS,facility,both,,,,3537,3537,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC MOL PATH LEVEL 5, FMF",31060011,CDM,310,RC,81229,HCPCS,facility,both,,,,1397,1397,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC AVPR2 GENE SEQUENCING,31060013,CDM,310,RC,81240,HCPCS,facility,both,,,,215,215,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC MOL PATH,PANCREATITIS,LEVEL-5",31060014,CDM,310,RC,81246,HCPCS,facility,both,,,,267,267,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC MOL PATH,LEVEL-5,TWIST1 GENE",31060016,CDM,310,RC,81265,HCPCS,facility,both,,,,1907,1907,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC MOL PATH,LEVEL-5,INS GENE",31060016,CDM,310,RC,81265,HCPCS,facility,both,,,,650,650,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE "HC MOL PATH,LEVEL-5,PDX1 GENE",31060019,CDM,310,RC,81277,HCPCS,facility,both,,,,1397,1397,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE "HC MOL PATH,LEVEL-5,HNF1B,SEQ",31060019,CDM,310,RC,81277,HCPCS,facility,both,,,,1065,1065,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC MOL PATH,LEVEL-5,INS,SEQ",31060023,CDM,310,RC,81302,HCPCS,facility,both,,,,1397,1397,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC MOL PATH,LEVEL-5,PDX1,SEQ",31060023,CDM,310,RC,81302,HCPCS,facility,both,,,,600,600,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE "HC MOL PATH,LEVEL-5,CD40L,SEQ",31060026,CDM,310,RC,81325,HCPCS,facility,both,,,,600,600,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE "HC MOL PATH,LEVEL-5,MEFV,SEQ",31060028,CDM,310,RC,81329,HCPCS,facility,both,,,,500,500,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE "HC AUTISM PANEL,MOL PATH,LEVEL-5",31060029,CDM,310,RC,81340,HCPCS,facility,both,,,,1219,1219,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC CD40L GENE SEQ,IBD PANEL",31060030,CDM,310,RC,81350,HCPCS,facility,both,,,,1906,1906,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC MEFV GENE SEQ,IBD PANEL",31060031,CDM,310,RC,81364,HCPCS,facility,both,,,,956,956,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC EPILEPSY PANEL,ARX GENE SEQ",31060034,CDM,310,RC,81400,HCPCS,facility,both,,,,206,206,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC EPILEPSY PANEL,CSTB GENE SEQ",31060034,CDM,310,RC,81400,HCPCS,facility,both,,,,400,400,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE "HC EPILEPSY PANEL,EPM2A GENE SEQ",31060037,CDM,310,RC,81401,HCPCS,facility,both,,,,1665,1665,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MEFV GENE SEQUENCING,31060038,CDM,310,RC,81401,HCPCS,facility,both,,,,987,987,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC DUAL GENOME,TIS,MOL PATH,LVL 6",31060039,CDM,310,RC,81401,HCPCS,facility,both,,,,528,528,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CARDIOMYOPATHY DEL-DUP (ONLY),31060040,CDM,310,RC,81401,HCPCS,facility,both,,,,528,528,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC EPILEPSY,CDKL5 GENE,DEL-DUP",31060041,CDM,310,RC,81402,HCPCS,facility,both,,,,667,667,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC EPILEPSY,PDHA1 GENE,DEL-DUP",31060042,CDM,310,RC,81402,HCPCS,facility,both,,,,483,483,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC EPILEPSY,TSC1 GENE,DEL-DUP",31060043,CDM,310,RC,81403,HCPCS,facility,both,,,,1284,1284,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ZEB2 GENE SEQUENCING DEL/DUP,31060044,CDM,310,RC,81403,HCPCS,facility,both,,,,1284,1284,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC MOL PATH,PANCREATITIS,LEVEL-6",31060050,CDM,310,RC,81403,HCPCS,facility,both,,,,596,596,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC STK11 GENE SEQUENCE,31060051,CDM,310,RC,81403,HCPCS,facility,both,,,,596,596,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ENG GENE DEL-DUP,31060053,CDM,310,RC,81403,HCPCS,facility,both,,,,596,596,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC SMAD4 GENE DEL-DUP,31060054,CDM,310,RC,81403,HCPCS,facility,both,,,,596,596,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC MOL PATH,LEVEL-6,FGFR1 GENE",31060055,CDM,310,RC,81403,HCPCS,facility,both,,,,596,596,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC MOL PATH,LEVEL-6,TGFBR1 GENE",31060056,CDM,310,RC,81403,HCPCS,facility,both,,,,596,596,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC MOL PATH,LEVEL-6,HNF1A GENE",31060057,CDM,310,RC,81403,HCPCS,facility,both,,,,596,596,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC MOL PATH,LEVEL-6,HNF1A,SEQ",31060058,CDM,310,RC,81403,HCPCS,facility,both,,,,596,596,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC MOL PATH,LEVEL-6,STAT3,SEQ",31060059,CDM,310,RC,81404,HCPCS,facility,both,,,,1710,1710,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC MOL PATH,LEVEL-6,IL2RG,SEQ",31060067,CDM,310,RC,81404,HCPCS,facility,both,,,,883,883,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC AUTISM PANEL,MOL PATH,LEVEL-6",31060068,CDM,310,RC,81404,HCPCS,facility,both,,,,883,883,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC BM FAILURE,RPS19 GENE SEQ",31060069,CDM,310,RC,81404,HCPCS,facility,both,,,,1247,1247,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC IL2RG GENE SEQ,IBD PANEL",31060070,CDM,310,RC,81404,HCPCS,facility,both,,,,3326,3326,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC STAT3 GENE SEQ,IBD PANEL",31060071,CDM,310,RC,81404,HCPCS,facility,both,,,,3238,3238,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC EPILEPSY PANEL,CHRNA4 GENE SEQ",31060073,CDM,310,RC,81404,HCPCS,facility,both,,,,883,883,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC EPILEPSY PANEL,PCDH19 GENE SEQ",31060074,CDM,310,RC,81404,HCPCS,facility,both,,,,883,883,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC DUAL GENOME,TIS,MOL PATH,L7 AD",31060075,CDM,310,RC,81404,HCPCS,facility,both,,,,883,883,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC DUAL GENOME,TIS,MOL PATH,LVL 7",31060076,CDM,310,RC,81404,HCPCS,facility,both,,,,883,883,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC EPILEPSY,TSC2 GENE,DEL-DUP",31060077,CDM,310,RC,81404,HCPCS,facility,both,,,,883,883,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AIRE GENE ANALYSIS,31060078,CDM,310,RC,81404,HCPCS,facility,both,,,,883,883,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ENG GENE SEQUENCE,31060079,CDM,310,RC,81404,HCPCS,facility,both,,,,883,883,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC SMAD4 GENE SEQUENCE,31060080,CDM,310,RC,81404,HCPCS,facility,both,,,,883,883,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC MOL PATH,LEVEL-7,GCK GENE",31060081,CDM,310,RC,81404,HCPCS,facility,both,,,,883,883,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC MOL PATH,LEVEL-7,GLUD1 GENE",31060082,CDM,310,RC,81404,HCPCS,facility,both,,,,883,883,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC MOL PATH,LEVEL-7,HNF4A GENE",31060083,CDM,310,RC,81404,HCPCS,facility,both,,,,883,883,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC MOL PATH,LEVEL-7,GCK,SEQ",31060084,CDM,310,RC,81404,HCPCS,facility,both,,,,883,883,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC MOL PATH,LEVEL-7,HNF4A,SEQ",31060085,CDM,310,RC,81404,HCPCS,facility,both,,,,883,883,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC MOL PATH,LEVEL-7,GLUD1,SEQ",31060086,CDM,310,RC,81404,HCPCS,facility,both,,,,883,883,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC MOL PATH,LEVEL-7,SLC37A4,SEQ",31060087,CDM,310,RC,81404,HCPCS,facility,both,,,,883,883,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC MOL PATH,LEVEL-7,BTK,SEQ",31060088,CDM,310,RC,81404,HCPCS,facility,both,,,,883,883,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC MOL PATH,LEVEL-7,AIRE,SEQ",31060089,CDM,310,RC,81405,HCPCS,facility,both,,,,2564,2564,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC AUTISM PANEL,MOL PATH,LEVEL-7",31060100,CDM,310,RC,81405,HCPCS,facility,both,,,,969,969,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC BM FAILURE,PALB2 GENE SEQ",31060101,CDM,310,RC,81405,HCPCS,facility,both,,,,969,969,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC BM FAILURE,WAS GENE SEQ",31060102,CDM,310,RC,81405,HCPCS,facility,both,,,,969,969,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC BTK GENE SEQ,IBD PANEL",31060103,CDM,310,RC,81405,HCPCS,facility,both,,,,969,969,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC SLC37A4 GENE SEQ,IBD PANEL",31060105,CDM,310,RC,81405,HCPCS,facility,both,,,,2942,2942,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC WAS GENE SEQ,IBD PANEL",31060106,CDM,310,RC,81405,HCPCS,facility,both,,,,969,969,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC EPILEPSY PANEL,ALDH7A1 SEQ",31060107,CDM,310,RC,81405,HCPCS,facility,both,,,,1204,1204,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC EPILEPSY PANEL,ATP1A2 GENE SEQ",31060108,CDM,310,RC,81405,HCPCS,facility,both,,,,969,969,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC EPILEPSY PANEL,KCNQ2 GENE SEQ",31060109,CDM,310,RC,81405,HCPCS,facility,both,,,,969,969,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC CHD,JAG-1,DEL-DUP",31060110,CDM,310,RC,81405,HCPCS,facility,both,,,,969,969,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC DUAL GENOME,TIS,MOL PATH,LVL 8",31060111,CDM,310,RC,81405,HCPCS,facility,both,,,,969,969,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC SCN1A DNA GENE SEQUENCE,31060112,CDM,310,RC,81405,HCPCS,facility,both,,,,969,969,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC JAUNDICECHIP GENE (JAG-1),31060113,CDM,310,RC,81405,HCPCS,facility,both,,,,969,969,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC FACTOR VIII SEQUENCE ANALYSIS,31060114,CDM,310,RC,81405,HCPCS,facility,both,,,,969,969,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC MOL PATH,LEVEL-8,ABCC8 GENE",31060115,CDM,310,RC,81405,HCPCS,facility,both,,,,969,969,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC MOL PATH,LEVEL-8,ABCC8,SEQ",31060116,CDM,310,RC,81405,HCPCS,facility,both,,,,969,969,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC MOL PATH,LEVEL-8,CHD7,SEQ",31060117,CDM,310,RC,81405,HCPCS,facility,both,,,,969,969,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC AUTISM PANEL,MOL PATH,LEVEL-8",31060118,CDM,310,RC,81405,HCPCS,facility,both,,,,969,969,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC EPILEPSY PANEL,CACNA1A SEQ",31060119,CDM,310,RC,81405,HCPCS,facility,both,,,,969,969,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ATM GENE SEQUENCE,31060120,CDM,310,RC,81405,HCPCS,facility,both,,,,969,969,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC MOL PATH,LEVEL-9,ATM,SEQ",31060121,CDM,310,RC,81405,HCPCS,facility,both,,,,969,969,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC MOL PATH,LEVEL-9,VPS13B,SEQ",31060124,CDM,310,RC,81406,HCPCS,facility,both,,,,4936,4936,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC AUTISM PANEL,MOL PATH,LEVEL-9",31060125,CDM,310,RC,81406,HCPCS,facility,both,,,,4936,4936,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC STICKLER SYN,AORTIC DYS,SEQ",31060142,CDM,310,RC,81406,HCPCS,facility,both,,,,1225,1225,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC STICKLER SYN,AORTIC DYS,SEQ",31060143,CDM,310,RC,81406,HCPCS,facility,both,,,,1222,1222,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC STICKLER SYN,AORTIC DYS,D/D",31060145,CDM,310,RC,81406,HCPCS,facility,both,,,,1225,1225,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC STICKLER SYN,AORTIC DYS,D/D",31060146,CDM,310,RC,81406,HCPCS,facility,both,,,,1225,1225,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC WHOLE EXOME SEQUENCING GDX,31060147,CDM,310,RC,81406,HCPCS,facility,both,,,,1225,1225,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC CARDIOMYOPATHY,MOL LEVEL-8",31060148,CDM,310,RC,81406,HCPCS,facility,both,,,,1225,1225,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC NOONAN'S SYNDROME GENE SEQ,31060149,CDM,310,RC,81406,HCPCS,facility,both,,,,1225,1225,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MITOCHONDRIAL GENOME SEQUENCE,31060150,CDM,310,RC,81406,HCPCS,facility,both,,,,1225,1225,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MITOCHONDRIAL GENOME LG DEL,31060151,CDM,310,RC,81406,HCPCS,facility,both,,,,1225,1225,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC DUAL GENOME,TIS,UNLISTED MOL P",31060152,CDM,310,RC,81406,HCPCS,facility,both,,,,1225,1225,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC NOONAN'S SYN,DEL-DUP ONLY",31060153,CDM,310,RC,81406,HCPCS,facility,both,,,,1225,1225,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC EPILEPSY,UNLISTED GENE,DEL-DUP",31060154,CDM,310,RC,81406,HCPCS,facility,both,,,,1225,1225,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ATG16L GENE,31060155,CDM,310,RC,81406,HCPCS,facility,both,,,,1225,1225,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ECM-1 GENE,31060156,CDM,310,RC,81406,HCPCS,facility,both,,,,1225,1225,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC NKX2 GENE,31060157,CDM,310,RC,81406,HCPCS,facility,both,,,,1225,1225,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC STAT3 GENE,31060158,CDM,310,RC,81406,HCPCS,facility,both,,,,1225,1225,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC T-CELL RECEPTOR (TREC),31060159,CDM,310,RC,81406,HCPCS,facility,both,,,,1225,1225,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ELA2 GENE SEQ ANALYSIS,31060160,CDM,310,RC,81406,HCPCS,facility,both,,,,1225,1225,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC JAUNDICECHIP GENE (ABCB11),31060161,CDM,310,RC,81406,HCPCS,facility,both,,,,1225,1225,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC MOL PATHOLOGY, UNLISTED, FMF",31060162,CDM,310,RC,81406,HCPCS,facility,both,,,,1225,1225,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MITO-DNA DELETIONS,31060163,CDM,310,RC,81406,HCPCS,facility,both,,,,1225,1225,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC JAUNDICECHIP GENE (ABCB4),31060164,CDM,310,RC,81406,HCPCS,facility,both,,,,1225,1225,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC JAUNDICECHIP GENE (AKR1D1),31060167,CDM,310,RC,81406,HCPCS,facility,both,,,,1225,1225,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC JAUNDICECHIP GENE (ATP8B1),31060168,CDM,310,RC,81407,HCPCS,facility,both,,,,5506,5506,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC MOLECULAR PATH PROC, UNLISTED",31060175,CDM,310,RC,81407,HCPCS,facility,both,,,,2721,2721,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MYH9 GENE MUTATION BCW,31060176,CDM,310,RC,81407,HCPCS,facility,both,,,,6685,6685,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC JAUNDICECHIP GENE (SERP1NA1),31060178,CDM,310,RC,81407,HCPCS,facility,both,,,,3862,3862,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC JAUNDICECHIP GENE (SLC25A13),31060179,CDM,310,RC,81407,HCPCS,facility,both,,,,2721,2721,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC EXOME SLICE,31060180,CDM,310,RC,81407,HCPCS,facility,both,,,,2721,2721,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC UNLISTED MOL/PATH,PANCREATITIS",31060181,CDM,310,RC,81407,HCPCS,facility,both,,,,2721,2721,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ACVRL1 GENE SEQUENCE,31060182,CDM,310,RC,81407,HCPCS,facility,both,,,,2721,2721,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC RASA1 GENE SEQUENCE,31060183,CDM,310,RC,81407,HCPCS,facility,both,,,,2721,2721,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ATM GENE DEL-DUP,31060189,CDM,310,RC,81408,HCPCS,facility,both,,,,6430,6430,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ACVRL1 GENE DEL-DUP,31060190,CDM,310,RC,81408,HCPCS,facility,both,,,,6430,6430,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC RASA1 GENE DEL-DUP,31060191,CDM,310,RC,81408,HCPCS,facility,both,,,,6430,6430,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC IGF1R GENE SEQUENCING,31060192,CDM,310,RC,81408,HCPCS,facility,both,,,,6430,6430,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC MOL PATH,UNLISTED CRANIO GENES",31060194,CDM,310,RC,81410,HCPCS,facility,both,,,,4181,4181,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC MOL PATH,UNLIST,HYPERINS GENE",31060194,CDM,310,RC,81410,HCPCS,facility,both,,,,2000,2000,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE "HC MOL PATH,UNLISTED,POLR1D GENE",31060195,CDM,310,RC,81411,HCPCS,facility,both,,,,900,900,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE "HC MOL PATH,UNLISTED,POLR1C GENE",31060195,CDM,310,RC,81411,HCPCS,facility,both,,,,2768,2768,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC MOL PATH,UNLISTED SEQ/DEL-DUP",31060197,CDM,310,RC,81415,HCPCS,facility,both,,,,16903,16903,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PERIODIC FEVER SYNDROME,31060198,CDM,310,RC,81439,HCPCS,facility,both,,,,2000,2000,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE "HC MOL PATH,UNLISTED GENE SEQ",31060199,CDM,310,RC,81442,HCPCS,facility,both,,,,2000,2000,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE "HC MOL PATH,UNLISTED GENE DEL-DUP",31060201,CDM,310,RC,81460,HCPCS,facility,both,,,,3713,3713,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC AUTISM PANEL,MOL PATH,UNLISTED",31060202,CDM,310,RC,81465,HCPCS,facility,both,,,,3009,3009,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC BM FAILURE,UNLIST GENE DEL-DUP",31060203,CDM,310,RC,81479,HCPCS,facility,both,,,,950,950,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC BM FAILURE,UNLIST GENE SEQ",31060224,CDM,310,RC,81479,HCPCS,facility,both,,,,1596,1596,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC UNLISTED GENE SEQ,IBD PANEL",31060225,CDM,310,RC,81479,HCPCS,facility,both,,,,1596,1596,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC UNLISTED DEL-DUP,IBD PANEL",31060226,CDM,310,RC,81479,HCPCS,facility,both,,,,312,312,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC EPILEPSY PANEL,UNLISTED SEQ",31060227,CDM,310,RC,81479,HCPCS,facility,both,,,,312,312,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC EPILEPSY PANEL,UNLIST DEL-DUP",31060228,CDM,310,RC,81479,HCPCS,facility,both,,,,312,312,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC STICKLER SYN,UNLISTED,SEQ",31060229,CDM,310,RC,81479,HCPCS,facility,both,,,,312,312,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC STICKLER SYN,UNLISTED,DEL-DUP",31060230,CDM,310,RC,81479,HCPCS,facility,both,,,,2499,2499,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC SALL1 GENE SEQUENCING,31060231,CDM,310,RC,81479,HCPCS,facility,both,,,,1692,1692,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC SALL1 GENE DELETION-DUP,31060232,CDM,310,RC,81479,HCPCS,facility,both,,,,38,38,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC CHD,UNLISTED GENE,DEL-DUP",31060233,CDM,310,RC,81479,HCPCS,facility,both,,,,563,563,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ALLOMAP GENE EXPRESSION(IP),31060234,CDM,310,RC,81479,HCPCS,facility,both,,,,953,953,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC LIVER FIBROSIS (FIBROTEST) PAN,31060235,CDM,310,RC,81479,HCPCS,facility,both,,,,38,38,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC THAW AND EXPANSION-FROZEN CELL,31060236,CDM,310,RC,81479,HCPCS,facility,both,,,,38,38,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC THAW AND EXPANSION-FROZEN CELL,31060237,CDM,310,RC,81479,HCPCS,facility,both,,,,38,38,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC SCORE 100 CELLS,FANC-DEB",31060238,CDM,310,RC,81479,HCPCS,facility,both,,,,991,991,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC COUNT 5 CELLS, 1 KARYOTYPE",31060239,CDM,310,RC,81479,HCPCS,facility,both,,,,2505,2505,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC COUNT 5 CELLS, 1 KARYOTYPE",31060241,CDM,310,RC,81479,HCPCS,facility,both,,,,38,38,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC CNT 45 CELLS,MOSAIC,2 KARYOTYP",31060242,CDM,310,RC,81479,HCPCS,facility,both,,,,38,38,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC CNT 45 CELLS,MOSAIC,2 KARYOTYP",31060243,CDM,310,RC,81479,HCPCS,facility,both,,,,6108,6108,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC COMPLEX CYTO INTERP & REPORT,31060244,CDM,310,RC,81479,HCPCS,facility,both,,,,353,353,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC COMPLEX CYTO INTERP & REPORT,31060245,CDM,310,RC,81479,HCPCS,facility,both,,,,509,509,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC CYTOGENETICS INTERP, FANCONI A",31060246,CDM,310,RC,81479,HCPCS,facility,both,,,,509,509,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "DEAC 4/1/2025 HC NKC,INTERPRETATION CCH",31060247,CDM,310,RC,81479,HCPCS,facility,both,,,,509,509,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "DEAC 4/1/2025 HC FLOW CYTOMETRY, INTERPRETATION; 2 TO 8 MARKERS",31060248,CDM,310,RC,81479,HCPCS,facility,both,,,,509,509,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "DEAC 4/1/2025 HC XIAP,INTERPRETATION,FLOW",31060249,CDM,310,RC,81479,HCPCS,facility,both,,,,509,509,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "DEAC 4/1/2025 HC TH17 CYTOKINE,INTERPRETATION",31060250,CDM,310,RC,81479,HCPCS,facility,both,,,,1952,1952,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "DEAC 4/1/2025 HC APOPTOSIS,FLOW,INTERPRETATION",31060251,CDM,310,RC,81479,HCPCS,facility,both,,,,266,266,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "DEAC 4/1/2025 HC DOCK8,PROTEIN EXP(FLOW),INTERP",31060252,CDM,310,RC,81479,HCPCS,facility,both,,,,212,212,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "DEAC 4/1/2025 HC CD107A,INTERPRETATION",31060253,CDM,310,RC,81479,HCPCS,facility,both,,,,1472,1472,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "DEAC 4/1/2025 HC WASP,FLOW CYTOMETRY,INTERP",31060254,CDM,310,RC,81479,HCPCS,facility,both,,,,1472,1472,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "DEAC 4/1/2025 HC INTERPRETATION, FLOW, XLP1",31060255,CDM,310,RC,81479,HCPCS,facility,both,,,,765,765,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "DEAC 4/1/2025 HC INTERPRETATION,MRD FLOW PANEL",31060256,CDM,310,RC,81479,HCPCS,facility,both,,,,1344,1344,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC CONSULT/REPORT,REFERRED SPEC",31060257,CDM,310,RC,81479,HCPCS,facility,both,,,,254,254,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC CONSULTATION,EM (STANFORD)",31060258,CDM,310,RC,81479,HCPCS,facility,both,,,,254,254,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC CONSULTATION, COMP, (STANFORF)",31060259,CDM,310,RC,81479,HCPCS,facility,both,,,,443,443,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC BLOCK RECUT,H&E STAIN",31060260,CDM,310,RC,81479,HCPCS,facility,both,,,,1065,1065,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC BLOCK RECUT,UNSTAINED",31060261,CDM,310,RC,81479,HCPCS,facility,both,,,,1065,1065,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DX BRONCHOSCOPE/WASH INCL FLUORO,31060262,CDM,310,RC,81479,HCPCS,facility,both,,,,1065,1065,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC INSERT LEFT HEART VENT BY THORACIC INC ECMO/ECLS,31060263,CDM,310,RC,81479,HCPCS,facility,both,,,,1065,1065,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC REMOVAL LT HEART VENT BY THORACIC INCIS ECMO/ECLS,31060264,CDM,310,RC,81479,HCPCS,facility,both,,,,1015,1015,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC INTRACARD ECHOCARD W/THER/DX IVNTJ INCL IMG S&I,31060265,CDM,310,RC,81479,HCPCS,facility,both,,,,1114,1114,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ABLATE L/R ATRIAL FIBRIL W/ISOLATED PULM VEIN ADDL,31060266,CDM,310,RC,81479,HCPCS,facility,both,,,,1015,1015,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC INTRACARD CATH ABLATION ARRHYTHMIA ADD ON,31060267,CDM,310,RC,81479,HCPCS,facility,both,,,,1114,1114,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC COMPRE ELECTROPHYSIOL XM W/LEFT ATRIAL PACNG/REC,31060268,CDM,310,RC,81479,HCPCS,facility,both,,,,1114,1114,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC INTRACARDIAC ELECTROPHYSIOLOGIC 3D MAPPING,31060269,CDM,310,RC,81479,HCPCS,facility,both,,,,1065,1065,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC COMPRE ELECTROPHYSIOL XM W/LEFT VENTR PACNG/REC,31060273,CDM,310,RC,81479,HCPCS,facility,both,,,,1596,1596,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MAP TACHYCARDIA W/CATH MANIPULATION ADD-ON,31060274,CDM,310,RC,81595,HCPCS,facility,both,,,,13124,13124,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC LEFT HEART CATH BY TRANSEPTAL PUNCTURE,31060275,CDM,310,RC,81596,HCPCS,facility,both,,,,874,874,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC JOINT SURVEY SINGLE VIEW 2+ JOINTS,31060276,CDM,310,RC,88241,HCPCS,facility,both,,,,62,62,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC TEETH; COMPLETE; FULL MOUTH,31060276,CDM,310,RC,88241,HCPCS,facility,both,,,,87,87,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC NONSELECTIVE CATH PLACEMENT IN VEIN,31060277,CDM,310,RC,88249,HCPCS,facility,both,,,,2704,2704,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CT ANGIO ABD&PELV W/O&W/DYE,31060278,CDM,310,RC,88261,HCPCS,facility,both,,,,607,607,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC LYMPHANGIOGRAM PELVIC/ABD; BILAT,31060278,CDM,310,RC,88261,HCPCS,facility,both,,,,96,96,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC REPLACE CATH ONLY OF VAD,31060279,CDM,310,RC,88263,HCPCS,facility,both,,,,238,238,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC MAGNETIC RESONANCE SPECTROSCOPY,31060279,CDM,310,RC,88263,HCPCS,facility,both,,,,346,346,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PLACE CATH XTRNL CAROTID,31060280,CDM,310,RC,88291,HCPCS,facility,both,,,,22,22,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC US GUIDE - ENDOMYOCARDIAL BX,31060280,CDM,310,RC,88291,HCPCS,facility,both,,,,254,254,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PLACE CATH CAROTID/INOM ART W/ ANGIO EXTRACRANIAL,31060281,CDM,310,RC,88291,HCPCS,facility,both,,,,254,254,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CLOTTING; FACTOR VIII RELATED ANTIGEN,31060285,CDM,310,RC,81479,HCPCS,facility,both,,,,2315,2315,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC COAG TIME; ACTIVATED,31060286,CDM,310,RC,81440,HCPCS,facility,both,,,,10686,10686,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC OSMOTIC FRAGILITY RBC; UNINCUBATED,31060287,CDM,310,RC,81460,HCPCS,facility,both,,,,3861,3861,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC LAB BACTERIOLOY AND MICROBIOLOGY,31060288,CDM,310,RC,81465,HCPCS,facility,both,,,,2808,2808,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HIV-1 AG W/HIV-1 & HIV-2 AB,31060289,CDM,310,RC,81470,HCPCS,facility,both,,,,2742,2742,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HERPES 6 NA QUAN,31060290,CDM,310,RC,81471,HCPCS,facility,both,,,,2742,2742,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CHEMODENERV 1 EXTREM 5/> MUS,31060300,CDM,310,RC,81269,HCPCS,facility,both,,,,1124,1124,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CHEMODENERV 1 EXTREM 5/> EA,31060302,CDM,310,RC,81434,HCPCS,facility,both,,,,1922,1922,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HUGGIE AND CATCHER,31060303,CDM,310,RC,81419,HCPCS,facility,both,,,,5020,5020,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC THRMB/INFUS DIAL CIRC & INTRAPRC PHARM THRMB INJ,31060308,CDM,310,RC,81243,HCPCS,facility,both,,,,185,185,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC THRMB/INFUS DIAL CIRC W/TRNSLUM BAL ANGIOPLASTY,31060309,CDM,310,RC,81244,HCPCS,facility,both,,,,146,146,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC FLOW CYTOMETRY TC 1ST MARKER,31100002,CDM,311,RC,88142,HCPCS,facility,both,,,,66,66,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC FLOW CYTOMETRY EA ADDTL MARKER,31100004,CDM,311,RC,88172,HCPCS,facility,both,,,,174,174,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC FLOW CYTOMETRY TC 1ST MARKER,31100004,CDM,311,RC,88172,HCPCS,facility,both,,,,323,323,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC TISSUE CULTURE; LYMPHOCYTE,31100005,CDM,311,RC,88173,HCPCS,facility,both,,,,322,322,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC FLOW CYTOMETRY EA ADDTL MARKER,31100005,CDM,311,RC,88173,HCPCS,facility,both,,,,93,93,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC TISSUE CULTURE; SKIN OR SOLID BX,31100006,CDM,311,RC,88184,HCPCS,facility,both,,,,50,50,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC TISSUE CULTURE; LYMPHOCYTE,31100006,CDM,311,RC,88184,HCPCS,facility,both,,,,665,665,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CHROM ANALY; 20-25 CELLS,31100007,CDM,310,RC,88240,HCPCS,facility,both,,,,174,174,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DRAIN/INJ MAJOR JOINT/BURSA W/US,31100007,CDM,310,RC,88240,HCPCS,facility,both,,,,123,123,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC CELL COUNT NOT BLOOD,31100009,CDM,310,RC,88348,HCPCS,facility,both,,,,2183,2183,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DIFF CELL COUNT NOT BLOOD,31100009,CDM,310,RC,88348,HCPCS,facility,both,,,,755,755,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC COLLECT SWEAT FOR TEST,31100010,CDM,312,RC,88365,HCPCS,facility,both,,,,162,162,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC PHLEBOTOMY THERAPEUTIC,31100010,CDM,312,RC,88365,HCPCS,facility,both,,,,388,388,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC INJECTION FOR WRIST ARTHROGRAPHY,31100051,CDM,319,RC,88182,HCPCS,facility,both,,,,750,750,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CALC GENE COM VARIANTS (210),31100061,CDM,312,RC,88364,HCPCS,facility,both,,,,259,259,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DRUG TEST(S); READ BY DIRECT OPTICAL OBSER ONLY,31100063,CDM,311,RC,88184,HCPCS,facility,both,,,,232,232,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC UNLISTED CARDIOVASCULAR SERVICE,31100064,CDM,311,RC,88185,HCPCS,facility,both,,,,74,74,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PLACE CATH CAROTID/INOM ART W/ ANGIO INTRACRANIAL,31160001,CDM,311,RC,88187,HCPCS,facility,both,,,,334,334,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PLACE CATH CAROTD ART,31160002,CDM,311,RC,88187,HCPCS,facility,both,,,,358,358,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PLACE CATH SUBCLAVIAN ART,31160003,CDM,311,RC,88187,HCPCS,facility,both,,,,358,358,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PLACE CATH VERTEBRAL ART,31160004,CDM,311,RC,88187,HCPCS,facility,both,,,,358,358,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC THROMBOLYTIC ART THERAPY,31160005,CDM,311,RC,88187,HCPCS,facility,both,,,,358,358,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC THROMBOLYTIC VENOUS THERAPY,31160006,CDM,311,RC,88187,HCPCS,facility,both,,,,358,358,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC THROMBLYTIC ART/VEN THERAPY,31160007,CDM,311,RC,88187,HCPCS,facility,both,,,,358,358,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CESSJ THERAPY CATH REMOVAL,31160008,CDM,311,RC,88187,HCPCS,facility,both,,,,358,358,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PERQ&IC ALLG TEST DRUGS/BIOL,31160009,CDM,311,RC,88187,HCPCS,facility,both,,,,358,358,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC INGEST CHALLENGE INIITIAL 120 MIN,31160010,CDM,311,RC,88189,HCPCS,facility,both,,,,558,558,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AMINO ACIDS; SINGLE QUAL EA,31200000,CDM,312,RC,,,facility,both,,,,1.2,1.2,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC EVAL OF FNA; INT & REP,31200001,CDM,311,RC,88108,HCPCS,facility,both,,,,93,93,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC EVAL OF FNA; INT & REP,31200001,CDM,311,RC,88108,HCPCS,facility,both,,,,176,176,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC TISSUE EXAM BY PATHOLOGIST LVL 3,31200002,CDM,310,RC,88300,HCPCS,facility,both,,,,173,173,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC TISSUE EXAM BY PATHOLOGIST LVL 3,31200002,CDM,310,RC,88300,HCPCS,facility,both,,,,56,56,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC TISSUE EXAM BY PATHOLOGIST LVL 4,31200003,CDM,310,RC,88302,HCPCS,facility,both,,,,201,201,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC TISSUE EXAM BY PATHOLOGIST LVL 4,31200003,CDM,310,RC,88302,HCPCS,facility,both,,,,98,98,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC TISSUE EXAM BY PATHOLOGIST LVL 5,31200004,CDM,310,RC,88304,HCPCS,facility,both,,,,323,323,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC TISSUE EXAM BY PATHOLOGIST LVL 6,31200004,CDM,310,RC,88304,HCPCS,facility,both,,,,152,152,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC DECALCIFICATION,31200005,CDM,310,RC,88307,HCPCS,facility,both,,,,1091,1091,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC SPECIAL STAINS GROUP 1,31200005,CDM,310,RC,88307,HCPCS,facility,both,,,,341,341,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC SPECIAL STAINS GROUP 1,31200006,CDM,310,RC,88309,HCPCS,facility,both,,,,444,444,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC SPECIAL STAINS GROUP 2,31200006,CDM,310,RC,88309,HCPCS,facility,both,,,,1596,1596,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC SPECIAL STAINS GROUP 2,31200007,CDM,310,RC,88311,HCPCS,facility,both,,,,126,126,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HISTOCHEMICAL STAINS ADD-ON,31200007,CDM,310,RC,88311,HCPCS,facility,both,,,,56,56,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC HISTOCHEMICAL STAINS ADD-ON,31200008,CDM,310,RC,88312,HCPCS,facility,both,,,,98,98,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC ENZYME HISTOCHEMISTRY,31200008,CDM,310,RC,88312,HCPCS,facility,both,,,,371,371,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC SP CONSULT; 1ST TB W FS SGL SP,31200009,CDM,310,RC,88313,HCPCS,facility,both,,,,98,98,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC ENZYME HISTOCHEMISTRY,31200009,CDM,310,RC,88313,HCPCS,facility,both,,,,388,388,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PATH CONSULT INTRAOP ADDL,31200010,CDM,310,RC,88314,HCPCS,facility,both,,,,345,345,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC SP CONSULT; 1ST TB W FS SGL SP,31200010,CDM,310,RC,88314,HCPCS,facility,both,,,,98,98,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC INTRAOP CYTO PATH CONSULT 2,31200011,CDM,310,RC,88331,HCPCS,facility,both,,,,189,189,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE "HC IF STAIN , INITIAL",31200011,CDM,310,RC,88331,HCPCS,facility,both,,,,714,714,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC IF STAIN , INITIAL",31200012,CDM,310,RC,88332,HCPCS,facility,both,,,,222,222,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ELECTRON MICRO; DX,31200012,CDM,310,RC,88332,HCPCS,facility,both,,,,178,178,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC INGEST CHALLENGE ADDL 60 MIN,31260001,CDM,312,RC,88321,HCPCS,facility,both,,,,122,122,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC HA DIGITIAL, STANDARD, MONAURAL, ITC",31260002,CDM,312,RC,88325,HCPCS,facility,both,,,,646,646,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC HA DIGITIAL, STANDARD, BINAURAL, ITC",31260003,CDM,312,RC,88325,HCPCS,facility,both,,,,646,646,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC HA DIGITAL, STANDARD, MONAURAL, CIC",31260005,CDM,312,RC,88399,HCPCS,facility,both,,,,33,33,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE "HC HA DIGITAL, STANDARD, MONAURAL, RITE",31260006,CDM,312,RC,88399,HCPCS,facility,both,,,,33,33,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC TISSUE CULTURE; OTHER TISSUE,31900001,CDM,319,RC,88233,HCPCS,facility,both,,,,405,405,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC TISSUE CULTURE; OTHER TISSUE,31900001,CDM,319,RC,88233,HCPCS,facility,both,,,,263,263,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC CRYOPRESERVATION EA CELL LINE,31900002,CDM,319,RC,88235,HCPCS,facility,both,,,,649,649,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MCG; DNA PROBE EA,31900004,CDM,310,RC,88262,HCPCS,facility,both,,,,450,450,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MCG; DNA PROBE EA,31900004,CDM,310,RC,88262,HCPCS,facility,both,,,,279,279,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC MCG; SITU HYBRID 3-5 CELLS,31900005,CDM,310,RC,88264,HCPCS,facility,both,,,,316,316,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC MCG; SITU HYBRID 3-5 CELLS,31900005,CDM,310,RC,88264,HCPCS,facility,both,,,,488,488,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CHROM ANALY; ADDTL CELL COUNTS,31900007,CDM,310,RC,88275,HCPCS,facility,both,,,,277,277,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CHROM ANALY; ADDTL HI RESOLN,31900007,CDM,310,RC,88275,HCPCS,facility,both,,,,230,230,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC SURG PATH LEVEL-I GROSS ONLY,31900008,CDM,310,RC,88280,HCPCS,facility,both,,,,105,105,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC SURG PATH LEVEL-I GROSS ONLY,31900008,CDM,310,RC,88280,HCPCS,facility,both,,,,52,52,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE "HC ULTRASOUND BREAST UNILAT, LIMITED",31900009,CDM,319,RC,88289,HCPCS,facility,both,,,,196,196,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC BLOOD SPLIT UNIT,31900011,CDM,319,RC,88368,HCPCS,facility,both,,,,904,904,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC X-RAY EXAM OF EYE, DETECTION OF FOREIGN BODY",32000001,CDM,320,RC,70015,HCPCS,facility,both,,,,2541,2541,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC MANDIBLE, MIN 4 VIEWS",32000002,CDM,320,RC,70030,HCPCS,facility,both,,,,270,270,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC FACIAL BONES, MIN 3 VIEWS",32000004,CDM,320,RC,70110,HCPCS,facility,both,,,,549,549,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC NASAL BONES, MIN 3 VIEWS",32000006,CDM,320,RC,70150,HCPCS,facility,both,,,,549,549,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC ORBITS, MIN 4 VIEWS",32000007,CDM,320,RC,70160,HCPCS,facility,both,,,,347,347,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC SINUSES, PARANASAL, LESS THAN 3 VIEWS",32000008,CDM,320,RC,70200,HCPCS,facility,both,,,,618,618,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC SINUSES, PARANASAL, MIN 3 VIEWS",32000009,CDM,320,RC,70210,HCPCS,facility,both,,,,428,428,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC SKULL, LESS THAN 4 VIEWS",32000010,CDM,320,RC,70220,HCPCS,facility,both,,,,602,602,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC SKULL, MIN 4 VIEWS",32000011,CDM,320,RC,70250,HCPCS,facility,both,,,,692,692,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MRI OF TEMPOROMANDIBULAR JOINT(S),32000012,CDM,320,RC,70260,HCPCS,facility,both,,,,800,800,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC CT HEAD OR BRAIN, W/O CONTRAST",32000014,CDM,320,RC,70360,HCPCS,facility,both,,,,445,445,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC SPINE, CERVICAL, MIN 4 VIEWS",32000015,CDM,320,RC,72020,HCPCS,facility,both,,,,414,414,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC SPINE, CERVICAL, COMPLETE",32000016,CDM,320,RC,72040,HCPCS,facility,both,,,,551,551,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC SPINE, THORAX, 2 VIEWS",32000017,CDM,320,RC,72050,HCPCS,facility,both,,,,662,662,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC SPINE, THORAX, MIN 4 VIEWS",32000018,CDM,320,RC,72052,HCPCS,facility,both,,,,1092,1092,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC SPINE, THORACOLUMBAR, 2 VIEWS",32000019,CDM,320,RC,72070,HCPCS,facility,both,,,,662,662,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC SPINE, LUMBOSACRAL, 2 OR 3 VIEWS",32000021,CDM,320,RC,72074,HCPCS,facility,both,,,,694,694,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC SPINE, LUMBOSACRAL, MIN 4 VIEWS",32000022,CDM,320,RC,72080,HCPCS,facility,both,,,,313,313,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC CT CERVICAL SPINE, W/O CONTRAST",32000024,CDM,320,RC,72100,HCPCS,facility,both,,,,563,563,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC CT CERVICAL SPINE, W CONTRAST",32000025,CDM,320,RC,72110,HCPCS,facility,both,,,,626,626,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CTA PELVIS W & W/O CONTRAST,32000027,CDM,320,RC,72170,HCPCS,facility,both,,,,631,631,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CT PELVIS W/O CONTRAST,32000028,CDM,320,RC,72190,HCPCS,facility,both,,,,428,428,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC MYELOGRAPHY, CERVICAL S & I",32000029,CDM,320,RC,72202,HCPCS,facility,both,,,,549,549,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC MYELOGRAPHY, THORACIC S & I",32000030,CDM,320,RC,72220,HCPCS,facility,both,,,,362,362,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC MYELOGRAPHY, LUMBOSACRAL S & I",32000031,CDM,320,RC,72240,HCPCS,facility,both,,,,2023,2023,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC MYELOGRAPHY, 2 OR MORE REGIONS S & I",32000032,CDM,320,RC,72255,HCPCS,facility,both,,,,1519,1519,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC RAD EXAM CLAVICLE, COMPLETE",32000033,CDM,320,RC,72265,HCPCS,facility,both,,,,2023,2023,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC RAD EXAM SCAPULA, COMPLETE",32000034,CDM,320,RC,72270,HCPCS,facility,both,,,,1759,1759,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC RAD EXAM SHOULDER, MIN 2 VIEWS",32000038,CDM,320,RC,73000,HCPCS,facility,both,,,,410,410,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC RAD EXAM SHOULDER, ARTHROGRAPHY",32000039,CDM,320,RC,73010,HCPCS,facility,both,,,,347,347,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC RAD EXAM ACROMIOCLAVICULAR JOINTS, BILAT",32000041,CDM,320,RC,73030,HCPCS,facility,both,,,,631,631,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC RAD EXAM ELBOW, 2 VIEWS",32000042,CDM,320,RC,73050,HCPCS,facility,both,,,,457,457,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC RAD EXAM ELBOW, MIN 3 VIEWS",32000043,CDM,320,RC,73060,HCPCS,facility,both,,,,414,414,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC RAD EXAM ELBOW, ARTHROGRAPHY",32000044,CDM,320,RC,73070,HCPCS,facility,both,,,,414,414,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC RAD EXAM FOREARM, 2 VIEWS",32000045,CDM,320,RC,73080,HCPCS,facility,both,,,,456,456,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC RAD EXAM WRIST, 2 VIEWS",32000046,CDM,320,RC,73090,HCPCS,facility,both,,,,414,414,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC RAD EXAM WRIST, MIN 3 VIEWS",32000047,CDM,320,RC,73092,HCPCS,facility,both,,,,414,414,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC RAD EXAM WRIST ARTHROGRAPHY,32000048,CDM,320,RC,73100,HCPCS,facility,both,,,,414,414,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC RAD EXAM HAND, 2 VIEWS",32000049,CDM,320,RC,73110,HCPCS,facility,both,,,,414,414,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC RAD EXAM FINGER(S), MIN 2 VIEWS",32000050,CDM,320,RC,73120,HCPCS,facility,both,,,,428,428,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CT UPPER EXT W/O CONTRAST,32000051,CDM,320,RC,73130,HCPCS,facility,both,,,,414,414,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CT UPPER EXT W CONTRAST,32000052,CDM,320,RC,73140,HCPCS,facility,both,,,,414,414,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC RAD EXAM KNEE 4 OR MORE VIEWS,32000059,CDM,320,RC,73560,HCPCS,facility,both,,,,414,414,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC RAD EXAM BOTH KNEES STANDING AP MIN 3 VIEWS,32000060,CDM,320,RC,73562,HCPCS,facility,both,,,,662,662,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC RAD EXAM KNEE ARTHROGRAPHY,32000061,CDM,320,RC,73564,HCPCS,facility,both,,,,729,729,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC RAD EXAM TIBIA AND FIBULA 2 VIEWS,32000062,CDM,320,RC,73565,HCPCS,facility,both,,,,345,345,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC RAD EXAM ANKLE 2 VIEWS,32000063,CDM,320,RC,73590,HCPCS,facility,both,,,,414,414,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC RAD EXAM ANKLE MIN 3 VIEWS,32000064,CDM,320,RC,73592,HCPCS,facility,both,,,,623,623,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC RAD EXAM ANKLE ARTHROGRAPHY,32000065,CDM,320,RC,73600,HCPCS,facility,both,,,,305,305,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC RAD EXAM FOOT MIN 3 VIEWS,32000067,CDM,320,RC,73610,HCPCS,facility,both,,,,662,662,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC RAD EXAM TOE(S) MIN 2 VIEWS,32000068,CDM,320,RC,73630,HCPCS,facility,both,,,,414,414,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CT LOWER EXT W/O CONTRAST,32000069,CDM,320,RC,73650,HCPCS,facility,both,,,,345,345,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CT LOWER EXT W CONTRAST,32000070,CDM,320,RC,73660,HCPCS,facility,both,,,,431,431,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CT ABDOMEN W CONTRAST,32000074,CDM,320,RC,74022,HCPCS,facility,both,,,,879,879,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC RAD EX, SWALL FUNC W/CIN/VID RAD, INCL SCOUT RAD(S)&IMG(S), CONTR STDY",32000075,CDM,320,RC,74190,HCPCS,facility,both,,,,842,842,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC RAD EXM, SM INT,INCL MULTI IMGS&SCOUT ABD RAD(S), SNGL-CONTR STDY",32000077,CDM,320,RC,74220,HCPCS,facility,both,,,,672,672,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC RAD EXM, SM INT,INCL MULTI IMGS&SCOUT ABD RAD(S), DBL- CONTR STDY",32000078,CDM,320,RC,74230,HCPCS,facility,both,,,,672,672,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC RAD EXM, COLON, W/SCOUT ABD RAD(S) & DELAY IMG(S); WHEN PERF; SNGL STDY",32000082,CDM,320,RC,74250,HCPCS,facility,both,,,,633,633,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC THERAPEUTIC ENEMA CONTRAST OR AIR FOR OBSTRC,32000083,CDM,320,RC,74251,HCPCS,facility,both,,,,611,611,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CHOLANGIOGRAPHY/PANCREATOGRAPHY INTRAOP,32000084,CDM,320,RC,74270,HCPCS,facility,both,,,,1130,1130,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC INTRO LONG GI TUBE INC MULTI FLUORO & FILMS,32000086,CDM,320,RC,74283,HCPCS,facility,both,,,,886,886,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PERC TRANSHEPATIC DILATION BILIARY DUCT,32000087,CDM,320,RC,74300,HCPCS,facility,both,,,,325,325,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC UROGRAPHY IV W OR W/O KUB/TOMOGRAPH,32000092,CDM,320,RC,74340,HCPCS,facility,both,,,,998,998,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC UROGRAPHY RETROGRADE W OR W/O KUB,32000093,CDM,320,RC,74363,HCPCS,facility,both,,,,5022,5022,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CYSTOGRAPHY MIN 3 VIEWS,32000094,CDM,320,RC,74400,HCPCS,facility,both,,,,1644,1644,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC URETHROCYSTOGRAPHY RETROGRADE S & I,32000095,CDM,320,RC,74420,HCPCS,facility,both,,,,1827,1827,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC URETHROCYSTOGRAPHY VOIDING S & I,32000097,CDM,320,RC,74430,HCPCS,facility,both,,,,1494,1494,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DILATE URETER(S) OR URETHRA,32000098,CDM,320,RC,74450,HCPCS,facility,both,,,,1644,1644,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PERINEOGRAM FOR SEX DETERMIN/ANOMALY,32000099,CDM,320,RC,74455,HCPCS,facility,both,,,,1619,1619,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CARDIAC MRI FOR MORPH & FUNC W/O CONTRAST,32000102,CDM,320,RC,74485,HCPCS,facility,both,,,,4142,4142,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CARDIAC MRI FOR MORPH & FUNC W/W/O CON,32000104,CDM,320,RC,74775,HCPCS,facility,both,,,,1484,1484,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC VENOGRAPHY EXT UNILATERAL,32000106,CDM,320,RC,75801,HCPCS,facility,both,,,,1993,1993,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC VENOGRAPHY EXT BILATERAL,32000107,CDM,320,RC,75805,HCPCS,facility,both,,,,4316,4316,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC VENOGRAPHY CAVAL INFERIOR W/SERIALOGRAPHY,32000109,CDM,320,RC,75820,HCPCS,facility,both,,,,3276,3276,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC VENOGRAPHY CAVAL SUPERIOR W/SERIALOGRAPH,32000110,CDM,320,RC,75822,HCPCS,facility,both,,,,3712,3712,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC VENOGRAPHY RENAL UNILATERAL SELECTIVE,32000111,CDM,320,RC,75825,HCPCS,facility,both,,,,5144,5144,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC VENOGRAPHY RENAL BILATERAL SELECTIVE,32000112,CDM,320,RC,75827,HCPCS,facility,both,,,,3072,3072,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC VENOGRAPHY VENOUS SINUS/JUGULAR CATHETER,32000113,CDM,320,RC,75831,HCPCS,facility,both,,,,11947,11947,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DISOPYRAMIDE,32000114,CDM,320,RC,75833,HCPCS,facility,both,,,,19951,19951,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC VENOGRAPHY SUPERIOR SAGITTAL SINUS,32000115,CDM,320,RC,75860,HCPCS,facility,both,,,,5273,5273,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PERCUT TRANSHEPATIC PORTOGRAM W/O HDM,32000116,CDM,320,RC,75870,HCPCS,facility,both,,,,4180,4180,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HEPATIC VENOGRAPHY W/ HDM,32000117,CDM,320,RC,75885,HCPCS,facility,both,,,,4874,4874,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AMIODARONE,32000118,CDM,320,RC,75887,HCPCS,facility,both,,,,4838,4838,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC S CEREVISIAE AB,32000119,CDM,320,RC,75889,HCPCS,facility,both,,,,4918,4918,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC E HISTOLYTICA AB,32000120,CDM,320,RC,75891,HCPCS,facility,both,,,,4950,4950,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC IDENT BY DNA SEQUENCE,32000121,CDM,320,RC,75893,HCPCS,facility,both,,,,8876,8876,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC LEGIONELLA AG,32000122,CDM,320,RC,75894,HCPCS,facility,both,,,,14393,14393,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC STREP PNUMO AG,32000124,CDM,320,RC,75898,HCPCS,facility,both,,,,3309,3309,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC TRANSCATHETER BIOPSY,32000126,CDM,320,RC,75901,HCPCS,facility,both,,,,1458,1458,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PERC DRAINAGE CATH PLACEMENT W/ RAD GUID,32000127,CDM,320,RC,75902,HCPCS,facility,both,,,,700,700,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC FLUOROSCOPE EXAMINATION UP TO 1 HOUR,32000135,CDM,320,RC,75970,HCPCS,facility,both,,,,6056,6056,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC RAD EX FISTULA OR SINUS TRACT STUDY S & I,32000139,CDM,320,RC,75984,HCPCS,facility,both,,,,1142,1142,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC 3D RENDERING W/O POSTPROCESS,32000140,CDM,320,RC,75989,HCPCS,facility,both,,,,1309,1309,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC 3D RENDERING W POSTPROCESS,32000141,CDM,320,RC,76000,HCPCS,facility,both,,,,948,948,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CT LIMITED OR LOCALIZED FOLLOW-UP STUDY,32000143,CDM,320,RC,76080,HCPCS,facility,both,,,,1658,1658,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ULTRASOUND CHEST INCLS MEDIASTINUM,32000145,CDM,320,RC,76499,HCPCS,facility,both,,,,1375,1375,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CT SCAN FOR NEEDLE BIOPSY,32000146,CDM,320,RC,77001,HCPCS,facility,both,,,,1377,1377,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CT GUIDANCE TISSUE ABLATION,32000147,CDM,320,RC,77002,HCPCS,facility,both,,,,684,684,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC BONE AGE STUDIES,32000148,CDM,320,RC,77003,HCPCS,facility,both,,,,824,824,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC RAD EXAM OSSEOUS SURVEY COMPLETE,32000152,CDM,320,RC,77072,HCPCS,facility,both,,,,545,545,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC RAD EXAM OSSEOUS SURVEY INFANT,32000153,CDM,320,RC,77073,HCPCS,facility,both,,,,454,454,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC DXA BONE DENSITY STUDY, AXIAL 1+ SITES",32000154,CDM,320,RC,77074,HCPCS,facility,both,,,,523,523,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC LYMPHATICS AND LYMPH NODE IMAGING,32000155,CDM,320,RC,77075,HCPCS,facility,both,,,,920,920,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HEPATOBILIARY SYSTEM IMAG INC GALLBLADDER,32000156,CDM,320,RC,77076,HCPCS,facility,both,,,,1101,1101,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC GASTROESOPHAGEAL REFLUX SCAN,32000157,CDM,320,RC,77080,HCPCS,facility,both,,,,1039,1039,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC REPOSITIONING CENTRAL VENOUS CATHETER W/FLOURO,32000161,CDM,320,RC,75842,HCPCS,facility,both,,,,8541,8541,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC REPLACE GASTRO/CECO TUBE PERCUTANEOUS,32000162,CDM,320,RC,75840,HCPCS,facility,both,,,,6107,6107,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MRI LEXTREM W&WO CONTR,32000202,CDM,320,RC,70371,HCPCS,facility,both,,,,989,989,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC INSERT CATHETER RENAL ARTERY 1ST UNILATERAL,32000203,CDM,320,RC,72120,HCPCS,facility,both,,,,549,549,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC US INFANT HIPS; DYNAMIC,32000204,CDM,320,RC,72200,HCPCS,facility,both,,,,350,350,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC LIVER & SPLEEN; STATIC ONLY,32000206,CDM,320,RC,73620,HCPCS,facility,both,,,,261,261,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HEPATOBIL SYST IMAGE W/DRUG,32000207,CDM,320,RC,74240,HCPCS,facility,both,,,,977,977,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ESOPHAGEAL MOTILITY,32000208,CDM,320,RC,74246,HCPCS,facility,both,,,,447,447,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MRA ABDOMEN WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST,32000215,CDM,320,RC,76010,HCPCS,facility,both,,,,423,423,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC FINE NEEDLE ASPIRATION BIOPSY, W/US GUIDANCE, 1ST LESION",32000218,CDM,320,RC,70390,HCPCS,facility,both,,,,1173,1173,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC FINE NEEDLE ASPIRATION BIOPSY, W/FLUORO GUIDANCE, 1ST LESION",32000226,CDM,320,RC,74470,HCPCS,facility,both,,,,2015,2015,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC FINGER CAST MATERIAL,32000250,CDM,320,RC,70320,HCPCS,facility,both,,,,166,166,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AUTO CELL PROC/PREP/STORE,32000252,CDM,320,RC,77077,HCPCS,facility,both,,,,523,523,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "DEAC 9/1/2020 HC LEUKOCYTE POOR BLOOD, PEDS, EA UNIT",32000255,CDM,320,RC,75807,HCPCS,facility,both,,,,8492,8492,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DRAIN/INJ SMALL JOINT/BURSA W/US,32000258,CDM,320,RC,77086,HCPCS,facility,both,,,,260,260,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC INFECTIOUS AGENT DRUG SUSCEPTIBILITY PHENOTYPE,32000262,CDM,320,RC,72081,HCPCS,facility,both,,,,422,422,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC SOMATOSENSORY TESTING; UPPER & LOWER LIMBS,32000263,CDM,320,RC,72082,HCPCS,facility,both,,,,701,701,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CENTRAL MOTOR EVOKED UPPER & LOWER LIMBS,32000264,CDM,320,RC,72083,HCPCS,facility,both,,,,416,416,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC INFECTIOUS AGENT GENOTYPE ANALYSIS BY NUCLEIC ACID, RT/PR",32000265,CDM,320,RC,72084,HCPCS,facility,both,,,,845,845,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC INFECTIOUS AGENT GENOTYPE ANALYSIS BY NUCLEIC ACID, OTHER REGION",32000266,CDM,320,RC,73501,HCPCS,facility,both,,,,229,229,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC INSERTION/REPLACEMENT SUBCUTANEOUS DEFIBRILLATOR,32000267,CDM,320,RC,73502,HCPCS,facility,both,,,,464,464,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC INSERT SUBCUTANEOUS IMPLANTABLE DEFIBRILLATOR ELECTRODE,32000269,CDM,320,RC,73521,HCPCS,facility,both,,,,673,673,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC REMOVAL OF SUBCUTANEOUS IMPLANTABLE DEFIBRILLATOR,32000272,CDM,320,RC,73551,HCPCS,facility,both,,,,205,205,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC REPOSITIONING PREVIOUS IMPLANTED SUBQ DEFIB ELECTRODE,32000273,CDM,320,RC,73552,HCPCS,facility,both,,,,603,603,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE DEAC 11/01/2023 HC ADM SARSCV2 BVL 3 MCG/0.2ML 2ND DOSE,32000274,CDM,320,RC,70355,HCPCS,facility,both,,,,379,379,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC DXA BONE DENSITY STDY, 1+ SITES; AXIAL SKEL, INCL VERTEB FRACTURE ASSESS",32000276,CDM,320,RC,77085,HCPCS,facility,both,,,,886,886,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MUSCLE TEST DONE W/NERVE TEST LIMITED,32000277,CDM,320,RC,75803,HCPCS,facility,both,,,,3516,3516,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC X-RAY EXAM CHEST 2 VIEWS,32000278,CDM,320,RC,74018,HCPCS,facility,both,,,,423,423,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC X-RAY EXAM CHEST 3 VIEWS,32000279,CDM,320,RC,74019,HCPCS,facility,both,,,,678,678,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC X-RAY EXAM CHEST 4 OR MORE VIEWS,32000280,CDM,320,RC,74021,HCPCS,facility,both,,,,755,755,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HEALTH BEHAVIOR INTERV GROUP FACE TO FACE; 1ST 30 MIN,32000281,CDM,320,RC,74248,HCPCS,facility,both,,,,135,135,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CYTOGENOMIC NEO MICRORA ALYS (350),32000283,CDM,921,RC,93986,HCPCS,facility,both,,,,397,397,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC COMPRE ELECTROPHYSIOLOGIC ARRHYTHMIA INDUCTION,32000284,CDM,320,RC,76496,HCPCS,facility,both,,,,993,993,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ELECTROPHYSIOLOGY EVALUATION,32000285,CDM,320,RC,75880,HCPCS,facility,both,,,,2885,2885,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ESOPHAGEAL REC ATRIAL W/WO VENTR ELECTRGRAMS W/PACG,32000286,CDM,320,RC,75872,HCPCS,facility,both,,,,3815,3815,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC RAD EXAM HUMERUS, MIN 2 VIEWS",32200001,CDM,322,RC,73040,HCPCS,facility,both,,,,1970,1970,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC RAD EXAM UPPER EXT INFANT MIN 2 VIEWS,32200002,CDM,322,RC,73085,HCPCS,facility,both,,,,1584,1584,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC RAD EXAM HAND, MIN 3 VIEWS",32200003,CDM,322,RC,73115,HCPCS,facility,both,,,,2334,2334,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC RAD EXAM KNEE 3 VIEWS,32200004,CDM,322,RC,73525,HCPCS,facility,both,,,,1642,1642,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC RAD EXAM LOWER EXT INFANT MIN 2 VIEWS,32200005,CDM,322,RC,73580,HCPCS,facility,both,,,,1791,1791,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC RAD EXAM CALCANEUS MIN 2 VIEWS,32200006,CDM,322,RC,73615,HCPCS,facility,both,,,,1477,1477,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AORTOGRAM ABDOMINAL W/ BILATERAL RUNOFF,32300001,CDM,323,RC,75605,HCPCS,facility,both,,,,8848,8848,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ANGIOGRAPHY SPINAL SELECTIVE,32300002,CDM,323,RC,75625,HCPCS,facility,both,,,,7274,7274,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ANGIOGRAPHY EXT UNILATERAL S & I,32300003,CDM,323,RC,75630,HCPCS,facility,both,,,,5064,5064,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ANGIOGRAPHY EXT BILATERAL S & I,32300012,CDM,323,RC,75705,HCPCS,facility,both,,,,10054,10054,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ANGIOGRAPHY VISCERAL SELECT/SUPRASELECT,32300013,CDM,323,RC,75710,HCPCS,facility,both,,,,4534,4534,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ANGIOGRAPHY ADRENAL UNILATERAL SELECTIVE,32300014,CDM,323,RC,75716,HCPCS,facility,both,,,,5280,5280,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ANGIOGRAPHY ADRENAL BILATERAL SELECTIVE,32300015,CDM,323,RC,75726,HCPCS,facility,both,,,,8099,8099,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ANGIOGRAPHY PELVIC SELECT/SUPRASELECT,32300016,CDM,323,RC,75731,HCPCS,facility,both,,,,3981,3981,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ANGIOGRAPHY PULMONARY UNILAT SELECTIVE,32300017,CDM,323,RC,75733,HCPCS,facility,both,,,,6107,6107,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ANGIOGRAPHY PULMONARY BILAT SELECTIVE,32300018,CDM,323,RC,75736,HCPCS,facility,both,,,,7934,7934,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ANGIOGRAPHY PULMONARY NONSEL CATH/INJECT,32300019,CDM,323,RC,75741,HCPCS,facility,both,,,,3948,3948,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ANGIOGRAPHY SELECTIVE EA ADDTL VESSEL,32300020,CDM,323,RC,75743,HCPCS,facility,both,,,,5648,5648,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC LYMPHANGIOGRAPHY EXT ONLY UNILAT,32300021,CDM,323,RC,75746,HCPCS,facility,both,,,,4929,4929,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC LYMPHANGIOGRAPHY PELVIC/ABDOMINAL UNILAT,32300023,CDM,323,RC,75774,HCPCS,facility,both,,,,2000,2000,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC RIBS X-RAY, BILAT, MIN 4 VIEWS INCL CHEST",32400009,CDM,320,RC,71101,HCPCS,facility,both,,,,538,538,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC STERNUM X-RAY MIN 2 VIEWS,32400010,CDM,320,RC,71111,HCPCS,facility,both,,,,619,619,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC STERNOCLAVICULAR JT(S) X-RAY MIN 3 VIEWS,32400011,CDM,320,RC,71120,HCPCS,facility,both,,,,305,305,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DX CT THORAX W/O CONTRAST,32400012,CDM,320,RC,71130,HCPCS,facility,both,,,,355,355,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC RAD EXM, UGI, W/SCOUT ABD RAD(S) & DELAY IMG(S); WHEN PERF; SNGL STDY",32400020,CDM,320,RC,71100,HCPCS,facility,both,,,,361,361,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC RAD EXM, UGI, W/SCOUT ABD RAD(S) & DELAY IMG(S); WHEN PERF; DBL STDY",32400022,CDM,320,RC,71110,HCPCS,facility,both,,,,604,604,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC IMMUNOGLOBULIN; IGA, IGD, IGG, IGM EACH",32400025,CDM,324,RC,71045,HCPCS,facility,both,,,,795,795,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC ENDOMYSIAL AB (EMA), EA IMMUNOGLOBULIN (IG) CLASS",32400026,CDM,324,RC,71046,HCPCS,facility,both,,,,1118,1118,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CINE OR VIDEO SPEECH EVAL,32400026,CDM,324,RC,71046,HCPCS,facility,both,,,,15,15,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC X-RAY EXAM OF RIBS 2 VIEWS UNILAT,32400027,CDM,324,RC,71047,HCPCS,facility,both,,,,1440,1440,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC X-RAY EXAM OF RIBS 3 VIEWS BILAT,32400028,CDM,324,RC,71048,HCPCS,facility,both,,,,1536,1536,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC CHEMOTHERAPY ADMIN, IVP EA ADDL",33100001,CDM,331,RC,96401,HCPCS,facility,both,,,,513,513,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC CHEMOTHERAPY IV INFUSION, 1ST HR",33100002,CDM,331,RC,96402,HCPCS,facility,both,,,,521,521,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC CHEMOTHERAPY IV INFUSION, EA ADDL HR",33100003,CDM,331,RC,96409,HCPCS,facility,both,,,,838,838,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC CHEMOTHERAPY IV INFUSION, EA ADDL SEQ",33100004,CDM,331,RC,96411,HCPCS,facility,both,,,,267,267,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PARAFFIN BATH THERAPY,33100005,CDM,331,RC,96450,HCPCS,facility,both,,,,2785,2785,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ELECTRICAL STIMULATION EA 15 MINS,33100006,CDM,331,RC,96542,HCPCS,facility,both,,,,629,629,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC CHEMOTHERAPY ADMIN, CNS W/LP",33500001,CDM,335,RC,96413,HCPCS,facility,both,,,,1320,1320,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CHEMOTHERAPY INJ VIA SQ RESERVOIR,33500002,CDM,335,RC,96415,HCPCS,facility,both,,,,319,319,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC IRRIGATION OF IMPLANTED VAD,33500003,CDM,335,RC,96417,HCPCS,facility,both,,,,634,634,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC ABLATE, 1 OR MORE PULM TUMOR, PERQ, UNIL; RF",33500005,CDM,335,RC,96416,HCPCS,facility,both,,,,1403,1403,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ACUTE GASTROINTESTINAL BLOOD LOSS IMAGING,34100009,CDM,341,RC,78195,HCPCS,facility,both,,,,1741,1741,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC INTESTINE IMAGING E.G. MECKEL'S LOCALIZATION,34100013,CDM,341,RC,78226,HCPCS,facility,both,,,,1936,1936,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC BONE AND/OR JOINT IMAGING, LIMITED AREA",34100014,CDM,341,RC,78262,HCPCS,facility,both,,,,1949,1949,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC BONE AND/OR JOINT IMAGING, WHOLE BODY",34100018,CDM,341,RC,78278,HCPCS,facility,both,,,,1698,1698,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC BONE AND/OR JOINT IMAGING , 3 PHASE STUDY",34100019,CDM,341,RC,78290,HCPCS,facility,both,,,,1713,1713,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PULMONARY PERFUSION IMAGING PARTICULATE,34100021,CDM,341,RC,78300,HCPCS,facility,both,,,,1724,1724,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC BRAIN IMAGING, PET, METABOLIC EVALUATION",34100022,CDM,341,RC,78306,HCPCS,facility,both,,,,2081,2081,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CEREBROSPINAL FLUID FLOW IMG CISTERNOGRAM,34100023,CDM,341,RC,78315,HCPCS,facility,both,,,,1294,1294,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CEREBROSPINAL FLUID FLOW IMG SHUNT EVAL,34100031,CDM,341,RC,78580,HCPCS,facility,both,,,,1490,1490,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC KIDNEY IMAGING W/VASC FLOW & FUNCTION,34100035,CDM,341,RC,78630,HCPCS,facility,both,,,,2741,2741,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC KIDNEY IMAGING W/VASC FLOW & FUNC W/DRUG,34100036,CDM,341,RC,78645,HCPCS,facility,both,,,,2878,2878,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC KIDNEY STUDY NON-IMAGING RADIOISOTOPIC,34100037,CDM,341,RC,78650,HCPCS,facility,both,,,,3952,3952,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC URETER REFLUX STUDY RADIOPHARM CYSTOGRAM,34100038,CDM,341,RC,78707,HCPCS,facility,both,,,,1817,1817,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC RADIOPHARM LOCAL TUMOR; PLANAR, SINGLE AREA, SINGLE DAY IMG",34100039,CDM,341,RC,78708,HCPCS,facility,both,,,,2182,2182,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC RADIOPHARM LOCAL TUMOR ; PLANAR, WHOLE BODY, SINGLE DAY IMG",34100041,CDM,341,RC,78725,HCPCS,facility,both,,,,1399,1399,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PET IMAGING W/CT SKULL BASE TO MID-THIGH,34100042,CDM,341,RC,78740,HCPCS,facility,both,,,,2389,2389,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PET IMAGING W/CT WHOLE BODY,34100044,CDM,341,RC,78800,HCPCS,facility,both,,,,2040,2040,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC UNLISTED MISC PROC DIAGNOSTIC NUCLEAR MED,34100045,CDM,341,RC,78802,HCPCS,facility,both,,,,2719,2719,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MRA LOWER EXTREMITY WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST,34100063,CDM,341,RC,78215,HCPCS,facility,both,,,,1936,1936,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MRA PELVIS WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST,34100064,CDM,341,RC,78216,HCPCS,facility,both,,,,1332,1332,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PREFAB AFO,34100065,CDM,341,RC,78227,HCPCS,facility,both,,,,1955,1955,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC BREATHING RESPONSE TO CO2,34100066,CDM,341,RC,78258,HCPCS,facility,both,,,,1340,1340,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC INTRO NEEDLE OR INTRACATHETER, UPPER OR LOWER EXTREMITY ARTERY",34100085,CDM,341,RC,78597,HCPCS,facility,both,,,,2456,2456,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC INSERT SWAN GANZ CATH BEDSIDE,34100120,CDM,341,RC,78700,HCPCS,facility,both,,,,2509,2509,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC INSERT CATHETER RENAL ARTERY 2ND, UNILAT",34100130,CDM,341,RC,78804,HCPCS,facility,both,,,,5201,5201,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PLEURA CATHETER INSERTION W/IMAGE,34100136,CDM,341,RC,78104,HCPCS,facility,both,,,,1251,1251,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HA DISPENSING FEE UNSPECIFIED,34100141,CDM,341,RC,78013,HCPCS,facility,both,,,,893,893,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC HA, DIGITAL, ADVANCED, MONAURAL, ITC",34100142,CDM,341,RC,78014,HCPCS,facility,both,,,,1593,1593,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MRA SPINAL CANAL WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST,34100157,CDM,341,RC,78830,HCPCS,facility,both,,,,3878,3878,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC TARGETED GENOMIC SEQ ANALYSIS (467),34100159,CDM,341,RC,78832,HCPCS,facility,both,,,,3878,3878,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC IH BRONCHIAL CHALLENGE; W HISTAMINE,34100203,CDM,341,RC,78072,HCPCS,facility,both,,,,1279,1279,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC INJECT INTERLAMINAR CRV/THRC; W/IMG,34100205,CDM,341,RC,78264,HCPCS,facility,both,,,,2046,2046,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CT SOFT TISSUE NECK W/CONTRAST,35000001,CDM,350,RC,70490,HCPCS,facility,both,,,,1643,1643,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CT SOFT TISSUE NECK W/O & W/CONTRAST,35000002,CDM,350,RC,70491,HCPCS,facility,both,,,,2374,2374,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CT ANGIO HEAD W/CONTRAST MATERIAL(S),35000003,CDM,350,RC,70492,HCPCS,facility,both,,,,2579,2579,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MRI ORBIT/FACE/NECK W/O CONTRAST,35000004,CDM,350,RC,70498,HCPCS,facility,both,,,,1456,1456,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CT HEART W/CON FOR CONGENTIAL HEART DIS,35000005,CDM,350,RC,75571,HCPCS,facility,both,,,,545,545,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CTA HEART W/CON W/3D IMAGE POSTPROCESS,35000006,CDM,350,RC,75572,HCPCS,facility,both,,,,1300,1300,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AORTOGRAPHY THORACIC BY SERIALOGRAPHY,35000007,CDM,350,RC,75573,HCPCS,facility,both,,,,1129,1129,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AORTOGRAPHY ABDOMINAL BY SERIALOGRAPHY,35000008,CDM,350,RC,75574,HCPCS,facility,both,,,,1349,1349,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC UNLISTED CT PROCEDURE,35000009,CDM,350,RC,76376,HCPCS,facility,both,,,,1167,1167,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC UNLISTED MAGNETIC RESONANCE PROCEDURE,35000010,CDM,350,RC,76377,HCPCS,facility,both,,,,1397,1397,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC UNLISTED DIAGNOSTIC RADIOGRAPHIC PROCEDURE,35000011,CDM,350,RC,76380,HCPCS,facility,both,,,,1214,1214,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC BONE LENGTH STUDIES,35000013,CDM,350,RC,77012,HCPCS,facility,both,,,,3417,3417,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC RAD EXAM OSSEOUS SURVEY LIMITED,35000014,CDM,350,RC,77013,HCPCS,facility,both,,,,1890,1890,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC INTRACARDIAC CATH ABLATION ATRIOVENTR NODE FUNCTION,35000016,CDM,350,RC,,,facility,both,,,,3680,3680,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC CT HEAD OR BRAIN, W CONTRAST",35100001,CDM,351,RC,70450,HCPCS,facility,both,,,,1983,1983,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC CT HEAD OR BRAIN, W & W/O CONTRAST",35100002,CDM,351,RC,70460,HCPCS,facility,both,,,,2056,2056,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC CT ORBIT, SELLA, POSTERIOR FOSSA W/O CONTRAST",35100003,CDM,351,RC,70470,HCPCS,facility,both,,,,2455,2455,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC CT ORBIT, SELLA, POSTERIOR FOSSA W CONTRAST",35100004,CDM,351,RC,70480,HCPCS,facility,both,,,,2160,2160,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC CT ORBIT, SELLA, P. FOSSA W/O & W CONTRAST",35100005,CDM,351,RC,70481,HCPCS,facility,both,,,,2238,2238,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CT MAXILLOFACIAL W/O CONTRAST,35100006,CDM,351,RC,70482,HCPCS,facility,both,,,,2455,2455,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CT MAXILLOFACIAL W/CONTRAST,35100007,CDM,351,RC,70486,HCPCS,facility,both,,,,1983,1983,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CT MAXILLOFACIAL W/O & W/CONTRAST,35100008,CDM,351,RC,70487,HCPCS,facility,both,,,,2351,2351,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CT SOFT TISSUE NECK W/O CONTRAST,35100009,CDM,351,RC,70488,HCPCS,facility,both,,,,2455,2455,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CT ANGIO NECK W/CONTRAST MATERIAL(S),35100010,CDM,351,RC,70496,HCPCS,facility,both,,,,1472,1472,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DX CT THORAX W CONTRAST,35200001,CDM,352,RC,71250,HCPCS,facility,both,,,,2476,2476,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DX CT THORAX W & W/O CONTRAST,35200002,CDM,352,RC,71260,HCPCS,facility,both,,,,2965,2965,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MRI CHEST W/O CONTRAST,35200003,CDM,352,RC,71270,HCPCS,facility,both,,,,3064,3064,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MRI CHEST W & W/O CONTRAST,35200004,CDM,352,RC,71275,HCPCS,facility,both,,,,1759,1759,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC CT THORACIC SPINE, W/O CONTRAST",35200005,CDM,352,RC,72125,HCPCS,facility,both,,,,2574,2574,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC CT THORACIC SPINE, W CONTRAST",35200006,CDM,352,RC,72126,HCPCS,facility,both,,,,2696,2696,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC CT LUMBAR SPINE, W/O CONTRAST",35200008,CDM,352,RC,72128,HCPCS,facility,both,,,,2451,2451,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC CT LUMBAR SPINE, W CONTRAST",35200009,CDM,352,RC,72129,HCPCS,facility,both,,,,2696,2696,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC MRI SPINE CERVICAL, W/O CONTRAST",35200011,CDM,352,RC,72131,HCPCS,facility,both,,,,2152,2152,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC MRI SPINE CERVICAL, W CONTRAST",35200012,CDM,352,RC,72132,HCPCS,facility,both,,,,2364,2364,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CT PELVIS W CONTRAST,35200014,CDM,352,RC,72191,HCPCS,facility,both,,,,1303,1303,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CT PELVIS W & W/O CONTRAST,35200015,CDM,352,RC,72192,HCPCS,facility,both,,,,2358,2358,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MRI PELVIS W/O CONTRAST,35200016,CDM,352,RC,72193,HCPCS,facility,both,,,,2698,2698,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MRI PELVIS W CONTRAST,35200017,CDM,352,RC,72194,HCPCS,facility,both,,,,2940,2940,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CTA UPPER EXT W & W/O CONTRAST,35200019,CDM,352,RC,73200,HCPCS,facility,both,,,,1723,1723,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MRI UPPER EXT NOT JOINT W/O CONTRAST,35200020,CDM,352,RC,73201,HCPCS,facility,both,,,,2052,2052,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MRI UPPER EXT NOT JOINT W & W/O CONTRAST,35200021,CDM,352,RC,73206,HCPCS,facility,both,,,,1456,1456,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CT LOWER EXT W & W/O CONTRAST,35200022,CDM,352,RC,73700,HCPCS,facility,both,,,,2162,2162,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CTA LOWER EXT W/O & W CONTRAST,35200023,CDM,352,RC,73701,HCPCS,facility,both,,,,2264,2264,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MRI LOWER EXT NOT JOINT W/O CONTRAST,35200024,CDM,352,RC,73702,HCPCS,facility,both,,,,2488,2488,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MRI ANY JOINT LOWER EXT W/O CONTRAST,35200025,CDM,352,RC,73706,HCPCS,facility,both,,,,2488,2488,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CT ABDOMEN W & W/O CONTRAST,35200026,CDM,352,RC,74150,HCPCS,facility,both,,,,1285,1285,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CTA ABDOMEN W/O AND W CONTRAST,35200027,CDM,352,RC,74160,HCPCS,facility,both,,,,2614,2614,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CT ABDOMEN AND PELVIS W/O CONTRAST,35200028,CDM,352,RC,74170,HCPCS,facility,both,,,,2787,2787,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CT ABDOMEN AND PELVIS W CONTRAST,35200029,CDM,352,RC,74175,HCPCS,facility,both,,,,1520,1520,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CT ABDOMEN AND PELVIS W & W/O CONTRAST,35200030,CDM,352,RC,74176,HCPCS,facility,both,,,,4852,4852,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MRI ABDOMEN W/O CONTRAST,35200031,CDM,352,RC,74177,HCPCS,facility,both,,,,5727,5727,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MRI ABDOMEN W CONTRAST,35200032,CDM,352,RC,74178,HCPCS,facility,both,,,,6001,6001,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC FINE NEEDLE ASPIRATION BIOPSY, W/US GUIDANCE, EA ADDL LESION",35200041,CDM,352,RC,73202,HCPCS,facility,both,,,,2342,2342,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "DEAC 9/1/2020 HC PLATELETS PHERESIS LR, PEDS, EA UNIT",35200050,CDM,352,RC,74174,HCPCS,facility,both,,,,1692,1692,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC ABLATE BONE TUMOR, PERQ, W/IMAG PERF, CRYO",36000005,CDM,360,RC,,,facility,both,,,,35901.6,35901.6,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC HA DIGITAL, PREMIUM, MONAURAL BTE",36000124,CDM,360,RC,,,facility,both,,,,2704,2704,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC HA DIGITAL, PREMIUM, MONAURAL CIC",36000125,CDM,360,RC,,,facility,both,,,,2704,2704,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "DEAC 7/1/2023 HC APPLY CAST, FINGER",36000129,CDM,360,RC,,,facility,both,,,,12155.36,12155.36,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC INSERTION PICC W/O GUIDE <5 YRS,36000130,CDM,360,RC,,,facility,both,,,,15471.68,15471.68,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC INSERTION PICC W/GUIDE <5 YRS,36000131,CDM,360,RC,,,facility,both,,,,12155.36,12155.36,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC REPAIR CVA CATH W/O SUBQ PORT/PUMP,36000132,CDM,360,RC,,,facility,both,,,,210,210,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CSF SHUNT REPROGRAMMING,36000133,CDM,360,RC,,,facility,both,,,,83,83,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ALPHA-GLOBIN GENE ANALYSIS,36000134,CDM,360,RC,,,facility,both,,,,243,243,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC RETINAL RPGR GENE SEQUENCE,36000135,CDM,360,RC,,,facility,both,,,,98,98,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HSV-6 IGG AB,36000136,CDM,360,RC,,,facility,both,,,,279,279,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DIALYSIS TRAINING/COMPLETE,36000137,CDM,360,RC,,,facility,both,,,,119,119,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC HA DIGITAL, BASIC MONAURAL, CIC",36000138,CDM,360,RC,,,facility,both,,,,314,314,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC HA DIGITAL, BASIC MONAURAL, ITC",36000139,CDM,360,RC,,,facility,both,,,,167,167,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC HA DIGITAL, BASIC MONAURAL, ITE",36000140,CDM,360,RC,,,facility,both,,,,348,348,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC HA DIGITAL, BASIC MONAURAL, BTE",36000141,CDM,360,RC,,,facility,both,,,,188,188,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC X-LINKED INTELLECTUAL (AUTISM) DUP/DEL GENE ANAL,36000144,CDM,360,RC,,,facility,both,,,,8672.16,8672.16,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DRUG/SUBSTANCE NOS 7/MORE (135),36100002,CDM,361,RC,,,facility,both,,,,224,224,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC EXTEMITY VENOGRAPHY INJECTION,36100053,CDM,761,RC,20500,HCPCS,facility,both,,,,3577,3577,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC NONSELECTIVE CATH, SUPERIOR/INFERIOR VENA CAVA",36100055,CDM,761,RC,20550,HCPCS,facility,both,,,,2631,2631,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC SELECTIVE CATHETER, FIRST ORDER FAMILY",36100058,CDM,761,RC,20605,HCPCS,facility,both,,,,1948,1948,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC SELECTIVE CATHETER, SECOND ORDER FAMILY",36100065,CDM,761,RC,23350,HCPCS,facility,both,,,,750,750,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC SELECTIVE CATH ARTERY, BRACH-CEPH, FIRST ORDER",36100066,CDM,761,RC,24220,HCPCS,facility,both,,,,4985,4985,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC INSERT CATHETER ABD/L-EXT ART 2ND,36100067,CDM,761,RC,25246,HCPCS,facility,both,,,,5045,5045,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC INSERT CATHETER ABD/L-EXT ART 3RD,36100068,CDM,761,RC,27093,HCPCS,facility,both,,,,7989,7989,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC INJECTION(S) OF SCLEROSANT FOR SPIDER VEINS, LIMB OR TRUNK",36100073,CDM,761,RC,36005,HCPCS,facility,both,,,,3552,3552,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC INSERT NON-TUNNELED CV CATHETER, AGE 5 OR OLDER",36100074,CDM,761,RC,36010,HCPCS,facility,both,,,,643,643,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC INSERT TUNNELED CV CATHETER, AGE 5 OR OLDER",36100075,CDM,761,RC,36011,HCPCS,facility,both,,,,1075,1075,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC INSERT TUNNELED CVAD W/PORT, 5YRS OR OLDER",36100076,CDM,761,RC,36012,HCPCS,facility,both,,,,1075,1075,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC REPLACE TUNNELED CV CATHETER, SAME VENOUS",36100078,CDM,761,RC,36215,HCPCS,facility,both,,,,2204,2204,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC REPLACE TUNNELED CVAD WITH PORT,36100080,CDM,761,RC,36246,HCPCS,facility,both,,,,2510,2510,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC REPLACE PICC CATHETER, INCL IMAGE GUIDE",36100081,CDM,761,RC,36247,HCPCS,facility,both,,,,2510,2510,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC REMOVE TUNNELED CV CATHETER, WO PORT",36100082,CDM,761,RC,36468,HCPCS,facility,both,,,,953,953,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC REMOVE TUNNELED CVAD, WITH PORT OR PUMP",36100085,CDM,761,RC,36556,HCPCS,facility,both,,,,7349,7349,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC INSERT ENDOVASCULAR VENA CAVA FILTER,36100086,CDM,761,RC,36558,HCPCS,facility,both,,,,11015,11015,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC REMOVE ENDOVASCULAR VENA CAVE FILTER,36100087,CDM,761,RC,36561,HCPCS,facility,both,,,,14245,14245,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC TRANSCATHETER BIOPSY,36100088,CDM,761,RC,36581,HCPCS,facility,both,,,,5552,5552,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC REVASC, ILIAC ARTERY, UNIL, 1ST VESSEL; W STENT",36100089,CDM,761,RC,36582,HCPCS,facility,both,,,,5940,5940,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC REVASC, OPEN/PERCUT, FEMORAL/POPLITEAL W/TLA; UNIL",36100090,CDM,761,RC,36584,HCPCS,facility,both,,,,6238,6238,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC UNLISTED VASCULAR SURGERY PROCEDURE,36100091,CDM,761,RC,36589,HCPCS,facility,both,,,,1483,1483,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC REPOSITION GASTROSTOMY TUBE,36100092,CDM,761,RC,36590,HCPCS,facility,both,,,,3808,3808,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PERCUT DILATION BILARY STRICTURE WO STENT,36100094,CDM,761,RC,37191,HCPCS,facility,both,,,,13240,13240,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PERCUT DILATION BILARY STRICTURE WITH STENT,36100095,CDM,761,RC,37193,HCPCS,facility,both,,,,5780,5780,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC CONTRAST INJECTION, ASSESS CYST VIA EXIST CATH",36100096,CDM,761,RC,37200,HCPCS,facility,both,,,,9167,9167,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC PLACE GASTROSTOMY TUBE, PERCUT, UNDER FLUORO GUIDE",36100101,CDM,761,RC,37221,HCPCS,facility,both,,,,16455,16455,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC REMOVE RENAL TUBE W/FLUORO,36100102,CDM,761,RC,37224,HCPCS,facility,both,,,,8310,8310,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC INJECT ILEAL CONDUIT/URETEROPYELOGRAM,36100105,CDM,761,RC,37799,HCPCS,facility,both,,,,13343,13343,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC INJECTION CYSTOGRAPHY OR VOIDING URETHROCYSTOGRAPHY,36100108,CDM,761,RC,43761,HCPCS,facility,both,,,,5261,5261,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC MYELOGRAM INJECT, SPINAL NOT C1-C2",36100114,CDM,761,RC,47555,HCPCS,facility,both,,,,5691,5691,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC INJECTION DISCOGRAPHY, EACH LEVEL; LUMBAR",36100115,CDM,761,RC,47556,HCPCS,facility,both,,,,6126,6126,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC INJ(S), ANESTH AGENT(S) &/OR STERIOD; TRIGEMINAL NERVE, EA BRCH",36100118,CDM,761,RC,49424,HCPCS,facility,both,,,,4439,4439,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC INJ(S), ANESTH AGENT(S) &/OR STERIOD; GREATER OCCIPITAL NERVE",36100119,CDM,761,RC,49440,HCPCS,facility,both,,,,5342,5342,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC INJ(S), ANESTH AGENT(S) &/OR STERIOD; INTERCOSTAL NERVE, SNGL LEVEL",36100123,CDM,761,RC,50389,HCPCS,facility,both,,,,2829,2829,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC INJ(S), ANESTH AGENT(S) &/OR STERIOD; INTERCOSTAL NERVE EA ADDL LEVEL",36100129,CDM,761,RC,50690,HCPCS,facility,both,,,,1988,1988,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC INJ PARAVERTEBRAL FACET, LUMBAR/SACRAL, 1 LEVEL",36100130,CDM,761,RC,51600,HCPCS,facility,both,,,,797,797,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC INJ PARAVERTEBRAL FACET, LUMBAR/SACRAL, 2 LEVEL",36100133,CDM,761,RC,62284,HCPCS,facility,both,,,,4388,4388,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC NERVE BLOCK INJ, CELIAC PLEXUS",36100135,CDM,761,RC,62290,HCPCS,facility,both,,,,6399,6399,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC RBC DEGLYCEROLIZED EACH UNIT,36100143,CDM,761,RC,64400,HCPCS,facility,both,,,,2448,2448,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC RBC LR IRRADIATED EACH UNIT,36100144,CDM,761,RC,64405,HCPCS,facility,both,,,,2448,2448,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC FFP 8-24 HRS OF COLLECT EA UNIT,36100145,CDM,761,RC,64420,HCPCS,facility,both,,,,2410,2410,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PLATELETS PHERESIS LR EA UNIT,36100146,CDM,761,RC,64421,HCPCS,facility,both,,,,2983,2983,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PLATELETS PHERESIS LR IRRAD EA UNIT,36100155,CDM,761,RC,64493,HCPCS,facility,both,,,,4338,4338,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC CONTINUOUS INHALATION TX, 1ST HOUR",36100156,CDM,761,RC,64494,HCPCS,facility,both,,,,2631,2631,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC CONTINUOUS INHALATION TX, EA ADD HOUR",36100161,CDM,761,RC,64530,HCPCS,facility,both,,,,3084,3084,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC BX BREAST 1ST LESION US IMAG,36100200,CDM,761,RC,37211,HCPCS,facility,both,,,,11490,11490,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC BX BREAST ADD LESION US IMAG,36100201,CDM,761,RC,37212,HCPCS,facility,both,,,,11490,11490,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC BX BREAST 1ST LESION MR IMAG,36100202,CDM,761,RC,37213,HCPCS,facility,both,,,,10756,10756,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC BX BREAST ADD LESION MR IMAG,36100203,CDM,761,RC,37214,HCPCS,facility,both,,,,10756,10756,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE DEAC 5/15/2025 HC NASOGASTRIC TUBING WITH STYLET,36100252,CDM,761,RC,36000,HCPCS,facility,both,,,,225,225,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC WHOLE BLD,LEUKO-REDUCED,PEDS",36100254,CDM,761,RC,36578,HCPCS,facility,both,,,,5929,5929,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC HA DIGITAL, PREMIUM, MONAURAL, ITE",36100261,CDM,761,RC,37236,HCPCS,facility,both,,,,76330,76330,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DRUG SCREEN QUANT EVEROLIMUS,36100266,CDM,761,RC,37242,HCPCS,facility,both,,,,70657,70657,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DRUG SCREEN QUANT GABAPENTIN,36100267,CDM,761,RC,37243,HCPCS,facility,both,,,,52568,52568,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DRUG SCREEN QUAN LAMOTRIGINE,36100268,CDM,761,RC,37244,HCPCS,facility,both,,,,52568,52568,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DRUG SCRN QUAN LEVETIRACETAM,36100269,CDM,761,RC,49405,HCPCS,facility,both,,,,4761,4761,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DRUG SCRN QUAN MYCOPHENOLATE,36100270,CDM,761,RC,49406,HCPCS,facility,both,,,,4761,4761,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DRUG SCRN QUANT OXCARBAZEPIN,36100272,CDM,761,RC,64642,HCPCS,facility,both,,,,2401,2401,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DRUG SCREEN QUANT ZONISAMIDE,36100273,CDM,761,RC,64643,HCPCS,facility,both,,,,2401,2401,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ASPA GENE,36100274,CDM,761,RC,64644,HCPCS,facility,both,,,,2401,2401,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC BLM GENE,36100275,CDM,761,RC,64645,HCPCS,facility,both,,,,2401,2401,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC ANTI-DEPRESS,SEROTO 1-2 (70)",36100279,CDM,761,RC,20982,HCPCS,facility,both,,,,27633,27633,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC SPINAL PUNCTURE LUMBAR DIAGNOSTIC; W/O IMG,36100280,CDM,761,RC,49407,HCPCS,facility,both,,,,4761,4761,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DUPLEX LE ART/BPG; BILAT,36100282,CDM,761,RC,10030,HCPCS,facility,both,,,,5025,5025,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC VENOGRAM, ORBIT",36100285,CDM,761,RC,33240,HCPCS,facility,both,,,,41545,41545,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC EP EVAL & TX ATRIAL FIB PULM VEIN ISOLATION,36100286,CDM,761,RC,33235,HCPCS,facility,both,,,,18283,18283,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC EPHYS EVAL W/ABLATION VENTRICULAR TACHYCARDIA,36100287,CDM,761,RC,33234,HCPCS,facility,both,,,,18283,18283,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC IMAGE CATH FLUID COLXN VISC,36100300,CDM,761,RC,36568,HCPCS,facility,both,,,,5053,5053,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC IMAGE CATH FLUID PERI/RETRO,36100301,CDM,761,RC,36572,HCPCS,facility,both,,,,5615,5615,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CHEMODENERV 1 EXTREMITY 1-4,36100302,CDM,761,RC,36575,HCPCS,facility,both,,,,5445,5445,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CHEMODENERV 1 EXTREM 1-4 EA,36100303,CDM,761,RC,62252,HCPCS,facility,both,,,,727,727,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE DEAC 9/1/2020 HC FRESH FROZ PLASMA/PED FBS,36200001,CDM,361,RC,,,facility,both,,,,8707,8707,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC COMPARATOR EXOME (247),37000006,CDM,370,RC,99152,HCPCS,facility,both,,,,71.5,71.5,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC COMPARATOR EXOME (493),37000008,CDM,370,RC,99155,HCPCS,facility,both,,,,531.3,531.3,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC EXOME SEQUENCE ANALYSIS (1232),37000009,CDM,370,RC,99157,HCPCS,facility,both,,,,250,250,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC EXOME RE-EVALUATION (493),37000010,CDM,370,RC,99156,HCPCS,facility,both,,,,531.3,531.3,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC HA DIGITAL, BASIC MONAURAL, RITE",37000013,CDM,370,RC,,,facility,both,,,,176.96,176.96,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC HA DIGITAL, BASIC BINAURAL, CIC",37000014,CDM,370,RC,,,facility,both,,,,78.4,78.4,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AQUATIC THERAPY/EXERCISE EA 15 MINS,38100001,CDM,390,RC,,,facility,both,,,,1193,1193,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC WOUND CARE NON-SELECTIVE, WO ANES, PER SESSION",38100003,CDM,390,RC,,,facility,both,,,,1153,1153,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC FLUCONAZOLE, SERUM QUEST",38100010,CDM,381,RC,,,facility,both,,,,1510,1510,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC MASS SPECT, EACH ANALYTE",38100015,CDM,,,,,facility,both,,,,312,312,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MT-DNA GENOME FULL SEQUENCE,38100016,CDM,390,RC,,,facility,both,,,,455,455,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "DEAC 4/1/2025 HC IV INFUS/SUBSQ INJ, CASIRIVIMAB & IMDEVIMAB W/POST ADM MONITOR, REPEAT DOSES",38120004,CDM,390,RC,,,facility,both,,,,1098,1098,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC EYE EXAM W ANESTH; COMPLETE,38200002,CDM,390,RC,,,facility,both,,,,936,936,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ECMO/ECLS INITIATION VENOUS - DAILY MGMT,38200004,CDM,390,RC,,,facility,both,,,,1087,1087,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC METHOTREXATE,38200006,CDM,382,RC,,,facility,both,,,,773,773,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC CLOSEQ,BMA,IN-PATIENT ONLY",38200007,CDM,382,RC,,,facility,both,,,,563,563,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CANDIDA NA AMPLIFIED PROBE,38300002,CDM,390,RC,,,facility,both,,,,360,360,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ECMO/ECLS INITIATION ARTERY - DAILY MGMT,38300003,CDM,390,RC,,,facility,both,,,,897,897,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PRA SCREEN; QUICK METHOD,38360001,CDM,,,,,facility,both,,,,86,86,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC PHYSICAL PERFORMANCE TEST, EA 15 MINS",38400002,CDM,390,RC,,,facility,both,,,,1766,1766,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC SLV TREATMENT GROUP, 2 OR MORE 2-4",38400003,CDM,390,RC,,,facility,both,,,,2106,2106,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC SULFATE,UR STONE RISK",38400013,CDM,384,RC,,,facility,both,,,,2405,2405,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC ENZYME ACTIVITY, LYSOSOMAL GGC, EACH SPECIMEN",38400014,CDM,,,,,facility,both,,,,789,789,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC LAB HEMATOLOGY,38460001,CDM,390,RC,,,facility,both,,,,1185,1185,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ECMO/ECLS DAILY MGMT-VENOUS,38600001,CDM,390,RC,,,facility,both,,,,3166.8,3166.8,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC VOL REDUCTION OF BLOOD/PROD,39000001,CDM,300,RC,86920,HCPCS,facility,both,,,,487,487,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC VERTEBRAL FRACTURE ASSESSMENT VIA DXA,39000003,CDM,390,RC,,,facility,both,,,,1479,1479,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC OPIOIDS AND OPIATE ANALOGS 1/2 (30),39000004,CDM,390,RC,,,facility,both,,,,340,340,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC TRAMADOL (30),39000005,CDM,390,RC,,,facility,both,,,,813,813,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC CANNABINOIDS,NATURAL",39000006,CDM,390,RC,,,facility,both,,,,360,360,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE DEAC 11/01/2023 HC ADM SARSCOV2 10MCG/0.2 ML; TRIS-SUCROSE FORM; 2ND DOSE,39000009,CDM,390,RC,,,facility,both,,,,345,345,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ECMO/ECLS DAILY MGMT ARTERY,39000010,CDM,390,RC,,,facility,both,,,,235,235,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE DEAC 11/01/2023 HC ADM SARSCOV2 10MCG/0.2 ML; TRIS-SUCROSE FORM; 1ST DOSE,39000206,CDM,390,RC,,,facility,both,,,,279,279,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MITOCHONDRIAL NUCLEAR GENE,39000214,CDM,,,,,facility,both,,,,455,455,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC DAPTOMYCIN, SERUM",39000215,CDM,,,,,facility,both,,,,959,959,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC FFP HIGH TITER COVID-19 CONVALESCENT, FROZEN - 8 HR COLLECT, EA UNIT (439)",39000216,CDM,390,RC,,,facility,both,,,,2391,2391,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC THERAPEUTIC APHERESIS,39100001,CDM,391,RC,36430,HCPCS,facility,both,,,,1814,1814,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ULTRASOUND ABDOMEN COMPLETE,40200001,CDM,402,RC,76506,HCPCS,facility,both,,,,659,659,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC ULTRASOUND ABDOMEN LIMITED - 1 ORGAN, QUAD",40200002,CDM,402,RC,76536,HCPCS,facility,both,,,,920,920,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ULTRASOUND RETROPERITONEAL COMPLETE,40200003,CDM,402,RC,76604,HCPCS,facility,both,,,,876,876,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ULTRASOUND RETROPERITONEAL LIMITED,40200005,CDM,402,RC,76700,HCPCS,facility,both,,,,920,920,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ULTRASOUND TRANSPLANTED KIDNEY W/DOPPLER,40200006,CDM,402,RC,76705,HCPCS,facility,both,,,,920,920,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ULTRASOUND SPINAL CANAL AND CONTENTS,40200007,CDM,402,RC,76770,HCPCS,facility,both,,,,920,920,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CRYPT AG TITER,40200008,CDM,402,RC,76775,HCPCS,facility,both,,,,467,467,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC LEUKOREDUCTION,40200009,CDM,402,RC,76776,HCPCS,facility,both,,,,665,665,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC TRICH. VAGINALIS AMP PROBE,40200010,CDM,402,RC,76800,HCPCS,facility,both,,,,622,622,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DOPPLER ECHOCARDIOLOGY FETAL F/U,40200025,CDM,483,RC,76825,HCPCS,facility,both,,,,1648,1648,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC ULTRASOUND TRANSVAGINAL, NON OB",40200026,CDM,483,RC,76826,HCPCS,facility,both,,,,1404,1404,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ULTRASOUND PELVIC EXAM COMPLETE NON OB,40200027,CDM,483,RC,76827,HCPCS,facility,both,,,,724,724,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ULTRASOUND PELVIC EXAM LIMITED NON OB,40200028,CDM,483,RC,76828,HCPCS,facility,both,,,,568,568,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ULTRASOUND SCROTUM AND CONTRASTENTS,40200029,CDM,402,RC,76830,HCPCS,facility,both,,,,920,920,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC US COMPLETE JOINT,40200030,CDM,402,RC,76856,HCPCS,facility,both,,,,920,920,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC US LIMITED, JOINT OR FOCAL EVAL OF OTHER NONVASCULAR EXTREMITY STRUCTURE(S)",40200031,CDM,402,RC,76857,HCPCS,facility,both,,,,625,625,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC US INFANT HIPS; LIMITED/STATIC,40200032,CDM,402,RC,76870,HCPCS,facility,both,,,,920,920,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC US GUIDANCE VASCULAR ACCESS,40200035,CDM,402,RC,76881,HCPCS,facility,both,,,,761,761,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC US GUIDANCE TISSUE ABLATION,40200036,CDM,402,RC,76882,HCPCS,facility,both,,,,575,575,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC US GUIDED NEEDLE PLACEMENT,40200037,CDM,402,RC,76886,HCPCS,facility,both,,,,420,420,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC US GUIDANCE INTRAOPERATIVE,40200039,CDM,402,RC,76937,HCPCS,facility,both,,,,1288,1288,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC FLUOROGUIDE CENTRAL VEN ACCESS DEV PLCMNT,40200040,CDM,402,RC,76940,HCPCS,facility,both,,,,1675,1675,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC FLUOROSCOPIC GUIDANCE FOR NEEDLE PLCMNT,40200042,CDM,402,RC,76942,HCPCS,facility,both,,,,706,706,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC FLUOROSCOPIC GUIDANCE FOR SPINE INJECTION,40200047,CDM,402,RC,76998,HCPCS,facility,both,,,,1001,1001,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MRA LEXTREM W CONT,40200051,CDM,402,RC,76885,HCPCS,facility,both,,,,725,725,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "DEAC 9/1/2020 HC PLATELETS PHERESIS LR IRRAD, PEDS, EA UNIT",40200061,CDM,402,RC,76932,HCPCS,facility,both,,,,3193,3193,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC TISSUE EXAM BY PATHOLOGIST LVL 5,40200063,CDM,402,RC,76642,HCPCS,facility,both,,,,625,625,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC GENOME SEQUENCE ANALYSIS (1970),40200066,CDM,402,RC,76706,HCPCS,facility,both,,,,609,609,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC INFECTIOUS AGENT DETECTION BY DNA/RNA PNEUMOCYSTIS JIROVECII, AMP PROBE",40200068,CDM,402,RC,76981,HCPCS,facility,both,,,,369,369,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC EPHYS EVAL SUBQ IMPLANTABLE DEFIBRILLATOR,40200073,CDM,402,RC,76970,HCPCS,facility,both,,,,325,325,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CEREBROSPINAL FLUID LEAKAGE IMAGING,40400003,CDM,404,RC,78608,HCPCS,facility,both,,,,13892,13892,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC IMMUNIZATION ADMIN SQ/IM, SINGLE",40400005,CDM,404,RC,78815,HCPCS,facility,both,,,,12316,12316,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC IMMUNIZATION ADMIN SQ/IM, EA ADDL",40400006,CDM,404,RC,78816,HCPCS,facility,both,,,,10479,10479,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CATHETER ASPIRATION: NASOTRACHEAL,41000001,CDM,410,RC,31500,HCPCS,facility,both,,,,727,727,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC TRANSFUSION BLOOD OR BLOOD COMPONENTS,41000002,CDM,410,RC,31720,HCPCS,facility,both,,,,355,355,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PULMONARY FUNCTION TST PLETHYSMOGRAPHY,41000026,CDM,410,RC,94642,HCPCS,facility,both,,,,989,989,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CO/MEMBRANE DIFFUSE CAPACITY,41000031,CDM,410,RC,94664,HCPCS,facility,both,,,,1158,1158,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC X-RAY EXAM ABDOMEN 1 VIEW,41000037,CDM,410,RC,94669,HCPCS,facility,both,,,,924,924,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC CYP2D6, GENE ANALYSIS, COMMON VARIANTS(30)",41000038,CDM,410,RC,33946,HCPCS,facility,both,,,,52173,52173,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC CYP3A4, GENE ANALYSIS, COMMON VARIANTS(30)",41000039,CDM,410,RC,33947,HCPCS,facility,both,,,,52173,52173,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC CYP3A5, GENE ANALYSIS, COMMON VARIANTS(30)",41000040,CDM,410,RC,33948,HCPCS,facility,both,,,,52173,52173,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC DPYD, GENE ANALYSIS, COMMON VARIANTS(30)",41000041,CDM,410,RC,33949,HCPCS,facility,both,,,,52173,52173,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC CHEST PT, INITIAL TX",41000042,CDM,410,RC,94002,HCPCS,facility,both,,,,3361,3361,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AB; CRYPTOCOCCUS,41000044,CDM,410,RC,94003,HCPCS,facility,both,,,,3200,3200,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AB; EBNA,41000048,CDM,410,RC,94660,HCPCS,facility,both,,,,1424,1424,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC ALTERNATIVE GAS THERAPY, PER DAY",41000049,CDM,410,RC,94667,HCPCS,facility,both,,,,1017,1017,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AB; HISTOPLASMA,41000050,CDM,410,RC,94668,HCPCS,facility,both,,,,324,324,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ATTENDANCE AT DELIVERY INIT STABILIZATION OF NB,41000052,CDM,410,RC,94662,HCPCS,facility,both,,,,1990,1990,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC PUNCTURE ASPIRATION OF ABSCESS, HEMATOMA, BULLA, OR CYST",41000200,CDM,410,RC,94644,HCPCS,facility,both,,,,725,725,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MOPATH PROCEDURE LEVEL 7 (1490),41000201,CDM,410,RC,94645,HCPCS,facility,both,,,,95,95,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC LAB CYCTOLOGY,41000203,CDM,410,RC,94799,HCPCS,facility,both,,,,2165,2165,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC HA DIGITAL, ADVANCED, MONAURAL, CIC",41060001,CDM,410,RC,94640,HCPCS,facility,both,,,,492,492,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC X-LINKED INTELLECTUAL (AUTISM) SEQ ANAL,41060002,CDM,410,RC,94799,HCPCS,facility,both,,,,137,137,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC THERAPEUTIC EXERCISES EA 15 MINS,42000004,CDM,420,RC,97032,HCPCS,facility,both,,,,115,115,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC NEUROMUSCULAR REEDUCATION EA 15 MINS,42000005,CDM,420,RC,97033,HCPCS,facility,both,,,,184,184,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC GAIT TRAINING THERAPY EA 15 MINS,42000006,CDM,420,RC,97035,HCPCS,facility,both,,,,76,76,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MASSAGE THERAPY EA 15 MINS,42000007,CDM,420,RC,97110,HCPCS,facility,both,,,,194,194,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MANUAL THERAPY EA 15 MINS,42000008,CDM,420,RC,97112,HCPCS,facility,both,,,,215,215,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC THERAPEUTIC REHAB GROUP 2 OR MORE,42000009,CDM,420,RC,97116,HCPCS,facility,both,,,,172,172,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC THERAPEUTIC ACTIVITY DIR EA 15 MINS,42000010,CDM,420,RC,97124,HCPCS,facility,both,,,,162,162,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ADL/SELF HOME MGMT EA 15 MINS,42000011,CDM,420,RC,97140,HCPCS,facility,both,,,,207,207,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ASSISTIVE TECHNOLOGY ASSESSMENT EA 15 MIN,42000012,CDM,420,RC,97597,HCPCS,facility,both,,,,745,745,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC ORTHOTIC MGMT & TRAINING, INITIAL ENCOUNTER, EA 15 MINS",42000013,CDM,420,RC,97598,HCPCS,facility,both,,,,58,58,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC PROSTHETIC TRAINING, INITIAL ENCOUNTER, EA 15 MINS",42000014,CDM,420,RC,97605,HCPCS,facility,both,,,,711,711,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC MNT, INDIV, EA 15 MIN, INITIAL ASSESSMENT",42000015,CDM,420,RC,97606,HCPCS,facility,both,,,,1266,1266,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC OFFICE/OUTPATIENT VISIT EST LVL 2,42000017,CDM,420,RC,97760,HCPCS,facility,both,,,,189,189,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC EMERGENCY DEPT VISIT LVL 1,42000018,CDM,420,RC,97761,HCPCS,facility,both,,,,174,174,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC MNT, INDIV, EA 15 MIN, RE-ASSESSMENT",42000022,CDM,420,RC,97755,HCPCS,facility,both,,,,208,208,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ASHKENAZI JEWISH ASSOC DIS (730),42000051,CDM,420,RC,97113,HCPCS,facility,both,,,,268,268,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "DEAC 7/1/2023 HC APPLY CAST, HAND AND LOWER FOREARM (GAUNTLET)",42000052,CDM,420,RC,97602,HCPCS,facility,both,,,,599,599,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC INJECTION, EPIDURAL, OF BLOOD OR CLOT PATCH",42000053,CDM,420,RC,97750,HCPCS,facility,both,,,,198,198,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC REMOVAL INDWELLING URETERAL STENT, PERQ APPROACH",42000060,CDM,420,RC,29405,HCPCS,facility,both,,,,617,617,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC TISSUE TRANSGLUTAMINASE, EACH IG CLASS",42000061,CDM,420,RC,97763,HCPCS,facility,both,,,,208,208,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC XOMEDXXPRESS (739),42400003,CDM,424,RC,97161,HCPCS,facility,both,,,,355,355,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC XOMEDXXPRESS SEQ ANALYSIS, EA COMPARATOR EXOME (370)",42400004,CDM,424,RC,97162,HCPCS,facility,both,,,,475,475,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CYTOKINE 13 PANEL (13),42400005,CDM,424,RC,97163,HCPCS,facility,both,,,,711,711,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC MOLECULAR PATH PROC, LEVEL 4  (71)",42400006,CDM,424,RC,97164,HCPCS,facility,both,,,,323,323,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ULTRASOUND THERAPY EA 15 MINS,43000010,CDM,430,RC,97018,HCPCS,facility,both,,,,74,74,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC SELECTIVE DEBRIDEMENT 20 SQ CM OR LESS,43000014,CDM,430,RC,97530,HCPCS,facility,both,,,,209,209,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC NEG PRESSURE WOUND TX W/DME, LESS THAN 50 SQ CM",43000017,CDM,430,RC,97535,HCPCS,facility,both,,,,205,205,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC NEG PRESSURE WOUND TX W/DME, GREATER THAN 50 SQ CM",43000019,CDM,430,RC,97542,HCPCS,facility,both,,,,198,198,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC WHEELCHAIR MGMT TRAINING EA 15 MINS,43000020,CDM,430,RC,97150,HCPCS,facility,both,,,,101,101,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DRUG ASSAY LACOSAMIDE (80),43000028,CDM,430,RC,97129,HCPCS,facility,both,,,,92,92,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DRUG ASSAY VORICONAZOLE (45),43000029,CDM,430,RC,97130,HCPCS,facility,both,,,,88,88,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC FLUORESCENT NONINFECT AB; SCRN EA AB,43400003,CDM,434,RC,97165,HCPCS,facility,both,,,,347,347,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MOPATH PROCEDURE LEVEL 5 (246),43400004,CDM,434,RC,97166,HCPCS,facility,both,,,,460,460,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MOPATH PROCEDURE LEVEL 6 (123),43400005,CDM,434,RC,97167,HCPCS,facility,both,,,,691,691,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MOPATH PROCEDURE LEVEL 7 (83),43400006,CDM,434,RC,97168,HCPCS,facility,both,,,,302,302,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC TYMPANOMETRY & REFLEX THRESH,44000001,CDM,440,RC,92507,HCPCS,facility,both,,,,509,509,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC SCREENING TEST, PURE TONE AIR ONLY",44000003,CDM,440,RC,92526,HCPCS,facility,both,,,,641,641,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC COCHLEAR IMPLT EXAM 7 > W PROG,44000004,CDM,440,RC,92597,HCPCS,facility,both,,,,344,344,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC EVALUATE SWALLOWING FUNCTION,44000006,CDM,440,RC,92607,HCPCS,facility,both,,,,742,742,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC MOTION FLUORO SWALLOW FCN, CINE/VIDEO",44000007,CDM,440,RC,92608,HCPCS,facility,both,,,,301,301,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC EVAL AUDITORY FUNCTION, 1ST HR",44000008,CDM,440,RC,92609,HCPCS,facility,both,,,,658,658,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC EVAL AUDITORY FUNCTION, EA ADDL 15 MIN",44000009,CDM,444,RC,92610,HCPCS,facility,both,,,,659,659,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AUD REHAB PRE-LING HEAR LOSS,44000010,CDM,440,RC,92611,HCPCS,facility,both,,,,522,522,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DUPLEX EXT VEINS; BILAT,44000014,CDM,440,RC,92626,HCPCS,facility,both,,,,517,517,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DUPLEX EXT VEINS; UNIL/LIMIT,44000015,CDM,440,RC,92627,HCPCS,facility,both,,,,69,69,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DUPLEX ARTERIAL FLOW; COMPL,44000016,CDM,440,RC,92630,HCPCS,facility,both,,,,784,784,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC INJ(S), ANESTH AGENT(S) &/OR STERIOD; OTHER PERIPHER NERVE OR BRCH",44000050,CDM,440,RC,92508,HCPCS,facility,both,,,,134,134,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CFTR GENE KNOWN FAM VARIANTS,44400002,CDM,444,RC,92521,HCPCS,facility,both,,,,678,678,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CYP2D6 GENE COM VARIANTS,44400003,CDM,444,RC,92522,HCPCS,facility,both,,,,671,671,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CYP2C9 GENE COM VARIANTS,44400004,CDM,444,RC,92523,HCPCS,facility,both,,,,892,892,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CYTOGEN M ARRAY COPY NO&SNP,44400005,CDM,444,RC,92524,HCPCS,facility,both,,,,584,584,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CRITICAL CARE FIRST HOUR,45000107,CDM,450,RC,10160,HCPCS,facility,both,,,,937,937,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HEARING AID EXAM ONE EAR,45000245,CDM,450,RC,29085,HCPCS,facility,both,,,,718,718,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HEARING AID EXAM BOTH EARS,45000272,CDM,450,RC,51705,HCPCS,facility,both,,,,678,678,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC TILT TABLE EVALUATION - STANDARD,45000277,CDM,450,RC,62273,HCPCS,facility,both,,,,1640,1640,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ECG UP TO 48 HRS RECORDING,45000278,CDM,450,RC,64450,HCPCS,facility,both,,,,3119,3119,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ESOPHAGUS MOTILITY STUDY,45000293,CDM,450,RC,99291,HCPCS,facility,both,,,,6362,6362,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC GASTROESOPHAGEAL REFLUX TEST,45000294,CDM,450,RC,99292,HCPCS,facility,both,,,,1184,1184,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MUSC TEST DONE W/NERVE TEST COMP,45000318,CDM,450,RC,17250,HCPCS,facility,both,,,,1187,1187,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HEARING AID CHECK MONAURAL,45000325,CDM,450,RC,,,facility,both,,,,909.44,909.44,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HEARING AID CHECK BINAURAL,45000326,CDM,450,RC,,,facility,both,,,,2629.76,2629.76,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HEARING AID CHECK BINAURAL,45000327,CDM,450,RC,,,facility,both,,,,10178.56,10178.56,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC CC/MS, NON-DRUG ANALYTE(S) NES, QUAL OR QNT, EA SP",45000329,CDM,450,RC,41899,HCPCS,facility,both,,,,890,890,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC LACTATION CLASSES, NON-PHYSICIAN PROVIDER, PER SESSION",45000330,CDM,450,RC,41599,HCPCS,facility,both,,,,7695,7695,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC EMERGENCY DEPT VISIT LVL 5,45100001,CDM,451,RC,99281,HCPCS,facility,both,,,,736,736,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ARTHROCENTESIS MAJOR JOINT OR BURSA,45200002,CDM,452,RC,99282,HCPCS,facility,both,,,,1221,1221,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ASPIRATION & INJ TX OF BONE CYST,45200003,CDM,452,RC,99283,HCPCS,facility,both,,,,1840,1840,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PLEURA BIOSPY; PERCUTANEOUS NEEDLE,45200004,CDM,452,RC,99284,HCPCS,facility,both,,,,2821,2821,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DEAC 01/01/2021 PERCUTANEOUS BIOPSY LUNG/MEDIASTINUM,45200005,CDM,452,RC,99285,HCPCS,facility,both,,,,4874,4874,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HB RESPIRATORY FLOW VOLUME LOOP - NON-MARYLAND,46000003,CDM,460,RC,94010,HCPCS,facility,both,,,,335,335,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC CARDIOPULM EXERCISE TEST, INCL MEASURE MIN VENT, CO2, O2 & ECG",46000004,CDM,460,RC,94060,HCPCS,facility,both,,,,1080,1080,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AEROSOL PENTAMIDINE FOR P. CARINII,46000005,CDM,460,RC,94070,HCPCS,facility,both,,,,1306,1306,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC EVALUATE PT USE OF INHALER/PER DAY,46000008,CDM,460,RC,94375,HCPCS,facility,both,,,,898,898,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC OXYGEN UPTAKE, % O2",46000009,CDM,460,RC,94621,HCPCS,facility,both,,,,643,643,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PULSE OXIMETRY,46000011,CDM,460,RC,94681,HCPCS,facility,both,,,,974,974,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC PULSE OX MULTIPLE, EG EXERCISE",46000013,CDM,460,RC,94726,HCPCS,facility,both,,,,698,698,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MSLT- SLEEP LATENCY,46000014,CDM,460,RC,94729,HCPCS,facility,both,,,,735,735,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC POLYSOMNOGRAPHY W/4> PARAM,46000015,CDM,460,RC,94760,HCPCS,facility,both,,,,112,112,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC CPAP- SLEEP STAGING, >4 PAR",46000016,CDM,460,RC,94761,HCPCS,facility,both,,,,607,607,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ANORECTAL MANOMETRY,46000053,CDM,460,RC,94762,HCPCS,facility,both,,,,748,748,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC X-RAY EXAM ABDOMEN 2 VIEWS,46000054,CDM,460,RC,94610,HCPCS,facility,both,,,,1403,1403,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE DEAC 11/01/2023 HC ADMN SARSCOV2 BIVALENT 3 MCG/0.2ML ADDL DOSE,46000060,CDM,460,RC,94452,HCPCS,facility,both,,,,698,698,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC F5 GENE ANALYSIS,46000061,CDM,460,RC,94453,HCPCS,facility,both,,,,638,638,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC DGP ANTIBODY, EACH IMMUNOGLOBULIN (IG) CLASS",46000063,CDM,460,RC,94618,HCPCS,facility,both,,,,665,665,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC CONTINOUS AEROSOL MIST W/WO OXYGEN, PER DAY",46000065,CDM,460,RC,94799,HCPCS,facility,both,,,,1023,1023,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HEXAGNAL PHOSPH PLTLT NEUTRL,46000066,CDM,460,RC,94799,HCPCS,facility,both,,,,1236,1236,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CRYPTOSPORIDIUM AG EIA,46000067,CDM,460,RC,94799,HCPCS,facility,both,,,,332,332,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC RESP SYNCYTIAL AG EIA,46000068,CDM,460,RC,94799,HCPCS,facility,both,,,,332,332,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CHLAMYDIA P AMPLIF NA PROBE,46000069,CDM,460,RC,94799,HCPCS,facility,both,,,,14461,14461,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CELL MARKER STUDY,46000070,CDM,460,RC,94799,HCPCS,facility,both,,,,332,332,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC INJECTION; SINGLE TENDON SHEATH/LIGAMENT,46000071,CDM,460,RC,94799,HCPCS,facility,both,,,,332,332,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC SERUM PRETX; RC ABSORPT,46000072,CDM,460,RC,94799,HCPCS,facility,both,,,,332,332,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC FECAL LEUKO CNT QUAL/SEMIQUAN,46000073,CDM,460,RC,94799,HCPCS,facility,both,,,,2070,2070,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC EXAM SYNOVIAL FLUID CRYSTALS,46000075,CDM,460,RC,94799,HCPCS,facility,both,,,,332,332,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DRUG ADMINISTRATION (NITRIC OXIDE) & HEMODYNMIC MEASURES,46000076,CDM,460,RC,94799,HCPCS,facility,both,,,,874,874,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC VENTILATOR MGT, INITIAL DAY - ADULT",46000078,CDM,460,RC,93463,HCPCS,facility,both,,,,357,357,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HEALTH BEHAVIOR INTERV INDIV FACE TO FACE; EA ADDL 15 MIN,46000087,CDM,460,RC,94728,HCPCS,facility,both,,,,837,837,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC REPROGRAM COCHLEAR IMPLT 7 YRS & OLDER,47000001,CDM,470,RC,92601,HCPCS,facility,both,,,,641,641,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC EVAL FOR SPEECH DEVICE RX, 1ST HR",47000002,CDM,470,RC,92602,HCPCS,facility,both,,,,771,771,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC EVAL FOR SPEECH DEVICE RX, EA ADDL 30 MIN",47000003,CDM,470,RC,92603,HCPCS,facility,both,,,,668,668,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC THERAPEUTIC SP DEVICE SERVICE,47000004,CDM,471,RC,92604,HCPCS,facility,both,,,,639,639,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC PURE TONE AUDIOMETRY, AIR ONLY",47000013,CDM,470,RC,92550,HCPCS,facility,both,,,,491,491,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC PURE TONE AUDIOMETRY, AIR ONLY",47000013,CDM,470,RC,92550,HCPCS,facility,both,,,,142,142,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC ASO ; TITER,47000016,CDM,470,RC,,,facility,both,,,,120,120,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC 3D ECHOCARDIOGRAPHIC IMAGING & POSTPROCESSING DURING TEE/TTE (ADD-ON CODE),47000017,CDM,471,RC,92650,HCPCS,facility,both,,,,280,280,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC UNLISTED CHEM PROC (25),47000018,CDM,471,RC,92651,HCPCS,facility,both,,,,567,567,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC AB, VRUS NES (50)",47000019,CDM,471,RC,92652,HCPCS,facility,both,,,,981,981,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC HA, DIGITAL, PREMIUM, MONAURAL, ITC",47080003,CDM,470,RC,,,facility,both,,,,156,156,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC HA, DIGITAL, STANDARD MONAURAL, ITE",47080003,CDM,470,RC,,,facility,both,,,,34,34,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE "HC HA, DIGITAL, ADVANCED, MONAURAL, BTE",47080008,CDM,470,RC,,,facility,both,,,,304,304,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE "HC HA, DIGITAL, ADVANCED, MONAURAL, BTE, RITE",47080008,CDM,470,RC,,,facility,both,,,,625.2,625.2,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC HA, DIGITAL, PREMIUM, MONAURAL, BTE, RITE",47080009,CDM,470,RC,,,facility,both,,,,938.4,938.4,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC HA, DIGITIAL, STANDARD BINAURAL, CIC",47080010,CDM,470,RC,,,facility,both,,,,200,200,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE "HC HA, DIGITAL, STANDARD MONAURAL, BTE",47080010,CDM,470,RC,,,facility,both,,,,256.8,256.8,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC TRAUMA ALERT 1 W/CRITICAL CARE,47080012,CDM,470,RC,,,facility,both,,,,109,109,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC LAB HISTOLOGY,47080013,CDM,470,RC,,,facility,both,,,,480,480,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC WHOLE BLD FOR TRANSFUSION/UNIT,47080015,CDM,470,RC,,,facility,both,,,,480,480,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC PURE TONE AUDIOMETRY, AIR & BONE",47100001,CDM,471,RC,92551,HCPCS,facility,both,,,,79,79,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC PURE TONE AUDIOMETRY, AIR & BONE",47100002,CDM,471,RC,92552,HCPCS,facility,both,,,,480,480,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC SPEECH AUDIOMETRY THRESHOLD,47100002,CDM,471,RC,92552,HCPCS,facility,both,,,,235,235,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC SPEECH AUDIOMETRY THESHOLD W/SR,47100003,CDM,471,RC,92553,HCPCS,facility,both,,,,480,480,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC SPEECH AUDIOMETRY THRESHOLD,47100003,CDM,471,RC,92553,HCPCS,facility,both,,,,235,235,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE "HC SPEECH AUDIOMETRY W/SR, COMPREHENSIVE",47100004,CDM,471,RC,92556,HCPCS,facility,both,,,,105,105,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC TYMPANOMETRY (IMP TESTING),47100004,CDM,471,RC,92556,HCPCS,facility,both,,,,392,392,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC TYMPANOMETRY (IMP TESTING),47100005,CDM,471,RC,92557,HCPCS,facility,both,,,,652,652,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ACOUSTIC REFLEX TESTING,47100005,CDM,471,RC,92557,HCPCS,facility,both,,,,340,340,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC ACOUSTIC IMMITTANCE TESTING,47100006,CDM,471,RC,92567,HCPCS,facility,both,,,,290,290,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ACOUSTIC IMMITTANCE TESTING,47100006,CDM,471,RC,92567,HCPCS,facility,both,,,,142,142,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC VISUAL REINFORCE AUDIOMETRY,47100007,CDM,471,RC,92568,HCPCS,facility,both,,,,176,176,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CONDITIONING PLAY AUDIOMETRY,47100008,CDM,471,RC,92579,HCPCS,facility,both,,,,235,235,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC SELECT PICTURE AUDIOMETRY,47100008,CDM,471,RC,92579,HCPCS,facility,both,,,,525,525,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC SELECT PICTURE AUDIOMETRY,47100009,CDM,471,RC,92582,HCPCS,facility,both,,,,599,599,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DEAC 01/01/2021 AUDITORY EP - COMPREHENSIVE,47100009,CDM,471,RC,92582,HCPCS,facility,both,,,,235,235,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC DEAC 01/01/2021 AUDITORY EP - LIMITED,47100010,CDM,471,RC,92585,HCPCS,facility,both,,,,1411,1411,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC EVOKED AUDITORY TEST LIMITED,47100010,CDM,471,RC,92585,HCPCS,facility,both,,,,238,238,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC EVOKED AUDITORY TEST LIMITED,47100011,CDM,471,RC,92586,HCPCS,facility,both,,,,238,238,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC EVOKED AUDITORY TEST COMPLETE,47100011,CDM,471,RC,92586,HCPCS,facility,both,,,,752,752,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC ELECTRO HEARING AID TEST, MONAURAL",47100012,CDM,471,RC,92587,HCPCS,facility,both,,,,132,132,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC EVOKED AUDITORY TEST COMPLETE,47100012,CDM,471,RC,92587,HCPCS,facility,both,,,,250,250,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC EVAL TO USE/FIT VOICE PROSTHETIC,47100013,CDM,471,RC,92594,HCPCS,facility,both,,,,52,52,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE "HC ELECTRO HEARING AID TEST, BINAURAL",47100013,CDM,471,RC,92594,HCPCS,facility,both,,,,65,65,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC COCHLEAR IMPLT EXAM < 7 W PROG,47100014,CDM,471,RC,92595,HCPCS,facility,both,,,,52,52,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC REPROGRAM COCHLEAR IMPLT UNDER AGE 7,47100014,CDM,471,RC,92595,HCPCS,facility,both,,,,87,87,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC SPEECH AUDIOMETRY THESHOLD W/SR,47100015,CDM,471,RC,92555,HCPCS,facility,both,,,,227,227,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC SPEECH AUDIOMETRY W/SR, COMPREHENSIVE",47100015,CDM,471,RC,92555,HCPCS,facility,both,,,,105,105,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC VISUAL REINFORCE AUDIOMETRY,47100016,CDM,471,RC,92570,HCPCS,facility,both,,,,581,581,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CONDITIONING PLAY AUDIOMETRY,47100016,CDM,471,RC,92570,HCPCS,facility,both,,,,142,142,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC DEAC 01/01/2021 AUDITORY EP - LIMITED,47100017,CDM,471,RC,92583,HCPCS,facility,both,,,,852,852,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DEAC 01/01/2021 AUDITORY EP - COMPREHENSIVE,47100017,CDM,471,RC,92583,HCPCS,facility,both,,,,95,95,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE "HC ELECTRO HEARING AID TEST, BINAURAL",47100019,CDM,471,RC,92588,HCPCS,facility,both,,,,290,290,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC ELECTRO HEARING AID TEST, MONAURAL",47100019,CDM,471,RC,92588,HCPCS,facility,both,,,,132,132,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC HEMODIALYSIS ONE EVALUATION,47100151,CDM,471,RC,92590,HCPCS,facility,both,,,,208,208,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MOTOR SENSORY NERVE CONDUCT TEST,47100152,CDM,471,RC,92591,HCPCS,facility,both,,,,208,208,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC SARS-COV-2 (24),47100153,CDM,471,RC,92565,HCPCS,facility,both,,,,216,216,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HERPES S NA QUAN,47100163,CDM,471,RC,92558,HCPCS,facility,both,,,,290,290,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC LINEZOLID, SERUM",47100165,CDM,471,RC,92563,HCPCS,facility,both,,,,207,207,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC URINE DRUG SCREEN (QLT),47100166,CDM,471,RC,92577,HCPCS,facility,both,,,,992,992,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC DRUG SCREEN,QLT,HAIR",47100167,CDM,471,RC,92620,HCPCS,facility,both,,,,748,748,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC PREGNANCY SCREEN,URINE,QLT",47100167,CDM,471,RC,92620,HCPCS,facility,both,,,,595,595,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC MECP2 DELETION/DUPLICATION ASS,47100168,CDM,471,RC,92621,HCPCS,facility,both,,,,120,120,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC URINE TOTAL VOLUME,47100168,CDM,471,RC,92621,HCPCS,facility,both,,,,96,96,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE "HC TRANSPLANT, TISSUE TYPING, HLA",47100169,CDM,471,RC,92592,HCPCS,facility,both,,,,52,52,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC TCR V-BETA SPECTRATYPING,47100169,CDM,471,RC,92592,HCPCS,facility,both,,,,115,115,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC SPECIAL AB IDENTIFICATION, ADD",47100170,CDM,471,RC,92593,HCPCS,facility,both,,,,134,134,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HLA-DQB1,47100170,CDM,471,RC,92593,HCPCS,facility,both,,,,52,52,,,,,,,,,,,,,Gross Charge Type: ACH CLIENT BILLING FEE SCHEDULE HC CONVERT NEPHROSTOMY CATHETER,47100171,CDM,471,RC,,,facility,both,,,,28,28,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC EXCHANGE NEPHROSTOMY CATHETER,47100172,CDM,471,RC,,,facility,both,,,,12,12,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC PLMT URETERAL STENT PRQ, PRE-EXISTING NEPHR TRACT",47100173,CDM,471,RC,,,facility,both,,,,48,48,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC PLMT URETERAL STENT PRQ, NEW ACCESS, W/O SEPAR CATH",47100174,CDM,471,RC,,,facility,both,,,,62,62,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC PLMT URETERAL STENT PRQ, NEW ACCESS, W/ SEPAR CATH",47100175,CDM,471,RC,,,facility,both,,,,6,6,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ENDOVASC PROLONG ADMIN RX AGENT 1ST,47100176,CDM,471,RC,,,facility,both,,,,20,20,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ENDOVASC PROLONG ADMIN RX AGENT ADD,47100177,CDM,471,RC,,,facility,both,,,,10,10,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC X-RAY EXAM ENTIRE SPINE, 1 VW",47100178,CDM,471,RC,,,facility,both,,,,20,20,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC X-RAY EXAM ENTIRE SPINE, 2/3 VW",47100179,CDM,471,RC,,,facility,both,,,,14,14,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC X-RAY EXAM ENTIRE SPINE, 4/5 VW",47100180,CDM,471,RC,,,facility,both,,,,24,24,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC X-RAY EXAM ENTIRE SPINE, 6/> VW",47100181,CDM,471,RC,,,facility,both,,,,3,3,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC X-RAY EXAM HIP UNIL, W/PELVIS WHEN PERFORMED, 1 VW",47100182,CDM,471,RC,,,facility,both,,,,38,38,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC X-RAY EXAM HIP UNIL, W/PELVIS WHEN PERFORMED, 2-3 VW",47100183,CDM,471,RC,,,facility,both,,,,25,25,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC X-RAY EXAM HIPS BIL, W/PELVIS WHEN PERFORMED, 2 VW",47100184,CDM,471,RC,,,facility,both,,,,14,14,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC MOG-IGG1 ANTIBODY FLOW CYTOMETRY, EA",47100185,CDM,471,RC,,,facility,both,,,,7,7,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DRUG ASSAY ADALIMUMAB,47100186,CDM,471,RC,,,facility,both,,,,6,6,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC TARGETED GENOMIC SEQ ANALYSIS (263),47100187,CDM,471,RC,,,facility,both,,,,12,12,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC INFECT DS (BACTERIAL/VIRAL), TRAIL IP-10 C-REACT PRTN SERUM (41)",47100188,CDM,471,RC,,,facility,both,,,,5,5,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC IMMUMOASSAY QUANT NOS NONAB,47100189,CDM,471,RC,,,facility,both,,,,17,17,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC FENTANYL DRUG SCREEN,47100190,CDM,471,RC,,,facility,both,,,,78,78,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC BUPRENORPHINE DRUG SCREEN,47100191,CDM,471,RC,,,facility,both,,,,40,40,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC COMPLEMENT; AG EA,47100192,CDM,471,RC,,,facility,both,,,,180,180,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC FMR1 GENE ANALYSIS; EVAL TO DETECT ABN ALLELES,47100193,CDM,471,RC,,,facility,both,,,,72,72,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DRUG/SUBSTANCE NOS 7/MORE (40),48000001,CDM,480,RC,,,facility,both,,,,303.6,303.6,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC IMMUMOASSAY QUANT NOS NONAB (90),48000003,CDM,483,RC,93356,HCPCS,facility,both,,,,168,168,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC FLUORO EXAM GASTRO/COLON TUBE,48100011,CDM,481,RC,36254,HCPCS,facility,both,,,,10615,10615,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ASPIRATE PLEURA W/IMAGING,48100012,CDM,481,RC,36253,HCPCS,facility,both,,,,7605,7605,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC EEG W/O VID BY TECH EA INCR 12-26HR UNMONITORED,48100014,CDM,481,RC,93503,HCPCS,facility,both,,,,3839,3839,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC VEEG BY TECH 2-12 HOURS UNMONITORED,48100015,CDM,481,RC,36140,HCPCS,facility,both,,,,2912,2912,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MRA ABD W CONTRAST,48100017,CDM,481,RC,36251,HCPCS,facility,both,,,,4446,4446,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC INJECTION HIP ARTHROGRAPHY; WO ANESTHESIA,48100018,CDM,481,RC,36252,HCPCS,facility,both,,,,5339,5339,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC VISUAL EVOKED POTENTIAL, CHECKERBD/FLASH TEST, CNS, EXCEPT GLAUCOMA",48100050,CDM,481,RC,93660,HCPCS,facility,both,,,,36889,36889,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC LUNG PERFUSION DIFFERENTIAL,48100052,CDM,481,RC,36248,HCPCS,facility,both,,,,2510,2510,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC BONE MARROW IMAGING; WHOLE BODY,48100053,CDM,481,RC,36218,HCPCS,facility,both,,,,1961,1961,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC SELECTIVE ADRENAL VENOGRAM, BILATERAL",48100054,CDM,481,RC,36217,HCPCS,facility,both,,,,1961,1961,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC SELECTIVE ADRENAL VENOGRAM, UNILATERAL",48100055,CDM,481,RC,36216,HCPCS,facility,both,,,,1961,1961,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC INSERT CATHETER RENAL ARTERY 2ND, BILAT",48100056,CDM,481,RC,36200,HCPCS,facility,both,,,,3880,3880,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC BARTONELLA AMPLIF NAP,48100058,CDM,481,RC,92960,HCPCS,facility,both,,,,1901,1901,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC COMPLEMENT C3A,48100075,CDM,481,RC,93623,HCPCS,facility,both,,,,31081,31081,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ELECTROPHYSIOLOGY EVALUATION,48100076,CDM,481,RC,93618,HCPCS,facility,both,,,,10106,10106,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HA REPAIR MONAURAL OUT WA,48100078,CDM,481,RC,36221,HCPCS,facility,both,,,,7407,7407,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "DEAC 9/1/2020 HC RBC FROZ LEUK REDUC IRRAD, PEDS, EA UNIT",48100110,CDM,481,RC,36227,HCPCS,facility,both,,,,9817,9817,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC EXPRESSED BREAST MILK PREP/STORE/DISTRIBUTION,48100112,CDM,481,RC,36222,HCPCS,facility,both,,,,11775,11775,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE DEAC 09/24/2022 HC INITIATE RESCUE EQUIP-BAG/MASK,48100113,CDM,481,RC,36223,HCPCS,facility,both,,,,22097,22097,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC CYSTO W/REM FB, STENT,CALCULS",48100114,CDM,481,RC,36224,HCPCS,facility,both,,,,13232,13232,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC BX BREAST 1ST LESION STEREOTACTIC GUIDANCE,48100115,CDM,481,RC,36225,HCPCS,facility,both,,,,11775,11775,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC BX BREAST ADD LESION STEREOTACTIC GUIDANCE,48100116,CDM,481,RC,36226,HCPCS,facility,both,,,,13232,13232,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC EVOKED AUDITORY TEST QUAL, SCREENING",48100118,CDM,482,RC,93662,HCPCS,facility,both,,,,11188,11188,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ALD FM/DM TRANSMITTER,48100119,CDM,481,RC,93657,HCPCS,facility,both,,,,36002,36002,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC INTRAVENTRICULAR PACING,48100120,CDM,481,RC,93656,HCPCS,facility,both,,,,86975,86975,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC ALD FM/DM RECEIVER, NOS",48100121,CDM,481,RC,93655,HCPCS,facility,both,,,,36002,36002,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC INTRA-ATRIAL PACING,48100122,CDM,481,RC,93654,HCPCS,facility,both,,,,100877,100877,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC RIGHT VENTRICULAR RECORDING,48100123,CDM,481,RC,93653,HCPCS,facility,both,,,,73502,73502,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC INTRA-ATRIAL RECORDING,48100124,CDM,481,RC,93650,HCPCS,facility,both,,,,49385,49385,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PERQ TRANSCATH CLOSURE PDA,48100125,CDM,481,RC,93644,HCPCS,facility,both,,,,4412,4412,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ELBOW-FINGER CAST MATERIAL,48100126,CDM,481,RC,93622,HCPCS,facility,both,,,,22152,22152,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC LONG LEG CASTING MATERIAL,48100127,CDM,480,RC,93621,HCPCS,facility,both,,,,26384,26384,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC TRANSCATH CLOSURE OF VSD,48100128,CDM,481,RC,93620,HCPCS,facility,both,,,,20478,20478,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC TRANSCATH CLOSURE OF ASD,48100129,CDM,481,RC,93619,HCPCS,facility,both,,,,9342,9342,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC INJECT HEART CONGENITAL ART/GRFT,48100130,CDM,481,RC,93616,HCPCS,facility,both,,,,3736,3736,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC SHORT LEG CASTING MATERIAL,48100131,CDM,480,RC,93613,HCPCS,facility,both,,,,15958,15958,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE DEAC 1/1/2022 HC CMBN RT/LT HEART CATH THRU OPEN SEPTUM,48100132,CDM,481,RC,93612,HCPCS,facility,both,,,,12516,12516,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE DEAC 1/1/2022 HC CMBN RT/LT HEART CATH THRU INTACT SEPTUM,48100133,CDM,481,RC,93610,HCPCS,facility,both,,,,13195,13195,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC SHOULDER-HAND CAST MATERIAL,48100134,CDM,480,RC,93609,HCPCS,facility,both,,,,10930,10930,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE DEAC 1/1/2022 HC RT/LT HEART & RETROGR CATH COGENITAL ANOMALY,48100135,CDM,481,RC,93603,HCPCS,facility,both,,,,3560,3560,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE DEAC 1/1/2022 HC RT HRT CATH CONGENITAL CARDIAC ANOMALY,48100136,CDM,481,RC,93602,HCPCS,facility,both,,,,11855,11855,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ENDOMYOCARDIAL BIOPSY,48100137,CDM,481,RC,93582,HCPCS,facility,both,,,,122784,122784,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC RT & LT HEART CATH WINJX HRT ART& L VENTR IMG,48100138,CDM,481,RC,93581,HCPCS,facility,both,,,,22039,22039,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CATH PLMT LT HEART & ARTS W/NJX & ANGIO IMG S&I,48100139,CDM,481,RC,93580,HCPCS,facility,both,,,,45913,45913,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CATH PLACEMENT & NJX CORONARY ART ANGIO IMG S&I,48100144,CDM,481,RC,93564,HCPCS,facility,both,,,,476,476,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC RT & LT HEART CATH W/VENTRICULOGRAPHY,48100147,CDM,481,RC,93533,HCPCS,facility,both,,,,10089,10089,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC LEFT HEART CATH W/NJX L VENTRICULOGRAPHY IMG S&I,48100148,CDM,481,RC,93532,HCPCS,facility,both,,,,9568,9568,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC RIGHT HEART CATH O2 SATURATION & CARDIAC OUTPUT,48100149,CDM,481,RC,93531,HCPCS,facility,both,,,,14132,14132,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PRQ TRLUML PULMONARY ART BALLOON ANGIOP SINGLE VSL,48100150,CDM,481,RC,93530,HCPCS,facility,both,,,,13318,13318,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PRQ BALLOON VALVULOPLASTY PULMONARY VALVE,48100151,CDM,481,RC,93505,HCPCS,facility,both,,,,7078,7078,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC FOREARM-HAND CAST MATERIAL,48100152,CDM,481,RC,93462,HCPCS,facility,both,,,,22465,22465,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PRQ BALLOON VALVULOPLASTY MITRAL VALVE,48100153,CDM,481,RC,93460,HCPCS,facility,both,,,,22970,22970,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PRQ BALLOON VALVULOPLASTY AORTIC VALVE,48100154,CDM,481,RC,93458,HCPCS,facility,both,,,,22313,22313,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PRQ TRLUML CORONARY STENT W/ANGIO ONE ART/BRNCH,48100155,CDM,481,RC,93454,HCPCS,facility,both,,,,11816,11816,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PRQ CARDIAC ANGIOPLAST SINGLE ART/BRANCH,48100156,CDM,481,RC,93453,HCPCS,facility,both,,,,29301,29301,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC EEG DURING NONINTRACRANIAL SURGERY,48100157,CDM,481,RC,93452,HCPCS,facility,both,,,,21970,21970,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC SLEEP STUDY; ATTENDED,48100158,CDM,481,RC,93451,HCPCS,facility,both,,,,18548,18548,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC STIMULATION & PACING S/P IV DRUG,48100160,CDM,481,RC,92997,HCPCS,facility,both,,,,20386,20386,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ARRHYTHMIA INDUCTION,48100163,CDM,481,RC,92990,HCPCS,facility,both,,,,20806,20806,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ACTIGRAPHY TESTING 73 HRS-14 CONS DAYS,48100164,CDM,481,RC,92987,HCPCS,facility,both,,,,17892,17892,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC LITHOTRIPSY EXTRACORPOREAL SHOCK WAVE,48100165,CDM,481,RC,92986,HCPCS,facility,both,,,,16593,16593,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC FUNCTIONAL BRAIN MAPPING,48100169,CDM,481,RC,92928,HCPCS,facility,both,,,,45870,45870,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC EYE MUSCLE EVAL 1+ MUSC, 1-2 EYES",48100170,CDM,481,RC,92920,HCPCS,facility,both,,,,33369,33369,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC PM DEVICE PROGR EVAL, DUAL",48200001,CDM,482,RC,93017,HCPCS,facility,both,,,,1945,1945,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC ICD DEVICE PROGR EVAL, DUAL",48300001,CDM,483,RC,93279,HCPCS,facility,both,,,,114,114,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ILR DEVICE EVAL PROGR,48300002,CDM,483,RC,93280,HCPCS,facility,both,,,,145,145,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HPA-5 GENOTYPING (35),48300004,CDM,483,RC,93282,HCPCS,facility,both,,,,124,124,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PM DEVICE EVAL IN PERSON,48300005,CDM,483,RC,93283,HCPCS,facility,both,,,,315,315,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CAR ION CHNNLPATH INC 2 GN (2675),48300007,CDM,483,RC,93285,HCPCS,facility,both,,,,125,125,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ILR DEVICE INTERROGATE,48300010,CDM,483,RC,93288,HCPCS,facility,both,,,,136,136,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC TTE CONG ABN; LIMITED/F-UP,48300011,CDM,483,RC,93289,HCPCS,facility,both,,,,139,139,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC TTE W/DOPPLER COMPLETE,48300012,CDM,483,RC,93291,HCPCS,facility,both,,,,58,58,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ECHO TRANSESOPHAGEAL COMPLETE,48300014,CDM,483,RC,93303,HCPCS,facility,both,,,,2946,2946,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC TEE CONGENITAL; GLOBAL,48300015,CDM,483,RC,93304,HCPCS,facility,both,,,,1829,1829,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DOPPLER ECHO; COMPLETE,48300016,CDM,483,RC,93306,HCPCS,facility,both,,,,4673,4673,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DOPPLER ECHO; LIMITED/ F-UP,48300018,CDM,483,RC,93308,HCPCS,facility,both,,,,1515,1515,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DOPPLER COLOR FLOW,48300019,CDM,483,RC,93312,HCPCS,facility,both,,,,4068,4068,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC STRESS TTE ONLY,48300020,CDM,483,RC,93315,HCPCS,facility,both,,,,2935,2935,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC INTERROGATION VAD IN PERSON,48300022,CDM,483,RC,93320,HCPCS,facility,both,,,,1337,1337,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC IMAGE-GUIDED CATHETER FLUID COLLECTION DRAINAGE,48300023,CDM,483,RC,93321,HCPCS,facility,both,,,,703,703,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CAROTID DUPLEX SCAN; BILAT,48300024,CDM,483,RC,93325,HCPCS,facility,both,,,,896,896,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC INTRACRANIAL ARTERY DOPPLER; COMPL,48300025,CDM,483,RC,93350,HCPCS,facility,both,,,,2934,2934,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HLA CLAS II HIGH DEFIN QUAL,48300027,CDM,483,RC,,,facility,both,,,,3352,3352,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HOSPITAL OBSERVATION SERVICE PER HR,48300028,CDM,483,RC,,,facility,both,,,,1715,1715,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PROCALCITONIN (PCT),48300031,CDM,483,RC,93351,HCPCS,facility,both,,,,3074,3074,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CUSTOM SWIM PLUG SET,48300039,CDM,483,RC,93319,HCPCS,facility,both,,,,116,116,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC IMMUMOASSAY QUANT NOS NONAB (115),48900002,CDM,489,RC,93642,HCPCS,facility,both,,,,6326,6326,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC MITO GENOME SEQUENCING HETEROPLASMY DETECTION, IF PERFRMD (148)",48900003,CDM,489,RC,93799,HCPCS,facility,both,,,,11873,11873,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC CISTERNOGRAPHY, POSITIVE CONTRAST, S & I",49000003,CDM,920,RC,51785,HCPCS,facility,both,,,,3861,3861,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC EMERGENCY DEPT VISIT LVL 4,51000007,CDM,510,RC,99212,HCPCS,facility,both,,,,486,486,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC NECK, SOFT TISSUE",61000001,CDM,610,RC,70336,HCPCS,facility,both,,,,3541,3541,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MRI ORBIT/FACE/NECK W/CONTRAST,61000002,CDM,610,RC,70540,HCPCS,facility,both,,,,4420,4420,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MRI ORBIT/FACE/NECK W/O & W/CONTRAST,61000003,CDM,610,RC,70542,HCPCS,facility,both,,,,4863,4863,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MRA HEAD W/O CONTRAST,61000004,CDM,610,RC,70543,HCPCS,facility,both,,,,6796,6796,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MRA CHEST W OR W/O CONTRAST,61000005,CDM,610,RC,71550,HCPCS,facility,both,,,,3595,3595,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC SPINE, SINGLE VIEW, SPECIFY LEVEL",61000007,CDM,610,RC,71552,HCPCS,facility,both,,,,6859,6859,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MRI PELVIS W & W/O CONTRAST,61000008,CDM,610,RC,72195,HCPCS,facility,both,,,,3577,3577,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC RAD EXAM SACROILIAC JOINTS, 3 OR MORE VIEWS",61000009,CDM,610,RC,72196,HCPCS,facility,both,,,,3935,3935,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC RAD EXAM SACRUM AND COCCYX, MIN 2 VIEWS",61000010,CDM,610,RC,72197,HCPCS,facility,both,,,,5763,5763,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MRI UPPER EXT ANY JOINT W/O CONTRAST,61000011,CDM,610,RC,73218,HCPCS,facility,both,,,,3422,3422,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MRI UPPER EXT ANY JOINT W CONTRAST,61000013,CDM,610,RC,73220,HCPCS,facility,both,,,,6843,6843,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MRI UPPER EXT ANY JOINT W & W/O CONTRAST,61000014,CDM,610,RC,73221,HCPCS,facility,both,,,,3774,3774,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MRA UPPER EXT W OR W/O CONTRAST,61000015,CDM,610,RC,73222,HCPCS,facility,both,,,,3894,3894,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC RAD EXAM HIP ARTHROGRAPHY,61000016,CDM,610,RC,73223,HCPCS,facility,both,,,,6843,6843,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MRI ANY JOINT LOWER EXT W/CONTRAST,61000017,CDM,610,RC,73718,HCPCS,facility,both,,,,3267,3267,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MRI ANY JOINT LOWER EXT W/O & W CON,61000019,CDM,610,RC,73721,HCPCS,facility,both,,,,3125,3125,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MRA LOWER EXT W/W/O CONTRAST,61000020,CDM,610,RC,73722,HCPCS,facility,both,,,,3749,3749,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC RAD EXM; COMPL ACUTE ABD SERIES, INCL 2+ VIEWS ABD, & SNGL VIEW CHEST",61000021,CDM,610,RC,73723,HCPCS,facility,both,,,,5929,5929,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MRI ABDOMEN W & W/O CONTRAST,61000022,CDM,610,RC,74181,HCPCS,facility,both,,,,3577,3577,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MRA ABDOMEN W OR W/O CONTRAST,61000023,CDM,610,RC,74182,HCPCS,facility,both,,,,4329,4329,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PERITONEOGRAM AFTER INJECTION S & I,61000024,CDM,610,RC,74183,HCPCS,facility,both,,,,5508,5508,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CARDIAC MRI W & W/O CONTRAST W/STRESS,61000025,CDM,610,RC,75557,HCPCS,facility,both,,,,3098,3098,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CT HEART W/O CONTRAST W/CALCIUM QUANT,61000026,CDM,610,RC,75561,HCPCS,facility,both,,,,4131,4131,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CT HEART W/CONTRAST INC W/3 D POSTPROC,61000027,CDM,610,RC,75563,HCPCS,facility,both,,,,8590,8590,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC ULTRASOUND, SOFT TISSUES HEAD & NECK",61000028,CDM,610,RC,76498,HCPCS,facility,both,,,,7172,7172,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC LIVER & SPLEEN; W VASC FLOW,61000040,CDM,610,RC,73720,HCPCS,facility,both,,,,5290,5290,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "DEAC 9/1/2020 HC WASHED RED BLOOD CELLS, PEDS, EA UNIT",61000045,CDM,610,RC,76390,HCPCS,facility,both,,,,3706,3706,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC GJB2 GENE FULL SEQUENCE (470),61000046,CDM,610,RC,75565,HCPCS,facility,both,,,,2682,2682,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC HEARING AID, BINAURAL, BTE/BTE",61000054,CDM,610,RC,74712,HCPCS,facility,both,,,,3460,3460,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC METHYLENEDIOXYAMPHETAMINES (29),61000056,CDM,610,RC,76391,HCPCS,facility,both,,,,2813,2813,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DRUG SCREENING COCAINE (39),61000057,CDM,610,RC,77022,HCPCS,facility,both,,,,1736,1736,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MRI BRAIN W CONTRAST,61100001,CDM,611,RC,70551,HCPCS,facility,both,,,,3952,3952,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MRI BRAIN W & W/O CONTRAST,61100002,CDM,611,RC,70552,HCPCS,facility,both,,,,4680,4680,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC MRI BRAIN, FUNCTIONAL, BY TECH",61100003,CDM,611,RC,70553,HCPCS,facility,both,,,,6287,6287,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC MRI BRAIN, FUNCTIONAL, BY PHYSICIAN/PSYCH",61100004,CDM,611,RC,70554,HCPCS,facility,both,,,,1013,1013,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC RIBS X-RAY, UNILAT, MIN 3 VIEWS INCL CHEST",61100005,CDM,611,RC,70555,HCPCS,facility,both,,,,1424,1424,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC MRI SPINE THORACIC, W/O CONTRAST",61200001,CDM,612,RC,72141,HCPCS,facility,both,,,,4466,4466,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC MRI SPINE THORACIC, W CONTRAST",61200002,CDM,612,RC,72142,HCPCS,facility,both,,,,4663,4663,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC MRI SPINE LUMBAR, W/O CONTRAST",61200003,CDM,612,RC,72146,HCPCS,facility,both,,,,4588,4588,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC MRI SPINE LUMBAR, W CONTRAST",61200004,CDM,612,RC,72147,HCPCS,facility,both,,,,4806,4806,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC MRI SPINE CERVICAL, W & W/O CONTRAST",61200005,CDM,612,RC,72148,HCPCS,facility,both,,,,4027,4027,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC MRI SPINE THORACIC, W & W/O CONTRAST",61200006,CDM,612,RC,72149,HCPCS,facility,both,,,,4370,4370,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC MRI SPINE LUMBAR, W & W/O CONTRAST",61200007,CDM,612,RC,72156,HCPCS,facility,both,,,,7250,7250,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MRA SPINE W OR W/O CONTRAST,61200008,CDM,612,RC,72157,HCPCS,facility,both,,,,6807,6807,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC RAD EXAM PELVIS, 1 OR 2 VIEWS",61200009,CDM,612,RC,72158,HCPCS,facility,both,,,,6141,6141,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MRA HEAD W CONTRAST,61500001,CDM,615,RC,70544,HCPCS,facility,both,,,,4202,4202,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MRA HEAD W & W/O CONTRAST,61500002,CDM,615,RC,70545,HCPCS,facility,both,,,,4622,4622,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MRA NECK W/O CONTRAST,61500003,CDM,615,RC,70546,HCPCS,facility,both,,,,7398,7398,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MRA NECK W CONTRAST,61500004,CDM,615,RC,70547,HCPCS,facility,both,,,,3927,3927,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MRA NECK W & W/O CONTRAST,61500005,CDM,615,RC,70548,HCPCS,facility,both,,,,4114,4114,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MRI BRAIN W/O CONTRAST,61500006,CDM,615,RC,70549,HCPCS,facility,both,,,,7398,7398,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CT ABDOMEN W/O CONTRAST,61600001,CDM,616,RC,73725,HCPCS,facility,both,,,,6814,6814,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC RAPID RESPONSE TEAM,61600005,CDM,616,RC,,,facility,both,,,,6814,6814,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC TRANSCUTANEOUS BEDSIDE MONITORING, PER DAY",61600006,CDM,616,RC,,,facility,both,,,,6814,6814,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC SPINE, CERVICAL, 2 OR 3 VIEWS",61800001,CDM,618,RC,71555,HCPCS,facility,both,,,,7608,7608,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC RAD EXAM PELVIS, MIN 3 VIEWS",61800002,CDM,618,RC,72159,HCPCS,facility,both,,,,5460,5460,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC RAD EXAM KNEE 1 OR 2 VIEWS,61800003,CDM,618,RC,73225,HCPCS,facility,both,,,,6814,6814,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC RAD EXM; ESOPH, INCL SCOUT RAD(S)&DLY IMG(S), SNGL-CONTRAST STDY",61800004,CDM,618,RC,74185,HCPCS,facility,both,,,,7608,7608,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC NOSE TO RECTUM FOR FB CHILD,61800010,CDM,618,RC,72198,HCPCS,facility,both,,,,8658,8658,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CONTINUOUS NEG PRESSURE VENTILATION/PER DAY,61800011,CDM,618,RC,,,facility,both,,,,10317,10317,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC CONT AEROSOL TX W/O BRONCHODILATION, PER DAY",61800012,CDM,618,RC,,,facility,both,,,,7636,7636,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC COMPATIBILITY TEST INCUBATE,61800014,CDM,618,RC,,,facility,both,,,,8658,8658,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC TUMOR IMAGING WHOLE BODY 2+ DAYS,61800015,CDM,618,RC,,,facility,both,,,,8658,8658,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC KIDNEY IMAGING MORPHOLOGY,61800016,CDM,618,RC,,,facility,both,,,,7608,7608,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HEP-B AMPLIF NA PROBE,61800025,CDM,618,RC,,,facility,both,,,,971,971,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HERPES S NA QUAN,61800026,CDM,618,RC,,,facility,both,,,,7608,7608,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC INS IMPLNTBL DEFIB PULSE GEN W/1 EXISTING LD,61800027,CDM,618,RC,,,facility,both,,,,6814,6814,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC REMOVE TRANSVNS PM ELTRD DUAL LEAD SYS,61800028,CDM,618,RC,,,facility,both,,,,6814,6814,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC REMOVE TRANSVNS PM ELTRD 1 LEAD SYS ATR/VENTR,61800029,CDM,618,RC,,,facility,both,,,,6814,6814,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC RADIOLOGY MISCELLANEOUS,61800031,CDM,618,RC,,,facility,both,,,,818,818,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CEREBRAL PERFUSION ANALYS CT W/BLOOD FLOW&VOLUME,61800032,CDM,618,RC,,,facility,both,,,,699,699,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC ASSISTIVE LISTENING DEVICE, NOT OTHERWISE SPECIFIED",68200001,CDM,682,RC,,,facility,both,,,,8841,8841,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC AMPHETAMINE:CONFIRMATION,URINE",68200002,CDM,682,RC,,,facility,both,,,,14734,14734,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC OPIATES,CONFIRMATION,URINE",68200003,CDM,682,RC,,,facility,both,,,,11788,11788,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HERPES-6 (HHV-6) PCR SLI,68200004,CDM,682,RC,,,facility,both,,,,12788,12788,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC SEP&HAND ONLY/BLOOD&COMP,68200005,CDM,682,RC,,,facility,both,,,,15395,15395,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MISCELLANEOUS LAB TEST,68200006,CDM,682,RC,,,facility,both,,,,8841,8841,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC APPLY SHORT ARM CAST,70000001,CDM,700,RC,29065,HCPCS,facility,both,,,,1586,1586,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC APPLY LONG LEG CAST,70000002,CDM,700,RC,29075,HCPCS,facility,both,,,,1586,1586,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC ENDOTRACHEAL, INTUBATION EMERGENCY",70000005,CDM,700,RC,29345,HCPCS,facility,both,,,,1188,1188,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC VASC EMBOLIZE/OCCLUDE BLEED,70000010,CDM,700,RC,29086,HCPCS,facility,both,,,,718,718,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC HA DIGITAL, BASIC BINAURAL, ITC",71000362,CDM,710,RC,,,facility,both,,,,203.84,203.84,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC HA DIGITAL, BASIC BINAURAL, ITE",71000363,CDM,710,RC,,,facility,both,,,,80.64,80.64,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC HA DIGITAL, BASIC BINAURAL, BTE",71000364,CDM,710,RC,,,facility,both,,,,100.8,100.8,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC HA DIGITAL, BASIC BINAURAL, RITE",71000365,CDM,710,RC,,,facility,both,,,,53.76,53.76,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ROUTINE VENIPUNCTURE,72000025,CDM,720,RC,,,facility,both,,,,3051,3051,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CPR PER SESSION,72000065,CDM,722,RC,99464,HCPCS,facility,both,,,,894,894,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC REMOTE PT 30 DAY ECG REV/REPORT,73000001,CDM,730,RC,93005,HCPCS,facility,both,,,,545,545,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC NONSELECTIVE CATHETER - AORTA,73000003,CDM,730,RC,93041,HCPCS,facility,both,,,,310,310,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HPA-4 GENOTYPING (35),73100001,CDM,731,RC,93226,HCPCS,facility,both,,,,1440,1440,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC ICD DEVICE PROG EVAL, 1 SINGLE",73100002,CDM,731,RC,93270,HCPCS,facility,both,,,,208,208,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC KEY CHAIN BAT TESTER,73100010,CDM,731,RC,93242,HCPCS,facility,both,,,,132,132,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HA CARE KIT (ADULT),73100011,CDM,731,RC,93246,HCPCS,facility,both,,,,217,217,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC MEDICAL NUTRITION THERAPY, GROUP, EA 30 MIN",73100100,CDM,731,RC,93225,HCPCS,facility,both,,,,683,683,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC EXTENDED EEG 41-60 MIN,74000001,CDM,740,RC,95805,HCPCS,facility,both,,,,4045,4045,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC EEG EXTENDED MONITORING; 61-119 MIN,74000002,CDM,740,RC,95810,HCPCS,facility,both,,,,7624,7624,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC EEG AWAKE & DROWSY,74000003,CDM,740,RC,95811,HCPCS,facility,both,,,,9508,9508,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC EEG AWAKE & ASLEEP,74000004,CDM,740,RC,95812,HCPCS,facility,both,,,,1222,1222,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC EEG-SLEEP ONLY,74000005,CDM,740,RC,95813,HCPCS,facility,both,,,,1350,1350,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC EEG; CEREBRAL SILENCE,74000006,CDM,740,RC,95816,HCPCS,facility,both,,,,1093,1093,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC EMG- ONE EXTREMITY,74000007,CDM,740,RC,95819,HCPCS,facility,both,,,,1093,1093,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC EMG-TWO EXTREMITIES,74000008,CDM,740,RC,95822,HCPCS,facility,both,,,,912,912,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC EMG-THREE EXTREMITIES,74000009,CDM,740,RC,95824,HCPCS,facility,both,,,,992,992,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HYDRATION IV INFUSION 1ST HOUR,74000011,CDM,740,RC,95957,HCPCS,facility,both,,,,594,594,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HYDRATION IV INFUSION EACH ADDL HOUR,74000012,CDM,740,RC,95958,HCPCS,facility,both,,,,5044,5044,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC IV INFUSION DRUG THERAPY 1ST HOUR,74000013,CDM,740,RC,95961,HCPCS,facility,both,,,,1916,1916,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HA REPAIR BINAURAL OUT WA,74000060,CDM,740,RC,95782,HCPCS,facility,both,,,,7941,7941,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HA REPAIR MONAURAL OUT WA,74000061,CDM,740,RC,95783,HCPCS,facility,both,,,,4833,4833,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC IMMUMOASSAY QUANT NOS NONAB (190),74000064,CDM,740,RC,95806,HCPCS,facility,both,,,,568,568,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE DEAC 11/01/2023 HC ADM SARSCV2 BVL 10 MCG/0.2ML 1ST DOSE,74000066,CDM,740,RC,95962,HCPCS,facility,both,,,,1581,1581,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC TWO KNOWN FAMILIAL VARIANTS IN A NUCLEAR GENE (98),74000067,CDM,740,RC,95829,HCPCS,facility,both,,,,6031,6031,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC INSERT 1 ELECTRODE PM-DEFIB,74000068,CDM,740,RC,95700,HCPCS,facility,both,,,,1028,1028,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC INSERT 2 ELECTRODE PM-DEFIB,74000069,CDM,740,RC,95705,HCPCS,facility,both,,,,3086,3086,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC THER INTERV COG FUNCT/COMP STRATG; DIR CONTACT; 1ST 15 MIN,74000072,CDM,740,RC,95708,HCPCS,facility,both,,,,5915,5915,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC THER INTERV COG FUNCT/COMP STRATG; DIR CONTACT; EA ADDL 15 MIN,74000075,CDM,740,RC,95711,HCPCS,facility,both,,,,4501,4501,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC UNLISTED PROCEDURE MUSCULOSKELETAL SYSTEM GENERAL,74000076,CDM,740,RC,95712,HCPCS,facility,both,,,,4886,4886,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC DUPLEX SCAN ARTERIAL INFLOW & VENOUS OUTFLOW, PREOP, COMPLT UNI STUDY",74000077,CDM,740,RC,95713,HCPCS,facility,both,,,,5658,5658,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DRUG ASSAY ADALIMUMAB (265),74000078,CDM,740,RC,95714,HCPCS,facility,both,,,,7330,7330,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DRUG ASSAY POSACONAZOLE (30),74000079,CDM,740,RC,95715,HCPCS,facility,both,,,,7716,7716,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DRUG ASSAY INFLIXIMAB (165),74000080,CDM,740,RC,95716,HCPCS,facility,both,,,,8488,8488,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC NEEDLE ELECTROMYOGRAPHY LARYNX,74000081,CDM,740,RC,95955,HCPCS,facility,both,,,,1352,1352,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MYOCRD STRAIN IMG USING SPECKLE TRCK ASSMT OF MYOCRD MECHAN,74000082,CDM,740,RC,95807,HCPCS,facility,both,,,,2074,2074,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC SLEEP STUDY UNATTENDED & RESP EFFORT,74000083,CDM,740,RC,95803,HCPCS,facility,both,,,,258,258,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PROCEDURE ENDO LEVEL 1 INIT 15 MIN,75000025,CDM,750,RC,,,facility,both,,,,217,217,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PROCEDURE ENDO LEVEL 2 INIT 15 MIN,75000026,CDM,750,RC,,,facility,both,,,,239,239,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC LITHOTRIPSY-KIDNEY-ESWL,75000102,CDM,750,RC,,,facility,both,,,,3446.24,3446.24,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CHEMO PROLONG 8+ HRS INFUSE W/PUMP,75000103,CDM,750,RC,,,facility,both,,,,7266.56,7266.56,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC REMOVAL TUNNELED INTRAPERITONEAL CATHETER,75000106,CDM,750,RC,,,facility,both,,,,3446.24,3446.24,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PROCEDURE ENDO LEVEL 1 EA ADDL 15 MINUTE,75000125,CDM,750,RC,,,facility,both,,,,110,110,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PROCEDURE ENDO LEVEL 2 EA ADDL 15 MINUTE,75000126,CDM,750,RC,,,facility,both,,,,121,121,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HA REPAIR/MODIFICATION COMPLETE,75000127,CDM,750,RC,,,facility,both,,,,261,261,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HA REPAIR/MODIFICATION COMPLETE,75000128,CDM,750,RC,,,facility,both,,,,134,134,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ELECTROCORTICOGRAM AT SURGERY,75000340,CDM,750,RC,,,facility,both,,,,217,217,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC GENE TEST FOR HEART DISORDER,75000341,CDM,750,RC,,,facility,both,,,,110,110,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PT EVAL LOW COMPLEXITY,75000342,CDM,750,RC,,,facility,both,,,,239,239,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PT EVAL MODERATE COMPLEXITY,75000343,CDM,750,RC,,,facility,both,,,,121,121,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PT EVAL HIGH COMPLEXITY,75000344,CDM,750,RC,,,facility,both,,,,261,261,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PT RE-EVAL EST PLAN CARE,75000345,CDM,750,RC,,,facility,both,,,,134,134,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC COLLECTION OF BLOOD VIA PICC,76100001,CDM,761,RC,36591,HCPCS,facility,both,,,,418,418,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DECLOTTING VAD OR CATHETER,76100002,CDM,761,RC,36592,HCPCS,facility,both,,,,508,508,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC NEEDLE EMG ANAL/URETHRAL SPHINCTER,76100003,CDM,761,RC,36593,HCPCS,facility,both,,,,1259,1259,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC BONE BIOPSY TROCAR/NEEDLE; SUPERFICIAL,76100026,CDM,761,RC,20206,HCPCS,facility,both,,,,3845,3845,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC BONE BIOPSY TROCAR/NEEDLE; DEEP,76100027,CDM,761,RC,20220,HCPCS,facility,both,,,,3745,3745,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC APPLY LONG ARM CAST,76100028,CDM,761,RC,20225,HCPCS,facility,both,,,,3945,3945,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC APHERESIS WBC,76100030,CDM,761,RC,20610,HCPCS,facility,both,,,,2356,2356,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC APHERESIS RBC,76100031,CDM,761,RC,20615,HCPCS,facility,both,,,,2471,2471,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PHOTOPHERESIS EXTRACORPOREAL,76100035,CDM,761,RC,32400,HCPCS,facility,both,,,,3033,3033,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC INSERT PICC AGE 5 YRS/>, W/O IMAGE GUIDE",76100036,CDM,761,RC,32405,HCPCS,facility,both,,,,2350,2350,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CONTRAST INJ W/FLUORO EVAL CV DEVICE,76100038,CDM,761,RC,36511,HCPCS,facility,both,,,,8000,8000,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HARVEST STEM CELLS AUTOLOGOUS,76100039,CDM,761,RC,36512,HCPCS,facility,both,,,,6813,6813,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC THAW PRESERVED STEM CELLS,76100040,CDM,761,RC,36522,HCPCS,facility,both,,,,16105,16105,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DIAGNOSTIC BONE MARROW; ASPIRATION(S),76100041,CDM,761,RC,36569,HCPCS,facility,both,,,,5053,5053,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DIAGNOSTIC BONE MARROW: BIOPSY(IES),76100043,CDM,761,RC,36598,HCPCS,facility,both,,,,745,745,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC BONE MARROW STEM TRANSPLANT, AUTOLOGOUS",76100045,CDM,761,RC,38206,HCPCS,facility,both,,,,6608,6608,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ALLG SPEC IGE RECOMB EA,76100047,CDM,761,RC,38208,HCPCS,facility,both,,,,1969,1969,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC BIOPSY LYMPH NODES; SUPERFICIAL,76100051,CDM,761,RC,38220,HCPCS,facility,both,,,,3819,3819,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC BIOPSY SALIVARY GLAND; NEEDLE,76100052,CDM,761,RC,38221,HCPCS,facility,both,,,,3798,3798,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC BIOPSY LIVER; PERCUTANEOUS NEEDLE,76100055,CDM,761,RC,38241,HCPCS,facility,both,,,,4527,4527,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC BIOPSY PANCREAS PERCUTANEOUS NEEDLE,76100057,CDM,761,RC,38505,HCPCS,facility,both,,,,3799,3799,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ABD PARACENTESIS W/IMAGING,76100058,CDM,761,RC,42400,HCPCS,facility,both,,,,2741,2741,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PERC NDL BIOPSY ABD/RETROPERITONEAL MASS,76100060,CDM,761,RC,47000,HCPCS,facility,both,,,,8950,8950,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ASP &/OR INJ OF RENAL CYST/PELVIS; PERC,76100061,CDM,761,RC,48102,HCPCS,facility,both,,,,3067,3067,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DRAIN BLADDER W/CATH INSERTION,76100064,CDM,761,RC,49083,HCPCS,facility,both,,,,1666,1666,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC INSERT NON-DWELL BLADDER CATH,76100065,CDM,761,RC,49180,HCPCS,facility,both,,,,3840,3840,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC INSERT TEMP BLADDER CATHETER,76100066,CDM,761,RC,50200,HCPCS,facility,both,,,,8603,8603,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC INSERT BLADDER CATHETER COMPLEX,76100067,CDM,761,RC,50390,HCPCS,facility,both,,,,4452,4452,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PROSTATE NDL/PUNCH BIOPSY;SGL/MULT,76100068,CDM,761,RC,51102,HCPCS,facility,both,,,,5594,5594,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC IMAGE GUIDED CATH ABSCESS TRANSVAGINAL,76100070,CDM,761,RC,51701,HCPCS,facility,both,,,,614,614,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC TPMT GENE COM VARIANTS,76100071,CDM,761,RC,51702,HCPCS,facility,both,,,,3078,3078,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HPA-1 GENOTYPING (35),76100072,CDM,761,RC,51703,HCPCS,facility,both,,,,3078,3078,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC BIOPSY THYROID PERC CORE NEEDLE,76100077,CDM,761,RC,55700,HCPCS,facility,both,,,,4764,4764,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC 12 LEAD EKG; TRACING ONLY,76100106,CDM,761,RC,60100,HCPCS,facility,both,,,,1665,1665,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HPA-3 GENOTYPING (35),76100108,CDM,761,RC,62270,HCPCS,facility,both,,,,4757,4757,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC 12 CVSLR STRESS TEST; TRACING,76100109,CDM,761,RC,62272,HCPCS,facility,both,,,,2759,2759,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC COLLECTION OF BLOOD VIA VAD,76100118,CDM,761,RC,36514,HCPCS,facility,both,,,,6813,6813,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC VEEG BY TECH 2-12 HR INTERMITTENT MONITORING,76100152,CDM,761,RC,32557,HCPCS,facility,both,,,,11536,11536,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC VEEG BY TECH 2-12 HR CONTINUOUS REAL-TIME MONITORING,76100153,CDM,761,RC,36597,HCPCS,facility,both,,,,5445,5445,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC VEEG BY TECH EA INCR 12-26 HR UNMONITORED,76100154,CDM,761,RC,49450,HCPCS,facility,both,,,,4285,4285,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC VEEG BY TECH EA INCR 12-26 HR INTERMITTENT MNTR,76100155,CDM,761,RC,49465,HCPCS,facility,both,,,,1021,1021,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC VEEG BY TECH EA INCR 12-26 HR CONT REAL-TIME MNTR,76100156,CDM,761,RC,32555,HCPCS,facility,both,,,,6895,6895,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC REPAIR LEAD PACE-DEFIB ONE,76100300,CDM,761,RC,33206,HCPCS,facility,both,,,,62275,62275,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC REPAIR LEAD PACE-DEFIB DUAL,76100301,CDM,761,RC,33207,HCPCS,facility,both,,,,62275,62275,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC REVISE POCKET FOR DEFIB,76100302,CDM,761,RC,33208,HCPCS,facility,both,,,,89592,89592,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC REMOVE&REPLACE PM GEN SINGL,76100303,CDM,761,RC,33210,HCPCS,facility,both,,,,16928,16928,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC REMV&REPLC PM GEN DUAL LEAD,76100306,CDM,761,RC,33213,HCPCS,facility,both,,,,57279,57279,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC INSRT PULSE GEN W/DUAL LEADS,76100309,CDM,761,RC,33216,HCPCS,facility,both,,,,23696,23696,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC REMOVE PULSE GENERATOR,76100310,CDM,761,RC,33217,HCPCS,facility,both,,,,19747,19747,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC REM SC/DC CARD-DEFIBR ELECTROD OPEN,76100311,CDM,761,RC,33218,HCPCS,facility,both,,,,8599,8599,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC REM SC/DC ICD LEAD; TV EXTRACT,76100312,CDM,761,RC,33220,HCPCS,facility,both,,,,8617,8617,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC INSERT PACE-DEFIB W/LEAD,76100315,CDM,761,RC,33223,HCPCS,facility,both,,,,8049,8049,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC REMV&REPLC CVD GEN SING LEAD,76100319,CDM,761,RC,33227,HCPCS,facility,both,,,,12487,12487,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC REMV&REPLC CVD GEN DUAL LEAD,76100320,CDM,761,RC,33228,HCPCS,facility,both,,,,14794,14794,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC TEMPORARY TRANSCUTANEOUS PACING,76100322,CDM,761,RC,33230,HCPCS,facility,both,,,,43474,43474,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC ESOPHAGUS, REFLUX TEST; WITH MUCOSAL",76100325,CDM,761,RC,33241,HCPCS,facility,both,,,,11351,11351,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC EXCHANGE PREVIOUS DRAINAGE CATHETER,76100326,CDM,761,RC,33243,HCPCS,facility,both,,,,8599,8599,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC INSERT TUNNELED INTRAPERITONEAL CATH; PERC,76100327,CDM,761,RC,33244,HCPCS,facility,both,,,,8599,8599,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PERCUTANEOUS CHOLECYSTOSTOMY,76100328,CDM,761,RC,33249,HCPCS,facility,both,,,,109604,109604,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC NG TUBE PLACEMENT W/FLOURO,76100329,CDM,761,RC,33262,HCPCS,facility,both,,,,16930,16930,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC SA MECH REMOVAL, OBSTRUCTIVE CVAD",76100330,CDM,761,RC,33263,HCPCS,facility,both,,,,21049,21049,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC INSERT NON-TUNNEL CV CATH <5 YRS,76100337,CDM,761,RC,92953,HCPCS,facility,both,,,,2586,2586,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC INSTILLATION, AGENT FOR PLEURODESIS",76100338,CDM,750,RC,,,facility,both,,,,8326.08,8326.08,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC INJECTION SINUS TRACT; DIAGNOSTIC (SINOGRAM),76100346,CDM,761,RC,49423,HCPCS,facility,both,,,,4354,4354,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC RHYTHM ECG 1-3 LEADS TRACING,76100347,CDM,761,RC,49418,HCPCS,facility,both,,,,13074,13074,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC MRA W CONTRAST, PELVIS",76100351,CDM,761,RC,47490,HCPCS,facility,both,,,,6401,6401,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MRA ABD WO CONTRAST,76100353,CDM,761,RC,43752,HCPCS,facility,both,,,,1240,1240,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC SEL CATH ARTERIAL; ABD-LWR EXTREMITY; EA ADDL,76100357,CDM,761,RC,36595,HCPCS,facility,both,,,,12274,12274,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC SEL CATH ARTERIAL, BRACH-CEPH; EA ADDL",76100358,CDM,761,RC,36555,HCPCS,facility,both,,,,7381,7381,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC SEL CATH ARTERIAL, BRACH-CEPH; 3RD ORDER",76100359,CDM,761,RC,32560,HCPCS,facility,both,,,,2035,2035,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC SEL CATH ARTERIAL, BRACH-CEPH; 2ND ORDER",76100368,CDM,761,RC,20501,HCPCS,facility,both,,,,715,715,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HSV-6 IGM AB,76100377,CDM,761,RC,19081,HCPCS,facility,both,,,,4438,4438,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC CARNITINE, FREE & TOTAL, SERUM",76100378,CDM,761,RC,19082,HCPCS,facility,both,,,,3764,3764,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC CARNITINE, FREE & TOTAL, SERUM",76100379,CDM,761,RC,19083,HCPCS,facility,both,,,,5068,5068,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC VENTILATION ASSIST/MGMT SLP/SN,76100380,CDM,761,RC,19084,HCPCS,facility,both,,,,4392,4392,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DISPENSING FEE BINAURAL,76100381,CDM,761,RC,19085,HCPCS,facility,both,,,,5903,5903,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ANKLE GAUNTLET PREFAB OTS,76100382,CDM,761,RC,19086,HCPCS,facility,both,,,,5229,5229,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC DISPENSING FEE, CONTRALATERAL ROUTING SYSTEM, BINAURAL",76100383,CDM,761,RC,19281,HCPCS,facility,both,,,,3395,3395,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC INFLUENZA DNA AMP PROBE,76100384,CDM,761,RC,19282,HCPCS,facility,both,,,,2720,2720,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC BENZODIAZEPINE CONFIRMATION,UR",76100385,CDM,761,RC,19283,HCPCS,facility,both,,,,3395,3395,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CVVH INITIAL SET UP AND USE,76100386,CDM,761,RC,19284,HCPCS,facility,both,,,,2720,2720,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC STREP A ASSAY W/OPTIC,76100387,CDM,761,RC,19285,HCPCS,facility,both,,,,4019,4019,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC LAB PATHOLOGY,76100388,CDM,761,RC,19286,HCPCS,facility,both,,,,3345,3345,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC SPECIMEN HANDLING PT-LAB,76100389,CDM,761,RC,19287,HCPCS,facility,both,,,,4809,4809,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC LAB CHEMISTRY,76100390,CDM,761,RC,19288,HCPCS,facility,both,,,,4183,4183,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MCG; SITU HYBRID 10-30 CELLS,76100409,CDM,761,RC,20611,HCPCS,facility,both,,,,2592,2592,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC STREP A AMPLIF NA PROBE,76100417,CDM,761,RC,36596,HCPCS,facility,both,,,,6427,6427,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC HC AB, VIRUS NES (20)",76100419,CDM,761,RC,20604,HCPCS,facility,both,,,,1770,1770,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC UNLISTED MOLE PROC (900),76100420,CDM,761,RC,20606,HCPCS,facility,both,,,,2143,2143,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC QUANTITATIVE ASSAY DRUG (25),76100423,CDM,761,RC,27648,HCPCS,facility,both,,,,3756,3756,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HLA II TYPING 1 LOC LR (120),76100427,CDM,761,RC,47531,HCPCS,facility,both,,,,7081,7081,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HLA II TYPING 1 LOC HR (290),76100428,CDM,761,RC,47532,HCPCS,facility,both,,,,11206,11206,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HLA CLASS I PHENOTYPE QUAL,76100429,CDM,761,RC,47533,HCPCS,facility,both,,,,14057,14057,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HLA CLASS II PHENOTYPE QUAL,76100430,CDM,761,RC,47534,HCPCS,facility,both,,,,14057,14057,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HLA I TYPING 1 LOCUS LR (55),76100431,CDM,761,RC,47535,HCPCS,facility,both,,,,12327,12327,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HLA CLASS I&II ANTIBODY QUAL,76100432,CDM,761,RC,47536,HCPCS,facility,both,,,,12327,12327,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC GASTRIC EMPTYING IMAGING STUDY (SOLID, LIQUID OR BOTH)",76100433,CDM,761,RC,47537,HCPCS,facility,both,,,,2734,2734,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PMP22 GENE DUP/DELET (505),76100434,CDM,761,RC,47538,HCPCS,facility,both,,,,26589,26589,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PMP22 GENE DUP/DELET (505),76100435,CDM,761,RC,47539,HCPCS,facility,both,,,,23316,23316,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CARB DEFICIENT TRANSFERRIN (30),76100436,CDM,761,RC,47540,HCPCS,facility,both,,,,23316,23316,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC GJB6 GENE COM VAR (1),76100437,CDM,761,RC,47544,HCPCS,facility,both,,,,4964,4964,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC GJB6 GENE COM VAR (1),76100438,CDM,761,RC,50430,HCPCS,facility,both,,,,2699,2699,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC TARGETED GENOMIC ANALYSIS(170),76100439,CDM,761,RC,50431,HCPCS,facility,both,,,,2699,2699,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC VERSITI HEPARININDUCED THROMBOCYTOPENIA EVALUATION PEA(170),76100441,CDM,761,RC,50433,HCPCS,facility,both,,,,8528,8528,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ELECTRODE STIM BRAIN ADD-ON,76100442,CDM,761,RC,50434,HCPCS,facility,both,,,,2969,2969,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC NEEDLE EMG; FOUR EXTREMITIES,76100443,CDM,761,RC,50435,HCPCS,facility,both,,,,3771,3771,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PANORAMIC X-RAY OF JAWS,76100445,CDM,761,RC,50693,HCPCS,facility,both,,,,14486,14486,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HIGH ALTITUDE SIMULATION TEST,76100446,CDM,761,RC,50694,HCPCS,facility,both,,,,14486,14486,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HIGH ALTITUDE SIMULATION TEST WITH OXYGEN TITRATION,76100447,CDM,761,RC,50695,HCPCS,facility,both,,,,14486,14486,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HGB FRACTIONATION & QUANTITATION; ELECTROPHORESIS,76100448,CDM,761,RC,61650,HCPCS,facility,both,,,,9334,9334,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC UGT1A1, GENE ANALYSIS, COMMON VARIANTS(85)",76100449,CDM,761,RC,61651,HCPCS,facility,both,,,,4668,4668,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC IMMUNOASSAY QUANT NOS NONAB (184),76100459,CDM,761,RC,33270,HCPCS,facility,both,,,,237784,237784,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC FLT3 GENE (795),76100460,CDM,761,RC,33271,HCPCS,facility,both,,,,50502,50502,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC IMM ADMN SARSCOV2 VACCINE, SINGLE DOSE",76100461,CDM,761,RC,33272,HCPCS,facility,both,,,,18110,18110,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ADM RSV MONOC ANTB SEASONAL DOS IM CNSL PHY/QHP,76100462,CDM,761,RC,33273,HCPCS,facility,both,,,,18110,18110,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ONE KNOWN FAMILIAL VARIANT (136),76100466,CDM,761,RC,38205,HCPCS,facility,both,,,,5604,5604,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PRENATAL KNOWN FAMILIAL MUTATION (INCLUDES MCC) (370),76100467,CDM,761,RC,37220,HCPCS,facility,both,,,,9584,9584,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC UNLISTED MOLECULAR PATHOLOGY PROCEDURE (370),76100468,CDM,761,RC,37187,HCPCS,facility,both,,,,12133,12133,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC GENOME SEQUENCE ANALYSIS (985),76100475,CDM,761,RC,36901,HCPCS,facility,both,,,,4794,4794,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC GENOME SEQ ANALYSIS, EA CMPRTR (493)",76100476,CDM,761,RC,36902,HCPCS,facility,both,,,,33815,33815,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC GENOME SEQ ANALYSIS, EA CMPRTR (985)",76100477,CDM,761,RC,36903,HCPCS,facility,both,,,,68340,68340,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MOPATH PROCEDURE LEVEL 6 (99),76100478,CDM,761,RC,36904,HCPCS,facility,both,,,,33815,33815,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MOPATH PROCEDURE LEVEL 2 (99),76100479,CDM,761,RC,36905,HCPCS,facility,both,,,,68340,68340,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MOPATH PROCEDURE LEVEL 2 (49),76100480,CDM,761,RC,36906,HCPCS,facility,both,,,,103589,103589,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC DRUG SCREEN, INSTRUMENT SINGLE DRUG",76100481,CDM,761,RC,36907,HCPCS,facility,both,,,,935,935,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC DRUG SCREEN, INSTRUMENT 5 DRUG",76100484,CDM,761,RC,37246,HCPCS,facility,both,,,,33797,33797,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC BRAF GENE (205),76100485,CDM,761,RC,37247,HCPCS,facility,both,,,,16733,16733,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC IGH GENE REARRANGE AMP METH (180),76100486,CDM,761,RC,37248,HCPCS,facility,both,,,,33797,33797,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CHIMERISM ANAL NO CELL SELEC (170),76100487,CDM,761,RC,37249,HCPCS,facility,both,,,,16733,16733,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CHIMERISM ANAL WI/CELL SELECT (245),76100489,CDM,761,RC,62321,HCPCS,facility,both,,,,3432,3432,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC TRG GENE REARRANGEMENT ANAL (230),76100491,CDM,761,RC,62323,HCPCS,facility,both,,,,3432,3432,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC SCLEROTX FLUID COLLECT, PERC, INCL CONTRAST INJ(S), SCLERO INJ(S)",76100496,CDM,761,RC,47382,HCPCS,facility,both,,,,16013,16013,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC SCLEROTX FLUID COLLECT, PERC, INCL CONTRAST INJ(S), SCLERO INJ(S)",76100498,CDM,761,RC,49185,HCPCS,facility,both,,,,6082,6082,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PARATHYRD PLANAR W/SPECT&CT,76100501,CDM,761,RC,50384,HCPCS,facility,both,,,,9725,9725,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC RBC DNA HEA 35 AG 11 BLD GRP,76100524,CDM,761,RC,37228,HCPCS,facility,both,,,,18568,18568,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AB; PROTOZOA NES (20),76100526,CDM,761,RC,50592,HCPCS,facility,both,,,,18260,18260,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC DEVELOPMENTAL TEST EXTEND, FIRST HOUR",76100528,CDM,761,RC,49422,HCPCS,facility,both,,,,10142,10142,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC DEVELOPMENTAL TEST EXTEND, EA ADDL 30 MINUTES",76100529,CDM,761,RC,32561,HCPCS,facility,both,,,,1503,1503,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC FINE NEEDLE ASPIRATION BIOPSY, W/FLUORO GUIDANCE, EA ADDL LESION",76100530,CDM,761,RC,20983,HCPCS,facility,both,,,,25284,25284,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC FINE NEEDLE ASPIRATION BIOPSY, W/CT GUIDANCE, 1ST LESION",76100536,CDM,761,RC,32998,HCPCS,facility,both,,,,11892,11892,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC INSERTION, SUBQ CARDIAC RHYTHM MONITOR, INCL PROGRAM",76100538,CDM,761,RC,10005,HCPCS,facility,both,,,,2570,2570,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC REMOVAL, SUBQ CARDIAC RHYTHM MONITOR",76100539,CDM,761,RC,10006,HCPCS,facility,both,,,,1285,1285,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC INSERT PICC, INCLUDING IMAGING, 5 YR+",76100540,CDM,761,RC,10007,HCPCS,facility,both,,,,2827,2827,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC ULTRASOUND, ELASTOGRAPHY; PARENCHYMA (EG, ORGAN)",76100541,CDM,761,RC,10008,HCPCS,facility,both,,,,1413,1413,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HTT GENE DETC ABNOR ALLELES (225),76100542,CDM,761,RC,10009,HCPCS,facility,both,,,,3109,3109,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HTT GENE DETC ABNOR ALLELES (225),76100543,CDM,761,RC,10010,HCPCS,facility,both,,,,1556,1556,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DIHYDROTESTOSTERONE (DHT),76100547,CDM,761,RC,11104,HCPCS,facility,both,,,,960,960,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CAR-T; INFUSION CELL ADMINISTRATION; AUTOLOGOUS,76100552,CDM,761,RC,33285,HCPCS,facility,both,,,,56629,56629,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC POCT URINE HCG VISUAL COLOR,76100553,CDM,761,RC,33286,HCPCS,facility,both,,,,9337,9337,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC POCT GLUCOSE; BLOOD REAGENT STRIP,76100559,CDM,761,RC,36573,HCPCS,facility,both,,,,5615,5615,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HEALTH BEHAVIOR INTERV GROUP FACE TO FACE; EA ADDL 15 MIN,76100571,CDM,761,RC,33016,HCPCS,facility,both,,,,7488,7488,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HEALTH BEHAVIOR INTERV FAM W/PT FACE TO FACE; 1ST 30 MIN,76100572,CDM,761,RC,33017,HCPCS,facility,both,,,,7738,7738,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HEALTH BEHAVIOR INTERV FAM W/PT FACE TO FACE; EA ADD 15 MIN,76100573,CDM,761,RC,33018,HCPCS,facility,both,,,,8772,8772,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CYTOGENOMIC NEO MICRORA ALYS (350),76100579,CDM,761,RC,20999,HCPCS,facility,both,,,,5333,5333,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC DISPENSING FEE, CONTRALATERAL MONAURAL",76100584,CDM,761,RC,31622,HCPCS,facility,both,,,,4036,4036,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC CARDIOVERSION ELECTRICAL CONVERSION, EXTERNAL",76100596,CDM,761,RC,33988,HCPCS,facility,both,,,,2056,2056,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MRA CHEST WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST,76100597,CDM,761,RC,33989,HCPCS,facility,both,,,,2056,2056,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC IRC SURGICAL PRICE PER MINUTE,76200001,CDM,762,RC,,,facility,both,,,,276.64,276.64,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CCPD OUTPATIENT OR HOME,77100001,CDM,771,RC,90471,HCPCS,facility,both,,,,173,173,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC SLV THERAPY, INDIVIDUAL",77100002,CDM,771,RC,90472,HCPCS,facility,both,,,,379,379,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC TX SWALLOWING DYSFUNCTION,77100003,CDM,771,RC,90473,HCPCS,facility,both,,,,379,379,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MOPATH PROCEDURE LEVEL 2 (555),77100007,CDM,771,RC,90474,HCPCS,facility,both,,,,116,116,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC TARGETED GENOMIC SEQ ANALYSIS (1000),77100009,CDM,771,RC,,,facility,both,,,,86,86,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC CYTOPATH, ISH, URIN C MORPHOM (140)",77100010,CDM,771,RC,,,facility,both,,,,91.3,91.3,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ASSAY C-D TGREANSFER MEASURE (155),77100011,CDM,771,RC,,,facility,both,,,,50,50,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC ANTI-DEPRESS,SEROTO 1-2 (50)",77100012,CDM,771,RC,,,facility,both,,,,91.3,91.3,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DRI-AID KIT SUPER (JAR),77100013,CDM,771,RC,,,facility,both,,,,171,171,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DRI-AID KIT (MINI),77100014,CDM,771,RC,,,facility,both,,,,171,171,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HEARING AID RETAINER,77100015,CDM,771,RC,,,facility,both,,,,171,171,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC NUDT15, GENE ANALYSIS, COMMON VARIANTS(30)",77100021,CDM,771,RC,,,facility,both,,,,189,189,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC SLCO1BI, GENE ANALYSIS, COMMON VARIANTS(30)",77100022,CDM,771,RC,,,facility,both,,,,189,189,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "DEAC 4/1/2023 HC TPMT, GENE ANALYSIS, COMMON VARIANTS(30)",77100023,CDM,771,RC,,,facility,both,,,,189,189,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC JAK2 GENE (125),77100026,CDM,771,RC,,,facility,both,,,,189,189,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE DEAC 11/01/2023 HC IMM ADMN SARSCOV2 BIVALENT 30 MCG/0.3 ML BOOSTER,77100027,CDM,771,RC,,,facility,both,,,,189,189,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE DEAC 11/01/2023 HC IMM ADMN SARSCOV2 BIVALENT 10 MCG/0.2 ML BOOSTER,77100028,CDM,771,RC,,,facility,both,,,,189,189,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE DEAC 11/01/2023 HC IMM ADMN SARSCOV2 BIVALENT 50 MCG/0.5 ML BOOSTER,77100029,CDM,771,RC,,,facility,both,,,,189,189,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HEARING AID RETAINER - CLIP DOUBLE,77100030,CDM,771,RC,,,facility,both,,,,1484,1484,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC FLOW CYTOMETRY EA ADDTL MARKER,77100034,CDM,771,RC,,,facility,both,,,,171,171,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PAPPA SERUM,77100035,CDM,771,RC,,,facility,both,,,,171,171,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PTN GENE KNOWN (505),77100036,CDM,771,RC,,,facility,both,,,,171,171,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HCG FREE BETA CHAIN,77100037,CDM,771,RC,,,facility,both,,,,171,171,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC GBA GENE (65),77100038,CDM,771,RC,,,facility,both,,,,171,171,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ENDO LEVEL 1 EA ADDL MIN,77100039,CDM,771,RC,,,facility,both,,,,171,171,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ENDO LEVEL 2 INIT MIN,77100040,CDM,771,RC,,,facility,both,,,,171,171,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ENDO LEVEL 2 EA ADDL MIN,77100041,CDM,771,RC,,,facility,both,,,,171,171,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE DEAC 12/31/2023 HC LIVER DISEASE ALYS 3 BMRK SRM ALG (171),77100045,CDM,771,RC,,,facility,both,,,,171,171,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE DEAC 11/01/2023 HC ADMN SARSCOV2 5 MCG/0.5 ML BOOSTER DOSE,77100046,CDM,771,RC,,,facility,both,,,,171,171,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE DEAC 11/01/2023 HC ADMN SARSCOV2 5 MCG/0.5 ML BOOSTER DOSE,77100047,CDM,771,RC,,,facility,both,,,,171,171,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE DEAC 11/01/2023 HC ADMN SARSCOV2 BIVALENT 3 MCG/0.2 ML 3RD DOSE,77100048,CDM,771,RC,,,facility,both,,,,171,171,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC OT EVAL MOD COMPLEXITY,77100049,CDM,771,RC,,,facility,both,,,,130,130,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC OT EVAL HIGH COMPLEXITY,77100050,CDM,771,RC,,,facility,both,,,,130,130,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC OT RE-EVAL EST PLAN CARE,77100051,CDM,771,RC,,,facility,both,,,,130,130,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC COMBINED CARDIAC  PANEL SEQUENCING AT LEAST 10 GENES (148),77100052,CDM,771,RC,,,facility,both,,,,189,189,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ANTI-MULLERIAN HORMONE (AMH),77100053,CDM,771,RC,,,facility,both,,,,171,171,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ACETYLCHOLINE RECEPTOR (ACHR); BINDING ANTIBODY,77100054,CDM,771,RC,,,facility,both,,,,171,171,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ACETYLCHOLINE RECEPTOR (ACHR); BLOCKING ANTIBODY,77100055,CDM,771,RC,,,facility,both,,,,171,171,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ACETYLCHOLINE RECEPTOR (ACHR); MODULATING ANTIBODY,77100056,CDM,771,RC,,,facility,both,,,,171,171,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MUSCLE-SPECIFIC KINASE (MUSK) ANTIBODY,77100057,CDM,771,RC,,,facility,both,,,,171,171,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PROCEDURE ENDO LEVEL 2 INIT 15 MIN,77100058,CDM,771,RC,,,facility,both,,,,171,171,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC IMM ADMN SARSCOV2 VACCINE, SINGLE DOSE",77100059,CDM,771,RC,90480,HCPCS,facility,both,,,,201,201,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ADM RSV MONOC ANTB SEASONAL DOS IM CNSL PHY/QHP,77100060,CDM,771,RC,96380,HCPCS,facility,both,,,,327,327,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC ADM RSV MONOCLONAL ANTB SEASONAL DOSE IM NJX,77100061,CDM,771,RC,96381,HCPCS,facility,both,,,,283,283,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC INJ PROC, ANKLE ARTHROGRAPHY",79000001,CDM,790,RC,50590,HCPCS,facility,both,,,,19750,19750,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC GROWTH HORMONE AB ENDO,80000001,CDM,800,RC,90999,HCPCS,facility,both,,,,2847,2847,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC INSTILL (S), VIA CHEST TUBE/CATH, FIBRINOLYSIS AGENT, INIT DAY",80100050,CDM,801,RC,90935,HCPCS,facility,both,,,,2169,2169,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PERTUSSIS AG DETECTION BY DFA,80300002,CDM,803,RC,90945,HCPCS,facility,both,,,,2069,2069,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES),81500001,CDM,815,RC,,,facility,both,,,,11756,11756,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC CIPROFLOXACIN,SERUM",82000001,CDM,820,RC,90999,HCPCS,facility,both,,,,2847,2847,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC FACTOR XIII QUEST,82100001,CDM,821,RC,90999,HCPCS,facility,both,,,,2847,2847,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC OSMOTIC FRAGILITY/INTERP,82100002,CDM,821,RC,90999,HCPCS,facility,both,,,,2620,2620,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC EVALUATION OF SPEECH SOUND PRODUCTION,82100003,CDM,821,RC,90989,HCPCS,facility,both,,,,782,782,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC AMOXICILLIN, SERUM",84100001,CDM,841,RC,90945,HCPCS,facility,both,,,,2069,2069,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC TYMPANOMETRY & REFLEX THRESH,85100001,CDM,851,RC,90945,HCPCS,facility,both,,,,2069,2069,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC LYME(B.BURGDORFERI)PCR,CSF QST",85500001,CDM,855,RC,90993,HCPCS,facility,both,,,,124,124,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC HEARING AID, BINAURAL, ITE/ITE",87400001,CDM,874,RC,,,facility,both,,,,1987,1987,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DNA/RNA AMPLIFIED PROBE,87400008,CDM,874,RC,38228,HCPCS,facility,both,,,,1774,1774,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC EVAL CENTRAL AUDITORY FUNC W/REP, INIT 60 MIN",88000001,CDM,880,RC,,,facility,both,,,,6273.96,6273.96,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC EVAL CENTRAL AUDITORY FUNC W/REP, EA ADL 15 MIN",88000002,CDM,880,RC,,,facility,both,,,,6273.96,6273.96,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC EVAL CENTRAL AUDITORY FUNC W/REP, EA ADL 15 MIN",88000003,CDM,880,RC,,,facility,both,,,,1697.52,1697.52,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC GRANULOCYTES PHERESIS UNIT,88000004,CDM,880,RC,,,facility,both,,,,10455.72,10455.72,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC TUMOR NECROSIS FACTOR-ALPHAQST,88100001,CDM,881,RC,90945,HCPCS,facility,both,,,,2069,2069,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC SMEAR COMPLEX STAIN,89200006,CDM,812,RC,,,facility,both,,,,569546.4,569546.4,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HEALTH BEHAVIOR INTERV FAM W/O PT FACE TO FACE; 1ST 30 MIN,91400064,CDM,949,RC,96156,HCPCS,facility,both,,,,813,813,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HEALTH BEHAVIOR INTERV FAM W/O PT FACE TO FACE; EA ADDL 15,91400065,CDM,949,RC,96158,HCPCS,facility,both,,,,561,561,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC EEG CONT REC W/VIDEO BY TECH MIN 8 CHANNELS,91400066,CDM,949,RC,96159,HCPCS,facility,both,,,,194,194,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC EEG W/O VIDEO BY TECH 2-12 HR UNMONITORED,91500004,CDM,949,RC,96164,HCPCS,facility,both,,,,132,132,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC INSERT HEART PM ATRIAL,91500005,CDM,949,RC,96165,HCPCS,facility,both,,,,19,19,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC INSERT HEART PM VENTRICULAR,91600006,CDM,949,RC,96167,HCPCS,facility,both,,,,600,600,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC INSRT HEART PM ATRIAL & VENT,91600007,CDM,949,RC,96168,HCPCS,facility,both,,,,213,213,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC INSERT ELECTRD/PM CATH SNGL,91600008,CDM,949,RC,96170,HCPCS,facility,both,,,,581,581,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC INSERT PULSE GEN DUAL LEADS,91600009,CDM,949,RC,96171,HCPCS,facility,both,,,,209,209,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC FINE NEEDLE ASPIRATION BIOPSY, W/CT GUIDANCE, EA ADDL LESION",91800026,CDM,918,RC,96112,HCPCS,facility,both,,,,721,721,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC PUNCH BIOSPY OF SKIN, SINGLE LESION",91800027,CDM,918,RC,96113,HCPCS,facility,both,,,,270,270,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC AB; VIRUS NES (35),92000016,CDM,920,RC,93750,HCPCS,facility,both,,,,333,333,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DIGITAL ANALYSIS OF EEG,92000020,CDM,920,RC,95925,HCPCS,facility,both,,,,691,691,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC WADA ACTIVATION TEST,92000021,CDM,920,RC,95926,HCPCS,facility,both,,,,1188,1188,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HPA-15 GENOTYPING (35),92000022,CDM,920,RC,95928,HCPCS,facility,both,,,,1547,1547,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HLA CLASS I HIGH DEFIN QUAL,92000023,CDM,920,RC,95929,HCPCS,facility,both,,,,818,818,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC TRANSIENT O/P HEMODIALYSIS,92000070,CDM,920,RC,95940,HCPCS,facility,both,,,,439,439,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC STENGER TEST SPEECH,92000071,CDM,920,RC,95941,HCPCS,facility,both,,,,2027,2027,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC CYP2C9, GENE ANALYSIS, COMMON VARIANTS(30)",92000089,CDM,920,RC,92018,HCPCS,facility,both,,,,5424,5424,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC TARGETED GENOMIC SEQ ANALYSIS 51+ (795),92000093,CDM,920,RC,93260,HCPCS,facility,both,,,,187,187,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC IMMUMOASSAY QUANT NOS NONAB (25),92000101,CDM,920,RC,96020,HCPCS,facility,both,,,,963,963,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC IMMUMOASSAY QUANT NOS NONAB (35),92000102,CDM,920,RC,92265,HCPCS,facility,both,,,,286,286,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DUPLEX LE ART/BPG; UNIL/LIMIT,92100001,CDM,921,RC,93880,HCPCS,facility,both,,,,1855,1855,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HPA-9 GENOTYPING (35),92100003,CDM,921,RC,93886,HCPCS,facility,both,,,,1340,1340,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DUPLEX UE ART/BPG; UNIL/LIMIT,92100008,CDM,921,RC,93925,HCPCS,facility,both,,,,1456,1456,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DUPLEX A IVC IL/BPG; UNIL/LIM,92100009,CDM,921,RC,93926,HCPCS,facility,both,,,,1113,1113,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DUPLEX HEMODIALYSIS ACCESS,92100010,CDM,921,RC,93930,HCPCS,facility,both,,,,860,860,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CENTRAL MOTOR EVOKED UPP LIMBS,92100011,CDM,921,RC,93931,HCPCS,facility,both,,,,959,959,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DUPLEX ARTERIAL FLOW; LIMITED,92100012,CDM,921,RC,93970,HCPCS,facility,both,,,,2029,2029,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC DUPLEX A IVC IL/BPG; COMPL,92100013,CDM,921,RC,93971,HCPCS,facility,both,,,,1357,1357,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC SPIROMETRY,92100014,CDM,921,RC,93975,HCPCS,facility,both,,,,2051,2051,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC SPIROMETRY W/BRONCHODILATOR,92100015,CDM,921,RC,93976,HCPCS,facility,both,,,,1399,1399,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC BRONCHOSPASM PROVOCATION EVAL,92100016,CDM,921,RC,93978,HCPCS,facility,both,,,,805,805,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC FLT3 GENE (100),92100017,CDM,921,RC,93979,HCPCS,facility,both,,,,1042,1042,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CENTRAL MOTOR EVOKED LWR LIMBS,92100018,CDM,921,RC,93980,HCPCS,facility,both,,,,408,408,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC 2D TTE W OR W/O FOL W/CONTRAST,92100019,CDM,921,RC,93990,HCPCS,facility,both,,,,627,627,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC EMG CRANIAL NERVE - UNILAT,92200001,CDM,922,RC,95860,HCPCS,facility,both,,,,587,587,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC EMG CRANIAL NERVE; BILAT,92200002,CDM,922,RC,95861,HCPCS,facility,both,,,,979,979,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC EMG THORACIC PARASPINAL,92200003,CDM,922,RC,95863,HCPCS,facility,both,,,,640,640,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MUSCLE TEST NONPARASPINAL 1 EXT,92200004,CDM,922,RC,95867,HCPCS,facility,both,,,,771,771,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC SLS-EPS; PERIPH NRV; UPPER LIMBS,92200005,CDM,922,RC,95868,HCPCS,facility,both,,,,771,771,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC SLS-EPS; PERIPH NRV; LOWER LIMBS,92200006,CDM,922,RC,95869,HCPCS,facility,both,,,,566,566,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC NEUROMUSC JUNCTION TEST EA NRV,92200007,CDM,922,RC,95870,HCPCS,facility,both,,,,312,312,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC FUNCTION CORTICAL MAP; 1ST HR,92200013,CDM,922,RC,95937,HCPCS,facility,both,,,,995,995,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PROCEDURE ENDO LEVEL 3 EA ADDL 15 MINUTE,92200015,CDM,922,RC,95907,HCPCS,facility,both,,,,874,874,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC NS CATH, THORACIC AORTA W/ANGIO",92200016,CDM,922,RC,95908,HCPCS,facility,both,,,,874,874,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC POLYSOM <6 YRS CPAP/BILVL,92200017,CDM,922,RC,95909,HCPCS,facility,both,,,,1505,1505,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC POLYSOM <6 YRS 4> PARAMETERS,92200018,CDM,922,RC,95910,HCPCS,facility,both,,,,1505,1505,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC TRANSCUTANEOUS BILIRUBIN,92200019,CDM,922,RC,95911,HCPCS,facility,both,,,,1505,1505,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC THYROID IMAGING W/BLOOD FLOW,92200020,CDM,922,RC,95912,HCPCS,facility,both,,,,1711,1711,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC THYROID IMAGING W/BLOOD FLOW & 1+ UPTAKES,92200021,CDM,922,RC,95913,HCPCS,facility,both,,,,1505,1505,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC X-RAY SIALOGRAM,92200050,CDM,922,RC,95905,HCPCS,facility,both,,,,868,868,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC CT UPR EXTREMITY W/WO CONTRAST,92200051,CDM,922,RC,95930,HCPCS,facility,both,,,,874,874,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC X-RAY EXAM ABDOMEN 3 OR MORE VIEWS,92200052,CDM,922,RC,95885,HCPCS,facility,both,,,,316,316,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC ORTH/PROST MGMT, UP/LOW EXT, AND/OR TRUNK, SUBSQ ENC, EA 15 MIN",92200053,CDM,922,RC,95886,HCPCS,facility,both,,,,497,497,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC PULM STRESS TEST(6 MINUTE WALK) INC HR,OXIMET,OXY TITR, WHEN PERF",92200054,CDM,922,RC,95887,HCPCS,facility,both,,,,382,382,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC X-RAY EXAM CHEST 1 VIEW,92200055,CDM,922,RC,95873,HCPCS,facility,both,,,,307,307,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE DEAC 11/01/2023 HC ADM SARSCV2 BVL 3 MCG/0.2ML 1ST DOSE,92200056,CDM,922,RC,95864,HCPCS,facility,both,,,,1014,1014,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC MENNIGITIS-ENCEPH CSF BY PCR,92200057,CDM,922,RC,95938,HCPCS,facility,both,,,,1505,1505,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC INFCT DS BCT/VIR RESPIR DNA/RNA 22 TRGT SARSCOV2,92200058,CDM,922,RC,95939,HCPCS,facility,both,,,,1820,1820,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC IMMUMOASSAY QUANT NOS NONAB (40),92200060,CDM,922,RC,95865,HCPCS,facility,both,,,,347,347,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PERQ DEVICE BREAST 1ST IMAG,92400015,CDM,924,RC,95018,HCPCS,facility,both,,,,83,83,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PERQ DEVICE BREAST EA IMAG,92400020,CDM,924,RC,95076,HCPCS,facility,both,,,,1497,1497,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PERQ DEV BREAST 1ST STEREOTACTIC GUIDANCE,92400025,CDM,924,RC,95079,HCPCS,facility,both,,,,242,242,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC X-RAY EXAM CHEST 2 VIEWS,92400028,CDM,924,RC,95070,HCPCS,facility,both,,,,1213,1213,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC PCP QUAN ASSAY,94000012,CDM,940,RC,92950,HCPCS,facility,both,,,,1864,1864,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC HEROIN METABOLITE (25),94030001,CDM,940,RC,99195,HCPCS,facility,both,,,,438,438,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC EMERGENCY DEPT VISIT LVL 2,94200001,CDM,942,RC,97802,HCPCS,facility,both,,,,139,139,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC EMERGENCY DEPT VISIT LVL 3,94200002,CDM,942,RC,97803,HCPCS,facility,both,,,,132,132,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC IRC CARDIOLOGY PRICE PER MINUTE,94200005,CDM,942,RC,,,facility,both,,,,125,125,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE HC X-RAY RENAL CYST STUDY,94200051,CDM,942,RC,97804,HCPCS,facility,both,,,,96,96,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE "HC AMINO ACIDS, 6 OR MORE AMINO ACIDS, QNT,  SERUM, EACH SPECIMEN",94200064,CDM,942,RC,,,facility,both,,,,113,113,,,,,,,,,,,,,Gross Charge Type: ACH DEFAULT FEE SCHEDULE Rbc dna hea 35 ag 11 bld grp,0001U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3003.84,,,,,,,fee schedule,1080,3003.84, Rbc dna hea 35 ag 11 bld grp,0001U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1080,,,,,,,fee schedule,1080,3003.84, Rbc dna hea 35 ag 11 bld grp,0001U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1080,,,,,,,fee schedule,1080,3003.84, Liver dis 10 assays w/ash,0002M,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2100.18,,,,,,,fee schedule,2100.18,2100.18, Onc clrct 3 ur metab alg plp,0002U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,104.3,,,,,,,fee schedule,37.5,104.3, Onc clrct 3 ur metab alg plp,0002U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,37.5,,,,,,,fee schedule,37.5,104.3, Onc clrct 3 ur metab alg plp,0002U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,37.5,,,,,,,fee schedule,37.5,104.3, Liver dis 10 assays w/nash,0003M,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2100.18,,,,,,,fee schedule,2100.18,2100.18, Onc ovar 5 prtn ser alg scor,0003U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3963.4,,,,,,,fee schedule,1425,3963.4, Onc ovar 5 prtn ser alg scor,0003U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1425,,,,,,,fee schedule,1425,3963.4, Onc ovar 5 prtn ser alg scor,0003U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1425,,,,,,,fee schedule,1425,3963.4, Scoliosis dna alys,0004M,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,329.59,,,,,,,fee schedule,329.59,329.59, Onco prst8 3 gene ur alg,0005U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3170.72,,,,,,,fee schedule,1140,3170.72, Onco prst8 3 gene ur alg,0005U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1140,,,,,,,fee schedule,1140,3170.72, Onco prst8 3 gene ur alg,0005U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1140,,,,,,,fee schedule,1140,3170.72, Onc hep gene risk classifier,0006M,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,625.8,,,,,,,fee schedule,625.8,625.8, Onc gastro 51 gene nomogram,0007M,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1564.5,,,,,,,fee schedule,1564.5,1564.5, Rx test prsmv ur w/def conf,0007U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,477.4,,,,,,,fee schedule,171.65,477.4, Rx test prsmv ur w/def conf,0007U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,171.65,,,,,,,fee schedule,171.65,477.4, Rx test prsmv ur w/def conf,0007U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,171.65,,,,,,,fee schedule,171.65,477.4, Hpylori detcj abx rstnc dna,0008U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2494.48,,,,,,,fee schedule,896.87,2494.48, Hpylori detcj abx rstnc dna,0008U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,896.87,,,,,,,fee schedule,896.87,2494.48, Hpylori detcj abx rstnc dna,0008U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,896.87,,,,,,,fee schedule,896.87,2494.48, Onc brst ca erbb2 amp/nonamp,0009U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,446.4,,,,,,,fee schedule,160.5,446.4, Onc brst ca erbb2 amp/nonamp,0009U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,160.5,,,,,,,fee schedule,160.5,446.4, Onc brst ca erbb2 amp/nonamp,0009U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,160.5,,,,,,,fee schedule,160.5,446.4, Nfct ds strn typ whl gen seq,0010U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1782.53,,,,,,,fee schedule,640.89,1782.53, Nfct ds strn typ whl gen seq,0010U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,640.89,,,,,,,fee schedule,640.89,1782.53, Nfct ds strn typ whl gen seq,0010U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,640.89,,,,,,,fee schedule,640.89,1782.53, Onc prst8 ca mrna 12 gen alg,0011M,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3170.72,,,,,,,fee schedule,1140,3170.72, Onc prst8 ca mrna 12 gen alg,0011M,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1140,,,,,,,fee schedule,1140,3170.72, Onc prst8 ca mrna 12 gen alg,0011M,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1140,,,,,,,fee schedule,1140,3170.72, Rx mntr lc-ms/ms oral fluid,0011U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,477.4,,,,,,,fee schedule,171.65,477.4, Rx mntr lc-ms/ms oral fluid,0011U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,171.65,,,,,,,fee schedule,171.65,477.4, Rx mntr lc-ms/ms oral fluid,0011U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,171.65,,,,,,,fee schedule,171.65,477.4, Onc mrna 5 gen rsk urthl ca,0012M,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3170.72,,,,,,,fee schedule,1140,3170.72, Onc mrna 5 gen rsk urthl ca,0012M,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1140,,,,,,,fee schedule,1140,3170.72, Onc mrna 5 gen rsk urthl ca,0012M,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1140,,,,,,,fee schedule,1140,3170.72, Onc mrna 5 gen recr urthl ca,0013M,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3170.72,,,,,,,fee schedule,1140,3170.72, Onc mrna 5 gen recr urthl ca,0013M,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1140,,,,,,,fee schedule,1140,3170.72, Onc mrna 5 gen recr urthl ca,0013M,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1140,,,,,,,fee schedule,1140,3170.72, Adrnl cortcl tum bchm asy 25,0015M,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5446,,,,,,,fee schedule,1958.06,5446, Adrnl cortcl tum bchm asy 25,0015M,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1958.06,,,,,,,fee schedule,1958.06,5446, Adrnl cortcl tum bchm asy 25,0015M,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1958.06,,,,,,,fee schedule,1958.06,5446, Onc bladder mrna 209 gen alg,0016M,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,14558.74,,,,,,,fee schedule,5234.45,14558.74, Onc bladder mrna 209 gen alg,0016M,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5234.45,,,,,,,fee schedule,5234.45,14558.74, Onc bladder mrna 209 gen alg,0016M,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5234.45,,,,,,,fee schedule,5234.45,14558.74, Onc hmtlmf neo rna bcr/abl1,0016U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,684.04,,,,,,,fee schedule,245.94,684.04, Onc hmtlmf neo rna bcr/abl1,0016U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,245.94,,,,,,,fee schedule,245.94,684.04, Onc hmtlmf neo rna bcr/abl1,0016U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,245.94,,,,,,,fee schedule,245.94,684.04, Onc dlbcl mrna 20 genes alg,0017M,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10472.6,,,,,,,fee schedule,3765.32,10472.6, Onc dlbcl mrna 20 genes alg,0017M,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3765.32,,,,,,,fee schedule,3765.32,10472.6, Onc dlbcl mrna 20 genes alg,0017M,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3765.32,,,,,,,fee schedule,3765.32,10472.6, Onc hmtlmf neo jak2 mut dna,0017U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,382.41,,,,,,,fee schedule,137.49,382.41, Onc hmtlmf neo jak2 mut dna,0017U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,137.49,,,,,,,fee schedule,137.49,382.41, Onc hmtlmf neo jak2 mut dna,0017U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,137.49,,,,,,,fee schedule,137.49,382.41, Trnsplj rnl meas cd154+cll,0018M,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2673.13,,,,,,,fee schedule,961.1,2673.13, Trnsplj rnl meas cd154+cll,0018M,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,961.1,,,,,,,fee schedule,961.1,2673.13, Trnsplj rnl meas cd154+cll,0018M,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,961.1,,,,,,,fee schedule,961.1,2673.13, Onc thyr 10 microrna seq alg,0018U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12524.72,,,,,,,fee schedule,4503.14,12524.72, Onc thyr 10 microrna seq alg,0018U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4503.14,,,,,,,fee schedule,4503.14,12524.72, Onc thyr 10 microrna seq alg,0018U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4503.14,,,,,,,fee schedule,4503.14,12524.72, Cv ds plasma alys prtn bmrk,0019M,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2972.13,,,,,,,fee schedule,1068.6,2972.13, Cv ds plasma alys prtn bmrk,0019M,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1068.6,,,,,,,fee schedule,1068.6,2972.13, Cv ds plasma alys prtn bmrk,0019M,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1068.6,,,,,,,fee schedule,1068.6,2972.13, Onc rna tiss predict alg,0019U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,15332.1,,,,,,,fee schedule,5512.5,15332.1, Onc rna tiss predict alg,0019U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5512.5,,,,,,,fee schedule,5512.5,15332.1, Onc rna tiss predict alg,0019U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5512.5,,,,,,,fee schedule,5512.5,15332.1, Onc cns alys 30000 dna loci,0020M,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10430,,,,,,,fee schedule,10430,10430, Onc prst8 detcj 8 autoantb,0021U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3170.72,,,,,,,fee schedule,1140,3170.72, Onc prst8 detcj 8 autoantb,0021U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1140,,,,,,,fee schedule,1140,3170.72, Onc prst8 detcj 8 autoantb,0021U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1140,,,,,,,fee schedule,1140,3170.72, Trgt gen seq dna&rna 23 gene,0022U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8135.4,,,,,,,fee schedule,2925,8135.4, Trgt gen seq dna&rna 23 gene,0022U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2925,,,,,,,fee schedule,2925,8135.4, Trgt gen seq dna&rna 23 gene,0022U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2925,,,,,,,fee schedule,2925,8135.4, Onc aml dna detcj/nondetcj,0023U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1036.78,,,,,,,fee schedule,372.77,1036.78, Onc aml dna detcj/nondetcj,0023U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,372.77,,,,,,,fee schedule,372.77,1036.78, Onc aml dna detcj/nondetcj,0023U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,372.77,,,,,,,fee schedule,372.77,1036.78, Glyca nuc mr spectrsc quan,0024U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,142.64,,,,,,,fee schedule,51.29,142.64, Glyca nuc mr spectrsc quan,0024U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,51.29,,,,,,,fee schedule,51.29,142.64, Glyca nuc mr spectrsc quan,0024U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,51.29,,,,,,,fee schedule,51.29,142.64, Tenofovir liq chrom ur quan,0025U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,477.4,,,,,,,fee schedule,128.66,477.4, Tenofovir liq chrom ur quan,0025U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,128.66,,,,,,,fee schedule,128.66,477.4, Tenofovir liq chrom ur quan,0025U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,128.66,,,,,,,fee schedule,128.66,477.4, Onc thyr dna&mrna 112 genes,0026U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,15019.2,,,,,,,fee schedule,5400,15019.2, Onc thyr dna&mrna 112 genes,0026U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5400,,,,,,,fee schedule,5400,15019.2, Onc thyr dna&mrna 112 genes,0026U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5400,,,,,,,fee schedule,5400,15019.2, Jak2 gene trgt seq alys,0027U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,508.61,,,,,,,fee schedule,203.19,508.61, Jak2 gene trgt seq alys,0027U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,203.19,,,,,,,fee schedule,203.19,508.61, Jak2 gene trgt seq alys,0027U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,203.19,,,,,,,fee schedule,203.19,508.61, Rx metab advrs trgt seq alys,0029U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3096.75,,,,,,,fee schedule,1113.41,3096.75, Rx metab advrs trgt seq alys,0029U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1113.41,,,,,,,fee schedule,1113.41,3096.75, Rx metab advrs trgt seq alys,0029U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1113.41,,,,,,,fee schedule,1113.41,3096.75, Rx metab warf trgt seq alys,0030U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,559.59,,,,,,,fee schedule,201.2,559.59, Rx metab warf trgt seq alys,0030U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,201.2,,,,,,,fee schedule,201.2,559.59, Rx metab warf trgt seq alys,0030U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,201.2,,,,,,,fee schedule,201.2,559.59, Cyp1a2 gene,0031U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,729.31,,,,,,,fee schedule,262.22,729.31, Cyp1a2 gene,0031U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,262.22,,,,,,,fee schedule,262.22,729.31, Cyp1a2 gene,0031U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,262.22,,,,,,,fee schedule,262.22,729.31, Comt gene,0032U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,729.31,,,,,,,fee schedule,262.22,729.31, Comt gene,0032U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,262.22,,,,,,,fee schedule,262.22,729.31, Comt gene,0032U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,262.22,,,,,,,fee schedule,262.22,729.31, Htr2a htr2c genes,0033U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,524.43,,,,,,,fee schedule,524.43,524.43, Htr2a htr2c genes,0033U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,524.43,,,,,,,fee schedule,524.43,524.43, Tpmt nudt15 genes,0034U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1944.86,,,,,,,fee schedule,699.26,1944.86, Tpmt nudt15 genes,0034U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,699.26,,,,,,,fee schedule,699.26,1944.86, Tpmt nudt15 genes,0034U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,699.26,,,,,,,fee schedule,699.26,1944.86, Neuro csf prion prtn qual,0035U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2257.01,,,,,,,fee schedule,811.49,2257.01, Neuro csf prion prtn qual,0035U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,811.49,,,,,,,fee schedule,811.49,2257.01, Neuro csf prion prtn qual,0035U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,811.49,,,,,,,fee schedule,811.49,2257.01, Xome tum & nml spec seq alys,0036U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,19942.16,,,,,,,fee schedule,7170,19942.16, Xome tum & nml spec seq alys,0036U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7170,,,,,,,fee schedule,7170,19942.16, Xome tum & nml spec seq alys,0036U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,7170,,,,,,,fee schedule,7170,19942.16, Trgt gen seq dna 324 genes,0037U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,14602,,,,,,,fee schedule,5250,14602, Trgt gen seq dna 324 genes,0037U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5250,,,,,,,fee schedule,5250,14602, Trgt gen seq dna 324 genes,0037U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5250,,,,,,,fee schedule,5250,14602, Vitamin d srm microsamp quan,0038U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,123.49,,,,,,,fee schedule,44.4,123.49, Vitamin d srm microsamp quan,0038U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,44.4,,,,,,,fee schedule,44.4,123.49, Vitamin d srm microsamp quan,0038U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,44.4,,,,,,,fee schedule,44.4,123.49, Dna antb 2strand hi avidity,0039U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,57.32,,,,,,,fee schedule,20.61,57.32, Dna antb 2strand hi avidity,0039U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,20.61,,,,,,,fee schedule,20.61,57.32, Dna antb 2strand hi avidity,0039U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,20.61,,,,,,,fee schedule,20.61,57.32, Bcr/abl1 gene major bp quan,0040U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1710.1,,,,,,,fee schedule,614.85,1710.1, Bcr/abl1 gene major bp quan,0040U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,614.85,,,,,,,fee schedule,614.85,1710.1, Bcr/abl1 gene major bp quan,0040U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,614.85,,,,,,,fee schedule,614.85,1710.1, B brgdrferi antb 5 prtn igm,0041U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,71.8,,,,,,,fee schedule,25.82,71.8, B brgdrferi antb 5 prtn igm,0041U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25.82,,,,,,,fee schedule,25.82,71.8, B brgdrferi antb 5 prtn igm,0041U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,25.82,,,,,,,fee schedule,25.82,71.8, B brgdrferi antb 12 prtn igg,0042U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,71.8,,,,,,,fee schedule,25.82,71.8, B brgdrferi antb 12 prtn igg,0042U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25.82,,,,,,,fee schedule,25.82,71.8, B brgdrferi antb 12 prtn igg,0042U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,25.82,,,,,,,fee schedule,25.82,71.8, Tbrf b grp antb 4 prtn igm,0043U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,62,,,,,,,fee schedule,22.29,62, Tbrf b grp antb 4 prtn igm,0043U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22.29,,,,,,,fee schedule,22.29,62, Tbrf b grp antb 4 prtn igm,0043U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22.29,,,,,,,fee schedule,22.29,62, Tbrf b grp antb 4 prtn igg,0044U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,62,,,,,,,fee schedule,22.29,62, Tbrf b grp antb 4 prtn igg,0044U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22.29,,,,,,,fee schedule,22.29,62, Tbrf b grp antb 4 prtn igg,0044U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22.29,,,,,,,fee schedule,22.29,62, Onc brst dux carc is 12 gene,0045U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,16158.16,,,,,,,fee schedule,5809.5,16158.16, Onc brst dux carc is 12 gene,0045U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5809.5,,,,,,,fee schedule,5809.5,16158.16, Onc brst dux carc is 12 gene,0045U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5809.5,,,,,,,fee schedule,5809.5,16158.16, Flt3 gene itd variants quan,0046U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1699.8,,,,,,,fee schedule,248.48,1699.8, Flt3 gene itd variants quan,0046U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,248.48,,,,,,,fee schedule,248.48,1699.8, Flt3 gene itd variants quan,0046U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,248.48,,,,,,,fee schedule,248.48,1699.8, Onc prst8 mrna 17 gene alg,0047U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,16158.16,,,,,,,fee schedule,5809.5,16158.16, Onc prst8 mrna 17 gene alg,0047U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5809.5,,,,,,,fee schedule,5809.5,16158.16, Onc prst8 mrna 17 gene alg,0047U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5809.5,,,,,,,fee schedule,5809.5,16158.16, Onc sld org neo dna 468 gene,0048U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12180.57,,,,,,,fee schedule,4379.4,12180.57, Onc sld org neo dna 468 gene,0048U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4379.4,,,,,,,fee schedule,4379.4,12180.57, Onc sld org neo dna 468 gene,0048U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4379.4,,,,,,,fee schedule,4379.4,12180.57, Npm1 gene analysis quan,0049U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1699.8,,,,,,,fee schedule,369.74,1699.8, Npm1 gene analysis quan,0049U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,369.74,,,,,,,fee schedule,369.74,1699.8, Npm1 gene analysis quan,0049U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,369.74,,,,,,,fee schedule,369.74,1699.8, Trgt gen seq dna 194 genes,0050U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12168.06,,,,,,,fee schedule,4374.9,12168.06, Trgt gen seq dna 194 genes,0050U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4374.9,,,,,,,fee schedule,4374.9,12168.06, Trgt gen seq dna 194 genes,0050U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4374.9,,,,,,,fee schedule,4374.9,12168.06, Rx mntr lc-ms/ms ur 31 pnl,0051U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1030.15,,,,,,,fee schedule,290.57,1030.15, Rx mntr lc-ms/ms ur 31 pnl,0051U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,290.57,,,,,,,fee schedule,290.57,1030.15, Rx mntr lc-ms/ms ur 31 pnl,0051U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,290.57,,,,,,,fee schedule,290.57,1030.15, Lpoprtn bld w/5 maj classes,0052U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,141.26,,,,,,,fee schedule,50.79,141.26, Lpoprtn bld w/5 maj classes,0052U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,50.79,,,,,,,fee schedule,50.79,141.26, Lpoprtn bld w/5 maj classes,0052U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,50.79,,,,,,,fee schedule,50.79,141.26, Bone srgry cmptr fluor image,0054T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Bone srgry cmptr fluor image,0054T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Bone srgry cmptr fluor image,0054T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Rx mntr 14+ drugs & sbsts,0054U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,829.14,,,,,,,fee schedule,223.44,829.14, Rx mntr 14+ drugs & sbsts,0054U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,223.44,,,,,,,fee schedule,223.44,829.14, Rx mntr 14+ drugs & sbsts,0054U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,223.44,,,,,,,fee schedule,223.44,829.14, Bone srgry cmptr ct/mri imag,0055T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Bone srgry cmptr ct/mri imag,0055T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Bone srgry cmptr ct/mri imag,0055T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Card hrt trnspl 96 dna seq,0055U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,13517.28,,,,,,,fee schedule,4860,13517.28, Card hrt trnspl 96 dna seq,0055U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4860,,,,,,,fee schedule,4860,13517.28, Card hrt trnspl 96 dna seq,0055U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4860,,,,,,,fee schedule,4860,13517.28, Onc merkel cll carc srm quan,0058U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1347.39,,,,,,,fee schedule,484.44,1347.39, Onc merkel cll carc srm quan,0058U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,484.44,,,,,,,fee schedule,484.44,1347.39, Onc merkel cll carc srm quan,0058U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,484.44,,,,,,,fee schedule,484.44,1347.39, Onc merkel cll carc srm +/-,0059U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1347.39,,,,,,,fee schedule,484.44,1347.39, Onc merkel cll carc srm +/-,0059U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,484.44,,,,,,,fee schedule,484.44,1347.39, Onc merkel cll carc srm +/-,0059U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,484.44,,,,,,,fee schedule,484.44,1347.39, Twn zyg gen seq alys chrms2,0060U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3166.76,,,,,,,fee schedule,1138.58,3166.76, Twn zyg gen seq alys chrms2,0060U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1138.58,,,,,,,fee schedule,1138.58,3166.76, Twn zyg gen seq alys chrms2,0060U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1138.58,,,,,,,fee schedule,1138.58,3166.76, Tc meas 5 bmrk sfdi m-s alys,0061U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,104.72,,,,,,,fee schedule,37.65,104.72, Tc meas 5 bmrk sfdi m-s alys,0061U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,37.65,,,,,,,fee schedule,37.65,104.72, Tc meas 5 bmrk sfdi m-s alys,0061U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,37.65,,,,,,,fee schedule,37.65,104.72, Ai sle igg&igm alys 80 bmrk,0062U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1588.36,,,,,,,fee schedule,571.08,1588.36, Ai sle igg&igm alys 80 bmrk,0062U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,571.08,,,,,,,fee schedule,571.08,1588.36, Ai sle igg&igm alys 80 bmrk,0062U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,571.08,,,,,,,fee schedule,571.08,1588.36, Neuro autism 32 amines alg,0063U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3129,,,,,,,fee schedule,1125,3129, Neuro autism 32 amines alg,0063U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1125,,,,,,,fee schedule,1125,3129, Neuro autism 32 amines alg,0063U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1125,,,,,,,fee schedule,1125,3129, Antb tp total&rpr ia qual,0064U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,130.71,,,,,,,fee schedule,47,130.71, Antb tp total&rpr ia qual,0064U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,47,,,,,,,fee schedule,47,130.71, Antb tp total&rpr ia qual,0064U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,47,,,,,,,fee schedule,47,130.71, Syfls tst nontreponemal antb,0065U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,75.47,,,,,,,fee schedule,27.14,75.47, Syfls tst nontreponemal antb,0065U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,27.14,,,,,,,fee schedule,27.14,75.47, Syfls tst nontreponemal antb,0065U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,27.14,,,,,,,fee schedule,27.14,75.47, Onc brst imhchem prfl 4 bmrk,0067U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7914.28,,,,,,,fee schedule,2845.5,7914.28, Onc brst imhchem prfl 4 bmrk,0067U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2845.5,,,,,,,fee schedule,2845.5,7914.28, Onc brst imhchem prfl 4 bmrk,0067U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2845.5,,,,,,,fee schedule,2845.5,7914.28, Candida species pnl amp prb,0068U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,595.05,,,,,,,fee schedule,213.95,595.05, Candida species pnl amp prb,0068U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,213.95,,,,,,,fee schedule,213.95,595.05, Candida species pnl amp prb,0068U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,213.95,,,,,,,fee schedule,213.95,595.05, Onc clrct microrna mir-31-3p,0069U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1585.36,,,,,,,fee schedule,570,1585.36, Onc clrct microrna mir-31-3p,0069U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,570,,,,,,,fee schedule,570,1585.36, Onc clrct microrna mir-31-3p,0069U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,570,,,,,,,fee schedule,570,1585.36, Cyp2d6 gen com&slct rar vrnt,0070U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2821.82,,,,,,,fee schedule,1014.56,2821.82, Cyp2d6 gen com&slct rar vrnt,0070U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1014.56,,,,,,,fee schedule,1014.56,2821.82, Cyp2d6 gen com&slct rar vrnt,0070U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1014.56,,,,,,,fee schedule,1014.56,2821.82, Us leiomyomata ablate <200,0071T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,9846,10940, Us leiomyomata ablate <200,0071T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,9846,10940, Cyp2d6 full gene sequence,0071U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2503.2,,,,,,,fee schedule,452.03,2503.2, Cyp2d6 full gene sequence,0071U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,452.03,,,,,,,fee schedule,452.03,2503.2, Cyp2d6 full gene sequence,0071U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,452.03,,,,,,,fee schedule,452.03,2503.2, Us leiomyomata ablate >200,0072T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,9846,10940, Us leiomyomata ablate >200,0072T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,9846,10940, Cyp2d6 gen cyp2d6-2d7 hybrid,0072U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1881.2,,,,,,,fee schedule,676.37,1881.2, Cyp2d6 gen cyp2d6-2d7 hybrid,0072U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,676.37,,,,,,,fee schedule,676.37,1881.2, Cyp2d6 gen cyp2d6-2d7 hybrid,0072U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,676.37,,,,,,,fee schedule,676.37,1881.2, Cyp2d6 gen cyp2d7-2d6 hybrid,0073U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1881.2,,,,,,,fee schedule,676.37,1881.2, Cyp2d6 gen cyp2d7-2d6 hybrid,0073U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,676.37,,,,,,,fee schedule,676.37,1881.2, Cyp2d6 gen cyp2d7-2d6 hybrid,0073U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,676.37,,,,,,,fee schedule,676.37,1881.2, Cyp2d6 nonduplicated gene,0074U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1881.2,,,,,,,fee schedule,676.37,1881.2, Cyp2d6 nonduplicated gene,0074U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,676.37,,,,,,,fee schedule,676.37,1881.2, Cyp2d6 nonduplicated gene,0074U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,676.37,,,,,,,fee schedule,676.37,1881.2, Perq Stent/Chest Vert Art,0075T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Perq Stent/Chest Vert Art,0075T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Cyp2d6 5' gene dup/mlt,0075U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1881.2,,,,,,,fee schedule,676.37,1881.2, Cyp2d6 5' gene dup/mlt,0075U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,676.37,,,,,,,fee schedule,676.37,1881.2, Cyp2d6 5' gene dup/mlt,0075U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,676.37,,,,,,,fee schedule,676.37,1881.2, S&I Stent/Chest Vert Art,0076T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, S&I Stent/Chest Vert Art,0076T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Cyp2d6 3' gene dup/mlt,0076U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1881.2,,,,,,,fee schedule,676.37,1881.2, Cyp2d6 3' gene dup/mlt,0076U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,676.37,,,,,,,fee schedule,676.37,1881.2, Cyp2d6 3' gene dup/mlt,0076U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,676.37,,,,,,,fee schedule,676.37,1881.2, Ig paraprotein qual bld/ur,0077U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,181.19,,,,,,,fee schedule,65.15,181.19, Ig paraprotein qual bld/ur,0077U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,65.15,,,,,,,fee schedule,65.15,181.19, Ig paraprotein qual bld/ur,0077U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,65.15,,,,,,,fee schedule,65.15,181.19, Onc lng 5 clin rsk factr alg,0080U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,14685.44,,,,,,,fee schedule,5280,14685.44, Onc lng 5 clin rsk factr alg,0080U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5280,,,,,,,fee schedule,5280,14685.44, Onc lng 5 clin rsk factr alg,0080U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5280,,,,,,,fee schedule,5280,14685.44, Rx test def 90+ rx/sbsts ur,0082U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1030.15,,,,,,,fee schedule,370.38,1030.15, Rx test def 90+ rx/sbsts ur,0082U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,370.38,,,,,,,fee schedule,370.38,1030.15, Rx test def 90+ rx/sbsts ur,0082U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,370.38,,,,,,,fee schedule,370.38,1030.15, Onc rspse chemo cntrst tomog,0083U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,698.18,,,,,,,fee schedule,251.03,698.18, Onc rspse chemo cntrst tomog,0083U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,251.03,,,,,,,fee schedule,251.03,698.18, Onc rspse chemo cntrst tomog,0083U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,251.03,,,,,,,fee schedule,251.03,698.18, Rbc dna gnotyp 10 bld groups,0084U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3003.84,,,,,,,fee schedule,1080,3003.84, Rbc dna gnotyp 10 bld groups,0084U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1080,,,,,,,fee schedule,1080,3003.84, Rbc dna gnotyp 10 bld groups,0084U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1080,,,,,,,fee schedule,1080,3003.84, Nfct ds bact&fng org id 6+,0086U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,834.4,,,,,,,fee schedule,300,834.4, Nfct ds bact&fng org id 6+,0086U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,300,,,,,,,fee schedule,300,834.4, Nfct ds bact&fng org id 6+,0086U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,300,,,,,,,fee schedule,300,834.4, Crd hrt trnspl mrna 1283 gen,0087U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,13181.1,,,,,,,fee schedule,4739.13,13181.1, Crd hrt trnspl mrna 1283 gen,0087U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4739.13,,,,,,,fee schedule,4739.13,13181.1, Crd hrt trnspl mrna 1283 gen,0087U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4739.13,,,,,,,fee schedule,4739.13,13181.1, Trnsplj kdn algrft rej 1494,0088U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,13181.1,,,,,,,fee schedule,4739.13,13181.1, Trnsplj kdn algrft rej 1494,0088U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4739.13,,,,,,,fee schedule,4739.13,13181.1, Trnsplj kdn algrft rej 1494,0088U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4739.13,,,,,,,fee schedule,4739.13,13181.1, Onc mlnma prame & linc00518,0089U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3170.72,,,,,,,fee schedule,1140,3170.72, Onc mlnma prame & linc00518,0089U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1140,,,,,,,fee schedule,1140,3170.72, Onc mlnma prame & linc00518,0089U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1140,,,,,,,fee schedule,1140,3170.72, Onc cutan mlnma mrna 23 gene,0090U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8135.4,,,,,,,fee schedule,2925,8135.4, Onc cutan mlnma mrna 23 gene,0090U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2925,,,,,,,fee schedule,2925,8135.4, Onc cutan mlnma mrna 23 gene,0090U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2925,,,,,,,fee schedule,2925,8135.4, Onc lng 3 prtn bmrk plsm alg,0092U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10379.94,,,,,,,fee schedule,3732,10379.94, Onc lng 3 prtn bmrk plsm alg,0092U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3732,,,,,,,fee schedule,3732,10379.94, Onc lng 3 prtn bmrk plsm alg,0092U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3732,,,,,,,fee schedule,3732,10379.94, Rx mntr 65 com drugs urine,0093U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,259.25,,,,,,,fee schedule,93.21,259.25, Rx mntr 65 com drugs urine,0093U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,93.21,,,,,,,fee schedule,93.21,259.25, Rx mntr 65 com drugs urine,0093U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,93.21,,,,,,,fee schedule,93.21,259.25, Genome rapid sequence alys,0094U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,31632.94,,,,,,,fee schedule,11373.3,31632.94, Genome rapid sequence alys,0094U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11373.3,,,,,,,fee schedule,11373.3,31632.94, Genome rapid sequence alys,0094U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11373.3,,,,,,,fee schedule,11373.3,31632.94, Rmvl artific disc addl crvcl,0095T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,3195, Inflm ee elisa alys alg,0095U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3220.7,,,,,,,fee schedule,1157.97,3220.7, Inflm ee elisa alys alg,0095U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1157.97,,,,,,,fee schedule,1157.97,3220.7, Inflm ee elisa alys alg,0095U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1157.97,,,,,,,fee schedule,1157.97,3220.7, Hpv hi risk types male urine,0096U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,146.4,,,,,,,fee schedule,52.64,146.4, Hpv hi risk types male urine,0096U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,52.64,,,,,,,fee schedule,52.64,146.4, Hpv hi risk types male urine,0096U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,52.64,,,,,,,fee schedule,52.64,146.4, Rev Artific Disc Addl,0098T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,3195, Prosth Retina Receive&Gen,0100T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,8406,46177, Prosth Retina Receive&Gen,0100T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46177,,,,,,,fee schedule,8406,46177, Prosth Retina Receive&Gen,0100T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,41559,,,,,,,fee schedule,8406,46177, Extracorp shockwv tx hi enrg,0101T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,11539,12821, Extracorp shockwv tx hi enrg,0101T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,11539,12821, Hered colon ca do 15 genes,0101U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7275.76,,,,,,,fee schedule,1754.7,7275.76, Hered colon ca do 15 genes,0101U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1754.7,,,,,,,fee schedule,1754.7,7275.76, Hered colon ca do 15 genes,0101U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1754.7,,,,,,,fee schedule,1754.7,7275.76, Extracorp shockwv tx anesth,0102T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,11539,12821, Extracorp shockwv tx anesth,0102T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,11539,12821, Hered brst ca rltd do 17 gen,0102U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5440.08,,,,,,,fee schedule,1676.97,5440.08, Hered brst ca rltd do 17 gen,0102U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1676.97,,,,,,,fee schedule,1676.97,5440.08, Hered brst ca rltd do 17 gen,0102U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1676.97,,,,,,,fee schedule,1676.97,5440.08, Hered ova ca pnl 24 genes,0103U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7275.76,,,,,,,fee schedule,1676.97,7275.76, Hered ova ca pnl 24 genes,0103U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1676.97,,,,,,,fee schedule,1676.97,7275.76, Hered ova ca pnl 24 genes,0103U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1676.97,,,,,,,fee schedule,1676.97,7275.76, Neph ckd mult eclia tum nec,0105U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3963.4,,,,,,,fee schedule,1425,3963.4, Neph ckd mult eclia tum nec,0105U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1425,,,,,,,fee schedule,1425,3963.4, Neph ckd mult eclia tum nec,0105U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1425,,,,,,,fee schedule,1425,3963.4, Gstr emptg 7 timed brth spec,0106U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3648.37,,,,,,,fee schedule,1311.74,3648.37, Gstr emptg 7 timed brth spec,0106U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1311.74,,,,,,,fee schedule,1311.74,3648.37, Gstr emptg 7 timed brth spec,0106U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1311.74,,,,,,,fee schedule,1311.74,3648.37, C diff tox ag detcj ia stool,0107U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,66.75,,,,,,,fee schedule,24,66.75, C diff tox ag detcj ia stool,0107U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24,,,,,,,fee schedule,24,66.75, C diff tox ag detcj ia stool,0107U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,24,,,,,,,fee schedule,24,66.75, Gi barrett esoph 9 prtn bmrk,0108U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,20651.4,,,,,,,fee schedule,3769.88,20651.4, Gi barrett esoph 9 prtn bmrk,0108U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3769.88,,,,,,,fee schedule,3769.88,20651.4, Gi barrett esoph 9 prtn bmrk,0108U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3769.88,,,,,,,fee schedule,3769.88,20651.4, Id aspergillus dna 4 species,0109U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,595.05,,,,,,,fee schedule,213.95,595.05, Id aspergillus dna 4 species,0109U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,213.95,,,,,,,fee schedule,213.95,595.05, Id aspergillus dna 4 species,0109U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,213.95,,,,,,,fee schedule,213.95,595.05, Rx mntr 1+oral onc rx&sbsts,0110U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,113.1,,,,,,,fee schedule,40.67,113.1, Rx mntr 1+oral onc rx&sbsts,0110U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,40.67,,,,,,,fee schedule,40.67,113.1, Rx mntr 1+oral onc rx&sbsts,0110U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,40.67,,,,,,,fee schedule,40.67,113.1, Onc colon ca kras&nras alys,0111U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2846.51,,,,,,,fee schedule,1023.44,2846.51, Onc colon ca kras&nras alys,0111U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1023.44,,,,,,,fee schedule,1023.44,2846.51, Onc colon ca kras&nras alys,0111U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1023.44,,,,,,,fee schedule,1023.44,2846.51, Iadi 16s&18s rrna genes,0112U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1485.77,,,,,,,fee schedule,534.2,1485.77, Iadi 16s&18s rrna genes,0112U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,534.2,,,,,,,fee schedule,534.2,1485.77, Iadi 16s&18s rrna genes,0112U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,534.2,,,,,,,fee schedule,534.2,1485.77, Onc prst8 pca3&tmprss2-erg,0113U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3170.72,,,,,,,fee schedule,1140,3170.72, Onc prst8 pca3&tmprss2-erg,0113U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1140,,,,,,,fee schedule,1140,3170.72, Onc prst8 pca3&tmprss2-erg,0113U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1140,,,,,,,fee schedule,1140,3170.72, Gi barretts esoph vim&ccna1,0114U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8085.38,,,,,,,fee schedule,2907.02,8085.38, Gi barretts esoph vim&ccna1,0114U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2907.02,,,,,,,fee schedule,2907.02,8085.38, Gi barretts esoph vim&ccna1,0114U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2907.02,,,,,,,fee schedule,2907.02,8085.38, Respir iadna 18 viral&2 bact,0115U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1148.76,,,,,,,fee schedule,413.03,1148.76, Respir iadna 18 viral&2 bact,0115U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,413.03,,,,,,,fee schedule,413.03,1148.76, Respir iadna 18 viral&2 bact,0115U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,413.03,,,,,,,fee schedule,413.03,1148.76, Rx mntr nzm ia 35+oral flu,0116U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1030.15,,,,,,,fee schedule,370.38,1030.15, Rx mntr nzm ia 35+oral flu,0116U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,370.38,,,,,,,fee schedule,370.38,1030.15, Rx mntr nzm ia 35+oral flu,0116U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,370.38,,,,,,,fee schedule,370.38,1030.15, Pain mgmt 11 endogenous anal,0117U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3507.19,,,,,,,fee schedule,1260.98,3507.19, Pain mgmt 11 endogenous anal,0117U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1260.98,,,,,,,fee schedule,1260.98,3507.19, Pain mgmt 11 endogenous anal,0117U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1260.98,,,,,,,fee schedule,1260.98,3507.19, Trnsplj don-drv cll-fr dna,0118U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,11486.56,,,,,,,fee schedule,4129.88,11486.56, Trnsplj don-drv cll-fr dna,0118U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4129.88,,,,,,,fee schedule,4129.88,11486.56, Trnsplj don-drv cll-fr dna,0118U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4129.88,,,,,,,fee schedule,4129.88,11486.56, Crd ceramides liq chrom plsm,0119U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,349.45,,,,,,,fee schedule,125.64,349.45, Crd ceramides liq chrom plsm,0119U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,125.64,,,,,,,fee schedule,125.64,349.45, Crd ceramides liq chrom plsm,0119U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,125.64,,,,,,,fee schedule,125.64,349.45, Onc b cll lymphm mrna 58 gen,0120U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10472.6,,,,,,,fee schedule,4183.68,10472.6, Onc b cll lymphm mrna 58 gen,0120U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4183.68,,,,,,,fee schedule,4183.68,10472.6, Onc b cll lymphm mrna 58 gen,0120U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4183.68,,,,,,,fee schedule,4183.68,10472.6, Sc dis vcam-1 whole blood,0121U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2124.38,,,,,,,fee schedule,763.8,2124.38, Sc dis vcam-1 whole blood,0121U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,763.8,,,,,,,fee schedule,763.8,2124.38, Sc dis vcam-1 whole blood,0121U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,763.8,,,,,,,fee schedule,763.8,2124.38, Sc dis p-selectin whl blood,0122U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2195.43,,,,,,,fee schedule,789.35,2195.43, Sc dis p-selectin whl blood,0122U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,789.35,,,,,,,fee schedule,789.35,2195.43, Sc dis p-selectin whl blood,0122U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,789.35,,,,,,,fee schedule,789.35,2195.43, Mchnl fragility rbc prflg,0123U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1492.03,,,,,,,fee schedule,536.45,1492.03, Mchnl fragility rbc prflg,0123U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,536.45,,,,,,,fee schedule,536.45,1492.03, Mchnl fragility rbc prflg,0123U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,536.45,,,,,,,fee schedule,536.45,1492.03, Hered brst ca rltd do panel,0129U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5440.08,,,,,,,fee schedule,1676.97,5440.08, Hered brst ca rltd do panel,0129U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1676.97,,,,,,,fee schedule,1676.97,5440.08, Hered brst ca rltd do panel,0129U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1676.97,,,,,,,fee schedule,1676.97,5440.08, Hered colon ca do mrna pnl,0130U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2440.2,,,,,,,fee schedule,877.35,2440.2, Hered colon ca do mrna pnl,0130U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,877.35,,,,,,,fee schedule,877.35,2440.2, Hered colon ca do mrna pnl,0130U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,877.35,,,,,,,fee schedule,877.35,2440.2, Hered brst ca rltd do pnl 13,0131U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1065,,,,,,,fee schedule,1065,1065, Hered brst ca rltd do pnl 13,0131U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1065,,,,,,,fee schedule,1065,1065, Hered ova ca rltd do pnl 17,0132U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1112.46,,,,,,,fee schedule,1112.46,1112.46, Hered ova ca rltd do pnl 17,0132U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1112.46,,,,,,,fee schedule,1112.46,1112.46, Hered prst8 ca rltd do 11,0133U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2879.89,,,,,,,fee schedule,1035.44,2879.89, Hered prst8 ca rltd do 11,0133U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1035.44,,,,,,,fee schedule,1035.44,2879.89, Hered prst8 ca rltd do 11,0133U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1035.44,,,,,,,fee schedule,1035.44,2879.89, Hered pan ca mrna pnl 18 gen,0134U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3122.28,,,,,,,fee schedule,1122.59,3122.28, Hered pan ca mrna pnl 18 gen,0134U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1122.59,,,,,,,fee schedule,1122.59,3122.28, Hered pan ca mrna pnl 18 gen,0134U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1122.59,,,,,,,fee schedule,1122.59,3122.28, Hered gyn ca mrna pnl 12 gen,0135U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1050.84,,,,,,,fee schedule,1050.84,1050.84, Hered gyn ca mrna pnl 12 gen,0135U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1050.84,,,,,,,fee schedule,1050.84,1050.84, Atm mrna seq alys,0136U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1699.8,,,,,,,fee schedule,611.15,1699.8, Atm mrna seq alys,0136U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,611.15,,,,,,,fee schedule,611.15,1699.8, Atm mrna seq alys,0136U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,611.15,,,,,,,fee schedule,611.15,1699.8, Palb2 mrna seq alys,0137U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1180.18,,,,,,,fee schedule,424.32,1180.18, Palb2 mrna seq alys,0137U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,424.32,,,,,,,fee schedule,424.32,1180.18, Palb2 mrna seq alys,0137U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,424.32,,,,,,,fee schedule,424.32,1180.18, Brca1 brca2 mrna seq alys,0138U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1953.87,,,,,,,fee schedule,702.5,1953.87, Brca1 brca2 mrna seq alys,0138U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,702.5,,,,,,,fee schedule,702.5,1953.87, Brca1 brca2 mrna seq alys,0138U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,702.5,,,,,,,fee schedule,702.5,1953.87, Nfct ds fungi dna 15 trgt,0140U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,653.96,,,,,,,fee schedule,235.13,653.96, Nfct ds fungi dna 15 trgt,0140U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,235.13,,,,,,,fee schedule,235.13,653.96, Nfct ds fungi dna 15 trgt,0140U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,235.13,,,,,,,fee schedule,235.13,653.96, Nfct ds bact&fng gram pos,0141U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,653.96,,,,,,,fee schedule,235.13,653.96, Nfct ds bact&fng gram pos,0141U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,235.13,,,,,,,fee schedule,235.13,653.96, Nfct ds bact&fng gram pos,0141U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,235.13,,,,,,,fee schedule,235.13,653.96, Nfct ds bact&fng gram neg,0142U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,653.96,,,,,,,fee schedule,235.13,653.96, Nfct ds bact&fng gram neg,0142U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,235.13,,,,,,,fee schedule,235.13,653.96, Nfct ds bact&fng gram neg,0142U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,235.13,,,,,,,fee schedule,235.13,653.96, Nfct bct fng prst dna >1000,0152U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8870.51,,,,,,,fee schedule,3189.3,8870.51, Nfct bct fng prst dna >1000,0152U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3189.3,,,,,,,fee schedule,3189.3,8870.51, Nfct bct fng prst dna >1000,0152U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3189.3,,,,,,,fee schedule,3189.3,8870.51, Onc breast mrna 101 genes,0153U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,13181.1,,,,,,,fee schedule,4739.13,13181.1, Onc breast mrna 101 genes,0153U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4739.13,,,,,,,fee schedule,4739.13,13181.1, Onc breast mrna 101 genes,0153U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4739.13,,,,,,,fee schedule,4739.13,13181.1, Fgfr3 gene analysis,0154U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2011.49,,,,,,,fee schedule,310.97,2011.49, Fgfr3 gene analysis,0154U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,310.97,,,,,,,fee schedule,310.97,2011.49, Fgfr3 gene analysis,0154U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,310.97,,,,,,,fee schedule,310.97,2011.49, Pik3ca gene analysis,0155U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1146.59,,,,,,,fee schedule,412.25,1146.59, Pik3ca gene analysis,0155U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,412.25,,,,,,,fee schedule,412.25,1146.59, Pik3ca gene analysis,0155U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,412.25,,,,,,,fee schedule,412.25,1146.59, Copy number sequence alys,0156U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7259.28,,,,,,,fee schedule,2610,7259.28, Copy number sequence alys,0156U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2610,,,,,,,fee schedule,2610,7259.28, Copy number sequence alys,0156U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2610,,,,,,,fee schedule,2610,7259.28, Apc mrna seq alys,0157U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1180.18,,,,,,,fee schedule,424.32,1180.18, Apc mrna seq alys,0157U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,424.32,,,,,,,fee schedule,424.32,1180.18, Apc mrna seq alys,0157U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,424.32,,,,,,,fee schedule,424.32,1180.18, Mlh1 mrna seq alys,0158U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1180.18,,,,,,,fee schedule,424.32,1180.18, Mlh1 mrna seq alys,0158U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,424.32,,,,,,,fee schedule,424.32,1180.18, Mlh1 mrna seq alys,0158U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,424.32,,,,,,,fee schedule,424.32,1180.18, Msh2 mrna seq alys,0159U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1180.18,,,,,,,fee schedule,424.32,1180.18, Msh2 mrna seq alys,0159U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,424.32,,,,,,,fee schedule,424.32,1180.18, Msh2 mrna seq alys,0159U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,424.32,,,,,,,fee schedule,424.32,1180.18, Msh6 mrna seq alys,0160U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1180.18,,,,,,,fee schedule,424.32,1180.18, Msh6 mrna seq alys,0160U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,424.32,,,,,,,fee schedule,424.32,1180.18, Msh6 mrna seq alys,0160U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,424.32,,,,,,,fee schedule,424.32,1180.18, Pms2 mrna seq alys,0161U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1180.18,,,,,,,fee schedule,424.32,1180.18, Pms2 mrna seq alys,0161U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,424.32,,,,,,,fee schedule,424.32,1180.18, Pms2 mrna seq alys,0161U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,424.32,,,,,,,fee schedule,424.32,1180.18, Hered colon ca trgt mrna pnl,0162U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2029.84,,,,,,,fee schedule,729.81,2029.84, Hered colon ca trgt mrna pnl,0162U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,729.81,,,,,,,fee schedule,729.81,2029.84, Hered colon ca trgt mrna pnl,0162U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,729.81,,,,,,,fee schedule,729.81,2029.84, Onc clrct scr 3 prtn alg,0163U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1630.21,,,,,,,fee schedule,586.13,1630.21, Onc clrct scr 3 prtn alg,0163U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,586.13,,,,,,,fee schedule,586.13,1630.21, Onc clrct scr 3 prtn alg,0163U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,586.13,,,,,,,fee schedule,586.13,1630.21, Remove Lumb Artif Disc Addl,0164T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Remove Lumb Artif Disc Addl,0164T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Remove Lumb Artif Disc Addl,0164T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Gi ibs ia anti-cdtb&vinculin,0164U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,467.35,,,,,,,fee schedule,168.03,467.35, Gi ibs ia anti-cdtb&vinculin,0164U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,168.03,,,,,,,fee schedule,168.03,467.35, Gi ibs ia anti-cdtb&vinculin,0164U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,168.03,,,,,,,fee schedule,168.03,467.35, Revise Lumb Artif Disc Addl,0165T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Revise Lumb Artif Disc Addl,0165T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Revise Lumb Artif Disc Addl,0165T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Peanut allg spec asmt 64 epi,0165U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1934.81,,,,,,,fee schedule,695.64,1934.81, Peanut allg spec asmt 64 epi,0165U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,695.64,,,,,,,fee schedule,695.64,1934.81, Peanut allg spec asmt 64 epi,0165U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,695.64,,,,,,,fee schedule,695.64,1934.81, Liver ds 10 biochem asy srm,0166U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2100.18,,,,,,,fee schedule,755.1,2100.18, Liver ds 10 biochem asy srm,0166U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,755.1,,,,,,,fee schedule,755.1,2100.18, Liver ds 10 biochem asy srm,0166U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,755.1,,,,,,,fee schedule,755.1,2100.18, Nudt15&tpmt gene com vrnt,0169U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1944.86,,,,,,,fee schedule,699.26,1944.86, Nudt15&tpmt gene com vrnt,0169U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,699.26,,,,,,,fee schedule,699.26,1944.86, Nudt15&tpmt gene com vrnt,0169U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,699.26,,,,,,,fee schedule,699.26,1944.86, Neuro asd rna next gen seq,0170U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8135.4,,,,,,,fee schedule,2632.5,8135.4, Neuro asd rna next gen seq,0170U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2632.5,,,,,,,fee schedule,2632.5,8135.4, Neuro asd rna next gen seq,0170U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2632.5,,,,,,,fee schedule,2632.5,8135.4, Trgt gen seq alys pnl dna 23,0171U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6337.52,,,,,,,fee schedule,2278.59,6337.52, Trgt gen seq alys pnl dna 23,0171U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2278.59,,,,,,,fee schedule,2278.59,6337.52, Trgt gen seq alys pnl dna 23,0171U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2278.59,,,,,,,fee schedule,2278.59,6337.52, Onc sld tum alys brca1 brca2,0172U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12641.16,,,,,,,fee schedule,4545,12641.16, Onc sld tum alys brca1 brca2,0172U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4545,,,,,,,fee schedule,4545,12641.16, Onc sld tum alys brca1 brca2,0172U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4545,,,,,,,fee schedule,4545,12641.16, Psyc gen alys panel 14 genes,0173U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1944.86,,,,,,,fee schedule,699.26,1944.86, Psyc gen alys panel 14 genes,0173U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,699.26,,,,,,,fee schedule,699.26,1944.86, Psyc gen alys panel 14 genes,0173U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,699.26,,,,,,,fee schedule,699.26,1944.86, Onc solid tumor 30 prtn trgt,0174U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5446,,,,,,,fee schedule,1958.06,5446, Onc solid tumor 30 prtn trgt,0174U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1958.06,,,,,,,fee schedule,1958.06,5446, Onc solid tumor 30 prtn trgt,0174U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1958.06,,,,,,,fee schedule,1958.06,5446, Psyc gen alys panel 15 genes,0175U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5574.17,,,,,,,fee schedule,2004.14,5574.17, Psyc gen alys panel 15 genes,0175U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2004.14,,,,,,,fee schedule,2004.14,5574.17, Psyc gen alys panel 15 genes,0175U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2004.14,,,,,,,fee schedule,2004.14,5574.17, Cdtb&vinculin igg antb ia,0176U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,267.8,,,,,,,fee schedule,96.29,267.8, Cdtb&vinculin igg antb ia,0176U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,96.29,,,,,,,fee schedule,96.29,267.8, Cdtb&vinculin igg antb ia,0176U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,96.29,,,,,,,fee schedule,96.29,267.8, Onc brst ca dna pik3ca 11,0177U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1146.59,,,,,,,fee schedule,369.78,1146.59, Onc brst ca dna pik3ca 11,0177U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,369.78,,,,,,,fee schedule,369.78,1146.59, Onc brst ca dna pik3ca 11,0177U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,369.78,,,,,,,fee schedule,369.78,1146.59, Peanut allg asmt epi clin rx,0178U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1918.54,,,,,,,fee schedule,689.79,1918.54, Peanut allg asmt epi clin rx,0178U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,689.79,,,,,,,fee schedule,689.79,1918.54, Peanut allg asmt epi clin rx,0178U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,689.79,,,,,,,fee schedule,689.79,1918.54, Onc nonsm cll lng ca alys 23,0179U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8107.07,,,,,,,fee schedule,2914.82,8107.07, Onc nonsm cll lng ca alys 23,0179U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2914.82,,,,,,,fee schedule,2914.82,8107.07, Onc nonsm cll lng ca alys 23,0179U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2914.82,,,,,,,fee schedule,2914.82,8107.07, Abo gnotyp abo 7 exons,0180U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1146.59,,,,,,,fee schedule,412.25,1146.59, Abo gnotyp abo 7 exons,0180U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,412.25,,,,,,,fee schedule,412.25,1146.59, Abo gnotyp abo 7 exons,0180U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,412.25,,,,,,,fee schedule,412.25,1146.59, Co gnotyp aqp1 exon 1,0181U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,772.65,,,,,,,fee schedule,277.8,772.65, Co gnotyp aqp1 exon 1,0181U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,277.8,,,,,,,fee schedule,277.8,772.65, Co gnotyp aqp1 exon 1,0181U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,277.8,,,,,,,fee schedule,277.8,772.65, Crom gnotyp cd55 exons 1-10,0182U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1257.23,,,,,,,fee schedule,452.03,1257.23, Crom gnotyp cd55 exons 1-10,0182U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,452.03,,,,,,,fee schedule,452.03,1257.23, Crom gnotyp cd55 exons 1-10,0182U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,452.03,,,,,,,fee schedule,452.03,1257.23, Di gnotyp slc4a1 exon 19,0183U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,772.65,,,,,,,fee schedule,277.8,772.65, Di gnotyp slc4a1 exon 19,0183U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,277.8,,,,,,,fee schedule,277.8,772.65, Di gnotyp slc4a1 exon 19,0183U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,277.8,,,,,,,fee schedule,277.8,772.65, Exc rectal tumor endoscopic,0184T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,12821, Exc rectal tumor endoscopic,0184T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5248,12821, Exc rectal tumor endoscopic,0184T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5248,12821, Do gnotyp art4 exon 2,0184U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,772.65,,,,,,,fee schedule,277.8,772.65, Do gnotyp art4 exon 2,0184U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,277.8,,,,,,,fee schedule,277.8,772.65, Do gnotyp art4 exon 2,0184U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,277.8,,,,,,,fee schedule,277.8,772.65, Fut1 gnotyp fut1 exon 4,0185U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,772.65,,,,,,,fee schedule,277.8,772.65, Fut1 gnotyp fut1 exon 4,0185U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,277.8,,,,,,,fee schedule,277.8,772.65, Fut1 gnotyp fut1 exon 4,0185U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,277.8,,,,,,,fee schedule,277.8,772.65, Fut2 gnotyp fut2 exon 2,0186U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,772.65,,,,,,,fee schedule,277.8,772.65, Fut2 gnotyp fut2 exon 2,0186U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,277.8,,,,,,,fee schedule,277.8,772.65, Fut2 gnotyp fut2 exon 2,0186U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,277.8,,,,,,,fee schedule,277.8,772.65, Fy gnotyp ackr1 exons 1-2,0187U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1146.59,,,,,,,fee schedule,412.25,1146.59, Fy gnotyp ackr1 exons 1-2,0187U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,412.25,,,,,,,fee schedule,412.25,1146.59, Fy gnotyp ackr1 exons 1-2,0187U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,412.25,,,,,,,fee schedule,412.25,1146.59, Ge gnotyp gypc exons 1-4,0188U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1146.59,,,,,,,fee schedule,412.25,1146.59, Ge gnotyp gypc exons 1-4,0188U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,412.25,,,,,,,fee schedule,412.25,1146.59, Ge gnotyp gypc exons 1-4,0188U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,412.25,,,,,,,fee schedule,412.25,1146.59, Gypa gnotyp ntrns 1 5 exon 2,0189U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1146.59,,,,,,,fee schedule,412.25,1146.59, Gypa gnotyp ntrns 1 5 exon 2,0189U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,412.25,,,,,,,fee schedule,412.25,1146.59, Gypa gnotyp ntrns 1 5 exon 2,0189U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,412.25,,,,,,,fee schedule,412.25,1146.59, Gypb gnotyp ntrns 1 5 seux 3,0190U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1146.59,,,,,,,fee schedule,412.25,1146.59, Gypb gnotyp ntrns 1 5 seux 3,0190U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,412.25,,,,,,,fee schedule,412.25,1146.59, Gypb gnotyp ntrns 1 5 seux 3,0190U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,412.25,,,,,,,fee schedule,412.25,1146.59, In gnotyp cd44 exons 2 3 6,0191U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1146.59,,,,,,,fee schedule,412.25,1146.59, In gnotyp cd44 exons 2 3 6,0191U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,412.25,,,,,,,fee schedule,412.25,1146.59, In gnotyp cd44 exons 2 3 6,0191U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,412.25,,,,,,,fee schedule,412.25,1146.59, Jk gnotyp slc14a1 exon 9,0192U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1146.59,,,,,,,fee schedule,412.25,1146.59, Jk gnotyp slc14a1 exon 9,0192U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,412.25,,,,,,,fee schedule,412.25,1146.59, Jk gnotyp slc14a1 exon 9,0192U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,412.25,,,,,,,fee schedule,412.25,1146.59, Jr gnotyp abcg2 exons 2-26,0193U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1180.18,,,,,,,fee schedule,424.32,1180.18, Jr gnotyp abcg2 exons 2-26,0193U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,424.32,,,,,,,fee schedule,424.32,1180.18, Jr gnotyp abcg2 exons 2-26,0193U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,424.32,,,,,,,fee schedule,424.32,1180.18, Kel gnotyp kel exon 8,0194U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,772.65,,,,,,,fee schedule,277.8,772.65, Kel gnotyp kel exon 8,0194U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,277.8,,,,,,,fee schedule,277.8,772.65, Kel gnotyp kel exon 8,0194U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,277.8,,,,,,,fee schedule,277.8,772.65, Klf1 targeted sequencing,0195U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1565.54,,,,,,,fee schedule,562.88,1565.54, Klf1 targeted sequencing,0195U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,562.88,,,,,,,fee schedule,562.88,1565.54, Klf1 targeted sequencing,0195U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,562.88,,,,,,,fee schedule,562.88,1565.54, Lu gnotyp bcam exon 3,0196U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,772.65,,,,,,,fee schedule,277.8,772.65, Lu gnotyp bcam exon 3,0196U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,277.8,,,,,,,fee schedule,277.8,772.65, Lu gnotyp bcam exon 3,0196U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,277.8,,,,,,,fee schedule,277.8,772.65, Lw gnotyp icam4 exon 1,0197U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,772.65,,,,,,,fee schedule,277.8,772.65, Lw gnotyp icam4 exon 1,0197U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,277.8,,,,,,,fee schedule,277.8,772.65, Lw gnotyp icam4 exon 1,0197U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,277.8,,,,,,,fee schedule,277.8,772.65, Rhd&rhce gntyp rhd1-10&rhce5,0198U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1180.18,,,,,,,fee schedule,424.32,1180.18, Rhd&rhce gntyp rhd1-10&rhce5,0198U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,424.32,,,,,,,fee schedule,424.32,1180.18, Rhd&rhce gntyp rhd1-10&rhce5,0198U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,424.32,,,,,,,fee schedule,424.32,1180.18, Sc gnotyp ermap exons 4 12,0199U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1146.59,,,,,,,fee schedule,412.25,1146.59, Sc gnotyp ermap exons 4 12,0199U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,412.25,,,,,,,fee schedule,412.25,1146.59, Sc gnotyp ermap exons 4 12,0199U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,412.25,,,,,,,fee schedule,412.25,1146.59, Perq sacral augmt unilat inj,0200T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,11539,12821, Perq sacral augmt unilat inj,0200T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,11539,12821, Xk gnotyp xk exons 1-3,0200U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1146.59,,,,,,,fee schedule,412.25,1146.59, Xk gnotyp xk exons 1-3,0200U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,412.25,,,,,,,fee schedule,412.25,1146.59, Xk gnotyp xk exons 1-3,0200U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,412.25,,,,,,,fee schedule,412.25,1146.59, Perq sacral augmt bilat inj,0201T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,11539,12821, Perq sacral augmt bilat inj,0201T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,11539,12821, Yt gnotyp ache exon 2,0201U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,772.65,,,,,,,fee schedule,277.8,772.65, Yt gnotyp ache exon 2,0201U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,277.8,,,,,,,fee schedule,277.8,772.65, Yt gnotyp ache exon 2,0201U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,277.8,,,,,,,fee schedule,277.8,772.65, Post vert arthrplst 1 lumbar,0202T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,22111, Post vert arthrplst 1 lumbar,0202T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6979,22111, Post vert arthrplst 1 lumbar,0202T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6979,22111, Nfct ds 22 trgt sars-cov-2,0202U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1738.81,,,,,,,fee schedule,625.17,1738.81, Nfct ds 22 trgt sars-cov-2,0202U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,625.17,,,,,,,fee schedule,625.17,1738.81, Nfct ds 22 trgt sars-cov-2,0202U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,625.17,,,,,,,fee schedule,625.17,1738.81, Ai ibd mrna xprsn prfl 17,0203U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3170.72,,,,,,,fee schedule,1140,3170.72, Ai ibd mrna xprsn prfl 17,0203U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1140,,,,,,,fee schedule,1140,3170.72, Ai ibd mrna xprsn prfl 17,0203U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1140,,,,,,,fee schedule,1140,3170.72, Oph amd alys 3 gene variants,0205U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,196.08,,,,,,,fee schedule,70.5,196.08, Oph amd alys 3 gene variants,0205U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,70.5,,,,,,,fee schedule,70.5,196.08, Oph amd alys 3 gene variants,0205U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,70.5,,,,,,,fee schedule,70.5,196.08, Neuro alzheimer cell aggregj,0206U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9242.65,,,,,,,fee schedule,3323.1,9242.65, Neuro alzheimer cell aggregj,0206U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3323.1,,,,,,,fee schedule,3323.1,9242.65, Neuro alzheimer cell aggregj,0206U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3323.1,,,,,,,fee schedule,3323.1,9242.65, Clear eyelid gland w/heat,0207T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Clear eyelid gland w/heat,0207T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Clear eyelid gland w/heat,0207T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Neuro alzheimer quan imaging,0207U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2132.73,,,,,,,fee schedule,766.8,2132.73, Neuro alzheimer quan imaging,0207U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,766.8,,,,,,,fee schedule,766.8,2132.73, Neuro alzheimer quan imaging,0207U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,766.8,,,,,,,fee schedule,766.8,2132.73, Cytog const alys interrog,0209U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3283.99,,,,,,,fee schedule,1180.73,3283.99, Cytog const alys interrog,0209U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1180.73,,,,,,,fee schedule,1180.73,3283.99, Cytog const alys interrog,0209U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1180.73,,,,,,,fee schedule,1180.73,3283.99, Syphilis tst antb ia quan,0210U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,77.72,,,,,,,fee schedule,27.95,77.72, Syphilis tst antb ia quan,0210U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,27.95,,,,,,,fee schedule,27.95,77.72, Syphilis tst antb ia quan,0210U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,27.95,,,,,,,fee schedule,27.95,77.72, Onc pan-tum dna&rna gnrj seq,0211U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,35274.26,,,,,,,fee schedule,5512.5,35274.26, Onc pan-tum dna&rna gnrj seq,0211U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5512.5,,,,,,,fee schedule,5512.5,35274.26, Onc pan-tum dna&rna gnrj seq,0211U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5512.5,,,,,,,fee schedule,5512.5,35274.26, Rare ds gen dna alys proband,0212U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,22842.53,,,,,,,fee schedule,8212.8,22842.53, Rare ds gen dna alys proband,0212U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8212.8,,,,,,,fee schedule,8212.8,22842.53, Rare ds gen dna alys proband,0212U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,8212.8,,,,,,,fee schedule,8212.8,22842.53, Njx paravert w/us cer/thor,0213T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,4047,4497, Njx paravert w/us cer/thor,0213T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,4047,4497, Rare ds gen dna alys ea comp,0213U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,11305.91,,,,,,,fee schedule,4064.93,11305.91, Rare ds gen dna alys ea comp,0213U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4064.93,,,,,,,fee schedule,4064.93,11305.91, Rare ds gen dna alys ea comp,0213U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4064.93,,,,,,,fee schedule,4064.93,11305.91, Njx paravert w/us cer/thor,0214T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,2782, Njx paravert w/us cer/thor,0214T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,2782, Rare ds xom dna alys proband,0214U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,21797.03,,,,,,,fee schedule,7836.9,21797.03, Rare ds xom dna alys proband,0214U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7836.9,,,,,,,fee schedule,7836.9,21797.03, Rare ds xom dna alys proband,0214U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,7836.9,,,,,,,fee schedule,7836.9,21797.03, Njx paravert w/us cer/thor,0215T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,2782, Njx paravert w/us cer/thor,0215T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,2782, Rare ds xom dna alys ea comp,0215U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10741.44,,,,,,,fee schedule,3861.98,10741.44, Rare ds xom dna alys ea comp,0215U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3861.98,,,,,,,fee schedule,3861.98,10741.44, Rare ds xom dna alys ea comp,0215U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3861.98,,,,,,,fee schedule,3861.98,10741.44, Njx paravert w/us lumb/sac,0216T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,4497, Njx paravert w/us lumb/sac,0216T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,3195,4497, Njx paravert w/us lumb/sac,0216T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,3195,4497, Neuro inh ataxia dna 12 com,0216U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6412.45,,,,,,,fee schedule,2305.53,6412.45, Neuro inh ataxia dna 12 com,0216U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2305.53,,,,,,,fee schedule,2305.53,6412.45, Neuro inh ataxia dna 12 com,0216U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2305.53,,,,,,,fee schedule,2305.53,6412.45, Njx paravert w/us lumb/sac,0217T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Njx paravert w/us lumb/sac,0217T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Njx paravert w/us lumb/sac,0217T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Neuro inh ataxia dna 51 gene,0217U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9171.52,,,,,,,fee schedule,3297.53,9171.52, Neuro inh ataxia dna 51 gene,0217U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3297.53,,,,,,,fee schedule,3297.53,9171.52, Neuro inh ataxia dna 51 gene,0217U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3297.53,,,,,,,fee schedule,3297.53,9171.52, Njx paravert w/us lumb/sac,0218T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Njx paravert w/us lumb/sac,0218T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Njx paravert w/us lumb/sac,0218T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Neuro musc dys dmd seq alys,0218U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9507.99,,,,,,,fee schedule,3418.5,9507.99, Neuro musc dys dmd seq alys,0218U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3418.5,,,,,,,fee schedule,3418.5,9507.99, Neuro musc dys dmd seq alys,0218U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3418.5,,,,,,,fee schedule,3418.5,9507.99, Plmt post facet implt cerv,0219T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,22111, Plmt post facet implt cerv,0219T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6044,22111, Plmt post facet implt cerv,0219T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6044,22111, Nfct agt hiv gnrj seq alys,0219U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3024.7,,,,,,,fee schedule,1087.5,3024.7, Nfct agt hiv gnrj seq alys,0219U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1087.5,,,,,,,fee schedule,1087.5,3024.7, Nfct agt hiv gnrj seq alys,0219U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1087.5,,,,,,,fee schedule,1087.5,3024.7, Plmt post facet implt thor,0220T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,22111, Plmt post facet implt thor,0220T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6044,22111, Plmt post facet implt thor,0220T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6044,22111, Onc brst ca ai assmt 12 feat,0220U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2946.48,,,,,,,fee schedule,1059.38,2946.48, Onc brst ca ai assmt 12 feat,0220U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1059.38,,,,,,,fee schedule,1059.38,2946.48, Onc brst ca ai assmt 12 feat,0220U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1059.38,,,,,,,fee schedule,1059.38,2946.48, Plmt post facet implt lumb,0221T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,12821, Plmt post facet implt lumb,0221T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,6044,12821, Plmt post facet implt lumb,0221T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,6044,12821, Abo gnotyp next gnrj seq abo,0221U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1146.59,,,,,,,fee schedule,412.25,1146.59, Abo gnotyp next gnrj seq abo,0221U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,412.25,,,,,,,fee schedule,412.25,1146.59, Abo gnotyp next gnrj seq abo,0221U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,412.25,,,,,,,fee schedule,412.25,1146.59, Plmt post facet implt addl,0222T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Plmt post facet implt addl,0222T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Plmt post facet implt addl,0222T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Rhd&rhce gntyp next gnrj seq,0222U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1180.18,,,,,,,fee schedule,424.32,1180.18, Rhd&rhce gntyp next gnrj seq,0222U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,424.32,,,,,,,fee schedule,424.32,1180.18, Rhd&rhce gntyp next gnrj seq,0222U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,424.32,,,,,,,fee schedule,424.32,1180.18, Nfct ds 22 trgt sars-cov-2,0223U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1738.81,,,,,,,fee schedule,625.16,1738.81, Nfct ds 22 trgt sars-cov-2,0223U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,625.16,,,,,,,fee schedule,625.16,1738.81, Nfct ds 22 trgt sars-cov-2,0223U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,625.16,,,,,,,fee schedule,625.16,1738.81, Antibody sars-cov-2 titer(s),0224U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,214.57,,,,,,,fee schedule,63.2,214.57, Antibody sars-cov-2 titer(s),0224U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,63.2,,,,,,,fee schedule,63.2,214.57, Antibody sars-cov-2 titer(s),0224U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,63.2,,,,,,,fee schedule,63.2,214.57, Nfct ds dna&rna 21 sarscov2,0225U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1738.81,,,,,,,fee schedule,625.16,1738.81, Nfct ds dna&rna 21 sarscov2,0225U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,625.16,,,,,,,fee schedule,625.16,1738.81, Nfct ds dna&rna 21 sarscov2,0225U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,625.16,,,,,,,fee schedule,625.16,1738.81, Svnt sarscov2 elisa plsm srm,0226U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,176.39,,,,,,,fee schedule,63.2,176.39, Svnt sarscov2 elisa plsm srm,0226U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,63.2,,,,,,,fee schedule,63.2,176.39, Svnt sarscov2 elisa plsm srm,0226U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,63.2,,,,,,,fee schedule,63.2,176.39, Rx asy prsmv 30+rx/metablt,0227U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,259.25,,,,,,,fee schedule,93.21,259.25, Rx asy prsmv 30+rx/metablt,0227U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,93.21,,,,,,,fee schedule,93.21,259.25, Rx asy prsmv 30+rx/metablt,0227U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,93.21,,,,,,,fee schedule,93.21,259.25, Onc prst8 ma molec prfl alg,0228U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,721.88,,,,,,,fee schedule,259.55,721.88, Onc prst8 ma molec prfl alg,0228U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,259.55,,,,,,,fee schedule,259.55,721.88, Onc prst8 ma molec prfl alg,0228U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,259.55,,,,,,,fee schedule,259.55,721.88, Bcat1 promoter mthyltn alys,0229U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1602.05,,,,,,,fee schedule,288,1602.05, Bcat1 promoter mthyltn alys,0229U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,288,,,,,,,fee schedule,288,1602.05, Bcat1 promoter mthyltn alys,0229U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,288,,,,,,,fee schedule,288,1602.05, Ar full sequence analysis,0230U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1257.23,,,,,,,fee schedule,452.03,1257.23, Ar full sequence analysis,0230U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,452.03,,,,,,,fee schedule,452.03,1257.23, Ar full sequence analysis,0230U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,452.03,,,,,,,fee schedule,452.03,1257.23, Cacna1a full gene analysis,0231U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3530.64,,,,,,,fee schedule,1269.41,3530.64, Cacna1a full gene analysis,0231U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1269.41,,,,,,,fee schedule,1269.41,3530.64, Cacna1a full gene analysis,0231U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1269.41,,,,,,,fee schedule,1269.41,3530.64, Njx platelet plasma,0232T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Njx platelet plasma,0232T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Njx platelet plasma,0232T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Cstb full gene analysis,0232U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1146.59,,,,,,,fee schedule,412.25,1146.59, Cstb full gene analysis,0232U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,412.25,,,,,,,fee schedule,412.25,1146.59, Cstb full gene analysis,0232U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,412.25,,,,,,,fee schedule,412.25,1146.59, Fxn gene analysis,0233U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1146.59,,,,,,,fee schedule,412.25,1146.59, Fxn gene analysis,0233U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,412.25,,,,,,,fee schedule,412.25,1146.59, Fxn gene analysis,0233U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,412.25,,,,,,,fee schedule,412.25,1146.59, Trluml perip athrc renal art,0234T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,25393, Trluml perip athrc renal art,0234T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,5248,25393, Trluml perip athrc renal art,0234T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,5248,25393, Mecp2 full gene analysis,0234U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2202.27,,,,,,,fee schedule,791.81,2202.27, Mecp2 full gene analysis,0234U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,791.81,,,,,,,fee schedule,791.81,2202.27, Mecp2 full gene analysis,0234U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,791.81,,,,,,,fee schedule,791.81,2202.27, Trluml perip athrc visceral,0235T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Trluml perip athrc visceral,0235T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Pten full gene analysis,0235U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2503.2,,,,,,,fee schedule,900,2503.2, Pten full gene analysis,0235U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,900,,,,,,,fee schedule,900,2503.2, Pten full gene analysis,0235U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,900,,,,,,,fee schedule,900,2503.2, Trluml perip athrc abd aorta,0236T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,25393, Trluml perip athrc abd aorta,0236T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,5248,25393, Trluml perip athrc abd aorta,0236T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,5248,25393, Smn1&smn2 full gene analysis,0236U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2514.46,,,,,,,fee schedule,904.05,2514.46, Smn1&smn2 full gene analysis,0236U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,904.05,,,,,,,fee schedule,904.05,2514.46, Smn1&smn2 full gene analysis,0236U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,904.05,,,,,,,fee schedule,904.05,2514.46, Trluml perip athrc brchiocph,0237T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,25393, Trluml perip athrc brchiocph,0237T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,5248,25393, Trluml perip athrc brchiocph,0237T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,5248,25393, Car ion chnlpthy gen seq pnl,0237U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2440.2,,,,,,,fee schedule,877.35,2440.2, Car ion chnlpthy gen seq pnl,0237U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,877.35,,,,,,,fee schedule,877.35,2440.2, Car ion chnlpthy gen seq pnl,0237U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,877.35,,,,,,,fee schedule,877.35,2440.2, Trluml perip athrc iliac art,0238T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,8406,25393, Trluml perip athrc iliac art,0238T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,8406,25393, Trluml perip athrc iliac art,0238T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,8406,25393, Onc lnch syn gen dna seq aly,0238U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2440.2,,,,,,,fee schedule,877.35,2440.2, Onc lnch syn gen dna seq aly,0238U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,877.35,,,,,,,fee schedule,877.35,2440.2, Onc lnch syn gen dna seq aly,0238U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,877.35,,,,,,,fee schedule,877.35,2440.2, Trgt gen seq alys pnl 311+,0239U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,14602,,,,,,,fee schedule,5250,14602, Trgt gen seq alys pnl 311+,0239U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5250,,,,,,,fee schedule,5250,14602, Trgt gen seq alys pnl 311+,0239U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5250,,,,,,,fee schedule,5250,14602, Trgt gen seq alys pnl 55-74,0242U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,20860,,,,,,,fee schedule,7500,20860, Trgt gen seq alys pnl 55-74,0242U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7500,,,,,,,fee schedule,7500,20860, Trgt gen seq alys pnl 55-74,0242U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,7500,,,,,,,fee schedule,7500,20860, Ob pe biochem assay pgf alg,0243U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,268.72,,,,,,,fee schedule,96.62,268.72, Ob pe biochem assay pgf alg,0243U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,96.62,,,,,,,fee schedule,96.62,268.72, Ob pe biochem assay pgf alg,0243U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,96.62,,,,,,,fee schedule,96.62,268.72, Onc solid orgn dna 257 genes,0244U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,14602,,,,,,,fee schedule,5250,14602, Onc solid orgn dna 257 genes,0244U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5250,,,,,,,fee schedule,5250,14602, Onc solid orgn dna 257 genes,0244U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5250,,,,,,,fee schedule,5250,14602, Onc thyr mut alys 10 gen&37,0245U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5282.04,,,,,,,fee schedule,1899.11,5282.04, Onc thyr mut alys 10 gen&37,0245U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1899.11,,,,,,,fee schedule,1899.11,5282.04, Onc thyr mut alys 10 gen&37,0245U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1899.11,,,,,,,fee schedule,1899.11,5282.04, Rbc dna gnotyp 16 bld groups,0246U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3003.84,,,,,,,fee schedule,1080,3003.84, Rbc dna gnotyp 16 bld groups,0246U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1080,,,,,,,fee schedule,1080,3003.84, Rbc dna gnotyp 16 bld groups,0246U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1080,,,,,,,fee schedule,1080,3003.84, Ob prtrm brth ibp4 shbg meas,0247U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3129,,,,,,,fee schedule,1125,3129, Ob prtrm brth ibp4 shbg meas,0247U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1125,,,,,,,fee schedule,1125,3129, Ob prtrm brth ibp4 shbg meas,0247U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1125,,,,,,,fee schedule,1125,3129, Onc brn sphrd cll 12 rx pnl,0248U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12657.26,,,,,,,fee schedule,4550.79,12657.26, Onc brn sphrd cll 12 rx pnl,0248U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4550.79,,,,,,,fee schedule,4550.79,12657.26, Onc brn sphrd cll 12 rx pnl,0248U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4550.79,,,,,,,fee schedule,4550.79,12657.26, Onc brst alys 32 phsprtn alg,0249U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9258.21,,,,,,,fee schedule,3328.7,9258.21, Onc brst alys 32 phsprtn alg,0249U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3328.7,,,,,,,fee schedule,3328.7,9258.21, Onc brst alys 32 phsprtn alg,0249U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3328.7,,,,,,,fee schedule,3328.7,9258.21, Onc sld org neo dna 505 gene,0250U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12180.57,,,,,,,fee schedule,4379.4,12180.57, Onc sld org neo dna 505 gene,0250U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4379.4,,,,,,,fee schedule,4379.4,12180.57, Onc sld org neo dna 505 gene,0250U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4379.4,,,,,,,fee schedule,4379.4,12180.57, Hepcidin-25 elisa serum/plsm,0251U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,72.05,,,,,,,fee schedule,25.91,72.05, Hepcidin-25 elisa serum/plsm,0251U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25.91,,,,,,,fee schedule,25.91,72.05, Hepcidin-25 elisa serum/plsm,0251U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,25.91,,,,,,,fee schedule,25.91,72.05, Ftl aneuploidy str alys dna,0252U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3166.76,,,,,,,fee schedule,1138.58,3166.76, Ftl aneuploidy str alys dna,0252U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1138.58,,,,,,,fee schedule,1138.58,3166.76, Ftl aneuploidy str alys dna,0252U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1138.58,,,,,,,fee schedule,1138.58,3166.76, Insert aqueous drain device,0253T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,13011,14456, Insert aqueous drain device,0253T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,13011,14456, Rprdtve med rna gen prfl 238,0253U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,13181.1,,,,,,,fee schedule,4739.13,13181.1, Rprdtve med rna gen prfl 238,0253U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4739.13,,,,,,,fee schedule,4739.13,13181.1, Rprdtve med rna gen prfl 238,0253U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4739.13,,,,,,,fee schedule,4739.13,13181.1, Reprdtve med alys 24 chrmsm,0254U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3166.76,,,,,,,fee schedule,1138.58,3166.76, Reprdtve med alys 24 chrmsm,0254U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1138.58,,,,,,,fee schedule,1138.58,3166.76, Reprdtve med alys 24 chrmsm,0254U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1138.58,,,,,,,fee schedule,1138.58,3166.76, Andrology infertility assmt,0255U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,131.84,,,,,,,fee schedule,47.4,131.84, Andrology infertility assmt,0255U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,47.4,,,,,,,fee schedule,47.4,131.84, Andrology infertility assmt,0255U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,47.4,,,,,,,fee schedule,47.4,131.84, Tma/tmao prfl ms/ms ur alg,0256U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,667.31,,,,,,,fee schedule,239.93,667.31, Tma/tmao prfl ms/ms ur alg,0256U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,239.93,,,,,,,fee schedule,239.93,667.31, Tma/tmao prfl ms/ms ur alg,0256U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,239.93,,,,,,,fee schedule,239.93,667.31, Vlcad leuk nzm actv whl bld,0257U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2972.42,,,,,,,fee schedule,1068.71,2972.42, Vlcad leuk nzm actv whl bld,0257U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1068.71,,,,,,,fee schedule,1068.71,2972.42, Vlcad leuk nzm actv whl bld,0257U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1068.71,,,,,,,fee schedule,1068.71,2972.42, Ai psor mrna 50-100 gen alg,0258U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,15332.1,,,,,,,fee schedule,5512.5,15332.1, Ai psor mrna 50-100 gen alg,0258U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5512.5,,,,,,,fee schedule,5512.5,15332.1, Ai psor mrna 50-100 gen alg,0258U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5512.5,,,,,,,fee schedule,5512.5,15332.1, Neph ckd nuc mrs meas gfr,0259U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,219.91,,,,,,,fee schedule,79.07,219.91, Neph ckd nuc mrs meas gfr,0259U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,79.07,,,,,,,fee schedule,79.07,219.91, Neph ckd nuc mrs meas gfr,0259U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,79.07,,,,,,,fee schedule,79.07,219.91, Rare ds id opt genome mapg,0260U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5271.45,,,,,,,fee schedule,1895.3,5271.45, Rare ds id opt genome mapg,0260U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1895.3,,,,,,,fee schedule,1895.3,5271.45, Rare ds id opt genome mapg,0260U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1895.3,,,,,,,fee schedule,1895.3,5271.45, Onc clrct ca img alys w/ai,0261U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10485.28,,,,,,,fee schedule,3769.88,10485.28, Onc clrct ca img alys w/ai,0261U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3769.88,,,,,,,fee schedule,3769.88,10485.28, Onc clrct ca img alys w/ai,0261U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3769.88,,,,,,,fee schedule,3769.88,10485.28, Onc sld tum rt-pcr 7 gen,0262U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,13350.4,,,,,,,fee schedule,4800,13350.4, Onc sld tum rt-pcr 7 gen,0262U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4800,,,,,,,fee schedule,4800,13350.4, Onc sld tum rt-pcr 7 gen,0262U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4800,,,,,,,fee schedule,4800,13350.4, Im b1 mrw cel ther cmpl,0263T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,13011,14456, Im b1 mrw cel ther cmpl,0263T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,13011,14456, Neuro asd meas 16 c metblt,0263U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3129,,,,,,,fee schedule,1125,3129, Neuro asd meas 16 c metblt,0263U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1125,,,,,,,fee schedule,1125,3129, Neuro asd meas 16 c metblt,0263U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1125,,,,,,,fee schedule,1125,3129, Im b1 mrw cel ther xcl hrvst,0264T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,13011,14456, Im b1 mrw cel ther xcl hrvst,0264T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,13011,14456, Rare ds id opt genome mapg,0264U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5271.45,,,,,,,fee schedule,1895.3,5271.45, Rare ds id opt genome mapg,0264U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1895.3,,,,,,,fee schedule,1895.3,5271.45, Rare ds id opt genome mapg,0264U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1895.3,,,,,,,fee schedule,1895.3,5271.45, Im b1 mrw cel ther hrvst onl,0265T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,13011,14456, Im b1 mrw cel ther hrvst onl,0265T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,13011,14456, Rar do whl gn&mtcdrl dna als,0265U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,22845.04,,,,,,,fee schedule,8213.7,22845.04, Rar do whl gn&mtcdrl dna als,0265U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8213.7,,,,,,,fee schedule,8213.7,22845.04, Rar do whl gn&mtcdrl dna als,0265U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,8213.7,,,,,,,fee schedule,8213.7,22845.04, Implt/rpl crtd sns dev total,0266T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,39251,,,,,,,fee schedule,35325,39251, Implt/rpl crtd sns dev total,0266T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,35325,,,,,,,fee schedule,35325,39251, Unxpl cnst hrtbl do gn xprsn,0266U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,13350.4,,,,,,,fee schedule,4800,13350.4, Unxpl cnst hrtbl do gn xprsn,0266U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4800,,,,,,,fee schedule,4800,13350.4, Unxpl cnst hrtbl do gn xprsn,0266U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4800,,,,,,,fee schedule,4800,13350.4, Implt/rpl crtd sns dev lead,0267T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,11539,12821, Implt/rpl crtd sns dev lead,0267T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,11539,12821, Rare do id opt gen mapg&seq,0267U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,28116.48,,,,,,,fee schedule,10109,28116.48, Rare do id opt gen mapg&seq,0267U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10109,,,,,,,fee schedule,10109,28116.48, Rare do id opt gen mapg&seq,0267U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,10109,,,,,,,fee schedule,10109,28116.48, Implt/rpl crtd sns dev gen,0268T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,39251,,,,,,,fee schedule,35325,39251, Implt/rpl crtd sns dev gen,0268T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,35325,,,,,,,fee schedule,35325,39251, Hem ahus gen seq alys 15 gen,0268U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2537.29,,,,,,,fee schedule,912.26,2537.29, Hem ahus gen seq alys 15 gen,0268U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,912.26,,,,,,,fee schedule,912.26,2537.29, Hem ahus gen seq alys 15 gen,0268U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,912.26,,,,,,,fee schedule,912.26,2537.29, Rev/remvl crtd sns dev total,0269T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,19899,22111, Rev/remvl crtd sns dev total,0269T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,19899,22111, Hem aut dm cgen trmbctpna 14,0269U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2537.29,,,,,,,fee schedule,912.26,2537.29, Hem aut dm cgen trmbctpna 14,0269U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,912.26,,,,,,,fee schedule,912.26,2537.29, Hem aut dm cgen trmbctpna 14,0269U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,912.26,,,,,,,fee schedule,912.26,2537.29, Rev/remvl crtd sns dev lead,0270T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,11539,12821, Rev/remvl crtd sns dev lead,0270T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,11539,12821, Hem cgen coagj do 20 genes,0270U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2537.29,,,,,,,fee schedule,912.26,2537.29, Hem cgen coagj do 20 genes,0270U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,912.26,,,,,,,fee schedule,912.26,2537.29, Hem cgen coagj do 20 genes,0270U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,912.26,,,,,,,fee schedule,912.26,2537.29, Rev/remvl crtd sns dev gen,0271T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,11539,12821, Rev/remvl crtd sns dev gen,0271T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,11539,12821, Hem cgen neutropenia 23 gen,0271U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2537.29,,,,,,,fee schedule,912.26,2537.29, Hem cgen neutropenia 23 gen,0271U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,912.26,,,,,,,fee schedule,912.26,2537.29, Hem cgen neutropenia 23 gen,0271U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,912.26,,,,,,,fee schedule,912.26,2537.29, Hem genetic bld do 51 genes,0272U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2537.29,,,,,,,fee schedule,912.26,2537.29, Hem genetic bld do 51 genes,0272U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,912.26,,,,,,,fee schedule,912.26,2537.29, Hem genetic bld do 51 genes,0272U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,912.26,,,,,,,fee schedule,912.26,2537.29, Hem gen hyprfibrnlysis 8 gen,0273U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2537.29,,,,,,,fee schedule,912.26,2537.29, Hem gen hyprfibrnlysis 8 gen,0273U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,912.26,,,,,,,fee schedule,912.26,2537.29, Hem gen hyprfibrnlysis 8 gen,0273U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,912.26,,,,,,,fee schedule,912.26,2537.29, Perq lamot/lam crv/thrc,0274T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,19899,22111, Perq lamot/lam crv/thrc,0274T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,19899,22111, Hem gen pltlt do 43 genes,0274U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2537.29,,,,,,,fee schedule,912.26,2537.29, Hem gen pltlt do 43 genes,0274U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,912.26,,,,,,,fee schedule,912.26,2537.29, Hem gen pltlt do 43 genes,0274U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,912.26,,,,,,,fee schedule,912.26,2537.29, Perq lamot/lam lumbar,0275T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,19899,22111, Perq lamot/lam lumbar,0275T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,19899,22111, Hem heprn nduc trmbctpna srm,0275U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,76.64,,,,,,,fee schedule,27.56,76.64, Hem heprn nduc trmbctpna srm,0275U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,27.56,,,,,,,fee schedule,27.56,76.64, Hem heprn nduc trmbctpna srm,0275U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,27.56,,,,,,,fee schedule,27.56,76.64, Hem inh thrombocytopenia 23,0276U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10215.39,,,,,,,fee schedule,3672.84,10215.39, Hem inh thrombocytopenia 23,0276U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3672.84,,,,,,,fee schedule,3672.84,10215.39, Hem inh thrombocytopenia 23,0276U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3672.84,,,,,,,fee schedule,3672.84,10215.39, Hem gen pltlt funcj do 31,0277U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2537.29,,,,,,,fee schedule,912.26,2537.29, Hem gen pltlt funcj do 31,0277U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,912.26,,,,,,,fee schedule,912.26,2537.29, Hem gen pltlt funcj do 31,0277U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,912.26,,,,,,,fee schedule,912.26,2537.29, Tempr,0278T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,2782, Tempr,0278T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,2782, Hem gen thrombosis 12 genes,0278U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2537.29,,,,,,,fee schedule,912.26,2537.29, Hem gen thrombosis 12 genes,0278U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,912.26,,,,,,,fee schedule,912.26,2537.29, Hem gen thrombosis 12 genes,0278U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,912.26,,,,,,,fee schedule,912.26,2537.29, Hem vw factor&clgn iii bndg,0279U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,48.1,,,,,,,fee schedule,17.3,48.1, Hem vw factor&clgn iii bndg,0279U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.3,,,,,,,fee schedule,17.3,48.1, Hem vw factor&clgn iii bndg,0279U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,17.3,,,,,,,fee schedule,17.3,48.1, Hem vw factor&clgn iv bndg,0280U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,72.05,,,,,,,fee schedule,25.91,72.05, Hem vw factor&clgn iv bndg,0280U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25.91,,,,,,,fee schedule,25.91,72.05, Hem vw factor&clgn iv bndg,0280U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,25.91,,,,,,,fee schedule,25.91,72.05, Hem vwd propeptide ag lvl,0281U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,72.05,,,,,,,fee schedule,25.91,72.05, Hem vwd propeptide ag lvl,0281U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25.91,,,,,,,fee schedule,25.91,72.05, Hem vwd propeptide ag lvl,0281U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,25.91,,,,,,,fee schedule,25.91,72.05, Rbc dna gntyp 12 bld grp gen,0282U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3003.84,,,,,,,fee schedule,1080,3003.84, Rbc dna gntyp 12 bld grp gen,0282U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1080,,,,,,,fee schedule,1080,3003.84, Rbc dna gntyp 12 bld grp gen,0282U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1080,,,,,,,fee schedule,1080,3003.84, Vw factor type 2b eval plsm,0283U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,76.76,,,,,,,fee schedule,27.6,76.76, Vw factor type 2b eval plsm,0283U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,27.6,,,,,,,fee schedule,27.6,76.76, Vw factor type 2b eval plsm,0283U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,27.6,,,,,,,fee schedule,27.6,76.76, Vw factor type 2n eval plsm,0284U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,72.05,,,,,,,fee schedule,25.91,72.05, Vw factor type 2n eval plsm,0284U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25.91,,,,,,,fee schedule,25.91,72.05, Vw factor type 2n eval plsm,0284U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,25.91,,,,,,,fee schedule,25.91,72.05, Onc rsps radj cll fr dna tox,0285U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1849.49,,,,,,,fee schedule,664.97,1849.49, Onc rsps radj cll fr dna tox,0285U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,664.97,,,,,,,fee schedule,664.97,1849.49, Onc rsps radj cll fr dna tox,0285U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,664.97,,,,,,,fee schedule,664.97,1849.49, Cep72 nudt15&tpmt gene alys,0286U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,559.59,,,,,,,fee schedule,201.2,559.59, Cep72 nudt15&tpmt gene alys,0286U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,201.2,,,,,,,fee schedule,201.2,559.59, Cep72 nudt15&tpmt gene alys,0286U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,201.2,,,,,,,fee schedule,201.2,559.59, Onc thyr dna&mrna 112 genes,0287U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,15019.2,,,,,,,fee schedule,5400,15019.2, Onc thyr dna&mrna 112 genes,0287U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5400,,,,,,,fee schedule,5400,15019.2, Onc thyr dna&mrna 112 genes,0287U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5400,,,,,,,fee schedule,5400,15019.2, Onc lung mrna quan pcr 11&3,0288U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,16158.16,,,,,,,fee schedule,5809.5,16158.16, Onc lung mrna quan pcr 11&3,0288U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5809.5,,,,,,,fee schedule,5809.5,16158.16, Onc lung mrna quan pcr 11&3,0288U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5809.5,,,,,,,fee schedule,5809.5,16158.16, Neuro alzheimer mrna 24 gen,0289U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3170.72,,,,,,,fee schedule,1140,3170.72, Neuro alzheimer mrna 24 gen,0289U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1140,,,,,,,fee schedule,1140,3170.72, Neuro alzheimer mrna 24 gen,0289U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1140,,,,,,,fee schedule,1140,3170.72, Pain mgmt mrna gen xprsn 36,0290U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3170.72,,,,,,,fee schedule,1140,3170.72, Pain mgmt mrna gen xprsn 36,0290U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1140,,,,,,,fee schedule,1140,3170.72, Pain mgmt mrna gen xprsn 36,0290U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1140,,,,,,,fee schedule,1140,3170.72, Psyc mood do mrna 144 genes,0291U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7321.86,,,,,,,fee schedule,2632.5,7321.86, Psyc mood do mrna 144 genes,0291U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2632.5,,,,,,,fee schedule,2632.5,7321.86, Psyc mood do mrna 144 genes,0291U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2632.5,,,,,,,fee schedule,2632.5,7321.86, Psyc strs do mrna 72 genes,0292U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7321.86,,,,,,,fee schedule,2632.5,7321.86, Psyc strs do mrna 72 genes,0292U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2632.5,,,,,,,fee schedule,2632.5,7321.86, Psyc strs do mrna 72 genes,0292U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2632.5,,,,,,,fee schedule,2632.5,7321.86, Psyc suicidal idea mrna 54,0293U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3170.72,,,,,,,fee schedule,1140,3170.72, Psyc suicidal idea mrna 54,0293U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1140,,,,,,,fee schedule,1140,3170.72, Psyc suicidal idea mrna 54,0293U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1140,,,,,,,fee schedule,1140,3170.72, Lngvty&mrtlty rsk mrna 18gen,0294U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3170.72,,,,,,,fee schedule,1140,3170.72, Lngvty&mrtlty rsk mrna 18gen,0294U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1140,,,,,,,fee schedule,1140,3170.72, Lngvty&mrtlty rsk mrna 18gen,0294U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1140,,,,,,,fee schedule,1140,3170.72, Onc brst dux carc 7 proteins,0295U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,22674.82,,,,,,,fee schedule,2845.5,22674.82, Onc brst dux carc 7 proteins,0295U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2845.5,,,,,,,fee schedule,2845.5,22674.82, Onc brst dux carc 7 proteins,0295U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2845.5,,,,,,,fee schedule,2845.5,22674.82, Onc orl&/orop ca 20 mlc feat,0296U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8135.4,,,,,,,fee schedule,2632.5,8135.4, Onc orl&/orop ca 20 mlc feat,0296U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2632.5,,,,,,,fee schedule,2632.5,8135.4, Onc orl&/orop ca 20 mlc feat,0296U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2632.5,,,,,,,fee schedule,2632.5,8135.4, Onc pan tum whl gen seq dna,0297U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12180.57,,,,,,,fee schedule,4379.4,12180.57, Onc pan tum whl gen seq dna,0297U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4379.4,,,,,,,fee schedule,4379.4,12180.57, Onc pan tum whl gen seq dna,0297U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4379.4,,,,,,,fee schedule,4379.4,12180.57, Onc pan tum whl trns seq rna,0298U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12180.57,,,,,,,fee schedule,4379.4,12180.57, Onc pan tum whl trns seq rna,0298U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4379.4,,,,,,,fee schedule,4379.4,12180.57, Onc pan tum whl trns seq rna,0298U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4379.4,,,,,,,fee schedule,4379.4,12180.57, Onc pan tum whl gen opt mapg,0299U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7773.35,,,,,,,fee schedule,2794.83,7773.35, Onc pan tum whl gen opt mapg,0299U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2794.83,,,,,,,fee schedule,2794.83,7773.35, Onc pan tum whl gen opt mapg,0299U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2794.83,,,,,,,fee schedule,2794.83,7773.35, Onc pan tum whl gen seq&opt,0300U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,17452.02,,,,,,,fee schedule,6274.7,17452.02, Onc pan tum whl gen seq&opt,0300U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6274.7,,,,,,,fee schedule,6274.7,17452.02, Onc pan tum whl gen seq&opt,0300U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,6274.7,,,,,,,fee schedule,6274.7,17452.02, Iadna bartonella ddpcr,0301U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1096.07,,,,,,,fee schedule,394.08,1096.07, Iadna bartonella ddpcr,0301U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,394.08,,,,,,,fee schedule,394.08,1096.07, Iadna bartonella ddpcr,0301U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,394.08,,,,,,,fee schedule,394.08,1096.07, Iadna brtnla ddpcr flwg liq,0302U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1507.64,,,,,,,fee schedule,542.06,1507.64, Iadna brtnla ddpcr flwg liq,0302U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,542.06,,,,,,,fee schedule,542.06,1507.64, Iadna brtnla ddpcr flwg liq,0302U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,542.06,,,,,,,fee schedule,542.06,1507.64, Hem rbc ads whl bld hypoxic,0303U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9185.16,,,,,,,fee schedule,3302.43,9185.16, Hem rbc ads whl bld hypoxic,0303U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3302.43,,,,,,,fee schedule,3302.43,9185.16, Hem rbc ads whl bld hypoxic,0303U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3302.43,,,,,,,fee schedule,3302.43,9185.16, Hem rbc ads whl bld normoxic,0304U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8660.24,,,,,,,fee schedule,3113.7,8660.24, Hem rbc ads whl bld normoxic,0304U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3113.7,,,,,,,fee schedule,3113.7,8660.24, Hem rbc ads whl bld normoxic,0304U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3113.7,,,,,,,fee schedule,3113.7,8660.24, Hem rbc fnclty&dfrm shr strs,0305U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2764.28,,,,,,,fee schedule,993.87,2764.28, Hem rbc fnclty&dfrm shr strs,0305U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,993.87,,,,,,,fee schedule,993.87,2764.28, Hem rbc fnclty&dfrm shr strs,0305U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,993.87,,,,,,,fee schedule,993.87,2764.28, Onc mrd nxt-gnrj alys 1st,0306U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,16180.89,,,,,,,fee schedule,5817.68,16180.89, Onc mrd nxt-gnrj alys 1st,0306U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5817.68,,,,,,,fee schedule,5817.68,16180.89, Onc mrd nxt-gnrj alys 1st,0306U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5817.68,,,,,,,fee schedule,5817.68,16180.89, Onc mrd nxt-gnrj alys sbsq,0307U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3314.61,,,,,,,fee schedule,1191.74,3314.61, Onc mrd nxt-gnrj alys sbsq,0307U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1191.74,,,,,,,fee schedule,1191.74,3314.61, Onc mrd nxt-gnrj alys sbsq,0307U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1191.74,,,,,,,fee schedule,1191.74,3314.61, Insj ocular telescope prosth,0308T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,39251, Insj ocular telescope prosth,0308T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,39251,,,,,,,fee schedule,4108,39251, Insj ocular telescope prosth,0308T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,35325,,,,,,,fee schedule,4108,39251, Crd cad alys 3 prtn plsm alg,0308U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1630.21,,,,,,,fee schedule,586.13,1630.21, Crd cad alys 3 prtn plsm alg,0308U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,586.13,,,,,,,fee schedule,586.13,1630.21, Crd cad alys 3 prtn plsm alg,0308U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,586.13,,,,,,,fee schedule,586.13,1630.21, Crd cv ds aly 4 prtn plm alg,0309U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1630.21,,,,,,,fee schedule,586.13,1630.21, Crd cv ds aly 4 prtn plm alg,0309U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,586.13,,,,,,,fee schedule,586.13,1630.21, Crd cv ds aly 4 prtn plm alg,0309U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,586.13,,,,,,,fee schedule,586.13,1630.21, Ped vsclts kd alys 3 bmrks,0310U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1630.21,,,,,,,fee schedule,586.13,1630.21, Ped vsclts kd alys 3 bmrks,0310U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,586.13,,,,,,,fee schedule,586.13,1630.21, Ped vsclts kd alys 3 bmrks,0310U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,586.13,,,,,,,fee schedule,586.13,1630.21, Nfct ds bct quan antmcrb sc,0311U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,33.71,,,,,,,fee schedule,12.12,33.71, Nfct ds bct quan antmcrb sc,0311U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.12,,,,,,,fee schedule,12.12,33.71, Nfct ds bct quan antmcrb sc,0311U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,12.12,,,,,,,fee schedule,12.12,33.71, Ai ds sle alys 8 igg autoant,0312U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3507.19,,,,,,,fee schedule,1260.98,3507.19, Ai ds sle alys 8 igg autoant,0312U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1260.98,,,,,,,fee schedule,1260.98,3507.19, Ai ds sle alys 8 igg autoant,0312U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1260.98,,,,,,,fee schedule,1260.98,3507.19, Onc pncrs dna&mrna seq 74,0313U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,15019.2,,,,,,,fee schedule,5400,15019.2, Onc pncrs dna&mrna seq 74,0313U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5400,,,,,,,fee schedule,5400,15019.2, Onc pncrs dna&mrna seq 74,0313U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5400,,,,,,,fee schedule,5400,15019.2, Onc cutan mlnma mrna 35 gene,0314U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8135.4,,,,,,,fee schedule,2925,8135.4, Onc cutan mlnma mrna 35 gene,0314U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2925,,,,,,,fee schedule,2925,8135.4, Onc cutan mlnma mrna 35 gene,0314U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2925,,,,,,,fee schedule,2925,8135.4, Onc cutan sq cll ca mrna 40,0315U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,35462,,,,,,,fee schedule,12750,35462, Onc cutan sq cll ca mrna 40,0315U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12750,,,,,,,fee schedule,12750,35462, Onc cutan sq cll ca mrna 40,0315U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,12750,,,,,,,fee schedule,12750,35462, B brgdrferi lyme ds ospa evl,0316U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,77.85,,,,,,,fee schedule,27.99,77.85, B brgdrferi lyme ds ospa evl,0316U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,27.99,,,,,,,fee schedule,27.99,77.85, B brgdrferi lyme ds ospa evl,0316U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,27.99,,,,,,,fee schedule,27.99,77.85, Onc lung ca 4-prb fish assay,0317U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8469.16,,,,,,,fee schedule,3045,8469.16, Onc lung ca 4-prb fish assay,0317U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3045,,,,,,,fee schedule,3045,8469.16, Onc lung ca 4-prb fish assay,0317U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3045,,,,,,,fee schedule,3045,8469.16, Ped whl gen mthyltn alys 50+,0318U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7386.44,,,,,,,fee schedule,2655.72,7386.44, Ped whl gen mthyltn alys 50+,0318U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2655.72,,,,,,,fee schedule,2655.72,7386.44, Ped whl gen mthyltn alys 50+,0318U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2655.72,,,,,,,fee schedule,2655.72,7386.44, Neph rna pretrnspl perph bld,0319U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,11055.8,,,,,,,fee schedule,3975,11055.8, Neph rna pretrnspl perph bld,0319U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3975,,,,,,,fee schedule,3975,11055.8, Neph rna pretrnspl perph bld,0319U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3975,,,,,,,fee schedule,3975,11055.8, Neph rna psttrnspl perph bld,0320U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,11055.8,,,,,,,fee schedule,3975,11055.8, Neph rna psttrnspl perph bld,0320U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3975,,,,,,,fee schedule,3975,11055.8, Neph rna psttrnspl perph bld,0320U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3975,,,,,,,fee schedule,3975,11055.8, Iadna gu pthgn 20bct&fng org,0321U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2648.55,,,,,,,fee schedule,952.26,2648.55, Iadna gu pthgn 20bct&fng org,0321U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,952.26,,,,,,,fee schedule,952.26,2648.55, Iadna gu pthgn 20bct&fng org,0321U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,952.26,,,,,,,fee schedule,952.26,2648.55, Neuro asd meas 14 acyl carn,0322U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3129,,,,,,,fee schedule,1125,3129, Neuro asd meas 14 acyl carn,0322U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1125,,,,,,,fee schedule,1125,3129, Neuro asd meas 14 acyl carn,0322U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1125,,,,,,,fee schedule,1125,3129, Iadna cns pthgn next gen seq,0323U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8870.51,,,,,,,fee schedule,3189.3,8870.51, Iadna cns pthgn next gen seq,0323U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3189.3,,,,,,,fee schedule,3189.3,8870.51, Iadna cns pthgn next gen seq,0323U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3189.3,,,,,,,fee schedule,3189.3,8870.51, Trgt gen seq alys pnl 83+,0326U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,20860,,,,,,,fee schedule,7500,20860, Trgt gen seq alys pnl 83+,0326U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7500,,,,,,,fee schedule,7500,20860, Trgt gen seq alys pnl 83+,0326U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,7500,,,,,,,fee schedule,7500,20860, Ftl aneuploidy trsmy dna seq,0327U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3316.74,,,,,,,fee schedule,1192.5,3316.74, Ftl aneuploidy trsmy dna seq,0327U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1192.5,,,,,,,fee schedule,1192.5,3316.74, Ftl aneuploidy trsmy dna seq,0327U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1192.5,,,,,,,fee schedule,1192.5,3316.74, Drug assay 120+ rx&metablt,0328U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,477.4,,,,,,,fee schedule,171.65,477.4, Drug assay 120+ rx&metablt,0328U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,171.65,,,,,,,fee schedule,171.65,477.4, Drug assay 120+ rx&metablt,0328U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,171.65,,,,,,,fee schedule,171.65,477.4, Onc neo xome&trns seq alys,0329U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,14343.25,,,,,,,fee schedule,5156.97,14343.25, Onc neo xome&trns seq alys,0329U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5156.97,,,,,,,fee schedule,5156.97,14343.25, Onc neo xome&trns seq alys,0329U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5156.97,,,,,,,fee schedule,5156.97,14343.25, Iadna vag pthgn panel 27 org,0330U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1738.81,,,,,,,fee schedule,625.17,1738.81, Iadna vag pthgn panel 27 org,0330U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,625.17,,,,,,,fee schedule,625.17,1738.81, Iadna vag pthgn panel 27 org,0330U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,625.17,,,,,,,fee schedule,625.17,1738.81, Onc hl neo opt gen mapping,0331U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7773.35,,,,,,,fee schedule,2794.83,7773.35, Onc hl neo opt gen mapping,0331U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2794.83,,,,,,,fee schedule,2794.83,7773.35, Onc hl neo opt gen mapping,0331U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2794.83,,,,,,,fee schedule,2794.83,7773.35, Onc pan tum gen prflg 8 dna,0332U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4764.67,,,,,,,fee schedule,1713.09,4764.67, Onc pan tum gen prflg 8 dna,0332U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1713.09,,,,,,,fee schedule,1713.09,4764.67, Onc pan tum gen prflg 8 dna,0332U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1713.09,,,,,,,fee schedule,1713.09,4764.67, Onc lvr surveilanc hcc cfdna,0333U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2763.2,,,,,,,fee schedule,993.48,2763.2, Onc lvr surveilanc hcc cfdna,0333U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,993.48,,,,,,,fee schedule,993.48,2763.2, Onc lvr surveilanc hcc cfdna,0333U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,993.48,,,,,,,fee schedule,993.48,2763.2, Onc sld orgn tgsa dna 84/+,0334U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,14602,,,,,,,fee schedule,4379.4,14602, Onc sld orgn tgsa dna 84/+,0334U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4379.4,,,,,,,fee schedule,4379.4,14602, Onc sld orgn tgsa dna 84/+,0334U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4379.4,,,,,,,fee schedule,4379.4,14602, Extraosseous joint stblztion,0335T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,10940, Extraosseous joint stblztion,0335T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,5248,10940, Extraosseous joint stblztion,0335T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,5248,10940, Rare ds whl gen seq fetal,0335U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,21797.03,,,,,,,fee schedule,7836.9,21797.03, Rare ds whl gen seq fetal,0335U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7836.9,,,,,,,fee schedule,7836.9,21797.03, Rare ds whl gen seq fetal,0335U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,7836.9,,,,,,,fee schedule,7836.9,21797.03, Rare ds whl gen seq bld/slv,0336U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10741.44,,,,,,,fee schedule,3861.98,10741.44, Rare ds whl gen seq bld/slv,0336U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3861.98,,,,,,,fee schedule,3861.98,10741.44, Rare ds whl gen seq bld/slv,0336U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3861.98,,,,,,,fee schedule,3861.98,10741.44, Onc plsm cell do&myeloma id,0337U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10158.82,,,,,,,fee schedule,3652.5,10158.82, Onc plsm cell do&myeloma id,0337U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3652.5,,,,,,,fee schedule,3652.5,10158.82, Onc plsm cell do&myeloma id,0337U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3652.5,,,,,,,fee schedule,3652.5,10158.82, Trnscth renal symp denrv unl,0338T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,8406,12821, Trnscth renal symp denrv unl,0338T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,8406,12821, Trnscth renal symp denrv unl,0338T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,8406,12821, Onc sld tum crcg tum cl slct,0338U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10158.82,,,,,,,fee schedule,3652.5,10158.82, Onc sld tum crcg tum cl slct,0338U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3652.5,,,,,,,fee schedule,3652.5,10158.82, Onc sld tum crcg tum cl slct,0338U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3652.5,,,,,,,fee schedule,3652.5,10158.82, Trnscth renal symp denrv bil,0339T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,8406,12821, Trnscth renal symp denrv bil,0339T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,8406,12821, Trnscth renal symp denrv bil,0339T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,8406,12821, Onc prst8 mrna hoxc6 & dlx1,0339U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3170.72,,,,,,,fee schedule,1140,3170.72, Onc prst8 mrna hoxc6 & dlx1,0339U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1140,,,,,,,fee schedule,1140,3170.72, Onc prst8 mrna hoxc6 & dlx1,0339U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1140,,,,,,,fee schedule,1140,3170.72, Onc pan ca alys mrd plasma,0340U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,14977.48,,,,,,,fee schedule,5880,14977.48, Onc pan ca alys mrd plasma,0340U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5880,,,,,,,fee schedule,5880,14977.48, Onc pan ca alys mrd plasma,0340U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5880,,,,,,,fee schedule,5880,14977.48, Ftl aneup dna seq cmpr alys,0341U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7927.63,,,,,,,fee schedule,2850.3,7927.63, Ftl aneup dna seq cmpr alys,0341U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2850.3,,,,,,,fee schedule,2850.3,7927.63, Ftl aneup dna seq cmpr alys,0341U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2850.3,,,,,,,fee schedule,2850.3,7927.63, Thxp apheresis w/hdl delip,0342T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,13011,14456, Thxp apheresis w/hdl delip,0342T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,13011,14456, Onc pncrtc ca mult ia eclia,0342U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3742.28,,,,,,,fee schedule,1345.5,3742.28, Onc pncrtc ca mult ia eclia,0342U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1345.5,,,,,,,fee schedule,1345.5,3742.28, Onc pncrtc ca mult ia eclia,0342U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1345.5,,,,,,,fee schedule,1345.5,3742.28, Onc prst8 xom aly 442 sncrna,0343U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3170.72,,,,,,,fee schedule,1140,3170.72, Onc prst8 xom aly 442 sncrna,0343U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1140,,,,,,,fee schedule,1140,3170.72, Onc prst8 xom aly 442 sncrna,0343U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1140,,,,,,,fee schedule,1140,3170.72, Hep nafld semiq evl 28 lipid,0344U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3304.93,,,,,,,fee schedule,1188.26,3304.93, Hep nafld semiq evl 28 lipid,0344U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1188.26,,,,,,,fee schedule,1188.26,3304.93, Hep nafld semiq evl 28 lipid,0344U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1188.26,,,,,,,fee schedule,1188.26,3304.93, Transcath mtral vlve repair,0345T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Transcath mtral vlve repair,0345T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Psyc genom alys pnl 15 gen,0345U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5574.17,,,,,,,fee schedule,2004.14,5574.17, Psyc genom alys pnl 15 gen,0345U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2004.14,,,,,,,fee schedule,2004.14,5574.17, Psyc genom alys pnl 15 gen,0345U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2004.14,,,,,,,fee schedule,2004.14,5574.17, Ins bone device for rsa,0347T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2505,4108, Ins bone device for rsa,0347T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,4108, Ins bone device for rsa,0347T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,4108, Rx metab/pcx dna 16 gen alys,0347U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5574.17,,,,,,,fee schedule,2004.14,5574.17, Rx metab/pcx dna 16 gen alys,0347U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2004.14,,,,,,,fee schedule,2004.14,5574.17, Rx metab/pcx dna 16 gen alys,0347U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2004.14,,,,,,,fee schedule,2004.14,5574.17, RSA spine exam,0348T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,252.18,252.18, RSA spine exam,0348T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,252.18,252.18, Rx metab/pcx dna 25 gen alys,0348U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3096.75,,,,,,,fee schedule,1113.41,3096.75, Rx metab/pcx dna 25 gen alys,0348U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1113.41,,,,,,,fee schedule,1113.41,3096.75, Rx metab/pcx dna 25 gen alys,0348U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1113.41,,,,,,,fee schedule,1113.41,3096.75, RSA upper extr exam,0349T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,252.18,252.18, RSA upper extr exam,0349T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,252.18,252.18, Rx metab/pcx dna 27gen rx ia,0349U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3096.75,,,,,,,fee schedule,1113.41,3096.75, Rx metab/pcx dna 27gen rx ia,0349U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1113.41,,,,,,,fee schedule,1113.41,3096.75, Rx metab/pcx dna 27gen rx ia,0349U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1113.41,,,,,,,fee schedule,1113.41,3096.75, RSA lower extr exam,0350T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,179.57,,,,,,,fee schedule,179.57,179.57, RSA lower extr exam,0350T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,179.57,,,,,,,fee schedule,179.57,179.57, Rx metab/pcx dna 27 gen alys,0350U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5574.17,,,,,,,fee schedule,2004.14,5574.17, Rx metab/pcx dna 27 gen alys,0350U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2004.14,,,,,,,fee schedule,2004.14,5574.17, Rx metab/pcx dna 27 gen alys,0350U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2004.14,,,,,,,fee schedule,2004.14,5574.17, Nfct ds bct/viral trail ip10,0351U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1086.81,,,,,,,fee schedule,390.75,1086.81, Nfct ds bct/viral trail ip10,0351U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,390.75,,,,,,,fee schedule,390.75,1086.81, Nfct ds bct/viral trail ip10,0351U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,390.75,,,,,,,fee schedule,390.75,1086.81, Oct brst/node i&r per spec,0352T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2185.7,,,,,,,fee schedule,2185.7,2185.7, Oct brst/node i&r per spec,0352T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2185.7,,,,,,,fee schedule,2185.7,2185.7, Oct breast surg cavity i&r,0354T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2185.7,,,,,,,fee schedule,2185.7,2185.7, Oct breast surg cavity i&r,0354T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2185.7,,,,,,,fee schedule,2185.7,2185.7, Apol1 risk variants,0355U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,571.56,,,,,,,fee schedule,205.5,571.56, Apol1 risk variants,0355U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,205.5,,,,,,,fee schedule,205.5,571.56, Apol1 risk variants,0355U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,205.5,,,,,,,fee schedule,205.5,571.56, Onc orop 17 dna ddpcr alg,0356U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7509.6,,,,,,,fee schedule,2700,7509.6, Onc orop 17 dna ddpcr alg,0356U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2700,,,,,,,fee schedule,2700,7509.6, Onc orop 17 dna ddpcr alg,0356U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2700,,,,,,,fee schedule,2700,7509.6, Neuro alys b-amyl 1-42&1-40,0358U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1086.81,,,,,,,fee schedule,390.75,1086.81, Neuro alys b-amyl 1-42&1-40,0358U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,390.75,,,,,,,fee schedule,390.75,1086.81, Neuro alys b-amyl 1-42&1-40,0358U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,390.75,,,,,,,fee schedule,390.75,1086.81, Onc prst8 ca alys all psa,0359U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3170.72,,,,,,,fee schedule,1140,3170.72, Onc prst8 ca alys all psa,0359U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1140,,,,,,,fee schedule,1140,3170.72, Onc prst8 ca alys all psa,0359U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1140,,,,,,,fee schedule,1140,3170.72, Onc lung elisa 7 autoant alg,0360U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3507.19,,,,,,,fee schedule,1260.98,3507.19, Onc lung elisa 7 autoant alg,0360U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1260.98,,,,,,,fee schedule,1260.98,3507.19, Onc lung elisa 7 autoant alg,0360U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1260.98,,,,,,,fee schedule,1260.98,3507.19, Neurflmnt lt chn dig ia quan,0361U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,174.35,,,,,,,fee schedule,174.35,174.35, Neurflmnt lt chn dig ia quan,0361U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,174.35,,,,,,,fee schedule,174.35,174.35, Onc pap thyr ca rna 82&10,0362U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,15019.2,,,,,,,fee schedule,5400,15019.2, Onc pap thyr ca rna 82&10,0362U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5400,,,,,,,fee schedule,5400,15019.2, Onc pap thyr ca rna 82&10,0362U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5400,,,,,,,fee schedule,5400,15019.2, Onc urthl mrna 5 gen alg,0363U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3170.72,,,,,,,fee schedule,1140,3170.72, Onc urthl mrna 5 gen alg,0363U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1140,,,,,,,fee schedule,1140,3170.72, Onc urthl mrna 5 gen alg,0363U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1140,,,,,,,fee schedule,1140,3170.72, Onc hl neo gen seq alys alg,0364U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8374.25,,,,,,,fee schedule,3010.88,8374.25, Onc hl neo gen seq alys alg,0364U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3010.88,,,,,,,fee schedule,3010.88,8374.25, Onc hl neo gen seq alys alg,0364U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3010.88,,,,,,,fee schedule,3010.88,8374.25, Onc bldr 10 prb bldr ca,0365U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3742.28,,,,,,,fee schedule,1345.5,3742.28, Onc bldr 10 prb bldr ca,0365U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1345.5,,,,,,,fee schedule,1345.5,3742.28, Onc bldr 10 prb bldr ca,0365U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1345.5,,,,,,,fee schedule,1345.5,3742.28, Onc bldr 10 prb recr bldr ca,0366U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3742.28,,,,,,,fee schedule,1345.5,3742.28, Onc bldr 10 prb recr bldr ca,0366U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1345.5,,,,,,,fee schedule,1345.5,3742.28, Onc bldr 10 prb recr bldr ca,0366U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1345.5,,,,,,,fee schedule,1345.5,3742.28, Onc bldr 10 flwg trurl rescj,0367U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3763.89,,,,,,,fee schedule,1353.27,3763.89, Onc bldr 10 flwg trurl rescj,0367U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1353.27,,,,,,,fee schedule,1353.27,3763.89, Onc bldr 10 flwg trurl rescj,0367U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1353.27,,,,,,,fee schedule,1353.27,3763.89, Onc clrct ca mut&mthyltn mrk,0368U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1738.81,,,,,,,fee schedule,625.17,1738.81, Onc clrct ca mut&mthyltn mrk,0368U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,625.17,,,,,,,fee schedule,625.17,1738.81, Onc clrct ca mut&mthyltn mrk,0368U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,625.17,,,,,,,fee schedule,625.17,1738.81, Iadna gu pthgn semiq dna16&1,0371U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1738.81,,,,,,,fee schedule,625.17,1738.81, Iadna gu pthgn semiq dna16&1,0371U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,625.17,,,,,,,fee schedule,625.17,1738.81, Iadna gu pthgn semiq dna16&1,0371U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,625.17,,,,,,,fee schedule,625.17,1738.81, Nfct ds gu pthgn arg detcj,0372U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1738.81,,,,,,,fee schedule,625.17,1738.81, Nfct ds gu pthgn arg detcj,0372U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,625.17,,,,,,,fee schedule,625.17,1738.81, Nfct ds gu pthgn arg detcj,0372U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,625.17,,,,,,,fee schedule,625.17,1738.81, Onc ovrn bchm asy 7 prtn alg,0375U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3742.28,,,,,,,fee schedule,1345.5,3742.28, Onc ovrn bchm asy 7 prtn alg,0375U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1345.5,,,,,,,fee schedule,1345.5,3742.28, Onc ovrn bchm asy 7 prtn alg,0375U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1345.5,,,,,,,fee schedule,1345.5,3742.28, Onc prst8 ca img alys 128,0376U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2946.48,,,,,,,fee schedule,1059.38,2946.48, Onc prst8 ca img alys 128,0376U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1059.38,,,,,,,fee schedule,1059.38,2946.48, Onc prst8 ca img alys 128,0376U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1059.38,,,,,,,fee schedule,1059.38,2946.48, Cv ds quan advsrm/plsm lprtn,0377U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,198.5,,,,,,,fee schedule,71.37,198.5, Cv ds quan advsrm/plsm lprtn,0377U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,71.37,,,,,,,fee schedule,71.37,198.5, Cv ds quan advsrm/plsm lprtn,0377U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,71.37,,,,,,,fee schedule,71.37,198.5, Rfc1 repeat xpnsj vrnt alys,0378U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,571.56,,,,,,,fee schedule,205.5,571.56, Rfc1 repeat xpnsj vrnt alys,0378U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,205.5,,,,,,,fee schedule,205.5,571.56, Rfc1 repeat xpnsj vrnt alys,0378U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,205.5,,,,,,,fee schedule,205.5,571.56, Tgsap sl or neo dna523&rna55,0379U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,13719.66,,,,,,,fee schedule,4932.77,13719.66, Tgsap sl or neo dna523&rna55,0379U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4932.77,,,,,,,fee schedule,4932.77,13719.66, Tgsap sl or neo dna523&rna55,0379U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4932.77,,,,,,,fee schedule,4932.77,13719.66, Maple syrup ur ds mntr quan,0381U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,184.07,,,,,,,fee schedule,66.18,184.07, Maple syrup ur ds mntr quan,0381U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,66.18,,,,,,,fee schedule,66.18,184.07, Maple syrup ur ds mntr quan,0381U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,66.18,,,,,,,fee schedule,66.18,184.07, Hyprphenylalninmia mntr quan,0382U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,215.44,,,,,,,fee schedule,77.46,215.44, Hyprphenylalninmia mntr quan,0382U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,77.46,,,,,,,fee schedule,77.46,215.44, Hyprphenylalninmia mntr quan,0382U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,77.46,,,,,,,fee schedule,77.46,215.44, Tyrosinemia typ i mntr quan,0383U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,217.15,,,,,,,fee schedule,78.08,217.15, Tyrosinemia typ i mntr quan,0383U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,78.08,,,,,,,fee schedule,78.08,217.15, Tyrosinemia typ i mntr quan,0383U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,78.08,,,,,,,fee schedule,78.08,217.15, Neph ckd rsk hi stg kdn ds,0384U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3129,,,,,,,fee schedule,1125,3129, Neph ckd rsk hi stg kdn ds,0384U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1125,,,,,,,fee schedule,1125,3129, Neph ckd rsk hi stg kdn ds,0384U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1125,,,,,,,fee schedule,1125,3129, Neph ckd alg rsk dbtc kdn ds,0385U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1630.21,,,,,,,fee schedule,586.13,1630.21, Neph ckd alg rsk dbtc kdn ds,0385U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,586.13,,,,,,,fee schedule,586.13,1630.21, Neph ckd alg rsk dbtc kdn ds,0385U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,586.13,,,,,,,fee schedule,586.13,1630.21, Onc mlnma ambra1&amlo,0387U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3957.14,,,,,,,fee schedule,1422.75,3957.14, Onc mlnma ambra1&amlo,0387U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1422.75,,,,,,,fee schedule,1422.75,3957.14, Onc mlnma ambra1&amlo,0387U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1422.75,,,,,,,fee schedule,1422.75,3957.14, Onc nonsm cll lng ca 37 gen,0388U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,14602,,,,,,,fee schedule,5250,14602, Onc nonsm cll lng ca 37 gen,0388U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5250,,,,,,,fee schedule,5250,14602, Onc nonsm cll lng ca 37 gen,0388U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5250,,,,,,,fee schedule,5250,14602, Ped fbrl kd ifi27&mcemp1 rna,0389U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,292.87,,,,,,,fee schedule,105.3,292.87, Ped fbrl kd ifi27&mcemp1 rna,0389U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,105.3,,,,,,,fee schedule,105.3,292.87, Ped fbrl kd ifi27&mcemp1 rna,0389U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,105.3,,,,,,,fee schedule,105.3,292.87, Ob pe kdr eng&rbp4 ia alg,0390U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,268.72,,,,,,,fee schedule,96.62,268.72, Ob pe kdr eng&rbp4 ia alg,0390U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,96.62,,,,,,,fee schedule,96.62,268.72, Ob pe kdr eng&rbp4 ia alg,0390U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,96.62,,,,,,,fee schedule,96.62,268.72, Onc sld tum dna&rna 437 gen,0391U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,15019.2,,,,,,,fee schedule,5400,15019.2, Onc sld tum dna&rna 437 gen,0391U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5400,,,,,,,fee schedule,5400,15019.2, Onc sld tum dna&rna 437 gen,0391U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5400,,,,,,,fee schedule,5400,15019.2, Rx metab genrx ia 16 genes,0392U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5574.17,,,,,,,fee schedule,2004.14,5574.17, Rx metab genrx ia 16 genes,0392U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2004.14,,,,,,,fee schedule,2004.14,5574.17, Rx metab genrx ia 16 genes,0392U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2004.14,,,,,,,fee schedule,2004.14,5574.17, Neu prksn msfl ?-syncln prtn,0393U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2257.01,,,,,,,fee schedule,811.49,2257.01, Neu prksn msfl ?-syncln prtn,0393U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,811.49,,,,,,,fee schedule,811.49,2257.01, Neu prksn msfl ?-syncln prtn,0393U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,811.49,,,,,,,fee schedule,811.49,2257.01, Pfas 16 pfas compnd lc ms/ms,0394U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,829.14,,,,,,,fee schedule,298.11,829.14, Pfas 16 pfas compnd lc ms/ms,0394U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,298.11,,,,,,,fee schedule,298.11,829.14, Pfas 16 pfas compnd lc ms/ms,0394U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,298.11,,,,,,,fee schedule,298.11,829.14, Onc lng multiomics plsm alg,0395U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3326.96,,,,,,,fee schedule,1196.18,3326.96, Onc lng multiomics plsm alg,0395U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1196.18,,,,,,,fee schedule,1196.18,3326.96, Onc lng multiomics plsm alg,0395U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1196.18,,,,,,,fee schedule,1196.18,3326.96, Ercp w/optical endomicroscpy,0397T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Ercp w/optical endomicroscpy,0397T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Ercp w/optical endomicroscpy,0397T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Gi baret esph dna mthyln aly,0398U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7321.86,,,,,,,fee schedule,2632.5,7321.86, Gi baret esph dna mthyln aly,0398U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2632.5,,,,,,,fee schedule,2632.5,7321.86, Gi baret esph dna mthyln aly,0398U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2632.5,,,,,,,fee schedule,2632.5,7321.86, Neuro cere folate defncy srm,0399U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1251.6,,,,,,,fee schedule,450,1251.6, Neuro cere folate defncy srm,0399U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,450,,,,,,,fee schedule,450,1251.6, Neuro cere folate defncy srm,0399U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,450,,,,,,,fee schedule,450,1251.6, Ob xpnd car scr 145 genes,0400U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6078.1,,,,,,,fee schedule,2185.32,6078.1, Ob xpnd car scr 145 genes,0400U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2185.32,,,,,,,fee schedule,2185.32,6078.1, Ob xpnd car scr 145 genes,0400U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2185.32,,,,,,,fee schedule,2185.32,6078.1, Crd c hrt ds 9 gen 12 vrnts,0401U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2042.94,,,,,,,fee schedule,734.52,2042.94, Crd c hrt ds 9 gen 12 vrnts,0401U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,734.52,,,,,,,fee schedule,734.52,2042.94, Crd c hrt ds 9 gen 12 vrnts,0401U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,734.52,,,,,,,fee schedule,734.52,2042.94, Collagen crosslinking cornea,0402T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,10940, Collagen crosslinking cornea,0402T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3195,10940, Collagen crosslinking cornea,0402T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3195,10940, Nfct agt sti mult amp prb tq,0402U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,595.05,,,,,,,fee schedule,213.95,595.05, Nfct agt sti mult amp prb tq,0402U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,213.95,,,,,,,fee schedule,213.95,595.05, Nfct agt sti mult amp prb tq,0402U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,213.95,,,,,,,fee schedule,213.95,595.05, Onc prst8 mrna 18 gen dre ur,0403U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3170.72,,,,,,,fee schedule,1140,3170.72, Onc prst8 mrna 18 gen dre ur,0403U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1140,,,,,,,fee schedule,1140,3170.72, Onc prst8 mrna 18 gen dre ur,0403U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1140,,,,,,,fee schedule,1140,3170.72, Onc brst semiq meas thym kn,0404U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1347.39,,,,,,,fee schedule,484.44,1347.39, Onc brst semiq meas thym kn,0404U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,484.44,,,,,,,fee schedule,484.44,1347.39, Onc brst semiq meas thym kn,0404U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,484.44,,,,,,,fee schedule,484.44,1347.39, Onc pncrtc 59 mthltn blk mrk,0405U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7386.44,,,,,,,fee schedule,2655.72,7386.44, Onc pncrtc 59 mthltn blk mrk,0405U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2655.72,,,,,,,fee schedule,2655.72,7386.44, Onc pncrtc 59 mthltn blk mrk,0405U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2655.72,,,,,,,fee schedule,2655.72,7386.44, Onc lung flow cytmtry 5 mrk,0406U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3170.72,,,,,,,fee schedule,1140,3170.72, Onc lung flow cytmtry 5 mrk,0406U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1140,,,,,,,fee schedule,1140,3170.72, Onc lung flow cytmtry 5 mrk,0406U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1140,,,,,,,fee schedule,1140,3170.72, Neph dbtc ckd mult eclia alg,0407U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3963.4,,,,,,,fee schedule,1425,3963.4, Neph dbtc ckd mult eclia alg,0407U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1425,,,,,,,fee schedule,1425,3963.4, Neph dbtc ckd mult eclia alg,0407U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1425,,,,,,,fee schedule,1425,3963.4, Insj/rplc cardiac modulj sys,0408T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,8406,46177, Insj/rplc cardiac modulj sys,0408T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46177,,,,,,,fee schedule,8406,46177, Insj/rplc cardiac modulj sys,0408T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,41559,,,,,,,fee schedule,8406,46177, Iaad blk ac wv bsnsr sarscv2,0408U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,58.95,,,,,,,fee schedule,21.2,58.95, Iaad blk ac wv bsnsr sarscv2,0408U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21.2,,,,,,,fee schedule,21.2,58.95, Iaad blk ac wv bsnsr sarscv2,0408U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,21.2,,,,,,,fee schedule,21.2,58.95, Insj/rplc car modulj pls gn,0409T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,8406,46177, Insj/rplc car modulj pls gn,0409T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46177,,,,,,,fee schedule,8406,46177, Insj/rplc car modulj pls gn,0409T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,41559,,,,,,,fee schedule,8406,46177, Onc sld tum dna 80 & rna 36,0409U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12180.57,,,,,,,fee schedule,4379.4,12180.57, Onc sld tum dna 80 & rna 36,0409U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4379.4,,,,,,,fee schedule,4379.4,12180.57, Onc sld tum dna 80 & rna 36,0409U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4379.4,,,,,,,fee schedule,4379.4,12180.57, Insj/rplc car modulj atr elt,0410T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,25393, Insj/rplc car modulj atr elt,0410T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,5363,25393, Insj/rplc car modulj atr elt,0410T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,5363,25393, Onc pncrtc dna whl gn seq 5-,0410U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4839.52,,,,,,,fee schedule,1740,4839.52, Onc pncrtc dna whl gn seq 5-,0410U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1740,,,,,,,fee schedule,1740,4839.52, Onc pncrtc dna whl gn seq 5-,0410U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1740,,,,,,,fee schedule,1740,4839.52, Insj/rplc car modulj vnt elt,0411T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,25393, Insj/rplc car modulj vnt elt,0411T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,5363,25393, Insj/rplc car modulj vnt elt,0411T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,5363,25393, Psyc genom alys pnl 15 gen,0411U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5574.17,,,,,,,fee schedule,2004.14,5574.17, Psyc genom alys pnl 15 gen,0411U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2004.14,,,,,,,fee schedule,2004.14,5574.17, Psyc genom alys pnl 15 gen,0411U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2004.14,,,,,,,fee schedule,2004.14,5574.17, Rmvl cardiac modulj pls gen,0412T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,12821, Rmvl cardiac modulj pls gen,0412T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5248,12821, Rmvl cardiac modulj pls gen,0412T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5248,12821, Beta amyloid a?42/40 imprcip,0412U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3129,,,,,,,fee schedule,1125,3129, Beta amyloid a?42/40 imprcip,0412U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1125,,,,,,,fee schedule,1125,3129, Beta amyloid a?42/40 imprcip,0412U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1125,,,,,,,fee schedule,1125,3129, Rmvl car modulj tranvns elt,0413T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,12821, Rmvl car modulj tranvns elt,0413T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5248,12821, Rmvl car modulj tranvns elt,0413T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5248,12821, Onc hl neo opt gen mapg dna,0413U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5271.45,,,,,,,fee schedule,1895.3,5271.45, Onc hl neo opt gen mapg dna,0413U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1895.3,,,,,,,fee schedule,1895.3,5271.45, Onc hl neo opt gen mapg dna,0413U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1895.3,,,,,,,fee schedule,1895.3,5271.45, Rmvl & rpl car modulj pls gn,0414T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,8406,46177, Rmvl & rpl car modulj pls gn,0414T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46177,,,,,,,fee schedule,8406,46177, Rmvl & rpl car modulj pls gn,0414T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,41559,,,,,,,fee schedule,8406,46177, Onc lng aug alg aly whl sld8,0414U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2946.48,,,,,,,fee schedule,1059.38,2946.48, Onc lng aug alg aly whl sld8,0414U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1059.38,,,,,,,fee schedule,1059.38,2946.48, Onc lng aug alg aly whl sld8,0414U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1059.38,,,,,,,fee schedule,1059.38,2946.48, Repos car modulj tranvns elt,0415T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4047,4497, Repos car modulj tranvns elt,0415T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,4047,4497, Repos car modulj tranvns elt,0415T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,4047,4497, Cv ds acs bld alg 5 yr score,0415U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1630.21,,,,,,,fee schedule,586.13,1630.21, Cv ds acs bld alg 5 yr score,0415U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,586.13,,,,,,,fee schedule,586.13,1630.21, Cv ds acs bld alg 5 yr score,0415U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,586.13,,,,,,,fee schedule,586.13,1630.21, Reloc skin pocket pls gen,0416T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,5664, Reloc skin pocket pls gen,0416T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4108,5664, Reloc skin pocket pls gen,0416T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4108,5664, Rare ds alys 335 nuc genes,0417U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,11859.04,,,,,,,fee schedule,4263.8,11859.04, Rare ds alys 335 nuc genes,0417U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4263.8,,,,,,,fee schedule,4263.8,11859.04, Rare ds alys 335 nuc genes,0417U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4263.8,,,,,,,fee schedule,4263.8,11859.04, Onc brst aug alg aly whl sl8,0418U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2946.48,,,,,,,fee schedule,1059.38,2946.48, Onc brst aug alg aly whl sl8,0418U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1059.38,,,,,,,fee schedule,1059.38,2946.48, Onc brst aug alg aly whl sl8,0418U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1059.38,,,,,,,fee schedule,1059.38,2946.48, Dstrj neurofibroma xtnsv,0419T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Dstrj neurofibroma xtnsv,0419T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Dstrj neurofibroma xtnsv,0419T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Nrpsyc gen seq vrnt aly 13,0419U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5574.17,,,,,,,fee schedule,2004.14,5574.17, Nrpsyc gen seq vrnt aly 13,0419U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2004.14,,,,,,,fee schedule,2004.14,5574.17, Nrpsyc gen seq vrnt aly 13,0419U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2004.14,,,,,,,fee schedule,2004.14,5574.17, Dstrj neurofibroma xtnsv,0420T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Dstrj neurofibroma xtnsv,0420T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Dstrj neurofibroma xtnsv,0420T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Onc urthl mrna xprsn 6 snp,0420U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5541.75,,,,,,,fee schedule,5541.75,5541.75, Waterjet prostate abltj cmpl,0421T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,14456, Waterjet prostate abltj cmpl,0421T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4108,14456, Waterjet prostate abltj cmpl,0421T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4108,14456, Onc clrct scr sgl amp 8 rna,0421U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2123.01,,,,,,,fee schedule,763.31,2123.01, Onc clrct scr sgl amp 8 rna,0421U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,763.31,,,,,,,fee schedule,763.31,2123.01, Onc clrct scr sgl amp 8 rna,0421U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,763.31,,,,,,,fee schedule,763.31,2123.01, Tactile breast img uni/bi,0422T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,179.57,,,,,,,fee schedule,179.57,179.57, Tactile breast img uni/bi,0422T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,179.57,,,,,,,fee schedule,179.57,179.57, Onc pan solid tum alys dna,0422U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8107.07,,,,,,,fee schedule,8107.07,8107.07, Psyc genomic alys pnl 26 gen,0423U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1738.81,,,,,,,fee schedule,625.17,1738.81, Psyc genomic alys pnl 26 gen,0423U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,625.17,,,,,,,fee schedule,625.17,1738.81, Psyc genomic alys pnl 26 gen,0423U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,625.17,,,,,,,fee schedule,625.17,1738.81, Onc prst8 xom alys 53 sncrna,0424U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3170.72,,,,,,,fee schedule,1140,3170.72, Onc prst8 xom alys 53 sncrna,0424U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1140,,,,,,,fee schedule,1140,3170.72, Onc prst8 xom alys 53 sncrna,0424U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1140,,,,,,,fee schedule,1140,3170.72, Genom rpd seq alys ea cmprtr,0425U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,17081.8,,,,,,,fee schedule,17081.8,17081.8, Genome ultra-rapid seq alys,0426U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,31632.94,,,,,,,fee schedule,31632.94,31632.94, Monocyte dstrbj wdth whl bld,0427U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,18.69,,,,,,,fee schedule,6.72,18.69, Monocyte dstrbj wdth whl bld,0427U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.72,,,,,,,fee schedule,6.72,18.69, Monocyte dstrbj wdth whl bld,0427U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,6.72,,,,,,,fee schedule,6.72,18.69, Hpv orop swab 14 hi-risk typ,0429U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,146.4,,,,,,,fee schedule,52.64,146.4, Hpv orop swab 14 hi-risk typ,0429U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,52.64,,,,,,,fee schedule,52.64,146.4, Hpv orop swab 14 hi-risk typ,0429U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,52.64,,,,,,,fee schedule,52.64,146.4, Gi malabs aat calpro pncrtc,0430U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,256.74,,,,,,,fee schedule,92.31,256.74, Gi malabs aat calpro pncrtc,0430U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,92.31,,,,,,,fee schedule,92.31,256.74, Gi malabs aat calpro pncrtc,0430U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,92.31,,,,,,,fee schedule,92.31,256.74, Gly rcptr alpha1 igg srm/csf,0431U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,152.57,,,,,,,fee schedule,54.86,152.57, Gly rcptr alpha1 igg srm/csf,0431U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,54.86,,,,,,,fee schedule,54.86,152.57, Gly rcptr alpha1 igg srm/csf,0431U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,54.86,,,,,,,fee schedule,54.86,152.57, Klhl11 antb sr/csf asy qual,0432U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,152.57,,,,,,,fee schedule,54.86,152.57, Klhl11 antb sr/csf asy qual,0432U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,54.86,,,,,,,fee schedule,54.86,152.57, Klhl11 antb sr/csf asy qual,0432U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,54.86,,,,,,,fee schedule,54.86,152.57, Onc prst8 5 dna reg mrk pcr,0433U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3170.72,,,,,,,fee schedule,1140,3170.72, Onc prst8 5 dna reg mrk pcr,0433U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1140,,,,,,,fee schedule,1140,3170.72, Onc prst8 5 dna reg mrk pcr,0433U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1140,,,,,,,fee schedule,1140,3170.72, Rx metab advrs vrnt alys 25,0434U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1738.81,,,,,,,fee schedule,625.17,1738.81, Rx metab advrs vrnt alys 25,0434U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,625.17,,,,,,,fee schedule,625.17,1738.81, Rx metab advrs vrnt alys 25,0434U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,625.17,,,,,,,fee schedule,625.17,1738.81, Onc chemo rx cytox csc 14 rx,0435U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12657.26,,,,,,,fee schedule,4550.79,12657.26, Onc chemo rx cytox csc 14 rx,0435U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4550.79,,,,,,,fee schedule,4550.79,12657.26, Onc chemo rx cytox csc 14 rx,0435U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4550.79,,,,,,,fee schedule,4550.79,12657.26, Onc lng plsm alys 388 prtn,0436U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6275.69,,,,,,,fee schedule,6275.69,6275.69, Impltj synth rnfcmt abdl wal,0437T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Impltj synth rnfcmt abdl wal,0437T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Impltj synth rnfcmt abdl wal,0437T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Psyc anxiety do mrna 15 bmrk,0437U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3170.72,,,,,,,fee schedule,1140,3170.72, Psyc anxiety do mrna 15 bmrk,0437U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1140,,,,,,,fee schedule,1140,3170.72, Psyc anxiety do mrna 15 bmrk,0437U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1140,,,,,,,fee schedule,1140,3170.72, Rx metab advrs vrnt alys 33,0438U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1738.81,,,,,,,fee schedule,625.17,1738.81, Rx metab advrs vrnt alys 33,0438U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,625.17,,,,,,,fee schedule,625.17,1738.81, Rx metab advrs vrnt alys 33,0438U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,625.17,,,,,,,fee schedule,625.17,1738.81, Crd chd dna alys 5 snp 3 dna,0439U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3562.89,,,,,,,fee schedule,3562.89,3562.89, Abltj perc uxtr/perph nrv,0440T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,14456, Abltj perc uxtr/perph nrv,0440T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3195,14456, Abltj perc uxtr/perph nrv,0440T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3195,14456, Crd chd dna alys 10 snp 6dna,0440U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3562.89,,,,,,,fee schedule,3562.89,3562.89, Abltj perc lxtr/perph nrv,0441T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,14456, Abltj perc lxtr/perph nrv,0441T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3195,14456, Abltj perc lxtr/perph nrv,0441T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3195,14456, Nfct ds bct fngl/viral semiq,0441U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1852.7,,,,,,,fee schedule,1852.7,1852.7, Abltj perc plex/trncl nrv,0442T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,14456, Abltj perc plex/trncl nrv,0442T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4108,14456, Abltj perc plex/trncl nrv,0442T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4108,14456, Nfct ds respir nfctj mxa&crp,0442U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,172.64,,,,,,,fee schedule,62.07,172.64, Nfct ds respir nfctj mxa&crp,0442U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,62.07,,,,,,,fee schedule,62.07,172.64, Nfct ds respir nfctj mxa&crp,0442U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,62.07,,,,,,,fee schedule,62.07,172.64, R-t spctrl alys prst8 tiss,0443T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,2782, R-t spctrl alys prst8 tiss,0443T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,2782, Neurflmnt lt chn ultrsens ia,0443U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,484.91,,,,,,,fee schedule,484.91,484.91, 1st plmt drug elut oc ins,0444T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2505,5248, 1st plmt drug elut oc ins,0444T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,5248, 1st plmt drug elut oc ins,0444T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,5248, Onc sld orgn neo tgsap 361,0444U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12180.57,,,,,,,fee schedule,4379.4,12180.57, Onc sld orgn neo tgsap 361,0444U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4379.4,,,,,,,fee schedule,4379.4,12180.57, Onc sld orgn neo tgsap 361,0444U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4379.4,,,,,,,fee schedule,4379.4,12180.57, Sbsqt plmt drug elut oc ins,0445T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2505,5248, Sbsqt plmt drug elut oc ins,0445T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,5248, Sbsqt plmt drug elut oc ins,0445T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,5248, Abeta42 & ptau181 eclia csf,0445U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1086.81,,,,,,,fee schedule,390.75,1086.81, Abeta42 & ptau181 eclia csf,0445U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,390.75,,,,,,,fee schedule,390.75,1086.81, Abeta42 & ptau181 eclia csf,0445U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,390.75,,,,,,,fee schedule,390.75,1086.81, Insj impltbl glucose sensor,0446T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,269.26,,,,,,,fee schedule,269.26,4108, Insj impltbl glucose sensor,0446T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,269.26,4108, Insj impltbl glucose sensor,0446T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,269.26,4108, Insj impltbl glucose sensor,0446T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,269.26,4108, Ai ds sle alys 10 cytokine,0446U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3507.19,,,,,,,fee schedule,1260.98,3507.19, Ai ds sle alys 10 cytokine,0446U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1260.98,,,,,,,fee schedule,1260.98,3507.19, Ai ds sle alys 10 cytokine,0446U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1260.98,,,,,,,fee schedule,1260.98,3507.19, Rmvl impltbl glucose sensor,0447T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,309.46,,,,,,,fee schedule,309.46,3195, Rmvl impltbl glucose sensor,0447T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,309.46,3195, Rmvl impltbl glucose sensor,0447T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,309.46,3195, Rmvl impltbl glucose sensor,0447T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,309.46,3195, Ai ds sle alys 11 cytokine,0447U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3507.19,,,,,,,fee schedule,1260.98,3507.19, Ai ds sle alys 11 cytokine,0447U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1260.98,,,,,,,fee schedule,1260.98,3507.19, Ai ds sle alys 11 cytokine,0447U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1260.98,,,,,,,fee schedule,1260.98,3507.19, Remvl insj impltbl gluc sens,0448T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,455.37,,,,,,,fee schedule,455.37,4108, Remvl insj impltbl gluc sens,0448T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,455.37,4108, Remvl insj impltbl gluc sens,0448T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,455.37,4108, Remvl insj impltbl gluc sens,0448T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,455.37,4108, Insj aqueous drain dev 1st,0449T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,14456, Insj aqueous drain dev 1st,0449T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5248,14456, Insj aqueous drain dev 1st,0449T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5248,14456, Car scr sev inh cond 5 genes,0449U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7613.4,,,,,,,fee schedule,2737.32,7613.4, Car scr sev inh cond 5 genes,0449U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2737.32,,,,,,,fee schedule,2737.32,7613.4, Car scr sev inh cond 5 genes,0449U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2737.32,,,,,,,fee schedule,2737.32,7613.4, Insj aqueous drain dev each,0450T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Insj aqueous drain dev each,0450T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Insj aqueous drain dev each,0450T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Onc mm lc-ms/ms monoc p-prtn,0450U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,65.15,,,,,,,fee schedule,65.15,65.15, Onc mm lc-ms/ms monoc p-prtn,0450U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,65.15,,,,,,,fee schedule,65.15,65.15, Onc mm lc-ms/ms pep ion quan,0451U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,65.15,,,,,,,fee schedule,65.15,65.15, Onc mm lc-ms/ms pep ion quan,0451U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,65.15,,,,,,,fee schedule,65.15,65.15, Onc bldr mthyl penk lte-qmsp,0452U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,801.02,,,,,,,fee schedule,288,801.02, Onc bldr mthyl penk lte-qmsp,0452U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,288,,,,,,,fee schedule,288,801.02, Onc bldr mthyl penk lte-qmsp,0452U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,288,,,,,,,fee schedule,288,801.02, Onc clrct ca cfdna qpcr asy,0453U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,801.02,,,,,,,fee schedule,288,801.02, Onc clrct ca cfdna qpcr asy,0453U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,288,,,,,,,fee schedule,288,801.02, Onc clrct ca cfdna qpcr asy,0453U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,288,,,,,,,fee schedule,288,801.02, U rare ds id opt genome mapg,0454U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5271.45,,,,,,,fee schedule,1895.3,5271.45, U rare ds id opt genome mapg,0454U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1895.3,,,,,,,fee schedule,1895.3,5271.45, U rare ds id opt genome mapg,0454U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1895.3,,,,,,,fee schedule,1895.3,5271.45, Nfct agt sti mult amp prb ur,0455U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,595.05,,,,,,,fee schedule,213.95,595.05, Nfct agt sti mult amp prb ur,0455U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,213.95,,,,,,,fee schedule,213.95,595.05, Nfct agt sti mult amp prb ur,0455U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,213.95,,,,,,,fee schedule,213.95,595.05, Pfas 9 cmpnd lcms/ms pls/sr,0457U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,829.14,,,,,,,fee schedule,298.11,829.14, Pfas 9 cmpnd lcms/ms pls/sr,0457U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,298.11,,,,,,,fee schedule,298.11,829.14, Pfas 9 cmpnd lcms/ms pls/sr,0457U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,298.11,,,,,,,fee schedule,298.11,829.14, Onc brst ca s100 a8&a9 elisa,0458U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1086.81,,,,,,,fee schedule,390.75,1086.81, Onc brst ca s100 a8&a9 elisa,0458U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,390.75,,,,,,,fee schedule,390.75,1086.81, Onc brst ca s100 a8&a9 elisa,0458U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,390.75,,,,,,,fee schedule,390.75,1086.81, Abeta42 & ttau eclia csf,0459U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1086.81,,,,,,,fee schedule,390.75,1086.81, Abeta42 & ttau eclia csf,0459U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,390.75,,,,,,,fee schedule,390.75,1086.81, Abeta42 & ttau eclia csf,0459U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,390.75,,,,,,,fee schedule,390.75,1086.81, Onc whl bld/bucc rtpcr 24gen,0460U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3826.06,,,,,,,fee schedule,3826.06,3826.06, Onc rxgenom alys rtpcr 24gen,0461U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3826.06,,,,,,,fee schedule,3826.06,3826.06, Melatonin lvl tst slp std7/9,0462U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,72.05,,,,,,,fee schedule,25.91,72.05, Melatonin lvl tst slp std7/9,0462U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25.91,,,,,,,fee schedule,25.91,72.05, Melatonin lvl tst slp std7/9,0462U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,25.91,,,,,,,fee schedule,25.91,72.05, Onc crvx mrna genxprsn 14bmk,0463U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3170.72,,,,,,,fee schedule,3170.72,3170.72, Onc clrct scr qrtsa dna mrk,0464U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2469.49,,,,,,,fee schedule,887.88,2469.49, Onc clrct scr qrtsa dna mrk,0464U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,887.88,,,,,,,fee schedule,887.88,2469.49, Onc clrct scr qrtsa dna mrk,0464U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,887.88,,,,,,,fee schedule,887.88,2469.49, Onc urthl carc dna qmsp 2gen,0465U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8085.38,,,,,,,fee schedule,2907.02,8085.38, Onc urthl carc dna qmsp 2gen,0465U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2907.02,,,,,,,fee schedule,2907.02,8085.38, Onc urthl carc dna qmsp 2gen,0465U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2907.02,,,,,,,fee schedule,2907.02,8085.38, Crd cad dna gwas 564856 snp,0466U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1441.13,,,,,,,fee schedule,1441.13,1441.13, Onc bldr dna ngs 60gen&aneup,0467U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6337.52,,,,,,,fee schedule,2278.59,6337.52, Onc bldr dna ngs 60gen&aneup,0467U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2278.59,,,,,,,fee schedule,2278.59,6337.52, Onc bldr dna ngs 60gen&aneup,0467U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2278.59,,,,,,,fee schedule,2278.59,6337.52, Hep nash mir34a5p ?2m ykl40,0468U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1050.09,,,,,,,fee schedule,377.55,1050.09, Hep nash mir34a5p ?2m ykl40,0468U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,377.55,,,,,,,fee schedule,377.55,1050.09, Hep nash mir34a5p ?2m ykl40,0468U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,377.55,,,,,,,fee schedule,377.55,1050.09, Rare ds whl gen seq ftl samp,0469U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4997.81,,,,,,,fee schedule,1796.91,4997.81, Rare ds whl gen seq ftl samp,0469U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1796.91,,,,,,,fee schedule,1796.91,4997.81, Rare ds whl gen seq ftl samp,0469U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1796.91,,,,,,,fee schedule,1796.91,4997.81, Onc orop detcj mrd 8 dna hpv,0470U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2494.48,,,,,,,fee schedule,2494.48,2494.48, Onc clrc ca 35 vrn kras&nras,0471U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3170.72,,,,,,,fee schedule,1140,3170.72, Onc clrc ca 35 vrn kras&nras,0471U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1140,,,,,,,fee schedule,1140,3170.72, Onc clrc ca 35 vrn kras&nras,0471U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1140,,,,,,,fee schedule,1140,3170.72, Ca vi psp&sp1 antb sj?gren,0472U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,116.4,,,,,,,fee schedule,116.4,116.4, Onc sld tum bld/slv 648 gene,0473U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,18774,,,,,,,fee schedule,6750,18774, Onc sld tum bld/slv 648 gene,0473U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6750,,,,,,,fee schedule,6750,18774, Onc sld tum bld/slv 648 gene,0473U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,6750,,,,,,,fee schedule,6750,18774, Insj aqueous drg dev io rsvr,0474T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,14456, Insj aqueous drg dev io rsvr,0474T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5248,14456, Insj aqueous drg dev io rsvr,0474T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5248,14456, Hered pan ca gsap 88gene ngs,0474U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5440.08,,,,,,,fee schedule,1955.93,5440.08, Hered pan ca gsap 88gene ngs,0474U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1955.93,,,,,,,fee schedule,1955.93,5440.08, Hered pan ca gsap 88gene ngs,0474U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1955.93,,,,,,,fee schedule,1955.93,5440.08, Hered prst8 ca gsap 23 genes,0475U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5440.08,,,,,,,fee schedule,1955.93,5440.08, Hered prst8 ca gsap 23 genes,0475U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1955.93,,,,,,,fee schedule,1955.93,5440.08, Hered prst8 ca gsap 23 genes,0475U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1955.93,,,,,,,fee schedule,1955.93,5440.08, Rx metab psyc 14gen&cyp2d6,0476U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1738.81,,,,,,,fee schedule,625.17,1738.81, Rx metab psyc 14gen&cyp2d6,0476U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,625.17,,,,,,,fee schedule,625.17,1738.81, Rx metab psyc 14gen&cyp2d6,0476U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,625.17,,,,,,,fee schedule,625.17,1738.81, Rx metab psy 14&cyp2d6 gn-rx,0477U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1738.81,,,,,,,fee schedule,625.17,1738.81, Rx metab psy 14&cyp2d6 gn-rx,0477U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,625.17,,,,,,,fee schedule,625.17,1738.81, Rx metab psy 14&cyp2d6 gn-rx,0477U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,625.17,,,,,,,fee schedule,625.17,1738.81, Onc nsclc dna&rna dpcr 9 gen,0478U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2307.07,,,,,,,fee schedule,2307.07,2307.07, Fxjl abl lsr 1st 100 sq cm,0479T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,4497, Fxjl abl lsr 1st 100 sq cm,0479T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,3195,4497, Fxjl abl lsr 1st 100 sq cm,0479T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,3195,4497, Tau phosphorylated ptau217,0479U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,72.05,,,,,,,fee schedule,25.91,72.05, Tau phosphorylated ptau217,0479U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25.91,,,,,,,fee schedule,25.91,72.05, Tau phosphorylated ptau217,0479U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,25.91,,,,,,,fee schedule,25.91,72.05, Fxjl abl lsr ea addl 100sqcm,0480T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Fxjl abl lsr ea addl 100sqcm,0480T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Fxjl abl lsr ea addl 100sqcm,0480T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Nfct ds csf metag ngs alys,0480U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8870.51,,,,,,,fee schedule,3189.3,8870.51, Nfct ds csf metag ngs alys,0480U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3189.3,,,,,,,fee schedule,3189.3,8870.51, Nfct ds csf metag ngs alys,0480U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3189.3,,,,,,,fee schedule,3189.3,8870.51, Njx autol wbc concentrate,0481T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Njx autol wbc concentrate,0481T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Njx autol wbc concentrate,0481T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Idh1 idh2&tert promoter ngs,0481U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2812.93,,,,,,,fee schedule,1011.36,2812.93, Idh1 idh2&tert promoter ngs,0481U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1011.36,,,,,,,fee schedule,1011.36,2812.93, Idh1 idh2&tert promoter ngs,0481U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1011.36,,,,,,,fee schedule,1011.36,2812.93, Ob pe biochem asy sfit1&pigf,0482U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,537.44,,,,,,,fee schedule,193.23,537.44, Ob pe biochem asy sfit1&pigf,0482U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,193.23,,,,,,,fee schedule,193.23,537.44, Ob pe biochem asy sfit1&pigf,0482U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,193.23,,,,,,,fee schedule,193.23,537.44, Tmvi percutaneous approach,0483T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Tmvi percutaneous approach,0483T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Tmvi percutaneous approach,0483T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Nfct ds ng gyra s91f pt mut,0483U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,146.4,,,,,,,fee schedule,146.4,146.4, Tmvi transthoracic exposure,0484T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Tmvi transthoracic exposure,0484T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Tmvi transthoracic exposure,0484T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Nfct ds mgen 23s rrna pt mut,0484U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,146.4,,,,,,,fee schedule,146.4,146.4, Onc sol tum cfdna&rna ngs gm,0485U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,15225.63,,,,,,,fee schedule,15225.63,15225.63, Onc pan sol tum ngs cfctdna,0486U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6859.81,,,,,,,fee schedule,6859.81,6859.81, Onc sol tum cfcdna tgsap 84,0487U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12180.57,,,,,,,fee schedule,4379.4,12180.57, Onc sol tum cfcdna tgsap 84,0487U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4379.4,,,,,,,fee schedule,4379.4,12180.57, Onc sol tum cfcdna tgsap 84,0487U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4379.4,,,,,,,fee schedule,4379.4,12180.57, Ob fetal ag nipt cfdna alys,0488U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3166.76,,,,,,,fee schedule,1138.58,3166.76, Ob fetal ag nipt cfdna alys,0488U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1138.58,,,,,,,fee schedule,1138.58,3166.76, Ob fetal ag nipt cfdna alys,0488U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1138.58,,,,,,,fee schedule,1138.58,3166.76, Regn cell tx scldr hands,0489T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,5664, Regn cell tx scldr hands,0489T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3195,5664, Regn cell tx scldr hands,0489T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3195,5664, Ob sgnipt cfdna seq alys 1+,0489U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4812.9,,,,,,,fee schedule,4812.9,4812.9, Regn cell tx scldr h mlt inj,0490T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,5664, Regn cell tx scldr h mlt inj,0490T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3195,5664, Regn cell tx scldr h mlt inj,0490T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3195,5664, Onc cutan/uveal mlnma cd146,0490U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10158.82,,,,,,,fee schedule,3652.5,10158.82, Onc cutan/uveal mlnma cd146,0490U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3652.5,,,,,,,fee schedule,3652.5,10158.82, Onc cutan/uveal mlnma cd146,0490U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3652.5,,,,,,,fee schedule,3652.5,10158.82, Onc sol tum ctc slct er prtn,0491U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10158.82,,,,,,,fee schedule,3652.5,10158.82, Onc sol tum ctc slct er prtn,0491U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3652.5,,,,,,,fee schedule,3652.5,10158.82, Onc sol tum ctc slct er prtn,0491U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3652.5,,,,,,,fee schedule,3652.5,10158.82, Onc sol tum ctc slctn pd-l1,0492U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10158.82,,,,,,,fee schedule,3652.5,10158.82, Onc sol tum ctc slctn pd-l1,0492U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3652.5,,,,,,,fee schedule,3652.5,10158.82, Onc sol tum ctc slctn pd-l1,0492U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3652.5,,,,,,,fee schedule,3652.5,10158.82, Trnspl med quan dd-cfdna ngs,0493U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,11486.56,,,,,,,fee schedule,4129.88,11486.56, Trnspl med quan dd-cfdna ngs,0493U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4129.88,,,,,,,fee schedule,4129.88,11486.56, Trnspl med quan dd-cfdna ngs,0493U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4129.88,,,,,,,fee schedule,4129.88,11486.56, Prep & cannulj cdvr don lung,0494T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Prep & cannulj cdvr don lung,0494T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Prep & cannulj cdvr don lung,0494T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Rbc ag ftl rhd gene alys ngs,0494U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3166.76,,,,,,,fee schedule,1138.58,3166.76, Rbc ag ftl rhd gene alys ngs,0494U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1138.58,,,,,,,fee schedule,1138.58,3166.76, Rbc ag ftl rhd gene alys ngs,0494U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1138.58,,,,,,,fee schedule,1138.58,3166.76, Mntr cdvr don lng 1st 2 hrs,0495T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Mntr cdvr don lng 1st 2 hrs,0495T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Onc prst8 alys crcg plsm prt,0495U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3170.72,,,,,,,fee schedule,1140,3170.72, Onc prst8 alys crcg plsm prt,0495U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1140,,,,,,,fee schedule,1140,3170.72, Onc prst8 alys crcg plsm prt,0495U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1140,,,,,,,fee schedule,1140,3170.72, Mntr cdvr don lng ea addl hr,0496T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Mntr cdvr don lng ea addl hr,0496T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Onc clrct cfdna 8/7 genes,0496U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2027.01,,,,,,,fee schedule,2027.01,2027.01, Onc prst8 mrna rt-pcr 6 gene,0497U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,16158.16,,,,,,,fee schedule,5809.5,16158.16, Onc prst8 mrna rt-pcr 6 gene,0497U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5809.5,,,,,,,fee schedule,5809.5,16158.16, Onc prst8 mrna rt-pcr 6 gene,0497U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5809.5,,,,,,,fee schedule,5809.5,16158.16, Onc clrct ngs mut detc 43gen,0498U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5612.63,,,,,,,fee schedule,5612.63,5612.63, Onc clrct&lng dna ngs 8gene,0499U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2494.48,,,,,,,fee schedule,896.87,2494.48, Onc clrct&lng dna ngs 8gene,0499U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,896.87,,,,,,,fee schedule,896.87,2494.48, Onc clrct&lng dna ngs 8gene,0499U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,896.87,,,,,,,fee schedule,896.87,2494.48, Autoinflam ds vexas synd dna,0500U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,731.77,,,,,,,fee schedule,263.1,731.77, Autoinflam ds vexas synd dna,0500U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,263.1,,,,,,,fee schedule,263.1,731.77, Autoinflam ds vexas synd dna,0500U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,263.1,,,,,,,fee schedule,263.1,731.77, Onc clrc bld quan meas cfdna,0501U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,801.02,,,,,,,fee schedule,801.02,801.02, Hpv e6/e7 mrk hi-rsk typ crv,0502U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,146.4,,,,,,,fee schedule,52.64,146.4, Hpv e6/e7 mrk hi-rsk typ crv,0502U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,52.64,,,,,,,fee schedule,52.64,146.4, Hpv e6/e7 mrk hi-rsk typ crv,0502U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,52.64,,,,,,,fee schedule,52.64,146.4, Neuro alz ds ?amyl&tau prtn,0503U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3129,,,,,,,fee schedule,1125,3129, Neuro alz ds ?amyl&tau prtn,0503U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1125,,,,,,,fee schedule,1125,3129, Neuro alz ds ?amyl&tau prtn,0503U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1125,,,,,,,fee schedule,1125,3129, Nfct ds uti id 17 path orgs,0504U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1738.81,,,,,,,fee schedule,625.17,1738.81, Nfct ds uti id 17 path orgs,0504U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,625.17,,,,,,,fee schedule,625.17,1738.81, Nfct ds uti id 17 path orgs,0504U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,625.17,,,,,,,fee schedule,625.17,1738.81, Ev fempop artl revsc,0505T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,25393, Ev fempop artl revsc,0505T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,5363,25393, Ev fempop artl revsc,0505T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,5363,25393, Nfct ds vag infctj id 32orgs,0505U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2836,,,,,,,fee schedule,1019.66,2836, Nfct ds vag infctj id 32orgs,0505U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1019.66,,,,,,,fee schedule,1019.66,2836, Nfct ds vag infctj id 32orgs,0505U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1019.66,,,,,,,fee schedule,1019.66,2836, Gi barretts esophgl cell 89,0506U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8085.38,,,,,,,fee schedule,2907.02,8085.38, Gi barretts esophgl cell 89,0506U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2907.02,,,,,,,fee schedule,2907.02,8085.38, Gi barretts esophgl cell 89,0506U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2907.02,,,,,,,fee schedule,2907.02,8085.38, Onc ovr dna whole gen w/5hmc,0507U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4839.52,,,,,,,fee schedule,1740,4839.52, Onc ovr dna whole gen w/5hmc,0507U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1740,,,,,,,fee schedule,1740,4839.52, Onc ovr dna whole gen w/5hmc,0507U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1740,,,,,,,fee schedule,1740,4839.52, Pattern erg w/i&r,0509T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,293.92,,,,,,,fee schedule,293.92,293.92, Rmvl sinus tarsi implant,0510T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,12821, Rmvl sinus tarsi implant,0510T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5248,12821, Rmvl sinus tarsi implant,0510T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5248,12821, Onc pncrtc ca alg alys 16gen,0510U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1977.15,,,,,,,fee schedule,1977.15,1977.15, Rmvl&rinsj sinus tarsi implt,0511T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,10940, Rmvl&rinsj sinus tarsi implt,0511T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,5248,10940, Rmvl&rinsj sinus tarsi implt,0511T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,5248,10940, Onc sol tum 3dmicroenvir 36+,0511U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12657.26,,,,,,,fee schedule,4550.79,12657.26, Onc sol tum 3dmicroenvir 36+,0511U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4550.79,,,,,,,fee schedule,4550.79,12657.26, Onc sol tum 3dmicroenvir 36+,0511U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4550.79,,,,,,,fee schedule,4550.79,12657.26, Esw integ wnd hlg 1st wnd,0512T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2505,6979, Esw integ wnd hlg 1st wnd,0512T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,6979, Esw integ wnd hlg 1st wnd,0512T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,6979, Onc prst8 alys dgtz img msi,0512U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2946.48,,,,,,,fee schedule,1059.38,2946.48, Onc prst8 alys dgtz img msi,0512U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1059.38,,,,,,,fee schedule,1059.38,2946.48, Onc prst8 alys dgtz img msi,0512U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1059.38,,,,,,,fee schedule,1059.38,2946.48, Esw integ wnd hlg ea addl,0513T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,2782, Esw integ wnd hlg ea addl,0513T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,2782, Onc prst8 alg alys msi&hrd,0513U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2946.48,,,,,,,fee schedule,1059.38,2946.48, Onc prst8 alg alys msi&hrd,0513U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1059.38,,,,,,,fee schedule,1059.38,2946.48, Onc prst8 alg alys msi&hrd,0513U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1059.38,,,,,,,fee schedule,1059.38,2946.48, Gi ibd ia quan deter adl lvl,0514U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,160.91,,,,,,,fee schedule,57.86,160.91, Gi ibd ia quan deter adl lvl,0514U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,57.86,,,,,,,fee schedule,57.86,160.91, Gi ibd ia quan deter adl lvl,0514U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,57.86,,,,,,,fee schedule,57.86,160.91, Insj wcs lv compl sys,0515T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,46177, Insj wcs lv compl sys,0515T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46177,,,,,,,fee schedule,5363,46177, Insj wcs lv compl sys,0515T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,41559,,,,,,,fee schedule,5363,46177, Gi ibd ia quan deter ifx lvl,0515U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,160.91,,,,,,,fee schedule,57.86,160.91, Gi ibd ia quan deter ifx lvl,0515U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,57.86,,,,,,,fee schedule,57.86,160.91, Gi ibd ia quan deter ifx lvl,0515U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,57.86,,,,,,,fee schedule,57.86,160.91, Insj wcs lv eltrd only,0516T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,25393, Insj wcs lv eltrd only,0516T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,5363,25393, Insj wcs lv eltrd only,0516T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,5363,25393, Rx metab rxgenomic gnotyp 40,0516U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1738.81,,,,,,,fee schedule,625.17,1738.81, Rx metab rxgenomic gnotyp 40,0516U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,625.17,,,,,,,fee schedule,625.17,1738.81, Rx metab rxgenomic gnotyp 40,0516U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,625.17,,,,,,,fee schedule,625.17,1738.81, Insj wcs lv pg compnt,0517T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,25393, Insj wcs lv pg compnt,0517T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,5363,25393, Insj wcs lv pg compnt,0517T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,5363,25393, Ther rx mntr 80+ psyactiv rx,0517U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1030.15,,,,,,,fee schedule,370.38,1030.15, Ther rx mntr 80+ psyactiv rx,0517U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,370.38,,,,,,,fee schedule,370.38,1030.15, Ther rx mntr 80+ psyactiv rx,0517U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,370.38,,,,,,,fee schedule,370.38,1030.15, Rmvl pg compnt wcs,0518T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,12821, Rmvl pg compnt wcs,0518T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5363,12821, Rmvl pg compnt wcs,0518T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5363,12821, Ther rx mntr 90+ pn&mtl hlth,0518U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1030.15,,,,,,,fee schedule,370.38,1030.15, Ther rx mntr 90+ pn&mtl hlth,0518U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,370.38,,,,,,,fee schedule,370.38,1030.15, Ther rx mntr 90+ pn&mtl hlth,0518U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,370.38,,,,,,,fee schedule,370.38,1030.15, Rmvl & rplcmt pg compnt wcs,0519T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,12821, Rmvl & rplcmt pg compnt wcs,0519T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5363,12821, Rmvl & rplcmt pg compnt wcs,0519T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5363,12821, Ther rx mntr meds p/d/a 110+,0519U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1030.15,,,,,,,fee schedule,370.38,1030.15, Ther rx mntr meds p/d/a 110+,0519U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,370.38,,,,,,,fee schedule,370.38,1030.15, Ther rx mntr meds p/d/a 110+,0519U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,370.38,,,,,,,fee schedule,370.38,1030.15, Rmvl&rplcmt pg wcs new eltrd,0520T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,46177, Rmvl&rplcmt pg wcs new eltrd,0520T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46177,,,,,,,fee schedule,5363,46177, Rmvl&rplcmt pg wcs new eltrd,0520T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,41559,,,,,,,fee schedule,5363,46177, Ther rx mntr 200+ rx/sbsts,0520U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1030.15,,,,,,,fee schedule,370.38,1030.15, Ther rx mntr 200+ rx/sbsts,0520U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,370.38,,,,,,,fee schedule,370.38,1030.15, Ther rx mntr 200+ rx/sbsts,0520U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,370.38,,,,,,,fee schedule,370.38,1030.15, Rf iga&igm ccp antb sr-a ia,0521U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,216.11,,,,,,,fee schedule,216.11,216.11, Ca vi psp&sp1 antb cl semiql,0522U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1086.81,,,,,,,fee schedule,1086.81,1086.81, Ntrapx c ffr w/3d funcjl map,0523T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,2782, Ntrapx c ffr w/3d funcjl map,0523T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,2782, Onc soltum dna ngs snv 22gen,0523U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5640.92,,,,,,,fee schedule,5640.92,5640.92, Ev cath dir chem abltj w/img,0524T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,12821, Ev cath dir chem abltj w/img,0524T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5248,12821, Ev cath dir chem abltj w/img,0524T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5248,12821, Ob pe sflt-1/plgf ia srm/pls,0524U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,537.44,,,,,,,fee schedule,537.44,537.44, Insj/rplcmt compl iims,0525T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8212,,,,,,,fee schedule,8212,25393, Insj/rplcmt compl iims,0525T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,8212,25393, Insj/rplcmt compl iims,0525T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,8212,25393, Onc sphrd cell cul 11-rx pnl,0525U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12657.26,,,,,,,fee schedule,12657.26,12657.26, Insj/rplcmt iims eltrd only,0526T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,25393, Insj/rplcmt iims eltrd only,0526T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,5363,25393, Insj/rplcmt iims eltrd only,0526T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,5363,25393, Insj/rplcmt iims implt mntr,0527T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,25393, Insj/rplcmt iims implt mntr,0527T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,5363,25393, Insj/rplcmt iims implt mntr,0527T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,5363,25393, Hsv 1&2 vzv amp prb tq pthgn,0527U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,595.05,,,,,,,fee schedule,595.05,595.05, Lrt iad 18bct/8vir&7arg rna,0528U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2648.55,,,,,,,fee schedule,2648.55,2648.55, Removal complete iims,0530T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,12821, Removal complete iims,0530T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5248,12821, Removal complete iims,0530T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5248,12821, Onc pan-sol tum ctdna 77 gen,0530U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12180.57,,,,,,,fee schedule,12180.57,12180.57, Removal iims electrode only,0531T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,12821, Removal iims electrode only,0531T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5248,12821, Removal iims electrode only,0531T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5248,12821, Removal iims implt mntr only,0532T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,12821, Removal iims implt mntr only,0532T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5248,12821, Removal iims implt mntr only,0532T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5248,12821, Rare ds whlgen&mitochdrl dna,0532U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,20990.17,,,,,,,fee schedule,20990.17,20990.17, Rx metab advrs gnotyp 16gens,0533U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1738.81,,,,,,,fee schedule,1738.81,1738.81, Pfas lc-ms/ms plsm/srm quan,0535U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,259.25,,,,,,,fee schedule,259.25,259.25, Rbcag ftl rhd pcr alys exon4,0536U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,801.02,,,,,,,fee schedule,801.02,801.02, Onc clrct ca cfdna >2500 dmr,0537U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6237.14,,,,,,,fee schedule,2242.5,6237.14, Onc clrct ca cfdna >2500 dmr,0537U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2242.5,,,,,,,fee schedule,2242.5,6237.14, Onc clrct ca cfdna >2500 dmr,0537U,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2242.5,,,,,,,fee schedule,2242.5,6237.14, Onc sol tum ngts ffpe 600gen,0538U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12472.4,,,,,,,fee schedule,12472.4,12472.4, Onc sol tumor cfctdna 152gen,0539U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,13719.66,,,,,,,fee schedule,13719.66,13719.66, Trnsplj med quan dd-cfdna,0540U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,11486.56,,,,,,,fee schedule,11486.56,11486.56, Ta mv rpr w/artif chord tend,0543T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Ta mv rpr w/artif chord tend,0543T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Onc sol tum ngs dna 517 gens,0543U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12472.4,,,,,,,fee schedule,12472.4,12472.4, Tcat mv annulus rcnstj,0544T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Tcat mv annulus rcnstj,0544T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Tcat tv annulus rcnstj,0545T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Tcat tv annulus rcnstj,0545T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Achr antb id imfluor livecll,0545U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,157.41,,,,,,,fee schedule,157.41,157.41, Ldns lrp4 antb imflr livecll,0546U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,157.41,,,,,,,fee schedule,157.41,157.41, B1 matrl qual tst mcrind tib,0547T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,591.95,3195, B1 matrl qual tst mcrind tib,0547T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,591.95,,,,,,,fee schedule,591.95,3195, B1 matrl qual tst mcrind tib,0547T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,591.95,,,,,,,fee schedule,591.95,3195, Neurflmnt lt chn cleia plsm,0547U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,484.91,,,,,,,fee schedule,484.91,484.91, Gfap cleia plasma,0548U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,484.91,,,,,,,fee schedule,484.91,484.91, Onc urthl dna mthyltd rt pcr,0549U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3170.72,,,,,,,fee schedule,3170.72,3170.72, Repr med pga embry te strux,0553U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3166.76,,,,,,,fee schedule,3166.76,3166.76, B1 str & fx rsk analysis,0554T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,87.71,,,,,,,fee schedule,87.71,87.71, B1 str & fx rsk analysis,0554T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,87.71,,,,,,,fee schedule,87.71,87.71, Repr med pga 24chrm te bx qc,0554U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3166.76,,,,,,,fee schedule,3166.76,3166.76, B1 str&fx rsk transmis data,0555T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,51.73,,,,,,,fee schedule,51.73,51.73, B1 str&fx rsk transmis data,0555T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,51.73,,,,,,,fee schedule,51.73,51.73, Repr med pga embryonic te qc,0555U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3166.76,,,,,,,fee schedule,3166.76,3166.76, B1 str & fx rsk assessment,0556T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,524.34,,,,,,,fee schedule,524.34,524.34, B1 str & fx rsk assessment,0556T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,524.34,,,,,,,fee schedule,524.34,524.34, Nfct ds p-s dna&rna 12 trgts,0556U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,595.05,,,,,,,fee schedule,595.05,595.05, B1 str & fx rsk i&r,0557T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21.92,,,,,,,fee schedule,21.92,21.92, B1 str & fx rsk i&r,0557T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,21.92,,,,,,,fee schedule,21.92,21.92, Nfct ds bv dna mrk vag fluid,0557U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1097.19,,,,,,,fee schedule,1097.19,1097.19, Ct scan f/biomchn ct alys,0558T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,179.57,,,,,,,fee schedule,179.57,179.57, Ct scan f/biomchn ct alys,0558T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,179.57,,,,,,,fee schedule,179.57,179.57, Onc clrct elisa bf7 ag serum,0558U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,86.82,,,,,,,fee schedule,86.82,86.82, Antmc mdl 3d print 1st cmpnt,0559T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,123.77,,,,,,,fee schedule,123.77,123.77, Antmc mdl 3d print 1st cmpnt,0559T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,123.77,,,,,,,fee schedule,123.77,123.77, Onc brs quan elisa bf9ag srm,0559U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,86.82,,,,,,,fee schedule,86.82,86.82, Onc mrd gsa cfdna baseline,0560U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,16180.89,,,,,,,fee schedule,16180.89,16180.89, Antmc guide 3d print 1st gd,0561T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,123.77,,,,,,,fee schedule,123.77,123.77, Antmc guide 3d print 1st gd,0561T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,123.77,,,,,,,fee schedule,123.77,123.77, Onc mrd gsa cfdna subsequent,0561U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3314.61,,,,,,,fee schedule,3314.61,3314.61, Onc sol tum tgsa 33gens snvs,0562U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2494.48,,,,,,,fee schedule,2494.48,2494.48, Evac meibomian glnd heat bi,0563T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Evac meibomian glnd heat bi,0563T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Evac meibomian glnd heat bi,0563T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Nfct ds pthgn-sna 11vir&4bct,0563U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1738.81,,,,,,,fee schedule,1738.81,1738.81, Nfct ds pthgn-sna 10vir&4bct,0564U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1738.81,,,,,,,fee schedule,1738.81,1738.81, Autol cell implt adps hrvg,0565T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2505,5248, Autol cell implt adps hrvg,0565T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,5248, Autol cell implt adps hrvg,0565T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,5248, Onc hcc ngs detc 6626epigalt,0565U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4839.52,,,,,,,fee schedule,4839.52,4839.52, Autol cell implt adps njx,0566T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Autol cell implt adps njx,0566T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Autol cell implt adps njx,0566T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Onc lng qpcr-bsd alys 13dmrs,0566U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1738.81,,,,,,,fee schedule,1738.81,1738.81, Rare ds whl gen seq srs&lrs,0567U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,20990.17,,,,,,,fee schedule,20990.17,20990.17, Neurol dementia ?amyl ptau,0568U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3742.28,,,,,,,fee schedule,3742.28,3742.28, Ttvr perq appr 1st prosth,0569T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Ttvr perq appr 1st prosth,0569T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Ttvr perq ea addl prosth,0570T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Ttvr perq ea addl prosth,0570T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Neurol tbi alys gfap&uch-l1,0570U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1086.81,,,,,,,fee schedule,1086.81,1086.81, Insj/rplcmt icds ss eltrd,0571T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,8406,46177, Insj/rplcmt icds ss eltrd,0571T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46177,,,,,,,fee schedule,8406,46177, Insj/rplcmt icds ss eltrd,0571T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,41559,,,,,,,fee schedule,8406,46177, Onc sol tum dna80&rna10g ngs,0571U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12180.57,,,,,,,fee schedule,12180.57,12180.57, Insertion ss dfb electrode,0572T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,25393, Insertion ss dfb electrode,0572T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,5248,25393, Insertion ss dfb electrode,0572T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,5248,25393, Removal ss dfb electrode,0573T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,12821, Removal ss dfb electrode,0573T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5248,12821, Removal ss dfb electrode,0573T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5248,12821, Repos prev ss impl dfb eltrd,0574T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,12821, Repos prev ss impl dfb eltrd,0574T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5248,12821, Repos prev ss impl dfb eltrd,0574T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5248,12821, Trnsplj med lar rtpcr 4genes,0575U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1585.36,,,,,,,fee schedule,1585.36,1585.36, Trnsplj med lar quan ddcfdna,0576U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,13517.28,,,,,,,fee schedule,13517.28,13517.28, Onc ovr serum alys 39 gps,0577U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1030.15,,,,,,,fee schedule,1030.15,1030.15, Onc cutan mln rna qpcr 10gen,0578U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,16158.16,,,,,,,fee schedule,16158.16,16158.16, Nfro dbtc ckd elisa apoa4,0579U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1630.21,,,,,,,fee schedule,1630.21,1630.21, Rmvl ss impl dfb pg only,0580T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,12821, Rmvl ss impl dfb pg only,0580T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5248,12821, Rmvl ss impl dfb pg only,0580T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5248,12821, Bbrgdrferi antb detc 24rprtn,0580U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,71.8,,,,,,,fee schedule,71.8,71.8, Abltj mal brst tum perq crtx,0581T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,10940, Abltj mal brst tum perq crtx,0581T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,5363,10940, Abltj mal brst tum perq crtx,0581T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,5363,10940, Trnspl med antb nohla 39trgt,0581U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1359.24,,,,,,,fee schedule,1359.24,1359.24, Trurl abltj mal prst8 tiss,0582T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,5664, Trurl abltj mal prst8 tiss,0582T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4108,5664, Trurl abltj mal prst8 tiss,0582T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4108,5664, Rare ds rpd whlgen dna vrnts,0582U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,31632.94,,,,,,,fee schedule,31632.94,31632.94, Tmpst auto tube dlvr sys,0583T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,684.48,,,,,,,fee schedule,684.48,5664, Tmpst auto tube dlvr sys,0583T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,684.48,5664, Tmpst auto tube dlvr sys,0583T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,684.48,5664, Tmpst auto tube dlvr sys,0583T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,684.48,5664, Rare ds rpd whlgen cmptr dna,0583U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,15816.47,,,,,,,fee schedule,15816.47,15816.47, Perq islet cell transplant,0584T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Perq islet cell transplant,0584T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Neuro csf prion prtn qual,0584U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2257.01,,,,,,,fee schedule,2257.01,2257.01, Laps islet cell transplant,0585T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Laps islet cell transplant,0585T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Tgsap so neo cfdna 521 genes,0585U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12180.57,,,,,,,fee schedule,12180.57,12180.57, Open islet cell transplant,0586T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Open islet cell transplant,0586T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Onc mrna gen xprsn 216 genes,0586U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12180.57,,,,,,,fee schedule,12180.57,12180.57, Perq impltj/rplcmt isdns ptn,0587T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,4497, Perq impltj/rplcmt isdns ptn,0587T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,3195,4497, Perq impltj/rplcmt isdns ptn,0587T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,3195,4497, Ther rx mntr 60-150rx&metabl,0587U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,477.4,,,,,,,fee schedule,477.4,477.4, Revision/removal isdns ptn,0588T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,12821, Revision/removal isdns ptn,0588T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3195,12821, Revision/removal isdns ptn,0588T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3195,12821, Nfct ds bct/vir 32genes mrna,0588U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3170.72,,,,,,,fee schedule,3170.72,3170.72, Pfas24cmpnd hi-perf lc-ms/ms,0589U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,829.14,,,,,,,fee schedule,829.14,829.14, Onc prst8 ca 3prtns plsm srm,0591U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3170.72,,,,,,,fee schedule,3170.72,3170.72, Onc hl neo dna tgs 417 genes,0592U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12180.57,,,,,,,fee schedule,12180.57,12180.57, Nfct ds gu pthgn dna 46trgt,0593U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2648.55,,,,,,,fee schedule,2648.55,2648.55, Osteot hum xtrnl lngth dev,0594T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,22111, Osteot hum xtrnl lngth dev,0594T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5363,22111, Osteot hum xtrnl lngth dev,0594T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5363,22111, Nfct ds tfp vctrbrn&zoonotic,0595U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1097.19,,,,,,,fee schedule,1097.19,1097.19, Temp fml iu vlv-pmp 1st insj,0596T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,609.05,,,,,,,fee schedule,609.05,4497, Temp fml iu vlv-pmp 1st insj,0596T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,609.05,4497, Temp fml iu vlv-pmp 1st insj,0596T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,609.05,4497, Temp fml iu vlv-pmp 1st insj,0596T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,609.05,4497, Temp fml iu valve-pmp rplcmt,0597T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,289.71,,,,,,,fee schedule,289.71,4497, Temp fml iu valve-pmp rplcmt,0597T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,289.71,4497, Temp fml iu valve-pmp rplcmt,0597T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,289.71,4497, Temp fml iu valve-pmp rplcmt,0597T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,289.71,4497, Ncntc r-t fluor wnd img 1st,0598T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,569.48,,,,,,,fee schedule,569.48,569.48, Ncntc r-t fluor wnd img 1st,0598T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,569.48,,,,,,,fee schedule,569.48,569.48, Gi ibs igg antb 18food items,0598U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1251.6,,,,,,,fee schedule,1251.6,1251.6, Onc pncrtc ca mult ia serum,0599U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3742.28,,,,,,,fee schedule,3742.28,3742.28, Ire abltj 1+tum organ perq,0600T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,22111, Ire abltj 1+tum organ perq,0600T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5363,22111, Ire abltj 1+tum organ perq,0600T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5363,22111, Ire abltj 1+tumors open,0601T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,22111, Ire abltj 1+tumors open,0601T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6044,22111, Ire abltj 1+tumors open,0601T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6044,22111, Transdermal gfr measurements,0602T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,452.99,,,,,,,fee schedule,452.99,452.99, Transdermal gfr measurements,0602T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,452.99,,,,,,,fee schedule,452.99,452.99, Transdermal gfr monitoring,0603T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1143.09,,,,,,,fee schedule,1143.09,1143.09, Transdermal gfr monitoring,0603T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1143.09,,,,,,,fee schedule,1143.09,1143.09, Rem oct rta dev setup&educaj,0604T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,260.84,,,,,,,fee schedule,260.84,260.84, Rem oct rta dev setup&educaj,0604T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,260.84,,,,,,,fee schedule,260.84,260.84, Rem oct rta techl sprt min 8,0605T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3919.87,,,,,,,fee schedule,81.56,3919.87, Rem oct rta techl sprt min 8,0605T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,81.56,,,,,,,fee schedule,81.56,3919.87, Rem oct rta techl sprt min 8,0605T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,81.56,,,,,,,fee schedule,81.56,3919.87, Rem oct rta phys/qhp ea 30d,0606T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,65.16,,,,,,,fee schedule,65.16,65.16, Rem oct rta phys/qhp ea 30d,0606T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,65.16,,,,,,,fee schedule,65.16,65.16, Mrs disc pain acquisj data,0609T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,517.79,,,,,,,fee schedule,517.79,517.79, Mrs disc pain acquisj data,0609T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,517.79,,,,,,,fee schedule,517.79,517.79, Mrs disc pain transmis data,0610T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,386.26,,,,,,,fee schedule,386.26,386.26, Mrs disc pain transmis data,0610T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,386.26,,,,,,,fee schedule,386.26,386.26, Mrs disc pain alg alys data,0611T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,517.79,,,,,,,fee schedule,517.79,517.79, Mrs disc pain alg alys data,0611T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,517.79,,,,,,,fee schedule,517.79,517.79, Mrs discogenic pain i&r,0612T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,63.59,,,,,,,fee schedule,63.59,63.59, Mrs discogenic pain i&r,0612T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,63.59,,,,,,,fee schedule,63.59,63.59, Perq tcat intratrl septl sht,0613T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Perq tcat intratrl septl sht,0613T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Rmvl&rplcmt ss impl dfb pg,0614T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,46177, Rmvl&rplcmt ss impl dfb pg,0614T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46177,,,,,,,fee schedule,6979,46177, Rmvl&rplcmt ss impl dfb pg,0614T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,41559,,,,,,,fee schedule,6979,46177, Insertion of iris prosthesis,0616T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Insj iris prosth w/rmvl&insj,0617T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Insj iris prosth sec io lens,0618T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Cysto w/prst8 commissurotomy,0619T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,10940, Cysto w/prst8 commissurotomy,0619T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,5248,10940, Cysto w/prst8 commissurotomy,0619T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,5248,10940, Evasc ven artlz tibl/prnl vn,0620T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,25393, Evasc ven artlz tibl/prnl vn,0620T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,5363,25393, Evasc ven artlz tibl/prnl vn,0620T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,5363,25393, Trabeculostomy interno laser,0621T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,14456, Trabeculostomy interno laser,0621T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5363,14456, Trabeculostomy interno laser,0621T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5363,14456, Trabeculostomy int lsr w/scp,0622T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5097,5664, Trabeculostomy int lsr w/scp,0622T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Trabeculostomy int lsr w/scp,0622T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Perq njx algc fluor lmbr 1st,0627T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,22111, Perq njx algc fluor lmbr 1st,0627T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3195,22111, Perq njx algc fluor lmbr 1st,0627T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3195,22111, Perq njx algc fluor lmbr ea,0628T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Perq njx algc fluor lmbr ea,0628T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Perq njx algc fluor lmbr ea,0628T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Perq njx algc ct lmbr 1st,0629T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,22111, Perq njx algc ct lmbr 1st,0629T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3195,22111, Perq njx algc ct lmbr 1st,0629T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3195,22111, Perq njx algc ct lmbr ea,0630T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Perq njx algc ct lmbr ea,0630T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Perq njx algc ct lmbr ea,0630T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Perq tcat us abltj nrv p-art,0632T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,8406,25393, Perq tcat us abltj nrv p-art,0632T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,8406,25393, Perq tcat us abltj nrv p-art,0632T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,8406,25393, Ct breast w/3d uni c-,0633T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,245.18,,,,,,,fee schedule,245.18,245.18, Ct breast w/3d uni c-,0633T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,245.18,,,,,,,fee schedule,245.18,245.18, Ct breast w/3d uni c+,0634T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,401.74,,,,,,,fee schedule,401.74,401.74, Ct breast w/3d uni c+,0634T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,401.74,,,,,,,fee schedule,401.74,401.74, Ct breast w/3d uni c-/c+,0635T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,401.74,,,,,,,fee schedule,401.74,401.74, Ct breast w/3d uni c-/c+,0635T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,401.74,,,,,,,fee schedule,401.74,401.74, Ct breast w/3d bi c-,0636T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,517.79,,,,,,,fee schedule,517.79,517.79, Ct breast w/3d bi c-,0636T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,517.79,,,,,,,fee schedule,517.79,517.79, Ct breast w/3d bi c+,0637T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,828.27,,,,,,,fee schedule,828.27,828.27, Ct breast w/3d bi c+,0637T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,828.27,,,,,,,fee schedule,828.27,828.27, Ct breast w/3d bi c-/c+,0638T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,828.27,,,,,,,fee schedule,828.27,828.27, Ct breast w/3d bi c-/c+,0638T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,828.27,,,,,,,fee schedule,828.27,828.27, Wrls skn snr anisotropy meas,0639T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,189.2,3195, Wrls skn snr anisotropy meas,0639T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,189.2,,,,,,,fee schedule,189.2,3195, Wrls skn snr anisotropy meas,0639T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,189.2,,,,,,,fee schedule,189.2,3195, Tcat l ventr rstrj dev implt,0643T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Tcat l ventr rstrj dev implt,0643T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Tcat rmvl/dblk icar mas perq,0644T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,8406,22111, Tcat rmvl/dblk icar mas perq,0644T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,8406,22111, Tcat rmvl/dblk icar mas perq,0644T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,8406,22111, Tcat impltj c sins rdctj dev,0645T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8212,,,,,,,fee schedule,8212,25393, Tcat impltj c sins rdctj dev,0645T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,8212,25393, Tcat impltj c sins rdctj dev,0645T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,8212,25393, Ttvi/rplcmt w/prstc vlv perq,0646T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Ttvi/rplcmt w/prstc vlv perq,0646T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Insj gtube perq mag gastrpxy,0647T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5097,5664, Insj gtube perq mag gastrpxy,0647T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Insj gtube perq mag gastrpxy,0647T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Quan mr alys tiss w/o mri,0648T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,517.79,,,,,,,fee schedule,517.79,517.79, Quan mr alys tiss w/o mri,0648T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,517.79,,,,,,,fee schedule,517.79,517.79, Mag ctrld capsule endoscopy,0651T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Mag ctrld capsule endoscopy,0651T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Mag ctrld capsule endoscopy,0651T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Egd flx transnasal dx br/wa,0652T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,5664, Egd flx transnasal dx br/wa,0652T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3195,5664, Egd flx transnasal dx br/wa,0652T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3195,5664, Egd flx transnasal bx 1/ml,0653T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,5664, Egd flx transnasal bx 1/ml,0653T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4108,5664, Egd flx transnasal bx 1/ml,0653T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4108,5664, Egd flx transnasal tube/cath,0654T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,5664, Egd flx transnasal tube/cath,0654T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4108,5664, Egd flx transnasal tube/cath,0654T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4108,5664, Tprnl focal abltj mal prst8,0655T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,10940, Tprnl focal abltj mal prst8,0655T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,4108,10940, Tprnl focal abltj mal prst8,0655T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,4108,10940, Vrt bdy tethering ant,0656T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Vrt bdy tethering ant,0656T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Vrt bdy tethering ant,0656T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Vrt bdy tethering ant 8+ seg,0657T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Vrt bdy tethering ant 8+ seg,0657T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Vrt bdy tethering ant 8+ seg,0657T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Elec impd spectrsc 1+skn les,0658T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,125.24,6979, Elec impd spectrsc 1+skn les,0658T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,125.24,,,,,,,fee schedule,125.24,6979, Elec impd spectrsc 1+skn les,0658T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,125.24,,,,,,,fee schedule,125.24,6979, Tcat intra-c nfs supersat o2,0659T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Tcat intra-c nfs supersat o2,0659T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Implt ant sgm io nbio rx sys,0660T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,14456, Implt ant sgm io nbio rx sys,0660T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5248,14456, Implt ant sgm io nbio rx sys,0660T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5248,14456, Rmvl&Rimpltj ant sgm implt,0661T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,14456, Rmvl&Rimpltj ant sgm implt,0661T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5248,14456, Rmvl&Rimpltj ant sgm implt,0661T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5248,14456, Scalp cool 1st meas&calbrj,0662T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Don hysterectomy open cdvr,0664T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,5097,8406, Don hysterectomy open cdvr,0664T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8406, Don hysterectomy open cdvr,0664T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8406, Don hysterectomy open liv,0665T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,5097,8406, Don hysterectomy open liv,0665T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8406, Don hysterectomy open liv,0665T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8406, Don hysterectomy laps liv,0666T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,5097,6044, Don hysterectomy laps liv,0666T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6044, Don hysterectomy laps liv,0666T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6044, Don hysterectomy rcp uter,0667T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Don hysterectomy rcp uter,0667T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Bkbench prep don uter algrft,0668T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Bkbench prep don uter algrft,0668T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Bkbench rcnstj don uter ven,0669T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Bkbench rcnstj don uter ven,0669T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Bkbench rcnstj don uter artl,0670T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Bkbench rcnstj don uter artl,0670T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Insj ant sgm aq drg dev 1+,0671T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,10940, Insj ant sgm aq drg dev 1+,0671T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,5248,10940, Insj ant sgm aq drg dev 1+,0671T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,5248,10940, Ndovag cryg rf remdl tiss,0672T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5097,5664, Ndovag cryg rf remdl tiss,0672T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Ndovag cryg rf remdl tiss,0672T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Abltj b9 thyr ndul perq lasr,0673T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,5664, Abltj b9 thyr ndul perq lasr,0673T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3195,5664, Abltj b9 thyr ndul perq lasr,0673T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3195,5664, Laps insj nw/rpcmt prm isdss,0674T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,39251, Laps insj nw/rpcmt prm isdss,0674T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,39251,,,,,,,fee schedule,5248,39251, Laps insj nw/rpcmt prm isdss,0674T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,35325,,,,,,,fee schedule,5248,39251, Laps insj nw/rpcmt isdss 1ld,0675T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,25393, Laps insj nw/rpcmt isdss 1ld,0675T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,5248,25393, Laps insj nw/rpcmt isdss 1ld,0675T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,5248,25393, Laps insj nw/rpcmt isdss ea,0676T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Laps insj nw/rpcmt isdss ea,0676T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Laps insj nw/rpcmt isdss ea,0676T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Laps repos lead isdss 1st ld,0677T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,22111, Laps repos lead isdss 1st ld,0677T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4108,22111, Laps repos lead isdss 1st ld,0677T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4108,22111, Laps repos lead isdss ea add,0678T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Laps repos lead isdss ea add,0678T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Laps repos lead isdss ea add,0678T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Laps rmvl lead isdss,0679T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,22111, Laps rmvl lead isdss,0679T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4108,22111, Laps rmvl lead isdss,0679T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4108,22111, Insj/rplcmt pg only isdss,0680T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,25393, Insj/rplcmt pg only isdss,0680T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,5248,25393, Insj/rplcmt pg only isdss,0680T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,5248,25393, Rlcj pulse gen only isdss,0681T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,12821, Rlcj pulse gen only isdss,0681T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4108,12821, Rlcj pulse gen only isdss,0681T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4108,12821, Removal pulse gen only isdss,0682T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,12821, Removal pulse gen only isdss,0682T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4108,12821, Removal pulse gen only isdss,0682T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4108,12821, Histotripsy mal hepatcel tis,0686T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,28126.13, Histotripsy mal hepatcel tis,0686T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,28126.13,,,,,,,fee schedule,5363,28126.13, Histotripsy mal hepatcel tis,0686T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,28126.13,,,,,,,fee schedule,5363,28126.13, Quan us tis charac w/o dx us,0689T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,185.87,,,,,,,fee schedule,185.87,185.87, Quan us tis charac w/o dx us,0689T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,185.87,,,,,,,fee schedule,185.87,185.87, Auto alys xst ct std vrt fx,0691T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.06,,,,,,,fee schedule,19.06,19.06, Auto alys xst ct std vrt fx,0691T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19.06,,,,,,,fee schedule,19.06,19.06, Compre ful bdy 3d mtn alys,0693T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,788.63,,,,,,,fee schedule,788.63,788.63, Compre ful bdy 3d mtn alys,0693T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,788.63,,,,,,,fee schedule,788.63,788.63, Quan mr tis wo mri mlt orgn,0697T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,528.75,,,,,,,fee schedule,528.75,528.75, Quan mr tis wo mri mlt orgn,0697T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,528.75,,,,,,,fee schedule,528.75,528.75, Njx pst chmbr eye medication,0699T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,10940, Njx pst chmbr eye medication,0699T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,6979,10940, Njx pst chmbr eye medication,0699T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,6979,10940, Molec fluor img sus nev 1st,0700T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,80.06,,,,,,,fee schedule,80.06,80.06, Molec fluor img sus nev 1st,0700T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,80.06,,,,,,,fee schedule,80.06,80.06, Molec fluor img sus nev ea,0701T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23.65,,,,,,,fee schedule,23.65,23.65, Molec fluor img sus nev ea,0701T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,23.65,,,,,,,fee schedule,23.65,23.65, Njx b1 sub mtrl sbchdrl dfct,0707T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,12821, Njx b1 sub mtrl sbchdrl dfct,0707T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4108,12821, Njx b1 sub mtrl sbchdrl dfct,0707T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4108,12821, Id ca immntx prep & 1st njx,0708T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Id ca immntx prep & 1st njx,0708T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Id ca immntx each addl njx,0709T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Id ca immntx each addl njx,0709T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Tprnl lsr ablt b9 prst8 hypr,0714T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,10940, Tprnl lsr ablt b9 prst8 hypr,0714T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,4108,10940, Tprnl lsr ablt b9 prst8 hypr,0714T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,4108,10940, Car acous wavfrm rec cad rsk,0716T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,2782, Car acous wavfrm rec cad rsk,0716T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,2782, Adrc ther prtl rc tear,0717T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,12821, Adrc ther prtl rc tear,0717T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5248,12821, Adrc ther prtl rc tear,0717T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5248,12821, Adrc ther prtl rc tear njx,0718T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,12821, Adrc ther prtl rc tear njx,0718T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3195,12821, Adrc ther prtl rc tear njx,0718T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3195,12821, Pst vrt jt rplcmt lmbr 1 sgm,0719T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Pst vrt jt rplcmt lmbr 1 sgm,0719T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Pst vrt jt rplcmt lmbr 1 sgm,0719T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Prq elc nrv stim cn wo implt,0720T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Prq elc nrv stim cn wo implt,0720T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Quan ct tiss charac w/o ct,0721T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1463.63,,,,,,,fee schedule,1463.63,1463.63, Quan ct tiss charac w/o ct,0721T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1463.63,,,,,,,fee schedule,1463.63,1463.63, Qmrcp w/o dx mri sm anat ses,0723T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2138.63,,,,,,,fee schedule,2138.63,2138.63, Qmrcp w/o dx mri sm anat ses,0723T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2138.63,,,,,,,fee schedule,2138.63,2138.63, Vestibular dev impltj uni,0725T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,5097,8406, Vestibular dev impltj uni,0725T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8406, Vestibular dev impltj uni,0725T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8406, Rmvl implt vstibular dev uni,0726T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5097,5664, Rmvl implt vstibular dev uni,0726T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Rmvl implt vstibular dev uni,0726T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Rmvl&rplcmt implt vstblr dev,0727T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,5097,8406, Rmvl&rplcmt implt vstblr dev,0727T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8406, Rmvl&rplcmt implt vstblr dev,0727T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8406, Trabeculotomy lsr w/oct gdn,0730T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5097,5664, Trabeculotomy lsr w/oct gdn,0730T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Trabeculotomy lsr w/oct gdn,0730T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Immntx admn electroporatn im,0732T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Immntx admn electroporatn im,0732T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Prep tum cav iort prim crnot,0735T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Prep tum cav iort prim crnot,0735T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Prep tum cav iort prim crnot,0735T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Colonic lavage 35+l water,0736T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Colonic lavage 35+l water,0736T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Colonic lavage 35+l water,0736T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Xenograft impltj artclr surf,0737T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,22111, Xenograft impltj artclr surf,0737T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4108,22111, Xenograft impltj artclr surf,0737T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4108,22111, Abltj mal prst8 mag fld ndct,0739T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,5664, Abltj mal prst8 mag fld ndct,0739T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4108,5664, Abltj mal prst8 mag fld ndct,0739T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4108,5664, B1 str & fx rsk vrt fx assmt,0743T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,543.87,,,,,,,fee schedule,543.87,543.87, B1 str & fx rsk vrt fx assmt,0743T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,543.87,,,,,,,fee schedule,543.87,543.87, Insj bioprostc vlv fem vn,0744T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,22111, Insj bioprostc vlv fem vn,0744T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6979,22111, Insj bioprostc vlv fem vn,0744T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6979,22111, Car ablt rad arr n-invas loc,0745T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Car ablt rad arr n-invas loc,0745T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Car ablt rad arr cnv loc map,0746T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Car ablt rad arr cnv loc map,0746T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Car ablt rad arrhyt dlvr rad,0747T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Car ablt rad arrhyt dlvr rad,0747T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Njx stm cl prdct anl sft tis,0748T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,5664, Njx stm cl prdct anl sft tis,0748T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3195,5664, Njx stm cl prdct anl sft tis,0748T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3195,5664, R-t prs sensing edrl gdn sys,0777T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,3195, Smmg cncrnt appl imu snr,0778T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,327.22,,,,,,,fee schedule,327.22,327.22, Smmg cncrnt appl imu snr,0778T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,327.22,,,,,,,fee schedule,327.22,327.22, Instlj fecal microbiota ssp,0780T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Instlj fecal microbiota ssp,0780T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Instlj fecal microbiota ssp,0780T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Brnchsc rf dstrj pulm nrv bi,0781T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5097,5664, Brnchsc rf dstrj pulm nrv bi,0781T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Brnchsc rf dstrj pulm nrv bi,0781T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Brnchsc rf dstrj plm nrv uni,0782T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5097,5664, Brnchsc rf dstrj plm nrv uni,0782T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Brnchsc rf dstrj plm nrv uni,0782T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Ins/rplmt eltrd ra spi nstim,0784T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,25393, Ins/rplmt eltrd ra spi nstim,0784T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,5248,25393, Ins/rplmt eltrd ra spi nstim,0784T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,5248,25393, Revj/rmvl nea spi w/nstim,0785T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,12821, Revj/rmvl nea spi w/nstim,0785T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3195,12821, Revj/rmvl nea spi w/nstim,0785T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3195,12821, Insj/rplcmt prq ra sac nstim,0786T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,25393, Insj/rplcmt prq ra sac nstim,0786T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,5248,25393, Insj/rplcmt prq ra sac nstim,0786T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,5248,25393, Revj/rmvl nea sac w/nstim,0787T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,12821, Revj/rmvl nea sac w/nstim,0787T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3195,12821, Revj/rmvl nea sac w/nstim,0787T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3195,12821, Revj rplcmt/rmvl vrt tethrg,0790T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Revj rplcmt/rmvl vrt tethrg,0790T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Revj rplcmt/rmvl vrt tethrg,0790T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Prq tcat thrm ablt nrv p-art,0793T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,8406,25393, Prq tcat thrm ablt nrv p-art,0793T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,8406,25393, Prq tcat thrm ablt nrv p-art,0793T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,8406,25393, Pt spec alg rx-onc tx option,0794T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,2782, Pt spec alg rx-onc tx option,0794T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,2782, Tcat ins 2chmbr ldls pm cmpl,0795T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,25393, Tcat ins 2chmbr ldls pm cmpl,0795T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,6979,25393, Tcat ins 2chmbr ldls pm cmpl,0795T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,6979,25393, Tcat ins 2chmbr ldls pm ra,0796T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,25393, Tcat ins 2chmbr ldls pm ra,0796T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,5363,25393, Tcat ins 2chmbr ldls pm ra,0796T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,5363,25393, Tcat ins 2chmbr ldls pm rv,0797T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,25393, Tcat ins 2chmbr ldls pm rv,0797T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,5363,25393, Tcat ins 2chmbr ldls pm rv,0797T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,5363,25393, Tcat rmv 2chmbr ldls pm cmpl,0798T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,12821, Tcat rmv 2chmbr ldls pm cmpl,0798T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,6044,12821, Tcat rmv 2chmbr ldls pm cmpl,0798T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,6044,12821, Tcat rmvl 2chmbr ldls pm ra,0799T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,12821, Tcat rmvl 2chmbr ldls pm ra,0799T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5363,12821, Tcat rmvl 2chmbr ldls pm ra,0799T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5363,12821, Tcat rmvl 2chmbr ldls pm rv,0800T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,12821, Tcat rmvl 2chmbr ldls pm rv,0800T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5363,12821, Tcat rmvl 2chmbr ldls pm rv,0800T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5363,12821, Tcat rmv&rpl 2chmbr ldls pm,0801T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,8406,25393, Tcat rmv&rpl 2chmbr ldls pm,0801T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,8406,25393, Tcat rmv&rpl 2chmbr ldls pm,0801T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,8406,25393, Tcat rmv&rpl2chmb ldls pm ra,0802T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,25393, Tcat rmv&rpl2chmb ldls pm ra,0802T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,6044,25393, Tcat rmv&rpl2chmb ldls pm ra,0802T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,6044,25393, Tcat rmv&rpl2chmb ldls pm rv,0803T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,25393, Tcat rmv&rpl2chmb ldls pm rv,0803T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,6044,25393, Tcat rmv&rpl2chmb ldls pm rv,0803T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,6044,25393, Tcat s&ivc prstc vl impl prq,0805T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Tcat s&ivc prstc vl impl prq,0805T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Tcat s&ivc prstc vl impl prq,0805T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Tcat s&ivc prstc vl impl opn,0806T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Tcat s&ivc prstc vl impl opn,0806T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Tcat s&ivc prstc vl impl opn,0806T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Pulm tiss vntj alys prev ct,0807T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,327.22,,,,,,,fee schedule,327.22,327.22, Pulm tiss vntj alys prev ct,0807T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,327.22,,,,,,,fee schedule,327.22,327.22, Pulm tiss vntj alys w/ct,0808T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,630.14,,,,,,,fee schedule,630.14,630.14, Pulm tiss vntj alys w/ct,0808T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,630.14,,,,,,,fee schedule,630.14,630.14, Subrta njx rx agt w/vtrc,0810T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,14456, Subrta njx rx agt w/vtrc,0810T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,6044,14456, Subrta njx rx agt w/vtrc,0810T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,6044,14456, Egd vol adjmt bariatric balo,0813T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,5664, Egd vol adjmt bariatric balo,0813T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4108,5664, Egd vol adjmt bariatric balo,0813T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4108,5664, Prq njx biod osteo matrl fem,0814T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,5664, Prq njx biod osteo matrl fem,0814T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3195,5664, Prq njx biod osteo matrl fem,0814T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3195,5664, Opn insj/rplcmt ins ptn subq,0816T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,25393, Opn insj/rplcmt ins ptn subq,0816T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,4108,25393, Opn insj/rplcmt ins ptn subq,0816T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,4108,25393, Opn insj/rplcmt ins ptn subf,0817T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,25393, Opn insj/rplcmt ins ptn subf,0817T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,4108,25393, Opn insj/rplcmt ins ptn subf,0817T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,4108,25393, Revj/rmvl ins ptn subq,0818T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,12821, Revj/rmvl ins ptn subq,0818T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3195,12821, Revj/rmvl ins ptn subq,0818T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3195,12821, Revj/rmvl ins ptn subf,0819T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,12821, Revj/rmvl ins ptn subf,0819T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3195,12821, Revj/rmvl ins ptn subf,0819T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3195,12821, Tcat ins 1chmbr ldls pm ra,0823T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,25393, Tcat ins 1chmbr ldls pm ra,0823T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,6979,25393, Tcat ins 1chmbr ldls pm ra,0823T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,6979,25393, Tcat rmv 1chmbr ldls pm ra,0824T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,12821, Tcat rmv 1chmbr ldls pm ra,0824T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5363,12821, Tcat rmv 1chmbr ldls pm ra,0824T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5363,12821, Tcat rmv&rpl1chmb ldls pm ra,0825T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,25393, Tcat rmv&rpl1chmb ldls pm ra,0825T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,6979,25393, Tcat rmv&rpl1chmb ldls pm ra,0825T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,6979,25393, Opto-acoustic img breast uni,0857T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,235.69,,,,,,,fee schedule,235.69,235.69, Opto-acoustic img breast uni,0857T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,235.69,,,,,,,fee schedule,235.69,235.69, Rmvl pg wcs lv both compnt,0861T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,12821, Rmvl pg wcs lv both compnt,0861T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5363,12821, Rmvl pg wcs lv both compnt,0861T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5363,12821, Rlcj pg wcs lv battery only,0862T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,5664, Rlcj pg wcs lv battery only,0862T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4108,5664, Rlcj pg wcs lv battery only,0862T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4108,5664, Rlcj pg wcs lv trnsmtr only,0863T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,5664, Rlcj pg wcs lv trnsmtr only,0863T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4108,5664, Rlcj pg wcs lv trnsmtr only,0863T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4108,5664, Low ntsty eswt corpus cvrnsm,0864T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,3195, Quan mri alys brn w/o dx mri,0865T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,525.31,,,,,,,fee schedule,525.31,525.31, Quan mri alys brn w/o dx mri,0865T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,525.31,,,,,,,fee schedule,525.31,525.31, Quan mri alys brn w/dx mri,0866T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,525.31,,,,,,,fee schedule,525.31,525.31, Quan mri alys brn w/dx mri,0866T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,525.31,,,,,,,fee schedule,525.31,525.31, Tpla b9 prst8 hyprplsa>=50ml,0867T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,10940, Tpla b9 prst8 hyprplsa>=50ml,0867T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,4108,10940, Tpla b9 prst8 hyprplsa>=50ml,0867T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,4108,10940, Njx b1 sub mtrl hw fixj aug,0869T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,12821, Njx b1 sub mtrl hw fixj aug,0869T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4108,12821, Njx b1 sub mtrl hw fixj aug,0869T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4108,12821, Imp subq prtl ascts pmp sys,0870T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,5664, Imp subq prtl ascts pmp sys,0870T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4108,5664, Imp subq prtl ascts pmp sys,0870T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4108,5664, Rplcmt subq prtl ascites pmp,0871T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,5664, Rplcmt subq prtl ascites pmp,0871T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4108,5664, Rplcmt subq prtl ascites pmp,0871T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4108,5664, Rplcmt ndwllg bldr&prtl cath,0872T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,5664, Rplcmt ndwllg bldr&prtl cath,0872T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4108,5664, Rplcmt ndwllg bldr&prtl cath,0872T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4108,5664, Revj subq prtl asct pmp sys,0873T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,5664, Revj subq prtl asct pmp sys,0873T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4108,5664, Revj subq prtl asct pmp sys,0873T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4108,5664, Rmvl pertl ascites pmp sys,0874T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,5664, Rmvl pertl ascites pmp sys,0874T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3195,5664, Rmvl pertl ascites pmp sys,0874T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3195,5664, Intraop ther estim pn ue 1st,0882T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Intraop ther estim pn ue 1st,0882T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Intraop ther estim pn ue 1st,0882T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Intraop ther estim pn ue ea,0883T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Intraop ther estim pn ue ea,0883T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Intraop ther estim pn ue ea,0883T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Esphgsc flx 1st tndsc dilat,0884T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,10940, Esphgsc flx 1st tndsc dilat,0884T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,5248,10940, Esphgsc flx 1st tndsc dilat,0884T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,5248,10940, Colsc flx 1st tndsc dilat,0885T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,10940, Colsc flx 1st tndsc dilat,0885T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,5248,10940, Colsc flx 1st tndsc dilat,0885T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,5248,10940, Sgmdsc flx 1st tndsc dilat,0886T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,10940, Sgmdsc flx 1st tndsc dilat,0886T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,4108,10940, Sgmdsc flx 1st tndsc dilat,0886T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,4108,10940, Histotripsy mal renal tissue,0888T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,39376.13, Histotripsy mal renal tissue,0888T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,39376.13,,,,,,,fee schedule,5363,39376.13, Histotripsy mal renal tissue,0888T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,39376.13,,,,,,,fee schedule,5363,39376.13, Cannulation liver allograft,0894T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Cannulation liver allograft,0894T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Plmt bone marrow smplg port,0901T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,5664, Plmt bone marrow smplg port,0901T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3195,5664, Plmt bone marrow smplg port,0901T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3195,5664, Opn imp int nstm sys vgs nrv,0908T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,5664, Opn imp int nstm sys vgs nrv,0908T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4108,5664, Opn imp int nstm sys vgs nrv,0908T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4108,5664, Rplcmt int nstim sys vgs nrv,0909T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,5664, Rplcmt int nstim sys vgs nrv,0909T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4108,5664, Rplcmt int nstim sys vgs nrv,0909T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4108,5664, Rmvl int nstim sys vagus nrv,0910T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,5664, Rmvl int nstim sys vagus nrv,0910T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3195,5664, Rmvl int nstim sys vagus nrv,0910T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3195,5664, Prq tcat ther rx ntrac balo1,0913T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,8406,22111, Prq tcat ther rx ntrac balo1,0913T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,8406,22111, Prq tcat ther rx ntrac balo1,0913T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,8406,22111, Prq tcat thr rx ntrc bal sep,0914T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Prq tcat thr rx ntrc bal sep,0914T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Prq tcat thr rx ntrc bal sep,0914T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Insj perm ccm-d sys pg&eltrd,0915T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,8406,46177, Insj perm ccm-d sys pg&eltrd,0915T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46177,,,,,,,fee schedule,8406,46177, Insj perm ccm-d sys pg&eltrd,0915T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,41559,,,,,,,fee schedule,8406,46177, Insj perm ccm-d sys pg only,0916T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,46177, Insj perm ccm-d sys pg only,0916T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46177,,,,,,,fee schedule,5248,46177, Insj perm ccm-d sys pg only,0916T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,41559,,,,,,,fee schedule,5248,46177, Insj perm ccm-d sys 1 lead,0917T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,25393, Insj perm ccm-d sys 1 lead,0917T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,5363,25393, Insj perm ccm-d sys 1 lead,0917T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,5363,25393, Insj perm ccm-d sys dual ld,0918T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,25393, Insj perm ccm-d sys dual ld,0918T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,5363,25393, Insj perm ccm-d sys dual ld,0918T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,5363,25393, Rmvl perm ccm-d sys pg only,0919T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,12821, Rmvl perm ccm-d sys pg only,0919T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5363,12821, Rmvl perm ccm-d sys pg only,0919T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5363,12821, Rmvl perm ccm-d sys 1 pac ld,0920T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,12821, Rmvl perm ccm-d sys 1 pac ld,0920T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5363,12821, Rmvl perm ccm-d sys 1 pac ld,0920T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5363,12821, Rmvl perm ccm-d sys 1 dfb ld,0921T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,12821, Rmvl perm ccm-d sys 1 dfb ld,0921T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5363,12821, Rmvl perm ccm-d sys 1 dfb ld,0921T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5363,12821, Rmvl perm ccm-d sys dual ld,0922T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,12821, Rmvl perm ccm-d sys dual ld,0922T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5363,12821, Rmvl perm ccm-d sys dual ld,0922T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5363,12821, Rmvl&rplcmt perm ccm-d pg,0923T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,46177, Rmvl&rplcmt perm ccm-d pg,0923T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46177,,,,,,,fee schedule,5248,46177, Rmvl&rplcmt perm ccm-d pg,0923T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,41559,,,,,,,fee schedule,5248,46177, Rpos prv ccm-d trnsvns eltrd,0924T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4047,4497, Rpos prv ccm-d trnsvns eltrd,0924T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,4047,4497, Rpos prv ccm-d trnsvns eltrd,0924T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,4047,4497, Rlcj skin pocket ccm-d pg,0925T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,5664, Rlcj skin pocket ccm-d pg,0925T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4108,5664, Rlcj skin pocket ccm-d pg,0925T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4108,5664, Ephys eval ccm-d ld 1st impl,0930T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,5664, Ephys eval ccm-d ld 1st impl,0930T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3195,5664, Ephys eval ccm-d ld 1st impl,0930T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3195,5664, Ephys eval ccm-d ld separate,0931T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,5664, Ephys eval ccm-d ld separate,0931T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4108,5664, Ephys eval ccm-d ld separate,0931T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4108,5664, Tcat impl wrls l atr prs snr,0933T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,8406,14456, Tcat impl wrls l atr prs snr,0933T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,8406,14456, Tcat impl wrls l atr prs snr,0933T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,8406,14456, Cysto w/rnl pel symp dnrvtj,0935T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5097,5664, Cysto w/rnl pel symp dnrvtj,0935T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Cysto w/rnl pel symp dnrvtj,0935T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Cysto flx ins&xpns urtl scaf,0941T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5097,5664, Cysto flx ins&xpns urtl scaf,0941T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Cysto flx ins&xpns urtl scaf,0941T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Cysto flx rmv&rplc urtl scaf,0942T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5097,5664, Cysto flx rmv&rplc urtl scaf,0942T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Cysto flx rmv&rplc urtl scaf,0942T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Cysto flx rmvl urtl scaffold,0943T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,5664, Cysto flx rmvl urtl scaffold,0943T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4108,5664, Cysto flx rmvl urtl scaffold,0943T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4108,5664, 3d cntr simula trgt lvr les,0944T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,543.87,,,,,,,fee schedule,543.87,543.87, 3d cntr simula trgt lvr les,0944T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,543.87,,,,,,,fee schedule,543.87,543.87, Intraop assmt abnl tum tiss,0945T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,5664, Intraop assmt abnl tum tiss,0945T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3195,5664, Intraop assmt abnl tum tiss,0945T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3195,5664, Ortho impl mvmt alys pair ct,0946T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,239.27,,,,,,,fee schedule,239.27,239.27, Ortho impl mvmt alys pair ct,0946T,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,239.27,,,,,,,fee schedule,239.27,239.27, Mrgfus strtctc bl-br disrpj,0947T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,5248, Abltj b9 prst8 tissue hifu,0950T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Prt crn ch cr&tun elt s-sclp,0956T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Rev s-sclp eltr ra rcvr&tlmt,0957T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Rmv s-sclp eltr ra rcvr&tlmt,0958T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Rmv/rplc magnet coil assem,0959T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Rpl s-sclp eltr ra rcvr&tlmt,0960T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Anosc sbmcsl njx bulking agt,0963T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, I&cust prep jaw xpnsj 1arch,0964T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, I&cst prp jw xpn dl arch non,0965T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, I&cst prp jw xpn dl arch fxd,0966T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Tranal ins tmp clrc anst dev,0967T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Ablt b9 brst tum perq lsr ea,0970T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Ablt mal brst tum pq lsr uni,0971T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Slctv nzmtc dbrdmt t/a/l 1st,0973T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Slctv nzmtc dbrdmt s/n/hf 1,0975T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Tcat impl wrls ivc snr,0981T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Opn ins/rplc ins ptn sbq&sbf,0988T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Revj/rmvl ins ptn subq&subf,0989T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Trncrv inst biod hydrgl mtrl,0990T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Cysto lo-nrg lithtrp&mcrsphr,0991T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Evasc dlvr a-wal stbl rx prq,0994T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Evasc dlvr a-wal stbl rx opn,0995T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Ins&sclr fix caps bag prosth,0996T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Fna bx w/o img gdn ea addl,10004,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,208.56,,,,,,,fee schedule,208.56,3195, Fna bx w/o img gdn ea addl,10004,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,208.56,3195, Fna bx w/o img gdn ea addl,10004,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,208.56,3195, Fna bx w/o img gdn ea addl,10004,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,208.56,3195, Fna bx w/us gdn 1st les,10005,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,350.2,,,,,,,fee schedule,350.2,4497, Fna bx w/us gdn 1st les,10005,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,350.2,4497, Fna bx w/us gdn 1st les,10005,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,350.2,4497, Fna bx w/us gdn 1st les,10005,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,350.2,4497, Fna bx w/us gdn ea addl,10006,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,240.88,,,,,,,fee schedule,240.88,3195, Fna bx w/us gdn ea addl,10006,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,240.88,3195, Fna bx w/us gdn ea addl,10006,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,240.88,3195, Fna bx w/us gdn ea addl,10006,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,240.88,3195, Fna bx w/fluor gdn 1st les,10007,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,454.07,,,,,,,fee schedule,454.07,4497, Fna bx w/fluor gdn 1st les,10007,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,454.07,4497, Fna bx w/fluor gdn 1st les,10007,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,454.07,4497, Fna bx w/fluor gdn 1st les,10007,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,454.07,4497, Fna bx w/fluor gdn ea addl,10008,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,266.83,,,,,,,fee schedule,266.83,3195, Fna bx w/fluor gdn ea addl,10008,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,266.83,3195, Fna bx w/fluor gdn ea addl,10008,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,266.83,3195, Fna bx w/fluor gdn ea addl,10008,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,266.83,3195, Fna bx w/ct gdn 1st les,10009,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,520.82,,,,,,,fee schedule,520.82,4497, Fna bx w/ct gdn 1st les,10009,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,520.82,4497, Fna bx w/ct gdn 1st les,10009,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,520.82,4497, Fna bx w/ct gdn 1st les,10009,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,520.82,4497, Fna bx w/ct gdn ea addl,10010,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,372.92,,,,,,,fee schedule,372.92,3195, Fna bx w/ct gdn ea addl,10010,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,372.92,3195, Fna bx w/ct gdn ea addl,10010,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,372.92,3195, Fna bx w/ct gdn ea addl,10010,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,372.92,3195, Fna bx w/mr gdn 1st les,10011,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,4497, Fna bx w/mr gdn 1st les,10011,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,3195,4497, Fna bx w/mr gdn 1st les,10011,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,3195,4497, Fna bx w/mr gdn ea addl,10012,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Fna bx w/mr gdn ea addl,10012,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Fna bx w/mr gdn ea addl,10012,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Fna w/o image,10021,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,259.49,,,,,,,fee schedule,259.49,3195, Fna w/o image,10021,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,259.49,3195, Fna w/o image,10021,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,259.49,3195, Fna w/o image,10021,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,259.49,3195, Guide cathet fluid drainage,10030,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,665.7,,,,,,,fee schedule,665.7,4497, Guide cathet fluid drainage,10030,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,665.7,4497, Guide cathet fluid drainage,10030,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,665.7,4497, Guide cathet fluid drainage,10030,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,665.7,4497, Perq dev soft tiss 1st imag,10035,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,396.93,,,,,,,fee schedule,396.93,4497, Perq dev soft tiss 1st imag,10035,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,396.93,4497, Perq dev soft tiss 1st imag,10035,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,396.93,4497, Perq dev soft tiss 1st imag,10035,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,396.93,4497, Perq dev soft tiss add imag,10036,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,206.94,,,,,,,fee schedule,206.94,3195, Perq dev soft tiss add imag,10036,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,206.94,3195, Perq dev soft tiss add imag,10036,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,206.94,3195, Perq dev soft tiss add imag,10036,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,206.94,3195, Arthrp 1st crp/mtcrpl prostc,1003T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Acne surgery,10040,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,233.75,,,,,,,fee schedule,233.75,6979, Acne surgery,10040,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,233.75,6979, Acne surgery,10040,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,233.75,6979, Acne surgery,10040,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,233.75,6979, Drainage of skin abscess,10060,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,540.9,,,,,,,fee schedule,540.9,3195, Drainage of skin abscess,10060,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,540.9,3195, Drainage of skin abscess,10060,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,540.9,3195, Drainage of skin abscess,10060,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,540.9,3195, Drainage of skin abscess,10061,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,945.7,,,,,,,fee schedule,945.7,3195, Drainage of skin abscess,10061,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,945.7,3195, Drainage of skin abscess,10061,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,945.7,3195, Drainage of skin abscess,10061,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,945.7,3195, Drainage of pilonidal cyst,10080,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,571.92,,,,,,,fee schedule,571.92,4497, Drainage of pilonidal cyst,10080,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,571.92,4497, Drainage of pilonidal cyst,10080,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,571.92,4497, Drainage of pilonidal cyst,10080,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,571.92,4497, Drainage of pilonidal cyst,10081,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,936.8,,,,,,,fee schedule,936.8,4497, Drainage of pilonidal cyst,10081,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,936.8,4497, Drainage of pilonidal cyst,10081,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,936.8,4497, Drainage of pilonidal cyst,10081,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,936.8,4497, Remove foreign body,10120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,550.5,,,,,,,fee schedule,550.5,3195, Remove foreign body,10120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,550.5,3195, Remove foreign body,10120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,550.5,3195, Remove foreign body,10120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,550.5,3195, Remove foreign body,10121,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,944.25,,,,,,,fee schedule,944.25,5664, Remove foreign body,10121,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,944.25,5664, Remove foreign body,10121,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,944.25,5664, Remove foreign body,10121,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,944.25,5664, Mtrz ab ntrno trph scl/tr mw,1012T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Lap srg imp/rpl eso nea&pg/r,1013T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Drainage of hematoma/fluid,10140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,629.07,,,,,,,fee schedule,629.07,5664, Drainage of hematoma/fluid,10140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,629.07,5664, Drainage of hematoma/fluid,10140,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,629.07,5664, Drainage of hematoma/fluid,10140,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,629.07,5664, Lap rv/rmv eso sph nstm eltr,1014T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Rev/rmv lw esoph sphnc npg/r,1015T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Puncture drainage of lesion,10160,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,497.57,,,,,,,fee schedule,497.57,3195, Puncture drainage of lesion,10160,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,497.57,3195, Puncture drainage of lesion,10160,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,497.57,3195, Puncture drainage of lesion,10160,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,497.57,3195, Complex drainage wound,10180,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,973.38,,,,,,,fee schedule,973.38,10940, Complex drainage wound,10180,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,973.38,10940, Complex drainage wound,10180,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,973.38,10940, Complex drainage wound,10180,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,973.38,10940, Lymphovenous bypass per xtr,1019T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Debride infected skin,11000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,135.39,,,,,,,fee schedule,135.39,3195, Debride infected skin,11000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,135.39,3195, Debride infected skin,11000,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,135.39,3195, Debride infected skin,11000,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,135.39,3195, Debride infected skin add-on,11001,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,70.74,,,,,,,fee schedule,70.74,3195, Debride infected skin add-on,11001,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,70.74,3195, Debride infected skin add-on,11001,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,70.74,3195, Debride infected skin add-on,11001,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,70.74,3195, Debride genitalia & perineum,11004,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2895.98,,,,,,,fee schedule,2895.98,6979, Debride genitalia & perineum,11004,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2895.98,6979, Debride genitalia & perineum,11004,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2895.98,6979, Debride genitalia & perineum,11004,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2895.98,6979, Debride abdom wall,11005,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4023.74,,,,,,,fee schedule,4023.74,6979, Debride abdom wall,11005,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4023.74,6979, Debride abdom wall,11005,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4023.74,6979, Debride abdom wall,11005,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4023.74,6979, Debride genit/per/abdom wall,11006,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3597.89,,,,,,,fee schedule,3597.89,6979, Debride genit/per/abdom wall,11006,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3597.89,6979, Debride genit/per/abdom wall,11006,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3597.89,6979, Debride genit/per/abdom wall,11006,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3597.89,6979, Remove mesh from abd wall,11008,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1423.2,,,,,,,fee schedule,1423.2,12821, Remove mesh from abd wall,11008,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1423.2,12821, Remove mesh from abd wall,11008,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,1423.2,12821, Remove mesh from abd wall,11008,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,1423.2,12821, Debride skin at fx site,11010,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1393.46,,,,,,,fee schedule,1393.46,4497, Debride skin at fx site,11010,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1393.46,4497, Debride skin at fx site,11010,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,1393.46,4497, Debride skin at fx site,11010,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,1393.46,4497, Debride skin musc at fx site,11011,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1498.25,,,,,,,fee schedule,1498.25,4497, Debride skin musc at fx site,11011,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1498.25,4497, Debride skin musc at fx site,11011,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,1498.25,4497, Debride skin musc at fx site,11011,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,1498.25,4497, Deb skin bone at fx site,11012,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2052.75,,,,,,,fee schedule,2052.75,4497, Deb skin bone at fx site,11012,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2052.75,4497, Deb skin bone at fx site,11012,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,2052.75,4497, Deb skin bone at fx site,11012,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,2052.75,4497, Deb subq tissue 20 sq cm/<,11042,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,308.33,,,,,,,fee schedule,308.33,4108, Deb subq tissue 20 sq cm/<,11042,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,308.33,4108, Deb subq tissue 20 sq cm/<,11042,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,308.33,4108, Deb subq tissue 20 sq cm/<,11042,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,308.33,4108, Deb musc/fascia 20 sq cm/<,11043,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,775.57,,,,,,,fee schedule,775.57,4108, Deb musc/fascia 20 sq cm/<,11043,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,775.57,4108, Deb musc/fascia 20 sq cm/<,11043,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,775.57,4108, Deb musc/fascia 20 sq cm/<,11043,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,775.57,4108, Deb bone 20 sq cm/<,11044,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1132.08,,,,,,,fee schedule,1132.08,4497, Deb bone 20 sq cm/<,11044,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1132.08,4497, Deb bone 20 sq cm/<,11044,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,1132.08,4497, Deb bone 20 sq cm/<,11044,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,1132.08,4497, Deb subq tissue add-on,11045,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,124.49,,,,,,,fee schedule,124.49,3195, Deb subq tissue add-on,11045,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,124.49,3195, Deb subq tissue add-on,11045,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,124.49,3195, Deb subq tissue add-on,11045,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,124.49,3195, Deb musc/fascia add-on,11046,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,273.04,,,,,,,fee schedule,273.04,3195, Deb musc/fascia add-on,11046,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,273.04,3195, Deb musc/fascia add-on,11046,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,273.04,3195, Deb musc/fascia add-on,11046,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,273.04,3195, Deb bone add-on,11047,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,487.85,,,,,,,fee schedule,487.85,3195, Deb bone add-on,11047,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,487.85,3195, Deb bone add-on,11047,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,487.85,3195, Deb bone add-on,11047,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,487.85,3195, Description Not Available,11050,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Description Not Available,11051,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Description Not Available,11052,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Trim skin lesion,11055,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,76.3,,,,,,,fee schedule,76.3,3195, Trim skin lesion,11055,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,76.3,3195, Trim skin lesion,11055,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,76.3,3195, Trim skin lesion,11055,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,76.3,3195, Trim skin lesions 2 to 4,11056,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,109.48,,,,,,,fee schedule,109.48,3195, Trim skin lesions 2 to 4,11056,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,109.48,3195, Trim skin lesions 2 to 4,11056,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,109.48,3195, Trim skin lesions 2 to 4,11056,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,109.48,3195, Trim skin lesions over 4,11057,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,140.89,,,,,,,fee schedule,140.89,3195, Trim skin lesions over 4,11057,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,140.89,3195, Trim skin lesions over 4,11057,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,140.89,3195, Trim skin lesions over 4,11057,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,140.89,3195, Tangntl bx skin single les,11102,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,166.03,,,,,,,fee schedule,166.03,3195, Tangntl bx skin single les,11102,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,166.03,3195, Tangntl bx skin single les,11102,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,166.03,3195, Tangntl bx skin single les,11102,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,166.03,3195, Tangntl bx skin ea sep/addl,11103,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,98.21,,,,,,,fee schedule,98.21,3195, Tangntl bx skin ea sep/addl,11103,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,98.21,3195, Tangntl bx skin ea sep/addl,11103,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,98.21,3195, Tangntl bx skin ea sep/addl,11103,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,98.21,3195, Punch bx skin single lesion,11104,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,211.74,,,,,,,fee schedule,211.74,3195, Punch bx skin single lesion,11104,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,211.74,3195, Punch bx skin single lesion,11104,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,211.74,3195, Punch bx skin single lesion,11104,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,211.74,3195, Punch bx skin ea sep/addl,11105,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,120.65,,,,,,,fee schedule,120.65,3195, Punch bx skin ea sep/addl,11105,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,120.65,3195, Punch bx skin ea sep/addl,11105,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,120.65,3195, Punch bx skin ea sep/addl,11105,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,120.65,3195, Incal bx skn single les,11106,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,259.12,,,,,,,fee schedule,259.12,4497, Incal bx skn single les,11106,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,259.12,4497, Incal bx skn single les,11106,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,259.12,4497, Incal bx skn single les,11106,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,259.12,4497, Incal bx skn ea sep/addl,11107,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,139.32,,,,,,,fee schedule,139.32,3195, Incal bx skn ea sep/addl,11107,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,139.32,3195, Incal bx skn ea sep/addl,11107,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,139.32,3195, Incal bx skn ea sep/addl,11107,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,139.32,3195, Removal of skin tags 2.0 cm,11303,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,320.58,,,,,,,fee schedule,320.58,6979, Shave skin lesion >2.0 cm,11303,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,320.58,6979, Shave skin lesion >2.0 cm,11303,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,320.58,6979, Shave skin lesion >2.0 cm,11303,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,320.58,6979, Shave skin lesion 0.5 cm/<,11305,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,181.95,,,,,,,fee schedule,181.95,6979, Shave skin lesion 0.5 cm/<,11305,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,181.95,6979, Shave skin lesion 0.5 cm/<,11305,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,181.95,6979, Shave skin lesion 0.5 cm/<,11305,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,181.95,6979, Shave skin lesion 0.6-1.0 cm,11306,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,225.55,,,,,,,fee schedule,225.55,6979, Shave skin lesion 0.6-1.0 cm,11306,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,225.55,6979, Shave skin lesion 0.6-1.0 cm,11306,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,225.55,6979, Shave skin lesion 0.6-1.0 cm,11306,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,225.55,6979, Shave skin lesion 1.1-2.0 cm,11307,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,285.45,,,,,,,fee schedule,285.45,6979, Shave skin lesion 1.1-2.0 cm,11307,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,285.45,6979, Shave skin lesion 1.1-2.0 cm,11307,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,285.45,6979, Shave skin lesion 1.1-2.0 cm,11307,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,285.45,6979, Shave skin lesion >2.0 cm,11308,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,332.5,,,,,,,fee schedule,332.5,6979, Shave skin lesion >2.0 cm,11308,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,332.5,6979, Shave skin lesion >2.0 cm,11308,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,332.5,6979, Shave skin lesion >2.0 cm,11308,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,332.5,6979, Shave skin lesion 0.5 cm/<,11310,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,200.89,,,,,,,fee schedule,200.89,6979, Shave skin lesion 0.5 cm/<,11310,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,200.89,6979, Shave skin lesion 0.5 cm/<,11310,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,200.89,6979, Shave skin lesion 0.5 cm/<,11310,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,200.89,6979, Shave skin lesion 0.6-1.0 cm,11311,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,281.24,,,,,,,fee schedule,281.24,6979, Shave skin lesion 0.6-1.0 cm,11311,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,281.24,6979, Shave skin lesion 0.6-1.0 cm,11311,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,281.24,6979, Shave skin lesion 0.6-1.0 cm,11311,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,281.24,6979, Shave skin lesion 1.1-2.0 cm,11312,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,334.77,,,,,,,fee schedule,334.77,6979, Shave skin lesion 1.1-2.0 cm,11312,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,334.77,6979, Shave skin lesion 1.1-2.0 cm,11312,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,334.77,6979, Shave skin lesion 1.1-2.0 cm,11312,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,334.77,6979, Shave skin lesion >2.0 cm,11313,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,427.79,,,,,,,fee schedule,427.79,6979, Shave skin lesion >2.0 cm,11313,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,427.79,6979, Shave skin lesion >2.0 cm,11313,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,427.79,6979, Shave skin lesion >2.0 cm,11313,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,427.79,6979, Exc tr-ext b9+marg 0.5 cm<,11400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,412.42,,,,,,,fee schedule,412.42,4497, Exc tr-ext b9+marg 0.5 cm<,11400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,412.42,4497, Exc tr-ext b9+marg 0.5 cm<,11400,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,412.42,4497, Exc tr-ext b9+marg 0.5 cm<,11400,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,412.42,4497, Exc tr-ext b9+marg 0.6-1 cm,11401,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,513.32,,,,,,,fee schedule,513.32,3195, Exc tr-ext b9+marg 0.6-1 cm,11401,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,513.32,3195, Exc tr-ext b9+marg 0.6-1 cm,11401,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,513.32,3195, Exc tr-ext b9+marg 0.6-1 cm,11401,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,513.32,3195, Exc tr-ext b9+marg 1.1-2 cm,11402,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,557.89,,,,,,,fee schedule,557.89,4497, Exc tr-ext b9+marg 1.1-2 cm,11402,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,557.89,4497, Exc tr-ext b9+marg 1.1-2 cm,11402,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,557.89,4497, Exc tr-ext b9+marg 1.1-2 cm,11402,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,557.89,4497, Exc tr-ext b9+marg 2.1-3cm/<,11403,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,738.39,,,,,,,fee schedule,738.39,4497, Exc tr-ext b9+marg 2.1-3cm/<,11403,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,738.39,4497, Exc tr-ext b9+marg 2.1-3cm/<,11403,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,738.39,4497, Exc tr-ext b9+marg 2.1-3cm/<,11403,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,738.39,4497, Exc tr-ext b9+marg 3.1-4 cm,11404,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,835.79,,,,,,,fee schedule,835.79,5664, Exc tr-ext b9+marg 3.1-4 cm,11404,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,835.79,5664, Exc tr-ext b9+marg 3.1-4 cm,11404,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,835.79,5664, Exc tr-ext b9+marg 3.1-4 cm,11404,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,835.79,5664, Exc tr-ext b9+marg >4.0 cm,11406,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1265.42,,,,,,,fee schedule,1265.42,5664, Exc tr-ext b9+marg >4.0 cm,11406,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1265.42,5664, Exc tr-ext b9+marg >4.0 cm,11406,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1265.42,5664, Exc tr-ext b9+marg >4.0 cm,11406,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1265.42,5664, Exc h-f-nk-sp b9+marg 0.5/<,11420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,411.61,,,,,,,fee schedule,411.61,4497, Exc h-f-nk-sp b9+marg 0.5/<,11420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,411.61,4497, Exc h-f-nk-sp b9+marg 0.5/<,11420,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,411.61,4497, Exc h-f-nk-sp b9+marg 0.5/<,11420,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,411.61,4497, Exc h-f-nk-sp b9+marg 0.6-1,11421,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,538.09,,,,,,,fee schedule,538.09,4497, Exc h-f-nk-sp b9+marg 0.6-1,11421,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,538.09,4497, Exc h-f-nk-sp b9+marg 0.6-1,11421,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,538.09,4497, Exc h-f-nk-sp b9+marg 0.6-1,11421,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,538.09,4497, Exc h-f-nk-sp b9+marg 1.1-2,11422,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,674.66,,,,,,,fee schedule,674.66,4497, Exc h-f-nk-sp b9+marg 1.1-2,11422,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,674.66,4497, Exc h-f-nk-sp b9+marg 1.1-2,11422,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,674.66,4497, Exc h-f-nk-sp b9+marg 1.1-2,11422,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,674.66,4497, Exc h-f-nk-sp b9+marg 2.1-3,11423,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,783.45,,,,,,,fee schedule,783.45,5664, Exc h-f-nk-sp b9+marg 2.1-3,11423,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,783.45,5664, Exc h-f-nk-sp b9+marg 2.1-3,11423,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,783.45,5664, Exc h-f-nk-sp b9+marg 2.1-3,11423,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,783.45,5664, Exc h-f-nk-sp b9+marg 3.1-4,11424,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,906.85,,,,,,,fee schedule,906.85,5664, Exc h-f-nk-sp b9+marg 3.1-4,11424,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,906.85,5664, Exc h-f-nk-sp b9+marg 3.1-4,11424,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,906.85,5664, Exc h-f-nk-sp b9+marg 3.1-4,11424,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,906.85,5664, Exc h-f-nk-sp b9+marg >4 cm,11426,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1357.69,,,,,,,fee schedule,1357.69,10940, Exc h-f-nk-sp b9+marg >4 cm,11426,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1357.69,10940, Exc h-f-nk-sp b9+marg >4 cm,11426,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1357.69,10940, Exc h-f-nk-sp b9+marg >4 cm,11426,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1357.69,10940, Exc face-mm b9+marg 0.5 cm/<,11440,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,523.79,,,,,,,fee schedule,523.79,4497, Exc face-mm b9+marg 0.5 cm/<,11440,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,523.79,4497, Exc face-mm b9+marg 0.5 cm/<,11440,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,523.79,4497, Exc face-mm b9+marg 0.5 cm/<,11440,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,523.79,4497, Exc face-mm b9+marg 0.6-1 cm,11441,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,650.81,,,,,,,fee schedule,650.81,4497, Exc face-mm b9+marg 0.6-1 cm,11441,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,650.81,4497, Exc face-mm b9+marg 0.6-1 cm,11441,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,650.81,4497, Exc face-mm b9+marg 0.6-1 cm,11441,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,650.81,4497, Exc face-mm b9+marg 1.1-2 cm,11442,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,716,,,,,,,fee schedule,716,4497, Exc face-mm b9+marg 1.1-2 cm,11442,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,716,4497, Exc face-mm b9+marg 1.1-2 cm,11442,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,716,4497, Exc face-mm b9+marg 1.1-2 cm,11442,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,716,4497, Exc face-mm b9+marg 2.1-3 cm,11443,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,869.51,,,,,,,fee schedule,869.51,4497, Exc face-mm b9+marg 2.1-3 cm,11443,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,869.51,4497, Exc face-mm b9+marg 2.1-3 cm,11443,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,869.51,4497, Exc face-mm b9+marg 2.1-3 cm,11443,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,869.51,4497, Exc face-mm b9+marg 3.1-4 cm,11444,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1099.17,,,,,,,fee schedule,1099.17,4497, Exc face-mm b9+marg 3.1-4 cm,11444,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1099.17,4497, Exc face-mm b9+marg 3.1-4 cm,11444,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,1099.17,4497, Exc face-mm b9+marg 3.1-4 cm,11444,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,1099.17,4497, Exc face-mm b9+marg >4 cm,11446,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1561.82,,,,,,,fee schedule,1561.82,10940, Exc face-mm b9+marg >4 cm,11446,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1561.82,10940, Exc face-mm b9+marg >4 cm,11446,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1561.82,10940, Exc face-mm b9+marg >4 cm,11446,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1561.82,10940, Removal sweat gland lesion,11450,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1410.51,,,,,,,fee schedule,1410.51,10940, Removal sweat gland lesion,11450,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1410.51,10940, Removal sweat gland lesion,11450,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1410.51,10940, Removal sweat gland lesion,11450,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1410.51,10940, Removal sweat gland lesion,11451,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1783.49,,,,,,,fee schedule,1783.49,10940, Removal sweat gland lesion,11451,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1783.49,10940, Removal sweat gland lesion,11451,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1783.49,10940, Removal sweat gland lesion,11451,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1783.49,10940, Removal sweat gland lesion,11462,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1338.96,,,,,,,fee schedule,1338.96,10940, Removal sweat gland lesion,11462,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1338.96,10940, Removal sweat gland lesion,11462,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1338.96,10940, Removal sweat gland lesion,11462,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1338.96,10940, Removal sweat gland lesion,11463,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1749.28,,,,,,,fee schedule,1749.28,10940, Removal sweat gland lesion,11463,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1749.28,10940, Removal sweat gland lesion,11463,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1749.28,10940, Removal sweat gland lesion,11463,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1749.28,10940, Removal sweat gland lesion,11470,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1555.88,,,,,,,fee schedule,1555.88,10940, Removal sweat gland lesion,11470,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1555.88,10940, Removal sweat gland lesion,11470,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1555.88,10940, Removal sweat gland lesion,11470,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1555.88,10940, Removal sweat gland lesion,11471,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1839.5,,,,,,,fee schedule,1839.5,10940, Removal sweat gland lesion,11471,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1839.5,10940, Removal sweat gland lesion,11471,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1839.5,10940, Removal sweat gland lesion,11471,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1839.5,10940, Exc tr-ext mal+marg 0.5 cm/<,11600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,593.29,,,,,,,fee schedule,593.29,4497, Exc tr-ext mal+marg 0.5 cm/<,11600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,593.29,4497, Exc tr-ext mal+marg 0.5 cm/<,11600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,593.29,4497, Exc tr-ext mal+marg 0.5 cm/<,11600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,593.29,4497, Exc tr-ext mal+marg 0.6-1 cm,11601,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,701.32,,,,,,,fee schedule,701.32,4497, Exc tr-ext mal+marg 0.6-1 cm,11601,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,701.32,4497, Exc tr-ext mal+marg 0.6-1 cm,11601,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,701.32,4497, Exc tr-ext mal+marg 0.6-1 cm,11601,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,701.32,4497, Exc tr-ext mal+marg 1.1-2 cm,11602,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,744.92,,,,,,,fee schedule,744.92,3195, Exc tr-ext mal+marg 1.1-2 cm,11602,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,744.92,3195, Exc tr-ext mal+marg 1.1-2 cm,11602,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,744.92,3195, Exc tr-ext mal+marg 1.1-2 cm,11602,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,744.92,3195, Exc tr-ext mal+marg 2.1-3 cm,11603,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,896.87,,,,,,,fee schedule,896.87,4497, Exc tr-ext mal+marg 2.1-3 cm,11603,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,896.87,4497, Exc tr-ext mal+marg 2.1-3 cm,11603,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,896.87,4497, Exc tr-ext mal+marg 2.1-3 cm,11603,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,896.87,4497, Exc tr-ext mal+marg 3.1-4 cm,11604,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,997.83,,,,,,,fee schedule,997.83,4497, Exc tr-ext mal+marg 3.1-4 cm,11604,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,997.83,4497, Exc tr-ext mal+marg 3.1-4 cm,11604,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,997.83,4497, Exc tr-ext mal+marg 3.1-4 cm,11604,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,997.83,4497, Exc tr-ext mal+marg >4 cm,11606,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1541.37,,,,,,,fee schedule,1541.37,5664, Exc tr-ext mal+marg >4 cm,11606,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1541.37,5664, Exc tr-ext mal+marg >4 cm,11606,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1541.37,5664, Exc tr-ext mal+marg >4 cm,11606,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1541.37,5664, Exc h-f-nk-sp mal+marg 0.5/<,11620,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,596.8,,,,,,,fee schedule,596.8,4497, Exc h-f-nk-sp mal+marg 0.5/<,11620,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,596.8,4497, Exc h-f-nk-sp mal+marg 0.5/<,11620,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,596.8,4497, Exc h-f-nk-sp mal+marg 0.5/<,11620,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,596.8,4497, Exc s/n/h/f/g mal+mrg 0.6-1,11621,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,706.55,,,,,,,fee schedule,706.55,4497, Exc s/n/h/f/g mal+mrg 0.6-1,11621,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,706.55,4497, Exc s/n/h/f/g mal+mrg 0.6-1,11621,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,706.55,4497, Exc s/n/h/f/g mal+mrg 0.6-1,11621,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,706.55,4497, Exc s/n/h/f/g mal+mrg 1.1-2,11622,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,786.9,,,,,,,fee schedule,786.9,4497, Exc s/n/h/f/g mal+mrg 1.1-2,11622,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,786.9,4497, Exc s/n/h/f/g mal+mrg 1.1-2,11622,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,786.9,4497, Exc s/n/h/f/g mal+mrg 1.1-2,11622,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,786.9,4497, Exc s/n/h/f/g mal+mrg 2.1-3,11623,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,978.13,,,,,,,fee schedule,978.13,4497, Exc s/n/h/f/g mal+mrg 2.1-3,11623,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,978.13,4497, Exc s/n/h/f/g mal+mrg 2.1-3,11623,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,978.13,4497, Exc s/n/h/f/g mal+mrg 2.1-3,11623,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,978.13,4497, Exc s/n/h/f/g mal+mrg 3.1-4,11624,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1122.91,,,,,,,fee schedule,1122.91,5664, Exc s/n/h/f/g mal+mrg 3.1-4,11624,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1122.91,5664, Exc s/n/h/f/g mal+mrg 3.1-4,11624,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1122.91,5664, Exc s/n/h/f/g mal+mrg 3.1-4,11624,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1122.91,5664, Exc s/n/h/f/g mal+mrg >4 cm,11626,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1421.74,,,,,,,fee schedule,1421.74,10940, Exc s/n/h/f/g mal+mrg >4 cm,11626,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1421.74,10940, Exc s/n/h/f/g mal+mrg >4 cm,11626,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1421.74,10940, Exc s/n/h/f/g mal+mrg >4 cm,11626,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1421.74,10940, Exc f/e/e/n/l mal+mrg 0.5cm<,11640,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,604.68,,,,,,,fee schedule,604.68,4497, Exc f/e/e/n/l mal+mrg 0.5cm<,11640,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,604.68,4497, Exc f/e/e/n/l mal+mrg 0.5cm<,11640,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,604.68,4497, Exc f/e/e/n/l mal+mrg 0.5cm<,11640,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,604.68,4497, Exc f/e/e/n/l mal+mrg 0.6-1,11641,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,736.82,,,,,,,fee schedule,736.82,4497, Exc f/e/e/n/l mal+mrg 0.6-1,11641,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,736.82,4497, Exc f/e/e/n/l mal+mrg 0.6-1,11641,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,736.82,4497, Exc f/e/e/n/l mal+mrg 0.6-1,11641,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,736.82,4497, Exc f/e/e/n/l mal+mrg 1.1-2,11642,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,847.55,,,,,,,fee schedule,847.55,4497, Exc f/e/e/n/l mal+mrg 1.1-2,11642,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,847.55,4497, Exc f/e/e/n/l mal+mrg 1.1-2,11642,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,847.55,4497, Exc f/e/e/n/l mal+mrg 1.1-2,11642,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,847.55,4497, Exc f/e/e/n/l mal+mrg 2.1-3,11643,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1066.41,,,,,,,fee schedule,1066.41,4497, Exc f/e/e/n/l mal+mrg 2.1-3,11643,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1066.41,4497, Exc f/e/e/n/l mal+mrg 2.1-3,11643,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,1066.41,4497, Exc f/e/e/n/l mal+mrg 2.1-3,11643,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,1066.41,4497, Exc f/e/e/n/l mal+mrg 3.1-4,11644,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1328.82,,,,,,,fee schedule,1328.82,5664, Exc f/e/e/n/l mal+mrg 3.1-4,11644,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1328.82,5664, Exc f/e/e/n/l mal+mrg 3.1-4,11644,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1328.82,5664, Exc f/e/e/n/l mal+mrg 3.1-4,11644,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1328.82,5664, Exc f/e/e/n/l mal+mrg >4 cm,11646,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1859.89,,,,,,,fee schedule,1859.89,10940, Exc f/e/e/n/l mal+mrg >4 cm,11646,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1859.89,10940, Exc f/e/e/n/l mal+mrg >4 cm,11646,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1859.89,10940, Exc f/e/e/n/l mal+mrg >4 cm,11646,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1859.89,10940, Description Not Available,11700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Description Not Available,11701,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Description Not Available,11710,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Description Not Available,11711,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Trim nail(s) any number,11719,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,36.8,,,,,,,fee schedule,36.8,6979, Trim nail(s) any number,11719,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,36.8,6979, Trim nail(s) any number,11719,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,36.8,6979, Trim nail(s) any number,11719,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,36.8,6979, Debride nail 1-5,11720,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,70.9,,,,,,,fee schedule,70.9,3195, Debride nail 1-5,11720,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,70.9,3195, Debride nail 1-5,11720,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,70.9,3195, Debride nail 1-5,11720,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,70.9,3195, Debride nail 6 or more,11721,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,119.41,,,,,,,fee schedule,119.41,3195, Debride nail 6 or more,11721,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,119.41,3195, Debride nail 6 or more,11721,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,119.41,3195, Debride nail 6 or more,11721,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,119.41,3195, Removal of nail plate,11730,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,267.53,,,,,,,fee schedule,267.53,3195, Removal of nail plate,11730,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,267.53,3195, Removal of nail plate,11730,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,267.53,3195, Removal of nail plate,11730,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,267.53,3195, Description Not Available,11731,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Remove nail plate add-on,11732,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,83.42,,,,,,,fee schedule,83.42,3195, Remove nail plate add-on,11732,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,83.42,3195, Remove nail plate add-on,11732,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,83.42,3195, Remove nail plate add-on,11732,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,83.42,3195, Drain blood from under nail,11740,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,167.76,,,,,,,fee schedule,167.76,3195, Drain blood from under nail,11740,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,167.76,3195, Drain blood from under nail,11740,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,167.76,3195, Drain blood from under nail,11740,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,167.76,3195, Removal of nail bed,11750,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,511.92,,,,,,,fee schedule,511.92,3195, Removal of nail bed,11750,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,511.92,3195, Removal of nail bed,11750,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,511.92,3195, Removal of nail bed,11750,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,511.92,3195, Biopsy nail unit,11755,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,301.37,,,,,,,fee schedule,301.37,4497, Biopsy nail unit,11755,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,301.37,4497, Biopsy nail unit,11755,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,301.37,4497, Biopsy nail unit,11755,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,301.37,4497, Repair of nail bed,11760,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,567.17,,,,,,,fee schedule,567.17,3195, Repair of nail bed,11760,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,567.17,3195, Repair of nail bed,11760,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,567.17,3195, Repair of nail bed,11760,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,567.17,3195, Reconstruction of nail bed,11762,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,959.14,,,,,,,fee schedule,959.14,5664, Reconstruction of nail bed,11762,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,959.14,5664, Reconstruction of nail bed,11762,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,959.14,5664, Reconstruction of nail bed,11762,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,959.14,5664, Excision of nail fold toe,11765,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,478.36,,,,,,,fee schedule,478.36,3195, Excision of nail fold toe,11765,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,478.36,3195, Excision of nail fold toe,11765,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,478.36,3195, Excision of nail fold toe,11765,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,478.36,3195, Remove pilonidal cyst simple,11770,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1014.56,,,,,,,fee schedule,1014.56,10940, Remove pilonidal cyst simple,11770,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1014.56,10940, Remove pilonidal cyst simple,11770,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1014.56,10940, Remove pilonidal cyst simple,11770,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1014.56,10940, Remove pilonidal cyst exten,11771,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2467.64,,,,,,,fee schedule,2467.64,10940, Remove pilonidal cyst exten,11771,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2467.64,10940, Remove pilonidal cyst exten,11771,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2467.64,10940, Remove pilonidal cyst exten,11771,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2467.64,10940, Remove pilonidal cyst compl,11772,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3182.88,,,,,,,fee schedule,3182.88,10940, Remove pilonidal cyst compl,11772,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3182.88,10940, Remove pilonidal cyst compl,11772,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3182.88,10940, Remove pilonidal cyst compl,11772,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3182.88,10940, Inject skin lesions <=w 7,11900,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,133.01,,,,,,,fee schedule,133.01,3195, Inject skin lesions <=w 7,11900,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,133.01,3195, Inject skin lesions <=w 7,11900,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,133.01,3195, Inject skin lesions <=w 7,11900,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,133.01,3195, Inject skin lesions >7,11901,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,200.89,,,,,,,fee schedule,200.89,3195, Inject skin lesions >7,11901,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,200.89,3195, Inject skin lesions >7,11901,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,200.89,3195, Inject skin lesions >7,11901,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,200.89,3195, Correct skin color 6.0 cm/<,11920,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,569.01,,,,,,,fee schedule,569.01,3195, Correct skin color 6.0 cm/<,11920,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,569.01,3195, Correct skin color 6.0 cm/<,11920,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,569.01,3195, Correct skin color 6.0 cm/<,11920,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,569.01,3195, Correct skn color 6.1-20.0cm,11921,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,647.3,,,,,,,fee schedule,647.3,3195, Correct skn color 6.1-20.0cm,11921,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,647.3,3195, Correct skn color 6.1-20.0cm,11921,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,647.3,3195, Correct skn color 6.1-20.0cm,11921,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,647.3,3195, Correct skin color ea 20.0cm,11922,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,137.49,,,,,,,fee schedule,137.49,3195, Correct skin color ea 20.0cm,11922,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,137.49,3195, Correct skin color ea 20.0cm,11922,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,137.49,3195, Correct skin color ea 20.0cm,11922,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,137.49,3195, Tx contour defects 1 cc/<,11950,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,250.43,,,,,,,fee schedule,250.43,6979, Tx contour defects 1 cc/<,11950,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,250.43,6979, Tx contour defects 1 cc/<,11950,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,250.43,6979, Tx contour defects 1 cc/<,11950,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,250.43,6979, Tx contour defects 1.1-5.0cc,11951,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,350.36,,,,,,,fee schedule,350.36,6979, Tx contour defects 1.1-5.0cc,11951,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,350.36,6979, Tx contour defects 1.1-5.0cc,11951,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,350.36,6979, Tx contour defects 1.1-5.0cc,11951,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,350.36,6979, Tx contour defects 5.1-10cc,11952,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,494.11,,,,,,,fee schedule,494.11,6979, Tx contour defects 5.1-10cc,11952,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,494.11,6979, Tx contour defects 5.1-10cc,11952,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,494.11,6979, Tx contour defects 5.1-10cc,11952,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,494.11,6979, Tx contour defects >10.0 cc,11954,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,545,,,,,,,fee schedule,545,6979, Tx contour defects >10.0 cc,11954,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,545,6979, Tx contour defects >10.0 cc,11954,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,545,6979, Tx contour defects >10.0 cc,11954,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,545,6979, Insert tissue expander(s),11960,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5175.63,,,,,,,fee schedule,4108,12821, Insert tissue expander(s),11960,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,12821, Insert tissue expander(s),11960,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4108,12821, Insert tissue expander(s),11960,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4108,12821, Replace tissue expander,11970,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2859.93,,,,,,,fee schedule,2859.93,14456, Replace tissue expander,11970,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2859.93,14456, Replace tissue expander,11970,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,2859.93,14456, Replace tissue expander,11970,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,2859.93,14456, Remove tissue expander(s),11971,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2840.78,,,,,,,fee schedule,2840.78,10940, Remove tissue expander(s),11971,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2840.78,10940, Remove tissue expander(s),11971,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2840.78,10940, Remove tissue expander(s),11971,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2840.78,10940, Remove contraceptive capsule,11976,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,456.88,,,,,,,fee schedule,456.88,4497, Remove contraceptive capsule,11976,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,456.88,4497, Remove contraceptive capsule,11976,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,456.88,4497, Remove contraceptive capsule,11976,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,456.88,4497, Implant hormone pellet(s),11980,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,273.09,,,,,,,fee schedule,273.09,3195, Implant hormone pellet(s),11980,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,273.09,3195, Implant hormone pellet(s),11980,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,273.09,3195, Implant hormone pellet(s),11980,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,273.09,3195, Insert drug implant device,11981,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,312.1,,,,,,,fee schedule,312.1,3195, Insert drug implant device,11981,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,312.1,3195, Insert drug implant device,11981,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,312.1,3195, Insert drug implant device,11981,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,312.1,3195, Remove drug implant device,11982,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,358.73,,,,,,,fee schedule,358.73,3195, Remove drug implant device,11982,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,358.73,3195, Remove drug implant device,11982,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,358.73,3195, Remove drug implant device,11982,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,358.73,3195, Remove/insert drug implant,11983,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,506.58,,,,,,,fee schedule,506.58,3195, Remove/insert drug implant,11983,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,506.58,3195, Remove/insert drug implant,11983,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,506.58,3195, Remove/insert drug implant,11983,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,506.58,3195, Rpr s/n/ax/gen/trnk 2.5cm/<,12001,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,251.67,,,,,,,fee schedule,251.67,3195, Rpr s/n/ax/gen/trnk 2.5cm/<,12001,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,251.67,3195, Rpr s/n/ax/gen/trnk 2.5cm/<,12001,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,251.67,3195, Rpr s/n/ax/gen/trnk 2.5cm/<,12001,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,251.67,3195, Rpr s/n/ax/gen/trnk2.6-7.5cm,12002,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,328.83,,,,,,,fee schedule,328.83,6979, Rpr s/n/ax/gen/trnk2.6-7.5cm,12002,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,328.83,6979, Rpr s/n/ax/gen/trnk2.6-7.5cm,12002,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,328.83,6979, Rpr s/n/ax/gen/trnk2.6-7.5cm,12002,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,328.83,6979, Rpr s/n/ax/gen/trk7.6-12.5cm,12004,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,415.82,,,,,,,fee schedule,415.82,3195, Rpr s/n/ax/gen/trk7.6-12.5cm,12004,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,415.82,3195, Rpr s/n/ax/gen/trk7.6-12.5cm,12004,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,415.82,3195, Rpr s/n/ax/gen/trk7.6-12.5cm,12004,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,415.82,3195, Rpr s/n/a/gen/trk12.6-20.0cm,12005,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,521.09,,,,,,,fee schedule,521.09,4108, Rpr s/n/a/gen/trk12.6-20.0cm,12005,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,521.09,4108, Rpr s/n/a/gen/trk12.6-20.0cm,12005,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,521.09,4108, Rpr s/n/a/gen/trk12.6-20.0cm,12005,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,521.09,4108, Rpr s/n/a/gen/trk20.1-30.0cm,12006,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,632.2,,,,,,,fee schedule,632.2,4108, Rpr s/n/a/gen/trk20.1-30.0cm,12006,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,632.2,4108, Rpr s/n/a/gen/trk20.1-30.0cm,12006,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,632.2,4108, Rpr s/n/a/gen/trk20.1-30.0cm,12006,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,632.2,4108, Rpr s/n/ax/gen/trnk >30.0 cm,12007,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,774.49,,,,,,,fee schedule,774.49,4108, Rpr s/n/ax/gen/trnk >30.0 cm,12007,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,774.49,4108, Rpr s/n/ax/gen/trnk >30.0 cm,12007,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,774.49,4108, Rpr s/n/ax/gen/trnk >30.0 cm,12007,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,774.49,4108, Rpr f/e/e/n/l/m 2.5 cm/<,12011,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,311.78,,,,,,,fee schedule,311.78,6979, Rpr f/e/e/n/l/m 2.5 cm/<,12011,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,311.78,6979, Rpr f/e/e/n/l/m 2.5 cm/<,12011,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,311.78,6979, Rpr f/e/e/n/l/m 2.5 cm/<,12011,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,311.78,6979, Rpr f/e/e/n/l/m 2.6-5.0 cm,12013,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,323.81,,,,,,,fee schedule,323.81,6979, Rpr f/e/e/n/l/m 2.6-5.0 cm,12013,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,323.81,6979, Rpr f/e/e/n/l/m 2.6-5.0 cm,12013,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,323.81,6979, Rpr f/e/e/n/l/m 2.6-5.0 cm,12013,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,323.81,6979, Rpr f/e/e/n/l/m 5.1-7.5 cm,12014,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,419.81,,,,,,,fee schedule,419.81,3195, Rpr f/e/e/n/l/m 5.1-7.5 cm,12014,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,419.81,3195, Rpr f/e/e/n/l/m 5.1-7.5 cm,12014,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,419.81,3195, Rpr f/e/e/n/l/m 5.1-7.5 cm,12014,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,419.81,3195, Rpr f/e/e/n/l/m 7.6-12.5 cm,12015,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,523.9,,,,,,,fee schedule,523.9,3195, Rpr f/e/e/n/l/m 7.6-12.5 cm,12015,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,523.9,3195, Rpr f/e/e/n/l/m 7.6-12.5 cm,12015,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,523.9,3195, Rpr f/e/e/n/l/m 7.6-12.5 cm,12015,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,523.9,3195, Rpr fe/e/en/l/m 12.6-20.0 cm,12016,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,711.46,,,,,,,fee schedule,711.46,4108, Rpr fe/e/en/l/m 12.6-20.0 cm,12016,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,711.46,4108, Rpr fe/e/en/l/m 12.6-20.0 cm,12016,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,711.46,4108, Rpr fe/e/en/l/m 12.6-20.0 cm,12016,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,711.46,4108, Rpr fe/e/en/l/m 20.1-30.0 cm,12017,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,897.52,,,,,,,fee schedule,897.52,4108, Rpr fe/e/en/l/m 20.1-30.0 cm,12017,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,897.52,4108, Rpr fe/e/en/l/m 20.1-30.0 cm,12017,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,897.52,4108, Rpr fe/e/en/l/m 20.1-30.0 cm,12017,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,897.52,4108, Rpr f/e/e/n/l/m >30.0 cm,12018,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1012.34,,,,,,,fee schedule,1012.34,4108, Rpr f/e/e/n/l/m >30.0 cm,12018,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1012.34,4108, Rpr f/e/e/n/l/m >30.0 cm,12018,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1012.34,4108, Rpr f/e/e/n/l/m >30.0 cm,12018,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1012.34,4108, Closure of split wound,12020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,984.82,,,,,,,fee schedule,984.82,3195, Closure of split wound,12020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,984.82,3195, Closure of split wound,12020,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,984.82,3195, Closure of split wound,12020,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,984.82,3195, Closure of split wound,12021,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,741.52,,,,,,,fee schedule,741.52,3195, Closure of split wound,12021,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,741.52,3195, Closure of split wound,12021,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,741.52,3195, Closure of split wound,12021,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,741.52,3195, Intmd rpr s/a/t/ext 2.5 cm/<,12031,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,725.6,,,,,,,fee schedule,725.6,3195, Intmd rpr s/a/t/ext 2.5 cm/<,12031,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,725.6,3195, Intmd rpr s/a/t/ext 2.5 cm/<,12031,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,725.6,3195, Intmd rpr s/a/t/ext 2.5 cm/<,12031,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,725.6,3195, Intmd rpr s/a/t/ext 2.6-7.5,12032,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,896.33,,,,,,,fee schedule,896.33,3195, Intmd rpr s/a/t/ext 2.6-7.5,12032,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,896.33,3195, Intmd rpr s/a/t/ext 2.6-7.5,12032,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,896.33,3195, Intmd rpr s/a/t/ext 2.6-7.5,12032,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,896.33,3195, Intmd rpr s/tr/ext 7.6-12.5,12034,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,990.17,,,,,,,fee schedule,990.17,4108, Intmd rpr s/tr/ext 7.6-12.5,12034,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,990.17,4108, Intmd rpr s/tr/ext 7.6-12.5,12034,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,990.17,4108, Intmd rpr s/tr/ext 7.6-12.5,12034,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,990.17,4108, Intmd rpr s/a/t/ext 12.6-20,12035,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1246.04,,,,,,,fee schedule,1246.04,4108, Intmd rpr s/a/t/ext 12.6-20,12035,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1246.04,4108, Intmd rpr s/a/t/ext 12.6-20,12035,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1246.04,4108, Intmd rpr s/a/t/ext 12.6-20,12035,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1246.04,4108, Intmd rpr s/a/t/ext 20.1-30,12036,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1515.3,,,,,,,fee schedule,1515.3,4108, Intmd rpr s/a/t/ext 20.1-30,12036,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1515.3,4108, Intmd rpr s/a/t/ext 20.1-30,12036,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1515.3,4108, Intmd rpr s/a/t/ext 20.1-30,12036,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1515.3,4108, Intmd rpr s/tr/ext >30.0 cm,12037,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1731.09,,,,,,,fee schedule,1731.09,5664, Intmd rpr s/tr/ext >30.0 cm,12037,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1731.09,5664, Intmd rpr s/tr/ext >30.0 cm,12037,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1731.09,5664, Intmd rpr s/tr/ext >30.0 cm,12037,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1731.09,5664, Intmd rpr n-hf/genit 2.5cm/<,12041,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,707.69,,,,,,,fee schedule,707.69,3195, Intmd rpr n-hf/genit 2.5cm/<,12041,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,707.69,3195, Intmd rpr n-hf/genit 2.5cm/<,12041,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,707.69,3195, Intmd rpr n-hf/genit 2.5cm/<,12041,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,707.69,3195, Intmd rpr n-hf/genit2.6-7.5,12042,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,919.53,,,,,,,fee schedule,919.53,3195, Intmd rpr n-hf/genit2.6-7.5,12042,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,919.53,3195, Intmd rpr n-hf/genit2.6-7.5,12042,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,919.53,3195, Intmd rpr n-hf/genit2.6-7.5,12042,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,919.53,3195, Intmd rpr n-hf/genit7.6-12.5,12044,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1051.9,,,,,,,fee schedule,1051.9,4108, Intmd rpr n-hf/genit7.6-12.5,12044,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1051.9,4108, Intmd rpr n-hf/genit7.6-12.5,12044,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1051.9,4108, Intmd rpr n-hf/genit7.6-12.5,12044,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1051.9,4108, Intmd rpr n-hf/genit12.6-20,12045,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1483.36,,,,,,,fee schedule,1483.36,4108, Intmd rpr n-hf/genit12.6-20,12045,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1483.36,4108, Intmd rpr n-hf/genit12.6-20,12045,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1483.36,4108, Intmd rpr n-hf/genit12.6-20,12045,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1483.36,4108, Intmd rpr n-hf/genit20.1-30,12046,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1759.85,,,,,,,fee schedule,1759.85,4497, Intmd rpr n-hf/genit20.1-30,12046,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1759.85,4497, Intmd rpr n-hf/genit20.1-30,12046,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,1759.85,4497, Intmd rpr n-hf/genit20.1-30,12046,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,1759.85,4497, Intmd rpr n-hf/genit >30.0cm,12047,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1948.82,,,,,,,fee schedule,1948.82,5664, Intmd rpr n-hf/genit >30.0cm,12047,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1948.82,5664, Intmd rpr n-hf/genit >30.0cm,12047,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1948.82,5664, Intmd rpr n-hf/genit >30.0cm,12047,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1948.82,5664, Intmd rpr face/mm 2.5 cm/<,12051,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,816.79,,,,,,,fee schedule,816.79,3195, Intmd rpr face/mm 2.5 cm/<,12051,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,816.79,3195, Intmd rpr face/mm 2.5 cm/<,12051,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,816.79,3195, Intmd rpr face/mm 2.5 cm/<,12051,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,816.79,3195, Intmd rpr face/mm 2.6-5.0 cm,12052,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,946.51,,,,,,,fee schedule,946.51,3195, Intmd rpr face/mm 2.6-5.0 cm,12052,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,946.51,3195, Intmd rpr face/mm 2.6-5.0 cm,12052,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,946.51,3195, Intmd rpr face/mm 2.6-5.0 cm,12052,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,946.51,3195, Intmd rpr face/mm 5.1-7.5 cm,12053,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1027.83,,,,,,,fee schedule,1027.83,3195, Intmd rpr face/mm 5.1-7.5 cm,12053,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1027.83,3195, Intmd rpr face/mm 5.1-7.5 cm,12053,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1027.83,3195, Intmd rpr face/mm 5.1-7.5 cm,12053,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1027.83,3195, Intmd rpr face/mm 7.6-12.5cm,12054,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1093.88,,,,,,,fee schedule,1093.88,4108, Intmd rpr face/mm 7.6-12.5cm,12054,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1093.88,4108, Intmd rpr face/mm 7.6-12.5cm,12054,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1093.88,4108, Intmd rpr face/mm 7.6-12.5cm,12054,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1093.88,4108, Intmd rpr face/mm 12.6-20 cm,12055,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1639.52,,,,,,,fee schedule,1639.52,4108, Intmd rpr face/mm 12.6-20 cm,12055,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1639.52,4108, Intmd rpr face/mm 12.6-20 cm,12055,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1639.52,4108, Intmd rpr face/mm 12.6-20 cm,12055,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1639.52,4108, Intmd rpr face/mm 20.1-30.0,12056,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1934.47,,,,,,,fee schedule,1934.47,4108, Intmd rpr face/mm 20.1-30.0,12056,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1934.47,4108, Intmd rpr face/mm 20.1-30.0,12056,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1934.47,4108, Intmd rpr face/mm 20.1-30.0,12056,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1934.47,4108, Intmd rpr face/mm >30.0 cm,12057,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2126.67,,,,,,,fee schedule,2126.67,4108, Intmd rpr face/mm >30.0 cm,12057,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2126.67,4108, Intmd rpr face/mm >30.0 cm,12057,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2126.67,4108, Intmd rpr face/mm >30.0 cm,12057,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2126.67,4108, Cmplx rpr trunk 1.1-2.5 cm,13100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,942.63,,,,,,,fee schedule,942.63,4108, Cmplx rpr trunk 1.1-2.5 cm,13100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,942.63,4108, Cmplx rpr trunk 1.1-2.5 cm,13100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,942.63,4108, Cmplx rpr trunk 1.1-2.5 cm,13100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,942.63,4108, Cmplx rpr trunk 2.6-7.5 cm,13101,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1150.27,,,,,,,fee schedule,1150.27,5248, Cmplx rpr trunk 2.6-7.5 cm,13101,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1150.27,5248, Cmplx rpr trunk 2.6-7.5 cm,13101,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1150.27,5248, Cmplx rpr trunk 2.6-7.5 cm,13101,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1150.27,5248, Cmplx rpr trunk addl 5cm/<,13102,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,337.74,,,,,,,fee schedule,337.74,3195, Cmplx rpr trunk addl 5cm/<,13102,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,337.74,3195, Cmplx rpr trunk addl 5cm/<,13102,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,337.74,3195, Cmplx rpr trunk addl 5cm/<,13102,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,337.74,3195, Cmplx rpr s/a/l 1.1-2.5 cm,13120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1085.89,,,,,,,fee schedule,1085.89,4108, Cmplx rpr s/a/l 1.1-2.5 cm,13120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1085.89,4108, Cmplx rpr s/a/l 1.1-2.5 cm,13120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1085.89,4108, Cmplx rpr s/a/l 1.1-2.5 cm,13120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1085.89,4108, Cmplx rpr s/a/l 2.6-7.5 cm,13121,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1185.66,,,,,,,fee schedule,1185.66,5248, Cmplx rpr s/a/l 2.6-7.5 cm,13121,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1185.66,5248, Cmplx rpr s/a/l 2.6-7.5 cm,13121,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1185.66,5248, Cmplx rpr s/a/l 2.6-7.5 cm,13121,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1185.66,5248, Cmplx rpr s/a/l addl 5 cm/>,13122,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,381.55,,,,,,,fee schedule,381.55,3195, Cmplx rpr s/a/l addl 5 cm/>,13122,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,381.55,3195, Cmplx rpr s/a/l addl 5 cm/>,13122,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,381.55,3195, Cmplx rpr s/a/l addl 5 cm/>,13122,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,381.55,3195, Cmplx rpr f/c/c/m/n/ax/g/h/f,13131,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1124.04,,,,,,,fee schedule,1124.04,4108, Cmplx rpr f/c/c/m/n/ax/g/h/f,13131,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1124.04,4108, Cmplx rpr f/c/c/m/n/ax/g/h/f,13131,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1124.04,4108, Cmplx rpr f/c/c/m/n/ax/g/h/f,13131,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1124.04,4108, Cmplx rpr f/c/c/m/n/ax/g/h/f,13132,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1382.94,,,,,,,fee schedule,1382.94,5248, Cmplx rpr f/c/c/m/n/ax/g/h/f,13132,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1382.94,5248, Cmplx rpr f/c/c/m/n/ax/g/h/f,13132,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1382.94,5248, Cmplx rpr f/c/c/m/n/ax/g/h/f,13132,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1382.94,5248, Cmplx rpr f/c/c/m/n/ax/g/h/f,13133,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,570.84,,,,,,,fee schedule,570.84,3195, Cmplx rpr f/c/c/m/n/ax/g/h/f,13133,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,570.84,3195, Cmplx rpr f/c/c/m/n/ax/g/h/f,13133,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,570.84,3195, Cmplx rpr f/c/c/m/n/ax/g/h/f,13133,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,570.84,3195, Cmplx rpr e/n/e/l 1.1-2.5 cm,13151,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1285.49,,,,,,,fee schedule,1285.49,5248, Cmplx rpr e/n/e/l 1.1-2.5 cm,13151,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1285.49,5248, Cmplx rpr e/n/e/l 1.1-2.5 cm,13151,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1285.49,5248, Cmplx rpr e/n/e/l 1.1-2.5 cm,13151,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1285.49,5248, Cmplx rpr e/n/e/l 2.6-7.5 cm,13152,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1538.45,,,,,,,fee schedule,1538.45,5248, Cmplx rpr e/n/e/l 2.6-7.5 cm,13152,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1538.45,5248, Cmplx rpr e/n/e/l 2.6-7.5 cm,13152,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1538.45,5248, Cmplx rpr e/n/e/l 2.6-7.5 cm,13152,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1538.45,5248, Cmplx rpr e/n/e/l addl 5cm/<,13153,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,639.7,,,,,,,fee schedule,639.7,5248, Cmplx rpr e/n/e/l addl 5cm/<,13153,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,639.7,5248, Cmplx rpr e/n/e/l addl 5cm/<,13153,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,639.7,5248, Cmplx rpr e/n/e/l addl 5cm/<,13153,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,639.7,5248, Late closure of wound,13160,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4121.79,,,,,,,fee schedule,4108,5664, Late closure of wound,13160,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,5664, Late closure of wound,13160,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4108,5664, Late closure of wound,13160,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4108,5664, Description Not Available,13300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Tis trnfr trunk 10 sq cm/<,14000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2556.84,,,,,,,fee schedule,2556.84,5664, Tis trnfr trunk 10 sq cm/<,14000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2556.84,5664, Tis trnfr trunk 10 sq cm/<,14000,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2556.84,5664, Tis trnfr trunk 10 sq cm/<,14000,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2556.84,5664, Tis trnfr trunk 10.1-30sqcm,14001,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3333.43,,,,,,,fee schedule,3333.43,5664, Tis trnfr trunk 10.1-30sqcm,14001,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3333.43,5664, Tis trnfr trunk 10.1-30sqcm,14001,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3333.43,5664, Tis trnfr trunk 10.1-30sqcm,14001,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3333.43,5664, Tis trnfr s/a/l 10 sq cm/<,14020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2757.9,,,,,,,fee schedule,2757.9,5664, Tis trnfr s/a/l 10 sq cm/<,14020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2757.9,5664, Tis trnfr s/a/l 10 sq cm/<,14020,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2757.9,5664, Tis trnfr s/a/l 10 sq cm/<,14020,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2757.9,5664, Tis trnfr s/a/l 10.1-30 sqcm,14021,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3403.96,,,,,,,fee schedule,3403.96,5664, Tis trnfr s/a/l 10.1-30 sqcm,14021,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3403.96,5664, Tis trnfr s/a/l 10.1-30 sqcm,14021,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3403.96,5664, Tis trnfr s/a/l 10.1-30 sqcm,14021,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3403.96,5664, Tis trnfr f/c/c/m/n/a/g/h/f,14040,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2989.17,,,,,,,fee schedule,2989.17,5664, Tis trnfr f/c/c/m/n/a/g/h/f,14040,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2989.17,5664, Tis trnfr f/c/c/m/n/a/g/h/f,14040,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2989.17,5664, Tis trnfr f/c/c/m/n/a/g/h/f,14040,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2989.17,5664, Tis trnfr f/c/c/m/n/a/g/h/f,14041,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3576.68,,,,,,,fee schedule,3576.68,5664, Tis trnfr f/c/c/m/n/a/g/h/f,14041,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3576.68,5664, Tis trnfr f/c/c/m/n/a/g/h/f,14041,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3576.68,5664, Tis trnfr f/c/c/m/n/a/g/h/f,14041,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3576.68,5664, Tis trnfr e/n/e/l 10 sq cm/<,14060,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3135.29,,,,,,,fee schedule,3135.29,5664, Tis trnfr e/n/e/l 10 sq cm/<,14060,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3135.29,5664, Tis trnfr e/n/e/l 10 sq cm/<,14060,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3135.29,5664, Tis trnfr e/n/e/l 10 sq cm/<,14060,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3135.29,5664, Tis trnfr e/n/e/l10.1-30sqcm,14061,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3824.42,,,,,,,fee schedule,3824.42,5664, Tis trnfr e/n/e/l10.1-30sqcm,14061,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3824.42,5664, Tis trnfr e/n/e/l10.1-30sqcm,14061,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3824.42,5664, Tis trnfr e/n/e/l10.1-30sqcm,14061,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3824.42,5664, Tis trnfr any 30.1-60 sq cm,14301,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4261.81,,,,,,,fee schedule,4261.81,12821, Tis trnfr any 30.1-60 sq cm,14301,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4261.81,12821, Tis trnfr any 30.1-60 sq cm,14301,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4261.81,12821, Tis trnfr any 30.1-60 sq cm,14301,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4261.81,12821, Tis trnfr addl 30 sq cm/<,14302,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1036.41,,,,,,,fee schedule,1036.41,3195, Tis trnfr addl 30 sq cm/<,14302,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1036.41,3195, Tis trnfr addl 30 sq cm/<,14302,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1036.41,3195, Tis trnfr addl 30 sq cm/<,14302,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1036.41,3195, Filleted finger/toe flap,14350,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3366.89,,,,,,,fee schedule,3366.89,5664, Filleted finger/toe flap,14350,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3366.89,5664, Filleted finger/toe flap,14350,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3366.89,5664, Filleted finger/toe flap,14350,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3366.89,5664, Wound prep trk/arm/leg,15002,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1108.88,,,,,,,fee schedule,1108.88,5664, Wound prep trk/arm/leg,15002,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1108.88,5664, Wound prep trk/arm/leg,15002,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1108.88,5664, Wound prep trk/arm/leg,15002,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1108.88,5664, Wound prep addl 100 cm,15003,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,228.95,,,,,,,fee schedule,228.95,3195, Wound prep addl 100 cm,15003,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,228.95,3195, Wound prep addl 100 cm,15003,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,228.95,3195, Wound prep addl 100 cm,15003,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,228.95,3195, Wound prep f/n/hf/g,15004,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1276.86,,,,,,,fee schedule,1276.86,4108, Wound prep f/n/hf/g,15004,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1276.86,4108, Wound prep f/n/hf/g,15004,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1276.86,4108, Wound prep f/n/hf/g,15004,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1276.86,4108, Wnd prep f/n/hf/g addl cm,15005,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,449.06,,,,,,,fee schedule,449.06,3195, Wnd prep f/n/hf/g addl cm,15005,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,449.06,3195, Wnd prep f/n/hf/g addl cm,15005,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,449.06,3195, Wnd prep f/n/hf/g addl cm,15005,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,449.06,3195, Hrv skn cll ssp agrft 1st 25,15011,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,5664, Hrv skn cll ssp agrft 1st 25,15011,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4108,5664, Hrv skn cll ssp agrft 1st 25,15011,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4108,5664, Hrv skn cll ssp agrft ea add,15012,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Hrv skn cll ssp agrft ea add,15012,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Hrv skn cll ssp agrft ea add,15012,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Prepj skn cll ssp agrft 1st,15013,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,22111, Prepj skn cll ssp agrft 1st,15013,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6979,22111, Prepj skn cll ssp agrft 1st,15013,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6979,22111, Prepj skn cll ssp agrft ea,15014,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,2782, Prepj skn cll ssp agrft ea,15014,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,2782, App skn cl ssp agrft t/a/l 1,15015,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,5664, App skn cl ssp agrft t/a/l 1,15015,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4108,5664, App skn cl ssp agrft t/a/l 1,15015,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4108,5664, App skn cl ssp agrf t/a/l ea,15016,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, App skn cl ssp agrf t/a/l ea,15016,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, App skn cl ssp agrf t/a/l ea,15016,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, App skn cll ssp f/n/g/hf 1st,15017,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,5664, App skn cll ssp f/n/g/hf 1st,15017,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4108,5664, App skn cll ssp f/n/g/hf 1st,15017,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4108,5664, App skn cll ssp f/n/g/hf ea,15018,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, App skn cll ssp f/n/g/hf ea,15018,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, App skn cll ssp f/n/g/hf ea,15018,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Harvest cultured skin graft,15040,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,640.45,,,,,,,fee schedule,640.45,5664, Harvest cultured skin graft,15040,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,640.45,5664, Harvest cultured skin graft,15040,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,640.45,5664, Harvest cultured skin graft,15040,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,640.45,5664, Skin pinch graft,15050,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2344.4,,,,,,,fee schedule,2344.4,4108, Skin pinch graft,15050,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2344.4,4108, Skin pinch graft,15050,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2344.4,4108, Skin pinch graft,15050,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2344.4,4108, Skin splt grft trnk/arm/leg,15100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3671.22,,,,,,,fee schedule,3671.22,5664, Skin splt grft trnk/arm/leg,15100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3671.22,5664, Skin splt grft trnk/arm/leg,15100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3671.22,5664, Skin splt grft trnk/arm/leg,15100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3671.22,5664, Skin splt grft t/a/l add-on,15101,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,569.39,,,,,,,fee schedule,569.39,5248, Skin splt grft t/a/l add-on,15101,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,569.39,5248, Skin splt grft t/a/l add-on,15101,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,569.39,5248, Skin splt grft t/a/l add-on,15101,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,569.39,5248, Epidrm autogrft trnk/arm/leg,15110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3764.03,,,,,,,fee schedule,3764.03,5664, Epidrm autogrft trnk/arm/leg,15110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3764.03,5664, Epidrm autogrft trnk/arm/leg,15110,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3764.03,5664, Epidrm autogrft trnk/arm/leg,15110,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3764.03,5664, Epidrm autogrft t/a/l add-on,15111,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,522.6,,,,,,,fee schedule,522.6,3195, Epidrm autogrft t/a/l add-on,15111,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,522.6,3195, Epidrm autogrft t/a/l add-on,15111,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,522.6,3195, Epidrm autogrft t/a/l add-on,15111,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,522.6,3195, Epidrm a-grft face/nck/hf/g,15115,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3633.67,,,,,,,fee schedule,3633.67,5664, Epidrm a-grft face/nck/hf/g,15115,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3633.67,5664, Epidrm a-grft face/nck/hf/g,15115,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3633.67,5664, Epidrm a-grft face/nck/hf/g,15115,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3633.67,5664, Epidrm a-grft f/n/hf/g addl,15116,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,706.93,,,,,,,fee schedule,706.93,3195, Epidrm a-grft f/n/hf/g addl,15116,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,706.93,3195, Epidrm a-grft f/n/hf/g addl,15116,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,706.93,3195, Epidrm a-grft f/n/hf/g addl,15116,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,706.93,3195, Skn splt a-grft fac/nck/hf/g,15120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3411.24,,,,,,,fee schedule,3411.24,12821, Skn splt a-grft fac/nck/hf/g,15120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3411.24,12821, Skn splt a-grft fac/nck/hf/g,15120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3411.24,12821, Skn splt a-grft fac/nck/hf/g,15120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3411.24,12821, Skn splt a-grft f/n/hf/g add,15121,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,671.96,,,,,,,fee schedule,671.96,5248, Skn splt a-grft f/n/hf/g add,15121,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,671.96,5248, Skn splt a-grft f/n/hf/g add,15121,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,671.96,5248, Skn splt a-grft f/n/hf/g add,15121,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,671.96,5248, Derm autograft trnk/arm/leg,15130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3030.83,,,,,,,fee schedule,3030.83,10940, Derm autograft trnk/arm/leg,15130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3030.83,10940, Derm autograft trnk/arm/leg,15130,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3030.83,10940, Derm autograft trnk/arm/leg,15130,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3030.83,10940, Derm autograft t/a/l add-on,15131,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,424.88,,,,,,,fee schedule,424.88,3195, Derm autograft t/a/l add-on,15131,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,424.88,3195, Derm autograft t/a/l add-on,15131,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,424.88,3195, Derm autograft t/a/l add-on,15131,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,424.88,3195, Derm autograft face/nck/hf/g,15135,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3721.03,,,,,,,fee schedule,3721.03,12821, Derm autograft face/nck/hf/g,15135,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3721.03,12821, Derm autograft face/nck/hf/g,15135,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3721.03,12821, Derm autograft face/nck/hf/g,15135,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3721.03,12821, Derm autograft f/n/hf/g add,15136,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,424.88,,,,,,,fee schedule,424.88,3195, Derm autograft f/n/hf/g add,15136,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,424.88,3195, Derm autograft f/n/hf/g add,15136,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,424.88,3195, Derm autograft f/n/hf/g add,15136,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,424.88,3195, Cult skin grft t/arm/leg,15150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3499.31,,,,,,,fee schedule,3499.31,5664, Cult skin grft t/arm/leg,15150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3499.31,5664, Cult skin grft t/arm/leg,15150,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3499.31,5664, Cult skin grft t/arm/leg,15150,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3499.31,5664, Cult skin grft t/a/l addl,15151,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,567.88,,,,,,,fee schedule,567.88,3195, Cult skin grft t/a/l addl,15151,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,567.88,3195, Cult skin grft t/a/l addl,15151,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,567.88,3195, Cult skin grft t/a/l addl,15151,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,567.88,3195, Cult skin graft t/a/l +%,15152,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,714.81,,,,,,,fee schedule,714.81,3195, Cult skin graft t/a/l +%,15152,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,714.81,3195, Cult skin graft t/a/l +%,15152,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,714.81,3195, Cult skin graft t/a/l +%,15152,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,714.81,3195, Cult skin graft f/n/hf/g,15155,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3648.02,,,,,,,fee schedule,3648.02,12821, Cult skin graft f/n/hf/g,15155,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3648.02,12821, Cult skin graft f/n/hf/g,15155,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3648.02,12821, Cult skin graft f/n/hf/g,15155,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3648.02,12821, Cult skin grft f/n/hfg add,15156,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,787.33,,,,,,,fee schedule,787.33,3195, Cult skin grft f/n/hfg add,15156,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,787.33,3195, Cult skin grft f/n/hfg add,15156,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,787.33,3195, Cult skin grft f/n/hfg add,15156,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,787.33,3195, Cult epiderm grft f/n/hfg +%,15157,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,864.44,,,,,,,fee schedule,864.44,3195, Cult epiderm grft f/n/hfg +%,15157,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,864.44,3195, Cult epiderm grft f/n/hfg +%,15157,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,864.44,3195, Cult epiderm grft f/n/hfg +%,15157,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,864.44,3195, Skin full graft trunk,15200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3340.72,,,,,,,fee schedule,3340.72,10940, Skin full graft trunk,15200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3340.72,10940, Skin full graft trunk,15200,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3340.72,10940, Skin full graft trunk,15200,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3340.72,10940, Skin full graft trunk add-on,15201,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,367.14,,,,,,,fee schedule,367.14,4108, Skin full graft trunk add-on,15201,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,367.14,4108, Skin full graft trunk add-on,15201,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,367.14,4108, Skin full graft trunk add-on,15201,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,367.14,4108, Skin full graft sclp/arm/leg,15220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2947.03,,,,,,,fee schedule,2947.03,5664, Skin full graft sclp/arm/leg,15220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2947.03,5664, Skin full graft sclp/arm/leg,15220,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2947.03,5664, Skin full graft sclp/arm/leg,15220,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2947.03,5664, Skin full graft add-on,15221,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,327,,,,,,,fee schedule,327,4108, Skin full graft add-on,15221,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,327,4108, Skin full graft add-on,15221,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,327,4108, Skin full graft add-on,15221,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,327,4108, Skin full grft face/genit/hf,15240,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3812.71,,,,,,,fee schedule,3812.71,5664, Skin full grft face/genit/hf,15240,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3812.71,5664, Skin full grft face/genit/hf,15240,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3812.71,5664, Skin full grft face/genit/hf,15240,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3812.71,5664, Skin full graft add-on,15241,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,504.69,,,,,,,fee schedule,504.69,5248, Skin full graft add-on,15241,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,504.69,5248, Skin full graft add-on,15241,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,504.69,5248, Skin full graft add-on,15241,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,504.69,5248, Skin full graft een & lips,15260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3971.89,,,,,,,fee schedule,3971.89,5664, Skin full graft een & lips,15260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3971.89,5664, Skin full graft een & lips,15260,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3971.89,5664, Skin full graft een & lips,15260,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3971.89,5664, Skin full graft add-on,15261,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,627.45,,,,,,,fee schedule,627.45,4108, Skin full graft add-on,15261,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,627.45,4108, Skin full graft add-on,15261,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,627.45,4108, Skin full graft add-on,15261,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,627.45,4108, Skin sub graft trnk/arm/leg,15271,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,419.97,,,,,,,fee schedule,419.97,5664, Skin sub graft trnk/arm/leg,15271,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,419.97,5664, Skin sub graft trnk/arm/leg,15271,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,419.97,5664, Skin sub graft trnk/arm/leg,15271,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,419.97,5664, Skin sub graft t/a/l add-on,15272,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,83.26,,,,,,,fee schedule,83.26,3195, Skin sub graft t/a/l add-on,15272,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,83.26,3195, Skin sub graft t/a/l add-on,15272,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,83.26,3195, Skin sub graft t/a/l add-on,15272,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,83.26,3195, Skin sub grft t/arm/lg child,15273,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,973.82,,,,,,,fee schedule,973.82,12821, Skin sub grft t/arm/lg child,15273,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,973.82,12821, Skin sub grft t/arm/lg child,15273,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,973.82,12821, Skin sub grft t/arm/lg child,15273,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,973.82,12821, Skn sub grft t/a/l child add,15274,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,224.53,,,,,,,fee schedule,224.53,3195, Skn sub grft t/a/l child add,15274,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,224.53,3195, Skn sub grft t/a/l child add,15274,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,224.53,3195, Skn sub grft t/a/l child add,15274,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,224.53,3195, Skin sub graft face/nk/hf/g,15275,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,468.05,,,,,,,fee schedule,468.05,5664, Skin sub graft face/nk/hf/g,15275,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,468.05,5664, Skin sub graft face/nk/hf/g,15275,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,468.05,5664, Skin sub graft face/nk/hf/g,15275,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,468.05,5664, Skin sub graft f/n/hf/g addl,15276,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,124.49,,,,,,,fee schedule,124.49,3195, Skin sub graft f/n/hf/g addl,15276,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,124.49,3195, Skin sub graft f/n/hf/g addl,15276,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,124.49,3195, Skin sub graft f/n/hf/g addl,15276,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,124.49,3195, Skn sub grft f/n/hf/g child,15277,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1119.24,,,,,,,fee schedule,1119.24,5664, Skn sub grft f/n/hf/g child,15277,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1119.24,5664, Skn sub grft f/n/hf/g child,15277,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1119.24,5664, Skn sub grft f/n/hf/g child,15277,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1119.24,5664, Skn sub grft f/n/hf/g ch add,15278,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,279.03,,,,,,,fee schedule,279.03,3195, Skn sub grft f/n/hf/g ch add,15278,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,279.03,3195, Skn sub grft f/n/hf/g ch add,15278,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,279.03,3195, Skn sub grft f/n/hf/g ch add,15278,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,279.03,3195, Skin pedicle flap trunk,15570,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3745.26,,,,,,,fee schedule,3745.26,5664, Skin pedicle flap trunk,15570,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3745.26,5664, Skin pedicle flap trunk,15570,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3745.26,5664, Skin pedicle flap trunk,15570,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3745.26,5664, Skin pedicle flap arms/legs,15572,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3708.13,,,,,,,fee schedule,3708.13,12821, Skin pedicle flap arms/legs,15572,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3708.13,12821, Skin pedicle flap arms/legs,15572,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3708.13,12821, Skin pedicle flap arms/legs,15572,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3708.13,12821, Pedcle fh/ch/ch/m/n/ax/g/h/f,15574,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3533.14,,,,,,,fee schedule,3533.14,5664, Pedcle fh/ch/ch/m/n/ax/g/h/f,15574,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3533.14,5664, Pedcle fh/ch/ch/m/n/ax/g/h/f,15574,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3533.14,5664, Pedcle fh/ch/ch/m/n/ax/g/h/f,15574,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3533.14,5664, Pedicle e/n/e/l/ntroral,15576,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3090.61,,,,,,,fee schedule,3090.61,5664, Pedicle e/n/e/l/ntroral,15576,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3090.61,5664, Pedicle e/n/e/l/ntroral,15576,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3090.61,5664, Pedicle e/n/e/l/ntroral,15576,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3090.61,5664, Description Not Available,15580,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Delay flap trunk,15600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1149.56,,,,,,,fee schedule,1149.56,12821, Delay flap trunk,15600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1149.56,12821, Delay flap trunk,15600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,1149.56,12821, Delay flap trunk,15600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,1149.56,12821, Delay flap arms/legs,15610,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1275.61,,,,,,,fee schedule,1275.61,10940, Delay flap arms/legs,15610,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1275.61,10940, Delay flap arms/legs,15610,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1275.61,10940, Delay flap arms/legs,15610,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1275.61,10940, Delay flap f/c/c/n/ax/g/h/f,15620,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1657.6,,,,,,,fee schedule,1657.6,5664, Delay flap f/c/c/n/ax/g/h/f,15620,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,1657.6,5664, Delay flap f/c/c/n/ax/g/h/f,15620,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1657.6,5664, Delay flap f/c/c/n/ax/g/h/f,15620,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1657.6,5664, Description Not Available,15625,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Delay flap eye/nos/ear/lip,15630,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1690.62,,,,,,,fee schedule,1690.62,5664, Delay flap eye/nos/ear/lip,15630,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1690.62,5664, Delay flap eye/nos/ear/lip,15630,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1690.62,5664, Delay flap eye/nos/ear/lip,15630,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1690.62,5664, Transfer skin pedicle flap,15650,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2097.21,,,,,,,fee schedule,2097.21,6044, Transfer skin pedicle flap,15650,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,2097.21,6044, Transfer skin pedicle flap,15650,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2097.21,6044, Transfer skin pedicle flap,15650,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2097.21,6044, Mdfc flap w/prsrv vasc pedcl,15730,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4286.53,,,,,,,fee schedule,4286.53,12821, Mdfc flap w/prsrv vasc pedcl,15730,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4286.53,12821, Mdfc flap w/prsrv vasc pedcl,15730,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4286.53,12821, Mdfc flap w/prsrv vasc pedcl,15730,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4286.53,12821, Forehead Flap w/Vasc Pedicle,15731,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4848.52,,,,,,,fee schedule,4848.52,12821, Forehead Flap w/Vasc Pedicle,15731,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4848.52,12821, Forehead Flap w/Vasc Pedicle,15731,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4848.52,12821, Forehead Flap w/Vasc Pedicle,15731,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4848.52,12821, Musc myoq/fscq flp h&n pedcl,15733,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5060.48,,,,,,,fee schedule,5060.48,12821, Musc myoq/fscq flp h&n pedcl,15733,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5060.48,12821, Musc myoq/fscq flp h&n pedcl,15733,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5060.48,12821, Musc myoq/fscq flp h&n pedcl,15733,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5060.48,12821, Muscle-skin graft trunk,15734,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7822.8,,,,,,,fee schedule,5248,12821, Muscle-skin graft trunk,15734,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,12821, Muscle-skin graft trunk,15734,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5248,12821, Muscle-skin graft trunk,15734,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5248,12821, Muscle-skin graft arm,15736,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6190.51,,,,,,,fee schedule,5097,6190.51, Muscle-skin graft arm,15736,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5097,6190.51, Muscle-skin graft arm,15736,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6190.51, Muscle-skin graft arm,15736,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6190.51, Muscle-skin graft leg,15738,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6427.77,,,,,,,fee schedule,5248,12821, Muscle-skin graft leg,15738,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,12821, Muscle-skin graft leg,15738,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5248,12821, Muscle-skin graft leg,15738,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5248,12821, Island pedicle flap graft,15740,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4147.74,,,,,,,fee schedule,4108,5664, Island pedicle flap graft,15740,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,5664, Island pedicle flap graft,15740,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4108,5664, Island pedicle flap graft,15740,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4108,5664, Neurovascular pedicle flap,15750,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4668.51,,,,,,,fee schedule,4108,12821, Neurovascular pedicle flap,15750,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,12821, Neurovascular pedicle flap,15750,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4108,12821, Neurovascular pedicle flap,15750,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4108,12821, Description Not Available,15755,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Free myo/skin flap microvasc,15756,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10987.28,,,,,,,fee schedule,5248,10987.28, Free myo/skin flap microvasc,15756,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,10987.28, Free myo/skin flap microvasc,15756,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,5248,10987.28, Free myo/skin flap microvasc,15756,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,5248,10987.28, Free skin flap microvasc,15757,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10886.7,,,,,,,fee schedule,5248,10940, Free skin flap microvasc,15757,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,10940, Free skin flap microvasc,15757,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,5248,10940, Free skin flap microvasc,15757,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,5248,10940, Free fascial flap microvasc,15758,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10864.36,,,,,,,fee schedule,5248,10940, Free fascial flap microvasc,15758,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,10940, Free fascial flap microvasc,15758,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,5248,10940, Free fascial flap microvasc,15758,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,5248,10940, Composite skin graft,15760,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3360.41,,,,,,,fee schedule,3360.41,5664, Composite skin graft,15760,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3360.41,5664, Composite skin graft,15760,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3360.41,5664, Composite skin graft,15760,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3360.41,5664, Grfg autol soft tiss dir exc,15769,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2527.76,,,,,,,fee schedule,2527.76,12821, Grfg autol soft tiss dir exc,15769,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2527.76,12821, Grfg autol soft tiss dir exc,15769,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2527.76,12821, Grfg autol soft tiss dir exc,15769,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2527.76,12821, Derma-fat-fascia graft,15770,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3335.59,,,,,,,fee schedule,3335.59,12821, Derma-fat-fascia graft,15770,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3335.59,12821, Derma-fat-fascia graft,15770,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3335.59,12821, Derma-fat-fascia graft,15770,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3335.59,12821, Grfg autol fat lipo 50 cc/<,15771,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2616.52,,,,,,,fee schedule,2616.52,12821, Grfg autol fat lipo 50 cc/<,15771,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2616.52,12821, Grfg autol fat lipo 50 cc/<,15771,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2616.52,12821, Grfg autol fat lipo 50 cc/<,15771,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2616.52,12821, Grfg autol fat lipo ea addl,15772,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,715.02,,,,,,,fee schedule,715.02,3195, Grfg autol fat lipo ea addl,15772,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,715.02,3195, Grfg autol fat lipo ea addl,15772,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,715.02,3195, Grfg autol fat lipo ea addl,15772,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,715.02,3195, Grfg autol fat lipo 25 cc/<,15773,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2506.55,,,,,,,fee schedule,2506.55,5664, Grfg autol fat lipo 25 cc/<,15773,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2506.55,5664, Grfg autol fat lipo 25 cc/<,15773,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2506.55,5664, Grfg autol fat lipo 25 cc/<,15773,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2506.55,5664, Gfrg autol fat lipo ea addl,15774,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,688.21,,,,,,,fee schedule,688.21,3195, Gfrg autol fat lipo ea addl,15774,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,688.21,3195, Gfrg autol fat lipo ea addl,15774,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,688.21,3195, Gfrg autol fat lipo ea addl,15774,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,688.21,3195, Hair trnspl 1-15 punch grfts,15775,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1251.49,,,,,,,fee schedule,1251.49,5248, Hair trnspl 1-15 punch grfts,15775,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1251.49,5248, Hair trnspl 1-15 punch grfts,15775,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1251.49,5248, Hair trnspl 1-15 punch grfts,15775,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1251.49,5248, Hair trnspl >15 punch grafts,15776,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1709.51,,,,,,,fee schedule,1709.51,5248, Hair trnspl >15 punch grafts,15776,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1709.51,5248, Hair trnspl >15 punch grafts,15776,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1709.51,5248, Hair trnspl >15 punch grafts,15776,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1709.51,5248, Acellular derm matrix implt,15777,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1035.06,,,,,,,fee schedule,1035.06,3195, Acellular derm matrix implt,15777,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1035.06,3195, Acellular derm matrix implt,15777,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1035.06,3195, Acellular derm matrix implt,15777,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1035.06,3195, Impl absrb msh/prsth dly cls,15778,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2045.03,,,,,,,fee schedule,2045.03,5664, Impl absrb msh/prsth dly cls,15778,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2045.03,5664, Impl absrb msh/prsth dly cls,15778,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2045.03,5664, Impl absrb msh/prsth dly cls,15778,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2045.03,5664, Dermabrasion total face,15780,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3060.45,,,,,,,fee schedule,3060.45,10940, Dermabrasion total face,15780,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3060.45,10940, Dermabrasion total face,15780,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3060.45,10940, Dermabrasion total face,15780,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3060.45,10940, Dermabrasion segmental face,15781,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1996.47,,,,,,,fee schedule,1996.47,6979, Dermabrasion segmental face,15781,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1996.47,6979, Dermabrasion segmental face,15781,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,1996.47,6979, Dermabrasion segmental face,15781,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,1996.47,6979, Dermabrasion other than face,15782,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1729.09,,,,,,,fee schedule,1729.09,6979, Dermabrasion other than face,15782,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1729.09,6979, Dermabrasion other than face,15782,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,1729.09,6979, Dermabrasion other than face,15782,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,1729.09,6979, Dermabrasion suprfl any site,15783,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1659.92,,,,,,,fee schedule,1659.92,6979, Dermabrasion suprfl any site,15783,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1659.92,6979, Dermabrasion suprfl any site,15783,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1659.92,6979, Dermabrasion suprfl any site,15783,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1659.92,6979, Abrasion lesion single,15786,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,649.19,,,,,,,fee schedule,649.19,6979, Abrasion lesion single,15786,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,649.19,6979, Abrasion lesion single,15786,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,649.19,6979, Abrasion lesion single,15786,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,649.19,6979, Abrasion lesions add-on,15787,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,78.62,,,,,,,fee schedule,78.62,2782, Abrasion lesions add-on,15787,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,78.62,2782, Abrasion lesions add-on,15787,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,78.62,2782, Chemical peel face epiderm,15788,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1047.53,,,,,,,fee schedule,1047.53,6979, Chemical peel face epiderm,15788,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1047.53,6979, Chemical peel face epiderm,15788,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1047.53,6979, Chemical peel face epiderm,15788,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1047.53,6979, Chemical peel face dermal,15789,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1932.63,,,,,,,fee schedule,1932.63,6979, Chemical peel face dermal,15789,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1932.63,6979, Chemical peel face dermal,15789,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1932.63,6979, Chemical peel face dermal,15789,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1932.63,6979, Chemical peel nonfacial,15792,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1025.78,,,,,,,fee schedule,1025.78,6979, Chemical peel nonfacial,15792,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1025.78,6979, Chemical peel nonfacial,15792,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,1025.78,6979, Chemical peel nonfacial,15792,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,1025.78,6979, Chemical peel nonfacial,15793,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1715.28,,,,,,,fee schedule,1715.28,6979, Chemical peel nonfacial,15793,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1715.28,6979, Chemical peel nonfacial,15793,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1715.28,6979, Chemical peel nonfacial,15793,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1715.28,6979, Plastic surgery neck,15819,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Revision of lower eyelid,15820,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2420.11,,,,,,,fee schedule,2420.11,5664, Revision of lower eyelid,15820,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2420.11,5664, Revision of lower eyelid,15820,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2420.11,5664, Revision of lower eyelid,15820,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2420.11,5664, Revision of lower eyelid,15821,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2611.88,,,,,,,fee schedule,2611.88,5664, Revision of lower eyelid,15821,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2611.88,5664, Revision of lower eyelid,15821,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2611.88,5664, Revision of lower eyelid,15821,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2611.88,5664, Revision of upper eyelid,15822,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1918.98,,,,,,,fee schedule,1918.98,5664, Revision of upper eyelid,15822,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1918.98,5664, Revision of upper eyelid,15822,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1918.98,5664, Revision of upper eyelid,15822,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1918.98,5664, Revision of upper eyelid,15823,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2594.4,,,,,,,fee schedule,2594.4,6044, Revision of upper eyelid,15823,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,2594.4,6044, Revision of upper eyelid,15823,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2594.4,6044, Revision of upper eyelid,15823,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2594.4,6044, Removal of forehead wrinkles,15824,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5097,5664, Removal of forehead wrinkles,15824,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Removal of forehead wrinkles,15824,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Removal of neck wrinkles,15825,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,12821, Removal of neck wrinkles,15825,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5248,12821, Removal of neck wrinkles,15825,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5248,12821, Removal of brow wrinkles,15826,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,12821, Removal of brow wrinkles,15826,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5248,12821, Removal of brow wrinkles,15826,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5248,12821, Removal of face wrinkles,15828,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,12821, Removal of face wrinkles,15828,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5248,12821, Removal of face wrinkles,15828,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5248,12821, Removal of skin wrinkles,15829,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,12821, Removal of skin wrinkles,15829,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,6044,12821, Removal of skin wrinkles,15829,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,6044,12821, Exc Skin Abd,15830,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5967.54,,,,,,,fee schedule,5248,14456, Exc Skin Abd,15830,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,14456, Exc Skin Abd,15830,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5248,14456, Exc Skin Abd,15830,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5248,14456, Excise excessive skin thigh,15832,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4677.47,,,,,,,fee schedule,4677.47,10940, Excise excessive skin thigh,15832,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4677.47,10940, Excise excessive skin thigh,15832,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,4677.47,10940, Excise excessive skin thigh,15832,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,4677.47,10940, Excise excessive skin leg,15833,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4420.24,,,,,,,fee schedule,4420.24,10940, Excise excessive skin leg,15833,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4420.24,10940, Excise excessive skin leg,15833,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,4420.24,10940, Excise excessive skin leg,15833,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,4420.24,10940, Excise excessive skin hip,15834,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4496.97,,,,,,,fee schedule,4496.97,10940, Excise excessive skin hip,15834,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4496.97,10940, Excise excessive skin hip,15834,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,4496.97,10940, Excise excessive skin hip,15834,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,4496.97,10940, Excise excessive skin buttck,15835,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4689.66,,,,,,,fee schedule,4689.66,10940, Excise excessive skin buttck,15835,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4689.66,10940, Excise excessive skin buttck,15835,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,4689.66,10940, Excise excessive skin buttck,15835,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,4689.66,10940, Excise excessive skin arm,15836,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4030.92,,,,,,,fee schedule,4030.92,5664, Excise excessive skin arm,15836,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4030.92,5664, Excise excessive skin arm,15836,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4030.92,5664, Excise excessive skin arm,15836,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4030.92,5664, Excise excess skin arm/hand,15837,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3640.47,,,,,,,fee schedule,3640.47,5664, Excise excess skin arm/hand,15837,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3640.47,5664, Excise excess skin arm/hand,15837,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3640.47,5664, Excise excess skin arm/hand,15837,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3640.47,5664, Excise excess skin fat pad,15838,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3304.19,,,,,,,fee schedule,3304.19,5664, Excise excess skin fat pad,15838,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3304.19,5664, Excise excess skin fat pad,15838,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3304.19,5664, Excise excess skin fat pad,15838,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3304.19,5664, Excise excess skin & tissue,15839,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3789.88,,,,,,,fee schedule,3789.88,5664, Excise excess skin & tissue,15839,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3789.88,5664, Excise excess skin & tissue,15839,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3789.88,5664, Excise excess skin & tissue,15839,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3789.88,5664, Nerve palsy fascial graft,15840,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4912.63,,,,,,,fee schedule,4912.63,12821, Nerve palsy fascial graft,15840,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4912.63,12821, Nerve palsy fascial graft,15840,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4912.63,12821, Nerve palsy fascial graft,15840,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4912.63,12821, Nerve palsy muscle graft,15841,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8820.3,,,,,,,fee schedule,5363,12821, Nerve palsy muscle graft,15841,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,12821, Nerve palsy muscle graft,15841,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5363,12821, Nerve palsy muscle graft,15841,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5363,12821, Nerve palsy microsurg graft,15842,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,13243.29,,,,,,,fee schedule,5097,13243.29, Nerve palsy microsurg graft,15842,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5097,13243.29, Nerve palsy microsurg graft,15842,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,13243.29, Nerve palsy microsurg graft,15842,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,13243.29, Skin and muscle repair face,15845,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5357.58,,,,,,,fee schedule,5357.58,12821, Skin and muscle repair face,15845,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5357.58,12821, Skin and muscle repair face,15845,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5357.58,12821, Skin and muscle repair face,15845,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5357.58,12821, Exc Skin Abd Add-on,15847,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2505,5248, Exc Skin Abd Add-on,15847,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,5248, Exc Skin Abd Add-on,15847,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,5248, Remove sutures diff surgeon,15851,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,322.84,,,,,,,fee schedule,322.84,5664, Remove sutures diff surgeon,15851,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,322.84,5664, Remove sutures diff surgeon,15851,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,322.84,5664, Remove sutures diff surgeon,15851,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,322.84,5664, Dressing change not for burn,15852,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,218.38,,,,,,,fee schedule,218.38,3195, Dressing change not for burn,15852,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,218.38,3195, Dressing change not for burn,15852,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,218.38,3195, Dressing change not for burn,15852,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,218.38,3195, Removal sutr/stapl xreq anes,15853,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,69.93,,,,,,,fee schedule,69.93,3195, Removal sutr/stapl xreq anes,15853,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,69.93,3195, Removal sutr/stapl xreq anes,15853,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,69.93,3195, Removal sutr/stapl xreq anes,15853,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,69.93,3195, Removal sutr&stapl xreq anes,15854,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,92.33,,,,,,,fee schedule,92.33,3195, Removal sutr&stapl xreq anes,15854,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,92.33,3195, Removal sutr&stapl xreq anes,15854,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,92.33,3195, Removal sutr&stapl xreq anes,15854,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,92.33,3195, Test for blood flow in graft,15860,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,532.26,,,,,,,fee schedule,532.26,3195, Test for blood flow in graft,15860,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,532.26,3195, Test for blood flow in graft,15860,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,532.26,3195, Test for blood flow in graft,15860,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,532.26,3195, Suction lipectomy head&neck,15876,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,12821, Suction lipectomy head&neck,15876,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5248,12821, Suction lipectomy head&neck,15876,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5248,12821, Suction lipectomy trunk,15877,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,12821, Suction lipectomy trunk,15877,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5248,12821, Suction lipectomy trunk,15877,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5248,12821, Suction lipectomy upr extrem,15878,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5097,5664, Suction lipectomy upr extrem,15878,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Suction lipectomy upr extrem,15878,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Suction lipectomy lwr extrem,15879,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,12821, Suction lipectomy lwr extrem,15879,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5248,12821, Suction lipectomy lwr extrem,15879,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5248,12821, Removal of tail bone ulcer,15920,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3518.03,,,,,,,fee schedule,3518.03,5664, Removal of tail bone ulcer,15920,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3518.03,5664, Removal of tail bone ulcer,15920,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3518.03,5664, Removal of tail bone ulcer,15920,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3518.03,5664, Removal of tail bone ulcer,15922,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4037.29,,,,,,,fee schedule,4037.29,12821, Removal of tail bone ulcer,15922,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4037.29,12821, Removal of tail bone ulcer,15922,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4037.29,12821, Removal of tail bone ulcer,15922,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4037.29,12821, Remove sacrum pressure sore,15931,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3789.07,,,,,,,fee schedule,3789.07,10940, Remove sacrum pressure sore,15931,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3789.07,10940, Remove sacrum pressure sore,15931,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3789.07,10940, Remove sacrum pressure sore,15931,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3789.07,10940, Remove sacrum pressure sore,15933,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4597.77,,,,,,,fee schedule,4597.77,10940, Remove sacrum pressure sore,15933,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4597.77,10940, Remove sacrum pressure sore,15933,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,4597.77,10940, Remove sacrum pressure sore,15933,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,4597.77,10940, Remove sacrum pressure sore,15934,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4933.51,,,,,,,fee schedule,4933.51,12821, Remove sacrum pressure sore,15934,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4933.51,12821, Remove sacrum pressure sore,15934,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4933.51,12821, Remove sacrum pressure sore,15934,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4933.51,12821, Remove sacrum pressure sore,15935,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5795.3,,,,,,,fee schedule,5363,12821, Remove sacrum pressure sore,15935,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,12821, Remove sacrum pressure sore,15935,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5363,12821, Remove sacrum pressure sore,15935,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5363,12821, Remove sacrum pressure sore,15936,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4718.59,,,,,,,fee schedule,4718.59,5664, Remove sacrum pressure sore,15936,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4718.59,5664, Remove sacrum pressure sore,15936,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4718.59,5664, Remove sacrum pressure sore,15936,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4718.59,5664, Remove sacrum pressure sore,15937,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5128.63,,,,,,,fee schedule,5097,5664, Remove sacrum pressure sore,15937,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5097,5664, Remove sacrum pressure sore,15937,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Remove sacrum pressure sore,15937,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Remove hip pressure sore,15940,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3729.77,,,,,,,fee schedule,3729.77,10940, Remove hip pressure sore,15940,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3729.77,10940, Remove hip pressure sore,15940,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3729.77,10940, Remove hip pressure sore,15940,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3729.77,10940, Remove hip pressure sore,15941,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4785.55,,,,,,,fee schedule,4785.55,10940, Remove hip pressure sore,15941,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4785.55,10940, Remove hip pressure sore,15941,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,4785.55,10940, Remove hip pressure sore,15941,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,4785.55,10940, Remove hip pressure sore,15944,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4708.23,,,,,,,fee schedule,4708.23,12821, Remove hip pressure sore,15944,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4708.23,12821, Remove hip pressure sore,15944,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4708.23,12821, Remove hip pressure sore,15944,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4708.23,12821, Remove hip pressure sore,15945,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5133.16,,,,,,,fee schedule,5097,5664, Remove hip pressure sore,15945,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5097,5664, Remove hip pressure sore,15945,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Remove hip pressure sore,15945,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Remove hip pressure sore,15946,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8202.35,,,,,,,fee schedule,5363,10940, Remove hip pressure sore,15946,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,10940, Remove hip pressure sore,15946,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,5363,10940, Remove hip pressure sore,15946,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,5363,10940, Remove thigh pressure sore,15950,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3241,,,,,,,fee schedule,3241,10940, Remove thigh pressure sore,15950,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3241,10940, Remove thigh pressure sore,15950,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3241,10940, Remove thigh pressure sore,15950,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3241,10940, Remove thigh pressure sore,15951,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4544.51,,,,,,,fee schedule,4544.51,10940, Remove thigh pressure sore,15951,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4544.51,10940, Remove thigh pressure sore,15951,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,4544.51,10940, Remove thigh pressure sore,15951,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,4544.51,10940, Remove thigh pressure sore,15952,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4611.21,,,,,,,fee schedule,4611.21,10940, Remove thigh pressure sore,15952,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4611.21,10940, Remove thigh pressure sore,15952,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,4611.21,10940, Remove thigh pressure sore,15952,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,4611.21,10940, Remove thigh pressure sore,15953,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5084.97,,,,,,,fee schedule,5084.97,12821, Remove thigh pressure sore,15953,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5084.97,12821, Remove thigh pressure sore,15953,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5084.97,12821, Remove thigh pressure sore,15953,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5084.97,12821, Remove thigh pressure sore,15956,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6129.05,,,,,,,fee schedule,5097,6129.05, Remove thigh pressure sore,15956,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5097,6129.05, Remove thigh pressure sore,15956,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6129.05, Remove thigh pressure sore,15956,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6129.05, Remove thigh pressure sore,15958,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6038.12,,,,,,,fee schedule,5363,12821, Remove thigh pressure sore,15958,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,12821, Remove thigh pressure sore,15958,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5363,12821, Remove thigh pressure sore,15958,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5363,12821, Removal of pressure sore,15999,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4047,6979, Removal of pressure sore,15999,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,4047,6979, Removal of pressure sore,15999,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,4047,6979, Initial treatment of burn(s),16000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,238.77,,,,,,,fee schedule,238.77,6979, Initial treatment of burn(s),16000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,238.77,6979, Initial treatment of burn(s),16000,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,238.77,6979, Initial treatment of burn(s),16000,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,238.77,6979, Dress/debrid p-thick burn s,16020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,298.13,,,,,,,fee schedule,298.13,3195, Dress/debrid p-thick burn s,16020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,298.13,3195, Dress/debrid p-thick burn s,16020,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,298.13,3195, Dress/debrid p-thick burn s,16020,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,298.13,3195, Dress/debrid p-thick burn m,16025,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,565.61,,,,,,,fee schedule,565.61,4108, Dress/debrid p-thick burn m,16025,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,565.61,4108, Dress/debrid p-thick burn m,16025,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,565.61,4108, Dress/debrid p-thick burn m,16025,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,565.61,4108, Dress/debrid p-thick burn l,16030,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,692.58,,,,,,,fee schedule,692.58,4108, Dress/debrid p-thick burn l,16030,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,692.58,4108, Dress/debrid p-thick burn l,16030,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,692.58,4108, Dress/debrid p-thick burn l,16030,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,692.58,4108, Incision of burn scab initi,16035,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1014.83,,,,,,,fee schedule,1014.83,4108, Incision of burn scab initi,16035,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1014.83,4108, Incision of burn scab initi,16035,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1014.83,4108, Incision of burn scab initi,16035,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1014.83,4108, Escharotomy addl incision,16036,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,426.12,,,,,,,fee schedule,426.12,6979, Escharotomy addl incision,16036,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,426.12,6979, Escharotomy addl incision,16036,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,426.12,6979, Escharotomy addl incision,16036,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,426.12,6979, Description Not Available,16040,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Description Not Available,16041,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Description Not Available,16042,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Destruct premalg lesion,17000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,257.01,,,,,,,fee schedule,257.01,3195, Destruct premalg lesion,17000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,257.01,3195, Destruct premalg lesion,17000,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,257.01,3195, Destruct premalg lesion,17000,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,257.01,3195, Description Not Available,17001,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Description Not Available,17002,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Destruct premalg les 2-14,17003,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8.96,,,,,,,fee schedule,8.96,3195, Destruct premalg les 2-14,17003,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,8.96,3195, Destruct premalg les 2-14,17003,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,8.96,3195, Destruct premalg les 2-14,17003,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,8.96,3195, Destroy premal lesions 15/>,17004,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,450.73,,,,,,,fee schedule,450.73,3195, Destroy premal lesions 15/>,17004,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,450.73,3195, Destroy premal lesions 15/>,17004,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,450.73,3195, Destroy premal lesions 15/>,17004,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,450.73,3195, Description Not Available,17100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Description Not Available,17101,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Description Not Available,17102,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Description Not Available,17104,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Description Not Available,17105,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Destruction of skin lesions,17106,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1305.35,,,,,,,fee schedule,1305.35,3195, Destruction of skin lesions,17106,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1305.35,3195, Destruction of skin lesions,17106,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1305.35,3195, Destruction of skin lesions,17106,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1305.35,3195, Destruction of skin lesions,17107,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1679.13,,,,,,,fee schedule,1679.13,3195, Destruction of skin lesions,17107,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1679.13,3195, Destruction of skin lesions,17107,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1679.13,3195, Destruction of skin lesions,17107,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1679.13,3195, Destruction of skin lesions,17108,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2487.45,,,,,,,fee schedule,2487.45,5664, Destruction of skin lesions,17108,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2487.45,5664, Destruction of skin lesions,17108,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2487.45,5664, Destruction of skin lesions,17108,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2487.45,5664, Destruct b9 lesion 1-14,17110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,334.5,,,,,,,fee schedule,334.5,3195, Destruct b9 lesion 1-14,17110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,334.5,3195, Destruct b9 lesion 1-14,17110,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,334.5,3195, Destruct b9 lesion 1-14,17110,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,334.5,3195, Destruct lesion 15 or more,17111,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,396.23,,,,,,,fee schedule,396.23,3195, Destruct lesion 15 or more,17111,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,396.23,3195, Destruct lesion 15 or more,17111,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,396.23,3195, Destruct lesion 15 or more,17111,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,396.23,3195, Description Not Available,17200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Description Not Available,17201,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Chemical cautery tissue,17250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,193.45,,,,,,,fee schedule,193.45,3195, Chemical cautery tissue,17250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,193.45,3195, Chemical cautery tissue,17250,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,193.45,3195, Chemical cautery tissue,17250,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,193.45,3195, Destruction of skin lesions,17260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,320.31,,,,,,,fee schedule,320.31,3195, Destruction of skin lesions,17260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,320.31,3195, Destruction of skin lesions,17260,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,320.31,3195, Destruction of skin lesions,17260,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,320.31,3195, Destruction of skin lesions,17261,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,405.51,,,,,,,fee schedule,405.51,3195, Destruction of skin lesions,17261,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,405.51,3195, Destruction of skin lesions,17261,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,405.51,3195, Destruction of skin lesions,17261,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,405.51,3195, Destruction of skin lesions,17262,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,509.11,,,,,,,fee schedule,509.11,3195, Destruction of skin lesions,17262,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,509.11,3195, Destruction of skin lesions,17262,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,509.11,3195, Destruction of skin lesions,17262,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,509.11,3195, Destruction of skin lesions,17263,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,560.91,,,,,,,fee schedule,560.91,3195, Destruction of skin lesions,17263,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,560.91,3195, Destruction of skin lesions,17263,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,560.91,3195, Destruction of skin lesions,17263,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,560.91,3195, Destruction of skin lesions,17264,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,597.55,,,,,,,fee schedule,597.55,3195, Destruction of skin lesions,17264,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,597.55,3195, Destruction of skin lesions,17264,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,597.55,3195, Destruction of skin lesions,17264,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,597.55,3195, Destruction of skin lesions,17266,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,699.32,,,,,,,fee schedule,699.32,4108, Destruction of skin lesions,17266,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,699.32,4108, Destruction of skin lesions,17266,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,699.32,4108, Destruction of skin lesions,17266,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,699.32,4108, Destruction of skin lesions,17270,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,442.15,,,,,,,fee schedule,442.15,3195, Destruction of skin lesions,17270,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,442.15,3195, Destruction of skin lesions,17270,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,442.15,3195, Destruction of skin lesions,17270,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,442.15,3195, Destruction of skin lesions,17271,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,486.72,,,,,,,fee schedule,486.72,3195, Destruction of skin lesions,17271,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,486.72,3195, Destruction of skin lesions,17271,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,486.72,3195, Destruction of skin lesions,17271,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,486.72,3195, Destruction of skin lesions,17272,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,555.57,,,,,,,fee schedule,555.57,3195, Destruction of skin lesions,17272,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,555.57,3195, Destruction of skin lesions,17272,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,555.57,3195, Destruction of skin lesions,17272,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,555.57,3195, Destruction of skin lesions,17273,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,626.96,,,,,,,fee schedule,626.96,3195, Destruction of skin lesions,17273,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,626.96,3195, Destruction of skin lesions,17273,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,626.96,3195, Destruction of skin lesions,17273,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,626.96,3195, Destruction of skin lesions,17274,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,761.81,,,,,,,fee schedule,761.81,3195, Destruction of skin lesions,17274,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,761.81,3195, Destruction of skin lesions,17274,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,761.81,3195, Destruction of skin lesions,17274,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,761.81,3195, Destruction of skin lesions,17276,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,923.63,,,,,,,fee schedule,923.63,4108, Destruction of skin lesions,17276,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,923.63,4108, Destruction of skin lesions,17276,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,923.63,4108, Destruction of skin lesions,17276,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,923.63,4108, Destruction of skin lesions,17280,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,405.51,,,,,,,fee schedule,405.51,3195, Destruction of skin lesions,17280,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,405.51,3195, Destruction of skin lesions,17280,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,405.51,3195, Destruction of skin lesions,17280,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,405.51,3195, Destruction of skin lesions,17281,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,543.92,,,,,,,fee schedule,543.92,3195, Destruction of skin lesions,17281,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,543.92,3195, Destruction of skin lesions,17281,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,543.92,3195, Destruction of skin lesions,17281,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,543.92,3195, Destruction of skin lesions,17282,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,623.45,,,,,,,fee schedule,623.45,3195, Destruction of skin lesions,17282,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,623.45,3195, Destruction of skin lesions,17282,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,623.45,3195, Destruction of skin lesions,17282,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,623.45,3195, Destruction of skin lesions,17283,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,772.55,,,,,,,fee schedule,772.55,3195, Destruction of skin lesions,17283,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,772.55,3195, Destruction of skin lesions,17283,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,772.55,3195, Destruction of skin lesions,17283,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,772.55,3195, Destruction of skin lesions,17284,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,910.14,,,,,,,fee schedule,910.14,3195, Destruction of skin lesions,17284,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,910.14,3195, Destruction of skin lesions,17284,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,910.14,3195, Destruction of skin lesions,17284,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,910.14,3195, Destruction of skin lesions,17286,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1237.84,,,,,,,fee schedule,1237.84,4108, Destruction of skin lesions,17286,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1237.84,4108, Destruction of skin lesions,17286,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1237.84,4108, Destruction of skin lesions,17286,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1237.84,4108, Mohs 1 stage h/n/hf/g,17311,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1586.21,,,,,,,fee schedule,1586.21,4108, Mohs 1 stage h/n/hf/g,17311,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1586.21,4108, Mohs 1 stage h/n/hf/g,17311,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1586.21,4108, Mohs 1 stage h/n/hf/g,17311,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1586.21,4108, Mohs Addl Stage,17312,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,847.23,,,,,,,fee schedule,847.23,3195, Mohs Addl Stage,17312,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,847.23,3195, Mohs Addl Stage,17312,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,847.23,3195, Mohs Addl Stage,17312,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,847.23,3195, Mohs 1 stage t/a/l,17313,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1423.68,,,,,,,fee schedule,1423.68,4108, Mohs 1 stage t/a/l,17313,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1423.68,4108, Mohs 1 stage t/a/l,17313,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1423.68,4108, Mohs 1 stage t/a/l,17313,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1423.68,4108, Mohs addl stage t/a/l,17314,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,772.44,,,,,,,fee schedule,772.44,3195, Mohs addl stage t/a/l,17314,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,772.44,3195, Mohs addl stage t/a/l,17314,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,772.44,3195, Mohs addl stage t/a/l,17314,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,772.44,3195, Mohs surg addl block,17315,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,220.43,,,,,,,fee schedule,220.43,3195, Mohs surg addl block,17315,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,220.43,3195, Mohs surg addl block,17315,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,220.43,3195, Mohs surg addl block,17315,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,220.43,3195, Cryotherapy of skin,17340,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,229.92,,,,,,,fee schedule,229.92,6979, Cryotherapy of skin,17340,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,229.92,6979, Cryotherapy of skin,17340,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,229.92,6979, Cryotherapy of skin,17340,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,229.92,6979, Skin peel therapy,17360,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,424.83,,,,,,,fee schedule,424.83,6979, Skin peel therapy,17360,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,424.83,6979, Skin peel therapy,17360,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,424.83,6979, Skin peel therapy,17360,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,424.83,6979, Hair removal by electrolysis,17380,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2505,6979, Hair removal by electrolysis,17380,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,6979, Hair removal by electrolysis,17380,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,6979, Skin tissue procedure,17999,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Skin tissue procedure,17999,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Skin tissue procedure,17999,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Drainage of breast lesion,19000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,205.16,,,,,,,fee schedule,205.16,4497, Drainage of breast lesion,19000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,205.16,4497, Drainage of breast lesion,19000,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,205.16,4497, Drainage of breast lesion,19000,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,205.16,4497, Drain breast lesion add-on,19001,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,101.23,,,,,,,fee schedule,101.23,3195, Drain breast lesion add-on,19001,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,101.23,3195, Drain breast lesion add-on,19001,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,101.23,3195, Drain breast lesion add-on,19001,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,101.23,3195, Incision of breast lesion,19020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1751.97,,,,,,,fee schedule,1751.97,10940, Incision of breast lesion,19020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1751.97,10940, Incision of breast lesion,19020,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1751.97,10940, Incision of breast lesion,19020,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1751.97,10940, Injection for breast x-ray,19030,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,357.43,,,,,,,fee schedule,357.43,3195, Injection for breast x-ray,19030,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,357.43,3195, Injection for breast x-ray,19030,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,357.43,3195, Injection for breast x-ray,19030,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,357.43,3195, Bx breast 1st lesion strtctc,19081,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,773.3,,,,,,,fee schedule,773.3,5664, Bx breast 1st lesion strtctc,19081,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,773.3,5664, Bx breast 1st lesion strtctc,19081,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,773.3,5664, Bx breast 1st lesion strtctc,19081,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,773.3,5664, Bx breast add lesion strtctc,19082,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,387.92,,,,,,,fee schedule,387.92,3195, Bx breast add lesion strtctc,19082,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,387.92,3195, Bx breast add lesion strtctc,19082,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,387.92,3195, Bx breast add lesion strtctc,19082,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,387.92,3195, Bx breast 1st lesion us imag,19083,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,731.16,,,,,,,fee schedule,731.16,5664, Bx breast 1st lesion us imag,19083,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,731.16,5664, Bx breast 1st lesion us imag,19083,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,731.16,5664, Bx breast 1st lesion us imag,19083,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,731.16,5664, Bx breast add lesion us imag,19084,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,363.74,,,,,,,fee schedule,363.74,3195, Bx breast add lesion us imag,19084,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,363.74,3195, Bx breast add lesion us imag,19084,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,363.74,3195, Bx breast add lesion us imag,19084,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,363.74,3195, Bx breast 1st lesion mr imag,19085,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,843.18,,,,,,,fee schedule,843.18,5664, Bx breast 1st lesion mr imag,19085,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,843.18,5664, Bx breast 1st lesion mr imag,19085,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,843.18,5664, Bx breast 1st lesion mr imag,19085,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,843.18,5664, Bx breast add lesion mr imag,19086,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,420.19,,,,,,,fee schedule,420.19,3195, Bx breast add lesion mr imag,19086,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,420.19,3195, Bx breast add lesion mr imag,19086,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,420.19,3195, Bx breast add lesion mr imag,19086,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,420.19,3195, Bx breast percut w/o image,19100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,358.19,,,,,,,fee schedule,358.19,5664, Bx breast percut w/o image,19100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,358.19,5664, Bx breast percut w/o image,19100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,358.19,5664, Bx breast percut w/o image,19100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,358.19,5664, Biopsy of breast open,19101,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1219.39,,,,,,,fee schedule,1219.39,10940, Biopsy of breast open,19101,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1219.39,10940, Biopsy of breast open,19101,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1219.39,10940, Biopsy of breast open,19101,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1219.39,10940, Cryosurg ablate fa each,19105,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1124.53,,,,,,,fee schedule,1124.53,12821, Cryosurg ablate fa each,19105,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,1124.53,12821, Cryosurg ablate fa each,19105,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,1124.53,12821, Cryosurg ablate fa each,19105,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,1124.53,12821, Nipple exploration,19110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1980.76,,,,,,,fee schedule,1980.76,10940, Nipple exploration,19110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1980.76,10940, Nipple exploration,19110,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1980.76,10940, Nipple exploration,19110,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1980.76,10940, Excise breast duct fistula,19112,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1836.47,,,,,,,fee schedule,1836.47,10940, Excise breast duct fistula,19112,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1836.47,10940, Excise breast duct fistula,19112,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1836.47,10940, Excise breast duct fistula,19112,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1836.47,10940, Removal of breast lesion,19120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2292.49,,,,,,,fee schedule,2292.49,10940, Removal of breast lesion,19120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2292.49,10940, Removal of breast lesion,19120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2292.49,10940, Removal of breast lesion,19120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2292.49,10940, Excision breast lesion,19125,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2551.98,,,,,,,fee schedule,2551.98,10940, Excision breast lesion,19125,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2551.98,10940, Excision breast lesion,19125,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2551.98,10940, Excision breast lesion,19125,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2551.98,10940, Excision addl breast lesion,19126,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,837.24,,,,,,,fee schedule,837.24,5248, Excision addl breast lesion,19126,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,837.24,5248, Excision addl breast lesion,19126,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,837.24,5248, Excision addl breast lesion,19126,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,837.24,5248, Perq device breast 1st imag,19281,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,463.25,,,,,,,fee schedule,463.25,5664, Perq device breast 1st imag,19281,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,463.25,5664, Perq device breast 1st imag,19281,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,463.25,5664, Perq device breast 1st imag,19281,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,463.25,5664, Perq device breast ea imag,19282,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,229.33,,,,,,,fee schedule,229.33,3195, Perq device breast ea imag,19282,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,229.33,3195, Perq device breast ea imag,19282,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,229.33,3195, Perq device breast ea imag,19282,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,229.33,3195, Perq dev breast 1st strtctc,19283,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,470.37,,,,,,,fee schedule,470.37,4497, Perq dev breast 1st strtctc,19283,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,470.37,4497, Perq dev breast 1st strtctc,19283,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,470.37,4497, Perq dev breast 1st strtctc,19283,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,470.37,4497, Perq dev breast add strtctc,19284,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,237.42,,,,,,,fee schedule,237.42,3195, Perq dev breast add strtctc,19284,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,237.42,3195, Perq dev breast add strtctc,19284,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,237.42,3195, Perq dev breast add strtctc,19284,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,237.42,3195, Perq dev breast 1st us imag,19285,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,401.35,,,,,,,fee schedule,401.35,4497, Perq dev breast 1st us imag,19285,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,401.35,4497, Perq dev breast 1st us imag,19285,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,401.35,4497, Perq dev breast 1st us imag,19285,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,401.35,4497, Perq dev breast add us imag,19286,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,201.54,,,,,,,fee schedule,201.54,3195, Perq dev breast add us imag,19286,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,201.54,3195, Perq dev breast add us imag,19286,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,201.54,3195, Perq dev breast add us imag,19286,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,201.54,3195, Perq dev breast 1st mr guide,19287,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,588.6,,,,,,,fee schedule,588.6,5248, Perq dev breast 1st mr guide,19287,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,588.6,5248, Perq dev breast 1st mr guide,19287,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,588.6,5248, Perq dev breast 1st mr guide,19287,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,588.6,5248, Perq dev breast add mr guide,19288,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,297.43,,,,,,,fee schedule,297.43,3195, Perq dev breast add mr guide,19288,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,297.43,3195, Perq dev breast add mr guide,19288,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,297.43,3195, Perq dev breast add mr guide,19288,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,297.43,3195, Prep tum cav iort prtl mast,19294,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,861.47,,,,,,,fee schedule,861.47,3195, Prep tum cav iort prtl mast,19294,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,861.47,3195, Prep tum cav iort prtl mast,19294,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,861.47,3195, Prep tum cav iort prtl mast,19294,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,861.47,3195, Place po breast cath for rad,19296,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1116.16,,,,,,,fee schedule,1116.16,22111, Place po breast cath for rad,19296,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10675,,,,,,,fee schedule,1116.16,22111, Place po breast cath for rad,19296,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,1116.16,22111, Place po breast cath for rad,19296,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,1116.16,22111, Place breast cath for rad,19297,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,482.78,,,,,,,fee schedule,482.78,22111, Place breast cath for rad,19297,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10675,,,,,,,fee schedule,482.78,22111, Place breast cath for rad,19297,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,482.78,22111, Place breast cath for rad,19297,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,482.78,22111, Place breast rad tube/caths,19298,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1447.32,,,,,,,fee schedule,1447.32,22111, Place breast rad tube/caths,19298,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1447.32,22111, Place breast rad tube/caths,19298,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,1447.32,22111, Place breast rad tube/caths,19298,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,1447.32,22111, Removal of Breast Tissue,19300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2357.19,,,,,,,fee schedule,2357.19,10940, Removal of Breast Tissue,19300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2357.19,10940, Removal of Breast Tissue,19300,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2357.19,10940, Removal of Breast Tissue,19300,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2357.19,10940, Partial Mastectomy,19301,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3592.12,,,,,,,fee schedule,3592.12,10940, Partial Mastectomy,19301,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3592.12,10940, Partial Mastectomy,19301,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3592.12,10940, Partial Mastectomy,19301,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3592.12,10940, P-Mastectomy w/LN Removal,19302,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4928.87,,,,,,,fee schedule,4928.87,14456, P-Mastectomy w/LN Removal,19302,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,4928.87,14456, P-Mastectomy w/LN Removal,19302,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4928.87,14456, P-Mastectomy w/LN Removal,19302,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4928.87,14456, Mast simple complete,19303,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5210.22,,,,,,,fee schedule,5210.22,12821, Mast simple complete,19303,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5210.22,12821, Mast simple complete,19303,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5210.22,12821, Mast simple complete,19303,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5210.22,12821, Mast radical,19305,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6224.39,,,,,,,fee schedule,5097,6979, Mast radical,19305,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Mast radical,19305,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Mast radical,19305,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Mast rad urban type,19306,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6678.41,,,,,,,fee schedule,5097,6979, Mast rad urban type,19306,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Mast rad urban type,19306,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Mast rad urban type,19306,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Mast mod rad,19307,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6397.39,,,,,,,fee schedule,6044,14456, Mast mod rad,19307,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,14456, Mast mod rad,19307,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,6044,14456, Mast mod rad,19307,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,6044,14456, Suspension of breast,19316,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4057.04,,,,,,,fee schedule,4057.04,12821, Suspension of breast,19316,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4057.04,12821, Suspension of breast,19316,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4057.04,12821, Suspension of breast,19316,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4057.04,12821, Reduction of large breast,19318,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5472.79,,,,,,,fee schedule,5363,14456, Reduction of large breast,19318,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,14456, Reduction of large breast,19318,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5363,14456, Reduction of large breast,19318,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5363,14456, Enlarge breast with implant,19325,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3129.19,,,,,,,fee schedule,3129.19,22111, Enlarge breast with implant,19325,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10675,,,,,,,fee schedule,3129.19,22111, Enlarge breast with implant,19325,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3129.19,22111, Enlarge breast with implant,19325,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3129.19,22111, Removal of breast implant,19328,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2843.8,,,,,,,fee schedule,2843.8,12821, Removal of breast implant,19328,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2843.8,12821, Removal of breast implant,19328,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2843.8,12821, Removal of breast implant,19328,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2843.8,12821, Removal of implant material,19330,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3292.86,,,,,,,fee schedule,3195,12821, Removal of implant material,19330,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,12821, Removal of implant material,19330,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3195,12821, Removal of implant material,19330,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3195,12821, Immediate breast prosthesis,19340,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3895.8,,,,,,,fee schedule,3895.8,14456, Immediate breast prosthesis,19340,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3895.8,14456, Immediate breast prosthesis,19340,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3895.8,14456, Immediate breast prosthesis,19340,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3895.8,14456, Delayed breast prosthesis,19342,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3851.5,,,,,,,fee schedule,3851.5,22111, Delayed breast prosthesis,19342,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3851.5,22111, Delayed breast prosthesis,19342,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3851.5,22111, Delayed breast prosthesis,19342,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3851.5,22111, Breast reconstruction,19350,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3412.27,,,,,,,fee schedule,3412.27,10940, Breast reconstruction,19350,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3412.27,10940, Breast reconstruction,19350,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3412.27,10940, Breast reconstruction,19350,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3412.27,10940, Correct inverted nipple(s),19355,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3116.57,,,,,,,fee schedule,3116.57,12821, Correct inverted nipple(s),19355,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3116.57,12821, Correct inverted nipple(s),19355,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3116.57,12821, Correct inverted nipple(s),19355,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3116.57,12821, Breast reconstruction,19357,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5917.2,,,,,,,fee schedule,5917.2,22111, Breast reconstruction,19357,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,5917.2,22111, Breast reconstruction,19357,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5917.2,22111, Breast reconstruction,19357,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5917.2,22111, Breast reconstr w/lat flap,19361,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7733.39,,,,,,,fee schedule,5097,7733.39, Breast reconstr w/lat flap,19361,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7733.39, Breast reconstr w/lat flap,19361,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7733.39, Breast reconstr w/lat flap,19361,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7733.39, Breast reconstruction,19364,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,13334.11,,,,,,,fee schedule,6044,14456, Breast reconstruction,19364,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,14456, Breast reconstruction,19364,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,6044,14456, Breast reconstruction,19364,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,6044,14456, Breast reconstruction,19367,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8728.35,,,,,,,fee schedule,6979,14456, Breast reconstruction,19367,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,14456, Breast reconstruction,19367,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,6979,14456, Breast reconstruction,19367,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,6979,14456, Breast reconstruction,19368,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10599.96,,,,,,,fee schedule,6979,14456, Breast reconstruction,19368,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,14456, Breast reconstruction,19368,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,6979,14456, Breast reconstruction,19368,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,6979,14456, Breast reconstruction,19369,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9859.95,,,,,,,fee schedule,6979,14456, Breast reconstruction,19369,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,14456, Breast reconstruction,19369,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,6979,14456, Breast reconstruction,19369,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,6979,14456, Surgery of breast capsule,19370,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3413.78,,,,,,,fee schedule,3413.78,12821, Surgery of breast capsule,19370,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3413.78,12821, Surgery of breast capsule,19370,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3413.78,12821, Surgery of breast capsule,19370,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3413.78,12821, Removal of breast capsule,19371,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3608.09,,,,,,,fee schedule,3608.09,12821, Removal of breast capsule,19371,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3608.09,12821, Removal of breast capsule,19371,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3608.09,12821, Removal of breast capsule,19371,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3608.09,12821, Revise breast reconstruction,19380,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4084.23,,,,,,,fee schedule,4084.23,14456, Revise breast reconstruction,19380,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4084.23,14456, Revise breast reconstruction,19380,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4084.23,14456, Revise breast reconstruction,19380,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4084.23,14456, Design custom breast implant,19396,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,706.55,,,,,,,fee schedule,706.55,12821, Design custom breast implant,19396,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,706.55,12821, Design custom breast implant,19396,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,706.55,12821, Design custom breast implant,19396,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,706.55,12821, Breast surgery procedure,19499,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,10940, Breast surgery procedure,19499,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3195,10940, Breast surgery procedure,19499,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3195,10940, Explore wound neck,20100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3114.52,,,,,,,fee schedule,2505,6979, Explore wound neck,20100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2505,6979, Explore wound neck,20100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,6979, Explore wound neck,20100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,6979, Explore wound chest,20101,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1148.48,,,,,,,fee schedule,1148.48,6979, Explore wound chest,20101,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1148.48,6979, Explore wound chest,20101,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1148.48,6979, Explore wound chest,20101,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1148.48,6979, Explore wound abdomen,20102,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1393.09,,,,,,,fee schedule,1393.09,6979, Explore wound abdomen,20102,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1393.09,6979, Explore wound abdomen,20102,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1393.09,6979, Explore wound abdomen,20102,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1393.09,6979, Explore wound extremity,20103,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1776.26,,,,,,,fee schedule,1776.26,4497, Explore wound extremity,20103,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1776.26,4497, Explore wound extremity,20103,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,1776.26,4497, Explore wound extremity,20103,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,1776.26,4497, Excise epiphyseal bar,20150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5165.05,,,,,,,fee schedule,5165.05,14456, Excise epiphyseal bar,20150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5165.05,14456, Excise epiphyseal bar,20150,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5165.05,14456, Excise epiphyseal bar,20150,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5165.05,14456, Muscle biopsy,20200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,512.94,,,,,,,fee schedule,512.94,5664, Muscle biopsy,20200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,512.94,5664, Muscle biopsy,20200,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,512.94,5664, Muscle biopsy,20200,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,512.94,5664, Deep muscle biopsy,20205,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,840.37,,,,,,,fee schedule,840.37,5664, Deep muscle biopsy,20205,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,840.37,5664, Deep muscle biopsy,20205,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,840.37,5664, Deep muscle biopsy,20205,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,840.37,5664, Needle biopsy muscle,20206,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,282.16,,,,,,,fee schedule,282.16,5664, Needle biopsy muscle,20206,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,282.16,5664, Needle biopsy muscle,20206,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,282.16,5664, Needle biopsy muscle,20206,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,282.16,5664, Bone biopsy trocar/needle,20220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,424.07,,,,,,,fee schedule,424.07,4497, Bone biopsy trocar/needle,20220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,424.07,4497, Bone biopsy trocar/needle,20220,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,424.07,4497, Bone biopsy trocar/needle,20220,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,424.07,4497, Bone biopsy trocar/needle,20225,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,628.69,,,,,,,fee schedule,628.69,5664, Bone biopsy trocar/needle,20225,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,628.69,5664, Bone biopsy trocar/needle,20225,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,628.69,5664, Bone biopsy trocar/needle,20225,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,628.69,5664, Bone biopsy open superficial,20240,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,702.72,,,,,,,fee schedule,702.72,10940, Bone biopsy open superficial,20240,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,702.72,10940, Bone biopsy open superficial,20240,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,702.72,10940, Bone biopsy open superficial,20240,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,702.72,10940, Bone biopsy open deep,20245,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1714.42,,,,,,,fee schedule,1714.42,10940, Bone biopsy open deep,20245,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1714.42,10940, Bone biopsy open deep,20245,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1714.42,10940, Bone biopsy open deep,20245,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1714.42,10940, Open bone biopsy,20250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2182.74,,,,,,,fee schedule,2182.74,12821, Open bone biopsy,20250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2182.74,12821, Open bone biopsy,20250,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2182.74,12821, Open bone biopsy,20250,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2182.74,12821, Open bone biopsy,20251,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2380.61,,,,,,,fee schedule,2380.61,12821, Open bone biopsy,20251,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2380.61,12821, Open bone biopsy,20251,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2380.61,12821, Open bone biopsy,20251,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2380.61,12821, Injection of sinus tract,20500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,455.48,,,,,,,fee schedule,455.48,5664, Injection of sinus tract,20500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,455.48,5664, Injection of sinus tract,20500,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,455.48,5664, Injection of sinus tract,20500,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,455.48,5664, Inject sinus tract for x-ray,20501,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,173,,,,,,,fee schedule,173,3195, Inject sinus tract for x-ray,20501,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,173,3195, Inject sinus tract for x-ray,20501,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,173,3195, Inject sinus tract for x-ray,20501,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,173,3195, Removal of foreign body,20520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,773.57,,,,,,,fee schedule,773.57,4497, Removal of foreign body,20520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,773.57,4497, Removal of foreign body,20520,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,773.57,4497, Removal of foreign body,20520,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,773.57,4497, Removal of foreign body,20525,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1295.09,,,,,,,fee schedule,1295.09,10940, Removal of foreign body,20525,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1295.09,10940, Removal of foreign body,20525,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1295.09,10940, Removal of foreign body,20525,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1295.09,10940, Ther injection carp tunnel,20526,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,279.08,,,,,,,fee schedule,279.08,3195, Ther injection carp tunnel,20526,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,279.08,3195, Ther injection carp tunnel,20526,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,279.08,3195, Ther injection carp tunnel,20526,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,279.08,3195, Inj dupuytren cord w/enzyme,20527,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,328.02,,,,,,,fee schedule,328.02,3195, Inj dupuytren cord w/enzyme,20527,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,328.02,3195, Inj dupuytren cord w/enzyme,20527,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,328.02,3195, Inj dupuytren cord w/enzyme,20527,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,328.02,3195, Inj tendon sheath/ligament,20550,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,186.97,,,,,,,fee schedule,186.97,3195, Inj tendon sheath/ligament,20550,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,186.97,3195, Inj tendon sheath/ligament,20550,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,186.97,3195, Inj tendon sheath/ligament,20550,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,186.97,3195, Inj tendon origin/insertion,20551,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,184.27,,,,,,,fee schedule,184.27,3195, Inj tendon origin/insertion,20551,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,184.27,3195, Inj tendon origin/insertion,20551,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,184.27,3195, Inj tendon origin/insertion,20551,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,184.27,3195, Inj trigger point 1/2 muscl,20552,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,196.36,,,,,,,fee schedule,196.36,3195, Inj trigger point 1/2 muscl,20552,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,196.36,3195, Inj trigger point 1/2 muscl,20552,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,196.36,3195, Inj trigger point 1/2 muscl,20552,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,196.36,3195, Inject trigger points 3/>,20553,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,223.88,,,,,,,fee schedule,223.88,3195, Inject trigger points 3/>,20553,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,223.88,3195, Inject trigger points 3/>,20553,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,223.88,3195, Inject trigger points 3/>,20553,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,223.88,3195, Place ndl musc/tis for rt,20555,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1533.92,,,,,,,fee schedule,1533.92,10940, Place ndl musc/tis for rt,20555,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1533.92,10940, Place ndl musc/tis for rt,20555,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1533.92,10940, Place ndl musc/tis for rt,20555,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1533.92,10940, Ndl insj w/o njx 1 or 2 musc,20560,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,67.18,,,,,,,fee schedule,67.18,3195, Ndl insj w/o njx 1 or 2 musc,20560,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,67.18,3195, Ndl insj w/o njx 1 or 2 musc,20560,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,67.18,3195, Ndl insj w/o njx 1 or 2 musc,20560,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,67.18,3195, Ndl insj w/o njx 3+ musc,20561,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,108.35,,,,,,,fee schedule,108.35,3195, Ndl insj w/o njx 3+ musc,20561,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,108.35,3195, Ndl insj w/o njx 3+ musc,20561,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,108.35,3195, Ndl insj w/o njx 3+ musc,20561,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,108.35,3195, Drain/inj joint/bursa w/o us,20600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,174.94,,,,,,,fee schedule,174.94,3195, Drain/inj joint/bursa w/o us,20600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,174.94,3195, Drain/inj joint/bursa w/o us,20600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,174.94,3195, Drain/inj joint/bursa w/o us,20600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,174.94,3195, Drain/inj joint/bursa w/us,20604,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,222.8,,,,,,,fee schedule,222.8,3195, Drain/inj joint/bursa w/us,20604,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,222.8,3195, Drain/inj joint/bursa w/us,20604,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,222.8,3195, Drain/inj joint/bursa w/us,20604,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,222.8,3195, Drain/inj joint/bursa w/o us,20605,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,178.55,,,,,,,fee schedule,178.55,3195, Drain/inj joint/bursa w/o us,20605,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,178.55,3195, Drain/inj joint/bursa w/o us,20605,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,178.55,3195, Drain/inj joint/bursa w/o us,20605,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,178.55,3195, Drain/inj joint/bursa w/us,20606,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,250.48,,,,,,,fee schedule,250.48,4497, Drain/inj joint/bursa w/us,20606,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,250.48,4497, Drain/inj joint/bursa w/us,20606,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,250.48,4497, Drain/inj joint/bursa w/us,20606,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,250.48,4497, Drain/inj joint/bursa w/o us,20610,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,223.93,,,,,,,fee schedule,223.93,3195, Drain/inj joint/bursa w/o us,20610,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,223.93,3195, Drain/inj joint/bursa w/o us,20610,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,223.93,3195, Drain/inj joint/bursa w/o us,20610,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,223.93,3195, Drain/inj joint/bursa w/us,20611,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,280.75,,,,,,,fee schedule,280.75,3195, Drain/inj joint/bursa w/us,20611,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,280.75,3195, Drain/inj joint/bursa w/us,20611,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,280.75,3195, Drain/inj joint/bursa w/us,20611,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,280.75,3195, Aspirate/inj ganglion cyst,20612,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,203.81,,,,,,,fee schedule,203.81,3195, Aspirate/inj ganglion cyst,20612,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,203.81,3195, Aspirate/inj ganglion cyst,20612,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,203.81,3195, Aspirate/inj ganglion cyst,20612,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,203.81,3195, Treatment of bone cyst,20615,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,787.01,,,,,,,fee schedule,787.01,4497, Treatment of bone cyst,20615,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,787.01,4497, Treatment of bone cyst,20615,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,787.01,4497, Treatment of bone cyst,20615,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,787.01,4497, Insert and remove bone pin,20650,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,880.41,,,,,,,fee schedule,880.41,12821, Insert and remove bone pin,20650,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,880.41,12821, Insert and remove bone pin,20650,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,880.41,12821, Insert and remove bone pin,20650,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,880.41,12821, Apply rem fixation device,20660,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1263.04,,,,,,,fee schedule,1263.04,5664, Apply rem fixation device,20660,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1263.04,5664, Apply rem fixation device,20660,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1263.04,5664, Apply rem fixation device,20660,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1263.04,5664, Application of head brace,20661,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3069.24,,,,,,,fee schedule,2505,5248, Application of head brace,20661,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2505,5248, Application of head brace,20661,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,5248, Application of head brace,20661,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,5248, Application of pelvis brace,20662,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2763.99,,,,,,,fee schedule,2763.99,10940, Application of pelvis brace,20662,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2763.99,10940, Application of pelvis brace,20662,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2763.99,10940, Application of pelvis brace,20662,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2763.99,10940, Application of thigh brace,20663,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2562.13,,,,,,,fee schedule,2562.13,12821, Application of thigh brace,20663,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2562.13,12821, Application of thigh brace,20663,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2562.13,12821, Application of thigh brace,20663,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2562.13,12821, Application of halo,20664,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5343.87,,,,,,,fee schedule,5097,5664, Application of halo,20664,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5097,5664, Application of halo,20664,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Application of halo,20664,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Removal of fixation device,20665,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,464.22,,,,,,,fee schedule,464.22,3195, Removal of fixation device,20665,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,464.22,3195, Removal of fixation device,20665,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,464.22,3195, Removal of fixation device,20665,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,464.22,3195, Removal of support implant,20670,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,762.45,,,,,,,fee schedule,762.45,5664, Removal of support implant,20670,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,762.45,5664, Removal of support implant,20670,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,762.45,5664, Removal of support implant,20670,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,762.45,5664, Removal of support implant,20680,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2185.43,,,,,,,fee schedule,2185.43,10940, Removal of support implant,20680,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2185.43,10940, Removal of support implant,20680,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2185.43,10940, Removal of support implant,20680,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2185.43,10940, Apply bone fixation device,20690,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3053.81,,,,,,,fee schedule,3053.81,12821, Apply bone fixation device,20690,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3053.81,12821, Apply bone fixation device,20690,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3053.81,12821, Apply bone fixation device,20690,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3053.81,12821, Apply bone fixation device,20692,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5816.29,,,,,,,fee schedule,5248,12821, Apply bone fixation device,20692,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,12821, Apply bone fixation device,20692,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5248,12821, Apply bone fixation device,20692,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5248,12821, Adjust bone fixation device,20693,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2367.87,,,,,,,fee schedule,2367.87,12821, Adjust bone fixation device,20693,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2367.87,12821, Adjust bone fixation device,20693,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2367.87,12821, Adjust bone fixation device,20693,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2367.87,12821, Remove bone fixation device,20694,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1804.69,,,,,,,fee schedule,1804.69,5664, Remove bone fixation device,20694,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1804.69,5664, Remove bone fixation device,20694,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1804.69,5664, Remove bone fixation device,20694,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1804.69,5664, Comp multiplane ext fixation,20696,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5909.97,,,,,,,fee schedule,5248,12821, Comp multiplane ext fixation,20696,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,12821, Comp multiplane ext fixation,20696,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5248,12821, Comp multiplane ext fixation,20696,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5248,12821, Comp ext fixate strut change,20697,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9858.6,,,,,,,fee schedule,4047,9858.6, Comp ext fixate strut change,20697,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4047,9858.6, Comp ext fixate strut change,20697,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,4047,9858.6, Comp ext fixate strut change,20697,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,4047,9858.6, Mnl prep&insj dp rx dlvr dev,20700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,402.49,,,,,,,fee schedule,402.49,3195, Mnl prep&insj dp rx dlvr dev,20700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,402.49,3195, Mnl prep&insj dp rx dlvr dev,20700,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,402.49,3195, Mnl prep&insj dp rx dlvr dev,20700,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,402.49,3195, Rmvl deep rx delivery device,20701,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,312,,,,,,,fee schedule,312,3195, Rmvl deep rx delivery device,20701,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,312,3195, Rmvl deep rx delivery device,20701,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,312,3195, Rmvl deep rx delivery device,20701,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,312,3195, Mnl prep&insj imed rx dev,20702,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,701.75,,,,,,,fee schedule,701.75,3195, Mnl prep&insj imed rx dev,20702,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,701.75,3195, Mnl prep&insj imed rx dev,20702,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,701.75,3195, Mnl prep&insj imed rx dev,20702,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,701.75,3195, Rmvl imed rx delivery device,20703,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,516.61,,,,,,,fee schedule,516.61,3195, Rmvl imed rx delivery device,20703,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,516.61,3195, Rmvl imed rx delivery device,20703,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,516.61,3195, Rmvl imed rx delivery device,20703,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,516.61,3195, Mnl prep&insj i-artic rx dev,20704,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,733.8,,,,,,,fee schedule,733.8,3195, Mnl prep&insj i-artic rx dev,20704,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,733.8,3195, Mnl prep&insj i-artic rx dev,20704,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,733.8,3195, Mnl prep&insj i-artic rx dev,20704,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,733.8,3195, Rmvl i-artic rx delivery dev,20705,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,606.94,,,,,,,fee schedule,606.94,3195, Rmvl i-artic rx delivery dev,20705,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,606.94,3195, Rmvl i-artic rx delivery dev,20705,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,606.94,3195, Rmvl i-artic rx delivery dev,20705,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,606.94,3195, Replantation arm complete,20802,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,13853.31,,,,,,,fee schedule,6979,25393, Replantation arm complete,20802,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,25393, Replantation arm complete,20802,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,6979,25393, Replantation arm complete,20802,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,6979,25393, Replant forearm complete,20805,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,16410.42,,,,,,,fee schedule,6979,25393, Replant forearm complete,20805,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,25393, Replant forearm complete,20805,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,6979,25393, Replant forearm complete,20805,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,6979,25393, Replantation hand complete,20808,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,19731.82,,,,,,,fee schedule,6979,25393, Replantation hand complete,20808,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,25393, Replantation hand complete,20808,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,6979,25393, Replantation hand complete,20808,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,6979,25393, Replantation digit complete,20816,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10370.3,,,,,,,fee schedule,6979,22111, Replantation digit complete,20816,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,22111, Replantation digit complete,20816,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6979,22111, Replantation digit complete,20816,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6979,22111, Replantation digit complete,20822,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9019.31,,,,,,,fee schedule,6979,10940, Replantation digit complete,20822,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,10940, Replantation digit complete,20822,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,6979,10940, Replantation digit complete,20822,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,6979,10940, Replantation thumb complete,20824,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10397.88,,,,,,,fee schedule,6979,22111, Replantation thumb complete,20824,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,22111, Replantation thumb complete,20824,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6979,22111, Replantation thumb complete,20824,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6979,22111, Replantation thumb complete,20827,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9254.3,,,,,,,fee schedule,6979,22111, Replantation thumb complete,20827,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,22111, Replantation thumb complete,20827,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6979,22111, Replantation thumb complete,20827,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6979,22111, Replantation foot complete,20838,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,14077.68,,,,,,,fee schedule,6979,25393, Replantation foot complete,20838,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,25393, Replantation foot complete,20838,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,6979,25393, Replantation foot complete,20838,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,6979,25393, Removal of bone for graft,20900,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,899.35,,,,,,,fee schedule,899.35,12821, Removal of bone for graft,20900,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,899.35,12821, Removal of bone for graft,20900,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,899.35,12821, Removal of bone for graft,20900,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,899.35,12821, Removal of bone for graft,20902,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1364.76,,,,,,,fee schedule,1364.76,12821, Removal of bone for graft,20902,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,1364.76,12821, Removal of bone for graft,20902,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,1364.76,12821, Removal of bone for graft,20902,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,1364.76,12821, Remove cartilage for graft,20910,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2549.39,,,,,,,fee schedule,2505,5248, Remove cartilage for graft,20910,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2505,5248, Remove cartilage for graft,20910,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,5248, Remove cartilage for graft,20910,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,5248, Remove cartilage for graft,20912,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2394.26,,,,,,,fee schedule,2394.26,12821, Remove cartilage for graft,20912,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2394.26,12821, Remove cartilage for graft,20912,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2394.26,12821, Remove cartilage for graft,20912,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2394.26,12821, Removal of fascia for graft,20920,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1965.82,,,,,,,fee schedule,1965.82,5664, Removal of fascia for graft,20920,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,1965.82,5664, Removal of fascia for graft,20920,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1965.82,5664, Removal of fascia for graft,20920,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1965.82,5664, Removal of fascia for graft,20922,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2630.17,,,,,,,fee schedule,2630.17,10940, Removal of fascia for graft,20922,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2630.17,10940, Removal of fascia for graft,20922,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2630.17,10940, Removal of fascia for graft,20922,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2630.17,10940, Removal of tendon for graft,20924,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2597.15,,,,,,,fee schedule,2597.15,12821, Removal of tendon for graft,20924,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2597.15,12821, Removal of tendon for graft,20924,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2597.15,12821, Removal of tendon for graft,20924,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2597.15,12821, Sp bone algrft morsel add-on,20930,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Sp bone algrft morsel add-on,20930,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Sp bone algrft morsel add-on,20930,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Sp bone algrft struct add-on,20931,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,578.67,,,,,,,fee schedule,578.67,3195, Sp bone algrft struct add-on,20931,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,578.67,3195, Sp bone algrft struct add-on,20931,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,578.67,3195, Sp bone algrft struct add-on,20931,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,578.67,3195, Osteoart algrft w/surf & b1,20932,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3712.83,,,,,,,fee schedule,2505,3712.83, Osteoart algrft w/surf & b1,20932,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3712.83, Osteoart algrft w/surf & b1,20932,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3712.83, Osteoart algrft w/surf & b1,20932,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3712.83, Hemicrt intrclry algrft prtl,20933,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3408.92,,,,,,,fee schedule,2505,3408.92, Hemicrt intrclry algrft prtl,20933,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3408.92, Hemicrt intrclry algrft prtl,20933,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3408.92, Hemicrt intrclry algrft prtl,20933,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3408.92, Intercalary algrft compl,20934,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3712.83,,,,,,,fee schedule,2505,3712.83, Intercalary algrft compl,20934,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3712.83, Intercalary algrft compl,20934,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3712.83, Intercalary algrft compl,20934,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3712.83, Sp bone agrft local add-on,20936,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,12821, Sp bone agrft local add-on,20936,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3195,12821, Sp bone agrft local add-on,20936,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3195,12821, Sp bone agrft morsel add-on,20937,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,859.31,,,,,,,fee schedule,859.31,12821, Sp bone agrft morsel add-on,20937,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,859.31,12821, Sp bone agrft morsel add-on,20937,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,859.31,12821, Sp bone agrft morsel add-on,20937,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,859.31,12821, Sp bone agrft struct add-on,20938,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,960.49,,,,,,,fee schedule,960.49,12821, Sp bone agrft struct add-on,20938,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,960.49,12821, Sp bone agrft struct add-on,20938,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,960.49,12821, Sp bone agrft struct add-on,20938,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,960.49,12821, Bone marrow aspir bone grfg,20939,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,359.54,,,,,,,fee schedule,359.54,3195, Bone marrow aspir bone grfg,20939,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,359.54,3195, Bone marrow aspir bone grfg,20939,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,359.54,3195, Bone marrow aspir bone grfg,20939,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,359.54,3195, Fluid pressure muscle,20950,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,462.22,,,,,,,fee schedule,462.22,4497, Fluid pressure muscle,20950,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,462.22,4497, Fluid pressure muscle,20950,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,462.22,4497, Fluid pressure muscle,20950,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,462.22,4497, Fibula bone graft microvasc,20955,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12730.19,,,,,,,fee schedule,5363,14456, Fibula bone graft microvasc,20955,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,14456, Fibula bone graft microvasc,20955,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5363,14456, Fibula bone graft microvasc,20955,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5363,14456, Iliac bone graft microvasc,20956,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,13314.95,,,,,,,fee schedule,5363,22111, Iliac bone graft microvasc,20956,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,22111, Iliac bone graft microvasc,20956,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5363,22111, Iliac bone graft microvasc,20956,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5363,22111, Mt bone graft microvasc,20957,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,13873.93,,,,,,,fee schedule,5363,22111, Mt bone graft microvasc,20957,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,22111, Mt bone graft microvasc,20957,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5363,22111, Mt bone graft microvasc,20957,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5363,22111, Description Not Available,20960,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Other bone graft microvasc,20962,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,13632.94,,,,,,,fee schedule,5363,14456, Other bone graft microvasc,20962,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,14456, Other bone graft microvasc,20962,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5363,14456, Other bone graft microvasc,20962,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5363,14456, Bone/skin graft microvasc,20969,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,13003.66,,,,,,,fee schedule,5363,14456, Bone/skin graft microvasc,20969,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,14456, Bone/skin graft microvasc,20969,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5363,14456, Bone/skin graft microvasc,20969,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5363,14456, Bone/skin graft iliac crest,20970,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,14366.53,,,,,,,fee schedule,5363,14456, Bone/skin graft iliac crest,20970,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,14456, Bone/skin graft iliac crest,20970,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5363,14456, Bone/skin graft iliac crest,20970,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5363,14456, Description Not Available,20971,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Bone/skin graft metatarsal,20972,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,14317.48,,,,,,,fee schedule,5363,22111, Bone/skin graft metatarsal,20972,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,22111, Bone/skin graft metatarsal,20972,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5363,22111, Bone/skin graft metatarsal,20972,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5363,22111, Bone/skin graft great toe,20973,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,15113.06,,,,,,,fee schedule,5363,22111, Bone/skin graft great toe,20973,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,22111, Bone/skin graft great toe,20973,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5363,22111, Bone/skin graft great toe,20973,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5363,22111, Electrical bone stimulation,20974,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,282.43,,,,,,,fee schedule,282.43,6979, Electrical bone stimulation,20974,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,282.43,6979, Electrical bone stimulation,20974,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,282.43,6979, Electrical bone stimulation,20974,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,282.43,6979, Electrical bone stimulation,20975,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,964.21,,,,,,,fee schedule,964.21,4108, Electrical bone stimulation,20975,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,964.21,4108, Electrical bone stimulation,20975,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,964.21,4108, Electrical bone stimulation,20975,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,964.21,4108, Us bone stimulation,20979,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,147.8,,,,,,,fee schedule,147.8,6979, Us bone stimulation,20979,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,147.8,6979, Us bone stimulation,20979,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,147.8,6979, Us bone stimulation,20979,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,147.8,6979, Ablate bone tumor(s) perq,20982,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1819.96,,,,,,,fee schedule,1819.96,14456, Ablate bone tumor(s) perq,20982,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1819.96,14456, Ablate bone tumor(s) perq,20982,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,1819.96,14456, Ablate bone tumor(s) perq,20982,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,1819.96,14456, Ablate bone tumor(s) perq,20983,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1696.07,,,,,,,fee schedule,1696.07,22111, Ablate bone tumor(s) perq,20983,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1696.07,22111, Ablate bone tumor(s) perq,20983,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,1696.07,22111, Ablate bone tumor(s) perq,20983,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,1696.07,22111, Cptr-asst dir ms px,20985,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,707.9,,,,,,,fee schedule,707.9,3195, Cptr-asst dir ms px,20985,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,707.9,3195, Cptr-asst dir ms px,20985,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,707.9,3195, Cptr-asst dir ms px,20985,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,707.9,3195, Musculoskeletal surgery,20999,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Musculoskeletal surgery,20999,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Musculoskeletal surgery,20999,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Incision of jaw joint,21010,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3709.26,,,,,,,fee schedule,3709.26,10940, Incision of jaw joint,21010,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3709.26,10940, Incision of jaw joint,21010,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3709.26,10940, Incision of jaw joint,21010,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3709.26,10940, Exc face les sc <2 cm,21011,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1365.94,,,,,,,fee schedule,1365.94,4497, Exc face les sc <2 cm,21011,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1365.94,4497, Exc face les sc <2 cm,21011,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,1365.94,4497, Exc face les sc <2 cm,21011,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,1365.94,4497, Exc face les sbq 2 cm/>,21012,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1795.47,,,,,,,fee schedule,1795.47,4497, Exc face les sbq 2 cm/>,21012,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1795.47,4497, Exc face les sbq 2 cm/>,21012,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,1795.47,4497, Exc face les sbq 2 cm/>,21012,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,1795.47,4497, Exc face tum deep < 2 cm,21013,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2056.2,,,,,,,fee schedule,2056.2,4497, Exc face tum deep < 2 cm,21013,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2056.2,4497, Exc face tum deep < 2 cm,21013,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,2056.2,4497, Exc face tum deep < 2 cm,21013,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,2056.2,4497, Exc face tum deep 2 cm/>,21014,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2662.93,,,,,,,fee schedule,2662.93,4497, Exc face tum deep 2 cm/>,21014,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2662.93,4497, Exc face tum deep 2 cm/>,21014,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,2662.93,4497, Exc face tum deep 2 cm/>,21014,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,2662.93,4497, Resect face/scalp tum < 2 cm,21015,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3542.64,,,,,,,fee schedule,3542.64,5664, Resect face/scalp tum < 2 cm,21015,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3542.64,5664, Resect face/scalp tum < 2 cm,21015,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3542.64,5664, Resect face/scalp tum < 2 cm,21015,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3542.64,5664, Resect face/scalp tum 2 cm/>,21016,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5039.54,,,,,,,fee schedule,4108,10940, Resect face/scalp tum 2 cm/>,21016,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,10940, Resect face/scalp tum 2 cm/>,21016,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,4108,10940, Resect face/scalp tum 2 cm/>,21016,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,4108,10940, Excision of bone lower jaw,21025,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3371.85,,,,,,,fee schedule,3371.85,14456, Excision of bone lower jaw,21025,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3371.85,14456, Excision of bone lower jaw,21025,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3371.85,14456, Excision of bone lower jaw,21025,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3371.85,14456, Excision of facial bone(s),21026,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2251.1,,,,,,,fee schedule,2251.1,10940, Excision of facial bone(s),21026,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2251.1,10940, Excision of facial bone(s),21026,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2251.1,10940, Excision of facial bone(s),21026,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2251.1,10940, Contour of face bone lesion,21029,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3144.3,,,,,,,fee schedule,3144.3,10940, Contour of face bone lesion,21029,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3144.3,10940, Contour of face bone lesion,21029,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3144.3,10940, Contour of face bone lesion,21029,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3144.3,10940, Excise max/zygoma b9 tumor,21030,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1832.97,,,,,,,fee schedule,1832.97,10940, Excise max/zygoma b9 tumor,21030,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1832.97,10940, Excise max/zygoma b9 tumor,21030,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1832.97,10940, Excise max/zygoma b9 tumor,21030,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1832.97,10940, Remove exostosis mandible,21031,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1373.98,,,,,,,fee schedule,1373.98,10940, Remove exostosis mandible,21031,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1373.98,10940, Remove exostosis mandible,21031,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1373.98,10940, Remove exostosis mandible,21031,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1373.98,10940, Remove exostosis maxilla,21032,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1327.74,,,,,,,fee schedule,1327.74,10940, Remove exostosis maxilla,21032,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1327.74,10940, Remove exostosis maxilla,21032,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1327.74,10940, Remove exostosis maxilla,21032,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1327.74,10940, Excise max/zygoma mal tumor,21034,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5477.53,,,,,,,fee schedule,5248,14456, Excise max/zygoma mal tumor,21034,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,14456, Excise max/zygoma mal tumor,21034,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5248,14456, Excise max/zygoma mal tumor,21034,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5248,14456, Excise mandible lesion,21040,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1838.09,,,,,,,fee schedule,1838.09,10940, Excise mandible lesion,21040,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1838.09,10940, Excise mandible lesion,21040,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1838.09,10940, Excise mandible lesion,21040,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1838.09,10940, Removal of jaw bone lesion,21044,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4227.06,,,,,,,fee schedule,4227.06,14456, Removal of jaw bone lesion,21044,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4227.06,14456, Removal of jaw bone lesion,21044,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4227.06,14456, Removal of jaw bone lesion,21044,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4227.06,14456, Extensive jaw surgery,21045,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5883.2,,,,,,,fee schedule,5363,14456, Extensive jaw surgery,21045,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,14456, Extensive jaw surgery,21045,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5363,14456, Extensive jaw surgery,21045,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5363,14456, Remove mandible cyst complex,21046,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4923.42,,,,,,,fee schedule,4108,14456, Remove mandible cyst complex,21046,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,14456, Remove mandible cyst complex,21046,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4108,14456, Remove mandible cyst complex,21046,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4108,14456, Excise lwr jaw cyst w/repair,21047,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5965.76,,,,,,,fee schedule,4108,14456, Excise lwr jaw cyst w/repair,21047,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,14456, Excise lwr jaw cyst w/repair,21047,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4108,14456, Excise lwr jaw cyst w/repair,21047,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4108,14456, Remove maxilla cyst complex,21048,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4965.18,,,,,,,fee schedule,4108,14456, Remove maxilla cyst complex,21048,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,14456, Remove maxilla cyst complex,21048,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4108,14456, Remove maxilla cyst complex,21048,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4108,14456, Excis uppr jaw cyst w/repair,21049,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5659.16,,,,,,,fee schedule,4108,14456, Excis uppr jaw cyst w/repair,21049,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,14456, Excis uppr jaw cyst w/repair,21049,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4108,14456, Excis uppr jaw cyst w/repair,21049,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4108,14456, Removal of jaw joint,21050,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4360.56,,,,,,,fee schedule,4360.56,14456, Removal of jaw joint,21050,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4360.56,14456, Removal of jaw joint,21050,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4360.56,14456, Removal of jaw joint,21050,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4360.56,14456, Remove jaw joint cartilage,21060,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3940.38,,,,,,,fee schedule,3940.38,14456, Remove jaw joint cartilage,21060,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3940.38,14456, Remove jaw joint cartilage,21060,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3940.38,14456, Remove jaw joint cartilage,21060,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3940.38,14456, Remove coronoid process,21070,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2974.01,,,,,,,fee schedule,2974.01,14456, Remove coronoid process,21070,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2974.01,14456, Remove coronoid process,21070,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,2974.01,14456, Remove coronoid process,21070,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,2974.01,14456, Mnpj of tmj w/anesth,21073,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1226.67,,,,,,,fee schedule,1226.67,5664, Mnpj of tmj w/anesth,21073,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1226.67,5664, Mnpj of tmj w/anesth,21073,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1226.67,5664, Mnpj of tmj w/anesth,21073,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1226.67,5664, Prepare face/oral prosthesis,21076,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3509.29,,,,,,,fee schedule,3509.29,6979, Prepare face/oral prosthesis,21076,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3509.29,6979, Prepare face/oral prosthesis,21076,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3509.29,6979, Prepare face/oral prosthesis,21076,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3509.29,6979, Prepare face/oral prosthesis,21077,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8514.78,,,,,,,fee schedule,6979,14456, Prepare face/oral prosthesis,21077,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,14456, Prepare face/oral prosthesis,21077,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,6979,14456, Prepare face/oral prosthesis,21077,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,6979,14456, Prepare face/oral prosthesis,21079,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5768.65,,,,,,,fee schedule,5768.65,14456, Prepare face/oral prosthesis,21079,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5768.65,14456, Prepare face/oral prosthesis,21079,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5768.65,14456, Prepare face/oral prosthesis,21079,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5768.65,14456, Prepare face/oral prosthesis,21080,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6480.16,,,,,,,fee schedule,6480.16,14456, Prepare face/oral prosthesis,21080,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6480.16,14456, Prepare face/oral prosthesis,21080,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,6480.16,14456, Prepare face/oral prosthesis,21080,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,6480.16,14456, Prepare face/oral prosthesis,21081,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5939,,,,,,,fee schedule,5939,14456, Prepare face/oral prosthesis,21081,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5939,14456, Prepare face/oral prosthesis,21081,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5939,14456, Prepare face/oral prosthesis,21081,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5939,14456, Prepare face/oral prosthesis,21082,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5522,,,,,,,fee schedule,5522,14456, Prepare face/oral prosthesis,21082,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5522,14456, Prepare face/oral prosthesis,21082,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5522,14456, Prepare face/oral prosthesis,21082,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5522,14456, Prepare face/oral prosthesis,21083,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5084.49,,,,,,,fee schedule,5084.49,14456, Prepare face/oral prosthesis,21083,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5084.49,14456, Prepare face/oral prosthesis,21083,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5084.49,14456, Prepare face/oral prosthesis,21083,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5084.49,14456, Prepare face/oral prosthesis,21084,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5871.93,,,,,,,fee schedule,5871.93,14456, Prepare face/oral prosthesis,21084,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5871.93,14456, Prepare face/oral prosthesis,21084,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5871.93,14456, Prepare face/oral prosthesis,21084,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5871.93,14456, Prepare face/oral prosthesis,21085,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2392.53,,,,,,,fee schedule,2392.53,6979, Prepare face/oral prosthesis,21085,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2392.53,6979, Prepare face/oral prosthesis,21085,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2392.53,6979, Prepare face/oral prosthesis,21085,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2392.53,6979, Prepare face/oral prosthesis,21086,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6276.2,,,,,,,fee schedule,6276.2,14456, Prepare face/oral prosthesis,21086,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6276.2,14456, Prepare face/oral prosthesis,21086,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,6276.2,14456, Prepare face/oral prosthesis,21086,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,6276.2,14456, Prepare face/oral prosthesis,21087,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6276.2,,,,,,,fee schedule,6276.2,14456, Prepare face/oral prosthesis,21087,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6276.2,14456, Prepare face/oral prosthesis,21087,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,6276.2,14456, Prepare face/oral prosthesis,21087,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,6276.2,14456, Prepare face/oral prosthesis,21088,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,14456, Prepare face/oral prosthesis,21088,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,6979,14456, Prepare face/oral prosthesis,21088,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,6979,14456, Prepare face/oral prosthesis,21089,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2505,6979, Prepare face/oral prosthesis,21089,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,6979, Prepare face/oral prosthesis,21089,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,6979, Maxillofacial fixation,21100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1801.24,,,,,,,fee schedule,1801.24,14456, Maxillofacial fixation,21100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1801.24,14456, Maxillofacial fixation,21100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,1801.24,14456, Maxillofacial fixation,21100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,1801.24,14456, Interdental fixation,21110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3596.81,,,,,,,fee schedule,3195,5664, Interdental fixation,21110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,5664, Interdental fixation,21110,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3195,5664, Interdental fixation,21110,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3195,5664, Injection jaw joint x-ray,21116,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,217.94,,,,,,,fee schedule,217.94,3195, Injection jaw joint x-ray,21116,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,217.94,3195, Injection jaw joint x-ray,21116,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,217.94,3195, Injection jaw joint x-ray,21116,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,217.94,3195, Reconstruction of chin,21120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2650.89,,,,,,,fee schedule,2650.89,10940, Reconstruction of chin,21120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,2650.89,10940, Reconstruction of chin,21120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2650.89,10940, Reconstruction of chin,21120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2650.89,10940, Reconstruction of chin,21121,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2658.29,,,,,,,fee schedule,2658.29,10940, Reconstruction of chin,21121,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,2658.29,10940, Reconstruction of chin,21121,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2658.29,10940, Reconstruction of chin,21121,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2658.29,10940, Reconstruction of chin,21122,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3833.53,,,,,,,fee schedule,3833.53,10940, Reconstruction of chin,21122,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,3833.53,10940, Reconstruction of chin,21122,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3833.53,10940, Reconstruction of chin,21122,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3833.53,10940, Reconstruction of chin,21123,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4259.33,,,,,,,fee schedule,4259.33,10940, Reconstruction of chin,21123,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,4259.33,10940, Reconstruction of chin,21123,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,4259.33,10940, Reconstruction of chin,21123,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,4259.33,10940, Augmentation lower jaw bone,21125,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3326.63,,,,,,,fee schedule,3326.63,10940, Augmentation lower jaw bone,21125,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,3326.63,10940, Augmentation lower jaw bone,21125,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3326.63,10940, Augmentation lower jaw bone,21125,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3326.63,10940, Augmentation lower jaw bone,21127,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3822.26,,,,,,,fee schedule,3822.26,14456, Augmentation lower jaw bone,21127,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3822.26,14456, Augmentation lower jaw bone,21127,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3822.26,14456, Augmentation lower jaw bone,21127,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3822.26,14456, Reduction of forehead,21137,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3795.44,,,,,,,fee schedule,3795.44,10940, Reduction of forehead,21137,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3795.44,10940, Reduction of forehead,21137,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3795.44,10940, Reduction of forehead,21137,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3795.44,10940, Reduction of forehead,21138,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4594.69,,,,,,,fee schedule,4594.69,14456, Reduction of forehead,21138,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4594.69,14456, Reduction of forehead,21138,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4594.69,14456, Reduction of forehead,21138,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4594.69,14456, Reduction of forehead,21139,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5461.94,,,,,,,fee schedule,5461.94,14456, Reduction of forehead,21139,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5461.94,14456, Reduction of forehead,21139,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5461.94,14456, Reduction of forehead,21139,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5461.94,14456, Lefort i-1 piece w/o graft,21141,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6657.26,,,,,,,fee schedule,5363,14456, Lefort i-1 piece w/o graft,21141,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,14456, Lefort i-1 piece w/o graft,21141,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5363,14456, Lefort i-1 piece w/o graft,21141,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5363,14456, Lefort i-2 piece w/o graft,21142,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6826.91,,,,,,,fee schedule,5363,14456, Lefort i-2 piece w/o graft,21142,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,14456, Lefort i-2 piece w/o graft,21142,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5363,14456, Lefort i-2 piece w/o graft,21142,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5363,14456, Lefort i-3/> piece w/o graft,21143,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7026.35,,,,,,,fee schedule,5363,14456, Lefort i-3/> piece w/o graft,21143,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,14456, Lefort i-3/> piece w/o graft,21143,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5363,14456, Lefort i-3/> piece w/o graft,21143,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5363,14456, Lefort i-1 piece w/ graft,21145,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7692.92,,,,,,,fee schedule,5363,14456, Lefort i-1 piece w/ graft,21145,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,14456, Lefort i-1 piece w/ graft,21145,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5363,14456, Lefort i-1 piece w/ graft,21145,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5363,14456, Lefort i-2 piece w/ graft,21146,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8033.46,,,,,,,fee schedule,5363,14456, Lefort i-2 piece w/ graft,21146,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,14456, Lefort i-2 piece w/ graft,21146,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5363,14456, Lefort i-2 piece w/ graft,21146,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5363,14456, Lefort i-3/> piece w/ graft,21147,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8443.39,,,,,,,fee schedule,5363,14456, Lefort i-3/> piece w/ graft,21147,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,14456, Lefort i-3/> piece w/ graft,21147,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5363,14456, Lefort i-3/> piece w/ graft,21147,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5363,14456, Lefort ii anterior intrusion,21150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7864.89,,,,,,,fee schedule,5363,14456, Lefort ii anterior intrusion,21150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,14456, Lefort ii anterior intrusion,21150,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5363,14456, Lefort ii anterior intrusion,21150,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5363,14456, Lefort ii w/bone grafts,21151,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8646.93,,,,,,,fee schedule,5363,14456, Lefort ii w/bone grafts,21151,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,14456, Lefort ii w/bone grafts,21151,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5363,14456, Lefort ii w/bone grafts,21151,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5363,14456, Lefort iii w/o lefort i,21154,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9315.65,,,,,,,fee schedule,5363,14456, Lefort iii w/o lefort i,21154,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,14456, Lefort iii w/o lefort i,21154,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5363,14456, Lefort iii w/o lefort i,21154,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5363,14456, Lefort iii w/ lefort i,21155,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10316.88,,,,,,,fee schedule,5363,14456, Lefort iii w/ lefort i,21155,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,14456, Lefort iii w/ lefort i,21155,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5363,14456, Lefort iii w/ lefort i,21155,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5363,14456, Lefort iii w/fhdw/o lefort i,21159,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12341.03,,,,,,,fee schedule,5363,14456, Lefort iii w/fhdw/o lefort i,21159,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,14456, Lefort iii w/fhdw/o lefort i,21159,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5363,14456, Lefort iii w/fhdw/o lefort i,21159,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5363,14456, Lefort iii w/fhd w/ lefort i,21160,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,13370.05,,,,,,,fee schedule,5363,14456, Lefort iii w/fhd w/ lefort i,21160,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,14456, Lefort iii w/fhd w/ lefort i,21160,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5363,14456, Lefort iii w/fhd w/ lefort i,21160,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5363,14456, Reconstruct orbit/forehead,21172,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12142.08,,,,,,,fee schedule,6044,14456, Reconstruct orbit/forehead,21172,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,14456, Reconstruct orbit/forehead,21172,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,6044,14456, Reconstruct orbit/forehead,21172,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,6044,14456, Reconstruct orbit/forehead,21175,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10824.75,,,,,,,fee schedule,6044,14456, Reconstruct orbit/forehead,21175,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,14456, Reconstruct orbit/forehead,21175,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,6044,14456, Reconstruct orbit/forehead,21175,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,6044,14456, Reconstruct entire forehead,21179,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7507.51,,,,,,,fee schedule,6044,14456, Reconstruct entire forehead,21179,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,14456, Reconstruct entire forehead,21179,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,6044,14456, Reconstruct entire forehead,21179,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,6044,14456, Reconstruct entire forehead,21180,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8369.9,,,,,,,fee schedule,6044,14456, Reconstruct entire forehead,21180,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,14456, Reconstruct entire forehead,21180,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,6044,14456, Reconstruct entire forehead,21180,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,6044,14456, Contour cranial bone lesion,21181,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3732.95,,,,,,,fee schedule,3732.95,10940, Contour cranial bone lesion,21181,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,3732.95,10940, Contour cranial bone lesion,21181,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3732.95,10940, Contour cranial bone lesion,21181,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3732.95,10940, Reconstruct cranial bone,21182,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10372.19,,,,,,,fee schedule,5363,14456, Reconstruct cranial bone,21182,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,14456, Reconstruct cranial bone,21182,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5363,14456, Reconstruct cranial bone,21182,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5363,14456, Reconstruct cranial bone,21183,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,11264.74,,,,,,,fee schedule,5363,14456, Reconstruct cranial bone,21183,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,14456, Reconstruct cranial bone,21183,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5363,14456, Reconstruct cranial bone,21183,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5363,14456, Reconstruct cranial bone,21184,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12103.07,,,,,,,fee schedule,5363,14456, Reconstruct cranial bone,21184,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,14456, Reconstruct cranial bone,21184,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5363,14456, Reconstruct cranial bone,21184,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5363,14456, Reconstruction of midface,21188,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7872.39,,,,,,,fee schedule,5363,14456, Reconstruction of midface,21188,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,14456, Reconstruction of midface,21188,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5363,14456, Reconstruction of midface,21188,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5363,14456, Reconst lwr jaw w/o graft,21193,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6129.05,,,,,,,fee schedule,6044,14456, Reconst lwr jaw w/o graft,21193,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,14456, Reconst lwr jaw w/o graft,21193,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,6044,14456, Reconst lwr jaw w/o graft,21193,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,6044,14456, Reconst lwr jaw w/graft,21194,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7072.21,,,,,,,fee schedule,5363,14456, Reconst lwr jaw w/graft,21194,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,14456, Reconst lwr jaw w/graft,21194,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5363,14456, Reconst lwr jaw w/graft,21194,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5363,14456, Reconst lwr jaw w/o fixation,21195,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6695.68,,,,,,,fee schedule,6044,14456, Reconst lwr jaw w/o fixation,21195,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,14456, Reconst lwr jaw w/o fixation,21195,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,6044,14456, Reconst lwr jaw w/o fixation,21195,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,6044,14456, Reconst lwr jaw w/fixation,21196,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7140.63,,,,,,,fee schedule,5363,14456, Reconst lwr jaw w/fixation,21196,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,14456, Reconst lwr jaw w/fixation,21196,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5363,14456, Reconst lwr jaw w/fixation,21196,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5363,14456, Reconstr lwr jaw segment,21198,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5007.97,,,,,,,fee schedule,5007.97,10940, Reconstr lwr jaw segment,21198,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5007.97,10940, Reconstr lwr jaw segment,21198,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,5007.97,10940, Reconstr lwr jaw segment,21198,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,5007.97,10940, Reconstr Lwr Jaw W/Advance,21199,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5037.54,,,,,,,fee schedule,5037.54,14456, Reconstr Lwr Jaw W/Advance,21199,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,5037.54,14456, Reconstr Lwr Jaw W/Advance,21199,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5037.54,14456, Reconstr Lwr Jaw W/Advance,21199,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5037.54,14456, Reconstruct upper jaw bone,21206,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4799.74,,,,,,,fee schedule,4799.74,14456, Reconstruct upper jaw bone,21206,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4799.74,14456, Reconstruct upper jaw bone,21206,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4799.74,14456, Reconstruct upper jaw bone,21206,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4799.74,14456, Augmentation of facial bones,21208,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3677.21,,,,,,,fee schedule,3677.21,14456, Augmentation of facial bones,21208,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,3677.21,14456, Augmentation of facial bones,21208,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3677.21,14456, Augmentation of facial bones,21208,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3677.21,14456, Reduction of facial bones,21209,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3007.14,,,,,,,fee schedule,3007.14,14456, Reduction of facial bones,21209,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,3007.14,14456, Reduction of facial bones,21209,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3007.14,14456, Reduction of facial bones,21209,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3007.14,14456, Face bone graft,21210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3797.76,,,,,,,fee schedule,3797.76,14456, Face bone graft,21210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,3797.76,14456, Face bone graft,21210,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3797.76,14456, Face bone graft,21210,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3797.76,14456, Lower jaw bone graft,21215,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3950.09,,,,,,,fee schedule,3950.09,14456, Lower jaw bone graft,21215,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,3950.09,14456, Lower jaw bone graft,21215,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3950.09,14456, Lower jaw bone graft,21215,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3950.09,14456, Rib cartilage graft,21230,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3661.83,,,,,,,fee schedule,3661.83,14456, Rib cartilage graft,21230,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,3661.83,14456, Rib cartilage graft,21230,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3661.83,14456, Rib cartilage graft,21230,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3661.83,14456, Ear cartilage graft,21235,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2768.9,,,,,,,fee schedule,2768.9,8406, Ear cartilage graft,21235,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,2768.9,8406, Ear cartilage graft,21235,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2768.9,8406, Ear cartilage graft,21235,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2768.9,8406, Reconstruction of jaw joint,21240,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5198.78,,,,,,,fee schedule,5198.78,14456, Reconstruction of jaw joint,21240,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5198.78,14456, Reconstruction of jaw joint,21240,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5198.78,14456, Reconstruction of jaw joint,21240,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5198.78,14456, Reconstruction of jaw joint,21242,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5078.34,,,,,,,fee schedule,5078.34,14456, Reconstruction of jaw joint,21242,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,5078.34,14456, Reconstruction of jaw joint,21242,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5078.34,14456, Reconstruction of jaw joint,21242,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5078.34,14456, Reconstruction of jaw joint,21243,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8025.36,,,,,,,fee schedule,6044,14456, Reconstruction of jaw joint,21243,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,14456, Reconstruction of jaw joint,21243,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,6044,14456, Reconstruction of jaw joint,21243,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,6044,14456, Reconstruction of lower jaw,21244,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4926.28,,,,,,,fee schedule,4926.28,14456, Reconstruction of lower jaw,21244,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,4926.28,14456, Reconstruction of lower jaw,21244,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4926.28,14456, Reconstruction of lower jaw,21244,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4926.28,14456, Reconstruction of jaw,21245,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4755.01,,,,,,,fee schedule,4755.01,14456, Reconstruction of jaw,21245,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,4755.01,14456, Reconstruction of jaw,21245,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4755.01,14456, Reconstruction of jaw,21245,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4755.01,14456, Reconstruction of jaw,21246,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4241.53,,,,,,,fee schedule,4241.53,14456, Reconstruction of jaw,21246,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,4241.53,14456, Reconstruction of jaw,21246,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4241.53,14456, Reconstruction of jaw,21246,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4241.53,14456, Reconstruct lower jaw bone,21247,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7849.62,,,,,,,fee schedule,5363,14456, Reconstruct lower jaw bone,21247,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,14456, Reconstruct lower jaw bone,21247,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5363,14456, Reconstruct lower jaw bone,21247,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5363,14456, Reconstruction of jaw,21248,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3989.75,,,,,,,fee schedule,3989.75,14456, Reconstruction of jaw,21248,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,3989.75,14456, Reconstruction of jaw,21248,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3989.75,14456, Reconstruction of jaw,21248,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3989.75,14456, Reconstruction of jaw,21249,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5584.97,,,,,,,fee schedule,5584.97,14456, Reconstruction of jaw,21249,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,5584.97,14456, Reconstruction of jaw,21249,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5584.97,14456, Reconstruction of jaw,21249,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5584.97,14456, Reconstruct lower jaw bone,21255,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6699.4,,,,,,,fee schedule,5363,14456, Reconstruct lower jaw bone,21255,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,14456, Reconstruct lower jaw bone,21255,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5363,14456, Reconstruct lower jaw bone,21255,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5363,14456, Reconstruction of orbit,21256,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6202.43,,,,,,,fee schedule,6202.43,14456, Reconstruction of orbit,21256,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6202.43,14456, Reconstruction of orbit,21256,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,6202.43,14456, Reconstruction of orbit,21256,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,6202.43,14456, Revise eye sockets,21260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6914.65,,,,,,,fee schedule,6914.65,14456, Revise eye sockets,21260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6914.65,14456, Revise eye sockets,21260,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,6914.65,14456, Revise eye sockets,21260,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,6914.65,14456, Revise eye sockets,21261,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12095.4,,,,,,,fee schedule,6979,14456, Revise eye sockets,21261,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,14456, Revise eye sockets,21261,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,6979,14456, Revise eye sockets,21261,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,6979,14456, Revise eye sockets,21263,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,11216.99,,,,,,,fee schedule,6979,14456, Revise eye sockets,21263,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,14456, Revise eye sockets,21263,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,6979,14456, Revise eye sockets,21263,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,6979,14456, Revise eye sockets,21267,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8095.4,,,,,,,fee schedule,8095.4,14456, Revise eye sockets,21267,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,8095.4,14456, Revise eye sockets,21267,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,8095.4,14456, Revise eye sockets,21267,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,8095.4,14456, Revise eye sockets,21268,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10086.96,,,,,,,fee schedule,5363,14456, Revise eye sockets,21268,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,14456, Revise eye sockets,21268,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5363,14456, Revise eye sockets,21268,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5363,14456, Augmentation cheek bone,21270,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3755.35,,,,,,,fee schedule,3755.35,14456, Augmentation cheek bone,21270,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,3755.35,14456, Augmentation cheek bone,21270,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3755.35,14456, Augmentation cheek bone,21270,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3755.35,14456, Revision orbitofacial bones,21275,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4243.2,,,,,,,fee schedule,4243.2,14456, Revision orbitofacial bones,21275,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,4243.2,14456, Revision orbitofacial bones,21275,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4243.2,14456, Revision orbitofacial bones,21275,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4243.2,14456, Revision of eyelid,21280,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2830.26,,,,,,,fee schedule,2830.26,14456, Revision of eyelid,21280,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,2830.26,14456, Revision of eyelid,21280,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,2830.26,14456, Revision of eyelid,21280,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,2830.26,14456, Revision of eyelid,21282,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1988.91,,,,,,,fee schedule,1988.91,6044, Revision of eyelid,21282,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,1988.91,6044, Revision of eyelid,21282,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1988.91,6044, Revision of eyelid,21282,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1988.91,6044, Revision of jaw muscle/bone,21295,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,994.86,,,,,,,fee schedule,994.86,5664, Revision of jaw muscle/bone,21295,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,994.86,5664, Revision of jaw muscle/bone,21295,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,994.86,5664, Revision of jaw muscle/bone,21295,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,994.86,5664, Revision of jaw muscle/bone,21296,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2010.39,,,,,,,fee schedule,2010.39,10940, Revision of jaw muscle/bone,21296,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2010.39,10940, Revision of jaw muscle/bone,21296,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2010.39,10940, Revision of jaw muscle/bone,21296,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2010.39,10940, Cranio/maxillofacial surgery,21299,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2505,6979, Cranio/maxillofacial surgery,21299,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,6979, Cranio/maxillofacial surgery,21299,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,6979, Closed tx nose fx w/o stablj,21315,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,300.61,,,,,,,fee schedule,300.61,5664, Closed tx nose fx w/o stablj,21315,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,300.61,5664, Closed tx nose fx w/o stablj,21315,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,300.61,5664, Closed tx nose fx w/o stablj,21315,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,300.61,5664, Closed tx nose fx w/ stablj,21320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,457.1,,,,,,,fee schedule,457.1,5664, Closed tx nose fx w/ stablj,21320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,457.1,5664, Closed tx nose fx w/ stablj,21320,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,457.1,5664, Closed tx nose fx w/ stablj,21320,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,457.1,5664, Open tx nose fx uncomplicatd,21325,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2223.58,,,,,,,fee schedule,2223.58,10940, Open tx nose fx uncomplicatd,21325,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2223.58,10940, Open tx nose fx uncomplicatd,21325,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2223.58,10940, Open tx nose fx uncomplicatd,21325,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2223.58,10940, Open tx nose fx w/skele fixj,21330,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2656.02,,,,,,,fee schedule,2656.02,10940, Open tx nose fx w/skele fixj,21330,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,2656.02,10940, Open tx nose fx w/skele fixj,21330,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2656.02,10940, Open tx nose fx w/skele fixj,21330,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2656.02,10940, Open tx nose & septal fx,21335,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3548.63,,,,,,,fee schedule,3548.63,10940, Open tx nose & septal fx,21335,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,3548.63,10940, Open tx nose & septal fx,21335,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3548.63,10940, Open tx nose & septal fx,21335,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3548.63,10940, Open tx septal fx w/wo stabj,21336,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3157.31,,,,,,,fee schedule,3157.31,10940, Open tx septal fx w/wo stabj,21336,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3157.31,10940, Open tx septal fx w/wo stabj,21336,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3157.31,10940, Open tx septal fx w/wo stabj,21336,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3157.31,10940, Closed tx septal&nose fx,21337,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1529.77,,,,,,,fee schedule,1529.77,5664, Closed tx septal&nose fx,21337,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1529.77,5664, Closed tx septal&nose fx,21337,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1529.77,5664, Closed tx septal&nose fx,21337,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1529.77,5664, Open nasoethmoid fx w/o fixj,21338,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3384.8,,,,,,,fee schedule,3384.8,10940, Open nasoethmoid fx w/o fixj,21338,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3384.8,10940, Open nasoethmoid fx w/o fixj,21338,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3384.8,10940, Open nasoethmoid fx w/o fixj,21338,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3384.8,10940, Open nasoethmoid fx w/ fixj,21339,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3796.46,,,,,,,fee schedule,3796.46,10940, Open nasoethmoid fx w/ fixj,21339,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,3796.46,10940, Open nasoethmoid fx w/ fixj,21339,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3796.46,10940, Open nasoethmoid fx w/ fixj,21339,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3796.46,10940, Perq tx nasoethmoid fx,21340,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3654.17,,,,,,,fee schedule,3654.17,14456, Perq tx nasoethmoid fx,21340,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3654.17,14456, Perq tx nasoethmoid fx,21340,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3654.17,14456, Perq tx nasoethmoid fx,21340,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3654.17,14456, Open tx dprsd front sinus fx,21343,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5340.53,,,,,,,fee schedule,5340.53,14456, Open tx dprsd front sinus fx,21343,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,5340.53,14456, Open tx dprsd front sinus fx,21343,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5340.53,14456, Open tx dprsd front sinus fx,21343,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5340.53,14456, Open tx compl front sinus fx,21344,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6737.5,,,,,,,fee schedule,6044,14456, Open tx compl front sinus fx,21344,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,14456, Open tx compl front sinus fx,21344,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,6044,14456, Open tx compl front sinus fx,21344,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,6044,14456, Closed tx nose/jaw fx,21345,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3128.06,,,,,,,fee schedule,3128.06,8406, Closed tx nose/jaw fx,21345,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,3128.06,8406, Closed tx nose/jaw fx,21345,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3128.06,8406, Closed tx nose/jaw fx,21345,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3128.06,8406, Opn tx nasomax fx w/fixj,21346,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4963.35,,,,,,,fee schedule,4963.35,10940, Opn tx nasomax fx w/fixj,21346,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4963.35,10940, Opn tx nasomax fx w/fixj,21346,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,4963.35,10940, Opn tx nasomax fx w/fixj,21346,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,4963.35,10940, Opn tx nasomax fx multple,21347,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5138.99,,,,,,,fee schedule,5138.99,14456, Opn tx nasomax fx multple,21347,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,5138.99,14456, Opn tx nasomax fx multple,21347,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5138.99,14456, Opn tx nasomax fx multple,21347,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5138.99,14456, Opn tx nasomax fx w/graft,21348,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5270.81,,,,,,,fee schedule,5270.81,14456, Opn tx nasomax fx w/graft,21348,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,5270.81,14456, Opn tx nasomax fx w/graft,21348,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5270.81,14456, Opn tx nasomax fx w/graft,21348,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5270.81,14456, Perq tx malar fracture,21355,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1613.51,,,,,,,fee schedule,1613.51,14456, Perq tx malar fracture,21355,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1613.51,14456, Perq tx malar fracture,21355,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,1613.51,14456, Perq tx malar fracture,21355,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,1613.51,14456, Opn tx dprsd zygomatic arch,21356,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2083.18,,,,,,,fee schedule,2083.18,10940, Opn tx dprsd zygomatic arch,21356,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2083.18,10940, Opn tx dprsd zygomatic arch,21356,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2083.18,10940, Opn tx dprsd zygomatic arch,21356,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2083.18,10940, Opn tx dprsd malar fracture,21360,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2575.51,,,,,,,fee schedule,2575.51,10940, Opn tx dprsd malar fracture,21360,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2575.51,10940, Opn tx dprsd malar fracture,21360,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2575.51,10940, Opn tx dprsd malar fracture,21360,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2575.51,10940, Opn tx complx malar fx,21365,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5350.73,,,,,,,fee schedule,5350.73,14456, Opn tx complx malar fx,21365,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,5350.73,14456, Opn tx complx malar fx,21365,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5350.73,14456, Opn tx complx malar fx,21365,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5350.73,14456, Opn tx complx malar w/grft,21366,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6348.83,,,,,,,fee schedule,6044,14456, Opn tx complx malar w/grft,21366,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,14456, Opn tx complx malar w/grft,21366,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,6044,14456, Opn tx complx malar w/grft,21366,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,6044,14456, Opn tx orbit fx transantral,21385,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3723.29,,,,,,,fee schedule,3723.29,14456, Opn tx orbit fx transantral,21385,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,3723.29,14456, Opn tx orbit fx transantral,21385,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3723.29,14456, Opn tx orbit fx transantral,21385,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3723.29,14456, Opn tx orbit fx periorbital,21386,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3499.31,,,,,,,fee schedule,3499.31,14456, Opn tx orbit fx periorbital,21386,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,3499.31,14456, Opn tx orbit fx periorbital,21386,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3499.31,14456, Opn tx orbit fx periorbital,21386,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3499.31,14456, Opn tx orbit fx combined,21387,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3880.37,,,,,,,fee schedule,3880.37,14456, Opn tx orbit fx combined,21387,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,3880.37,14456, Opn tx orbit fx combined,21387,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3880.37,14456, Opn tx orbit fx combined,21387,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3880.37,14456, Opn tx orbit periorbtl implt,21390,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3886.25,,,,,,,fee schedule,3886.25,14456, Opn tx orbit periorbtl implt,21390,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,3886.25,14456, Opn tx orbit periorbtl implt,21390,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3886.25,14456, Opn tx orbit periorbtl implt,21390,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3886.25,14456, Opn tx orbit periorbt w/grft,21395,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5001.17,,,,,,,fee schedule,5001.17,14456, Opn tx orbit periorbt w/grft,21395,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,5001.17,14456, Opn tx orbit periorbt w/grft,21395,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5001.17,14456, Opn tx orbit periorbt w/grft,21395,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5001.17,14456, Closed tx orbit w/o manipulj,21400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,930.49,,,,,,,fee schedule,930.49,4108, Closed tx orbit w/o manipulj,21400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,930.49,4108, Closed tx orbit w/o manipulj,21400,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,930.49,4108, Closed tx orbit w/o manipulj,21400,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,930.49,4108, Closed tx orbit w/manipulj,21401,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1721.76,,,,,,,fee schedule,1721.76,5664, Closed tx orbit w/manipulj,21401,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1721.76,5664, Closed tx orbit w/manipulj,21401,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1721.76,5664, Closed tx orbit w/manipulj,21401,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1721.76,5664, Opn tx orbit fx w/o implant,21406,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2986.63,,,,,,,fee schedule,2986.63,14456, Opn tx orbit fx w/o implant,21406,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2986.63,14456, Opn tx orbit fx w/o implant,21406,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,2986.63,14456, Opn tx orbit fx w/o implant,21406,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,2986.63,14456, Opn tx orbit fx w/implant,21407,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3168.1,,,,,,,fee schedule,3168.1,14456, Opn tx orbit fx w/implant,21407,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,3168.1,14456, Opn tx orbit fx w/implant,21407,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3168.1,14456, Opn tx orbit fx w/implant,21407,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3168.1,14456, Opn tx orbit fx w/bone grft,21408,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4528.22,,,,,,,fee schedule,4528.22,14456, Opn tx orbit fx w/bone grft,21408,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4528.22,14456, Opn tx orbit fx w/bone grft,21408,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4528.22,14456, Opn tx orbit fx w/bone grft,21408,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4528.22,14456, Treat mouth roof fracture,21421,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2761.62,,,,,,,fee schedule,2761.62,10940, Treat mouth roof fracture,21421,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2761.62,10940, Treat mouth roof fracture,21421,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2761.62,10940, Treat mouth roof fracture,21421,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2761.62,10940, Treat mouth roof fracture,21422,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3234.31,,,,,,,fee schedule,3234.31,14456, Treat mouth roof fracture,21422,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,3234.31,14456, Treat mouth roof fracture,21422,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3234.31,14456, Treat mouth roof fracture,21422,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3234.31,14456, Treat mouth roof fracture,21423,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4000.54,,,,,,,fee schedule,4000.54,14456, Treat mouth roof fracture,21423,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4000.54,14456, Treat mouth roof fracture,21423,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4000.54,14456, Treat mouth roof fracture,21423,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4000.54,14456, Treat craniofacial fracture,21431,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3485.28,,,,,,,fee schedule,3485.28,14456, Treat craniofacial fracture,21431,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3485.28,14456, Treat craniofacial fracture,21431,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3485.28,14456, Treat craniofacial fracture,21431,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3485.28,14456, Treat craniofacial fracture,21432,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3691.67,,,,,,,fee schedule,3691.67,14456, Treat craniofacial fracture,21432,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3691.67,14456, Treat craniofacial fracture,21432,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3691.67,14456, Treat craniofacial fracture,21432,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3691.67,14456, Treat craniofacial fracture,21433,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8546.67,,,,,,,fee schedule,5363,14456, Treat craniofacial fracture,21433,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,14456, Treat craniofacial fracture,21433,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5363,14456, Treat craniofacial fracture,21433,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5363,14456, Treat craniofacial fracture,21435,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7025.27,,,,,,,fee schedule,5363,14456, Treat craniofacial fracture,21435,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,14456, Treat craniofacial fracture,21435,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5363,14456, Treat craniofacial fracture,21435,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5363,14456, Treat craniofacial fracture,21436,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10084.91,,,,,,,fee schedule,5363,14456, Treat craniofacial fracture,21436,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,14456, Treat craniofacial fracture,21436,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5363,14456, Treat craniofacial fracture,21436,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5363,14456, Treat dental ridge fracture,21440,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3177.06,,,,,,,fee schedule,3177.06,10940, Treat dental ridge fracture,21440,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3177.06,10940, Treat dental ridge fracture,21440,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3177.06,10940, Treat dental ridge fracture,21440,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3177.06,10940, Treat dental ridge fracture,21445,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3040.32,,,,,,,fee schedule,3040.32,14456, Treat dental ridge fracture,21445,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3040.32,14456, Treat dental ridge fracture,21445,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3040.32,14456, Treat dental ridge fracture,21445,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3040.32,14456, Treat lower jaw fracture,21450,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2441.69,,,,,,,fee schedule,2441.69,5248, Treat lower jaw fracture,21450,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2441.69,5248, Treat lower jaw fracture,21450,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2441.69,5248, Treat lower jaw fracture,21450,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2441.69,5248, Treat lower jaw fracture,21451,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3242.4,,,,,,,fee schedule,3242.4,5664, Treat lower jaw fracture,21451,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3242.4,5664, Treat lower jaw fracture,21451,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3242.4,5664, Treat lower jaw fracture,21451,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3242.4,5664, Treat lower jaw fracture,21452,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2422.21,,,,,,,fee schedule,2422.21,5664, Treat lower jaw fracture,21452,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2422.21,5664, Treat lower jaw fracture,21452,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2422.21,5664, Treat lower jaw fracture,21452,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2422.21,5664, Treat lower jaw fracture,21453,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4748.37,,,,,,,fee schedule,4748.37,14456, Treat lower jaw fracture,21453,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4748.37,14456, Treat lower jaw fracture,21453,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4748.37,14456, Treat lower jaw fracture,21453,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4748.37,14456, Treat lower jaw fracture,21454,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2462.14,,,,,,,fee schedule,2462.14,10940, Treat lower jaw fracture,21454,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,2462.14,10940, Treat lower jaw fracture,21454,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2462.14,10940, Treat lower jaw fracture,21454,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2462.14,10940, Treat lower jaw fracture,21461,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5206.49,,,,,,,fee schedule,5206.49,14456, Treat lower jaw fracture,21461,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5206.49,14456, Treat lower jaw fracture,21461,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5206.49,14456, Treat lower jaw fracture,21461,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5206.49,14456, Treat lower jaw fracture,21462,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5952.17,,,,,,,fee schedule,5952.17,14456, Treat lower jaw fracture,21462,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,5952.17,14456, Treat lower jaw fracture,21462,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5952.17,14456, Treat lower jaw fracture,21462,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5952.17,14456, Treat lower jaw fracture,21465,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3979.12,,,,,,,fee schedule,3979.12,14456, Treat lower jaw fracture,21465,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3979.12,14456, Treat lower jaw fracture,21465,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3979.12,14456, Treat lower jaw fracture,21465,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3979.12,14456, Treat lower jaw fracture,21470,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5749.98,,,,,,,fee schedule,5749.98,14456, Treat lower jaw fracture,21470,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,5749.98,14456, Treat lower jaw fracture,21470,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5749.98,14456, Treat lower jaw fracture,21470,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5749.98,14456, Reset dislocated jaw,21480,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,174.29,,,,,,,fee schedule,174.29,3195, Reset dislocated jaw,21480,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,174.29,3195, Reset dislocated jaw,21480,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,174.29,3195, Reset dislocated jaw,21480,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,174.29,3195, Reset dislocated jaw,21485,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4081.37,,,,,,,fee schedule,4081.37,5664, Reset dislocated jaw,21485,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4081.37,5664, Reset dislocated jaw,21485,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4081.37,5664, Reset dislocated jaw,21485,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4081.37,5664, Repair dislocated jaw,21490,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3922.46,,,,,,,fee schedule,3922.46,14456, Repair dislocated jaw,21490,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3922.46,14456, Repair dislocated jaw,21490,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3922.46,14456, Repair dislocated jaw,21490,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3922.46,14456, Interdental wiring,21497,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2983.23,,,,,,,fee schedule,2983.23,5664, Interdental wiring,21497,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2983.23,5664, Interdental wiring,21497,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2983.23,5664, Interdental wiring,21497,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2983.23,5664, Head surgery procedure,21499,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2505,6979, Head surgery procedure,21499,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,6979, Head surgery procedure,21499,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,6979, Drain neck/chest lesion,21501,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1802.86,,,,,,,fee schedule,1802.86,10940, Drain neck/chest lesion,21501,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1802.86,10940, Drain neck/chest lesion,21501,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1802.86,10940, Drain neck/chest lesion,21501,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1802.86,10940, Drain chest lesion,21502,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2880.38,,,,,,,fee schedule,2880.38,10940, Drain chest lesion,21502,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2880.38,10940, Drain chest lesion,21502,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2880.38,10940, Drain chest lesion,21502,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2880.38,10940, Drainage of bone lesion,21510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2584.95,,,,,,,fee schedule,2584.95,14456, Drainage of bone lesion,21510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,2584.95,14456, Drainage of bone lesion,21510,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,2584.95,14456, Drainage of bone lesion,21510,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,2584.95,14456, Biopsy of neck/chest,21550,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,786.79,,,,,,,fee schedule,786.79,5664, Biopsy of neck/chest,21550,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,786.79,5664, Biopsy of neck/chest,21550,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,786.79,5664, Biopsy of neck/chest,21550,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,786.79,5664, Exc neck les sc 3 cm/>,21552,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2412.12,,,,,,,fee schedule,2412.12,10940, Exc neck les sc 3 cm/>,21552,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2412.12,10940, Exc neck les sc 3 cm/>,21552,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2412.12,10940, Exc neck les sc 3 cm/>,21552,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2412.12,10940, Exc neck tum deep 5 cm/>,21554,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3833.16,,,,,,,fee schedule,3833.16,10940, Exc neck tum deep 5 cm/>,21554,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3833.16,10940, Exc neck tum deep 5 cm/>,21554,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3833.16,10940, Exc neck tum deep 5 cm/>,21554,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3833.16,10940, Exc neck les sc < 3 cm,21555,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1646.64,,,,,,,fee schedule,1646.64,5664, Exc neck les sc < 3 cm,21555,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1646.64,5664, Exc neck les sc < 3 cm,21555,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1646.64,5664, Exc neck les sc < 3 cm,21555,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1646.64,5664, Exc neck tum deep < 5 cm,21556,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2739.71,,,,,,,fee schedule,2739.71,10940, Exc neck tum deep < 5 cm,21556,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2739.71,10940, Exc neck tum deep < 5 cm,21556,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2739.71,10940, Exc neck tum deep < 5 cm,21556,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2739.71,10940, Resect neck thorax tumor<5cm,21557,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4973.82,,,,,,,fee schedule,4108,5664, Resect neck thorax tumor<5cm,21557,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,5664, Resect neck thorax tumor<5cm,21557,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4108,5664, Resect neck thorax tumor<5cm,21557,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4108,5664, Resect neck tumor 5 cm/>,21558,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6911.52,,,,,,,fee schedule,5248,10940, Resect neck tumor 5 cm/>,21558,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,10940, Resect neck tumor 5 cm/>,21558,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,5248,10940, Resect neck tumor 5 cm/>,21558,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,5248,10940, Partial removal of rib,21600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3150.89,,,,,,,fee schedule,3150.89,12821, Partial removal of rib,21600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3150.89,12821, Partial removal of rib,21600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3150.89,12821, Partial removal of rib,21600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3150.89,12821, Exc chest wall tumor w/ribs,21601,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6309.43,,,,,,,fee schedule,6044,10940, Exc chest wall tumor w/ribs,21601,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,10940, Exc chest wall tumor w/ribs,21601,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,6044,10940, Exc chest wall tumor w/ribs,21601,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,6044,10940, Exc ch wal tum w/o lymphadec,21602,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8583.04,,,,,,,fee schedule,6044,22111, Exc ch wal tum w/o lymphadec,21602,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,22111, Exc ch wal tum w/o lymphadec,21602,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6044,22111, Exc ch wal tum w/o lymphadec,21602,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6044,22111, Exc ch wal tum w/lymphadec,21603,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9429.24,,,,,,,fee schedule,6044,22111, Exc ch wal tum w/lymphadec,21603,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,22111, Exc ch wal tum w/lymphadec,21603,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6044,22111, Exc ch wal tum w/lymphadec,21603,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6044,22111, Partial removal of rib,21610,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7047.39,,,,,,,fee schedule,4108,12821, Partial removal of rib,21610,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,12821, Partial removal of rib,21610,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4108,12821, Partial removal of rib,21610,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4108,12821, Removal of rib,21615,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3336.13,,,,,,,fee schedule,3336.13,22111, Removal of rib,21615,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,3336.13,22111, Removal of rib,21615,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3336.13,22111, Removal of rib,21615,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3336.13,22111, Removal of rib and nerves,21616,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3845.3,,,,,,,fee schedule,3845.3,22111, Removal of rib and nerves,21616,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,3845.3,22111, Removal of rib and nerves,21616,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3845.3,22111, Removal of rib and nerves,21616,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3845.3,22111, Partial removal of sternum,21620,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2806.95,,,,,,,fee schedule,2806.95,14456, Partial removal of sternum,21620,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2806.95,14456, Partial removal of sternum,21620,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,2806.95,14456, Partial removal of sternum,21620,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,2806.95,14456, Sternal debridement,21627,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3089.43,,,,,,,fee schedule,3089.43,22111, Sternal debridement,21627,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3089.43,22111, Sternal debridement,21627,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3089.43,22111, Sternal debridement,21627,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3089.43,22111, Extensive sternum surgery,21630,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6529.54,,,,,,,fee schedule,6044,22111, Extensive sternum surgery,21630,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,22111, Extensive sternum surgery,21630,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6044,22111, Extensive sternum surgery,21630,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6044,22111, Extensive sternum surgery,21632,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Hyoid myotomy & suspension,21685,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4785.66,,,,,,,fee schedule,4108,10940, Hyoid myotomy & suspension,21685,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,10940, Hyoid myotomy & suspension,21685,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,4108,10940, Hyoid myotomy & suspension,21685,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,4108,10940, Revision of neck muscle,21700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1917.95,,,,,,,fee schedule,1917.95,10940, Revision of neck muscle,21700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1917.95,10940, Revision of neck muscle,21700,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1917.95,10940, Revision of neck muscle,21700,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1917.95,10940, Revision of neck muscle/rib,21705,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2871.21,,,,,,,fee schedule,2871.21,22111, Revision of neck muscle/rib,21705,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,2871.21,22111, Revision of neck muscle/rib,21705,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,2871.21,22111, Revision of neck muscle/rib,21705,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,2871.21,22111, Revision of neck muscle,21720,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3243.1,,,,,,,fee schedule,3243.1,10940, Revision of neck muscle,21720,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3243.1,10940, Revision of neck muscle,21720,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3243.1,10940, Revision of neck muscle,21720,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3243.1,10940, Revision of neck muscle,21725,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2860.1,,,,,,,fee schedule,2860.1,5248, Revision of neck muscle,21725,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2860.1,5248, Revision of neck muscle,21725,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,2860.1,5248, Revision of neck muscle,21725,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,2860.1,5248, Reconstruction of sternum,21740,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5666.02,,,,,,,fee schedule,5363,22111, Reconstruction of sternum,21740,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,22111, Reconstruction of sternum,21740,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5363,22111, Reconstruction of sternum,21740,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5363,22111, Repair stern/nuss w/o scope,21742,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,14456, Repair stern/nuss w/o scope,21742,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,6979,14456, Repair stern/nuss w/o scope,21742,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,6979,14456, Repair sternum/nuss w/scope,21743,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,14456, Repair sternum/nuss w/scope,21743,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,6979,14456, Repair sternum/nuss w/scope,21743,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,6979,14456, Repair of sternum separation,21750,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3765.44,,,,,,,fee schedule,3765.44,22111, Repair of sternum separation,21750,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3765.44,22111, Repair of sternum separation,21750,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3765.44,22111, Repair of sternum separation,21750,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3765.44,22111, Optx of rib fx w/fixj scope,21811,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3149.97,,,,,,,fee schedule,3149.97,10940, Optx of rib fx w/fixj scope,21811,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3149.97,10940, Optx of rib fx w/fixj scope,21811,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3149.97,10940, Optx of rib fx w/fixj scope,21811,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3149.97,10940, Treatment of rib fracture,21812,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3783.78,,,,,,,fee schedule,3783.78,10940, Treatment of rib fracture,21812,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3783.78,10940, Treatment of rib fracture,21812,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3783.78,10940, Treatment of rib fracture,21812,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3783.78,10940, Treatment of rib fracture,21813,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5188.36,,,,,,,fee schedule,5188.36,10940, Treatment of rib fracture,21813,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5188.36,10940, Treatment of rib fracture,21813,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,5188.36,10940, Treatment of rib fracture,21813,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,5188.36,10940, Treat sternum fracture,21820,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,911.01,,,,,,,fee schedule,911.01,3195, Treat sternum fracture,21820,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,911.01,3195, Treat sternum fracture,21820,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,911.01,3195, Treat sternum fracture,21820,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,911.01,3195, Treat sternum fracture,21825,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3152.83,,,,,,,fee schedule,3152.83,22111, Treat sternum fracture,21825,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3152.83,22111, Treat sternum fracture,21825,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3152.83,22111, Treat sternum fracture,21825,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3152.83,22111, Neck/chest surgery procedure,21899,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2505,6979, Neck/chest surgery procedure,21899,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,6979, Neck/chest surgery procedure,21899,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,6979, Biopsy soft tissue of back,21920,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,779.94,,,,,,,fee schedule,779.94,4497, Biopsy soft tissue of back,21920,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,779.94,4497, Biopsy soft tissue of back,21920,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,779.94,4497, Biopsy soft tissue of back,21920,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,779.94,4497, Biopsy soft tissue of back,21925,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2060.19,,,,,,,fee schedule,2060.19,10940, Biopsy soft tissue of back,21925,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2060.19,10940, Biopsy soft tissue of back,21925,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2060.19,10940, Biopsy soft tissue of back,21925,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2060.19,10940, Exc back les sc < 3 cm,21930,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1956.32,,,,,,,fee schedule,1956.32,5664, Exc back les sc < 3 cm,21930,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1956.32,5664, Exc back les sc < 3 cm,21930,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1956.32,5664, Exc back les sc < 3 cm,21930,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1956.32,5664, Exc back les sc 3 cm/>,21931,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2556.73,,,,,,,fee schedule,2556.73,10940, Exc back les sc 3 cm/>,21931,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2556.73,10940, Exc back les sc 3 cm/>,21931,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2556.73,10940, Exc back les sc 3 cm/>,21931,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2556.73,10940, Exc back tum deep < 5 cm,21932,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3533.52,,,,,,,fee schedule,3533.52,5664, Exc back tum deep < 5 cm,21932,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3533.52,5664, Exc back tum deep < 5 cm,21932,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3533.52,5664, Exc back tum deep < 5 cm,21932,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3533.52,5664, Exc back tum deep 5 cm/>,21933,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3957.75,,,,,,,fee schedule,3957.75,10940, Exc back tum deep 5 cm/>,21933,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3957.75,10940, Exc back tum deep 5 cm/>,21933,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3957.75,10940, Exc back tum deep 5 cm/>,21933,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3957.75,10940, Resect back tum < 5 cm,21935,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5408.73,,,,,,,fee schedule,5097,5664, Resect back tum < 5 cm,21935,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5097,5664, Resect back tum < 5 cm,21935,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Resect back tum < 5 cm,21935,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Resect back tum 5 cm/>,21936,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7437.31,,,,,,,fee schedule,5248,10940, Resect back tum 5 cm/>,21936,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,10940, Resect back tum 5 cm/>,21936,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,5248,10940, Resect back tum 5 cm/>,21936,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,5248,10940, I&d p-spine c/t/cerv-thor,22010,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5397.35,,,,,,,fee schedule,5397.35,22111, I&d p-spine c/t/cerv-thor,22010,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,5397.35,22111, I&d p-spine c/t/cerv-thor,22010,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5397.35,22111, I&d p-spine c/t/cerv-thor,22010,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5397.35,22111, I&d abscess p-spine l/s/ls,22015,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5210.11,,,,,,,fee schedule,5210.11,22111, I&d abscess p-spine l/s/ls,22015,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,5210.11,22111, I&d abscess p-spine l/s/ls,22015,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5210.11,22111, I&d abscess p-spine l/s/ls,22015,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5210.11,22111, Remove part of neck vertebra,22100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5659.11,,,,,,,fee schedule,5248,22111, Remove part of neck vertebra,22100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,22111, Remove part of neck vertebra,22100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5248,22111, Remove part of neck vertebra,22100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5248,22111, Remove part thorax vertebra,22101,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4900.16,,,,,,,fee schedule,4900.16,22111, Remove part thorax vertebra,22101,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4900.16,22111, Remove part thorax vertebra,22101,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4900.16,22111, Remove part thorax vertebra,22101,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4900.16,22111, Remove part lumbar vertebra,22102,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3879.94,,,,,,,fee schedule,3879.94,22111, Remove part lumbar vertebra,22102,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3879.94,22111, Remove part lumbar vertebra,22102,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3879.94,22111, Remove part lumbar vertebra,22102,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3879.94,22111, Remove extra spine segment,22103,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,665.27,,,,,,,fee schedule,665.27,5248, Remove extra spine segment,22103,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,665.27,5248, Remove extra spine segment,22103,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,665.27,5248, Remove extra spine segment,22103,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,665.27,5248, Remove part of neck vertebra,22110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5798.92,,,,,,,fee schedule,5798.92,22111, Remove part of neck vertebra,22110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,5798.92,22111, Remove part of neck vertebra,22110,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5798.92,22111, Remove part of neck vertebra,22110,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5798.92,22111, Remove part thorax vertebra,22112,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6718.51,,,,,,,fee schedule,6044,22111, Remove part thorax vertebra,22112,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,22111, Remove part thorax vertebra,22112,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6044,22111, Remove part thorax vertebra,22112,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6044,22111, Remove part lumbar vertebra,22114,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6718.51,,,,,,,fee schedule,6044,22111, Remove part lumbar vertebra,22114,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,22111, Remove part lumbar vertebra,22114,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6044,22111, Remove part lumbar vertebra,22114,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6044,22111, Remove extra spine segment,22116,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,742.44,,,,,,,fee schedule,742.44,3195, Remove extra spine segment,22116,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,742.44,3195, Remove extra spine segment,22116,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,742.44,3195, Remove extra spine segment,22116,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,742.44,3195, Incis spine 3 column thorac,22206,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,13262.29,,,,,,,fee schedule,6044,22111, Incis spine 3 column thorac,22206,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,22111, Incis spine 3 column thorac,22206,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6044,22111, Incis spine 3 column thorac,22206,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6044,22111, Incis spine 3 column lumbar,22207,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12784.69,,,,,,,fee schedule,6044,22111, Incis spine 3 column lumbar,22207,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,22111, Incis spine 3 column lumbar,22207,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6044,22111, Incis spine 3 column lumbar,22207,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6044,22111, Incis spine 3 column adl seg,22208,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3114.25,,,,,,,fee schedule,2505,3195, Incis spine 3 column adl seg,22208,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Incis spine 3 column adl seg,22208,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Incis spine 3 column adl seg,22208,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Incis 1 vertebral seg cerv,22210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9834.86,,,,,,,fee schedule,6044,22111, Incis 1 vertebral seg cerv,22210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,22111, Incis 1 vertebral seg cerv,22210,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6044,22111, Incis 1 vertebral seg cerv,22210,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6044,22111, Incis 1 vertebral seg thorac,22212,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8297.97,,,,,,,fee schedule,6044,22111, Incis 1 vertebral seg thorac,22212,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,22111, Incis 1 vertebral seg thorac,22212,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6044,22111, Incis 1 vertebral seg thorac,22212,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6044,22111, Incis 1 vertebral seg lumbar,22214,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8221.08,,,,,,,fee schedule,6044,22111, Incis 1 vertebral seg lumbar,22214,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,22111, Incis 1 vertebral seg lumbar,22214,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6044,22111, Incis 1 vertebral seg lumbar,22214,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6044,22111, Incis addl spine segment,22216,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1875.22,,,,,,,fee schedule,1875.22,3195, Incis addl spine segment,22216,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1875.22,3195, Incis addl spine segment,22216,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1875.22,3195, Incis addl spine segment,22216,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1875.22,3195, Incis w/discectomy cervical,22220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8914.73,,,,,,,fee schedule,6044,22111, Incis w/discectomy cervical,22220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,22111, Incis w/discectomy cervical,22220,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6044,22111, Incis w/discectomy cervical,22220,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6044,22111, Incis w/discectomy thoracic,22222,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10267.72,,,,,,,fee schedule,6044,22111, Incis w/discectomy thoracic,22222,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,22111, Incis w/discectomy thoracic,22222,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6044,22111, Incis w/discectomy thoracic,22222,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6044,22111, Incis w/discectomy lumbar,22224,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8380.8,,,,,,,fee schedule,6044,22111, Incis w/discectomy lumbar,22224,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,22111, Incis w/discectomy lumbar,22224,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6044,22111, Incis w/discectomy lumbar,22224,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6044,22111, Revise extra spine segment,22226,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1869.07,,,,,,,fee schedule,1869.07,3195, Revise extra spine segment,22226,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1869.07,3195, Revise extra spine segment,22226,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1869.07,3195, Revise extra spine segment,22226,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1869.07,3195, Closed tx vert fx w/o manj,22310,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1608.71,,,,,,,fee schedule,1608.71,3195, Closed tx vert fx w/o manj,22310,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1608.71,3195, Closed tx vert fx w/o manj,22310,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1608.71,3195, Closed tx vert fx w/o manj,22310,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1608.71,3195, Closed tx vert fx w/manj,22315,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4227.77,,,,,,,fee schedule,4108,5664, Closed tx vert fx w/manj,22315,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,5664, Closed tx vert fx w/manj,22315,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4108,5664, Closed tx vert fx w/manj,22315,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4108,5664, Treat odontoid fx w/o graft,22318,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9440.68,,,,,,,fee schedule,6979,22111, Treat odontoid fx w/o graft,22318,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,22111, Treat odontoid fx w/o graft,22318,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6979,22111, Treat odontoid fx w/o graft,22318,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6979,22111, Treat odontoid fx w/graft,22319,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10562.13,,,,,,,fee schedule,6979,22111, Treat odontoid fx w/graft,22319,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,22111, Treat odontoid fx w/graft,22319,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6979,22111, Treat odontoid fx w/graft,22319,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6979,22111, Treat spine fracture,22325,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8274.28,,,,,,,fee schedule,6979,22111, Treat spine fracture,22325,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,22111, Treat spine fracture,22325,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6979,22111, Treat spine fracture,22325,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6979,22111, Treat neck spine fracture,22326,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8495.57,,,,,,,fee schedule,6979,22111, Treat neck spine fracture,22326,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,22111, Treat neck spine fracture,22326,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6979,22111, Treat neck spine fracture,22326,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6979,22111, Treat thorax spine fracture,22327,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8626.69,,,,,,,fee schedule,6979,22111, Treat thorax spine fracture,22327,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,22111, Treat thorax spine fracture,22327,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6979,22111, Treat thorax spine fracture,22327,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6979,22111, Treat each add spine fx,22328,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1491.99,,,,,,,fee schedule,1491.99,3195, Treat each add spine fx,22328,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1491.99,3195, Treat each add spine fx,22328,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1491.99,3195, Treat each add spine fx,22328,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1491.99,3195, Manipulation of spine,22505,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,883.92,,,,,,,fee schedule,883.92,5664, Manipulation of spine,22505,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,883.92,5664, Manipulation of spine,22505,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,883.92,5664, Manipulation of spine,22505,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,883.92,5664, Perq cervicothoracic inject,22510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2151.71,,,,,,,fee schedule,2151.71,12821, Perq cervicothoracic inject,22510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2151.71,12821, Perq cervicothoracic inject,22510,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2151.71,12821, Perq cervicothoracic inject,22510,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2151.71,12821, Perq lumbosacral injection,22511,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2026.47,,,,,,,fee schedule,2026.47,12821, Perq lumbosacral injection,22511,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2026.47,12821, Perq lumbosacral injection,22511,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2026.47,12821, Perq lumbosacral injection,22511,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2026.47,12821, Vertebroplasty addl inject,22512,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1037.49,,,,,,,fee schedule,1037.49,3195, Vertebroplasty addl inject,22512,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1037.49,3195, Vertebroplasty addl inject,22512,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1037.49,3195, Vertebroplasty addl inject,22512,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1037.49,3195, Perq vertebral augmentation,22513,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2561.48,,,,,,,fee schedule,2561.48,22111, Perq vertebral augmentation,22513,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,2561.48,22111, Perq vertebral augmentation,22513,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,2561.48,22111, Perq vertebral augmentation,22513,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,2561.48,22111, Perq vertebral augmentation,22514,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2391.94,,,,,,,fee schedule,2391.94,22111, Perq vertebral augmentation,22514,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,2391.94,22111, Perq vertebral augmentation,22514,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,2391.94,22111, Perq vertebral augmentation,22514,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,2391.94,22111, Perq vertebral augmentation,22515,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1084.06,,,,,,,fee schedule,1084.06,3195, Perq vertebral augmentation,22515,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1084.06,3195, Perq vertebral augmentation,22515,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1084.06,3195, Perq vertebral augmentation,22515,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1084.06,3195, Idet single level,22526,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,12821, Idet single level,22526,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5248,12821, Idet single level,22526,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5248,12821, Idet 1 or more levels,22527,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,12821, Idet 1 or more levels,22527,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5248,12821, Idet 1 or more levels,22527,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5248,12821, Lat thorax spine fusion,22532,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9999.11,,,,,,,fee schedule,6979,25393, Lat thorax spine fusion,22532,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,25393, Lat thorax spine fusion,22532,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,6979,25393, Lat thorax spine fusion,22532,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,6979,25393, Lat lumbar spine fusion,22533,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8832.71,,,,,,,fee schedule,6979,25393, Lat lumbar spine fusion,22533,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,25393, Lat lumbar spine fusion,22533,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,6979,25393, Lat lumbar spine fusion,22533,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,6979,25393, Lat thor/lumb addl seg,22534,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1904.19,,,,,,,fee schedule,1904.19,3195, Lat thor/lumb addl seg,22534,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1904.19,3195, Lat thor/lumb addl seg,22534,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1904.19,3195, Lat thor/lumb addl seg,22534,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1904.19,3195, Neck spine fusion,22548,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,11334.62,,,,,,,fee schedule,6979,25393, Neck spine fusion,22548,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,25393, Neck spine fusion,22548,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,6979,25393, Neck spine fusion,22548,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,6979,25393, Neck spine fuse&remov bel c2,22551,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9284.74,,,,,,,fee schedule,6979,22111, Neck spine fuse&remov bel c2,22551,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,22111, Neck spine fuse&remov bel c2,22551,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6979,22111, Neck spine fuse&remov bel c2,22551,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6979,22111, Addl neck spine fusion,22552,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2078.54,,,,,,,fee schedule,2078.54,14456, Addl neck spine fusion,22552,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2078.54,14456, Addl neck spine fusion,22552,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,2078.54,14456, Addl neck spine fusion,22552,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,2078.54,14456, Neck spine fusion,22554,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6983.07,,,,,,,fee schedule,6979,22111, Neck spine fusion,22554,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,22111, Neck spine fusion,22554,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6979,22111, Neck spine fusion,22554,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6979,22111, Thorax spine fusion,22556,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9199.1,,,,,,,fee schedule,6979,25393, Thorax spine fusion,22556,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,25393, Thorax spine fusion,22556,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,6979,25393, Thorax spine fusion,22556,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,6979,25393, Lumbar spine fusion,22558,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8166.95,,,,,,,fee schedule,6979,25393, Lumbar spine fusion,22558,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,25393, Lumbar spine fusion,22558,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,6979,25393, Lumbar spine fusion,22558,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,6979,25393, Additional spinal fusion,22585,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1684.9,,,,,,,fee schedule,1684.9,22111, Additional spinal fusion,22585,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,1684.9,22111, Additional spinal fusion,22585,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,1684.9,22111, Prescrl fuse w/ instr l5-s1,22586,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,11718.82,,,,,,,fee schedule,6979,25393, Prescrl fuse w/ instr l5-s1,22586,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,25393, Prescrl fuse w/ instr l5-s1,22586,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,6979,25393, Prescrl fuse w/ instr l5-s1,22586,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,6979,25393, Spine & skull spinal fusion,22590,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9004.9,,,,,,,fee schedule,6979,25393, Spine & skull spinal fusion,22590,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,25393, Spine & skull spinal fusion,22590,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,6979,25393, Spine & skull spinal fusion,22590,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,6979,25393, Neck spinal fusion,22595,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8648.6,,,,,,,fee schedule,6979,25393, Neck spinal fusion,22595,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,25393, Neck spinal fusion,22595,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,6979,25393, Neck spinal fusion,22595,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,6979,25393, Neck spine fusion,22600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7351.08,,,,,,,fee schedule,6979,25393, Neck spine fusion,22600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,25393, Neck spine fusion,22600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,6979,25393, Neck spine fusion,22600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,6979,25393, Thorax spine fusion,22610,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7180.24,,,,,,,fee schedule,6979,25393, Thorax spine fusion,22610,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,25393, Thorax spine fusion,22610,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,6979,25393, Thorax spine fusion,22610,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,6979,25393, Lumbar spine fusion,22612,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8405.46,,,,,,,fee schedule,6979,22111, Lumbar spine fusion,22612,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,22111, Lumbar spine fusion,22612,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6979,22111, Lumbar spine fusion,22612,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6979,22111, Spine fusion extra segment,22614,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2057.06,,,,,,,fee schedule,2057.06,3195, Spine fusion extra segment,22614,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2057.06,3195, Spine fusion extra segment,22614,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2057.06,3195, Spine fusion extra segment,22614,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2057.06,3195, Lumbar spine fusion,22630,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8740.87,,,,,,,fee schedule,6979,25393, Lumbar spine fusion,22630,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,25393, Lumbar spine fusion,22630,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,6979,25393, Lumbar spine fusion,22630,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,6979,25393, Spine fusion extra segment,22632,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1700.33,,,,,,,fee schedule,1700.33,3195, Spine fusion extra segment,22632,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1700.33,3195, Spine fusion extra segment,22632,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1700.33,3195, Spine fusion extra segment,22632,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1700.33,3195, Lumbar spine fusion combined,22633,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9811.38,,,,,,,fee schedule,6979,34630, Lumbar spine fusion combined,22633,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,34630, Lumbar spine fusion combined,22633,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,34630,,,,,,,fee schedule,6979,34630, Lumbar spine fusion combined,22633,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,31168,,,,,,,fee schedule,6979,34630, Spine fusion extra segment,22634,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2547.18,,,,,,,fee schedule,2505,3195, Spine fusion extra segment,22634,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Spine fusion extra segment,22634,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Spine fusion extra segment,22634,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Post fusion <=6 vert seg,22800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7491.75,,,,,,,fee schedule,6979,25393, Post fusion <=6 vert seg,22800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,25393, Post fusion <=6 vert seg,22800,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,6979,25393, Post fusion <=6 vert seg,22800,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,6979,25393, Post fusion 7-12 vert seg,22802,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,11104.16,,,,,,,fee schedule,6979,25393, Post fusion 7-12 vert seg,22802,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,25393, Post fusion 7-12 vert seg,22802,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,6979,25393, Post fusion 7-12 vert seg,22802,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,6979,25393, Post fusion 13/> vert seg,22804,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12776.22,,,,,,,fee schedule,6979,25393, Post fusion 13/> vert seg,22804,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,25393, Post fusion 13/> vert seg,22804,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,6979,25393, Post fusion 13/> vert seg,22804,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,6979,25393, Ant fusion 2-3 vert seg,22808,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10100.66,,,,,,,fee schedule,6979,25393, Ant fusion 2-3 vert seg,22808,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,25393, Ant fusion 2-3 vert seg,22808,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,6979,25393, Ant fusion 2-3 vert seg,22808,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,6979,25393, Ant fusion 4-7 vert seg,22810,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10153.92,,,,,,,fee schedule,6979,25393, Ant fusion 4-7 vert seg,22810,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,25393, Ant fusion 4-7 vert seg,22810,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,6979,25393, Ant fusion 4-7 vert seg,22810,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,6979,25393, Ant fusion 8/> vert seg,22812,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,11134.21,,,,,,,fee schedule,6979,25393, Ant fusion 8/> vert seg,22812,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,25393, Ant fusion 8/> vert seg,22812,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,6979,25393, Ant fusion 8/> vert seg,22812,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,6979,25393, Kyphectomy 1-2 segments,22818,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10831.82,,,,,,,fee schedule,6979,25393, Kyphectomy 1-2 segments,22818,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,25393, Kyphectomy 1-2 segments,22818,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,6979,25393, Kyphectomy 1-2 segments,22818,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,6979,25393, Kyphectomy 3 or more,22819,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12469.02,,,,,,,fee schedule,6979,25393, Kyphectomy 3 or more,22819,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,25393, Kyphectomy 3 or more,22819,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,6979,25393, Kyphectomy 3 or more,22819,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,6979,25393, Exploration of spinal fusion,22830,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4499.56,,,,,,,fee schedule,4499.56,22111, Exploration of spinal fusion,22830,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4499.56,22111, Exploration of spinal fusion,22830,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4499.56,22111, Exploration of spinal fusion,22830,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4499.56,22111, Ant thrc vrt body tethrg <7,22836,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10235.56,,,,,,,fee schedule,5097,10235.56, Ant thrc vrt body tethrg <7,22836,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,10235.56, Ant thrc vrt body tethrg <7,22836,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,10235.56, Ant thrc vrt body tethrg <7,22836,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,10235.56, Ant thrc vrt body tethrg 8+,22837,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9211.94,,,,,,,fee schedule,5097,9211.94, Ant thrc vrt body tethrg 8+,22837,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,9211.94, Ant thrc vrt body tethrg 8+,22837,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,9211.94, Ant thrc vrt body tethrg 8+,22837,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,9211.94, Rev rplc/rmv thrc vrt tethrg,22838,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9335.46,,,,,,,fee schedule,5097,9335.46, Rev rplc/rmv thrc vrt tethrg,22838,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,9335.46, Rev rplc/rmv thrc vrt tethrg,22838,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,9335.46, Rev rplc/rmv thrc vrt tethrg,22838,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,9335.46, Insert spine fixation device,22840,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3915.28,,,,,,,fee schedule,2505,3915.28, Insert spine fixation device,22840,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3915.28, Insert spine fixation device,22840,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3915.28, Insert spine fixation device,22840,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3915.28, Insert spine fixation device,22841,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Insert spine fixation device,22841,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Insert spine fixation device,22841,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Insert spine fixation device,22842,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4000.54,,,,,,,fee schedule,2505,4000.54, Insert spine fixation device,22842,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,4000.54, Insert spine fixation device,22842,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,4000.54, Insert spine fixation device,22842,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,4000.54, Insert spine fixation device,22843,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4286.69,,,,,,,fee schedule,2505,4286.69, Insert spine fixation device,22843,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,4286.69, Insert spine fixation device,22843,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,4286.69, Insert spine fixation device,22843,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,4286.69, Insert spine fixation device,22844,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5121.34,,,,,,,fee schedule,2505,5121.34, Insert spine fixation device,22844,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,5121.34, Insert spine fixation device,22844,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,5121.34, Insert spine fixation device,22844,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,5121.34, Insert spine fixation device,22845,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3812.76,,,,,,,fee schedule,3195,22111, Insert spine fixation device,22845,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,22111, Insert spine fixation device,22845,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3195,22111, Insert spine fixation device,22845,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3195,22111, Insert spine fixation device,22846,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3964.82,,,,,,,fee schedule,3195,22111, Insert spine fixation device,22846,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,22111, Insert spine fixation device,22846,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3195,22111, Insert spine fixation device,22846,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3195,22111, Insert spine fixation device,22847,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3934.49,,,,,,,fee schedule,3195,22111, Insert spine fixation device,22847,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,22111, Insert spine fixation device,22847,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3195,22111, Insert spine fixation device,22847,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3195,22111, Insert pelv fixation device,22848,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1856.44,,,,,,,fee schedule,1856.44,3195, Insert pelv fixation device,22848,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1856.44,3195, Insert pelv fixation device,22848,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1856.44,3195, Insert pelv fixation device,22848,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1856.44,3195, Reinsert spinal fixation,22849,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7046.69,,,,,,,fee schedule,6979,25393, Reinsert spinal fixation,22849,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,25393, Reinsert spinal fixation,22849,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,6979,25393, Reinsert spinal fixation,22849,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,6979,25393, Remove spine fixation device,22850,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4070.2,,,,,,,fee schedule,4070.2,22111, Remove spine fixation device,22850,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4070.2,22111, Remove spine fixation device,22850,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4070.2,22111, Remove spine fixation device,22850,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4070.2,22111, Remove spine fixation device,22852,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3923.54,,,,,,,fee schedule,3923.54,22111, Remove spine fixation device,22852,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3923.54,22111, Remove spine fixation device,22852,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3923.54,22111, Remove spine fixation device,22852,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3923.54,22111, Insj biomechanical device,22853,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1344.2,,,,,,,fee schedule,1344.2,3195, Insj biomechanical device,22853,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1344.2,3195, Insj biomechanical device,22853,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1344.2,3195, Insj biomechanical device,22853,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1344.2,3195, Insj biomechanical device,22854,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1774.64,,,,,,,fee schedule,1774.64,3195, Insj biomechanical device,22854,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1774.64,3195, Insj biomechanical device,22854,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1774.64,3195, Insj biomechanical device,22854,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1774.64,3195, Remove spine fixation device,22855,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6026.25,,,,,,,fee schedule,6026.25,22111, Remove spine fixation device,22855,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6026.25,22111, Remove spine fixation device,22855,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6026.25,22111, Remove spine fixation device,22855,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6026.25,22111, Cerv artific diskectomy,22856,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8767.26,,,,,,,fee schedule,6979,22111, Cerv artific diskectomy,22856,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,22111, Cerv artific diskectomy,22856,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6979,22111, Cerv artific diskectomy,22856,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6979,22111, Lumbar Artif Diskectomy,22857,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8857.8,,,,,,,fee schedule,6979,25393, Lumbar Artif Diskectomy,22857,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,25393, Lumbar Artif Diskectomy,22857,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,6979,25393, Lumbar Artif Diskectomy,22857,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,6979,25393, Second level cer diskectomy,22858,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2632.82,,,,,,,fee schedule,2505,3195, Second level cer diskectomy,22858,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Second level cer diskectomy,22858,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Second level cer diskectomy,22858,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Insj biomechanical device,22859,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1770.91,,,,,,,fee schedule,1770.91,3195, Insj biomechanical device,22859,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1770.91,3195, Insj biomechanical device,22859,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1770.91,3195, Insj biomechanical device,22859,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1770.91,3195, Tot disc arthrp 2ntrspc lmbr,22860,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1995.28,,,,,,,fee schedule,1995.28,5664, Tot disc arthrp 2ntrspc lmbr,22860,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1995.28,5664, Tot disc arthrp 2ntrspc lmbr,22860,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1995.28,5664, Tot disc arthrp 2ntrspc lmbr,22860,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1995.28,5664, Revise cerv artific disc,22861,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,13212.59,,,,,,,fee schedule,6979,25393, Revise cerv artific disc,22861,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,25393, Revise cerv artific disc,22861,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,6979,25393, Revise cerv artific disc,22861,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,6979,25393, Revise Lumbar Artif Disc,22862,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,13277.51,,,,,,,fee schedule,6979,25393, Revise Lumbar Artif Disc,22862,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,25393, Revise Lumbar Artif Disc,22862,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,6979,25393, Revise Lumbar Artif Disc,22862,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,6979,25393, Remove cerv artif disc,22864,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,11848.16,,,,,,,fee schedule,6979,22111, Remove cerv artif disc,22864,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,22111, Remove cerv artif disc,22864,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6979,22111, Remove cerv artif disc,22864,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6979,22111, Remove Lumb Artif Disc,22865,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12974.09,,,,,,,fee schedule,6979,22111, Remove Lumb Artif Disc,22865,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,22111, Remove Lumb Artif Disc,22865,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6979,22111, Remove Lumb Artif Disc,22865,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6979,22111, Insj stablj dev w/dcmprn,22867,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5763.63,,,,,,,fee schedule,5763.63,22111, Insj stablj dev w/dcmprn,22867,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,5763.63,22111, Insj stablj dev w/dcmprn,22867,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5763.63,22111, Insj stablj dev w/dcmprn,22867,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5763.63,22111, Insj stablj dev w/dcmprn,22868,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1259.1,,,,,,,fee schedule,1259.1,3195, Insj stablj dev w/dcmprn,22868,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1259.1,3195, Insj stablj dev w/dcmprn,22868,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1259.1,3195, Insj stablj dev w/dcmprn,22868,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1259.1,3195, Insj stablj dev w/o dcmprn,22869,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2157.7,,,,,,,fee schedule,2157.7,22111, Insj stablj dev w/o dcmprn,22869,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2157.7,22111, Insj stablj dev w/o dcmprn,22869,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,2157.7,22111, Insj stablj dev w/o dcmprn,22869,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,2157.7,22111, Insj stablj dev w/o dcmprn,22870,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,559.13,,,,,,,fee schedule,559.13,3195, Insj stablj dev w/o dcmprn,22870,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,559.13,3195, Insj stablj dev w/o dcmprn,22870,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,559.13,3195, Insj stablj dev w/o dcmprn,22870,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,559.13,3195, Spine surgery procedure,22899,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Spine surgery procedure,22899,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Spine surgery procedure,22899,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Exc abdl tum deep < 5 cm,22900,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3083.54,,,,,,,fee schedule,3083.54,10940, Exc abdl tum deep < 5 cm,22900,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3083.54,10940, Exc abdl tum deep < 5 cm,22900,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3083.54,10940, Exc abdl tum deep < 5 cm,22900,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3083.54,10940, Exc abdl tum deep 5 cm/>,22901,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3631.62,,,,,,,fee schedule,3631.62,10940, Exc abdl tum deep 5 cm/>,22901,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3631.62,10940, Exc abdl tum deep 5 cm/>,22901,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3631.62,10940, Exc abdl tum deep 5 cm/>,22901,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3631.62,10940, Exc abd les sc < 3 cm,22902,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1848.89,,,,,,,fee schedule,1848.89,5664, Exc abd les sc < 3 cm,22902,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1848.89,5664, Exc abd les sc < 3 cm,22902,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1848.89,5664, Exc abd les sc < 3 cm,22902,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1848.89,5664, Exc abd les sc 3 cm/>,22903,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2415.52,,,,,,,fee schedule,2415.52,10940, Exc abd les sc 3 cm/>,22903,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2415.52,10940, Exc abd les sc 3 cm/>,22903,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2415.52,10940, Exc abd les sc 3 cm/>,22903,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2415.52,10940, Radical resect abd tumor<5cm,22904,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5584.54,,,,,,,fee schedule,4108,5664, Radical resect abd tumor<5cm,22904,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,5664, Radical resect abd tumor<5cm,22904,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4108,5664, Radical resect abd tumor<5cm,22904,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4108,5664, Rad resect abd tumor 5 cm/>,22905,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7026.78,,,,,,,fee schedule,5248,10940, Rad resect abd tumor 5 cm/>,22905,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,10940, Rad resect abd tumor 5 cm/>,22905,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,5248,10940, Rad resect abd tumor 5 cm/>,22905,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,5248,10940, Abdomen surgery procedure,22999,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Abdomen surgery procedure,22999,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Abdomen surgery procedure,22999,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Removal of calcium deposits,23000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1837.01,,,,,,,fee schedule,1837.01,5664, Removal of calcium deposits,23000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1837.01,5664, Removal of calcium deposits,23000,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1837.01,5664, Removal of calcium deposits,23000,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1837.01,5664, Release shoulder joint,23020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3617.15,,,,,,,fee schedule,3617.15,12821, Release shoulder joint,23020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3617.15,12821, Release shoulder joint,23020,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3617.15,12821, Release shoulder joint,23020,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3617.15,12821, Drain shoulder lesion,23030,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1353.59,,,,,,,fee schedule,1353.59,10940, Drain shoulder lesion,23030,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1353.59,10940, Drain shoulder lesion,23030,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1353.59,10940, Drain shoulder lesion,23030,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1353.59,10940, Drain shoulder bursa,23031,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1190.84,,,,,,,fee schedule,1190.84,10940, Drain shoulder bursa,23031,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1190.84,10940, Drain shoulder bursa,23031,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1190.84,10940, Drain shoulder bursa,23031,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1190.84,10940, Drain shoulder bone lesion,23035,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3525.96,,,,,,,fee schedule,3525.96,10940, Drain shoulder bone lesion,23035,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3525.96,10940, Drain shoulder bone lesion,23035,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3525.96,10940, Drain shoulder bone lesion,23035,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3525.96,10940, Exploratory shoulder surgery,23040,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3740.51,,,,,,,fee schedule,3740.51,12821, Exploratory shoulder surgery,23040,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3740.51,12821, Exploratory shoulder surgery,23040,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3740.51,12821, Exploratory shoulder surgery,23040,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3740.51,12821, Exploratory shoulder surgery,23044,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3021.98,,,,,,,fee schedule,3021.98,12821, Exploratory shoulder surgery,23044,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3021.98,12821, Exploratory shoulder surgery,23044,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3021.98,12821, Exploratory shoulder surgery,23044,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3021.98,12821, Biopsy shoulder tissues,23065,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,808.64,,,,,,,fee schedule,808.64,4497, Biopsy shoulder tissues,23065,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,808.64,4497, Biopsy shoulder tissues,23065,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,808.64,4497, Biopsy shoulder tissues,23065,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,808.64,4497, Biopsy shoulder tissues,23066,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2014.06,,,,,,,fee schedule,2014.06,10940, Biopsy shoulder tissues,23066,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2014.06,10940, Biopsy shoulder tissues,23066,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2014.06,10940, Biopsy shoulder tissues,23066,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2014.06,10940, Exc shoulder les sc 3 cm/>,23071,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2281.11,,,,,,,fee schedule,2281.11,10940, Exc shoulder les sc 3 cm/>,23071,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2281.11,10940, Exc shoulder les sc 3 cm/>,23071,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2281.11,10940, Exc shoulder les sc 3 cm/>,23071,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2281.11,10940, Exc shoulder tum deep 5 cm/>,23073,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3699.93,,,,,,,fee schedule,3699.93,10940, Exc shoulder tum deep 5 cm/>,23073,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3699.93,10940, Exc shoulder tum deep 5 cm/>,23073,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3699.93,10940, Exc shoulder tum deep 5 cm/>,23073,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3699.93,10940, Exc shoulder les sc < 3 cm,23075,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1780.73,,,,,,,fee schedule,1780.73,5664, Exc shoulder les sc < 3 cm,23075,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1780.73,5664, Exc shoulder les sc < 3 cm,23075,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1780.73,5664, Exc shoulder les sc < 3 cm,23075,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1780.73,5664, Exc shoulder tum deep < 5 cm,23076,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2917.89,,,,,,,fee schedule,2917.89,5664, Exc shoulder tum deep < 5 cm,23076,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2917.89,5664, Exc shoulder tum deep < 5 cm,23076,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2917.89,5664, Exc shoulder tum deep < 5 cm,23076,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2917.89,5664, Resect shoulder tumor < 5 cm,23077,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5948.06,,,,,,,fee schedule,5097,5948.06, Resect shoulder tumor < 5 cm,23077,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5097,5948.06, Resect shoulder tumor < 5 cm,23077,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5948.06, Resect shoulder tumor < 5 cm,23077,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5948.06, Resect shoulder tumor 5 cm/>,23078,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7507.94,,,,,,,fee schedule,5248,10940, Resect shoulder tumor 5 cm/>,23078,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,10940, Resect shoulder tumor 5 cm/>,23078,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,5248,10940, Resect shoulder tumor 5 cm/>,23078,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,5248,10940, Biopsy of shoulder joint,23100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2709.71,,,,,,,fee schedule,2709.71,10940, Biopsy of shoulder joint,23100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2709.71,10940, Biopsy of shoulder joint,23100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2709.71,10940, Biopsy of shoulder joint,23100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2709.71,10940, Shoulder joint surgery,23101,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2450.7,,,,,,,fee schedule,2450.7,12821, Shoulder joint surgery,23101,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,2450.7,12821, Shoulder joint surgery,23101,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2450.7,12821, Shoulder joint surgery,23101,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2450.7,12821, Remove shoulder joint lining,23105,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3357.23,,,,,,,fee schedule,3357.23,12821, Remove shoulder joint lining,23105,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3357.23,12821, Remove shoulder joint lining,23105,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3357.23,12821, Remove shoulder joint lining,23105,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3357.23,12821, Incision of collarbone joint,23106,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2690.93,,,,,,,fee schedule,2690.93,12821, Incision of collarbone joint,23106,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2690.93,12821, Incision of collarbone joint,23106,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2690.93,12821, Incision of collarbone joint,23106,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2690.93,12821, Explore treat shoulder joint,23107,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3476.7,,,,,,,fee schedule,3476.7,12821, Explore treat shoulder joint,23107,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3476.7,12821, Explore treat shoulder joint,23107,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3476.7,12821, Explore treat shoulder joint,23107,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3476.7,12821, Partial removal collar bone,23120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3116.68,,,,,,,fee schedule,3116.68,12821, Partial removal collar bone,23120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,3116.68,12821, Partial removal collar bone,23120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3116.68,12821, Partial removal collar bone,23120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3116.68,12821, Removal of collar bone,23125,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3722.92,,,,,,,fee schedule,3722.92,12821, Removal of collar bone,23125,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,3722.92,12821, Removal of collar bone,23125,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3722.92,12821, Removal of collar bone,23125,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3722.92,12821, Remove shoulder bone part,23130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3264.85,,,,,,,fee schedule,3264.85,14456, Remove shoulder bone part,23130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,3264.85,14456, Remove shoulder bone part,23130,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3264.85,14456, Remove shoulder bone part,23130,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3264.85,14456, Removal of bone lesion,23140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2941.25,,,,,,,fee schedule,2941.25,10940, Removal of bone lesion,23140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2941.25,10940, Removal of bone lesion,23140,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2941.25,10940, Removal of bone lesion,23140,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2941.25,10940, Removal of bone lesion,23145,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3654.12,,,,,,,fee schedule,3654.12,12821, Removal of bone lesion,23145,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,3654.12,12821, Removal of bone lesion,23145,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3654.12,12821, Removal of bone lesion,23145,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3654.12,12821, Removal of bone lesion,23146,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3303.7,,,,,,,fee schedule,3303.7,12821, Removal of bone lesion,23146,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,3303.7,12821, Removal of bone lesion,23146,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3303.7,12821, Removal of bone lesion,23146,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3303.7,12821, Removal of humerus lesion,23150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3514.68,,,,,,,fee schedule,3514.68,12821, Removal of humerus lesion,23150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3514.68,12821, Removal of humerus lesion,23150,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3514.68,12821, Removal of humerus lesion,23150,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3514.68,12821, Removal of humerus lesion,23155,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4167.06,,,,,,,fee schedule,4167.06,12821, Removal of humerus lesion,23155,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4167.06,12821, Removal of humerus lesion,23155,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4167.06,12821, Removal of humerus lesion,23155,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4167.06,12821, Removal of humerus lesion,23156,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3572.8,,,,,,,fee schedule,3572.8,12821, Removal of humerus lesion,23156,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,3572.8,12821, Removal of humerus lesion,23156,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3572.8,12821, Removal of humerus lesion,23156,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3572.8,12821, Remove collar bone lesion,23170,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2991.22,,,,,,,fee schedule,2991.22,12821, Remove collar bone lesion,23170,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2991.22,12821, Remove collar bone lesion,23170,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2991.22,12821, Remove collar bone lesion,23170,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2991.22,12821, Remove shoulder blade lesion,23172,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3019.82,,,,,,,fee schedule,3019.82,12821, Remove shoulder blade lesion,23172,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3019.82,12821, Remove shoulder blade lesion,23172,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3019.82,12821, Remove shoulder blade lesion,23172,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3019.82,12821, Remove humerus lesion,23174,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4022.72,,,,,,,fee schedule,4022.72,12821, Remove humerus lesion,23174,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4022.72,12821, Remove humerus lesion,23174,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4022.72,12821, Remove humerus lesion,23174,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4022.72,12821, Remove collar bone lesion,23180,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3631.72,,,,,,,fee schedule,3631.72,12821, Remove collar bone lesion,23180,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3631.72,12821, Remove collar bone lesion,23180,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3631.72,12821, Remove collar bone lesion,23180,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3631.72,12821, Remove shoulder blade lesion,23182,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3548.46,,,,,,,fee schedule,3548.46,12821, Remove shoulder blade lesion,23182,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3548.46,12821, Remove shoulder blade lesion,23182,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3548.46,12821, Remove shoulder blade lesion,23182,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3548.46,12821, Remove humerus lesion,23184,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3870.12,,,,,,,fee schedule,3870.12,12821, Remove humerus lesion,23184,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3870.12,12821, Remove humerus lesion,23184,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3870.12,12821, Remove humerus lesion,23184,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3870.12,12821, Partial removal of scapula,23190,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3038.76,,,,,,,fee schedule,3038.76,12821, Partial removal of scapula,23190,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3038.76,12821, Partial removal of scapula,23190,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3038.76,12821, Partial removal of scapula,23190,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3038.76,12821, Removal of head of humerus,23195,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3953.43,,,,,,,fee schedule,3953.43,12821, Removal of head of humerus,23195,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,3953.43,12821, Removal of head of humerus,23195,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3953.43,12821, Removal of head of humerus,23195,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3953.43,12821, Resect clavicle tumor,23200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7685.58,,,,,,,fee schedule,6044,22111, Resect clavicle tumor,23200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,22111, Resect clavicle tumor,23200,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6044,22111, Resect clavicle tumor,23200,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6044,22111, Resect scapula tumor,23210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8964.48,,,,,,,fee schedule,6044,22111, Resect scapula tumor,23210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,22111, Resect scapula tumor,23210,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6044,22111, Resect scapula tumor,23210,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6044,22111, Resect prox humerus tumor,23220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9813.81,,,,,,,fee schedule,6044,22111, Resect prox humerus tumor,23220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,22111, Resect prox humerus tumor,23220,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6044,22111, Resect prox humerus tumor,23220,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6044,22111, Remove shoulder foreign body,23330,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,912.14,,,,,,,fee schedule,912.14,4497, Remove shoulder foreign body,23330,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,912.14,4497, Remove shoulder foreign body,23330,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,912.14,4497, Remove shoulder foreign body,23330,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,912.14,4497, Remove shoulder fb deep,23333,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2540.49,,,,,,,fee schedule,2540.49,4497, Remove shoulder fb deep,23333,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2540.49,4497, Remove shoulder fb deep,23333,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,2540.49,4497, Remove shoulder fb deep,23333,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,2540.49,4497, Shoulder prosthesis removal,23334,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5456.11,,,,,,,fee schedule,5248,10940, Shoulder prosthesis removal,23334,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,10940, Shoulder prosthesis removal,23334,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,5248,10940, Shoulder prosthesis removal,23334,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,5248,10940, Shoulder prosthesis removal,23335,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6440.34,,,,,,,fee schedule,5248,10940, Shoulder prosthesis removal,23335,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,10940, Shoulder prosthesis removal,23335,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,5248,10940, Shoulder prosthesis removal,23335,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,5248,10940, Injection for shoulder x-ray,23350,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,233.75,,,,,,,fee schedule,233.75,3195, Injection for shoulder x-ray,23350,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,233.75,3195, Injection for shoulder x-ray,23350,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,233.75,3195, Injection for shoulder x-ray,23350,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,233.75,3195, Muscle transfer shoulder/arm,23395,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6585.44,,,,,,,fee schedule,6044,14456, Muscle transfer shoulder/arm,23395,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,14456, Muscle transfer shoulder/arm,23395,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,6044,14456, Muscle transfer shoulder/arm,23395,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,6044,14456, Muscle transfers,23397,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5851.91,,,,,,,fee schedule,5851.91,14456, Muscle transfers,23397,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,5851.91,14456, Muscle transfers,23397,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5851.91,14456, Muscle transfers,23397,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5851.91,14456, Fixation of shoulder blade,23400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5028.75,,,,,,,fee schedule,5028.75,12821, Fixation of shoulder blade,23400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,5028.75,12821, Fixation of shoulder blade,23400,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5028.75,12821, Fixation of shoulder blade,23400,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5028.75,12821, Incision of tendon & muscle,23405,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3183.42,,,,,,,fee schedule,3183.42,12821, Incision of tendon & muscle,23405,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3183.42,12821, Incision of tendon & muscle,23405,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3183.42,12821, Incision of tendon & muscle,23405,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3183.42,12821, Incise tendon(s) & muscle(s),23406,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3708.02,,,,,,,fee schedule,3708.02,12821, Incise tendon(s) & muscle(s),23406,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3708.02,12821, Incise tendon(s) & muscle(s),23406,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3708.02,12821, Incise tendon(s) & muscle(s),23406,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3708.02,12821, Repair rotator cuff acute,23410,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4260.57,,,,,,,fee schedule,4260.57,14456, Repair rotator cuff acute,23410,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4260.57,14456, Repair rotator cuff acute,23410,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4260.57,14456, Repair rotator cuff acute,23410,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4260.57,14456, Repair rotator cuff chronic,23412,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4413.33,,,,,,,fee schedule,4413.33,14456, Repair rotator cuff chronic,23412,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,4413.33,14456, Repair rotator cuff chronic,23412,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4413.33,14456, Repair rotator cuff chronic,23412,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4413.33,14456, Release of shoulder ligament,23415,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3649.8,,,,,,,fee schedule,3649.8,14456, Release of shoulder ligament,23415,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,3649.8,14456, Release of shoulder ligament,23415,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3649.8,14456, Release of shoulder ligament,23415,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3649.8,14456, Repair of shoulder,23420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5054,,,,,,,fee schedule,5054,14456, Repair of shoulder,23420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,5054,14456, Repair of shoulder,23420,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5054,14456, Repair of shoulder,23420,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5054,14456, Repair biceps tendon,23430,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3867.31,,,,,,,fee schedule,3867.31,14456, Repair biceps tendon,23430,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3867.31,14456, Repair biceps tendon,23430,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3867.31,14456, Repair biceps tendon,23430,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3867.31,14456, Remove/transplant tendon,23440,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3914.47,,,,,,,fee schedule,3914.47,12821, Remove/transplant tendon,23440,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3914.47,12821, Remove/transplant tendon,23440,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3914.47,12821, Remove/transplant tendon,23440,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3914.47,12821, Repair shoulder capsule,23450,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4883.97,,,,,,,fee schedule,4883.97,22111, Repair shoulder capsule,23450,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4883.97,22111, Repair shoulder capsule,23450,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4883.97,22111, Repair shoulder capsule,23450,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4883.97,22111, Repair shoulder capsule,23455,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4924.39,,,,,,,fee schedule,4924.39,22111, Repair shoulder capsule,23455,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,4924.39,22111, Repair shoulder capsule,23455,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4924.39,22111, Repair shoulder capsule,23455,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4924.39,22111, Repair shoulder capsule,23460,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5607.79,,,,,,,fee schedule,5607.79,22111, Repair shoulder capsule,23460,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,5607.79,22111, Repair shoulder capsule,23460,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5607.79,22111, Repair shoulder capsule,23460,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5607.79,22111, Repair shoulder capsule,23462,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5484.49,,,,,,,fee schedule,5484.49,14456, Repair shoulder capsule,23462,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,5484.49,14456, Repair shoulder capsule,23462,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5484.49,14456, Repair shoulder capsule,23462,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5484.49,14456, Repair shoulder capsule,23465,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5745.44,,,,,,,fee schedule,5745.44,14456, Repair shoulder capsule,23465,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,5745.44,14456, Repair shoulder capsule,23465,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5745.44,14456, Repair shoulder capsule,23465,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5745.44,14456, Repair shoulder capsule,23466,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5769.67,,,,,,,fee schedule,5769.67,14456, Repair shoulder capsule,23466,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,5769.67,14456, Repair shoulder capsule,23466,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5769.67,14456, Repair shoulder capsule,23466,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5769.67,14456, Reconstruct shoulder joint,23470,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6101.1,,,,,,,fee schedule,6044,25393, Reconstruct shoulder joint,23470,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,25393, Reconstruct shoulder joint,23470,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,6044,25393, Reconstruct shoulder joint,23470,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,6044,25393, Reconstruct shoulder joint,23472,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7308.67,,,,,,,fee schedule,6044,25393, Reconstruct shoulder joint,23472,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,25393, Reconstruct shoulder joint,23472,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,6044,25393, Reconstruct shoulder joint,23472,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,6044,25393, Revis reconst shoulder joint,23473,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8105.06,,,,,,,fee schedule,6044,14456, Revis reconst shoulder joint,23473,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,14456, Revis reconst shoulder joint,23473,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,6044,14456, Revis reconst shoulder joint,23473,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,6044,14456, Revis reconst shoulder joint,23474,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8747.62,,,,,,,fee schedule,6044,22111, Revis reconst shoulder joint,23474,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,22111, Revis reconst shoulder joint,23474,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6044,22111, Revis reconst shoulder joint,23474,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6044,22111, Revision of collar bone,23480,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4266.35,,,,,,,fee schedule,4266.35,14456, Revision of collar bone,23480,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4266.35,14456, Revision of collar bone,23480,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4266.35,14456, Revision of collar bone,23480,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4266.35,14456, Revision of collar bone,23485,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4874.96,,,,,,,fee schedule,4874.96,22111, Revision of collar bone,23485,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,4874.96,22111, Revision of collar bone,23485,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4874.96,22111, Revision of collar bone,23485,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4874.96,22111, Reinforce clavicle,23490,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4473.55,,,,,,,fee schedule,4473.55,22111, Reinforce clavicle,23490,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4473.55,22111, Reinforce clavicle,23490,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4473.55,22111, Reinforce clavicle,23490,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4473.55,22111, Reinforce shoulder bones,23491,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5246.69,,,,,,,fee schedule,5246.69,22111, Reinforce shoulder bones,23491,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5246.69,22111, Reinforce shoulder bones,23491,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5246.69,22111, Reinforce shoulder bones,23491,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5246.69,22111, Treat clavicle fracture,23500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1326.12,,,,,,,fee schedule,1326.12,3195, Treat clavicle fracture,23500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1326.12,3195, Treat clavicle fracture,23500,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1326.12,3195, Treat clavicle fracture,23500,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1326.12,3195, Treat clavicle fracture,23505,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1891.03,,,,,,,fee schedule,1891.03,4497, Treat clavicle fracture,23505,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1891.03,4497, Treat clavicle fracture,23505,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,1891.03,4497, Treat clavicle fracture,23505,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,1891.03,4497, Treat clavicle fracture,23515,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3769.05,,,,,,,fee schedule,3769.05,22111, Treat clavicle fracture,23515,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3769.05,22111, Treat clavicle fracture,23515,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3769.05,22111, Treat clavicle fracture,23515,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3769.05,22111, Treat clavicle dislocation,23520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1335.62,,,,,,,fee schedule,1335.62,5664, Treat clavicle dislocation,23520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1335.62,5664, Treat clavicle dislocation,23520,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1335.62,5664, Treat clavicle dislocation,23520,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1335.62,5664, Treat clavicle dislocation,23525,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2000.84,,,,,,,fee schedule,2000.84,3195, Treat clavicle dislocation,23525,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2000.84,3195, Treat clavicle dislocation,23525,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2000.84,3195, Treat clavicle dislocation,23525,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2000.84,3195, Treat clavicle dislocation,23530,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3042.26,,,,,,,fee schedule,3042.26,22111, Treat clavicle dislocation,23530,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3042.26,22111, Treat clavicle dislocation,23530,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3042.26,22111, Treat clavicle dislocation,23530,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3042.26,22111, Treat clavicle dislocation,23532,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3311.8,,,,,,,fee schedule,3311.8,10940, Treat clavicle dislocation,23532,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3311.8,10940, Treat clavicle dislocation,23532,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3311.8,10940, Treat clavicle dislocation,23532,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3311.8,10940, Treat clavicle dislocation,23540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1391.52,,,,,,,fee schedule,1391.52,3195, Treat clavicle dislocation,23540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1391.52,3195, Treat clavicle dislocation,23540,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1391.52,3195, Treat clavicle dislocation,23540,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1391.52,3195, Treat clavicle dislocation,23545,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2306.9,,,,,,,fee schedule,2306.9,3195, Treat clavicle dislocation,23545,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2306.9,3195, Treat clavicle dislocation,23545,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2306.9,3195, Treat clavicle dislocation,23545,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2306.9,3195, Treat clavicle dislocation,23550,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2992.19,,,,,,,fee schedule,2992.19,22111, Treat clavicle dislocation,23550,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2992.19,22111, Treat clavicle dislocation,23550,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,2992.19,22111, Treat clavicle dislocation,23550,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,2992.19,22111, Treat clavicle dislocation,23552,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3393.11,,,,,,,fee schedule,3393.11,22111, Treat clavicle dislocation,23552,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3393.11,22111, Treat clavicle dislocation,23552,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3393.11,22111, Treat clavicle dislocation,23552,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3393.11,22111, Treat shoulder blade fx,23570,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1368.91,,,,,,,fee schedule,1368.91,3195, Treat shoulder blade fx,23570,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1368.91,3195, Treat shoulder blade fx,23570,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1368.91,3195, Treat shoulder blade fx,23570,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1368.91,3195, Treat shoulder blade fx,23575,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2075.03,,,,,,,fee schedule,2075.03,3195, Treat shoulder blade fx,23575,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2075.03,3195, Treat shoulder blade fx,23575,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2075.03,3195, Treat shoulder blade fx,23575,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2075.03,3195, Treat scapula fracture,23585,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5007.38,,,,,,,fee schedule,5007.38,22111, Treat scapula fracture,23585,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5007.38,22111, Treat scapula fracture,23585,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5007.38,22111, Treat scapula fracture,23585,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5007.38,22111, Treat humerus fracture,23600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1796.06,,,,,,,fee schedule,1796.06,3195, Treat humerus fracture,23600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1796.06,3195, Treat humerus fracture,23600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1796.06,3195, Treat humerus fracture,23600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1796.06,3195, Treat humerus fracture,23605,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2419.94,,,,,,,fee schedule,2419.94,10940, Treat humerus fracture,23605,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2419.94,10940, Treat humerus fracture,23605,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2419.94,10940, Treat humerus fracture,23605,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2419.94,10940, Treat humerus fracture,23615,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4589.51,,,,,,,fee schedule,4589.51,22111, Treat humerus fracture,23615,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4589.51,22111, Treat humerus fracture,23615,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4589.51,22111, Treat humerus fracture,23615,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4589.51,22111, Treat humerus fracture,23616,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6292.65,,,,,,,fee schedule,5363,22111, Treat humerus fracture,23616,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,22111, Treat humerus fracture,23616,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5363,22111, Treat humerus fracture,23616,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5363,22111, Treat humerus fracture,23620,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1469.87,,,,,,,fee schedule,1469.87,3195, Treat humerus fracture,23620,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1469.87,3195, Treat humerus fracture,23620,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1469.87,3195, Treat humerus fracture,23620,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1469.87,3195, Treat humerus fracture,23625,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2065.48,,,,,,,fee schedule,2065.48,5664, Treat humerus fracture,23625,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2065.48,5664, Treat humerus fracture,23625,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2065.48,5664, Treat humerus fracture,23625,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2065.48,5664, Treat humerus fracture,23630,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4076.95,,,,,,,fee schedule,4076.95,22111, Treat humerus fracture,23630,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4076.95,22111, Treat humerus fracture,23630,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4076.95,22111, Treat humerus fracture,23630,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4076.95,22111, Treat shoulder dislocation,23650,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2005.15,,,,,,,fee schedule,2005.15,3195, Treat shoulder dislocation,23650,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2005.15,3195, Treat shoulder dislocation,23650,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2005.15,3195, Treat shoulder dislocation,23650,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2005.15,3195, Treat shoulder dislocation,23655,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2297.99,,,,,,,fee schedule,2297.99,5664, Treat shoulder dislocation,23655,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2297.99,5664, Treat shoulder dislocation,23655,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2297.99,5664, Treat shoulder dislocation,23655,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2297.99,5664, Treat shoulder dislocation,23660,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3048.09,,,,,,,fee schedule,3048.09,22111, Treat shoulder dislocation,23660,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3048.09,22111, Treat shoulder dislocation,23660,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3048.09,22111, Treat shoulder dislocation,23660,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3048.09,22111, Treat dislocation/fracture,23665,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2283.21,,,,,,,fee schedule,2283.21,4497, Treat dislocation/fracture,23665,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2283.21,4497, Treat dislocation/fracture,23665,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,2283.21,4497, Treat dislocation/fracture,23665,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,2283.21,4497, Treat dislocation/fracture,23670,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4561.29,,,,,,,fee schedule,4561.29,22111, Treat dislocation/fracture,23670,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4561.29,22111, Treat dislocation/fracture,23670,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4561.29,22111, Treat dislocation/fracture,23670,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4561.29,22111, Treat dislocation/fracture,23675,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2815.79,,,,,,,fee schedule,2505,4108, Treat dislocation/fracture,23675,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2505,4108, Treat dislocation/fracture,23675,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,4108, Treat dislocation/fracture,23675,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,4108, Treat dislocation/fracture,23680,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4833.41,,,,,,,fee schedule,4833.41,22111, Treat dislocation/fracture,23680,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4833.41,22111, Treat dislocation/fracture,23680,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4833.41,22111, Treat dislocation/fracture,23680,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4833.41,22111, Fixation of shoulder,23700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1021.03,,,,,,,fee schedule,1021.03,5664, Fixation of shoulder,23700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1021.03,5664, Fixation of shoulder,23700,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1021.03,5664, Fixation of shoulder,23700,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1021.03,5664, Fusion of shoulder joint,23800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5297.58,,,,,,,fee schedule,5297.58,22111, Fusion of shoulder joint,23800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5297.58,22111, Fusion of shoulder joint,23800,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5297.58,22111, Fusion of shoulder joint,23800,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5297.58,22111, Fusion of shoulder joint,23802,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6619.49,,,,,,,fee schedule,6619.49,22111, Fusion of shoulder joint,23802,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,6619.49,22111, Fusion of shoulder joint,23802,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6619.49,22111, Fusion of shoulder joint,23802,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6619.49,22111, Amputation of arm & girdle,23900,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7067.79,,,,,,,fee schedule,6979,22111, Amputation of arm & girdle,23900,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,22111, Amputation of arm & girdle,23900,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6979,22111, Amputation of arm & girdle,23900,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6979,22111, Amputation at shoulder joint,23920,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5792.88,,,,,,,fee schedule,5792.88,22111, Amputation at shoulder joint,23920,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5792.88,22111, Amputation at shoulder joint,23920,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5792.88,22111, Amputation at shoulder joint,23920,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5792.88,22111, Amputation follow-up surgery,23921,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2531.7,,,,,,,fee schedule,2531.7,5664, Amputation follow-up surgery,23921,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2531.7,5664, Amputation follow-up surgery,23921,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2531.7,5664, Amputation follow-up surgery,23921,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2531.7,5664, Shoulder surgery procedure,23929,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Shoulder surgery procedure,23929,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Shoulder surgery procedure,23929,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Drainage of arm lesion,23930,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1141.2,,,,,,,fee schedule,1141.2,10940, Drainage of arm lesion,23930,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1141.2,10940, Drainage of arm lesion,23930,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1141.2,10940, Drainage of arm lesion,23930,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1141.2,10940, Drainage of arm bursa,23931,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,867.14,,,,,,,fee schedule,867.14,5664, Drainage of arm bursa,23931,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,867.14,5664, Drainage of arm bursa,23931,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,867.14,5664, Drainage of arm bursa,23931,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,867.14,5664, Drain arm/elbow bone lesion,23935,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2732.7,,,,,,,fee schedule,2732.7,10940, Drain arm/elbow bone lesion,23935,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2732.7,10940, Drain arm/elbow bone lesion,23935,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2732.7,10940, Drain arm/elbow bone lesion,23935,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2732.7,10940, Exploratory elbow surgery,24000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2546.8,,,,,,,fee schedule,2546.8,12821, Exploratory elbow surgery,24000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2546.8,12821, Exploratory elbow surgery,24000,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2546.8,12821, Exploratory elbow surgery,24000,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2546.8,12821, Release elbow joint,24006,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3692.7,,,,,,,fee schedule,3692.7,12821, Release elbow joint,24006,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3692.7,12821, Release elbow joint,24006,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3692.7,12821, Release elbow joint,24006,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3692.7,12821, Biopsy arm/elbow soft tissue,24065,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,810.86,,,,,,,fee schedule,810.86,5664, Biopsy arm/elbow soft tissue,24065,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,810.86,5664, Biopsy arm/elbow soft tissue,24065,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,810.86,5664, Biopsy arm/elbow soft tissue,24065,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,810.86,5664, Biopsy arm/elbow soft tissue,24066,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2304.85,,,,,,,fee schedule,2304.85,5664, Biopsy arm/elbow soft tissue,24066,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2304.85,5664, Biopsy arm/elbow soft tissue,24066,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2304.85,5664, Biopsy arm/elbow soft tissue,24066,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2304.85,5664, Exc arm/elbow les sc 3 cm/>,24071,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2194.34,,,,,,,fee schedule,2194.34,10940, Exc arm/elbow les sc 3 cm/>,24071,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2194.34,10940, Exc arm/elbow les sc 3 cm/>,24071,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2194.34,10940, Exc arm/elbow les sc 3 cm/>,24071,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2194.34,10940, Ex arm/elbow tum deep 5 cm/>,24073,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3670.36,,,,,,,fee schedule,3670.36,10940, Ex arm/elbow tum deep 5 cm/>,24073,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3670.36,10940, Ex arm/elbow tum deep 5 cm/>,24073,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3670.36,10940, Ex arm/elbow tum deep 5 cm/>,24073,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3670.36,10940, Exc arm/elbow les sc < 3 cm,24075,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1775.55,,,,,,,fee schedule,1775.55,5664, Exc arm/elbow les sc < 3 cm,24075,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1775.55,5664, Exc arm/elbow les sc < 3 cm,24075,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1775.55,5664, Exc arm/elbow les sc < 3 cm,24075,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1775.55,5664, Ex arm/elbow tum deep < 5 cm,24076,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2898.95,,,,,,,fee schedule,2898.95,5664, Ex arm/elbow tum deep < 5 cm,24076,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2898.95,5664, Ex arm/elbow tum deep < 5 cm,24076,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2898.95,5664, Ex arm/elbow tum deep < 5 cm,24076,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2898.95,5664, Resect arm/elbow tum < 5 cm,24077,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5411.16,,,,,,,fee schedule,5097,5664, Resect arm/elbow tum < 5 cm,24077,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5097,5664, Resect arm/elbow tum < 5 cm,24077,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Resect arm/elbow tum < 5 cm,24077,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Resect arm/elbow tum 5 cm/>,24079,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6939.96,,,,,,,fee schedule,5248,10940, Resect arm/elbow tum 5 cm/>,24079,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,10940, Resect arm/elbow tum 5 cm/>,24079,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,5248,10940, Resect arm/elbow tum 5 cm/>,24079,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,5248,10940, Biopsy elbow joint lining,24100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2265.67,,,,,,,fee schedule,2265.67,10940, Biopsy elbow joint lining,24100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2265.67,10940, Biopsy elbow joint lining,24100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2265.67,10940, Biopsy elbow joint lining,24100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2265.67,10940, Explore/treat elbow joint,24101,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2661.68,,,,,,,fee schedule,2661.68,12821, Explore/treat elbow joint,24101,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2661.68,12821, Explore/treat elbow joint,24101,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2661.68,12821, Explore/treat elbow joint,24101,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2661.68,12821, Remove elbow joint lining,24102,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3209.54,,,,,,,fee schedule,3209.54,12821, Remove elbow joint lining,24102,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3209.54,12821, Remove elbow joint lining,24102,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3209.54,12821, Remove elbow joint lining,24102,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3209.54,12821, Removal of elbow bursa,24105,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1950.28,,,,,,,fee schedule,1950.28,10940, Removal of elbow bursa,24105,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1950.28,10940, Removal of elbow bursa,24105,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1950.28,10940, Removal of elbow bursa,24105,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1950.28,10940, Remove humerus lesion,24110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3133.89,,,,,,,fee schedule,3133.89,10940, Remove humerus lesion,24110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3133.89,10940, Remove humerus lesion,24110,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3133.89,10940, Remove humerus lesion,24110,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3133.89,10940, Remove/graft bone lesion,24115,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3860.57,,,,,,,fee schedule,3860.57,12821, Remove/graft bone lesion,24115,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3860.57,12821, Remove/graft bone lesion,24115,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3860.57,12821, Remove/graft bone lesion,24115,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3860.57,12821, Remove/graft bone lesion,24116,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4461.2,,,,,,,fee schedule,4461.2,12821, Remove/graft bone lesion,24116,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4461.2,12821, Remove/graft bone lesion,24116,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4461.2,12821, Remove/graft bone lesion,24116,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4461.2,12821, Remove elbow lesion,24120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2802.09,,,,,,,fee schedule,2802.09,10940, Remove elbow lesion,24120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2802.09,10940, Remove elbow lesion,24120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2802.09,10940, Remove elbow lesion,24120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2802.09,10940, Remove/graft bone lesion,24125,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3296.52,,,,,,,fee schedule,3296.52,12821, Remove/graft bone lesion,24125,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3296.52,12821, Remove/graft bone lesion,24125,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3296.52,12821, Remove/graft bone lesion,24125,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3296.52,12821, Remove/graft bone lesion,24126,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3427.97,,,,,,,fee schedule,3427.97,12821, Remove/graft bone lesion,24126,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3427.97,12821, Remove/graft bone lesion,24126,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3427.97,12821, Remove/graft bone lesion,24126,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3427.97,12821, Removal of head of radius,24130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2674.42,,,,,,,fee schedule,2674.42,12821, Removal of head of radius,24130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2674.42,12821, Removal of head of radius,24130,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2674.42,12821, Removal of head of radius,24130,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2674.42,12821, Removal of arm bone lesion,24134,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3914.91,,,,,,,fee schedule,3914.91,12821, Removal of arm bone lesion,24134,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3914.91,12821, Removal of arm bone lesion,24134,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3914.91,12821, Removal of arm bone lesion,24134,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3914.91,12821, Remove radius bone lesion,24136,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3334.46,,,,,,,fee schedule,3334.46,12821, Remove radius bone lesion,24136,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3334.46,12821, Remove radius bone lesion,24136,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3334.46,12821, Remove radius bone lesion,24136,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3334.46,12821, Remove elbow bone lesion,24138,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3649.1,,,,,,,fee schedule,3649.1,12821, Remove elbow bone lesion,24138,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3649.1,12821, Remove elbow bone lesion,24138,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3649.1,12821, Remove elbow bone lesion,24138,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3649.1,12821, Partial removal of arm bone,24140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3646.13,,,,,,,fee schedule,3646.13,12821, Partial removal of arm bone,24140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3646.13,12821, Partial removal of arm bone,24140,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3646.13,12821, Partial removal of arm bone,24140,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3646.13,12821, Partial removal of radius,24145,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3141.55,,,,,,,fee schedule,3141.55,12821, Partial removal of radius,24145,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3141.55,12821, Partial removal of radius,24145,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3141.55,12821, Partial removal of radius,24145,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3141.55,12821, Partial removal of elbow,24147,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3288.7,,,,,,,fee schedule,3288.7,12821, Partial removal of elbow,24147,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3288.7,12821, Partial removal of elbow,24147,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3288.7,12821, Partial removal of elbow,24147,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3288.7,12821, Radical resection of elbow,24149,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6062.78,,,,,,,fee schedule,5363,12821, Radical resection of elbow,24149,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,12821, Radical resection of elbow,24149,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5363,12821, Radical resection of elbow,24149,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5363,12821, Resect distal humerus tumor,24150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7868.82,,,,,,,fee schedule,5248,14456, Resect distal humerus tumor,24150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,14456, Resect distal humerus tumor,24150,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5248,14456, Resect distal humerus tumor,24150,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5248,14456, Resect radius tumor,24152,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6878.55,,,,,,,fee schedule,5248,14456, Resect radius tumor,24152,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,14456, Resect radius tumor,24152,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5248,14456, Resect radius tumor,24152,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5248,14456, Removal of elbow joint,24155,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4422.78,,,,,,,fee schedule,4422.78,12821, Removal of elbow joint,24155,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4422.78,12821, Removal of elbow joint,24155,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4422.78,12821, Removal of elbow joint,24155,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4422.78,12821, Remove elbow joint implant,24160,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6450.22,,,,,,,fee schedule,4108,12821, Remove elbow joint implant,24160,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,12821, Remove elbow joint implant,24160,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4108,12821, Remove elbow joint implant,24160,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4108,12821, Remove radius head implant,24164,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3802.51,,,,,,,fee schedule,3802.51,12821, Remove radius head implant,24164,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3802.51,12821, Remove radius head implant,24164,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3802.51,12821, Remove radius head implant,24164,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3802.51,12821, Removal of arm foreign body,24200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,788.63,,,,,,,fee schedule,788.63,6979, Removal of arm foreign body,24200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,788.63,6979, Removal of arm foreign body,24200,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,788.63,6979, Removal of arm foreign body,24200,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,788.63,6979, Removal of arm foreign body,24201,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2158.45,,,,,,,fee schedule,2158.45,5664, Removal of arm foreign body,24201,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2158.45,5664, Removal of arm foreign body,24201,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2158.45,5664, Removal of arm foreign body,24201,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2158.45,5664, Injection for elbow x-ray,24220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,312.43,,,,,,,fee schedule,312.43,3195, Injection for elbow x-ray,24220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,312.43,3195, Injection for elbow x-ray,24220,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,312.43,3195, Injection for elbow x-ray,24220,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,312.43,3195, Manipulate elbow w/anesth,24300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2408.13,,,,,,,fee schedule,2408.13,5664, Manipulate elbow w/anesth,24300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2408.13,5664, Manipulate elbow w/anesth,24300,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2408.13,5664, Manipulate elbow w/anesth,24300,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2408.13,5664, Muscle/tendon transfer,24301,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3903.14,,,,,,,fee schedule,3903.14,12821, Muscle/tendon transfer,24301,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3903.14,12821, Muscle/tendon transfer,24301,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3903.14,12821, Muscle/tendon transfer,24301,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3903.14,12821, Arm tendon lengthening,24305,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2987.5,,,,,,,fee schedule,2987.5,12821, Arm tendon lengthening,24305,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2987.5,12821, Arm tendon lengthening,24305,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2987.5,12821, Arm tendon lengthening,24305,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2987.5,12821, Revision of arm tendon,24310,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2441.96,,,,,,,fee schedule,2441.96,10940, Revision of arm tendon,24310,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2441.96,10940, Revision of arm tendon,24310,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2441.96,10940, Revision of arm tendon,24310,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2441.96,10940, Repair of arm tendon,24320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4068.85,,,,,,,fee schedule,4068.85,12821, Repair of arm tendon,24320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4068.85,12821, Repair of arm tendon,24320,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4068.85,12821, Repair of arm tendon,24320,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4068.85,12821, Revision of arm muscles,24330,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3769.38,,,,,,,fee schedule,3769.38,22111, Revision of arm muscles,24330,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3769.38,22111, Revision of arm muscles,24330,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3769.38,22111, Revision of arm muscles,24330,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3769.38,22111, Revision of arm muscles,24331,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4095.67,,,,,,,fee schedule,4095.67,14456, Revision of arm muscles,24331,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4095.67,14456, Revision of arm muscles,24331,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4095.67,14456, Revision of arm muscles,24331,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4095.67,14456, Tenolysis triceps,24332,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3265.66,,,,,,,fee schedule,3265.66,12821, Tenolysis triceps,24332,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3265.66,12821, Tenolysis triceps,24332,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3265.66,12821, Tenolysis triceps,24332,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3265.66,12821, Repair of biceps tendon,24340,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3232.31,,,,,,,fee schedule,3232.31,14456, Repair of biceps tendon,24340,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3232.31,14456, Repair of biceps tendon,24340,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3232.31,14456, Repair of biceps tendon,24340,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3232.31,14456, Repair arm tendon/muscle,24341,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3906.54,,,,,,,fee schedule,3906.54,14456, Repair arm tendon/muscle,24341,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3906.54,14456, Repair arm tendon/muscle,24341,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3906.54,14456, Repair arm tendon/muscle,24341,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3906.54,14456, Repair of ruptured tendon,24342,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3986.13,,,,,,,fee schedule,3986.13,14456, Repair of ruptured tendon,24342,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3986.13,14456, Repair of ruptured tendon,24342,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3986.13,14456, Repair of ruptured tendon,24342,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3986.13,14456, Repr elbow lat ligmnt w/tiss,24343,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3737.11,,,,,,,fee schedule,3737.11,12821, Repr elbow lat ligmnt w/tiss,24343,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3737.11,12821, Repr elbow lat ligmnt w/tiss,24343,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3737.11,12821, Repr elbow lat ligmnt w/tiss,24343,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3737.11,12821, Reconstruct elbow lat ligmnt,24344,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5744.64,,,,,,,fee schedule,5744.64,14456, Reconstruct elbow lat ligmnt,24344,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8212,,,,,,,fee schedule,5744.64,14456, Reconstruct elbow lat ligmnt,24344,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5744.64,14456, Reconstruct elbow lat ligmnt,24344,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5744.64,14456, Repr elbw med ligmnt w/tissu,24345,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3730.74,,,,,,,fee schedule,3730.74,12821, Repr elbw med ligmnt w/tissu,24345,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3730.74,12821, Repr elbw med ligmnt w/tissu,24345,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3730.74,12821, Repr elbw med ligmnt w/tissu,24345,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3730.74,12821, Reconstruct elbow med ligmnt,24346,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5744.64,,,,,,,fee schedule,5363,14456, Reconstruct elbow med ligmnt,24346,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,14456, Reconstruct elbow med ligmnt,24346,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5363,14456, Reconstruct elbow med ligmnt,24346,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5363,14456, Repair elbow perc,24357,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2086.36,,,,,,,fee schedule,2086.36,10940, Repair elbow perc,24357,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2086.36,10940, Repair elbow perc,24357,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2086.36,10940, Repair elbow perc,24357,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2086.36,10940, Repair elbow w/deb open,24358,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2756.98,,,,,,,fee schedule,2756.98,12821, Repair elbow w/deb open,24358,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2756.98,12821, Repair elbow w/deb open,24358,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2756.98,12821, Repair elbow w/deb open,24358,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2756.98,12821, Repair elbow deb/attch open,24359,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3423.38,,,,,,,fee schedule,3423.38,12821, Repair elbow deb/attch open,24359,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3423.38,12821, Repair elbow deb/attch open,24359,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3423.38,12821, Repair elbow deb/attch open,24359,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3423.38,12821, Reconstruct elbow joint,24360,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4677.52,,,,,,,fee schedule,4677.52,14456, Reconstruct elbow joint,24360,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4677.52,14456, Reconstruct elbow joint,24360,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4677.52,14456, Reconstruct elbow joint,24360,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4677.52,14456, Reconstruct elbow joint,24361,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5207.46,,,,,,,fee schedule,5207.46,25393, Reconstruct elbow joint,24361,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,5207.46,25393, Reconstruct elbow joint,24361,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,5207.46,25393, Reconstruct elbow joint,24361,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,5207.46,25393, Reconstruct elbow joint,24362,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5466.63,,,,,,,fee schedule,5466.63,14456, Reconstruct elbow joint,24362,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,5466.63,14456, Reconstruct elbow joint,24362,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5466.63,14456, Reconstruct elbow joint,24362,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5466.63,14456, Replace elbow joint,24363,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7306.4,,,,,,,fee schedule,7306.4,25393, Replace elbow joint,24363,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,7306.4,25393, Replace elbow joint,24363,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,7306.4,25393, Replace elbow joint,24363,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,7306.4,25393, Reconstruct head of radius,24365,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3365.92,,,,,,,fee schedule,3365.92,14456, Reconstruct head of radius,24365,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,3365.92,14456, Reconstruct head of radius,24365,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3365.92,14456, Reconstruct head of radius,24365,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3365.92,14456, Reconstruct head of radius,24366,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3531.95,,,,,,,fee schedule,3531.95,25393, Reconstruct head of radius,24366,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,3531.95,25393, Reconstruct head of radius,24366,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,3531.95,25393, Reconstruct head of radius,24366,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,3531.95,25393, Revise reconst elbow joint,24370,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7738.84,,,,,,,fee schedule,6044,25393, Revise reconst elbow joint,24370,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,25393, Revise reconst elbow joint,24370,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,6044,25393, Revise reconst elbow joint,24370,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,6044,25393, Revise reconst elbow joint,24371,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8847.82,,,,,,,fee schedule,8406,25393, Revise reconst elbow joint,24371,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,8406,25393, Revise reconst elbow joint,24371,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,8406,25393, Revise reconst elbow joint,24371,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,8406,25393, Revision of humerus,24400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4315.72,,,,,,,fee schedule,4315.72,14456, Revision of humerus,24400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4315.72,14456, Revision of humerus,24400,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4315.72,14456, Revision of humerus,24400,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4315.72,14456, Revision of humerus,24410,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5465.18,,,,,,,fee schedule,5363,14456, Revision of humerus,24410,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,14456, Revision of humerus,24410,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5363,14456, Revision of humerus,24410,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5363,14456, Revision of humerus,24420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5554.48,,,,,,,fee schedule,5248,14456, Revision of humerus,24420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,14456, Revision of humerus,24420,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5248,14456, Revision of humerus,24420,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5248,14456, Repair of humerus,24430,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5421.52,,,,,,,fee schedule,5248,22111, Repair of humerus,24430,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,22111, Repair of humerus,24430,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5248,22111, Repair of humerus,24430,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5248,22111, Repair humerus with graft,24435,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5595.98,,,,,,,fee schedule,5363,22111, Repair humerus with graft,24435,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,22111, Repair humerus with graft,24435,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5363,22111, Repair humerus with graft,24435,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5363,22111, Revision of elbow joint,24470,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3545.87,,,,,,,fee schedule,3545.87,14456, Revision of elbow joint,24470,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3545.87,14456, Revision of elbow joint,24470,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3545.87,14456, Revision of elbow joint,24470,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3545.87,14456, Decompression of forearm,24495,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4912.84,,,,,,,fee schedule,4108,12821, Decompression of forearm,24495,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,12821, Decompression of forearm,24495,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4108,12821, Decompression of forearm,24495,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4108,12821, Reinforce humerus,24498,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4482.03,,,,,,,fee schedule,4482.03,22111, Reinforce humerus,24498,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4482.03,22111, Reinforce humerus,24498,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4482.03,22111, Reinforce humerus,24498,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4482.03,22111, Treat humerus fracture,24500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1894.16,,,,,,,fee schedule,1894.16,3195, Treat humerus fracture,24500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1894.16,3195, Treat humerus fracture,24500,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1894.16,3195, Treat humerus fracture,24500,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1894.16,3195, Treat humerus fracture,24505,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2602.27,,,,,,,fee schedule,2505,3195, Treat humerus fracture,24505,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Treat humerus fracture,24505,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Treat humerus fracture,24505,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Treat humerus fracture,24515,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4579.32,,,,,,,fee schedule,4579.32,22111, Treat humerus fracture,24515,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4579.32,22111, Treat humerus fracture,24515,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4579.32,22111, Treat humerus fracture,24515,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4579.32,22111, Treat humerus fracture,24516,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4455.32,,,,,,,fee schedule,4455.32,22111, Treat humerus fracture,24516,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4455.32,22111, Treat humerus fracture,24516,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4455.32,22111, Treat humerus fracture,24516,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4455.32,22111, Treat humerus fracture,24530,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1956.43,,,,,,,fee schedule,1956.43,3195, Treat humerus fracture,24530,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1956.43,3195, Treat humerus fracture,24530,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1956.43,3195, Treat humerus fracture,24530,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1956.43,3195, Treat humerus fracture,24535,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3113.49,,,,,,,fee schedule,2505,3195, Treat humerus fracture,24535,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Treat humerus fracture,24535,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Treat humerus fracture,24535,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Treat humerus fracture,24538,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4155.19,,,,,,,fee schedule,4108,10940, Treat humerus fracture,24538,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,10940, Treat humerus fracture,24538,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,4108,10940, Treat humerus fracture,24538,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,4108,10940, Treat humerus fracture,24545,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4803.36,,,,,,,fee schedule,4803.36,22111, Treat humerus fracture,24545,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4803.36,22111, Treat humerus fracture,24545,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4803.36,22111, Treat humerus fracture,24545,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4803.36,22111, Treat humerus fracture,24546,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5330.28,,,,,,,fee schedule,5330.28,22111, Treat humerus fracture,24546,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,5330.28,22111, Treat humerus fracture,24546,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5330.28,22111, Treat humerus fracture,24546,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5330.28,22111, Treat humerus fracture,24560,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1734.87,,,,,,,fee schedule,1734.87,3195, Treat humerus fracture,24560,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1734.87,3195, Treat humerus fracture,24560,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1734.87,3195, Treat humerus fracture,24560,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1734.87,3195, Treat humerus fracture,24565,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2677.87,,,,,,,fee schedule,2505,4108, Treat humerus fracture,24565,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2505,4108, Treat humerus fracture,24565,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,4108, Treat humerus fracture,24565,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,4108, Treat humerus fracture,24566,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3818.53,,,,,,,fee schedule,3818.53,10940, Treat humerus fracture,24566,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3818.53,10940, Treat humerus fracture,24566,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3818.53,10940, Treat humerus fracture,24566,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3818.53,10940, Treat humerus fracture,24575,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3850.21,,,,,,,fee schedule,3850.21,22111, Treat humerus fracture,24575,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3850.21,22111, Treat humerus fracture,24575,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3850.21,22111, Treat humerus fracture,24575,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3850.21,22111, Treat humerus fracture,24576,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1828.7,,,,,,,fee schedule,1828.7,3195, Treat humerus fracture,24576,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1828.7,3195, Treat humerus fracture,24576,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1828.7,3195, Treat humerus fracture,24576,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1828.7,3195, Treat humerus fracture,24577,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2740.41,,,,,,,fee schedule,2505,3195, Treat humerus fracture,24577,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Treat humerus fracture,24577,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Treat humerus fracture,24577,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Treat humerus fracture,24579,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4340.11,,,,,,,fee schedule,4340.11,22111, Treat humerus fracture,24579,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4340.11,22111, Treat humerus fracture,24579,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4340.11,22111, Treat humerus fracture,24579,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4340.11,22111, Treat humerus fracture,24582,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4324.19,,,,,,,fee schedule,4108,10940, Treat humerus fracture,24582,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,10940, Treat humerus fracture,24582,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,4108,10940, Treat humerus fracture,24582,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,4108,10940, Treat elbow fracture,24586,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5535.16,,,,,,,fee schedule,5363,22111, Treat elbow fracture,24586,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,22111, Treat elbow fracture,24586,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5363,22111, Treat elbow fracture,24586,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5363,22111, Treat elbow fracture,24587,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5599.75,,,,,,,fee schedule,5599.75,22111, Treat elbow fracture,24587,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,5599.75,22111, Treat elbow fracture,24587,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5599.75,22111, Treat elbow fracture,24587,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5599.75,22111, Treat elbow dislocation,24600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2208.85,,,,,,,fee schedule,2208.85,3195, Treat elbow dislocation,24600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2208.85,3195, Treat elbow dislocation,24600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2208.85,3195, Treat elbow dislocation,24600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2208.85,3195, Treat elbow dislocation,24605,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2634.44,,,,,,,fee schedule,2634.44,5664, Treat elbow dislocation,24605,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2634.44,5664, Treat elbow dislocation,24605,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2634.44,5664, Treat elbow dislocation,24605,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2634.44,5664, Treat elbow dislocation,24615,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3697.99,,,,,,,fee schedule,3697.99,22111, Treat elbow dislocation,24615,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3697.99,22111, Treat elbow dislocation,24615,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3697.99,22111, Treat elbow dislocation,24615,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3697.99,22111, Treat elbow fracture,24620,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3131.84,,,,,,,fee schedule,3131.84,5664, Treat elbow fracture,24620,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3131.84,5664, Treat elbow fracture,24620,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3131.84,5664, Treat elbow fracture,24620,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3131.84,5664, Treat elbow fracture,24635,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3540.86,,,,,,,fee schedule,3540.86,22111, Treat elbow fracture,24635,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3540.86,22111, Treat elbow fracture,24635,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3540.86,22111, Treat elbow fracture,24635,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3540.86,22111, Treat elbow dislocation,24640,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,385.27,,,,,,,fee schedule,385.27,6979, Treat elbow dislocation,24640,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,385.27,6979, Treat elbow dislocation,24640,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,385.27,6979, Treat elbow dislocation,24640,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,385.27,6979, Treat radius fracture,24650,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1395.84,,,,,,,fee schedule,1395.84,3195, Treat radius fracture,24650,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1395.84,3195, Treat radius fracture,24650,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1395.84,3195, Treat radius fracture,24650,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1395.84,3195, Treat radius fracture,24655,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2416.76,,,,,,,fee schedule,2416.76,3195, Treat radius fracture,24655,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2416.76,3195, Treat radius fracture,24655,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2416.76,3195, Treat radius fracture,24655,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2416.76,3195, Treat radius fracture,24665,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3436.28,,,,,,,fee schedule,3436.28,22111, Treat radius fracture,24665,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3436.28,22111, Treat radius fracture,24665,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3436.28,22111, Treat radius fracture,24665,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3436.28,22111, Treat radius fracture,24666,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3802.35,,,,,,,fee schedule,3802.35,22111, Treat radius fracture,24666,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3802.35,22111, Treat radius fracture,24666,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3802.35,22111, Treat radius fracture,24666,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3802.35,22111, Treat ulnar fracture,24670,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1526.53,,,,,,,fee schedule,1526.53,3195, Treat ulnar fracture,24670,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1526.53,3195, Treat ulnar fracture,24670,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1526.53,3195, Treat ulnar fracture,24670,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1526.53,3195, Treat ulnar fracture,24675,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2322.33,,,,,,,fee schedule,2322.33,3195, Treat ulnar fracture,24675,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2322.33,3195, Treat ulnar fracture,24675,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2322.33,3195, Treat ulnar fracture,24675,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2322.33,3195, Treat ulnar fracture,24685,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3439.3,,,,,,,fee schedule,3439.3,22111, Treat ulnar fracture,24685,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3439.3,22111, Treat ulnar fracture,24685,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3439.3,22111, Treat ulnar fracture,24685,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3439.3,22111, Fusion of elbow joint,24800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4350.26,,,,,,,fee schedule,4350.26,14456, Fusion of elbow joint,24800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4350.26,14456, Fusion of elbow joint,24800,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4350.26,14456, Fusion of elbow joint,24800,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4350.26,14456, Fusion/graft of elbow joint,24802,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5184.1,,,,,,,fee schedule,5184.1,22111, Fusion/graft of elbow joint,24802,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,5184.1,22111, Fusion/graft of elbow joint,24802,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5184.1,22111, Fusion/graft of elbow joint,24802,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5184.1,22111, Amputation of upper arm,24900,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4001.57,,,,,,,fee schedule,4001.57,22111, Amputation of upper arm,24900,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4001.57,22111, Amputation of upper arm,24900,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4001.57,22111, Amputation of upper arm,24900,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4001.57,22111, Amputation of upper arm,24920,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3829.6,,,,,,,fee schedule,3829.6,22111, Amputation of upper arm,24920,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3829.6,22111, Amputation of upper arm,24920,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3829.6,22111, Amputation of upper arm,24920,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3829.6,22111, Amputation follow-up surgery,24925,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3018.04,,,,,,,fee schedule,3018.04,10940, Amputation follow-up surgery,24925,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3018.04,10940, Amputation follow-up surgery,24925,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3018.04,10940, Amputation follow-up surgery,24925,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3018.04,10940, Amputation follow-up surgery,24930,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4030.7,,,,,,,fee schedule,4030.7,22111, Amputation follow-up surgery,24930,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4030.7,22111, Amputation follow-up surgery,24930,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4030.7,22111, Amputation follow-up surgery,24930,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4030.7,22111, Amputate upper arm & implant,24931,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4804.38,,,,,,,fee schedule,4804.38,22111, Amputate upper arm & implant,24931,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4804.38,22111, Amputate upper arm & implant,24931,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4804.38,22111, Amputate upper arm & implant,24931,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4804.38,22111, Revision of amputation,24935,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6330.21,,,,,,,fee schedule,6330.21,22111, Revision of amputation,24935,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6330.21,22111, Revision of amputation,24935,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6330.21,22111, Revision of amputation,24935,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6330.21,22111, Revision of upper arm,24940,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,22111, Revision of upper arm,24940,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5363,22111, Revision of upper arm,24940,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5363,22111, Upper arm/elbow surgery,24999,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Upper arm/elbow surgery,24999,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Upper arm/elbow surgery,24999,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Incision of tendon sheath,25000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1848.24,,,,,,,fee schedule,1848.24,10940, Incision of tendon sheath,25000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1848.24,10940, Incision of tendon sheath,25000,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1848.24,10940, Incision of tendon sheath,25000,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1848.24,10940, Incise flexor carpi radialis,25001,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1858.27,,,,,,,fee schedule,1858.27,10940, Incise flexor carpi radialis,25001,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1858.27,10940, Incise flexor carpi radialis,25001,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1858.27,10940, Incise flexor carpi radialis,25001,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1858.27,10940, Decompress forearm 1 space,25020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3882.69,,,,,,,fee schedule,3882.69,12821, Decompress forearm 1 space,25020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3882.69,12821, Decompress forearm 1 space,25020,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3882.69,12821, Decompress forearm 1 space,25020,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3882.69,12821, Decompress forearm 1 space,25023,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6896.9,,,,,,,fee schedule,5248,12821, Decompress forearm 1 space,25023,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,12821, Decompress forearm 1 space,25023,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5248,12821, Decompress forearm 1 space,25023,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5248,12821, Decompress forearm 2 spaces,25024,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4048.62,,,,,,,fee schedule,4048.62,12821, Decompress forearm 2 spaces,25024,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4048.62,12821, Decompress forearm 2 spaces,25024,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4048.62,12821, Decompress forearm 2 spaces,25024,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4048.62,12821, Decompress forearm 2 spaces,25025,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6305.12,,,,,,,fee schedule,5248,10940, Decompress forearm 2 spaces,25025,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,10940, Decompress forearm 2 spaces,25025,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,5248,10940, Decompress forearm 2 spaces,25025,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,5248,10940, Drainage of forearm lesion,25028,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3696.58,,,,,,,fee schedule,3195,10940, Drainage of forearm lesion,25028,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,10940, Drainage of forearm lesion,25028,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3195,10940, Drainage of forearm lesion,25028,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3195,10940, Drainage of forearm bursa,25031,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1998.73,,,,,,,fee schedule,1998.73,10940, Drainage of forearm bursa,25031,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1998.73,10940, Drainage of forearm bursa,25031,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1998.73,10940, Drainage of forearm bursa,25031,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1998.73,10940, Treat forearm bone lesion,25035,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3122.61,,,,,,,fee schedule,3122.61,10940, Treat forearm bone lesion,25035,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3122.61,10940, Treat forearm bone lesion,25035,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3122.61,10940, Treat forearm bone lesion,25035,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3122.61,10940, Explore/treat wrist joint,25040,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2907.8,,,,,,,fee schedule,2907.8,12821, Explore/treat wrist joint,25040,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,2907.8,12821, Explore/treat wrist joint,25040,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2907.8,12821, Explore/treat wrist joint,25040,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2907.8,12821, Biopsy forearm soft tissues,25065,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,796.34,,,,,,,fee schedule,796.34,4497, Biopsy forearm soft tissues,25065,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,796.34,4497, Biopsy forearm soft tissues,25065,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,796.34,4497, Biopsy forearm soft tissues,25065,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,796.34,4497, Biopsy forearm soft tissues,25066,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1962.63,,,,,,,fee schedule,1962.63,10940, Biopsy forearm soft tissues,25066,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1962.63,10940, Biopsy forearm soft tissues,25066,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1962.63,10940, Biopsy forearm soft tissues,25066,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1962.63,10940, Exc forearm les sc 3 cm/>,25071,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2258.44,,,,,,,fee schedule,2258.44,10940, Exc forearm les sc 3 cm/>,25071,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2258.44,10940, Exc forearm les sc 3 cm/>,25071,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2258.44,10940, Exc forearm les sc 3 cm/>,25071,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2258.44,10940, Exc forearm tum deep 3 cm/>,25073,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2820.76,,,,,,,fee schedule,2820.76,10940, Exc forearm tum deep 3 cm/>,25073,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2820.76,10940, Exc forearm tum deep 3 cm/>,25073,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2820.76,10940, Exc forearm tum deep 3 cm/>,25073,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2820.76,10940, Exc forearm les sc < 3 cm,25075,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1692.19,,,,,,,fee schedule,1692.19,5664, Exc forearm les sc < 3 cm,25075,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1692.19,5664, Exc forearm les sc < 3 cm,25075,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1692.19,5664, Exc forearm les sc < 3 cm,25075,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1692.19,5664, Exc forearm tum deep < 3 cm,25076,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2713.11,,,,,,,fee schedule,2713.11,5664, Exc forearm tum deep < 3 cm,25076,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2713.11,5664, Exc forearm tum deep < 3 cm,25076,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2713.11,5664, Exc forearm tum deep < 3 cm,25076,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2713.11,5664, Resect forearm/wrist tum<3cm,25077,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4716.37,,,,,,,fee schedule,4716.37,5664, Resect forearm/wrist tum<3cm,25077,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4716.37,5664, Resect forearm/wrist tum<3cm,25077,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4716.37,5664, Resect forearm/wrist tum<3cm,25077,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4716.37,5664, Resect forarm/wrist tum 3cm>,25078,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6102.88,,,,,,,fee schedule,5248,10940, Resect forarm/wrist tum 3cm>,25078,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,10940, Resect forarm/wrist tum 3cm>,25078,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,5248,10940, Resect forarm/wrist tum 3cm>,25078,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,5248,10940, Incision of wrist capsule,25085,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2346.67,,,,,,,fee schedule,2346.67,10940, Incision of wrist capsule,25085,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2346.67,10940, Incision of wrist capsule,25085,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2346.67,10940, Incision of wrist capsule,25085,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2346.67,10940, Biopsy of wrist joint,25100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1904.09,,,,,,,fee schedule,1904.09,10940, Biopsy of wrist joint,25100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1904.09,10940, Biopsy of wrist joint,25100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1904.09,10940, Biopsy of wrist joint,25100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1904.09,10940, Explore/treat wrist joint,25101,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2150.85,,,,,,,fee schedule,2150.85,12821, Explore/treat wrist joint,25101,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2150.85,12821, Explore/treat wrist joint,25101,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2150.85,12821, Explore/treat wrist joint,25101,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2150.85,12821, Remove wrist joint lining,25105,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2553.93,,,,,,,fee schedule,2553.93,12821, Remove wrist joint lining,25105,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2553.93,12821, Remove wrist joint lining,25105,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2553.93,12821, Remove wrist joint lining,25105,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2553.93,12821, Remove wrist joint cartilage,25107,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3235.01,,,,,,,fee schedule,3235.01,12821, Remove wrist joint cartilage,25107,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3235.01,12821, Remove wrist joint cartilage,25107,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3235.01,12821, Remove wrist joint cartilage,25107,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3235.01,12821, Excise tendon forearm/wrist,25109,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2791.24,,,,,,,fee schedule,2791.24,10940, Excise tendon forearm/wrist,25109,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2791.24,10940, Excise tendon forearm/wrist,25109,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2791.24,10940, Excise tendon forearm/wrist,25109,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2791.24,10940, Remove wrist tendon lesion,25110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1850.13,,,,,,,fee schedule,1850.13,10940, Remove wrist tendon lesion,25110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1850.13,10940, Remove wrist tendon lesion,25110,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1850.13,10940, Remove wrist tendon lesion,25110,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1850.13,10940, Remove wrist tendon lesion,25111,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1748.14,,,,,,,fee schedule,1748.14,10940, Remove wrist tendon lesion,25111,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1748.14,10940, Remove wrist tendon lesion,25111,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1748.14,10940, Remove wrist tendon lesion,25111,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1748.14,10940, Reremove wrist tendon lesion,25112,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2068.12,,,,,,,fee schedule,2068.12,10940, Reremove wrist tendon lesion,25112,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2068.12,10940, Reremove wrist tendon lesion,25112,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2068.12,10940, Reremove wrist tendon lesion,25112,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2068.12,10940, Remove wrist/forearm lesion,25115,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3892.03,,,,,,,fee schedule,3892.03,10940, Remove wrist/forearm lesion,25115,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3892.03,10940, Remove wrist/forearm lesion,25115,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3892.03,10940, Remove wrist/forearm lesion,25115,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3892.03,10940, Remove wrist/forearm lesion,25116,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3143.82,,,,,,,fee schedule,3143.82,10940, Remove wrist/forearm lesion,25116,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3143.82,10940, Remove wrist/forearm lesion,25116,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3143.82,10940, Remove wrist/forearm lesion,25116,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3143.82,10940, Excise wrist tendon sheath,25118,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2025.06,,,,,,,fee schedule,2025.06,10940, Excise wrist tendon sheath,25118,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2025.06,10940, Excise wrist tendon sheath,25118,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2025.06,10940, Excise wrist tendon sheath,25118,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2025.06,10940, Partial removal of ulna,25119,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2686.56,,,,,,,fee schedule,2686.56,12821, Partial removal of ulna,25119,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2686.56,12821, Partial removal of ulna,25119,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2686.56,12821, Partial removal of ulna,25119,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2686.56,12821, Removal of forearm lesion,25120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2618.62,,,,,,,fee schedule,2618.62,12821, Removal of forearm lesion,25120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2618.62,12821, Removal of forearm lesion,25120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2618.62,12821, Removal of forearm lesion,25120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2618.62,12821, Remove/graft forearm lesion,25125,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3160.71,,,,,,,fee schedule,3160.71,10940, Remove/graft forearm lesion,25125,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3160.71,10940, Remove/graft forearm lesion,25125,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3160.71,10940, Remove/graft forearm lesion,25125,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3160.71,10940, Remove/graft forearm lesion,25126,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3182.18,,,,,,,fee schedule,3182.18,12821, Remove/graft forearm lesion,25126,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3182.18,12821, Remove/graft forearm lesion,25126,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3182.18,12821, Remove/graft forearm lesion,25126,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3182.18,12821, Removal of wrist lesion,25130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2364.2,,,,,,,fee schedule,2364.2,12821, Removal of wrist lesion,25130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2364.2,12821, Removal of wrist lesion,25130,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2364.2,12821, Removal of wrist lesion,25130,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2364.2,12821, Remove & graft wrist lesion,25135,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2990.89,,,,,,,fee schedule,2990.89,12821, Remove & graft wrist lesion,25135,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2990.89,12821, Remove & graft wrist lesion,25135,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2990.89,12821, Remove & graft wrist lesion,25135,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2990.89,12821, Remove & graft wrist lesion,25136,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2666.87,,,,,,,fee schedule,2666.87,12821, Remove & graft wrist lesion,25136,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2666.87,12821, Remove & graft wrist lesion,25136,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2666.87,12821, Remove & graft wrist lesion,25136,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2666.87,12821, Remove forearm bone lesion,25145,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2774.08,,,,,,,fee schedule,2774.08,12821, Remove forearm bone lesion,25145,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2774.08,12821, Remove forearm bone lesion,25145,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2774.08,12821, Remove forearm bone lesion,25145,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2774.08,12821, Partial removal of ulna,25150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2957.6,,,,,,,fee schedule,2957.6,12821, Partial removal of ulna,25150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2957.6,12821, Partial removal of ulna,25150,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2957.6,12821, Partial removal of ulna,25150,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2957.6,12821, Partial removal of radius,25151,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3017.77,,,,,,,fee schedule,3017.77,12821, Partial removal of radius,25151,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3017.77,12821, Partial removal of radius,25151,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3017.77,12821, Partial removal of radius,25151,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3017.77,12821, Resect radius/ulnar tumor,25170,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7485.49,,,,,,,fee schedule,5248,12821, Resect radius/ulnar tumor,25170,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,12821, Resect radius/ulnar tumor,25170,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5248,12821, Resect radius/ulnar tumor,25170,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5248,12821, Removal of wrist bone,25210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2571.19,,,,,,,fee schedule,2571.19,12821, Removal of wrist bone,25210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2571.19,12821, Removal of wrist bone,25210,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2571.19,12821, Removal of wrist bone,25210,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2571.19,12821, Removal of wrist bones,25215,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3192.65,,,,,,,fee schedule,3192.65,12821, Removal of wrist bones,25215,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3192.65,12821, Removal of wrist bones,25215,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3192.65,12821, Removal of wrist bones,25215,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3192.65,12821, Partial removal of radius,25230,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2275.22,,,,,,,fee schedule,2275.22,12821, Partial removal of radius,25230,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2275.22,12821, Partial removal of radius,25230,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2275.22,12821, Partial removal of radius,25230,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2275.22,12821, Partial removal of ulna,25240,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2258.23,,,,,,,fee schedule,2258.23,12821, Partial removal of ulna,25240,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2258.23,12821, Partial removal of ulna,25240,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2258.23,12821, Partial removal of ulna,25240,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2258.23,12821, Injection for wrist x-ray,25246,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,342,,,,,,,fee schedule,342,3195, Injection for wrist x-ray,25246,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,342,3195, Injection for wrist x-ray,25246,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,342,3195, Injection for wrist x-ray,25246,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,342,3195, Remove forearm foreign body,25248,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2257.04,,,,,,,fee schedule,2257.04,10940, Remove forearm foreign body,25248,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2257.04,10940, Remove forearm foreign body,25248,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2257.04,10940, Remove forearm foreign body,25248,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2257.04,10940, Removal of wrist prosthesis,25250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2840.35,,,,,,,fee schedule,2840.35,5664, Removal of wrist prosthesis,25250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2840.35,5664, Removal of wrist prosthesis,25250,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2840.35,5664, Removal of wrist prosthesis,25250,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2840.35,5664, Removal of wrist prosthesis,25251,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3773.96,,,,,,,fee schedule,3195,12821, Removal of wrist prosthesis,25251,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,12821, Removal of wrist prosthesis,25251,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3195,12821, Removal of wrist prosthesis,25251,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3195,12821, Manipulate wrist w/anesthes,25259,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2364.53,,,,,,,fee schedule,2364.53,5664, Manipulate wrist w/anesthes,25259,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2364.53,5664, Manipulate wrist w/anesthes,25259,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2364.53,5664, Manipulate wrist w/anesthes,25259,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2364.53,5664, Repair forearm tendon/muscle,25260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3302.14,,,,,,,fee schedule,3302.14,12821, Repair forearm tendon/muscle,25260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3302.14,12821, Repair forearm tendon/muscle,25260,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3302.14,12821, Repair forearm tendon/muscle,25260,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3302.14,12821, Repair forearm tendon/muscle,25263,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3362.68,,,,,,,fee schedule,3362.68,12821, Repair forearm tendon/muscle,25263,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3362.68,12821, Repair forearm tendon/muscle,25263,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3362.68,12821, Repair forearm tendon/muscle,25263,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3362.68,12821, Repair forearm tendon/muscle,25265,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3808.93,,,,,,,fee schedule,3808.93,12821, Repair forearm tendon/muscle,25265,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3808.93,12821, Repair forearm tendon/muscle,25265,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3808.93,12821, Repair forearm tendon/muscle,25265,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3808.93,12821, Repair forearm tendon/muscle,25270,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2594.5,,,,,,,fee schedule,2594.5,12821, Repair forearm tendon/muscle,25270,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2594.5,12821, Repair forearm tendon/muscle,25270,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2594.5,12821, Repair forearm tendon/muscle,25270,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2594.5,12821, Repair forearm tendon/muscle,25272,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2965.37,,,,,,,fee schedule,2965.37,12821, Repair forearm tendon/muscle,25272,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2965.37,12821, Repair forearm tendon/muscle,25272,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2965.37,12821, Repair forearm tendon/muscle,25272,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2965.37,12821, Repair forearm tendon/muscle,25274,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3408.06,,,,,,,fee schedule,3408.06,12821, Repair forearm tendon/muscle,25274,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3408.06,12821, Repair forearm tendon/muscle,25274,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3408.06,12821, Repair forearm tendon/muscle,25274,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3408.06,12821, Repair forearm tendon sheath,25275,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3451.55,,,,,,,fee schedule,3451.55,12821, Repair forearm tendon sheath,25275,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3451.55,12821, Repair forearm tendon sheath,25275,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3451.55,12821, Repair forearm tendon sheath,25275,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3451.55,12821, Revise wrist/forearm tendon,25280,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2942.65,,,,,,,fee schedule,2942.65,12821, Revise wrist/forearm tendon,25280,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2942.65,12821, Revise wrist/forearm tendon,25280,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2942.65,12821, Revise wrist/forearm tendon,25280,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2942.65,12821, Incise wrist/forearm tendon,25290,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2279.76,,,,,,,fee schedule,2279.76,12821, Incise wrist/forearm tendon,25290,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2279.76,12821, Incise wrist/forearm tendon,25290,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2279.76,12821, Incise wrist/forearm tendon,25290,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2279.76,12821, Release wrist/forearm tendon,25295,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2739.98,,,,,,,fee schedule,2739.98,10940, Release wrist/forearm tendon,25295,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2739.98,10940, Release wrist/forearm tendon,25295,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2739.98,10940, Release wrist/forearm tendon,25295,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2739.98,10940, Fusion of tendons at wrist,25300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3639.76,,,,,,,fee schedule,3639.76,12821, Fusion of tendons at wrist,25300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3639.76,12821, Fusion of tendons at wrist,25300,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3639.76,12821, Fusion of tendons at wrist,25300,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3639.76,12821, Fusion of tendons at wrist,25301,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3318.22,,,,,,,fee schedule,3318.22,12821, Fusion of tendons at wrist,25301,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3318.22,12821, Fusion of tendons at wrist,25301,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3318.22,12821, Fusion of tendons at wrist,25301,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3318.22,12821, Transplant forearm tendon,25310,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3682.01,,,,,,,fee schedule,3682.01,12821, Transplant forearm tendon,25310,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3682.01,12821, Transplant forearm tendon,25310,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3682.01,12821, Transplant forearm tendon,25310,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3682.01,12821, Transplant forearm tendon,25312,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3686.6,,,,,,,fee schedule,3686.6,14456, Transplant forearm tendon,25312,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3686.6,14456, Transplant forearm tendon,25312,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3686.6,14456, Transplant forearm tendon,25312,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3686.6,14456, Revise palsy hand tendon(s),25315,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4018.67,,,,,,,fee schedule,4018.67,12821, Revise palsy hand tendon(s),25315,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4018.67,12821, Revise palsy hand tendon(s),25315,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4018.67,12821, Revise palsy hand tendon(s),25315,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4018.67,12821, Revise palsy hand tendon(s),25316,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4752.47,,,,,,,fee schedule,4752.47,22111, Revise palsy hand tendon(s),25316,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4752.47,22111, Revise palsy hand tendon(s),25316,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4752.47,22111, Revise palsy hand tendon(s),25316,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4752.47,22111, Repair/revise wrist joint,25320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5120.97,,,,,,,fee schedule,5120.97,14456, Repair/revise wrist joint,25320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5120.97,14456, Repair/revise wrist joint,25320,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5120.97,14456, Repair/revise wrist joint,25320,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5120.97,14456, Description Not Available,25330,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Description Not Available,25331,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Revise wrist joint,25332,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4307.03,,,,,,,fee schedule,4307.03,14456, Revise wrist joint,25332,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4307.03,14456, Revise wrist joint,25332,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4307.03,14456, Revise wrist joint,25332,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4307.03,14456, Realignment of hand,25335,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4889.21,,,,,,,fee schedule,4889.21,14456, Realignment of hand,25335,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4889.21,14456, Realignment of hand,25335,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4889.21,14456, Realignment of hand,25335,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4889.21,14456, Reconstruct ulna/radioulnar,25337,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4579.69,,,,,,,fee schedule,4579.69,14456, Reconstruct ulna/radioulnar,25337,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4579.69,14456, Reconstruct ulna/radioulnar,25337,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4579.69,14456, Reconstruct ulna/radioulnar,25337,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4579.69,14456, Revision of radius,25350,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3473.94,,,,,,,fee schedule,3473.94,14456, Revision of radius,25350,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3473.94,14456, Revision of radius,25350,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3473.94,14456, Revision of radius,25350,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3473.94,14456, Revision of radius,25355,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4003.56,,,,,,,fee schedule,4003.56,14456, Revision of radius,25355,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4003.56,14456, Revision of radius,25355,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4003.56,14456, Revision of radius,25355,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4003.56,14456, Revision of ulna,25360,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3378.44,,,,,,,fee schedule,3378.44,14456, Revision of ulna,25360,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3378.44,14456, Revision of ulna,25360,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3378.44,14456, Revision of ulna,25360,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3378.44,14456, Revise radius & ulna,25365,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4754.31,,,,,,,fee schedule,4754.31,14456, Revise radius & ulna,25365,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4754.31,14456, Revise radius & ulna,25365,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4754.31,14456, Revise radius & ulna,25365,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4754.31,14456, Revise radius or ulna,25370,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5249.88,,,,,,,fee schedule,5248,14456, Revise radius or ulna,25370,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,14456, Revise radius or ulna,25370,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5248,14456, Revise radius or ulna,25370,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5248,14456, Revise radius & ulna,25375,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4938.42,,,,,,,fee schedule,4938.42,14456, Revise radius & ulna,25375,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4938.42,14456, Revise radius & ulna,25375,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4938.42,14456, Revise radius & ulna,25375,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4938.42,14456, Shorten radius or ulna,25390,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3915.45,,,,,,,fee schedule,3915.45,14456, Shorten radius or ulna,25390,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3915.45,14456, Shorten radius or ulna,25390,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3915.45,14456, Shorten radius or ulna,25390,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3915.45,14456, Lengthen radius or ulna,25391,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5144.92,,,,,,,fee schedule,5144.92,14456, Lengthen radius or ulna,25391,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5144.92,14456, Lengthen radius or ulna,25391,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5144.92,14456, Lengthen radius or ulna,25391,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5144.92,14456, Shorten radius & ulna,25392,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5230.72,,,,,,,fee schedule,5230.72,12821, Shorten radius & ulna,25392,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5230.72,12821, Shorten radius & ulna,25392,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5230.72,12821, Shorten radius & ulna,25392,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5230.72,12821, Lengthen radius & ulna,25393,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5796.49,,,,,,,fee schedule,5363,14456, Lengthen radius & ulna,25393,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,14456, Lengthen radius & ulna,25393,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5363,14456, Lengthen radius & ulna,25393,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5363,14456, Repair carpal bone shorten,25394,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4099.77,,,,,,,fee schedule,4099.77,14456, Repair carpal bone shorten,25394,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4099.77,14456, Repair carpal bone shorten,25394,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4099.77,14456, Repair carpal bone shorten,25394,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4099.77,14456, Repair radius or ulna,25400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4102.85,,,,,,,fee schedule,4102.85,14456, Repair radius or ulna,25400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4102.85,14456, Repair radius or ulna,25400,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4102.85,14456, Repair radius or ulna,25400,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4102.85,14456, Repair/graft radius or ulna,25405,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5244.05,,,,,,,fee schedule,5244.05,22111, Repair/graft radius or ulna,25405,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5244.05,22111, Repair/graft radius or ulna,25405,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5244.05,22111, Repair/graft radius or ulna,25405,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5244.05,22111, Repair radius & ulna,25415,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5009.05,,,,,,,fee schedule,5009.05,22111, Repair radius & ulna,25415,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5009.05,22111, Repair radius & ulna,25415,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5009.05,22111, Repair radius & ulna,25415,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5009.05,22111, Repair/graft radius & ulna,25420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5992.64,,,,,,,fee schedule,5363,22111, Repair/graft radius & ulna,25420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,22111, Repair/graft radius & ulna,25420,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5363,22111, Repair/graft radius & ulna,25420,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5363,22111, Repair/graft radius or ulna,25425,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4984.07,,,,,,,fee schedule,4984.07,14456, Repair/graft radius or ulna,25425,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4984.07,14456, Repair/graft radius or ulna,25425,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4984.07,14456, Repair/graft radius or ulna,25425,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4984.07,14456, Repair/graft radius & ulna,25426,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5761.63,,,,,,,fee schedule,5363,14456, Repair/graft radius & ulna,25426,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,14456, Repair/graft radius & ulna,25426,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5363,14456, Repair/graft radius & ulna,25426,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5363,14456, Vasc graft into carpal bone,25430,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3861.54,,,,,,,fee schedule,3861.54,14456, Vasc graft into carpal bone,25430,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3861.54,14456, Vasc graft into carpal bone,25430,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3861.54,14456, Vasc graft into carpal bone,25430,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3861.54,14456, Repair nonunion carpal bone,25431,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4118.34,,,,,,,fee schedule,4118.34,14456, Repair nonunion carpal bone,25431,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4118.34,14456, Repair nonunion carpal bone,25431,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4118.34,14456, Repair nonunion carpal bone,25431,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4118.34,14456, Repair/graft wrist bone,25440,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3915.28,,,,,,,fee schedule,3915.28,14456, Repair/graft wrist bone,25440,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3915.28,14456, Repair/graft wrist bone,25440,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3915.28,14456, Repair/graft wrist bone,25440,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3915.28,14456, Reconstruct wrist joint,25441,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4857.16,,,,,,,fee schedule,4857.16,25393, Reconstruct wrist joint,25441,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4857.16,25393, Reconstruct wrist joint,25441,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,4857.16,25393, Reconstruct wrist joint,25441,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,4857.16,25393, Reconstruct wrist joint,25442,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4107.97,,,,,,,fee schedule,4107.97,25393, Reconstruct wrist joint,25442,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4107.97,25393, Reconstruct wrist joint,25442,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,4107.97,25393, Reconstruct wrist joint,25442,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,4107.97,25393, Reconstruct wrist joint,25443,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4103.71,,,,,,,fee schedule,4103.71,14456, Reconstruct wrist joint,25443,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4103.71,14456, Reconstruct wrist joint,25443,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4103.71,14456, Reconstruct wrist joint,25443,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4103.71,14456, Reconstruct wrist joint,25444,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4218.38,,,,,,,fee schedule,4218.38,22111, Reconstruct wrist joint,25444,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4218.38,22111, Reconstruct wrist joint,25444,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4218.38,22111, Reconstruct wrist joint,25444,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4218.38,22111, Reconstruct wrist joint,25445,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3685.09,,,,,,,fee schedule,3685.09,14456, Reconstruct wrist joint,25445,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,3685.09,14456, Reconstruct wrist joint,25445,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3685.09,14456, Reconstruct wrist joint,25445,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3685.09,14456, Wrist replacement,25446,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5882.88,,,,,,,fee schedule,5882.88,25393, Wrist replacement,25446,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,5882.88,25393, Wrist replacement,25446,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,5882.88,25393, Wrist replacement,25446,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,5882.88,25393, Repair wrist joints,25447,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4111.59,,,,,,,fee schedule,4111.59,14456, Repair wrist joints,25447,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4111.59,14456, Repair wrist joints,25447,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4111.59,14456, Repair wrist joints,25447,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4111.59,14456, Arthrp ntrcrpl/crp/mtcrp ssp,25448,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4535.01,,,,,,,fee schedule,4535.01,12821, Arthrp ntrcrpl/crp/mtcrp ssp,25448,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4535.01,12821, Arthrp ntrcrpl/crp/mtcrp ssp,25448,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4535.01,12821, Arthrp ntrcrpl/crp/mtcrp ssp,25448,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4535.01,12821, Remove wrist joint implant,25449,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5201.47,,,,,,,fee schedule,5201.47,14456, Remove wrist joint implant,25449,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,5201.47,14456, Remove wrist joint implant,25449,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5201.47,14456, Remove wrist joint implant,25449,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5201.47,14456, Revision of wrist joint,25450,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3271.54,,,,,,,fee schedule,3271.54,14456, Revision of wrist joint,25450,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3271.54,14456, Revision of wrist joint,25450,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3271.54,14456, Revision of wrist joint,25450,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3271.54,14456, Revision of wrist joint,25455,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3840.87,,,,,,,fee schedule,3840.87,14456, Revision of wrist joint,25455,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3840.87,14456, Revision of wrist joint,25455,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3840.87,14456, Revision of wrist joint,25455,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3840.87,14456, Reinforce radius,25490,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3775.58,,,,,,,fee schedule,3775.58,14456, Reinforce radius,25490,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3775.58,14456, Reinforce radius,25490,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3775.58,14456, Reinforce radius,25490,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3775.58,14456, Reinforce ulna,25491,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3870.39,,,,,,,fee schedule,3870.39,14456, Reinforce ulna,25491,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3870.39,14456, Reinforce ulna,25491,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3870.39,14456, Reinforce ulna,25491,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3870.39,14456, Reinforce radius and ulna,25492,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4706.77,,,,,,,fee schedule,4706.77,14456, Reinforce radius and ulna,25492,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4706.77,14456, Reinforce radius and ulna,25492,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4706.77,14456, Reinforce radius and ulna,25492,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4706.77,14456, Treat fracture of radius,25500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1478.13,,,,,,,fee schedule,1478.13,3195, Treat fracture of radius,25500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1478.13,3195, Treat fracture of radius,25500,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1478.13,3195, Treat fracture of radius,25500,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1478.13,3195, Treat fracture of radius,25505,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2691.52,,,,,,,fee schedule,2691.52,4497, Treat fracture of radius,25505,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2691.52,4497, Treat fracture of radius,25505,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,2691.52,4497, Treat fracture of radius,25505,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,2691.52,4497, Treat fracture of radius,25515,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3509.88,,,,,,,fee schedule,3509.88,22111, Treat fracture of radius,25515,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3509.88,22111, Treat fracture of radius,25515,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3509.88,22111, Treat fracture of radius,25515,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3509.88,22111, Treat fracture of radius,25520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2927.11,,,,,,,fee schedule,2505,3195, Treat fracture of radius,25520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Treat fracture of radius,25520,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Treat fracture of radius,25520,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Treat fracture of radius,25525,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4085.64,,,,,,,fee schedule,4085.64,22111, Treat fracture of radius,25525,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4085.64,22111, Treat fracture of radius,25525,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4085.64,22111, Treat fracture of radius,25525,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4085.64,22111, Treat fracture of radius,25526,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4988.49,,,,,,,fee schedule,4988.49,22111, Treat fracture of radius,25526,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4988.49,22111, Treat fracture of radius,25526,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4988.49,22111, Treat fracture of radius,25526,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4988.49,22111, Treat fracture of ulna,25530,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1371.88,,,,,,,fee schedule,1371.88,3195, Treat fracture of ulna,25530,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1371.88,3195, Treat fracture of ulna,25530,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1371.88,3195, Treat fracture of ulna,25530,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1371.88,3195, Treat fracture of ulna,25535,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2486.1,,,,,,,fee schedule,2486.1,3195, Treat fracture of ulna,25535,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2486.1,3195, Treat fracture of ulna,25535,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2486.1,3195, Treat fracture of ulna,25535,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2486.1,3195, Treat fracture of ulna,25545,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3283.84,,,,,,,fee schedule,3283.84,22111, Treat fracture of ulna,25545,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3283.84,22111, Treat fracture of ulna,25545,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3283.84,22111, Treat fracture of ulna,25545,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3283.84,22111, Treat fracture radius & ulna,25560,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1481.47,,,,,,,fee schedule,1481.47,3195, Treat fracture radius & ulna,25560,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1481.47,3195, Treat fracture radius & ulna,25560,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1481.47,3195, Treat fracture radius & ulna,25560,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1481.47,3195, Treat fracture radius & ulna,25565,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2803.65,,,,,,,fee schedule,2505,4108, Treat fracture radius & ulna,25565,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2505,4108, Treat fracture radius & ulna,25565,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,4108, Treat fracture radius & ulna,25565,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,4108, Treat fracture radius & ulna,25574,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3547.01,,,,,,,fee schedule,3547.01,22111, Treat fracture radius & ulna,25574,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3547.01,22111, Treat fracture radius & ulna,25574,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3547.01,22111, Treat fracture radius & ulna,25574,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3547.01,22111, Treat fracture radius/ulna,25575,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4702.18,,,,,,,fee schedule,4702.18,22111, Treat fracture radius/ulna,25575,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4702.18,22111, Treat fracture radius/ulna,25575,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4702.18,22111, Treat fracture radius/ulna,25575,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4702.18,22111, Treat fracture radius/ulna,25600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1840.09,,,,,,,fee schedule,1840.09,3195, Treat fracture radius/ulna,25600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1840.09,3195, Treat fracture radius/ulna,25600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1840.09,3195, Treat fracture radius/ulna,25600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1840.09,3195, Treat fracture radius/ulna,25605,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3017.71,,,,,,,fee schedule,3017.71,5248, Treat fracture radius/ulna,25605,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3017.71,5248, Treat fracture radius/ulna,25605,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,3017.71,5248, Treat fracture radius/ulna,25605,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,3017.71,5248, Treat Fx Distal Radial,25606,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3540.75,,,,,,,fee schedule,3540.75,10940, Treat Fx Distal Radial,25606,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3540.75,10940, Treat Fx Distal Radial,25606,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3540.75,10940, Treat Fx Distal Radial,25606,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3540.75,10940, Treat Fx Rad Extra-Articul,25607,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3856.9,,,,,,,fee schedule,3856.9,22111, Treat Fx Rad Extra-Articul,25607,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,3856.9,22111, Treat Fx Rad Extra-Articul,25607,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3856.9,22111, Treat Fx Rad Extra-Articul,25607,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3856.9,22111, Treat Fx Rad Intra-Articul,25608,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4281.4,,,,,,,fee schedule,4281.4,22111, Treat Fx Rad Intra-Articul,25608,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4281.4,22111, Treat Fx Rad Intra-Articul,25608,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4281.4,22111, Treat Fx Rad Intra-Articul,25608,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4281.4,22111, Treat Fx Radial 3+ Frag,25609,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5377.28,,,,,,,fee schedule,5377.28,22111, Treat Fx Radial 3+ Frag,25609,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,5377.28,22111, Treat Fx Radial 3+ Frag,25609,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5377.28,22111, Treat Fx Radial 3+ Frag,25609,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5377.28,22111, Treat wrist bone fracture,25622,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1601.37,,,,,,,fee schedule,1601.37,6979, Treat wrist bone fracture,25622,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1601.37,6979, Treat wrist bone fracture,25622,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1601.37,6979, Treat wrist bone fracture,25622,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1601.37,6979, Treat wrist bone fracture,25624,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2437.43,,,,,,,fee schedule,2437.43,4497, Treat wrist bone fracture,25624,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2437.43,4497, Treat wrist bone fracture,25624,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,2437.43,4497, Treat wrist bone fracture,25624,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,2437.43,4497, Treat wrist bone fracture,25628,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3703.44,,,,,,,fee schedule,3703.44,22111, Treat wrist bone fracture,25628,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3703.44,22111, Treat wrist bone fracture,25628,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3703.44,22111, Treat wrist bone fracture,25628,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3703.44,22111, Treat wrist bone fracture,25630,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1579.57,,,,,,,fee schedule,1579.57,3195, Treat wrist bone fracture,25630,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1579.57,3195, Treat wrist bone fracture,25630,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1579.57,3195, Treat wrist bone fracture,25630,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1579.57,3195, Treat wrist bone fracture,25635,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2313.32,,,,,,,fee schedule,2313.32,3195, Treat wrist bone fracture,25635,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2313.32,3195, Treat wrist bone fracture,25635,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2313.32,3195, Treat wrist bone fracture,25635,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2313.32,3195, Treat wrist bone fracture,25645,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3025.32,,,,,,,fee schedule,3025.32,22111, Treat wrist bone fracture,25645,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3025.32,22111, Treat wrist bone fracture,25645,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3025.32,22111, Treat wrist bone fracture,25645,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3025.32,22111, Treat wrist bone fracture,25650,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1766.54,,,,,,,fee schedule,1766.54,6979, Treat wrist bone fracture,25650,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1766.54,6979, Treat wrist bone fracture,25650,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1766.54,6979, Treat wrist bone fracture,25650,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1766.54,6979, Pin ulnar styloid fracture,25651,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2599.58,,,,,,,fee schedule,2599.58,10940, Pin ulnar styloid fracture,25651,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2599.58,10940, Pin ulnar styloid fracture,25651,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2599.58,10940, Pin ulnar styloid fracture,25651,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2599.58,10940, Treat fracture ulnar styloid,25652,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3265.12,,,,,,,fee schedule,3265.12,22111, Treat fracture ulnar styloid,25652,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3265.12,22111, Treat fracture ulnar styloid,25652,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3265.12,22111, Treat fracture ulnar styloid,25652,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3265.12,22111, Treat wrist dislocation,25660,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2442.28,,,,,,,fee schedule,2442.28,3195, Treat wrist dislocation,25660,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2442.28,3195, Treat wrist dislocation,25660,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2442.28,3195, Treat wrist dislocation,25660,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2442.28,3195, Treat wrist dislocation,25670,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3221.09,,,,,,,fee schedule,3221.09,10940, Treat wrist dislocation,25670,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3221.09,10940, Treat wrist dislocation,25670,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3221.09,10940, Treat wrist dislocation,25670,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3221.09,10940, Pin radioulnar dislocation,25671,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2877.58,,,,,,,fee schedule,2877.58,10940, Pin radioulnar dislocation,25671,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2877.58,10940, Pin radioulnar dislocation,25671,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2877.58,10940, Pin radioulnar dislocation,25671,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2877.58,10940, Treat wrist dislocation,25675,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2673.45,,,,,,,fee schedule,2505,3195, Treat wrist dislocation,25675,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Treat wrist dislocation,25675,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Treat wrist dislocation,25675,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Treat wrist dislocation,25676,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3293.18,,,,,,,fee schedule,3293.18,10940, Treat wrist dislocation,25676,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3293.18,10940, Treat wrist dislocation,25676,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3293.18,10940, Treat wrist dislocation,25676,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3293.18,10940, Treat wrist fracture,25680,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2853.84,,,,,,,fee schedule,2505,4108, Treat wrist fracture,25680,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2505,4108, Treat wrist fracture,25680,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,4108, Treat wrist fracture,25680,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,4108, Treat wrist fracture,25685,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3850.69,,,,,,,fee schedule,3850.69,10940, Treat wrist fracture,25685,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3850.69,10940, Treat wrist fracture,25685,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3850.69,10940, Treat wrist fracture,25685,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3850.69,10940, Treat wrist dislocation,25690,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2650.57,,,,,,,fee schedule,2650.57,5664, Treat wrist dislocation,25690,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2650.57,5664, Treat wrist dislocation,25690,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2650.57,5664, Treat wrist dislocation,25690,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2650.57,5664, Treat wrist dislocation,25695,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3339.04,,,,,,,fee schedule,3339.04,10940, Treat wrist dislocation,25695,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3339.04,10940, Treat wrist dislocation,25695,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3339.04,10940, Treat wrist dislocation,25695,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3339.04,10940, Fusion of wrist joint,25800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3736.78,,,,,,,fee schedule,3736.78,22111, Fusion of wrist joint,25800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3736.78,22111, Fusion of wrist joint,25800,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3736.78,22111, Fusion of wrist joint,25800,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3736.78,22111, Fusion/graft of wrist joint,25805,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4418.24,,,,,,,fee schedule,4418.24,22111, Fusion/graft of wrist joint,25805,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4418.24,22111, Fusion/graft of wrist joint,25805,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4418.24,22111, Fusion/graft of wrist joint,25805,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4418.24,22111, Fusion/graft of wrist joint,25810,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4404.86,,,,,,,fee schedule,4404.86,22111, Fusion/graft of wrist joint,25810,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4404.86,22111, Fusion/graft of wrist joint,25810,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4404.86,22111, Fusion/graft of wrist joint,25810,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4404.86,22111, Fusion of hand bones,25820,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3375.79,,,,,,,fee schedule,3375.79,14456, Fusion of hand bones,25820,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3375.79,14456, Fusion of hand bones,25820,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3375.79,14456, Fusion of hand bones,25820,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3375.79,14456, Fuse hand bones with graft,25825,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4088.55,,,,,,,fee schedule,4088.55,22111, Fuse hand bones with graft,25825,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4088.55,22111, Fuse hand bones with graft,25825,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4088.55,22111, Fuse hand bones with graft,25825,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4088.55,22111, Fusion radioulnar jnt/ulna,25830,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5296.28,,,,,,,fee schedule,5296.28,14456, Fusion radioulnar jnt/ulna,25830,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,5296.28,14456, Fusion radioulnar jnt/ulna,25830,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5296.28,14456, Fusion radioulnar jnt/ulna,25830,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5296.28,14456, Amputation of forearm,25900,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3716.01,,,,,,,fee schedule,3716.01,22111, Amputation of forearm,25900,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3716.01,22111, Amputation of forearm,25900,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3716.01,22111, Amputation of forearm,25900,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3716.01,22111, Amputation of forearm,25905,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3675,,,,,,,fee schedule,3675,22111, Amputation of forearm,25905,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3675,22111, Amputation of forearm,25905,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3675,22111, Amputation of forearm,25905,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3675,22111, Amputation follow-up surgery,25907,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3248.61,,,,,,,fee schedule,3248.61,10940, Amputation follow-up surgery,25907,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3248.61,10940, Amputation follow-up surgery,25907,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3248.61,10940, Amputation follow-up surgery,25907,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3248.61,10940, Amputation follow-up surgery,25909,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3594.6,,,,,,,fee schedule,3594.6,10940, Amputation follow-up surgery,25909,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3594.6,10940, Amputation follow-up surgery,25909,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3594.6,10940, Amputation follow-up surgery,25909,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3594.6,10940, Amputation of forearm,25915,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5958.69,,,,,,,fee schedule,5958.69,22111, Amputation of forearm,25915,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5958.69,22111, Amputation of forearm,25915,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5958.69,22111, Amputation of forearm,25915,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5958.69,22111, Amputate hand at wrist,25920,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3851.77,,,,,,,fee schedule,3851.77,22111, Amputate hand at wrist,25920,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3851.77,22111, Amputate hand at wrist,25920,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3851.77,22111, Amputate hand at wrist,25920,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3851.77,22111, Amputate hand at wrist,25922,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3434.5,,,,,,,fee schedule,3434.5,10940, Amputate hand at wrist,25922,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3434.5,10940, Amputate hand at wrist,25922,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3434.5,10940, Amputate hand at wrist,25922,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3434.5,10940, Amputation follow-up surgery,25924,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3765.22,,,,,,,fee schedule,3765.22,22111, Amputation follow-up surgery,25924,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3765.22,22111, Amputation follow-up surgery,25924,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3765.22,22111, Amputation follow-up surgery,25924,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3765.22,22111, Amputation of hand,25927,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4590.97,,,,,,,fee schedule,4590.97,12821, Amputation of hand,25927,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4590.97,12821, Amputation of hand,25927,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4590.97,12821, Amputation of hand,25927,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4590.97,12821, Amputation follow-up surgery,25929,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3170.91,,,,,,,fee schedule,3170.91,5664, Amputation follow-up surgery,25929,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3170.91,5664, Amputation follow-up surgery,25929,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3170.91,5664, Amputation follow-up surgery,25929,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3170.91,5664, Amputation follow-up surgery,25931,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4262.08,,,,,,,fee schedule,4262.08,10940, Amputation follow-up surgery,25931,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4262.08,10940, Amputation follow-up surgery,25931,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,4262.08,10940, Amputation follow-up surgery,25931,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,4262.08,10940, Forearm or wrist surgery,25999,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Forearm or wrist surgery,25999,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Forearm or wrist surgery,25999,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Drainage of finger abscess,26010,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,787.71,,,,,,,fee schedule,787.71,6979, Drainage of finger abscess,26010,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,787.71,6979, Drainage of finger abscess,26010,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,787.71,6979, Drainage of finger abscess,26010,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,787.71,6979, Drainage of finger abscess,26011,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1000.42,,,,,,,fee schedule,1000.42,5664, Drainage of finger abscess,26011,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1000.42,5664, Drainage of finger abscess,26011,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1000.42,5664, Drainage of finger abscess,26011,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1000.42,5664, Drain hand tendon sheath,26020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2926.79,,,,,,,fee schedule,2926.79,5664, Drain hand tendon sheath,26020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2926.79,5664, Drain hand tendon sheath,26020,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2926.79,5664, Drain hand tendon sheath,26020,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2926.79,5664, Drainage of palm bursa,26025,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2223.42,,,,,,,fee schedule,2223.42,5664, Drainage of palm bursa,26025,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2223.42,5664, Drainage of palm bursa,26025,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2223.42,5664, Drainage of palm bursa,26025,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2223.42,5664, Drainage of palm bursas,26030,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2569.2,,,,,,,fee schedule,2569.2,5664, Drainage of palm bursas,26030,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2569.2,5664, Drainage of palm bursas,26030,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2569.2,5664, Drainage of palm bursas,26030,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2569.2,5664, Treat hand bone lesion,26034,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2889.18,,,,,,,fee schedule,2889.18,5664, Treat hand bone lesion,26034,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2889.18,5664, Treat hand bone lesion,26034,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2889.18,5664, Treat hand bone lesion,26034,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2889.18,5664, Decompress fingers/hand,26035,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4526.49,,,,,,,fee schedule,4526.49,5664, Decompress fingers/hand,26035,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4526.49,5664, Decompress fingers/hand,26035,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4526.49,5664, Decompress fingers/hand,26035,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4526.49,5664, Decompress fingers/hand,26037,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2919.4,,,,,,,fee schedule,2919.4,5664, Decompress fingers/hand,26037,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2919.4,5664, Decompress fingers/hand,26037,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2919.4,5664, Decompress fingers/hand,26037,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2919.4,5664, Release palm contracture,26040,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1679.94,,,,,,,fee schedule,1679.94,5664, Release palm contracture,26040,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,1679.94,5664, Release palm contracture,26040,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1679.94,5664, Release palm contracture,26040,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1679.94,5664, Release palm contracture,26045,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2491.87,,,,,,,fee schedule,2491.87,12821, Release palm contracture,26045,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2491.87,12821, Release palm contracture,26045,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2491.87,12821, Release palm contracture,26045,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2491.87,12821, Incise finger tendon sheath,26055,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1564.73,,,,,,,fee schedule,1564.73,5664, Incise finger tendon sheath,26055,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1564.73,5664, Incise finger tendon sheath,26055,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1564.73,5664, Incise finger tendon sheath,26055,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1564.73,5664, Incision of finger tendon,26060,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1322.94,,,,,,,fee schedule,1322.94,5664, Incision of finger tendon,26060,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1322.94,5664, Incision of finger tendon,26060,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1322.94,5664, Incision of finger tendon,26060,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1322.94,5664, Explore/treat hand joint,26070,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1710.91,,,,,,,fee schedule,1710.91,5664, Explore/treat hand joint,26070,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1710.91,5664, Explore/treat hand joint,26070,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1710.91,5664, Explore/treat hand joint,26070,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1710.91,5664, Explore/treat finger joint,26075,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1804.53,,,,,,,fee schedule,1804.53,5664, Explore/treat finger joint,26075,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,1804.53,5664, Explore/treat finger joint,26075,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1804.53,5664, Explore/treat finger joint,26075,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1804.53,5664, Explore/treat finger joint,26080,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2117.82,,,,,,,fee schedule,2117.82,5664, Explore/treat finger joint,26080,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2117.82,5664, Explore/treat finger joint,26080,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2117.82,5664, Explore/treat finger joint,26080,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2117.82,5664, Biopsy hand joint lining,26100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1854.34,,,,,,,fee schedule,1854.34,5664, Biopsy hand joint lining,26100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1854.34,5664, Biopsy hand joint lining,26100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1854.34,5664, Biopsy hand joint lining,26100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1854.34,5664, Biopsy finger joint lining,26105,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1864.21,,,,,,,fee schedule,1864.21,5664, Biopsy finger joint lining,26105,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1864.21,5664, Biopsy finger joint lining,26105,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1864.21,5664, Biopsy finger joint lining,26105,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1864.21,5664, Biopsy finger joint lining,26110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1735.57,,,,,,,fee schedule,1735.57,5664, Biopsy finger joint lining,26110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1735.57,5664, Biopsy finger joint lining,26110,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1735.57,5664, Biopsy finger joint lining,26110,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1735.57,5664, Exc hand les sc 1.5 cm/>,26111,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2172.38,,,,,,,fee schedule,2172.38,10940, Exc hand les sc 1.5 cm/>,26111,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2172.38,10940, Exc hand les sc 1.5 cm/>,26111,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2172.38,10940, Exc hand les sc 1.5 cm/>,26111,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2172.38,10940, Exc hand tum deep 1.5 cm/>,26113,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2825.62,,,,,,,fee schedule,2825.62,10940, Exc hand tum deep 1.5 cm/>,26113,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2825.62,10940, Exc hand tum deep 1.5 cm/>,26113,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2825.62,10940, Exc hand tum deep 1.5 cm/>,26113,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2825.62,10940, Exc hand les sc < 1.5 cm,26115,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1762.06,,,,,,,fee schedule,1762.06,5664, Exc hand les sc < 1.5 cm,26115,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1762.06,5664, Exc hand les sc < 1.5 cm,26115,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1762.06,5664, Exc hand les sc < 1.5 cm,26115,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1762.06,5664, Exc hand tum deep < 1.5 cm,26116,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2723.68,,,,,,,fee schedule,2723.68,5664, Exc hand tum deep < 1.5 cm,26116,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2723.68,5664, Exc hand tum deep < 1.5 cm,26116,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2723.68,5664, Exc hand tum deep < 1.5 cm,26116,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2723.68,5664, Rad resect hand tumor < 3 cm,26117,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3855.71,,,,,,,fee schedule,3855.71,5664, Rad resect hand tumor < 3 cm,26117,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3855.71,5664, Rad resect hand tumor < 3 cm,26117,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3855.71,5664, Rad resect hand tumor < 3 cm,26117,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3855.71,5664, Rad resect hand tumor 3 cm/>,26118,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5425.68,,,,,,,fee schedule,5248,10940, Rad resect hand tumor 3 cm/>,26118,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,10940, Rad resect hand tumor 3 cm/>,26118,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,5248,10940, Rad resect hand tumor 3 cm/>,26118,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,5248,10940, Release palm contracture,26121,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3099.84,,,,,,,fee schedule,3099.84,12821, Release palm contracture,26121,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3099.84,12821, Release palm contracture,26121,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3099.84,12821, Release palm contracture,26121,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3099.84,12821, Release palm contracture,26123,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4313.4,,,,,,,fee schedule,4313.4,12821, Release palm contracture,26123,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4313.4,12821, Release palm contracture,26123,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4313.4,12821, Release palm contracture,26123,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4313.4,12821, Release palm contracture,26125,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1297.2,,,,,,,fee schedule,1297.2,5363, Release palm contracture,26125,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,1297.2,5363, Release palm contracture,26125,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1297.2,5363, Release palm contracture,26125,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1297.2,5363, Remove wrist joint lining,26130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2524.25,,,,,,,fee schedule,2524.25,5664, Remove wrist joint lining,26130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2524.25,5664, Remove wrist joint lining,26130,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2524.25,5664, Remove wrist joint lining,26130,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2524.25,5664, Revise finger joint each,26135,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2864.52,,,,,,,fee schedule,2864.52,12821, Revise finger joint each,26135,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2864.52,12821, Revise finger joint each,26135,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2864.52,12821, Revise finger joint each,26135,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2864.52,12821, Revise finger joint each,26140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2645.71,,,,,,,fee schedule,2645.71,5664, Revise finger joint each,26140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2645.71,5664, Revise finger joint each,26140,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2645.71,5664, Revise finger joint each,26140,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2645.71,5664, Tendon excision palm/finger,26145,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2681.65,,,,,,,fee schedule,2681.65,5664, Tendon excision palm/finger,26145,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2681.65,5664, Tendon excision palm/finger,26145,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2681.65,5664, Tendon excision palm/finger,26145,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2681.65,5664, Remove tendon sheath lesion,26160,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1684.74,,,,,,,fee schedule,1684.74,5664, Remove tendon sheath lesion,26160,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1684.74,5664, Remove tendon sheath lesion,26160,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1684.74,5664, Remove tendon sheath lesion,26160,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1684.74,5664, Removal of palm tendon each,26170,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2149.77,,,,,,,fee schedule,2149.77,5664, Removal of palm tendon each,26170,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2149.77,5664, Removal of palm tendon each,26170,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2149.77,5664, Removal of palm tendon each,26170,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2149.77,5664, Removal of finger tendon,26180,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2364.37,,,,,,,fee schedule,2364.37,5664, Removal of finger tendon,26180,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2364.37,5664, Removal of finger tendon,26180,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2364.37,5664, Removal of finger tendon,26180,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2364.37,5664, Remove finger bone,26185,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3006.54,,,,,,,fee schedule,3006.54,5664, Remove finger bone,26185,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3006.54,5664, Remove finger bone,26185,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3006.54,5664, Remove finger bone,26185,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3006.54,5664, Remove hand bone lesion,26200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2364.26,,,,,,,fee schedule,2364.26,5664, Remove hand bone lesion,26200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2364.26,5664, Remove hand bone lesion,26200,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2364.26,5664, Remove hand bone lesion,26200,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2364.26,5664, Remove/graft bone lesion,26205,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195.19,,,,,,,fee schedule,3195.19,12821, Remove/graft bone lesion,26205,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3195.19,12821, Remove/graft bone lesion,26205,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3195.19,12821, Remove/graft bone lesion,26205,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3195.19,12821, Removal of finger lesion,26210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2350.39,,,,,,,fee schedule,2350.39,5664, Removal of finger lesion,26210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2350.39,5664, Removal of finger lesion,26210,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2350.39,5664, Removal of finger lesion,26210,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2350.39,5664, Remove/graft finger lesion,26215,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3005.73,,,,,,,fee schedule,3005.73,5664, Remove/graft finger lesion,26215,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3005.73,5664, Remove/graft finger lesion,26215,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3005.73,5664, Remove/graft finger lesion,26215,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3005.73,5664, Partial removal of hand bone,26230,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2603.19,,,,,,,fee schedule,2603.19,8406, Partial removal of hand bone,26230,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,2603.19,8406, Partial removal of hand bone,26230,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2603.19,8406, Partial removal of hand bone,26230,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2603.19,8406, Partial removal finger bone,26235,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2562.94,,,,,,,fee schedule,2562.94,5664, Partial removal finger bone,26235,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2562.94,5664, Partial removal finger bone,26235,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2562.94,5664, Partial removal finger bone,26235,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2562.94,5664, Partial removal finger bone,26236,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2322.6,,,,,,,fee schedule,2322.6,5664, Partial removal finger bone,26236,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2322.6,5664, Partial removal finger bone,26236,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2322.6,5664, Partial removal finger bone,26236,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2322.6,5664, Extensive hand surgery,26250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5515.47,,,,,,,fee schedule,5097,5664, Extensive hand surgery,26250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5097,5664, Extensive hand surgery,26250,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Extensive hand surgery,26250,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Resect prox finger tumor,26260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4163.45,,,,,,,fee schedule,4163.45,5664, Resect prox finger tumor,26260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4163.45,5664, Resect prox finger tumor,26260,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4163.45,5664, Resect prox finger tumor,26260,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4163.45,5664, Resect distal finger tumor,26262,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3340.23,,,,,,,fee schedule,3340.23,5664, Resect distal finger tumor,26262,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3340.23,5664, Resect distal finger tumor,26262,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3340.23,5664, Resect distal finger tumor,26262,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3340.23,5664, Removal of implant from hand,26320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1850.56,,,,,,,fee schedule,1850.56,5664, Removal of implant from hand,26320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1850.56,5664, Removal of implant from hand,26320,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1850.56,5664, Removal of implant from hand,26320,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1850.56,5664, Manipulate finger w/anesth,26340,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1955.94,,,,,,,fee schedule,1955.94,3195, Manipulate finger w/anesth,26340,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1955.94,3195, Manipulate finger w/anesth,26340,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1955.94,3195, Manipulate finger w/anesth,26340,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1955.94,3195, Manipulat palm cord post inj,26341,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,401.14,,,,,,,fee schedule,401.14,3195, Manipulat palm cord post inj,26341,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,401.14,3195, Manipulat palm cord post inj,26341,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,401.14,3195, Manipulat palm cord post inj,26341,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,401.14,3195, Repair finger/hand tendon,26350,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3976.58,,,,,,,fee schedule,3195,12821, Repair finger/hand tendon,26350,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,12821, Repair finger/hand tendon,26350,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3195,12821, Repair finger/hand tendon,26350,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3195,12821, Repair/graft hand tendon,26352,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4357.49,,,,,,,fee schedule,4357.49,12821, Repair/graft hand tendon,26352,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4357.49,12821, Repair/graft hand tendon,26352,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4357.49,12821, Repair/graft hand tendon,26352,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4357.49,12821, Repair finger/hand tendon,26356,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4137.49,,,,,,,fee schedule,4137.49,12821, Repair finger/hand tendon,26356,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4137.49,12821, Repair finger/hand tendon,26356,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4137.49,12821, Repair finger/hand tendon,26356,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4137.49,12821, Repair finger/hand tendon,26357,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4712.16,,,,,,,fee schedule,4712.16,12821, Repair finger/hand tendon,26357,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4712.16,12821, Repair finger/hand tendon,26357,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4712.16,12821, Repair finger/hand tendon,26357,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4712.16,12821, Repair/graft hand tendon,26358,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5168.88,,,,,,,fee schedule,5168.88,12821, Repair/graft hand tendon,26358,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5168.88,12821, Repair/graft hand tendon,26358,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5168.88,12821, Repair/graft hand tendon,26358,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5168.88,12821, Repair finger/hand tendon,26370,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108.24,,,,,,,fee schedule,4108.24,12821, Repair finger/hand tendon,26370,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4108.24,12821, Repair finger/hand tendon,26370,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4108.24,12821, Repair finger/hand tendon,26370,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4108.24,12821, Repair/graft hand tendon,26372,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4885.43,,,,,,,fee schedule,4885.43,12821, Repair/graft hand tendon,26372,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4885.43,12821, Repair/graft hand tendon,26372,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4885.43,12821, Repair/graft hand tendon,26372,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4885.43,12821, Repair finger/hand tendon,26373,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4716.37,,,,,,,fee schedule,4716.37,12821, Repair finger/hand tendon,26373,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4716.37,12821, Repair finger/hand tendon,26373,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4716.37,12821, Repair finger/hand tendon,26373,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4716.37,12821, Revise hand/finger tendon,26390,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4658.04,,,,,,,fee schedule,4658.04,12821, Revise hand/finger tendon,26390,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4658.04,12821, Revise hand/finger tendon,26390,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4658.04,12821, Revise hand/finger tendon,26390,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4658.04,12821, Repair/graft hand tendon,26392,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5313.55,,,,,,,fee schedule,5248,12821, Repair/graft hand tendon,26392,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,12821, Repair/graft hand tendon,26392,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5248,12821, Repair/graft hand tendon,26392,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5248,12821, Repair hand tendon,26410,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3213.26,,,,,,,fee schedule,3213.26,5664, Repair hand tendon,26410,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3213.26,5664, Repair hand tendon,26410,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3213.26,5664, Repair hand tendon,26410,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3213.26,5664, Repair/graft hand tendon,26412,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3756.7,,,,,,,fee schedule,3756.7,12821, Repair/graft hand tendon,26412,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3756.7,12821, Repair/graft hand tendon,26412,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3756.7,12821, Repair/graft hand tendon,26412,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3756.7,12821, Excision hand/finger tendon,26415,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4538.25,,,,,,,fee schedule,4538.25,12821, Excision hand/finger tendon,26415,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4538.25,12821, Excision hand/finger tendon,26415,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4538.25,12821, Excision hand/finger tendon,26415,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4538.25,12821, Graft hand or finger tendon,26416,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4897.14,,,,,,,fee schedule,4897.14,12821, Graft hand or finger tendon,26416,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4897.14,12821, Graft hand or finger tendon,26416,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4897.14,12821, Graft hand or finger tendon,26416,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4897.14,12821, Repair finger tendon,26418,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3355.93,,,,,,,fee schedule,3355.93,5664, Repair finger tendon,26418,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3355.93,5664, Repair finger tendon,26418,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3355.93,5664, Repair finger tendon,26418,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3355.93,5664, Repair/graft finger tendon,26420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3884.36,,,,,,,fee schedule,3884.36,12821, Repair/graft finger tendon,26420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3884.36,12821, Repair/graft finger tendon,26420,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3884.36,12821, Repair/graft finger tendon,26420,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3884.36,12821, Repair finger/hand tendon,26426,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2619.49,,,,,,,fee schedule,2619.49,12821, Repair finger/hand tendon,26426,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2619.49,12821, Repair finger/hand tendon,26426,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2619.49,12821, Repair finger/hand tendon,26426,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2619.49,12821, Repair/graft finger tendon,26428,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4278.6,,,,,,,fee schedule,4278.6,12821, Repair/graft finger tendon,26428,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4278.6,12821, Repair/graft finger tendon,26428,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4278.6,12821, Repair/graft finger tendon,26428,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4278.6,12821, Repair finger tendon,26432,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2909.95,,,,,,,fee schedule,2909.95,5664, Repair finger tendon,26432,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2909.95,5664, Repair finger tendon,26432,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2909.95,5664, Repair finger tendon,26432,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2909.95,5664, Repair finger tendon,26433,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3053.16,,,,,,,fee schedule,3053.16,5664, Repair finger tendon,26433,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3053.16,5664, Repair finger tendon,26433,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3053.16,5664, Repair finger tendon,26433,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3053.16,5664, Repair/graft finger tendon,26434,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3754.48,,,,,,,fee schedule,3754.48,12821, Repair/graft finger tendon,26434,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3754.48,12821, Repair/graft finger tendon,26434,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3754.48,12821, Repair/graft finger tendon,26434,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3754.48,12821, Realignment of tendons,26437,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3507.99,,,,,,,fee schedule,3507.99,5664, Realignment of tendons,26437,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3507.99,5664, Realignment of tendons,26437,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3507.99,5664, Realignment of tendons,26437,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3507.99,5664, Release palm/finger tendon,26440,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3449.61,,,,,,,fee schedule,3449.61,5664, Release palm/finger tendon,26440,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3449.61,5664, Release palm/finger tendon,26440,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3449.61,5664, Release palm/finger tendon,26440,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3449.61,5664, Release palm & finger tendon,26442,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5213.94,,,,,,,fee schedule,5213.94,12821, Release palm & finger tendon,26442,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5213.94,12821, Release palm & finger tendon,26442,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5213.94,12821, Release palm & finger tendon,26442,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5213.94,12821, Release hand/finger tendon,26445,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3236.63,,,,,,,fee schedule,3236.63,5664, Release hand/finger tendon,26445,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3236.63,5664, Release hand/finger tendon,26445,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3236.63,5664, Release hand/finger tendon,26445,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3236.63,5664, Release forearm/hand tendon,26449,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3628.38,,,,,,,fee schedule,3628.38,12821, Release forearm/hand tendon,26449,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3628.38,12821, Release forearm/hand tendon,26449,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3628.38,12821, Release forearm/hand tendon,26449,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3628.38,12821, Incision of palm tendon,26450,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2464.78,,,,,,,fee schedule,2464.78,5664, Incision of palm tendon,26450,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2464.78,5664, Incision of palm tendon,26450,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2464.78,5664, Incision of palm tendon,26450,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2464.78,5664, Incision of finger tendon,26455,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2464.57,,,,,,,fee schedule,2464.57,5664, Incision of finger tendon,26455,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2464.57,5664, Incision of finger tendon,26455,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2464.57,5664, Incision of finger tendon,26455,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2464.57,5664, Incise hand/finger tendon,26460,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2405.75,,,,,,,fee schedule,2405.75,5664, Incise hand/finger tendon,26460,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2405.75,5664, Incise hand/finger tendon,26460,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2405.75,5664, Incise hand/finger tendon,26460,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2405.75,5664, Fusion of finger tendons,26471,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3471.35,,,,,,,fee schedule,3471.35,5664, Fusion of finger tendons,26471,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3471.35,5664, Fusion of finger tendons,26471,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3471.35,5664, Fusion of finger tendons,26471,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3471.35,5664, Fusion of finger tendons,26474,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3533.62,,,,,,,fee schedule,3533.62,5664, Fusion of finger tendons,26474,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3533.62,5664, Fusion of finger tendons,26474,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3533.62,5664, Fusion of finger tendons,26474,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3533.62,5664, Tendon lengthening,26476,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3496.18,,,,,,,fee schedule,3195,5664, Tendon lengthening,26476,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,5664, Tendon lengthening,26476,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3195,5664, Tendon lengthening,26476,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3195,5664, Tendon shortening,26477,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3305.64,,,,,,,fee schedule,3195,5664, Tendon shortening,26477,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,5664, Tendon shortening,26477,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3195,5664, Tendon shortening,26477,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3195,5664, Lengthening of hand tendon,26478,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3515.71,,,,,,,fee schedule,3195,5664, Lengthening of hand tendon,26478,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,5664, Lengthening of hand tendon,26478,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3195,5664, Lengthening of hand tendon,26478,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3195,5664, Shortening of hand tendon,26479,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3654.33,,,,,,,fee schedule,3195,5664, Shortening of hand tendon,26479,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,5664, Shortening of hand tendon,26479,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3195,5664, Shortening of hand tendon,26479,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3195,5664, Transplant hand tendon,26480,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3679.32,,,,,,,fee schedule,3679.32,12821, Transplant hand tendon,26480,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3679.32,12821, Transplant hand tendon,26480,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3679.32,12821, Transplant hand tendon,26480,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3679.32,12821, Transplant/graft hand tendon,26483,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4527.89,,,,,,,fee schedule,4527.89,12821, Transplant/graft hand tendon,26483,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4527.89,12821, Transplant/graft hand tendon,26483,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4527.89,12821, Transplant/graft hand tendon,26483,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4527.89,12821, Transplant palm tendon,26485,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4368.71,,,,,,,fee schedule,4108,12821, Transplant palm tendon,26485,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,12821, Transplant palm tendon,26485,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4108,12821, Transplant palm tendon,26485,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4108,12821, Transplant/graft palm tendon,26489,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5130.3,,,,,,,fee schedule,5130.3,12821, Transplant/graft palm tendon,26489,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5130.3,12821, Transplant/graft palm tendon,26489,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5130.3,12821, Transplant/graft palm tendon,26489,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5130.3,12821, Revise thumb tendon,26490,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4477.92,,,,,,,fee schedule,4477.92,12821, Revise thumb tendon,26490,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4477.92,12821, Revise thumb tendon,26490,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4477.92,12821, Revise thumb tendon,26490,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4477.92,12821, Tendon transfer with graft,26492,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4933.72,,,,,,,fee schedule,4933.72,12821, Tendon transfer with graft,26492,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4933.72,12821, Tendon transfer with graft,26492,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4933.72,12821, Tendon transfer with graft,26492,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4933.72,12821, Hand tendon/muscle transfer,26494,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4494.06,,,,,,,fee schedule,4494.06,12821, Hand tendon/muscle transfer,26494,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4494.06,12821, Hand tendon/muscle transfer,26494,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4494.06,12821, Hand tendon/muscle transfer,26494,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4494.06,12821, Revise thumb tendon,26496,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4820.35,,,,,,,fee schedule,4820.35,12821, Revise thumb tendon,26496,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4820.35,12821, Revise thumb tendon,26496,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4820.35,12821, Revise thumb tendon,26496,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4820.35,12821, Finger tendon transfer,26497,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4815.01,,,,,,,fee schedule,4815.01,12821, Finger tendon transfer,26497,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4815.01,12821, Finger tendon transfer,26497,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4815.01,12821, Finger tendon transfer,26497,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4815.01,12821, Finger tendon transfer,26498,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6177.93,,,,,,,fee schedule,5363,12821, Finger tendon transfer,26498,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,12821, Finger tendon transfer,26498,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5363,12821, Finger tendon transfer,26498,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5363,12821, Revision of finger,26499,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4645.96,,,,,,,fee schedule,4645.96,10940, Revision of finger,26499,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4645.96,10940, Revision of finger,26499,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,4645.96,10940, Revision of finger,26499,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,4645.96,10940, Hand tendon reconstruction,26500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3717.84,,,,,,,fee schedule,3717.84,5664, Hand tendon reconstruction,26500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3717.84,5664, Hand tendon reconstruction,26500,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3717.84,5664, Hand tendon reconstruction,26500,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3717.84,5664, Hand tendon reconstruction,26502,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4048.46,,,,,,,fee schedule,4048.46,12821, Hand tendon reconstruction,26502,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4048.46,12821, Hand tendon reconstruction,26502,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4048.46,12821, Hand tendon reconstruction,26502,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4048.46,12821, Release thumb contracture,26508,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3458.51,,,,,,,fee schedule,3458.51,5664, Release thumb contracture,26508,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3458.51,5664, Release thumb contracture,26508,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3458.51,5664, Release thumb contracture,26508,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3458.51,5664, Thumb tendon transfer,26510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3384.37,,,,,,,fee schedule,3384.37,12821, Thumb tendon transfer,26510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3384.37,12821, Thumb tendon transfer,26510,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3384.37,12821, Thumb tendon transfer,26510,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3384.37,12821, Fusion of knuckle joint,26516,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3892.73,,,,,,,fee schedule,3195,12821, Fusion of knuckle joint,26516,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,12821, Fusion of knuckle joint,26516,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3195,12821, Fusion of knuckle joint,26516,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3195,12821, Fusion of knuckle joints,26517,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4616.44,,,,,,,fee schedule,4616.44,12821, Fusion of knuckle joints,26517,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4616.44,12821, Fusion of knuckle joints,26517,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4616.44,12821, Fusion of knuckle joints,26517,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4616.44,12821, Fusion of knuckle joints,26518,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4671.86,,,,,,,fee schedule,4671.86,12821, Fusion of knuckle joints,26518,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4671.86,12821, Fusion of knuckle joints,26518,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4671.86,12821, Fusion of knuckle joints,26518,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4671.86,12821, Release knuckle contracture,26520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3602.64,,,,,,,fee schedule,3602.64,5664, Release knuckle contracture,26520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3602.64,5664, Release knuckle contracture,26520,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3602.64,5664, Release knuckle contracture,26520,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3602.64,5664, Release finger contracture,26525,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3637.61,,,,,,,fee schedule,3637.61,5664, Release finger contracture,26525,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3637.61,5664, Release finger contracture,26525,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3637.61,5664, Release finger contracture,26525,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3637.61,5664, Revise knuckle joint,26530,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2808.73,,,,,,,fee schedule,2808.73,14456, Revise knuckle joint,26530,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2808.73,14456, Revise knuckle joint,26530,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,2808.73,14456, Revise knuckle joint,26530,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,2808.73,14456, Revise knuckle with implant,26531,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3244.02,,,,,,,fee schedule,3244.02,14456, Revise knuckle with implant,26531,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,3244.02,14456, Revise knuckle with implant,26531,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3244.02,14456, Revise knuckle with implant,26531,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3244.02,14456, Revise finger joint,26535,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2306.2,,,,,,,fee schedule,2306.2,14456, Revise finger joint,26535,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,2306.2,14456, Revise finger joint,26535,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,2306.2,14456, Revise finger joint,26535,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,2306.2,14456, Revise/implant finger joint,26536,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3942.7,,,,,,,fee schedule,3942.7,14456, Revise/implant finger joint,26536,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,3942.7,14456, Revise/implant finger joint,26536,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3942.7,14456, Revise/implant finger joint,26536,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3942.7,14456, Repair hand joint,26540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3677.91,,,,,,,fee schedule,3677.91,5664, Repair hand joint,26540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3677.91,5664, Repair hand joint,26540,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3677.91,5664, Repair hand joint,26540,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3677.91,5664, Repair hand joint with graft,26541,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4355.65,,,,,,,fee schedule,4355.65,12821, Repair hand joint with graft,26541,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,4355.65,12821, Repair hand joint with graft,26541,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4355.65,12821, Repair hand joint with graft,26541,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4355.65,12821, Repair hand joint with graft,26542,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3776.12,,,,,,,fee schedule,3776.12,5664, Repair hand joint with graft,26542,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3776.12,5664, Repair hand joint with graft,26542,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3776.12,5664, Repair hand joint with graft,26542,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3776.12,5664, Reconstruct finger joint,26545,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3833.43,,,,,,,fee schedule,3833.43,12821, Reconstruct finger joint,26545,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3833.43,12821, Reconstruct finger joint,26545,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3833.43,12821, Reconstruct finger joint,26545,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3833.43,12821, Repair nonunion hand,26546,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5407.12,,,,,,,fee schedule,5363,12821, Repair nonunion hand,26546,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,12821, Repair nonunion hand,26546,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5363,12821, Repair nonunion hand,26546,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5363,12821, Reconstruct finger joint,26548,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4165.23,,,,,,,fee schedule,4165.23,12821, Reconstruct finger joint,26548,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4165.23,12821, Reconstruct finger joint,26548,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4165.23,12821, Reconstruct finger joint,26548,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4165.23,12821, Construct thumb replacement,26550,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8547.48,,,,,,,fee schedule,4108,12821, Construct thumb replacement,26550,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,12821, Construct thumb replacement,26550,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4108,12821, Construct thumb replacement,26550,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4108,12821, Great toe-hand transfer,26551,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,16719.18,,,,,,,fee schedule,5363,16719.18, Great toe-hand transfer,26551,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,16719.18, Great toe-hand transfer,26551,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5363,16719.18, Great toe-hand transfer,26551,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5363,16719.18, Description Not Available,26552,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Single transfer toe-hand,26553,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,16606.73,,,,,,,fee schedule,5363,16606.73, Single transfer toe-hand,26553,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,16606.73, Single transfer toe-hand,26553,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5363,16606.73, Single transfer toe-hand,26553,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5363,16606.73, Double transfer toe-hand,26554,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,19284.87,,,,,,,fee schedule,5363,19284.87, Double transfer toe-hand,26554,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,19284.87, Double transfer toe-hand,26554,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5363,19284.87, Double transfer toe-hand,26554,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5363,19284.87, Positional change of finger,26555,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7234.53,,,,,,,fee schedule,5248,12821, Positional change of finger,26555,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,12821, Positional change of finger,26555,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5248,12821, Positional change of finger,26555,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5248,12821, Toe joint transfer,26556,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,17294.94,,,,,,,fee schedule,5363,22111, Toe joint transfer,26556,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,22111, Toe joint transfer,26556,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5363,22111, Toe joint transfer,26556,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5363,22111, Description Not Available,26557,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Description Not Available,26558,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Description Not Available,26559,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Repair of web finger,26560,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3446.96,,,,,,,fee schedule,3446.96,5664, Repair of web finger,26560,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3446.96,5664, Repair of web finger,26560,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3446.96,5664, Repair of web finger,26560,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3446.96,5664, Repair of web finger,26561,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5194.84,,,,,,,fee schedule,5194.84,12821, Repair of web finger,26561,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5194.84,12821, Repair of web finger,26561,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5194.84,12821, Repair of web finger,26561,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5194.84,12821, Repair of web finger,26562,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7228.7,,,,,,,fee schedule,5363,12821, Repair of web finger,26562,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,12821, Repair of web finger,26562,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5363,12821, Repair of web finger,26562,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5363,12821, Correct metacarpal flaw,26565,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3744.07,,,,,,,fee schedule,3744.07,12821, Correct metacarpal flaw,26565,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,3744.07,12821, Correct metacarpal flaw,26565,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3744.07,12821, Correct metacarpal flaw,26565,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3744.07,12821, Correct finger deformity,26567,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3796.63,,,,,,,fee schedule,3796.63,12821, Correct finger deformity,26567,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,3796.63,12821, Correct finger deformity,26567,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3796.63,12821, Correct finger deformity,26567,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3796.63,12821, Lengthen metacarpal/finger,26568,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4961.35,,,,,,,fee schedule,4961.35,12821, Lengthen metacarpal/finger,26568,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4961.35,12821, Lengthen metacarpal/finger,26568,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4961.35,12821, Lengthen metacarpal/finger,26568,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4961.35,12821, Repair hand deformity,26580,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8026.17,,,,,,,fee schedule,5097,8026.17, Repair hand deformity,26580,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,5097,8026.17, Repair hand deformity,26580,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8026.17, Repair hand deformity,26580,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8026.17, Reconstruct extra finger,26587,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5419.42,,,,,,,fee schedule,5097,6044, Reconstruct extra finger,26587,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,5097,6044, Reconstruct extra finger,26587,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6044, Reconstruct extra finger,26587,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6044, Repair finger deformity,26590,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7437.85,,,,,,,fee schedule,5097,7437.85, Repair finger deformity,26590,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,5097,7437.85, Repair finger deformity,26590,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7437.85, Repair finger deformity,26590,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7437.85, Repair muscles of hand,26591,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2626.99,,,,,,,fee schedule,2626.99,10940, Repair muscles of hand,26591,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2626.99,10940, Repair muscles of hand,26591,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2626.99,10940, Repair muscles of hand,26591,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2626.99,10940, Release muscles of hand,26593,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3423.92,,,,,,,fee schedule,3423.92,5664, Release muscles of hand,26593,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3423.92,5664, Release muscles of hand,26593,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3423.92,5664, Release muscles of hand,26593,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3423.92,5664, Excision constricting tissue,26596,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4347.67,,,,,,,fee schedule,4108,5664, Excision constricting tissue,26596,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,5664, Excision constricting tissue,26596,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4108,5664, Excision constricting tissue,26596,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4108,5664, Treat metacarpal fracture,26600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1619.18,,,,,,,fee schedule,1619.18,6979, Treat metacarpal fracture,26600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1619.18,6979, Treat metacarpal fracture,26600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1619.18,6979, Treat metacarpal fracture,26600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1619.18,6979, Treat metacarpal fracture,26605,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1692.83,,,,,,,fee schedule,1692.83,4108, Treat metacarpal fracture,26605,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1692.83,4108, Treat metacarpal fracture,26605,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1692.83,4108, Treat metacarpal fracture,26605,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1692.83,4108, Treat metacarpal fracture,26607,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2720.29,,,,,,,fee schedule,2720.29,5664, Treat metacarpal fracture,26607,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2720.29,5664, Treat metacarpal fracture,26607,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2720.29,5664, Treat metacarpal fracture,26607,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2720.29,5664, Treat metacarpal fracture,26608,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2543.35,,,,,,,fee schedule,2543.35,10940, Treat metacarpal fracture,26608,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2543.35,10940, Treat metacarpal fracture,26608,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2543.35,10940, Treat metacarpal fracture,26608,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2543.35,10940, Treat metacarpal fracture,26615,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3011.51,,,,,,,fee schedule,3011.51,22111, Treat metacarpal fracture,26615,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3011.51,22111, Treat metacarpal fracture,26615,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3011.51,22111, Treat metacarpal fracture,26615,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3011.51,22111, Treat thumb dislocation,26641,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2098.18,,,,,,,fee schedule,2098.18,6979, Treat thumb dislocation,26641,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2098.18,6979, Treat thumb dislocation,26641,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2098.18,6979, Treat thumb dislocation,26641,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2098.18,6979, Treat thumb fracture,26645,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2151.17,,,,,,,fee schedule,2151.17,3195, Treat thumb fracture,26645,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2151.17,3195, Treat thumb fracture,26645,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2151.17,3195, Treat thumb fracture,26645,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2151.17,3195, Treat thumb fracture,26650,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2571.63,,,,,,,fee schedule,2571.63,10940, Treat thumb fracture,26650,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2571.63,10940, Treat thumb fracture,26650,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2571.63,10940, Treat thumb fracture,26650,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2571.63,10940, Treat thumb fracture,26665,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3172.31,,,,,,,fee schedule,3172.31,22111, Treat thumb fracture,26665,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3172.31,22111, Treat thumb fracture,26665,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3172.31,22111, Treat thumb fracture,26665,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3172.31,22111, Treat hand dislocation,26670,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1957.99,,,,,,,fee schedule,1957.99,6979, Treat hand dislocation,26670,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1957.99,6979, Treat hand dislocation,26670,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1957.99,6979, Treat hand dislocation,26670,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1957.99,6979, Treat hand dislocation,26675,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2300.31,,,,,,,fee schedule,2300.31,4108, Treat hand dislocation,26675,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2300.31,4108, Treat hand dislocation,26675,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2300.31,4108, Treat hand dislocation,26675,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2300.31,4108, Pin hand dislocation,26676,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2672.37,,,,,,,fee schedule,2672.37,10940, Pin hand dislocation,26676,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2672.37,10940, Pin hand dislocation,26676,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2672.37,10940, Pin hand dislocation,26676,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2672.37,10940, Treat hand dislocation,26685,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2933.97,,,,,,,fee schedule,2933.97,10940, Treat hand dislocation,26685,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2933.97,10940, Treat hand dislocation,26685,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2933.97,10940, Treat hand dislocation,26685,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2933.97,10940, Treat hand dislocation,26686,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3286.43,,,,,,,fee schedule,3286.43,22111, Treat hand dislocation,26686,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3286.43,22111, Treat hand dislocation,26686,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3286.43,22111, Treat hand dislocation,26686,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3286.43,22111, Treat knuckle dislocation,26700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1908.51,,,,,,,fee schedule,1908.51,6979, Treat knuckle dislocation,26700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1908.51,6979, Treat knuckle dislocation,26700,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1908.51,6979, Treat knuckle dislocation,26700,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1908.51,6979, Treat knuckle dislocation,26705,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2168.81,,,,,,,fee schedule,2168.81,4108, Treat knuckle dislocation,26705,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2168.81,4108, Treat knuckle dislocation,26705,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2168.81,4108, Treat knuckle dislocation,26705,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2168.81,4108, Pin knuckle dislocation,26706,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2286.02,,,,,,,fee schedule,2286.02,5664, Pin knuckle dislocation,26706,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2286.02,5664, Pin knuckle dislocation,26706,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2286.02,5664, Pin knuckle dislocation,26706,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2286.02,5664, Treat knuckle dislocation,26715,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2996.4,,,,,,,fee schedule,2996.4,10940, Treat knuckle dislocation,26715,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2996.4,10940, Treat knuckle dislocation,26715,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2996.4,10940, Treat knuckle dislocation,26715,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2996.4,10940, Treat finger fracture each,26720,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1107.04,,,,,,,fee schedule,1107.04,3195, Treat finger fracture each,26720,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1107.04,3195, Treat finger fracture each,26720,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1107.04,3195, Treat finger fracture each,26720,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1107.04,3195, Treat finger fracture each,26725,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1758.83,,,,,,,fee schedule,1758.83,4108, Treat finger fracture each,26725,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1758.83,4108, Treat finger fracture each,26725,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1758.83,4108, Treat finger fracture each,26725,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1758.83,4108, Treat finger fracture each,26727,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2501.48,,,,,,,fee schedule,2501.48,10940, Treat finger fracture each,26727,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,2501.48,10940, Treat finger fracture each,26727,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2501.48,10940, Treat finger fracture each,26727,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2501.48,10940, Treat finger fracture each,26735,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3107.23,,,,,,,fee schedule,3107.23,10940, Treat finger fracture each,26735,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3107.23,10940, Treat finger fracture each,26735,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3107.23,10940, Treat finger fracture each,26735,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3107.23,10940, Treat finger fracture each,26740,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1220.95,,,,,,,fee schedule,1220.95,3195, Treat finger fracture each,26740,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1220.95,3195, Treat finger fracture each,26740,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1220.95,3195, Treat finger fracture each,26740,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1220.95,3195, Treat finger fracture each,26742,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1867.18,,,,,,,fee schedule,1867.18,4108, Treat finger fracture each,26742,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1867.18,4108, Treat finger fracture each,26742,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1867.18,4108, Treat finger fracture each,26742,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1867.18,4108, Treat finger fracture each,26746,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3806.34,,,,,,,fee schedule,3806.34,10940, Treat finger fracture each,26746,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,3806.34,10940, Treat finger fracture each,26746,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3806.34,10940, Treat finger fracture each,26746,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3806.34,10940, Treat finger fracture each,26750,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1125.61,,,,,,,fee schedule,1125.61,6979, Treat finger fracture each,26750,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1125.61,6979, Treat finger fracture each,26750,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1125.61,6979, Treat finger fracture each,26750,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1125.61,6979, Treat finger fracture each,26755,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1635.85,,,,,,,fee schedule,1635.85,6979, Treat finger fracture each,26755,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1635.85,6979, Treat finger fracture each,26755,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1635.85,6979, Treat finger fracture each,26755,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1635.85,6979, Pin finger fracture each,26756,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2261.19,,,,,,,fee schedule,2261.19,10940, Pin finger fracture each,26756,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2261.19,10940, Pin finger fracture each,26756,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2261.19,10940, Pin finger fracture each,26756,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2261.19,10940, Treat finger fracture each,26765,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2666.11,,,,,,,fee schedule,2666.11,10940, Treat finger fracture each,26765,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2666.11,10940, Treat finger fracture each,26765,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2666.11,10940, Treat finger fracture each,26765,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2666.11,10940, Treat finger dislocation,26770,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1679.29,,,,,,,fee schedule,1679.29,6979, Treat finger dislocation,26770,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1679.29,6979, Treat finger dislocation,26770,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1679.29,6979, Treat finger dislocation,26770,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1679.29,6979, Treat finger dislocation,26775,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1948.66,,,,,,,fee schedule,1948.66,6979, Treat finger dislocation,26775,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1948.66,6979, Treat finger dislocation,26775,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1948.66,6979, Treat finger dislocation,26775,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1948.66,6979, Pin finger dislocation,26776,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2373.65,,,,,,,fee schedule,2373.65,10940, Pin finger dislocation,26776,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2373.65,10940, Pin finger dislocation,26776,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2373.65,10940, Pin finger dislocation,26776,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2373.65,10940, Treat finger dislocation,26785,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2879.41,,,,,,,fee schedule,2879.41,10940, Treat finger dislocation,26785,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2879.41,10940, Treat finger dislocation,26785,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2879.41,10940, Treat finger dislocation,26785,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2879.41,10940, Thumb fusion with graft,26820,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4436.86,,,,,,,fee schedule,4436.86,12821, Thumb fusion with graft,26820,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4436.86,12821, Thumb fusion with graft,26820,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4436.86,12821, Thumb fusion with graft,26820,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4436.86,12821, Fusion of thumb,26841,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4070.9,,,,,,,fee schedule,4070.9,12821, Fusion of thumb,26841,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4070.9,12821, Fusion of thumb,26841,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4070.9,12821, Fusion of thumb,26841,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4070.9,12821, Thumb fusion with graft,26842,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4448.52,,,,,,,fee schedule,4448.52,12821, Thumb fusion with graft,26842,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4448.52,12821, Thumb fusion with graft,26842,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4448.52,12821, Thumb fusion with graft,26842,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4448.52,12821, Fusion of hand joint,26843,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4189.72,,,,,,,fee schedule,4189.72,12821, Fusion of hand joint,26843,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4189.72,12821, Fusion of hand joint,26843,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4189.72,12821, Fusion of hand joint,26843,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4189.72,12821, Fusion/graft of hand joint,26844,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4589.68,,,,,,,fee schedule,4589.68,12821, Fusion/graft of hand joint,26844,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4589.68,12821, Fusion/graft of hand joint,26844,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4589.68,12821, Fusion/graft of hand joint,26844,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4589.68,12821, Fusion of knuckle,26850,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3829.49,,,,,,,fee schedule,3829.49,12821, Fusion of knuckle,26850,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3829.49,12821, Fusion of knuckle,26850,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3829.49,12821, Fusion of knuckle,26850,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3829.49,12821, Fusion of knuckle with graft,26852,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4328.56,,,,,,,fee schedule,4328.56,12821, Fusion of knuckle with graft,26852,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4328.56,12821, Fusion of knuckle with graft,26852,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4328.56,12821, Fusion of knuckle with graft,26852,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4328.56,12821, Fusion of finger joint,26860,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3256.43,,,,,,,fee schedule,3256.43,12821, Fusion of finger joint,26860,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3256.43,12821, Fusion of finger joint,26860,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3256.43,12821, Fusion of finger joint,26860,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3256.43,12821, Fusion of finger jnt add-on,26861,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,494.98,,,,,,,fee schedule,494.98,4108, Fusion of finger jnt add-on,26861,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,494.98,4108, Fusion of finger jnt add-on,26861,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,494.98,4108, Fusion of finger jnt add-on,26861,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,494.98,4108, Fusion/graft of finger joint,26862,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3999.89,,,,,,,fee schedule,3999.89,12821, Fusion/graft of finger joint,26862,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3999.89,12821, Fusion/graft of finger joint,26862,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3999.89,12821, Fusion/graft of finger joint,26862,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3999.89,12821, Fuse/graft added joint,26863,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1088.05,,,,,,,fee schedule,1088.05,5248, Fuse/graft added joint,26863,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1088.05,5248, Fuse/graft added joint,26863,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1088.05,5248, Fuse/graft added joint,26863,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1088.05,5248, Amputate metacarpal bone,26910,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4027.09,,,,,,,fee schedule,4027.09,12821, Amputate metacarpal bone,26910,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4027.09,12821, Amputate metacarpal bone,26910,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4027.09,12821, Amputate metacarpal bone,26910,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4027.09,12821, Amputation of finger/thumb,26951,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3770.02,,,,,,,fee schedule,3770.02,5664, Amputation of finger/thumb,26951,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3770.02,5664, Amputation of finger/thumb,26951,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3770.02,5664, Amputation of finger/thumb,26951,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3770.02,5664, Amputation of finger/thumb,26952,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3615.7,,,,,,,fee schedule,3615.7,5664, Amputation of finger/thumb,26952,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3615.7,5664, Amputation of finger/thumb,26952,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3615.7,5664, Amputation of finger/thumb,26952,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3615.7,5664, Hand/finger surgery,26989,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Hand/finger surgery,26989,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Hand/finger surgery,26989,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Drainage of pelvis lesion,26990,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3635.18,,,,,,,fee schedule,3195,10940, Drainage of pelvis lesion,26990,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,10940, Drainage of pelvis lesion,26990,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3195,10940, Drainage of pelvis lesion,26990,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3195,10940, Drainage of pelvis bursa,26991,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2729.84,,,,,,,fee schedule,2729.84,10940, Drainage of pelvis bursa,26991,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2729.84,10940, Drainage of pelvis bursa,26991,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2729.84,10940, Drainage of pelvis bursa,26991,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2729.84,10940, Drainage of bone lesion,26992,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5261.53,,,,,,,fee schedule,4108,14456, Drainage of bone lesion,26992,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,14456, Drainage of bone lesion,26992,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4108,14456, Drainage of bone lesion,26992,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4108,14456, Incision of hip tendon,27000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1971.05,,,,,,,fee schedule,1971.05,10940, Incision of hip tendon,27000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1971.05,10940, Incision of hip tendon,27000,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1971.05,10940, Incision of hip tendon,27000,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1971.05,10940, Incision of hip tendon,27001,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2851.84,,,,,,,fee schedule,2851.84,12821, Incision of hip tendon,27001,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2851.84,12821, Incision of hip tendon,27001,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2851.84,12821, Incision of hip tendon,27001,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2851.84,12821, Incision of hip tendon,27003,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3169.12,,,,,,,fee schedule,3169.12,12821, Incision of hip tendon,27003,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3169.12,12821, Incision of hip tendon,27003,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3169.12,12821, Incision of hip tendon,27003,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3169.12,12821, Incision of hip tendon,27005,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3753.08,,,,,,,fee schedule,3753.08,22111, Incision of hip tendon,27005,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3753.08,22111, Incision of hip tendon,27005,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3753.08,22111, Incision of hip tendon,27005,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3753.08,22111, Incision of hip tendons,27006,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3590.88,,,,,,,fee schedule,3590.88,12821, Incision of hip tendons,27006,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3590.88,12821, Incision of hip tendons,27006,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3590.88,12821, Incision of hip tendons,27006,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3590.88,12821, Incision of hip/thigh fascia,27025,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4895.9,,,,,,,fee schedule,4108,22111, Incision of hip/thigh fascia,27025,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,22111, Incision of hip/thigh fascia,27025,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4108,22111, Incision of hip/thigh fascia,27025,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4108,22111, Buttock fasciotomy,27027,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4536.63,,,,,,,fee schedule,4108,12821, Buttock fasciotomy,27027,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,12821, Buttock fasciotomy,27027,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4108,12821, Buttock fasciotomy,27027,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4108,12821, Drainage of hip joint,27030,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4823.75,,,,,,,fee schedule,4823.75,14456, Drainage of hip joint,27030,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4823.75,14456, Drainage of hip joint,27030,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4823.75,14456, Drainage of hip joint,27030,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4823.75,14456, Exploration of hip joint,27033,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5005.06,,,,,,,fee schedule,5005.06,14456, Exploration of hip joint,27033,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5005.06,14456, Exploration of hip joint,27033,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5005.06,14456, Exploration of hip joint,27033,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5005.06,14456, Denervation of hip joint,27035,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5563.44,,,,,,,fee schedule,5363,12821, Denervation of hip joint,27035,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,12821, Denervation of hip joint,27035,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5363,12821, Denervation of hip joint,27035,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5363,12821, Excision of hip joint/muscle,27036,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5268.06,,,,,,,fee schedule,5268.06,14456, Excision of hip joint/muscle,27036,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5268.06,14456, Excision of hip joint/muscle,27036,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5268.06,14456, Excision of hip joint/muscle,27036,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5268.06,14456, Biopsy of soft tissues,27040,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1007.49,,,,,,,fee schedule,1007.49,4497, Biopsy of soft tissues,27040,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1007.49,4497, Biopsy of soft tissues,27040,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,1007.49,4497, Biopsy of soft tissues,27040,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,1007.49,4497, Biopsy of soft tissues,27041,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3655.74,,,,,,,fee schedule,3655.74,4497, Biopsy of soft tissues,27041,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3655.74,4497, Biopsy of soft tissues,27041,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,3655.74,4497, Biopsy of soft tissues,27041,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,3655.74,4497, Exc hip pelvis les sc 3 cm/>,27043,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2557.43,,,,,,,fee schedule,2557.43,10940, Exc hip pelvis les sc 3 cm/>,27043,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2557.43,10940, Exc hip pelvis les sc 3 cm/>,27043,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2557.43,10940, Exc hip pelvis les sc 3 cm/>,27043,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2557.43,10940, Exc hip/pelv tum deep 5 cm/>,27045,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3893.97,,,,,,,fee schedule,3893.97,10940, Exc hip/pelv tum deep 5 cm/>,27045,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3893.97,10940, Exc hip/pelv tum deep 5 cm/>,27045,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3893.97,10940, Exc hip/pelv tum deep 5 cm/>,27045,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3893.97,10940, Exc hip/pelvis les sc < 3 cm,27047,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1963.98,,,,,,,fee schedule,1963.98,5664, Exc hip/pelvis les sc < 3 cm,27047,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1963.98,5664, Exc hip/pelvis les sc < 3 cm,27047,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1963.98,5664, Exc hip/pelvis les sc < 3 cm,27047,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1963.98,5664, Exc hip/pelv tum deep < 5 cm,27048,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3293.93,,,,,,,fee schedule,3293.93,5664, Exc hip/pelv tum deep < 5 cm,27048,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3293.93,5664, Exc hip/pelv tum deep < 5 cm,27048,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3293.93,5664, Exc hip/pelv tum deep < 5 cm,27048,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3293.93,5664, Resect hip/pelv tum < 5 cm,27049,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7271.92,,,,,,,fee schedule,5097,7271.92, Resect hip/pelv tum < 5 cm,27049,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5097,7271.92, Resect hip/pelv tum < 5 cm,27049,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7271.92, Resect hip/pelv tum < 5 cm,27049,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7271.92, Biopsy of sacroiliac joint,27050,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2197.68,,,,,,,fee schedule,2197.68,10940, Biopsy of sacroiliac joint,27050,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2197.68,10940, Biopsy of sacroiliac joint,27050,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2197.68,10940, Biopsy of sacroiliac joint,27050,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2197.68,10940, Biopsy of hip joint,27052,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3078.69,,,,,,,fee schedule,3078.69,10940, Biopsy of hip joint,27052,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3078.69,10940, Biopsy of hip joint,27052,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3078.69,10940, Biopsy of hip joint,27052,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3078.69,10940, Removal of hip joint lining,27054,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3619.37,,,,,,,fee schedule,3619.37,12821, Removal of hip joint lining,27054,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3619.37,12821, Removal of hip joint lining,27054,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3619.37,12821, Removal of hip joint lining,27054,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3619.37,12821, Buttock fasciotomy w/dbrdmt,27057,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5170.29,,,,,,,fee schedule,4108,10940, Buttock fasciotomy w/dbrdmt,27057,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,10940, Buttock fasciotomy w/dbrdmt,27057,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,4108,10940, Buttock fasciotomy w/dbrdmt,27057,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,4108,10940, Resect hip/pelv tum 5 cm/>,27059,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9320.08,,,,,,,fee schedule,5248,10940, Resect hip/pelv tum 5 cm/>,27059,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,10940, Resect hip/pelv tum 5 cm/>,27059,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,5248,10940, Resect hip/pelv tum 5 cm/>,27059,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,5248,10940, Removal of ischial bursa,27060,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2489.98,,,,,,,fee schedule,2489.98,10940, Removal of ischial bursa,27060,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,2489.98,10940, Removal of ischial bursa,27060,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2489.98,10940, Removal of ischial bursa,27060,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2489.98,10940, Remove femur lesion/bursa,27062,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2387.95,,,,,,,fee schedule,2387.95,10940, Remove femur lesion/bursa,27062,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,2387.95,10940, Remove femur lesion/bursa,27062,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2387.95,10940, Remove femur lesion/bursa,27062,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2387.95,10940, Remove hip bone les super,27065,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2806.19,,,,,,,fee schedule,2806.19,10940, Remove hip bone les super,27065,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,2806.19,10940, Remove hip bone les super,27065,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2806.19,10940, Remove hip bone les super,27065,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2806.19,10940, Remove hip bone les deep,27066,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4222.37,,,,,,,fee schedule,4222.37,12821, Remove hip bone les deep,27066,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4222.37,12821, Remove hip bone les deep,27066,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4222.37,12821, Remove hip bone les deep,27066,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4222.37,12821, Remove/graft hip bone lesion,27067,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5352.62,,,,,,,fee schedule,5352.62,12821, Remove/graft hip bone lesion,27067,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,5352.62,12821, Remove/graft hip bone lesion,27067,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5352.62,12821, Remove/graft hip bone lesion,27067,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5352.62,12821, Part remove hip bone super,27070,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4572.19,,,,,,,fee schedule,4572.19,22111, Part remove hip bone super,27070,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4572.19,22111, Part remove hip bone super,27070,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4572.19,22111, Part remove hip bone super,27070,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4572.19,22111, Part removal hip bone deep,27071,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5073.43,,,,,,,fee schedule,5073.43,22111, Part removal hip bone deep,27071,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,5073.43,22111, Part removal hip bone deep,27071,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5073.43,22111, Part removal hip bone deep,27071,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5073.43,22111, Resect hip tumor,27075,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10509.14,,,,,,,fee schedule,6044,22111, Resect hip tumor,27075,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,22111, Resect hip tumor,27075,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6044,22111, Resect hip tumor,27075,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6044,22111, Resect hip tum incl acetabul,27076,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12653.35,,,,,,,fee schedule,6044,22111, Resect hip tum incl acetabul,27076,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,22111, Resect hip tum incl acetabul,27076,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6044,22111, Resect hip tum incl acetabul,27076,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6044,22111, Resect hip tum w/innom bone,27077,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,14086.15,,,,,,,fee schedule,6044,22111, Resect hip tum w/innom bone,27077,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,22111, Resect hip tum w/innom bone,27077,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6044,22111, Resect hip tum w/innom bone,27077,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6044,22111, Rsect hip tum incl femur,27078,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10367.87,,,,,,,fee schedule,6044,22111, Rsect hip tum incl femur,27078,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,22111, Rsect hip tum incl femur,27078,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6044,22111, Rsect hip tum incl femur,27078,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6044,22111, Removal of tail bone,27080,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2802.68,,,,,,,fee schedule,2802.68,12821, Removal of tail bone,27080,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2802.68,12821, Removal of tail bone,27080,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2802.68,12821, Removal of tail bone,27080,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2802.68,12821, Remove hip foreign body,27086,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,917.48,,,,,,,fee schedule,917.48,5664, Remove hip foreign body,27086,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,917.48,5664, Remove hip foreign body,27086,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,917.48,5664, Remove hip foreign body,27086,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,917.48,5664, Remove hip foreign body,27087,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3341.74,,,,,,,fee schedule,3341.74,10940, Remove hip foreign body,27087,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3341.74,10940, Remove hip foreign body,27087,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3341.74,10940, Remove hip foreign body,27087,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3341.74,10940, Removal of hip prosthesis,27090,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4314.8,,,,,,,fee schedule,4314.8,10940, Removal of hip prosthesis,27090,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4314.8,10940, Removal of hip prosthesis,27090,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,4314.8,10940, Removal of hip prosthesis,27090,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,4314.8,10940, Removal of hip prosthesis,27091,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8098.26,,,,,,,fee schedule,5248,10940, Removal of hip prosthesis,27091,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,10940, Removal of hip prosthesis,27091,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,5248,10940, Removal of hip prosthesis,27091,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,5248,10940, Injection for hip x-ray,27093,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,322.95,,,,,,,fee schedule,322.95,3195, Injection for hip x-ray,27093,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,322.95,3195, Injection for hip x-ray,27093,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,322.95,3195, Injection for hip x-ray,27093,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,322.95,3195, Injection for hip x-ray,27095,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,393.37,,,,,,,fee schedule,393.37,3195, Injection for hip x-ray,27095,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,393.37,3195, Injection for hip x-ray,27095,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,393.37,3195, Injection for hip x-ray,27095,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,393.37,3195, Inject sacroiliac joint,27096,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,406,,,,,,,fee schedule,406,3195, Inject sacroiliac joint,27096,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,406,3195, Inject sacroiliac joint,27096,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,406,3195, Inject sacroiliac joint,27096,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,406,3195, Revision of hip tendon,27097,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3582.94,,,,,,,fee schedule,3582.94,12821, Revision of hip tendon,27097,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3582.94,12821, Revision of hip tendon,27097,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3582.94,12821, Revision of hip tendon,27097,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3582.94,12821, Transfer tendon to pelvis,27098,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3656.71,,,,,,,fee schedule,3656.71,10940, Transfer tendon to pelvis,27098,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3656.71,10940, Transfer tendon to pelvis,27098,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3656.71,10940, Transfer tendon to pelvis,27098,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3656.71,10940, Transfer of abdominal muscle,27100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4335.09,,,,,,,fee schedule,4335.09,14456, Transfer of abdominal muscle,27100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4335.09,14456, Transfer of abdominal muscle,27100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4335.09,14456, Transfer of abdominal muscle,27100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4335.09,14456, Transfer of spinal muscle,27105,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4531.67,,,,,,,fee schedule,4531.67,14456, Transfer of spinal muscle,27105,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4531.67,14456, Transfer of spinal muscle,27105,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4531.67,14456, Transfer of spinal muscle,27105,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4531.67,14456, Transfer of iliopsoas muscle,27110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5026.81,,,,,,,fee schedule,5026.81,14456, Transfer of iliopsoas muscle,27110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5026.81,14456, Transfer of iliopsoas muscle,27110,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5026.81,14456, Transfer of iliopsoas muscle,27110,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5026.81,14456, Transfer of iliopsoas muscle,27111,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4691.61,,,,,,,fee schedule,4691.61,14456, Transfer of iliopsoas muscle,27111,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4691.61,14456, Transfer of iliopsoas muscle,27111,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4691.61,14456, Transfer of iliopsoas muscle,27111,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4691.61,14456, Reconstruction of hip socket,27120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6643.39,,,,,,,fee schedule,6044,22111, Reconstruction of hip socket,27120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,22111, Reconstruction of hip socket,27120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6044,22111, Reconstruction of hip socket,27120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6044,22111, Reconstruction of hip socket,27122,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5666.56,,,,,,,fee schedule,5666.56,22111, Reconstruction of hip socket,27122,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,5666.56,22111, Reconstruction of hip socket,27122,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5666.56,22111, Reconstruction of hip socket,27122,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5666.56,22111, Partial hip replacement,27125,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5809.82,,,,,,,fee schedule,5809.82,22111, Partial hip replacement,27125,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5809.82,22111, Partial hip replacement,27125,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5809.82,22111, Partial hip replacement,27125,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5809.82,22111, Total hip arthroplasty,27130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6545.19,,,,,,,fee schedule,6545.19,25393, Total hip arthroplasty,27130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6545.19,25393, Total hip arthroplasty,27130,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,6545.19,25393, Total hip arthroplasty,27130,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,6545.19,25393, Total hip arthroplasty,27132,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8480.84,,,,,,,fee schedule,6979,25393, Total hip arthroplasty,27132,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,25393, Total hip arthroplasty,27132,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,6979,25393, Total hip arthroplasty,27132,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,6979,25393, Revise hip joint replacement,27134,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9599.21,,,,,,,fee schedule,6979,25393, Revise hip joint replacement,27134,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,25393, Revise hip joint replacement,27134,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,6979,25393, Revise hip joint replacement,27134,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,6979,25393, Revise hip joint replacement,27137,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7437.09,,,,,,,fee schedule,6979,25393, Revise hip joint replacement,27137,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,25393, Revise hip joint replacement,27137,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,6979,25393, Revise hip joint replacement,27137,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,6979,25393, Revise hip joint replacement,27138,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7718.6,,,,,,,fee schedule,6979,25393, Revise hip joint replacement,27138,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,25393, Revise hip joint replacement,27138,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,6979,25393, Revise hip joint replacement,27138,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,6979,25393, Transplant femur ridge,27140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4643.47,,,,,,,fee schedule,4643.47,22111, Transplant femur ridge,27140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4643.47,22111, Transplant femur ridge,27140,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4643.47,22111, Transplant femur ridge,27140,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4643.47,22111, Incision of hip bone,27146,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6564.29,,,,,,,fee schedule,6044,22111, Incision of hip bone,27146,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,22111, Incision of hip bone,27146,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6044,22111, Incision of hip bone,27146,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6044,22111, Revision of hip bone,27147,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7462.56,,,,,,,fee schedule,6044,22111, Revision of hip bone,27147,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,22111, Revision of hip bone,27147,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6044,22111, Revision of hip bone,27147,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6044,22111, Incision of hip bones,27151,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8049.75,,,,,,,fee schedule,6044,22111, Incision of hip bones,27151,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,22111, Incision of hip bones,27151,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6044,22111, Incision of hip bones,27151,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6044,22111, Revision of hip bones,27156,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8650.44,,,,,,,fee schedule,6044,22111, Revision of hip bones,27156,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,22111, Revision of hip bones,27156,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6044,22111, Revision of hip bones,27156,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6044,22111, Revision of pelvis,27158,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7131.3,,,,,,,fee schedule,6044,22111, Revision of pelvis,27158,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,22111, Revision of pelvis,27158,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6044,22111, Revision of pelvis,27158,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6044,22111, Incision of neck of femur,27161,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6258.93,,,,,,,fee schedule,6044,22111, Incision of neck of femur,27161,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,22111, Incision of neck of femur,27161,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6044,22111, Incision of neck of femur,27161,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6044,22111, Incision/fixation of femur,27165,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7069.41,,,,,,,fee schedule,6044,22111, Incision/fixation of femur,27165,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,22111, Incision/fixation of femur,27165,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6044,22111, Incision/fixation of femur,27165,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6044,22111, Repair/graft femur head/neck,27170,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5990.69,,,,,,,fee schedule,5363,22111, Repair/graft femur head/neck,27170,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,22111, Repair/graft femur head/neck,27170,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5363,22111, Repair/graft femur head/neck,27170,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5363,22111, Treat slipped epiphysis,27175,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3467.9,,,,,,,fee schedule,3467.9,22111, Treat slipped epiphysis,27175,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,3467.9,22111, Treat slipped epiphysis,27175,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3467.9,22111, Treat slipped epiphysis,27175,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3467.9,22111, Treat slipped epiphysis,27176,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4783.66,,,,,,,fee schedule,4783.66,22111, Treat slipped epiphysis,27176,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4783.66,22111, Treat slipped epiphysis,27176,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4783.66,22111, Treat slipped epiphysis,27176,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4783.66,22111, Treat slipped epiphysis,27177,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5748.52,,,,,,,fee schedule,5748.52,22111, Treat slipped epiphysis,27177,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,5748.52,22111, Treat slipped epiphysis,27177,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5748.52,22111, Treat slipped epiphysis,27177,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5748.52,22111, Treat slipped epiphysis,27178,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4783.66,,,,,,,fee schedule,4783.66,22111, Treat slipped epiphysis,27178,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4783.66,22111, Treat slipped epiphysis,27178,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4783.66,22111, Treat slipped epiphysis,27178,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4783.66,22111, Revise head/neck of femur,27179,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5057.35,,,,,,,fee schedule,5057.35,22111, Revise head/neck of femur,27179,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5057.35,22111, Revise head/neck of femur,27179,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5057.35,22111, Revise head/neck of femur,27179,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5057.35,22111, Treat slipped epiphysis,27181,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5781.22,,,,,,,fee schedule,5781.22,22111, Treat slipped epiphysis,27181,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,5781.22,22111, Treat slipped epiphysis,27181,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5781.22,22111, Treat slipped epiphysis,27181,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5781.22,22111, Revision of femur epiphysis,27185,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3769.38,,,,,,,fee schedule,3769.38,22111, Revision of femur epiphysis,27185,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,3769.38,22111, Revision of femur epiphysis,27185,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3769.38,22111, Revision of femur epiphysis,27185,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3769.38,22111, Reinforce hip bones,27187,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5145.03,,,,,,,fee schedule,5145.03,22111, Reinforce hip bones,27187,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5145.03,22111, Reinforce hip bones,27187,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5145.03,22111, Reinforce hip bones,27187,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5145.03,22111, Clsd tx pelvic ring fx,27197,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,678.92,,,,,,,fee schedule,678.92,3195, Clsd tx pelvic ring fx,27197,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,678.92,3195, Clsd tx pelvic ring fx,27197,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,678.92,3195, Clsd tx pelvic ring fx,27197,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,678.92,3195, Clsd tx pelvic ring fx,27198,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1600.62,,,,,,,fee schedule,1600.62,3195, Clsd tx pelvic ring fx,27198,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1600.62,3195, Clsd tx pelvic ring fx,27198,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1600.62,3195, Clsd tx pelvic ring fx,27198,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1600.62,3195, Treat tail bone fracture,27200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1088.8,,,,,,,fee schedule,1088.8,3195, Treat tail bone fracture,27200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1088.8,3195, Treat tail bone fracture,27200,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1088.8,3195, Treat tail bone fracture,27200,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1088.8,3195, Treat tail bone fracture,27202,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2766.53,,,,,,,fee schedule,2766.53,22111, Treat tail bone fracture,27202,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2766.53,22111, Treat tail bone fracture,27202,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,2766.53,22111, Treat tail bone fracture,27202,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,2766.53,22111, Treat pelvic fracture(s),27215,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4047,6979, Treat pelvic fracture(s),27215,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,4047,6979, Treat pelvic fracture(s),27215,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,4047,6979, Treat pelvic ring fracture,27216,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,12821, Treat pelvic ring fracture,27216,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,6979,12821, Treat pelvic ring fracture,27216,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,6979,12821, Treat pelvic ring fracture,27217,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Treat pelvic ring fracture,27217,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Treat pelvic ring fracture,27217,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Treat pelvic ring fracture,27218,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Treat pelvic ring fracture,27218,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Treat pelvic ring fracture,27218,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Treat hip socket fracture,27220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2169.08,,,,,,,fee schedule,2169.08,6979, Treat hip socket fracture,27220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2169.08,6979, Treat hip socket fracture,27220,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2169.08,6979, Treat hip socket fracture,27220,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2169.08,6979, Treat hip socket fracture,27222,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5124.69,,,,,,,fee schedule,2505,5124.69, Treat hip socket fracture,27222,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,5124.69, Treat hip socket fracture,27222,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,5124.69, Treat hip socket fracture,27222,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,5124.69, Treat hip wall fracture,27226,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5429.62,,,,,,,fee schedule,5429.62,14456, Treat hip wall fracture,27226,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,5429.62,14456, Treat hip wall fracture,27226,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5429.62,14456, Treat hip wall fracture,27226,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5429.62,14456, Treat hip fracture(s),27227,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8397.9,,,,,,,fee schedule,6044,14456, Treat hip fracture(s),27227,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,14456, Treat hip fracture(s),27227,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,6044,14456, Treat hip fracture(s),27227,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,6044,14456, Treat hip fracture(s),27228,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9525.18,,,,,,,fee schedule,6044,14456, Treat hip fracture(s),27228,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,14456, Treat hip fracture(s),27228,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,6044,14456, Treat hip fracture(s),27228,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,6044,14456, Treat thigh fracture,27230,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2604.92,,,,,,,fee schedule,2505,3195, Treat thigh fracture,27230,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Treat thigh fracture,27230,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Treat thigh fracture,27230,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Treat thigh fracture,27232,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3932.28,,,,,,,fee schedule,3195,5664, Treat thigh fracture,27232,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,5664, Treat thigh fracture,27232,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3195,5664, Treat thigh fracture,27232,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3195,5664, Treat thigh fracture,27235,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4675.26,,,,,,,fee schedule,4675.26,12821, Treat thigh fracture,27235,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4675.26,12821, Treat thigh fracture,27235,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4675.26,12821, Treat thigh fracture,27235,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4675.26,12821, Treat thigh fracture,27236,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6114.26,,,,,,,fee schedule,6044,22111, Treat thigh fracture,27236,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,22111, Treat thigh fracture,27236,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6044,22111, Treat thigh fracture,27236,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6044,22111, Treat thigh fracture,27238,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2524.3,,,,,,,fee schedule,2505,3195, Treat thigh fracture,27238,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Treat thigh fracture,27238,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Treat thigh fracture,27238,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Treat thigh fracture,27240,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5028.75,,,,,,,fee schedule,3195,5664, Treat thigh fracture,27240,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,5664, Treat thigh fracture,27240,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3195,5664, Treat thigh fracture,27240,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3195,5664, Treat thigh fracture,27244,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6294.43,,,,,,,fee schedule,6044,22111, Treat thigh fracture,27244,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,22111, Treat thigh fracture,27244,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6044,22111, Treat thigh fracture,27244,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6044,22111, Treat thigh fracture,27245,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6275.01,,,,,,,fee schedule,6044,14456, Treat thigh fracture,27245,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,14456, Treat thigh fracture,27245,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,6044,14456, Treat thigh fracture,27245,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,6044,14456, Treat thigh fracture,27246,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2083.94,,,,,,,fee schedule,2083.94,3195, Treat thigh fracture,27246,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2083.94,3195, Treat thigh fracture,27246,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2083.94,3195, Treat thigh fracture,27246,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2083.94,3195, Treat thigh fracture,27248,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3838.55,,,,,,,fee schedule,3838.55,22111, Treat thigh fracture,27248,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,3838.55,22111, Treat thigh fracture,27248,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3838.55,22111, Treat thigh fracture,27248,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3838.55,22111, Treat hip dislocation,27250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1019.36,,,,,,,fee schedule,1019.36,3195, Treat hip dislocation,27250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1019.36,3195, Treat hip dislocation,27250,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1019.36,3195, Treat hip dislocation,27250,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1019.36,3195, Treat hip dislocation,27252,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4024.12,,,,,,,fee schedule,4024.12,4497, Treat hip dislocation,27252,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4024.12,4497, Treat hip dislocation,27252,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,4024.12,4497, Treat hip dislocation,27252,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,4024.12,4497, Treat hip dislocation,27253,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4870.7,,,,,,,fee schedule,4870.7,12821, Treat hip dislocation,27253,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4870.7,12821, Treat hip dislocation,27253,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4870.7,12821, Treat hip dislocation,27253,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4870.7,12821, Treat hip dislocation,27254,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6502.45,,,,,,,fee schedule,5363,12821, Treat hip dislocation,27254,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,12821, Treat hip dislocation,27254,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5363,12821, Treat hip dislocation,27254,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5363,12821, Treat hip dislocation,27256,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1487.41,,,,,,,fee schedule,1487.41,4108, Treat hip dislocation,27256,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1487.41,4108, Treat hip dislocation,27256,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1487.41,4108, Treat hip dislocation,27256,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1487.41,4108, Treat hip dislocation,27257,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1852.66,,,,,,,fee schedule,1852.66,5248, Treat hip dislocation,27257,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1852.66,5248, Treat hip dislocation,27257,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,1852.66,5248, Treat hip dislocation,27257,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,1852.66,5248, Treat hip dislocation,27258,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5712.31,,,,,,,fee schedule,5363,12821, Treat hip dislocation,27258,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,12821, Treat hip dislocation,27258,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5363,12821, Treat hip dislocation,27258,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5363,12821, Treat hip dislocation,27259,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7880.59,,,,,,,fee schedule,5363,12821, Treat hip dislocation,27259,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,12821, Treat hip dislocation,27259,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5363,12821, Treat hip dislocation,27259,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5363,12821, Treat hip dislocation,27265,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2706.69,,,,,,,fee schedule,2505,3195, Treat hip dislocation,27265,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Treat hip dislocation,27265,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Treat hip dislocation,27265,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Treat hip dislocation,27266,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3097.3,,,,,,,fee schedule,3097.3,5664, Treat hip dislocation,27266,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3097.3,5664, Treat hip dislocation,27266,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3097.3,5664, Treat hip dislocation,27266,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3097.3,5664, Cltx thigh fx,27267,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2377.32,,,,,,,fee schedule,2377.32,5664, Cltx thigh fx,27267,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2377.32,5664, Cltx thigh fx,27267,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2377.32,5664, Cltx thigh fx,27267,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2377.32,5664, Cltx thigh fx w/mnpj,27268,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2863.71,,,,,,,fee schedule,2863.71,12821, Cltx thigh fx w/mnpj,27268,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2863.71,12821, Cltx thigh fx w/mnpj,27268,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2863.71,12821, Cltx thigh fx w/mnpj,27268,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2863.71,12821, Optx thigh fx,27269,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6313.7,,,,,,,fee schedule,4108,6313.7, Optx thigh fx,27269,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,6313.7, Optx thigh fx,27269,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4108,6313.7, Optx thigh fx,27269,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4108,6313.7, Manipulation of hip joint,27275,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,985.09,,,,,,,fee schedule,985.09,5664, Manipulation of hip joint,27275,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,985.09,5664, Manipulation of hip joint,27275,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,985.09,5664, Manipulation of hip joint,27275,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,985.09,5664, Arthrd si jt prq wo tfxj dev,27278,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2410.29,,,,,,,fee schedule,2410.29,25393, Arthrd si jt prq wo tfxj dev,27278,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,2410.29,25393, Arthrd si jt prq wo tfxj dev,27278,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,2410.29,25393, Arthrd si jt prq wo tfxj dev,27278,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,2410.29,25393, Arthrodesis sacroiliac joint,27279,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4265.05,,,,,,,fee schedule,4265.05,25393, Arthrodesis sacroiliac joint,27279,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4265.05,25393, Arthrodesis sacroiliac joint,27279,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,4265.05,25393, Arthrodesis sacroiliac joint,27279,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,4265.05,25393, Fusion of sacroiliac joint,27280,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7371.64,,,,,,,fee schedule,6979,25393, Fusion of sacroiliac joint,27280,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,25393, Fusion of sacroiliac joint,27280,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,6979,25393, Fusion of sacroiliac joint,27280,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,6979,25393, Fusion of pubic bones,27282,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4478.95,,,,,,,fee schedule,4478.95,22111, Fusion of pubic bones,27282,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4478.95,22111, Fusion of pubic bones,27282,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4478.95,22111, Fusion of pubic bones,27282,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4478.95,22111, Fusion of hip joint,27284,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8114.34,,,,,,,fee schedule,6979,25393, Fusion of hip joint,27284,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,25393, Fusion of hip joint,27284,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,6979,25393, Fusion of hip joint,27284,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,6979,25393, Fusion of hip joint,27286,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8347.34,,,,,,,fee schedule,6979,25393, Fusion of hip joint,27286,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,25393, Fusion of hip joint,27286,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,6979,25393, Fusion of hip joint,27286,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,6979,25393, Amputation of leg at hip,27290,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8257.39,,,,,,,fee schedule,6979,25393, Amputation of leg at hip,27290,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,25393, Amputation of leg at hip,27290,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,6979,25393, Amputation of leg at hip,27290,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,6979,25393, Amputation of leg at hip,27295,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6486.86,,,,,,,fee schedule,6486.86,25393, Amputation of leg at hip,27295,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6486.86,25393, Amputation of leg at hip,27295,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,6486.86,25393, Amputation of leg at hip,27295,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,6486.86,25393, Pelvis/hip joint surgery,27299,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Pelvis/hip joint surgery,27299,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Pelvis/hip joint surgery,27299,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Drain thigh/knee lesion,27301,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2696.22,,,,,,,fee schedule,2696.22,10940, Drain thigh/knee lesion,27301,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2696.22,10940, Drain thigh/knee lesion,27301,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2696.22,10940, Drain thigh/knee lesion,27301,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2696.22,10940, Drainage of bone lesion,27303,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3353.45,,,,,,,fee schedule,3353.45,14456, Drainage of bone lesion,27303,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3353.45,14456, Drainage of bone lesion,27303,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3353.45,14456, Drainage of bone lesion,27303,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3353.45,14456, Incise thigh tendon & fascia,27305,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2566.01,,,,,,,fee schedule,2566.01,10940, Incise thigh tendon & fascia,27305,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2566.01,10940, Incise thigh tendon & fascia,27305,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2566.01,10940, Incise thigh tendon & fascia,27305,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2566.01,10940, Incision of thigh tendon,27306,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1759.47,,,,,,,fee schedule,1759.47,10940, Incision of thigh tendon,27306,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1759.47,10940, Incision of thigh tendon,27306,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1759.47,10940, Incision of thigh tendon,27306,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1759.47,10940, Incision of thigh tendons,27307,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2043.2,,,,,,,fee schedule,2043.2,12821, Incision of thigh tendons,27307,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2043.2,12821, Incision of thigh tendons,27307,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2043.2,12821, Incision of thigh tendons,27307,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2043.2,12821, Exploration of knee joint,27310,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3833.97,,,,,,,fee schedule,3833.97,12821, Exploration of knee joint,27310,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3833.97,12821, Exploration of knee joint,27310,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3833.97,12821, Exploration of knee joint,27310,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3833.97,12821, Biopsy thigh soft tissues,27323,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,860.82,,,,,,,fee schedule,860.82,4497, Biopsy thigh soft tissues,27323,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,860.82,4497, Biopsy thigh soft tissues,27323,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,860.82,4497, Biopsy thigh soft tissues,27323,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,860.82,4497, Biopsy thigh soft tissues,27324,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2226.55,,,,,,,fee schedule,2226.55,10940, Biopsy thigh soft tissues,27324,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2226.55,10940, Biopsy thigh soft tissues,27324,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2226.55,10940, Biopsy thigh soft tissues,27324,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2226.55,10940, Neurectomy hamstring,27325,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2989.38,,,,,,,fee schedule,2989.38,5664, Neurectomy hamstring,27325,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2989.38,5664, Neurectomy hamstring,27325,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2989.38,5664, Neurectomy hamstring,27325,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2989.38,5664, Neurectomy popliteal,27326,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2782.88,,,,,,,fee schedule,2782.88,5664, Neurectomy popliteal,27326,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2782.88,5664, Neurectomy popliteal,27326,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2782.88,5664, Neurectomy popliteal,27326,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2782.88,5664, Exc thigh/knee les sc < 3 cm,27327,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1710.15,,,,,,,fee schedule,1710.15,10940, Exc thigh/knee les sc < 3 cm,27327,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1710.15,10940, Exc thigh/knee les sc < 3 cm,27327,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1710.15,10940, Exc thigh/knee les sc < 3 cm,27327,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1710.15,10940, Exc thigh/knee tum deep <5cm,27328,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3306.24,,,,,,,fee schedule,3306.24,5664, Exc thigh/knee tum deep <5cm,27328,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3306.24,5664, Exc thigh/knee tum deep <5cm,27328,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3306.24,5664, Exc thigh/knee tum deep <5cm,27328,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3306.24,5664, Resect thigh/knee tum < 5 cm,27329,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5447.59,,,,,,,fee schedule,5097,5664, Resect thigh/knee tum < 5 cm,27329,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5097,5664, Resect thigh/knee tum < 5 cm,27329,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Resect thigh/knee tum < 5 cm,27329,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Biopsy knee joint lining,27330,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2274.63,,,,,,,fee schedule,2274.63,12821, Biopsy knee joint lining,27330,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2274.63,12821, Biopsy knee joint lining,27330,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2274.63,12821, Biopsy knee joint lining,27330,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2274.63,12821, Explore/treat knee joint,27331,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2538.66,,,,,,,fee schedule,2538.66,12821, Explore/treat knee joint,27331,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2538.66,12821, Explore/treat knee joint,27331,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2538.66,12821, Explore/treat knee joint,27331,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2538.66,12821, Removal of knee cartilage,27332,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3410,,,,,,,fee schedule,3410,12821, Removal of knee cartilage,27332,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3410,12821, Removal of knee cartilage,27332,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3410,12821, Removal of knee cartilage,27332,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3410,12821, Removal of knee cartilage,27333,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3124.07,,,,,,,fee schedule,3124.07,12821, Removal of knee cartilage,27333,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3124.07,12821, Removal of knee cartilage,27333,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3124.07,12821, Removal of knee cartilage,27333,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3124.07,12821, Remove knee joint lining,27334,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3611.33,,,,,,,fee schedule,3611.33,12821, Remove knee joint lining,27334,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3611.33,12821, Remove knee joint lining,27334,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3611.33,12821, Remove knee joint lining,27334,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3611.33,12821, Remove knee joint lining,27335,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4007.12,,,,,,,fee schedule,4007.12,12821, Remove knee joint lining,27335,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4007.12,12821, Remove knee joint lining,27335,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4007.12,12821, Remove knee joint lining,27335,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4007.12,12821, Exc thigh/knee les sc 3 cm/>,27337,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2288.23,,,,,,,fee schedule,2288.23,10940, Exc thigh/knee les sc 3 cm/>,27337,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2288.23,10940, Exc thigh/knee les sc 3 cm/>,27337,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2288.23,10940, Exc thigh/knee les sc 3 cm/>,27337,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2288.23,10940, Exc thigh/knee tum dep 5cm/>,27339,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4020.02,,,,,,,fee schedule,4020.02,10940, Exc thigh/knee tum dep 5cm/>,27339,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4020.02,10940, Exc thigh/knee tum dep 5cm/>,27339,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,4020.02,10940, Exc thigh/knee tum dep 5cm/>,27339,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,4020.02,10940, Removal of kneecap bursa,27340,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2027.49,,,,,,,fee schedule,2027.49,10940, Removal of kneecap bursa,27340,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2027.49,10940, Removal of kneecap bursa,27340,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2027.49,10940, Removal of kneecap bursa,27340,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2027.49,10940, Removal of knee cyst,27345,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2587,,,,,,,fee schedule,2587,10940, Removal of knee cyst,27345,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2587,10940, Removal of knee cyst,27345,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2587,10940, Removal of knee cyst,27345,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2587,10940, Remove knee cyst,27347,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2804.84,,,,,,,fee schedule,2804.84,10940, Remove knee cyst,27347,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2804.84,10940, Remove knee cyst,27347,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2804.84,10940, Remove knee cyst,27347,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2804.84,10940, Removal of kneecap,27350,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3440.06,,,,,,,fee schedule,3440.06,12821, Removal of kneecap,27350,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3440.06,12821, Removal of kneecap,27350,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3440.06,12821, Removal of kneecap,27350,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3440.06,12821, Remove femur lesion,27355,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3202.63,,,,,,,fee schedule,3202.63,12821, Remove femur lesion,27355,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3202.63,12821, Remove femur lesion,27355,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3202.63,12821, Remove femur lesion,27355,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3202.63,12821, Remove femur lesion/graft,27356,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3878.27,,,,,,,fee schedule,3878.27,12821, Remove femur lesion/graft,27356,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3878.27,12821, Remove femur lesion/graft,27356,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3878.27,12821, Remove femur lesion/graft,27356,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3878.27,12821, Remove femur lesion/graft,27357,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4268.34,,,,,,,fee schedule,4268.34,12821, Remove femur lesion/graft,27357,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4268.34,12821, Remove femur lesion/graft,27357,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4268.34,12821, Remove femur lesion/graft,27357,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4268.34,12821, Remove femur lesion/fixation,27358,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1355.04,,,,,,,fee schedule,1355.04,6044, Remove femur lesion/fixation,27358,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,1355.04,6044, Remove femur lesion/fixation,27358,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1355.04,6044, Remove femur lesion/fixation,27358,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1355.04,6044, Partial removal leg bone(s),27360,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4742.76,,,,,,,fee schedule,4742.76,12821, Partial removal leg bone(s),27360,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4742.76,12821, Partial removal leg bone(s),27360,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4742.76,12821, Partial removal leg bone(s),27360,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4742.76,12821, Resect thigh/knee tum 5 cm/>,27364,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8095.46,,,,,,,fee schedule,5248,10940, Resect thigh/knee tum 5 cm/>,27364,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,10940, Resect thigh/knee tum 5 cm/>,27364,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,5248,10940, Resect thigh/knee tum 5 cm/>,27364,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,5248,10940, Resect femur/knee tumor,27365,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10387.08,,,,,,,fee schedule,5248,22111, Resect femur/knee tumor,27365,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,22111, Resect femur/knee tumor,27365,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5248,22111, Resect femur/knee tumor,27365,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5248,22111, Njx cntrst kne arthg/ct/mri,27369,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,189.56,,,,,,,fee schedule,189.56,3195, Njx cntrst kne arthg/ct/mri,27369,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,189.56,3195, Njx cntrst kne arthg/ct/mri,27369,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,189.56,3195, Njx cntrst kne arthg/ct/mri,27369,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,189.56,3195, Removal of foreign body,27372,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2165.15,,,,,,,fee schedule,2165.15,10940, Removal of foreign body,27372,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,2165.15,10940, Removal of foreign body,27372,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2165.15,10940, Removal of foreign body,27372,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2165.15,10940, Repair of kneecap tendon,27380,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3289.62,,,,,,,fee schedule,3195,12821, Repair of kneecap tendon,27380,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,12821, Repair of kneecap tendon,27380,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3195,12821, Repair of kneecap tendon,27380,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3195,12821, Repair/graft kneecap tendon,27381,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4298.18,,,,,,,fee schedule,4298.18,12821, Repair/graft kneecap tendon,27381,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4298.18,12821, Repair/graft kneecap tendon,27381,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4298.18,12821, Repair/graft kneecap tendon,27381,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4298.18,12821, Repair of thigh muscle,27385,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3224.6,,,,,,,fee schedule,3224.6,12821, Repair of thigh muscle,27385,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3224.6,12821, Repair of thigh muscle,27385,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3224.6,12821, Repair of thigh muscle,27385,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3224.6,12821, Repair/graft of thigh muscle,27386,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4469.4,,,,,,,fee schedule,4469.4,12821, Repair/graft of thigh muscle,27386,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4469.4,12821, Repair/graft of thigh muscle,27386,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4469.4,12821, Repair/graft of thigh muscle,27386,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4469.4,12821, Incision of thigh tendon,27390,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2317.26,,,,,,,fee schedule,2317.26,10940, Incision of thigh tendon,27390,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2317.26,10940, Incision of thigh tendon,27390,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2317.26,10940, Incision of thigh tendon,27390,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2317.26,10940, Incision of thigh tendons,27391,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3054.14,,,,,,,fee schedule,3054.14,10940, Incision of thigh tendons,27391,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3054.14,10940, Incision of thigh tendons,27391,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3054.14,10940, Incision of thigh tendons,27391,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3054.14,10940, Incision of thigh tendons,27392,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3746.93,,,,,,,fee schedule,3746.93,12821, Incision of thigh tendons,27392,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3746.93,12821, Incision of thigh tendons,27392,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3746.93,12821, Incision of thigh tendons,27392,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3746.93,12821, Lengthening of thigh tendon,27393,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2636.65,,,,,,,fee schedule,2636.65,12821, Lengthening of thigh tendon,27393,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2636.65,12821, Lengthening of thigh tendon,27393,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2636.65,12821, Lengthening of thigh tendon,27393,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2636.65,12821, Lengthening of thigh tendons,27394,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3441.84,,,,,,,fee schedule,3441.84,12821, Lengthening of thigh tendons,27394,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3441.84,12821, Lengthening of thigh tendons,27394,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3441.84,12821, Lengthening of thigh tendons,27394,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3441.84,12821, Lengthening of thigh tendons,27395,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4587.09,,,,,,,fee schedule,4587.09,14456, Lengthening of thigh tendons,27395,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4587.09,14456, Lengthening of thigh tendons,27395,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4587.09,14456, Lengthening of thigh tendons,27395,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4587.09,14456, Transplant of thigh tendon,27396,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3265.61,,,,,,,fee schedule,3265.61,12821, Transplant of thigh tendon,27396,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3265.61,12821, Transplant of thigh tendon,27396,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3265.61,12821, Transplant of thigh tendon,27396,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3265.61,12821, Transplants of thigh tendons,27397,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4773.95,,,,,,,fee schedule,4773.95,14456, Transplants of thigh tendons,27397,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4773.95,14456, Transplants of thigh tendons,27397,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4773.95,14456, Transplants of thigh tendons,27397,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4773.95,14456, Revise thigh muscles/tendons,27400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3662.91,,,,,,,fee schedule,3662.91,14456, Revise thigh muscles/tendons,27400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3662.91,14456, Revise thigh muscles/tendons,27400,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3662.91,14456, Revise thigh muscles/tendons,27400,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3662.91,14456, Repair of knee cartilage,27403,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3389.77,,,,,,,fee schedule,3389.77,12821, Repair of knee cartilage,27403,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3389.77,12821, Repair of knee cartilage,27403,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3389.77,12821, Repair of knee cartilage,27403,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3389.77,12821, Repair of knee ligament,27405,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3535.14,,,,,,,fee schedule,3535.14,14456, Repair of knee ligament,27405,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3535.14,14456, Repair of knee ligament,27405,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3535.14,14456, Repair of knee ligament,27405,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3535.14,14456, Repair of knee ligament,27407,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4165.28,,,,,,,fee schedule,4165.28,22111, Repair of knee ligament,27407,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4165.28,22111, Repair of knee ligament,27407,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4165.28,22111, Repair of knee ligament,27407,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4165.28,22111, Repair of knee ligaments,27409,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5009.86,,,,,,,fee schedule,5009.86,14456, Repair of knee ligaments,27409,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5009.86,14456, Repair of knee ligaments,27409,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5009.86,14456, Repair of knee ligaments,27409,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5009.86,14456, Autochondrocyte implant knee,27412,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8407.51,,,,,,,fee schedule,5248,22111, Autochondrocyte implant knee,27412,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,22111, Autochondrocyte implant knee,27412,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5248,22111, Autochondrocyte implant knee,27412,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5248,22111, Osteochondral knee allograft,27415,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7056.08,,,,,,,fee schedule,5248,22111, Osteochondral knee allograft,27415,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,22111, Osteochondral knee allograft,27415,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5248,22111, Osteochondral knee allograft,27415,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5248,22111, Osteochondral knee autograft,27416,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5054.92,,,,,,,fee schedule,5054.92,14456, Osteochondral knee autograft,27416,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5054.92,14456, Osteochondral knee autograft,27416,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5054.92,14456, Osteochondral knee autograft,27416,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5054.92,14456, Repair degenerated kneecap,27418,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4249.57,,,,,,,fee schedule,4249.57,14456, Repair degenerated kneecap,27418,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4249.57,14456, Repair degenerated kneecap,27418,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4249.57,14456, Repair degenerated kneecap,27418,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4249.57,14456, Revision of unstable kneecap,27420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3926.56,,,,,,,fee schedule,3926.56,14456, Revision of unstable kneecap,27420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3926.56,14456, Revision of unstable kneecap,27420,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3926.56,14456, Revision of unstable kneecap,27420,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3926.56,14456, Revision of unstable kneecap,27422,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3888.52,,,,,,,fee schedule,3888.52,14456, Revision of unstable kneecap,27422,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,3888.52,14456, Revision of unstable kneecap,27422,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3888.52,14456, Revision of unstable kneecap,27422,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3888.52,14456, Revision/removal of kneecap,27424,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3921.22,,,,,,,fee schedule,3921.22,14456, Revision/removal of kneecap,27424,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3921.22,14456, Revision/removal of kneecap,27424,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3921.22,14456, Revision/removal of kneecap,27424,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3921.22,14456, Lat retinacular release open,27425,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2435.86,,,,,,,fee schedule,2435.86,12821, Lat retinacular release open,27425,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,2435.86,12821, Lat retinacular release open,27425,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2435.86,12821, Lat retinacular release open,27425,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2435.86,12821, Reconstruction knee,27427,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3678.56,,,,,,,fee schedule,3678.56,22111, Reconstruction knee,27427,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3678.56,22111, Reconstruction knee,27427,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3678.56,22111, Reconstruction knee,27427,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3678.56,22111, Reconstruction knee,27428,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5806.1,,,,,,,fee schedule,5363,22111, Reconstruction knee,27428,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,22111, Reconstruction knee,27428,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5363,22111, Reconstruction knee,27428,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5363,22111, Reconstruction knee,27429,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6540.49,,,,,,,fee schedule,5363,22111, Reconstruction knee,27429,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,22111, Reconstruction knee,27429,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5363,22111, Reconstruction knee,27429,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5363,22111, Revision of thigh muscles,27430,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3891.87,,,,,,,fee schedule,3891.87,14456, Revision of thigh muscles,27430,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3891.87,14456, Revision of thigh muscles,27430,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3891.87,14456, Revision of thigh muscles,27430,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3891.87,14456, Incision of knee joint,27435,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4225.34,,,,,,,fee schedule,4225.34,12821, Incision of knee joint,27435,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4225.34,12821, Incision of knee joint,27435,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4225.34,12821, Incision of knee joint,27435,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4225.34,12821, Revise kneecap,27437,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3474.21,,,,,,,fee schedule,3474.21,14456, Revise kneecap,27437,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3474.21,14456, Revise kneecap,27437,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3474.21,14456, Revise kneecap,27437,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3474.21,14456, Revise kneecap with implant,27438,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4365.04,,,,,,,fee schedule,4365.04,22111, Revise kneecap with implant,27438,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4365.04,22111, Revise kneecap with implant,27438,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4365.04,22111, Revise kneecap with implant,27438,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4365.04,22111, Revision of knee joint,27440,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4160.96,,,,,,,fee schedule,4160.96,14456, Revision of knee joint,27440,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4160.96,14456, Revision of knee joint,27440,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4160.96,14456, Revision of knee joint,27440,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4160.96,14456, Revision of knee joint,27441,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4290.47,,,,,,,fee schedule,4290.47,14456, Revision of knee joint,27441,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4290.47,14456, Revision of knee joint,27441,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4290.47,14456, Revision of knee joint,27441,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4290.47,14456, Revision of knee joint,27442,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4497.51,,,,,,,fee schedule,4497.51,14456, Revision of knee joint,27442,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4497.51,14456, Revision of knee joint,27442,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4497.51,14456, Revision of knee joint,27442,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4497.51,14456, Revision of knee joint,27443,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4252.05,,,,,,,fee schedule,4252.05,14456, Revision of knee joint,27443,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4252.05,14456, Revision of knee joint,27443,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4252.05,14456, Revision of knee joint,27443,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4252.05,14456, Revision of knee joint,27445,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,22111, Revision of knee joint,27445,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6979,22111, Revision of knee joint,27445,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6979,22111, Revision of knee joint,27446,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5883.8,,,,,,,fee schedule,5883.8,25393, Revision of knee joint,27446,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,5883.8,25393, Revision of knee joint,27446,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,5883.8,25393, Revision of knee joint,27446,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,5883.8,25393, Total knee arthroplasty,27447,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6528.46,,,,,,,fee schedule,6528.46,25393, Total knee arthroplasty,27447,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6528.46,25393, Total knee arthroplasty,27447,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,6528.46,25393, Total knee arthroplasty,27447,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,6528.46,25393, Incision of thigh,27448,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4260.9,,,,,,,fee schedule,4260.9,22111, Incision of thigh,27448,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4260.9,22111, Incision of thigh,27448,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4260.9,22111, Incision of thigh,27448,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4260.9,22111, Incision of thigh,27450,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5191.76,,,,,,,fee schedule,5191.76,22111, Incision of thigh,27450,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,5191.76,22111, Incision of thigh,27450,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5191.76,22111, Incision of thigh,27450,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5191.76,22111, Realignment of thigh bone,27454,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6634.87,,,,,,,fee schedule,6044,22111, Realignment of thigh bone,27454,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,22111, Realignment of thigh bone,27454,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6044,22111, Realignment of thigh bone,27454,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6044,22111, Realignment of knee,27455,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4982.02,,,,,,,fee schedule,4982.02,22111, Realignment of knee,27455,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4982.02,22111, Realignment of knee,27455,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4982.02,22111, Realignment of knee,27455,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4982.02,22111, Realignment of knee,27457,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4935.51,,,,,,,fee schedule,4935.51,14456, Realignment of knee,27457,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4935.51,14456, Realignment of knee,27457,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4935.51,14456, Realignment of knee,27457,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4935.51,14456, Osteot femur imed lngth dev,27458,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9649.18,,,,,,,fee schedule,6979,9649.18, Osteot femur imed lngth dev,27458,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,9649.18, Shortening of thigh bone,27465,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7269.38,,,,,,,fee schedule,6044,22111, Shortening of thigh bone,27465,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,22111, Shortening of thigh bone,27465,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6044,22111, Shortening of thigh bone,27465,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6044,22111, Lengthening of thigh bone,27466,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7703.76,,,,,,,fee schedule,6044,22111, Lengthening of thigh bone,27466,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,22111, Lengthening of thigh bone,27466,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6044,22111, Lengthening of thigh bone,27466,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6044,22111, Shorten/lengthen thighs,27468,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,22111, Shorten/lengthen thighs,27468,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6044,22111, Shorten/lengthen thighs,27468,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6044,22111, Repair of thigh,27470,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6080.54,,,,,,,fee schedule,6044,22111, Repair of thigh,27470,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,22111, Repair of thigh,27470,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6044,22111, Repair of thigh,27470,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6044,22111, Repair/graft of thigh,27472,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6490.58,,,,,,,fee schedule,6044,22111, Repair/graft of thigh,27472,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,22111, Repair/graft of thigh,27472,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6044,22111, Repair/graft of thigh,27472,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6044,22111, Surgery to stop leg growth,27475,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3487.27,,,,,,,fee schedule,3487.27,12821, Surgery to stop leg growth,27475,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3487.27,12821, Surgery to stop leg growth,27475,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3487.27,12821, Surgery to stop leg growth,27475,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3487.27,12821, Surgery to stop leg growth,27477,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3831.43,,,,,,,fee schedule,3831.43,12821, Surgery to stop leg growth,27477,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,3831.43,12821, Surgery to stop leg growth,27477,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3831.43,12821, Surgery to stop leg growth,27477,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3831.43,12821, Surgery to stop leg growth,27479,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4752.53,,,,,,,fee schedule,4752.53,12821, Surgery to stop leg growth,27479,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4752.53,12821, Surgery to stop leg growth,27479,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4752.53,12821, Surgery to stop leg growth,27479,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4752.53,12821, Surgery to stop leg growth,27485,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3524.72,,,,,,,fee schedule,3524.72,12821, Surgery to stop leg growth,27485,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,3524.72,12821, Surgery to stop leg growth,27485,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3524.72,12821, Surgery to stop leg growth,27485,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3524.72,12821, Revise/replace knee joint,27486,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7168.86,,,,,,,fee schedule,6979,25393, Revise/replace knee joint,27486,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,25393, Revise/replace knee joint,27486,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,6979,25393, Revise/replace knee joint,27486,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,6979,25393, Revise/replace knee joint,27487,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8883.97,,,,,,,fee schedule,6979,25393, Revise/replace knee joint,27487,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,25393, Revise/replace knee joint,27487,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,6979,25393, Revise/replace knee joint,27487,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,6979,25393, Removal of knee prosthesis,27488,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6167.84,,,,,,,fee schedule,6044,22111, Removal of knee prosthesis,27488,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,22111, Removal of knee prosthesis,27488,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6044,22111, Removal of knee prosthesis,27488,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6044,22111, Reinforce thigh,27495,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5809.12,,,,,,,fee schedule,5809.12,22111, Reinforce thigh,27495,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,5809.12,22111, Reinforce thigh,27495,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5809.12,22111, Reinforce thigh,27495,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5809.12,22111, Decompression of thigh/knee,27496,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2930.03,,,,,,,fee schedule,2930.03,12821, Decompression of thigh/knee,27496,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,2930.03,12821, Decompression of thigh/knee,27496,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2930.03,12821, Decompression of thigh/knee,27496,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2930.03,12821, Decompression of thigh/knee,27497,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3066.38,,,,,,,fee schedule,3066.38,10940, Decompression of thigh/knee,27497,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3066.38,10940, Decompression of thigh/knee,27497,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3066.38,10940, Decompression of thigh/knee,27497,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3066.38,10940, Decompression of thigh/knee,27498,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3467.15,,,,,,,fee schedule,3467.15,12821, Decompression of thigh/knee,27498,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3467.15,12821, Decompression of thigh/knee,27498,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3467.15,12821, Decompression of thigh/knee,27498,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3467.15,12821, Decompression of thigh/knee,27499,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3689.73,,,,,,,fee schedule,3689.73,12821, Decompression of thigh/knee,27499,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3689.73,12821, Decompression of thigh/knee,27499,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3689.73,12821, Decompression of thigh/knee,27499,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3689.73,12821, Treatment of thigh fracture,27500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2576.27,,,,,,,fee schedule,2505,3195, Treatment of thigh fracture,27500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Treatment of thigh fracture,27500,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Treatment of thigh fracture,27500,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Treatment of thigh fracture,27501,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2654.24,,,,,,,fee schedule,2505,4108, Treatment of thigh fracture,27501,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2505,4108, Treatment of thigh fracture,27501,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,4108, Treatment of thigh fracture,27501,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,4108, Treatment of thigh fracture,27502,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4218.27,,,,,,,fee schedule,4108,5664, Treatment of thigh fracture,27502,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,5664, Treatment of thigh fracture,27502,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4108,5664, Treatment of thigh fracture,27502,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4108,5664, Treatment of thigh fracture,27503,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4191.4,,,,,,,fee schedule,2505,5248, Treatment of thigh fracture,27503,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2505,5248, Treatment of thigh fracture,27503,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,5248, Treatment of thigh fracture,27503,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,5248, Treatment of thigh fracture,27506,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6858.91,,,,,,,fee schedule,6044,14456, Treatment of thigh fracture,27506,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,14456, Treatment of thigh fracture,27506,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,6044,14456, Treatment of thigh fracture,27506,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,6044,14456, Treatment of thigh fracture,27507,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4964.1,,,,,,,fee schedule,4964.1,14456, Treatment of thigh fracture,27507,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4964.1,14456, Treatment of thigh fracture,27507,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4964.1,14456, Treatment of thigh fracture,27507,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4964.1,14456, Treatment of thigh fracture,27508,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2694.92,,,,,,,fee schedule,2505,3195, Treatment of thigh fracture,27508,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Treatment of thigh fracture,27508,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Treatment of thigh fracture,27508,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Treatment of thigh fracture,27509,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3593.36,,,,,,,fee schedule,3593.36,10940, Treatment of thigh fracture,27509,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3593.36,10940, Treatment of thigh fracture,27509,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3593.36,10940, Treatment of thigh fracture,27509,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3593.36,10940, Treatment of thigh fracture,27510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3755.94,,,,,,,fee schedule,2505,3755.94, Treatment of thigh fracture,27510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3755.94, Treatment of thigh fracture,27510,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3755.94, Treatment of thigh fracture,27510,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3755.94, Treatment of thigh fracture,27511,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5070.35,,,,,,,fee schedule,5070.35,14456, Treatment of thigh fracture,27511,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5070.35,14456, Treatment of thigh fracture,27511,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5070.35,14456, Treatment of thigh fracture,27511,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5070.35,14456, Treatment of thigh fracture,27513,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6249.32,,,,,,,fee schedule,6044,14456, Treatment of thigh fracture,27513,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,14456, Treatment of thigh fracture,27513,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,6044,14456, Treatment of thigh fracture,27513,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,6044,14456, Treatment of thigh fracture,27514,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4922.99,,,,,,,fee schedule,4922.99,14456, Treatment of thigh fracture,27514,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4922.99,14456, Treatment of thigh fracture,27514,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4922.99,14456, Treatment of thigh fracture,27514,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4922.99,14456, Treat thigh fx growth plate,27516,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2622.46,,,,,,,fee schedule,2505,3195, Treat thigh fx growth plate,27516,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Treat thigh fx growth plate,27516,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Treat thigh fx growth plate,27516,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Treat thigh fx growth plate,27517,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3629.73,,,,,,,fee schedule,2505,3629.73, Treat thigh fx growth plate,27517,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3629.73, Treat thigh fx growth plate,27517,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3629.73, Treat thigh fx growth plate,27517,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3629.73, Treat thigh fx growth plate,27519,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4557.03,,,,,,,fee schedule,4557.03,14456, Treat thigh fx growth plate,27519,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4557.03,14456, Treat thigh fx growth plate,27519,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4557.03,14456, Treat thigh fx growth plate,27519,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4557.03,14456, Treat kneecap fracture,27520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1687.76,,,,,,,fee schedule,1687.76,3195, Treat kneecap fracture,27520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1687.76,3195, Treat kneecap fracture,27520,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1687.76,3195, Treat kneecap fracture,27520,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1687.76,3195, Treat kneecap fracture,27524,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3925.48,,,,,,,fee schedule,3925.48,22111, Treat kneecap fracture,27524,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3925.48,22111, Treat kneecap fracture,27524,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3925.48,22111, Treat kneecap fracture,27524,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3925.48,22111, Treat knee fracture,27530,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1625.17,,,,,,,fee schedule,1625.17,3195, Treat knee fracture,27530,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1625.17,3195, Treat knee fracture,27530,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1625.17,3195, Treat knee fracture,27530,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1625.17,3195, Treat knee fracture,27532,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3077.28,,,,,,,fee schedule,3077.28,5664, Treat knee fracture,27532,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3077.28,5664, Treat knee fracture,27532,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3077.28,5664, Treat knee fracture,27532,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3077.28,5664, Treat knee fracture,27535,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4580.61,,,,,,,fee schedule,4580.61,14456, Treat knee fracture,27535,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4580.61,14456, Treat knee fracture,27535,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4580.61,14456, Treat knee fracture,27535,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4580.61,14456, Treat knee fracture,27536,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6116.74,,,,,,,fee schedule,6044,14456, Treat knee fracture,27536,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,14456, Treat knee fracture,27536,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,6044,14456, Treat knee fracture,27536,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,6044,14456, Treat knee fracture(s),27538,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2468.18,,,,,,,fee schedule,2468.18,3195, Treat knee fracture(s),27538,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2468.18,3195, Treat knee fracture(s),27538,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2468.18,3195, Treat knee fracture(s),27538,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2468.18,3195, Treat knee fracture,27540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4250.75,,,,,,,fee schedule,4250.75,14456, Treat knee fracture,27540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4250.75,14456, Treat knee fracture,27540,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4250.75,14456, Treat knee fracture,27540,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4250.75,14456, Treat knee dislocation,27550,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2875.58,,,,,,,fee schedule,2505,3195, Treat knee dislocation,27550,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Treat knee dislocation,27550,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Treat knee dislocation,27550,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Treat knee dislocation,27552,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3356.15,,,,,,,fee schedule,3195,5664, Treat knee dislocation,27552,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,5664, Treat knee dislocation,27552,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3195,5664, Treat knee dislocation,27552,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3195,5664, Treat knee dislocation,27556,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4486.45,,,,,,,fee schedule,4486.45,14456, Treat knee dislocation,27556,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4486.45,14456, Treat knee dislocation,27556,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4486.45,14456, Treat knee dislocation,27556,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4486.45,14456, Treat knee dislocation,27557,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5315.01,,,,,,,fee schedule,5315.01,14456, Treat knee dislocation,27557,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,5315.01,14456, Treat knee dislocation,27557,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5315.01,14456, Treat knee dislocation,27557,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5315.01,14456, Treat knee dislocation,27558,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6026.52,,,,,,,fee schedule,6026.52,14456, Treat knee dislocation,27558,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6026.52,14456, Treat knee dislocation,27558,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,6026.52,14456, Treat knee dislocation,27558,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,6026.52,14456, Treat kneecap dislocation,27560,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2174.37,,,,,,,fee schedule,2174.37,3195, Treat kneecap dislocation,27560,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2174.37,3195, Treat kneecap dislocation,27560,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2174.37,3195, Treat kneecap dislocation,27560,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2174.37,3195, Treat kneecap dislocation,27562,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2626.5,,,,,,,fee schedule,2505,3195, Treat kneecap dislocation,27562,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Treat kneecap dislocation,27562,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Treat kneecap dislocation,27562,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Treat kneecap dislocation,27566,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4622,,,,,,,fee schedule,4108,22111, Treat kneecap dislocation,27566,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,22111, Treat kneecap dislocation,27566,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4108,22111, Treat kneecap dislocation,27566,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4108,22111, Fixation of knee joint,27570,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,823.97,,,,,,,fee schedule,823.97,5664, Fixation of knee joint,27570,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,823.97,5664, Fixation of knee joint,27570,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,823.97,5664, Fixation of knee joint,27570,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,823.97,5664, Fusion of knee,27580,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7581.49,,,,,,,fee schedule,6044,22111, Fusion of knee,27580,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,22111, Fusion of knee,27580,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6044,22111, Fusion of knee,27580,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6044,22111, Amputate leg at thigh,27590,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4146.5,,,,,,,fee schedule,4146.5,25393, Amputate leg at thigh,27590,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4146.5,25393, Amputate leg at thigh,27590,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,4146.5,25393, Amputate leg at thigh,27590,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,4146.5,25393, Amputate leg at thigh,27591,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4981.32,,,,,,,fee schedule,4981.32,25393, Amputate leg at thigh,27591,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4981.32,25393, Amputate leg at thigh,27591,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,4981.32,25393, Amputate leg at thigh,27591,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,4981.32,25393, Amputate leg at thigh,27592,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3583.21,,,,,,,fee schedule,3583.21,25393, Amputate leg at thigh,27592,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3583.21,25393, Amputate leg at thigh,27592,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,3583.21,25393, Amputate leg at thigh,27592,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,3583.21,25393, Amputation follow-up surgery,27594,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2686.67,,,,,,,fee schedule,2686.67,10940, Amputation follow-up surgery,27594,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2686.67,10940, Amputation follow-up surgery,27594,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2686.67,10940, Amputation follow-up surgery,27594,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2686.67,10940, Amputation follow-up surgery,27596,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3752.27,,,,,,,fee schedule,3752.27,22111, Amputation follow-up surgery,27596,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3752.27,22111, Amputation follow-up surgery,27596,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3752.27,22111, Amputation follow-up surgery,27596,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3752.27,22111, Amputate lower leg at knee,27598,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3678.83,,,,,,,fee schedule,3678.83,22111, Amputate lower leg at knee,27598,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3678.83,22111, Amputate lower leg at knee,27598,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3678.83,22111, Amputate lower leg at knee,27598,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3678.83,22111, Leg surgery procedure,27599,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Leg surgery procedure,27599,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Leg surgery procedure,27599,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Decompression of lower leg,27600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2105.3,,,,,,,fee schedule,2105.3,10940, Decompression of lower leg,27600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2105.3,10940, Decompression of lower leg,27600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2105.3,10940, Decompression of lower leg,27600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2105.3,10940, Decompression of lower leg,27601,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2314.4,,,,,,,fee schedule,2314.4,10940, Decompression of lower leg,27601,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2314.4,10940, Decompression of lower leg,27601,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2314.4,10940, Decompression of lower leg,27601,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2314.4,10940, Decompression of lower leg,27602,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2535.63,,,,,,,fee schedule,2535.63,12821, Decompression of lower leg,27602,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2535.63,12821, Decompression of lower leg,27602,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2535.63,12821, Decompression of lower leg,27602,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2535.63,12821, Drain lower leg lesion,27603,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2047.13,,,,,,,fee schedule,2047.13,10940, Drain lower leg lesion,27603,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2047.13,10940, Drain lower leg lesion,27603,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2047.13,10940, Drain lower leg lesion,27603,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2047.13,10940, Drain lower leg bursa,27604,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1749.76,,,,,,,fee schedule,1749.76,10940, Drain lower leg bursa,27604,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1749.76,10940, Drain lower leg bursa,27604,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1749.76,10940, Drain lower leg bursa,27604,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1749.76,10940, Incision of achilles tendon,27605,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,944.46,,,,,,,fee schedule,944.46,10940, Incision of achilles tendon,27605,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,944.46,10940, Incision of achilles tendon,27605,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,944.46,10940, Incision of achilles tendon,27605,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,944.46,10940, Incision of achilles tendon,27606,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1411.11,,,,,,,fee schedule,1411.11,10940, Incision of achilles tendon,27606,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1411.11,10940, Incision of achilles tendon,27606,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1411.11,10940, Incision of achilles tendon,27606,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1411.11,10940, Treat lower leg bone lesion,27607,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3154.93,,,,,,,fee schedule,3154.93,10940, Treat lower leg bone lesion,27607,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3154.93,10940, Treat lower leg bone lesion,27607,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3154.93,10940, Treat lower leg bone lesion,27607,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3154.93,10940, Explore/treat ankle joint,27610,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3376.76,,,,,,,fee schedule,3376.76,12821, Explore/treat ankle joint,27610,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3376.76,12821, Explore/treat ankle joint,27610,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3376.76,12821, Explore/treat ankle joint,27610,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3376.76,12821, Exploration of ankle joint,27612,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2979.29,,,,,,,fee schedule,2979.29,12821, Exploration of ankle joint,27612,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2979.29,12821, Exploration of ankle joint,27612,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2979.29,12821, Exploration of ankle joint,27612,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2979.29,12821, Biopsy lower leg soft tissue,27613,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,828.45,,,,,,,fee schedule,828.45,4497, Biopsy lower leg soft tissue,27613,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,828.45,4497, Biopsy lower leg soft tissue,27613,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,828.45,4497, Biopsy lower leg soft tissue,27613,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,828.45,4497, Biopsy lower leg soft tissue,27614,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2156.67,,,,,,,fee schedule,2156.67,10940, Biopsy lower leg soft tissue,27614,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2156.67,10940, Biopsy lower leg soft tissue,27614,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2156.67,10940, Biopsy lower leg soft tissue,27614,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2156.67,10940, Resect leg/ankle tum < 5 cm,27615,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5309.99,,,,,,,fee schedule,5097,5664, Resect leg/ankle tum < 5 cm,27615,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5097,5664, Resect leg/ankle tum < 5 cm,27615,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Resect leg/ankle tum < 5 cm,27615,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Resect leg/ankle tum 5 cm/>,27616,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6540.01,,,,,,,fee schedule,5248,10940, Resect leg/ankle tum 5 cm/>,27616,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,10940, Resect leg/ankle tum 5 cm/>,27616,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,5248,10940, Resect leg/ankle tum 5 cm/>,27616,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,5248,10940, Exc leg/ankle tum < 3 cm,27618,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1646.16,,,,,,,fee schedule,1646.16,5664, Exc leg/ankle tum < 3 cm,27618,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1646.16,5664, Exc leg/ankle tum < 3 cm,27618,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1646.16,5664, Exc leg/ankle tum < 3 cm,27618,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1646.16,5664, Exc leg/ankle tum deep <5 cm,27619,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2415.09,,,,,,,fee schedule,2415.09,5664, Exc leg/ankle tum deep <5 cm,27619,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2415.09,5664, Exc leg/ankle tum deep <5 cm,27619,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2415.09,5664, Exc leg/ankle tum deep <5 cm,27619,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2415.09,5664, Explore/treat ankle joint,27620,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2395.93,,,,,,,fee schedule,2395.93,12821, Explore/treat ankle joint,27620,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2395.93,12821, Explore/treat ankle joint,27620,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2395.93,12821, Explore/treat ankle joint,27620,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2395.93,12821, Remove ankle joint lining,27625,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3025.21,,,,,,,fee schedule,3025.21,12821, Remove ankle joint lining,27625,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3025.21,12821, Remove ankle joint lining,27625,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3025.21,12821, Remove ankle joint lining,27625,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3025.21,12821, Remove ankle joint lining,27626,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3111.6,,,,,,,fee schedule,3111.6,12821, Remove ankle joint lining,27626,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3111.6,12821, Remove ankle joint lining,27626,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3111.6,12821, Remove ankle joint lining,27626,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3111.6,12821, Removal of tendon lesion,27630,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1897.67,,,,,,,fee schedule,1897.67,10940, Removal of tendon lesion,27630,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1897.67,10940, Removal of tendon lesion,27630,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1897.67,10940, Removal of tendon lesion,27630,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1897.67,10940, Exc leg/ankle les sc 3 cm/>,27632,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2193.96,,,,,,,fee schedule,2193.96,10940, Exc leg/ankle les sc 3 cm/>,27632,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2193.96,10940, Exc leg/ankle les sc 3 cm/>,27632,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2193.96,10940, Exc leg/ankle les sc 3 cm/>,27632,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2193.96,10940, Exc leg/ankle tum dep 5 cm/>,27634,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3482.79,,,,,,,fee schedule,3482.79,10940, Exc leg/ankle tum dep 5 cm/>,27634,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3482.79,10940, Exc leg/ankle tum dep 5 cm/>,27634,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3482.79,10940, Exc leg/ankle tum dep 5 cm/>,27634,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3482.79,10940, Remove lower leg bone lesion,27635,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3014.53,,,,,,,fee schedule,3014.53,12821, Remove lower leg bone lesion,27635,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3014.53,12821, Remove lower leg bone lesion,27635,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3014.53,12821, Remove lower leg bone lesion,27635,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3014.53,12821, Remove/graft leg bone lesion,27637,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3927.91,,,,,,,fee schedule,3927.91,12821, Remove/graft leg bone lesion,27637,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3927.91,12821, Remove/graft leg bone lesion,27637,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3927.91,12821, Remove/graft leg bone lesion,27637,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3927.91,12821, Remove/graft leg bone lesion,27638,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3880.8,,,,,,,fee schedule,3880.8,12821, Remove/graft leg bone lesion,27638,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3880.8,12821, Remove/graft leg bone lesion,27638,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3880.8,12821, Remove/graft leg bone lesion,27638,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3880.8,12821, Partial removal of tibia,27640,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4274.17,,,,,,,fee schedule,4108,12821, Partial removal of tibia,27640,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,12821, Partial removal of tibia,27640,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4108,12821, Partial removal of tibia,27640,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4108,12821, Partial removal of fibula,27641,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3374.06,,,,,,,fee schedule,3374.06,12821, Partial removal of fibula,27641,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3374.06,12821, Partial removal of fibula,27641,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3374.06,12821, Partial removal of fibula,27641,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3374.06,12821, Resect tibia tumor,27645,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8964.48,,,,,,,fee schedule,6044,22111, Resect tibia tumor,27645,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,22111, Resect tibia tumor,27645,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6044,22111, Resect tibia tumor,27645,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6044,22111, Resect fibula tumor,27646,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7824.09,,,,,,,fee schedule,6044,22111, Resect fibula tumor,27646,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,22111, Resect fibula tumor,27646,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6044,22111, Resect fibula tumor,27646,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6044,22111, Resect talus/calcaneus tum,27647,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5001.93,,,,,,,fee schedule,5001.93,12821, Resect talus/calcaneus tum,27647,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5001.93,12821, Resect talus/calcaneus tum,27647,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5001.93,12821, Resect talus/calcaneus tum,27647,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5001.93,12821, Injection for ankle x-ray,27648,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,246.97,,,,,,,fee schedule,246.97,3195, Injection for ankle x-ray,27648,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,246.97,3195, Injection for ankle x-ray,27648,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,246.97,3195, Injection for ankle x-ray,27648,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,246.97,3195, Repair achilles tendon,27650,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3434.45,,,,,,,fee schedule,3434.45,14456, Repair achilles tendon,27650,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3434.45,14456, Repair achilles tendon,27650,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3434.45,14456, Repair achilles tendon,27650,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3434.45,14456, Repair/graft achilles tendon,27652,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3401.04,,,,,,,fee schedule,3401.04,14456, Repair/graft achilles tendon,27652,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3401.04,14456, Repair/graft achilles tendon,27652,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3401.04,14456, Repair/graft achilles tendon,27652,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3401.04,14456, Repair of achilles tendon,27654,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3728.53,,,,,,,fee schedule,3728.53,14456, Repair of achilles tendon,27654,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3728.53,14456, Repair of achilles tendon,27654,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3728.53,14456, Repair of achilles tendon,27654,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3728.53,14456, Repair leg fascia defect,27656,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1752.35,,,,,,,fee schedule,1752.35,10940, Repair leg fascia defect,27656,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1752.35,10940, Repair leg fascia defect,27656,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1752.35,10940, Repair leg fascia defect,27656,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1752.35,10940, Repair of leg tendon each,27658,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1956.37,,,,,,,fee schedule,1956.37,10940, Repair of leg tendon each,27658,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1956.37,10940, Repair of leg tendon each,27658,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1956.37,10940, Repair of leg tendon each,27658,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1956.37,10940, Repair of leg tendon each,27659,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2456.15,,,,,,,fee schedule,2456.15,10940, Repair of leg tendon each,27659,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2456.15,10940, Repair of leg tendon each,27659,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2456.15,10940, Repair of leg tendon each,27659,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2456.15,10940, Repair of leg tendon each,27664,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1881.26,,,,,,,fee schedule,1881.26,12821, Repair of leg tendon each,27664,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1881.26,12821, Repair of leg tendon each,27664,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,1881.26,12821, Repair of leg tendon each,27664,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,1881.26,12821, Repair of leg tendon each,27665,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2189.53,,,,,,,fee schedule,2189.53,12821, Repair of leg tendon each,27665,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2189.53,12821, Repair of leg tendon each,27665,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2189.53,12821, Repair of leg tendon each,27665,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2189.53,12821, Repair lower leg tendons,27675,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2583.17,,,,,,,fee schedule,2583.17,10940, Repair lower leg tendons,27675,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2583.17,10940, Repair lower leg tendons,27675,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2583.17,10940, Repair lower leg tendons,27675,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2583.17,10940, Repair lower leg tendons,27676,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3175.28,,,,,,,fee schedule,3175.28,12821, Repair lower leg tendons,27676,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3175.28,12821, Repair lower leg tendons,27676,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3175.28,12821, Repair lower leg tendons,27676,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3175.28,12821, Release of lower leg tendon,27680,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2247.33,,,,,,,fee schedule,2247.33,12821, Release of lower leg tendon,27680,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2247.33,12821, Release of lower leg tendon,27680,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2247.33,12821, Release of lower leg tendon,27680,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2247.33,12821, Release of lower leg tendons,27681,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2702.64,,,,,,,fee schedule,2702.64,12821, Release of lower leg tendons,27681,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2702.64,12821, Release of lower leg tendons,27681,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2702.64,12821, Release of lower leg tendons,27681,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2702.64,12821, Revision of lower leg tendon,27685,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2430.57,,,,,,,fee schedule,2430.57,12821, Revision of lower leg tendon,27685,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2430.57,12821, Revision of lower leg tendon,27685,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2430.57,12821, Revision of lower leg tendon,27685,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2430.57,12821, Revise lower leg tendons,27686,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2775.11,,,,,,,fee schedule,2775.11,12821, Revise lower leg tendons,27686,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2775.11,12821, Revise lower leg tendons,27686,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2775.11,12821, Revise lower leg tendons,27686,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2775.11,12821, Revision of calf tendon,27687,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2386.11,,,,,,,fee schedule,2386.11,12821, Revision of calf tendon,27687,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2386.11,12821, Revision of calf tendon,27687,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2386.11,12821, Revision of calf tendon,27687,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2386.11,12821, Revise lower leg tendon,27690,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3342.55,,,,,,,fee schedule,3342.55,14456, Revise lower leg tendon,27690,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3342.55,14456, Revise lower leg tendon,27690,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3342.55,14456, Revise lower leg tendon,27690,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3342.55,14456, Revise lower leg tendon,27691,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3878.11,,,,,,,fee schedule,3878.11,14456, Revise lower leg tendon,27691,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3878.11,14456, Revise lower leg tendon,27691,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3878.11,14456, Revise lower leg tendon,27691,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3878.11,14456, Revise additional leg tendon,27692,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,510.73,,,,,,,fee schedule,510.73,5248, Revise additional leg tendon,27692,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,510.73,5248, Revise additional leg tendon,27692,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,510.73,5248, Revise additional leg tendon,27692,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,510.73,5248, Repair of ankle ligament,27695,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2559.16,,,,,,,fee schedule,2559.16,12821, Repair of ankle ligament,27695,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2559.16,12821, Repair of ankle ligament,27695,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2559.16,12821, Repair of ankle ligament,27695,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2559.16,12821, Repair of ankle ligaments,27696,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2809.54,,,,,,,fee schedule,2809.54,12821, Repair of ankle ligaments,27696,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2809.54,12821, Repair of ankle ligaments,27696,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2809.54,12821, Repair of ankle ligaments,27696,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2809.54,12821, Repair of ankle ligament,27698,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3301.22,,,,,,,fee schedule,3301.22,12821, Repair of ankle ligament,27698,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3301.22,12821, Repair of ankle ligament,27698,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3301.22,12821, Repair of ankle ligament,27698,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3301.22,12821, Revision of ankle joint,27700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3724.8,,,,,,,fee schedule,3724.8,14456, Revision of ankle joint,27700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,3724.8,14456, Revision of ankle joint,27700,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3724.8,14456, Revision of ankle joint,27700,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3724.8,14456, Reconstruct ankle joint,27702,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4937.77,,,,,,,fee schedule,4937.77,22111, Reconstruct ankle joint,27702,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4937.77,22111, Reconstruct ankle joint,27702,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4937.77,22111, Reconstruct ankle joint,27702,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4937.77,22111, Reconstruction ankle joint,27703,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5689.6,,,,,,,fee schedule,5689.6,22111, Reconstruction ankle joint,27703,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5689.6,22111, Reconstruction ankle joint,27703,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5689.6,22111, Reconstruction ankle joint,27703,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5689.6,22111, Removal of ankle implant,27704,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2920.48,,,,,,,fee schedule,2920.48,12821, Removal of ankle implant,27704,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2920.48,12821, Removal of ankle implant,27704,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2920.48,12821, Removal of ankle implant,27704,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2920.48,12821, Incision of tibia,27705,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3850.75,,,,,,,fee schedule,3850.75,14456, Incision of tibia,27705,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3850.75,14456, Incision of tibia,27705,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3850.75,14456, Incision of tibia,27705,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3850.75,14456, Incision of fibula,27707,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2149.23,,,,,,,fee schedule,2149.23,12821, Incision of fibula,27707,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2149.23,12821, Incision of fibula,27707,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2149.23,12821, Incision of fibula,27707,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2149.23,12821, Incision of tibia & fibula,27709,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5889.68,,,,,,,fee schedule,4108,12821, Incision of tibia & fibula,27709,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,12821, Incision of tibia & fibula,27709,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4108,12821, Incision of tibia & fibula,27709,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4108,12821, Realignment of lower leg,27712,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5691.86,,,,,,,fee schedule,5691.86,22111, Realignment of lower leg,27712,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,5691.86,22111, Realignment of lower leg,27712,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5691.86,22111, Realignment of lower leg,27712,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5691.86,22111, Osteot tibia imed lngth dev,27713,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9782.25,,,,,,,fee schedule,6979,9782.25, Osteot tibia imed lngth dev,27713,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,9782.25, Revision of lower leg,27715,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7661.83,,,,,,,fee schedule,5363,22111, Revision of lower leg,27715,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,22111, Revision of lower leg,27715,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5363,22111, Revision of lower leg,27715,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5363,22111, Repair of tibia,27720,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4518.34,,,,,,,fee schedule,4518.34,22111, Repair of tibia,27720,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4518.34,22111, Repair of tibia,27720,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4518.34,22111, Repair of tibia,27720,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4518.34,22111, Repair/graft of tibia,27722,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4650.54,,,,,,,fee schedule,4650.54,22111, Repair/graft of tibia,27722,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4650.54,22111, Repair/graft of tibia,27722,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4650.54,22111, Repair/graft of tibia,27722,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4650.54,22111, Repair/graft of tibia,27724,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6392.8,,,,,,,fee schedule,6044,22111, Repair/graft of tibia,27724,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,22111, Repair/graft of tibia,27724,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6044,22111, Repair/graft of tibia,27724,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6044,22111, Repair of lower leg,27725,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6286.66,,,,,,,fee schedule,6044,22111, Repair of lower leg,27725,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,22111, Repair of lower leg,27725,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6044,22111, Repair of lower leg,27725,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6044,22111, Repair fibula nonunion,27726,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4897.25,,,,,,,fee schedule,4897.25,22111, Repair fibula nonunion,27726,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4897.25,22111, Repair fibula nonunion,27726,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4897.25,22111, Repair fibula nonunion,27726,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4897.25,22111, Repair of lower leg,27727,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5358.01,,,,,,,fee schedule,5358.01,22111, Repair of lower leg,27727,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,5358.01,22111, Repair of lower leg,27727,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5358.01,22111, Repair of lower leg,27727,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5358.01,22111, Repair of tibia epiphysis,27730,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3112.95,,,,,,,fee schedule,3112.95,12821, Repair of tibia epiphysis,27730,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3112.95,12821, Repair of tibia epiphysis,27730,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3112.95,12821, Repair of tibia epiphysis,27730,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3112.95,12821, Repair of fibula epiphysis,27732,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2434.14,,,,,,,fee schedule,2434.14,12821, Repair of fibula epiphysis,27732,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2434.14,12821, Repair of fibula epiphysis,27732,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2434.14,12821, Repair of fibula epiphysis,27732,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2434.14,12821, Repair lower leg epiphyses,27734,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3458.67,,,,,,,fee schedule,3458.67,12821, Repair lower leg epiphyses,27734,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3458.67,12821, Repair lower leg epiphyses,27734,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3458.67,12821, Repair lower leg epiphyses,27734,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3458.67,12821, Repair of leg epiphyses,27740,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3713.04,,,,,,,fee schedule,3713.04,12821, Repair of leg epiphyses,27740,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3713.04,12821, Repair of leg epiphyses,27740,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3713.04,12821, Repair of leg epiphyses,27740,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3713.04,12821, Repair of leg epiphyses,27742,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4067.29,,,,,,,fee schedule,4067.29,14456, Repair of leg epiphyses,27742,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4067.29,14456, Repair of leg epiphyses,27742,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4067.29,14456, Repair of leg epiphyses,27742,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4067.29,14456, Reinforce tibia,27745,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3770.56,,,,,,,fee schedule,3770.56,22111, Reinforce tibia,27745,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3770.56,22111, Reinforce tibia,27745,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3770.56,22111, Reinforce tibia,27745,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3770.56,22111, Treatment of tibia fracture,27750,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1814.41,,,,,,,fee schedule,1814.41,3195, Treatment of tibia fracture,27750,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1814.41,3195, Treatment of tibia fracture,27750,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1814.41,3195, Treatment of tibia fracture,27750,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1814.41,3195, Treatment of tibia fracture,27752,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2763.35,,,,,,,fee schedule,2763.35,5664, Treatment of tibia fracture,27752,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2763.35,5664, Treatment of tibia fracture,27752,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2763.35,5664, Treatment of tibia fracture,27752,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2763.35,5664, Treatment of tibia fracture,27756,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3120.29,,,,,,,fee schedule,3120.29,10940, Treatment of tibia fracture,27756,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3120.29,10940, Treatment of tibia fracture,27756,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3120.29,10940, Treatment of tibia fracture,27756,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3120.29,10940, Treatment of tibia fracture,27758,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4649.25,,,,,,,fee schedule,4649.25,22111, Treatment of tibia fracture,27758,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4649.25,22111, Treatment of tibia fracture,27758,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4649.25,22111, Treatment of tibia fracture,27758,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4649.25,22111, Treatment of tibia fracture,27759,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5141.09,,,,,,,fee schedule,5141.09,22111, Treatment of tibia fracture,27759,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5141.09,22111, Treatment of tibia fracture,27759,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5141.09,22111, Treatment of tibia fracture,27759,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5141.09,22111, Cltx medial ankle fx,27760,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1731.9,,,,,,,fee schedule,1731.9,3195, Cltx medial ankle fx,27760,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1731.9,3195, Cltx medial ankle fx,27760,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1731.9,3195, Cltx medial ankle fx,27760,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1731.9,3195, Cltx med ankle fx w/mnpj,27762,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2692.66,,,,,,,fee schedule,2692.66,5664, Cltx med ankle fx w/mnpj,27762,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2692.66,5664, Cltx med ankle fx w/mnpj,27762,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2692.66,5664, Cltx med ankle fx w/mnpj,27762,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2692.66,5664, Optx medial ankle fx,27766,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3199.02,,,,,,,fee schedule,3199.02,22111, Optx medial ankle fx,27766,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3199.02,22111, Optx medial ankle fx,27766,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3199.02,22111, Optx medial ankle fx,27766,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3199.02,22111, Cltx post ankle fx,27767,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1618.42,,,,,,,fee schedule,1618.42,3195, Cltx post ankle fx,27767,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1618.42,3195, Cltx post ankle fx,27767,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1618.42,3195, Cltx post ankle fx,27767,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1618.42,3195, Cltx post ankle fx w/mnpj,27768,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2426.47,,,,,,,fee schedule,2426.47,3195, Cltx post ankle fx w/mnpj,27768,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2426.47,3195, Cltx post ankle fx w/mnpj,27768,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2426.47,3195, Cltx post ankle fx w/mnpj,27768,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2426.47,3195, Optx post ankle fx,27769,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3758.31,,,,,,,fee schedule,3758.31,22111, Optx post ankle fx,27769,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3758.31,22111, Optx post ankle fx,27769,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3758.31,22111, Optx post ankle fx,27769,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3758.31,22111, Treatment of fibula fracture,27780,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1614,,,,,,,fee schedule,1614,3195, Treatment of fibula fracture,27780,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1614,3195, Treatment of fibula fracture,27780,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1614,3195, Treatment of fibula fracture,27780,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1614,3195, Treatment of fibula fracture,27781,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2231.03,,,,,,,fee schedule,2231.03,4497, Treatment of fibula fracture,27781,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2231.03,4497, Treatment of fibula fracture,27781,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,2231.03,4497, Treatment of fibula fracture,27781,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,2231.03,4497, Treatment of fibula fracture,27784,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3730.04,,,,,,,fee schedule,3730.04,22111, Treatment of fibula fracture,27784,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3730.04,22111, Treatment of fibula fracture,27784,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3730.04,22111, Treatment of fibula fracture,27784,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3730.04,22111, Treatment of ankle fracture,27786,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1591.06,,,,,,,fee schedule,1591.06,3195, Treatment of ankle fracture,27786,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1591.06,3195, Treatment of ankle fracture,27786,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1591.06,3195, Treatment of ankle fracture,27786,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1591.06,3195, Treatment of ankle fracture,27788,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2269.99,,,,,,,fee schedule,2269.99,3195, Treatment of ankle fracture,27788,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2269.99,3195, Treatment of ankle fracture,27788,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2269.99,3195, Treatment of ankle fracture,27788,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2269.99,3195, Treatment of ankle fracture,27792,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3362.25,,,,,,,fee schedule,3362.25,22111, Treatment of ankle fracture,27792,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3362.25,22111, Treatment of ankle fracture,27792,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3362.25,22111, Treatment of ankle fracture,27792,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3362.25,22111, Treatment of ankle fracture,27808,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1731.2,,,,,,,fee schedule,1731.2,3195, Treatment of ankle fracture,27808,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1731.2,3195, Treatment of ankle fracture,27808,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1731.2,3195, Treatment of ankle fracture,27808,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1731.2,3195, Treatment of ankle fracture,27810,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2551.5,,,,,,,fee schedule,2551.5,4497, Treatment of ankle fracture,27810,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2551.5,4497, Treatment of ankle fracture,27810,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,2551.5,4497, Treatment of ankle fracture,27810,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,2551.5,4497, Treatment of ankle fracture,27814,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3968.7,,,,,,,fee schedule,3968.7,22111, Treatment of ankle fracture,27814,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3968.7,22111, Treatment of ankle fracture,27814,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3968.7,22111, Treatment of ankle fracture,27814,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3968.7,22111, Treatment of ankle fracture,27816,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1702.76,,,,,,,fee schedule,1702.76,3195, Treatment of ankle fracture,27816,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1702.76,3195, Treatment of ankle fracture,27816,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1702.76,3195, Treatment of ankle fracture,27816,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1702.76,3195, Treatment of ankle fracture,27818,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2624.24,,,,,,,fee schedule,2624.24,4497, Treatment of ankle fracture,27818,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2624.24,4497, Treatment of ankle fracture,27818,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,2624.24,4497, Treatment of ankle fracture,27818,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,2624.24,4497, Treatment of ankle fracture,27822,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4560.38,,,,,,,fee schedule,4560.38,22111, Treatment of ankle fracture,27822,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4560.38,22111, Treatment of ankle fracture,27822,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4560.38,22111, Treatment of ankle fracture,27822,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4560.38,22111, Treatment of ankle fracture,27823,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5113.57,,,,,,,fee schedule,5113.57,22111, Treatment of ankle fracture,27823,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5113.57,22111, Treatment of ankle fracture,27823,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5113.57,22111, Treatment of ankle fracture,27823,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5113.57,22111, Treat lower leg fracture,27824,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1728.28,,,,,,,fee schedule,1728.28,3195, Treat lower leg fracture,27824,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1728.28,3195, Treat lower leg fracture,27824,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1728.28,3195, Treat lower leg fracture,27824,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1728.28,3195, Treat lower leg fracture,27825,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2655.59,,,,,,,fee schedule,2655.59,5664, Treat lower leg fracture,27825,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2655.59,5664, Treat lower leg fracture,27825,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2655.59,5664, Treat lower leg fracture,27825,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2655.59,5664, Treat lower leg fracture,27826,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4485.64,,,,,,,fee schedule,4485.64,22111, Treat lower leg fracture,27826,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4485.64,22111, Treat lower leg fracture,27826,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4485.64,22111, Treat lower leg fracture,27826,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4485.64,22111, Treat lower leg fracture,27827,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5836.85,,,,,,,fee schedule,5248,22111, Treat lower leg fracture,27827,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,22111, Treat lower leg fracture,27827,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5248,22111, Treat lower leg fracture,27827,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5248,22111, Treat lower leg fracture,27828,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6847.2,,,,,,,fee schedule,5363,22111, Treat lower leg fracture,27828,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,22111, Treat lower leg fracture,27828,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5363,22111, Treat lower leg fracture,27828,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5363,22111, Treat lower leg joint,27829,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3700.58,,,,,,,fee schedule,3700.58,22111, Treat lower leg joint,27829,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3700.58,22111, Treat lower leg joint,27829,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3700.58,22111, Treat lower leg joint,27829,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3700.58,22111, Treat lower leg dislocation,27830,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1973.26,,,,,,,fee schedule,1973.26,3195, Treat lower leg dislocation,27830,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1973.26,3195, Treat lower leg dislocation,27830,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1973.26,3195, Treat lower leg dislocation,27830,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1973.26,3195, Treat lower leg dislocation,27831,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2213.12,,,,,,,fee schedule,2213.12,4497, Treat lower leg dislocation,27831,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2213.12,4497, Treat lower leg dislocation,27831,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,2213.12,4497, Treat lower leg dislocation,27831,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,2213.12,4497, Treat lower leg dislocation,27832,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3984.24,,,,,,,fee schedule,3984.24,22111, Treat lower leg dislocation,27832,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3984.24,22111, Treat lower leg dislocation,27832,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3984.24,22111, Treat lower leg dislocation,27832,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3984.24,22111, Treat ankle dislocation,27840,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2479.73,,,,,,,fee schedule,2479.73,3195, Treat ankle dislocation,27840,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2479.73,3195, Treat ankle dislocation,27840,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2479.73,3195, Treat ankle dislocation,27840,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2479.73,3195, Treat ankle dislocation,27842,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2711.92,,,,,,,fee schedule,2711.92,5664, Treat ankle dislocation,27842,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2711.92,5664, Treat ankle dislocation,27842,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2711.92,5664, Treat ankle dislocation,27842,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2711.92,5664, Treat ankle dislocation,27846,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3749.95,,,,,,,fee schedule,3749.95,22111, Treat ankle dislocation,27846,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3749.95,22111, Treat ankle dislocation,27846,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3749.95,22111, Treat ankle dislocation,27846,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3749.95,22111, Treat ankle dislocation,27848,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108.41,,,,,,,fee schedule,4108.41,22111, Treat ankle dislocation,27848,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4108.41,22111, Treat ankle dislocation,27848,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4108.41,22111, Treat ankle dislocation,27848,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4108.41,22111, Fixation of ankle joint,27860,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,850.73,,,,,,,fee schedule,850.73,5664, Fixation of ankle joint,27860,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,850.73,5664, Fixation of ankle joint,27860,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,850.73,5664, Fixation of ankle joint,27860,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,850.73,5664, Fusion of ankle joint open,27870,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5170.82,,,,,,,fee schedule,5170.82,22111, Fusion of ankle joint open,27870,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5170.82,22111, Fusion of ankle joint open,27870,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5170.82,22111, Fusion of ankle joint open,27870,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5170.82,22111, Fusion of tibiofibular joint,27871,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3593.63,,,,,,,fee schedule,3593.63,22111, Fusion of tibiofibular joint,27871,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3593.63,22111, Fusion of tibiofibular joint,27871,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3593.63,22111, Fusion of tibiofibular joint,27871,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3593.63,22111, Amputation of lower leg,27880,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4724.47,,,,,,,fee schedule,4724.47,25393, Amputation of lower leg,27880,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4724.47,25393, Amputation of lower leg,27880,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,4724.47,25393, Amputation of lower leg,27880,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,4724.47,25393, Amputation of lower leg,27881,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4332.29,,,,,,,fee schedule,4332.29,22111, Amputation of lower leg,27881,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4332.29,22111, Amputation of lower leg,27881,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4332.29,22111, Amputation of lower leg,27881,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4332.29,22111, Amputation of lower leg,27882,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3160.22,,,,,,,fee schedule,3160.22,22111, Amputation of lower leg,27882,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3160.22,22111, Amputation of lower leg,27882,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3160.22,22111, Amputation of lower leg,27882,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3160.22,22111, Amputation follow-up surgery,27884,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3095.58,,,,,,,fee schedule,3095.58,10940, Amputation follow-up surgery,27884,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3095.58,10940, Amputation follow-up surgery,27884,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3095.58,10940, Amputation follow-up surgery,27884,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3095.58,10940, Amputation follow-up surgery,27886,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3415.02,,,,,,,fee schedule,3415.02,22111, Amputation follow-up surgery,27886,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3415.02,22111, Amputation follow-up surgery,27886,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3415.02,22111, Amputation follow-up surgery,27886,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3415.02,22111, Amputation of foot at ankle,27888,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3084.46,,,,,,,fee schedule,3084.46,22111, Amputation of foot at ankle,27888,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3084.46,22111, Amputation of foot at ankle,27888,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3084.46,22111, Amputation of foot at ankle,27888,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3084.46,22111, Amputation of foot at ankle,27889,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3393.22,,,,,,,fee schedule,3393.22,12821, Amputation of foot at ankle,27889,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3393.22,12821, Amputation of foot at ankle,27889,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3393.22,12821, Amputation of foot at ankle,27889,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3393.22,12821, Decompression of leg,27892,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2894.47,,,,,,,fee schedule,2894.47,12821, Decompression of leg,27892,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2894.47,12821, Decompression of leg,27892,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2894.47,12821, Decompression of leg,27892,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2894.47,12821, Decompression of leg,27893,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3253.52,,,,,,,fee schedule,3253.52,12821, Decompression of leg,27893,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3253.52,12821, Decompression of leg,27893,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3253.52,12821, Decompression of leg,27893,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3253.52,12821, Decompression of leg,27894,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4279.08,,,,,,,fee schedule,4279.08,12821, Decompression of leg,27894,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4279.08,12821, Decompression of leg,27894,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4279.08,12821, Decompression of leg,27894,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4279.08,12821, Leg/ankle surgery procedure,27899,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Leg/ankle surgery procedure,27899,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Leg/ankle surgery procedure,27899,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Drainage of bursa of foot,28001,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,481.22,,,,,,,fee schedule,481.22,5664, Drainage of bursa of foot,28001,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,481.22,5664, Drainage of bursa of foot,28001,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,481.22,5664, Drainage of bursa of foot,28001,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,481.22,5664, Treatment of foot infection,28002,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,702.67,,,,,,,fee schedule,702.67,10940, Treatment of foot infection,28002,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,702.67,10940, Treatment of foot infection,28002,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,702.67,10940, Treatment of foot infection,28002,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,702.67,10940, Treatment of foot infection,28003,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1284.68,,,,,,,fee schedule,1284.68,10940, Treatment of foot infection,28003,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1284.68,10940, Treatment of foot infection,28003,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1284.68,10940, Treatment of foot infection,28003,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1284.68,10940, Treat foot bone lesion,28005,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2926.14,,,,,,,fee schedule,2926.14,10940, Treat foot bone lesion,28005,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2926.14,10940, Treat foot bone lesion,28005,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2926.14,10940, Treat foot bone lesion,28005,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2926.14,10940, Incision of foot fascia,28008,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1502.84,,,,,,,fee schedule,1502.84,10940, Incision of foot fascia,28008,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1502.84,10940, Incision of foot fascia,28008,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1502.84,10940, Incision of foot fascia,28008,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1502.84,10940, Incision of toe tendon,28010,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1070.35,,,,,,,fee schedule,1070.35,10940, Incision of toe tendon,28010,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1070.35,10940, Incision of toe tendon,28010,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1070.35,10940, Incision of toe tendon,28010,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1070.35,10940, Incision of toe tendons,28011,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1438.09,,,,,,,fee schedule,1438.09,10940, Incision of toe tendons,28011,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1438.09,10940, Incision of toe tendons,28011,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1438.09,10940, Incision of toe tendons,28011,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1438.09,10940, Exploration of foot joint,28020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1919.68,,,,,,,fee schedule,1919.68,10940, Exploration of foot joint,28020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1919.68,10940, Exploration of foot joint,28020,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1919.68,10940, Exploration of foot joint,28020,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1919.68,10940, Exploration of foot joint,28022,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1711.07,,,,,,,fee schedule,1711.07,10940, Exploration of foot joint,28022,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1711.07,10940, Exploration of foot joint,28022,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1711.07,10940, Exploration of foot joint,28022,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1711.07,10940, Exploration of toe joint,28024,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1620.2,,,,,,,fee schedule,1620.2,10940, Exploration of toe joint,28024,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1620.2,10940, Exploration of toe joint,28024,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1620.2,10940, Exploration of toe joint,28024,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1620.2,10940, Decompression of tibia nerve,28035,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1878.51,,,,,,,fee schedule,1878.51,10940, Decompression of tibia nerve,28035,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,1878.51,10940, Decompression of tibia nerve,28035,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1878.51,10940, Decompression of tibia nerve,28035,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1878.51,10940, Exc foot/toe tum sc 1.5 cm/>,28039,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1726.56,,,,,,,fee schedule,1726.56,10940, Exc foot/toe tum sc 1.5 cm/>,28039,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1726.56,10940, Exc foot/toe tum sc 1.5 cm/>,28039,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1726.56,10940, Exc foot/toe tum sc 1.5 cm/>,28039,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1726.56,10940, Exc foot/toe tum dep 1.5cm/>,28041,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2309.65,,,,,,,fee schedule,2309.65,10940, Exc foot/toe tum dep 1.5cm/>,28041,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2309.65,10940, Exc foot/toe tum dep 1.5cm/>,28041,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2309.65,10940, Exc foot/toe tum dep 1.5cm/>,28041,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2309.65,10940, Exc foot/toe tum sc < 1.5 cm,28043,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1346.79,,,,,,,fee schedule,1346.79,5664, Exc foot/toe tum sc < 1.5 cm,28043,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1346.79,5664, Exc foot/toe tum sc < 1.5 cm,28043,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1346.79,5664, Exc foot/toe tum sc < 1.5 cm,28043,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1346.79,5664, Exc foot/toe tum deep <1.5cm,28045,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1794.22,,,,,,,fee schedule,1794.22,5664, Exc foot/toe tum deep <1.5cm,28045,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1794.22,5664, Exc foot/toe tum deep <1.5cm,28045,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1794.22,5664, Exc foot/toe tum deep <1.5cm,28045,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1794.22,5664, Resect foot/toe tumor < 3 cm,28046,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3652.93,,,,,,,fee schedule,3652.93,5664, Resect foot/toe tumor < 3 cm,28046,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3652.93,5664, Resect foot/toe tumor < 3 cm,28046,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3652.93,5664, Resect foot/toe tumor < 3 cm,28046,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3652.93,5664, Resect foot/toe tumor 3 cm/>,28047,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5340.21,,,,,,,fee schedule,5248,10940, Resect foot/toe tumor 3 cm/>,28047,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,10940, Resect foot/toe tumor 3 cm/>,28047,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,5248,10940, Resect foot/toe tumor 3 cm/>,28047,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,5248,10940, Biopsy of foot joint lining,28050,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1428.16,,,,,,,fee schedule,1428.16,10940, Biopsy of foot joint lining,28050,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1428.16,10940, Biopsy of foot joint lining,28050,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1428.16,10940, Biopsy of foot joint lining,28050,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1428.16,10940, Biopsy of foot joint lining,28052,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1316.84,,,,,,,fee schedule,1316.84,10940, Biopsy of foot joint lining,28052,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1316.84,10940, Biopsy of foot joint lining,28052,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1316.84,10940, Biopsy of foot joint lining,28052,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1316.84,10940, Biopsy of toe joint lining,28054,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1203.69,,,,,,,fee schedule,1203.69,10940, Biopsy of toe joint lining,28054,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1203.69,10940, Biopsy of toe joint lining,28054,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1203.69,10940, Biopsy of toe joint lining,28054,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1203.69,10940, Neurectomy foot,28055,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2034.35,,,,,,,fee schedule,2034.35,10940, Neurectomy foot,28055,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2034.35,10940, Neurectomy foot,28055,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2034.35,10940, Neurectomy foot,28055,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2034.35,10940, Partial removal foot fascia,28060,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1874.89,,,,,,,fee schedule,1874.89,10940, Partial removal foot fascia,28060,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1874.89,10940, Partial removal foot fascia,28060,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1874.89,10940, Partial removal foot fascia,28060,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1874.89,10940, Removal of foot fascia,28062,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2098.23,,,,,,,fee schedule,2098.23,10940, Removal of foot fascia,28062,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2098.23,10940, Removal of foot fascia,28062,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2098.23,10940, Removal of foot fascia,28062,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2098.23,10940, Removal of foot joint lining,28070,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1788.72,,,,,,,fee schedule,1788.72,10940, Removal of foot joint lining,28070,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1788.72,10940, Removal of foot joint lining,28070,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1788.72,10940, Removal of foot joint lining,28070,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1788.72,10940, Removal of foot joint lining,28072,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1701.74,,,,,,,fee schedule,1701.74,10940, Removal of foot joint lining,28072,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1701.74,10940, Removal of foot joint lining,28072,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1701.74,10940, Removal of foot joint lining,28072,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1701.74,10940, Removal of foot lesion,28080,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1999.16,,,,,,,fee schedule,1999.16,10940, Removal of foot lesion,28080,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1999.16,10940, Removal of foot lesion,28080,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1999.16,10940, Removal of foot lesion,28080,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1999.16,10940, Excise foot tendon sheath,28086,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1833.78,,,,,,,fee schedule,1833.78,10940, Excise foot tendon sheath,28086,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1833.78,10940, Excise foot tendon sheath,28086,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1833.78,10940, Excise foot tendon sheath,28086,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1833.78,10940, Excise foot tendon sheath,28088,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1551.51,,,,,,,fee schedule,1551.51,10940, Excise foot tendon sheath,28088,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1551.51,10940, Excise foot tendon sheath,28088,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1551.51,10940, Excise foot tendon sheath,28088,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1551.51,10940, Removal of foot lesion,28090,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1602.23,,,,,,,fee schedule,1602.23,10940, Removal of foot lesion,28090,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1602.23,10940, Removal of foot lesion,28090,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1602.23,10940, Removal of foot lesion,28090,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1602.23,10940, Removal of toe lesions,28092,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1413.37,,,,,,,fee schedule,1413.37,10940, Removal of toe lesions,28092,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1413.37,10940, Removal of toe lesions,28092,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1413.37,10940, Removal of toe lesions,28092,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1413.37,10940, Removal of ankle/heel lesion,28100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2214.19,,,,,,,fee schedule,2214.19,10940, Removal of ankle/heel lesion,28100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2214.19,10940, Removal of ankle/heel lesion,28100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2214.19,10940, Removal of ankle/heel lesion,28100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2214.19,10940, Remove/graft foot lesion,28102,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3231.29,,,,,,,fee schedule,3231.29,22111, Remove/graft foot lesion,28102,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3231.29,22111, Remove/graft foot lesion,28102,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3231.29,22111, Remove/graft foot lesion,28102,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3231.29,22111, Remove/graft foot lesion,28103,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1971.81,,,,,,,fee schedule,1971.81,22111, Remove/graft foot lesion,28103,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1971.81,22111, Remove/graft foot lesion,28103,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,1971.81,22111, Remove/graft foot lesion,28103,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,1971.81,22111, Removal of foot lesion,28104,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1854.34,,,,,,,fee schedule,1854.34,10940, Removal of foot lesion,28104,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1854.34,10940, Removal of foot lesion,28104,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1854.34,10940, Removal of foot lesion,28104,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1854.34,10940, Remove/graft foot lesion,28106,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2162.93,,,,,,,fee schedule,2162.93,22111, Remove/graft foot lesion,28106,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2162.93,22111, Remove/graft foot lesion,28106,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,2162.93,22111, Remove/graft foot lesion,28106,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,2162.93,22111, Remove/graft foot lesion,28107,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1767.14,,,,,,,fee schedule,1767.14,22111, Remove/graft foot lesion,28107,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1767.14,22111, Remove/graft foot lesion,28107,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,1767.14,22111, Remove/graft foot lesion,28107,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,1767.14,22111, Removal of toe lesions,28108,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1489.24,,,,,,,fee schedule,1489.24,10940, Removal of toe lesions,28108,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1489.24,10940, Removal of toe lesions,28108,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1489.24,10940, Removal of toe lesions,28108,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1489.24,10940, Part removal of metatarsal,28110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1533.87,,,,,,,fee schedule,1533.87,10940, Part removal of metatarsal,28110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1533.87,10940, Part removal of metatarsal,28110,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1533.87,10940, Part removal of metatarsal,28110,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1533.87,10940, Part removal of metatarsal,28111,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1653.33,,,,,,,fee schedule,1653.33,10940, Part removal of metatarsal,28111,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1653.33,10940, Part removal of metatarsal,28111,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1653.33,10940, Part removal of metatarsal,28111,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1653.33,10940, Part removal of metatarsal,28112,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1615.83,,,,,,,fee schedule,1615.83,10940, Part removal of metatarsal,28112,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1615.83,10940, Part removal of metatarsal,28112,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1615.83,10940, Part removal of metatarsal,28112,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1615.83,10940, Part removal of metatarsal,28113,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2203.29,,,,,,,fee schedule,2203.29,10940, Part removal of metatarsal,28113,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2203.29,10940, Part removal of metatarsal,28113,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2203.29,10940, Part removal of metatarsal,28113,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2203.29,10940, Removal of metatarsal heads,28114,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4373.94,,,,,,,fee schedule,4373.94,10940, Removal of metatarsal heads,28114,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4373.94,10940, Removal of metatarsal heads,28114,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,4373.94,10940, Removal of metatarsal heads,28114,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,4373.94,10940, Revision of foot,28116,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2650.84,,,,,,,fee schedule,2650.84,10940, Revision of foot,28116,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2650.84,10940, Revision of foot,28116,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2650.84,10940, Revision of foot,28116,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2650.84,10940, Removal of heel bone,28118,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2225.69,,,,,,,fee schedule,2225.69,10940, Removal of heel bone,28118,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2225.69,10940, Removal of heel bone,28118,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2225.69,10940, Removal of heel bone,28118,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2225.69,10940, Removal of heel spur,28119,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1886.17,,,,,,,fee schedule,1886.17,10940, Removal of heel spur,28119,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,1886.17,10940, Removal of heel spur,28119,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1886.17,10940, Removal of heel spur,28119,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1886.17,10940, Part removal of ankle/heel,28120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2568.55,,,,,,,fee schedule,2568.55,10940, Part removal of ankle/heel,28120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,2568.55,10940, Part removal of ankle/heel,28120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2568.55,10940, Part removal of ankle/heel,28120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2568.55,10940, Partial removal of foot bone,28122,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2274.79,,,,,,,fee schedule,2274.79,10940, Partial removal of foot bone,28122,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2274.79,10940, Partial removal of foot bone,28122,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2274.79,10940, Partial removal of foot bone,28122,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2274.79,10940, Partial removal of toe,28124,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1725.32,,,,,,,fee schedule,1725.32,10940, Partial removal of toe,28124,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1725.32,10940, Partial removal of toe,28124,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1725.32,10940, Partial removal of toe,28124,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1725.32,10940, Partial removal of toe,28126,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1294.12,,,,,,,fee schedule,1294.12,10940, Partial removal of toe,28126,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1294.12,10940, Partial removal of toe,28126,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1294.12,10940, Partial removal of toe,28126,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1294.12,10940, Removal of ankle bone,28130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3299.82,,,,,,,fee schedule,3299.82,10940, Removal of ankle bone,28130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3299.82,10940, Removal of ankle bone,28130,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3299.82,10940, Removal of ankle bone,28130,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3299.82,10940, Removal of metatarsal,28140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2186.41,,,,,,,fee schedule,2186.41,10940, Removal of metatarsal,28140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2186.41,10940, Removal of metatarsal,28140,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2186.41,10940, Removal of metatarsal,28140,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2186.41,10940, Removal of toe,28150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1444.83,,,,,,,fee schedule,1444.83,10940, Removal of toe,28150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1444.83,10940, Removal of toe,28150,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1444.83,10940, Removal of toe,28150,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1444.83,10940, Partial removal of toe,28153,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1358.87,,,,,,,fee schedule,1358.87,10940, Partial removal of toe,28153,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1358.87,10940, Partial removal of toe,28153,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1358.87,10940, Partial removal of toe,28153,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1358.87,10940, Partial removal of toe,28160,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1386.5,,,,,,,fee schedule,1386.5,10940, Partial removal of toe,28160,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1386.5,10940, Partial removal of toe,28160,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1386.5,10940, Partial removal of toe,28160,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1386.5,10940, Resect tarsal tumor,28171,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5684.52,,,,,,,fee schedule,5248,10940, Resect tarsal tumor,28171,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,10940, Resect tarsal tumor,28171,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,5248,10940, Resect tarsal tumor,28171,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,5248,10940, Resect metatarsal tumor,28173,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3660.81,,,,,,,fee schedule,3660.81,10940, Resect metatarsal tumor,28173,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3660.81,10940, Resect metatarsal tumor,28173,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3660.81,10940, Resect metatarsal tumor,28173,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3660.81,10940, Resect phalanx of toe tumor,28175,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2384.82,,,,,,,fee schedule,2384.82,10940, Resect phalanx of toe tumor,28175,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2384.82,10940, Resect phalanx of toe tumor,28175,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2384.82,10940, Resect phalanx of toe tumor,28175,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2384.82,10940, Removal of foot foreign body,28190,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,694.41,,,,,,,fee schedule,694.41,4497, Removal of foot foreign body,28190,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,694.41,4497, Removal of foot foreign body,28190,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,694.41,4497, Removal of foot foreign body,28190,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,694.41,4497, Removal of foot foreign body,28192,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1596.84,,,,,,,fee schedule,1596.84,5664, Removal of foot foreign body,28192,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1596.84,5664, Removal of foot foreign body,28192,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1596.84,5664, Removal of foot foreign body,28192,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1596.84,5664, Removal of foot foreign body,28193,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1857.03,,,,,,,fee schedule,1857.03,5363, Removal of foot foreign body,28193,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,1857.03,5363, Removal of foot foreign body,28193,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,1857.03,5363, Removal of foot foreign body,28193,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,1857.03,5363, Repair of foot tendon,28200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1706.32,,,,,,,fee schedule,1706.32,10940, Repair of foot tendon,28200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1706.32,10940, Repair of foot tendon,28200,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1706.32,10940, Repair of foot tendon,28200,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1706.32,10940, Repair/graft of foot tendon,28202,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2227.2,,,,,,,fee schedule,2227.2,10940, Repair/graft of foot tendon,28202,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2227.2,10940, Repair/graft of foot tendon,28202,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2227.2,10940, Repair/graft of foot tendon,28202,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2227.2,10940, Repair of foot tendon,28208,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1687.33,,,,,,,fee schedule,1687.33,10940, Repair of foot tendon,28208,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1687.33,10940, Repair of foot tendon,28208,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1687.33,10940, Repair of foot tendon,28208,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1687.33,10940, Repair/graft of foot tendon,28210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2177.72,,,,,,,fee schedule,2177.72,22111, Repair/graft of foot tendon,28210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2177.72,22111, Repair/graft of foot tendon,28210,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,2177.72,22111, Repair/graft of foot tendon,28210,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,2177.72,22111, Release of foot tendon,28220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1568.13,,,,,,,fee schedule,1568.13,10940, Release of foot tendon,28220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1568.13,10940, Release of foot tendon,28220,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1568.13,10940, Release of foot tendon,28220,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1568.13,10940, Release of foot tendons,28222,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1906.24,,,,,,,fee schedule,1906.24,10940, Release of foot tendons,28222,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1906.24,10940, Release of foot tendons,28222,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1906.24,10940, Release of foot tendons,28222,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1906.24,10940, Release of foot tendon,28225,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1363.41,,,,,,,fee schedule,1363.41,10940, Release of foot tendon,28225,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1363.41,10940, Release of foot tendon,28225,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1363.41,10940, Release of foot tendon,28225,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1363.41,10940, Release of foot tendons,28226,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2148.63,,,,,,,fee schedule,2148.63,10940, Release of foot tendons,28226,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2148.63,10940, Release of foot tendons,28226,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2148.63,10940, Release of foot tendons,28226,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2148.63,10940, Incision of foot tendon(s),28230,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1468.31,,,,,,,fee schedule,1468.31,10940, Incision of foot tendon(s),28230,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1468.31,10940, Incision of foot tendon(s),28230,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1468.31,10940, Incision of foot tendon(s),28230,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1468.31,10940, Incision of toe tendon,28232,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1252.95,,,,,,,fee schedule,1252.95,10940, Incision of toe tendon,28232,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1252.95,10940, Incision of toe tendon,28232,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1252.95,10940, Incision of toe tendon,28232,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1252.95,10940, Incision of foot tendon,28234,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1409.49,,,,,,,fee schedule,1409.49,10940, Incision of foot tendon,28234,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1409.49,10940, Incision of foot tendon,28234,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1409.49,10940, Incision of foot tendon,28234,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1409.49,10940, Revision of foot tendon,28238,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2524.36,,,,,,,fee schedule,2524.36,22111, Revision of foot tendon,28238,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2524.36,22111, Revision of foot tendon,28238,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,2524.36,22111, Revision of foot tendon,28238,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,2524.36,22111, Release of big toe,28240,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1506.4,,,,,,,fee schedule,1506.4,10940, Release of big toe,28240,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1506.4,10940, Release of big toe,28240,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1506.4,10940, Release of big toe,28240,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1506.4,10940, Revision of foot fascia,28250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2123.92,,,,,,,fee schedule,2123.92,10940, Revision of foot fascia,28250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2123.92,10940, Revision of foot fascia,28250,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2123.92,10940, Revision of foot fascia,28250,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2123.92,10940, Release of midfoot joint,28260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2811.48,,,,,,,fee schedule,2811.48,10940, Release of midfoot joint,28260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2811.48,10940, Release of midfoot joint,28260,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2811.48,10940, Release of midfoot joint,28260,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2811.48,10940, Revision of foot tendon,28261,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4371.52,,,,,,,fee schedule,4371.52,10940, Revision of foot tendon,28261,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4371.52,10940, Revision of foot tendon,28261,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,4371.52,10940, Revision of foot tendon,28261,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,4371.52,10940, Revision of foot and ankle,28262,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5781.27,,,,,,,fee schedule,5363,10940, Revision of foot and ankle,28262,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,10940, Revision of foot and ankle,28262,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,5363,10940, Revision of foot and ankle,28262,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,5363,10940, Release of midfoot joint,28264,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3624.82,,,,,,,fee schedule,3195,14456, Release of midfoot joint,28264,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,14456, Release of midfoot joint,28264,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3195,14456, Release of midfoot joint,28264,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3195,14456, Release of foot contracture,28270,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1727.75,,,,,,,fee schedule,1727.75,10940, Release of foot contracture,28270,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1727.75,10940, Release of foot contracture,28270,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1727.75,10940, Release of foot contracture,28270,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1727.75,10940, Release of toe joint each,28272,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1300.22,,,,,,,fee schedule,1300.22,10940, Release of toe joint each,28272,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1300.22,10940, Release of toe joint each,28272,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1300.22,10940, Release of toe joint each,28272,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1300.22,10940, Fusion of toes,28280,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1755.48,,,,,,,fee schedule,1755.48,10940, Fusion of toes,28280,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1755.48,10940, Fusion of toes,28280,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1755.48,10940, Fusion of toes,28280,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1755.48,10940, Repair of hammertoe,28285,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2017.13,,,,,,,fee schedule,2017.13,10940, Repair of hammertoe,28285,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2017.13,10940, Repair of hammertoe,28285,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2017.13,10940, Repair of hammertoe,28285,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2017.13,10940, Repair of hammertoe,28286,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1509.32,,,,,,,fee schedule,1509.32,10940, Repair of hammertoe,28286,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,1509.32,10940, Repair of hammertoe,28286,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1509.32,10940, Repair of hammertoe,28286,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1509.32,10940, Partial removal of foot bone,28288,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2262.17,,,,,,,fee schedule,2262.17,10940, Partial removal of foot bone,28288,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2262.17,10940, Partial removal of foot bone,28288,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2262.17,10940, Partial removal of foot bone,28288,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2262.17,10940, Corrj halux rigdus w/o implt,28289,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2400.19,,,,,,,fee schedule,2400.19,10940, Corrj halux rigdus w/o implt,28289,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2400.19,10940, Corrj halux rigdus w/o implt,28289,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2400.19,10940, Corrj halux rigdus w/o implt,28289,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2400.19,10940, Corrj halux rigdus w/implt,28291,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2417.62,,,,,,,fee schedule,2417.62,22111, Corrj halux rigdus w/implt,28291,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2417.62,22111, Corrj halux rigdus w/implt,28291,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,2417.62,22111, Corrj halux rigdus w/implt,28291,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,2417.62,22111, Correction hallux valgus,28292,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2506.98,,,,,,,fee schedule,2506.98,12821, Correction hallux valgus,28292,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2506.98,12821, Correction hallux valgus,28292,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2506.98,12821, Correction hallux valgus,28292,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2506.98,12821, Correction hallux valgus,28295,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3089.86,,,,,,,fee schedule,3089.86,12821, Correction hallux valgus,28295,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3089.86,12821, Correction hallux valgus,28295,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3089.86,12821, Correction hallux valgus,28295,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3089.86,12821, Correction hallux valgus,28296,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2642.96,,,,,,,fee schedule,2642.96,12821, Correction hallux valgus,28296,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2642.96,12821, Correction hallux valgus,28296,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2642.96,12821, Correction hallux valgus,28296,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2642.96,12821, Correction hallux valgus,28297,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3080.36,,,,,,,fee schedule,3080.36,12821, Correction hallux valgus,28297,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3080.36,12821, Correction hallux valgus,28297,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3080.36,12821, Correction hallux valgus,28297,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3080.36,12821, Correction hallux valgus,28298,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2650.73,,,,,,,fee schedule,2650.73,12821, Correction hallux valgus,28298,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2650.73,12821, Correction hallux valgus,28298,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2650.73,12821, Correction hallux valgus,28298,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2650.73,12821, Correction hallux valgus,28299,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3089.97,,,,,,,fee schedule,3089.97,12821, Correction hallux valgus,28299,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,3089.97,12821, Correction hallux valgus,28299,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3089.97,12821, Correction hallux valgus,28299,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3089.97,12821, Incision of heel bone,28300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3387.07,,,,,,,fee schedule,3387.07,22111, Incision of heel bone,28300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3387.07,22111, Incision of heel bone,28300,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3387.07,22111, Incision of heel bone,28300,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3387.07,22111, Incision of ankle bone,28302,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3751.52,,,,,,,fee schedule,3751.52,10940, Incision of ankle bone,28302,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3751.52,10940, Incision of ankle bone,28302,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3751.52,10940, Incision of ankle bone,28302,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3751.52,10940, Incision of midfoot bones,28304,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3216.39,,,,,,,fee schedule,3216.39,22111, Incision of midfoot bones,28304,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3216.39,22111, Incision of midfoot bones,28304,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3216.39,22111, Incision of midfoot bones,28304,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3216.39,22111, Incise/graft midfoot bones,28305,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3458.62,,,,,,,fee schedule,3458.62,22111, Incise/graft midfoot bones,28305,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3458.62,22111, Incise/graft midfoot bones,28305,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3458.62,22111, Incise/graft midfoot bones,28305,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3458.62,22111, Incision of metatarsal,28306,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2117.34,,,,,,,fee schedule,2117.34,10940, Incision of metatarsal,28306,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2117.34,10940, Incision of metatarsal,28306,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2117.34,10940, Incision of metatarsal,28306,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2117.34,10940, Incision of metatarsal,28307,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2747.97,,,,,,,fee schedule,2747.97,10940, Incision of metatarsal,28307,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2747.97,10940, Incision of metatarsal,28307,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2747.97,10940, Incision of metatarsal,28307,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2747.97,10940, Incision of metatarsal,28308,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2027.12,,,,,,,fee schedule,2027.12,10940, Incision of metatarsal,28308,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2027.12,10940, Incision of metatarsal,28308,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2027.12,10940, Incision of metatarsal,28308,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2027.12,10940, Incision of metatarsals,28309,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4642.29,,,,,,,fee schedule,4642.29,22111, Incision of metatarsals,28309,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4642.29,22111, Incision of metatarsals,28309,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4642.29,22111, Incision of metatarsals,28309,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4642.29,22111, Revision of big toe,28310,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1913.1,,,,,,,fee schedule,1913.1,10940, Revision of big toe,28310,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1913.1,10940, Revision of big toe,28310,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1913.1,10940, Revision of big toe,28310,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1913.1,10940, Revision of toe,28312,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1895.72,,,,,,,fee schedule,1895.72,10940, Revision of toe,28312,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1895.72,10940, Revision of toe,28312,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1895.72,10940, Revision of toe,28312,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1895.72,10940, Repair deformity of toe,28313,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1897.29,,,,,,,fee schedule,1897.29,10940, Repair deformity of toe,28313,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1897.29,10940, Repair deformity of toe,28313,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1897.29,10940, Repair deformity of toe,28313,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1897.29,10940, Removal of sesamoid bone,28315,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1696.07,,,,,,,fee schedule,1696.07,10940, Removal of sesamoid bone,28315,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,1696.07,10940, Removal of sesamoid bone,28315,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1696.07,10940, Removal of sesamoid bone,28315,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1696.07,10940, Repair of foot bones,28320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3190.33,,,,,,,fee schedule,3190.33,22111, Repair of foot bones,28320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3190.33,22111, Repair of foot bones,28320,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3190.33,22111, Repair of foot bones,28320,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3190.33,22111, Repair of metatarsals,28322,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2982.96,,,,,,,fee schedule,2982.96,10940, Repair of metatarsals,28322,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2982.96,10940, Repair of metatarsals,28322,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2982.96,10940, Repair of metatarsals,28322,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2982.96,10940, Resect enlarged toe tissue,28340,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2077.68,,,,,,,fee schedule,2077.68,10940, Resect enlarged toe tissue,28340,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2077.68,10940, Resect enlarged toe tissue,28340,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2077.68,10940, Resect enlarged toe tissue,28340,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2077.68,10940, Resect enlarged toe,28341,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2462.73,,,,,,,fee schedule,2462.73,10940, Resect enlarged toe,28341,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2462.73,10940, Resect enlarged toe,28341,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2462.73,10940, Resect enlarged toe,28341,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2462.73,10940, Repair extra toe(s),28344,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1431.67,,,,,,,fee schedule,1431.67,10940, Repair extra toe(s),28344,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,1431.67,10940, Repair extra toe(s),28344,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1431.67,10940, Repair extra toe(s),28344,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1431.67,10940, Repair webbed toe(s),28345,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1842.57,,,,,,,fee schedule,1842.57,10940, Repair webbed toe(s),28345,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,1842.57,10940, Repair webbed toe(s),28345,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1842.57,10940, Repair webbed toe(s),28345,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1842.57,10940, Reconstruct cleft foot,28360,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5707.94,,,,,,,fee schedule,5707.94,22111, Reconstruct cleft foot,28360,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5707.94,22111, Reconstruct cleft foot,28360,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5707.94,22111, Reconstruct cleft foot,28360,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5707.94,22111, Treatment of heel fracture,28400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1262.12,,,,,,,fee schedule,1262.12,3195, Treatment of heel fracture,28400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1262.12,3195, Treatment of heel fracture,28400,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1262.12,3195, Treatment of heel fracture,28400,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1262.12,3195, Treatment of heel fracture,28405,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2197.68,,,,,,,fee schedule,2197.68,4108, Treatment of heel fracture,28405,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2197.68,4108, Treatment of heel fracture,28405,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2197.68,4108, Treatment of heel fracture,28405,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2197.68,4108, Treatment of heel fracture,28406,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3004.38,,,,,,,fee schedule,3004.38,10940, Treatment of heel fracture,28406,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3004.38,10940, Treatment of heel fracture,28406,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3004.38,10940, Treatment of heel fracture,28406,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3004.38,10940, Treat heel fracture,28415,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5802.64,,,,,,,fee schedule,5248,22111, Treat heel fracture,28415,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,22111, Treat heel fracture,28415,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5248,22111, Treat heel fracture,28415,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5248,22111, Treat/graft heel fracture,28420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6728.87,,,,,,,fee schedule,5363,22111, Treat/graft heel fracture,28420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,22111, Treat/graft heel fracture,28420,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5363,22111, Treat/graft heel fracture,28420,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5363,22111, Treatment of ankle fracture,28430,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1171.85,,,,,,,fee schedule,1171.85,3195, Treatment of ankle fracture,28430,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1171.85,3195, Treatment of ankle fracture,28430,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1171.85,3195, Treatment of ankle fracture,28430,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1171.85,3195, Treatment of ankle fracture,28435,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1796.49,,,,,,,fee schedule,1796.49,5664, Treatment of ankle fracture,28435,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1796.49,5664, Treatment of ankle fracture,28435,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1796.49,5664, Treatment of ankle fracture,28435,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1796.49,5664, Treatment of ankle fracture,28436,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2703.29,,,,,,,fee schedule,2703.29,10940, Treatment of ankle fracture,28436,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2703.29,10940, Treatment of ankle fracture,28436,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2703.29,10940, Treatment of ankle fracture,28436,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2703.29,10940, Treat ankle fracture,28445,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5432.32,,,,,,,fee schedule,5248,22111, Treat ankle fracture,28445,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,22111, Treat ankle fracture,28445,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5248,22111, Treat ankle fracture,28445,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5248,22111, Osteochondral talus autogrft,28446,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6305.33,,,,,,,fee schedule,5363,22111, Osteochondral talus autogrft,28446,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,22111, Osteochondral talus autogrft,28446,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5363,22111, Osteochondral talus autogrft,28446,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5363,22111, Treat midfoot fracture each,28450,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1046.12,,,,,,,fee schedule,1046.12,3195, Treat midfoot fracture each,28450,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1046.12,3195, Treat midfoot fracture each,28450,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1046.12,3195, Treat midfoot fracture each,28450,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1046.12,3195, Treat midfoot fracture each,28455,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1191.33,,,,,,,fee schedule,1191.33,3195, Treat midfoot fracture each,28455,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1191.33,3195, Treat midfoot fracture each,28455,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1191.33,3195, Treat midfoot fracture each,28455,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1191.33,3195, Treat midfoot fracture,28456,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2058.3,,,,,,,fee schedule,2058.3,10940, Treat midfoot fracture,28456,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2058.3,10940, Treat midfoot fracture,28456,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2058.3,10940, Treat midfoot fracture,28456,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2058.3,10940, Treat midfoot fracture each,28465,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3398.29,,,,,,,fee schedule,3398.29,22111, Treat midfoot fracture each,28465,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3398.29,22111, Treat midfoot fracture each,28465,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3398.29,22111, Treat midfoot fracture each,28465,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3398.29,22111, Treat metatarsal fracture,28470,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1121.18,,,,,,,fee schedule,1121.18,3195, Treat metatarsal fracture,28470,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1121.18,3195, Treat metatarsal fracture,28470,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1121.18,3195, Treat metatarsal fracture,28470,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1121.18,3195, Treat metatarsal fracture,28475,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1219.55,,,,,,,fee schedule,1219.55,3195, Treat metatarsal fracture,28475,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1219.55,3195, Treat metatarsal fracture,28475,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1219.55,3195, Treat metatarsal fracture,28475,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1219.55,3195, Treat metatarsal fracture,28476,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2082.48,,,,,,,fee schedule,2082.48,10940, Treat metatarsal fracture,28476,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2082.48,10940, Treat metatarsal fracture,28476,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2082.48,10940, Treat metatarsal fracture,28476,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2082.48,10940, Treat metatarsal fracture,28485,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2954.47,,,,,,,fee schedule,2954.47,22111, Treat metatarsal fracture,28485,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2954.47,22111, Treat metatarsal fracture,28485,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,2954.47,22111, Treat metatarsal fracture,28485,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,2954.47,22111, Treat big toe fracture,28490,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,708.12,,,,,,,fee schedule,708.12,3195, Treat big toe fracture,28490,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,708.12,3195, Treat big toe fracture,28490,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,708.12,3195, Treat big toe fracture,28490,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,708.12,3195, Treat big toe fracture,28495,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,828.77,,,,,,,fee schedule,828.77,3195, Treat big toe fracture,28495,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,828.77,3195, Treat big toe fracture,28495,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,828.77,3195, Treat big toe fracture,28495,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,828.77,3195, Treat big toe fracture,28496,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1517.52,,,,,,,fee schedule,1517.52,10940, Treat big toe fracture,28496,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1517.52,10940, Treat big toe fracture,28496,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1517.52,10940, Treat big toe fracture,28496,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1517.52,10940, Treat big toe fracture,28505,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2578.86,,,,,,,fee schedule,2578.86,10940, Treat big toe fracture,28505,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2578.86,10940, Treat big toe fracture,28505,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2578.86,10940, Treat big toe fracture,28505,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2578.86,10940, Treatment of toe fracture,28510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,668.24,,,,,,,fee schedule,668.24,3195, Treatment of toe fracture,28510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,668.24,3195, Treatment of toe fracture,28510,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,668.24,3195, Treatment of toe fracture,28510,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,668.24,3195, Treatment of toe fracture,28515,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,777.56,,,,,,,fee schedule,777.56,3195, Treatment of toe fracture,28515,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,777.56,3195, Treatment of toe fracture,28515,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,777.56,3195, Treatment of toe fracture,28515,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,777.56,3195, Treat toe fracture,28525,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2101.58,,,,,,,fee schedule,2101.58,10940, Treat toe fracture,28525,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2101.58,10940, Treat toe fracture,28525,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2101.58,10940, Treat toe fracture,28525,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2101.58,10940, Treat sesamoid bone fracture,28530,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,552.82,,,,,,,fee schedule,552.82,3195, Treat sesamoid bone fracture,28530,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,552.82,3195, Treat sesamoid bone fracture,28530,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,552.82,3195, Treat sesamoid bone fracture,28530,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,552.82,3195, Treat sesamoid bone fracture,28531,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,941.76,,,,,,,fee schedule,941.76,10940, Treat sesamoid bone fracture,28531,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,941.76,10940, Treat sesamoid bone fracture,28531,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,941.76,10940, Treat sesamoid bone fracture,28531,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,941.76,10940, Treat foot dislocation,28540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,916.89,,,,,,,fee schedule,916.89,3195, Treat foot dislocation,28540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,916.89,3195, Treat foot dislocation,28540,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,916.89,3195, Treat foot dislocation,28540,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,916.89,3195, Treat foot dislocation,28545,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1502.52,,,,,,,fee schedule,1502.52,10940, Treat foot dislocation,28545,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1502.52,10940, Treat foot dislocation,28545,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1502.52,10940, Treat foot dislocation,28545,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1502.52,10940, Treat foot dislocation,28546,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1940.67,,,,,,,fee schedule,1940.67,10940, Treat foot dislocation,28546,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1940.67,10940, Treat foot dislocation,28546,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1940.67,10940, Treat foot dislocation,28546,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1940.67,10940, Repair foot dislocation,28555,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3378.06,,,,,,,fee schedule,3378.06,22111, Repair foot dislocation,28555,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3378.06,22111, Repair foot dislocation,28555,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3378.06,22111, Repair foot dislocation,28555,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3378.06,22111, Treat foot dislocation,28570,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1108.07,,,,,,,fee schedule,1108.07,3195, Treat foot dislocation,28570,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1108.07,3195, Treat foot dislocation,28570,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1108.07,3195, Treat foot dislocation,28570,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1108.07,3195, Treat foot dislocation,28575,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1860.59,,,,,,,fee schedule,1860.59,5664, Treat foot dislocation,28575,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1860.59,5664, Treat foot dislocation,28575,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1860.59,5664, Treat foot dislocation,28575,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1860.59,5664, Treat foot dislocation,28576,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2123.76,,,,,,,fee schedule,2123.76,10940, Treat foot dislocation,28576,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2123.76,10940, Treat foot dislocation,28576,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2123.76,10940, Treat foot dislocation,28576,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2123.76,10940, Repair foot dislocation,28585,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3720.54,,,,,,,fee schedule,3720.54,10940, Repair foot dislocation,28585,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3720.54,10940, Repair foot dislocation,28585,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3720.54,10940, Repair foot dislocation,28585,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3720.54,10940, Treat foot dislocation,28600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,847.39,,,,,,,fee schedule,847.39,3195, Treat foot dislocation,28600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,847.39,3195, Treat foot dislocation,28600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,847.39,3195, Treat foot dislocation,28600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,847.39,3195, Treat foot dislocation,28605,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1691.54,,,,,,,fee schedule,1691.54,3195, Treat foot dislocation,28605,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1691.54,3195, Treat foot dislocation,28605,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1691.54,3195, Treat foot dislocation,28605,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1691.54,3195, Treat foot dislocation,28606,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2127,,,,,,,fee schedule,2127,10940, Treat foot dislocation,28606,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2127,10940, Treat foot dislocation,28606,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2127,10940, Treat foot dislocation,28606,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2127,10940, Repair foot dislocation,28615,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4356.24,,,,,,,fee schedule,4356.24,22111, Repair foot dislocation,28615,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4356.24,22111, Repair foot dislocation,28615,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4356.24,22111, Repair foot dislocation,28615,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4356.24,22111, Treat toe dislocation,28630,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,614.17,,,,,,,fee schedule,614.17,3195, Treat toe dislocation,28630,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,614.17,3195, Treat toe dislocation,28630,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,614.17,3195, Treat toe dislocation,28630,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,614.17,3195, Treat toe dislocation,28635,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,670.88,,,,,,,fee schedule,670.88,5664, Treat toe dislocation,28635,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,670.88,5664, Treat toe dislocation,28635,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,670.88,5664, Treat toe dislocation,28635,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,670.88,5664, Treat toe dislocation,28636,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1199.26,,,,,,,fee schedule,1199.26,10940, Treat toe dislocation,28636,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1199.26,10940, Treat toe dislocation,28636,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1199.26,10940, Treat toe dislocation,28636,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1199.26,10940, Repair toe dislocation,28645,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2525.71,,,,,,,fee schedule,2525.71,10940, Repair toe dislocation,28645,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2525.71,10940, Repair toe dislocation,28645,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2525.71,10940, Repair toe dislocation,28645,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2525.71,10940, Treat toe dislocation,28660,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,554.92,,,,,,,fee schedule,554.92,3195, Treat toe dislocation,28660,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,554.92,3195, Treat toe dislocation,28660,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,554.92,3195, Treat toe dislocation,28660,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,554.92,3195, Treat toe dislocation,28665,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,652.54,,,,,,,fee schedule,652.54,3195, Treat toe dislocation,28665,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,652.54,3195, Treat toe dislocation,28665,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,652.54,3195, Treat toe dislocation,28665,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,652.54,3195, Treat toe dislocation,28666,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,887.26,,,,,,,fee schedule,887.26,10940, Treat toe dislocation,28666,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,887.26,10940, Treat toe dislocation,28666,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,887.26,10940, Treat toe dislocation,28666,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,887.26,10940, Repair of toe dislocation,28675,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2145.61,,,,,,,fee schedule,2145.61,10940, Repair of toe dislocation,28675,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2145.61,10940, Repair of toe dislocation,28675,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2145.61,10940, Repair of toe dislocation,28675,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2145.61,10940, Fusion of foot bones,28705,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6172.11,,,,,,,fee schedule,5363,22111, Fusion of foot bones,28705,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,22111, Fusion of foot bones,28705,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5363,22111, Fusion of foot bones,28705,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5363,22111, Fusion of foot bones,28715,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4895.47,,,,,,,fee schedule,4895.47,22111, Fusion of foot bones,28715,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4895.47,22111, Fusion of foot bones,28715,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4895.47,22111, Fusion of foot bones,28715,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4895.47,22111, Fusion of foot bones,28725,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4030.49,,,,,,,fee schedule,4030.49,22111, Fusion of foot bones,28725,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4030.49,22111, Fusion of foot bones,28725,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4030.49,22111, Fusion of foot bones,28725,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4030.49,22111, Fusion of foot bones,28730,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3741.86,,,,,,,fee schedule,3741.86,22111, Fusion of foot bones,28730,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3741.86,22111, Fusion of foot bones,28730,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3741.86,22111, Fusion of foot bones,28730,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3741.86,22111, Fusion of foot bones,28735,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4031.84,,,,,,,fee schedule,4031.84,22111, Fusion of foot bones,28735,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4031.84,22111, Fusion of foot bones,28735,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4031.84,22111, Fusion of foot bones,28735,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4031.84,22111, Revision of foot bones,28737,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3477.29,,,,,,,fee schedule,3477.29,22111, Revision of foot bones,28737,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,3477.29,22111, Revision of foot bones,28737,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3477.29,22111, Revision of foot bones,28737,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3477.29,22111, Fusion of foot bones,28740,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3178.14,,,,,,,fee schedule,3178.14,22111, Fusion of foot bones,28740,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3178.14,22111, Fusion of foot bones,28740,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3178.14,22111, Fusion of foot bones,28740,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3178.14,22111, Fusion of big toe joint,28750,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2950.16,,,,,,,fee schedule,2950.16,22111, Fusion of big toe joint,28750,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2950.16,22111, Fusion of big toe joint,28750,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,2950.16,22111, Fusion of big toe joint,28750,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,2950.16,22111, Fusion of big toe joint,28755,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2558.19,,,,,,,fee schedule,2558.19,10940, Fusion of big toe joint,28755,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2558.19,10940, Fusion of big toe joint,28755,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2558.19,10940, Fusion of big toe joint,28755,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2558.19,10940, Fusion of big toe joint,28760,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2943.03,,,,,,,fee schedule,2943.03,22111, Fusion of big toe joint,28760,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2943.03,22111, Fusion of big toe joint,28760,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,2943.03,22111, Fusion of big toe joint,28760,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,2943.03,22111, Amputation of midfoot,28800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2703.07,,,,,,,fee schedule,2703.07,12821, Amputation of midfoot,28800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2703.07,12821, Amputation of midfoot,28800,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2703.07,12821, Amputation of midfoot,28800,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2703.07,12821, Amputation thru metatarsal,28805,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3601.56,,,,,,,fee schedule,3601.56,10940, Amputation thru metatarsal,28805,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3601.56,10940, Amputation thru metatarsal,28805,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3601.56,10940, Amputation thru metatarsal,28805,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3601.56,10940, Amputation toe & metatarsal,28810,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2192.88,,,,,,,fee schedule,2192.88,10940, Amputation toe & metatarsal,28810,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2192.88,10940, Amputation toe & metatarsal,28810,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2192.88,10940, Amputation toe & metatarsal,28810,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2192.88,10940, Amputation of toe,28820,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,902.48,,,,,,,fee schedule,902.48,10940, Amputation of toe,28820,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,902.48,10940, Amputation of toe,28820,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,902.48,10940, Amputation of toe,28820,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,902.48,10940, Partial amputation of toe,28825,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,871.13,,,,,,,fee schedule,871.13,10940, Partial amputation of toe,28825,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,871.13,10940, Partial amputation of toe,28825,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,871.13,10940, Partial amputation of toe,28825,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,871.13,10940, Hi enrgy eswt plantar fascia,28890,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1116.59,,,,,,,fee schedule,1116.59,12821, Hi enrgy eswt plantar fascia,28890,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,1116.59,12821, Hi enrgy eswt plantar fascia,28890,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,1116.59,12821, Hi enrgy eswt plantar fascia,28890,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,1116.59,12821, Foot/toes surgery procedure,28899,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Foot/toes surgery procedure,28899,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Foot/toes surgery procedure,28899,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Application of body cast,29000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1193.54,,,,,,,fee schedule,1193.54,6979, Application of body cast,29000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1193.54,6979, Application of body cast,29000,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1193.54,6979, Application of body cast,29000,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1193.54,6979, Application of body cast,29010,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,849.17,,,,,,,fee schedule,849.17,6979, Application of body cast,29010,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,849.17,6979, Application of body cast,29010,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,849.17,6979, Application of body cast,29010,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,849.17,6979, Application of body cast,29015,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,942.95,,,,,,,fee schedule,942.95,6979, Application of body cast,29015,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,942.95,6979, Application of body cast,29015,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,942.95,6979, Application of body cast,29015,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,942.95,6979, Application of body cast,29035,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,766.99,,,,,,,fee schedule,766.99,6979, Application of body cast,29035,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,766.99,6979, Application of body cast,29035,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,766.99,6979, Application of body cast,29035,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,766.99,6979, Application of body cast,29040,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,912.68,,,,,,,fee schedule,912.68,6979, Application of body cast,29040,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,912.68,6979, Application of body cast,29040,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,912.68,6979, Application of body cast,29040,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,912.68,6979, Application of body cast,29044,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,885.86,,,,,,,fee schedule,885.86,6979, Application of body cast,29044,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,885.86,6979, Application of body cast,29044,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,885.86,6979, Application of body cast,29044,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,885.86,6979, Application of body cast,29046,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,987.79,,,,,,,fee schedule,987.79,6979, Application of body cast,29046,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,987.79,6979, Application of body cast,29046,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,987.79,6979, Application of body cast,29046,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,987.79,6979, Application of figure eight,29049,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,371.95,,,,,,,fee schedule,371.95,6979, Application of figure eight,29049,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,371.95,6979, Application of figure eight,29049,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,371.95,6979, Application of figure eight,29049,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,371.95,6979, Application of shoulder cast,29055,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,727.43,,,,,,,fee schedule,727.43,6979, Application of shoulder cast,29055,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,727.43,6979, Application of shoulder cast,29055,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,727.43,6979, Application of shoulder cast,29055,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,727.43,6979, Application of shoulder cast,29058,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,487.2,,,,,,,fee schedule,487.2,6979, Application of shoulder cast,29058,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,487.2,6979, Application of shoulder cast,29058,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,487.2,6979, Application of shoulder cast,29058,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,487.2,6979, Application of long arm cast,29065,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,356.03,,,,,,,fee schedule,356.03,6979, Application of long arm cast,29065,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,356.03,6979, Application of long arm cast,29065,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,356.03,6979, Application of long arm cast,29065,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,356.03,6979, Application of forearm cast,29075,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,323,,,,,,,fee schedule,323,6979, Application of forearm cast,29075,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,323,6979, Application of forearm cast,29075,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,323,6979, Application of forearm cast,29075,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,323,6979, Apply hand/wrist cast,29085,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,349.88,,,,,,,fee schedule,349.88,6979, Apply hand/wrist cast,29085,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,349.88,6979, Apply hand/wrist cast,29085,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,349.88,6979, Apply hand/wrist cast,29085,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,349.88,6979, Apply finger cast,29086,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,247.46,,,,,,,fee schedule,247.46,6979, Apply finger cast,29086,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,247.46,6979, Apply finger cast,29086,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,247.46,6979, Apply finger cast,29086,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,247.46,6979, Apply long arm splint,29105,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,217.62,,,,,,,fee schedule,217.62,6979, Apply long arm splint,29105,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,217.62,6979, Apply long arm splint,29105,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,217.62,6979, Apply long arm splint,29105,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,217.62,6979, Apply forearm splint,29125,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,224.69,,,,,,,fee schedule,224.69,6979, Apply forearm splint,29125,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,224.69,6979, Apply forearm splint,29125,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,224.69,6979, Apply forearm splint,29125,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,224.69,6979, Apply forearm splint,29126,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,248.43,,,,,,,fee schedule,248.43,6979, Apply forearm splint,29126,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,248.43,6979, Apply forearm splint,29126,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,248.43,6979, Apply forearm splint,29126,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,248.43,6979, Application of finger splint,29130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,144.45,,,,,,,fee schedule,144.45,6979, Application of finger splint,29130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,144.45,6979, Application of finger splint,29130,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,144.45,6979, Application of finger splint,29130,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,144.45,6979, Application of finger splint,29131,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,172.4,,,,,,,fee schedule,172.4,6979, Application of finger splint,29131,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,172.4,6979, Application of finger splint,29131,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,172.4,6979, Application of finger splint,29131,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,172.4,6979, Strapping of chest,29200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,83.26,,,,,,,fee schedule,83.26,6979, Strapping of chest,29200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,83.26,6979, Strapping of chest,29200,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,83.26,6979, Strapping of chest,29200,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,83.26,6979, Strapping of shoulder,29240,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,83.26,,,,,,,fee schedule,83.26,6979, Strapping of shoulder,29240,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,83.26,6979, Strapping of shoulder,29240,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,83.26,6979, Strapping of shoulder,29240,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,83.26,6979, Strapping of elbow or wrist,29260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,85.96,,,,,,,fee schedule,85.96,6979, Strapping of elbow or wrist,29260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,85.96,6979, Strapping of elbow or wrist,29260,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,85.96,6979, Strapping of elbow or wrist,29260,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,85.96,6979, Strapping of hand or finger,29280,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,94.81,,,,,,,fee schedule,94.81,6979, Strapping of hand or finger,29280,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,94.81,6979, Strapping of hand or finger,29280,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,94.81,6979, Strapping of hand or finger,29280,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,94.81,6979, Application of hip cast,29305,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,839.35,,,,,,,fee schedule,839.35,3195, Application of hip cast,29305,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,839.35,3195, Application of hip cast,29305,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,839.35,3195, Application of hip cast,29305,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,839.35,3195, Application of hip casts,29325,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,932.64,,,,,,,fee schedule,932.64,4108, Application of hip casts,29325,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,932.64,4108, Application of hip casts,29325,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,932.64,4108, Application of hip casts,29325,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,932.64,4108, Application of long leg cast,29345,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,508.63,,,,,,,fee schedule,508.63,3195, Application of long leg cast,29345,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,508.63,3195, Application of long leg cast,29345,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,508.63,3195, Application of long leg cast,29345,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,508.63,3195, Application of long leg cast,29355,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,539.11,,,,,,,fee schedule,539.11,6979, Application of long leg cast,29355,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,539.11,6979, Application of long leg cast,29355,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,539.11,6979, Application of long leg cast,29355,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,539.11,6979, Apply long leg cast brace,29358,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,534.1,,,,,,,fee schedule,534.1,6979, Apply long leg cast brace,29358,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,534.1,6979, Apply long leg cast brace,29358,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,534.1,6979, Apply long leg cast brace,29358,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,534.1,6979, Application of long leg cast,29365,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,455.64,,,,,,,fee schedule,455.64,6979, Application of long leg cast,29365,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,455.64,6979, Application of long leg cast,29365,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,455.64,6979, Application of long leg cast,29365,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,455.64,6979, Apply short leg cast,29405,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,306.76,,,,,,,fee schedule,306.76,6979, Apply short leg cast,29405,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,306.76,6979, Apply short leg cast,29405,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,306.76,6979, Apply short leg cast,29405,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,306.76,6979, Apply short leg cast,29425,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,278.7,,,,,,,fee schedule,278.7,6979, Apply short leg cast,29425,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,278.7,6979, Apply short leg cast,29425,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,278.7,6979, Apply short leg cast,29425,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,278.7,6979, Apply short leg cast,29435,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,451.48,,,,,,,fee schedule,451.48,6979, Apply short leg cast,29435,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,451.48,6979, Apply short leg cast,29435,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,451.48,6979, Apply short leg cast,29435,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,451.48,6979, Addition of walker to cast,29440,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,142.02,,,,,,,fee schedule,142.02,6979, Addition of walker to cast,29440,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,142.02,6979, Addition of walker to cast,29440,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,142.02,6979, Addition of walker to cast,29440,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,142.02,6979, Apply rigid leg cast,29445,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,500.43,,,,,,,fee schedule,500.43,6979, Apply rigid leg cast,29445,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,500.43,6979, Apply rigid leg cast,29445,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,500.43,6979, Apply rigid leg cast,29445,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,500.43,6979, Application of leg cast,29450,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,551.96,,,,,,,fee schedule,551.96,6979, Application of leg cast,29450,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,551.96,6979, Application of leg cast,29450,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,551.96,6979, Application of leg cast,29450,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,551.96,6979, Application long leg splint,29505,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,300.72,,,,,,,fee schedule,300.72,6979, Application long leg splint,29505,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,300.72,6979, Application long leg splint,29505,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,300.72,6979, Application long leg splint,29505,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,300.72,6979, Application lower leg splint,29515,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,274.17,,,,,,,fee schedule,274.17,6979, Application lower leg splint,29515,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,274.17,6979, Application lower leg splint,29515,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,274.17,6979, Application lower leg splint,29515,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,274.17,6979, Strapping of hip,29520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,83.26,,,,,,,fee schedule,83.26,6979, Strapping of hip,29520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,83.26,6979, Strapping of hip,29520,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,83.26,6979, Strapping of hip,29520,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,83.26,6979, Strapping of knee,29530,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,83.26,,,,,,,fee schedule,83.26,6979, Strapping of knee,29530,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,83.26,6979, Strapping of knee,29530,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,83.26,6979, Strapping of knee,29530,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,83.26,6979, Strapping of ankle and/or ft,29540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,85.2,,,,,,,fee schedule,85.2,6979, Strapping of ankle and/or ft,29540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,85.2,6979, Strapping of ankle and/or ft,29540,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,85.2,6979, Strapping of ankle and/or ft,29540,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,85.2,6979, Strapping of toes,29550,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,53.85,,,,,,,fee schedule,53.85,6979, Strapping of toes,29550,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,53.85,6979, Strapping of toes,29550,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,53.85,6979, Strapping of toes,29550,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,53.85,6979, Application of paste boot,29580,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,131.77,,,,,,,fee schedule,131.77,6979, Application of paste boot,29580,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,131.77,6979, Application of paste boot,29580,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,131.77,6979, Application of paste boot,29580,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,131.77,6979, Apply multlay comprs lwr leg,29581,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,124.54,,,,,,,fee schedule,124.54,6979, Apply multlay comprs lwr leg,29581,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,124.54,6979, Apply multlay comprs lwr leg,29581,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,124.54,6979, Apply multlay comprs lwr leg,29581,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,124.54,6979, Appl multlay comprs arm/hand,29584,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,72.58,,,,,,,fee schedule,72.58,6979, Appl multlay comprs arm/hand,29584,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,72.58,6979, Appl multlay comprs arm/hand,29584,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,72.58,6979, Appl multlay comprs arm/hand,29584,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,72.58,6979, Removal/revision of cast,29700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,168.41,,,,,,,fee schedule,168.41,6979, Removal/revision of cast,29700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,168.41,6979, Removal/revision of cast,29700,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,168.41,6979, Removal/revision of cast,29700,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,168.41,6979, Removal/revision of cast,29705,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,228.9,,,,,,,fee schedule,228.9,6979, Removal/revision of cast,29705,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,228.9,6979, Removal/revision of cast,29705,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,228.9,6979, Removal/revision of cast,29705,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,228.9,6979, Removal/revision of cast,29710,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,410.91,,,,,,,fee schedule,410.91,6979, Removal/revision of cast,29710,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,410.91,6979, Removal/revision of cast,29710,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,410.91,6979, Removal/revision of cast,29710,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,410.91,6979, Repair of body cast,29720,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,218.92,,,,,,,fee schedule,218.92,6979, Repair of body cast,29720,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,218.92,6979, Repair of body cast,29720,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,218.92,6979, Repair of body cast,29720,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,218.92,6979, Windowing of cast,29730,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,217.51,,,,,,,fee schedule,217.51,6979, Windowing of cast,29730,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,217.51,6979, Windowing of cast,29730,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,217.51,6979, Windowing of cast,29730,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,217.51,6979, Wedging of cast,29740,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,342.21,,,,,,,fee schedule,342.21,6979, Wedging of cast,29740,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,342.21,6979, Wedging of cast,29740,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,342.21,6979, Wedging of cast,29740,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,342.21,6979, Wedging of clubfoot cast,29750,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,382.47,,,,,,,fee schedule,382.47,6979, Wedging of clubfoot cast,29750,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,382.47,6979, Wedging of clubfoot cast,29750,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,382.47,6979, Wedging of clubfoot cast,29750,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,382.47,6979, Casting/strapping procedure,29799,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,2782, Casting/strapping procedure,29799,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,2782, Jaw arthroscopy/surgery,29800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2817.04,,,,,,,fee schedule,2817.04,12821, Jaw arthroscopy/surgery,29800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2817.04,12821, Jaw arthroscopy/surgery,29800,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2817.04,12821, Jaw arthroscopy/surgery,29800,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2817.04,12821, Jaw arthroscopy/surgery,29804,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2975.73,,,,,,,fee schedule,2975.73,12821, Jaw arthroscopy/surgery,29804,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2975.73,12821, Jaw arthroscopy/surgery,29804,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2975.73,12821, Jaw arthroscopy/surgery,29804,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2975.73,12821, Shoulder arthroscopy dx,29805,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2481.62,,,,,,,fee schedule,2481.62,12821, Shoulder arthroscopy dx,29805,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2481.62,12821, Shoulder arthroscopy dx,29805,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2481.62,12821, Shoulder arthroscopy dx,29805,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2481.62,12821, Shoulder arthroscopy/surgery,29806,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5433.93,,,,,,,fee schedule,5248,22111, Shoulder arthroscopy/surgery,29806,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,22111, Shoulder arthroscopy/surgery,29806,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5248,22111, Shoulder arthroscopy/surgery,29806,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5248,22111, Shoulder arthroscopy/surgery,29807,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5312.85,,,,,,,fee schedule,5248,22111, Shoulder arthroscopy/surgery,29807,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,22111, Shoulder arthroscopy/surgery,29807,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5248,22111, Shoulder arthroscopy/surgery,29807,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5248,22111, Shoulder arthroscopy/surgery,29819,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3045.93,,,,,,,fee schedule,3045.93,22111, Shoulder arthroscopy/surgery,29819,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3045.93,22111, Shoulder arthroscopy/surgery,29819,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3045.93,22111, Shoulder arthroscopy/surgery,29819,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3045.93,22111, Shoulder arthroscopy/surgery,29820,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2776.78,,,,,,,fee schedule,2776.78,22111, Shoulder arthroscopy/surgery,29820,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2776.78,22111, Shoulder arthroscopy/surgery,29820,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,2776.78,22111, Shoulder arthroscopy/surgery,29820,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,2776.78,22111, Shoulder arthroscopy/surgery,29821,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3088.51,,,,,,,fee schedule,3088.51,22111, Shoulder arthroscopy/surgery,29821,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3088.51,22111, Shoulder arthroscopy/surgery,29821,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3088.51,22111, Shoulder arthroscopy/surgery,29821,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3088.51,22111, Shoulder arthroscopy/surgery,29822,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2855.4,,,,,,,fee schedule,2855.4,12821, Shoulder arthroscopy/surgery,29822,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2855.4,12821, Shoulder arthroscopy/surgery,29822,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2855.4,12821, Shoulder arthroscopy/surgery,29822,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2855.4,12821, Shoulder arthroscopy/surgery,29823,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3098.11,,,,,,,fee schedule,3098.11,22111, Shoulder arthroscopy/surgery,29823,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3098.11,22111, Shoulder arthroscopy/surgery,29823,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3098.11,22111, Shoulder arthroscopy/surgery,29823,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3098.11,22111, Shoulder arthroscopy/surgery,29824,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3539.07,,,,,,,fee schedule,3539.07,22111, Shoulder arthroscopy/surgery,29824,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,3539.07,22111, Shoulder arthroscopy/surgery,29824,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3539.07,22111, Shoulder arthroscopy/surgery,29824,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3539.07,22111, Shoulder arthroscopy/surgery,29825,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3065.14,,,,,,,fee schedule,3065.14,22111, Shoulder arthroscopy/surgery,29825,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3065.14,22111, Shoulder arthroscopy/surgery,29825,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3065.14,22111, Shoulder arthroscopy/surgery,29825,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3065.14,22111, Shoulder arthroscopy/surgery,29826,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,841.99,,,,,,,fee schedule,841.99,5248, Shoulder arthroscopy/surgery,29826,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,841.99,5248, Shoulder arthroscopy/surgery,29826,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,841.99,5248, Shoulder arthroscopy/surgery,29826,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,841.99,5248, Arthroscop rotator cuff repr,29827,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5457.57,,,,,,,fee schedule,5457.57,22111, Arthroscop rotator cuff repr,29827,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,5457.57,22111, Arthroscop rotator cuff repr,29827,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5457.57,22111, Arthroscop rotator cuff repr,29827,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5457.57,22111, Arthroscopy biceps tenodesis,29828,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4708.44,,,,,,,fee schedule,4708.44,22111, Arthroscopy biceps tenodesis,29828,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4708.44,22111, Arthroscopy biceps tenodesis,29828,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4708.44,22111, Arthroscopy biceps tenodesis,29828,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4708.44,22111, Elbow arthroscopy,29830,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2432.46,,,,,,,fee schedule,2432.46,22111, Elbow arthroscopy,29830,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2432.46,22111, Elbow arthroscopy,29830,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,2432.46,22111, Elbow arthroscopy,29830,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,2432.46,22111, Elbow arthroscopy/surgery,29834,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2591.27,,,,,,,fee schedule,2591.27,12821, Elbow arthroscopy/surgery,29834,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2591.27,12821, Elbow arthroscopy/surgery,29834,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2591.27,12821, Elbow arthroscopy/surgery,29834,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2591.27,12821, Elbow arthroscopy/surgery,29835,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2697.35,,,,,,,fee schedule,2697.35,22111, Elbow arthroscopy/surgery,29835,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2697.35,22111, Elbow arthroscopy/surgery,29835,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,2697.35,22111, Elbow arthroscopy/surgery,29835,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,2697.35,22111, Elbow arthroscopy/surgery,29836,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3030.12,,,,,,,fee schedule,3030.12,22111, Elbow arthroscopy/surgery,29836,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3030.12,22111, Elbow arthroscopy/surgery,29836,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3030.12,22111, Elbow arthroscopy/surgery,29836,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3030.12,22111, Elbow arthroscopy/surgery,29837,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2810.94,,,,,,,fee schedule,2810.94,12821, Elbow arthroscopy/surgery,29837,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2810.94,12821, Elbow arthroscopy/surgery,29837,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2810.94,12821, Elbow arthroscopy/surgery,29837,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2810.94,12821, Elbow arthroscopy/surgery,29838,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3093.58,,,,,,,fee schedule,3093.58,12821, Elbow arthroscopy/surgery,29838,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3093.58,12821, Elbow arthroscopy/surgery,29838,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3093.58,12821, Elbow arthroscopy/surgery,29838,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3093.58,12821, Wrist arthroscopy,29840,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2437.37,,,,,,,fee schedule,2437.37,12821, Wrist arthroscopy,29840,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2437.37,12821, Wrist arthroscopy,29840,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2437.37,12821, Wrist arthroscopy,29840,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2437.37,12821, Wrist arthroscopy/surgery,29843,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2596.34,,,,,,,fee schedule,2596.34,12821, Wrist arthroscopy/surgery,29843,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2596.34,12821, Wrist arthroscopy/surgery,29843,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2596.34,12821, Wrist arthroscopy/surgery,29843,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2596.34,12821, Wrist arthroscopy/surgery,29844,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2603.03,,,,,,,fee schedule,2603.03,12821, Wrist arthroscopy/surgery,29844,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2603.03,12821, Wrist arthroscopy/surgery,29844,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2603.03,12821, Wrist arthroscopy/surgery,29844,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2603.03,12821, Wrist arthroscopy/surgery,29845,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3023,,,,,,,fee schedule,3023,12821, Wrist arthroscopy/surgery,29845,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3023,12821, Wrist arthroscopy/surgery,29845,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3023,12821, Wrist arthroscopy/surgery,29845,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3023,12821, Wrist arthroscopy/surgery,29846,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2697.78,,,,,,,fee schedule,2697.78,12821, Wrist arthroscopy/surgery,29846,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2697.78,12821, Wrist arthroscopy/surgery,29846,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2697.78,12821, Wrist arthroscopy/surgery,29846,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2697.78,12821, Wrist arthroscopy/surgery,29847,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2869.92,,,,,,,fee schedule,2869.92,22111, Wrist arthroscopy/surgery,29847,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2869.92,22111, Wrist arthroscopy/surgery,29847,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,2869.92,22111, Wrist arthroscopy/surgery,29847,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,2869.92,22111, Wrist endoscopy/surgery,29848,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2673.93,,,,,,,fee schedule,2673.93,12821, Wrist endoscopy/surgery,29848,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2673.93,12821, Wrist endoscopy/surgery,29848,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2673.93,12821, Wrist endoscopy/surgery,29848,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2673.93,12821, Knee arthroscopy/surgery,29850,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3294.31,,,,,,,fee schedule,3294.31,12821, Knee arthroscopy/surgery,29850,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3294.31,12821, Knee arthroscopy/surgery,29850,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3294.31,12821, Knee arthroscopy/surgery,29850,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3294.31,12821, Knee arthroscopy/surgery,29851,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4819.01,,,,,,,fee schedule,4819.01,14456, Knee arthroscopy/surgery,29851,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4819.01,14456, Knee arthroscopy/surgery,29851,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4819.01,14456, Knee arthroscopy/surgery,29851,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4819.01,14456, Tibial arthroscopy/surgery,29855,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4060.92,,,,,,,fee schedule,4060.92,22111, Tibial arthroscopy/surgery,29855,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4060.92,22111, Tibial arthroscopy/surgery,29855,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4060.92,22111, Tibial arthroscopy/surgery,29855,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4060.92,22111, Tibial arthroscopy/surgery,29856,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5138.02,,,,,,,fee schedule,5138.02,22111, Tibial arthroscopy/surgery,29856,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5138.02,22111, Tibial arthroscopy/surgery,29856,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5138.02,22111, Tibial arthroscopy/surgery,29856,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5138.02,22111, Hip arthroscopy dx,29860,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3410,,,,,,,fee schedule,3410,22111, Hip arthroscopy dx,29860,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3410,22111, Hip arthroscopy dx,29860,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3410,22111, Hip arthroscopy dx,29860,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3410,22111, Hip arthro w/fb removal,29861,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3648.45,,,,,,,fee schedule,3648.45,22111, Hip arthro w/fb removal,29861,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3648.45,22111, Hip arthro w/fb removal,29861,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3648.45,22111, Hip arthro w/fb removal,29861,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3648.45,22111, Hip arthr0 w/debridement,29862,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4220.16,,,,,,,fee schedule,4220.16,22111, Hip arthr0 w/debridement,29862,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4220.16,22111, Hip arthr0 w/debridement,29862,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4220.16,22111, Hip arthr0 w/debridement,29862,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4220.16,22111, Hip arthr0 w/synovectomy,29863,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4201.43,,,,,,,fee schedule,4201.43,22111, Hip arthr0 w/synovectomy,29863,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4201.43,22111, Hip arthr0 w/synovectomy,29863,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4201.43,22111, Hip arthr0 w/synovectomy,29863,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4201.43,22111, Autgrft implnt knee w/scope,29866,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5464.96,,,,,,,fee schedule,5248,22111, Autgrft implnt knee w/scope,29866,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,22111, Autgrft implnt knee w/scope,29866,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5248,22111, Autgrft implnt knee w/scope,29866,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5248,22111, Allgrft implnt knee w/scope,29867,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6600.28,,,,,,,fee schedule,5248,22111, Allgrft implnt knee w/scope,29867,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,22111, Allgrft implnt knee w/scope,29867,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5248,22111, Allgrft implnt knee w/scope,29867,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5248,22111, Meniscal trnspl knee w/scpe,29868,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8507.5,,,,,,,fee schedule,5248,22111, Meniscal trnspl knee w/scpe,29868,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,22111, Meniscal trnspl knee w/scpe,29868,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5248,22111, Meniscal trnspl knee w/scpe,29868,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5248,22111, Knee arthroscopy dx,29870,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2204.1,,,,,,,fee schedule,2204.1,12821, Knee arthroscopy dx,29870,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2204.1,12821, Knee arthroscopy dx,29870,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2204.1,12821, Knee arthroscopy dx,29870,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2204.1,12821, Knee arthroscopy/drainage,29871,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2719.37,,,,,,,fee schedule,2719.37,12821, Knee arthroscopy/drainage,29871,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2719.37,12821, Knee arthroscopy/drainage,29871,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2719.37,12821, Knee arthroscopy/drainage,29871,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2719.37,12821, Knee arthroscopy/surgery,29873,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2860.31,,,,,,,fee schedule,2860.31,12821, Knee arthroscopy/surgery,29873,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2860.31,12821, Knee arthroscopy/surgery,29873,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2860.31,12821, Knee arthroscopy/surgery,29873,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2860.31,12821, Knee arthroscopy/surgery,29874,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2805.92,,,,,,,fee schedule,2805.92,12821, Knee arthroscopy/surgery,29874,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2805.92,12821, Knee arthroscopy/surgery,29874,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2805.92,12821, Knee arthroscopy/surgery,29874,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2805.92,12821, Knee arthroscopy/surgery,29875,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2625.69,,,,,,,fee schedule,2625.69,12821, Knee arthroscopy/surgery,29875,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2625.69,12821, Knee arthroscopy/surgery,29875,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2625.69,12821, Knee arthroscopy/surgery,29875,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2625.69,12821, Knee arthroscopy/surgery,29876,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3415.18,,,,,,,fee schedule,3415.18,12821, Knee arthroscopy/surgery,29876,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3415.18,12821, Knee arthroscopy/surgery,29876,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3415.18,12821, Knee arthroscopy/surgery,29876,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3415.18,12821, Knee arthroscopy/surgery,29877,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3255.14,,,,,,,fee schedule,3255.14,12821, Knee arthroscopy/surgery,29877,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3255.14,12821, Knee arthroscopy/surgery,29877,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3255.14,12821, Knee arthroscopy/surgery,29877,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3255.14,12821, Knee arthroscopy/surgery,29879,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3464.12,,,,,,,fee schedule,3464.12,12821, Knee arthroscopy/surgery,29879,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3464.12,12821, Knee arthroscopy/surgery,29879,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3464.12,12821, Knee arthroscopy/surgery,29879,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3464.12,12821, Knee arthroscopy/surgery,29880,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2952.04,,,,,,,fee schedule,2952.04,12821, Knee arthroscopy/surgery,29880,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2952.04,12821, Knee arthroscopy/surgery,29880,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2952.04,12821, Knee arthroscopy/surgery,29880,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2952.04,12821, Knee arthroscopy/surgery,29881,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2852.65,,,,,,,fee schedule,2852.65,12821, Knee arthroscopy/surgery,29881,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2852.65,12821, Knee arthroscopy/surgery,29881,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2852.65,12821, Knee arthroscopy/surgery,29881,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2852.65,12821, Knee arthroscopy/surgery,29882,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3569.24,,,,,,,fee schedule,3569.24,12821, Knee arthroscopy/surgery,29882,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3569.24,12821, Knee arthroscopy/surgery,29882,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3569.24,12821, Knee arthroscopy/surgery,29882,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3569.24,12821, Knee arthroscopy/surgery,29883,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4382.9,,,,,,,fee schedule,4382.9,12821, Knee arthroscopy/surgery,29883,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4382.9,12821, Knee arthroscopy/surgery,29883,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4382.9,12821, Knee arthroscopy/surgery,29883,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4382.9,12821, Knee arthroscopy/surgery,29884,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3251.52,,,,,,,fee schedule,3251.52,12821, Knee arthroscopy/surgery,29884,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3251.52,12821, Knee arthroscopy/surgery,29884,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3251.52,12821, Knee arthroscopy/surgery,29884,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3251.52,12821, Knee arthroscopy/surgery,29885,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3963.09,,,,,,,fee schedule,3963.09,22111, Knee arthroscopy/surgery,29885,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3963.09,22111, Knee arthroscopy/surgery,29885,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3963.09,22111, Knee arthroscopy/surgery,29885,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3963.09,22111, Knee arthroscopy/surgery,29886,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3359.55,,,,,,,fee schedule,3359.55,12821, Knee arthroscopy/surgery,29886,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3359.55,12821, Knee arthroscopy/surgery,29886,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3359.55,12821, Knee arthroscopy/surgery,29886,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3359.55,12821, Knee arthroscopy/surgery,29887,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3951.44,,,,,,,fee schedule,3951.44,12821, Knee arthroscopy/surgery,29887,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3951.44,12821, Knee arthroscopy/surgery,29887,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3951.44,12821, Knee arthroscopy/surgery,29887,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3951.44,12821, Knee arthroscopy/surgery,29888,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4969.07,,,,,,,fee schedule,4969.07,22111, Knee arthroscopy/surgery,29888,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4969.07,22111, Knee arthroscopy/surgery,29888,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4969.07,22111, Knee arthroscopy/surgery,29888,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4969.07,22111, Knee arthroscopy/surgery,29889,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6331.5,,,,,,,fee schedule,5248,22111, Knee arthroscopy/surgery,29889,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,22111, Knee arthroscopy/surgery,29889,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5248,22111, Knee arthroscopy/surgery,29889,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5248,22111, Ankle arthroscopy/surgery,29891,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3499.85,,,,,,,fee schedule,3499.85,22111, Ankle arthroscopy/surgery,29891,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3499.85,22111, Ankle arthroscopy/surgery,29891,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3499.85,22111, Ankle arthroscopy/surgery,29891,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3499.85,22111, Ankle arthroscopy/surgery,29892,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3286.06,,,,,,,fee schedule,3286.06,14456, Ankle arthroscopy/surgery,29892,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3286.06,14456, Ankle arthroscopy/surgery,29892,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3286.06,14456, Ankle arthroscopy/surgery,29892,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3286.06,14456, Scope plantar fasciotomy,29893,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2259.52,,,,,,,fee schedule,2259.52,10940, Scope plantar fasciotomy,29893,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2259.52,10940, Scope plantar fasciotomy,29893,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2259.52,10940, Scope plantar fasciotomy,29893,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2259.52,10940, Ankle arthroscopy/surgery,29894,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2625.26,,,,,,,fee schedule,2625.26,12821, Ankle arthroscopy/surgery,29894,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2625.26,12821, Ankle arthroscopy/surgery,29894,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2625.26,12821, Ankle arthroscopy/surgery,29894,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2625.26,12821, Ankle arthroscopy/surgery,29895,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2389.19,,,,,,,fee schedule,2389.19,12821, Ankle arthroscopy/surgery,29895,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2389.19,12821, Ankle arthroscopy/surgery,29895,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2389.19,12821, Ankle arthroscopy/surgery,29895,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2389.19,12821, Ankle arthroscopy/surgery,29897,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2569.41,,,,,,,fee schedule,2569.41,12821, Ankle arthroscopy/surgery,29897,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2569.41,12821, Ankle arthroscopy/surgery,29897,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2569.41,12821, Ankle arthroscopy/surgery,29897,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2569.41,12821, Ankle arthroscopy/surgery,29898,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2891.55,,,,,,,fee schedule,2891.55,12821, Ankle arthroscopy/surgery,29898,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2891.55,12821, Ankle arthroscopy/surgery,29898,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2891.55,12821, Ankle arthroscopy/surgery,29898,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2891.55,12821, Ankle arthroscopy/surgery,29899,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5137.37,,,,,,,fee schedule,5137.37,22111, Ankle arthroscopy/surgery,29899,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5137.37,22111, Ankle arthroscopy/surgery,29899,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5137.37,22111, Ankle arthroscopy/surgery,29899,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5137.37,22111, Mcp joint arthroscopy dx,29900,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2715.05,,,,,,,fee schedule,2715.05,12821, Mcp joint arthroscopy dx,29900,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2715.05,12821, Mcp joint arthroscopy dx,29900,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2715.05,12821, Mcp joint arthroscopy dx,29900,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2715.05,12821, Mcp joint arthroscopy surg,29901,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2885.78,,,,,,,fee schedule,2885.78,22111, Mcp joint arthroscopy surg,29901,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2885.78,22111, Mcp joint arthroscopy surg,29901,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,2885.78,22111, Mcp joint arthroscopy surg,29901,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,2885.78,22111, Mcp joint arthroscopy surg,29902,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3051.11,,,,,,,fee schedule,3051.11,12821, Mcp joint arthroscopy surg,29902,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3051.11,12821, Mcp joint arthroscopy surg,29902,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3051.11,12821, Mcp joint arthroscopy surg,29902,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3051.11,12821, Subtalar arthro w/fb rmvl,29904,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3348.92,,,,,,,fee schedule,3348.92,12821, Subtalar arthro w/fb rmvl,29904,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3348.92,12821, Subtalar arthro w/fb rmvl,29904,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3348.92,12821, Subtalar arthro w/fb rmvl,29904,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3348.92,12821, Subtalar arthro w/exc,29905,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2611.77,,,,,,,fee schedule,2611.77,12821, Subtalar arthro w/exc,29905,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2611.77,12821, Subtalar arthro w/exc,29905,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2611.77,12821, Subtalar arthro w/exc,29905,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2611.77,12821, Subtalar arthro w/deb,29906,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3460.29,,,,,,,fee schedule,3460.29,12821, Subtalar arthro w/deb,29906,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3460.29,12821, Subtalar arthro w/deb,29906,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3460.29,12821, Subtalar arthro w/deb,29906,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3460.29,12821, Subtalar arthro w/fusion,29907,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4573.65,,,,,,,fee schedule,4573.65,22111, Subtalar arthro w/fusion,29907,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4573.65,22111, Subtalar arthro w/fusion,29907,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4573.65,22111, Subtalar arthro w/fusion,29907,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4573.65,22111, Hip arthro w/femoroplasty,29914,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5113.47,,,,,,,fee schedule,5113.47,22111, Hip arthro w/femoroplasty,29914,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5113.47,22111, Hip arthro w/femoroplasty,29914,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5113.47,22111, Hip arthro w/femoroplasty,29914,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5113.47,22111, Hip arthro acetabuloplasty,29915,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5211.83,,,,,,,fee schedule,5211.83,22111, Hip arthro acetabuloplasty,29915,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5211.83,22111, Hip arthro acetabuloplasty,29915,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5211.83,22111, Hip arthro acetabuloplasty,29915,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5211.83,22111, Hip arthro w/labral repair,29916,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5202.23,,,,,,,fee schedule,5202.23,22111, Hip arthro w/labral repair,29916,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5202.23,22111, Hip arthro w/labral repair,29916,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5202.23,22111, Hip arthro w/labral repair,29916,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5202.23,22111, Arthroscopy of joint,29999,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Arthroscopy of joint,29999,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Arthroscopy of joint,29999,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Drainage of nose lesion,30000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,602.46,,,,,,,fee schedule,602.46,3195, Drainage of nose lesion,30000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,602.46,3195, Drainage of nose lesion,30000,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,602.46,3195, Drainage of nose lesion,30000,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,602.46,3195, Drainage of nose lesion,30020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,607.59,,,,,,,fee schedule,607.59,3195, Drainage of nose lesion,30020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,607.59,3195, Drainage of nose lesion,30020,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,607.59,3195, Drainage of nose lesion,30020,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,607.59,3195, Intranasal biopsy,30100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,335.42,,,,,,,fee schedule,335.42,5664, Intranasal biopsy,30100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,335.42,5664, Intranasal biopsy,30100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,335.42,5664, Intranasal biopsy,30100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,335.42,5664, Removal of nose polyp(s),30110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,654.27,,,,,,,fee schedule,654.27,5664, Removal of nose polyp(s),30110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,654.27,5664, Removal of nose polyp(s),30110,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,654.27,5664, Removal of nose polyp(s),30110,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,654.27,5664, Removal of nose polyp(s),30115,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2331.94,,,,,,,fee schedule,2331.94,10940, Removal of nose polyp(s),30115,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2331.94,10940, Removal of nose polyp(s),30115,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2331.94,10940, Removal of nose polyp(s),30115,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2331.94,10940, Removal of intranasal lesion,30117,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2015.95,,,,,,,fee schedule,2015.95,5664, Removal of intranasal lesion,30117,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2015.95,5664, Removal of intranasal lesion,30117,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2015.95,5664, Removal of intranasal lesion,30117,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2015.95,5664, Removal of intranasal lesion,30118,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3451.71,,,,,,,fee schedule,3451.71,10940, Removal of intranasal lesion,30118,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3451.71,10940, Removal of intranasal lesion,30118,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3451.71,10940, Removal of intranasal lesion,30118,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3451.71,10940, Revision of nose,30120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2047.13,,,,,,,fee schedule,2047.13,10940, Revision of nose,30120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2047.13,10940, Revision of nose,30120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2047.13,10940, Revision of nose,30120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2047.13,10940, Removal of nose lesion,30124,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1511.26,,,,,,,fee schedule,1511.26,5664, Removal of nose lesion,30124,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1511.26,5664, Removal of nose lesion,30124,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1511.26,5664, Removal of nose lesion,30124,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1511.26,5664, Removal of nose lesion,30125,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3207.98,,,,,,,fee schedule,3207.98,14456, Removal of nose lesion,30125,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3207.98,14456, Removal of nose lesion,30125,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3207.98,14456, Removal of nose lesion,30125,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3207.98,14456, Excise inferior turbinate,30130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2102.12,,,,,,,fee schedule,2102.12,10940, Excise inferior turbinate,30130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2102.12,10940, Excise inferior turbinate,30130,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2102.12,10940, Excise inferior turbinate,30130,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2102.12,10940, Resect inferior turbinate,30140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,856.51,,,,,,,fee schedule,856.51,10940, Resect inferior turbinate,30140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,856.51,10940, Resect inferior turbinate,30140,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,856.51,10940, Resect inferior turbinate,30140,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,856.51,10940, Partial removal of nose,30150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3913.88,,,,,,,fee schedule,3913.88,14456, Partial removal of nose,30150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3913.88,14456, Partial removal of nose,30150,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3913.88,14456, Partial removal of nose,30150,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3913.88,14456, Removal of nose,30160,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3973.4,,,,,,,fee schedule,3973.4,14456, Removal of nose,30160,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3973.4,14456, Removal of nose,30160,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3973.4,14456, Removal of nose,30160,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3973.4,14456, Injection treatment of nose,30200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,296.02,,,,,,,fee schedule,296.02,6979, Injection treatment of nose,30200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,296.02,6979, Injection treatment of nose,30200,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,296.02,6979, Injection treatment of nose,30200,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,296.02,6979, Nasal sinus therapy,30210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,521.47,,,,,,,fee schedule,521.47,6979, Nasal sinus therapy,30210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,521.47,6979, Nasal sinus therapy,30210,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,521.47,6979, Nasal sinus therapy,30210,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,521.47,6979, Insert nasal septal button,30220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,631.87,,,,,,,fee schedule,631.87,5664, Insert nasal septal button,30220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,631.87,5664, Insert nasal septal button,30220,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,631.87,5664, Insert nasal septal button,30220,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,631.87,5664, Remove nasal foreign body,30300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,620.32,,,,,,,fee schedule,620.32,6979, Remove nasal foreign body,30300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,620.32,6979, Remove nasal foreign body,30300,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,620.32,6979, Remove nasal foreign body,30300,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,620.32,6979, Remove nasal foreign body,30310,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1025.24,,,,,,,fee schedule,1025.24,5664, Remove nasal foreign body,30310,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1025.24,5664, Remove nasal foreign body,30310,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1025.24,5664, Remove nasal foreign body,30310,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1025.24,5664, Remove nasal foreign body,30320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2438.07,,,,,,,fee schedule,2438.07,5664, Remove nasal foreign body,30320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2438.07,5664, Remove nasal foreign body,30320,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2438.07,5664, Remove nasal foreign body,30320,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2438.07,5664, Reconstruction of nose,30400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6447.3,,,,,,,fee schedule,5363,10940, Reconstruction of nose,30400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,10940, Reconstruction of nose,30400,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,5363,10940, Reconstruction of nose,30400,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,5363,10940, Reconstruction of nose,30410,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7344.5,,,,,,,fee schedule,6044,14456, Reconstruction of nose,30410,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,14456, Reconstruction of nose,30410,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,6044,14456, Reconstruction of nose,30410,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,6044,14456, Reconstruction of nose,30420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7146.84,,,,,,,fee schedule,6044,14456, Reconstruction of nose,30420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,14456, Reconstruction of nose,30420,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,6044,14456, Reconstruction of nose,30420,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,6044,14456, Revision of nose,30430,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5693.91,,,,,,,fee schedule,5248,10940, Revision of nose,30430,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,10940, Revision of nose,30430,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,5248,10940, Revision of nose,30430,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,5248,10940, Revision of nose,30435,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6983.88,,,,,,,fee schedule,6044,14456, Revision of nose,30435,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,14456, Revision of nose,30435,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,6044,14456, Revision of nose,30435,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,6044,14456, Revision of nose,30450,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8966.43,,,,,,,fee schedule,8406,14456, Revision of nose,30450,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,8406,14456, Revision of nose,30450,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,8406,14456, Revision of nose,30450,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,8406,14456, Revision of nose,30460,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4223.61,,,,,,,fee schedule,4223.61,14456, Revision of nose,30460,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,4223.61,14456, Revision of nose,30460,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4223.61,14456, Revision of nose,30460,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4223.61,14456, Revision of nose,30462,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8058.49,,,,,,,fee schedule,8058.49,14456, Revision of nose,30462,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,8058.49,14456, Revision of nose,30462,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,8058.49,14456, Revision of nose,30462,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,8058.49,14456, Repair Nasal Stenosis,30465,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5032.69,,,,,,,fee schedule,5032.69,14456, Repair Nasal Stenosis,30465,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,5032.69,14456, Repair Nasal Stenosis,30465,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5032.69,14456, Repair Nasal Stenosis,30465,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5032.69,14456, Rpr nsl vlv collapse w/implt,30468,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,812.31,,,,,,,fee schedule,812.31,14456, Rpr nsl vlv collapse w/implt,30468,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,812.31,14456, Rpr nsl vlv collapse w/implt,30468,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,812.31,14456, Rpr nsl vlv collapse w/implt,30468,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,812.31,14456, Rpr nsl vlv collapse w/rmdlg,30469,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,722.9,,,,,,,fee schedule,722.9,14456, Rpr nsl vlv collapse w/rmdlg,30469,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,722.9,14456, Rpr nsl vlv collapse w/rmdlg,30469,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,722.9,14456, Rpr nsl vlv collapse w/rmdlg,30469,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,722.9,14456, Repair of nasal septum,30520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3317.19,,,,,,,fee schedule,3317.19,10940, Repair of nasal septum,30520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3317.19,10940, Repair of nasal septum,30520,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3317.19,10940, Repair of nasal septum,30520,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3317.19,10940, Repair nasal defect,30540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3642.79,,,,,,,fee schedule,3642.79,14456, Repair nasal defect,30540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,3642.79,14456, Repair nasal defect,30540,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3642.79,14456, Repair nasal defect,30540,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3642.79,14456, Repair nasal defect,30545,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4906.37,,,,,,,fee schedule,4906.37,14456, Repair nasal defect,30545,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4906.37,14456, Repair nasal defect,30545,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4906.37,14456, Repair nasal defect,30545,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4906.37,14456, Release of nasal adhesions,30560,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,749.13,,,,,,,fee schedule,749.13,4108, Release of nasal adhesions,30560,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,749.13,4108, Release of nasal adhesions,30560,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,749.13,4108, Release of nasal adhesions,30560,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,749.13,4108, Repair upper jaw fistula,30580,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2303.82,,,,,,,fee schedule,2303.82,14456, Repair upper jaw fistula,30580,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2303.82,14456, Repair upper jaw fistula,30580,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,2303.82,14456, Repair upper jaw fistula,30580,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,2303.82,14456, Repair mouth/nose fistula,30600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2120.79,,,,,,,fee schedule,2120.79,14456, Repair mouth/nose fistula,30600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2120.79,14456, Repair mouth/nose fistula,30600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,2120.79,14456, Repair mouth/nose fistula,30600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,2120.79,14456, Intranasal reconstruction,30620,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3320.27,,,,,,,fee schedule,3320.27,14456, Intranasal reconstruction,30620,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,3320.27,14456, Intranasal reconstruction,30620,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3320.27,14456, Intranasal reconstruction,30620,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3320.27,14456, Repair nasal septum defect,30630,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3297.77,,,,,,,fee schedule,3297.77,10940, Repair nasal septum defect,30630,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,3297.77,10940, Repair nasal septum defect,30630,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3297.77,10940, Repair nasal septum defect,30630,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3297.77,10940, Ablate inf turbinate superf,30801,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,748.26,,,,,,,fee schedule,748.26,5664, Ablate inf turbinate superf,30801,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,748.26,5664, Ablate inf turbinate superf,30801,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,748.26,5664, Ablate inf turbinate superf,30801,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,748.26,5664, Ablate inf turbinate submuc,30802,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,990.6,,,,,,,fee schedule,990.6,5664, Ablate inf turbinate submuc,30802,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,990.6,5664, Ablate inf turbinate submuc,30802,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,990.6,5664, Ablate inf turbinate submuc,30802,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,990.6,5664, Control of nosebleed,30901,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,283.94,,,,,,,fee schedule,283.94,3195, Control of nosebleed,30901,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,283.94,3195, Control of nosebleed,30901,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,283.94,3195, Control of nosebleed,30901,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,283.94,3195, Control of nosebleed,30903,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,399.63,,,,,,,fee schedule,399.63,3195, Control of nosebleed,30903,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,399.63,3195, Control of nosebleed,30903,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,399.63,3195, Control of nosebleed,30903,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,399.63,3195, Control of nosebleed,30905,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,565.39,,,,,,,fee schedule,565.39,3195, Control of nosebleed,30905,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,565.39,3195, Control of nosebleed,30905,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,565.39,3195, Control of nosebleed,30905,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,565.39,3195, Repeat control of nosebleed,30906,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,676.44,,,,,,,fee schedule,676.44,3195, Repeat control of nosebleed,30906,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,676.44,3195, Repeat control of nosebleed,30906,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,676.44,3195, Repeat control of nosebleed,30906,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,676.44,3195, Ligation nasal sinus artery,30915,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2952.53,,,,,,,fee schedule,2952.53,12821, Ligation nasal sinus artery,30915,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2952.53,12821, Ligation nasal sinus artery,30915,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2952.53,12821, Ligation nasal sinus artery,30915,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2952.53,12821, Ligation upper jaw artery,30920,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4244.44,,,,,,,fee schedule,4244.44,12821, Ligation upper jaw artery,30920,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4244.44,12821, Ligation upper jaw artery,30920,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4244.44,12821, Ligation upper jaw artery,30920,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4244.44,12821, Ther fx nasal inf turbinate,30930,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,589.62,,,,,,,fee schedule,589.62,10940, Ther fx nasal inf turbinate,30930,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,589.62,10940, Ther fx nasal inf turbinate,30930,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,589.62,10940, Ther fx nasal inf turbinate,30930,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,589.62,10940, Nasal surgery procedure,30999,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Nasal surgery procedure,30999,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Nasal surgery procedure,30999,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Irrigation maxillary sinus,31000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,552.28,,,,,,,fee schedule,552.28,3195, Irrigation maxillary sinus,31000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,552.28,3195, Irrigation maxillary sinus,31000,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,552.28,3195, Irrigation maxillary sinus,31000,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,552.28,3195, Irrigation sphenoid sinus,31002,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,897.09,,,,,,,fee schedule,897.09,5664, Irrigation sphenoid sinus,31002,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,897.09,5664, Irrigation sphenoid sinus,31002,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,897.09,5664, Irrigation sphenoid sinus,31002,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,897.09,5664, Exploration maxillary sinus,31020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1747.01,,,,,,,fee schedule,1747.01,10940, Exploration maxillary sinus,31020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1747.01,10940, Exploration maxillary sinus,31020,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1747.01,10940, Exploration maxillary sinus,31020,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1747.01,10940, Exploration maxillary sinus,31030,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2570.06,,,,,,,fee schedule,2570.06,14456, Exploration maxillary sinus,31030,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2570.06,14456, Exploration maxillary sinus,31030,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,2570.06,14456, Exploration maxillary sinus,31030,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,2570.06,14456, Explore sinus remove polyps,31032,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2989.82,,,,,,,fee schedule,2989.82,14456, Explore sinus remove polyps,31032,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2989.82,14456, Explore sinus remove polyps,31032,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,2989.82,14456, Explore sinus remove polyps,31032,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,2989.82,14456, Exploration behind upper jaw,31040,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3940,,,,,,,fee schedule,3940,10940, Exploration behind upper jaw,31040,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3940,10940, Exploration behind upper jaw,31040,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3940,10940, Exploration behind upper jaw,31040,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3940,10940, Exploration sphenoid sinus,31050,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2578.91,,,,,,,fee schedule,2578.91,14456, Exploration sphenoid sinus,31050,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2578.91,14456, Exploration sphenoid sinus,31050,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,2578.91,14456, Exploration sphenoid sinus,31050,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,2578.91,14456, Sphenoid sinus surgery,31051,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3436.77,,,,,,,fee schedule,3436.77,14456, Sphenoid sinus surgery,31051,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3436.77,14456, Sphenoid sinus surgery,31051,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3436.77,14456, Sphenoid sinus surgery,31051,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3436.77,14456, Exploration of frontal sinus,31070,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2379.85,,,,,,,fee schedule,2379.85,10940, Exploration of frontal sinus,31070,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2379.85,10940, Exploration of frontal sinus,31070,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2379.85,10940, Exploration of frontal sinus,31070,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2379.85,10940, Exploration of frontal sinus,31075,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4072.04,,,,,,,fee schedule,4072.04,14456, Exploration of frontal sinus,31075,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4072.04,14456, Exploration of frontal sinus,31075,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4072.04,14456, Exploration of frontal sinus,31075,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4072.04,14456, Removal of frontal sinus,31080,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5345.06,,,,,,,fee schedule,5345.06,14456, Removal of frontal sinus,31080,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5345.06,14456, Removal of frontal sinus,31080,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5345.06,14456, Removal of frontal sinus,31080,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5345.06,14456, Removal of frontal sinus,31081,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5719.17,,,,,,,fee schedule,5363,14456, Removal of frontal sinus,31081,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,14456, Removal of frontal sinus,31081,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5363,14456, Removal of frontal sinus,31081,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5363,14456, Removal of frontal sinus,31084,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5913.31,,,,,,,fee schedule,5363,14456, Removal of frontal sinus,31084,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,14456, Removal of frontal sinus,31084,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5363,14456, Removal of frontal sinus,31084,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5363,14456, Removal of frontal sinus,31085,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6085.07,,,,,,,fee schedule,5363,14456, Removal of frontal sinus,31085,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,14456, Removal of frontal sinus,31085,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5363,14456, Removal of frontal sinus,31085,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5363,14456, Removal of frontal sinus,31086,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5762.98,,,,,,,fee schedule,5363,14456, Removal of frontal sinus,31086,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,14456, Removal of frontal sinus,31086,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5363,14456, Removal of frontal sinus,31086,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5363,14456, Removal of frontal sinus,31087,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5478.88,,,,,,,fee schedule,5363,14456, Removal of frontal sinus,31087,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,14456, Removal of frontal sinus,31087,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5363,14456, Removal of frontal sinus,31087,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5363,14456, Exploration of sinuses,31090,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5460.37,,,,,,,fee schedule,5460.37,14456, Exploration of sinuses,31090,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,5460.37,14456, Exploration of sinuses,31090,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5460.37,14456, Exploration of sinuses,31090,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5460.37,14456, Removal of ethmoid sinus,31200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3095.69,,,,,,,fee schedule,3095.69,14456, Removal of ethmoid sinus,31200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3095.69,14456, Removal of ethmoid sinus,31200,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3095.69,14456, Removal of ethmoid sinus,31200,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3095.69,14456, Removal of ethmoid sinus,31201,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3847.46,,,,,,,fee schedule,3847.46,6044, Removal of ethmoid sinus,31201,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,3847.46,6044, Removal of ethmoid sinus,31201,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3847.46,6044, Removal of ethmoid sinus,31201,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3847.46,6044, Removal of ethmoid sinus,31205,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4511.06,,,,,,,fee schedule,4511.06,10940, Removal of ethmoid sinus,31205,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4511.06,10940, Removal of ethmoid sinus,31205,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,4511.06,10940, Removal of ethmoid sinus,31205,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,4511.06,10940, Removal of upper jaw,31225,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8718.86,,,,,,,fee schedule,5097,8718.86, Removal of upper jaw,31225,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8718.86, Removal of upper jaw,31225,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8718.86, Removal of upper jaw,31225,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8718.86, Removal of upper jaw,31230,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9669.42,,,,,,,fee schedule,5097,9669.42, Removal of upper jaw,31230,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,9669.42, Removal of upper jaw,31230,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,9669.42, Removal of upper jaw,31230,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,9669.42, Nasal endoscopy dx,31231,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,306.82,,,,,,,fee schedule,306.82,4108, Nasal endoscopy dx,31231,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,306.82,4108, Nasal endoscopy dx,31231,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,306.82,4108, Nasal endoscopy dx,31231,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,306.82,4108, Nasal/sinus endoscopy dx,31233,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,651.24,,,,,,,fee schedule,651.24,4108, Nasal/sinus endoscopy dx,31233,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,651.24,4108, Nasal/sinus endoscopy dx,31233,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,651.24,4108, Nasal/sinus endoscopy dx,31233,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,651.24,4108, Nasal/sinus endoscopy dx,31235,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,768.44,,,,,,,fee schedule,768.44,5664, Nasal/sinus endoscopy dx,31235,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,768.44,5664, Nasal/sinus endoscopy dx,31235,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,768.44,5664, Nasal/sinus endoscopy dx,31235,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,768.44,5664, Nasal/sinus endoscopy surg,31237,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,769.96,,,,,,,fee schedule,769.96,5664, Nasal/sinus endoscopy surg,31237,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,769.96,5664, Nasal/sinus endoscopy surg,31237,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,769.96,5664, Nasal/sinus endoscopy surg,31237,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,769.96,5664, Nasal/sinus endoscopy surg,31238,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,803.95,,,,,,,fee schedule,803.95,5664, Nasal/sinus endoscopy surg,31238,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,803.95,5664, Nasal/sinus endoscopy surg,31238,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,803.95,5664, Nasal/sinus endoscopy surg,31238,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,803.95,5664, Nasal/sinus endoscopy surg,31239,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2874.34,,,,,,,fee schedule,2874.34,10940, Nasal/sinus endoscopy surg,31239,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2874.34,10940, Nasal/sinus endoscopy surg,31239,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2874.34,10940, Nasal/sinus endoscopy surg,31239,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2874.34,10940, Nasal/sinus endoscopy surg,31240,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,761.32,,,,,,,fee schedule,761.32,10940, Nasal/sinus endoscopy surg,31240,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,761.32,10940, Nasal/sinus endoscopy surg,31240,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,761.32,10940, Nasal/sinus endoscopy surg,31240,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,761.32,10940, Nsl/sins ndsc w/artery lig,31241,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2098.83,,,,,,,fee schedule,2098.83,10940, Nsl/sins ndsc w/artery lig,31241,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2098.83,10940, Nsl/sins ndsc w/artery lig,31241,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2098.83,10940, Nsl/sins ndsc w/artery lig,31241,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2098.83,10940, Nsl/sinus ndsc rf abltj pnn,31242,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,755.39,,,,,,,fee schedule,755.39,14456, Nsl/sinus ndsc rf abltj pnn,31242,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,755.39,14456, Nsl/sinus ndsc rf abltj pnn,31242,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,755.39,14456, Nsl/sinus ndsc rf abltj pnn,31242,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,755.39,14456, Nsl/sinus ndsc cryoabltj pnn,31243,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,755.39,,,,,,,fee schedule,755.39,14456, Nsl/sinus ndsc cryoabltj pnn,31243,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,755.39,14456, Nsl/sinus ndsc cryoabltj pnn,31243,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,755.39,14456, Nsl/sinus ndsc cryoabltj pnn,31243,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,755.39,14456, Nsl/sins ndsc total,31253,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2364.37,,,,,,,fee schedule,2364.37,12821, Nsl/sins ndsc total,31253,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,2364.37,12821, Nsl/sins ndsc total,31253,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2364.37,12821, Nsl/sins ndsc total,31253,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2364.37,12821, Revision of ethmoid sinus,31254,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1153.5,,,,,,,fee schedule,1153.5,10940, Revision of ethmoid sinus,31254,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,1153.5,10940, Revision of ethmoid sinus,31254,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1153.5,10940, Revision of ethmoid sinus,31254,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1153.5,10940, Removal of ethmoid sinus,31255,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1534.73,,,,,,,fee schedule,1534.73,12821, Removal of ethmoid sinus,31255,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,1534.73,12821, Removal of ethmoid sinus,31255,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,1534.73,12821, Removal of ethmoid sinus,31255,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,1534.73,12821, Exploration maxillary sinus,31256,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,853.86,,,,,,,fee schedule,853.86,10940, Exploration maxillary sinus,31256,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,853.86,10940, Exploration maxillary sinus,31256,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,853.86,10940, Exploration maxillary sinus,31256,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,853.86,10940, Nsl/sins ndsc tot w/sphendt,31257,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2109.19,,,,,,,fee schedule,2109.19,12821, Nsl/sins ndsc tot w/sphendt,31257,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,2109.19,12821, Nsl/sins ndsc tot w/sphendt,31257,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2109.19,12821, Nsl/sins ndsc tot w/sphendt,31257,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2109.19,12821, Nsl/sins ndsc sphn tiss rmvl,31259,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2234.54,,,,,,,fee schedule,2234.54,12821, Nsl/sins ndsc sphn tiss rmvl,31259,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,2234.54,12821, Nsl/sins ndsc sphn tiss rmvl,31259,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2234.54,12821, Nsl/sins ndsc sphn tiss rmvl,31259,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2234.54,12821, Endoscopy maxillary sinus,31267,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1257.38,,,,,,,fee schedule,1257.38,10940, Endoscopy maxillary sinus,31267,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1257.38,10940, Endoscopy maxillary sinus,31267,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1257.38,10940, Endoscopy maxillary sinus,31267,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1257.38,10940, Sinus endoscopy surgical,31276,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1787.16,,,,,,,fee schedule,1787.16,12821, Sinus endoscopy surgical,31276,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1787.16,12821, Sinus endoscopy surgical,31276,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,1787.16,12821, Sinus endoscopy surgical,31276,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,1787.16,12821, Nasal/sinus endoscopy surg,31287,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,953.1,,,,,,,fee schedule,953.1,12821, Nasal/sinus endoscopy surg,31287,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,953.1,12821, Nasal/sinus endoscopy surg,31287,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,953.1,12821, Nasal/sinus endoscopy surg,31287,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,953.1,12821, Nasal/sinus endoscopy surg,31288,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1110.66,,,,,,,fee schedule,1110.66,12821, Nasal/sinus endoscopy surg,31288,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1110.66,12821, Nasal/sinus endoscopy surg,31288,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,1110.66,12821, Nasal/sinus endoscopy surg,31288,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,1110.66,12821, Nasal/sinus endoscopy surg,31290,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5542.88,,,,,,,fee schedule,5097,5664, Nasal/sinus endoscopy surg,31290,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5097,5664, Nasal/sinus endoscopy surg,31290,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Nasal/sinus endoscopy surg,31290,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Nasal/sinus endoscopy surg,31291,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6068.02,,,,,,,fee schedule,5097,6068.02, Nasal/sinus endoscopy surg,31291,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5097,6068.02, Nasal/sinus endoscopy surg,31291,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6068.02, Nasal/sinus endoscopy surg,31291,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6068.02, Nasal/sinus endoscopy surg,31292,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4755.17,,,,,,,fee schedule,4755.17,12821, Nasal/sinus endoscopy surg,31292,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4755.17,12821, Nasal/sinus endoscopy surg,31292,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4755.17,12821, Nasal/sinus endoscopy surg,31292,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4755.17,12821, Nasal/sinus endoscopy surg,31293,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5142.93,,,,,,,fee schedule,5142.93,12821, Nasal/sinus endoscopy surg,31293,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5142.93,12821, Nasal/sinus endoscopy surg,31293,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5142.93,12821, Nasal/sinus endoscopy surg,31293,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5142.93,12821, Nasal/sinus endoscopy surg,31294,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5870.42,,,,,,,fee schedule,5248,12821, Nasal/sinus endoscopy surg,31294,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,12821, Nasal/sinus endoscopy surg,31294,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5248,12821, Nasal/sinus endoscopy surg,31294,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5248,12821, Sinus endo w/balloon dil,31295,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,755.39,,,,,,,fee schedule,755.39,12821, Sinus endo w/balloon dil,31295,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,755.39,12821, Sinus endo w/balloon dil,31295,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,755.39,12821, Sinus endo w/balloon dil,31295,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,755.39,12821, Sinus endo w/balloon dil,31296,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,852.03,,,,,,,fee schedule,852.03,12821, Sinus endo w/balloon dil,31296,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,852.03,12821, Sinus endo w/balloon dil,31296,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,852.03,12821, Sinus endo w/balloon dil,31296,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,852.03,12821, Sinus endo w/balloon dil,31297,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,691.88,,,,,,,fee schedule,691.88,10940, Sinus endo w/balloon dil,31297,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,691.88,10940, Sinus endo w/balloon dil,31297,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,691.88,10940, Sinus endo w/balloon dil,31297,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,691.88,10940, Nsl/sins ndsc w/sins dilat,31298,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1209.03,,,,,,,fee schedule,1209.03,12821, Nsl/sins ndsc w/sins dilat,31298,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,1209.03,12821, Nsl/sins ndsc w/sins dilat,31298,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,1209.03,12821, Nsl/sins ndsc w/sins dilat,31298,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,1209.03,12821, Sinus surgery procedure,31299,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2505,6979, Sinus surgery procedure,31299,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,6979, Sinus surgery procedure,31299,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,6979, Removal of larynx lesion,31300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6131.69,,,,,,,fee schedule,6044,10940, Removal of larynx lesion,31300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,10940, Removal of larynx lesion,31300,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,6044,10940, Removal of larynx lesion,31300,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,6044,10940, Removal of larynx,31360,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9969.76,,,,,,,fee schedule,5097,9969.76, Removal of larynx,31360,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,9969.76, Removal of larynx,31360,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,9969.76, Removal of larynx,31360,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,9969.76, Removal of larynx,31365,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12293.22,,,,,,,fee schedule,5097,12293.22, Removal of larynx,31365,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,12293.22, Removal of larynx,31365,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,12293.22, Removal of larynx,31365,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,12293.22, Partial removal of larynx,31367,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10578.48,,,,,,,fee schedule,5097,10578.48, Partial removal of larynx,31367,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,10578.48, Partial removal of larynx,31367,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,10578.48, Partial removal of larynx,31367,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,10578.48, Partial removal of larynx,31368,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,11673.54,,,,,,,fee schedule,5097,11673.54, Partial removal of larynx,31368,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,11673.54, Partial removal of larynx,31368,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,11673.54, Partial removal of larynx,31368,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,11673.54, Partial removal of larynx,31370,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9950.39,,,,,,,fee schedule,5097,9950.39, Partial removal of larynx,31370,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,9950.39, Partial removal of larynx,31370,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,9950.39, Partial removal of larynx,31370,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,9950.39, Partial removal of larynx,31375,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9470.9,,,,,,,fee schedule,5097,9470.9, Partial removal of larynx,31375,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,9470.9, Partial removal of larynx,31375,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,9470.9, Partial removal of larynx,31375,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,9470.9, Partial removal of larynx,31380,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9342.9,,,,,,,fee schedule,5097,9342.9, Partial removal of larynx,31380,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,9342.9, Partial removal of larynx,31380,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,9342.9, Partial removal of larynx,31380,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,9342.9, Partial removal of larynx,31382,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10206.32,,,,,,,fee schedule,5097,10206.32, Partial removal of larynx,31382,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,10206.32, Partial removal of larynx,31382,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,10206.32, Partial removal of larynx,31382,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,10206.32, Removal of larynx & pharynx,31390,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,13465.23,,,,,,,fee schedule,5097,13465.23, Removal of larynx & pharynx,31390,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,13465.23, Removal of larynx & pharynx,31390,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,13465.23, Removal of larynx & pharynx,31390,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,13465.23, Reconstruct larynx & pharynx,31395,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,14129.75,,,,,,,fee schedule,5097,14129.75, Reconstruct larynx & pharynx,31395,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,14129.75, Reconstruct larynx & pharynx,31395,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,14129.75, Reconstruct larynx & pharynx,31395,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,14129.75, Revision of larynx,31400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5069.92,,,,,,,fee schedule,4108,14456, Revision of larynx,31400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,14456, Revision of larynx,31400,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4108,14456, Revision of larynx,31400,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4108,14456, Removal of epiglottis,31420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4074.14,,,,,,,fee schedule,4074.14,14456, Removal of epiglottis,31420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4074.14,14456, Removal of epiglottis,31420,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4074.14,14456, Removal of epiglottis,31420,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4074.14,14456, Insert emergency airway,31500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,756.3,,,,,,,fee schedule,756.3,3195, Insert emergency airway,31500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,756.3,3195, Insert emergency airway,31500,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,756.3,3195, Insert emergency airway,31500,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,756.3,3195, Change of windpipe airway,31502,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,169.65,,,,,,,fee schedule,169.65,3195, Change of windpipe airway,31502,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,169.65,3195, Change of windpipe airway,31502,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,169.65,3195, Change of windpipe airway,31502,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,169.65,3195, Diagnostic laryngoscopy,31505,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,242.44,,,,,,,fee schedule,242.44,6979, Diagnostic laryngoscopy,31505,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,242.44,6979, Diagnostic laryngoscopy,31505,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,242.44,6979, Diagnostic laryngoscopy,31505,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,242.44,6979, Laryngoscopy with biopsy,31510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,583.2,,,,,,,fee schedule,583.2,5664, Laryngoscopy with biopsy,31510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,583.2,5664, Laryngoscopy with biopsy,31510,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,583.2,5664, Laryngoscopy with biopsy,31510,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,583.2,5664, Remove foreign body larynx,31511,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,647.63,,,,,,,fee schedule,647.63,4108, Remove foreign body larynx,31511,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,647.63,4108, Remove foreign body larynx,31511,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,647.63,4108, Remove foreign body larynx,31511,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,647.63,4108, Removal of larynx lesion,31512,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,625.29,,,,,,,fee schedule,625.29,10940, Removal of larynx lesion,31512,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,625.29,10940, Removal of larynx lesion,31512,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,625.29,10940, Removal of larynx lesion,31512,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,625.29,10940, Injection into vocal cord,31513,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,630.68,,,,,,,fee schedule,630.68,4108, Injection into vocal cord,31513,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,630.68,4108, Injection into vocal cord,31513,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,630.68,4108, Injection into vocal cord,31513,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,630.68,4108, Laryngoscopy for aspiration,31515,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,563.4,,,,,,,fee schedule,563.4,3195, Laryngoscopy for aspiration,31515,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,563.4,3195, Laryngoscopy for aspiration,31515,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,563.4,3195, Laryngoscopy for aspiration,31515,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,563.4,3195, Dx laryngoscopy newborn,31520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,752.42,,,,,,,fee schedule,752.42,3195, Dx laryngoscopy newborn,31520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,752.42,3195, Dx laryngoscopy newborn,31520,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,752.42,3195, Dx laryngoscopy newborn,31520,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,752.42,3195, Dx laryngoscopy excl nb,31525,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,767.63,,,,,,,fee schedule,767.63,5664, Dx laryngoscopy excl nb,31525,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,767.63,5664, Dx laryngoscopy excl nb,31525,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,767.63,5664, Dx laryngoscopy excl nb,31525,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,767.63,5664, Dx laryngoscopy w/oper scope,31526,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,754.2,,,,,,,fee schedule,754.2,5664, Dx laryngoscopy w/oper scope,31526,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,754.2,5664, Dx laryngoscopy w/oper scope,31526,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,754.2,5664, Dx laryngoscopy w/oper scope,31526,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,754.2,5664, Laryngoscopy for treatment,31527,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,930.43,,,,,,,fee schedule,930.43,10940, Laryngoscopy for treatment,31527,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,930.43,10940, Laryngoscopy for treatment,31527,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,930.43,10940, Laryngoscopy for treatment,31527,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,930.43,10940, Laryngoscopy and dilation,31528,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,697.22,,,,,,,fee schedule,697.22,10940, Laryngoscopy and dilation,31528,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,697.22,10940, Laryngoscopy and dilation,31528,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,697.22,10940, Laryngoscopy and dilation,31528,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,697.22,10940, Laryngoscopy and dilation,31529,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,769.74,,,,,,,fee schedule,769.74,10940, Laryngoscopy and dilation,31529,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,769.74,10940, Laryngoscopy and dilation,31529,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,769.74,10940, Laryngoscopy and dilation,31529,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,769.74,10940, Laryngoscopy w/fb removal,31530,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,968.96,,,,,,,fee schedule,968.96,5664, Laryngoscopy w/fb removal,31530,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,968.96,5664, Laryngoscopy w/fb removal,31530,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,968.96,5664, Laryngoscopy w/fb removal,31530,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,968.96,5664, Laryngoscopy w/fb & op scope,31531,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1014.29,,,,,,,fee schedule,1014.29,5664, Laryngoscopy w/fb & op scope,31531,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1014.29,5664, Laryngoscopy w/fb & op scope,31531,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1014.29,5664, Laryngoscopy w/fb & op scope,31531,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1014.29,5664, Laryngoscopy w/biopsy,31535,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,904.42,,,,,,,fee schedule,904.42,10940, Laryngoscopy w/biopsy,31535,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,904.42,10940, Laryngoscopy w/biopsy,31535,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,904.42,10940, Laryngoscopy w/biopsy,31535,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,904.42,10940, Laryngoscopy w/bx & op scope,31536,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,999.29,,,,,,,fee schedule,999.29,10940, Laryngoscopy w/bx & op scope,31536,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,999.29,10940, Laryngoscopy w/bx & op scope,31536,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,999.29,10940, Laryngoscopy w/bx & op scope,31536,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,999.29,10940, Laryngoscopy w/exc of tumor,31540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1148.7,,,,,,,fee schedule,1148.7,10940, Laryngoscopy w/exc of tumor,31540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1148.7,10940, Laryngoscopy w/exc of tumor,31540,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1148.7,10940, Laryngoscopy w/exc of tumor,31540,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1148.7,10940, Larynscop w/tumr exc + scope,31541,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1250.74,,,,,,,fee schedule,1250.74,10940, Larynscop w/tumr exc + scope,31541,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,1250.74,10940, Larynscop w/tumr exc + scope,31541,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1250.74,10940, Larynscop w/tumr exc + scope,31541,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1250.74,10940, Remove vc lesion w/scope,31545,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1713.99,,,,,,,fee schedule,1713.99,10940, Remove vc lesion w/scope,31545,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,1713.99,10940, Remove vc lesion w/scope,31545,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1713.99,10940, Remove vc lesion w/scope,31545,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1713.99,10940, Remove vc lesion scope/graft,31546,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2586.36,,,,,,,fee schedule,2586.36,12821, Remove vc lesion scope/graft,31546,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2586.36,12821, Remove vc lesion scope/graft,31546,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2586.36,12821, Remove vc lesion scope/graft,31546,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2586.36,12821, Laryngoplasty laryngeal sten,31551,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7541.61,,,,,,,fee schedule,6044,14456, Laryngoplasty laryngeal sten,31551,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,14456, Laryngoplasty laryngeal sten,31551,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,6044,14456, Laryngoplasty laryngeal sten,31551,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,6044,14456, Laryngoplasty laryngeal sten,31552,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7295.34,,,,,,,fee schedule,6044,14456, Laryngoplasty laryngeal sten,31552,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,14456, Laryngoplasty laryngeal sten,31552,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,6044,14456, Laryngoplasty laryngeal sten,31552,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,6044,14456, Laryngoplasty laryngeal sten,31553,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8214.01,,,,,,,fee schedule,6044,14456, Laryngoplasty laryngeal sten,31553,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,14456, Laryngoplasty laryngeal sten,31553,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,6044,14456, Laryngoplasty laryngeal sten,31553,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,6044,14456, Laryngoplasty laryngeal sten,31554,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8217.46,,,,,,,fee schedule,6044,14456, Laryngoplasty laryngeal sten,31554,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,14456, Laryngoplasty laryngeal sten,31554,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,6044,14456, Laryngoplasty laryngeal sten,31554,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,6044,14456, Laryngoscop w/arytenoidectom,31560,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1481.15,,,,,,,fee schedule,1481.15,12821, Laryngoscop w/arytenoidectom,31560,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,1481.15,12821, Laryngoscop w/arytenoidectom,31560,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,1481.15,12821, Laryngoscop w/arytenoidectom,31560,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,1481.15,12821, Larynscop remve cart + scop,31561,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1615.35,,,,,,,fee schedule,1615.35,10940, Larynscop remve cart + scop,31561,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,1615.35,10940, Larynscop remve cart + scop,31561,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1615.35,10940, Larynscop remve cart + scop,31561,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1615.35,10940, Laryngoscope w/vc inj,31570,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1102.08,,,,,,,fee schedule,1102.08,5664, Laryngoscope w/vc inj,31570,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1102.08,5664, Laryngoscope w/vc inj,31570,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1102.08,5664, Laryngoscope w/vc inj,31570,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1102.08,5664, Laryngoscop w/vc inj + scope,31571,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1182.75,,,,,,,fee schedule,1182.75,10940, Laryngoscop w/vc inj + scope,31571,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1182.75,10940, Laryngoscop w/vc inj + scope,31571,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1182.75,10940, Laryngoscop w/vc inj + scope,31571,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1182.75,10940, Largsc w/laser dstrj les,31572,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,865.09,,,,,,,fee schedule,865.09,10940, Largsc w/laser dstrj les,31572,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,865.09,10940, Largsc w/laser dstrj les,31572,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,865.09,10940, Largsc w/laser dstrj les,31572,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,865.09,10940, Largsc w/ther injection,31573,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,719.39,,,,,,,fee schedule,719.39,5664, Largsc w/ther injection,31573,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,719.39,5664, Largsc w/ther injection,31573,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,719.39,5664, Largsc w/ther injection,31573,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,719.39,5664, Largsc w/njx augmentation,31574,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,721.07,,,,,,,fee schedule,721.07,5664, Largsc w/njx augmentation,31574,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,721.07,5664, Largsc w/njx augmentation,31574,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,721.07,5664, Largsc w/njx augmentation,31574,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,721.07,5664, Diagnostic laryngoscopy,31575,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,335.42,,,,,,,fee schedule,335.42,4108, Diagnostic laryngoscopy,31575,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,335.42,4108, Diagnostic laryngoscopy,31575,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,335.42,4108, Diagnostic laryngoscopy,31575,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,335.42,4108, Laryngoscopy with biopsy,31576,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,576.08,,,,,,,fee schedule,576.08,5664, Laryngoscopy with biopsy,31576,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,576.08,5664, Laryngoscopy with biopsy,31576,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,576.08,5664, Laryngoscopy with biopsy,31576,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,576.08,5664, Largsc w/rmvl foreign bdy(s),31577,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,663.87,,,,,,,fee schedule,663.87,4108, Largsc w/rmvl foreign bdy(s),31577,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,663.87,4108, Largsc w/rmvl foreign bdy(s),31577,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,663.87,4108, Largsc w/rmvl foreign bdy(s),31577,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,663.87,4108, Largsc w/removal lesion,31578,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,721.07,,,,,,,fee schedule,721.07,5664, Largsc w/removal lesion,31578,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,721.07,5664, Largsc w/removal lesion,31578,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,721.07,5664, Largsc w/removal lesion,31578,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,721.07,5664, Laryngoscopy telescopic,31579,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,574.03,,,,,,,fee schedule,574.03,4108, Laryngoscopy telescopic,31579,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,574.03,4108, Laryngoscopy telescopic,31579,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,574.03,4108, Laryngoscopy telescopic,31579,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,574.03,4108, Laryngoplasty laryngeal web,31580,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6331.29,,,,,,,fee schedule,6044,14456, Laryngoplasty laryngeal web,31580,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,14456, Laryngoplasty laryngeal web,31580,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,6044,14456, Laryngoplasty laryngeal web,31580,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,6044,14456, Laryngoplasty fx rdctj fixj,31584,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6916.05,,,,,,,fee schedule,5363,12821, Laryngoplasty fx rdctj fixj,31584,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,12821, Laryngoplasty fx rdctj fixj,31584,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5363,12821, Laryngoplasty fx rdctj fixj,31584,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5363,12821, Laryngoplasty cricoid split,31587,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5957.67,,,,,,,fee schedule,5363,14456, Laryngoplasty cricoid split,31587,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,14456, Laryngoplasty cricoid split,31587,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5363,14456, Laryngoplasty cricoid split,31587,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5363,14456, Reinnervate larynx,31590,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4721.55,,,,,,,fee schedule,4721.55,14456, Reinnervate larynx,31590,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4721.55,14456, Reinnervate larynx,31590,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4721.55,14456, Reinnervate larynx,31590,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4721.55,14456, Laryngoplasty medialization,31591,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5452.06,,,,,,,fee schedule,5363,14456, Laryngoplasty medialization,31591,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,14456, Laryngoplasty medialization,31591,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5363,14456, Laryngoplasty medialization,31591,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5363,14456, Cricotracheal resection,31592,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8442.58,,,,,,,fee schedule,5363,14456, Cricotracheal resection,31592,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,14456, Cricotracheal resection,31592,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5363,14456, Cricotracheal resection,31592,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5363,14456, Larynx surgery procedure,31599,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Larynx surgery procedure,31599,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Larynx surgery procedure,31599,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Incision of windpipe,31600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1557.88,,,,,,,fee schedule,1557.88,10940, Incision of windpipe,31600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1557.88,10940, Incision of windpipe,31600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1557.88,10940, Incision of windpipe,31600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1557.88,10940, Incision of windpipe,31601,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2131.58,,,,,,,fee schedule,2131.58,10940, Incision of windpipe,31601,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2131.58,10940, Incision of windpipe,31601,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2131.58,10940, Incision of windpipe,31601,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2131.58,10940, Incision of windpipe,31603,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1589.88,,,,,,,fee schedule,1589.88,5664, Incision of windpipe,31603,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1589.88,5664, Incision of windpipe,31603,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1589.88,5664, Incision of windpipe,31603,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1589.88,5664, Incision of windpipe,31605,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1745.98,,,,,,,fee schedule,1745.98,3195, Incision of windpipe,31605,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1745.98,3195, Incision of windpipe,31605,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1745.98,3195, Incision of windpipe,31605,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1745.98,3195, Incision of windpipe,31610,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4722.26,,,,,,,fee schedule,4722.26,10940, Incision of windpipe,31610,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4722.26,10940, Incision of windpipe,31610,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,4722.26,10940, Incision of windpipe,31610,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,4722.26,10940, Surgery/speech prosthesis,31611,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2664.98,,,,,,,fee schedule,2664.98,10940, Surgery/speech prosthesis,31611,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2664.98,10940, Surgery/speech prosthesis,31611,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2664.98,10940, Surgery/speech prosthesis,31611,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2664.98,10940, Puncture/clear windpipe,31612,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,236.24,,,,,,,fee schedule,236.24,10940, Puncture/clear windpipe,31612,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,236.24,10940, Puncture/clear windpipe,31612,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,236.24,10940, Puncture/clear windpipe,31612,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,236.24,10940, Repair windpipe opening,31613,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2153.81,,,,,,,fee schedule,2153.81,10940, Repair windpipe opening,31613,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2153.81,10940, Repair windpipe opening,31613,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2153.81,10940, Repair windpipe opening,31613,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2153.81,10940, Repair windpipe opening,31614,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3501.3,,,,,,,fee schedule,3501.3,14456, Repair windpipe opening,31614,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3501.3,14456, Repair windpipe opening,31614,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3501.3,14456, Repair windpipe opening,31614,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3501.3,14456, Visualization of windpipe,31615,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,564.37,,,,,,,fee schedule,564.37,3195, Visualization of windpipe,31615,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,564.37,3195, Visualization of windpipe,31615,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,564.37,3195, Visualization of windpipe,31615,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,564.37,3195, Dx bronchoscope/wash,31622,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,669.43,,,,,,,fee schedule,669.43,5664, Dx bronchoscope/wash,31622,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,669.43,5664, Dx bronchoscope/wash,31622,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,669.43,5664, Dx bronchoscope/wash,31622,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,669.43,5664, Dx bronchoscope/brush,31623,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,659.07,,,,,,,fee schedule,659.07,5664, Dx bronchoscope/brush,31623,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,659.07,5664, Dx bronchoscope/brush,31623,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,659.07,5664, Dx bronchoscope/brush,31623,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,659.07,5664, Dx bronchoscope/lavage,31624,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,667.7,,,,,,,fee schedule,667.7,5664, Dx bronchoscope/lavage,31624,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,667.7,5664, Dx bronchoscope/lavage,31624,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,667.7,5664, Dx bronchoscope/lavage,31624,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,667.7,5664, Bronchoscopy w/biopsy(s),31625,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,778.97,,,,,,,fee schedule,778.97,5664, Bronchoscopy w/biopsy(s),31625,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,778.97,5664, Bronchoscopy w/biopsy(s),31625,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,778.97,5664, Bronchoscopy w/biopsy(s),31625,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,778.97,5664, Bronchoscopy w/markers,31626,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,991.95,,,,,,,fee schedule,991.95,12821, Bronchoscopy w/markers,31626,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,991.95,12821, Bronchoscopy w/markers,31626,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,991.95,12821, Bronchoscopy w/markers,31626,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,991.95,12821, Navigational bronchoscopy,31627,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,474.52,,,,,,,fee schedule,474.52,3195, Navigational bronchoscopy,31627,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,474.52,3195, Navigational bronchoscopy,31627,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,474.52,3195, Navigational bronchoscopy,31627,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,474.52,3195, Bronchoscopy/lung bx each,31628,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,878.41,,,,,,,fee schedule,878.41,5664, Bronchoscopy/lung bx each,31628,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,878.41,5664, Bronchoscopy/lung bx each,31628,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,878.41,5664, Bronchoscopy/lung bx each,31628,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,878.41,5664, Bronchoscopy/needle bx each,31629,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,932.91,,,,,,,fee schedule,932.91,12821, Bronchoscopy/needle bx each,31629,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,932.91,12821, Bronchoscopy/needle bx each,31629,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,932.91,12821, Bronchoscopy/needle bx each,31629,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,932.91,12821, Bronchoscopy dilate/fx repr,31630,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,984.28,,,,,,,fee schedule,984.28,12821, Bronchoscopy dilate/fx repr,31630,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,984.28,12821, Bronchoscopy dilate/fx repr,31630,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,984.28,12821, Bronchoscopy dilate/fx repr,31630,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,984.28,12821, Bronchoscopy dilate w/stent,31631,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1111.36,,,,,,,fee schedule,1111.36,12821, Bronchoscopy dilate w/stent,31631,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1111.36,12821, Bronchoscopy dilate w/stent,31631,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,1111.36,12821, Bronchoscopy dilate w/stent,31631,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,1111.36,12821, Bronchoscopy/lung bx addl,31632,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,238.07,,,,,,,fee schedule,238.07,4108, Bronchoscopy/lung bx addl,31632,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,238.07,4108, Bronchoscopy/lung bx addl,31632,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,238.07,4108, Bronchoscopy/lung bx addl,31632,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,238.07,4108, Bronchoscopy/needle bx addl,31633,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,311.51,,,,,,,fee schedule,311.51,4108, Bronchoscopy/needle bx addl,31633,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,311.51,4108, Bronchoscopy/needle bx addl,31633,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,311.51,4108, Bronchoscopy/needle bx addl,31633,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,311.51,4108, Bronch w/balloon occlusion,31634,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,943.27,,,,,,,fee schedule,943.27,12821, Bronch w/balloon occlusion,31634,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,943.27,12821, Bronch w/balloon occlusion,31634,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,943.27,12821, Bronch w/balloon occlusion,31634,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,943.27,12821, Bronchoscopy w/fb removal,31635,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,878.63,,,,,,,fee schedule,878.63,5664, Bronchoscopy w/fb removal,31635,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,878.63,5664, Bronchoscopy w/fb removal,31635,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,878.63,5664, Bronchoscopy w/fb removal,31635,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,878.63,5664, Bronchoscopy bronch stents,31636,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1084.54,,,,,,,fee schedule,1084.54,12821, Bronchoscopy bronch stents,31636,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1084.54,12821, Bronchoscopy bronch stents,31636,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,1084.54,12821, Bronchoscopy bronch stents,31636,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,1084.54,12821, Bronchoscopy stent add-on,31637,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,373.35,,,,,,,fee schedule,373.35,3195, Bronchoscopy stent add-on,31637,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,373.35,3195, Bronchoscopy stent add-on,31637,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,373.35,3195, Bronchoscopy stent add-on,31637,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,373.35,3195, Bronchoscopy revise stent,31638,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1215.34,,,,,,,fee schedule,1215.34,12821, Bronchoscopy revise stent,31638,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1215.34,12821, Bronchoscopy revise stent,31638,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,1215.34,12821, Bronchoscopy revise stent,31638,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,1215.34,12821, Bronchoscopy w/tumor excise,31640,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1206.65,,,,,,,fee schedule,1206.65,12821, Bronchoscopy w/tumor excise,31640,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1206.65,12821, Bronchoscopy w/tumor excise,31640,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,1206.65,12821, Bronchoscopy w/tumor excise,31640,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,1206.65,12821, Bronchoscopy treat blockage,31641,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1244.97,,,,,,,fee schedule,1244.97,12821, Bronchoscopy treat blockage,31641,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1244.97,12821, Bronchoscopy treat blockage,31641,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,1244.97,12821, Bronchoscopy treat blockage,31641,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,1244.97,12821, Diag bronchoscope/catheter,31643,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,840.27,,,,,,,fee schedule,840.27,5664, Diag bronchoscope/catheter,31643,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,840.27,5664, Diag bronchoscope/catheter,31643,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,840.27,5664, Diag bronchoscope/catheter,31643,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,840.27,5664, Bronchoscopy clear airways,31645,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,738.33,,,,,,,fee schedule,738.33,5664, Bronchoscopy clear airways,31645,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,738.33,5664, Bronchoscopy clear airways,31645,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,738.33,5664, Bronchoscopy clear airways,31645,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,738.33,5664, Bronchoscopy reclear airway,31646,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,713.19,,,,,,,fee schedule,713.19,3195, Bronchoscopy reclear airway,31646,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,713.19,3195, Bronchoscopy reclear airway,31646,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,713.19,3195, Bronchoscopy reclear airway,31646,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,713.19,3195, Bronchial valve init insert,31647,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1024.11,,,,,,,fee schedule,1024.11,12821, Bronchial valve init insert,31647,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1024.11,12821, Bronchial valve init insert,31647,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,1024.11,12821, Bronchial valve init insert,31647,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,1024.11,12821, Bronchial valve remov init,31648,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,980.18,,,,,,,fee schedule,980.18,12821, Bronchial valve remov init,31648,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,980.18,12821, Bronchial valve remov init,31648,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,980.18,12821, Bronchial valve remov init,31648,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,980.18,12821, Bronchial valve remov addl,31649,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,343.67,,,,,,,fee schedule,343.67,5664, Bronchial valve remov addl,31649,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,343.67,5664, Bronchial valve remov addl,31649,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,343.67,5664, Bronchial valve remov addl,31649,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,343.67,5664, Bronchial valve addl insert,31651,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,373.35,,,,,,,fee schedule,373.35,3195, Bronchial valve addl insert,31651,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,373.35,3195, Bronchial valve addl insert,31651,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,373.35,3195, Bronchial valve addl insert,31651,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,373.35,3195, Bronch ebus samplng 1/2 node,31652,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1098.63,,,,,,,fee schedule,1098.63,10940, Bronch ebus samplng 1/2 node,31652,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1098.63,10940, Bronch ebus samplng 1/2 node,31652,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1098.63,10940, Bronch ebus samplng 1/2 node,31652,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1098.63,10940, Bronch ebus samplng 3/> node,31653,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1215.02,,,,,,,fee schedule,1215.02,10940, Bronch ebus samplng 3/> node,31653,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1215.02,10940, Bronch ebus samplng 3/> node,31653,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1215.02,10940, Bronch ebus samplng 3/> node,31653,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1215.02,10940, Bronch ebus ivntj perph les,31654,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,332.12,,,,,,,fee schedule,332.12,3195, Bronch ebus ivntj perph les,31654,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,332.12,3195, Bronch ebus ivntj perph les,31654,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,332.12,3195, Bronch ebus ivntj perph les,31654,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,332.12,3195, Bronch thermoplsty 1 lobe,31660,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,939.71,,,,,,,fee schedule,939.71,12821, Bronch thermoplsty 1 lobe,31660,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,939.71,12821, Bronch thermoplsty 1 lobe,31660,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,939.71,12821, Bronch thermoplsty 1 lobe,31660,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,939.71,12821, Bronch thermoplsty 2/> lobes,31661,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,990.11,,,,,,,fee schedule,990.11,12821, Bronch thermoplsty 2/> lobes,31661,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,990.11,12821, Bronch thermoplsty 2/> lobes,31661,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,990.11,12821, Bronch thermoplsty 2/> lobes,31661,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,990.11,12821, Bronchial brush biopsy,31717,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,532.1,,,,,,,fee schedule,532.1,3195, Bronchial brush biopsy,31717,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,532.1,3195, Bronchial brush biopsy,31717,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,532.1,3195, Bronchial brush biopsy,31717,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,532.1,3195, Clearance of airways,31720,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,251.35,,,,,,,fee schedule,251.35,3195, Clearance of airways,31720,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,251.35,3195, Clearance of airways,31720,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,251.35,3195, Clearance of airways,31720,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,251.35,3195, Clearance of airways,31725,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,390.62,,,,,,,fee schedule,390.62,5664, Clearance of airways,31725,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,390.62,5664, Clearance of airways,31725,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,390.62,5664, Clearance of airways,31725,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,390.62,5664, Intro windpipe wire/tube,31730,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,763.75,,,,,,,fee schedule,763.75,5664, Intro windpipe wire/tube,31730,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,763.75,5664, Intro windpipe wire/tube,31730,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,763.75,5664, Intro windpipe wire/tube,31730,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,763.75,5664, Repair of windpipe,31750,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6782.45,,,,,,,fee schedule,6044,14456, Repair of windpipe,31750,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,14456, Repair of windpipe,31750,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,6044,14456, Repair of windpipe,31750,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,6044,14456, Repair of windpipe,31755,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8602.57,,,,,,,fee schedule,4108,14456, Repair of windpipe,31755,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,14456, Repair of windpipe,31755,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4108,14456, Repair of windpipe,31755,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4108,14456, Repair of windpipe,31760,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7526.72,,,,,,,fee schedule,5097,7526.72, Repair of windpipe,31760,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7526.72, Repair of windpipe,31760,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7526.72, Repair of windpipe,31760,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7526.72, Reconstruction of windpipe,31766,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9619.07,,,,,,,fee schedule,5097,9619.07, Reconstruction of windpipe,31766,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,9619.07, Reconstruction of windpipe,31766,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,9619.07, Reconstruction of windpipe,31766,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,9619.07, Repair/graft of bronchus,31770,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7215.59,,,,,,,fee schedule,5097,7215.59, Repair/graft of bronchus,31770,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7215.59, Repair/graft of bronchus,31770,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7215.59, Repair/graft of bronchus,31770,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7215.59, Reconstruct bronchus,31775,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7607.01,,,,,,,fee schedule,5097,7607.01, Reconstruct bronchus,31775,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7607.01, Reconstruct bronchus,31775,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7607.01, Reconstruct bronchus,31775,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7607.01, Reconstruct windpipe,31780,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5746.85,,,,,,,fee schedule,5097,6979, Reconstruct windpipe,31780,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Reconstruct windpipe,31780,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Reconstruct windpipe,31780,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Reconstruct windpipe,31781,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6861.12,,,,,,,fee schedule,5097,6979, Reconstruct windpipe,31781,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Reconstruct windpipe,31781,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Reconstruct windpipe,31781,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Remove windpipe lesion,31785,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5139.2,,,,,,,fee schedule,5139.2,10940, Remove windpipe lesion,31785,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5139.2,10940, Remove windpipe lesion,31785,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,5139.2,10940, Remove windpipe lesion,31785,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,5139.2,10940, Remove windpipe lesion,31786,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7831.21,,,,,,,fee schedule,5097,7831.21, Remove windpipe lesion,31786,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7831.21, Remove windpipe lesion,31786,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7831.21, Remove windpipe lesion,31786,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7831.21, Repair of windpipe injury,31800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3504.05,,,,,,,fee schedule,3504.05,5664, Repair of windpipe injury,31800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3504.05,5664, Repair of windpipe injury,31800,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3504.05,5664, Repair of windpipe injury,31800,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3504.05,5664, Repair of windpipe injury,31805,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4528.86,,,,,,,fee schedule,4528.86,6979, Repair of windpipe injury,31805,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4528.86,6979, Repair of windpipe injury,31805,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4528.86,6979, Repair of windpipe injury,31805,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4528.86,6979, Closure of windpipe lesion,31820,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1652.85,,,,,,,fee schedule,1652.85,10940, Closure of windpipe lesion,31820,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1652.85,10940, Closure of windpipe lesion,31820,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1652.85,10940, Closure of windpipe lesion,31820,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1652.85,10940, Repair of windpipe defect,31825,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2376.4,,,,,,,fee schedule,2376.4,10940, Repair of windpipe defect,31825,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2376.4,10940, Repair of windpipe defect,31825,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2376.4,10940, Repair of windpipe defect,31825,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2376.4,10940, Revise windpipe scar,31830,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1807.28,,,,,,,fee schedule,1807.28,10940, Revise windpipe scar,31830,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1807.28,10940, Revise windpipe scar,31830,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1807.28,10940, Revise windpipe scar,31830,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1807.28,10940, Airways surgical procedure,31899,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Airways surgical procedure,31899,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Airways surgical procedure,31899,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Description Not Available,32001,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Thoracostomy w/rib resection,32035,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4112.13,,,,,,,fee schedule,4112.13,6979, Thoracostomy w/rib resection,32035,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4112.13,6979, Thoracostomy w/rib resection,32035,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4112.13,6979, Thoracostomy w/rib resection,32035,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4112.13,6979, Thoracostomy w/flap drainage,32036,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4388.46,,,,,,,fee schedule,4388.46,6979, Thoracostomy w/flap drainage,32036,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4388.46,6979, Thoracostomy w/flap drainage,32036,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4388.46,6979, Thoracostomy w/flap drainage,32036,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4388.46,6979, Open wedge/bx lung infiltr,32096,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4376.91,,,,,,,fee schedule,4376.91,6979, Open wedge/bx lung infiltr,32096,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4376.91,6979, Open wedge/bx lung infiltr,32096,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4376.91,6979, Open wedge/bx lung infiltr,32096,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4376.91,6979, Open wedge/bx lung nodule,32097,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4405.19,,,,,,,fee schedule,4405.19,6979, Open wedge/bx lung nodule,32097,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4405.19,6979, Open wedge/bx lung nodule,32097,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4405.19,6979, Open wedge/bx lung nodule,32097,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4405.19,6979, Open biopsy of lung pleura,32098,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4123.25,,,,,,,fee schedule,4123.25,6979, Open biopsy of lung pleura,32098,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4123.25,6979, Open biopsy of lung pleura,32098,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4123.25,6979, Open biopsy of lung pleura,32098,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4123.25,6979, Exploration of chest,32100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4442.1,,,,,,,fee schedule,4442.1,6979, Exploration of chest,32100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4442.1,6979, Exploration of chest,32100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4442.1,6979, Exploration of chest,32100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4442.1,6979, Explore/repair chest,32110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7997.3,,,,,,,fee schedule,5097,7997.3, Explore/repair chest,32110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7997.3, Explore/repair chest,32110,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7997.3, Explore/repair chest,32110,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7997.3, Re-exploration of chest,32120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4835.25,,,,,,,fee schedule,4835.25,6979, Re-exploration of chest,32120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4835.25,6979, Re-exploration of chest,32120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4835.25,6979, Re-exploration of chest,32120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4835.25,6979, Explore chest free adhesions,32124,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5126.47,,,,,,,fee schedule,5097,6979, Explore chest free adhesions,32124,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Explore chest free adhesions,32124,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Explore chest free adhesions,32124,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Removal of lung lesion(s),32140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5458.81,,,,,,,fee schedule,5097,6979, Removal of lung lesion(s),32140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Removal of lung lesion(s),32140,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Removal of lung lesion(s),32140,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Remove/treat lung lesions,32141,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8253.99,,,,,,,fee schedule,5097,8253.99, Remove/treat lung lesions,32141,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8253.99, Remove/treat lung lesions,32141,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8253.99, Remove/treat lung lesions,32141,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8253.99, Removal of lung lesion(s),32150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5565.22,,,,,,,fee schedule,5097,6979, Removal of lung lesion(s),32150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Removal of lung lesion(s),32150,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Removal of lung lesion(s),32150,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Remove lung foreign body,32151,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5536.89,,,,,,,fee schedule,5097,6979, Remove lung foreign body,32151,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Remove lung foreign body,32151,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Remove lung foreign body,32151,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Open chest heart massage,32160,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4390.51,,,,,,,fee schedule,4390.51,6979, Open chest heart massage,32160,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4390.51,6979, Open chest heart massage,32160,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4390.51,6979, Open chest heart massage,32160,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4390.51,6979, Drain open lung lesion,32200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6316.34,,,,,,,fee schedule,5097,6979, Drain open lung lesion,32200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Drain open lung lesion,32200,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Drain open lung lesion,32200,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Treat chest lining,32215,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4457.53,,,,,,,fee schedule,4457.53,6979, Treat chest lining,32215,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4457.53,6979, Treat chest lining,32215,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4457.53,6979, Treat chest lining,32215,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4457.53,6979, Release of lung,32220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8780.05,,,,,,,fee schedule,5097,8780.05, Release of lung,32220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8780.05, Release of lung,32220,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8780.05, Release of lung,32220,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8780.05, Partial release of lung,32225,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5470.63,,,,,,,fee schedule,5097,6979, Partial release of lung,32225,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Partial release of lung,32225,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Partial release of lung,32225,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Removal of chest lining,32310,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5076.23,,,,,,,fee schedule,5076.23,6979, Removal of chest lining,32310,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5076.23,6979, Removal of chest lining,32310,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5076.23,6979, Removal of chest lining,32310,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5076.23,6979, Free/remove chest lining,32320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8768.28,,,,,,,fee schedule,5097,8768.28, Free/remove chest lining,32320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8768.28, Free/remove chest lining,32320,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8768.28, Free/remove chest lining,32320,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8768.28, Needle biopsy chest lining,32400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,405.29,,,,,,,fee schedule,405.29,5664, Needle biopsy chest lining,32400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,405.29,5664, Needle biopsy chest lining,32400,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,405.29,5664, Needle biopsy chest lining,32400,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,405.29,5664, Core ndl bx lng/med perq,32408,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,731.81,,,,,,,fee schedule,731.81,5664, Core ndl bx lng/med perq,32408,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,731.81,5664, Core ndl bx lng/med perq,32408,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,731.81,5664, Core ndl bx lng/med perq,32408,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,731.81,5664, Remove lung pneumonectomy,32440,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8555.09,,,,,,,fee schedule,5097,8555.09, Remove lung pneumonectomy,32440,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8555.09, Remove lung pneumonectomy,32440,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8555.09, Remove lung pneumonectomy,32440,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8555.09, Sleeve pneumonectomy,32442,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,16386.14,,,,,,,fee schedule,5097,16386.14, Sleeve pneumonectomy,32442,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,16386.14, Sleeve pneumonectomy,32442,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,16386.14, Sleeve pneumonectomy,32442,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,16386.14, Removal of lung extrapleural,32445,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,19037.9,,,,,,,fee schedule,5097,19037.9, Removal of lung extrapleural,32445,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,19037.9, Removal of lung extrapleural,32445,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,19037.9, Removal of lung extrapleural,32445,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,19037.9, Partial removal of lung,32480,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8054.61,,,,,,,fee schedule,5097,8054.61, Partial removal of lung,32480,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8054.61, Partial removal of lung,32480,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8054.61, Partial removal of lung,32480,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8054.61, Bilobectomy,32482,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8631.39,,,,,,,fee schedule,5097,8631.39, Bilobectomy,32482,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8631.39, Bilobectomy,32482,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8631.39, Bilobectomy,32482,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8631.39, Segmentectomy,32484,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7788.42,,,,,,,fee schedule,5097,7788.42, Segmentectomy,32484,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7788.42, Segmentectomy,32484,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7788.42, Segmentectomy,32484,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7788.42, Sleeve lobectomy,32486,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12597.07,,,,,,,fee schedule,5097,12597.07, Sleeve lobectomy,32486,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,12597.07, Sleeve lobectomy,32486,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,12597.07, Sleeve lobectomy,32486,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,12597.07, Completion pneumonectomy,32488,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12925.58,,,,,,,fee schedule,5097,12925.58, Completion pneumonectomy,32488,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,12925.58, Completion pneumonectomy,32488,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,12925.58, Completion pneumonectomy,32488,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,12925.58, Lung volume reduction,32491,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8067.18,,,,,,,fee schedule,5097,8067.18, Lung volume reduction,32491,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8067.18, Lung volume reduction,32491,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8067.18, Lung volume reduction,32491,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8067.18, Repair bronchus add-on,32501,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1288.46,,,,,,,fee schedule,1288.46,6979, Repair bronchus add-on,32501,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1288.46,6979, Repair bronchus add-on,32501,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1288.46,6979, Repair bronchus add-on,32501,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1288.46,6979, Resect apical lung tumor,32503,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9749.33,,,,,,,fee schedule,5097,9749.33, Resect apical lung tumor,32503,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,9749.33, Resect apical lung tumor,32503,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,9749.33, Resect apical lung tumor,32503,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,9749.33, Resect apical lung tum/chest,32504,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,11070.97,,,,,,,fee schedule,5097,11070.97, Resect apical lung tum/chest,32504,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,11070.97, Resect apical lung tum/chest,32504,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,11070.97, Resect apical lung tum/chest,32504,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,11070.97, Wedge resect of lung initial,32505,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5113.36,,,,,,,fee schedule,5097,6979, Wedge resect of lung initial,32505,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Wedge resect of lung initial,32505,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Wedge resect of lung initial,32505,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Wedge resect of lung add-on,32506,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,823.05,,,,,,,fee schedule,823.05,6979, Wedge resect of lung add-on,32506,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,823.05,6979, Wedge resect of lung add-on,32506,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,823.05,6979, Wedge resect of lung add-on,32506,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,823.05,6979, Wedge resect of lung diag,32507,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,823.05,,,,,,,fee schedule,823.05,6979, Wedge resect of lung diag,32507,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,823.05,6979, Wedge resect of lung diag,32507,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,823.05,6979, Wedge resect of lung diag,32507,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,823.05,6979, Removal of lung lesion,32540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9396.38,,,,,,,fee schedule,5097,9396.38, Removal of lung lesion,32540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,9396.38, Removal of lung lesion,32540,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,9396.38, Removal of lung lesion,32540,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,9396.38, Insert pleural cath,32550,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1016.17,,,,,,,fee schedule,1016.17,12821, Insert pleural cath,32550,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1016.17,12821, Insert pleural cath,32550,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,1016.17,12821, Insert pleural cath,32550,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,1016.17,12821, Insertion of chest tube,32551,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,815.12,,,,,,,fee schedule,815.12,4497, Insertion of chest tube,32551,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,815.12,4497, Insertion of chest tube,32551,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,815.12,4497, Insertion of chest tube,32551,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,815.12,4497, Remove lung catheter,32552,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,816.63,,,,,,,fee schedule,816.63,4497, Remove lung catheter,32552,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,816.63,4497, Remove lung catheter,32552,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,816.63,4497, Remove lung catheter,32552,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,816.63,4497, Ins mark thor for rt perq,32553,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,848.84,,,,,,,fee schedule,848.84,5664, Ins mark thor for rt perq,32553,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,848.84,5664, Ins mark thor for rt perq,32553,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,848.84,5664, Ins mark thor for rt perq,32553,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,848.84,5664, Aspirate pleura w/o imaging,32554,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,443.12,,,,,,,fee schedule,443.12,4497, Aspirate pleura w/o imaging,32554,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,443.12,4497, Aspirate pleura w/o imaging,32554,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,443.12,4497, Aspirate pleura w/o imaging,32554,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,443.12,4497, Aspirate pleura w/ imaging,32555,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,523.36,,,,,,,fee schedule,523.36,4497, Aspirate pleura w/ imaging,32555,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,523.36,4497, Aspirate pleura w/ imaging,32555,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,523.36,4497, Aspirate pleura w/ imaging,32555,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,523.36,4497, Insert cath pleura w/o image,32556,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,633.06,,,,,,,fee schedule,633.06,5664, Insert cath pleura w/o image,32556,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,633.06,5664, Insert cath pleura w/o image,32556,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,633.06,5664, Insert cath pleura w/o image,32556,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,633.06,5664, Insert cath pleura w/ image,32557,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,723.44,,,,,,,fee schedule,723.44,4497, Insert cath pleura w/ image,32557,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,723.44,4497, Insert cath pleura w/ image,32557,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,723.44,4497, Insert cath pleura w/ image,32557,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,723.44,4497, Treat pleurodesis w/agent,32560,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,387.81,,,,,,,fee schedule,387.81,4497, Treat pleurodesis w/agent,32560,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,387.81,4497, Treat pleurodesis w/agent,32560,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,387.81,4497, Treat pleurodesis w/agent,32560,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,387.81,4497, Lyse chest fibrin init day,32561,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,335.74,,,,,,,fee schedule,335.74,4497, Lyse chest fibrin init day,32561,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,335.74,4497, Lyse chest fibrin init day,32561,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,335.74,4497, Lyse chest fibrin init day,32561,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,335.74,4497, Lyse chest fibrin subq day,32562,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,299.8,,,,,,,fee schedule,299.8,4497, Lyse chest fibrin subq day,32562,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,299.8,4497, Lyse chest fibrin subq day,32562,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,299.8,4497, Lyse chest fibrin subq day,32562,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,299.8,4497, Thoracoscopy diagnostic,32601,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1658.62,,,,,,,fee schedule,1658.62,14456, Thoracoscopy diagnostic,32601,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1658.62,14456, Thoracoscopy diagnostic,32601,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,1658.62,14456, Thoracoscopy diagnostic,32601,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,1658.62,14456, Thoracoscopy wbx sac,32604,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2579.99,,,,,,,fee schedule,2579.99,14456, Thoracoscopy wbx sac,32604,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2579.99,14456, Thoracoscopy wbx sac,32604,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,2579.99,14456, Thoracoscopy wbx sac,32604,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,2579.99,14456, Thoracoscopy w/bx med space,32606,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2477.57,,,,,,,fee schedule,2477.57,14456, Thoracoscopy w/bx med space,32606,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2477.57,14456, Thoracoscopy w/bx med space,32606,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,2477.57,14456, Thoracoscopy w/bx med space,32606,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,2477.57,14456, Thoracoscopy w/bx infiltrate,32607,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1665.75,,,,,,,fee schedule,1665.75,14456, Thoracoscopy w/bx infiltrate,32607,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1665.75,14456, Thoracoscopy w/bx infiltrate,32607,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,1665.75,14456, Thoracoscopy w/bx infiltrate,32607,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,1665.75,14456, Thoracoscopy w/bx nodule,32608,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2038.77,,,,,,,fee schedule,2038.77,14456, Thoracoscopy w/bx nodule,32608,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2038.77,14456, Thoracoscopy w/bx nodule,32608,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,2038.77,14456, Thoracoscopy w/bx nodule,32608,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,2038.77,14456, Thoracoscopy w/bx pleura,32609,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1361.03,,,,,,,fee schedule,1361.03,14456, Thoracoscopy w/bx pleura,32609,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1361.03,14456, Thoracoscopy w/bx pleura,32609,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,1361.03,14456, Thoracoscopy w/bx pleura,32609,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,1361.03,14456, Thoracoscopy w/pleurodesis,32650,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3690.81,,,,,,,fee schedule,3690.81,25393, Thoracoscopy w/pleurodesis,32650,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3690.81,25393, Thoracoscopy w/pleurodesis,32650,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,3690.81,25393, Thoracoscopy w/pleurodesis,32650,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,3690.81,25393, Thoracoscopy remove cortex,32651,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5957.51,,,,,,,fee schedule,5957.51,25393, Thoracoscopy remove cortex,32651,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5957.51,25393, Thoracoscopy remove cortex,32651,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,5957.51,25393, Thoracoscopy remove cortex,32651,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,5957.51,25393, Thoracoscopy rem totl cortex,32652,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9024.32,,,,,,,fee schedule,6979,25393, Thoracoscopy rem totl cortex,32652,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,25393, Thoracoscopy rem totl cortex,32652,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,6979,25393, Thoracoscopy rem totl cortex,32652,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,6979,25393, Thoracoscopy remov fb/fibrin,32653,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5748.95,,,,,,,fee schedule,5748.95,22111, Thoracoscopy remov fb/fibrin,32653,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5748.95,22111, Thoracoscopy remov fb/fibrin,32653,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5748.95,22111, Thoracoscopy remov fb/fibrin,32653,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5748.95,22111, Thoracoscopy contrl bleeding,32654,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6453.45,,,,,,,fee schedule,5097,6979, Thoracoscopy contrl bleeding,32654,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Thoracoscopy contrl bleeding,32654,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Thoracoscopy contrl bleeding,32654,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Thoracoscopy resect bullae,32655,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5238.98,,,,,,,fee schedule,5238.98,25393, Thoracoscopy resect bullae,32655,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5238.98,25393, Thoracoscopy resect bullae,32655,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,5238.98,25393, Thoracoscopy resect bullae,32655,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,5238.98,25393, Thoracoscopy w/pleurectomy,32656,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4441.72,,,,,,,fee schedule,4441.72,25393, Thoracoscopy w/pleurectomy,32656,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4441.72,25393, Thoracoscopy w/pleurectomy,32656,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,4441.72,25393, Thoracoscopy w/pleurectomy,32656,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,4441.72,25393, Thoracoscopy w/sac fb remove,32658,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3960.83,,,,,,,fee schedule,3960.83,6979, Thoracoscopy w/sac fb remove,32658,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3960.83,6979, Thoracoscopy w/sac fb remove,32658,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3960.83,6979, Thoracoscopy w/sac fb remove,32658,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3960.83,6979, Thoracoscopy w/sac drainage,32659,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4075.06,,,,,,,fee schedule,4075.06,6979, Thoracoscopy w/sac drainage,32659,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4075.06,6979, Thoracoscopy w/sac drainage,32659,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4075.06,6979, Thoracoscopy w/sac drainage,32659,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4075.06,6979, Thoracoscopy w/pericard exc,32661,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4404.65,,,,,,,fee schedule,4404.65,6979, Thoracoscopy w/pericard exc,32661,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4404.65,6979, Thoracoscopy w/pericard exc,32661,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4404.65,6979, Thoracoscopy w/pericard exc,32661,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4404.65,6979, Thoracoscopy w/mediast exc,32662,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4916.94,,,,,,,fee schedule,4916.94,6979, Thoracoscopy w/mediast exc,32662,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4916.94,6979, Thoracoscopy w/mediast exc,32662,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4916.94,6979, Thoracoscopy w/mediast exc,32662,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4916.94,6979, Thoracoscopy w/lobectomy,32663,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7587.42,,,,,,,fee schedule,5097,7587.42, Thoracoscopy w/lobectomy,32663,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7587.42, Thoracoscopy w/lobectomy,32663,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7587.42, Thoracoscopy w/lobectomy,32663,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7587.42, Thoracoscopy w/ th nrv exc,32664,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4666.46,,,,,,,fee schedule,4108,12821, Thoracoscopy w/ th nrv exc,32664,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,12821, Thoracoscopy w/ th nrv exc,32664,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4108,12821, Thoracoscopy w/ th nrv exc,32664,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4108,12821, Thoracoscop w/esoph musc exc,32665,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6707.93,,,,,,,fee schedule,5097,6979, Thoracoscop w/esoph musc exc,32665,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Thoracoscop w/esoph musc exc,32665,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Thoracoscop w/esoph musc exc,32665,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Thoracoscopy w/wedge resect,32666,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4791.32,,,,,,,fee schedule,4791.32,6979, Thoracoscopy w/wedge resect,32666,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4791.32,6979, Thoracoscopy w/wedge resect,32666,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4791.32,6979, Thoracoscopy w/wedge resect,32666,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4791.32,6979, Thoracoscopy w/w resect addl,32667,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,825.75,,,,,,,fee schedule,825.75,6979, Thoracoscopy w/w resect addl,32667,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,825.75,6979, Thoracoscopy w/w resect addl,32667,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,825.75,6979, Thoracoscopy w/w resect addl,32667,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,825.75,6979, Thoracoscopy w/w resect diag,32668,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,827.48,,,,,,,fee schedule,827.48,6979, Thoracoscopy w/w resect diag,32668,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,827.48,6979, Thoracoscopy w/w resect diag,32668,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,827.48,6979, Thoracoscopy w/w resect diag,32668,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,827.48,6979, Thoracoscopy remove segment,32669,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7289.56,,,,,,,fee schedule,5097,7289.56, Thoracoscopy remove segment,32669,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7289.56, Thoracoscopy remove segment,32669,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7289.56, Thoracoscopy remove segment,32669,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7289.56, Thoracoscopy bilobectomy,32670,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8642.77,,,,,,,fee schedule,5097,8642.77, Thoracoscopy bilobectomy,32670,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8642.77, Thoracoscopy bilobectomy,32670,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8642.77, Thoracoscopy bilobectomy,32670,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8642.77, Thoracoscopy pneumonectomy,32671,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9584.05,,,,,,,fee schedule,5097,9584.05, Thoracoscopy pneumonectomy,32671,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,9584.05, Thoracoscopy pneumonectomy,32671,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,9584.05, Thoracoscopy pneumonectomy,32671,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,9584.05, Thoracoscopy for lvrs,32672,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8223.88,,,,,,,fee schedule,5097,8223.88, Thoracoscopy for lvrs,32672,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8223.88, Thoracoscopy for lvrs,32672,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8223.88, Thoracoscopy for lvrs,32672,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8223.88, Thoracoscopy w/thymus resect,32673,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6609.56,,,,,,,fee schedule,5097,6979, Thoracoscopy w/thymus resect,32673,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Thoracoscopy w/thymus resect,32673,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Thoracoscopy w/thymus resect,32673,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Thoracoscopy lymph node exc,32674,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1140.39,,,,,,,fee schedule,1140.39,6979, Thoracoscopy lymph node exc,32674,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1140.39,6979, Thoracoscopy lymph node exc,32674,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1140.39,6979, Thoracoscopy lymph node exc,32674,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1140.39,6979, Thorax stereo rad targetw/tx,32701,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1074.4,,,,,,,fee schedule,1074.4,6979, Thorax stereo rad targetw/tx,32701,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1074.4,6979, Repair lung hernia,32800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5226.51,,,,,,,fee schedule,5097,6979, Repair lung hernia,32800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Repair lung hernia,32800,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Repair lung hernia,32800,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Close chest after drainage,32810,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4983.85,,,,,,,fee schedule,4983.85,6979, Close chest after drainage,32810,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4983.85,6979, Close chest after drainage,32810,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4983.85,6979, Close chest after drainage,32810,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4983.85,6979, Close bronchial fistula,32815,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,15163.25,,,,,,,fee schedule,5097,15163.25, Close bronchial fistula,32815,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,15163.25, Close bronchial fistula,32815,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,15163.25, Close bronchial fistula,32815,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,15163.25, Reconstruct injured chest,32820,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7493.64,,,,,,,fee schedule,5097,7493.64, Reconstruct injured chest,32820,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7493.64, Reconstruct injured chest,32820,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7493.64, Reconstruct injured chest,32820,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7493.64, Donor pneumonectomy,32850,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Donor pneumonectomy,32850,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Donor pneumonectomy,32850,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Lung transplant single,32851,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,17627.38,,,,,,,fee schedule,5097,17627.38, Lung transplant single,32851,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,17627.38, Lung transplant single,32851,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,17627.38, Lung transplant single,32851,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,17627.38, Lung transplant with bypass,32852,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,19184.13,,,,,,,fee schedule,5097,19184.13, Lung transplant with bypass,32852,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,19184.13, Lung transplant with bypass,32852,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,19184.13, Lung transplant with bypass,32852,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,19184.13, Lung transplant double,32853,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,24550.83,,,,,,,fee schedule,5097,24550.83, Lung transplant double,32853,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,24550.83, Lung transplant double,32853,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,24550.83, Lung transplant double,32853,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,24550.83, Lung transplant with bypass,32854,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,26051.35,,,,,,,fee schedule,5097,26051.35, Lung transplant with bypass,32854,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,26051.35, Lung transplant with bypass,32854,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,26051.35, Lung transplant with bypass,32854,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,26051.35, Prepare donor lung single,32855,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Prepare donor lung single,32855,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Prepare donor lung single,32855,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Prepare donor lung double,32856,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Prepare donor lung double,32856,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Prepare donor lung double,32856,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Removal of rib(s),32900,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7425.38,,,,,,,fee schedule,5097,7425.38, Removal of rib(s),32900,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7425.38, Removal of rib(s),32900,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7425.38, Removal of rib(s),32900,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7425.38, Revise & repair chest wall,32905,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7282.82,,,,,,,fee schedule,5097,7282.82, Revise & repair chest wall,32905,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7282.82, Revise & repair chest wall,32905,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7282.82, Revise & repair chest wall,32905,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7282.82, Revise & repair chest wall,32906,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8940.74,,,,,,,fee schedule,5097,8940.74, Revise & repair chest wall,32906,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8940.74, Revise & repair chest wall,32906,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8940.74, Revise & repair chest wall,32906,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8940.74, Revision of lung,32940,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6742.19,,,,,,,fee schedule,5097,6979, Revision of lung,32940,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Revision of lung,32940,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Revision of lung,32940,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Therapeutic pneumothorax,32960,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,452.83,,,,,,,fee schedule,452.83,6979, Therapeutic pneumothorax,32960,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,452.83,6979, Therapeutic pneumothorax,32960,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,452.83,6979, Therapeutic pneumothorax,32960,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,452.83,6979, Ablate pulm tumor perq crybl,32994,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2132.61,,,,,,,fee schedule,2132.61,22111, Ablate pulm tumor perq crybl,32994,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2132.61,22111, Ablate pulm tumor perq crybl,32994,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,2132.61,22111, Ablate pulm tumor perq crybl,32994,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,2132.61,22111, Total lung lavage,32997,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1663.69,,,,,,,fee schedule,1663.69,6979, Total lung lavage,32997,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1663.69,6979, Total lung lavage,32997,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1663.69,6979, Total lung lavage,32997,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1663.69,6979, Perq rf ablate tx pul tumor,32998,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2134.55,,,,,,,fee schedule,2134.55,22111, Perq rf ablate tx pul tumor,32998,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2134.55,22111, Perq rf ablate tx pul tumor,32998,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,2134.55,22111, Perq rf ablate tx pul tumor,32998,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,2134.55,22111, Chest surgery procedure,32999,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4047,6979, Chest surgery procedure,32999,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,4047,6979, Chest surgery procedure,32999,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,4047,6979, Pericardiocentesis w/imaging,33016,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1184.37,,,,,,,fee schedule,1184.37,4497, Pericardiocentesis w/imaging,33016,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1184.37,4497, Pericardiocentesis w/imaging,33016,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,1184.37,4497, Pericardiocentesis w/imaging,33016,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,1184.37,4497, Prcrd drg 6yr+ w/o cgen car,33017,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1242.64,,,,,,,fee schedule,1242.64,6979, Prcrd drg 6yr+ w/o cgen car,33017,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1242.64,6979, Prcrd drg 6yr+ w/o cgen car,33017,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1242.64,6979, Prcrd drg 6yr+ w/o cgen car,33017,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1242.64,6979, Prcrd drg 0-5yr or w/anomly,33018,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1464.42,,,,,,,fee schedule,1464.42,6979, Prcrd drg 0-5yr or w/anomly,33018,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1464.42,6979, Prcrd drg 0-5yr or w/anomly,33018,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1464.42,6979, Prcrd drg 0-5yr or w/anomly,33018,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1464.42,6979, Perq prcrd drg insj cath ct,33019,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1008.67,,,,,,,fee schedule,1008.67,6979, Perq prcrd drg insj cath ct,33019,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1008.67,6979, Perq prcrd drg insj cath ct,33019,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1008.67,6979, Perq prcrd drg insj cath ct,33019,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1008.67,6979, Incision of heart sac,33020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4488.99,,,,,,,fee schedule,4488.99,6979, Incision of heart sac,33020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4488.99,6979, Incision of heart sac,33020,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4488.99,6979, Incision of heart sac,33020,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4488.99,6979, Incision of heart sac,33025,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4233.76,,,,,,,fee schedule,4233.76,6979, Incision of heart sac,33025,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4233.76,6979, Incision of heart sac,33025,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4233.76,6979, Incision of heart sac,33025,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4233.76,6979, Partial removal of heart sac,33030,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10822.81,,,,,,,fee schedule,5097,10822.81, Partial removal of heart sac,33030,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,10822.81, Partial removal of heart sac,33030,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,10822.81, Partial removal of heart sac,33030,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,10822.81, Partial removal of heart sac,33031,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,13345.55,,,,,,,fee schedule,5097,13345.55, Partial removal of heart sac,33031,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,13345.55, Partial removal of heart sac,33031,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,13345.55, Partial removal of heart sac,33031,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,13345.55, Resect heart sac lesion,33050,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5542.5,,,,,,,fee schedule,5097,6979, Resect heart sac lesion,33050,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Resect heart sac lesion,33050,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Resect heart sac lesion,33050,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Removal of heart lesion,33120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,11275.81,,,,,,,fee schedule,5097,11275.81, Removal of heart lesion,33120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,11275.81, Removal of heart lesion,33120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,11275.81, Removal of heart lesion,33120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,11275.81, Removal of heart lesion,33130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7499.63,,,,,,,fee schedule,5097,7499.63, Removal of heart lesion,33130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7499.63, Removal of heart lesion,33130,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7499.63, Removal of heart lesion,33130,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7499.63, Heart revascularize (tmr),33140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8470.96,,,,,,,fee schedule,5097,8470.96, Heart revascularize (tmr),33140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8470.96, Heart revascularize (tmr),33140,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8470.96, Heart revascularize (tmr),33140,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8470.96, Heart Tmr W/Other Procedure,33141,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,697.65,,,,,,,fee schedule,697.65,6979, Heart Tmr W/Other Procedure,33141,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,697.65,6979, Heart Tmr W/Other Procedure,33141,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,697.65,6979, Heart Tmr W/Other Procedure,33141,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,697.65,6979, Insert epicard eltrd open,33202,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4237.96,,,,,,,fee schedule,4237.96,6979, Insert epicard eltrd open,33202,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4237.96,6979, Insert epicard eltrd open,33202,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4237.96,6979, Insert epicard eltrd open,33202,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4237.96,6979, Insert epicard eltrd endo,33203,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4424.61,,,,,,,fee schedule,4424.61,6979, Insert epicard eltrd endo,33203,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4424.61,6979, Insert epicard eltrd endo,33203,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4424.61,6979, Insert epicard eltrd endo,33203,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4424.61,6979, Insert heart pm atrial,33206,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2290.39,,,,,,,fee schedule,2290.39,25393, Insert heart pm atrial,33206,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,2290.39,25393, Insert heart pm atrial,33206,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,2290.39,25393, Insert heart pm atrial,33206,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,2290.39,25393, Insert heart pm ventricular,33207,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2413.74,,,,,,,fee schedule,2413.74,25393, Insert heart pm ventricular,33207,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,2413.74,25393, Insert heart pm ventricular,33207,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,2413.74,25393, Insert heart pm ventricular,33207,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,2413.74,25393, Insrt heart pm atrial & vent,33208,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2610.05,,,,,,,fee schedule,2610.05,34630, Insrt heart pm atrial & vent,33208,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,2610.05,34630, Insrt heart pm atrial & vent,33208,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,34630,,,,,,,fee schedule,2610.05,34630, Insrt heart pm atrial & vent,33208,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,31168,,,,,,,fee schedule,2610.05,34630, Insert electrd/pm cath sngl,33210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,813.02,,,,,,,fee schedule,813.02,22111, Insert electrd/pm cath sngl,33210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,813.02,22111, Insert electrd/pm cath sngl,33210,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,813.02,22111, Insert electrd/pm cath sngl,33210,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,813.02,22111, Insert card electrodes dual,33211,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,841.56,,,,,,,fee schedule,841.56,22111, Insert card electrodes dual,33211,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,841.56,22111, Insert card electrodes dual,33211,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,841.56,22111, Insert card electrodes dual,33211,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,841.56,22111, Insert pulse gen sngl lead,33212,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1660.67,,,,,,,fee schedule,1660.67,25393, Insert pulse gen sngl lead,33212,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1660.67,25393, Insert pulse gen sngl lead,33212,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,1660.67,25393, Insert pulse gen sngl lead,33212,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,1660.67,25393, Insert pulse gen dual leads,33213,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1727.31,,,,,,,fee schedule,1727.31,25393, Insert pulse gen dual leads,33213,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1727.31,25393, Insert pulse gen dual leads,33213,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,1727.31,25393, Insert pulse gen dual leads,33213,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,1727.31,25393, Upgrade of pacemaker system,33214,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2422.37,,,,,,,fee schedule,2422.37,34630, Upgrade of pacemaker system,33214,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,2422.37,34630, Upgrade of pacemaker system,33214,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,34630,,,,,,,fee schedule,2422.37,34630, Upgrade of pacemaker system,33214,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,31168,,,,,,,fee schedule,2422.37,34630, Reposition pacing-defib lead,33215,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1570.24,,,,,,,fee schedule,1570.24,12821, Reposition pacing-defib lead,33215,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1570.24,12821, Reposition pacing-defib lead,33215,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,1570.24,12821, Reposition pacing-defib lead,33215,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,1570.24,12821, Insert 1 electrode pm-defib,33216,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1879.86,,,,,,,fee schedule,1879.86,22111, Insert 1 electrode pm-defib,33216,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,1879.86,22111, Insert 1 electrode pm-defib,33216,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,1879.86,22111, Insert 1 electrode pm-defib,33216,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,1879.86,22111, Insert 2 electrode pm-defib,33217,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1874.46,,,,,,,fee schedule,1874.46,22111, Insert 2 electrode pm-defib,33217,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,1874.46,22111, Insert 2 electrode pm-defib,33217,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,1874.46,22111, Insert 2 electrode pm-defib,33217,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,1874.46,22111, Repair lead pace-defib one,33218,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1973.21,,,,,,,fee schedule,1973.21,12821, Repair lead pace-defib one,33218,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,1973.21,12821, Repair lead pace-defib one,33218,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,1973.21,12821, Repair lead pace-defib one,33218,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,1973.21,12821, Repair lead pace-defib dual,33220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1940.62,,,,,,,fee schedule,1940.62,12821, Repair lead pace-defib dual,33220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,1940.62,12821, Repair lead pace-defib dual,33220,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,1940.62,12821, Repair lead pace-defib dual,33220,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,1940.62,12821, Insert pulse gen mult leads,33221,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1813.81,,,,,,,fee schedule,1813.81,25393, Insert pulse gen mult leads,33221,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1813.81,25393, Insert pulse gen mult leads,33221,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,1813.81,25393, Insert pulse gen mult leads,33221,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,1813.81,25393, Relocation pocket pacemaker,33222,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1748.63,,,,,,,fee schedule,1748.63,5664, Relocation pocket pacemaker,33222,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1748.63,5664, Relocation pocket pacemaker,33222,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1748.63,5664, Relocation pocket pacemaker,33222,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1748.63,5664, Relocate pocket for defib,33223,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2068.72,,,,,,,fee schedule,2068.72,5664, Relocate pocket for defib,33223,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2068.72,5664, Relocate pocket for defib,33223,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2068.72,5664, Relocate pocket for defib,33223,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2068.72,5664, Insert pacing lead & connect,33224,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2552.74,,,,,,,fee schedule,2552.74,34630, Insert pacing lead & connect,33224,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2552.74,34630, Insert pacing lead & connect,33224,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,34630,,,,,,,fee schedule,2552.74,34630, Insert pacing lead & connect,33224,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,31168,,,,,,,fee schedule,2552.74,34630, L ventric pacing lead add-on,33225,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2287.58,,,,,,,fee schedule,2287.58,34630, L ventric pacing lead add-on,33225,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2287.58,34630, L ventric pacing lead add-on,33225,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,34630,,,,,,,fee schedule,2287.58,34630, L ventric pacing lead add-on,33225,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,31168,,,,,,,fee schedule,2287.58,34630, Reposition l ventric lead,33226,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2448.33,,,,,,,fee schedule,2448.33,12821, Reposition l ventric lead,33226,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2448.33,12821, Reposition l ventric lead,33226,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2448.33,12821, Reposition l ventric lead,33226,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2448.33,12821, Remove&replace pm gen singl,33227,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1717.49,,,,,,,fee schedule,1717.49,25393, Remove&replace pm gen singl,33227,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1717.49,25393, Remove&replace pm gen singl,33227,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,1717.49,25393, Remove&replace pm gen singl,33227,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,1717.49,25393, Remv&replc pm gen dual lead,33228,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1795.36,,,,,,,fee schedule,1795.36,25393, Remv&replc pm gen dual lead,33228,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1795.36,25393, Remv&replc pm gen dual lead,33228,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,1795.36,25393, Remv&replc pm gen dual lead,33228,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,1795.36,25393, Remv&replc pm gen mult leads,33229,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1876.51,,,,,,,fee schedule,1876.51,25393, Remv&replc pm gen mult leads,33229,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1876.51,25393, Remv&replc pm gen mult leads,33229,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,1876.51,25393, Remv&replc pm gen mult leads,33229,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,1876.51,25393, Insrt pulse gen w/dual leads,33230,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1903.82,,,,,,,fee schedule,1903.82,46177, Insrt pulse gen w/dual leads,33230,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1903.82,46177, Insrt pulse gen w/dual leads,33230,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46177,,,,,,,fee schedule,1903.82,46177, Insrt pulse gen w/dual leads,33230,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,41559,,,,,,,fee schedule,1903.82,46177, Insrt pulse gen w/mult leads,33231,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2023.5,,,,,,,fee schedule,2023.5,46177, Insrt pulse gen w/mult leads,33231,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2023.5,46177, Insrt pulse gen w/mult leads,33231,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46177,,,,,,,fee schedule,2023.5,46177, Insrt pulse gen w/mult leads,33231,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,41559,,,,,,,fee schedule,2023.5,46177, Removal of pm generator,33233,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1191.06,,,,,,,fee schedule,1191.06,12821, Removal of pm generator,33233,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1191.06,12821, Removal of pm generator,33233,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,1191.06,12821, Removal of pm generator,33233,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,1191.06,12821, Removal of pacemaker system,33234,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2446.82,,,,,,,fee schedule,2446.82,12821, Removal of pacemaker system,33234,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2446.82,12821, Removal of pacemaker system,33234,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2446.82,12821, Removal of pacemaker system,33234,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2446.82,12821, Removal pacemaker electrode,33235,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3230.42,,,,,,,fee schedule,3230.42,12821, Removal pacemaker electrode,33235,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3230.42,12821, Removal pacemaker electrode,33235,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3230.42,12821, Removal pacemaker electrode,33235,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3230.42,12821, Remove electrode/thoracotomy,33236,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4405.83,,,,,,,fee schedule,4405.83,6979, Remove electrode/thoracotomy,33236,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4405.83,6979, Remove electrode/thoracotomy,33236,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4405.83,6979, Remove electrode/thoracotomy,33236,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4405.83,6979, Remove electrode/thoracotomy,33237,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4707.85,,,,,,,fee schedule,4707.85,6979, Remove electrode/thoracotomy,33237,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4707.85,6979, Remove electrode/thoracotomy,33237,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4707.85,6979, Remove electrode/thoracotomy,33237,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4707.85,6979, Remove electrode/thoracotomy,33238,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5308.8,,,,,,,fee schedule,5097,6979, Remove electrode/thoracotomy,33238,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Remove electrode/thoracotomy,33238,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Remove electrode/thoracotomy,33238,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Insrt pulse gen w/singl lead,33240,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1829.35,,,,,,,fee schedule,1829.35,46177, Insrt pulse gen w/singl lead,33240,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,1829.35,46177, Insrt pulse gen w/singl lead,33240,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46177,,,,,,,fee schedule,1829.35,46177, Insrt pulse gen w/singl lead,33240,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,41559,,,,,,,fee schedule,1829.35,46177, Remove pulse generator,33241,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1112.49,,,,,,,fee schedule,1112.49,12821, Remove pulse generator,33241,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,1112.49,12821, Remove pulse generator,33241,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,1112.49,12821, Remove pulse generator,33241,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,1112.49,12821, Description Not Available,33242,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Remove eltrd/thoracotomy,33243,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7456.79,,,,,,,fee schedule,6979,14456, Remove eltrd/thoracotomy,33243,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,14456, Remove eltrd/thoracotomy,33243,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,6979,14456, Remove eltrd/thoracotomy,33243,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,6979,14456, Remove elctrd transvenously,33244,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4374.11,,,,,,,fee schedule,4374.11,12821, Remove elctrd transvenously,33244,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4374.11,12821, Remove elctrd transvenously,33244,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4374.11,12821, Remove elctrd transvenously,33244,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4374.11,12821, Description Not Available,33247,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Insj/rplcmt defib w/lead(s),33249,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4569.82,,,,,,,fee schedule,4569.82,46177, Insj/rplcmt defib w/lead(s),33249,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,4569.82,46177, Insj/rplcmt defib w/lead(s),33249,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46177,,,,,,,fee schedule,4569.82,46177, Insj/rplcmt defib w/lead(s),33249,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,41559,,,,,,,fee schedule,4569.82,46177, Ablate heart dysrhythm focus,33250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7976.48,,,,,,,fee schedule,5097,7976.48, Ablate heart dysrhythm focus,33250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7976.48, Ablate heart dysrhythm focus,33250,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7976.48, Ablate heart dysrhythm focus,33250,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7976.48, Ablate heart dysrhythm focus,33251,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8832.23,,,,,,,fee schedule,5097,8832.23, Ablate heart dysrhythm focus,33251,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8832.23, Ablate heart dysrhythm focus,33251,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8832.23, Ablate heart dysrhythm focus,33251,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8832.23, Ablate atria lmtd,33254,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7414.81,,,,,,,fee schedule,5097,7414.81, Ablate atria lmtd,33254,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7414.81, Ablate atria lmtd,33254,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7414.81, Ablate atria lmtd,33254,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7414.81, Ablate atria w/o bypass ext,33255,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8890.13,,,,,,,fee schedule,5097,8890.13, Ablate atria w/o bypass ext,33255,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8890.13, Ablate atria w/o bypass ext,33255,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8890.13, Ablate atria w/o bypass ext,33255,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8890.13, Ablate atria w/bypass exten,33256,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10498.19,,,,,,,fee schedule,5097,10498.19, Ablate atria w/bypass exten,33256,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,10498.19, Ablate atria w/bypass exten,33256,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,10498.19, Ablate atria w/bypass exten,33256,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,10498.19, Ablate atria lmtd add-on,33257,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3240.19,,,,,,,fee schedule,3240.19,6979, Ablate atria lmtd add-on,33257,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3240.19,6979, Ablate atria lmtd add-on,33257,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3240.19,6979, Ablate atria lmtd add-on,33257,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3240.19,6979, Ablate atria x10sv add-on,33258,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3620.77,,,,,,,fee schedule,3620.77,6979, Ablate atria x10sv add-on,33258,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3620.77,6979, Ablate atria x10sv add-on,33258,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3620.77,6979, Ablate atria x10sv add-on,33258,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3620.77,6979, Ablate atria w/bypass add-on,33259,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4675.74,,,,,,,fee schedule,4675.74,6979, Ablate atria w/bypass add-on,33259,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4675.74,6979, Ablate atria w/bypass add-on,33259,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4675.74,6979, Ablate atria w/bypass add-on,33259,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4675.74,6979, Ablate heart dysrhythm focus,33261,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8801.15,,,,,,,fee schedule,5097,8801.15, Ablate heart dysrhythm focus,33261,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8801.15, Ablate heart dysrhythm focus,33261,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8801.15, Ablate heart dysrhythm focus,33261,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8801.15, Rmvl& replc pulse gen 1 lead,33262,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1874.89,,,,,,,fee schedule,1874.89,46177, Rmvl& replc pulse gen 1 lead,33262,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1874.89,46177, Rmvl& replc pulse gen 1 lead,33262,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46177,,,,,,,fee schedule,1874.89,46177, Rmvl& replc pulse gen 1 lead,33262,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,41559,,,,,,,fee schedule,1874.89,46177, Rmvl & rplcmt dfb gen 2 lead,33263,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1951.14,,,,,,,fee schedule,1951.14,46177, Rmvl & rplcmt dfb gen 2 lead,33263,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1951.14,46177, Rmvl & rplcmt dfb gen 2 lead,33263,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46177,,,,,,,fee schedule,1951.14,46177, Rmvl & rplcmt dfb gen 2 lead,33263,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,41559,,,,,,,fee schedule,1951.14,46177, Rmvl & rplcmt dfb gen mlt ld,33264,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2026.31,,,,,,,fee schedule,2026.31,46177, Rmvl & rplcmt dfb gen mlt ld,33264,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2026.31,46177, Rmvl & rplcmt dfb gen mlt ld,33264,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46177,,,,,,,fee schedule,2026.31,46177, Rmvl & rplcmt dfb gen mlt ld,33264,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,41559,,,,,,,fee schedule,2026.31,46177, Ablate atria lmtd endo,33265,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7420.96,,,,,,,fee schedule,5097,7420.96, Ablate atria lmtd endo,33265,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7420.96, Ablate atria lmtd endo,33265,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7420.96, Ablate atria lmtd endo,33265,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7420.96, Ablate atria x10sv endo,33266,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10022.48,,,,,,,fee schedule,5097,10022.48, Ablate atria x10sv endo,33266,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,10022.48, Ablate atria x10sv endo,33266,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,10022.48, Ablate atria x10sv endo,33266,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,10022.48, Excl laa open any method,33267,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5679.94,,,,,,,fee schedule,5097,6979, Excl laa open any method,33267,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Excl laa open any method,33267,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Excl laa open any method,33267,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Excl laa opn oth px any meth,33268,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,682.27,,,,,,,fee schedule,682.27,6979, Excl laa opn oth px any meth,33268,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,682.27,6979, Excl laa opn oth px any meth,33268,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,682.27,6979, Excl laa opn oth px any meth,33268,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,682.27,6979, Excl laa thrscp any method,33269,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4560.38,,,,,,,fee schedule,4560.38,6979, Excl laa thrscp any method,33269,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4560.38,6979, Excl laa thrscp any method,33269,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4560.38,6979, Excl laa thrscp any method,33269,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4560.38,6979, Ins/rep subq defibrillator,33270,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2818.55,,,,,,,fee schedule,2818.55,46177, Ins/rep subq defibrillator,33270,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2818.55,46177, Ins/rep subq defibrillator,33270,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46177,,,,,,,fee schedule,2818.55,46177, Ins/rep subq defibrillator,33270,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,41559,,,,,,,fee schedule,2818.55,46177, Insj subq impltbl dfb elctrd,33271,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2325.68,,,,,,,fee schedule,2325.68,25393, Insj subq impltbl dfb elctrd,33271,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2325.68,25393, Insj subq impltbl dfb elctrd,33271,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,2325.68,25393, Insj subq impltbl dfb elctrd,33271,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,2325.68,25393, Rmvl of subq defibrillator,33272,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1763.79,,,,,,,fee schedule,1763.79,12821, Rmvl of subq defibrillator,33272,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1763.79,12821, Rmvl of subq defibrillator,33272,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,1763.79,12821, Rmvl of subq defibrillator,33272,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,1763.79,12821, Repos prev impltbl subq dfb,33273,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2050.37,,,,,,,fee schedule,2050.37,12821, Repos prev impltbl subq dfb,33273,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2050.37,12821, Repos prev impltbl subq dfb,33273,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2050.37,12821, Repos prev impltbl subq dfb,33273,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2050.37,12821, Tcat insj/rpl perm ldls pm,33274,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2398.95,,,,,,,fee schedule,2398.95,39251, Tcat insj/rpl perm ldls pm,33274,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2398.95,39251, Tcat insj/rpl perm ldls pm,33274,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,39251,,,,,,,fee schedule,2398.95,39251, Tcat insj/rpl perm ldls pm,33274,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,35325,,,,,,,fee schedule,2398.95,39251, Tcat rmvl perm ldls pm,33275,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2570.76,,,,,,,fee schedule,2570.76,12821, Tcat rmvl perm ldls pm,33275,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2570.76,12821, Tcat rmvl perm ldls pm,33275,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2570.76,12821, Tcat rmvl perm ldls pm,33275,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2570.76,12821, Insj phrnc nrv stim sys,33276,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2888.37,,,,,,,fee schedule,2888.37,46177, Insj phrnc nrv stim sys,33276,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2888.37,46177, Insj phrnc nrv stim sys,33276,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46177,,,,,,,fee schedule,2888.37,46177, Insj phrnc nrv stim sys,33276,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,41559,,,,,,,fee schedule,2888.37,46177, Insj phrnc nrv stim transvns,33277,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1485.25,,,,,,,fee schedule,1485.25,3195, Insj phrnc nrv stim transvns,33277,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1485.25,3195, Insj phrnc nrv stim transvns,33277,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1485.25,3195, Insj phrnc nrv stim transvns,33277,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1485.25,3195, Rmvl phrnc nrv stim sys,33278,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2840.78,,,,,,,fee schedule,2840.78,12821, Rmvl phrnc nrv stim sys,33278,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2840.78,12821, Rmvl phrnc nrv stim sys,33278,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2840.78,12821, Rmvl phrnc nrv stim sys,33278,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2840.78,12821, Rmvl phrnc nrv stim transvns,33279,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1761.09,,,,,,,fee schedule,1761.09,12821, Rmvl phrnc nrv stim transvns,33279,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1761.09,12821, Rmvl phrnc nrv stim transvns,33279,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,1761.09,12821, Rmvl phrnc nrv stim transvns,33279,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,1761.09,12821, Rmvl phrnc nrv stim pg only,33280,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1083.19,,,,,,,fee schedule,1083.19,12821, Rmvl phrnc nrv stim pg only,33280,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1083.19,12821, Rmvl phrnc nrv stim pg only,33280,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,1083.19,12821, Rmvl phrnc nrv stim pg only,33280,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,1083.19,12821, Reposg phrnc nrv stim trnsvn,33281,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1931.55,,,,,,,fee schedule,1931.55,12821, Reposg phrnc nrv stim trnsvn,33281,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1931.55,12821, Reposg phrnc nrv stim trnsvn,33281,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,1931.55,12821, Reposg phrnc nrv stim trnsvn,33281,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,1931.55,12821, Insj subq car rhythm mntr,33285,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,438.43,,,,,,,fee schedule,438.43,25393, Insj subq car rhythm mntr,33285,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,438.43,25393, Insj subq car rhythm mntr,33285,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,438.43,25393, Insj subq car rhythm mntr,33285,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,438.43,25393, Rmvl subq car rhythm mntr,33286,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,433.03,,,,,,,fee schedule,433.03,4497, Rmvl subq car rhythm mntr,33286,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,433.03,4497, Rmvl subq car rhythm mntr,33286,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,433.03,4497, Rmvl subq car rhythm mntr,33286,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,433.03,4497, Rmv&rplcmt phrnc nrv stim pg,33287,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1938.08,,,,,,,fee schedule,1938.08,39251, Rmv&rplcmt phrnc nrv stim pg,33287,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1938.08,39251, Rmv&rplcmt phrnc nrv stim pg,33287,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,39251,,,,,,,fee schedule,1938.08,39251, Rmv&rplcmt phrnc nrv stim pg,33287,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,35325,,,,,,,fee schedule,1938.08,39251, Rmv&rplcmt phrnc nrv stim ld,33288,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2600.87,,,,,,,fee schedule,2600.87,25393, Rmv&rplcmt phrnc nrv stim ld,33288,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2600.87,25393, Rmv&rplcmt phrnc nrv stim ld,33288,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,2600.87,25393, Rmv&rplcmt phrnc nrv stim ld,33288,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,2600.87,25393, Tcat impl wrls p-art prs snr,33289,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1629.97,,,,,,,fee schedule,1629.97,46177, Tcat impl wrls p-art prs snr,33289,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,1629.97,46177, Tcat impl wrls p-art prs snr,33289,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46177,,,,,,,fee schedule,1629.97,46177, Tcat impl wrls p-art prs snr,33289,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,41559,,,,,,,fee schedule,1629.97,46177, Repair of heart wound,33300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,13121.83,,,,,,,fee schedule,5097,13121.83, Repair of heart wound,33300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,13121.83, Repair of heart wound,33300,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,13121.83, Repair of heart wound,33300,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,13121.83, Repair of heart wound,33305,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,21870.04,,,,,,,fee schedule,5097,21870.04, Repair of heart wound,33305,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,21870.04, Repair of heart wound,33305,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,21870.04, Repair of heart wound,33305,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,21870.04, Exploratory heart surgery,33310,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6454.48,,,,,,,fee schedule,5097,6979, Exploratory heart surgery,33310,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Exploratory heart surgery,33310,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Exploratory heart surgery,33310,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Exploratory heart surgery,33315,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10294.76,,,,,,,fee schedule,5097,10294.76, Exploratory heart surgery,33315,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,10294.76, Exploratory heart surgery,33315,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,10294.76, Exploratory heart surgery,33315,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,10294.76, Repair major blood vessel(s),33320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5840.25,,,,,,,fee schedule,5097,6979, Repair major blood vessel(s),33320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Repair major blood vessel(s),33320,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Repair major blood vessel(s),33320,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Repair major vessel,33321,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6541.35,,,,,,,fee schedule,5097,6979, Repair major vessel,33321,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Repair major vessel,33321,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Repair major vessel,33321,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Repair major blood vessel(s),33322,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7625.84,,,,,,,fee schedule,5097,7625.84, Repair major blood vessel(s),33322,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7625.84, Repair major blood vessel(s),33322,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7625.84, Repair major blood vessel(s),33322,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7625.84, Insert major vessel graft,33330,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7811.52,,,,,,,fee schedule,5097,7811.52, Insert major vessel graft,33330,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7811.52, Insert major vessel graft,33330,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7811.52, Insert major vessel graft,33330,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7811.52, Insert major vessel graft,33335,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10169.03,,,,,,,fee schedule,5097,10169.03, Insert major vessel graft,33335,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,10169.03, Insert major vessel graft,33335,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,10169.03, Insert major vessel graft,33335,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,10169.03, Perq clsr tcat l atr apndge,33340,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3501.9,,,,,,,fee schedule,3501.9,14456, Perq clsr tcat l atr apndge,33340,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3501.9,14456, Perq clsr tcat l atr apndge,33340,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3501.9,14456, Replace aortic valve perq,33361,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6259.36,,,,,,,fee schedule,5097,6979, Replace aortic valve perq,33361,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Replace aortic valve perq,33361,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Replace aortic valve perq,33361,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Replace aortic valve open,33362,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6822.86,,,,,,,fee schedule,5097,6979, Replace aortic valve open,33362,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Replace aortic valve open,33362,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Replace aortic valve open,33362,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Replace aortic valve open,33363,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7089.75,,,,,,,fee schedule,5097,7089.75, Replace aortic valve open,33363,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7089.75, Replace aortic valve open,33363,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7089.75, Replace aortic valve open,33363,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7089.75, Replace aortic valve open,33364,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7324.26,,,,,,,fee schedule,5097,7324.26, Replace aortic valve open,33364,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7324.26, Replace aortic valve open,33364,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7324.26, Replace aortic valve open,33364,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7324.26, Replace aortic valve open,33365,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7398.02,,,,,,,fee schedule,5097,7398.02, Replace aortic valve open,33365,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7398.02, Replace aortic valve open,33365,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7398.02, Replace aortic valve open,33365,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7398.02, Trcath replace aortic valve,33366,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8127.83,,,,,,,fee schedule,5097,8127.83, Trcath replace aortic valve,33366,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8127.83, Trcath replace aortic valve,33366,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8127.83, Trcath replace aortic valve,33366,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8127.83, Replace aortic valve w/byp,33367,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3244.83,,,,,,,fee schedule,3244.83,6979, Replace aortic valve w/byp,33367,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3244.83,6979, Replace aortic valve w/byp,33367,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3244.83,6979, Replace aortic valve w/byp,33367,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3244.83,6979, Replace aortic valve w/byp,33368,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3932.34,,,,,,,fee schedule,3932.34,6979, Replace aortic valve w/byp,33368,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3932.34,6979, Replace aortic valve w/byp,33368,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3932.34,6979, Replace aortic valve w/byp,33368,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3932.34,6979, Replace aortic valve w/byp,33369,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5197.16,,,,,,,fee schedule,5097,6979, Replace aortic valve w/byp,33369,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Replace aortic valve w/byp,33369,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Replace aortic valve w/byp,33369,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Tcat plmt&rmvl cepd perq,33370,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,673.42,,,,,,,fee schedule,673.42,3195, Tcat plmt&rmvl cepd perq,33370,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,673.42,3195, Tcat plmt&rmvl cepd perq,33370,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,673.42,3195, Tcat plmt&rmvl cepd perq,33370,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,673.42,3195, Valvuloplasty aortic valve,33390,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10232.22,,,,,,,fee schedule,5097,10232.22, Valvuloplasty aortic valve,33390,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,10232.22, Valvuloplasty aortic valve,33390,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,10232.22, Valvuloplasty aortic valve,33391,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12210.61,,,,,,,fee schedule,5097,12210.61, Valvuloplasty aortic valve,33391,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,12210.61, Valvuloplasty aortic valve,33391,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,12210.61, Prepare heart-aorta conduit,33404,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9552.7,,,,,,,fee schedule,5097,9552.7, Prepare heart-aorta conduit,33404,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,9552.7, Prepare heart-aorta conduit,33404,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,9552.7, Prepare heart-aorta conduit,33404,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,9552.7, Replacement aortic valve opn,33405,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12270.34,,,,,,,fee schedule,5097,12270.34, Replacement aortic valve opn,33405,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,12270.34, Replacement aortic valve opn,33405,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,12270.34, Replacement aortic valve opn,33405,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,12270.34, Replacement aortic valve opn,33406,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,15507.94,,,,,,,fee schedule,5097,15507.94, Replacement aortic valve opn,33406,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,15507.94, Replacement aortic valve opn,33406,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,15507.94, Replacement aortic valve opn,33406,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,15507.94, Replacement aortic valve opn,33410,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,13768,,,,,,,fee schedule,5097,13768, Replacement aortic valve opn,33410,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,13768, Replacement aortic valve opn,33410,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,13768, Replacement aortic valve opn,33410,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,13768, Replacement of aortic valve,33411,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,18035.37,,,,,,,fee schedule,5097,18035.37, Replacement of aortic valve,33411,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,18035.37, Replacement of aortic valve,33411,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,18035.37, Replacement of aortic valve,33411,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,18035.37, Replacement of aortic valve,33412,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,16950.19,,,,,,,fee schedule,5097,16950.19, Replacement of aortic valve,33412,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,16950.19, Replacement of aortic valve,33412,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,16950.19, Replacement of aortic valve,33412,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,16950.19, Replacement of aortic valve,33413,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,17396.7,,,,,,,fee schedule,5097,17396.7, Replacement of aortic valve,33413,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,17396.7, Replacement of aortic valve,33413,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,17396.7, Replacement of aortic valve,33413,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,17396.7, Repair of aortic valve,33414,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,11560.88,,,,,,,fee schedule,5097,11560.88, Repair of aortic valve,33414,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,11560.88, Repair of aortic valve,33414,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,11560.88, Repair of aortic valve,33414,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,11560.88, Revision subvalvular tissue,33415,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10998.34,,,,,,,fee schedule,5097,10998.34, Revision subvalvular tissue,33415,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,10998.34, Revision subvalvular tissue,33415,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,10998.34, Revision subvalvular tissue,33415,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,10998.34, Revise ventricle muscle,33416,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10959.87,,,,,,,fee schedule,5097,10959.87, Revise ventricle muscle,33416,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,10959.87, Revise ventricle muscle,33416,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,10959.87, Revise ventricle muscle,33416,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,10959.87, Repair of aortic valve,33417,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9090.16,,,,,,,fee schedule,5097,9090.16, Repair of aortic valve,33417,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,9090.16, Repair of aortic valve,33417,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,9090.16, Repair of aortic valve,33417,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,9090.16, Repair tcat mitral valve,33418,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9136.83,,,,,,,fee schedule,5097,9136.83, Repair tcat mitral valve,33418,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,9136.83, Repair tcat mitral valve,33418,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,9136.83, Repair tcat mitral valve,33418,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,9136.83, Repair tcat mitral valve,33419,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2139.46,,,,,,,fee schedule,2139.46,2782, Repair tcat mitral valve,33419,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2139.46,2782, Repair tcat mitral valve,33419,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2139.46,2782, Revision of mitral valve,33420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7948.58,,,,,,,fee schedule,5097,7948.58, Revision of mitral valve,33420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7948.58, Revision of mitral valve,33420,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7948.58, Revision of mitral valve,33420,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7948.58, Revision of mitral valve,33422,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9108.99,,,,,,,fee schedule,5097,9108.99, Revision of mitral valve,33422,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,9108.99, Revision of mitral valve,33422,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,9108.99, Revision of mitral valve,33422,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,9108.99, Repair of mitral valve,33425,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,14721.8,,,,,,,fee schedule,5097,14721.8, Repair of mitral valve,33425,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,14721.8, Repair of mitral valve,33425,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,14721.8, Repair of mitral valve,33425,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,14721.8, Repair of mitral valve,33426,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12876.04,,,,,,,fee schedule,5097,12876.04, Repair of mitral valve,33426,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,12876.04, Repair of mitral valve,33426,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,12876.04, Repair of mitral valve,33426,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,12876.04, Repair of mitral valve,33427,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,13109.58,,,,,,,fee schedule,5097,13109.58, Repair of mitral valve,33427,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,13109.58, Repair of mitral valve,33427,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,13109.58, Repair of mitral valve,33427,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,13109.58, Replacement of mitral valve,33430,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,15132.33,,,,,,,fee schedule,5097,15132.33, Replacement of mitral valve,33430,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,15132.33, Replacement of mitral valve,33430,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,15132.33, Replacement of mitral valve,33430,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,15132.33, Rplcmt a-valve tlcj autol pv,33440,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,18314.4,,,,,,,fee schedule,5097,18314.4, Rplcmt a-valve tlcj autol pv,33440,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,18314.4, Rplcmt a-valve tlcj autol pv,33440,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,18314.4, Rplcmt a-valve tlcj autol pv,33440,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,18314.4, Revision of tricuspid valve,33460,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12953.75,,,,,,,fee schedule,5097,12953.75, Revision of tricuspid valve,33460,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,12953.75, Revision of tricuspid valve,33460,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,12953.75, Revision of tricuspid valve,33460,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,12953.75, Valvuloplasty tricuspid,33463,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,16559.84,,,,,,,fee schedule,5097,16559.84, Valvuloplasty tricuspid,33463,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,16559.84, Valvuloplasty tricuspid,33463,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,16559.84, Valvuloplasty tricuspid,33463,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,16559.84, Valvuloplasty tricuspid,33464,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,13099.28,,,,,,,fee schedule,5097,13099.28, Valvuloplasty tricuspid,33464,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,13099.28, Valvuloplasty tricuspid,33464,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,13099.28, Valvuloplasty tricuspid,33464,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,13099.28, Replace tricuspid valve,33465,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,14810.89,,,,,,,fee schedule,5097,14810.89, Replace tricuspid valve,33465,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,14810.89, Replace tricuspid valve,33465,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,14810.89, Replace tricuspid valve,33465,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,14810.89, Revision of tricuspid valve,33468,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,13163.38,,,,,,,fee schedule,5097,13163.38, Revision of tricuspid valve,33468,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,13163.38, Revision of tricuspid valve,33468,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,13163.38, Revision of tricuspid valve,33468,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,13163.38, Valvotomy pulmonary valve,33471,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Revision of pulmonary valve,33474,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,11774.02,,,,,,,fee schedule,5097,11774.02, Revision of pulmonary valve,33474,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,11774.02, Revision of pulmonary valve,33474,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,11774.02, Revision of pulmonary valve,33474,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,11774.02, Replacement pulmonary valve,33475,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12378.1,,,,,,,fee schedule,5097,12378.1, Replacement pulmonary valve,33475,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,12378.1, Replacement pulmonary valve,33475,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,12378.1, Replacement pulmonary valve,33475,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,12378.1, Revision of heart chamber,33476,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8321.93,,,,,,,fee schedule,5097,8321.93, Revision of heart chamber,33476,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8321.93, Revision of heart chamber,33476,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8321.93, Revision of heart chamber,33476,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8321.93, Implant tcat pulm vlv perq,33477,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6420.38,,,,,,,fee schedule,5097,6979, Implant tcat pulm vlv perq,33477,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Implant tcat pulm vlv perq,33477,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Implant tcat pulm vlv perq,33477,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Revision of heart chamber,33478,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8581.96,,,,,,,fee schedule,5097,8581.96, Revision of heart chamber,33478,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8581.96, Revision of heart chamber,33478,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8581.96, Revision of heart chamber,33478,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8581.96, Repair prosth valve clot,33496,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9103.11,,,,,,,fee schedule,5097,9103.11, Repair prosth valve clot,33496,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,9103.11, Repair prosth valve clot,33496,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,9103.11, Repair prosth valve clot,33496,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,9103.11, Repair heart vessel fistula,33500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8535.82,,,,,,,fee schedule,5097,8535.82, Repair heart vessel fistula,33500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8535.82, Repair heart vessel fistula,33500,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8535.82, Repair heart vessel fistula,33500,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8535.82, Repair heart vessel fistula,33501,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6145.77,,,,,,,fee schedule,5097,6979, Repair heart vessel fistula,33501,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Repair heart vessel fistula,33501,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Repair heart vessel fistula,33501,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Coronary artery correction,33502,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7017.34,,,,,,,fee schedule,5097,7017.34, Coronary artery correction,33502,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7017.34, Coronary artery correction,33502,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7017.34, Coronary artery correction,33502,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7017.34, Coronary artery graft,33503,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7309.75,,,,,,,fee schedule,5097,7309.75, Coronary artery graft,33503,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7309.75, Coronary artery graft,33503,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7309.75, Coronary artery graft,33503,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7309.75, Coronary artery graft,33504,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8018.62,,,,,,,fee schedule,5097,8018.62, Coronary artery graft,33504,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8018.62, Coronary artery graft,33504,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8018.62, Coronary artery graft,33504,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8018.62, Repair artery w/tunnel,33505,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,11018.47,,,,,,,fee schedule,5097,11018.47, Repair artery w/tunnel,33505,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,11018.47, Repair artery w/tunnel,33505,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,11018.47, Repair artery w/tunnel,33505,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,11018.47, Repair artery translocation,33506,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,11014.15,,,,,,,fee schedule,5097,11014.15, Repair artery translocation,33506,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,11014.15, Repair artery translocation,33506,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,11014.15, Repair artery translocation,33506,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,11014.15, Repair art intramural,33507,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9276.1,,,,,,,fee schedule,5097,9276.1, Repair art intramural,33507,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,9276.1, Repair art intramural,33507,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,9276.1, Repair art intramural,33507,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,9276.1, Endoscopic vein harvest,33508,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,83.37,,,,,,,fee schedule,83.37,2782, Endoscopic vein harvest,33508,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,83.37,2782, Endoscopic vein harvest,33508,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,83.37,2782, Ndsc hrv uxtr art 1 sgm cab,33509,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,920.67,,,,,,,fee schedule,920.67,6979, Ndsc hrv uxtr art 1 sgm cab,33509,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,920.67,6979, Ndsc hrv uxtr art 1 sgm cab,33509,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,920.67,6979, Ndsc hrv uxtr art 1 sgm cab,33509,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,920.67,6979, Cabg vein single,33510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10456.8,,,,,,,fee schedule,5097,10456.8, Cabg vein single,33510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,10456.8, Cabg vein single,33510,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,10456.8, Cabg vein single,33510,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,10456.8, Cabg vein two,33511,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,11500.01,,,,,,,fee schedule,5097,11500.01, Cabg vein two,33511,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,11500.01, Cabg vein two,33511,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,11500.01, Cabg vein two,33511,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,11500.01, Cabg vein three,33512,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,13026.43,,,,,,,fee schedule,5097,13026.43, Cabg vein three,33512,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,13026.43, Cabg vein three,33512,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,13026.43, Cabg vein three,33512,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,13026.43, Cabg vein four,33513,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,13295.2,,,,,,,fee schedule,5097,13295.2, Cabg vein four,33513,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,13295.2, Cabg vein four,33513,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,13295.2, Cabg vein four,33513,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,13295.2, Cabg vein five,33514,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,14133.2,,,,,,,fee schedule,5097,14133.2, Cabg vein five,33514,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,14133.2, Cabg vein five,33514,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,14133.2, Cabg vein five,33514,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,14133.2, Cabg vein six or more,33516,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,14636.06,,,,,,,fee schedule,5097,14636.06, Cabg vein six or more,33516,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,14636.06, Cabg vein six or more,33516,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,14636.06, Cabg vein six or more,33516,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,14636.06, Cabg artery-vein single,33517,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,992.43,,,,,,,fee schedule,992.43,6979, Cabg artery-vein single,33517,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,992.43,6979, Cabg artery-vein single,33517,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,992.43,6979, Cabg artery-vein single,33517,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,992.43,6979, Cabg artery-vein two,33518,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2177.66,,,,,,,fee schedule,2177.66,6979, Cabg artery-vein two,33518,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2177.66,6979, Cabg artery-vein two,33518,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2177.66,6979, Cabg artery-vein two,33518,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2177.66,6979, Cabg artery-vein three,33519,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2877.9,,,,,,,fee schedule,2877.9,6979, Cabg artery-vein three,33519,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2877.9,6979, Cabg artery-vein three,33519,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2877.9,6979, Cabg artery-vein three,33519,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2877.9,6979, Cabg artery-vein four,33521,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3456.19,,,,,,,fee schedule,3456.19,6979, Cabg artery-vein four,33521,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3456.19,6979, Cabg artery-vein four,33521,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3456.19,6979, Cabg artery-vein four,33521,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3456.19,6979, Cabg artery-vein five,33522,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3875.78,,,,,,,fee schedule,3875.78,6979, Cabg artery-vein five,33522,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3875.78,6979, Cabg artery-vein five,33522,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3875.78,6979, Cabg artery-vein five,33522,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3875.78,6979, Cabg art-vein six or more,33523,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4396.66,,,,,,,fee schedule,4396.66,6979, Cabg art-vein six or more,33523,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4396.66,6979, Cabg art-vein six or more,33523,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4396.66,6979, Cabg art-vein six or more,33523,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4396.66,6979, Coronary artery bypass/reop,33530,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2779.1,,,,,,,fee schedule,2779.1,6979, Coronary artery bypass/reop,33530,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2779.1,6979, Coronary artery bypass/reop,33530,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2779.1,6979, Coronary artery bypass/reop,33530,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2779.1,6979, Cabg arterial single,33533,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10130.72,,,,,,,fee schedule,5097,10130.72, Cabg arterial single,33533,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,10130.72, Cabg arterial single,33533,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,10130.72, Cabg arterial single,33533,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,10130.72, Cabg arterial two,33534,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,11888.47,,,,,,,fee schedule,5097,11888.47, Cabg arterial two,33534,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,11888.47, Cabg arterial two,33534,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,11888.47, Cabg arterial two,33534,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,11888.47, Cabg arterial three,33535,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,13193.38,,,,,,,fee schedule,5097,13193.38, Cabg arterial three,33535,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,13193.38, Cabg arterial three,33535,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,13193.38, Cabg arterial three,33535,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,13193.38, Cabg arterial four or more,33536,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,14216.41,,,,,,,fee schedule,5097,14216.41, Cabg arterial four or more,33536,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,14216.41, Cabg arterial four or more,33536,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,14216.41, Cabg arterial four or more,33536,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,14216.41, Removal of heart lesion,33542,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,14185.87,,,,,,,fee schedule,5097,14185.87, Removal of heart lesion,33542,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,14185.87, Removal of heart lesion,33542,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,14185.87, Removal of heart lesion,33542,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,14185.87, Repair of heart damage,33545,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,16553.74,,,,,,,fee schedule,5097,16553.74, Repair of heart damage,33545,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,16553.74, Repair of heart damage,33545,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,16553.74, Repair of heart damage,33545,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,16553.74, Restore/remodel ventricle,33548,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,15986.95,,,,,,,fee schedule,5097,15986.95, Restore/remodel ventricle,33548,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,15986.95, Restore/remodel ventricle,33548,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,15986.95, Restore/remodel ventricle,33548,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,15986.95, Open coronary endarterectomy,33572,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1220.14,,,,,,,fee schedule,1220.14,6979, Open coronary endarterectomy,33572,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1220.14,6979, Open coronary endarterectomy,33572,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1220.14,6979, Open coronary endarterectomy,33572,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1220.14,6979, Closure of valve,33600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9353.7,,,,,,,fee schedule,5097,9353.7, Closure of valve,33600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,9353.7, Closure of valve,33600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,9353.7, Closure of valve,33600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,9353.7, Closure of valve,33602,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9091.99,,,,,,,fee schedule,5097,9091.99, Closure of valve,33602,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,9091.99, Closure of valve,33602,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,9091.99, Closure of valve,33602,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,9091.99, Anastomosis/artery-aorta,33606,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9659.81,,,,,,,fee schedule,5097,9659.81, Anastomosis/artery-aorta,33606,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,9659.81, Anastomosis/artery-aorta,33606,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,9659.81, Anastomosis/artery-aorta,33606,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,9659.81, Repair anomaly w/conduit,33608,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9789.53,,,,,,,fee schedule,5097,9789.53, Repair anomaly w/conduit,33608,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,9789.53, Repair anomaly w/conduit,33608,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,9789.53, Repair anomaly w/conduit,33608,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,9789.53, Repair by enlargement,33610,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9656.84,,,,,,,fee schedule,5097,9656.84, Repair by enlargement,33610,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,9656.84, Repair by enlargement,33610,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,9656.84, Repair by enlargement,33610,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,9656.84, Repair double ventricle,33611,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10506.39,,,,,,,fee schedule,5097,10506.39, Repair double ventricle,33611,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,10506.39, Repair double ventricle,33611,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,10506.39, Repair double ventricle,33611,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,10506.39, Repair double ventricle,33612,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10786.17,,,,,,,fee schedule,5097,10786.17, Repair double ventricle,33612,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,10786.17, Repair double ventricle,33612,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,10786.17, Repair double ventricle,33612,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,10786.17, Repair modified fontan,33615,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10806.19,,,,,,,fee schedule,5097,10806.19, Repair modified fontan,33615,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,10806.19, Repair modified fontan,33615,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,10806.19, Repair modified fontan,33615,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,10806.19, Repair single ventricle,33617,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,11690.33,,,,,,,fee schedule,5097,11690.33, Repair single ventricle,33617,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,11690.33, Repair single ventricle,33617,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,11690.33, Repair single ventricle,33617,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,11690.33, Repair single ventricle,33619,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,14851.36,,,,,,,fee schedule,5097,14851.36, Repair single ventricle,33619,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,14851.36, Repair single ventricle,33619,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,14851.36, Repair single ventricle,33619,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,14851.36, Apply r&l pulm art bands,33620,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8890.56,,,,,,,fee schedule,5097,8890.56, Apply r&l pulm art bands,33620,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8890.56, Apply r&l pulm art bands,33620,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8890.56, Apply r&l pulm art bands,33620,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8890.56, Transthor cath for stent,33621,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5082.49,,,,,,,fee schedule,5082.49,6979, Transthor cath for stent,33621,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5082.49,6979, Transthor cath for stent,33621,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5082.49,6979, Transthor cath for stent,33621,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5082.49,6979, Redo compl cardiac anomaly,33622,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,18342.84,,,,,,,fee schedule,5097,18342.84, Redo compl cardiac anomaly,33622,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,18342.84, Redo compl cardiac anomaly,33622,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,18342.84, Redo compl cardiac anomaly,33622,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,18342.84, Repair heart septum defect,33641,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8860.18,,,,,,,fee schedule,5097,8860.18, Repair heart septum defect,33641,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8860.18, Repair heart septum defect,33641,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8860.18, Repair heart septum defect,33641,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8860.18, Revision of heart veins,33645,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9348.14,,,,,,,fee schedule,5097,9348.14, Revision of heart veins,33645,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,9348.14, Revision of heart veins,33645,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,9348.14, Revision of heart veins,33645,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,9348.14, Repair heart septum defects,33647,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9799.03,,,,,,,fee schedule,5097,9799.03, Repair heart septum defects,33647,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,9799.03, Repair heart septum defects,33647,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,9799.03, Repair heart septum defects,33647,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,9799.03, Repair of heart defects,33660,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9479.69,,,,,,,fee schedule,5097,9479.69, Repair of heart defects,33660,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,9479.69, Repair of heart defects,33660,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,9479.69, Repair of heart defects,33660,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,9479.69, Repair of heart defects,33665,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10312.78,,,,,,,fee schedule,5097,10312.78, Repair of heart defects,33665,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,10312.78, Repair of heart defects,33665,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,10312.78, Repair of heart defects,33665,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,10312.78, Repair of heart chambers,33670,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10552.26,,,,,,,fee schedule,5097,10552.26, Repair of heart chambers,33670,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,10552.26, Repair of heart chambers,33670,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,10552.26, Repair of heart chambers,33670,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,10552.26, Close Mult Vsd,33675,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10617.39,,,,,,,fee schedule,5097,10617.39, Close Mult Vsd,33675,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,10617.39, Close Mult Vsd,33675,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,10617.39, Close Mult Vsd,33675,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,10617.39, Close mult vsd w/resection,33676,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10892.74,,,,,,,fee schedule,5097,10892.74, Close mult vsd w/resection,33676,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,10892.74, Close mult vsd w/resection,33676,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,10892.74, Close mult vsd w/resection,33676,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,10892.74, Cl mult vsd w/rem pul band,33677,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,11300.68,,,,,,,fee schedule,5097,11300.68, Cl mult vsd w/rem pul band,33677,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,11300.68, Cl mult vsd w/rem pul band,33677,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,11300.68, Cl mult vsd w/rem pul band,33677,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,11300.68, Repair heart septum defect,33681,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10039.96,,,,,,,fee schedule,5097,10039.96, Repair heart septum defect,33681,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,10039.96, Repair heart septum defect,33681,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,10039.96, Repair heart septum defect,33681,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,10039.96, Repair heart septum defect,33684,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10180.04,,,,,,,fee schedule,5097,10180.04, Repair heart septum defect,33684,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,10180.04, Repair heart septum defect,33684,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,10180.04, Repair heart septum defect,33684,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,10180.04, Repair heart septum defect,33688,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10100.56,,,,,,,fee schedule,5097,10100.56, Repair heart septum defect,33688,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,10100.56, Repair heart septum defect,33688,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,10100.56, Repair heart septum defect,33688,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,10100.56, Reinforce pulmonary artery,33690,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6610.96,,,,,,,fee schedule,5097,6979, Reinforce pulmonary artery,33690,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Reinforce pulmonary artery,33690,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Reinforce pulmonary artery,33690,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Repair of heart defects,33692,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10488.8,,,,,,,fee schedule,5097,10488.8, Repair of heart defects,33692,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,10488.8, Repair of heart defects,33692,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,10488.8, Repair of heart defects,33692,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,10488.8, Repair of heart defects,33694,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10506.39,,,,,,,fee schedule,5097,10506.39, Repair of heart defects,33694,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,10506.39, Repair of heart defects,33694,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,10506.39, Repair of heart defects,33694,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,10506.39, Repair of heart defects,33697,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,11058.78,,,,,,,fee schedule,5097,11058.78, Repair of heart defects,33697,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,11058.78, Repair of heart defects,33697,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,11058.78, Repair of heart defects,33697,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,11058.78, Repair of heart defects,33702,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8419.43,,,,,,,fee schedule,5097,8419.43, Repair of heart defects,33702,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8419.43, Repair of heart defects,33702,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8419.43, Repair of heart defects,33702,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8419.43, Repair of heart defects,33710,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,11039.03,,,,,,,fee schedule,5097,11039.03, Repair of heart defects,33710,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,11039.03, Repair of heart defects,33710,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,11039.03, Repair of heart defects,33710,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,11039.03, Repair of heart defect,33720,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8427.47,,,,,,,fee schedule,5097,8427.47, Repair of heart defect,33720,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8427.47, Repair of heart defect,33720,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8427.47, Repair of heart defect,33720,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8427.47, Repair Venous Anomaly,33724,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8320.31,,,,,,,fee schedule,5097,8320.31, Repair Venous Anomaly,33724,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8320.31, Repair Venous Anomaly,33724,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8320.31, Repair Venous Anomaly,33724,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8320.31, Repair Pul Venous Stenosis,33726,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10940.34,,,,,,,fee schedule,5097,10940.34, Repair Pul Venous Stenosis,33726,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,10940.34, Repair Pul Venous Stenosis,33726,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,10940.34, Repair Pul Venous Stenosis,33726,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,10940.34, Repair heart-vein defect(s),33730,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10847.85,,,,,,,fee schedule,5097,10847.85, Repair heart-vein defect(s),33730,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,10847.85, Repair heart-vein defect(s),33730,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,10847.85, Repair heart-vein defect(s),33730,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,10847.85, Repair heart-vein defect,33732,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8983.42,,,,,,,fee schedule,5097,8983.42, Repair heart-vein defect,33732,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8983.42, Repair heart-vein defect,33732,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8983.42, Repair heart-vein defect,33732,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8983.42, Revision of heart chamber,33735,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7122.02,,,,,,,fee schedule,5097,7122.02, Revision of heart chamber,33735,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7122.02, Revision of heart chamber,33735,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7122.02, Revision of heart chamber,33735,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7122.02, Revision of heart chamber,33736,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7707.54,,,,,,,fee schedule,5097,7707.54, Revision of heart chamber,33736,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7707.54, Revision of heart chamber,33736,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7707.54, Revision of heart chamber,33736,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7707.54, Revision of heart chamber,33737,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Tas congenital car anomal,33741,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3780.87,,,,,,,fee schedule,3780.87,5664, Tas congenital car anomal,33741,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3780.87,5664, Tas congenital car anomal,33741,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3780.87,5664, Tis cgen car anomal 1st shnt,33745,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5409.44,,,,,,,fee schedule,5097,5664, Tis cgen car anomal 1st shnt,33745,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Tis cgen car anomal 1st shnt,33745,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Tis cgen car anomal ea addl,33746,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2159.48,,,,,,,fee schedule,2159.48,5664, Tis cgen car anomal ea addl,33746,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2159.48,5664, Tis cgen car anomal ea addl,33746,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2159.48,5664, Major vessel shunt,33750,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6865.38,,,,,,,fee schedule,5097,6979, Major vessel shunt,33750,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Major vessel shunt,33750,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Major vessel shunt,33750,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Major vessel shunt,33755,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7233.18,,,,,,,fee schedule,5097,7233.18, Major vessel shunt,33755,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7233.18, Major vessel shunt,33755,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7233.18, Major vessel shunt,33755,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7233.18, Major vessel shunt,33762,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6973.03,,,,,,,fee schedule,5097,6979, Major vessel shunt,33762,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Major vessel shunt,33762,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Major vessel shunt,33762,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Major vessel shunt & graft,33764,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7233.18,,,,,,,fee schedule,5097,7233.18, Major vessel shunt & graft,33764,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7233.18, Major vessel shunt & graft,33764,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7233.18, Major vessel shunt & graft,33764,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7233.18, Major vessel shunt,33766,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7237.49,,,,,,,fee schedule,5097,7237.49, Major vessel shunt,33766,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7237.49, Major vessel shunt,33766,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7237.49, Major vessel shunt,33766,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7237.49, Major vessel shunt,33767,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7715.42,,,,,,,fee schedule,5097,7715.42, Major vessel shunt,33767,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7715.42, Major vessel shunt,33767,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7715.42, Major vessel shunt,33767,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7715.42, Cavopulmonary shunting,33768,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2202.11,,,,,,,fee schedule,2202.11,6979, Cavopulmonary shunting,33768,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2202.11,6979, Cavopulmonary shunting,33768,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2202.11,6979, Cavopulmonary shunting,33768,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2202.11,6979, Repair great vessels defect,33770,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,11356.64,,,,,,,fee schedule,5097,11356.64, Repair great vessels defect,33770,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,11356.64, Repair great vessels defect,33770,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,11356.64, Repair great vessels defect,33770,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,11356.64, Repair great vessels defect,33771,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,11643.49,,,,,,,fee schedule,5097,11643.49, Repair great vessels defect,33771,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,11643.49, Repair great vessels defect,33771,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,11643.49, Repair great vessels defect,33771,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,11643.49, Repair great vessels defect,33774,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9802.7,,,,,,,fee schedule,5097,9802.7, Repair great vessels defect,33774,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,9802.7, Repair great vessels defect,33774,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,9802.7, Repair great vessels defect,33774,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,9802.7, Repair great vessels defect,33775,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10066.02,,,,,,,fee schedule,5097,10066.02, Repair great vessels defect,33775,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,10066.02, Repair great vessels defect,33775,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,10066.02, Repair great vessels defect,33775,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,10066.02, Repair great vessels defect,33776,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10653.65,,,,,,,fee schedule,5097,10653.65, Repair great vessels defect,33776,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,10653.65, Repair great vessels defect,33776,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,10653.65, Repair great vessels defect,33776,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,10653.65, Repair great vessels defect,33777,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10209.56,,,,,,,fee schedule,5097,10209.56, Repair great vessels defect,33777,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,10209.56, Repair great vessels defect,33777,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,10209.56, Repair great vessels defect,33777,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,10209.56, Repair great vessels defect,33778,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12668.89,,,,,,,fee schedule,5097,12668.89, Repair great vessels defect,33778,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,12668.89, Repair great vessels defect,33778,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,12668.89, Repair great vessels defect,33778,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,12668.89, Repair great vessels defect,33779,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12438.05,,,,,,,fee schedule,5097,12438.05, Repair great vessels defect,33779,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,12438.05, Repair great vessels defect,33779,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,12438.05, Repair great vessels defect,33779,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,12438.05, Repair great vessels defect,33780,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12686.43,,,,,,,fee schedule,5097,12686.43, Repair great vessels defect,33780,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,12686.43, Repair great vessels defect,33780,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,12686.43, Repair great vessels defect,33780,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,12686.43, Repair great vessels defect,33781,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12349.02,,,,,,,fee schedule,5097,12349.02, Repair great vessels defect,33781,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,12349.02, Repair great vessels defect,33781,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,12349.02, Repair great vessels defect,33781,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,12349.02, Nikaidoh proc,33782,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,17267.79,,,,,,,fee schedule,5097,17267.79, Nikaidoh proc,33782,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,17267.79, Nikaidoh proc,33782,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,17267.79, Nikaidoh proc,33782,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,17267.79, Nikaidoh proc w/ostia implt,33783,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,18641.4,,,,,,,fee schedule,5097,18641.4, Nikaidoh proc w/ostia implt,33783,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,18641.4, Nikaidoh proc w/ostia implt,33783,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,18641.4, Nikaidoh proc w/ostia implt,33783,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,18641.4, Repair arterial trunk,33786,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12217.25,,,,,,,fee schedule,5097,12217.25, Repair arterial trunk,33786,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,12217.25, Repair arterial trunk,33786,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,12217.25, Repair arterial trunk,33786,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,12217.25, Revision of pulmonary artery,33788,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8292.79,,,,,,,fee schedule,5097,8292.79, Revision of pulmonary artery,33788,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8292.79, Revision of pulmonary artery,33788,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8292.79, Revision of pulmonary artery,33788,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8292.79, Aortic suspension,33800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5381.21,,,,,,,fee schedule,5097,6979, Aortic suspension,33800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Aortic suspension,33800,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Aortic suspension,33800,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Repair vessel defect,33802,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5979.69,,,,,,,fee schedule,5097,6979, Repair vessel defect,33802,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Repair vessel defect,33802,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Repair vessel defect,33802,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Repair vessel defect,33803,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6251.97,,,,,,,fee schedule,5097,6979, Repair vessel defect,33803,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Repair vessel defect,33803,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Repair vessel defect,33803,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Repair septal defect,33813,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Repair septal defect,33814,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8327.11,,,,,,,fee schedule,5097,8327.11, Repair septal defect,33814,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8327.11, Repair septal defect,33814,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8327.11, Repair septal defect,33814,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8327.11, Revise major vessel,33820,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5304.97,,,,,,,fee schedule,5304.97,34630, Revise major vessel,33820,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5304.97,34630, Revise major vessel,33820,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,34630,,,,,,,fee schedule,5304.97,34630, Revise major vessel,33820,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,31168,,,,,,,fee schedule,5304.97,34630, Revise major vessel,33822,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5582.97,,,,,,,fee schedule,5582.97,25393, Revise major vessel,33822,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5582.97,25393, Revise major vessel,33822,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,5582.97,25393, Revise major vessel,33822,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,5582.97,25393, Revise major vessel,33824,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6480.22,,,,,,,fee schedule,6480.22,34630, Revise major vessel,33824,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6480.22,34630, Revise major vessel,33824,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,34630,,,,,,,fee schedule,6480.22,34630, Revise major vessel,33824,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,31168,,,,,,,fee schedule,6480.22,34630, Remove aorta constriction,33840,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6795.61,,,,,,,fee schedule,5097,6979, Remove aorta constriction,33840,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Remove aorta constriction,33840,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Remove aorta constriction,33840,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Remove aorta constriction,33845,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7320.16,,,,,,,fee schedule,5097,7320.16, Remove aorta constriction,33845,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7320.16, Remove aorta constriction,33845,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7320.16, Remove aorta constriction,33845,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7320.16, Remove aorta constriction,33851,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6973.09,,,,,,,fee schedule,5097,6979, Remove aorta constriction,33851,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Remove aorta constriction,33851,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Remove aorta constriction,33851,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Repair septal defect,33852,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7644.73,,,,,,,fee schedule,5097,7644.73, Repair septal defect,33852,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7644.73, Repair septal defect,33852,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7644.73, Repair septal defect,33852,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7644.73, Repair septal defect,33853,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9962.58,,,,,,,fee schedule,5097,9962.58, Repair septal defect,33853,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,9962.58, Repair septal defect,33853,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,9962.58, Repair septal defect,33853,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,9962.58, As-aort grf f/aortic dsj,33858,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,18164.88,,,,,,,fee schedule,5097,18164.88, As-aort grf f/aortic dsj,33858,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,18164.88, As-aort grf f/aortic dsj,33858,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,18164.88, As-aort grf f/aortic dsj,33858,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,18164.88, As-aort grf f/ds oth/thn dsj,33859,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,13087.78,,,,,,,fee schedule,5097,13087.78, As-aort grf f/ds oth/thn dsj,33859,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,13087.78, As-aort grf f/ds oth/thn dsj,33859,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,13087.78, As-aort grf f/ds oth/thn dsj,33859,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,13087.78, Ascending aortic graft,33863,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,16838.76,,,,,,,fee schedule,5097,16838.76, Ascending aortic graft,33863,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,16838.76, Ascending aortic graft,33863,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,16838.76, Ascending aortic graft,33863,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,16838.76, Ascending aortic graft,33864,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,17188.2,,,,,,,fee schedule,5097,17188.2, Ascending aortic graft,33864,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,17188.2, Ascending aortic graft,33864,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,17188.2, Ascending aortic graft,33864,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,17188.2, Aortic hemiarch graft,33866,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4874.37,,,,,,,fee schedule,2505,4874.37, Aortic hemiarch graft,33866,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,4874.37, Aortic hemiarch graft,33866,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,4874.37, Transvrs a-arch grf hypthrm,33871,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,17415.27,,,,,,,fee schedule,5097,17415.27, Transvrs a-arch grf hypthrm,33871,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,17415.27, Transvrs a-arch grf hypthrm,33871,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,17415.27, Transvrs a-arch grf hypthrm,33871,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,17415.27, Thoracic aortic graft,33875,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,14694.01,,,,,,,fee schedule,5097,14694.01, Thoracic aortic graft,33875,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,14694.01, Thoracic aortic graft,33875,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,14694.01, Thoracic aortic graft,33875,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,14694.01, Thoracoabdominal graft,33877,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,19199.29,,,,,,,fee schedule,5097,19199.29, Thoracoabdominal graft,33877,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,19199.29, Thoracoabdominal graft,33877,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,19199.29, Thoracoabdominal graft,33877,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,19199.29, Endovasc taa repr incl subcl,33880,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7497.96,,,,,,,fee schedule,5097,7497.96, Endovasc taa repr incl subcl,33880,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7497.96, Endovasc taa repr incl subcl,33880,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7497.96, Endovasc taa repr incl subcl,33880,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7497.96, Endovasc taa repr w/o subcl,33881,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6291.14,,,,,,,fee schedule,5097,6979, Endovasc taa repr w/o subcl,33881,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Endovasc taa repr w/o subcl,33881,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Endovasc taa repr w/o subcl,33881,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Evasc rpr ta dplmt mltpc sys,33882,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10167.2,,,,,,,fee schedule,6979,10167.2, Evasc rpr ta dplmt mltpc sys,33882,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,10167.2, Insert endovasc prosth taa,33883,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5585.72,,,,,,,fee schedule,5097,6979, Insert endovasc prosth taa,33883,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Insert endovasc prosth taa,33883,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Insert endovasc prosth taa,33883,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Endovasc prosth taa add-on,33884,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Endovasc prosth taa add-on,33884,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Endovasc prosth taa add-on,33884,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Endovasc prosth delayed,33886,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5586.48,,,,,,,fee schedule,5097,6979, Endovasc prosth delayed,33886,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Endovasc prosth delayed,33886,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Endovasc prosth delayed,33886,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Artery transpose/endovas taa,33889,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Artery transpose/endovas taa,33889,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Artery transpose/endovas taa,33889,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Car-car bp grft/endovas taa,33891,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Car-car bp grft/endovas taa,33891,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Car-car bp grft/endovas taa,33891,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Evasc st rpr thrc/aa acrs br,33894,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4935.94,,,,,,,fee schedule,4935.94,6979, Evasc st rpr thrc/aa acrs br,33894,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4935.94,6979, Evasc st rpr thrc/aa acrs br,33894,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4935.94,6979, Evasc st rpr thrc/aa acrs br,33894,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4935.94,6979, Evasc st rpr thrc/aa x crsg,33895,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3928.88,,,,,,,fee schedule,3928.88,6979, Evasc st rpr thrc/aa x crsg,33895,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3928.88,6979, Evasc st rpr thrc/aa x crsg,33895,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3928.88,6979, Evasc st rpr thrc/aa x crsg,33895,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3928.88,6979, Perq trluml angp nt/recr coa,33897,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2919.99,,,,,,,fee schedule,2919.99,6979, Perq trluml angp nt/recr coa,33897,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2919.99,6979, Perq trluml angp nt/recr coa,33897,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2919.99,6979, Perq trluml angp nt/recr coa,33897,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2919.99,6979, Perq p-art revsc 1 nm nt uni,33900,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2978.27,,,,,,,fee schedule,2978.27,25393, Perq p-art revsc 1 nm nt uni,33900,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,2978.27,25393, Perq p-art revsc 1 nm nt uni,33900,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,2978.27,25393, Perq p-art revsc 1 nm nt uni,33900,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,2978.27,25393, Perq p-art revsc 1 nm nt bi,33901,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3917.23,,,,,,,fee schedule,3917.23,25393, Perq p-art revsc 1 nm nt bi,33901,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,3917.23,25393, Perq p-art revsc 1 nm nt bi,33901,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,3917.23,25393, Perq p-art revsc 1 nm nt bi,33901,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,3917.23,25393, Perq p-art revsc 1 abnor uni,33902,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3780.87,,,,,,,fee schedule,3780.87,25393, Perq p-art revsc 1 abnor uni,33902,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8212,,,,,,,fee schedule,3780.87,25393, Perq p-art revsc 1 abnor uni,33902,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,3780.87,25393, Perq p-art revsc 1 abnor uni,33902,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,3780.87,25393, Perq p-art revsc 1 abnor bi,33903,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4462.44,,,,,,,fee schedule,4462.44,25393, Perq p-art revsc 1 abnor bi,33903,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8212,,,,,,,fee schedule,4462.44,25393, Perq p-art revsc 1 abnor bi,33903,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,4462.44,25393, Perq p-art revsc 1 abnor bi,33903,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,4462.44,25393, Perq p-art revsc each addl,33904,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1497.61,,,,,,,fee schedule,1497.61,3195, Perq p-art revsc each addl,33904,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1497.61,3195, Perq p-art revsc each addl,33904,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1497.61,3195, Perq p-art revsc each addl,33904,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1497.61,3195, Remove lung artery emboli,33910,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,14148.15,,,,,,,fee schedule,5097,14148.15, Remove lung artery emboli,33910,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,14148.15, Remove lung artery emboli,33910,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,14148.15, Remove lung artery emboli,33910,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,14148.15, Remove lung artery emboli,33915,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7490.89,,,,,,,fee schedule,5097,7490.89, Remove lung artery emboli,33915,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7490.89, Remove lung artery emboli,33915,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7490.89, Remove lung artery emboli,33915,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7490.89, Surgery of great vessel,33916,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,22341.81,,,,,,,fee schedule,5097,22341.81, Surgery of great vessel,33916,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,22341.81, Surgery of great vessel,33916,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,22341.81, Surgery of great vessel,33916,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,22341.81, Repair pulmonary artery,33917,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7975.56,,,,,,,fee schedule,5097,7975.56, Repair pulmonary artery,33917,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7975.56, Repair pulmonary artery,33917,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7975.56, Repair pulmonary artery,33917,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7975.56, Repair pulmonary atresia,33920,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9765.2,,,,,,,fee schedule,5097,9765.2, Repair pulmonary atresia,33920,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,9765.2, Repair pulmonary atresia,33920,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,9765.2, Repair pulmonary atresia,33920,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,9765.2, Transect pulmonary artery,33922,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7592.77,,,,,,,fee schedule,5097,7592.77, Transect pulmonary artery,33922,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7592.77, Transect pulmonary artery,33922,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7592.77, Transect pulmonary artery,33922,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7592.77, Remove pulmonary shunt,33924,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1507.16,,,,,,,fee schedule,1507.16,6979, Remove pulmonary shunt,33924,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1507.16,6979, Remove pulmonary shunt,33924,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1507.16,6979, Remove pulmonary shunt,33924,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1507.16,6979, Rpr pul art unifocal w/o cpb,33925,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9246.48,,,,,,,fee schedule,5097,9246.48, Rpr pul art unifocal w/o cpb,33925,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,9246.48, Rpr pul art unifocal w/o cpb,33925,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,9246.48, Rpr pul art unifocal w/o cpb,33925,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,9246.48, Repr pul art unifocal w/cpb,33926,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12949.59,,,,,,,fee schedule,5097,12949.59, Repr pul art unifocal w/cpb,33926,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,12949.59, Repr pul art unifocal w/cpb,33926,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,12949.59, Repr pul art unifocal w/cpb,33926,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,12949.59, Impltj tot rplcmt hrt sys,33927,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,13501.44,,,,,,,fee schedule,5097,13501.44, Impltj tot rplcmt hrt sys,33927,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,13501.44, Impltj tot rplcmt hrt sys,33927,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,13501.44, Impltj tot rplcmt hrt sys,33927,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,13501.44, Rmvl & rplcmt tot hrt sys,33928,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Rmvl & rplcmt tot hrt sys,33928,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Rmvl & rplcmt tot hrt sys,33928,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Rmvl rplcmt hrt sys f/trnspl,33929,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Rmvl rplcmt hrt sys f/trnspl,33929,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Rmvl rplcmt hrt sys f/trnspl,33929,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Removal of donor heart/lung,33930,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Removal of donor heart/lung,33930,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Removal of donor heart/lung,33930,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Prepare donor heart/lung,33933,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Prepare donor heart/lung,33933,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Prepare donor heart/lung,33933,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Transplantation heart/lung,33935,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,26585.66,,,,,,,fee schedule,5097,26585.66, Transplantation heart/lung,33935,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,26585.66, Transplantation heart/lung,33935,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,26585.66, Transplantation heart/lung,33935,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,26585.66, Removal of donor heart,33940,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Removal of donor heart,33940,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Removal of donor heart,33940,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Prepare donor heart,33944,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Prepare donor heart,33944,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Prepare donor heart,33944,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Transplantation of heart,33945,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,26119.77,,,,,,,fee schedule,5097,26119.77, Transplantation of heart,33945,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,26119.77, Transplantation of heart,33945,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,26119.77, Transplantation of heart,33945,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,26119.77, Ecmo/ecls initiation venous,33946,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1612.76,,,,,,,fee schedule,1612.76,6979, Ecmo/ecls initiation venous,33946,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1612.76,6979, Ecmo/ecls initiation venous,33946,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1612.76,6979, Ecmo/ecls initiation venous,33946,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1612.76,6979, Ecmo/ecls initiation artery,33947,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1780.57,,,,,,,fee schedule,1780.57,6979, Ecmo/ecls initiation artery,33947,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1780.57,6979, Ecmo/ecls initiation artery,33947,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1780.57,6979, Ecmo/ecls initiation artery,33947,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1780.57,6979, Ecmo/ecls daily mgmt-venous,33948,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1236.39,,,,,,,fee schedule,1236.39,6979, Ecmo/ecls daily mgmt-venous,33948,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1236.39,6979, Ecmo/ecls daily mgmt-venous,33948,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1236.39,6979, Ecmo/ecls daily mgmt-venous,33948,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1236.39,6979, Ecmo/ecls daily mgmt artery,33949,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1188.15,,,,,,,fee schedule,1188.15,6979, Ecmo/ecls daily mgmt artery,33949,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1188.15,6979, Ecmo/ecls daily mgmt artery,33949,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1188.15,6979, Ecmo/ecls daily mgmt artery,33949,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1188.15,6979, Ecmo/ecls insj prph cannula,33951,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2258.66,,,,,,,fee schedule,2258.66,6979, Ecmo/ecls insj prph cannula,33951,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2258.66,6979, Ecmo/ecls insj prph cannula,33951,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2258.66,6979, Ecmo/ecls insj prph cannula,33951,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2258.66,6979, Ecmo/ecls insj prph cannula,33952,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2227.36,,,,,,,fee schedule,2227.36,6979, Ecmo/ecls insj prph cannula,33952,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2227.36,6979, Ecmo/ecls insj prph cannula,33952,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2227.36,6979, Ecmo/ecls insj prph cannula,33952,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2227.36,6979, Ecmo/ecls insj prph cannula,33953,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2514.16,,,,,,,fee schedule,2514.16,6979, Ecmo/ecls insj prph cannula,33953,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2514.16,6979, Ecmo/ecls insj prph cannula,33953,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2514.16,6979, Ecmo/ecls insj prph cannula,33953,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2514.16,6979, Ecmo/ecls insj prph cannula,33954,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2505.31,,,,,,,fee schedule,2505.31,6979, Ecmo/ecls insj prph cannula,33954,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2505.31,6979, Ecmo/ecls insj prph cannula,33954,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2505.31,6979, Ecmo/ecls insj prph cannula,33954,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2505.31,6979, Ecmo/ecls insj ctr cannula,33955,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4401.95,,,,,,,fee schedule,4401.95,6979, Ecmo/ecls insj ctr cannula,33955,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4401.95,6979, Ecmo/ecls insj ctr cannula,33955,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4401.95,6979, Ecmo/ecls insj ctr cannula,33955,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4401.95,6979, Ecmo/ecls insj ctr cannula,33956,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4395.31,,,,,,,fee schedule,4395.31,6979, Ecmo/ecls insj ctr cannula,33956,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4395.31,6979, Ecmo/ecls insj ctr cannula,33956,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4395.31,6979, Ecmo/ecls insj ctr cannula,33956,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4395.31,6979, Ecmo/ecls repos perph cnula,33957,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,984.99,,,,,,,fee schedule,984.99,6979, Ecmo/ecls repos perph cnula,33957,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,984.99,6979, Ecmo/ecls repos perph cnula,33957,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,984.99,6979, Ecmo/ecls repos perph cnula,33957,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,984.99,6979, Ecmo/ecls repos perph cnula,33958,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,984.99,,,,,,,fee schedule,984.99,6979, Ecmo/ecls repos perph cnula,33958,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,984.99,6979, Ecmo/ecls repos perph cnula,33958,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,984.99,6979, Ecmo/ecls repos perph cnula,33958,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,984.99,6979, Ecmo/ecls repos perph cnula,33959,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1253.87,,,,,,,fee schedule,1253.87,6979, Ecmo/ecls repos perph cnula,33959,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1253.87,6979, Ecmo/ecls repos perph cnula,33959,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1253.87,6979, Ecmo/ecls repos perph cnula,33959,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1253.87,6979, Ecmo/ecls repos perph cnula,33962,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1253.87,,,,,,,fee schedule,1253.87,6979, Ecmo/ecls repos perph cnula,33962,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1253.87,6979, Ecmo/ecls repos perph cnula,33962,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1253.87,6979, Ecmo/ecls repos perph cnula,33962,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1253.87,6979, Ecmo/ecls repos perph cnula,33963,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2487.29,,,,,,,fee schedule,2487.29,6979, Ecmo/ecls repos perph cnula,33963,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2487.29,6979, Ecmo/ecls repos perph cnula,33963,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2487.29,6979, Ecmo/ecls repos perph cnula,33963,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2487.29,6979, Ecmo/ecls repos perph cnula,33964,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2620.84,,,,,,,fee schedule,2620.84,6979, Ecmo/ecls repos perph cnula,33964,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2620.84,6979, Ecmo/ecls repos perph cnula,33964,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2620.84,6979, Ecmo/ecls repos perph cnula,33964,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2620.84,6979, Ecmo/ecls rmvl perph cannula,33965,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,984.99,,,,,,,fee schedule,984.99,6979, Ecmo/ecls rmvl perph cannula,33965,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,984.99,6979, Ecmo/ecls rmvl perph cannula,33965,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,984.99,6979, Ecmo/ecls rmvl perph cannula,33965,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,984.99,6979, Ecmo/ecls rmvl prph cannula,33966,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1249.44,,,,,,,fee schedule,1249.44,6979, Ecmo/ecls rmvl prph cannula,33966,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1249.44,6979, Ecmo/ecls rmvl prph cannula,33966,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1249.44,6979, Ecmo/ecls rmvl prph cannula,33966,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1249.44,6979, Insert i-aort percut device,33967,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1304.48,,,,,,,fee schedule,1304.48,39251, Insert i-aort percut device,33967,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1304.48,39251, Insert i-aort percut device,33967,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,39251,,,,,,,fee schedule,1304.48,39251, Insert i-aort percut device,33967,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,35325,,,,,,,fee schedule,1304.48,39251, Remove aortic assist device,33968,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,172.08,,,,,,,fee schedule,172.08,39251, Remove aortic assist device,33968,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,172.08,39251, Remove aortic assist device,33968,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,39251,,,,,,,fee schedule,172.08,39251, Remove aortic assist device,33968,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,35325,,,,,,,fee schedule,172.08,39251, Ecmo/ecls rmvl perph cannula,33969,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1452.87,,,,,,,fee schedule,1452.87,6979, Ecmo/ecls rmvl perph cannula,33969,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1452.87,6979, Ecmo/ecls rmvl perph cannula,33969,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1452.87,6979, Ecmo/ecls rmvl perph cannula,33969,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1452.87,6979, Aortic circulation assist,33970,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1828.22,,,,,,,fee schedule,1828.22,6979, Aortic circulation assist,33970,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1828.22,6979, Aortic circulation assist,33970,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1828.22,6979, Aortic circulation assist,33970,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1828.22,6979, Aortic circulation assist,33971,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3829.06,,,,,,,fee schedule,3829.06,6979, Aortic circulation assist,33971,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3829.06,6979, Aortic circulation assist,33971,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3829.06,6979, Aortic circulation assist,33971,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3829.06,6979, Insert balloon device,33973,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2664.92,,,,,,,fee schedule,2664.92,6979, Insert balloon device,33973,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2664.92,6979, Insert balloon device,33973,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2664.92,6979, Insert balloon device,33973,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2664.92,6979, Remove intra-aortic balloon,33974,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4958.28,,,,,,,fee schedule,4958.28,6979, Remove intra-aortic balloon,33974,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4958.28,6979, Remove intra-aortic balloon,33974,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4958.28,6979, Remove intra-aortic balloon,33974,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4958.28,6979, Implant ventricular device,33975,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6863.87,,,,,,,fee schedule,5097,6979, Implant ventricular device,33975,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Implant ventricular device,33975,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Implant ventricular device,33975,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Implant ventricular device,33976,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8413.39,,,,,,,fee schedule,5097,8413.39, Implant ventricular device,33976,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8413.39, Implant ventricular device,33976,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8413.39, Implant ventricular device,33976,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8413.39, Remove ventricular device,33977,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5990.64,,,,,,,fee schedule,5097,6979, Remove ventricular device,33977,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Remove ventricular device,33977,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Remove ventricular device,33977,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Remove ventricular device,33978,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7149.38,,,,,,,fee schedule,5097,7149.38, Remove ventricular device,33978,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7149.38, Remove ventricular device,33978,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7149.38, Remove ventricular device,33978,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7149.38, Insert intracorporeal device,33979,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10301.56,,,,,,,fee schedule,5097,10301.56, Insert intracorporeal device,33979,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,10301.56, Insert intracorporeal device,33979,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,10301.56, Insert intracorporeal device,33979,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,10301.56, Remove intracorporeal device,33980,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9495.61,,,,,,,fee schedule,5097,9495.61, Remove intracorporeal device,33980,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,9495.61, Remove intracorporeal device,33980,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,9495.61, Remove intracorporeal device,33980,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,9495.61, Replace vad pump ext,33981,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4403.78,,,,,,,fee schedule,4403.78,6979, Replace vad pump ext,33981,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4403.78,6979, Replace vad pump ext,33981,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4403.78,6979, Replace vad pump ext,33981,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4403.78,6979, Replace vad intra w/o bp,33982,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10354.01,,,,,,,fee schedule,5097,10354.01, Replace vad intra w/o bp,33982,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,10354.01, Replace vad intra w/o bp,33982,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,10354.01, Replace vad intra w/o bp,33982,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,10354.01, Replace vad intra w/bp,33983,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12192.42,,,,,,,fee schedule,5097,12192.42, Replace vad intra w/bp,33983,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,12192.42, Replace vad intra w/bp,33983,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,12192.42, Replace vad intra w/bp,33983,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,12192.42, Ecmo/ecls rmvl prph cannula,33984,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1504.94,,,,,,,fee schedule,1504.94,6979, Ecmo/ecls rmvl prph cannula,33984,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1504.94,6979, Ecmo/ecls rmvl prph cannula,33984,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1504.94,6979, Ecmo/ecls rmvl prph cannula,33984,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1504.94,6979, Ecmo/ecls rmvl ctr cannula,33985,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2732.91,,,,,,,fee schedule,2732.91,6979, Ecmo/ecls rmvl ctr cannula,33985,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2732.91,6979, Ecmo/ecls rmvl ctr cannula,33985,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2732.91,6979, Ecmo/ecls rmvl ctr cannula,33985,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2732.91,6979, Ecmo/ecls rmvl ctr cannula,33986,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2777.11,,,,,,,fee schedule,2777.11,6979, Ecmo/ecls rmvl ctr cannula,33986,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2777.11,6979, Ecmo/ecls rmvl ctr cannula,33986,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2777.11,6979, Ecmo/ecls rmvl ctr cannula,33986,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2777.11,6979, Artery expos/graft artery,33987,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1107.04,,,,,,,fee schedule,1107.04,6979, Artery expos/graft artery,33987,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1107.04,6979, Artery expos/graft artery,33987,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1107.04,6979, Artery expos/graft artery,33987,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1107.04,6979, Insertion of left heart vent,33988,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4126.64,,,,,,,fee schedule,4126.64,6979, Insertion of left heart vent,33988,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4126.64,6979, Insertion of left heart vent,33988,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4126.64,6979, Insertion of left heart vent,33988,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4126.64,6979, Removal of left heart vent,33989,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2620.84,,,,,,,fee schedule,2620.84,6979, Removal of left heart vent,33989,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2620.84,6979, Removal of left heart vent,33989,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2620.84,6979, Removal of left heart vent,33989,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2620.84,6979, Insert vad artery access,33990,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1817.48,,,,,,,fee schedule,1817.48,6979, Insert vad artery access,33990,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1817.48,6979, Insert vad artery access,33990,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1817.48,6979, Insert vad artery access,33990,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1817.48,6979, Insert vad art&vein access,33991,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2416.6,,,,,,,fee schedule,2416.6,6979, Insert vad art&vein access,33991,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2416.6,6979, Insert vad art&vein access,33991,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2416.6,6979, Insert vad art&vein access,33991,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2416.6,6979, Remove vad different session,33992,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,959.46,,,,,,,fee schedule,959.46,6979, Remove vad different session,33992,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,959.46,6979, Remove vad different session,33992,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,959.46,6979, Remove vad different session,33992,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,959.46,6979, Reposition vad diff session,33993,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,815.12,,,,,,,fee schedule,815.12,6979, Reposition vad diff session,33993,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,815.12,6979, Reposition vad diff session,33993,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,815.12,6979, Reposition vad diff session,33993,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,815.12,6979, Insj perq vad r hrt venous,33995,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1812.79,,,,,,,fee schedule,1812.79,5664, Insj perq vad r hrt venous,33995,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1812.79,5664, Insj perq vad r hrt venous,33995,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1812.79,5664, Rmvl perq right heart vad,33997,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,809.51,,,,,,,fee schedule,809.51,5664, Rmvl perq right heart vad,33997,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,809.51,5664, Rmvl perq right heart vad,33997,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,809.51,5664, Cardiac surgery procedure,33999,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4047,6979, Cardiac surgery procedure,33999,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,4047,6979, Cardiac surgery procedure,33999,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,4047,6979, Removal of artery clot,34001,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4885.43,,,,,,,fee schedule,4885.43,6979, Removal of artery clot,34001,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4885.43,6979, Removal of artery clot,34001,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4885.43,6979, Removal of artery clot,34001,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4885.43,6979, Removal of artery clot,34051,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5501.33,,,,,,,fee schedule,5097,6979, Removal of artery clot,34051,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Removal of artery clot,34051,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Removal of artery clot,34051,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Removal of artery clot,34101,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3157.74,,,,,,,fee schedule,3157.74,22111, Removal of artery clot,34101,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3157.74,22111, Removal of artery clot,34101,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3157.74,22111, Removal of artery clot,34101,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3157.74,22111, Removal of arm artery clot,34111,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3157.52,,,,,,,fee schedule,3157.52,22111, Removal of arm artery clot,34111,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3157.52,22111, Removal of arm artery clot,34111,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3157.52,22111, Removal of arm artery clot,34111,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3157.52,22111, Removal of artery clot,34151,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7368.24,,,,,,,fee schedule,5097,7368.24, Removal of artery clot,34151,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7368.24, Removal of artery clot,34151,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7368.24, Removal of artery clot,34151,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7368.24, Removal of artery clot,34201,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5410.84,,,,,,,fee schedule,5410.84,22111, Removal of artery clot,34201,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5410.84,22111, Removal of artery clot,34201,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5410.84,22111, Removal of artery clot,34201,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5410.84,22111, Removal of leg artery clot,34203,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5024.59,,,,,,,fee schedule,5024.59,22111, Removal of leg artery clot,34203,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5024.59,22111, Removal of leg artery clot,34203,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5024.59,22111, Removal of leg artery clot,34203,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5024.59,22111, Removal of vein clot,34401,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7143.01,,,,,,,fee schedule,5097,7143.01, Removal of vein clot,34401,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7143.01, Removal of vein clot,34401,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7143.01, Removal of vein clot,34401,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7143.01, Removal of vein clot,34421,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3707.86,,,,,,,fee schedule,3707.86,12821, Removal of vein clot,34421,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3707.86,12821, Removal of vein clot,34421,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3707.86,12821, Removal of vein clot,34421,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3707.86,12821, Removal of vein clot,34451,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7660.16,,,,,,,fee schedule,5097,7660.16, Removal of vein clot,34451,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7660.16, Removal of vein clot,34451,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7660.16, Removal of vein clot,34451,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7660.16, Removal of vein clot,34471,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5755.05,,,,,,,fee schedule,4047,6979, Removal of vein clot,34471,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4047,6979, Removal of vein clot,34471,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,4047,6979, Removal of vein clot,34471,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,4047,6979, Removal of vein clot,34490,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3074.91,,,,,,,fee schedule,3074.91,12821, Removal of vein clot,34490,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3074.91,12821, Removal of vein clot,34490,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3074.91,12821, Removal of vein clot,34490,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3074.91,12821, Repair valve femoral vein,34501,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4776.81,,,,,,,fee schedule,4776.81,22111, Repair valve femoral vein,34501,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4776.81,22111, Repair valve femoral vein,34501,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4776.81,22111, Repair valve femoral vein,34501,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4776.81,22111, Reconstruct vena cava,34502,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8157.24,,,,,,,fee schedule,5097,8157.24, Reconstruct vena cava,34502,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8157.24, Reconstruct vena cava,34502,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8157.24, Reconstruct vena cava,34502,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8157.24, Transposition of vein valve,34510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5447.42,,,,,,,fee schedule,5447.42,22111, Transposition of vein valve,34510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5447.42,22111, Transposition of vein valve,34510,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5447.42,22111, Transposition of vein valve,34510,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5447.42,22111, Cross-over vein graft,34520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5277.56,,,,,,,fee schedule,5277.56,22111, Cross-over vein graft,34520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5277.56,22111, Cross-over vein graft,34520,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5277.56,22111, Cross-over vein graft,34520,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5277.56,22111, Leg vein fusion,34530,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5018.5,,,,,,,fee schedule,5018.5,12821, Leg vein fusion,34530,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5018.5,12821, Leg vein fusion,34530,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5018.5,12821, Leg vein fusion,34530,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5018.5,12821, Evasc rpr a-ao ndgft,34701,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6509.73,,,,,,,fee schedule,5097,6979, Evasc rpr a-ao ndgft,34701,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Evasc rpr a-ao ndgft,34701,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Evasc rpr a-ao ndgft,34701,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Evasc rpr a-ao ndgft rpt,34702,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9560.85,,,,,,,fee schedule,5097,9560.85, Evasc rpr a-ao ndgft rpt,34702,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,9560.85, Evasc rpr a-ao ndgft rpt,34702,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,9560.85, Evasc rpr a-ao ndgft rpt,34702,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,9560.85, Evasc rpr a-unilac ndgft,34703,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7230.37,,,,,,,fee schedule,5097,7230.37, Evasc rpr a-unilac ndgft,34703,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7230.37, Evasc rpr a-unilac ndgft,34703,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7230.37, Evasc rpr a-unilac ndgft,34703,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7230.37, Evasc rpr a-unilac ndgft rpt,34704,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,11874.38,,,,,,,fee schedule,5097,11874.38, Evasc rpr a-unilac ndgft rpt,34704,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,11874.38, Evasc rpr a-unilac ndgft rpt,34704,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,11874.38, Evasc rpr a-unilac ndgft rpt,34704,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,11874.38, Evac rpr a-biiliac ndgft,34705,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8032.43,,,,,,,fee schedule,5097,8032.43, Evac rpr a-biiliac ndgft,34705,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8032.43, Evac rpr a-biiliac ndgft,34705,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8032.43, Evac rpr a-biiliac ndgft,34705,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8032.43, Evasc rpr a-biiliac rpt,34706,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12019.59,,,,,,,fee schedule,5097,12019.59, Evasc rpr a-biiliac rpt,34706,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,12019.59, Evasc rpr a-biiliac rpt,34706,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,12019.59, Evasc rpr a-biiliac rpt,34706,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,12019.59, Evasc rpr ilio-iliac ndgft,34707,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6128.18,,,,,,,fee schedule,5097,8212, Evasc rpr ilio-iliac ndgft,34707,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8212,,,,,,,fee schedule,5097,8212, Evasc rpr ilio-iliac ndgft,34707,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8212, Evasc rpr ilio-iliac ndgft,34707,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8212, Evasc rpr ilio-iliac rpt,34708,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9689.6,,,,,,,fee schedule,5097,9689.6, Evasc rpr ilio-iliac rpt,34708,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8212,,,,,,,fee schedule,5097,9689.6, Evasc rpr ilio-iliac rpt,34708,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,9689.6, Evasc rpr ilio-iliac rpt,34708,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,9689.6, Plmt xtn prosth evasc rpr,34709,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1695.69,,,,,,,fee schedule,1695.69,5664, Plmt xtn prosth evasc rpr,34709,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1695.69,5664, Plmt xtn prosth evasc rpr,34709,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1695.69,5664, Plmt xtn prosth evasc rpr,34709,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1695.69,5664, Dlyd plmt xtn prosth 1st vsl,34710,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4202.73,,,,,,,fee schedule,4202.73,5664, Dlyd plmt xtn prosth 1st vsl,34710,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4202.73,5664, Dlyd plmt xtn prosth 1st vsl,34710,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4202.73,5664, Dlyd plmt xtn prosth 1st vsl,34710,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4202.73,5664, Dlyd plmt xtn prosth ea addl,34711,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1553.24,,,,,,,fee schedule,1553.24,5664, Dlyd plmt xtn prosth ea addl,34711,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1553.24,5664, Dlyd plmt xtn prosth ea addl,34711,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1553.24,5664, Dlyd plmt xtn prosth ea addl,34711,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1553.24,5664, Tcat dlvr enhncd fixj dev,34712,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3443.19,,,,,,,fee schedule,3443.19,5664, Tcat dlvr enhncd fixj dev,34712,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3443.19,5664, Tcat dlvr enhncd fixj dev,34712,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3443.19,5664, Tcat dlvr enhncd fixj dev,34712,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3443.19,5664, Perq access & clsr fem art,34713,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,647.09,,,,,,,fee schedule,647.09,3195, Perq access & clsr fem art,34713,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,647.09,3195, Perq access & clsr fem art,34713,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,647.09,3195, Perq access & clsr fem art,34713,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,647.09,3195, Opn fem art expos cndt crtj,34714,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1431.5,,,,,,,fee schedule,1431.5,3195, Opn fem art expos cndt crtj,34714,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1431.5,3195, Opn fem art expos cndt crtj,34714,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1431.5,3195, Opn fem art expos cndt crtj,34714,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1431.5,3195, Opn ax/subcla art expos,34715,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1582.75,,,,,,,fee schedule,1582.75,3195, Opn ax/subcla art expos,34715,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1582.75,3195, Opn ax/subcla art expos,34715,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1582.75,3195, Opn ax/subcla art expos,34715,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1582.75,3195, Opn ax/subcla art expos cndt,34716,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1971.54,,,,,,,fee schedule,1971.54,3195, Opn ax/subcla art expos cndt,34716,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1971.54,3195, Opn ax/subcla art expos cndt,34716,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1971.54,3195, Opn ax/subcla art expos cndt,34716,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1971.54,3195, Evasc rpr a-iliac ndgft,34717,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2334.42,,,,,,,fee schedule,2334.42,6979, Evasc rpr a-iliac ndgft,34717,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2334.42,6979, Evasc rpr a-iliac ndgft,34717,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2334.42,6979, Evasc rpr a-iliac ndgft,34717,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2334.42,6979, Evasc rpr n/a a-iliac ndgft,34718,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6505.58,,,,,,,fee schedule,5097,6979, Evasc rpr n/a a-iliac ndgft,34718,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Evasc rpr n/a a-iliac ndgft,34718,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Evasc rpr n/a a-iliac ndgft,34718,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Endovas iliac a device addon,34808,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1070.73,,,,,,,fee schedule,1070.73,6979, Endovas iliac a device addon,34808,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1070.73,6979, Endovas iliac a device addon,34808,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1070.73,6979, Endovas iliac a device addon,34808,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1070.73,6979, Xpose for endoprosth femorl,34812,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1089.02,,,,,,,fee schedule,1089.02,6979, Xpose for endoprosth femorl,34812,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1089.02,6979, Xpose for endoprosth femorl,34812,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1089.02,6979, Xpose for endoprosth femorl,34812,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1089.02,6979, Femoral endovas graft add-on,34813,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1248.69,,,,,,,fee schedule,1248.69,6979, Femoral endovas graft add-on,34813,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1248.69,6979, Femoral endovas graft add-on,34813,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1248.69,6979, Femoral endovas graft add-on,34813,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1248.69,6979, Xpose for endoprosth iliac,34820,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1795.36,,,,,,,fee schedule,1795.36,6979, Xpose for endoprosth iliac,34820,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1795.36,6979, Xpose for endoprosth iliac,34820,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1795.36,6979, Xpose for endoprosth iliac,34820,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1795.36,6979, Open Aortic Tube Prosth Repr,34830,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9399.08,,,,,,,fee schedule,5097,9399.08, Open Aortic Tube Prosth Repr,34830,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,9399.08, Open Aortic Tube Prosth Repr,34830,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,9399.08, Open Aortic Tube Prosth Repr,34830,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,9399.08, Open Aortoiliac Prosth Repr,34831,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10271.61,,,,,,,fee schedule,5097,10271.61, Open Aortoiliac Prosth Repr,34831,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,10271.61, Open Aortoiliac Prosth Repr,34831,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,10271.61, Open Aortoiliac Prosth Repr,34831,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,10271.61, Open Aortofemor Prosth Repr,34832,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10102.5,,,,,,,fee schedule,5097,10102.5, Open Aortofemor Prosth Repr,34832,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,10102.5, Open Aortofemor Prosth Repr,34832,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,10102.5, Open Aortofemor Prosth Repr,34832,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,10102.5, Xpose for endoprosth iliac,34833,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2095.81,,,,,,,fee schedule,2095.81,8212, Xpose for endoprosth iliac,34833,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8212,,,,,,,fee schedule,2095.81,8212, Xpose for endoprosth iliac,34833,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2095.81,8212, Xpose for endoprosth iliac,34833,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2095.81,8212, Xpose endoprosth brachial,34834,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,685.89,,,,,,,fee schedule,685.89,8212, Xpose endoprosth brachial,34834,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8212,,,,,,,fee schedule,685.89,8212, Xpose endoprosth brachial,34834,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,685.89,8212, Xpose endoprosth brachial,34834,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,685.89,8212, Plnning pt spec fenest graft,34839,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Endovasc visc aorta 1 graft,34841,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Endovasc visc aorta 1 graft,34841,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Endovasc visc aorta 1 graft,34841,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Endovasc visc aorta 2 graft,34842,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Endovasc visc aorta 2 graft,34842,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Endovasc visc aorta 2 graft,34842,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Endovasc visc aorta 3 graft,34843,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Endovasc visc aorta 3 graft,34843,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Endovasc visc aorta 3 graft,34843,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Endovasc visc aorta 4 graft,34844,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Endovasc visc aorta 4 graft,34844,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Endovasc visc aorta 4 graft,34844,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Visc & infraren abd 1 prosth,34845,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Visc & infraren abd 1 prosth,34845,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Visc & infraren abd 1 prosth,34845,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Visc & infraren abd 2 prosth,34846,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Visc & infraren abd 2 prosth,34846,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Visc & infraren abd 2 prosth,34846,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Visc & infraren abd 3 prosth,34847,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Visc & infraren abd 3 prosth,34847,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Visc & infraren abd 3 prosth,34847,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Visc & infraren abd 4+ prost,34848,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Visc & infraren abd 4+ prost,34848,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Visc & infraren abd 4+ prost,34848,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Repair defect of artery,35001,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5859.79,,,,,,,fee schedule,5097,6979, Repair defect of artery,35001,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Repair defect of artery,35001,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Repair defect of artery,35001,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Repair artery rupture neck,35002,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6066.24,,,,,,,fee schedule,5097,6979, Repair artery rupture neck,35002,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Repair artery rupture neck,35002,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Repair artery rupture neck,35002,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Repair defect of artery,35005,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5310.69,,,,,,,fee schedule,5097,6979, Repair defect of artery,35005,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Repair defect of artery,35005,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Repair defect of artery,35005,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Repair defect of artery,35011,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5321.97,,,,,,,fee schedule,5321.97,22111, Repair defect of artery,35011,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5321.97,22111, Repair defect of artery,35011,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5321.97,22111, Repair defect of artery,35011,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5321.97,22111, Repair artery rupture arm,35013,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6316.5,,,,,,,fee schedule,5097,6979, Repair artery rupture arm,35013,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Repair artery rupture arm,35013,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Repair artery rupture arm,35013,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Repair defect of artery,35021,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6917.46,,,,,,,fee schedule,5097,6979, Repair defect of artery,35021,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Repair defect of artery,35021,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Repair defect of artery,35021,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Repair artery rupture chest,35022,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7888.3,,,,,,,fee schedule,5097,7888.3, Repair artery rupture chest,35022,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7888.3, Repair artery rupture chest,35022,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7888.3, Repair artery rupture chest,35022,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7888.3, Repair defect of arm artery,35045,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5066.63,,,,,,,fee schedule,5066.63,22111, Repair defect of arm artery,35045,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5066.63,22111, Repair defect of arm artery,35045,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5066.63,22111, Repair defect of arm artery,35045,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5066.63,22111, Repair defect of artery,35081,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9199.32,,,,,,,fee schedule,5097,9199.32, Repair defect of artery,35081,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,9199.32, Repair defect of artery,35081,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,9199.32, Repair defect of artery,35081,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,9199.32, Repair artery rupture aorta,35082,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,11438.22,,,,,,,fee schedule,5097,11438.22, Repair artery rupture aorta,35082,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,11438.22, Repair artery rupture aorta,35082,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,11438.22, Repair artery rupture aorta,35082,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,11438.22, Repair defect of artery,35091,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9409.87,,,,,,,fee schedule,5097,9409.87, Repair defect of artery,35091,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,9409.87, Repair defect of artery,35091,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,9409.87, Repair defect of artery,35091,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,9409.87, Repair artery rupture aorta,35092,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,13467.01,,,,,,,fee schedule,5097,13467.01, Repair artery rupture aorta,35092,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,13467.01, Repair artery rupture aorta,35092,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,13467.01, Repair artery rupture aorta,35092,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,13467.01, Repair defect of artery,35102,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9950.22,,,,,,,fee schedule,5097,9950.22, Repair defect of artery,35102,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,9950.22, Repair defect of artery,35102,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,9950.22, Repair defect of artery,35102,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,9950.22, Repair artery rupture aorta,35103,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,11554.24,,,,,,,fee schedule,5097,11554.24, Repair artery rupture aorta,35103,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,11554.24, Repair artery rupture aorta,35103,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,11554.24, Repair artery rupture aorta,35103,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,11554.24, Repair defect of artery,35111,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7082.79,,,,,,,fee schedule,5097,7082.79, Repair defect of artery,35111,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7082.79, Repair defect of artery,35111,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7082.79, Repair defect of artery,35111,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7082.79, Repair artery rupture spleen,35112,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8716.32,,,,,,,fee schedule,5097,8716.32, Repair artery rupture spleen,35112,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8716.32, Repair artery rupture spleen,35112,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8716.32, Repair artery rupture spleen,35112,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8716.32, Repair defect of artery,35121,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8431.95,,,,,,,fee schedule,5097,8431.95, Repair defect of artery,35121,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8431.95, Repair defect of artery,35121,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8431.95, Repair defect of artery,35121,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8431.95, Repair artery rupture belly,35122,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10078.16,,,,,,,fee schedule,5097,10078.16, Repair artery rupture belly,35122,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,10078.16, Repair artery rupture belly,35122,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,10078.16, Repair artery rupture belly,35122,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,10078.16, Repair defect of artery,35131,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7346.6,,,,,,,fee schedule,5097,7346.6, Repair defect of artery,35131,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7346.6, Repair defect of artery,35131,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7346.6, Repair defect of artery,35131,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7346.6, Repair artery rupture groin,35132,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8716.32,,,,,,,fee schedule,5097,8716.32, Repair artery rupture groin,35132,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8716.32, Repair artery rupture groin,35132,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8716.32, Repair artery rupture groin,35132,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8716.32, Repair defect of artery,35141,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5781.81,,,,,,,fee schedule,5097,6979, Repair defect of artery,35141,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Repair defect of artery,35141,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Repair defect of artery,35141,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Repair artery rupture thigh,35142,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6971.96,,,,,,,fee schedule,5097,6979, Repair artery rupture thigh,35142,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Repair artery rupture thigh,35142,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Repair artery rupture thigh,35142,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Repair defect of artery,35151,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6557.87,,,,,,,fee schedule,5097,6979, Repair defect of artery,35151,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Repair defect of artery,35151,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Repair defect of artery,35151,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Repair ruptd popliteal art,35152,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7447.24,,,,,,,fee schedule,5097,7447.24, Repair ruptd popliteal art,35152,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7447.24, Repair ruptd popliteal art,35152,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7447.24, Repair ruptd popliteal art,35152,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7447.24, Repair blood vessel lesion,35180,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4185.73,,,,,,,fee schedule,4047,6979, Repair blood vessel lesion,35180,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4047,6979, Repair blood vessel lesion,35180,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,4047,6979, Repair blood vessel lesion,35180,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,4047,6979, Repair blood vessel lesion,35182,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9722.03,,,,,,,fee schedule,5097,9722.03, Repair blood vessel lesion,35182,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,9722.03, Repair blood vessel lesion,35182,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,9722.03, Repair blood vessel lesion,35182,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,9722.03, Repair blood vessel lesion,35184,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5146.27,,,,,,,fee schedule,5146.27,12821, Repair blood vessel lesion,35184,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5146.27,12821, Repair blood vessel lesion,35184,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5146.27,12821, Repair blood vessel lesion,35184,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5146.27,12821, Repair blood vessel lesion,35188,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7386.15,,,,,,,fee schedule,5363,22111, Repair blood vessel lesion,35188,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,22111, Repair blood vessel lesion,35188,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5363,22111, Repair blood vessel lesion,35188,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5363,22111, Repair blood vessel lesion,35189,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8047.11,,,,,,,fee schedule,5097,8047.11, Repair blood vessel lesion,35189,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8047.11, Repair blood vessel lesion,35189,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8047.11, Repair blood vessel lesion,35189,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8047.11, Repair blood vessel lesion,35190,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3972.05,,,,,,,fee schedule,3972.05,22111, Repair blood vessel lesion,35190,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3972.05,22111, Repair blood vessel lesion,35190,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3972.05,22111, Repair blood vessel lesion,35190,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3972.05,22111, Repair blood vessel lesion,35201,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4889.91,,,,,,,fee schedule,4889.91,22111, Repair blood vessel lesion,35201,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4889.91,22111, Repair blood vessel lesion,35201,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4889.91,22111, Repair blood vessel lesion,35201,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4889.91,22111, Repair blood vessel lesion,35206,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4151.03,,,,,,,fee schedule,4151.03,12821, Repair blood vessel lesion,35206,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4151.03,12821, Repair blood vessel lesion,35206,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4151.03,12821, Repair blood vessel lesion,35206,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4151.03,12821, Repair blood vessel lesion,35207,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3812.98,,,,,,,fee schedule,3812.98,12821, Repair blood vessel lesion,35207,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3812.98,12821, Repair blood vessel lesion,35207,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3812.98,12821, Repair blood vessel lesion,35207,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3812.98,12821, Repair blood vessel lesion,35211,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7585.75,,,,,,,fee schedule,5097,7585.75, Repair blood vessel lesion,35211,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7585.75, Repair blood vessel lesion,35211,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7585.75, Repair blood vessel lesion,35211,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7585.75, Repair blood vessel lesion,35216,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10970.99,,,,,,,fee schedule,5097,10970.99, Repair blood vessel lesion,35216,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,10970.99, Repair blood vessel lesion,35216,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,10970.99, Repair blood vessel lesion,35216,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,10970.99, Repair blood vessel lesion,35221,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7757.34,,,,,,,fee schedule,5097,7757.34, Repair blood vessel lesion,35221,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7757.34, Repair blood vessel lesion,35221,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7757.34, Repair blood vessel lesion,35221,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7757.34, Repair blood vessel lesion,35226,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4390.62,,,,,,,fee schedule,4047,5363, Repair blood vessel lesion,35226,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4047,5363, Repair blood vessel lesion,35226,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,4047,5363, Repair blood vessel lesion,35226,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,4047,5363, Repair blood vessel lesion,35231,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6135.31,,,,,,,fee schedule,6135.31,12821, Repair blood vessel lesion,35231,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6135.31,12821, Repair blood vessel lesion,35231,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,6135.31,12821, Repair blood vessel lesion,35231,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,6135.31,12821, Repair blood vessel lesion,35236,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5287.76,,,,,,,fee schedule,5287.76,22111, Repair blood vessel lesion,35236,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5287.76,22111, Repair blood vessel lesion,35236,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5287.76,22111, Repair blood vessel lesion,35236,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5287.76,22111, Repair blood vessel lesion,35241,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7855.12,,,,,,,fee schedule,5097,7855.12, Repair blood vessel lesion,35241,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7855.12, Repair blood vessel lesion,35241,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7855.12, Repair blood vessel lesion,35241,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7855.12, Repair blood vessel lesion,35246,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8523.25,,,,,,,fee schedule,5097,8523.25, Repair blood vessel lesion,35246,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8523.25, Repair blood vessel lesion,35246,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8523.25, Repair blood vessel lesion,35246,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8523.25, Repair blood vessel lesion,35251,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9096.36,,,,,,,fee schedule,5097,9096.36, Repair blood vessel lesion,35251,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,9096.36, Repair blood vessel lesion,35251,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,9096.36, Repair blood vessel lesion,35251,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,9096.36, Repair blood vessel lesion,35256,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5377.76,,,,,,,fee schedule,5377.76,22111, Repair blood vessel lesion,35256,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5377.76,22111, Repair blood vessel lesion,35256,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5377.76,22111, Repair blood vessel lesion,35256,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5377.76,22111, Repair blood vessel lesion,35261,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5242.7,,,,,,,fee schedule,5242.7,12821, Repair blood vessel lesion,35261,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5242.7,12821, Repair blood vessel lesion,35261,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5242.7,12821, Repair blood vessel lesion,35261,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5242.7,12821, Repair blood vessel lesion,35266,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4573.38,,,,,,,fee schedule,4573.38,22111, Repair blood vessel lesion,35266,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4573.38,22111, Repair blood vessel lesion,35266,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4573.38,22111, Repair blood vessel lesion,35266,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4573.38,22111, Repair blood vessel lesion,35271,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7576.36,,,,,,,fee schedule,5097,7576.36, Repair blood vessel lesion,35271,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7576.36, Repair blood vessel lesion,35271,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7576.36, Repair blood vessel lesion,35271,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7576.36, Repair blood vessel lesion,35276,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7987.75,,,,,,,fee schedule,5097,7987.75, Repair blood vessel lesion,35276,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7987.75, Repair blood vessel lesion,35276,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7987.75, Repair blood vessel lesion,35276,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7987.75, Repair blood vessel lesion,35281,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8632.84,,,,,,,fee schedule,5097,8632.84, Repair blood vessel lesion,35281,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8632.84, Repair blood vessel lesion,35281,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8632.84, Repair blood vessel lesion,35281,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8632.84, Repair blood vessel lesion,35286,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4894.87,,,,,,,fee schedule,4894.87,22111, Repair blood vessel lesion,35286,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4894.87,22111, Repair blood vessel lesion,35286,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4894.87,22111, Repair blood vessel lesion,35286,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4894.87,22111, Rechanneling of artery,35301,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5983.41,,,,,,,fee schedule,5097,6979, Rechanneling of artery,35301,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Rechanneling of artery,35301,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Rechanneling of artery,35301,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Rechanneling of Artery,35302,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5910.08,,,,,,,fee schedule,5097,6979, Rechanneling of Artery,35302,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Rechanneling of Artery,35302,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Rechanneling of Artery,35302,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Rechanneling of Artery,35303,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6503.74,,,,,,,fee schedule,5097,6979, Rechanneling of Artery,35303,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Rechanneling of Artery,35303,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Rechanneling of Artery,35303,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Rechanneling of Artery,35304,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6759.14,,,,,,,fee schedule,5097,6979, Rechanneling of Artery,35304,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Rechanneling of Artery,35304,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Rechanneling of Artery,35304,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Rechanneling of Artery,35305,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6439.21,,,,,,,fee schedule,5097,6979, Rechanneling of Artery,35305,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Rechanneling of Artery,35305,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Rechanneling of Artery,35305,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Rechanneling of Artery,35306,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2375.48,,,,,,,fee schedule,2375.48,6979, Rechanneling of Artery,35306,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2375.48,6979, Rechanneling of Artery,35306,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2375.48,6979, Rechanneling of Artery,35306,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2375.48,6979, Rechanneling of artery,35311,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8420.35,,,,,,,fee schedule,5097,8420.35, Rechanneling of artery,35311,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8420.35, Rechanneling of artery,35311,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8420.35, Rechanneling of artery,35311,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8420.35, Rechanneling of artery,35321,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4797.48,,,,,,,fee schedule,4797.48,22111, Rechanneling of artery,35321,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4797.48,22111, Rechanneling of artery,35321,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4797.48,22111, Rechanneling of artery,35321,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4797.48,22111, Rechanneling of artery,35331,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7450.63,,,,,,,fee schedule,5097,7450.63, Rechanneling of artery,35331,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7450.63, Rechanneling of artery,35331,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7450.63, Rechanneling of artery,35331,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7450.63, Rechanneling of artery,35341,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7256,,,,,,,fee schedule,5097,7256, Rechanneling of artery,35341,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7256, Rechanneling of artery,35341,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7256, Rechanneling of artery,35341,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7256, Rechanneling of artery,35351,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6831.5,,,,,,,fee schedule,5097,6979, Rechanneling of artery,35351,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Rechanneling of artery,35351,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Rechanneling of artery,35351,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Rechanneling of artery,35355,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5450.23,,,,,,,fee schedule,5097,6979, Rechanneling of artery,35355,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Rechanneling of artery,35355,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Rechanneling of artery,35355,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Rechanneling of artery,35361,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8117.26,,,,,,,fee schedule,5097,8117.26, Rechanneling of artery,35361,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8117.26, Rechanneling of artery,35361,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8117.26, Rechanneling of artery,35361,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8117.26, Rechanneling of artery,35363,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8659.72,,,,,,,fee schedule,5097,8659.72, Rechanneling of artery,35363,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8659.72, Rechanneling of artery,35363,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8659.72, Rechanneling of artery,35363,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8659.72, Rechanneling of artery,35371,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4309.52,,,,,,,fee schedule,4309.52,6979, Rechanneling of artery,35371,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4309.52,6979, Rechanneling of artery,35371,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4309.52,6979, Rechanneling of artery,35371,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4309.52,6979, Rechanneling of artery,35372,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5166.89,,,,,,,fee schedule,5166.89,22111, Rechanneling of artery,35372,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,5166.89,22111, Rechanneling of artery,35372,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5166.89,22111, Rechanneling of artery,35372,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5166.89,22111, Reoperation carotid add-on,35390,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,841.72,,,,,,,fee schedule,841.72,6979, Reoperation carotid add-on,35390,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,841.72,6979, Reoperation carotid add-on,35390,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,841.72,6979, Reoperation carotid add-on,35390,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,841.72,6979, Angioscopy,35400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,772.6,,,,,,,fee schedule,772.6,6979, Angioscopy,35400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,772.6,6979, Angioscopy,35400,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,772.6,6979, Angioscopy,35400,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,772.6,6979, Harvest vein for bypass,35500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1685.66,,,,,,,fee schedule,1685.66,2782, Harvest vein for bypass,35500,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1685.66,2782, Harvest vein for bypass,35500,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1685.66,2782, Art byp grft ipsilat carotid,35501,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7786.16,,,,,,,fee schedule,5097,7786.16, Art byp grft ipsilat carotid,35501,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7786.16, Art byp grft ipsilat carotid,35501,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7786.16, Art byp grft ipsilat carotid,35501,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7786.16, Art byp grft subclav-carotid,35506,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6796.8,,,,,,,fee schedule,5097,6979, Art byp grft subclav-carotid,35506,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Art byp grft subclav-carotid,35506,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Art byp grft subclav-carotid,35506,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Art byp grft carotid-vertbrl,35508,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7089.21,,,,,,,fee schedule,5097,7089.21, Art byp grft carotid-vertbrl,35508,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7089.21, Art byp grft carotid-vertbrl,35508,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7089.21, Art byp grft carotid-vertbrl,35508,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7089.21, Art byp grft contral carotid,35509,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7534.97,,,,,,,fee schedule,5097,7534.97, Art byp grft contral carotid,35509,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7534.97, Art byp grft contral carotid,35509,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7534.97, Art byp grft contral carotid,35509,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7534.97, Art byp grft carotid-brchial,35510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6558.35,,,,,,,fee schedule,5097,6979, Art byp grft carotid-brchial,35510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Art byp grft carotid-brchial,35510,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Art byp grft carotid-brchial,35510,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Art byp grft subclav-subclav,35511,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5977.2,,,,,,,fee schedule,5097,6979, Art byp grft subclav-subclav,35511,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Art byp grft subclav-subclav,35511,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Art byp grft subclav-subclav,35511,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Art byp grft subclav-brchial,35512,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6432.36,,,,,,,fee schedule,5097,6979, Art byp grft subclav-brchial,35512,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Art byp grft subclav-brchial,35512,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Art byp grft subclav-brchial,35512,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Art byp grft subclav-vertbrl,35515,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7089.21,,,,,,,fee schedule,5097,7089.21, Art byp grft subclav-vertbrl,35515,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7089.21, Art byp grft subclav-vertbrl,35515,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7089.21, Art byp grft subclav-vertbrl,35515,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7089.21, Art byp grft subclav-axilary,35516,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6507.2,,,,,,,fee schedule,5097,6979, Art byp grft subclav-axilary,35516,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Art byp grft subclav-axilary,35516,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Art byp grft subclav-axilary,35516,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Art byp grft axillary-axilry,35518,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6086.96,,,,,,,fee schedule,5097,6979, Art byp grft axillary-axilry,35518,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Art byp grft axillary-axilry,35518,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Art byp grft axillary-axilry,35518,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Art byp grft axill-femoral,35521,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6552.2,,,,,,,fee schedule,5097,6979, Art byp grft axill-femoral,35521,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Art byp grft axill-femoral,35521,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Art byp grft axill-femoral,35521,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Art byp grft axill-brachial,35522,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6238.1,,,,,,,fee schedule,5097,6979, Art byp grft axill-brachial,35522,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Art byp grft axill-brachial,35522,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Art byp grft axill-brachial,35522,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Art byp grft brchl-ulnr-rdl,35523,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6557.33,,,,,,,fee schedule,5097,6979, Art byp grft brchl-ulnr-rdl,35523,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Art byp grft brchl-ulnr-rdl,35523,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Art byp grft brchl-ulnr-rdl,35523,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Art byp grft brachial-brchl,35525,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5863.94,,,,,,,fee schedule,5097,6979, Art byp grft brachial-brchl,35525,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Art byp grft brachial-brchl,35525,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Art byp grft brachial-brchl,35525,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Art byp grft aor/carot/innom,35526,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9403.93,,,,,,,fee schedule,5097,9403.93, Art byp grft aor/carot/innom,35526,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,9403.93, Art byp grft aor/carot/innom,35526,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,9403.93, Art byp grft aor/carot/innom,35526,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,9403.93, Art byp grft aorcel/aormesen,35531,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10397.5,,,,,,,fee schedule,5097,10397.5, Art byp grft aorcel/aormesen,35531,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,10397.5, Art byp grft aorcel/aormesen,35531,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,10397.5, Art byp grft aorcel/aormesen,35531,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,10397.5, Art byp grft axill/fem/fem,35533,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8031.84,,,,,,,fee schedule,5097,8031.84, Art byp grft axill/fem/fem,35533,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8031.84, Art byp grft axill/fem/fem,35533,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8031.84, Art byp grft axill/fem/fem,35533,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8031.84, Art byp grft hepatorenal,35535,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10148.26,,,,,,,fee schedule,5097,10148.26, Art byp grft hepatorenal,35535,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,10148.26, Art byp grft hepatorenal,35535,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,10148.26, Art byp grft hepatorenal,35535,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,10148.26, Art byp grft splenorenal,35536,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9009.65,,,,,,,fee schedule,5097,9009.65, Art byp grft splenorenal,35536,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,9009.65, Art byp grft splenorenal,35536,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,9009.65, Art byp grft splenorenal,35536,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,9009.65, Art byp grft aortoiliac,35537,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,11114.14,,,,,,,fee schedule,5097,11114.14, Art byp grft aortoiliac,35537,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,11114.14, Art byp grft aortoiliac,35537,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,11114.14, Art byp grft aortoiliac,35537,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,11114.14, Art byp grft aortobi-iliac,35538,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12449.33,,,,,,,fee schedule,5097,12449.33, Art byp grft aortobi-iliac,35538,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,12449.33, Art byp grft aortobi-iliac,35538,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,12449.33, Art byp grft aortobi-iliac,35538,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,12449.33, Art byp grft aortofemoral,35539,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,11685.31,,,,,,,fee schedule,5097,11685.31, Art byp grft aortofemoral,35539,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,11685.31, Art byp grft aortofemoral,35539,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,11685.31, Art byp grft aortofemoral,35539,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,11685.31, Art byp grft aortbifemoral,35540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,13030.91,,,,,,,fee schedule,5097,13030.91, Art byp grft aortbifemoral,35540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,13030.91, Art byp grft aortbifemoral,35540,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,13030.91, Art byp grft aortbifemoral,35540,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,13030.91, Art byp grft fem-popliteal,35556,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7368.99,,,,,,,fee schedule,5097,7368.99, Art byp grft fem-popliteal,35556,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7368.99, Art byp grft fem-popliteal,35556,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7368.99, Art byp grft fem-popliteal,35556,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7368.99, Art byp grft fem-femoral,35558,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6429.93,,,,,,,fee schedule,5097,6979, Art byp grft fem-femoral,35558,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Art byp grft fem-femoral,35558,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Art byp grft fem-femoral,35558,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Art byp grft aortorenal,35560,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9092.42,,,,,,,fee schedule,5097,9092.42, Art byp grft aortorenal,35560,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,9092.42, Art byp grft aortorenal,35560,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,9092.42, Art byp grft aortorenal,35560,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,9092.42, Art byp grft ilioiliac,35563,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7055.97,,,,,,,fee schedule,5097,7055.97, Art byp grft ilioiliac,35563,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7055.97, Art byp grft ilioiliac,35563,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7055.97, Art byp grft ilioiliac,35563,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7055.97, Art byp grft iliofemoral,35565,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6802.36,,,,,,,fee schedule,5097,6979, Art byp grft iliofemoral,35565,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Art byp grft iliofemoral,35565,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Art byp grft iliofemoral,35565,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Art byp fem-ant-post tib/prl,35566,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8791.38,,,,,,,fee schedule,5097,8791.38, Art byp fem-ant-post tib/prl,35566,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8791.38, Art byp fem-ant-post tib/prl,35566,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8791.38, Art byp fem-ant-post tib/prl,35566,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8791.38, Art byp tibial-tib/peroneal,35570,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7859.27,,,,,,,fee schedule,5097,7859.27, Art byp tibial-tib/peroneal,35570,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7859.27, Art byp tibial-tib/peroneal,35570,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7859.27, Art byp tibial-tib/peroneal,35570,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7859.27, Art byp pop-tibl-prl-other,35571,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7017.82,,,,,,,fee schedule,5097,7017.82, Art byp pop-tibl-prl-other,35571,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7017.82, Art byp pop-tibl-prl-other,35571,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7017.82, Art byp pop-tibl-prl-other,35571,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7017.82, Harvest femoropopliteal vein,35572,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1801.72,,,,,,,fee schedule,1801.72,2782, Harvest femoropopliteal vein,35572,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1801.72,2782, Harvest femoropopliteal vein,35572,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1801.72,2782, Vein byp grft fem-popliteal,35583,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7610.14,,,,,,,fee schedule,5097,7610.14, Vein byp grft fem-popliteal,35583,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7610.14, Vein byp grft fem-popliteal,35583,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7610.14, Vein byp grft fem-popliteal,35583,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7610.14, Vein byp fem-tibial peroneal,35585,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8824.13,,,,,,,fee schedule,5097,8824.13, Vein byp fem-tibial peroneal,35585,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8824.13, Vein byp fem-tibial peroneal,35585,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8824.13, Vein byp fem-tibial peroneal,35585,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8824.13, Vein byp pop-tibl peroneal,35587,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7100.92,,,,,,,fee schedule,5097,7100.92, Vein byp pop-tibl peroneal,35587,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7100.92, Vein byp pop-tibl peroneal,35587,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7100.92, Vein byp pop-tibl peroneal,35587,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7100.92, Harvest art for cabg add-on,35600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,984.39,,,,,,,fee schedule,984.39,6979, Harvest art for cabg add-on,35600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,984.39,6979, Harvest art for cabg add-on,35600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,984.39,6979, Harvest art for cabg add-on,35600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,984.39,6979, Art byp common ipsi carotid,35601,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7426.3,,,,,,,fee schedule,5097,7426.3, Art byp common ipsi carotid,35601,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7426.3, Art byp common ipsi carotid,35601,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7426.3, Art byp common ipsi carotid,35601,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7426.3, Bpg crtd-clat crtd,35602,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6736.53,,,,,,,fee schedule,6736.53,6979, Bpg crtd-clat crtd,35602,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6736.53,6979, Art byp carotid-subclavian,35606,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6215.76,,,,,,,fee schedule,5097,6979, Art byp carotid-subclavian,35606,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Art byp carotid-subclavian,35606,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Art byp carotid-subclavian,35606,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Art byp subclav-subclavian,35612,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5573.64,,,,,,,fee schedule,5097,6979, Art byp subclav-subclavian,35612,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Art byp subclav-subclavian,35612,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Art byp subclav-subclavian,35612,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Art byp subclav-axillary,35616,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5876.46,,,,,,,fee schedule,5097,6979, Art byp subclav-axillary,35616,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Art byp subclav-axillary,35616,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Art byp subclav-axillary,35616,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Art byp axillary-femoral,35621,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5785.91,,,,,,,fee schedule,5097,6979, Art byp axillary-femoral,35621,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Art byp axillary-femoral,35621,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Art byp axillary-femoral,35621,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Art byp axillary-pop-tibial,35623,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7004.66,,,,,,,fee schedule,5097,7004.66, Art byp axillary-pop-tibial,35623,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7004.66, Art byp axillary-pop-tibial,35623,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7004.66, Art byp axillary-pop-tibial,35623,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7004.66, Art byp aorsubcl/carot/innom,35626,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8561.89,,,,,,,fee schedule,5097,8561.89, Art byp aorsubcl/carot/innom,35626,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8561.89, Art byp aorsubcl/carot/innom,35626,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8561.89, Art byp aorsubcl/carot/innom,35626,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8561.89, Art byp aor-celiac-msn-renal,35631,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9794.71,,,,,,,fee schedule,5097,9794.71, Art byp aor-celiac-msn-renal,35631,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,9794.71, Art byp aor-celiac-msn-renal,35631,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,9794.71, Art byp aor-celiac-msn-renal,35631,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,9794.71, Art byp ilio-celiac,35632,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9631.05,,,,,,,fee schedule,5097,9631.05, Art byp ilio-celiac,35632,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,9631.05, Art byp ilio-celiac,35632,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,9631.05, Art byp ilio-celiac,35632,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,9631.05, Art byp ilio-mesenteric,35633,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10558.03,,,,,,,fee schedule,5097,10558.03, Art byp ilio-mesenteric,35633,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,10558.03, Art byp ilio-mesenteric,35633,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,10558.03, Art byp ilio-mesenteric,35633,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,10558.03, Art byp iliorenal,35634,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9426,,,,,,,fee schedule,5097,9426, Art byp iliorenal,35634,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,9426, Art byp iliorenal,35634,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,9426, Art byp iliorenal,35634,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,9426, Art byp spenorenal,35636,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8505.93,,,,,,,fee schedule,5097,8505.93, Art byp spenorenal,35636,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8505.93, Art byp spenorenal,35636,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8505.93, Art byp spenorenal,35636,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8505.93, Art byp aortoiliac,35637,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8846.53,,,,,,,fee schedule,5097,8846.53, Art byp aortoiliac,35637,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8846.53, Art byp aortoiliac,35637,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8846.53, Art byp aortoiliac,35637,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8846.53, Art byp aortobi-iliac,35638,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9232.83,,,,,,,fee schedule,5097,9232.83, Art byp aortobi-iliac,35638,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,9232.83, Art byp aortobi-iliac,35638,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,9232.83, Art byp aortobi-iliac,35638,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,9232.83, Art byp carotid-vertebral,35642,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5279.45,,,,,,,fee schedule,5097,6979, Art byp carotid-vertebral,35642,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Art byp carotid-vertebral,35642,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Art byp carotid-vertebral,35642,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Art byp subclav-vertebrl,35645,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5055.13,,,,,,,fee schedule,5055.13,6979, Art byp subclav-vertebrl,35645,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5055.13,6979, Art byp subclav-vertebrl,35645,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5055.13,6979, Art byp subclav-vertebrl,35645,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5055.13,6979, Art byp aortobifemoral,35646,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9020.82,,,,,,,fee schedule,5097,9020.82, Art byp aortobifemoral,35646,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,9020.82, Art byp aortobifemoral,35646,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,9020.82, Art byp aortobifemoral,35646,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,9020.82, Art byp aortofemoral,35647,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7972.32,,,,,,,fee schedule,5097,7972.32, Art byp aortofemoral,35647,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7972.32, Art byp aortofemoral,35647,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7972.32, Art byp aortofemoral,35647,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7972.32, Art byp axillary-axillary,35650,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5454.55,,,,,,,fee schedule,5097,6979, Art byp axillary-axillary,35650,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Art byp axillary-axillary,35650,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Art byp axillary-axillary,35650,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Art byp axill-fem-femoral,35654,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7224.54,,,,,,,fee schedule,5097,7224.54, Art byp axill-fem-femoral,35654,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7224.54, Art byp axill-fem-femoral,35654,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7224.54, Art byp axill-fem-femoral,35654,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7224.54, Art byp femoral-popliteal,35656,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5672.06,,,,,,,fee schedule,5097,6979, Art byp femoral-popliteal,35656,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Art byp femoral-popliteal,35656,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Art byp femoral-popliteal,35656,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Art byp femoral-femoral,35661,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5721.59,,,,,,,fee schedule,5097,6979, Art byp femoral-femoral,35661,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Art byp femoral-femoral,35661,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Art byp femoral-femoral,35661,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Art byp ilioiliac,35663,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6499.16,,,,,,,fee schedule,5097,6979, Art byp ilioiliac,35663,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Art byp ilioiliac,35663,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Art byp ilioiliac,35663,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Art byp iliofemoral,35665,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6215.87,,,,,,,fee schedule,5097,6979, Art byp iliofemoral,35665,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Art byp iliofemoral,35665,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Art byp iliofemoral,35665,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Art byp fem-ant-post tib/prl,35666,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6787.25,,,,,,,fee schedule,5097,6979, Art byp fem-ant-post tib/prl,35666,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Art byp fem-ant-post tib/prl,35666,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Art byp fem-ant-post tib/prl,35666,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Art byp pop-tibl-prl-other,35671,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5976.18,,,,,,,fee schedule,5097,6979, Art byp pop-tibl-prl-other,35671,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Art byp pop-tibl-prl-other,35671,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Art byp pop-tibl-prl-other,35671,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Composite byp grft pros&vein,35681,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,422.24,,,,,,,fee schedule,422.24,6979, Composite byp grft pros&vein,35681,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,422.24,6979, Composite byp grft pros&vein,35681,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,422.24,6979, Composite byp grft pros&vein,35681,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,422.24,6979, Composite byp grft 2 veins,35682,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1857.57,,,,,,,fee schedule,1857.57,6979, Composite byp grft 2 veins,35682,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1857.57,6979, Composite byp grft 2 veins,35682,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1857.57,6979, Composite byp grft 2 veins,35682,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1857.57,6979, Composite byp grft 3/> segmt,35683,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2177.61,,,,,,,fee schedule,2177.61,6979, Composite byp grft 3/> segmt,35683,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2177.61,6979, Composite byp grft 3/> segmt,35683,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2177.61,6979, Composite byp grft 3/> segmt,35683,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2177.61,6979, Bypass graft patency/patch,35685,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1053.62,,,,,,,fee schedule,1053.62,2782, Bypass graft patency/patch,35685,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1053.62,2782, Bypass graft patency/patch,35685,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1053.62,2782, Bypass graft/av fist patency,35686,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,857.21,,,,,,,fee schedule,857.21,2782, Bypass graft/av fist patency,35686,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,857.21,2782, Bypass graft/av fist patency,35686,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,857.21,2782, Art trnsposj vertbrl carotid,35691,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5046.12,,,,,,,fee schedule,5046.12,6979, Art trnsposj vertbrl carotid,35691,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5046.12,6979, Art trnsposj vertbrl carotid,35691,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5046.12,6979, Art trnsposj vertbrl carotid,35691,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5046.12,6979, Art trnsposj subclavian,35693,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4466.59,,,,,,,fee schedule,4466.59,6979, Art trnsposj subclavian,35693,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4466.59,6979, Art trnsposj subclavian,35693,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4466.59,6979, Art trnsposj subclavian,35693,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4466.59,6979, Art trnsposj subclav carotid,35694,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5270.97,,,,,,,fee schedule,5097,6979, Art trnsposj subclav carotid,35694,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Art trnsposj subclav carotid,35694,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Art trnsposj subclav carotid,35694,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Art trnsposj carotid subclav,35695,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5467.07,,,,,,,fee schedule,5097,6979, Art trnsposj carotid subclav,35695,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Art trnsposj carotid subclav,35695,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Art trnsposj carotid subclav,35695,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Reimplant artery each,35697,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,775.78,,,,,,,fee schedule,775.78,6979, Reimplant artery each,35697,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,775.78,6979, Reimplant artery each,35697,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,775.78,6979, Reimplant artery each,35697,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,775.78,6979, Reoperation bypass graft,35700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,805.41,,,,,,,fee schedule,805.41,6979, Reoperation bypass graft,35700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,805.41,6979, Reoperation bypass graft,35700,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,805.41,6979, Reoperation bypass graft,35700,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,805.41,6979, Exploration carotid artery,35701,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2164.17,,,,,,,fee schedule,2164.17,6979, Exploration carotid artery,35701,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2164.17,6979, Exploration carotid artery,35701,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2164.17,6979, Exploration carotid artery,35701,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2164.17,6979, Expl n/flwd surg uxtr art,35702,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2137.14,,,,,,,fee schedule,2137.14,5664, Expl n/flwd surg uxtr art,35702,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2137.14,5664, Expl n/flwd surg uxtr art,35702,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2137.14,5664, Expl n/flwd surg uxtr art,35702,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2137.14,5664, Expl n/flwd surg lxtr art,35703,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2190.56,,,,,,,fee schedule,2190.56,5664, Expl n/flwd surg lxtr art,35703,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2190.56,5664, Expl n/flwd surg lxtr art,35703,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2190.56,5664, Expl n/flwd surg lxtr art,35703,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2190.56,5664, Explore neck vessels,35800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3735.06,,,,,,,fee schedule,3735.06,22111, Explore neck vessels,35800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,3735.06,22111, Explore neck vessels,35800,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3735.06,22111, Explore neck vessels,35800,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3735.06,22111, Explore chest vessels,35820,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10805.38,,,,,,,fee schedule,5097,10805.38, Explore chest vessels,35820,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,10805.38, Explore chest vessels,35820,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,10805.38, Explore chest vessels,35820,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,10805.38, Explore abdominal vessels,35840,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6449.84,,,,,,,fee schedule,5097,6979, Explore abdominal vessels,35840,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Explore abdominal vessels,35840,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Explore abdominal vessels,35840,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Explore limb vessels,35860,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4482.51,,,,,,,fee schedule,4482.51,12821, Explore limb vessels,35860,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4482.51,12821, Explore limb vessels,35860,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4482.51,12821, Explore limb vessels,35860,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4482.51,12821, Repair vessel graft defect,35870,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6650.03,,,,,,,fee schedule,5097,6979, Repair vessel graft defect,35870,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Repair vessel graft defect,35870,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Repair vessel graft defect,35870,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Removal of clot in graft,35875,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3120.61,,,,,,,fee schedule,3120.61,22111, Removal of clot in graft,35875,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,3120.61,22111, Removal of clot in graft,35875,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3120.61,22111, Removal of clot in graft,35875,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3120.61,22111, Removal of clot in graft,35876,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4982.45,,,,,,,fee schedule,4982.45,22111, Removal of clot in graft,35876,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,4982.45,22111, Removal of clot in graft,35876,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4982.45,22111, Removal of clot in graft,35876,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4982.45,22111, Revise graft w/vein,35879,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4899.03,,,,,,,fee schedule,4899.03,22111, Revise graft w/vein,35879,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4899.03,22111, Revise graft w/vein,35879,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4899.03,22111, Revise graft w/vein,35879,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4899.03,22111, Revise graft w/vein,35881,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5439.92,,,,,,,fee schedule,5439.92,22111, Revise graft w/vein,35881,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5439.92,22111, Revise graft w/vein,35881,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5439.92,22111, Revise graft w/vein,35881,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5439.92,22111, Revise Graft w/Nonauto Graft,35883,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6334.31,,,,,,,fee schedule,5363,22111, Revise Graft w/Nonauto Graft,35883,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,22111, Revise Graft w/Nonauto Graft,35883,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5363,22111, Revise Graft w/Nonauto Graft,35883,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5363,22111, Revise graft w/vein,35884,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6612.04,,,,,,,fee schedule,5363,22111, Revise graft w/vein,35884,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,22111, Revise graft w/vein,35884,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5363,22111, Revise graft w/vein,35884,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5363,22111, Excision graft neck,35901,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2533.91,,,,,,,fee schedule,2533.91,6979, Excision graft neck,35901,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2533.91,6979, Excision graft neck,35901,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2533.91,6979, Excision graft neck,35901,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2533.91,6979, Excision graft extremity,35903,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2979.73,,,,,,,fee schedule,2979.73,12821, Excision graft extremity,35903,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2979.73,12821, Excision graft extremity,35903,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2979.73,12821, Excision graft extremity,35903,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2979.73,12821, Excision graft thorax,35905,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8956.5,,,,,,,fee schedule,5097,8956.5, Excision graft thorax,35905,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8956.5, Excision graft thorax,35905,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8956.5, Excision graft thorax,35905,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8956.5, Excision graft abdomen,35907,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10088.15,,,,,,,fee schedule,5097,10088.15, Excision graft abdomen,35907,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,10088.15, Excision graft abdomen,35907,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,10088.15, Excision graft abdomen,35907,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,10088.15, Place needle in vein,36000,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,2782, Place needle in vein,36000,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,2782, Pseudoaneurysm injection trt,36002,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,518.56,,,,,,,fee schedule,518.56,4497, Pseudoaneurysm injection trt,36002,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,518.56,4497, Pseudoaneurysm injection trt,36002,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,518.56,4497, Pseudoaneurysm injection trt,36002,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,518.56,4497, Injection ext venography,36005,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,238.5,,,,,,,fee schedule,238.5,3195, Injection ext venography,36005,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,238.5,3195, Injection ext venography,36005,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,238.5,3195, Injection ext venography,36005,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,238.5,3195, Place catheter in vein,36010,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,548.4,,,,,,,fee schedule,548.4,3195, Place catheter in vein,36010,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,548.4,3195, Place catheter in vein,36010,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,548.4,3195, Place catheter in vein,36010,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,548.4,3195, Place catheter in vein,36011,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,782.2,,,,,,,fee schedule,782.2,3195, Place catheter in vein,36011,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,782.2,3195, Place catheter in vein,36011,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,782.2,3195, Place catheter in vein,36011,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,782.2,3195, Place catheter in vein,36012,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,880.84,,,,,,,fee schedule,880.84,3195, Place catheter in vein,36012,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,880.84,3195, Place catheter in vein,36012,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,880.84,3195, Place catheter in vein,36012,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,880.84,3195, Place catheter in artery,36013,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,637.86,,,,,,,fee schedule,637.86,3195, Place catheter in artery,36013,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,637.86,3195, Place catheter in artery,36013,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,637.86,3195, Place catheter in artery,36013,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,637.86,3195, Place catheter in artery,36014,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,744.32,,,,,,,fee schedule,744.32,3195, Place catheter in artery,36014,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,744.32,3195, Place catheter in artery,36014,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,744.32,3195, Place catheter in artery,36014,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,744.32,3195, Place catheter in artery,36015,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,843.88,,,,,,,fee schedule,843.88,3195, Place catheter in artery,36015,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,843.88,3195, Place catheter in artery,36015,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,843.88,3195, Place catheter in artery,36015,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,843.88,3195, Establish access to artery,36100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,783.23,,,,,,,fee schedule,783.23,3195, Establish access to artery,36100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,783.23,3195, Establish access to artery,36100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,783.23,3195, Establish access to artery,36100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,783.23,3195, Establish access to artery,36140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,456.77,,,,,,,fee schedule,456.77,3195, Establish access to artery,36140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,456.77,3195, Establish access to artery,36140,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,456.77,3195, Establish access to artery,36140,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,456.77,3195, Establish access to aorta,36160,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,606.35,,,,,,,fee schedule,606.35,4108, Establish access to aorta,36160,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,606.35,4108, Establish access to aorta,36160,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,606.35,4108, Establish access to aorta,36160,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,606.35,4108, Place catheter in aorta,36200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,716.59,,,,,,,fee schedule,716.59,4108, Place catheter in aorta,36200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,716.59,4108, Place catheter in aorta,36200,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,716.59,4108, Place catheter in aorta,36200,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,716.59,4108, Place catheter in artery,36215,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1063.44,,,,,,,fee schedule,1063.44,4108, Place catheter in artery,36215,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1063.44,4108, Place catheter in artery,36215,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1063.44,4108, Place catheter in artery,36215,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1063.44,4108, Place catheter in artery,36216,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1408.25,,,,,,,fee schedule,1408.25,4108, Place catheter in artery,36216,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1408.25,4108, Place catheter in artery,36216,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1408.25,4108, Place catheter in artery,36216,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1408.25,4108, Place catheter in artery,36217,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1755.32,,,,,,,fee schedule,1755.32,4108, Place catheter in artery,36217,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1755.32,4108, Place catheter in artery,36217,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1755.32,4108, Place catheter in artery,36217,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1755.32,4108, Place catheter in artery,36218,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,267.97,,,,,,,fee schedule,267.97,4108, Place catheter in artery,36218,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,267.97,4108, Place catheter in artery,36218,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,267.97,4108, Place catheter in artery,36218,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,267.97,4108, Place cath thoracic aorta,36221,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1037.38,,,,,,,fee schedule,1037.38,12821, Place cath thoracic aorta,36221,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1037.38,12821, Place cath thoracic aorta,36221,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,1037.38,12821, Place cath thoracic aorta,36221,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,1037.38,12821, Place cath carotid/inom art,36222,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1472.57,,,,,,,fee schedule,1472.57,12821, Place cath carotid/inom art,36222,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1472.57,12821, Place cath carotid/inom art,36222,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,1472.57,12821, Place cath carotid/inom art,36222,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,1472.57,12821, Place cath carotid/inom art,36223,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1746.58,,,,,,,fee schedule,1746.58,22111, Place cath carotid/inom art,36223,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1746.58,22111, Place cath carotid/inom art,36223,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,1746.58,22111, Place cath carotid/inom art,36223,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,1746.58,22111, Place cath carotd art,36224,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1954.22,,,,,,,fee schedule,1954.22,22111, Place cath carotd art,36224,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1954.22,22111, Place cath carotd art,36224,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,1954.22,22111, Place cath carotd art,36224,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,1954.22,22111, Place cath subclavian art,36225,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1729.09,,,,,,,fee schedule,1729.09,12821, Place cath subclavian art,36225,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1729.09,12821, Place cath subclavian art,36225,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,1729.09,12821, Place cath subclavian art,36225,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,1729.09,12821, Place cath vertebral art,36226,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1936.46,,,,,,,fee schedule,1936.46,22111, Place cath vertebral art,36226,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1936.46,22111, Place cath vertebral art,36226,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,1936.46,22111, Place cath vertebral art,36226,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,1936.46,22111, Place cath xtrnl carotid,36227,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,638.51,,,,,,,fee schedule,638.51,3195, Place cath xtrnl carotid,36227,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,638.51,3195, Place cath xtrnl carotid,36227,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,638.51,3195, Place cath xtrnl carotid,36227,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,638.51,3195, Place cath intracranial art,36228,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1333.41,,,,,,,fee schedule,1333.41,3195, Place cath intracranial art,36228,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1333.41,3195, Place cath intracranial art,36228,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1333.41,3195, Place cath intracranial art,36228,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1333.41,3195, Ins cath abd/l-ext art 1st,36245,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1188.95,,,,,,,fee schedule,1188.95,4108, Ins cath abd/l-ext art 1st,36245,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1188.95,4108, Ins cath abd/l-ext art 1st,36245,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1188.95,4108, Ins cath abd/l-ext art 1st,36245,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1188.95,4108, Ins cath abd/l-ext art 2nd,36246,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1284.63,,,,,,,fee schedule,1284.63,4108, Ins cath abd/l-ext art 2nd,36246,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1284.63,4108, Ins cath abd/l-ext art 2nd,36246,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1284.63,4108, Ins cath abd/l-ext art 2nd,36246,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1284.63,4108, Ins cath abd/l-ext art 3rd,36247,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1479.64,,,,,,,fee schedule,1479.64,4108, Ins cath abd/l-ext art 3rd,36247,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1479.64,4108, Ins cath abd/l-ext art 3rd,36247,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1479.64,4108, Ins cath abd/l-ext art 3rd,36247,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1479.64,4108, Ins cath abd/l-ext art addl,36248,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,233.27,,,,,,,fee schedule,233.27,4108, Ins cath abd/l-ext art addl,36248,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,233.27,4108, Ins cath abd/l-ext art addl,36248,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,233.27,4108, Ins cath abd/l-ext art addl,36248,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,233.27,4108, Ins cath ren art 1st unilat,36251,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1290.94,,,,,,,fee schedule,1290.94,12821, Ins cath ren art 1st unilat,36251,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1290.94,12821, Ins cath ren art 1st unilat,36251,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,1290.94,12821, Ins cath ren art 1st unilat,36251,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,1290.94,12821, Ins cath ren art 1st bilat,36252,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1795.25,,,,,,,fee schedule,1795.25,12821, Ins cath ren art 1st bilat,36252,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1795.25,12821, Ins cath ren art 1st bilat,36252,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,1795.25,12821, Ins cath ren art 1st bilat,36252,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,1795.25,12821, Ins cath ren art 2nd+ unilat,36253,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1716.31,,,,,,,fee schedule,1716.31,22111, Ins cath ren art 2nd+ unilat,36253,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1716.31,22111, Ins cath ren art 2nd+ unilat,36253,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,1716.31,22111, Ins cath ren art 2nd+ unilat,36253,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,1716.31,22111, Ins cath ren art 2nd+ bilat,36254,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2101.09,,,,,,,fee schedule,2101.09,12821, Ins cath ren art 2nd+ bilat,36254,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2101.09,12821, Ins cath ren art 2nd+ bilat,36254,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2101.09,12821, Ins cath ren art 2nd+ bilat,36254,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2101.09,12821, Insertion of infusion pump,36260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3597.78,,,,,,,fee schedule,3597.78,22111, Insertion of infusion pump,36260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3597.78,22111, Insertion of infusion pump,36260,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3597.78,22111, Insertion of infusion pump,36260,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3597.78,22111, Revision of infusion pump,36261,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2289.52,,,,,,,fee schedule,2289.52,12821, Revision of infusion pump,36261,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2289.52,12821, Revision of infusion pump,36261,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2289.52,12821, Revision of infusion pump,36261,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2289.52,12821, Removal of infusion pump,36262,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1769.94,,,,,,,fee schedule,1769.94,12821, Removal of infusion pump,36262,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1769.94,12821, Removal of infusion pump,36262,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,1769.94,12821, Removal of infusion pump,36262,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,1769.94,12821, Vessel injection procedure,36299,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,2782, Vessel injection procedure,36299,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,2782, Bl draw < 3 yrs fem/jugular,36400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,85.9,,,,,,,fee schedule,85.9,85.9, Bl draw <3 yrs scalp vein,36405,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,69.82,,,,,,,fee schedule,69.82,69.82, Bl draw <3 yrs other vein,36406,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,42.03,,,,,,,fee schedule,42.03,42.03, Non-routine bl draw 3/> yrs,36410,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,44.73,,,,,,,fee schedule,44.73,44.73, Routine venipuncture,36415,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,38.97,,,,,,,fee schedule,4.5,38.97, Routine venipuncture,36415,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.5,,,,,,,fee schedule,4.5,38.97, Routine venipuncture,36415,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4.5,,,,,,,fee schedule,4.5,38.97, Capillary blood draw,36416,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.34,,,,,,,fee schedule,4.34,4.34, Capillary blood draw,36416,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4.34,,,,,,,fee schedule,4.34,4.34, Vein access cutdown < 1 yr,36420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,269.21,,,,,,,fee schedule,269.21,3195, Vein access cutdown < 1 yr,36420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,269.21,3195, Vein access cutdown < 1 yr,36420,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,269.21,3195, Vein access cutdown < 1 yr,36420,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,269.21,3195, Vein access cutdown > 1 yr,36425,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,185.3,,,,,,,fee schedule,185.3,3195, Vein access cutdown > 1 yr,36425,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,185.3,3195, Vein access cutdown > 1 yr,36425,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,185.3,3195, Vein access cutdown > 1 yr,36425,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,185.3,3195, Blood transfusion service,36430,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,247.62,,,,,,,fee schedule,247.62,3195, Blood transfusion service,36430,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,247.62,3195, Blood transfusion service,36430,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,247.62,3195, Blood transfusion service,36430,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,247.62,3195, Bl push transfuse 2 yr/<,36440,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,230.95,,,,,,,fee schedule,230.95,3195, Bl push transfuse 2 yr/<,36440,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,230.95,3195, Bl push transfuse 2 yr/<,36440,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,230.95,3195, Bl push transfuse 2 yr/<,36440,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,230.95,3195, Bl exchange/transfuse nb,36450,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,790.35,,,,,,,fee schedule,790.35,3195, Bl exchange/transfuse nb,36450,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,790.35,3195, Bl exchange/transfuse nb,36450,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,790.35,3195, Bl exchange/transfuse nb,36450,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,790.35,3195, Bl exchange/transfuse non-nb,36455,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,666.24,,,,,,,fee schedule,666.24,3195, Bl exchange/transfuse non-nb,36455,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,666.24,3195, Bl exchange/transfuse non-nb,36455,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,666.24,3195, Bl exchange/transfuse non-nb,36455,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,666.24,3195, Prtl exchange transfuse nb,36456,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,451.16,,,,,,,fee schedule,451.16,3195, Prtl exchange transfuse nb,36456,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,451.16,3195, Prtl exchange transfuse nb,36456,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,451.16,3195, Prtl exchange transfuse nb,36456,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,451.16,3195, Transfusion service fetal,36460,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1697.53,,,,,,,fee schedule,1697.53,3195, Transfusion service fetal,36460,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1697.53,3195, Transfusion service fetal,36460,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1697.53,3195, Transfusion service fetal,36460,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1697.53,3195, Njx noncmpnd sclrsnt 1 vein,36465,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,609.96,,,,,,,fee schedule,609.96,5664, Njx noncmpnd sclrsnt 1 vein,36465,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,609.96,5664, Njx noncmpnd sclrsnt 1 vein,36465,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,609.96,5664, Njx noncmpnd sclrsnt 1 vein,36465,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,609.96,5664, Njx noncmpnd sclrsnt mlt vn,36466,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,768.88,,,,,,,fee schedule,768.88,5664, Njx noncmpnd sclrsnt mlt vn,36466,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,768.88,5664, Njx noncmpnd sclrsnt mlt vn,36466,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,768.88,5664, Njx noncmpnd sclrsnt mlt vn,36466,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,768.88,5664, Injection(s) spider veins,36468,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Injection(s) spider veins,36468,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Injection(s) spider veins,36468,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Injection therapy of vein,36470,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,194.58,,,,,,,fee schedule,194.58,3195, Injection therapy of vein,36470,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,194.58,3195, Injection therapy of vein,36470,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,194.58,3195, Injection therapy of vein,36470,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,194.58,3195, Injection therapy of veins,36471,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,384.79,,,,,,,fee schedule,384.79,3195, Injection therapy of veins,36471,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,384.79,3195, Injection therapy of veins,36471,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,384.79,3195, Injection therapy of veins,36471,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,384.79,3195, Endovenous mchnchem 1st vein,36473,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,917.7,,,,,,,fee schedule,917.7,12821, Endovenous mchnchem 1st vein,36473,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,917.7,12821, Endovenous mchnchem 1st vein,36473,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,917.7,12821, Endovenous mchnchem 1st vein,36473,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,917.7,12821, Endovenous mchnchem add-on,36474,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,454.18,,,,,,,fee schedule,454.18,3195, Endovenous mchnchem add-on,36474,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,454.18,3195, Endovenous mchnchem add-on,36474,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,454.18,3195, Endovenous mchnchem add-on,36474,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,454.18,3195, Endovenous rf 1st vein,36475,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1425.95,,,,,,,fee schedule,1425.95,12821, Endovenous rf 1st vein,36475,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1425.95,12821, Endovenous rf 1st vein,36475,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,1425.95,12821, Endovenous rf 1st vein,36475,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,1425.95,12821, Endovenous rf vein add-on,36476,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,683.13,,,,,,,fee schedule,683.13,3195, Endovenous rf vein add-on,36476,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,683.13,3195, Endovenous rf vein add-on,36476,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,683.13,3195, Endovenous rf vein add-on,36476,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,683.13,3195, Endovenous laser 1st vein,36478,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1421.74,,,,,,,fee schedule,1421.74,12821, Endovenous laser 1st vein,36478,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1421.74,12821, Endovenous laser 1st vein,36478,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,1421.74,12821, Endovenous laser 1st vein,36478,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,1421.74,12821, Endovenous laser vein addon,36479,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,688.8,,,,,,,fee schedule,688.8,3195, Endovenous laser vein addon,36479,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,688.8,3195, Endovenous laser vein addon,36479,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,688.8,3195, Endovenous laser vein addon,36479,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,688.8,3195, Insertion of catheter vein,36481,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1576.71,,,,,,,fee schedule,1576.71,3195, Insertion of catheter vein,36481,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1576.71,3195, Insertion of catheter vein,36481,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1576.71,3195, Insertion of catheter vein,36481,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1576.71,3195, Endoven ther chem adhes 1st,36482,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,919.42,,,,,,,fee schedule,919.42,22111, Endoven ther chem adhes 1st,36482,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,919.42,22111, Endoven ther chem adhes 1st,36482,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,919.42,22111, Endoven ther chem adhes 1st,36482,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,919.42,22111, Endoven ther chem adhes sbsq,36483,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,463.08,,,,,,,fee schedule,463.08,3195, Endoven ther chem adhes sbsq,36483,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,463.08,3195, Endoven ther chem adhes sbsq,36483,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,463.08,3195, Endoven ther chem adhes sbsq,36483,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,463.08,3195, Insertion of catheter vein,36500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,920.23,,,,,,,fee schedule,920.23,3195, Insertion of catheter vein,36500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,920.23,3195, Insertion of catheter vein,36500,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,920.23,3195, Insertion of catheter vein,36500,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,920.23,3195, Insertion of catheter vein,36510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,247.89,,,,,,,fee schedule,247.89,2782, Insertion of catheter vein,36510,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,247.89,2782, Insertion of catheter vein,36510,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,247.89,2782, Apheresis wbc,36511,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,498.64,,,,,,,fee schedule,498.64,5664, Apheresis wbc,36511,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,498.64,5664, Apheresis wbc,36511,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,498.64,5664, Apheresis wbc,36511,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,498.64,5664, Apheresis rbc,36512,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,470.1,,,,,,,fee schedule,470.1,5664, Apheresis rbc,36512,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,470.1,5664, Apheresis rbc,36512,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,470.1,5664, Apheresis rbc,36512,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,470.1,5664, Apheresis platelets,36513,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,486.13,,,,,,,fee schedule,486.13,4108, Apheresis platelets,36513,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,486.13,4108, Apheresis platelets,36513,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,486.13,4108, Apheresis platelets,36513,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,486.13,4108, Apheresis plasma,36514,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,432.92,,,,,,,fee schedule,432.92,5664, Apheresis plasma,36514,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,432.92,5664, Apheresis plasma,36514,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,432.92,5664, Apheresis plasma,36514,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,432.92,5664, Apheresis selective,36516,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,430.82,,,,,,,fee schedule,430.82,14456, Apheresis selective,36516,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,430.82,14456, Apheresis selective,36516,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,430.82,14456, Apheresis selective,36516,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,430.82,14456, Photopheresis,36522,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,429.58,,,,,,,fee schedule,429.58,14456, Photopheresis,36522,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,429.58,14456, Photopheresis,36522,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,429.58,14456, Photopheresis,36522,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,429.58,14456, Insert non-tunnel cv cath,36555,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,439.02,,,,,,,fee schedule,439.02,4497, Insert non-tunnel cv cath,36555,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,439.02,4497, Insert non-tunnel cv cath,36555,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,439.02,4497, Insert non-tunnel cv cath,36555,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,439.02,4497, Insert non-tunnel cv cath,36556,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,436,,,,,,,fee schedule,436,4497, Insert non-tunnel cv cath,36556,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,436,4497, Insert non-tunnel cv cath,36556,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,436,4497, Insert non-tunnel cv cath,36556,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,436,4497, Insert tunneled cv cath,36557,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1754.35,,,,,,,fee schedule,1754.35,22111, Insert tunneled cv cath,36557,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1754.35,22111, Insert tunneled cv cath,36557,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,1754.35,22111, Insert tunneled cv cath,36557,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,1754.35,22111, Insert tunneled cv cath,36558,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1297.85,,,,,,,fee schedule,1297.85,12821, Insert tunneled cv cath,36558,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1297.85,12821, Insert tunneled cv cath,36558,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,1297.85,12821, Insert tunneled cv cath,36558,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,1297.85,12821, Insert tunneled cv cath,36560,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2081.29,,,,,,,fee schedule,2081.29,12821, Insert tunneled cv cath,36560,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2081.29,12821, Insert tunneled cv cath,36560,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2081.29,12821, Insert tunneled cv cath,36560,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2081.29,12821, Insert tunneled cv cath,36561,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1685.71,,,,,,,fee schedule,1685.71,12821, Insert tunneled cv cath,36561,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1685.71,12821, Insert tunneled cv cath,36561,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,1685.71,12821, Insert tunneled cv cath,36561,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,1685.71,12821, Insert tunneled cv cath,36563,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1951.41,,,,,,,fee schedule,1951.41,22111, Insert tunneled cv cath,36563,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1951.41,22111, Insert tunneled cv cath,36563,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,1951.41,22111, Insert tunneled cv cath,36563,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,1951.41,22111, Insert tunneled cv cath,36565,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1779.55,,,,,,,fee schedule,1779.55,12821, Insert tunneled cv cath,36565,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1779.55,12821, Insert tunneled cv cath,36565,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,1779.55,12821, Insert tunneled cv cath,36565,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,1779.55,12821, Insert tunneled cv cath,36566,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1888.92,,,,,,,fee schedule,1888.92,22111, Insert tunneled cv cath,36566,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1888.92,22111, Insert tunneled cv cath,36566,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,1888.92,22111, Insert tunneled cv cath,36566,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,1888.92,22111, Insert picc cath,36568,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,474.47,,,,,,,fee schedule,474.47,4497, Insert picc cath,36568,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,474.47,4497, Insert picc cath,36568,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,474.47,4497, Insert picc cath,36568,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,474.47,4497, Insert picc cath,36569,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,491.74,,,,,,,fee schedule,491.74,4497, Insert picc cath,36569,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,491.74,4497, Insert picc cath,36569,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,491.74,4497, Insert picc cath,36569,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,491.74,4497, Insert picvad cath,36570,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1814.35,,,,,,,fee schedule,1814.35,12821, Insert picvad cath,36570,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1814.35,12821, Insert picvad cath,36570,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,1814.35,12821, Insert picvad cath,36570,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,1814.35,12821, Insert picvad cath,36571,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1661.05,,,,,,,fee schedule,1661.05,12821, Insert picvad cath,36571,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1661.05,12821, Insert picvad cath,36571,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,1661.05,12821, Insert picvad cath,36571,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,1661.05,12821, Insj picc rs&i <5 yr,36572,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,414.79,,,,,,,fee schedule,414.79,4497, Insj picc rs&i <5 yr,36572,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,414.79,4497, Insj picc rs&i <5 yr,36572,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,414.79,4497, Insj picc rs&i <5 yr,36572,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,414.79,4497, Insj picc rs&i 5 yr+,36573,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,403.08,,,,,,,fee schedule,403.08,5664, Insj picc rs&i 5 yr+,36573,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,403.08,5664, Insj picc rs&i 5 yr+,36573,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,403.08,5664, Insj picc rs&i 5 yr+,36573,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,403.08,5664, Repair tunneled cv cath,36575,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,165.39,,,,,,,fee schedule,165.39,4497, Repair tunneled cv cath,36575,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,165.39,4497, Repair tunneled cv cath,36575,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,165.39,4497, Repair tunneled cv cath,36575,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,165.39,4497, Repair tunneled cv cath,36576,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,959.79,,,,,,,fee schedule,959.79,4497, Repair tunneled cv cath,36576,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,959.79,4497, Repair tunneled cv cath,36576,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,959.79,4497, Repair tunneled cv cath,36576,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,959.79,4497, Replace tunneled cv cath,36578,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1064.74,,,,,,,fee schedule,1064.74,12821, Replace tunneled cv cath,36578,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1064.74,12821, Replace tunneled cv cath,36578,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,1064.74,12821, Replace tunneled cv cath,36578,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,1064.74,12821, Replace cvad cath,36580,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,324.25,,,,,,,fee schedule,324.25,4497, Replace cvad cath,36580,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,324.25,4497, Replace cvad cath,36580,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,324.25,4497, Replace cvad cath,36580,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,324.25,4497, Replace tunneled cv cath,36581,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,916.83,,,,,,,fee schedule,916.83,12821, Replace tunneled cv cath,36581,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,916.83,12821, Replace tunneled cv cath,36581,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,916.83,12821, Replace tunneled cv cath,36581,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,916.83,12821, Replace tunneled cv cath,36582,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1457.51,,,,,,,fee schedule,1457.51,12821, Replace tunneled cv cath,36582,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1457.51,12821, Replace tunneled cv cath,36582,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,1457.51,12821, Replace tunneled cv cath,36582,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,1457.51,12821, Replace tunneled cv cath,36583,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1794.6,,,,,,,fee schedule,1794.6,22111, Replace tunneled cv cath,36583,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1794.6,22111, Replace tunneled cv cath,36583,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,1794.6,22111, Replace tunneled cv cath,36583,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,1794.6,22111, Replace picc cath,36584,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,283.99,,,,,,,fee schedule,283.99,4497, Replace picc cath,36584,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,283.99,4497, Replace picc cath,36584,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,283.99,4497, Replace picc cath,36584,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,283.99,4497, Replace picvad cath,36585,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1671.09,,,,,,,fee schedule,1671.09,12821, Replace picvad cath,36585,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1671.09,12821, Replace picvad cath,36585,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,1671.09,12821, Replace picvad cath,36585,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,1671.09,12821, Removal tunneled cv cath,36589,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,698.24,,,,,,,fee schedule,698.24,4497, Removal tunneled cv cath,36589,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,698.24,4497, Removal tunneled cv cath,36589,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,698.24,4497, Removal tunneled cv cath,36589,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,698.24,4497, Removal tunneled cv cath,36590,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,967.02,,,,,,,fee schedule,967.02,5664, Removal tunneled cv cath,36590,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,967.02,5664, Removal tunneled cv cath,36590,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,967.02,5664, Removal tunneled cv cath,36590,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,967.02,5664, Draw blood off venous device,36591,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,157.78,,,,,,,fee schedule,157.78,2782, Draw blood off venous device,36591,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,157.78,2782, Draw blood off venous device,36591,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,157.78,2782, Collect blood from picc,36592,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,174.99,,,,,,,fee schedule,174.99,2782, Collect blood from picc,36592,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,174.99,2782, Collect blood from picc,36592,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,174.99,2782, Declot vascular device,36593,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,198.41,,,,,,,fee schedule,198.41,3195, Declot vascular device,36593,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,198.41,3195, Declot vascular device,36593,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,198.41,3195, Declot vascular device,36593,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,198.41,3195, Mech remov tunneled cv cath,36595,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,882.41,,,,,,,fee schedule,882.41,12821, Mech remov tunneled cv cath,36595,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,882.41,12821, Mech remov tunneled cv cath,36595,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,882.41,12821, Mech remov tunneled cv cath,36595,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,882.41,12821, Mech remov tunneled cv cath,36596,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,228.57,,,,,,,fee schedule,228.57,4497, Mech remov tunneled cv cath,36596,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,228.57,4497, Mech remov tunneled cv cath,36596,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,228.57,4497, Mech remov tunneled cv cath,36596,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,228.57,4497, Reposition venous catheter,36597,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,292.95,,,,,,,fee schedule,292.95,4497, Reposition venous catheter,36597,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,292.95,4497, Reposition venous catheter,36597,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,292.95,4497, Reposition venous catheter,36597,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,292.95,4497, Inj w/fluor eval cv device,36598,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,169.38,,,,,,,fee schedule,169.38,4108, Inj w/fluor eval cv device,36598,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,169.38,4108, Inj w/fluor eval cv device,36598,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,169.38,4108, Inj w/fluor eval cv device,36598,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,169.38,4108, Withdrawal of arterial blood,36600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,71.6,,,,,,,fee schedule,71.6,2782, Withdrawal of arterial blood,36600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,71.6,2782, Withdrawal of arterial blood,36600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,71.6,2782, Insertion catheter artery,36620,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,225.88,,,,,,,fee schedule,225.88,3195, Insertion catheter artery,36620,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,225.88,3195, Insertion catheter artery,36620,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,225.88,3195, Insertion catheter artery,36620,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,225.88,3195, Insertion catheter artery,36625,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,541.65,,,,,,,fee schedule,541.65,2782, Insertion catheter artery,36625,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,541.65,2782, Insertion catheter artery,36625,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,541.65,2782, Insertion catheter artery,36640,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,550.39,,,,,,,fee schedule,550.39,12821, Insertion catheter artery,36640,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,550.39,12821, Insertion catheter artery,36640,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,550.39,12821, Insertion catheter artery,36640,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,550.39,12821, Insertion catheter artery,36660,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,314.1,,,,,,,fee schedule,314.1,6979, Insertion catheter artery,36660,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,314.1,6979, Insertion catheter artery,36660,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,314.1,6979, Insertion catheter artery,36660,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,314.1,6979, Insert needle bone cavity,36680,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,330.02,,,,,,,fee schedule,330.02,3195, Insert needle bone cavity,36680,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,330.02,3195, Insert needle bone cavity,36680,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,330.02,3195, Insert needle bone cavity,36680,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,330.02,3195, Insertion of cannula,36800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,600.2,,,,,,,fee schedule,600.2,22111, Insertion of cannula,36800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,600.2,22111, Insertion of cannula,36800,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,600.2,22111, Insertion of cannula,36800,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,600.2,22111, Insertion of cannula,36810,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,979.05,,,,,,,fee schedule,979.05,12821, Insertion of cannula,36810,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,979.05,12821, Insertion of cannula,36810,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,979.05,12821, Insertion of cannula,36810,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,979.05,12821, Insertion of cannula,36815,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,719.12,,,,,,,fee schedule,719.12,22111, Insertion of cannula,36815,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,719.12,22111, Insertion of cannula,36815,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,719.12,22111, Insertion of cannula,36815,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,719.12,22111, Av fuse uppr arm cephalic,36818,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3639.17,,,,,,,fee schedule,3639.17,22111, Av fuse uppr arm cephalic,36818,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3639.17,22111, Av fuse uppr arm cephalic,36818,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3639.17,22111, Av fuse uppr arm cephalic,36818,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3639.17,22111, Av fuse uppr arm basilic,36819,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3852.74,,,,,,,fee schedule,3852.74,22111, Av fuse uppr arm basilic,36819,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3852.74,22111, Av fuse uppr arm basilic,36819,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3852.74,22111, Av fuse uppr arm basilic,36819,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3852.74,22111, Av fusion/forearm vein,36820,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3844.06,,,,,,,fee schedule,3844.06,22111, Av fusion/forearm vein,36820,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3844.06,22111, Av fusion/forearm vein,36820,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3844.06,22111, Av fusion/forearm vein,36820,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3844.06,22111, Av fusion direct any site,36821,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3482.52,,,,,,,fee schedule,3482.52,12821, Av fusion direct any site,36821,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3482.52,12821, Av fusion direct any site,36821,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3482.52,12821, Av fusion direct any site,36821,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3482.52,12821, Insertion of cannula(s),36823,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7563.09,,,,,,,fee schedule,6979,10940, Insertion of cannula(s),36823,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,10940, Insertion of cannula(s),36823,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,6979,10940, Insertion of cannula(s),36823,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,6979,10940, Artery-vein autograft,36825,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4179.58,,,,,,,fee schedule,4179.58,22111, Artery-vein autograft,36825,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4179.58,22111, Artery-vein autograft,36825,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4179.58,22111, Artery-vein autograft,36825,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4179.58,22111, Artery-vein nonautograft,36830,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3521.21,,,,,,,fee schedule,3521.21,22111, Artery-vein nonautograft,36830,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3521.21,22111, Artery-vein nonautograft,36830,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3521.21,22111, Artery-vein nonautograft,36830,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3521.21,22111, Open thrombect av fistula,36831,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3274.99,,,,,,,fee schedule,3274.99,22111, Open thrombect av fistula,36831,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,3274.99,22111, Open thrombect av fistula,36831,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3274.99,22111, Open thrombect av fistula,36831,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3274.99,22111, Av fistula revision open,36832,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3982.79,,,,,,,fee schedule,3982.79,22111, Av fistula revision open,36832,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3982.79,22111, Av fistula revision open,36832,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3982.79,22111, Av fistula revision open,36832,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3982.79,22111, Av fistula revision,36833,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4267.26,,,,,,,fee schedule,4267.26,22111, Av fistula revision,36833,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4267.26,22111, Av fistula revision,36833,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4267.26,22111, Av fistula revision,36833,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4267.26,22111, Artery to vein shunt,36835,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2698.16,,,,,,,fee schedule,2698.16,12821, Artery to vein shunt,36835,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2698.16,12821, Artery to vein shunt,36835,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2698.16,12821, Artery to vein shunt,36835,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2698.16,12821, Prq av fstl crtj uxtr 1 acs,36836,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1775.12,,,,,,,fee schedule,1775.12,25393, Prq av fstl crtj uxtr 1 acs,36836,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,1775.12,25393, Prq av fstl crtj uxtr 1 acs,36836,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,1775.12,25393, Prq av fstl crtj uxtr 1 acs,36836,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,1775.12,25393, Prq av fstl crt uxtr sep acs,36837,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2278.57,,,,,,,fee schedule,2278.57,25393, Prq av fstl crt uxtr sep acs,36837,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,2278.57,25393, Prq av fstl crt uxtr sep acs,36837,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,2278.57,25393, Prq av fstl crt uxtr sep acs,36837,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,2278.57,25393, Dist revas ligation hemo,36838,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6014.6,,,,,,,fee schedule,5363,22111, Dist revas ligation hemo,36838,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,22111, Dist revas ligation hemo,36838,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5363,22111, Dist revas ligation hemo,36838,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5363,22111, External cannula declotting,36860,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,572.41,,,,,,,fee schedule,572.41,4497, External cannula declotting,36860,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,572.41,4497, External cannula declotting,36860,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,572.41,4497, External cannula declotting,36860,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,572.41,4497, Cannula declotting,36861,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,721.12,,,,,,,fee schedule,721.12,22111, Cannula declotting,36861,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,721.12,22111, Cannula declotting,36861,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,721.12,22111, Cannula declotting,36861,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,721.12,22111, Intro cath dialysis circuit,36901,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,836.16,,,,,,,fee schedule,836.16,5664, Intro cath dialysis circuit,36901,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,836.16,5664, Intro cath dialysis circuit,36901,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,836.16,5664, Intro cath dialysis circuit,36901,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,836.16,5664, Intro cath dialysis circuit,36902,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1192.08,,,,,,,fee schedule,1192.08,22111, Intro cath dialysis circuit,36902,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,1192.08,22111, Intro cath dialysis circuit,36902,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,1192.08,22111, Intro cath dialysis circuit,36902,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,1192.08,22111, Intro cath dialysis circuit,36903,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1582.75,,,,,,,fee schedule,1582.75,25393, Intro cath dialysis circuit,36903,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,1582.75,25393, Intro cath dialysis circuit,36903,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,1582.75,25393, Intro cath dialysis circuit,36903,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,1582.75,25393, Thrmbc/nfs dialysis circuit,36904,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1823.47,,,,,,,fee schedule,1823.47,22111, Thrmbc/nfs dialysis circuit,36904,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,1823.47,22111, Thrmbc/nfs dialysis circuit,36904,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,1823.47,22111, Thrmbc/nfs dialysis circuit,36904,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,1823.47,22111, Thrmbc/nfs dialysis circuit,36905,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2186.89,,,,,,,fee schedule,2186.89,25393, Thrmbc/nfs dialysis circuit,36905,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,2186.89,25393, Thrmbc/nfs dialysis circuit,36905,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,2186.89,25393, Thrmbc/nfs dialysis circuit,36905,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,2186.89,25393, Thrmbc/nfs dialysis circuit,36906,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2525.22,,,,,,,fee schedule,2525.22,39251, Thrmbc/nfs dialysis circuit,36906,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,2525.22,39251, Thrmbc/nfs dialysis circuit,36906,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,39251,,,,,,,fee schedule,2525.22,39251, Thrmbc/nfs dialysis circuit,36906,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,35325,,,,,,,fee schedule,2525.22,39251, Balo angiop ctr dialysis seg,36907,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,725.82,,,,,,,fee schedule,725.82,3195, Balo angiop ctr dialysis seg,36907,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,725.82,3195, Balo angiop ctr dialysis seg,36907,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,725.82,3195, Balo angiop ctr dialysis seg,36907,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,725.82,3195, Stent plmt ctr dialysis seg,36908,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1038.19,,,,,,,fee schedule,1038.19,3195, Stent plmt ctr dialysis seg,36908,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1038.19,3195, Stent plmt ctr dialysis seg,36908,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1038.19,3195, Stent plmt ctr dialysis seg,36908,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1038.19,3195, Dialysis circuit embolj,36909,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1004.25,,,,,,,fee schedule,1004.25,3195, Dialysis circuit embolj,36909,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1004.25,3195, Dialysis circuit embolj,36909,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1004.25,3195, Dialysis circuit embolj,36909,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1004.25,3195, Revision of circulation,37140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12366.77,,,,,,,fee schedule,5097,12366.77, Revision of circulation,37140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,12366.77, Revision of circulation,37140,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,12366.77, Revision of circulation,37140,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,12366.77, Revision of circulation,37145,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,11482.74,,,,,,,fee schedule,5097,11482.74, Revision of circulation,37145,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,11482.74, Revision of circulation,37145,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,11482.74, Revision of circulation,37145,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,11482.74, Revision of circulation,37160,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,11791.77,,,,,,,fee schedule,5097,11791.77, Revision of circulation,37160,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,11791.77, Revision of circulation,37160,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,11791.77, Revision of circulation,37160,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,11791.77, Revision of circulation,37180,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,11340.29,,,,,,,fee schedule,5097,11340.29, Revision of circulation,37180,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,11340.29, Revision of circulation,37180,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,11340.29, Revision of circulation,37180,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,11340.29, Splice spleen/kidney veins,37181,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12366.77,,,,,,,fee schedule,5097,12366.77, Splice spleen/kidney veins,37181,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,12366.77, Splice spleen/kidney veins,37181,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,12366.77, Splice spleen/kidney veins,37181,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,12366.77, Insert hepatic shunt (tips),37182,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3930.23,,,,,,,fee schedule,3930.23,25393, Insert hepatic shunt (tips),37182,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10675,,,,,,,fee schedule,3930.23,25393, Insert hepatic shunt (tips),37182,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,3930.23,25393, Insert hepatic shunt (tips),37182,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,3930.23,25393, Remove hepatic shunt (tips),37183,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1804.64,,,,,,,fee schedule,1804.64,25393, Remove hepatic shunt (tips),37183,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10675,,,,,,,fee schedule,1804.64,25393, Remove hepatic shunt (tips),37183,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,1804.64,25393, Remove hepatic shunt (tips),37183,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,1804.64,25393, Prim art m-thrmbc 1st vsl,37184,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2155.7,,,,,,,fee schedule,2155.7,22111, Prim art m-thrmbc 1st vsl,37184,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10675,,,,,,,fee schedule,2155.7,22111, Prim art m-thrmbc 1st vsl,37184,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,2155.7,22111, Prim art m-thrmbc 1st vsl,37184,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,2155.7,22111, Prim art m-thrmbc sbsq vsl,37185,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,812.37,,,,,,,fee schedule,812.37,4108, Prim art m-thrmbc sbsq vsl,37185,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,812.37,4108, Prim art m-thrmbc sbsq vsl,37185,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,812.37,4108, Prim art m-thrmbc sbsq vsl,37185,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,812.37,4108, Sec art thrombectomy add-on,37186,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1265.96,,,,,,,fee schedule,1265.96,3195, Sec art thrombectomy add-on,37186,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1265.96,3195, Sec art thrombectomy add-on,37186,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1265.96,3195, Sec art thrombectomy add-on,37186,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1265.96,3195, Venous mech thrombectomy,37187,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1972.67,,,,,,,fee schedule,1972.67,22111, Venous mech thrombectomy,37187,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10675,,,,,,,fee schedule,1972.67,22111, Venous mech thrombectomy,37187,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,1972.67,22111, Venous mech thrombectomy,37187,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,1972.67,22111, Venous m-thrombectomy add-on,37188,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1438.95,,,,,,,fee schedule,1438.95,12821, Venous m-thrombectomy add-on,37188,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10675,,,,,,,fee schedule,1438.95,12821, Venous m-thrombectomy add-on,37188,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,1438.95,12821, Venous m-thrombectomy add-on,37188,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,1438.95,12821, Ins endovas vena cava filtr,37191,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1083.14,,,,,,,fee schedule,1083.14,22111, Ins endovas vena cava filtr,37191,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1083.14,22111, Ins endovas vena cava filtr,37191,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,1083.14,22111, Ins endovas vena cava filtr,37191,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,1083.14,22111, Redo endovas vena cava filtr,37192,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1834.21,,,,,,,fee schedule,1834.21,12821, Redo endovas vena cava filtr,37192,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1834.21,12821, Redo endovas vena cava filtr,37192,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,1834.21,12821, Redo endovas vena cava filtr,37192,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,1834.21,12821, Rem endovas vena cava filter,37193,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1717.98,,,,,,,fee schedule,1717.98,12821, Rem endovas vena cava filter,37193,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1717.98,12821, Rem endovas vena cava filter,37193,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,1717.98,12821, Rem endovas vena cava filter,37193,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,1717.98,12821, Thrombolytic therapy stroke,37195,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2505,6979, Thrombolytic therapy stroke,37195,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,6979, Thrombolytic therapy stroke,37195,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,6979, Remove intrvas foreign body,37197,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1515.84,,,,,,,fee schedule,1515.84,12821, Remove intrvas foreign body,37197,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1515.84,12821, Remove intrvas foreign body,37197,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,1515.84,12821, Remove intrvas foreign body,37197,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,1515.84,12821, Transcatheter biopsy,37200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1037.06,,,,,,,fee schedule,1037.06,22111, Transcatheter biopsy,37200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,1037.06,22111, Transcatheter biopsy,37200,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,1037.06,22111, Transcatheter biopsy,37200,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,1037.06,22111, Thrombolytic art therapy,37211,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1953.24,,,,,,,fee schedule,1953.24,22111, Thrombolytic art therapy,37211,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1953.24,22111, Thrombolytic art therapy,37211,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,1953.24,22111, Thrombolytic art therapy,37211,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,1953.24,22111, Thrombolytic venous therapy,37212,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1691.65,,,,,,,fee schedule,1691.65,12821, Thrombolytic venous therapy,37212,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1691.65,12821, Thrombolytic venous therapy,37212,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,1691.65,12821, Thrombolytic venous therapy,37212,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,1691.65,12821, Thromblytic art/ven therapy,37213,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1164.67,,,,,,,fee schedule,1164.67,5248, Thromblytic art/ven therapy,37213,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1164.67,5248, Thromblytic art/ven therapy,37213,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,1164.67,5248, Thromblytic art/ven therapy,37213,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,1164.67,5248, Cessj therapy cath removal,37214,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,618.71,,,,,,,fee schedule,618.71,5248, Cessj therapy cath removal,37214,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,618.71,5248, Cessj therapy cath removal,37214,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,618.71,5248, Cessj therapy cath removal,37214,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,618.71,5248, Transcath stent cca w/eps,37215,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5181.13,,,,,,,fee schedule,5097,5664, Transcath stent cca w/eps,37215,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5097,5664, Transcath stent cca w/eps,37215,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Transcath stent cca w/eps,37215,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Transcath stent cca w/o eps,37216,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5097,5664, Transcath stent cca w/o eps,37216,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Transcath stent cca w/o eps,37216,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Stent placemt retro carotid,37217,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5704.33,,,,,,,fee schedule,5097,5704.33, Stent placemt retro carotid,37217,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5097,5704.33, Stent placemt retro carotid,37217,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5704.33, Stent placemt retro carotid,37217,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5704.33, Stent placemt ante carotid,37218,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4293.76,,,,,,,fee schedule,4293.76,5664, Stent placemt ante carotid,37218,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4293.76,5664, Stent placemt ante carotid,37218,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4293.76,5664, Stent placemt ante carotid,37218,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4293.76,5664, Iliac revasc,37220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,22111, Iliac revasc,37220,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5363,22111, Iliac revasc,37220,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5363,22111, Iliac revasc w/stent,37221,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,25393, Iliac revasc w/stent,37221,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,5363,25393, Iliac revasc w/stent,37221,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,5363,25393, Iliac revasc add-on,37222,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,22111, Iliac revasc add-on,37222,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3195,22111, Iliac revasc add-on,37222,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3195,22111, Iliac revasc w/stent add-on,37223,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,22111, Iliac revasc w/stent add-on,37223,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3195,22111, Iliac revasc w/stent add-on,37223,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3195,22111, Fem/popl revas w/tla,37224,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,22111, Fem/popl revas w/tla,37224,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5363,22111, Fem/popl revas w/tla,37224,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5363,22111, Fem/popl revas w/ather,37225,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,25393, Fem/popl revas w/ather,37225,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,5363,25393, Fem/popl revas w/ather,37225,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,5363,25393, Fem/popl revasc w/stent,37226,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,25393, Fem/popl revasc w/stent,37226,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,5363,25393, Fem/popl revasc w/stent,37226,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,5363,25393, Fem/popl revasc stnt & ather,37227,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,39251, Fem/popl revasc stnt & ather,37227,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,39251,,,,,,,fee schedule,5363,39251, Fem/popl revasc stnt & ather,37227,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,35325,,,,,,,fee schedule,5363,39251, Tib/per revasc w/tla,37228,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,22111, Tib/per revasc w/tla,37228,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5363,22111, Tib/per revasc w/tla,37228,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5363,22111, Tib/per revasc w/ather,37229,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,25393, Tib/per revasc w/ather,37229,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,5363,25393, Tib/per revasc w/ather,37229,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,5363,25393, Tib/per revasc w/stent,37230,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,25393, Tib/per revasc w/stent,37230,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,5363,25393, Tib/per revasc w/stent,37230,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,5363,25393, Tib/per revasc stent & ather,37231,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,39251, Tib/per revasc stent & ather,37231,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,39251,,,,,,,fee schedule,5363,39251, Tib/per revasc stent & ather,37231,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,35325,,,,,,,fee schedule,5363,39251, Tib/per revasc add-on,37232,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,22111, Tib/per revasc add-on,37232,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3195,22111, Tib/per revasc add-on,37232,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3195,22111, Tibper revasc w/ather add-on,37233,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,25393, Tibper revasc w/ather add-on,37233,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,3195,25393, Tibper revasc w/ather add-on,37233,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,3195,25393, Revsc opn/prq tib/pero stent,37234,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,22111, Revsc opn/prq tib/pero stent,37234,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3195,22111, Revsc opn/prq tib/pero stent,37234,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3195,22111, Tib/per revasc stnt & ather,37235,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,22111, Tib/per revasc stnt & ather,37235,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3195,22111, Tib/per revasc stnt & ather,37235,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3195,22111, Open/perq place stent 1st,37236,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2274.36,,,,,,,fee schedule,2274.36,25393, Open/perq place stent 1st,37236,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2274.36,25393, Open/perq place stent 1st,37236,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,2274.36,25393, Open/perq place stent 1st,37236,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,2274.36,25393, Open/perq place stent ea add,37237,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1099.76,,,,,,,fee schedule,1099.76,22111, Open/perq place stent ea add,37237,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1099.76,22111, Open/perq place stent ea add,37237,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,1099.76,22111, Open/perq place stent ea add,37237,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,1099.76,22111, Open/perq place stent same,37238,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1566.3,,,,,,,fee schedule,1566.3,25393, Open/perq place stent same,37238,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1566.3,25393, Open/perq place stent same,37238,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,1566.3,25393, Open/perq place stent same,37238,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,1566.3,25393, Open/perq place stent ea add,37239,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,760.03,,,,,,,fee schedule,760.03,22111, Open/perq place stent ea add,37239,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,760.03,22111, Open/perq place stent ea add,37239,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,760.03,22111, Open/perq place stent ea add,37239,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,760.03,22111, Vasc embolize/occlude venous,37241,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2107.14,,,,,,,fee schedule,2107.14,25393, Vasc embolize/occlude venous,37241,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2107.14,25393, Vasc embolize/occlude venous,37241,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,2107.14,25393, Vasc embolize/occlude venous,37241,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,2107.14,25393, Vasc embolize/occlude artery,37242,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2354.81,,,,,,,fee schedule,2354.81,25393, Vasc embolize/occlude artery,37242,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2354.81,25393, Vasc embolize/occlude artery,37242,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,2354.81,25393, Vasc embolize/occlude artery,37242,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,2354.81,25393, Vasc embolize/occlude organ,37243,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2707.01,,,,,,,fee schedule,2707.01,25393, Vasc embolize/occlude organ,37243,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2707.01,25393, Vasc embolize/occlude organ,37243,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,2707.01,25393, Vasc embolize/occlude organ,37243,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,2707.01,25393, Vasc embolize/occlude bleed,37244,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3177.7,,,,,,,fee schedule,3177.7,25393, Vasc embolize/occlude bleed,37244,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3177.7,25393, Vasc embolize/occlude bleed,37244,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,3177.7,25393, Vasc embolize/occlude bleed,37244,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,3177.7,25393, Trluml balo angiop 1st art,37246,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1776.63,,,,,,,fee schedule,1776.63,22111, Trluml balo angiop 1st art,37246,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,1776.63,22111, Trluml balo angiop 1st art,37246,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,1776.63,22111, Trluml balo angiop 1st art,37246,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,1776.63,22111, Trluml balo angiop addl art,37247,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,872.16,,,,,,,fee schedule,872.16,3195, Trluml balo angiop addl art,37247,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,872.16,3195, Trluml balo angiop addl art,37247,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,872.16,3195, Trluml balo angiop addl art,37247,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,872.16,3195, Trluml balo angiop 1st vein,37248,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1480.28,,,,,,,fee schedule,1480.28,22111, Trluml balo angiop 1st vein,37248,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,1480.28,22111, Trluml balo angiop 1st vein,37248,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,1480.28,22111, Trluml balo angiop 1st vein,37248,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,1480.28,22111, Trluml balo angiop addl vein,37249,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,737.85,,,,,,,fee schedule,737.85,3195, Trluml balo angiop addl vein,37249,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,737.85,3195, Trluml balo angiop addl vein,37249,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,737.85,3195, Trluml balo angiop addl vein,37249,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,737.85,3195, Intrvasc us noncoronary 1st,37252,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,458.77,,,,,,,fee schedule,458.77,3195, Intrvasc us noncoronary 1st,37252,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,458.77,3195, Intrvasc us noncoronary 1st,37252,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,458.77,3195, Intrvasc us noncoronary 1st,37252,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,458.77,3195, Intrvasc us noncoronary addl,37253,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,360.88,,,,,,,fee schedule,360.88,3195, Intrvasc us noncoronary addl,37253,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,360.88,3195, Intrvasc us noncoronary addl,37253,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,360.88,3195, Intrvasc us noncoronary addl,37253,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,360.88,3195, Revsc evasc ivt angio sf 1st,37254,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1958.1,,,,,,,fee schedule,1958.1,6979, Revsc evasc ivt angio sf 1st,37254,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1958.1,6979, Revsc evasc ivt angio sf ea,37255,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,795.05,,,,,,,fee schedule,795.05,795.05, Revsc evasc ivt angio cplx 1,37256,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2870.67,,,,,,,fee schedule,2870.67,6979, Revsc evasc ivt angio cplx 1,37256,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2870.67,6979, Revsc evsc ivt angio cplx ea,37257,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1029.56,,,,,,,fee schedule,1029.56,1029.56, Revsc evasc ivt stent sf 1st,37258,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2344.78,,,,,,,fee schedule,2344.78,6979, Revsc evasc ivt stent sf 1st,37258,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2344.78,6979, Revsc evasc ivt stent sf ea,37259,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1063.93,,,,,,,fee schedule,1063.93,1063.93, Revsc evasc ivt st cplx 1st,37260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3389.5,,,,,,,fee schedule,3389.5,6979, Revsc evasc ivt st cplx 1st,37260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3389.5,6979, Revsc evasc ivt st cplx ea,37261,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1130.41,,,,,,,fee schedule,1130.41,1130.41, Iv lithotrp ivt w/in sm art,37262,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,784.2,,,,,,,fee schedule,784.2,784.2, Revsc evasc fpvt angio sf 1,37263,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2078.59,,,,,,,fee schedule,2078.59,6979, Revsc evasc fpvt angio sf 1,37263,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2078.59,6979, Revsc evasc fpvt angio sf ea,37264,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,795.8,,,,,,,fee schedule,795.8,795.8, Revsc evsc fpvt angio cplx 1,37265,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2812.34,,,,,,,fee schedule,2812.34,6979, Revsc evsc fpvt angio cplx 1,37265,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2812.34,6979, Rvsc evsc fpvt angio cplx ea,37266,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1059.02,,,,,,,fee schedule,1059.02,1059.02, Revsc evsc fpvt stent sf 1st,37267,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2346.5,,,,,,,fee schedule,2346.5,6979, Revsc evsc fpvt stent sf 1st,37267,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2346.5,6979, Revsc evasc fpvt stent sf ea,37268,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,992.59,,,,,,,fee schedule,992.59,992.59, Revsc evasc fpvt st cplx 1st,37269,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3945.45,,,,,,,fee schedule,3945.45,6979, Revsc evasc fpvt st cplx 1st,37269,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3945.45,6979, Revsc evasc fpvt st cplx ea,37270,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1333.03,,,,,,,fee schedule,1333.03,1333.03, Revsc evsc fpvt athrc sf 1st,37271,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2391.29,,,,,,,fee schedule,2391.29,6979, Revsc evsc fpvt athrc sf 1st,37271,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2391.29,6979, Revsc evsc fpvt athrc sf ea,37272,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1055.08,,,,,,,fee schedule,1055.08,1055.08, Revsc evsc fpvt athrc cplx 1,37273,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3349.41,,,,,,,fee schedule,3349.41,6979, Revsc evsc fpvt athrc cplx 1,37273,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3349.41,6979, Rvsc evsc fpvt athrc cplx ea,37274,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1453.68,,,,,,,fee schedule,1453.68,1453.68, Rvsc evsc fpvt st athrc sf 1,37275,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2920.91,,,,,,,fee schedule,2920.91,6979, Rvsc evsc fpvt st athrc sf 1,37275,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2920.91,6979, Rvsc evsc fpvt st athr sf ea,37276,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1124.47,,,,,,,fee schedule,1124.47,1124.47, Rvsc evsc fpvt st athr cpx 1,37277,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3971.78,,,,,,,fee schedule,3971.78,6979, Rvsc evsc fpvt st athr cpx 1,37277,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3971.78,6979, Rvsc evsc fpvt st ath cpx ea,37278,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1578.06,,,,,,,fee schedule,1578.06,1578.06, Iv lithotrp fpvt w/in sm art,37279,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1048.87,,,,,,,fee schedule,1048.87,1048.87, Revsc evsc tpvt angio sf 1st,37280,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2614.31,,,,,,,fee schedule,2614.31,6979, Revsc evsc tpvt angio sf 1st,37280,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2614.31,6979, Revsc evsc tpvt angio sf ea,37281,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,783.23,,,,,,,fee schedule,783.23,783.23, Rvsc evsc tpvt angio cplx 1,37282,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3279.9,,,,,,,fee schedule,3279.9,6979, Rvsc evsc tpvt angio cplx 1,37282,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3279.9,6979, Rvsc evsc tpvt angio cplx ea,37283,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1116.43,,,,,,,fee schedule,1116.43,1116.43, Revsc evasc tpvt st sf 1st,37284,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2687.26,,,,,,,fee schedule,2687.26,6979, Revsc evasc tpvt st sf 1st,37284,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2687.26,6979, Revsc evasc tpvt st sf ea,37285,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,884.13,,,,,,,fee schedule,884.13,884.13, Revsc evasc tpvt st cplx 1st,37286,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3602.15,,,,,,,fee schedule,3602.15,6979, Revsc evasc tpvt st cplx 1st,37286,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3602.15,6979, Revsc evasc tpvt st cplx ea,37287,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1332.06,,,,,,,fee schedule,1332.06,1332.06, Revsc evsc tpvt athrc sf 1st,37288,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3531.52,,,,,,,fee schedule,3531.52,6979, Revsc evsc tpvt athrc sf 1st,37288,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3531.52,6979, Revsc evsc tpvt athrc sf ea,37289,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1245.13,,,,,,,fee schedule,1245.13,1245.13, Revsc evsc tpvt athrc cplx 1,37290,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4443.77,,,,,,,fee schedule,4443.77,6979, Revsc evsc tpvt athrc cplx 1,37290,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4443.77,6979, Revsc evsc tpvt athr cplx ea,37291,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1695.69,,,,,,,fee schedule,1695.69,1695.69, Rvsc evsc tpvt st athrc sf 1,37292,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3921.54,,,,,,,fee schedule,3921.54,6979, Rvsc evsc tpvt st athrc sf 1,37292,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3921.54,6979, Rvsc evsc tpvt st athr sf ea,37293,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1724.02,,,,,,,fee schedule,1724.02,1724.02, Rvsc evsc tpvt st athr cpx 1,37294,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4701.53,,,,,,,fee schedule,4701.53,6979, Rvsc evsc tpvt st athr cpx 1,37294,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4701.53,6979, Rvsc evsc tpvt st ath cpx ea,37295,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2176.1,,,,,,,fee schedule,2176.1,2176.1, Revsc evasc imvt angio sf 1,37296,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2926.84,,,,,,,fee schedule,2926.84,6979, Revsc evasc imvt angio sf 1,37296,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2926.84,6979, Revsc evasc imvt angio sf ea,37297,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1045.48,,,,,,,fee schedule,1045.48,1045.48, Revsc evsc imvt angio cplx 1,37298,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3600.37,,,,,,,fee schedule,3600.37,6979, Revsc evsc imvt angio cplx 1,37298,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3600.37,6979, Revsc evsc imvt angio cpx ea,37299,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1299.57,,,,,,,fee schedule,1299.57,1299.57, Endoscopy ligate perf veins,37500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,22111, Endoscopy ligate perf veins,37500,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5248,22111, Endoscopy ligate perf veins,37500,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5248,22111, Vascular endoscopy procedure,37501,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4047,6979, Vascular endoscopy procedure,37501,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,4047,6979, Vascular endoscopy procedure,37501,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,4047,6979, Ligation of neck vein,37565,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3697.56,,,,,,,fee schedule,3697.56,6979, Ligation of neck vein,37565,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3697.56,6979, Ligation of neck vein,37565,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,3697.56,6979, Ligation of neck vein,37565,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,3697.56,6979, Ligation of neck artery,37600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3722.75,,,,,,,fee schedule,3722.75,12821, Ligation of neck artery,37600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3722.75,12821, Ligation of neck artery,37600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3722.75,12821, Ligation of neck artery,37600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3722.75,12821, Ligation of neck artery,37605,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3945.29,,,,,,,fee schedule,3945.29,12821, Ligation of neck artery,37605,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3945.29,12821, Ligation of neck artery,37605,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3945.29,12821, Ligation of neck artery,37605,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3945.29,12821, Ligation of neck artery,37606,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4342.16,,,,,,,fee schedule,4342.16,12821, Ligation of neck artery,37606,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4342.16,12821, Ligation of neck artery,37606,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4342.16,12821, Ligation of neck artery,37606,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4342.16,12821, Ligation of a-v fistula,37607,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1979.25,,,,,,,fee schedule,1979.25,12821, Ligation of a-v fistula,37607,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1979.25,12821, Ligation of a-v fistula,37607,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,1979.25,12821, Ligation of a-v fistula,37607,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,1979.25,12821, Temporal artery procedure,37609,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1057.67,,,,,,,fee schedule,1057.67,5664, Temporal artery procedure,37609,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1057.67,5664, Temporal artery procedure,37609,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1057.67,5664, Temporal artery procedure,37609,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1057.67,5664, Ligation of neck artery,37615,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2587.71,,,,,,,fee schedule,2587.71,6979, Ligation of neck artery,37615,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2587.71,6979, Ligation of neck artery,37615,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,2587.71,6979, Ligation of neck artery,37615,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,2587.71,6979, Ligation of chest artery,37616,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6120.25,,,,,,,fee schedule,5097,6979, Ligation of chest artery,37616,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Ligation of chest artery,37616,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Ligation of chest artery,37616,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Ligation of abdomen artery,37617,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6938.39,,,,,,,fee schedule,6938.39,12821, Ligation of abdomen artery,37617,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6938.39,12821, Ligation of abdomen artery,37617,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,6938.39,12821, Ligation of abdomen artery,37617,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,6938.39,12821, Ligation of extremity artery,37618,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2092.3,,,,,,,fee schedule,2092.3,6979, Ligation of extremity artery,37618,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2092.3,6979, Ligation of extremity artery,37618,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2092.3,6979, Ligation of extremity artery,37618,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2092.3,6979, Ligation of inf vena cava,37619,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9170.23,,,,,,,fee schedule,5248,22111, Ligation of inf vena cava,37619,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,22111, Ligation of inf vena cava,37619,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5248,22111, Ligation of inf vena cava,37619,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5248,22111, Revision of major vein,37650,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2458.47,,,,,,,fee schedule,2458.47,12821, Revision of major vein,37650,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2458.47,12821, Revision of major vein,37650,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2458.47,12821, Revision of major vein,37650,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2458.47,12821, Revision of major vein,37660,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7042.64,,,,,,,fee schedule,5097,7042.64, Revision of major vein,37660,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7042.64, Revision of major vein,37660,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7042.64, Revision of major vein,37660,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7042.64, Revise leg vein,37700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1298.28,,,,,,,fee schedule,1298.28,12821, Revise leg vein,37700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1298.28,12821, Revise leg vein,37700,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,1298.28,12821, Revise leg vein,37700,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,1298.28,12821, Ligate/strip short leg vein,37718,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2099.8,,,,,,,fee schedule,2099.8,12821, Ligate/strip short leg vein,37718,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2099.8,12821, Ligate/strip short leg vein,37718,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2099.8,12821, Ligate/strip short leg vein,37718,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2099.8,12821, Ligate/strip long leg vein,37722,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2452.48,,,,,,,fee schedule,2452.48,12821, Ligate/strip long leg vein,37722,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2452.48,12821, Ligate/strip long leg vein,37722,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2452.48,12821, Ligate/strip long leg vein,37722,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2452.48,12821, Removal of leg veins/lesion,37735,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3109.98,,,,,,,fee schedule,3109.98,12821, Removal of leg veins/lesion,37735,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3109.98,12821, Removal of leg veins/lesion,37735,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3109.98,12821, Removal of leg veins/lesion,37735,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3109.98,12821, Ligate leg veins radical,37760,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3078.53,,,,,,,fee schedule,3078.53,12821, Ligate leg veins radical,37760,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3078.53,12821, Ligate leg veins radical,37760,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3078.53,12821, Ligate leg veins radical,37760,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3078.53,12821, Ligate leg veins open,37761,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2805.06,,,,,,,fee schedule,2805.06,5248, Ligate leg veins open,37761,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2805.06,5248, Ligate leg veins open,37761,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,2805.06,5248, Ligate leg veins open,37761,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,2805.06,5248, Stab phleb veins xtr 10-20,37765,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1411,,,,,,,fee schedule,1411,12821, Stab phleb veins xtr 10-20,37765,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1411,12821, Stab phleb veins xtr 10-20,37765,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,1411,12821, Stab phleb veins xtr 10-20,37765,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,1411,12821, Phleb veins - extrem 20+,37766,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1737.35,,,,,,,fee schedule,1737.35,12821, Phleb veins - extrem 20+,37766,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1737.35,12821, Phleb veins - extrem 20+,37766,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,1737.35,12821, Phleb veins - extrem 20+,37766,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,1737.35,12821, Revision of leg vein,37780,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1266.87,,,,,,,fee schedule,1266.87,5248, Revision of leg vein,37780,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1266.87,5248, Revision of leg vein,37780,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,1266.87,5248, Revision of leg vein,37780,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,1266.87,5248, Ligate/divide/excise vein,37785,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1332.87,,,,,,,fee schedule,1332.87,12821, Ligate/divide/excise vein,37785,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1332.87,12821, Ligate/divide/excise vein,37785,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,1332.87,12821, Ligate/divide/excise vein,37785,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,1332.87,12821, Revascularization penis,37788,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6277.54,,,,,,,fee schedule,5097,6979, Revascularization penis,37788,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Revascularization penis,37788,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Revascularization penis,37788,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Penile venous occlusion,37790,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2451.94,,,,,,,fee schedule,2451.94,12821, Penile venous occlusion,37790,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2451.94,12821, Penile venous occlusion,37790,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2451.94,12821, Penile venous occlusion,37790,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2451.94,12821, Vascular surgery procedure,37799,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4047,4497, Vascular surgery procedure,37799,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,4047,4497, Vascular surgery procedure,37799,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,4047,4497, Removal of spleen total,38100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6163.85,,,,,,,fee schedule,5097,6979, Removal of spleen total,38100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Removal of spleen total,38100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Removal of spleen total,38100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Removal of spleen partial,38101,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6256.93,,,,,,,fee schedule,5097,6979, Removal of spleen partial,38101,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Removal of spleen partial,38101,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Removal of spleen partial,38101,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Removal of spleen total,38102,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1366.59,,,,,,,fee schedule,1366.59,6979, Removal of spleen total,38102,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1366.59,6979, Removal of spleen total,38102,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1366.59,6979, Removal of spleen total,38102,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1366.59,6979, Repair of ruptured spleen,38115,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6930.46,,,,,,,fee schedule,5097,6979, Repair of ruptured spleen,38115,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Repair of ruptured spleen,38115,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Repair of ruptured spleen,38115,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Laparoscopy splenectomy,38120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5701.79,,,,,,,fee schedule,5701.79,22111, Laparoscopy splenectomy,38120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,5701.79,22111, Laparoscopy splenectomy,38120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5701.79,22111, Laparoscopy splenectomy,38120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5701.79,22111, Laparoscope proc spleen,38129,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,14456, Laparoscope proc spleen,38129,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5248,14456, Laparoscope proc spleen,38129,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5248,14456, Injection for spleen x-ray,38200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,607.48,,,,,,,fee schedule,607.48,3195, Injection for spleen x-ray,38200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,607.48,3195, Injection for spleen x-ray,38200,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,607.48,3195, Injection for spleen x-ray,38200,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,607.48,3195, Harvest allogeneic stem cell,38205,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,374.43,,,,,,,fee schedule,374.43,6979, Harvest allogeneic stem cell,38205,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,374.43,6979, Harvest allogeneic stem cell,38205,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,374.43,6979, Harvest allogeneic stem cell,38205,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,374.43,6979, Harvest auto stem cells,38206,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,368.49,,,,,,,fee schedule,368.49,6979, Harvest auto stem cells,38206,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,368.49,6979, Harvest auto stem cells,38206,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,368.49,6979, Harvest auto stem cells,38206,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,368.49,6979, Cryopreserve stem cells,38207,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2505,6979, Cryopreserve stem cells,38207,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,6979, Cryopreserve stem cells,38207,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,6979, Thaw preserved stem cells,38208,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2505,6979, Thaw preserved stem cells,38208,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,6979, Thaw preserved stem cells,38208,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,6979, Wash harvest stem cells,38209,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2505,6979, Wash harvest stem cells,38209,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,6979, Wash harvest stem cells,38209,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,6979, T-cell depletion of harvest,38210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2505,6979, T-cell depletion of harvest,38210,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,6979, T-cell depletion of harvest,38210,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,6979, Tumor cell deplete of harvst,38211,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2505,6979, Tumor cell deplete of harvst,38211,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,6979, Tumor cell deplete of harvst,38211,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,6979, Rbc depletion of harvest,38212,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2505,6979, Rbc depletion of harvest,38212,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,6979, Rbc depletion of harvest,38212,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,6979, Platelet deplete of harvest,38213,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2505,6979, Platelet deplete of harvest,38213,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,6979, Platelet deplete of harvest,38213,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,6979, Volume deplete of harvest,38214,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2505,6979, Volume deplete of harvest,38214,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,6979, Volume deplete of harvest,38214,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,6979, Harvest stem cell concentrte,38215,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2505,6979, Harvest stem cell concentrte,38215,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,6979, Harvest stem cell concentrte,38215,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,6979, Bone marrow aspiration,38220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,304.17,,,,,,,fee schedule,304.17,4497, Bone marrow aspiration,38220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,304.17,4497, Bone marrow aspiration,38220,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,304.17,4497, Bone marrow aspiration,38220,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,304.17,4497, Bone marrow biopsy,38221,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,318.85,,,,,,,fee schedule,318.85,4497, Bone marrow biopsy,38221,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,318.85,4497, Bone marrow biopsy,38221,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,318.85,4497, Bone marrow biopsy,38221,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,318.85,4497, Dx bone marrow bx & aspir,38222,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,346.1,,,,,,,fee schedule,346.1,5664, Dx bone marrow bx & aspir,38222,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,346.1,5664, Dx bone marrow bx & aspir,38222,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,346.1,5664, Dx bone marrow bx & aspir,38222,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,346.1,5664, Car-t hrv bld-drv t lymphcyt,38225,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Car-t hrv bld-drv t lymphcyt,38225,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Car-t prep t lymphcyt f/trns,38226,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Car-t prep t lymphcyt f/trns,38226,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Car-t receipt&prepj admn,38227,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Car-t receipt&prepj admn,38227,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Car-t admn autologous,38228,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,817.12,,,,,,,fee schedule,817.12,2782, Car-t admn autologous,38228,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,817.12,2782, Car-t admn autologous,38228,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,817.12,2782, Bone marrow harvest allogen,38230,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,995.72,,,,,,,fee schedule,995.72,6044, Bone marrow harvest allogen,38230,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,995.72,6044, Bone marrow harvest allogen,38230,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,995.72,6044, Bone marrow harvest allogen,38230,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,995.72,6044, Bone marrow harvest autolog,38232,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,886.4,,,,,,,fee schedule,886.4,14456, Bone marrow harvest autolog,38232,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,886.4,14456, Bone marrow harvest autolog,38232,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,886.4,14456, Bone marrow harvest autolog,38232,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,886.4,14456, Transplt allo hct/donor,38240,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1096.25,,,,,,,fee schedule,1096.25,14456, Transplt allo hct/donor,38240,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,1096.25,14456, Transplt allo hct/donor,38240,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,1096.25,14456, Transplt allo hct/donor,38240,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,1096.25,14456, Transplt autol hct/donor,38241,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,811.4,,,,,,,fee schedule,811.4,6044, Transplt autol hct/donor,38241,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,811.4,6044, Transplt autol hct/donor,38241,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,811.4,6044, Transplt autol hct/donor,38241,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,811.4,6044, Transplt allo lymphocytes,38242,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,576.35,,,,,,,fee schedule,576.35,6979, Transplt allo lymphocytes,38242,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,576.35,6979, Transplt allo lymphocytes,38242,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,576.35,6979, Transplt allo lymphocytes,38242,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,576.35,6979, Transplj hematopoietic boost,38243,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,554.12,,,,,,,fee schedule,554.12,5664, Transplj hematopoietic boost,38243,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,554.12,5664, Transplj hematopoietic boost,38243,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,554.12,5664, Transplj hematopoietic boost,38243,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,554.12,5664, Drainage lymph node lesion,38300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1193.16,,,,,,,fee schedule,1193.16,5664, Drainage lymph node lesion,38300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1193.16,5664, Drainage lymph node lesion,38300,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1193.16,5664, Drainage lymph node lesion,38300,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1193.16,5664, Drainage lymph node lesion,38305,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2757.73,,,,,,,fee schedule,2757.73,10940, Drainage lymph node lesion,38305,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2757.73,10940, Drainage lymph node lesion,38305,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2757.73,10940, Drainage lymph node lesion,38305,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2757.73,10940, Incision of lymph channels,38308,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2510.38,,,,,,,fee schedule,2510.38,10940, Incision of lymph channels,38308,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2510.38,10940, Incision of lymph channels,38308,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2510.38,10940, Incision of lymph channels,38308,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2510.38,10940, Thoracic duct procedure,38380,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2870.67,,,,,,,fee schedule,2870.67,6979, Thoracic duct procedure,38380,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2870.67,6979, Thoracic duct procedure,38380,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2870.67,6979, Thoracic duct procedure,38380,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2870.67,6979, Thoracic duct procedure,38381,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4400.11,,,,,,,fee schedule,4400.11,6979, Thoracic duct procedure,38381,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4400.11,6979, Thoracic duct procedure,38381,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4400.11,6979, Thoracic duct procedure,38381,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4400.11,6979, Thoracic duct procedure,38382,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3811.52,,,,,,,fee schedule,3811.52,6979, Thoracic duct procedure,38382,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3811.52,6979, Thoracic duct procedure,38382,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3811.52,6979, Thoracic duct procedure,38382,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3811.52,6979, Biopsy/removal lymph nodes,38500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1384.51,,,,,,,fee schedule,1384.51,10940, Biopsy/removal lymph nodes,38500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1384.51,10940, Biopsy/removal lymph nodes,38500,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1384.51,10940, Biopsy/removal lymph nodes,38500,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1384.51,10940, Needle biopsy lymph nodes,38505,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,415.01,,,,,,,fee schedule,415.01,5664, Needle biopsy lymph nodes,38505,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,415.01,5664, Needle biopsy lymph nodes,38505,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,415.01,5664, Needle biopsy lymph nodes,38505,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,415.01,5664, Biopsy/removal lymph nodes,38510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2127.75,,,,,,,fee schedule,2127.75,10940, Biopsy/removal lymph nodes,38510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2127.75,10940, Biopsy/removal lymph nodes,38510,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2127.75,10940, Biopsy/removal lymph nodes,38510,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2127.75,10940, Biopsy/removal lymph nodes,38520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2475.58,,,,,,,fee schedule,2475.58,10940, Biopsy/removal lymph nodes,38520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2475.58,10940, Biopsy/removal lymph nodes,38520,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2475.58,10940, Biopsy/removal lymph nodes,38520,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2475.58,10940, Biopsy/removal lymph nodes,38525,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2429.39,,,,,,,fee schedule,2429.39,10940, Biopsy/removal lymph nodes,38525,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2429.39,10940, Biopsy/removal lymph nodes,38525,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2429.39,10940, Biopsy/removal lymph nodes,38525,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2429.39,10940, Biopsy/removal lymph nodes,38530,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2971.9,,,,,,,fee schedule,2971.9,10940, Biopsy/removal lymph nodes,38530,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2971.9,10940, Biopsy/removal lymph nodes,38530,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2971.9,10940, Biopsy/removal lymph nodes,38530,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2971.9,10940, Open bx/exc inguinofem nodes,38531,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2444.12,,,,,,,fee schedule,2444.12,12821, Open bx/exc inguinofem nodes,38531,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2444.12,12821, Open bx/exc inguinofem nodes,38531,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2444.12,12821, Open bx/exc inguinofem nodes,38531,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2444.12,12821, Explore deep node(s) neck,38542,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2615.12,,,,,,,fee schedule,2615.12,22111, Explore deep node(s) neck,38542,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2615.12,22111, Explore deep node(s) neck,38542,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,2615.12,22111, Explore deep node(s) neck,38542,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,2615.12,22111, Removal neck/armpit lesion,38550,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2908.01,,,,,,,fee schedule,2908.01,10940, Removal neck/armpit lesion,38550,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2908.01,10940, Removal neck/armpit lesion,38550,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2908.01,10940, Removal neck/armpit lesion,38550,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2908.01,10940, Removal neck/armpit lesion,38555,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5593.33,,,,,,,fee schedule,5363,10940, Removal neck/armpit lesion,38555,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,10940, Removal neck/armpit lesion,38555,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,5363,10940, Removal neck/armpit lesion,38555,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,5363,10940, Removal pelvic lymph nodes,38562,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3761.93,,,,,,,fee schedule,3761.93,22111, Removal pelvic lymph nodes,38562,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3761.93,22111, Removal pelvic lymph nodes,38562,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3761.93,22111, Removal pelvic lymph nodes,38562,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3761.93,22111, Removal abdomen lymph nodes,38564,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3748.28,,,,,,,fee schedule,3748.28,6979, Removal abdomen lymph nodes,38564,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3748.28,6979, Removal abdomen lymph nodes,38564,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3748.28,6979, Removal abdomen lymph nodes,38564,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3748.28,6979, Laparoscopy lymph node biop,38570,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2715.64,,,,,,,fee schedule,2715.64,22111, Laparoscopy lymph node biop,38570,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2715.64,22111, Laparoscopy lymph node biop,38570,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,2715.64,22111, Laparoscopy lymph node biop,38570,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,2715.64,22111, Laparoscopy lymphadenectomy,38571,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3334.73,,,,,,,fee schedule,3334.73,22111, Laparoscopy lymphadenectomy,38571,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10675,,,,,,,fee schedule,3334.73,22111, Laparoscopy lymphadenectomy,38571,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3334.73,22111, Laparoscopy lymphadenectomy,38571,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3334.73,22111, Laparoscopy lymphadenectomy,38572,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4667.76,,,,,,,fee schedule,4667.76,22111, Laparoscopy lymphadenectomy,38572,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10675,,,,,,,fee schedule,4667.76,22111, Laparoscopy lymphadenectomy,38572,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4667.76,22111, Laparoscopy lymphadenectomy,38572,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4667.76,22111, Laps pelvic lymphadec,38573,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6146.31,,,,,,,fee schedule,6146.31,22111, Laps pelvic lymphadec,38573,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6146.31,22111, Laps pelvic lymphadec,38573,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6146.31,22111, Laps pelvic lymphadec,38573,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6146.31,22111, Laparoscope proc lymphatic,38589,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,14456, Laparoscope proc lymphatic,38589,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5248,14456, Laparoscope proc lymphatic,38589,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5248,14456, Removal of lymph nodes neck,38700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3952.46,,,,,,,fee schedule,3952.46,10940, Removal of lymph nodes neck,38700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3952.46,10940, Removal of lymph nodes neck,38700,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3952.46,10940, Removal of lymph nodes neck,38700,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3952.46,10940, Removal of lymph nodes neck,38720,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6710.25,,,,,,,fee schedule,5363,10940, Removal of lymph nodes neck,38720,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,10940, Removal of lymph nodes neck,38720,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,5363,10940, Removal of lymph nodes neck,38720,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,5363,10940, Removal of lymph nodes neck,38724,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7061.96,,,,,,,fee schedule,5363,10940, Removal of lymph nodes neck,38724,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,10940, Removal of lymph nodes neck,38724,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,5363,10940, Removal of lymph nodes neck,38724,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,5363,10940, Remove armpit lymph nodes,38740,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3822.26,,,,,,,fee schedule,3822.26,22111, Remove armpit lymph nodes,38740,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3822.26,22111, Remove armpit lymph nodes,38740,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3822.26,22111, Remove armpit lymph nodes,38740,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3822.26,22111, Remove armpit lymph nodes,38745,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4776.76,,,,,,,fee schedule,4776.76,22111, Remove armpit lymph nodes,38745,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4776.76,22111, Remove armpit lymph nodes,38745,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4776.76,22111, Remove armpit lymph nodes,38745,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4776.76,22111, Remove thoracic lymph nodes,38746,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1140.39,,,,,,,fee schedule,1140.39,6979, Remove thoracic lymph nodes,38746,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1140.39,6979, Remove thoracic lymph nodes,38746,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1140.39,6979, Remove thoracic lymph nodes,38746,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1140.39,6979, Remove abdominal lymph nodes,38747,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1390.44,,,,,,,fee schedule,1390.44,6979, Remove abdominal lymph nodes,38747,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1390.44,6979, Remove abdominal lymph nodes,38747,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1390.44,6979, Remove abdominal lymph nodes,38747,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1390.44,6979, Remove groin lymph nodes,38760,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4420.83,,,,,,,fee schedule,4108,10940, Remove groin lymph nodes,38760,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,10940, Remove groin lymph nodes,38760,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,4108,10940, Remove groin lymph nodes,38760,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,4108,10940, Remove groin lymph nodes,38765,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6967.26,,,,,,,fee schedule,5097,6979, Remove groin lymph nodes,38765,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Remove groin lymph nodes,38765,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Remove groin lymph nodes,38765,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Remove pelvis lymph nodes,38770,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4149.47,,,,,,,fee schedule,4149.47,6979, Remove pelvis lymph nodes,38770,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4149.47,6979, Remove pelvis lymph nodes,38770,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4149.47,6979, Remove pelvis lymph nodes,38770,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4149.47,6979, Remove abdomen lymph nodes,38780,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5538.99,,,,,,,fee schedule,5097,6979, Remove abdomen lymph nodes,38780,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Remove abdomen lymph nodes,38780,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Remove abdomen lymph nodes,38780,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Inject for lymphatic x-ray,38790,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,420.83,,,,,,,fee schedule,420.83,3195, Inject for lymphatic x-ray,38790,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,420.83,3195, Inject for lymphatic x-ray,38790,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,420.83,3195, Inject for lymphatic x-ray,38790,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,420.83,3195, Ra tracer id of sentinl node,38792,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,153.19,,,,,,,fee schedule,153.19,3195, Ra tracer id of sentinl node,38792,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,153.19,3195, Ra tracer id of sentinl node,38792,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,153.19,3195, Ra tracer id of sentinl node,38792,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,153.19,3195, Access thoracic lymph duct,38794,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1421.52,,,,,,,fee schedule,1421.52,2782, Access thoracic lymph duct,38794,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1421.52,2782, Access thoracic lymph duct,38794,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1421.52,2782, Io map of sent lymph node,38900,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,711.57,,,,,,,fee schedule,711.57,3195, Io map of sent lymph node,38900,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,711.57,3195, Io map of sent lymph node,38900,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,711.57,3195, Io map of sent lymph node,38900,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,711.57,3195, Blood/lymph system procedure,38999,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Blood/lymph system procedure,38999,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Blood/lymph system procedure,38999,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Exploration of chest,39000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2763.13,,,,,,,fee schedule,2763.13,6979, Exploration of chest,39000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2763.13,6979, Exploration of chest,39000,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2763.13,6979, Exploration of chest,39000,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2763.13,6979, Exploration of chest,39010,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4343.46,,,,,,,fee schedule,4343.46,6979, Exploration of chest,39010,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4343.46,6979, Exploration of chest,39010,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4343.46,6979, Exploration of chest,39010,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4343.46,6979, Resect mediastinal cyst,39200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4771.74,,,,,,,fee schedule,4771.74,6979, Resect mediastinal cyst,39200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4771.74,6979, Resect mediastinal cyst,39200,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4771.74,6979, Resect mediastinal cyst,39200,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4771.74,6979, Resect mediastinal tumor,39220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6097.32,,,,,,,fee schedule,5097,6979, Resect mediastinal tumor,39220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Resect mediastinal tumor,39220,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Resect mediastinal tumor,39220,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Mediastinoscpy w/medstnl bx,39401,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1681.5,,,,,,,fee schedule,1681.5,14456, Mediastinoscpy w/medstnl bx,39401,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1681.5,14456, Mediastinoscpy w/medstnl bx,39401,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,1681.5,14456, Mediastinoscpy w/medstnl bx,39401,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,1681.5,14456, Mediastinoscpy w/lmph nod bx,39402,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2178.31,,,,,,,fee schedule,2178.31,14456, Mediastinoscpy w/lmph nod bx,39402,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2178.31,14456, Mediastinoscpy w/lmph nod bx,39402,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,2178.31,14456, Mediastinoscpy w/lmph nod bx,39402,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,2178.31,14456, Chest procedure,39499,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Chest procedure,39499,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Chest procedure,39499,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Repair diaphragm laceration,39501,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4612.72,,,,,,,fee schedule,4612.72,6979, Repair diaphragm laceration,39501,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4612.72,6979, Repair diaphragm laceration,39501,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4612.72,6979, Repair diaphragm laceration,39501,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4612.72,6979, Repair of diaphragm hernia,39503,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,31092.51,,,,,,,fee schedule,5097,31092.51, Repair of diaphragm hernia,39503,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,31092.51, Repair of diaphragm hernia,39503,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,31092.51, Repair of diaphragm hernia,39503,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,31092.51, Repair of diaphragm hernia,39540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4689.99,,,,,,,fee schedule,4689.99,6979, Repair of diaphragm hernia,39540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4689.99,6979, Repair of diaphragm hernia,39540,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4689.99,6979, Repair of diaphragm hernia,39540,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4689.99,6979, Repair of diaphragm hernia,39541,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5095.66,,,,,,,fee schedule,5095.66,6979, Repair of diaphragm hernia,39541,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5095.66,6979, Repair of diaphragm hernia,39541,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5095.66,6979, Repair of diaphragm hernia,39541,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5095.66,6979, Revision of diaphragm,39545,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4969.55,,,,,,,fee schedule,4969.55,6979, Revision of diaphragm,39545,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4969.55,6979, Revision of diaphragm,39545,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4969.55,6979, Revision of diaphragm,39545,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4969.55,6979, Resect diaphragm simple,39560,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4314.37,,,,,,,fee schedule,4314.37,6979, Resect diaphragm simple,39560,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4314.37,6979, Resect diaphragm simple,39560,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4314.37,6979, Resect diaphragm simple,39560,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4314.37,6979, Resect diaphragm complex,39561,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6925.66,,,,,,,fee schedule,5097,6979, Resect diaphragm complex,39561,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Resect diaphragm complex,39561,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Resect diaphragm complex,39561,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Diaphragm surgery procedure,39599,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Diaphragm surgery procedure,39599,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Diaphragm surgery procedure,39599,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Biopsy of lip,40490,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,310.76,,,,,,,fee schedule,310.76,6979, Biopsy of lip,40490,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,310.76,6979, Biopsy of lip,40490,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,310.76,6979, Biopsy of lip,40490,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,310.76,6979, Partial excision of lip,40500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1808.63,,,,,,,fee schedule,1808.63,5664, Partial excision of lip,40500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1808.63,5664, Partial excision of lip,40500,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1808.63,5664, Partial excision of lip,40500,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1808.63,5664, Partial excision of lip,40510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1742.15,,,,,,,fee schedule,1742.15,10940, Partial excision of lip,40510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1742.15,10940, Partial excision of lip,40510,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1742.15,10940, Partial excision of lip,40510,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1742.15,10940, Partial excision of lip,40520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1794.82,,,,,,,fee schedule,1794.82,5664, Partial excision of lip,40520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1794.82,5664, Partial excision of lip,40520,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1794.82,5664, Partial excision of lip,40520,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1794.82,5664, Reconstruct lip with flap,40525,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2747.05,,,,,,,fee schedule,2747.05,10940, Reconstruct lip with flap,40525,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2747.05,10940, Reconstruct lip with flap,40525,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2747.05,10940, Reconstruct lip with flap,40525,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2747.05,10940, Reconstruct lip with flap,40527,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3057.27,,,,,,,fee schedule,3057.27,10940, Reconstruct lip with flap,40527,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3057.27,10940, Reconstruct lip with flap,40527,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3057.27,10940, Reconstruct lip with flap,40527,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3057.27,10940, Partial removal of lip,40530,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2021.18,,,,,,,fee schedule,2021.18,10940, Partial removal of lip,40530,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2021.18,10940, Partial removal of lip,40530,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2021.18,10940, Partial removal of lip,40530,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2021.18,10940, Repair lip,40650,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1914.07,,,,,,,fee schedule,1914.07,5248, Repair lip,40650,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1914.07,5248, Repair lip,40650,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1914.07,5248, Repair lip,40650,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1914.07,5248, Repair lip,40652,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1982.87,,,,,,,fee schedule,1982.87,5248, Repair lip,40652,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1982.87,5248, Repair lip,40652,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1982.87,5248, Repair lip,40652,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1982.87,5248, Repair lip,40654,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2165.47,,,,,,,fee schedule,2165.47,5664, Repair lip,40654,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2165.47,5664, Repair lip,40654,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2165.47,5664, Repair lip,40654,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2165.47,5664, Repair cleft lip/nasal,40700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5065.06,,,,,,,fee schedule,5065.06,14456, Repair cleft lip/nasal,40700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,5065.06,14456, Repair cleft lip/nasal,40700,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5065.06,14456, Repair cleft lip/nasal,40700,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5065.06,14456, Repair cleft lip/nasal,40701,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5934.52,,,,,,,fee schedule,5934.52,14456, Repair cleft lip/nasal,40701,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,5934.52,14456, Repair cleft lip/nasal,40701,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5934.52,14456, Repair cleft lip/nasal,40701,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5934.52,14456, Repair cleft lip/nasal,40702,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5004.74,,,,,,,fee schedule,5004.74,14456, Repair cleft lip/nasal,40702,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5004.74,14456, Repair cleft lip/nasal,40702,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5004.74,14456, Repair cleft lip/nasal,40702,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5004.74,14456, Repair cleft lip/nasal,40720,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5135.97,,,,,,,fee schedule,5135.97,14456, Repair cleft lip/nasal,40720,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,5135.97,14456, Repair cleft lip/nasal,40720,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5135.97,14456, Repair cleft lip/nasal,40720,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5135.97,14456, Repair cleft lip/nasal,40761,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5371.12,,,,,,,fee schedule,5248,14456, Repair cleft lip/nasal,40761,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,14456, Repair cleft lip/nasal,40761,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5248,14456, Repair cleft lip/nasal,40761,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5248,14456, Lip surgery procedure,40799,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2505,6979, Lip surgery procedure,40799,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,6979, Lip surgery procedure,40799,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,6979, Drainage of mouth lesion,40800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,623.18,,,,,,,fee schedule,623.18,6979, Drainage of mouth lesion,40800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,623.18,6979, Drainage of mouth lesion,40800,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,623.18,6979, Drainage of mouth lesion,40800,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,623.18,6979, Drainage of mouth lesion,40801,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1030.74,,,,,,,fee schedule,1030.74,4108, Drainage of mouth lesion,40801,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1030.74,4108, Drainage of mouth lesion,40801,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1030.74,4108, Drainage of mouth lesion,40801,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1030.74,4108, Removal foreign body mouth,40804,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,624.96,,,,,,,fee schedule,624.96,6979, Removal foreign body mouth,40804,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,624.96,6979, Removal foreign body mouth,40804,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,624.96,6979, Removal foreign body mouth,40804,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,624.96,6979, Removal foreign body mouth,40805,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1000.53,,,,,,,fee schedule,1000.53,4108, Removal foreign body mouth,40805,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1000.53,4108, Removal foreign body mouth,40805,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1000.53,4108, Removal foreign body mouth,40805,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1000.53,4108, Incision of lip fold,40806,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,156.48,,,,,,,fee schedule,156.48,3195, Incision of lip fold,40806,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,156.48,3195, Incision of lip fold,40806,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,156.48,3195, Incision of lip fold,40806,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,156.48,3195, Biopsy of mouth lesion,40808,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,447.49,,,,,,,fee schedule,447.49,3195, Biopsy of mouth lesion,40808,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,447.49,3195, Biopsy of mouth lesion,40808,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,447.49,3195, Biopsy of mouth lesion,40808,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,447.49,3195, Excision of mouth lesion,40810,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,621.03,,,,,,,fee schedule,621.03,5664, Excision of mouth lesion,40810,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,621.03,5664, Excision of mouth lesion,40810,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,621.03,5664, Excision of mouth lesion,40810,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,621.03,5664, Excise/repair mouth lesion,40812,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,915.32,,,,,,,fee schedule,915.32,5664, Excise/repair mouth lesion,40812,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,915.32,5664, Excise/repair mouth lesion,40812,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,915.32,5664, Excise/repair mouth lesion,40812,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,915.32,5664, Excise/repair mouth lesion,40814,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1435.23,,,,,,,fee schedule,1435.23,10940, Excise/repair mouth lesion,40814,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1435.23,10940, Excise/repair mouth lesion,40814,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1435.23,10940, Excise/repair mouth lesion,40814,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1435.23,10940, Excision of mouth lesion,40816,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1521.35,,,,,,,fee schedule,1521.35,10940, Excision of mouth lesion,40816,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1521.35,10940, Excision of mouth lesion,40816,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1521.35,10940, Excision of mouth lesion,40816,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1521.35,10940, Excise oral mucosa for graft,40818,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1327.96,,,,,,,fee schedule,1327.96,3195, Excise oral mucosa for graft,40818,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1327.96,3195, Excise oral mucosa for graft,40818,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1327.96,3195, Excise oral mucosa for graft,40818,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1327.96,3195, Excise lip or cheek fold,40819,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1019.57,,,,,,,fee schedule,1019.57,5664, Excise lip or cheek fold,40819,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1019.57,5664, Excise lip or cheek fold,40819,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1019.57,5664, Excise lip or cheek fold,40819,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1019.57,5664, Treatment of mouth lesion,40820,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,816.04,,,,,,,fee schedule,816.04,5664, Treatment of mouth lesion,40820,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,816.04,5664, Treatment of mouth lesion,40820,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,816.04,5664, Treatment of mouth lesion,40820,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,816.04,5664, Repair mouth laceration,40830,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,751.77,,,,,,,fee schedule,751.77,6979, Repair mouth laceration,40830,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,751.77,6979, Repair mouth laceration,40830,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,751.77,6979, Repair mouth laceration,40830,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,751.77,6979, Repair mouth laceration,40831,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1051.03,,,,,,,fee schedule,1051.03,3195, Repair mouth laceration,40831,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1051.03,3195, Repair mouth laceration,40831,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1051.03,3195, Repair mouth laceration,40831,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1051.03,3195, Reconstruction of mouth,40840,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3109.82,,,,,,,fee schedule,3109.82,10940, Reconstruction of mouth,40840,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3109.82,10940, Reconstruction of mouth,40840,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3109.82,10940, Reconstruction of mouth,40840,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3109.82,10940, Reconstruction of mouth,40842,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3010.37,,,,,,,fee schedule,3010.37,10940, Reconstruction of mouth,40842,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3010.37,10940, Reconstruction of mouth,40842,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3010.37,10940, Reconstruction of mouth,40842,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3010.37,10940, Reconstruction of mouth,40843,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4343.94,,,,,,,fee schedule,4343.94,10940, Reconstruction of mouth,40843,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4343.94,10940, Reconstruction of mouth,40843,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,4343.94,10940, Reconstruction of mouth,40843,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,4343.94,10940, Reconstruction of mouth,40844,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5896.69,,,,,,,fee schedule,5896.69,14456, Reconstruction of mouth,40844,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,5896.69,14456, Reconstruction of mouth,40844,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5896.69,14456, Reconstruction of mouth,40844,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5896.69,14456, Reconstruction of mouth,40845,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5832.81,,,,,,,fee schedule,5832.81,14456, Reconstruction of mouth,40845,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,5832.81,14456, Reconstruction of mouth,40845,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5832.81,14456, Reconstruction of mouth,40845,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5832.81,14456, Mouth surgery procedure,40899,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,2505,6044, Mouth surgery procedure,40899,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,6044, Mouth surgery procedure,40899,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,6044, Drainage of mouth lesion,41000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,558.92,,,,,,,fee schedule,558.92,3195, Drainage of mouth lesion,41000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,558.92,3195, Drainage of mouth lesion,41000,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,558.92,3195, Drainage of mouth lesion,41000,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,558.92,3195, Drainage of mouth lesion,41005,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,603.11,,,,,,,fee schedule,603.11,3195, Drainage of mouth lesion,41005,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,603.11,3195, Drainage of mouth lesion,41005,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,603.11,3195, Drainage of mouth lesion,41005,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,603.11,3195, Drainage of mouth lesion,41006,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1174.66,,,,,,,fee schedule,1174.66,5664, Drainage of mouth lesion,41006,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1174.66,5664, Drainage of mouth lesion,41006,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1174.66,5664, Drainage of mouth lesion,41006,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1174.66,5664, Drainage of mouth lesion,41007,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1125.07,,,,,,,fee schedule,1125.07,5664, Drainage of mouth lesion,41007,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1125.07,5664, Drainage of mouth lesion,41007,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1125.07,5664, Drainage of mouth lesion,41007,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1125.07,5664, Drainage of mouth lesion,41008,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1337.99,,,,,,,fee schedule,1337.99,5664, Drainage of mouth lesion,41008,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1337.99,5664, Drainage of mouth lesion,41008,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1337.99,5664, Drainage of mouth lesion,41008,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1337.99,5664, Drainage of mouth lesion,41009,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1438.95,,,,,,,fee schedule,1438.95,3195, Drainage of mouth lesion,41009,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1438.95,3195, Drainage of mouth lesion,41009,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1438.95,3195, Drainage of mouth lesion,41009,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1438.95,3195, Incision of tongue fold,41010,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,553.31,,,,,,,fee schedule,553.31,5664, Incision of tongue fold,41010,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,553.31,5664, Incision of tongue fold,41010,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,553.31,5664, Incision of tongue fold,41010,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,553.31,5664, Drainage of mouth lesion,41015,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1519.78,,,,,,,fee schedule,1519.78,3195, Drainage of mouth lesion,41015,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1519.78,3195, Drainage of mouth lesion,41015,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1519.78,3195, Drainage of mouth lesion,41015,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1519.78,3195, Drainage of mouth lesion,41016,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1765.84,,,,,,,fee schedule,1765.84,10940, Drainage of mouth lesion,41016,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1765.84,10940, Drainage of mouth lesion,41016,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1765.84,10940, Drainage of mouth lesion,41016,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1765.84,10940, Drainage of mouth lesion,41017,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1744.2,,,,,,,fee schedule,1744.2,5664, Drainage of mouth lesion,41017,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1744.2,5664, Drainage of mouth lesion,41017,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1744.2,5664, Drainage of mouth lesion,41017,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1744.2,5664, Drainage of mouth lesion,41018,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2043.57,,,,,,,fee schedule,2043.57,5664, Drainage of mouth lesion,41018,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2043.57,5664, Drainage of mouth lesion,41018,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2043.57,5664, Drainage of mouth lesion,41018,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2043.57,5664, Place needles h&n for rt,41019,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2228.87,,,,,,,fee schedule,2228.87,10940, Place needles h&n for rt,41019,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2228.87,10940, Place needles h&n for rt,41019,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2228.87,10940, Place needles h&n for rt,41019,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2228.87,10940, Biopsy of tongue,41100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,532.8,,,,,,,fee schedule,532.8,3195, Biopsy of tongue,41100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,532.8,3195, Biopsy of tongue,41100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,532.8,3195, Biopsy of tongue,41100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,532.8,3195, Biopsy of tongue,41105,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,549.69,,,,,,,fee schedule,549.69,5664, Biopsy of tongue,41105,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,549.69,5664, Biopsy of tongue,41105,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,549.69,5664, Biopsy of tongue,41105,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,549.69,5664, Biopsy of floor of mouth,41108,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,457.47,,,,,,,fee schedule,457.47,4497, Biopsy of floor of mouth,41108,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,457.47,4497, Biopsy of floor of mouth,41108,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,457.47,4497, Biopsy of floor of mouth,41108,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,457.47,4497, Excision of tongue lesion,41110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,646.17,,,,,,,fee schedule,646.17,5664, Excision of tongue lesion,41110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,646.17,5664, Excision of tongue lesion,41110,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,646.17,5664, Excision of tongue lesion,41110,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,646.17,5664, Excision of tongue lesion,41112,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1224.08,,,,,,,fee schedule,1224.08,5664, Excision of tongue lesion,41112,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1224.08,5664, Excision of tongue lesion,41112,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1224.08,5664, Excision of tongue lesion,41112,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1224.08,5664, Excision of tongue lesion,41113,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1330.82,,,,,,,fee schedule,1330.82,5664, Excision of tongue lesion,41113,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1330.82,5664, Excision of tongue lesion,41113,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1330.82,5664, Excision of tongue lesion,41113,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1330.82,5664, Excision of tongue lesion,41114,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3021.6,,,,,,,fee schedule,3021.6,10940, Excision of tongue lesion,41114,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3021.6,10940, Excision of tongue lesion,41114,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3021.6,10940, Excision of tongue lesion,41114,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3021.6,10940, Excision of tongue fold,41115,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,726.03,,,,,,,fee schedule,726.03,5664, Excision of tongue fold,41115,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,726.03,5664, Excision of tongue fold,41115,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,726.03,5664, Excision of tongue fold,41115,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,726.03,5664, Excision of mouth lesion,41116,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1093.99,,,,,,,fee schedule,1093.99,10940, Excision of mouth lesion,41116,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1093.99,10940, Excision of mouth lesion,41116,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1093.99,10940, Excision of mouth lesion,41116,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1093.99,10940, Partial removal of tongue,41120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5288.08,,,,,,,fee schedule,5288.08,14456, Partial removal of tongue,41120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,5288.08,14456, Partial removal of tongue,41120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5288.08,14456, Partial removal of tongue,41120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5288.08,14456, Partial removal of tongue,41130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6458.04,,,,,,,fee schedule,5097,6979, Partial removal of tongue,41130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Partial removal of tongue,41130,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Partial removal of tongue,41130,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Tongue and neck surgery,41135,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10551.28,,,,,,,fee schedule,6979,10940, Tongue and neck surgery,41135,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,10940, Tongue and neck surgery,41135,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,6979,10940, Tongue and neck surgery,41135,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,6979,10940, Removal of tongue,41140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10575.3,,,,,,,fee schedule,5097,10575.3, Removal of tongue,41140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,10575.3, Removal of tongue,41140,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,10575.3, Removal of tongue,41140,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,10575.3, Tongue removal neck surgery,41145,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,13289.86,,,,,,,fee schedule,5097,13289.86, Tongue removal neck surgery,41145,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,13289.86, Tongue removal neck surgery,41145,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,13289.86, Tongue removal neck surgery,41145,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,13289.86, Tongue mouth jaw surgery,41150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10675.07,,,,,,,fee schedule,5097,10675.07, Tongue mouth jaw surgery,41150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,10675.07, Tongue mouth jaw surgery,41150,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,10675.07, Tongue mouth jaw surgery,41150,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,10675.07, Tongue mouth neck surgery,41153,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,11578.04,,,,,,,fee schedule,5097,11578.04, Tongue mouth neck surgery,41153,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,11578.04, Tongue mouth neck surgery,41153,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,11578.04, Tongue mouth neck surgery,41153,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,11578.04, Tongue jaw & neck surgery,41155,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,14458.26,,,,,,,fee schedule,5097,14458.26, Tongue jaw & neck surgery,41155,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,14458.26, Tongue jaw & neck surgery,41155,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,14458.26, Tongue jaw & neck surgery,41155,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,14458.26, Repair tongue laceration,41250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,916.35,,,,,,,fee schedule,916.35,4108, Repair tongue laceration,41250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,916.35,4108, Repair tongue laceration,41250,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,916.35,4108, Repair tongue laceration,41250,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,916.35,4108, Repair tongue laceration,41251,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1242.05,,,,,,,fee schedule,1242.05,4108, Repair tongue laceration,41251,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1242.05,4108, Repair tongue laceration,41251,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1242.05,4108, Repair tongue laceration,41251,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1242.05,4108, Repair tongue laceration,41252,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1080.55,,,,,,,fee schedule,1080.55,4108, Repair tongue laceration,41252,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1080.55,4108, Repair tongue laceration,41252,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1080.55,4108, Repair tongue laceration,41252,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1080.55,4108, Tongue to lip surgery,41510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2297.13,,,,,,,fee schedule,2297.13,5664, Tongue to lip surgery,41510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2297.13,5664, Tongue to lip surgery,41510,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2297.13,5664, Tongue to lip surgery,41510,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2297.13,5664, Tongue suspension,41512,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3343.42,,,,,,,fee schedule,3343.42,14456, Tongue suspension,41512,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3343.42,14456, Tongue suspension,41512,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3343.42,14456, Tongue suspension,41512,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3343.42,14456, Reconstruction tongue fold,41520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1250.2,,,,,,,fee schedule,1250.2,14456, Reconstruction tongue fold,41520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1250.2,14456, Reconstruction tongue fold,41520,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,1250.2,14456, Reconstruction tongue fold,41520,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,1250.2,14456, Tongue base vol reduction,41530,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1940.4,,,,,,,fee schedule,1940.4,10940, Tongue base vol reduction,41530,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1940.4,10940, Tongue base vol reduction,41530,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1940.4,10940, Tongue base vol reduction,41530,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1940.4,10940, Tongue and mouth surgery,41599,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2505,6979, Tongue and mouth surgery,41599,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,6979, Tongue and mouth surgery,41599,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,6979, Drainage of gum lesion,41800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1010.67,,,,,,,fee schedule,1010.67,3195, Drainage of gum lesion,41800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1010.67,3195, Drainage of gum lesion,41800,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1010.67,3195, Drainage of gum lesion,41800,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1010.67,3195, Removal foreign body gum,41805,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1018.12,,,,,,,fee schedule,1018.12,5664, Removal foreign body gum,41805,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1018.12,5664, Removal foreign body gum,41805,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1018.12,5664, Removal foreign body gum,41805,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1018.12,5664, Removal foreign body jawbone,41806,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1415.32,,,,,,,fee schedule,1415.32,5664, Removal foreign body jawbone,41806,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1415.32,5664, Removal foreign body jawbone,41806,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1415.32,5664, Removal foreign body jawbone,41806,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1415.32,5664, Excision gum each quadrant,41820,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,10940, Excision gum each quadrant,41820,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3195,10940, Excision gum each quadrant,41820,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3195,10940, Excision of gum flap,41821,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,5664, Excision of gum flap,41821,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3195,5664, Excision of gum flap,41821,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3195,5664, Excision of gum lesion,41822,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1032.79,,,,,,,fee schedule,1032.79,5664, Excision of gum lesion,41822,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1032.79,5664, Excision of gum lesion,41822,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1032.79,5664, Excision of gum lesion,41822,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1032.79,5664, Excision of gum lesion,41823,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1936.41,,,,,,,fee schedule,1936.41,10940, Excision of gum lesion,41823,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1936.41,10940, Excision of gum lesion,41823,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1936.41,10940, Excision of gum lesion,41823,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1936.41,10940, Excision of gum lesion,41825,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,600.63,,,,,,,fee schedule,600.63,5664, Excision of gum lesion,41825,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,600.63,5664, Excision of gum lesion,41825,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,600.63,5664, Excision of gum lesion,41825,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,600.63,5664, Excision of gum lesion,41826,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,970.74,,,,,,,fee schedule,970.74,10940, Excision of gum lesion,41826,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,970.74,10940, Excision of gum lesion,41826,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,970.74,10940, Excision of gum lesion,41826,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,970.74,10940, Excision of gum lesion,41827,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1438.84,,,,,,,fee schedule,1438.84,14456, Excision of gum lesion,41827,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1438.84,14456, Excision of gum lesion,41827,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,1438.84,14456, Excision of gum lesion,41827,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,1438.84,14456, Excision of gum lesion,41828,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1113.3,,,,,,,fee schedule,1113.3,5664, Excision of gum lesion,41828,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1113.3,5664, Excision of gum lesion,41828,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1113.3,5664, Excision of gum lesion,41828,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1113.3,5664, Removal of gum tissue,41830,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1609.2,,,,,,,fee schedule,1609.2,10940, Removal of gum tissue,41830,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1609.2,10940, Removal of gum tissue,41830,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1609.2,10940, Removal of gum tissue,41830,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1609.2,10940, Treatment of gum lesion,41850,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,5664, Treatment of gum lesion,41850,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3195,5664, Treatment of gum lesion,41850,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3195,5664, Gum graft,41870,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,5664, Gum graft,41870,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4108,5664, Gum graft,41870,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4108,5664, Repair gum,41872,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1618.58,,,,,,,fee schedule,1618.58,14456, Repair gum,41872,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1618.58,14456, Repair gum,41872,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,1618.58,14456, Repair gum,41872,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,1618.58,14456, Repair tooth socket,41874,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1228.13,,,,,,,fee schedule,1228.13,5664, Repair tooth socket,41874,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1228.13,5664, Repair tooth socket,41874,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1228.13,5664, Repair tooth socket,41874,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1228.13,5664, Dental surgery procedure,41899,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Dental surgery procedure,41899,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Dental surgery procedure,41899,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Drainage mouth roof lesion,42000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,539.38,,,,,,,fee schedule,539.38,4108, Drainage mouth roof lesion,42000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,539.38,4108, Drainage mouth roof lesion,42000,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,539.38,4108, Drainage mouth roof lesion,42000,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,539.38,4108, Biopsy roof of mouth,42100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,552.06,,,,,,,fee schedule,552.06,5664, Biopsy roof of mouth,42100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,552.06,5664, Biopsy roof of mouth,42100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,552.06,5664, Biopsy roof of mouth,42100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,552.06,5664, Excision lesion mouth roof,42104,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,667.11,,,,,,,fee schedule,667.11,5664, Excision lesion mouth roof,42104,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,667.11,5664, Excision lesion mouth roof,42104,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,667.11,5664, Excision lesion mouth roof,42104,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,667.11,5664, Excision lesion mouth roof,42106,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,816.9,,,,,,,fee schedule,816.9,5664, Excision lesion mouth roof,42106,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,816.9,5664, Excision lesion mouth roof,42106,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,816.9,5664, Excision lesion mouth roof,42106,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,816.9,5664, Excision lesion mouth roof,42107,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1664.83,,,,,,,fee schedule,1664.83,10940, Excision lesion mouth roof,42107,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1664.83,10940, Excision lesion mouth roof,42107,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1664.83,10940, Excision lesion mouth roof,42107,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1664.83,10940, Remove palate/lesion,42120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4963.83,,,,,,,fee schedule,4963.83,10940, Remove palate/lesion,42120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4963.83,10940, Remove palate/lesion,42120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,4963.83,10940, Remove palate/lesion,42120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,4963.83,10940, Excision of uvula,42140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,819.81,,,,,,,fee schedule,819.81,5664, Excision of uvula,42140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,819.81,5664, Excision of uvula,42140,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,819.81,5664, Excision of uvula,42140,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,819.81,5664, Repair palate pharynx/uvula,42145,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3352,,,,,,,fee schedule,3352,10940, Repair palate pharynx/uvula,42145,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,3352,10940, Repair palate pharynx/uvula,42145,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3352,10940, Repair palate pharynx/uvula,42145,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3352,10940, Treatment mouth roof lesion,42160,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,701.05,,,,,,,fee schedule,701.05,5664, Treatment mouth roof lesion,42160,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,701.05,5664, Treatment mouth roof lesion,42160,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,701.05,5664, Treatment mouth roof lesion,42160,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,701.05,5664, Repair palate,42180,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,925.36,,,,,,,fee schedule,925.36,3195, Repair palate,42180,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,925.36,3195, Repair palate,42180,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,925.36,3195, Repair palate,42180,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,925.36,3195, Repair palate,42182,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1258.24,,,,,,,fee schedule,1258.24,10940, Repair palate,42182,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1258.24,10940, Repair palate,42182,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1258.24,10940, Repair palate,42182,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1258.24,10940, Reconstruct cleft palate,42200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4667.86,,,,,,,fee schedule,4667.86,14456, Reconstruct cleft palate,42200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4667.86,14456, Reconstruct cleft palate,42200,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4667.86,14456, Reconstruct cleft palate,42200,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4667.86,14456, Reconstruct cleft palate,42205,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4828.23,,,,,,,fee schedule,4828.23,14456, Reconstruct cleft palate,42205,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4828.23,14456, Reconstruct cleft palate,42205,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4828.23,14456, Reconstruct cleft palate,42205,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4828.23,14456, Reconstruct cleft palate,42210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5389.69,,,,,,,fee schedule,5389.69,14456, Reconstruct cleft palate,42210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,5389.69,14456, Reconstruct cleft palate,42210,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5389.69,14456, Reconstruct cleft palate,42210,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5389.69,14456, Reconstruct cleft palate,42215,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3578.03,,,,,,,fee schedule,3578.03,14456, Reconstruct cleft palate,42215,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,3578.03,14456, Reconstruct cleft palate,42215,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3578.03,14456, Reconstruct cleft palate,42215,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3578.03,14456, Reconstruct cleft palate,42220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2966.18,,,,,,,fee schedule,2966.18,14456, Reconstruct cleft palate,42220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,2966.18,14456, Reconstruct cleft palate,42220,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,2966.18,14456, Reconstruct cleft palate,42220,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,2966.18,14456, Reconstruct cleft palate,42225,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5249.28,,,,,,,fee schedule,5249.28,14456, Reconstruct cleft palate,42225,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,5249.28,14456, Reconstruct cleft palate,42225,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5249.28,14456, Reconstruct cleft palate,42225,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5249.28,14456, Lengthening of palate,42226,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4530.75,,,,,,,fee schedule,4530.75,14456, Lengthening of palate,42226,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4530.75,14456, Lengthening of palate,42226,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4530.75,14456, Lengthening of palate,42226,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4530.75,14456, Lengthening of palate,42227,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4211.96,,,,,,,fee schedule,4211.96,14456, Lengthening of palate,42227,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4211.96,14456, Lengthening of palate,42227,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4211.96,14456, Lengthening of palate,42227,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4211.96,14456, Repair palate,42235,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3732.36,,,,,,,fee schedule,3732.36,14456, Repair palate,42235,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,3732.36,14456, Repair palate,42235,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3732.36,14456, Repair palate,42235,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3732.36,14456, Repair nose to lip fistula,42260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3250.98,,,,,,,fee schedule,3250.98,10940, Repair nose to lip fistula,42260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3250.98,10940, Repair nose to lip fistula,42260,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3250.98,10940, Repair nose to lip fistula,42260,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3250.98,10940, Preparation palate mold,42280,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,540.57,,,,,,,fee schedule,540.57,3195, Preparation palate mold,42280,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,540.57,3195, Preparation palate mold,42280,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,540.57,3195, Preparation palate mold,42280,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,540.57,3195, Insertion palate prosthesis,42281,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,834.49,,,,,,,fee schedule,834.49,5664, Insertion palate prosthesis,42281,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,834.49,5664, Insertion palate prosthesis,42281,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,834.49,5664, Insertion palate prosthesis,42281,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,834.49,5664, Palate/uvula surgery,42299,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2505,6979, Palate/uvula surgery,42299,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,6979, Palate/uvula surgery,42299,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,6979, Drainage of salivary gland,42300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,771.52,,,,,,,fee schedule,771.52,5664, Drainage of salivary gland,42300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,771.52,5664, Drainage of salivary gland,42300,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,771.52,5664, Drainage of salivary gland,42300,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,771.52,5664, Drainage of salivary gland,42305,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2122.41,,,,,,,fee schedule,2122.41,10940, Drainage of salivary gland,42305,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2122.41,10940, Drainage of salivary gland,42305,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2122.41,10940, Drainage of salivary gland,42305,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2122.41,10940, Drainage of salivary gland,42310,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,694.03,,,,,,,fee schedule,694.03,3195, Drainage of salivary gland,42310,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,694.03,3195, Drainage of salivary gland,42310,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,694.03,3195, Drainage of salivary gland,42310,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,694.03,3195, Drainage of salivary gland,42320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,888.72,,,,,,,fee schedule,888.72,3195, Drainage of salivary gland,42320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,888.72,3195, Drainage of salivary gland,42320,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,888.72,3195, Drainage of salivary gland,42320,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,888.72,3195, Removal of salivary stone,42330,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,825.32,,,,,,,fee schedule,825.32,5664, Removal of salivary stone,42330,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,825.32,5664, Removal of salivary stone,42330,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,825.32,5664, Removal of salivary stone,42330,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,825.32,5664, Removal of salivary stone,42335,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1309.07,,,,,,,fee schedule,1309.07,10940, Removal of salivary stone,42335,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1309.07,10940, Removal of salivary stone,42335,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1309.07,10940, Removal of salivary stone,42335,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1309.07,10940, Removal of salivary stone,42340,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1695.32,,,,,,,fee schedule,1695.32,5664, Removal of salivary stone,42340,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1695.32,5664, Removal of salivary stone,42340,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1695.32,5664, Removal of salivary stone,42340,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1695.32,5664, Biopsy of salivary gland,42400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,260.3,,,,,,,fee schedule,260.3,4497, Biopsy of salivary gland,42400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,260.3,4497, Biopsy of salivary gland,42400,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,260.3,4497, Biopsy of salivary gland,42400,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,260.3,4497, Biopsy of salivary gland,42405,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1113.63,,,,,,,fee schedule,1113.63,5664, Biopsy of salivary gland,42405,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1113.63,5664, Biopsy of salivary gland,42405,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1113.63,5664, Biopsy of salivary gland,42405,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1113.63,5664, Excision of salivary cyst,42408,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1773.13,,,,,,,fee schedule,1773.13,10940, Excision of salivary cyst,42408,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1773.13,10940, Excision of salivary cyst,42408,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1773.13,10940, Excision of salivary cyst,42408,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1773.13,10940, Drainage of salivary cyst,42409,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1149.4,,,,,,,fee schedule,1149.4,10940, Drainage of salivary cyst,42409,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1149.4,10940, Drainage of salivary cyst,42409,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1149.4,10940, Drainage of salivary cyst,42409,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1149.4,10940, Excise parotid gland/lesion,42410,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3090.94,,,,,,,fee schedule,3090.94,14456, Excise parotid gland/lesion,42410,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3090.94,14456, Excise parotid gland/lesion,42410,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3090.94,14456, Excise parotid gland/lesion,42410,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3090.94,14456, Excise parotid gland/lesion,42415,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5127.01,,,,,,,fee schedule,5127.01,14456, Excise parotid gland/lesion,42415,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,5127.01,14456, Excise parotid gland/lesion,42415,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5127.01,14456, Excise parotid gland/lesion,42415,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5127.01,14456, Excise parotid gland/lesion,42420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5721.38,,,,,,,fee schedule,5721.38,14456, Excise parotid gland/lesion,42420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,5721.38,14456, Excise parotid gland/lesion,42420,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5721.38,14456, Excise parotid gland/lesion,42420,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5721.38,14456, Excise parotid gland/lesion,42425,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4063.19,,,,,,,fee schedule,4063.19,14456, Excise parotid gland/lesion,42425,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,4063.19,14456, Excise parotid gland/lesion,42425,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4063.19,14456, Excise parotid gland/lesion,42425,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4063.19,14456, Excise parotid gland/lesion,42426,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6533.31,,,,,,,fee schedule,6533.31,10940, Excise parotid gland/lesion,42426,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6533.31,10940, Excise parotid gland/lesion,42426,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,6533.31,10940, Excise parotid gland/lesion,42426,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,6533.31,10940, Excise submaxillary gland,42440,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2046.06,,,,,,,fee schedule,2046.06,14456, Excise submaxillary gland,42440,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2046.06,14456, Excise submaxillary gland,42440,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,2046.06,14456, Excise submaxillary gland,42440,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,2046.06,14456, Excise sublingual gland,42450,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1800.59,,,,,,,fee schedule,1800.59,10940, Excise sublingual gland,42450,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1800.59,10940, Excise sublingual gland,42450,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1800.59,10940, Excise sublingual gland,42450,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1800.59,10940, Repair salivary duct,42500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1711.5,,,,,,,fee schedule,1711.5,10940, Repair salivary duct,42500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1711.5,10940, Repair salivary duct,42500,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1711.5,10940, Repair salivary duct,42500,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1711.5,10940, Repair salivary duct,42505,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2253.42,,,,,,,fee schedule,2253.42,14456, Repair salivary duct,42505,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2253.42,14456, Repair salivary duct,42505,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,2253.42,14456, Repair salivary duct,42505,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,2253.42,14456, Parotid duct diversion,42507,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2413.85,,,,,,,fee schedule,2413.85,14456, Parotid duct diversion,42507,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2413.85,14456, Parotid duct diversion,42507,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,2413.85,14456, Parotid duct diversion,42507,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,2413.85,14456, Parotid duct diversion,42509,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3963.52,,,,,,,fee schedule,3963.52,14456, Parotid duct diversion,42509,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3963.52,14456, Parotid duct diversion,42509,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3963.52,14456, Parotid duct diversion,42509,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3963.52,14456, Parotid duct diversion,42510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2955.17,,,,,,,fee schedule,2955.17,14456, Parotid duct diversion,42510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2955.17,14456, Parotid duct diversion,42510,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,2955.17,14456, Parotid duct diversion,42510,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,2955.17,14456, Injection for salivary x-ray,42550,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,290.3,,,,,,,fee schedule,290.3,3195, Injection for salivary x-ray,42550,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,290.3,3195, Injection for salivary x-ray,42550,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,290.3,3195, Injection for salivary x-ray,42550,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,290.3,3195, Closure of salivary fistula,42600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1754.46,,,,,,,fee schedule,1754.46,5664, Closure of salivary fistula,42600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1754.46,5664, Closure of salivary fistula,42600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1754.46,5664, Closure of salivary fistula,42600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1754.46,5664, Dilation of salivary duct,42650,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,292.46,,,,,,,fee schedule,292.46,5664, Dilation of salivary duct,42650,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,292.46,5664, Dilation of salivary duct,42650,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,292.46,5664, Dilation of salivary duct,42650,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,292.46,5664, Dilation of salivary duct,42660,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,386.35,,,,,,,fee schedule,386.35,3195, Dilation of salivary duct,42660,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,386.35,3195, Dilation of salivary duct,42660,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,386.35,3195, Dilation of salivary duct,42660,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,386.35,3195, Ligation of salivary duct,42665,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1076.07,,,,,,,fee schedule,1076.07,10940, Ligation of salivary duct,42665,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,1076.07,10940, Ligation of salivary duct,42665,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1076.07,10940, Ligation of salivary duct,42665,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1076.07,10940, Salivary surgery procedure,42699,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Salivary surgery procedure,42699,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Salivary surgery procedure,42699,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Drainage of tonsil abscess,42700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,700.18,,,,,,,fee schedule,700.18,3195, Drainage of tonsil abscess,42700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,700.18,3195, Drainage of tonsil abscess,42700,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,700.18,3195, Drainage of tonsil abscess,42700,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,700.18,3195, Drainage of throat abscess,42720,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1861.51,,,,,,,fee schedule,1861.51,5664, Drainage of throat abscess,42720,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1861.51,5664, Drainage of throat abscess,42720,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1861.51,5664, Drainage of throat abscess,42720,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1861.51,5664, Drainage of throat abscess,42725,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3938,,,,,,,fee schedule,3938,14456, Drainage of throat abscess,42725,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3938,14456, Drainage of throat abscess,42725,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3938,14456, Drainage of throat abscess,42725,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3938,14456, Biopsy of throat,42800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,579.75,,,,,,,fee schedule,579.75,4497, Biopsy of throat,42800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,579.75,4497, Biopsy of throat,42800,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,579.75,4497, Biopsy of throat,42800,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,579.75,4497, Biopsy of upper nose/throat,42804,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,610.13,,,,,,,fee schedule,610.13,5664, Biopsy of upper nose/throat,42804,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,610.13,5664, Biopsy of upper nose/throat,42804,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,610.13,5664, Biopsy of upper nose/throat,42804,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,610.13,5664, Biopsy of upper nose/throat,42806,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,697.65,,,,,,,fee schedule,697.65,10940, Biopsy of upper nose/throat,42806,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,697.65,10940, Biopsy of upper nose/throat,42806,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,697.65,10940, Biopsy of upper nose/throat,42806,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,697.65,10940, Excise pharynx lesion,42808,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,817.66,,,,,,,fee schedule,817.66,10940, Excise pharynx lesion,42808,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,817.66,10940, Excise pharynx lesion,42808,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,817.66,10940, Excise pharynx lesion,42808,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,817.66,10940, Remove pharynx foreign body,42809,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,645.04,,,,,,,fee schedule,645.04,3195, Remove pharynx foreign body,42809,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,645.04,3195, Remove pharynx foreign body,42809,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,645.04,3195, Remove pharynx foreign body,42809,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,645.04,3195, Excision of neck cyst,42810,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1402.69,,,,,,,fee schedule,1402.69,10940, Excision of neck cyst,42810,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1402.69,10940, Excision of neck cyst,42810,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1402.69,10940, Excision of neck cyst,42810,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1402.69,10940, Excision of neck cyst,42815,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2627.42,,,,,,,fee schedule,2627.42,14456, Excision of neck cyst,42815,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,2627.42,14456, Excision of neck cyst,42815,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,2627.42,14456, Excision of neck cyst,42815,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,2627.42,14456, Remove tonsils and adenoids,42820,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1436.42,,,,,,,fee schedule,1436.42,10940, Remove tonsils and adenoids,42820,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1436.42,10940, Remove tonsils and adenoids,42820,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1436.42,10940, Remove tonsils and adenoids,42820,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1436.42,10940, Remove tonsils and adenoids,42821,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1498.09,,,,,,,fee schedule,1498.09,10940, Remove tonsils and adenoids,42821,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,1498.09,10940, Remove tonsils and adenoids,42821,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1498.09,10940, Remove tonsils and adenoids,42821,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1498.09,10940, Removal of tonsils,42825,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1330.49,,,,,,,fee schedule,1330.49,10940, Removal of tonsils,42825,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,1330.49,10940, Removal of tonsils,42825,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1330.49,10940, Removal of tonsils,42825,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1330.49,10940, Removal of tonsils,42826,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1268.01,,,,,,,fee schedule,1268.01,10940, Removal of tonsils,42826,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,1268.01,10940, Removal of tonsils,42826,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1268.01,10940, Removal of tonsils,42826,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1268.01,10940, Removal of adenoids,42830,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1065.87,,,,,,,fee schedule,1065.87,10940, Removal of adenoids,42830,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,1065.87,10940, Removal of adenoids,42830,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1065.87,10940, Removal of adenoids,42830,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1065.87,10940, Removal of adenoids,42831,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1158.74,,,,,,,fee schedule,1158.74,10940, Removal of adenoids,42831,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,1158.74,10940, Removal of adenoids,42831,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1158.74,10940, Removal of adenoids,42831,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1158.74,10940, Removal of adenoids,42835,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,998.85,,,,,,,fee schedule,998.85,10940, Removal of adenoids,42835,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,998.85,10940, Removal of adenoids,42835,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,998.85,10940, Removal of adenoids,42835,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,998.85,10940, Removal of adenoids,42836,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1219.82,,,,,,,fee schedule,1219.82,10940, Removal of adenoids,42836,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,1219.82,10940, Removal of adenoids,42836,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1219.82,10940, Removal of adenoids,42836,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1219.82,10940, Extensive surgery of throat,42842,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4967.67,,,,,,,fee schedule,4967.67,10940, Extensive surgery of throat,42842,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4967.67,10940, Extensive surgery of throat,42842,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,4967.67,10940, Extensive surgery of throat,42842,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,4967.67,10940, Extensive surgery of throat,42844,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6732.05,,,,,,,fee schedule,6732.05,14456, Extensive surgery of throat,42844,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6732.05,14456, Extensive surgery of throat,42844,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,6732.05,14456, Extensive surgery of throat,42844,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,6732.05,14456, Extensive surgery of throat,42845,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10664.76,,,,,,,fee schedule,5097,10664.76, Extensive surgery of throat,42845,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,10664.76, Extensive surgery of throat,42845,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,10664.76, Extensive surgery of throat,42845,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,10664.76, Excision of tonsil tags,42860,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,978.24,,,,,,,fee schedule,978.24,10940, Excision of tonsil tags,42860,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,978.24,10940, Excision of tonsil tags,42860,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,978.24,10940, Excision of tonsil tags,42860,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,978.24,10940, Excision of lingual tonsil,42870,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2949.72,,,,,,,fee schedule,2949.72,10940, Excision of lingual tonsil,42870,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2949.72,10940, Excision of lingual tonsil,42870,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2949.72,10940, Excision of lingual tonsil,42870,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2949.72,10940, Description Not Available,42880,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Partial removal of pharynx,42890,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6895.06,,,,,,,fee schedule,6895.06,14456, Partial removal of pharynx,42890,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,6895.06,14456, Partial removal of pharynx,42890,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,6895.06,14456, Partial removal of pharynx,42890,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,6895.06,14456, Revision of pharyngeal walls,42892,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9032.9,,,,,,,fee schedule,8406,14456, Revision of pharyngeal walls,42892,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,8406,14456, Revision of pharyngeal walls,42892,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,8406,14456, Revision of pharyngeal walls,42892,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,8406,14456, Revision of pharyngeal walls,42894,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,11430.67,,,,,,,fee schedule,5097,11430.67, Revision of pharyngeal walls,42894,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,11430.67, Revision of pharyngeal walls,42894,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,11430.67, Revision of pharyngeal walls,42894,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,11430.67, Repair throat wound,42900,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1606.23,,,,,,,fee schedule,1606.23,5664, Repair throat wound,42900,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1606.23,5664, Repair throat wound,42900,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1606.23,5664, Repair throat wound,42900,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1606.23,5664, Reconstruction of throat,42950,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3964.23,,,,,,,fee schedule,3964.23,10940, Reconstruction of throat,42950,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3964.23,10940, Reconstruction of throat,42950,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3964.23,10940, Reconstruction of throat,42950,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3964.23,10940, Repair throat esophagus,42953,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4826.51,,,,,,,fee schedule,4826.51,6979, Repair throat esophagus,42953,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4826.51,6979, Repair throat esophagus,42953,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4826.51,6979, Repair throat esophagus,42953,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4826.51,6979, Surgical opening of throat,42955,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3768.51,,,,,,,fee schedule,3768.51,5664, Surgical opening of throat,42955,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3768.51,5664, Surgical opening of throat,42955,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3768.51,5664, Surgical opening of throat,42955,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3768.51,5664, Control throat bleeding,42960,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,806.11,,,,,,,fee schedule,806.11,3195, Control throat bleeding,42960,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,806.11,3195, Control throat bleeding,42960,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,806.11,3195, Control throat bleeding,42960,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,806.11,3195, Control throat bleeding,42961,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2048.38,,,,,,,fee schedule,2048.38,10940, Control throat bleeding,42961,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2048.38,10940, Control throat bleeding,42961,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2048.38,10940, Control throat bleeding,42961,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2048.38,10940, Control throat bleeding,42962,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2523.98,,,,,,,fee schedule,2523.98,10940, Control throat bleeding,42962,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2523.98,10940, Control throat bleeding,42962,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2523.98,10940, Control throat bleeding,42962,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2523.98,10940, Control nose/throat bleeding,42970,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2006.61,,,,,,,fee schedule,2006.61,3195, Control nose/throat bleeding,42970,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2006.61,3195, Control nose/throat bleeding,42970,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2006.61,3195, Control nose/throat bleeding,42970,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2006.61,3195, Control nose/throat bleeding,42971,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2205.18,,,,,,,fee schedule,2205.18,6979, Control nose/throat bleeding,42971,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2205.18,6979, Control nose/throat bleeding,42971,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2205.18,6979, Control nose/throat bleeding,42971,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2205.18,6979, Control nose/throat bleeding,42972,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2458.47,,,,,,,fee schedule,2458.47,5664, Control nose/throat bleeding,42972,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2458.47,5664, Control nose/throat bleeding,42972,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2458.47,5664, Control nose/throat bleeding,42972,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2458.47,5664, Dise eval slp do brth flx dx,42975,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,463.68,,,,,,,fee schedule,463.68,4108, Dise eval slp do brth flx dx,42975,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,463.68,4108, Dise eval slp do brth flx dx,42975,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,463.68,4108, Dise eval slp do brth flx dx,42975,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,463.68,4108, Throat surgery procedure,42999,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Throat surgery procedure,42999,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Throat surgery procedure,42999,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Incision of esophagus,43020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3120.99,,,,,,,fee schedule,3120.99,6979, Incision of esophagus,43020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3120.99,6979, Incision of esophagus,43020,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3120.99,6979, Incision of esophagus,43020,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3120.99,6979, Throat muscle surgery,43030,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2589.11,,,,,,,fee schedule,2589.11,14456, Throat muscle surgery,43030,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2589.11,14456, Throat muscle surgery,43030,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,2589.11,14456, Throat muscle surgery,43030,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,2589.11,14456, Incision of esophagus,43045,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7190.87,,,,,,,fee schedule,5097,7190.87, Incision of esophagus,43045,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7190.87, Incision of esophagus,43045,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7190.87, Incision of esophagus,43045,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7190.87, Excision of esophagus lesion,43100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3087.91,,,,,,,fee schedule,3087.91,6979, Excision of esophagus lesion,43100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3087.91,6979, Excision of esophagus lesion,43100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3087.91,6979, Excision of esophagus lesion,43100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3087.91,6979, Excision of esophagus lesion,43101,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5541.75,,,,,,,fee schedule,5097,6979, Excision of esophagus lesion,43101,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Excision of esophagus lesion,43101,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Excision of esophagus lesion,43101,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Removal of esophagus,43107,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,15898.4,,,,,,,fee schedule,5097,15898.4, Removal of esophagus,43107,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,15898.4, Removal of esophagus,43107,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,15898.4, Removal of esophagus,43107,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,15898.4, Removal of esophagus,43108,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,23797.22,,,,,,,fee schedule,5097,23797.22, Removal of esophagus,43108,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,23797.22, Removal of esophagus,43108,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,23797.22, Removal of esophagus,43108,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,23797.22, Removal of esophagus,43112,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,18483.13,,,,,,,fee schedule,5097,18483.13, Removal of esophagus,43112,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,18483.13, Removal of esophagus,43112,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,18483.13, Removal of esophagus,43112,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,18483.13, Removal of esophagus,43113,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,23356.21,,,,,,,fee schedule,5097,23356.21, Removal of esophagus,43113,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,23356.21, Removal of esophagus,43113,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,23356.21, Removal of esophagus,43113,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,23356.21, Partial removal of esophagus,43116,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,26591.97,,,,,,,fee schedule,5097,26591.97, Partial removal of esophagus,43116,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,26591.97, Partial removal of esophagus,43116,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,26591.97, Partial removal of esophagus,43116,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,26591.97, Partial removal of esophagus,43117,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,17460.11,,,,,,,fee schedule,5097,17460.11, Partial removal of esophagus,43117,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,17460.11, Partial removal of esophagus,43117,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,17460.11, Partial removal of esophagus,43117,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,17460.11, Partial removal of esophagus,43118,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,19446.7,,,,,,,fee schedule,5097,19446.7, Partial removal of esophagus,43118,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,19446.7, Partial removal of esophagus,43118,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,19446.7, Partial removal of esophagus,43118,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,19446.7, Partial removal of esophagus,43121,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,15464.29,,,,,,,fee schedule,5097,15464.29, Partial removal of esophagus,43121,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,15464.29, Partial removal of esophagus,43121,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,15464.29, Partial removal of esophagus,43121,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,15464.29, Partial removal of esophagus,43122,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,13465.72,,,,,,,fee schedule,5097,13465.72, Partial removal of esophagus,43122,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,13465.72, Partial removal of esophagus,43122,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,13465.72, Partial removal of esophagus,43122,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,13465.72, Partial removal of esophagus,43123,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,24198.09,,,,,,,fee schedule,5097,24198.09, Partial removal of esophagus,43123,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,24198.09, Partial removal of esophagus,43123,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,24198.09, Partial removal of esophagus,43123,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,24198.09, Removal of esophagus,43124,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,20539.28,,,,,,,fee schedule,5097,20539.28, Removal of esophagus,43124,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,20539.28, Removal of esophagus,43124,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,20539.28, Removal of esophagus,43124,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,20539.28, Removal of esophagus pouch,43130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4001.3,,,,,,,fee schedule,4001.3,14456, Removal of esophagus pouch,43130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4001.3,14456, Removal of esophagus pouch,43130,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4001.3,14456, Removal of esophagus pouch,43130,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4001.3,14456, Removal of esophagus pouch,43135,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7998.87,,,,,,,fee schedule,5097,7998.87, Removal of esophagus pouch,43135,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7998.87, Removal of esophagus pouch,43135,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7998.87, Removal of esophagus pouch,43135,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7998.87, Esophagoscopy rigid trnso,43180,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2669.72,,,,,,,fee schedule,2669.72,10940, Esophagoscopy rigid trnso,43180,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2669.72,10940, Esophagoscopy rigid trnso,43180,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2669.72,10940, Esophagoscopy rigid trnso,43180,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2669.72,10940, Esophagoscopy rigid trnso dx,43191,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,755.28,,,,,,,fee schedule,755.28,5664, Esophagoscopy rigid trnso dx,43191,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,755.28,5664, Esophagoscopy rigid trnso dx,43191,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,755.28,5664, Esophagoscopy rigid trnso dx,43191,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,755.28,5664, Esophagoscp rig trnso inject,43192,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,819.11,,,,,,,fee schedule,819.11,5664, Esophagoscp rig trnso inject,43192,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,819.11,5664, Esophagoscp rig trnso inject,43192,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,819.11,5664, Esophagoscp rig trnso inject,43192,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,819.11,5664, Esophagoscp rig trnso biopsy,43193,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,825.26,,,,,,,fee schedule,825.26,5664, Esophagoscp rig trnso biopsy,43193,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,825.26,5664, Esophagoscp rig trnso biopsy,43193,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,825.26,5664, Esophagoscp rig trnso biopsy,43193,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,825.26,5664, Esophagoscp rig trnso rem fb,43194,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,908.36,,,,,,,fee schedule,908.36,5664, Esophagoscp rig trnso rem fb,43194,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,908.36,5664, Esophagoscp rig trnso rem fb,43194,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,908.36,5664, Esophagoscp rig trnso rem fb,43194,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,908.36,5664, Esophagoscopy rigid balloon,43195,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,887.97,,,,,,,fee schedule,887.97,5664, Esophagoscopy rigid balloon,43195,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,887.97,5664, Esophagoscopy rigid balloon,43195,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,887.97,5664, Esophagoscopy rigid balloon,43195,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,887.97,5664, Esophagoscp guide wire dilat,43196,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,955.63,,,,,,,fee schedule,955.63,5664, Esophagoscp guide wire dilat,43196,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,955.63,5664, Esophagoscp guide wire dilat,43196,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,955.63,5664, Esophagoscp guide wire dilat,43196,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,955.63,5664, Esophagoscopy flex dx brush,43197,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,385.65,,,,,,,fee schedule,385.65,5664, Esophagoscopy flex dx brush,43197,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,385.65,5664, Esophagoscopy flex dx brush,43197,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,385.65,5664, Esophagoscopy flex dx brush,43197,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,385.65,5664, Esophagosc flex trnsn biopsy,43198,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,460.82,,,,,,,fee schedule,460.82,5664, Esophagosc flex trnsn biopsy,43198,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,460.82,5664, Esophagosc flex trnsn biopsy,43198,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,460.82,5664, Esophagosc flex trnsn biopsy,43198,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,460.82,5664, Esophagoscopy flexible brush,43200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,441.72,,,,,,,fee schedule,441.72,5664, Esophagoscopy flexible brush,43200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,441.72,5664, Esophagoscopy flexible brush,43200,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,441.72,5664, Esophagoscopy flexible brush,43200,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,441.72,5664, Esoph scope w/submucous inj,43201,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,510.57,,,,,,,fee schedule,510.57,5664, Esoph scope w/submucous inj,43201,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,510.57,5664, Esoph scope w/submucous inj,43201,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,510.57,5664, Esoph scope w/submucous inj,43201,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,510.57,5664, Esophagoscopy flex biopsy,43202,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,514.72,,,,,,,fee schedule,514.72,5664, Esophagoscopy flex biopsy,43202,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,514.72,5664, Esophagoscopy flex biopsy,43202,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,514.72,5664, Esophagoscopy flex biopsy,43202,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,514.72,5664, Esoph scope w/sclerosis inj,43204,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,664.68,,,,,,,fee schedule,664.68,5664, Esoph scope w/sclerosis inj,43204,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,664.68,5664, Esoph scope w/sclerosis inj,43204,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,664.68,5664, Esoph scope w/sclerosis inj,43204,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,664.68,5664, Esophagus endoscopy/ligation,43205,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,694.09,,,,,,,fee schedule,694.09,5664, Esophagus endoscopy/ligation,43205,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,694.09,5664, Esophagus endoscopy/ligation,43205,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,694.09,5664, Esophagus endoscopy/ligation,43205,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,694.09,5664, Esoph optical endomicroscopy,43206,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,653.02,,,,,,,fee schedule,653.02,5664, Esoph optical endomicroscopy,43206,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,653.02,5664, Esoph optical endomicroscopy,43206,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,653.02,5664, Esoph optical endomicroscopy,43206,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,653.02,5664, Egd esophagogastrc fndoplsty,43210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2125.75,,,,,,,fee schedule,2125.75,12821, Egd esophagogastrc fndoplsty,43210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2125.75,12821, Egd esophagogastrc fndoplsty,43210,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2125.75,12821, Egd esophagogastrc fndoplsty,43210,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2125.75,12821, Esophagoscop mucosal resect,43211,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1143.41,,,,,,,fee schedule,1143.41,5664, Esophagoscop mucosal resect,43211,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1143.41,5664, Esophagoscop mucosal resect,43211,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1143.41,5664, Esophagoscop mucosal resect,43211,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1143.41,5664, Esophagoscop stent placement,43212,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,951.91,,,,,,,fee schedule,951.91,12821, Esophagoscop stent placement,43212,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,951.91,12821, Esophagoscop stent placement,43212,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,951.91,12821, Esophagoscop stent placement,43212,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,951.91,12821, Esophagoscopy retro balloon,43213,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1264.88,,,,,,,fee schedule,1264.88,5664, Esophagoscopy retro balloon,43213,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1264.88,5664, Esophagoscopy retro balloon,43213,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1264.88,5664, Esophagoscopy retro balloon,43213,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1264.88,5664, Esophagosc dilate balloon 30,43214,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,944.03,,,,,,,fee schedule,944.03,5664, Esophagosc dilate balloon 30,43214,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,944.03,5664, Esophagosc dilate balloon 30,43214,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,944.03,5664, Esophagosc dilate balloon 30,43214,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,944.03,5664, Esophagoscopy flex remove fb,43215,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,712.54,,,,,,,fee schedule,712.54,5664, Esophagoscopy flex remove fb,43215,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,712.54,5664, Esophagoscopy flex remove fb,43215,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,712.54,5664, Esophagoscopy flex remove fb,43215,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,712.54,5664, Esophagoscopy lesion removal,43216,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.53,,,,,,,fee schedule,656.53,10940, Esophagoscopy lesion removal,43216,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,656.53,10940, Esophagoscopy lesion removal,43216,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,656.53,10940, Esophagoscopy lesion removal,43216,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,656.53,10940, Esophagoscopy snare les remv,43217,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,785.23,,,,,,,fee schedule,785.23,5664, Esophagoscopy snare les remv,43217,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,785.23,5664, Esophagoscopy snare les remv,43217,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,785.23,5664, Esophagoscopy snare les remv,43217,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,785.23,5664, Esophagoscopy balloon <30mm,43220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,587.3,,,,,,,fee schedule,587.3,5664, Esophagoscopy balloon <30mm,43220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,587.3,5664, Esophagoscopy balloon <30mm,43220,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,587.3,5664, Esophagoscopy balloon <30mm,43220,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,587.3,5664, Esoph endoscopy dilation,43226,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,657.56,,,,,,,fee schedule,657.56,5664, Esoph endoscopy dilation,43226,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,657.56,5664, Esoph endoscopy dilation,43226,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,657.56,5664, Esoph endoscopy dilation,43226,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,657.56,5664, Esophagoscopy control bleed,43227,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,815.98,,,,,,,fee schedule,815.98,5664, Esophagoscopy control bleed,43227,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,815.98,5664, Esophagoscopy control bleed,43227,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,815.98,5664, Esophagoscopy control bleed,43227,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,815.98,5664, Esophagoscopy lesion ablate,43229,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,968.53,,,,,,,fee schedule,968.53,10940, Esophagoscopy lesion ablate,43229,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,968.53,10940, Esophagoscopy lesion ablate,43229,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,968.53,10940, Esophagoscopy lesion ablate,43229,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,968.53,10940, Esophagoscop ultrasound exam,43231,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,759.86,,,,,,,fee schedule,759.86,5664, Esophagoscop ultrasound exam,43231,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,759.86,5664, Esophagoscop ultrasound exam,43231,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,759.86,5664, Esophagoscop ultrasound exam,43231,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,759.86,5664, Esophagoscopy w/us needle bx,43232,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,981.1,,,,,,,fee schedule,981.1,5664, Esophagoscopy w/us needle bx,43232,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,981.1,5664, Esophagoscopy w/us needle bx,43232,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,981.1,5664, Esophagoscopy w/us needle bx,43232,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,981.1,5664, Egd balloon dil esoph30 mm/>,43233,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1145.35,,,,,,,fee schedule,1145.35,5664, Egd balloon dil esoph30 mm/>,43233,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1145.35,5664, Egd balloon dil esoph30 mm/>,43233,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1145.35,5664, Egd balloon dil esoph30 mm/>,43233,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1145.35,5664, Egd diagnostic brush wash,43235,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,610.18,,,,,,,fee schedule,610.18,5664, Egd diagnostic brush wash,43235,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,610.18,5664, Egd diagnostic brush wash,43235,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,610.18,5664, Egd diagnostic brush wash,43235,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,610.18,5664, Uppr gi scope w/submuc inj,43236,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,682.59,,,,,,,fee schedule,682.59,5664, Uppr gi scope w/submuc inj,43236,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,682.59,5664, Uppr gi scope w/submuc inj,43236,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,682.59,5664, Uppr gi scope w/submuc inj,43236,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,682.59,5664, Endoscopic us exam esoph,43237,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,956.76,,,,,,,fee schedule,956.76,5664, Endoscopic us exam esoph,43237,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,956.76,5664, Endoscopic us exam esoph,43237,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,956.76,5664, Endoscopic us exam esoph,43237,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,956.76,5664, Egd us fine needle bx/aspir,43238,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1130.03,,,,,,,fee schedule,1130.03,5664, Egd us fine needle bx/aspir,43238,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1130.03,5664, Egd us fine needle bx/aspir,43238,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1130.03,5664, Egd us fine needle bx/aspir,43238,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1130.03,5664, Egd biopsy single/multiple,43239,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,682.59,,,,,,,fee schedule,682.59,5664, Egd biopsy single/multiple,43239,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,682.59,5664, Egd biopsy single/multiple,43239,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,682.59,5664, Egd biopsy single/multiple,43239,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,682.59,5664, Egd w/transmural drain cyst,43240,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1897.5,,,,,,,fee schedule,1897.5,10940, Egd w/transmural drain cyst,43240,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1897.5,10940, Egd w/transmural drain cyst,43240,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1897.5,10940, Egd w/transmural drain cyst,43240,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1897.5,10940, Egd tube/cath insertion,43241,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,703.58,,,,,,,fee schedule,703.58,5664, Egd tube/cath insertion,43241,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,703.58,5664, Egd tube/cath insertion,43241,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,703.58,5664, Egd tube/cath insertion,43241,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,703.58,5664, Egd us fine needle bx/aspir,43242,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1270.27,,,,,,,fee schedule,1270.27,5664, Egd us fine needle bx/aspir,43242,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1270.27,5664, Egd us fine needle bx/aspir,43242,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1270.27,5664, Egd us fine needle bx/aspir,43242,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1270.27,5664, Egd injection varices,43243,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1163.86,,,,,,,fee schedule,1163.86,5664, Egd injection varices,43243,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1163.86,5664, Egd injection varices,43243,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1163.86,5664, Egd injection varices,43243,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1163.86,5664, Egd varices ligation,43244,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1191.71,,,,,,,fee schedule,1191.71,5664, Egd varices ligation,43244,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1191.71,5664, Egd varices ligation,43244,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1191.71,5664, Egd varices ligation,43244,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1191.71,5664, Egd dilate stricture,43245,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,875.02,,,,,,,fee schedule,875.02,5664, Egd dilate stricture,43245,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,875.02,5664, Egd dilate stricture,43245,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,875.02,5664, Egd dilate stricture,43245,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,875.02,5664, Egd place gastrostomy tube,43246,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,999.88,,,,,,,fee schedule,999.88,5664, Egd place gastrostomy tube,43246,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,999.88,5664, Egd place gastrostomy tube,43246,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,999.88,5664, Egd place gastrostomy tube,43246,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,999.88,5664, Egd remove foreign body,43247,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,873.02,,,,,,,fee schedule,873.02,5664, Egd remove foreign body,43247,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,873.02,5664, Egd remove foreign body,43247,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,873.02,5664, Egd remove foreign body,43247,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,873.02,5664, Egd guide wire insertion,43248,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,819.33,,,,,,,fee schedule,819.33,5664, Egd guide wire insertion,43248,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,819.33,5664, Egd guide wire insertion,43248,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,819.33,5664, Egd guide wire insertion,43248,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,819.33,5664, Esoph egd dilation <30 mm,43249,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,753.17,,,,,,,fee schedule,753.17,5664, Esoph egd dilation <30 mm,43249,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,753.17,5664, Esoph egd dilation <30 mm,43249,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,753.17,5664, Esoph egd dilation <30 mm,43249,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,753.17,5664, Egd cautery tumor polyp,43250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,851.81,,,,,,,fee schedule,851.81,5664, Egd cautery tumor polyp,43250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,851.81,5664, Egd cautery tumor polyp,43250,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,851.81,5664, Egd cautery tumor polyp,43250,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,851.81,5664, Egd remove lesion snare,43251,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,957.79,,,,,,,fee schedule,957.79,5664, Egd remove lesion snare,43251,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,957.79,5664, Egd remove lesion snare,43251,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,957.79,5664, Egd remove lesion snare,43251,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,957.79,5664, Egd optical endomicroscopy,43252,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,831.04,,,,,,,fee schedule,831.04,5664, Egd optical endomicroscopy,43252,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,831.04,5664, Egd optical endomicroscopy,43252,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,831.04,5664, Egd optical endomicroscopy,43252,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,831.04,5664, Egd us transmural injxn/mark,43253,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1273.02,,,,,,,fee schedule,1273.02,5664, Egd us transmural injxn/mark,43253,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1273.02,5664, Egd us transmural injxn/mark,43253,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1273.02,5664, Egd us transmural injxn/mark,43253,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1273.02,5664, Egd endo mucosal resection,43254,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1311.55,,,,,,,fee schedule,1311.55,5664, Egd endo mucosal resection,43254,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1311.55,5664, Egd endo mucosal resection,43254,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1311.55,5664, Egd endo mucosal resection,43254,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1311.55,5664, Egd control bleeding any,43255,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,979.16,,,,,,,fee schedule,979.16,5664, Egd control bleeding any,43255,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,979.16,5664, Egd control bleeding any,43255,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,979.16,5664, Egd control bleeding any,43255,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,979.16,5664, Egd w/thrml txmnt gerd,43257,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1130.95,,,,,,,fee schedule,1130.95,10940, Egd w/thrml txmnt gerd,43257,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1130.95,10940, Egd w/thrml txmnt gerd,43257,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1130.95,10940, Egd w/thrml txmnt gerd,43257,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1130.95,10940, Egd us exam duodenum/jejunum,43259,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1098.84,,,,,,,fee schedule,1098.84,5664, Egd us exam duodenum/jejunum,43259,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1098.84,5664, Egd us exam duodenum/jejunum,43259,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1098.84,5664, Egd us exam duodenum/jejunum,43259,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1098.84,5664, Ercp w/specimen collection,43260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1555.4,,,,,,,fee schedule,1555.4,10940, Ercp w/specimen collection,43260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1555.4,10940, Ercp w/specimen collection,43260,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1555.4,10940, Ercp w/specimen collection,43260,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1555.4,10940, Endo cholangiopancreatograph,43261,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1638.5,,,,,,,fee schedule,1638.5,10940, Endo cholangiopancreatograph,43261,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1638.5,10940, Endo cholangiopancreatograph,43261,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1638.5,10940, Endo cholangiopancreatograph,43261,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1638.5,10940, Endo cholangiopancreatograph,43262,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1725.16,,,,,,,fee schedule,1725.16,10940, Endo cholangiopancreatograph,43262,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1725.16,10940, Endo cholangiopancreatograph,43262,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1725.16,10940, Endo cholangiopancreatograph,43262,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1725.16,10940, Ercp sphincter pressure meas,43263,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1728.55,,,,,,,fee schedule,1728.55,10940, Ercp sphincter pressure meas,43263,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1728.55,10940, Ercp sphincter pressure meas,43263,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1728.55,10940, Ercp sphincter pressure meas,43263,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1728.55,10940, Ercp remove duct calculi,43264,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1759.1,,,,,,,fee schedule,1759.1,10940, Ercp remove duct calculi,43264,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1759.1,10940, Ercp remove duct calculi,43264,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1759.1,10940, Ercp remove duct calculi,43264,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1759.1,10940, Ercp lithotripsy calculi,43265,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2090.63,,,,,,,fee schedule,2090.63,10940, Ercp lithotripsy calculi,43265,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2090.63,10940, Ercp lithotripsy calculi,43265,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2090.63,10940, Ercp lithotripsy calculi,43265,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2090.63,10940, Egd endoscopic stent place,43266,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1070.08,,,,,,,fee schedule,1070.08,12821, Egd endoscopic stent place,43266,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1070.08,12821, Egd endoscopic stent place,43266,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,1070.08,12821, Egd endoscopic stent place,43266,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,1070.08,12821, Egd lesion ablation,43270,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1094.42,,,,,,,fee schedule,1094.42,5664, Egd lesion ablation,43270,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1094.42,5664, Egd lesion ablation,43270,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1094.42,5664, Egd lesion ablation,43270,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1094.42,5664, Endoscopic pancreatoscopy,43273,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,565.5,,,,,,,fee schedule,565.5,4108, Endoscopic pancreatoscopy,43273,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,565.5,4108, Endoscopic pancreatoscopy,43273,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,565.5,4108, Endoscopic pancreatoscopy,43273,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,565.5,4108, Ercp duct stent placement,43274,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2230.76,,,,,,,fee schedule,2230.76,10940, Ercp duct stent placement,43274,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2230.76,10940, Ercp duct stent placement,43274,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2230.76,10940, Ercp duct stent placement,43274,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2230.76,10940, Ercp remove forgn body duct,43275,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1821.69,,,,,,,fee schedule,1821.69,5664, Ercp remove forgn body duct,43275,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1821.69,5664, Ercp remove forgn body duct,43275,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1821.69,5664, Ercp remove forgn body duct,43275,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1821.69,5664, Ercp stent exchange w/dilate,43276,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2327.35,,,,,,,fee schedule,2327.35,10940, Ercp stent exchange w/dilate,43276,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2327.35,10940, Ercp stent exchange w/dilate,43276,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2327.35,10940, Ercp stent exchange w/dilate,43276,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2327.35,10940, Ercp ea duct/ampulla dilate,43277,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1829.62,,,,,,,fee schedule,1829.62,10940, Ercp ea duct/ampulla dilate,43277,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1829.62,10940, Ercp ea duct/ampulla dilate,43277,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1829.62,10940, Ercp ea duct/ampulla dilate,43277,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1829.62,10940, Ercp lesion ablate w/dilate,43278,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2088.85,,,,,,,fee schedule,2088.85,10940, Ercp lesion ablate w/dilate,43278,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2088.85,10940, Ercp lesion ablate w/dilate,43278,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2088.85,10940, Ercp lesion ablate w/dilate,43278,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2088.85,10940, Lap myotomy heller,43279,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6910.06,,,,,,,fee schedule,6910.06,22111, Lap myotomy heller,43279,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6910.06,22111, Lap myotomy heller,43279,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6910.06,22111, Lap myotomy heller,43279,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6910.06,22111, Laparoscopy fundoplasty,43280,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5814.19,,,,,,,fee schedule,5814.19,22111, Laparoscopy fundoplasty,43280,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,5814.19,22111, Laparoscopy fundoplasty,43280,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5814.19,22111, Laparoscopy fundoplasty,43280,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5814.19,22111, Lap paraesophag hern repair,43281,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8221.51,,,,,,,fee schedule,6044,22111, Lap paraesophag hern repair,43281,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,22111, Lap paraesophag hern repair,43281,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6044,22111, Lap paraesophag hern repair,43281,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6044,22111, Lap paraesoph her rpr w/mesh,43282,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9255.44,,,,,,,fee schedule,6044,22111, Lap paraesoph her rpr w/mesh,43282,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,22111, Lap paraesoph her rpr w/mesh,43282,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6044,22111, Lap paraesoph her rpr w/mesh,43282,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6044,22111, Lap esoph lengthening,43283,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,827.1,,,,,,,fee schedule,827.1,6979, Lap esoph lengthening,43283,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,827.1,6979, Lap esoph lengthening,43283,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,827.1,6979, Lap esoph lengthening,43283,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,827.1,6979, Laps esophgl sphnctr agmntj,43284,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3569.99,,,,,,,fee schedule,3569.99,22111, Laps esophgl sphnctr agmntj,43284,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,3569.99,22111, Laps esophgl sphnctr agmntj,43284,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3569.99,22111, Laps esophgl sphnctr agmntj,43284,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3569.99,22111, Rmvl esophgl sphnctr dev,43285,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3670.36,,,,,,,fee schedule,3670.36,22111, Rmvl esophgl sphnctr dev,43285,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3670.36,22111, Rmvl esophgl sphnctr dev,43285,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3670.36,22111, Rmvl esophgl sphnctr dev,43285,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3670.36,22111, Esphg tot w/laps moblj,43286,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,16970.42,,,,,,,fee schedule,5097,16970.42, Esphg tot w/laps moblj,43286,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,16970.42, Esphg tot w/laps moblj,43286,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,16970.42, Esphg tot w/laps moblj,43286,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,16970.42, Esphg dstl 2/3 w/laps moblj,43287,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,19011.51,,,,,,,fee schedule,5097,19011.51, Esphg dstl 2/3 w/laps moblj,43287,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,19011.51, Esphg dstl 2/3 w/laps moblj,43287,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,19011.51, Esphg dstl 2/3 w/laps moblj,43287,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,19011.51, Esphg thrsc moblj,43288,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,20002.92,,,,,,,fee schedule,5097,20002.92, Esphg thrsc moblj,43288,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,20002.92, Esphg thrsc moblj,43288,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,20002.92, Esphg thrsc moblj,43288,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,20002.92, Laparoscope proc esoph,43289,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,14456, Laparoscope proc esoph,43289,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5248,14456, Laparoscope proc esoph,43289,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5248,14456, Egd flx trnsorl dplmnt balo,43290,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,871.08,,,,,,,fee schedule,871.08,5664, Egd flx trnsorl dplmnt balo,43290,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,871.08,5664, Egd flx trnsorl dplmnt balo,43290,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,871.08,5664, Egd flx trnsorl dplmnt balo,43290,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,871.08,5664, Egd flx trnsorl rmvl balo,43291,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,785.23,,,,,,,fee schedule,785.23,5664, Egd flx trnsorl rmvl balo,43291,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,785.23,5664, Egd flx trnsorl rmvl balo,43291,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,785.23,5664, Egd flx trnsorl rmvl balo,43291,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,785.23,5664, Repair of esophagus,43300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3048.69,,,,,,,fee schedule,3048.69,6979, Repair of esophagus,43300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3048.69,6979, Repair of esophagus,43300,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3048.69,6979, Repair of esophagus,43300,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3048.69,6979, Repair esophagus and fistula,43305,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5261.8,,,,,,,fee schedule,5097,6979, Repair esophagus and fistula,43305,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Repair esophagus and fistula,43305,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Repair esophagus and fistula,43305,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Repair of esophagus,43310,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8062.49,,,,,,,fee schedule,5097,8062.49, Repair of esophagus,43310,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8062.49, Repair of esophagus,43310,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8062.49, Repair of esophagus,43310,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8062.49, Repair esophagus and fistula,43312,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8563.78,,,,,,,fee schedule,5097,8563.78, Repair esophagus and fistula,43312,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8563.78, Repair esophagus and fistula,43312,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8563.78, Repair esophagus and fistula,43312,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8563.78, Esophagoplasty congenital,43313,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,15598.06,,,,,,,fee schedule,5097,15598.06, Esophagoplasty congenital,43313,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,15598.06, Esophagoplasty congenital,43313,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,15598.06, Esophagoplasty congenital,43313,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,15598.06, Tracheo-esophagoplasty cong,43314,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,16602.09,,,,,,,fee schedule,5097,16602.09, Tracheo-esophagoplasty cong,43314,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,16602.09, Tracheo-esophagoplasty cong,43314,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,16602.09, Tracheo-esophagoplasty cong,43314,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,16602.09, Fuse esophagus & stomach,43320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7526.99,,,,,,,fee schedule,5097,7526.99, Fuse esophagus & stomach,43320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7526.99, Fuse esophagus & stomach,43320,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7526.99, Fuse esophagus & stomach,43320,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7526.99, Revise esophagus & stomach,43325,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7321.83,,,,,,,fee schedule,5097,7321.83, Revise esophagus & stomach,43325,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7321.83, Revise esophagus & stomach,43325,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7321.83, Revise esophagus & stomach,43325,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7321.83, Esoph fundoplasty lap,43327,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4527.14,,,,,,,fee schedule,4527.14,6979, Esoph fundoplasty lap,43327,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4527.14,6979, Esoph fundoplasty lap,43327,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4527.14,6979, Esoph fundoplasty lap,43327,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4527.14,6979, Esoph fundoplasty thor,43328,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6109.03,,,,,,,fee schedule,5097,6979, Esoph fundoplasty thor,43328,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Esoph fundoplasty thor,43328,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Esoph fundoplasty thor,43328,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Esophagomyotomy abdominal,43330,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7200.04,,,,,,,fee schedule,5097,7200.04, Esophagomyotomy abdominal,43330,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7200.04, Esophagomyotomy abdominal,43330,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7200.04, Esophagomyotomy abdominal,43330,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7200.04, Esophagomyotomy thoracic,43331,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7350.92,,,,,,,fee schedule,5097,7350.92, Esophagomyotomy thoracic,43331,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7350.92, Esophagomyotomy thoracic,43331,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7350.92, Esophagomyotomy thoracic,43331,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7350.92, Transab esoph hiat hern rpr,43332,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6192.99,,,,,,,fee schedule,5097,6979, Transab esoph hiat hern rpr,43332,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Transab esoph hiat hern rpr,43332,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Transab esoph hiat hern rpr,43332,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Transab esoph hiat hern rpr,43333,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6764.26,,,,,,,fee schedule,5097,6979, Transab esoph hiat hern rpr,43333,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Transab esoph hiat hern rpr,43333,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Transab esoph hiat hern rpr,43333,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Transthor diaphrag hern rpr,43334,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6726.82,,,,,,,fee schedule,5097,6979, Transthor diaphrag hern rpr,43334,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Transthor diaphrag hern rpr,43334,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Transthor diaphrag hern rpr,43334,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Transthor diaphrag hern rpr,43335,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7228.05,,,,,,,fee schedule,5097,7228.05, Transthor diaphrag hern rpr,43335,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7228.05, Transthor diaphrag hern rpr,43335,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7228.05, Transthor diaphrag hern rpr,43335,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7228.05, Thorabd diaphr hern repair,43336,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7861.32,,,,,,,fee schedule,5097,7861.32, Thorabd diaphr hern repair,43336,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7861.32, Thorabd diaphr hern repair,43336,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7861.32, Thorabd diaphr hern repair,43336,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7861.32, Thorabd diaphr hern repair,43337,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8366.98,,,,,,,fee schedule,5097,8366.98, Thorabd diaphr hern repair,43337,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8366.98, Thorabd diaphr hern repair,43337,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8366.98, Thorabd diaphr hern repair,43337,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8366.98, Esoph lengthening,43338,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,603.43,,,,,,,fee schedule,603.43,6979, Esoph lengthening,43338,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,603.43,6979, Esoph lengthening,43338,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,603.43,6979, Esoph lengthening,43338,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,603.43,6979, Fuse esophagus & intestine,43340,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7435.63,,,,,,,fee schedule,5097,7435.63, Fuse esophagus & intestine,43340,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7435.63, Fuse esophagus & intestine,43340,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7435.63, Fuse esophagus & intestine,43340,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7435.63, Fuse esophagus & intestine,43341,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7675.54,,,,,,,fee schedule,5097,7675.54, Fuse esophagus & intestine,43341,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7675.54, Fuse esophagus & intestine,43341,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7675.54, Fuse esophagus & intestine,43341,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7675.54, Surgical opening esophagus,43351,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7284.01,,,,,,,fee schedule,5097,7284.01, Surgical opening esophagus,43351,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7284.01, Surgical opening esophagus,43351,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7284.01, Surgical opening esophagus,43351,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7284.01, Surgical opening esophagus,43352,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5901.93,,,,,,,fee schedule,5097,6979, Surgical opening esophagus,43352,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Surgical opening esophagus,43352,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Surgical opening esophagus,43352,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Gastrointestinal repair,43360,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12227.77,,,,,,,fee schedule,5097,12227.77, Gastrointestinal repair,43360,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,12227.77, Gastrointestinal repair,43360,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,12227.77, Gastrointestinal repair,43360,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,12227.77, Gastrointestinal repair,43361,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,14466.68,,,,,,,fee schedule,5097,14466.68, Gastrointestinal repair,43361,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,14466.68, Gastrointestinal repair,43361,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,14466.68, Gastrointestinal repair,43361,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,14466.68, Ligate esophagus veins,43400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8181.74,,,,,,,fee schedule,6979,22111, Ligate esophagus veins,43400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,22111, Ligate esophagus veins,43400,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6979,22111, Ligate esophagus veins,43400,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6979,22111, Ligate/staple esophagus,43405,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8022.83,,,,,,,fee schedule,5097,8022.83, Ligate/staple esophagus,43405,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8022.83, Ligate/staple esophagus,43405,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8022.83, Ligate/staple esophagus,43405,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8022.83, Repair esophagus wound,43410,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5011.43,,,,,,,fee schedule,5011.43,6979, Repair esophagus wound,43410,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5011.43,6979, Repair esophagus wound,43410,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5011.43,6979, Repair esophagus wound,43410,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5011.43,6979, Repair esophagus wound,43415,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,13888.12,,,,,,,fee schedule,5097,13888.12, Repair esophagus wound,43415,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,13888.12, Repair esophagus wound,43415,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,13888.12, Repair esophagus wound,43415,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,13888.12, Repair esophagus opening,43420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4898.6,,,,,,,fee schedule,4108,10940, Repair esophagus opening,43420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,10940, Repair esophagus opening,43420,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,4108,10940, Repair esophagus opening,43420,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,4108,10940, Repair esophagus opening,43425,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7897.96,,,,,,,fee schedule,5097,7897.96, Repair esophagus opening,43425,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7897.96, Repair esophagus opening,43425,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7897.96, Repair esophagus opening,43425,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7897.96, Dilate esophagus 1/mult pass,43450,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,402.06,,,,,,,fee schedule,402.06,5664, Dilate esophagus 1/mult pass,43450,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,402.06,5664, Dilate esophagus 1/mult pass,43450,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,402.06,5664, Dilate esophagus 1/mult pass,43450,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,402.06,5664, Dilate esophagus,43453,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,428.33,,,,,,,fee schedule,428.33,5664, Dilate esophagus,43453,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,428.33,5664, Dilate esophagus,43453,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,428.33,5664, Dilate esophagus,43453,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,428.33,5664, Pressure treatment esophagus,43460,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1039.05,,,,,,,fee schedule,1039.05,6979, Pressure treatment esophagus,43460,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1039.05,6979, Pressure treatment esophagus,43460,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1039.05,6979, Pressure treatment esophagus,43460,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1039.05,6979, Free jejunum flap microvasc,43496,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Free jejunum flap microvasc,43496,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Free jejunum flap microvasc,43496,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Transorl lwr esophgl myotomy,43497,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3986.4,,,,,,,fee schedule,3986.4,10940, Transorl lwr esophgl myotomy,43497,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3986.4,10940, Transorl lwr esophgl myotomy,43497,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3986.4,10940, Transorl lwr esophgl myotomy,43497,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3986.4,10940, Esophagus surgery procedure,43499,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,5664, Esophagus surgery procedure,43499,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3195,5664, Esophagus surgery procedure,43499,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3195,5664, Surgical opening of stomach,43500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4297.81,,,,,,,fee schedule,4297.81,6979, Surgical opening of stomach,43500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4297.81,6979, Surgical opening of stomach,43500,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4297.81,6979, Surgical opening of stomach,43500,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4297.81,6979, Surgical repair of stomach,43501,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7293.56,,,,,,,fee schedule,5097,7293.56, Surgical repair of stomach,43501,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7293.56, Surgical repair of stomach,43501,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7293.56, Surgical repair of stomach,43501,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7293.56, Surgical repair of stomach,43502,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8199.92,,,,,,,fee schedule,5097,8199.92, Surgical repair of stomach,43502,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8199.92, Surgical repair of stomach,43502,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8199.92, Surgical repair of stomach,43502,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8199.92, Surgical opening of stomach,43510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5166.94,,,,,,,fee schedule,5097,6979, Surgical opening of stomach,43510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Surgical opening of stomach,43510,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Surgical opening of stomach,43510,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Incision of pyloric muscle,43520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3890.35,,,,,,,fee schedule,3890.35,6979, Incision of pyloric muscle,43520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3890.35,6979, Incision of pyloric muscle,43520,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3890.35,6979, Incision of pyloric muscle,43520,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3890.35,6979, Biopsy of stomach,43605,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4589.08,,,,,,,fee schedule,4589.08,10940, Biopsy of stomach,43605,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4589.08,10940, Biopsy of stomach,43605,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,4589.08,10940, Biopsy of stomach,43605,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,4589.08,10940, Excision of stomach lesion,43610,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5272.76,,,,,,,fee schedule,5097,6979, Excision of stomach lesion,43610,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Excision of stomach lesion,43610,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Excision of stomach lesion,43610,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Excision of stomach lesion,43611,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6573.73,,,,,,,fee schedule,5097,6979, Excision of stomach lesion,43611,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Excision of stomach lesion,43611,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Excision of stomach lesion,43611,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Removal of stomach,43620,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10602.44,,,,,,,fee schedule,5097,10602.44, Removal of stomach,43620,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,10602.44, Removal of stomach,43620,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,10602.44, Removal of stomach,43620,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,10602.44, Removal of stomach,43621,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12059.3,,,,,,,fee schedule,5097,12059.3, Removal of stomach,43621,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,12059.3, Removal of stomach,43621,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,12059.3, Removal of stomach,43621,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,12059.3, Removal of stomach,43622,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12324.95,,,,,,,fee schedule,5097,12324.95, Removal of stomach,43622,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,12324.95, Removal of stomach,43622,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,12324.95, Removal of stomach,43622,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,12324.95, Removal of stomach partial,43631,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7788.53,,,,,,,fee schedule,5097,7788.53, Removal of stomach partial,43631,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7788.53, Removal of stomach partial,43631,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7788.53, Removal of stomach partial,43631,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7788.53, Removal of stomach partial,43632,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10806.08,,,,,,,fee schedule,5097,10806.08, Removal of stomach partial,43632,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,10806.08, Removal of stomach partial,43632,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,10806.08, Removal of stomach partial,43632,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,10806.08, Removal of stomach partial,43633,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10226.88,,,,,,,fee schedule,5097,10226.88, Removal of stomach partial,43633,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,10226.88, Removal of stomach partial,43633,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,10226.88, Removal of stomach partial,43633,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,10226.88, Removal of stomach partial,43634,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,11347.68,,,,,,,fee schedule,5097,11347.68, Removal of stomach partial,43634,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,11347.68, Removal of stomach partial,43634,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,11347.68, Removal of stomach partial,43634,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,11347.68, Removal of stomach partial,43635,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,588.54,,,,,,,fee schedule,588.54,6979, Removal of stomach partial,43635,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,588.54,6979, Removal of stomach partial,43635,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,588.54,6979, Removal of stomach partial,43635,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,588.54,6979, Vagotomy & pylorus repair,43640,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6438.88,,,,,,,fee schedule,5097,6979, Vagotomy & pylorus repair,43640,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Vagotomy & pylorus repair,43640,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Vagotomy & pylorus repair,43640,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Vagotomy & pylorus repair,43641,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6508.76,,,,,,,fee schedule,5097,6979, Vagotomy & pylorus repair,43641,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Vagotomy & pylorus repair,43641,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Vagotomy & pylorus repair,43641,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Lap gastric bypass/roux-en-y,43644,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9328.55,,,,,,,fee schedule,6979,22111, Lap gastric bypass/roux-en-y,43644,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,22111, Lap gastric bypass/roux-en-y,43644,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6979,22111, Lap gastric bypass/roux-en-y,43644,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6979,22111, Lap gastr bypass incl smll i,43645,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9906.46,,,,,,,fee schedule,6979,22111, Lap gastr bypass incl smll i,43645,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,22111, Lap gastr bypass incl smll i,43645,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6979,22111, Lap gastr bypass incl smll i,43645,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6979,22111, Lap impl electrode antrum,43647,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,25393, Lap impl electrode antrum,43647,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,5248,25393, Lap impl electrode antrum,43647,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,5248,25393, Lap revise/remv eltrd antrum,43648,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,14456, Lap revise/remv eltrd antrum,43648,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5248,14456, Lap revise/remv eltrd antrum,43648,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5248,14456, Laparoscopy vagus nerve,43651,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3607.93,,,,,,,fee schedule,3607.93,22111, Laparoscopy vagus nerve,43651,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,3607.93,22111, Laparoscopy vagus nerve,43651,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3607.93,22111, Laparoscopy vagus nerve,43651,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3607.93,22111, Laparoscopy vagus nerve,43652,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4183.9,,,,,,,fee schedule,4183.9,22111, Laparoscopy vagus nerve,43652,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4183.9,22111, Laparoscopy vagus nerve,43652,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4183.9,22111, Laparoscopy vagus nerve,43652,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4183.9,22111, Laparoscopy gastrostomy,43653,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3193.84,,,,,,,fee schedule,3193.84,22111, Laparoscopy gastrostomy,43653,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3193.84,22111, Laparoscopy gastrostomy,43653,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3193.84,22111, Laparoscopy gastrostomy,43653,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3193.84,22111, Laparoscope proc stom,43659,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,14456, Laparoscope proc stom,43659,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5248,14456, Laparoscope proc stom,43659,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5248,14456, Nasal/orogastric w/tube plmt,43752,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,192.58,,,,,,,fee schedule,192.58,4108, Nasal/orogastric w/tube plmt,43752,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,192.58,4108, Nasal/orogastric w/tube plmt,43752,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,192.58,4108, Nasal/orogastric w/tube plmt,43752,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,192.58,4108, Tx gastro intub w/asp,43753,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,116.5,,,,,,,fee schedule,116.5,3195, Tx gastro intub w/asp,43753,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,116.5,3195, Tx gastro intub w/asp,43753,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,116.5,3195, Tx gastro intub w/asp,43753,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,116.5,3195, Dx gastr intub w/asp spec,43754,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,260.73,,,,,,,fee schedule,260.73,3195, Dx gastr intub w/asp spec,43754,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,260.73,3195, Dx gastr intub w/asp spec,43754,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,260.73,3195, Dx gastr intub w/asp spec,43754,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,260.73,3195, Dx gastr intub w/asp specs,43755,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,300.45,,,,,,,fee schedule,300.45,3195, Dx gastr intub w/asp specs,43755,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,300.45,3195, Dx gastr intub w/asp specs,43755,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,300.45,3195, Dx gastr intub w/asp specs,43755,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,300.45,3195, Dx duod intub w/asp spec,43756,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,255.77,,,,,,,fee schedule,255.77,5664, Dx duod intub w/asp spec,43756,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,255.77,5664, Dx duod intub w/asp spec,43756,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,255.77,5664, Dx duod intub w/asp spec,43756,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,255.77,5664, Dx duod intub w/asp specs,43757,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,385.38,,,,,,,fee schedule,385.38,5664, Dx duod intub w/asp specs,43757,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,385.38,5664, Dx duod intub w/asp specs,43757,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,385.38,5664, Dx duod intub w/asp specs,43757,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,385.38,5664, Reposition gastrostomy tube,43761,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,499.72,,,,,,,fee schedule,499.72,3195, Reposition gastrostomy tube,43761,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,499.72,3195, Reposition gastrostomy tube,43761,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,499.72,3195, Reposition gastrostomy tube,43761,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,499.72,3195, Rplc gtube no revj trc,43762,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,198.03,,,,,,,fee schedule,198.03,3195, Rplc gtube no revj trc,43762,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,198.03,3195, Rplc gtube no revj trc,43762,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,198.03,3195, Rplc gtube no revj trc,43762,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,198.03,3195, Rplc gtube revj gstrst trc,43763,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,467.51,,,,,,,fee schedule,467.51,3195, Rplc gtube revj gstrst trc,43763,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,467.51,3195, Rplc gtube revj gstrst trc,43763,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,467.51,3195, Rplc gtube revj gstrst trc,43763,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,467.51,3195, Lap place gastr adj device,43770,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6116.15,,,,,,,fee schedule,5248,22111, Lap place gastr adj device,43770,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,22111, Lap place gastr adj device,43770,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5248,22111, Lap place gastr adj device,43770,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5248,22111, Lap revise gastr adj device,43771,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6916.86,,,,,,,fee schedule,5248,12821, Lap revise gastr adj device,43771,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,12821, Lap revise gastr adj device,43771,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5248,12821, Lap revise gastr adj device,43771,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5248,12821, Lap rmvl gastr adj device,43772,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5128.74,,,,,,,fee schedule,5128.74,12821, Lap rmvl gastr adj device,43772,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5128.74,12821, Lap rmvl gastr adj device,43772,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5128.74,12821, Lap rmvl gastr adj device,43772,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5128.74,12821, Lap replace gastr adj device,43773,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6916.86,,,,,,,fee schedule,5248,14456, Lap replace gastr adj device,43773,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,14456, Lap replace gastr adj device,43773,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5248,14456, Lap replace gastr adj device,43773,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5248,14456, Lap rmvl gastr adj all parts,43774,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5204.55,,,,,,,fee schedule,5204.55,25393, Lap rmvl gastr adj all parts,43774,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5204.55,25393, Lap rmvl gastr adj all parts,43774,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,5204.55,25393, Lap rmvl gastr adj all parts,43774,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,5204.55,25393, Lap sleeve gastrectomy,43775,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5834.86,,,,,,,fee schedule,5834.86,22111, Lap sleeve gastrectomy,43775,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5834.86,22111, Lap sleeve gastrectomy,43775,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5834.86,22111, Lap sleeve gastrectomy,43775,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5834.86,22111, Reconstruction of pylorus,43800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4981.59,,,,,,,fee schedule,4981.59,6979, Reconstruction of pylorus,43800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4981.59,6979, Reconstruction of pylorus,43800,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4981.59,6979, Reconstruction of pylorus,43800,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4981.59,6979, Fusion of stomach and bowel,43810,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5495.56,,,,,,,fee schedule,5097,6979, Fusion of stomach and bowel,43810,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Fusion of stomach and bowel,43810,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Fusion of stomach and bowel,43810,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Fusion of stomach and bowel,43820,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7202.36,,,,,,,fee schedule,5097,7202.36, Fusion of stomach and bowel,43820,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7202.36, Fusion of stomach and bowel,43820,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7202.36, Fusion of stomach and bowel,43820,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7202.36, Fusion of stomach and bowel,43825,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7075.83,,,,,,,fee schedule,5097,7075.83, Fusion of stomach and bowel,43825,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7075.83, Fusion of stomach and bowel,43825,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7075.83, Fusion of stomach and bowel,43825,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7075.83, Place gastrostomy tube,43830,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3835.48,,,,,,,fee schedule,3835.48,10940, Place gastrostomy tube,43830,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3835.48,10940, Place gastrostomy tube,43830,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3835.48,10940, Place gastrostomy tube,43830,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3835.48,10940, Place gastrostomy tube,43831,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3371.91,,,,,,,fee schedule,3371.91,6979, Place gastrostomy tube,43831,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3371.91,6979, Place gastrostomy tube,43831,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3371.91,6979, Place gastrostomy tube,43831,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3371.91,6979, Place gastrostomy tube,43832,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5652.26,,,,,,,fee schedule,5097,6979, Place gastrostomy tube,43832,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Place gastrostomy tube,43832,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Place gastrostomy tube,43832,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Repair of stomach lesion,43840,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7306.08,,,,,,,fee schedule,6979,12821, Repair of stomach lesion,43840,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,12821, Repair of stomach lesion,43840,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,6979,12821, Repair of stomach lesion,43840,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,6979,12821, V-band gastroplasty,43842,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, V-band gastroplasty,43842,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, V-band gastroplasty,43842,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Gastroplasty w/o v-band,43843,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6932.67,,,,,,,fee schedule,6932.67,14456, Gastroplasty w/o v-band,43843,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6932.67,14456, Gastroplasty w/o v-band,43843,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,6932.67,14456, Gastroplasty w/o v-band,43843,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,6932.67,14456, Gastroplasty duodenal switch,43845,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10527.27,,,,,,,fee schedule,5097,10527.27, Gastroplasty duodenal switch,43845,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,10527.27, Gastroplasty duodenal switch,43845,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,10527.27, Gastroplasty duodenal switch,43845,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,10527.27, Gastric bypass for obesity,43846,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8900.49,,,,,,,fee schedule,5097,8900.49, Gastric bypass for obesity,43846,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8900.49, Gastric bypass for obesity,43846,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8900.49, Gastric bypass for obesity,43846,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8900.49, Gastric bypass incl small i,43847,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9721,,,,,,,fee schedule,5097,9721, Gastric bypass incl small i,43847,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,9721, Gastric bypass incl small i,43847,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,9721, Gastric bypass incl small i,43847,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,9721, Revision gastroplasty,43848,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10317.42,,,,,,,fee schedule,5097,10317.42, Revision gastroplasty,43848,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,10317.42, Revision gastroplasty,43848,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,10317.42, Revision gastroplasty,43848,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,10317.42, Revise stomach-bowel fusion,43860,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8717.62,,,,,,,fee schedule,5097,8717.62, Revise stomach-bowel fusion,43860,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8717.62, Revise stomach-bowel fusion,43860,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8717.62, Revise stomach-bowel fusion,43860,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8717.62, Revise stomach-bowel fusion,43865,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9163.81,,,,,,,fee schedule,5097,9163.81, Revise stomach-bowel fusion,43865,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,9163.81, Revise stomach-bowel fusion,43865,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,9163.81, Revise stomach-bowel fusion,43865,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,9163.81, Repair stomach opening,43870,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3831.92,,,,,,,fee schedule,3195,10940, Repair stomach opening,43870,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,10940, Repair stomach opening,43870,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3195,10940, Repair stomach opening,43870,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3195,10940, Repair stomach-bowel fistula,43880,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8629.93,,,,,,,fee schedule,5097,8629.93, Repair stomach-bowel fistula,43880,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8629.93, Repair stomach-bowel fistula,43880,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8629.93, Repair stomach-bowel fistula,43880,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8629.93, Impl/redo electrd antrum,43881,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Impl/redo electrd antrum,43881,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Impl/redo electrd antrum,43881,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Revise/remove electrd antrum,43882,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Revise/remove electrd antrum,43882,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Revise/remove electrd antrum,43882,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Revise gastric port open,43886,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2078,,,,,,,fee schedule,2078,12821, Revise gastric port open,43886,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2078,12821, Revise gastric port open,43886,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2078,12821, Revise gastric port open,43886,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2078,12821, Remove gastric port open,43887,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1874.68,,,,,,,fee schedule,1874.68,5664, Remove gastric port open,43887,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1874.68,5664, Remove gastric port open,43887,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1874.68,5664, Remove gastric port open,43887,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1874.68,5664, Change gastric port open,43888,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2593.91,,,,,,,fee schedule,2593.91,12821, Change gastric port open,43888,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2593.91,12821, Change gastric port open,43888,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2593.91,12821, Change gastric port open,43888,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2593.91,12821, Gstr rstcv px trnsorl esg,43889,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4008.9,,,,,,,fee schedule,4008.9,6979, Gstr rstcv px trnsorl esg,43889,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4008.9,6979, Stomach surgery procedure,43999,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,5664, Stomach surgery procedure,43999,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3195,5664, Stomach surgery procedure,43999,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3195,5664, Freeing of bowel adhesion,44005,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5854.12,,,,,,,fee schedule,5097,8406, Freeing of bowel adhesion,44005,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,5097,8406, Freeing of bowel adhesion,44005,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8406, Freeing of bowel adhesion,44005,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8406, Incision of small bowel,44010,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4407.51,,,,,,,fee schedule,4407.51,6979, Incision of small bowel,44010,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4407.51,6979, Incision of small bowel,44010,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4407.51,6979, Incision of small bowel,44010,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4407.51,6979, Insert needle cath bowel,44015,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,734.34,,,,,,,fee schedule,734.34,6979, Insert needle cath bowel,44015,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,734.34,6979, Insert needle cath bowel,44015,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,734.34,6979, Insert needle cath bowel,44015,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,734.34,6979, Explore small intestine,44020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5243.72,,,,,,,fee schedule,5097,6979, Explore small intestine,44020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Explore small intestine,44020,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Explore small intestine,44020,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Decompress small bowel,44021,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5204.82,,,,,,,fee schedule,5097,6979, Decompress small bowel,44021,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Decompress small bowel,44021,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Decompress small bowel,44021,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Incision of large bowel,44025,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5258.56,,,,,,,fee schedule,5097,6979, Incision of large bowel,44025,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Incision of large bowel,44025,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Incision of large bowel,44025,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Reduce bowel obstruction,44050,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5048.55,,,,,,,fee schedule,5048.55,6979, Reduce bowel obstruction,44050,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5048.55,6979, Reduce bowel obstruction,44050,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5048.55,6979, Reduce bowel obstruction,44050,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5048.55,6979, Correct malrotation of bowel,44055,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7930.61,,,,,,,fee schedule,5097,8406, Correct malrotation of bowel,44055,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,5097,8406, Correct malrotation of bowel,44055,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8406, Correct malrotation of bowel,44055,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8406, Biopsy of bowel,44100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,508.36,,,,,,,fee schedule,508.36,5664, Biopsy of bowel,44100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,508.36,5664, Biopsy of bowel,44100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,508.36,5664, Biopsy of bowel,44100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,508.36,5664, Excise intestine lesion(s),44110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4534.91,,,,,,,fee schedule,4534.91,6979, Excise intestine lesion(s),44110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4534.91,6979, Excise intestine lesion(s),44110,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4534.91,6979, Excise intestine lesion(s),44110,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4534.91,6979, Excision of bowel lesion(s),44111,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5136.99,,,,,,,fee schedule,5097,6979, Excision of bowel lesion(s),44111,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Excision of bowel lesion(s),44111,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Excision of bowel lesion(s),44111,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Removal of small intestine,44120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6525.44,,,,,,,fee schedule,5097,6979, Removal of small intestine,44120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Removal of small intestine,44120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Removal of small intestine,44120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Removal of small intestine,44121,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1256.35,,,,,,,fee schedule,1256.35,6979, Removal of small intestine,44121,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1256.35,6979, Removal of small intestine,44121,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1256.35,6979, Removal of small intestine,44121,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1256.35,6979, Removal of small intestine,44125,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6280.03,,,,,,,fee schedule,5097,6979, Removal of small intestine,44125,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Removal of small intestine,44125,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Removal of small intestine,44125,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Enterectomy w/o taper cong,44126,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,13204.71,,,,,,,fee schedule,5097,13204.71, Enterectomy w/o taper cong,44126,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,13204.71, Enterectomy w/o taper cong,44126,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,13204.71, Enterectomy w/o taper cong,44126,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,13204.71, Enterectomy w/taper cong,44127,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,15204.96,,,,,,,fee schedule,5097,15204.96, Enterectomy w/taper cong,44127,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,15204.96, Enterectomy w/taper cong,44127,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,15204.96, Enterectomy w/taper cong,44127,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,15204.96, Enterectomy cong add-on,44128,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1275.56,,,,,,,fee schedule,1275.56,6979, Enterectomy cong add-on,44128,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1275.56,6979, Enterectomy cong add-on,44128,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1275.56,6979, Enterectomy cong add-on,44128,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1275.56,6979, Bowel to bowel fusion,44130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7046.74,,,,,,,fee schedule,5097,7046.74, Bowel to bowel fusion,44130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7046.74, Bowel to bowel fusion,44130,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7046.74, Bowel to bowel fusion,44130,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7046.74, Enterectomy cadaver donor,44132,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Enterectomy cadaver donor,44132,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Enterectomy cadaver donor,44132,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Enterectomy live donor,44133,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Enterectomy live donor,44133,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Enterectomy live donor,44133,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Intestine transplnt cadaver,44135,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Intestine transplnt cadaver,44135,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Intestine transplnt cadaver,44135,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Intestine transplant live,44136,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Intestine transplant live,44136,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Intestine transplant live,44136,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Remove intestinal allograft,44137,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Remove intestinal allograft,44137,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Remove intestinal allograft,44137,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Mobilization of colon,44139,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,616.87,,,,,,,fee schedule,616.87,6979, Mobilization of colon,44139,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,616.87,6979, Mobilization of colon,44139,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,616.87,6979, Mobilization of colon,44139,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,616.87,6979, Partial removal of colon,44140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7156.28,,,,,,,fee schedule,5097,7156.28, Partial removal of colon,44140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7156.28, Partial removal of colon,44140,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7156.28, Partial removal of colon,44140,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7156.28, Partial removal of colon,44141,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9660.73,,,,,,,fee schedule,5097,9660.73, Partial removal of colon,44141,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,9660.73, Partial removal of colon,44141,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,9660.73, Partial removal of colon,44141,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,9660.73, Partial removal of colon,44143,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8762.13,,,,,,,fee schedule,5097,8762.13, Partial removal of colon,44143,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8762.13, Partial removal of colon,44143,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8762.13, Partial removal of colon,44143,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8762.13, Partial removal of colon,44144,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9355.75,,,,,,,fee schedule,5097,9355.75, Partial removal of colon,44144,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,9355.75, Partial removal of colon,44144,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,9355.75, Partial removal of colon,44144,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,9355.75, Partial removal of colon,44145,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8646.6,,,,,,,fee schedule,5097,8646.6, Partial removal of colon,44145,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8646.6, Partial removal of colon,44145,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8646.6, Partial removal of colon,44145,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8646.6, Partial removal of colon,44146,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,11069.35,,,,,,,fee schedule,5097,11069.35, Partial removal of colon,44146,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,11069.35, Partial removal of colon,44146,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,11069.35, Partial removal of colon,44146,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,11069.35, Partial removal of colon,44147,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10058.47,,,,,,,fee schedule,5097,10058.47, Partial removal of colon,44147,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,10058.47, Partial removal of colon,44147,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,10058.47, Partial removal of colon,44147,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,10058.47, Removal of colon,44150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9829.73,,,,,,,fee schedule,5097,9829.73, Removal of colon,44150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,9829.73, Removal of colon,44150,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,9829.73, Removal of colon,44150,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,9829.73, Removal of colon/ileostomy,44151,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,11544.36,,,,,,,fee schedule,5097,11544.36, Removal of colon/ileostomy,44151,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,11544.36, Removal of colon/ileostomy,44151,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,11544.36, Removal of colon/ileostomy,44151,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,11544.36, Removal of colon/ileostomy,44155,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10908.18,,,,,,,fee schedule,5097,10908.18, Removal of colon/ileostomy,44155,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,10908.18, Removal of colon/ileostomy,44155,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,10908.18, Removal of colon/ileostomy,44155,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,10908.18, Removal of colon/ileostomy,44156,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12333.42,,,,,,,fee schedule,5097,12333.42, Removal of colon/ileostomy,44156,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,12333.42, Removal of colon/ileostomy,44156,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,12333.42, Removal of colon/ileostomy,44156,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,12333.42, Colectomy w/Ileoanal Anast,44157,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,11729.34,,,,,,,fee schedule,5097,11729.34, Colectomy w/Ileoanal Anast,44157,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,11729.34, Colectomy w/Ileoanal Anast,44157,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,11729.34, Colectomy w/Ileoanal Anast,44157,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,11729.34, Colectomy w/Neo-Rectum Pouch,44158,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12015.97,,,,,,,fee schedule,5097,12015.97, Colectomy w/Neo-Rectum Pouch,44158,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,12015.97, Colectomy w/Neo-Rectum Pouch,44158,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,12015.97, Colectomy w/Neo-Rectum Pouch,44158,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,12015.97, Removal of colon,44160,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6614.85,,,,,,,fee schedule,5097,6979, Removal of colon,44160,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Removal of colon,44160,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Removal of colon,44160,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Lap enterolysis,44180,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4950.88,,,,,,,fee schedule,4950.88,22111, Lap enterolysis,44180,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4950.88,22111, Lap enterolysis,44180,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4950.88,22111, Lap enterolysis,44180,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4950.88,22111, Lap jejunostomy,44186,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3559.36,,,,,,,fee schedule,3559.36,22111, Lap jejunostomy,44186,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,3559.36,22111, Lap jejunostomy,44186,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3559.36,22111, Lap jejunostomy,44186,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3559.36,22111, Lap ileo/jejuno-stomy,44187,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5755.97,,,,,,,fee schedule,5097,5755.97, Lap ileo/jejuno-stomy,44187,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5097,5755.97, Lap ileo/jejuno-stomy,44187,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5755.97, Lap ileo/jejuno-stomy,44187,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5755.97, Lap colostomy,44188,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6443.58,,,,,,,fee schedule,5097,6443.58, Lap colostomy,44188,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5097,6443.58, Lap colostomy,44188,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6443.58, Lap colostomy,44188,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6443.58, Lap enterectomy,44202,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7381.08,,,,,,,fee schedule,6044,14456, Lap enterectomy,44202,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,14456, Lap enterectomy,44202,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,6044,14456, Lap enterectomy,44202,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,6044,14456, Lap resect s/intestine addl,44203,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1254.62,,,,,,,fee schedule,1254.62,14456, Lap resect s/intestine addl,44203,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1254.62,14456, Lap resect s/intestine addl,44203,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,1254.62,14456, Lap resect s/intestine addl,44203,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,1254.62,14456, Laparo partial colectomy,44204,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8061.19,,,,,,,fee schedule,6979,14456, Laparo partial colectomy,44204,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,14456, Laparo partial colectomy,44204,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,6979,14456, Laparo partial colectomy,44204,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,6979,14456, Lap colectomy part w/ileum,44205,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6973.9,,,,,,,fee schedule,5097,6979, Lap colectomy part w/ileum,44205,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Lap colectomy part w/ileum,44205,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Lap colectomy part w/ileum,44205,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Lap part colectomy w/stoma,44206,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9133.76,,,,,,,fee schedule,5097,9133.76, Lap part colectomy w/stoma,44206,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,9133.76, Lap part colectomy w/stoma,44206,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,9133.76, Lap part colectomy w/stoma,44206,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,9133.76, L colectomy/coloproctostomy,44207,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9382.03,,,,,,,fee schedule,5097,9382.03, L colectomy/coloproctostomy,44207,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,9382.03, L colectomy/coloproctostomy,44207,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,9382.03, L colectomy/coloproctostomy,44207,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,9382.03, L colectomy/coloproctostomy,44208,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10219.97,,,,,,,fee schedule,5097,10219.97, L colectomy/coloproctostomy,44208,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,10219.97, L colectomy/coloproctostomy,44208,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,10219.97, L colectomy/coloproctostomy,44208,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,10219.97, Laparo total proctocolectomy,44210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9174.06,,,,,,,fee schedule,5097,9174.06, Laparo total proctocolectomy,44210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,9174.06, Laparo total proctocolectomy,44210,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,9174.06, Laparo total proctocolectomy,44210,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,9174.06, Lap colectomy w/proctectomy,44211,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10740.09,,,,,,,fee schedule,5097,10740.09, Lap colectomy w/proctectomy,44211,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,10740.09, Lap colectomy w/proctectomy,44211,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,10740.09, Lap colectomy w/proctectomy,44211,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,10740.09, Laparo total proctocolectomy,44212,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10466.68,,,,,,,fee schedule,5097,10466.68, Laparo total proctocolectomy,44212,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,10466.68, Laparo total proctocolectomy,44212,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,10466.68, Laparo total proctocolectomy,44212,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,10466.68, Lap mobil splenic fl add-on,44213,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,947.21,,,,,,,fee schedule,947.21,5664, Lap mobil splenic fl add-on,44213,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,947.21,5664, Lap mobil splenic fl add-on,44213,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,947.21,5664, Lap mobil splenic fl add-on,44213,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,947.21,5664, Lap close enterostomy,44227,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8670.45,,,,,,,fee schedule,5097,8670.45, Lap close enterostomy,44227,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5097,8670.45, Lap close enterostomy,44227,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8670.45, Lap close enterostomy,44227,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8670.45, Laparoscope proc intestine,44238,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,14456, Laparoscope proc intestine,44238,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,6979,14456, Laparoscope proc intestine,44238,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,6979,14456, Open bowel to skin,44300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4548.23,,,,,,,fee schedule,4108,5664, Open bowel to skin,44300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,5664, Open bowel to skin,44300,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4108,5664, Open bowel to skin,44300,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4108,5664, Ileostomy/jejunostomy,44310,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5507.1,,,,,,,fee schedule,5097,6979, Ileostomy/jejunostomy,44310,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Ileostomy/jejunostomy,44310,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Ileostomy/jejunostomy,44310,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Revision of ileostomy,44312,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3199.88,,,,,,,fee schedule,3195,12821, Revision of ileostomy,44312,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,12821, Revision of ileostomy,44312,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3195,12821, Revision of ileostomy,44312,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3195,12821, Revision of ileostomy,44314,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5286.84,,,,,,,fee schedule,5286.84,12821, Revision of ileostomy,44314,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5286.84,12821, Revision of ileostomy,44314,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5286.84,12821, Revision of ileostomy,44314,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5286.84,12821, Devise bowel pouch,44316,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7621.42,,,,,,,fee schedule,5097,7621.42, Devise bowel pouch,44316,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7621.42, Devise bowel pouch,44316,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7621.42, Devise bowel pouch,44316,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7621.42, Colostomy,44320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6385.14,,,,,,,fee schedule,5097,6979, Colostomy,44320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Colostomy,44320,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Colostomy,44320,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Colostomy with biopsies,44322,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5519.35,,,,,,,fee schedule,5097,6979, Colostomy with biopsies,44322,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Colostomy with biopsies,44322,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Colostomy with biopsies,44322,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Revision of colostomy,44340,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3402.34,,,,,,,fee schedule,3402.34,12821, Revision of colostomy,44340,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3402.34,12821, Revision of colostomy,44340,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3402.34,12821, Revision of colostomy,44340,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3402.34,12821, Revision of colostomy,44345,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5592.63,,,,,,,fee schedule,5363,12821, Revision of colostomy,44345,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,12821, Revision of colostomy,44345,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5363,12821, Revision of colostomy,44345,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5363,12821, Revision of colostomy,44346,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6243.44,,,,,,,fee schedule,5363,12821, Revision of colostomy,44346,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,12821, Revision of colostomy,44346,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5363,12821, Revision of colostomy,44346,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5363,12821, Small bowel endoscopy,44360,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,703.1,,,,,,,fee schedule,703.1,5664, Small bowel endoscopy,44360,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,703.1,5664, Small bowel endoscopy,44360,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,703.1,5664, Small bowel endoscopy,44360,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,703.1,5664, Small bowel endoscopy/biopsy,44361,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,775.41,,,,,,,fee schedule,775.41,5664, Small bowel endoscopy/biopsy,44361,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,775.41,5664, Small bowel endoscopy/biopsy,44361,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,775.41,5664, Small bowel endoscopy/biopsy,44361,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,775.41,5664, Small bowel endoscopy,44363,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,939.01,,,,,,,fee schedule,939.01,5664, Small bowel endoscopy,44363,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,939.01,5664, Small bowel endoscopy,44363,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,939.01,5664, Small bowel endoscopy,44363,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,939.01,5664, Small bowel endoscopy,44364,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,996.96,,,,,,,fee schedule,996.96,5664, Small bowel endoscopy,44364,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,996.96,5664, Small bowel endoscopy,44364,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,996.96,5664, Small bowel endoscopy,44364,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,996.96,5664, Small bowel endoscopy,44365,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,889.8,,,,,,,fee schedule,889.8,5664, Small bowel endoscopy,44365,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,889.8,5664, Small bowel endoscopy,44365,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,889.8,5664, Small bowel endoscopy,44365,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,889.8,5664, Small bowel endoscopy,44366,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1163.11,,,,,,,fee schedule,1163.11,5664, Small bowel endoscopy,44366,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1163.11,5664, Small bowel endoscopy,44366,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1163.11,5664, Small bowel endoscopy,44366,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1163.11,5664, Small bowel endoscopy,44369,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1193.49,,,,,,,fee schedule,1193.49,5664, Small bowel endoscopy,44369,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1193.49,5664, Small bowel endoscopy,44369,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1193.49,5664, Small bowel endoscopy,44369,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1193.49,5664, Small Bowel Endoscopy/Stent,44370,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1299.25,,,,,,,fee schedule,1299.25,12821, Small Bowel Endoscopy/Stent,44370,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,1299.25,12821, Small Bowel Endoscopy/Stent,44370,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,1299.25,12821, Small Bowel Endoscopy/Stent,44370,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,1299.25,12821, Small bowel endoscopy,44372,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1181.56,,,,,,,fee schedule,1181.56,5664, Small bowel endoscopy,44372,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1181.56,5664, Small bowel endoscopy,44372,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1181.56,5664, Small bowel endoscopy,44372,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1181.56,5664, Small bowel endoscopy,44373,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,947.38,,,,,,,fee schedule,947.38,5664, Small bowel endoscopy,44373,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,947.38,5664, Small bowel endoscopy,44373,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,947.38,5664, Small bowel endoscopy,44373,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,947.38,5664, Small bowel endoscopy,44376,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1374.95,,,,,,,fee schedule,1374.95,5664, Small bowel endoscopy,44376,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1374.95,5664, Small bowel endoscopy,44376,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1374.95,5664, Small bowel endoscopy,44376,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1374.95,5664, Small bowel endoscopy/biopsy,44377,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1445.7,,,,,,,fee schedule,1445.7,5664, Small bowel endoscopy/biopsy,44377,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1445.7,5664, Small bowel endoscopy/biopsy,44377,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1445.7,5664, Small bowel endoscopy/biopsy,44377,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1445.7,5664, Small bowel endoscopy,44378,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1857.36,,,,,,,fee schedule,1857.36,5664, Small bowel endoscopy,44378,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1857.36,5664, Small bowel endoscopy,44378,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1857.36,5664, Small bowel endoscopy,44378,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1857.36,5664, S Bowel Endoscope W/Stent,44379,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1987.29,,,,,,,fee schedule,1987.29,12821, S Bowel Endoscope W/Stent,44379,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,1987.29,12821, S Bowel Endoscope W/Stent,44379,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,1987.29,12821, S Bowel Endoscope W/Stent,44379,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,1987.29,12821, Small bowel endoscopy br/wa,44380,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,289.55,,,,,,,fee schedule,289.55,5664, Small bowel endoscopy br/wa,44380,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,289.55,5664, Small bowel endoscopy br/wa,44380,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,289.55,5664, Small bowel endoscopy br/wa,44380,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,289.55,5664, Small bowel endoscopy br/wa,44381,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,427.2,,,,,,,fee schedule,427.2,5664, Small bowel endoscopy br/wa,44381,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,427.2,5664, Small bowel endoscopy br/wa,44381,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,427.2,5664, Small bowel endoscopy br/wa,44381,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,427.2,5664, Small bowel endoscopy,44382,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,371.62,,,,,,,fee schedule,371.62,5664, Small bowel endoscopy,44382,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,371.62,5664, Small bowel endoscopy,44382,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,371.62,5664, Small bowel endoscopy,44382,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,371.62,5664, Small bowel endoscopy,44384,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,753.66,,,,,,,fee schedule,753.66,5664, Small bowel endoscopy,44384,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,753.66,5664, Small bowel endoscopy,44384,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,753.66,5664, Small bowel endoscopy,44384,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,753.66,5664, Endoscopy of bowel pouch,44385,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,374.1,,,,,,,fee schedule,374.1,5664, Endoscopy of bowel pouch,44385,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,374.1,5664, Endoscopy of bowel pouch,44385,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,374.1,5664, Endoscopy of bowel pouch,44385,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,374.1,5664, Endoscopy bowel pouch/biop,44386,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,448.03,,,,,,,fee schedule,448.03,5664, Endoscopy bowel pouch/biop,44386,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,448.03,5664, Endoscopy bowel pouch/biop,44386,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,448.03,5664, Endoscopy bowel pouch/biop,44386,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,448.03,5664, Colonoscopy thru stoma spx,44388,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,396.55,,,,,,,fee schedule,396.55,5664, Colonoscopy thru stoma spx,44388,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,788.57,,,,,,,fee schedule,396.55,5664, Colonoscopy thru stoma spx,44388,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,396.55,5664, Colonoscopy thru stoma spx,44388,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,396.55,5664, Colonoscopy thru stoma spx,44388,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,396.55,5664, Colonoscopy with biopsy,44389,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,855.32,,,,,,,fee schedule,855.32,5664, Colonoscopy with biopsy,44389,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,855.32,5664, Colonoscopy with biopsy,44389,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,855.32,5664, Colonoscopy with biopsy,44389,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,855.32,5664, Colonoscopy for foreign body,44390,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1027.34,,,,,,,fee schedule,1027.34,5664, Colonoscopy for foreign body,44390,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1027.34,5664, Colonoscopy for foreign body,44390,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1027.34,5664, Colonoscopy for foreign body,44390,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1027.34,5664, Colonoscopy for bleeding,44391,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1125.82,,,,,,,fee schedule,1125.82,5664, Colonoscopy for bleeding,44391,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1125.82,5664, Colonoscopy for bleeding,44391,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1125.82,5664, Colonoscopy for bleeding,44391,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1125.82,5664, Colonoscopy & polypectomy,44392,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1012.45,,,,,,,fee schedule,1012.45,5664, Colonoscopy & polypectomy,44392,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1012.45,5664, Colonoscopy & polypectomy,44392,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1012.45,5664, Colonoscopy & polypectomy,44392,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1012.45,5664, Colonoscopy w/snare,44394,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1111.79,,,,,,,fee schedule,1111.79,5664, Colonoscopy w/snare,44394,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1111.79,5664, Colonoscopy w/snare,44394,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1111.79,5664, Colonoscopy w/snare,44394,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1111.79,5664, Colonoscopy with ablation,44401,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1179.19,,,,,,,fee schedule,1179.19,5664, Colonoscopy with ablation,44401,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1179.19,5664, Colonoscopy with ablation,44401,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1179.19,5664, Colonoscopy with ablation,44401,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1179.19,5664, Colonoscopy w/stent plcmt,44402,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1267.57,,,,,,,fee schedule,1267.57,5664, Colonoscopy w/stent plcmt,44402,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1267.57,5664, Colonoscopy w/stent plcmt,44402,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1267.57,5664, Colonoscopy w/stent plcmt,44402,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1267.57,5664, Colonoscopy w/resection,44403,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1472.19,,,,,,,fee schedule,1472.19,5664, Colonoscopy w/resection,44403,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1472.19,5664, Colonoscopy w/resection,44403,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1472.19,5664, Colonoscopy w/resection,44403,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1472.19,5664, Colonoscopy w/injection,44404,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,850.9,,,,,,,fee schedule,850.9,5664, Colonoscopy w/injection,44404,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,850.9,5664, Colonoscopy w/injection,44404,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,850.9,5664, Colonoscopy w/injection,44404,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,850.9,5664, Colonoscopy w/dilation,44405,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,899.57,,,,,,,fee schedule,899.57,5664, Colonoscopy w/dilation,44405,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,899.57,5664, Colonoscopy w/dilation,44405,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,899.57,5664, Colonoscopy w/dilation,44405,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,899.57,5664, Colonoscopy w/ultrasound,44406,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1117.51,,,,,,,fee schedule,1117.51,5664, Colonoscopy w/ultrasound,44406,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1117.51,5664, Colonoscopy w/ultrasound,44406,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1117.51,5664, Colonoscopy w/ultrasound,44406,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1117.51,5664, Colonoscopy w/ndl aspir/bx,44407,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1334.65,,,,,,,fee schedule,1334.65,5664, Colonoscopy w/ndl aspir/bx,44407,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1334.65,5664, Colonoscopy w/ndl aspir/bx,44407,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1334.65,5664, Colonoscopy w/ndl aspir/bx,44407,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1334.65,5664, Colonoscopy w/decompression,44408,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1126.47,,,,,,,fee schedule,1126.47,5664, Colonoscopy w/decompression,44408,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1126.47,5664, Colonoscopy w/decompression,44408,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1126.47,5664, Colonoscopy w/decompression,44408,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1126.47,5664, Intro gastrointestinal tube,44500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,91.41,,,,,,,fee schedule,91.41,6979, Intro gastrointestinal tube,44500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,91.41,6979, Intro gastrointestinal tube,44500,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,91.41,6979, Intro gastrointestinal tube,44500,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,91.41,6979, Suture small intestine,44602,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7438.6,,,,,,,fee schedule,6979,10940, Suture small intestine,44602,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,10940, Suture small intestine,44602,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,6979,10940, Suture small intestine,44602,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,6979,10940, Suture small intestine,44603,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8531.4,,,,,,,fee schedule,5097,8531.4, Suture small intestine,44603,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8531.4, Suture small intestine,44603,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8531.4, Suture small intestine,44603,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8531.4, Suture large intestine,44604,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5589.18,,,,,,,fee schedule,5097,6979, Suture large intestine,44604,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Suture large intestine,44604,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Suture large intestine,44604,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Repair of bowel lesion,44605,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7019.71,,,,,,,fee schedule,5097,7019.71, Repair of bowel lesion,44605,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7019.71, Repair of bowel lesion,44605,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7019.71, Repair of bowel lesion,44605,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7019.71, Intestinal stricturoplasty,44615,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5681.45,,,,,,,fee schedule,5097,6979, Intestinal stricturoplasty,44615,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Intestinal stricturoplasty,44615,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Intestinal stricturoplasty,44615,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Repair bowel opening,44620,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4558.54,,,,,,,fee schedule,4558.54,6979, Repair bowel opening,44620,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4558.54,6979, Repair bowel opening,44620,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4558.54,6979, Repair bowel opening,44620,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4558.54,6979, Repair bowel opening,44625,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5292.5,,,,,,,fee schedule,5097,6979, Repair bowel opening,44625,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Repair bowel opening,44625,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Repair bowel opening,44625,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Repair bowel opening,44626,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8341.24,,,,,,,fee schedule,5097,8341.24, Repair bowel opening,44626,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8341.24, Repair bowel opening,44626,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8341.24, Repair bowel opening,44626,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8341.24, Repair bowel-skin fistula,44640,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7345.74,,,,,,,fee schedule,5097,7345.74, Repair bowel-skin fistula,44640,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7345.74, Repair bowel-skin fistula,44640,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7345.74, Repair bowel-skin fistula,44640,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7345.74, Repair bowel fistula,44650,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7562.98,,,,,,,fee schedule,5097,7562.98, Repair bowel fistula,44650,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7562.98, Repair bowel fistula,44650,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7562.98, Repair bowel fistula,44650,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7562.98, Repair bowel-bladder fistula,44660,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6889.88,,,,,,,fee schedule,5097,6979, Repair bowel-bladder fistula,44660,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Repair bowel-bladder fistula,44660,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Repair bowel-bladder fistula,44660,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Repair bowel-bladder fistula,44661,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8080.51,,,,,,,fee schedule,5097,8080.51, Repair bowel-bladder fistula,44661,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8080.51, Repair bowel-bladder fistula,44661,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8080.51, Repair bowel-bladder fistula,44661,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8080.51, Surgical revision intestine,44680,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5808.15,,,,,,,fee schedule,5097,6979, Surgical revision intestine,44680,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Surgical revision intestine,44680,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Surgical revision intestine,44680,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Suspend bowel w/prosthesis,44700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5168.67,,,,,,,fee schedule,5097,6979, Suspend bowel w/prosthesis,44700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Suspend bowel w/prosthesis,44700,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Suspend bowel w/prosthesis,44700,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Intraop colon lavage add-on,44701,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,889.48,,,,,,,fee schedule,889.48,2782, Intraop colon lavage add-on,44701,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,889.48,2782, Intraop colon lavage add-on,44701,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,889.48,2782, Prepare fecal microbiota,44705,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,3195, Prepare donor intestine,44715,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Prepare donor intestine,44715,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Prepare donor intestine,44715,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Prep donor intestine/venous,44720,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1437.71,,,,,,,fee schedule,1437.71,6979, Prep donor intestine/venous,44720,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1437.71,6979, Prep donor intestine/venous,44720,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1437.71,6979, Prep donor intestine/venous,44720,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1437.71,6979, Prep donor intestine/artery,44721,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2010.01,,,,,,,fee schedule,2010.01,6979, Prep donor intestine/artery,44721,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2010.01,6979, Prep donor intestine/artery,44721,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2010.01,6979, Prep donor intestine/artery,44721,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2010.01,6979, Unlisted px small intestine,44799,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,5664, Unlisted px small intestine,44799,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3195,5664, Unlisted px small intestine,44799,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3195,5664, Excision of bowel pouch,44800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4196.52,,,,,,,fee schedule,4196.52,6979, Excision of bowel pouch,44800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4196.52,6979, Excision of bowel pouch,44800,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4196.52,6979, Excision of bowel pouch,44800,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4196.52,6979, Excision of mesentery lesion,44820,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4628.8,,,,,,,fee schedule,4628.8,6979, Excision of mesentery lesion,44820,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4628.8,6979, Excision of mesentery lesion,44820,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4628.8,6979, Excision of mesentery lesion,44820,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4628.8,6979, Repair of mesentery,44850,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4040.2,,,,,,,fee schedule,4040.2,6979, Repair of mesentery,44850,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4040.2,6979, Repair of mesentery,44850,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4040.2,6979, Repair of mesentery,44850,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4040.2,6979, Bowel surgery procedure,44899,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Bowel surgery procedure,44899,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Bowel surgery procedure,44899,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Drain appendix abscess open,44900,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4256.74,,,,,,,fee schedule,4256.74,6979, Drain appendix abscess open,44900,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4256.74,6979, Drain appendix abscess open,44900,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4256.74,6979, Drain appendix abscess open,44900,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4256.74,6979, Appendectomy,44950,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3463.15,,,,,,,fee schedule,3463.15,12821, Appendectomy,44950,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3463.15,12821, Appendectomy,44950,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3463.15,12821, Appendectomy,44950,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3463.15,12821, Appendectomy add-on,44955,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,433.24,,,,,,,fee schedule,433.24,2782, Appendectomy add-on,44955,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,433.24,2782, Appendectomy add-on,44955,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,433.24,2782, Appendectomy,44960,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4730.78,,,,,,,fee schedule,4730.78,6979, Appendectomy,44960,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4730.78,6979, Appendectomy,44960,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4730.78,6979, Appendectomy,44960,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4730.78,6979, Laparoscopy appendectomy,44970,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3290.21,,,,,,,fee schedule,3290.21,22111, Laparoscopy appendectomy,44970,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3290.21,22111, Laparoscopy appendectomy,44970,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3290.21,22111, Laparoscopy appendectomy,44970,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3290.21,22111, Laparoscope proc app,44979,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,14456, Laparoscope proc app,44979,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5248,14456, Laparoscope proc app,44979,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5248,14456, Drainage of pelvic abscess,45000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2289.74,,,,,,,fee schedule,2289.74,5664, Drainage of pelvic abscess,45000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2289.74,5664, Drainage of pelvic abscess,45000,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2289.74,5664, Drainage of pelvic abscess,45000,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2289.74,5664, Drainage of rectal abscess,45005,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,961.89,,,,,,,fee schedule,961.89,5664, Drainage of rectal abscess,45005,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,961.89,5664, Drainage of rectal abscess,45005,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,961.89,5664, Drainage of rectal abscess,45005,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,961.89,5664, Drainage of rectal abscess,45020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3073.35,,,,,,,fee schedule,3073.35,5664, Drainage of rectal abscess,45020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3073.35,5664, Drainage of rectal abscess,45020,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3073.35,5664, Drainage of rectal abscess,45020,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3073.35,5664, Biopsy of rectum,45100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1667.47,,,,,,,fee schedule,1667.47,5664, Biopsy of rectum,45100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1667.47,5664, Biopsy of rectum,45100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1667.47,5664, Biopsy of rectum,45100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1667.47,5664, Removal of anorectal lesion,45108,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2093.59,,,,,,,fee schedule,2093.59,10940, Removal of anorectal lesion,45108,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2093.59,10940, Removal of anorectal lesion,45108,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2093.59,10940, Removal of anorectal lesion,45108,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2093.59,10940, Removal of rectum,45110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9410.14,,,,,,,fee schedule,5097,9410.14, Removal of rectum,45110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,9410.14, Removal of rectum,45110,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,9410.14, Removal of rectum,45110,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,9410.14, Partial removal of rectum,45111,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5710.96,,,,,,,fee schedule,5097,6979, Partial removal of rectum,45111,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Partial removal of rectum,45111,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Partial removal of rectum,45111,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Removal of rectum,45112,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9179.41,,,,,,,fee schedule,5097,9179.41, Removal of rectum,45112,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,9179.41, Removal of rectum,45112,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,9179.41, Removal of rectum,45112,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,9179.41, Partial proctectomy,45113,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9462.26,,,,,,,fee schedule,5097,9462.26, Partial proctectomy,45113,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,9462.26, Partial proctectomy,45113,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,9462.26, Partial proctectomy,45113,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,9462.26, Partial removal of rectum,45114,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9739.51,,,,,,,fee schedule,5097,9739.51, Partial removal of rectum,45114,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,9739.51, Partial removal of rectum,45114,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,9739.51, Partial removal of rectum,45114,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,9739.51, Partial removal of rectum,45116,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7855.17,,,,,,,fee schedule,5097,7855.17, Partial removal of rectum,45116,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7855.17, Partial removal of rectum,45116,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7855.17, Partial removal of rectum,45116,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7855.17, Remove rectum w/reservoir,45119,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9531.22,,,,,,,fee schedule,5097,9531.22, Remove rectum w/reservoir,45119,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,9531.22, Remove rectum w/reservoir,45119,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,9531.22, Remove rectum w/reservoir,45119,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,9531.22, Removal of rectum,45120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8609.1,,,,,,,fee schedule,5097,8609.1, Removal of rectum,45120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8609.1, Removal of rectum,45120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8609.1, Removal of rectum,45120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8609.1, Removal of rectum and colon,45121,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9383.1,,,,,,,fee schedule,5097,9383.1, Removal of rectum and colon,45121,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,9383.1, Removal of rectum and colon,45121,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,9383.1, Removal of rectum and colon,45121,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,9383.1, Partial proctectomy,45123,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5796.76,,,,,,,fee schedule,5796.76,22111, Partial proctectomy,45123,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5796.76,22111, Partial proctectomy,45123,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5796.76,22111, Partial proctectomy,45123,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5796.76,22111, Pelvic exenteration,45126,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,14005.05,,,,,,,fee schedule,5097,14005.05, Pelvic exenteration,45126,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,14005.05, Pelvic exenteration,45126,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,14005.05, Pelvic exenteration,45126,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,14005.05, Excision of rectal prolapse,45130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5645.3,,,,,,,fee schedule,5097,6979, Excision of rectal prolapse,45130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Excision of rectal prolapse,45130,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Excision of rectal prolapse,45130,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Excision of rectal prolapse,45135,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6651.54,,,,,,,fee schedule,5097,6979, Excision of rectal prolapse,45135,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Excision of rectal prolapse,45135,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Excision of rectal prolapse,45135,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Excise ileoanal reservior,45136,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9098.36,,,,,,,fee schedule,5097,9098.36, Excise ileoanal reservior,45136,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,9098.36, Excise ileoanal reservior,45136,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,9098.36, Excise ileoanal reservior,45136,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,9098.36, Excision of rectal stricture,45150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2351.25,,,,,,,fee schedule,2351.25,5664, Excision of rectal stricture,45150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2351.25,5664, Excision of rectal stricture,45150,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2351.25,5664, Excision of rectal stricture,45150,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2351.25,5664, Excision of rectal lesion,45160,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5581.62,,,,,,,fee schedule,4108,10940, Excision of rectal lesion,45160,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,10940, Excision of rectal lesion,45160,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,4108,10940, Excision of rectal lesion,45160,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,4108,10940, Exc rect tum transanal part,45171,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3373.26,,,,,,,fee schedule,3195,10940, Exc rect tum transanal part,45171,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,10940, Exc rect tum transanal part,45171,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3195,10940, Exc rect tum transanal part,45171,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3195,10940, Exc rect tum transanal full,45172,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4407.51,,,,,,,fee schedule,4108,12821, Exc rect tum transanal full,45172,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,12821, Exc rect tum transanal full,45172,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4108,12821, Exc rect tum transanal full,45172,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4108,12821, Destruction rectal tumor,45190,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3691.94,,,,,,,fee schedule,3691.94,10940, Destruction rectal tumor,45190,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3691.94,10940, Destruction rectal tumor,45190,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3691.94,10940, Destruction rectal tumor,45190,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3691.94,10940, Proctosigmoidoscopy dx,45300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,251.62,,,,,,,fee schedule,251.62,4497, Proctosigmoidoscopy dx,45300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,251.62,4497, Proctosigmoidoscopy dx,45300,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,251.62,4497, Proctosigmoidoscopy dx,45300,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,251.62,4497, Proctosigmoidoscopy dilate,45303,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,447.06,,,,,,,fee schedule,447.06,5664, Proctosigmoidoscopy dilate,45303,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,447.06,5664, Proctosigmoidoscopy dilate,45303,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,447.06,5664, Proctosigmoidoscopy dilate,45303,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,447.06,5664, Proctosigmoidoscopy w/bx,45305,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,385.27,,,,,,,fee schedule,385.27,5664, Proctosigmoidoscopy w/bx,45305,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,385.27,5664, Proctosigmoidoscopy w/bx,45305,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,385.27,5664, Proctosigmoidoscopy w/bx,45305,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,385.27,5664, Proctosigmoidoscopy fb,45307,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,548.29,,,,,,,fee schedule,548.29,10940, Proctosigmoidoscopy fb,45307,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,548.29,10940, Proctosigmoidoscopy fb,45307,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,548.29,10940, Proctosigmoidoscopy fb,45307,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,548.29,10940, Proctosigmoidoscopy removal,45308,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,464.97,,,,,,,fee schedule,464.97,5664, Proctosigmoidoscopy removal,45308,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,464.97,5664, Proctosigmoidoscopy removal,45308,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,464.97,5664, Proctosigmoidoscopy removal,45308,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,464.97,5664, Proctosigmoidoscopy removal,45309,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,491.9,,,,,,,fee schedule,491.9,5664, Proctosigmoidoscopy removal,45309,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,491.9,5664, Proctosigmoidoscopy removal,45309,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,491.9,5664, Proctosigmoidoscopy removal,45309,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,491.9,5664, Proctosigmoidoscopy removal,45315,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,572.46,,,,,,,fee schedule,572.46,5664, Proctosigmoidoscopy removal,45315,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,572.46,5664, Proctosigmoidoscopy removal,45315,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,572.46,5664, Proctosigmoidoscopy removal,45315,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,572.46,5664, Proctosigmoidoscopy bleed,45317,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,573.22,,,,,,,fee schedule,573.22,5664, Proctosigmoidoscopy bleed,45317,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,573.22,5664, Proctosigmoidoscopy bleed,45317,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,573.22,5664, Proctosigmoidoscopy bleed,45317,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,573.22,5664, Proctosigmoidoscopy ablate,45320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,568.85,,,,,,,fee schedule,568.85,10940, Proctosigmoidoscopy ablate,45320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,568.85,10940, Proctosigmoidoscopy ablate,45320,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,568.85,10940, Proctosigmoidoscopy ablate,45320,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,568.85,10940, Proctosigmoidoscopy volvul,45321,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,561.72,,,,,,,fee schedule,561.72,10940, Proctosigmoidoscopy volvul,45321,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,561.72,10940, Proctosigmoidoscopy volvul,45321,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,561.72,10940, Proctosigmoidoscopy volvul,45321,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,561.72,10940, Proctosigmoidoscopy W/Stent,45327,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,628.85,,,,,,,fee schedule,628.85,12821, Proctosigmoidoscopy W/Stent,45327,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,628.85,12821, Proctosigmoidoscopy W/Stent,45327,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,628.85,12821, Proctosigmoidoscopy W/Stent,45327,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,628.85,12821, Diagnostic sigmoidoscopy,45330,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,295.75,,,,,,,fee schedule,295.75,4497, Diagnostic sigmoidoscopy,45330,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,295.75,4497, Diagnostic sigmoidoscopy,45330,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,295.75,4497, Diagnostic sigmoidoscopy,45330,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,295.75,4497, Sigmoidoscopy and biopsy,45331,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,367.2,,,,,,,fee schedule,367.2,4497, Sigmoidoscopy and biopsy,45331,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,367.2,4497, Sigmoidoscopy and biopsy,45331,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,367.2,4497, Sigmoidoscopy and biopsy,45331,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,367.2,4497, Sigmoidoscopy w/fb removal,45332,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,529.83,,,,,,,fee schedule,529.83,5664, Sigmoidoscopy w/fb removal,45332,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,529.83,5664, Sigmoidoscopy w/fb removal,45332,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,529.83,5664, Sigmoidoscopy w/fb removal,45332,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,529.83,5664, Sigmoidoscopy & polypectomy,45333,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,479.92,,,,,,,fee schedule,479.92,4497, Sigmoidoscopy & polypectomy,45333,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,479.92,4497, Sigmoidoscopy & polypectomy,45333,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,479.92,4497, Sigmoidoscopy & polypectomy,45333,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,479.92,4497, Sigmoidoscopy for bleeding,45334,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,583.36,,,,,,,fee schedule,583.36,5664, Sigmoidoscopy for bleeding,45334,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,583.36,5664, Sigmoidoscopy for bleeding,45334,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,583.36,5664, Sigmoidoscopy for bleeding,45334,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,583.36,5664, Sigmoidoscopy w/submuc inj,45335,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,344,,,,,,,fee schedule,344,4497, Sigmoidoscopy w/submuc inj,45335,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,344,4497, Sigmoidoscopy w/submuc inj,45335,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,344,4497, Sigmoidoscopy w/submuc inj,45335,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,344,4497, Sigmoidoscopy & decompress,45337,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,555.09,,,,,,,fee schedule,555.09,5664, Sigmoidoscopy & decompress,45337,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,555.09,5664, Sigmoidoscopy & decompress,45337,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,555.09,5664, Sigmoidoscopy & decompress,45337,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,555.09,5664, Sigmoidoscopy w/tumr remove,45338,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,602.19,,,,,,,fee schedule,602.19,5664, Sigmoidoscopy w/tumr remove,45338,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,602.19,5664, Sigmoidoscopy w/tumr remove,45338,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,602.19,5664, Sigmoidoscopy w/tumr remove,45338,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,602.19,5664, Sig w/tndsc balloon dilation,45340,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,400.33,,,,,,,fee schedule,400.33,5664, Sig w/tndsc balloon dilation,45340,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,400.33,5664, Sig w/tndsc balloon dilation,45340,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,400.33,5664, Sig w/tndsc balloon dilation,45340,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,400.33,5664, Sigmoidoscopy W/Ultrasound,45341,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,614.55,,,,,,,fee schedule,614.55,5664, Sigmoidoscopy W/Ultrasound,45341,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,614.55,5664, Sigmoidoscopy W/Ultrasound,45341,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,614.55,5664, Sigmoidoscopy W/Ultrasound,45341,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,614.55,5664, Sigmoidoscopy W/Us Guide Bx,45342,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,840.8,,,,,,,fee schedule,840.8,5664, Sigmoidoscopy W/Us Guide Bx,45342,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,840.8,5664, Sigmoidoscopy W/Us Guide Bx,45342,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,840.8,5664, Sigmoidoscopy W/Us Guide Bx,45342,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,840.8,5664, Sigmoidoscopy w/ablation,45346,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,794.4,,,,,,,fee schedule,794.4,5664, Sigmoidoscopy w/ablation,45346,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,794.4,5664, Sigmoidoscopy w/ablation,45346,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,794.4,5664, Sigmoidoscopy w/ablation,45346,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,794.4,5664, Sigmoidoscopy w/plcmt stent,45347,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,755.28,,,,,,,fee schedule,755.28,5664, Sigmoidoscopy w/plcmt stent,45347,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,755.28,5664, Sigmoidoscopy w/plcmt stent,45347,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,755.28,5664, Sigmoidoscopy w/plcmt stent,45347,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,755.28,5664, Sigmoidoscopy w/resection,45349,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,970.25,,,,,,,fee schedule,970.25,5664, Sigmoidoscopy w/resection,45349,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,970.25,5664, Sigmoidoscopy w/resection,45349,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,970.25,5664, Sigmoidoscopy w/resection,45349,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,970.25,5664, Sgmdsc w/band ligation,45350,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,507.55,,,,,,,fee schedule,507.55,5664, Sgmdsc w/band ligation,45350,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,507.55,5664, Sgmdsc w/band ligation,45350,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,507.55,5664, Sgmdsc w/band ligation,45350,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,507.55,5664, Diagnostic colonoscopy,45378,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,458.88,,,,,,,fee schedule,458.88,5664, Diagnostic colonoscopy,45378,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,915.11,,,,,,,fee schedule,458.88,5664, Diagnostic colonoscopy,45378,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,458.88,5664, Diagnostic colonoscopy,45378,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,458.88,5664, Diagnostic colonoscopy,45378,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,458.88,5664, Colonoscopy w/fb removal,45379,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1165.16,,,,,,,fee schedule,1165.16,5664, Colonoscopy w/fb removal,45379,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1165.16,5664, Colonoscopy w/fb removal,45379,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1165.16,5664, Colonoscopy w/fb removal,45379,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1165.16,5664, Colonoscopy and biopsy,45380,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,985.58,,,,,,,fee schedule,985.58,5664, Colonoscopy and biopsy,45380,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,985.58,5664, Colonoscopy and biopsy,45380,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,985.58,5664, Colonoscopy and biopsy,45380,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,985.58,5664, Colonoscopy submucous njx,45381,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,985.58,,,,,,,fee schedule,985.58,5664, Colonoscopy submucous njx,45381,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,985.58,5664, Colonoscopy submucous njx,45381,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,985.58,5664, Colonoscopy submucous njx,45381,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,985.58,5664, Colonoscopy w/control bleed,45382,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1255.22,,,,,,,fee schedule,1255.22,5664, Colonoscopy w/control bleed,45382,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1255.22,5664, Colonoscopy w/control bleed,45382,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1255.22,5664, Colonoscopy w/control bleed,45382,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1255.22,5664, Colonoscopy w/lesion removal,45384,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1140.93,,,,,,,fee schedule,1140.93,5664, Colonoscopy w/lesion removal,45384,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1140.93,5664, Colonoscopy w/lesion removal,45384,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1140.93,5664, Colonoscopy w/lesion removal,45384,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1140.93,5664, Colonoscopy w/lesion removal,45385,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1238.33,,,,,,,fee schedule,1238.33,5664, Colonoscopy w/lesion removal,45385,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1238.33,5664, Colonoscopy w/lesion removal,45385,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1238.33,5664, Colonoscopy w/lesion removal,45385,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1238.33,5664, Colonoscopy w/balloon dilat,45386,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1039.16,,,,,,,fee schedule,1039.16,5664, Colonoscopy w/balloon dilat,45386,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1039.16,5664, Colonoscopy w/balloon dilat,45386,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1039.16,5664, Colonoscopy w/balloon dilat,45386,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1039.16,5664, Colonoscopy w/ablation,45388,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1327.15,,,,,,,fee schedule,1327.15,5664, Colonoscopy w/ablation,45388,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1327.15,5664, Colonoscopy w/ablation,45388,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1327.15,5664, Colonoscopy w/ablation,45388,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1327.15,5664, Colonoscopy w/stent plcmt,45389,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1403.77,,,,,,,fee schedule,1403.77,5664, Colonoscopy w/stent plcmt,45389,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1403.77,5664, Colonoscopy w/stent plcmt,45389,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1403.77,5664, Colonoscopy w/stent plcmt,45389,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1403.77,5664, Colonoscopy w/resection,45390,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1608.06,,,,,,,fee schedule,1608.06,5664, Colonoscopy w/resection,45390,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1608.06,5664, Colonoscopy w/resection,45390,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1608.06,5664, Colonoscopy w/resection,45390,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1608.06,5664, Colonoscopy w/endoscope us,45391,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1250.63,,,,,,,fee schedule,1250.63,5664, Colonoscopy w/endoscope us,45391,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1250.63,5664, Colonoscopy w/endoscope us,45391,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1250.63,5664, Colonoscopy w/endoscope us,45391,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1250.63,5664, Colonoscopy w/endoscopic fnb,45392,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1474.13,,,,,,,fee schedule,1474.13,5664, Colonoscopy w/endoscopic fnb,45392,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1474.13,5664, Colonoscopy w/endoscopic fnb,45392,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1474.13,5664, Colonoscopy w/endoscopic fnb,45392,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1474.13,5664, Colonoscopy w/decompression,45393,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1218.2,,,,,,,fee schedule,1218.2,5664, Colonoscopy w/decompression,45393,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1218.2,5664, Colonoscopy w/decompression,45393,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1218.2,5664, Colonoscopy w/decompression,45393,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1218.2,5664, Lap removal of rectum,45395,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10128.56,,,,,,,fee schedule,5097,10128.56, Lap removal of rectum,45395,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5097,10128.56, Lap removal of rectum,45395,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,10128.56, Lap removal of rectum,45395,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,10128.56, Lap remove rectum w/pouch,45397,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10907.1,,,,,,,fee schedule,5097,10907.1, Lap remove rectum w/pouch,45397,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5097,10907.1, Lap remove rectum w/pouch,45397,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,10907.1, Lap remove rectum w/pouch,45397,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,10907.1, Colonoscopy w/band ligation,45398,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1172.01,,,,,,,fee schedule,1172.01,5664, Colonoscopy w/band ligation,45398,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1172.01,5664, Colonoscopy w/band ligation,45398,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1172.01,5664, Colonoscopy w/band ligation,45398,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1172.01,5664, Unlisted procedure colon,45399,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,5664, Unlisted procedure colon,45399,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3195,5664, Unlisted procedure colon,45399,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3195,5664, Laparoscopic proc,45400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5869.39,,,,,,,fee schedule,5248,12821, Laparoscopic proc,45400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,12821, Laparoscopic proc,45400,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5248,12821, Laparoscopic proc,45400,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5248,12821, Lap proctopexy w/sig resect,45402,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7883.88,,,,,,,fee schedule,5097,7883.88, Lap proctopexy w/sig resect,45402,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5097,7883.88, Lap proctopexy w/sig resect,45402,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7883.88, Lap proctopexy w/sig resect,45402,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7883.88, Laparoscope proc rectum,45499,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,14456, Laparoscope proc rectum,45499,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5248,14456, Laparoscope proc rectum,45499,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5248,14456, Repair of rectum,45500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3199.13,,,,,,,fee schedule,3199.13,10940, Repair of rectum,45500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3199.13,10940, Repair of rectum,45500,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3199.13,10940, Repair of rectum,45500,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3199.13,10940, Repair of rectum,45505,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3273.81,,,,,,,fee schedule,3273.81,12821, Repair of rectum,45505,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3273.81,12821, Repair of rectum,45505,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3273.81,12821, Repair of rectum,45505,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3273.81,12821, Treatment of rectal prolapse,45520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,205.86,,,,,,,fee schedule,205.86,4497, Treatment of rectal prolapse,45520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,205.86,4497, Treatment of rectal prolapse,45520,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,205.86,4497, Treatment of rectal prolapse,45520,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,205.86,4497, Correct rectal prolapse,45540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5479.64,,,,,,,fee schedule,5097,6979, Correct rectal prolapse,45540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Correct rectal prolapse,45540,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Correct rectal prolapse,45540,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Correct rectal prolapse,45541,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4998.96,,,,,,,fee schedule,4108,12821, Correct rectal prolapse,45541,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,12821, Correct rectal prolapse,45541,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4108,12821, Correct rectal prolapse,45541,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4108,12821, Repair rectum/remove sigmoid,45550,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7619.75,,,,,,,fee schedule,5097,7619.75, Repair rectum/remove sigmoid,45550,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7619.75, Repair rectum/remove sigmoid,45550,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7619.75, Repair rectum/remove sigmoid,45550,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7619.75, Repair of rectocele,45560,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3546.74,,,,,,,fee schedule,3546.74,12821, Repair of rectocele,45560,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3546.74,12821, Repair of rectocele,45560,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3546.74,12821, Repair of rectocele,45560,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3546.74,12821, Exploration/repair of rectum,45562,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6395.88,,,,,,,fee schedule,5097,6979, Exploration/repair of rectum,45562,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Exploration/repair of rectum,45562,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Exploration/repair of rectum,45562,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Exploration/repair of rectum,45563,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8978.4,,,,,,,fee schedule,5097,8978.4, Exploration/repair of rectum,45563,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8978.4, Exploration/repair of rectum,45563,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8978.4, Exploration/repair of rectum,45563,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8978.4, Repair rect/bladder fistula,45800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6917.56,,,,,,,fee schedule,5097,6979, Repair rect/bladder fistula,45800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Repair rect/bladder fistula,45800,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Repair rect/bladder fistula,45800,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Repair fistula w/colostomy,45805,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7966.44,,,,,,,fee schedule,5097,7966.44, Repair fistula w/colostomy,45805,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7966.44, Repair fistula w/colostomy,45805,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7966.44, Repair fistula w/colostomy,45805,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7966.44, Repair rectourethral fistula,45820,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6932.83,,,,,,,fee schedule,5097,6979, Repair rectourethral fistula,45820,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Repair rectourethral fistula,45820,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Repair rectourethral fistula,45820,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Repair fistula w/colostomy,45825,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8352.36,,,,,,,fee schedule,5097,8352.36, Repair fistula w/colostomy,45825,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8352.36, Repair fistula w/colostomy,45825,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8352.36, Repair fistula w/colostomy,45825,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8352.36, Reduction of rectal prolapse,45900,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1191.71,,,,,,,fee schedule,1191.71,4497, Reduction of rectal prolapse,45900,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1191.71,4497, Reduction of rectal prolapse,45900,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,1191.71,4497, Reduction of rectal prolapse,45900,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,1191.71,4497, Dilation of anal sphincter,45905,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,931.4,,,,,,,fee schedule,931.4,5664, Dilation of anal sphincter,45905,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,931.4,5664, Dilation of anal sphincter,45905,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,931.4,5664, Dilation of anal sphincter,45905,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,931.4,5664, Dilation of rectal narrowing,45910,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1039.43,,,,,,,fee schedule,1039.43,5664, Dilation of rectal narrowing,45910,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1039.43,5664, Dilation of rectal narrowing,45910,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1039.43,5664, Dilation of rectal narrowing,45910,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1039.43,5664, Remove rectal obstruction,45915,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1281.55,,,,,,,fee schedule,1281.55,5664, Remove rectal obstruction,45915,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1281.55,5664, Remove rectal obstruction,45915,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1281.55,5664, Remove rectal obstruction,45915,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1281.55,5664, Surg dx exam anorectal,45990,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,561.94,,,,,,,fee schedule,561.94,5664, Surg dx exam anorectal,45990,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,561.94,5664, Surg dx exam anorectal,45990,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,561.94,5664, Surg dx exam anorectal,45990,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,561.94,5664, Rectum surgery procedure,45999,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4047,6979, Rectum surgery procedure,45999,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,4047,6979, Rectum surgery procedure,45999,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,4047,6979, Placement of seton,46020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,621.89,,,,,,,fee schedule,621.89,10940, Placement of seton,46020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,621.89,10940, Placement of seton,46020,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,621.89,10940, Placement of seton,46020,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,621.89,10940, Removal of rectal marker,46030,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,450.35,,,,,,,fee schedule,450.35,5664, Removal of rectal marker,46030,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,450.35,5664, Removal of rectal marker,46030,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,450.35,5664, Removal of rectal marker,46030,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,450.35,5664, Incision of rectal abscess,46040,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2403.22,,,,,,,fee schedule,2403.22,5664, Incision of rectal abscess,46040,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2403.22,5664, Incision of rectal abscess,46040,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2403.22,5664, Incision of rectal abscess,46040,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2403.22,5664, Incision of rectal abscess,46045,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2477.41,,,,,,,fee schedule,2477.41,10940, Incision of rectal abscess,46045,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2477.41,10940, Incision of rectal abscess,46045,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2477.41,10940, Incision of rectal abscess,46045,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2477.41,10940, Incision of anal abscess,46050,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,567.39,,,,,,,fee schedule,567.39,4497, Incision of anal abscess,46050,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,567.39,4497, Incision of anal abscess,46050,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,567.39,4497, Incision of anal abscess,46050,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,567.39,4497, Incision of rectal abscess,46060,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2703.83,,,,,,,fee schedule,2703.83,5664, Incision of rectal abscess,46060,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2703.83,5664, Incision of rectal abscess,46060,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2703.83,5664, Incision of rectal abscess,46060,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2703.83,5664, Incision of anal septum,46070,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1586.42,,,,,,,fee schedule,1586.42,5664, Incision of anal septum,46070,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1586.42,5664, Incision of anal septum,46070,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1586.42,5664, Incision of anal septum,46070,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1586.42,5664, Incision of anal sphincter,46080,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,841.45,,,,,,,fee schedule,841.45,5664, Incision of anal sphincter,46080,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,841.45,5664, Incision of anal sphincter,46080,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,841.45,5664, Incision of anal sphincter,46080,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,841.45,5664, Incise external hemorrhoid,46083,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,593.61,,,,,,,fee schedule,593.61,3195, Incise external hemorrhoid,46083,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,593.61,3195, Incise external hemorrhoid,46083,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,593.61,3195, Incise external hemorrhoid,46083,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,593.61,3195, Removal of anal fissure,46200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1880.56,,,,,,,fee schedule,1880.56,10940, Removal of anal fissure,46200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1880.56,10940, Removal of anal fissure,46200,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1880.56,10940, Removal of anal fissure,46200,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1880.56,10940, Excise anal ext tag/papilla,46220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,657.88,,,,,,,fee schedule,657.88,5664, Excise anal ext tag/papilla,46220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,657.88,5664, Excise anal ext tag/papilla,46220,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,657.88,5664, Excise anal ext tag/papilla,46220,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,657.88,5664, Ligation of hemorrhoid(s),46221,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1070.3,,,,,,,fee schedule,1070.3,4497, Ligation of hemorrhoid(s),46221,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1070.3,4497, Ligation of hemorrhoid(s),46221,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,1070.3,4497, Ligation of hemorrhoid(s),46221,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,1070.3,4497, Removal of anal tags,46230,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,925.58,,,,,,,fee schedule,925.58,5664, Removal of anal tags,46230,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,925.58,5664, Removal of anal tags,46230,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,925.58,5664, Removal of anal tags,46230,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,925.58,5664, Remove ext hem groups 2+,46250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1759.42,,,,,,,fee schedule,1759.42,10940, Remove ext hem groups 2+,46250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1759.42,10940, Remove ext hem groups 2+,46250,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1759.42,10940, Remove ext hem groups 2+,46250,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1759.42,10940, Remove int/ext hem 1 group,46255,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1937.27,,,,,,,fee schedule,1937.27,10940, Remove int/ext hem 1 group,46255,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1937.27,10940, Remove int/ext hem 1 group,46255,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1937.27,10940, Remove int/ext hem 1 group,46255,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1937.27,10940, Remove in/ex hem grp & fiss,46257,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2269.56,,,,,,,fee schedule,2269.56,10940, Remove in/ex hem grp & fiss,46257,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2269.56,10940, Remove in/ex hem grp & fiss,46257,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2269.56,10940, Remove in/ex hem grp & fiss,46257,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2269.56,10940, Remove in/ex hem grp w/fistu,46258,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2695.36,,,,,,,fee schedule,2695.36,10940, Remove in/ex hem grp w/fistu,46258,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2695.36,10940, Remove in/ex hem grp w/fistu,46258,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2695.36,10940, Remove in/ex hem grp w/fistu,46258,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2695.36,10940, Remove in/ex hem groups 2+,46260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2658.39,,,,,,,fee schedule,2658.39,10940, Remove in/ex hem groups 2+,46260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2658.39,10940, Remove in/ex hem groups 2+,46260,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2658.39,10940, Remove in/ex hem groups 2+,46260,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2658.39,10940, Remove in/ex hem grps & fiss,46261,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2860.58,,,,,,,fee schedule,2860.58,10940, Remove in/ex hem grps & fiss,46261,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2860.58,10940, Remove in/ex hem grps & fiss,46261,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2860.58,10940, Remove in/ex hem grps & fiss,46261,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2860.58,10940, Remove in/ex hem grps w/fist,46262,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3296.74,,,,,,,fee schedule,3296.74,10940, Remove in/ex hem grps w/fist,46262,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3296.74,10940, Remove in/ex hem grps w/fist,46262,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3296.74,10940, Remove in/ex hem grps w/fist,46262,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3296.74,10940, Remove anal fist subq,46270,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2241.17,,,,,,,fee schedule,2241.17,10940, Remove anal fist subq,46270,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2241.17,10940, Remove anal fist subq,46270,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2241.17,10940, Remove anal fist subq,46270,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2241.17,10940, Remove anal fist inter,46275,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2331.88,,,,,,,fee schedule,2331.88,10940, Remove anal fist inter,46275,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2331.88,10940, Remove anal fist inter,46275,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2331.88,10940, Remove anal fist inter,46275,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2331.88,10940, Remove anal fist complex,46280,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2653.54,,,,,,,fee schedule,2653.54,10940, Remove anal fist complex,46280,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2653.54,10940, Remove anal fist complex,46280,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2653.54,10940, Remove anal fist complex,46280,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2653.54,10940, Remove anal fist 2 stage,46285,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2341.49,,,,,,,fee schedule,2341.49,10940, Remove anal fist 2 stage,46285,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2341.49,10940, Remove anal fist 2 stage,46285,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2341.49,10940, Remove anal fist 2 stage,46285,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2341.49,10940, Repair anal fistula,46288,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3051.17,,,,,,,fee schedule,3051.17,12821, Repair anal fistula,46288,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3051.17,12821, Repair anal fistula,46288,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3051.17,12821, Repair anal fistula,46288,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3051.17,12821, Removal of hemorrhoid clot,46320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,598.52,,,,,,,fee schedule,598.52,5664, Removal of hemorrhoid clot,46320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,598.52,5664, Removal of hemorrhoid clot,46320,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,598.52,5664, Removal of hemorrhoid clot,46320,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,598.52,5664, Injection into hemorrhoid(s),46500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1042.88,,,,,,,fee schedule,1042.88,6979, Injection into hemorrhoid(s),46500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1042.88,6979, Injection into hemorrhoid(s),46500,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,1042.88,6979, Injection into hemorrhoid(s),46500,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,1042.88,6979, Chemodenervation anal musc,46505,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1350.4,,,,,,,fee schedule,1350.4,5664, Chemodenervation anal musc,46505,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1350.4,5664, Chemodenervation anal musc,46505,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1350.4,5664, Chemodenervation anal musc,46505,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1350.4,5664, Diagnostic anoscopy spx,46600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,220.64,,,,,,,fee schedule,220.64,3195, Diagnostic anoscopy spx,46600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,220.64,3195, Diagnostic anoscopy spx,46600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,220.64,3195, Diagnostic anoscopy spx,46600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,220.64,3195, Diagnostic anoscopy,46601,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,474.15,,,,,,,fee schedule,474.15,3195, Diagnostic anoscopy,46601,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,474.15,3195, Diagnostic anoscopy,46601,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,474.15,3195, Diagnostic anoscopy,46601,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,474.15,3195, Anoscopy and dilation,46604,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,347.88,,,,,,,fee schedule,347.88,5664, Anoscopy and dilation,46604,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,347.88,5664, Anoscopy and dilation,46604,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,347.88,5664, Anoscopy and dilation,46604,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,347.88,5664, Anoscopy and biopsy,46606,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,396.01,,,,,,,fee schedule,396.01,5664, Anoscopy and biopsy,46606,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,396.01,5664, Anoscopy and biopsy,46606,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,396.01,5664, Anoscopy and biopsy,46606,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,396.01,5664, Diagnostic anoscopy & biopsy,46607,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,630.74,,,,,,,fee schedule,630.74,5664, Diagnostic anoscopy & biopsy,46607,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,630.74,5664, Diagnostic anoscopy & biopsy,46607,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,630.74,5664, Diagnostic anoscopy & biopsy,46607,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,630.74,5664, Anoscopy remove for body,46608,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,464.97,,,,,,,fee schedule,464.97,5664, Anoscopy remove for body,46608,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,464.97,5664, Anoscopy remove for body,46608,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,464.97,5664, Anoscopy remove for body,46608,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,464.97,5664, Anoscopy remove lesion,46610,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,425.42,,,,,,,fee schedule,425.42,10940, Anoscopy remove lesion,46610,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,425.42,10940, Anoscopy remove lesion,46610,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,425.42,10940, Anoscopy remove lesion,46610,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,425.42,10940, Anoscopy,46611,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,415.76,,,,,,,fee schedule,415.76,5664, Anoscopy,46611,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,415.76,5664, Anoscopy,46611,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,415.76,5664, Anoscopy,46611,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,415.76,5664, Anoscopy remove lesions,46612,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,516.94,,,,,,,fee schedule,516.94,10940, Anoscopy remove lesions,46612,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,516.94,10940, Anoscopy remove lesions,46612,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,516.94,10940, Anoscopy remove lesions,46612,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,516.94,10940, Anoscopy control bleeding,46614,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,340.6,,,,,,,fee schedule,340.6,5664, Anoscopy control bleeding,46614,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,340.6,5664, Anoscopy control bleeding,46614,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,340.6,5664, Anoscopy control bleeding,46614,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,340.6,5664, Anoscopy,46615,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,464.76,,,,,,,fee schedule,464.76,10940, Anoscopy,46615,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,464.76,10940, Anoscopy,46615,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,464.76,10940, Anoscopy,46615,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,464.76,10940, Repair of anal stricture,46700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3532.11,,,,,,,fee schedule,3532.11,10940, Repair of anal stricture,46700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3532.11,10940, Repair of anal stricture,46700,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3532.11,10940, Repair of anal stricture,46700,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3532.11,10940, Repair of anal stricture,46705,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3221.63,,,,,,,fee schedule,3221.63,6979, Repair of anal stricture,46705,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3221.63,6979, Repair of anal stricture,46705,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3221.63,6979, Repair of anal stricture,46705,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3221.63,6979, Repr of anal fistula w/glue,46706,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,998.37,,,,,,,fee schedule,998.37,10940, Repr of anal fistula w/glue,46706,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,998.37,10940, Repr of anal fistula w/glue,46706,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,998.37,10940, Repr of anal fistula w/glue,46706,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,998.37,10940, Repair anorectal fist w/plug,46707,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2861.34,,,,,,,fee schedule,2861.34,12821, Repair anorectal fist w/plug,46707,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2861.34,12821, Repair anorectal fist w/plug,46707,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2861.34,12821, Repair anorectal fist w/plug,46707,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2861.34,12821, Repr per/vag pouch sngl proc,46710,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6080.7,,,,,,,fee schedule,5097,6080.7, Repr per/vag pouch sngl proc,46710,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5097,6080.7, Repr per/vag pouch sngl proc,46710,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6080.7, Repr per/vag pouch sngl proc,46710,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6080.7, Repr per/vag pouch dbl proc,46712,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,11934.06,,,,,,,fee schedule,5097,11934.06, Repr per/vag pouch dbl proc,46712,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5097,11934.06, Repr per/vag pouch dbl proc,46712,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,11934.06, Repr per/vag pouch dbl proc,46712,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,11934.06, Rep perf anoper fistu,46715,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3112.57,,,,,,,fee schedule,3112.57,6979, Rep perf anoper fistu,46715,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3112.57,6979, Rep perf anoper fistu,46715,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3112.57,6979, Rep perf anoper fistu,46715,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3112.57,6979, Rep perf anoper/vestib fistu,46716,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6854.48,,,,,,,fee schedule,5097,6979, Rep perf anoper/vestib fistu,46716,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Rep perf anoper/vestib fistu,46716,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Rep perf anoper/vestib fistu,46716,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Construction of absent anus,46730,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10865.76,,,,,,,fee schedule,5097,10865.76, Construction of absent anus,46730,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,10865.76, Construction of absent anus,46730,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,10865.76, Construction of absent anus,46730,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,10865.76, Construction of absent anus,46735,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12438.75,,,,,,,fee schedule,5097,12438.75, Construction of absent anus,46735,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,12438.75, Construction of absent anus,46735,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,12438.75, Construction of absent anus,46735,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,12438.75, Construction of absent anus,46740,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,11824.15,,,,,,,fee schedule,5097,11824.15, Construction of absent anus,46740,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,11824.15, Construction of absent anus,46740,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,11824.15, Construction of absent anus,46740,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,11824.15, Repair of imperforated anus,46742,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,13595.17,,,,,,,fee schedule,5097,13595.17, Repair of imperforated anus,46742,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,13595.17, Repair of imperforated anus,46742,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,13595.17, Repair of imperforated anus,46742,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,13595.17, Repair of cloacal anomaly,46744,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,19017.01,,,,,,,fee schedule,5097,19017.01, Repair of cloacal anomaly,46744,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,19017.01, Repair of cloacal anomaly,46744,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,19017.01, Repair of cloacal anomaly,46744,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,19017.01, Repair of cloacal anomaly,46746,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,20908.58,,,,,,,fee schedule,5097,20908.58, Repair of cloacal anomaly,46746,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,20908.58, Repair of cloacal anomaly,46746,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,20908.58, Repair of cloacal anomaly,46746,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,20908.58, Repair of cloacal anomaly,46748,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,22627.59,,,,,,,fee schedule,5097,22627.59, Repair of cloacal anomaly,46748,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,22627.59, Repair of cloacal anomaly,46748,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,22627.59, Repair of cloacal anomaly,46748,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,22627.59, Repair of anal sphincter,46750,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3841.3,,,,,,,fee schedule,3841.3,12821, Repair of anal sphincter,46750,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3841.3,12821, Repair of anal sphincter,46750,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3841.3,12821, Repair of anal sphincter,46750,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3841.3,12821, Repair of anal sphincter,46751,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3735.87,,,,,,,fee schedule,3735.87,6979, Repair of anal sphincter,46751,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3735.87,6979, Repair of anal sphincter,46751,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3735.87,6979, Repair of anal sphincter,46751,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3735.87,6979, Reconstruction of anus,46753,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3468.82,,,,,,,fee schedule,3468.82,10940, Reconstruction of anus,46753,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3468.82,10940, Reconstruction of anus,46753,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3468.82,10940, Reconstruction of anus,46753,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3468.82,10940, Removal of suture from anus,46754,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1301.79,,,,,,,fee schedule,1301.79,5664, Removal of suture from anus,46754,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1301.79,5664, Removal of suture from anus,46754,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1301.79,5664, Removal of suture from anus,46754,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1301.79,5664, Repair of anal sphincter,46760,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5787.7,,,,,,,fee schedule,4108,12821, Repair of anal sphincter,46760,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,12821, Repair of anal sphincter,46760,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4108,12821, Repair of anal sphincter,46760,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4108,12821, Repair of anal sphincter,46761,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4654.27,,,,,,,fee schedule,4654.27,12821, Repair of anal sphincter,46761,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4654.27,12821, Repair of anal sphincter,46761,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4654.27,12821, Repair of anal sphincter,46761,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4654.27,12821, Destruction anal lesion(s),46900,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,722.69,,,,,,,fee schedule,722.69,3195, Destruction anal lesion(s),46900,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,722.69,3195, Destruction anal lesion(s),46900,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,722.69,3195, Destruction anal lesion(s),46900,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,722.69,3195, Destruction anal lesion(s),46910,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,714.59,,,,,,,fee schedule,714.59,5664, Destruction anal lesion(s),46910,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,714.59,5664, Destruction anal lesion(s),46910,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,714.59,5664, Destruction anal lesion(s),46910,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,714.59,5664, Cryosurgery anal lesion(s),46916,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,665.11,,,,,,,fee schedule,665.11,4108, Cryosurgery anal lesion(s),46916,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,665.11,4108, Cryosurgery anal lesion(s),46916,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,665.11,4108, Cryosurgery anal lesion(s),46916,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,665.11,4108, Laser surgery anal lesions,46917,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,667.05,,,,,,,fee schedule,667.05,10940, Laser surgery anal lesions,46917,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,667.05,10940, Laser surgery anal lesions,46917,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,667.05,10940, Laser surgery anal lesions,46917,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,667.05,10940, Excision of anal lesion(s),46922,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,742.87,,,,,,,fee schedule,742.87,10940, Excision of anal lesion(s),46922,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,742.87,10940, Excision of anal lesion(s),46922,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,742.87,10940, Excision of anal lesion(s),46922,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,742.87,10940, Destruction anal lesion(s),46924,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,951.48,,,,,,,fee schedule,951.48,10940, Destruction anal lesion(s),46924,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,951.48,10940, Destruction anal lesion(s),46924,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,951.48,10940, Destruction anal lesion(s),46924,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,951.48,10940, Destroy internal hemorrhoids,46930,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,847.39,,,,,,,fee schedule,847.39,4497, Destroy internal hemorrhoids,46930,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,847.39,4497, Destroy internal hemorrhoids,46930,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,847.39,4497, Destroy internal hemorrhoids,46930,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,847.39,4497, Treatment of anal fissure,46940,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,757.38,,,,,,,fee schedule,757.38,5664, Treatment of anal fissure,46940,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,757.38,5664, Treatment of anal fissure,46940,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,757.38,5664, Treatment of anal fissure,46940,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,757.38,5664, Treatment of anal fissure,46942,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,682.11,,,,,,,fee schedule,682.11,4497, Treatment of anal fissure,46942,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,682.11,4497, Treatment of anal fissure,46942,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,682.11,4497, Treatment of anal fissure,46942,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,682.11,4497, Remove by ligat int hem grp,46945,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1897.13,,,,,,,fee schedule,1897.13,10940, Remove by ligat int hem grp,46945,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1897.13,10940, Remove by ligat int hem grp,46945,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1897.13,10940, Remove by ligat int hem grp,46945,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1897.13,10940, Remove by ligat int hem grps,46946,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2080.59,,,,,,,fee schedule,2080.59,10940, Remove by ligat int hem grps,46946,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2080.59,10940, Remove by ligat int hem grps,46946,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2080.59,10940, Remove by ligat int hem grps,46946,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2080.59,10940, Hemorrhoidopexy by stapling,46947,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2120.68,,,,,,,fee schedule,2120.68,12821, Hemorrhoidopexy by stapling,46947,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,2120.68,12821, Hemorrhoidopexy by stapling,46947,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2120.68,12821, Hemorrhoidopexy by stapling,46947,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2120.68,12821, Int hrhc tranal dartlzj 2+,46948,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2449.03,,,,,,,fee schedule,2449.03,10940, Int hrhc tranal dartlzj 2+,46948,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2449.03,10940, Int hrhc tranal dartlzj 2+,46948,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2449.03,10940, Int hrhc tranal dartlzj 2+,46948,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2449.03,10940, Anus surgery procedure,46999,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,4497, Anus surgery procedure,46999,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,3195,4497, Anus surgery procedure,46999,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,3195,4497, Needle biopsy of liver,47000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,424.07,,,,,,,fee schedule,424.07,5664, Needle biopsy of liver,47000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,424.07,5664, Needle biopsy of liver,47000,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,424.07,5664, Needle biopsy of liver,47000,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,424.07,5664, Needle biopsy liver add-on,47001,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,538.3,,,,,,,fee schedule,538.3,3195, Needle biopsy liver add-on,47001,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,538.3,3195, Needle biopsy liver add-on,47001,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,538.3,3195, Needle biopsy liver add-on,47001,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,538.3,3195, Open drainage liver lesion,47010,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6525.33,,,,,,,fee schedule,5097,6979, Open drainage liver lesion,47010,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Open drainage liver lesion,47010,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Open drainage liver lesion,47010,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Inject/aspirate liver cyst,47015,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6314.51,,,,,,,fee schedule,5097,6979, Inject/aspirate liver cyst,47015,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Inject/aspirate liver cyst,47015,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Inject/aspirate liver cyst,47015,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Wedge biopsy of liver,47100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4615.79,,,,,,,fee schedule,4615.79,10940, Wedge biopsy of liver,47100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4615.79,10940, Wedge biopsy of liver,47100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,4615.79,10940, Wedge biopsy of liver,47100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,4615.79,10940, Partial removal of liver,47120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12418.3,,,,,,,fee schedule,5097,12418.3, Partial removal of liver,47120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,12418.3, Partial removal of liver,47120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,12418.3, Partial removal of liver,47120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,12418.3, Extensive removal of liver,47122,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,18158.84,,,,,,,fee schedule,5097,18158.84, Extensive removal of liver,47122,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,18158.84, Extensive removal of liver,47122,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,18158.84, Extensive removal of liver,47122,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,18158.84, Partial removal of liver,47125,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,16298.46,,,,,,,fee schedule,5097,16298.46, Partial removal of liver,47125,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,16298.46, Partial removal of liver,47125,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,16298.46, Partial removal of liver,47125,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,16298.46, Partial removal of liver,47130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,17436.09,,,,,,,fee schedule,5097,17436.09, Partial removal of liver,47130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,17436.09, Partial removal of liver,47130,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,17436.09, Partial removal of liver,47130,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,17436.09, Removal of donor liver,47133,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Removal of donor liver,47133,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Removal of donor liver,47133,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Transplantation of liver,47135,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,28976.41,,,,,,,fee schedule,5097,28976.41, Transplantation of liver,47135,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,28976.41, Transplantation of liver,47135,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,28976.41, Transplantation of liver,47135,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,28976.41, Partial removal donor liver,47140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,19245.32,,,,,,,fee schedule,5097,19245.32, Partial removal donor liver,47140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,19245.32, Partial removal donor liver,47140,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,19245.32, Partial removal donor liver,47140,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,19245.32, Partial removal donor liver,47141,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,22952.37,,,,,,,fee schedule,5097,22952.37, Partial removal donor liver,47141,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,22952.37, Partial removal donor liver,47141,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,22952.37, Partial removal donor liver,47141,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,22952.37, Partial removal donor liver,47142,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,25230.29,,,,,,,fee schedule,5097,25230.29, Partial removal donor liver,47142,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,25230.29, Partial removal donor liver,47142,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,25230.29, Partial removal donor liver,47142,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,25230.29, Prep donor liver whole,47143,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Prep donor liver whole,47143,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Prep donor liver whole,47143,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Prep donor liver 3-segment,47144,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Prep donor liver 3-segment,47144,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Prep donor liver 3-segment,47144,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Prep donor liver lobe split,47145,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Prep donor liver lobe split,47145,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Prep donor liver lobe split,47145,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Prep donor liver/venous,47146,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1721.59,,,,,,,fee schedule,1721.59,6979, Prep donor liver/venous,47146,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1721.59,6979, Prep donor liver/venous,47146,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1721.59,6979, Prep donor liver/venous,47146,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1721.59,6979, Prep donor liver/arterial,47147,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2003.59,,,,,,,fee schedule,2003.59,6979, Prep donor liver/arterial,47147,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2003.59,6979, Prep donor liver/arterial,47147,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2003.59,6979, Prep donor liver/arterial,47147,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2003.59,6979, Surgery for liver lesion,47300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6119.23,,,,,,,fee schedule,5097,6979, Surgery for liver lesion,47300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Surgery for liver lesion,47300,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Surgery for liver lesion,47300,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Repair liver wound,47350,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7332.25,,,,,,,fee schedule,5097,7332.25, Repair liver wound,47350,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7332.25, Repair liver wound,47350,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7332.25, Repair liver wound,47350,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7332.25, Repair liver wound,47360,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10047.57,,,,,,,fee schedule,5097,10047.57, Repair liver wound,47360,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,10047.57, Repair liver wound,47360,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,10047.57, Repair liver wound,47360,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,10047.57, Repair liver wound,47361,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,15976.53,,,,,,,fee schedule,5097,15976.53, Repair liver wound,47361,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,15976.53, Repair liver wound,47361,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,15976.53, Repair liver wound,47361,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,15976.53, Repair liver wound,47362,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7633.51,,,,,,,fee schedule,5097,7633.51, Repair liver wound,47362,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7633.51, Repair liver wound,47362,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7633.51, Repair liver wound,47362,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7633.51, Laparo ablate liver tumor rf,47370,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6717.32,,,,,,,fee schedule,5363,25393, Laparo ablate liver tumor rf,47370,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,25393, Laparo ablate liver tumor rf,47370,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,5363,25393, Laparo ablate liver tumor rf,47370,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,5363,25393, Laparo ablate liver cryosurg,47371,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6794.64,,,,,,,fee schedule,5363,25393, Laparo ablate liver cryosurg,47371,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,25393, Laparo ablate liver cryosurg,47371,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,5363,25393, Laparo ablate liver cryosurg,47371,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,5363,25393, Laparoscope procedure liver,47379,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,14456, Laparoscope procedure liver,47379,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,6044,14456, Laparoscope procedure liver,47379,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,6044,14456, Open ablate liver tumor rf,47380,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7702.79,,,,,,,fee schedule,5097,7702.79, Open ablate liver tumor rf,47380,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,5097,7702.79, Open ablate liver tumor rf,47380,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7702.79, Open ablate liver tumor rf,47380,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7702.79, Open ablate liver tumor cryo,47381,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7964.5,,,,,,,fee schedule,5097,7964.5, Open ablate liver tumor cryo,47381,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,5097,7964.5, Open ablate liver tumor cryo,47381,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7964.5, Open ablate liver tumor cryo,47381,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7964.5, Percut ablate liver rf,47382,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3582.19,,,,,,,fee schedule,3582.19,22111, Percut ablate liver rf,47382,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3582.19,22111, Percut ablate liver rf,47382,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3582.19,22111, Percut ablate liver rf,47382,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3582.19,22111, Perq abltj lvr cryoablation,47383,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2258.77,,,,,,,fee schedule,2258.77,22111, Perq abltj lvr cryoablation,47383,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10675,,,,,,,fee schedule,2258.77,22111, Perq abltj lvr cryoablation,47383,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,2258.77,22111, Perq abltj lvr cryoablation,47383,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,2258.77,22111, Abltj ire liver 1+ tum perq,47384,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2373.27,,,,,,,fee schedule,2373.27,6979, Abltj ire liver 1+ tum perq,47384,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2373.27,6979, Liver surgery procedure,47399,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4047,6979, Liver surgery procedure,47399,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,4047,6979, Liver surgery procedure,47399,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,4047,6979, Incision of liver duct,47400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,11499.63,,,,,,,fee schedule,5097,11499.63, Incision of liver duct,47400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,11499.63, Incision of liver duct,47400,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,11499.63, Incision of liver duct,47400,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,11499.63, Incision of bile duct,47420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7091.37,,,,,,,fee schedule,5097,7091.37, Incision of bile duct,47420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7091.37, Incision of bile duct,47420,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7091.37, Incision of bile duct,47420,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7091.37, Incision of bile duct,47425,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7372.93,,,,,,,fee schedule,5097,7372.93, Incision of bile duct,47425,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7372.93, Incision of bile duct,47425,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7372.93, Incision of bile duct,47425,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7372.93, Incise bile duct sphincter,47460,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6855.24,,,,,,,fee schedule,5097,6979, Incise bile duct sphincter,47460,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Incise bile duct sphincter,47460,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Incise bile duct sphincter,47460,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Incision of gallbladder,47480,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4737.26,,,,,,,fee schedule,4737.26,6979, Incision of gallbladder,47480,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4737.26,6979, Incision of gallbladder,47480,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4737.26,6979, Incision of gallbladder,47480,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4737.26,6979, Incision of gallbladder,47490,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1623.76,,,,,,,fee schedule,1623.76,12821, Incision of gallbladder,47490,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1623.76,12821, Incision of gallbladder,47490,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,1623.76,12821, Incision of gallbladder,47490,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,1623.76,12821, Injection for cholangiogram,47531,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,342.65,,,,,,,fee schedule,342.65,12821, Injection for cholangiogram,47531,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,342.65,12821, Injection for cholangiogram,47531,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,342.65,12821, Injection for cholangiogram,47531,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,342.65,12821, Injection for cholangiogram,47532,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1023.62,,,,,,,fee schedule,1023.62,12821, Injection for cholangiogram,47532,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1023.62,12821, Injection for cholangiogram,47532,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,1023.62,12821, Injection for cholangiogram,47532,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,1023.62,12821, Plmt biliary drainage cath,47533,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1267.74,,,,,,,fee schedule,1267.74,12821, Plmt biliary drainage cath,47533,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1267.74,12821, Plmt biliary drainage cath,47533,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,1267.74,12821, Plmt biliary drainage cath,47533,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,1267.74,12821, Plmt biliary drainage cath,47534,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1774.74,,,,,,,fee schedule,1774.74,12821, Plmt biliary drainage cath,47534,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1774.74,12821, Plmt biliary drainage cath,47534,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,1774.74,12821, Plmt biliary drainage cath,47534,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,1774.74,12821, Conversion ext bil drg cath,47535,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,946.51,,,,,,,fee schedule,946.51,12821, Conversion ext bil drg cath,47535,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,946.51,12821, Conversion ext bil drg cath,47535,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,946.51,12821, Conversion ext bil drg cath,47535,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,946.51,12821, Exchange biliary drg cath,47536,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,638.72,,,,,,,fee schedule,638.72,12821, Exchange biliary drg cath,47536,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,638.72,12821, Exchange biliary drg cath,47536,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,638.72,12821, Exchange biliary drg cath,47536,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,638.72,12821, Removal biliary drg cath,47537,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,466.38,,,,,,,fee schedule,466.38,5664, Removal biliary drg cath,47537,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,466.38,5664, Removal biliary drg cath,47537,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,466.38,5664, Removal biliary drg cath,47537,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,466.38,5664, Perq plmt bile duct stent,47538,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1128.41,,,,,,,fee schedule,1128.41,22111, Perq plmt bile duct stent,47538,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1128.41,22111, Perq plmt bile duct stent,47538,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,1128.41,22111, Perq plmt bile duct stent,47538,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,1128.41,22111, Perq plmt bile duct stent,47539,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2057.12,,,,,,,fee schedule,2057.12,22111, Perq plmt bile duct stent,47539,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2057.12,22111, Perq plmt bile duct stent,47539,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,2057.12,22111, Perq plmt bile duct stent,47539,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,2057.12,22111, Perq plmt bile duct stent,47540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2106.27,,,,,,,fee schedule,2106.27,22111, Perq plmt bile duct stent,47540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2106.27,22111, Perq plmt bile duct stent,47540,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,2106.27,22111, Perq plmt bile duct stent,47540,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,2106.27,22111, Plmt access bil tree sm bwl,47541,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1650.53,,,,,,,fee schedule,1650.53,12821, Plmt access bil tree sm bwl,47541,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1650.53,12821, Plmt access bil tree sm bwl,47541,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,1650.53,12821, Plmt access bil tree sm bwl,47541,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,1650.53,12821, Dilate biliary duct/ampulla,47542,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,659.34,,,,,,,fee schedule,659.34,3195, Dilate biliary duct/ampulla,47542,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,659.34,3195, Dilate biliary duct/ampulla,47542,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,659.34,3195, Dilate biliary duct/ampulla,47542,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,659.34,3195, Endoluminal bx biliary tree,47543,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,689.82,,,,,,,fee schedule,689.82,3195, Endoluminal bx biliary tree,47543,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,689.82,3195, Endoluminal bx biliary tree,47543,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,689.82,3195, Endoluminal bx biliary tree,47543,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,689.82,3195, Removal duct glbldr calculi,47544,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,756.25,,,,,,,fee schedule,756.25,3195, Removal duct glbldr calculi,47544,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,756.25,3195, Removal duct glbldr calculi,47544,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,756.25,3195, Removal duct glbldr calculi,47544,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,756.25,3195, Bile duct endoscopy add-on,47550,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,841.07,,,,,,,fee schedule,841.07,2782, Bile duct endoscopy add-on,47550,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,841.07,2782, Bile duct endoscopy add-on,47550,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,841.07,2782, Biliary endo perq dx w/speci,47552,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1438.2,,,,,,,fee schedule,1438.2,12821, Biliary endo perq dx w/speci,47552,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1438.2,12821, Biliary endo perq dx w/speci,47552,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,1438.2,12821, Biliary endo perq dx w/speci,47552,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,1438.2,12821, Biliary endoscopy thru skin,47553,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1431.45,,,,,,,fee schedule,1431.45,22111, Biliary endoscopy thru skin,47553,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1431.45,22111, Biliary endoscopy thru skin,47553,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,1431.45,22111, Biliary endoscopy thru skin,47553,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,1431.45,22111, Biliary endoscopy thru skin,47554,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2238.37,,,,,,,fee schedule,2238.37,22111, Biliary endoscopy thru skin,47554,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2238.37,22111, Biliary endoscopy thru skin,47554,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,2238.37,22111, Biliary endoscopy thru skin,47554,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,2238.37,22111, Biliary endoscopy thru skin,47555,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1703.73,,,,,,,fee schedule,1703.73,12821, Biliary endoscopy thru skin,47555,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1703.73,12821, Biliary endoscopy thru skin,47555,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,1703.73,12821, Biliary endoscopy thru skin,47555,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,1703.73,12821, Biliary endoscopy thru skin,47556,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1931.07,,,,,,,fee schedule,1931.07,22111, Biliary endoscopy thru skin,47556,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1931.07,22111, Biliary endoscopy thru skin,47556,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,1931.07,22111, Biliary endoscopy thru skin,47556,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,1931.07,22111, Laparoscopic cholecystectomy,47562,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3604.15,,,,,,,fee schedule,3604.15,22111, Laparoscopic cholecystectomy,47562,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,3604.15,22111, Laparoscopic cholecystectomy,47562,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3604.15,22111, Laparoscopic cholecystectomy,47562,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3604.15,22111, Laparo cholecystectomy/graph,47563,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3908.97,,,,,,,fee schedule,3908.97,22111, Laparo cholecystectomy/graph,47563,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,3908.97,22111, Laparo cholecystectomy/graph,47563,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3908.97,22111, Laparo cholecystectomy/graph,47563,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3908.97,22111, Laparo cholecystectomy/explr,47564,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6068.4,,,,,,,fee schedule,6068.4,22111, Laparo cholecystectomy/explr,47564,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,6068.4,22111, Laparo cholecystectomy/explr,47564,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6068.4,22111, Laparo cholecystectomy/explr,47564,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6068.4,22111, Laparo cholecystoenterostomy,47570,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4217.03,,,,,,,fee schedule,4217.03,8406, Laparo cholecystoenterostomy,47570,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,4217.03,8406, Laparo cholecystoenterostomy,47570,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4217.03,8406, Laparo cholecystoenterostomy,47570,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4217.03,8406, Laparoscope proc biliary,47579,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,14456, Laparoscope proc biliary,47579,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5248,14456, Laparoscope proc biliary,47579,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5248,14456, Removal of gallbladder,47600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5776.09,,,,,,,fee schedule,5363,14456, Removal of gallbladder,47600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,14456, Removal of gallbladder,47600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5363,14456, Removal of gallbladder,47600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5363,14456, Removal of gallbladder,47605,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6078.05,,,,,,,fee schedule,5097,6078.05, Removal of gallbladder,47605,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,5097,6078.05, Removal of gallbladder,47605,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6078.05, Removal of gallbladder,47605,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6078.05, Removal of gallbladder,47610,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6738.96,,,,,,,fee schedule,5097,6979, Removal of gallbladder,47610,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Removal of gallbladder,47610,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Removal of gallbladder,47610,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Removal of gallbladder,47612,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6855.13,,,,,,,fee schedule,5097,6979, Removal of gallbladder,47612,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Removal of gallbladder,47612,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Removal of gallbladder,47612,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Removal of gallbladder,47620,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7389.93,,,,,,,fee schedule,5097,8406, Removal of gallbladder,47620,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,5097,8406, Removal of gallbladder,47620,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8406, Removal of gallbladder,47620,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8406, Exploration of bile ducts,47700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5753.27,,,,,,,fee schedule,5097,6979, Exploration of bile ducts,47700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Exploration of bile ducts,47700,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Exploration of bile ducts,47700,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Bile duct revision,47701,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9317.87,,,,,,,fee schedule,5097,9317.87, Bile duct revision,47701,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,9317.87, Bile duct revision,47701,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,9317.87, Bile duct revision,47701,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,9317.87, Excision of bile duct tumor,47711,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8290.09,,,,,,,fee schedule,5097,8290.09, Excision of bile duct tumor,47711,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8290.09, Excision of bile duct tumor,47711,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8290.09, Excision of bile duct tumor,47711,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8290.09, Excision of bile duct tumor,47712,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10687.59,,,,,,,fee schedule,5097,10687.59, Excision of bile duct tumor,47712,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,10687.59, Excision of bile duct tumor,47712,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,10687.59, Excision of bile duct tumor,47712,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,10687.59, Excision of bile duct cyst,47715,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7187.85,,,,,,,fee schedule,5097,7187.85, Excision of bile duct cyst,47715,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7187.85, Excision of bile duct cyst,47715,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7187.85, Excision of bile duct cyst,47715,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7187.85, Fuse gallbladder & bowel,47720,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6267.94,,,,,,,fee schedule,5097,6979, Fuse gallbladder & bowel,47720,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Fuse gallbladder & bowel,47720,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Fuse gallbladder & bowel,47720,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Fuse upper gi structures,47721,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7316.81,,,,,,,fee schedule,5097,7316.81, Fuse upper gi structures,47721,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7316.81, Fuse upper gi structures,47721,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7316.81, Fuse upper gi structures,47721,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7316.81, Fuse gallbladder & bowel,47740,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7098.28,,,,,,,fee schedule,5097,7098.28, Fuse gallbladder & bowel,47740,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7098.28, Fuse gallbladder & bowel,47740,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7098.28, Fuse gallbladder & bowel,47740,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7098.28, Fuse gallbladder & bowel,47741,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7952.84,,,,,,,fee schedule,5097,7952.84, Fuse gallbladder & bowel,47741,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7952.84, Fuse gallbladder & bowel,47741,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7952.84, Fuse gallbladder & bowel,47741,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7952.84, Fuse bile ducts and bowel,47760,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,11943.83,,,,,,,fee schedule,5097,11943.83, Fuse bile ducts and bowel,47760,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,11943.83, Fuse bile ducts and bowel,47760,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,11943.83, Fuse bile ducts and bowel,47760,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,11943.83, Fuse liver ducts & bowel,47765,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,16157.84,,,,,,,fee schedule,5097,16157.84, Fuse liver ducts & bowel,47765,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,16157.84, Fuse liver ducts & bowel,47765,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,16157.84, Fuse liver ducts & bowel,47765,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,16157.84, Fuse bile ducts and bowel,47780,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,13147.52,,,,,,,fee schedule,5097,13147.52, Fuse bile ducts and bowel,47780,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,13147.52, Fuse bile ducts and bowel,47780,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,13147.52, Fuse bile ducts and bowel,47780,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,13147.52, Fuse bile ducts and bowel,47785,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,17150.75,,,,,,,fee schedule,5097,17150.75, Fuse bile ducts and bowel,47785,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,17150.75, Fuse bile ducts and bowel,47785,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,17150.75, Fuse bile ducts and bowel,47785,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,17150.75, Reconstruction of bile ducts,47800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8380.58,,,,,,,fee schedule,5097,8380.58, Reconstruction of bile ducts,47800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8380.58, Reconstruction of bile ducts,47800,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8380.58, Reconstruction of bile ducts,47800,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8380.58, Placement bile duct support,47801,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5902.58,,,,,,,fee schedule,5097,6979, Placement bile duct support,47801,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Placement bile duct support,47801,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Placement bile duct support,47801,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Fuse liver duct & intestine,47802,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Suture bile duct injury,47900,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7445.89,,,,,,,fee schedule,5097,7445.89, Suture bile duct injury,47900,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7445.89, Suture bile duct injury,47900,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7445.89, Suture bile duct injury,47900,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7445.89, Bile tract surgery procedure,47999,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Bile tract surgery procedure,47999,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Bile tract surgery procedure,47999,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Drainage of abdomen,48000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10079.62,,,,,,,fee schedule,5097,10079.62, Drainage of abdomen,48000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,10079.62, Drainage of abdomen,48000,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,10079.62, Drainage of abdomen,48000,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,10079.62, Placement of drain pancreas,48001,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12310,,,,,,,fee schedule,5097,12310, Placement of drain pancreas,48001,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,12310, Placement of drain pancreas,48001,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,12310, Placement of drain pancreas,48001,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,12310, Removal of pancreatic stone,48020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6382.82,,,,,,,fee schedule,5097,6979, Removal of pancreatic stone,48020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Removal of pancreatic stone,48020,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Removal of pancreatic stone,48020,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Biopsy of pancreas open,48100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4816.85,,,,,,,fee schedule,4816.85,6979, Biopsy of pancreas open,48100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4816.85,6979, Biopsy of pancreas open,48100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4816.85,6979, Biopsy of pancreas open,48100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4816.85,6979, Needle biopsy pancreas,48102,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1135.64,,,,,,,fee schedule,1135.64,5664, Needle biopsy pancreas,48102,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1135.64,5664, Needle biopsy pancreas,48102,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1135.64,5664, Needle biopsy pancreas,48102,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1135.64,5664, Resect/Debride Pancreas,48105,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,14591.65,,,,,,,fee schedule,5097,14591.65, Resect/Debride Pancreas,48105,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,14591.65, Resect/Debride Pancreas,48105,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,14591.65, Resect/Debride Pancreas,48105,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,14591.65, Removal of pancreas lesion,48120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6017.19,,,,,,,fee schedule,5097,6979, Removal of pancreas lesion,48120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Removal of pancreas lesion,48120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Removal of pancreas lesion,48120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Partial removal of pancreas,48140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8352.41,,,,,,,fee schedule,5097,8352.41, Partial removal of pancreas,48140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8352.41, Partial removal of pancreas,48140,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8352.41, Partial removal of pancreas,48140,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8352.41, Partial removal of pancreas,48145,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8772.65,,,,,,,fee schedule,5097,8772.65, Partial removal of pancreas,48145,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8772.65, Partial removal of pancreas,48145,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8772.65, Partial removal of pancreas,48145,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8772.65, Pancreatectomy,48146,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10143.24,,,,,,,fee schedule,5097,10143.24, Pancreatectomy,48146,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,10143.24, Pancreatectomy,48146,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,10143.24, Pancreatectomy,48146,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,10143.24, Removal of pancreatic duct,48148,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6757.19,,,,,,,fee schedule,5097,6979, Removal of pancreatic duct,48148,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Removal of pancreatic duct,48148,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Removal of pancreatic duct,48148,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Partial removal of pancreas,48150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,16493.31,,,,,,,fee schedule,5097,16493.31, Partial removal of pancreas,48150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,16493.31, Partial removal of pancreas,48150,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,16493.31, Partial removal of pancreas,48150,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,16493.31, Pancreatectomy,48152,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,15417.45,,,,,,,fee schedule,5097,15417.45, Pancreatectomy,48152,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,15417.45, Pancreatectomy,48152,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,15417.45, Pancreatectomy,48152,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,15417.45, Pancreatectomy,48153,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,16491.26,,,,,,,fee schedule,5097,16491.26, Pancreatectomy,48153,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,16491.26, Pancreatectomy,48153,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,16491.26, Pancreatectomy,48153,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,16491.26, Pancreatectomy,48154,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,15483.77,,,,,,,fee schedule,5097,15483.77, Pancreatectomy,48154,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,15483.77, Pancreatectomy,48154,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,15483.77, Pancreatectomy,48154,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,15483.77, Removal of pancreas,48155,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9775.07,,,,,,,fee schedule,5097,9775.07, Removal of pancreas,48155,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,9775.07, Removal of pancreas,48155,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,9775.07, Removal of pancreas,48155,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,9775.07, Pancreas removal/transplant,48160,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Pancreas removal/transplant,48160,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Pancreas removal/transplant,48160,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Injection intraop add-on,48400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,554.44,,,,,,,fee schedule,554.44,6979, Injection intraop add-on,48400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,554.44,6979, Injection intraop add-on,48400,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,554.44,6979, Injection intraop add-on,48400,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,554.44,6979, Surgery of pancreatic cyst,48500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6240.26,,,,,,,fee schedule,5097,6979, Surgery of pancreatic cyst,48500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Surgery of pancreatic cyst,48500,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Surgery of pancreatic cyst,48500,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Drain pancreatic pseudocyst,48510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5958.96,,,,,,,fee schedule,5097,6979, Drain pancreatic pseudocyst,48510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Drain pancreatic pseudocyst,48510,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Drain pancreatic pseudocyst,48510,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Fuse pancreas cyst and bowel,48520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5943.8,,,,,,,fee schedule,5097,6979, Fuse pancreas cyst and bowel,48520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Fuse pancreas cyst and bowel,48520,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Fuse pancreas cyst and bowel,48520,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Fuse pancreas cyst and bowel,48540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7029.42,,,,,,,fee schedule,5097,7029.42, Fuse pancreas cyst and bowel,48540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7029.42, Fuse pancreas cyst and bowel,48540,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7029.42, Fuse pancreas cyst and bowel,48540,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7029.42, Pancreatorrhaphy,48545,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7259.83,,,,,,,fee schedule,5097,7259.83, Pancreatorrhaphy,48545,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7259.83, Pancreatorrhaphy,48545,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7259.83, Pancreatorrhaphy,48545,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7259.83, Duodenal exclusion,48547,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9605.91,,,,,,,fee schedule,5097,9605.91, Duodenal exclusion,48547,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,9605.91, Duodenal exclusion,48547,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,9605.91, Duodenal exclusion,48547,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,9605.91, Fuse Pancreas and Bowel,48548,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8972.52,,,,,,,fee schedule,5097,8972.52, Fuse Pancreas and Bowel,48548,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8972.52, Fuse Pancreas and Bowel,48548,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8972.52, Fuse Pancreas and Bowel,48548,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8972.52, Donor pancreatectomy,48550,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Prep donor pancreas,48551,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Prep donor pancreas/venous,48552,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1234.34,,,,,,,fee schedule,1234.34,6979, Prep donor pancreas/venous,48552,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1234.34,6979, Transpl allograft pancreas,48554,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,14461.87,,,,,,,fee schedule,6979,14461.87, Transpl allograft pancreas,48554,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,14461.87, Removal allograft pancreas,48556,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7077.93,,,,,,,fee schedule,6979,7077.93, Removal allograft pancreas,48556,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,7077.93, Pancreas surgery procedure,48999,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4047,6979, Pancreas surgery procedure,48999,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,4047,6979, Pancreas surgery procedure,48999,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,4047,6979, Exploration of abdomen,49000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4153.36,,,,,,,fee schedule,4153.36,12821, Exploration of abdomen,49000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4153.36,12821, Exploration of abdomen,49000,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4153.36,12821, Exploration of abdomen,49000,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4153.36,12821, Reopening of abdomen,49002,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5583.3,,,,,,,fee schedule,5097,6979, Reopening of abdomen,49002,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Reopening of abdomen,49002,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Reopening of abdomen,49002,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Exploration behind abdomen,49010,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4965.83,,,,,,,fee schedule,4965.83,12821, Exploration behind abdomen,49010,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4965.83,12821, Exploration behind abdomen,49010,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4965.83,12821, Exploration behind abdomen,49010,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4965.83,12821, Prpertl pel pack hemrrg trma,49013,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2394.37,,,,,,,fee schedule,2394.37,6979, Prpertl pel pack hemrrg trma,49013,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2394.37,6979, Prpertl pel pack hemrrg trma,49013,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2394.37,6979, Prpertl pel pack hemrrg trma,49013,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2394.37,6979, Reexploration pelvic wound,49014,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2009.58,,,,,,,fee schedule,2009.58,6979, Reexploration pelvic wound,49014,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2009.58,6979, Reexploration pelvic wound,49014,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2009.58,6979, Reexploration pelvic wound,49014,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2009.58,6979, Drainage abdom abscess open,49020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8507.23,,,,,,,fee schedule,5097,8507.23, Drainage abdom abscess open,49020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8507.23, Drainage abdom abscess open,49020,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8507.23, Drainage abdom abscess open,49020,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8507.23, Drain open abdom abscess,49040,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5483.63,,,,,,,fee schedule,5097,6979, Drain open abdom abscess,49040,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Drain open abdom abscess,49040,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Drain open abdom abscess,49040,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Drain open retroperi abscess,49060,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5854.39,,,,,,,fee schedule,5097,6979, Drain open retroperi abscess,49060,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Drain open retroperi abscess,49060,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Drain open retroperi abscess,49060,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Drain to peritoneal cavity,49062,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4191.67,,,,,,,fee schedule,4191.67,6979, Drain to peritoneal cavity,49062,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4191.67,6979, Drain to peritoneal cavity,49062,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4191.67,6979, Drain to peritoneal cavity,49062,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4191.67,6979, Abd paracentesis,49082,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,396.34,,,,,,,fee schedule,396.34,5664, Abd paracentesis,49082,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,396.34,5664, Abd paracentesis,49082,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,396.34,5664, Abd paracentesis,49082,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,396.34,5664, Abd paracentesis w/imaging,49083,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,515.16,,,,,,,fee schedule,515.16,5664, Abd paracentesis w/imaging,49083,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,515.16,5664, Abd paracentesis w/imaging,49083,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,515.16,5664, Abd paracentesis w/imaging,49083,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,515.16,5664, Peritoneal lavage,49084,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,555.3,,,,,,,fee schedule,555.3,5664, Peritoneal lavage,49084,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,555.3,5664, Peritoneal lavage,49084,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,555.3,5664, Peritoneal lavage,49084,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,555.3,5664, Biopsy abdominal mass,49180,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,398.17,,,,,,,fee schedule,398.17,5664, Biopsy abdominal mass,49180,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,398.17,5664, Biopsy abdominal mass,49180,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,398.17,5664, Biopsy abdominal mass,49180,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,398.17,5664, Sclerotx fluid collection,49185,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,590.48,,,,,,,fee schedule,590.48,4497, Sclerotx fluid collection,49185,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,590.48,4497, Sclerotx fluid collection,49185,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,590.48,4497, Sclerotx fluid collection,49185,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,590.48,4497, Opn exc/dstr ntra-abd 5 cm/<,49186,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6948.32,,,,,,,fee schedule,6948.32,10940, Opn exc/dstr ntra-abd 5 cm/<,49186,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6948.32,10940, Opn exc/dstr ntra-abd 5 cm/<,49186,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,6948.32,10940, Opn exc/dstr ntra-abd 5 cm/<,49186,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,6948.32,10940, Opn exc/dstr ntra-abd 5.1-10,49187,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8831.96,,,,,,,fee schedule,6979,10940, Opn exc/dstr ntra-abd 5.1-10,49187,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,10940, Opn exc/dstr ntra-abd 5.1-10,49187,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,6979,10940, Opn exc/dstr ntra-abd 5.1-10,49187,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,6979,10940, Opn exc/dst ntra-abd 10.1-20,49188,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10571.9,,,,,,,fee schedule,6979,10940, Opn exc/dst ntra-abd 10.1-20,49188,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,10940, Opn exc/dst ntra-abd 10.1-20,49188,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,6979,10940, Opn exc/dst ntra-abd 10.1-20,49188,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,6979,10940, Opn exc/dst ntra-abd 20.1-30,49189,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12273.8,,,,,,,fee schedule,6979,12821, Opn exc/dst ntra-abd 20.1-30,49189,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,12821, Opn exc/dst ntra-abd 20.1-30,49189,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,6979,12821, Opn exc/dst ntra-abd 20.1-30,49189,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,6979,12821, Opn exc/dstr ntra-abd >30 cm,49190,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,15095.42,,,,,,,fee schedule,6979,15095.42, Opn exc/dstr ntra-abd >30 cm,49190,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,15095.42, Opn exc/dstr ntra-abd >30 cm,49190,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,6979,15095.42, Opn exc/dstr ntra-abd >30 cm,49190,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,6979,15095.42, Exc abd tum 5 cm or less,49203,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Exc abd tum over 5 cm,49204,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Exc abd tum over 10 cm,49205,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Excise sacral spine tumor,49215,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,11423.49,,,,,,,fee schedule,5097,11423.49, Excise sacral spine tumor,49215,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,11423.49, Excise sacral spine tumor,49215,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,11423.49, Excise sacral spine tumor,49215,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,11423.49, Excision of umbilicus,49250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3207.49,,,,,,,fee schedule,3207.49,12821, Excision of umbilicus,49250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3207.49,12821, Excision of umbilicus,49250,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3207.49,12821, Excision of umbilicus,49250,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3207.49,12821, Removal of omentum,49255,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4257.61,,,,,,,fee schedule,4257.61,10940, Removal of omentum,49255,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4257.61,10940, Removal of omentum,49255,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,4257.61,10940, Removal of omentum,49255,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,4257.61,10940, Diag laparo separate proc,49320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1792.66,,,,,,,fee schedule,1792.66,14456, Diag laparo separate proc,49320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1792.66,14456, Diag laparo separate proc,49320,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,1792.66,14456, Diag laparo separate proc,49320,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,1792.66,14456, Laparoscopy biopsy,49321,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1865.13,,,,,,,fee schedule,1865.13,14456, Laparoscopy biopsy,49321,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,1865.13,14456, Laparoscopy biopsy,49321,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,1865.13,14456, Laparoscopy biopsy,49321,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,1865.13,14456, Laparoscopy aspiration,49322,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2019.72,,,,,,,fee schedule,2019.72,14456, Laparoscopy aspiration,49322,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2019.72,14456, Laparoscopy aspiration,49322,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,2019.72,14456, Laparoscopy aspiration,49322,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,2019.72,14456, Laparo drain lymphocele,49323,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3425.7,,,,,,,fee schedule,3425.7,14456, Laparo drain lymphocele,49323,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3425.7,14456, Laparo drain lymphocele,49323,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3425.7,14456, Laparo drain lymphocele,49323,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3425.7,14456, Lap insert tunnel ip cath,49324,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2095.97,,,,,,,fee schedule,2095.97,14456, Lap insert tunnel ip cath,49324,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2095.97,14456, Lap insert tunnel ip cath,49324,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,2095.97,14456, Lap insert tunnel ip cath,49324,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,2095.97,14456, Lap Revision Perm IP Cath,49325,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2228.87,,,,,,,fee schedule,2228.87,14456, Lap Revision Perm IP Cath,49325,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2228.87,14456, Lap Revision Perm IP Cath,49325,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,2228.87,14456, Lap Revision Perm IP Cath,49325,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,2228.87,14456, Lap w/Omentopexy Add-on,49326,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,989.36,,,,,,,fee schedule,989.36,3195, Lap w/Omentopexy Add-on,49326,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,989.36,3195, Lap w/Omentopexy Add-on,49326,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,989.36,3195, Lap w/Omentopexy Add-on,49326,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,989.36,3195, Lap ins device for rt,49327,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,679.84,,,,,,,fee schedule,679.84,3195, Lap ins device for rt,49327,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,679.84,3195, Lap ins device for rt,49327,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,679.84,3195, Lap ins device for rt,49327,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,679.84,3195, Laparo proc abdm/per/oment,49329,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,14456, Laparo proc abdm/per/oment,49329,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3195,14456, Laparo proc abdm/per/oment,49329,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3195,14456, Air injection into abdomen,49400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,440.1,,,,,,,fee schedule,440.1,3195, Air injection into abdomen,49400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,440.1,3195, Air injection into abdomen,49400,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,440.1,3195, Air injection into abdomen,49400,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,440.1,3195, Remove foreign body adbomen,49402,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4561.13,,,,,,,fee schedule,4108,12821, Remove foreign body adbomen,49402,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,12821, Remove foreign body adbomen,49402,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4108,12821, Remove foreign body adbomen,49402,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4108,12821, Image cath fluid colxn visc,49405,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,932.11,,,,,,,fee schedule,932.11,5664, Image cath fluid colxn visc,49405,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,932.11,5664, Image cath fluid colxn visc,49405,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,932.11,5664, Image cath fluid colxn visc,49405,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,932.11,5664, Image cath fluid peri/retro,49406,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,932.11,,,,,,,fee schedule,932.11,5664, Image cath fluid peri/retro,49406,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,932.11,5664, Image cath fluid peri/retro,49406,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,932.11,5664, Image cath fluid peri/retro,49406,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,932.11,5664, Image cath fluid trns/vgnl,49407,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1011.8,,,,,,,fee schedule,1011.8,5664, Image cath fluid trns/vgnl,49407,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1011.8,5664, Image cath fluid trns/vgnl,49407,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1011.8,5664, Image cath fluid trns/vgnl,49407,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1011.8,5664, Ins mark abd/pel for rt perq,49411,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,879.82,,,,,,,fee schedule,879.82,5664, Ins mark abd/pel for rt perq,49411,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,879.82,5664, Ins mark abd/pel for rt perq,49411,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,879.82,5664, Ins mark abd/pel for rt perq,49411,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,879.82,5664, Ins device for rt guide open,49412,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,430.82,,,,,,,fee schedule,430.82,6979, Ins device for rt guide open,49412,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,430.82,6979, Ins device for rt guide open,49412,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,430.82,6979, Ins device for rt guide open,49412,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,430.82,6979, Insert tun ip cath perc,49418,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,975.11,,,,,,,fee schedule,975.11,12821, Insert tun ip cath perc,49418,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,975.11,12821, Insert tun ip cath perc,49418,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,975.11,12821, Insert tun ip cath perc,49418,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,975.11,12821, Insert tun ip cath w/port,49419,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2230.81,,,,,,,fee schedule,2230.81,22111, Insert tun ip cath w/port,49419,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2230.81,22111, Insert tun ip cath w/port,49419,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,2230.81,22111, Insert tun ip cath w/port,49419,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,2230.81,22111, Ins tun ip cath for dial opn,49421,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1200.61,,,,,,,fee schedule,1200.61,12821, Ins tun ip cath for dial opn,49421,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1200.61,12821, Ins tun ip cath for dial opn,49421,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,1200.61,12821, Ins tun ip cath for dial opn,49421,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,1200.61,12821, Remove tunneled ip cath,49422,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1166.29,,,,,,,fee schedule,1166.29,12821, Remove tunneled ip cath,49422,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1166.29,12821, Remove tunneled ip cath,49422,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,1166.29,12821, Remove tunneled ip cath,49422,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,1166.29,12821, Exchange drainage catheter,49423,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,340.65,,,,,,,fee schedule,340.65,5664, Exchange drainage catheter,49423,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,340.65,5664, Exchange drainage catheter,49423,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,340.65,5664, Exchange drainage catheter,49423,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,340.65,5664, Assess cyst contrast inject,49424,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,178.18,,,,,,,fee schedule,178.18,3195, Assess cyst contrast inject,49424,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,178.18,3195, Assess cyst contrast inject,49424,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,178.18,3195, Assess cyst contrast inject,49424,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,178.18,3195, Insert abdomen-venous drain,49425,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4258.9,,,,,,,fee schedule,4108,5664, Insert abdomen-venous drain,49425,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,5664, Insert abdomen-venous drain,49425,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4108,5664, Insert abdomen-venous drain,49425,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4108,5664, Revise abdomen-venous shunt,49426,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3662.75,,,,,,,fee schedule,3662.75,12821, Revise abdomen-venous shunt,49426,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3662.75,12821, Revise abdomen-venous shunt,49426,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3662.75,12821, Revise abdomen-venous shunt,49426,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3662.75,12821, Injection abdominal shunt,49427,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,200.41,,,,,,,fee schedule,200.41,3195, Injection abdominal shunt,49427,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,200.41,3195, Injection abdominal shunt,49427,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,200.41,3195, Injection abdominal shunt,49427,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,200.41,3195, Ligation of shunt,49428,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2351.36,,,,,,,fee schedule,2351.36,6979, Ligation of shunt,49428,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2351.36,6979, Ligation of shunt,49428,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2351.36,6979, Ligation of shunt,49428,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2351.36,6979, Removal of shunt,49429,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2490.36,,,,,,,fee schedule,2490.36,12821, Removal of shunt,49429,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2490.36,12821, Removal of shunt,49429,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2490.36,12821, Removal of shunt,49429,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2490.36,12821, Insert Subq Exten to IP Cath,49435,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,619.73,,,,,,,fee schedule,619.73,5664, Insert Subq Exten to IP Cath,49435,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,619.73,5664, Insert Subq Exten to IP Cath,49435,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,619.73,5664, Insert Subq Exten to IP Cath,49435,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,619.73,5664, Embedded IP Cath Exit-Site,49436,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1004.68,,,,,,,fee schedule,1004.68,5664, Embedded IP Cath Exit-Site,49436,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1004.68,5664, Embedded IP Cath Exit-Site,49436,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1004.68,5664, Embedded IP Cath Exit-Site,49436,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1004.68,5664, Place gastrostomy tube perc,49440,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,992.86,,,,,,,fee schedule,992.86,5664, Place gastrostomy tube perc,49440,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,992.86,5664, Place gastrostomy tube perc,49440,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,992.86,5664, Place gastrostomy tube perc,49440,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,992.86,5664, Place duod/jej tube perc,49441,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1226.67,,,,,,,fee schedule,1226.67,5664, Place duod/jej tube perc,49441,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1226.67,5664, Place duod/jej tube perc,49441,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1226.67,5664, Place duod/jej tube perc,49441,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1226.67,5664, Place cecostomy tube perc,49442,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,984.61,,,,,,,fee schedule,984.61,5664, Place cecostomy tube perc,49442,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,984.61,5664, Place cecostomy tube perc,49442,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,984.61,5664, Place cecostomy tube perc,49442,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,984.61,5664, Change g-tube to g-j perc,49446,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,709.41,,,,,,,fee schedule,709.41,5664, Change g-tube to g-j perc,49446,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,709.41,5664, Change g-tube to g-j perc,49446,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,709.41,5664, Change g-tube to g-j perc,49446,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,709.41,5664, Replace g/c tube perc,49450,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,316.53,,,,,,,fee schedule,316.53,5664, Replace g/c tube perc,49450,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,316.53,5664, Replace g/c tube perc,49450,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,316.53,5664, Replace g/c tube perc,49450,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,316.53,5664, Replace duod/jej tube perc,49451,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,427.74,,,,,,,fee schedule,427.74,5664, Replace duod/jej tube perc,49451,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,427.74,5664, Replace duod/jej tube perc,49451,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,427.74,5664, Replace duod/jej tube perc,49451,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,427.74,5664, Replace g-j tube perc,49452,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,654.75,,,,,,,fee schedule,654.75,5664, Replace g-j tube perc,49452,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,654.75,5664, Replace g-j tube perc,49452,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,654.75,5664, Replace g-j tube perc,49452,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,654.75,5664, Fix g/colon tube w/device,49460,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,239.85,,,,,,,fee schedule,239.85,5664, Fix g/colon tube w/device,49460,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,239.85,5664, Fix g/colon tube w/device,49460,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,239.85,5664, Fix g/colon tube w/device,49460,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,239.85,5664, Fluoro exam of g/colon tube,49465,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,143.37,,,,,,,fee schedule,143.37,3195, Fluoro exam of g/colon tube,49465,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,143.37,3195, Fluoro exam of g/colon tube,49465,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,143.37,3195, Fluoro exam of g/colon tube,49465,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,143.37,3195, Rpr hern preemie reduc,49491,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4358.83,,,,,,,fee schedule,4358.83,12821, Rpr hern preemie reduc,49491,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4358.83,12821, Rpr hern preemie reduc,49491,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4358.83,12821, Rpr hern preemie reduc,49491,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4358.83,12821, Rpr ing hern premie blocked,49492,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5215.94,,,,,,,fee schedule,5215.94,12821, Rpr ing hern premie blocked,49492,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,5215.94,12821, Rpr ing hern premie blocked,49492,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5215.94,12821, Rpr ing hern premie blocked,49492,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5215.94,12821, Rpr ing hernia baby reduc,49495,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2268.42,,,,,,,fee schedule,2268.42,12821, Rpr ing hernia baby reduc,49495,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2268.42,12821, Rpr ing hernia baby reduc,49495,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2268.42,12821, Rpr ing hernia baby reduc,49495,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2268.42,12821, Rpr ing hernia baby blocked,49496,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3390.9,,,,,,,fee schedule,3390.9,12821, Rpr ing hernia baby blocked,49496,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3390.9,12821, Rpr ing hernia baby blocked,49496,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3390.9,12821, Rpr ing hernia baby blocked,49496,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3390.9,12821, Rpr ing hernia init reduce,49500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2321.9,,,,,,,fee schedule,2321.9,12821, Rpr ing hernia init reduce,49500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2321.9,12821, Rpr ing hernia init reduce,49500,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2321.9,12821, Rpr ing hernia init reduce,49500,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2321.9,12821, Rpr ing hernia init blocked,49501,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3338.56,,,,,,,fee schedule,3338.56,12821, Rpr ing hernia init blocked,49501,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3338.56,12821, Rpr ing hernia init blocked,49501,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3338.56,12821, Rpr ing hernia init blocked,49501,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3338.56,12821, Prp i/hern init reduc >5 yr,49505,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2884.32,,,,,,,fee schedule,2884.32,12821, Prp i/hern init reduc >5 yr,49505,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2884.32,12821, Prp i/hern init reduc >5 yr,49505,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2884.32,12821, Prp i/hern init reduc >5 yr,49505,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2884.32,12821, Prp i/hern init block >5 yr,49507,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3229.83,,,,,,,fee schedule,3229.83,12821, Prp i/hern init block >5 yr,49507,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3229.83,12821, Prp i/hern init block >5 yr,49507,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3229.83,12821, Prp i/hern init block >5 yr,49507,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3229.83,12821, Rerepair ing hernia reduce,49520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3467.2,,,,,,,fee schedule,3467.2,12821, Rerepair ing hernia reduce,49520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3467.2,12821, Rerepair ing hernia reduce,49520,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3467.2,12821, Rerepair ing hernia reduce,49520,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3467.2,12821, Rerepair ing hernia blocked,49521,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3910.48,,,,,,,fee schedule,3910.48,12821, Rerepair ing hernia blocked,49521,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3910.48,12821, Rerepair ing hernia blocked,49521,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3910.48,12821, Rerepair ing hernia blocked,49521,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3910.48,12821, Repair ing hernia sliding,49525,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3154.07,,,,,,,fee schedule,3154.07,12821, Repair ing hernia sliding,49525,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3154.07,12821, Repair ing hernia sliding,49525,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3154.07,12821, Repair ing hernia sliding,49525,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3154.07,12821, Repair lumbar hernia,49540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3669.44,,,,,,,fee schedule,3669.44,12821, Repair lumbar hernia,49540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3669.44,12821, Repair lumbar hernia,49540,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3669.44,12821, Repair lumbar hernia,49540,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3669.44,12821, Rpr rem hernia init reduce,49550,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3177.16,,,,,,,fee schedule,3177.16,12821, Rpr rem hernia init reduce,49550,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,3177.16,12821, Rpr rem hernia init reduce,49550,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3177.16,12821, Rpr rem hernia init reduce,49550,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3177.16,12821, Rpr fem hernia init blocked,49553,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3466.17,,,,,,,fee schedule,3466.17,12821, Rpr fem hernia init blocked,49553,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3466.17,12821, Rpr fem hernia init blocked,49553,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3466.17,12821, Rpr fem hernia init blocked,49553,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3466.17,12821, Rerepair fem hernia reduce,49555,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3325.29,,,,,,,fee schedule,3325.29,12821, Rerepair fem hernia reduce,49555,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,3325.29,12821, Rerepair fem hernia reduce,49555,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3325.29,12821, Rerepair fem hernia reduce,49555,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3325.29,12821, Rerepair fem hernia blocked,49557,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3952.46,,,,,,,fee schedule,3952.46,12821, Rerepair fem hernia blocked,49557,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3952.46,12821, Rerepair fem hernia blocked,49557,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3952.46,12821, Rerepair fem hernia blocked,49557,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3952.46,12821, Rpr aa hrn 1st < 3 cm rdc,49591,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1821.2,,,,,,,fee schedule,1821.2,12821, Rpr aa hrn 1st < 3 cm rdc,49591,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,1821.2,12821, Rpr aa hrn 1st < 3 cm rdc,49591,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,1821.2,12821, Rpr aa hrn 1st < 3 cm rdc,49591,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,1821.2,12821, Rpr aa hrn 1st < 3 ncr/strn,49592,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2532.07,,,,,,,fee schedule,2532.07,22111, Rpr aa hrn 1st < 3 ncr/strn,49592,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2532.07,22111, Rpr aa hrn 1st < 3 ncr/strn,49592,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,2532.07,22111, Rpr aa hrn 1st < 3 ncr/strn,49592,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,2532.07,22111, Rpr aa hrn 1st 3-10 rdc,49593,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3045.18,,,,,,,fee schedule,3045.18,12821, Rpr aa hrn 1st 3-10 rdc,49593,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3045.18,12821, Rpr aa hrn 1st 3-10 rdc,49593,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3045.18,12821, Rpr aa hrn 1st 3-10 rdc,49593,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3045.18,12821, Rpr aa hrn 1st 3-10 ncr/strn,49594,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3964.28,,,,,,,fee schedule,3964.28,22111, Rpr aa hrn 1st 3-10 ncr/strn,49594,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3964.28,22111, Rpr aa hrn 1st 3-10 ncr/strn,49594,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3964.28,22111, Rpr aa hrn 1st 3-10 ncr/strn,49594,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3964.28,22111, Rpr aa hrn 1st > 10 rdc,49595,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4083.69,,,,,,,fee schedule,4083.69,12821, Rpr aa hrn 1st > 10 rdc,49595,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4083.69,12821, Rpr aa hrn 1st > 10 rdc,49595,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4083.69,12821, Rpr aa hrn 1st > 10 rdc,49595,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4083.69,12821, Rpr aa hrn 1st > 10 ncr/strn,49596,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5441.97,,,,,,,fee schedule,5363,22111, Rpr aa hrn 1st > 10 ncr/strn,49596,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,22111, Rpr aa hrn 1st > 10 ncr/strn,49596,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5363,22111, Rpr aa hrn 1st > 10 ncr/strn,49596,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5363,22111, Repair umbilical lesion,49600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4016.4,,,,,,,fee schedule,4016.4,12821, Repair umbilical lesion,49600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4016.4,12821, Repair umbilical lesion,49600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4016.4,12821, Repair umbilical lesion,49600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4016.4,12821, Repair umbilical lesion,49605,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,26082.81,,,,,,,fee schedule,5097,26082.81, Repair umbilical lesion,49605,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5097,26082.81, Repair umbilical lesion,49605,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,26082.81, Repair umbilical lesion,49605,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,26082.81, Repair umbilical lesion,49606,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6102.82,,,,,,,fee schedule,5097,6979, Repair umbilical lesion,49606,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Repair umbilical lesion,49606,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Repair umbilical lesion,49606,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Repair umbilical lesion,49610,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3782.81,,,,,,,fee schedule,3782.81,6979, Repair umbilical lesion,49610,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3782.81,6979, Repair umbilical lesion,49610,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3782.81,6979, Repair umbilical lesion,49610,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3782.81,6979, Repair umbilical lesion,49611,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3356.37,,,,,,,fee schedule,3356.37,6979, Repair umbilical lesion,49611,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3356.37,6979, Repair umbilical lesion,49611,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3356.37,6979, Repair umbilical lesion,49611,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3356.37,6979, Rpr aa hrn rcr < 3 rdc,49613,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2237.67,,,,,,,fee schedule,2237.67,12821, Rpr aa hrn rcr < 3 rdc,49613,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2237.67,12821, Rpr aa hrn rcr < 3 rdc,49613,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2237.67,12821, Rpr aa hrn rcr < 3 rdc,49613,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2237.67,12821, Rpr aa hrn rcr < 3 ncr/strn,49614,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3039.94,,,,,,,fee schedule,3039.94,22111, Rpr aa hrn rcr < 3 ncr/strn,49614,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,3039.94,22111, Rpr aa hrn rcr < 3 ncr/strn,49614,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3039.94,22111, Rpr aa hrn rcr < 3 ncr/strn,49614,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3039.94,22111, Rpr aa hrn rcr 3-10 rdc,49615,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3387.29,,,,,,,fee schedule,3387.29,12821, Rpr aa hrn rcr 3-10 rdc,49615,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3387.29,12821, Rpr aa hrn rcr 3-10 rdc,49615,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3387.29,12821, Rpr aa hrn rcr 3-10 rdc,49615,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3387.29,12821, Rpr aa hrn rcr 3-10 ncr/strn,49616,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4550.12,,,,,,,fee schedule,4550.12,22111, Rpr aa hrn rcr 3-10 ncr/strn,49616,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4550.12,22111, Rpr aa hrn rcr 3-10 ncr/strn,49616,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4550.12,22111, Rpr aa hrn rcr 3-10 ncr/strn,49616,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4550.12,22111, Rpr aa hrn rcr > 10 rdc,49617,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4687.99,,,,,,,fee schedule,4687.99,22111, Rpr aa hrn rcr > 10 rdc,49617,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4687.99,22111, Rpr aa hrn rcr > 10 rdc,49617,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4687.99,22111, Rpr aa hrn rcr > 10 rdc,49617,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4687.99,22111, Rpr aa hrn rcr > 10 ncr/strn,49618,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6573.78,,,,,,,fee schedule,6044,22111, Rpr aa hrn rcr > 10 ncr/strn,49618,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,22111, Rpr aa hrn rcr > 10 ncr/strn,49618,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6044,22111, Rpr aa hrn rcr > 10 ncr/strn,49618,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6044,22111, Rpr parastomal hernia rdc,49621,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3942.75,,,,,,,fee schedule,3942.75,22111, Rpr parastomal hernia rdc,49621,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3942.75,22111, Rpr parastomal hernia rdc,49621,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3942.75,22111, Rpr parastomal hernia rdc,49621,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3942.75,22111, Rpr parastomal hrna ncr/strn,49622,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4919.43,,,,,,,fee schedule,4919.43,22111, Rpr parastomal hrna ncr/strn,49622,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4919.43,22111, Rpr parastomal hrna ncr/strn,49622,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4919.43,22111, Rpr parastomal hrna ncr/strn,49622,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4919.43,22111, Rmvl ninfct mesh hernia rpr,49623,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1072.08,,,,,,,fee schedule,1072.08,3195, Rmvl ninfct mesh hernia rpr,49623,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1072.08,3195, Rmvl ninfct mesh hernia rpr,49623,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1072.08,3195, Rmvl ninfct mesh hernia rpr,49623,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1072.08,3195, Lap ing hernia repair init,49650,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2398.09,,,,,,,fee schedule,2398.09,22111, Lap ing hernia repair init,49650,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2398.09,22111, Lap ing hernia repair init,49650,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,2398.09,22111, Lap ing hernia repair init,49650,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,2398.09,22111, Lap ing hernia repair recur,49651,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3114.57,,,,,,,fee schedule,3114.57,22111, Lap ing hernia repair recur,49651,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,3114.57,22111, Lap ing hernia repair recur,49651,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3114.57,22111, Lap ing hernia repair recur,49651,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3114.57,22111, Laparo proc hernia repair,49659,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,14456, Laparo proc hernia repair,49659,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,6044,14456, Laparo proc hernia repair,49659,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,6044,14456, Repair of abdominal wall,49900,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4524.01,,,,,,,fee schedule,4524.01,6979, Repair of abdominal wall,49900,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4524.01,6979, Repair of abdominal wall,49900,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4524.01,6979, Repair of abdominal wall,49900,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4524.01,6979, Omental flap extra-abdom,49904,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7312.39,,,,,,,fee schedule,5097,7312.39, Omental flap extra-abdom,49904,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7312.39, Omental flap extra-abdom,49904,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7312.39, Omental flap extra-abdom,49904,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7312.39, Omental flap intra-abdom,49905,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1821.31,,,,,,,fee schedule,1821.31,14456, Omental flap intra-abdom,49905,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1821.31,14456, Omental flap intra-abdom,49905,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,1821.31,14456, Omental flap intra-abdom,49905,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,1821.31,14456, Free omental flap microvasc,49906,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Free omental flap microvasc,49906,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Free omental flap microvasc,49906,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Abdomen surgery procedure,49999,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,5664, Abdomen surgery procedure,49999,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3195,5664, Abdomen surgery procedure,49999,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3195,5664, Exploration of kidney,50010,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3553.97,,,,,,,fee schedule,3553.97,6979, Exploration of kidney,50010,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3553.97,6979, Exploration of kidney,50010,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3553.97,6979, Exploration of kidney,50010,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3553.97,6979, Renal abscess open drain,50020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5089.83,,,,,,,fee schedule,4108,10940, Renal abscess open drain,50020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,10940, Renal abscess open drain,50020,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,4108,10940, Renal abscess open drain,50020,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,4108,10940, Drainage of kidney,50040,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4632.2,,,,,,,fee schedule,4632.2,10940, Drainage of kidney,50040,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4632.2,10940, Drainage of kidney,50040,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,4632.2,10940, Drainage of kidney,50040,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,4632.2,10940, Exploration of kidney,50045,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4667.97,,,,,,,fee schedule,4667.97,6979, Exploration of kidney,50045,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4667.97,6979, Exploration of kidney,50045,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4667.97,6979, Exploration of kidney,50045,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4667.97,6979, Removal of kidney stone,50060,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5677.24,,,,,,,fee schedule,5097,6979, Removal of kidney stone,50060,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Removal of kidney stone,50060,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Removal of kidney stone,50060,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Incision of kidney,50065,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6009.47,,,,,,,fee schedule,5097,6979, Incision of kidney,50065,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Incision of kidney,50065,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Incision of kidney,50065,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Incision of kidney,50070,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5895.83,,,,,,,fee schedule,5097,6979, Incision of kidney,50070,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Incision of kidney,50070,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Incision of kidney,50070,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Removal of kidney stone,50075,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7232.37,,,,,,,fee schedule,5097,7232.37, Removal of kidney stone,50075,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7232.37, Removal of kidney stone,50075,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7232.37, Removal of kidney stone,50075,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7232.37, Removal of kidney stone,50080,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3492.45,,,,,,,fee schedule,3492.45,14456, Removal of kidney stone,50080,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3492.45,14456, Removal of kidney stone,50080,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3492.45,14456, Removal of kidney stone,50080,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3492.45,14456, Removal of kidney stone,50081,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5586.32,,,,,,,fee schedule,5586.32,14456, Removal of kidney stone,50081,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,5586.32,14456, Removal of kidney stone,50081,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5586.32,14456, Removal of kidney stone,50081,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5586.32,14456, Revise kidney blood vessels,50100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5868.69,,,,,,,fee schedule,5097,6979, Revise kidney blood vessels,50100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Revise kidney blood vessels,50100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Revise kidney blood vessels,50100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Exploration of kidney,50120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4748.32,,,,,,,fee schedule,4748.32,6979, Exploration of kidney,50120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4748.32,6979, Exploration of kidney,50120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4748.32,6979, Exploration of kidney,50120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4748.32,6979, Explore and drain kidney,50125,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4907.07,,,,,,,fee schedule,4907.07,6979, Explore and drain kidney,50125,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4907.07,6979, Explore and drain kidney,50125,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4907.07,6979, Explore and drain kidney,50125,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4907.07,6979, Removal of kidney stone,50130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5156.09,,,,,,,fee schedule,5097,6979, Removal of kidney stone,50130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Removal of kidney stone,50130,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Removal of kidney stone,50130,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Exploration of kidney,50135,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Renal biopsy perq,50200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,610.67,,,,,,,fee schedule,610.67,5664, Renal biopsy perq,50200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,610.67,5664, Renal biopsy perq,50200,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,610.67,5664, Renal biopsy perq,50200,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,610.67,5664, Renal biopsy open,50205,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4067.4,,,,,,,fee schedule,4067.4,6979, Renal biopsy open,50205,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4067.4,6979, Renal biopsy open,50205,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4067.4,6979, Renal biopsy open,50205,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4067.4,6979, Remove kidney open,50220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5413.27,,,,,,,fee schedule,5097,6979, Remove kidney open,50220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Remove kidney open,50220,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Remove kidney open,50220,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Removal kidney open complex,50225,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5905.65,,,,,,,fee schedule,5097,6979, Removal kidney open complex,50225,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Removal kidney open complex,50225,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Removal kidney open complex,50225,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Removal kidney open radical,50230,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6400.84,,,,,,,fee schedule,5097,6979, Removal kidney open radical,50230,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Removal kidney open radical,50230,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Removal kidney open radical,50230,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Removal of kidney & ureter,50234,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6484.97,,,,,,,fee schedule,5097,6979, Removal of kidney & ureter,50234,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Removal of kidney & ureter,50234,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Removal of kidney & ureter,50234,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Removal of kidney & ureter,50236,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7284.44,,,,,,,fee schedule,5097,7284.44, Removal of kidney & ureter,50236,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7284.44, Removal of kidney & ureter,50236,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7284.44, Removal of kidney & ureter,50236,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7284.44, Partial removal of kidney,50240,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6643.18,,,,,,,fee schedule,5097,6979, Partial removal of kidney,50240,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Partial removal of kidney,50240,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Partial removal of kidney,50240,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Cryoablate renal mass open,50250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6059.38,,,,,,,fee schedule,5097,8406, Cryoablate renal mass open,50250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,5097,8406, Cryoablate renal mass open,50250,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8406, Cryoablate renal mass open,50250,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8406, Removal of kidney lesion,50280,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4731.59,,,,,,,fee schedule,4731.59,6979, Removal of kidney lesion,50280,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4731.59,6979, Removal of kidney lesion,50280,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4731.59,6979, Removal of kidney lesion,50280,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4731.59,6979, Removal of kidney lesion,50290,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4502.37,,,,,,,fee schedule,4502.37,6979, Removal of kidney lesion,50290,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4502.37,6979, Removal of kidney lesion,50290,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4502.37,6979, Removal of kidney lesion,50290,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4502.37,6979, Remove cadaver donor kidney,50300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Remove cadaver donor kidney,50300,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Remove cadaver donor kidney,50300,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Remove kidney living donor,50320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8400.33,,,,,,,fee schedule,5097,8400.33, Remove kidney living donor,50320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8400.33, Remove kidney living donor,50320,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8400.33, Remove kidney living donor,50320,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8400.33, Prep cadaver renal allograft,50323,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Prep cadaver renal allograft,50323,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Prep cadaver renal allograft,50323,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Prep donor renal graft,50325,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Prep donor renal graft,50325,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Prep donor renal graft,50325,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Prep renal graft/venous,50327,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1134.02,,,,,,,fee schedule,1134.02,6979, Prep renal graft/venous,50327,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1134.02,6979, Prep renal graft/venous,50327,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1134.02,6979, Prep renal graft/venous,50327,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1134.02,6979, Prep renal graft/arterial,50328,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,988.82,,,,,,,fee schedule,988.82,6979, Prep renal graft/arterial,50328,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,988.82,6979, Prep renal graft/arterial,50328,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,988.82,6979, Prep renal graft/arterial,50328,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,988.82,6979, Prep renal graft/ureteral,50329,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,946.78,,,,,,,fee schedule,946.78,6979, Prep renal graft/ureteral,50329,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,946.78,6979, Prep renal graft/ureteral,50329,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,946.78,6979, Prep renal graft/ureteral,50329,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,946.78,6979, Removal of kidney,50340,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5306.64,,,,,,,fee schedule,5097,6979, Removal of kidney,50340,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Removal of kidney,50340,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Removal of kidney,50340,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Transplantation of kidney,50360,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,13127.33,,,,,,,fee schedule,5097,13127.33, Transplantation of kidney,50360,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,13127.33, Transplantation of kidney,50360,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,13127.33, Transplantation of kidney,50360,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,13127.33, Transplantation of kidney,50365,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,15987.92,,,,,,,fee schedule,5097,15987.92, Transplantation of kidney,50365,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,15987.92, Transplantation of kidney,50365,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,15987.92, Transplantation of kidney,50365,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,15987.92, Remove transplanted kidney,50370,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6641.13,,,,,,,fee schedule,5097,6979, Remove transplanted kidney,50370,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Remove transplanted kidney,50370,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Remove transplanted kidney,50370,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Reimplantation of kidney,50380,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,11215.8,,,,,,,fee schedule,5097,11215.8, Reimplantation of kidney,50380,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,11215.8, Reimplantation of kidney,50380,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,11215.8, Reimplantation of kidney,50380,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,11215.8, Change ureter stent percut,50382,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1215.02,,,,,,,fee schedule,1215.02,10940, Change ureter stent percut,50382,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1215.02,10940, Change ureter stent percut,50382,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1215.02,10940, Change ureter stent percut,50382,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1215.02,10940, Remove ureter stent percut,50384,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1102.08,,,,,,,fee schedule,1102.08,10940, Remove ureter stent percut,50384,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1102.08,10940, Remove ureter stent percut,50384,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1102.08,10940, Remove ureter stent percut,50384,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1102.08,10940, Change stent via transureth,50385,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1058.7,,,,,,,fee schedule,1058.7,10940, Change stent via transureth,50385,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1058.7,10940, Change stent via transureth,50385,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1058.7,10940, Change stent via transureth,50385,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1058.7,10940, Remove stent via transureth,50386,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,803.63,,,,,,,fee schedule,803.63,10940, Remove stent via transureth,50386,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,803.63,10940, Remove stent via transureth,50386,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,803.63,10940, Remove stent via transureth,50386,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,803.63,10940, Change nephroureteral cath,50387,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,402.76,,,,,,,fee schedule,402.76,5664, Change nephroureteral cath,50387,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,402.76,5664, Change nephroureteral cath,50387,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,402.76,5664, Change nephroureteral cath,50387,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,402.76,5664, Remove renal tube w/fluoro,50389,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,256.36,,,,,,,fee schedule,256.36,4497, Remove renal tube w/fluoro,50389,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,256.36,4497, Remove renal tube w/fluoro,50389,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,256.36,4497, Remove renal tube w/fluoro,50389,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,256.36,4497, Drainage of kidney lesion,50390,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,452.83,,,,,,,fee schedule,452.83,4497, Drainage of kidney lesion,50390,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,452.83,4497, Drainage of kidney lesion,50390,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,452.83,4497, Drainage of kidney lesion,50390,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,452.83,4497, Instll rx agnt into rnal tub,50391,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,476.47,,,,,,,fee schedule,476.47,3195, Instll rx agnt into rnal tub,50391,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,476.47,3195, Instll rx agnt into rnal tub,50391,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,476.47,3195, Instll rx agnt into rnal tub,50391,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,476.47,3195, Measure kidney pressure,50396,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,552.82,,,,,,,fee schedule,552.82,4497, Measure kidney pressure,50396,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,552.82,4497, Measure kidney pressure,50396,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,552.82,4497, Measure kidney pressure,50396,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,552.82,4497, Revision of kidney/ureter,50400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5756.99,,,,,,,fee schedule,5756.99,12821, Revision of kidney/ureter,50400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5756.99,12821, Revision of kidney/ureter,50400,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5756.99,12821, Revision of kidney/ureter,50400,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5756.99,12821, Revision of kidney/ureter,50405,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6934.13,,,,,,,fee schedule,6934.13,12821, Revision of kidney/ureter,50405,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6934.13,12821, Revision of kidney/ureter,50405,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,6934.13,12821, Revision of kidney/ureter,50405,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,6934.13,12821, Njx px nfrosgrm &/urtrgrm,50430,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,755.49,,,,,,,fee schedule,755.49,4497, Njx px nfrosgrm &/urtrgrm,50430,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,755.49,4497, Njx px nfrosgrm &/urtrgrm,50430,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,755.49,4497, Njx px nfrosgrm &/urtrgrm,50430,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,755.49,4497, Njx px nfrosgrm &/urtrgrm,50431,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,325.27,,,,,,,fee schedule,325.27,4497, Njx px nfrosgrm &/urtrgrm,50431,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,325.27,4497, Njx px nfrosgrm &/urtrgrm,50431,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,325.27,4497, Njx px nfrosgrm &/urtrgrm,50431,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,325.27,4497, Plmt nephrostomy catheter,50432,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,989.95,,,,,,,fee schedule,989.95,10940, Plmt nephrostomy catheter,50432,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,989.95,10940, Plmt nephrostomy catheter,50432,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,989.95,10940, Plmt nephrostomy catheter,50432,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,989.95,10940, Plmt nephroureteral catheter,50433,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1223.27,,,,,,,fee schedule,1223.27,10940, Plmt nephroureteral catheter,50433,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1223.27,10940, Plmt nephroureteral catheter,50433,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1223.27,10940, Plmt nephroureteral catheter,50433,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1223.27,10940, Convert nephrostomy catheter,50434,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,929.25,,,,,,,fee schedule,929.25,4497, Convert nephrostomy catheter,50434,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,929.25,4497, Convert nephrostomy catheter,50434,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,929.25,4497, Convert nephrostomy catheter,50434,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,929.25,4497, Exchange nephrostomy cath,50435,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,486.88,,,,,,,fee schedule,486.88,4497, Exchange nephrostomy cath,50435,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,486.88,4497, Exchange nephrostomy cath,50435,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,486.88,4497, Exchange nephrostomy cath,50435,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,486.88,4497, Dilat xst trc ndurlgc px,50436,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,759,,,,,,,fee schedule,759,10940, Dilat xst trc ndurlgc px,50436,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,759,10940, Dilat xst trc ndurlgc px,50436,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,759,10940, Dilat xst trc ndurlgc px,50436,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,759,10940, Dilat xst trc new access rcs,50437,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1249.82,,,,,,,fee schedule,1249.82,12821, Dilat xst trc new access rcs,50437,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1249.82,12821, Dilat xst trc new access rcs,50437,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,1249.82,12821, Dilat xst trc new access rcs,50437,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,1249.82,12821, Repair of kidney wound,50500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6953.45,,,,,,,fee schedule,5097,6979, Repair of kidney wound,50500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Repair of kidney wound,50500,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Repair of kidney wound,50500,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Close kidney-skin fistula,50520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6279.81,,,,,,,fee schedule,3195,6279.81, Close kidney-skin fistula,50520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,6279.81, Close kidney-skin fistula,50520,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,3195,6279.81, Close kidney-skin fistula,50520,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,3195,6279.81, Close nephrovisceral fistula,50525,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7928.18,,,,,,,fee schedule,5097,7928.18, Close nephrovisceral fistula,50525,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7928.18, Close nephrovisceral fistula,50525,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7928.18, Close nephrovisceral fistula,50525,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7928.18, Close nephrovisceral fistula,50526,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8477.22,,,,,,,fee schedule,5097,8477.22, Close nephrovisceral fistula,50526,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8477.22, Close nephrovisceral fistula,50526,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8477.22, Close nephrovisceral fistula,50526,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8477.22, Revision of horseshoe kidney,50540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5713.02,,,,,,,fee schedule,5097,6979, Revision of horseshoe kidney,50540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Revision of horseshoe kidney,50540,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Revision of horseshoe kidney,50540,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Laparo ablate renal cyst,50541,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4577.48,,,,,,,fee schedule,4577.48,14456, Laparo ablate renal cyst,50541,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4577.48,14456, Laparo ablate renal cyst,50541,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4577.48,14456, Laparo ablate renal cyst,50541,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4577.48,14456, Laparo ablate renal mass,50542,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5822.93,,,,,,,fee schedule,5822.93,25393, Laparo ablate renal mass,50542,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,5822.93,25393, Laparo ablate renal mass,50542,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,5822.93,25393, Laparo ablate renal mass,50542,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,5822.93,25393, Laparo partial nephrectomy,50543,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7412.32,,,,,,,fee schedule,7412.32,22111, Laparo partial nephrectomy,50543,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,7412.32,22111, Laparo partial nephrectomy,50543,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,7412.32,22111, Laparo partial nephrectomy,50543,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,7412.32,22111, Laparoscopy pyeloplasty,50544,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6162.66,,,,,,,fee schedule,6044,22111, Laparoscopy pyeloplasty,50544,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,22111, Laparoscopy pyeloplasty,50544,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6044,22111, Laparoscopy pyeloplasty,50544,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6044,22111, Laparo Radical Nephrectomy,50545,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6627.37,,,,,,,fee schedule,5097,6979, Laparo Radical Nephrectomy,50545,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Laparo Radical Nephrectomy,50545,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Laparo Radical Nephrectomy,50545,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Laparoscopic nephrectomy,50546,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6027.93,,,,,,,fee schedule,5097,6044, Laparoscopic nephrectomy,50546,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,5097,6044, Laparoscopic nephrectomy,50546,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6044, Laparoscopic nephrectomy,50546,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6044, Laparo removal donor kidney,50547,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8770.55,,,,,,,fee schedule,5097,8770.55, Laparo removal donor kidney,50547,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,5097,8770.55, Laparo removal donor kidney,50547,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8770.55, Laparo removal donor kidney,50547,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8770.55, Laparo remove w/ureter,50548,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6657.8,,,,,,,fee schedule,5097,6657.8, Laparo remove w/ureter,50548,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,5097,6657.8, Laparo remove w/ureter,50548,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6657.8, Laparo remove w/ureter,50548,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6657.8, Laparoscope proc renal,50549,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,14456, Laparoscope proc renal,50549,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5248,14456, Laparoscope proc renal,50549,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5248,14456, Kidney endoscopy,50551,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1450.98,,,,,,,fee schedule,1450.98,5664, Kidney endoscopy,50551,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1450.98,5664, Kidney endoscopy,50551,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1450.98,5664, Kidney endoscopy,50551,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1450.98,5664, Kidney endoscopy,50553,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1546.82,,,,,,,fee schedule,1546.82,10940, Kidney endoscopy,50553,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1546.82,10940, Kidney endoscopy,50553,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1546.82,10940, Kidney endoscopy,50553,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1546.82,10940, Kidney endoscopy & biopsy,50555,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1678.53,,,,,,,fee schedule,1678.53,5664, Kidney endoscopy & biopsy,50555,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1678.53,5664, Kidney endoscopy & biopsy,50555,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1678.53,5664, Kidney endoscopy & biopsy,50555,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1678.53,5664, Kidney endoscopy & treatment,50557,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1699.09,,,,,,,fee schedule,1699.09,10940, Kidney endoscopy & treatment,50557,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1699.09,10940, Kidney endoscopy & treatment,50557,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1699.09,10940, Kidney endoscopy & treatment,50557,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1699.09,10940, Kidney endoscopy & treatment,50561,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1940.02,,,,,,,fee schedule,1940.02,10940, Kidney endoscopy & treatment,50561,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1940.02,10940, Kidney endoscopy & treatment,50561,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1940.02,10940, Kidney endoscopy & treatment,50561,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1940.02,10940, Renal scope w/tumor resect,50562,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2860.47,,,,,,,fee schedule,2860.47,4497, Renal scope w/tumor resect,50562,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2860.47,4497, Renal scope w/tumor resect,50562,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,2860.47,4497, Renal scope w/tumor resect,50562,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,2860.47,4497, Kidney endoscopy,50570,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2412.17,,,,,,,fee schedule,2412.17,4497, Kidney endoscopy,50570,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2412.17,4497, Kidney endoscopy,50570,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,2412.17,4497, Kidney endoscopy,50570,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,2412.17,4497, Kidney endoscopy,50572,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2603.03,,,,,,,fee schedule,2603.03,4497, Kidney endoscopy,50572,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2603.03,4497, Kidney endoscopy,50572,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,2603.03,4497, Kidney endoscopy,50572,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,2603.03,4497, Kidney endoscopy & biopsy,50574,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2765.02,,,,,,,fee schedule,2765.02,4497, Kidney endoscopy & biopsy,50574,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2765.02,4497, Kidney endoscopy & biopsy,50574,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,2765.02,4497, Kidney endoscopy & biopsy,50574,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,2765.02,4497, Kidney endoscopy,50575,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3488.68,,,,,,,fee schedule,3488.68,14456, Kidney endoscopy,50575,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3488.68,14456, Kidney endoscopy,50575,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3488.68,14456, Kidney endoscopy,50575,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3488.68,14456, Kidney endoscopy & treatment,50576,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2755.2,,,,,,,fee schedule,2755.2,5664, Kidney endoscopy & treatment,50576,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2755.2,5664, Kidney endoscopy & treatment,50576,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2755.2,5664, Kidney endoscopy & treatment,50576,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2755.2,5664, Kidney endoscopy & treatment,50580,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2970.12,,,,,,,fee schedule,2970.12,5664, Kidney endoscopy & treatment,50580,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2970.12,5664, Kidney endoscopy & treatment,50580,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2970.12,5664, Kidney endoscopy & treatment,50580,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2970.12,5664, Fragmenting of kidney stone,50590,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2884.76,,,,,,,fee schedule,2884.76,22111, Fragmenting of kidney stone,50590,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10675,,,,,,,fee schedule,2884.76,22111, Fragmenting of kidney stone,50590,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,2884.76,22111, Fragmenting of kidney stone,50590,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,2884.76,22111, Perc rf ablate renal tumor,50592,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1653.93,,,,,,,fee schedule,1653.93,22111, Perc rf ablate renal tumor,50592,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,1653.93,22111, Perc rf ablate renal tumor,50592,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,1653.93,22111, Perc rf ablate renal tumor,50592,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,1653.93,22111, Perc cryo ablate renal tum,50593,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2219.59,,,,,,,fee schedule,2219.59,22111, Perc cryo ablate renal tum,50593,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10675,,,,,,,fee schedule,2219.59,22111, Perc cryo ablate renal tum,50593,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,2219.59,22111, Perc cryo ablate renal tum,50593,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,2219.59,22111, Exploration of ureter,50600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4679.79,,,,,,,fee schedule,4679.79,6044, Exploration of ureter,50600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4679.79,6044, Exploration of ureter,50600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4679.79,6044, Exploration of ureter,50600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4679.79,6044, Insert ureteral support,50605,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5338.26,,,,,,,fee schedule,5097,6044, Insert ureteral support,50605,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,5097,6044, Insert ureteral support,50605,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6044, Insert ureteral support,50605,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6044, Endoluminal bx urtr rnl plvs,50606,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,713.46,,,,,,,fee schedule,713.46,3195, Endoluminal bx urtr rnl plvs,50606,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,713.46,3195, Endoluminal bx urtr rnl plvs,50606,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,713.46,3195, Endoluminal bx urtr rnl plvs,50606,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,713.46,3195, Removal of ureter stone,50610,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4714.16,,,,,,,fee schedule,4714.16,6044, Removal of ureter stone,50610,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4714.16,6044, Removal of ureter stone,50610,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4714.16,6044, Removal of ureter stone,50610,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4714.16,6044, Removal of ureter stone,50620,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4515.32,,,,,,,fee schedule,4515.32,6044, Removal of ureter stone,50620,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4515.32,6044, Removal of ureter stone,50620,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4515.32,6044, Removal of ureter stone,50620,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4515.32,6044, Removal of ureter stone,50630,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4461.63,,,,,,,fee schedule,4461.63,6044, Removal of ureter stone,50630,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4461.63,6044, Removal of ureter stone,50630,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4461.63,6044, Removal of ureter stone,50630,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4461.63,6044, Removal of ureter,50650,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5194.73,,,,,,,fee schedule,5097,6979, Removal of ureter,50650,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Removal of ureter,50650,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Removal of ureter,50650,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Removal of ureter,50660,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5692.46,,,,,,,fee schedule,5097,6979, Removal of ureter,50660,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Removal of ureter,50660,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Removal of ureter,50660,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Injection for ureter x-ray,50684,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,254.96,,,,,,,fee schedule,254.96,3195, Injection for ureter x-ray,50684,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,254.96,3195, Injection for ureter x-ray,50684,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,254.96,3195, Injection for ureter x-ray,50684,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,254.96,3195, Measure ureter pressure,50686,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,445.66,,,,,,,fee schedule,445.66,6979, Measure ureter pressure,50686,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,445.66,6979, Measure ureter pressure,50686,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,445.66,6979, Measure ureter pressure,50686,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,445.66,6979, Change of ureter tube/stent,50688,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,389.11,,,,,,,fee schedule,389.11,5664, Change of ureter tube/stent,50688,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,389.11,5664, Change of ureter tube/stent,50688,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,389.11,5664, Change of ureter tube/stent,50688,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,389.11,5664, Injection for ureter x-ray,50690,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,341.3,,,,,,,fee schedule,341.3,3195, Injection for ureter x-ray,50690,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,341.3,3195, Injection for ureter x-ray,50690,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,341.3,3195, Injection for ureter x-ray,50690,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,341.3,3195, Plmt ureteral stent prq,50693,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,981.75,,,,,,,fee schedule,981.75,12821, Plmt ureteral stent prq,50693,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,981.75,12821, Plmt ureteral stent prq,50693,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,981.75,12821, Plmt ureteral stent prq,50693,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,981.75,12821, Plmt ureteral stent prq,50694,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1276.8,,,,,,,fee schedule,1276.8,12821, Plmt ureteral stent prq,50694,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1276.8,12821, Plmt ureteral stent prq,50694,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,1276.8,12821, Plmt ureteral stent prq,50694,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,1276.8,12821, Plmt ureteral stent prq,50695,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1635.37,,,,,,,fee schedule,1635.37,12821, Plmt ureteral stent prq,50695,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1635.37,12821, Plmt ureteral stent prq,50695,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,1635.37,12821, Plmt ureteral stent prq,50695,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,1635.37,12821, Revision of ureter,50700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4633.98,,,,,,,fee schedule,4633.98,6979, Revision of ureter,50700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4633.98,6979, Revision of ureter,50700,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4633.98,6979, Revision of ureter,50700,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4633.98,6979, Ureteral embolization/occl,50705,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,903.07,,,,,,,fee schedule,903.07,3195, Ureteral embolization/occl,50705,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,903.07,3195, Ureteral embolization/occl,50705,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,903.07,3195, Ureteral embolization/occl,50705,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,903.07,3195, Balloon dilate urtrl strix,50706,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,871.02,,,,,,,fee schedule,871.02,3195, Balloon dilate urtrl strix,50706,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,871.02,3195, Balloon dilate urtrl strix,50706,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,871.02,3195, Balloon dilate urtrl strix,50706,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,871.02,3195, Release of ureter,50715,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6355.09,,,,,,,fee schedule,5097,6979, Release of ureter,50715,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Release of ureter,50715,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Release of ureter,50715,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Release of ureter,50722,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5101.92,,,,,,,fee schedule,5097,6979, Release of ureter,50722,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Release of ureter,50722,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Release of ureter,50722,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Release/revise ureter,50725,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5493.72,,,,,,,fee schedule,5097,6979, Release/revise ureter,50725,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Release/revise ureter,50725,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Release/revise ureter,50725,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Revise ureter,50727,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2616.68,,,,,,,fee schedule,2616.68,10940, Revise ureter,50727,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2616.68,10940, Revise ureter,50727,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2616.68,10940, Revise ureter,50727,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2616.68,10940, Revise ureter,50728,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3528.88,,,,,,,fee schedule,3528.88,6979, Revise ureter,50728,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3528.88,6979, Revise ureter,50728,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3528.88,6979, Revise ureter,50728,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3528.88,6979, Fusion of ureter & kidney,50740,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6621.11,,,,,,,fee schedule,5097,6979, Fusion of ureter & kidney,50740,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Fusion of ureter & kidney,50740,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Fusion of ureter & kidney,50740,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Fusion of ureter & kidney,50750,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5740.8,,,,,,,fee schedule,5097,6979, Fusion of ureter & kidney,50750,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Fusion of ureter & kidney,50750,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Fusion of ureter & kidney,50750,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Fusion of ureters,50760,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5780.73,,,,,,,fee schedule,5097,6979, Fusion of ureters,50760,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Fusion of ureters,50760,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Fusion of ureters,50760,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Splicing of ureters,50770,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5740.8,,,,,,,fee schedule,5097,6979, Splicing of ureters,50770,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Splicing of ureters,50770,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Splicing of ureters,50770,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Reimplant ureter in bladder,50780,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5648.1,,,,,,,fee schedule,5648.1,10940, Reimplant ureter in bladder,50780,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5648.1,10940, Reimplant ureter in bladder,50780,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,5648.1,10940, Reimplant ureter in bladder,50780,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,5648.1,10940, Reimplant ureter in bladder,50782,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5365.67,,,,,,,fee schedule,5097,6979, Reimplant ureter in bladder,50782,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Reimplant ureter in bladder,50782,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Reimplant ureter in bladder,50782,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Reimplant ureter in bladder,50783,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5616.43,,,,,,,fee schedule,5097,6979, Reimplant ureter in bladder,50783,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Reimplant ureter in bladder,50783,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Reimplant ureter in bladder,50783,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Reimplant ureter in bladder,50785,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6061,,,,,,,fee schedule,5097,6979, Reimplant ureter in bladder,50785,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Reimplant ureter in bladder,50785,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Reimplant ureter in bladder,50785,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Implant ureter in bowel,50800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4623.72,,,,,,,fee schedule,4623.72,6979, Implant ureter in bowel,50800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4623.72,6979, Implant ureter in bowel,50800,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4623.72,6979, Implant ureter in bowel,50800,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4623.72,6979, Fusion of ureter & bowel,50810,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7614.78,,,,,,,fee schedule,5097,7614.78, Fusion of ureter & bowel,50810,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7614.78, Fusion of ureter & bowel,50810,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7614.78, Fusion of ureter & bowel,50810,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7614.78, Urine shunt to intestine,50815,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6106.22,,,,,,,fee schedule,5097,6979, Urine shunt to intestine,50815,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Urine shunt to intestine,50815,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Urine shunt to intestine,50815,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Construct bowel bladder,50820,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6587.06,,,,,,,fee schedule,5097,6979, Construct bowel bladder,50820,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Construct bowel bladder,50820,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Construct bowel bladder,50820,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Construct bowel bladder,50825,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8170.41,,,,,,,fee schedule,5097,8170.41, Construct bowel bladder,50825,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8170.41, Construct bowel bladder,50825,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8170.41, Construct bowel bladder,50825,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8170.41, Revise urine flow,50830,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8924.5,,,,,,,fee schedule,5097,8924.5, Revise urine flow,50830,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8924.5, Revise urine flow,50830,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8924.5, Revise urine flow,50830,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8924.5, Replace ureter by bowel,50840,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6142.97,,,,,,,fee schedule,5097,6979, Replace ureter by bowel,50840,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Replace ureter by bowel,50840,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Replace ureter by bowel,50840,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Appendico-vesicostomy,50845,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6273.71,,,,,,,fee schedule,5097,6979, Appendico-vesicostomy,50845,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Appendico-vesicostomy,50845,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Appendico-vesicostomy,50845,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Transplant ureter to skin,50860,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4729.81,,,,,,,fee schedule,4729.81,6979, Transplant ureter to skin,50860,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4729.81,6979, Transplant ureter to skin,50860,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4729.81,6979, Transplant ureter to skin,50860,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4729.81,6979, Repair of ureter,50900,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4228.36,,,,,,,fee schedule,4228.36,6979, Repair of ureter,50900,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4228.36,6979, Repair of ureter,50900,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4228.36,6979, Repair of ureter,50900,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4228.36,6979, Closure ureter/skin fistula,50920,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4418.19,,,,,,,fee schedule,4418.19,6979, Closure ureter/skin fistula,50920,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4418.19,6979, Closure ureter/skin fistula,50920,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4418.19,6979, Closure ureter/skin fistula,50920,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4418.19,6979, Closure ureter/bowel fistula,50930,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5491.89,,,,,,,fee schedule,5097,6979, Closure ureter/bowel fistula,50930,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Closure ureter/bowel fistula,50930,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Closure ureter/bowel fistula,50930,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Release of ureter,50940,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4450.4,,,,,,,fee schedule,4450.4,6979, Release of ureter,50940,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4450.4,6979, Release of ureter,50940,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4450.4,6979, Release of ureter,50940,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4450.4,6979, Laparoscopy ureterolithotomy,50945,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4833.68,,,,,,,fee schedule,4833.68,22111, Laparoscopy ureterolithotomy,50945,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4833.68,22111, Laparoscopy ureterolithotomy,50945,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4833.68,22111, Laparoscopy ureterolithotomy,50945,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4833.68,22111, Laparo New Ureter/Bladder,50947,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6891.45,,,,,,,fee schedule,6891.45,22111, Laparo New Ureter/Bladder,50947,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6891.45,22111, Laparo New Ureter/Bladder,50947,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6891.45,22111, Laparo New Ureter/Bladder,50947,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6891.45,22111, Laparo New Ureter/Bladder,50948,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6317.69,,,,,,,fee schedule,6317.69,22111, Laparo New Ureter/Bladder,50948,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6317.69,22111, Laparo New Ureter/Bladder,50948,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6317.69,22111, Laparo New Ureter/Bladder,50948,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6317.69,22111, Laparoscope proc ureter,50949,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,14456, Laparoscope proc ureter,50949,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,6044,14456, Laparoscope proc ureter,50949,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,6044,14456, Endoscopy of ureter,50951,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1504.78,,,,,,,fee schedule,1504.78,4497, Endoscopy of ureter,50951,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1504.78,4497, Endoscopy of ureter,50951,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,1504.78,4497, Endoscopy of ureter,50951,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,1504.78,4497, Endoscopy of ureter,50953,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1609.52,,,,,,,fee schedule,1609.52,5664, Endoscopy of ureter,50953,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1609.52,5664, Endoscopy of ureter,50953,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1609.52,5664, Endoscopy of ureter,50953,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1609.52,5664, Ureter endoscopy & biopsy,50955,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1733.14,,,,,,,fee schedule,1733.14,10940, Ureter endoscopy & biopsy,50955,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1733.14,10940, Ureter endoscopy & biopsy,50955,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1733.14,10940, Ureter endoscopy & biopsy,50955,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1733.14,10940, Ureter endoscopy & treatment,50957,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1742.04,,,,,,,fee schedule,1742.04,10940, Ureter endoscopy & treatment,50957,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1742.04,10940, Ureter endoscopy & treatment,50957,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1742.04,10940, Ureter endoscopy & treatment,50957,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1742.04,10940, Ureter endoscopy & treatment,50961,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1562.09,,,,,,,fee schedule,1562.09,10940, Ureter endoscopy & treatment,50961,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1562.09,10940, Ureter endoscopy & treatment,50961,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1562.09,10940, Ureter endoscopy & treatment,50961,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1562.09,10940, Ureter endoscopy,50970,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1820.34,,,,,,,fee schedule,1820.34,4497, Ureter endoscopy,50970,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1820.34,4497, Ureter endoscopy,50970,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,1820.34,4497, Ureter endoscopy,50970,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,1820.34,4497, Ureter endoscopy & catheter,50972,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1760.34,,,,,,,fee schedule,1760.34,4497, Ureter endoscopy & catheter,50972,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1760.34,4497, Ureter endoscopy & catheter,50972,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,1760.34,4497, Ureter endoscopy & catheter,50972,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,1760.34,4497, Ureter endoscopy & biopsy,50974,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2317.26,,,,,,,fee schedule,2317.26,5664, Ureter endoscopy & biopsy,50974,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2317.26,5664, Ureter endoscopy & biopsy,50974,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2317.26,5664, Ureter endoscopy & biopsy,50974,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2317.26,5664, Ureter endoscopy & treatment,50976,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2285.96,,,,,,,fee schedule,2285.96,5664, Ureter endoscopy & treatment,50976,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2285.96,5664, Ureter endoscopy & treatment,50976,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2285.96,5664, Ureter endoscopy & treatment,50976,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2285.96,5664, Ureter endoscopy & treatment,50980,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1748.68,,,,,,,fee schedule,1748.68,10940, Ureter endoscopy & treatment,50980,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1748.68,10940, Ureter endoscopy & treatment,50980,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1748.68,10940, Ureter endoscopy & treatment,50980,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1748.68,10940, Incise & treat bladder,51020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2402.89,,,,,,,fee schedule,2402.89,10940, Incise & treat bladder,51020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2402.89,10940, Incise & treat bladder,51020,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2402.89,10940, Incise & treat bladder,51020,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2402.89,10940, Incise & treat bladder,51030,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Incise & drain bladder,51040,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1497.66,,,,,,,fee schedule,1497.66,10940, Incise & drain bladder,51040,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,1497.66,10940, Incise & drain bladder,51040,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1497.66,10940, Incise & drain bladder,51040,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1497.66,10940, Incise bladder/drain ureter,51045,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2535.96,,,,,,,fee schedule,2535.96,5363, Incise bladder/drain ureter,51045,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2535.96,5363, Incise bladder/drain ureter,51045,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,2535.96,5363, Incise bladder/drain ureter,51045,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,2535.96,5363, Removal of bladder stone,51050,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2399.39,,,,,,,fee schedule,2399.39,10940, Removal of bladder stone,51050,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2399.39,10940, Removal of bladder stone,51050,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2399.39,10940, Removal of bladder stone,51050,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2399.39,10940, Removal of ureter stone,51060,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2950.1,,,,,,,fee schedule,2950.1,14456, Removal of ureter stone,51060,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2950.1,14456, Removal of ureter stone,51060,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,2950.1,14456, Removal of ureter stone,51060,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,2950.1,14456, Remove ureter calculus,51065,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2934.56,,,,,,,fee schedule,2934.56,10940, Remove ureter calculus,51065,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2934.56,10940, Remove ureter calculus,51065,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2934.56,10940, Remove ureter calculus,51065,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2934.56,10940, Drainage of bladder abscess,51080,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2088.58,,,,,,,fee schedule,2088.58,5664, Drainage of bladder abscess,51080,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2088.58,5664, Drainage of bladder abscess,51080,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2088.58,5664, Drainage of bladder abscess,51080,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2088.58,5664, Drain bladder by needle,51100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,188.91,,,,,,,fee schedule,188.91,3195, Drain bladder by needle,51100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,188.91,3195, Drain bladder by needle,51100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,188.91,3195, Drain bladder by needle,51100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,188.91,3195, Drain bladder by trocar/cath,51101,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,249.83,,,,,,,fee schedule,249.83,5664, Drain bladder by trocar/cath,51101,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,249.83,5664, Drain bladder by trocar/cath,51101,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,249.83,5664, Drain bladder by trocar/cath,51101,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,249.83,5664, Drain bl w/cath insertion,51102,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,702.99,,,,,,,fee schedule,702.99,10940, Drain bl w/cath insertion,51102,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,702.99,10940, Drain bl w/cath insertion,51102,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,702.99,10940, Drain bl w/cath insertion,51102,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,702.99,10940, Removal of bladder cyst,51500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3213.32,,,,,,,fee schedule,3213.32,12821, Removal of bladder cyst,51500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3213.32,12821, Removal of bladder cyst,51500,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3213.32,12821, Removal of bladder cyst,51500,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3213.32,12821, Removal of bladder lesion,51520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3014.58,,,,,,,fee schedule,3014.58,10940, Removal of bladder lesion,51520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3014.58,10940, Removal of bladder lesion,51520,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3014.58,10940, Removal of bladder lesion,51520,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3014.58,10940, Removal of bladder lesion,51525,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4305.14,,,,,,,fee schedule,4305.14,12821, Removal of bladder lesion,51525,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4305.14,12821, Removal of bladder lesion,51525,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4305.14,12821, Removal of bladder lesion,51525,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4305.14,12821, Removal of bladder lesion,51530,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3868.07,,,,,,,fee schedule,3868.07,12821, Removal of bladder lesion,51530,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3868.07,12821, Removal of bladder lesion,51530,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3868.07,12821, Removal of bladder lesion,51530,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3868.07,12821, Repair of ureter lesion,51535,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3912.8,,,,,,,fee schedule,3912.8,10940, Repair of ureter lesion,51535,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3912.8,10940, Repair of ureter lesion,51535,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3912.8,10940, Repair of ureter lesion,51535,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3912.8,10940, Partial removal of bladder,51550,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4874.04,,,,,,,fee schedule,4874.04,6979, Partial removal of bladder,51550,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4874.04,6979, Partial removal of bladder,51550,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4874.04,6979, Partial removal of bladder,51550,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4874.04,6979, Partial removal of bladder,51555,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6311.32,,,,,,,fee schedule,5097,6979, Partial removal of bladder,51555,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Partial removal of bladder,51555,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Partial removal of bladder,51555,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Revise bladder & ureter(s),51565,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6413.42,,,,,,,fee schedule,5097,6979, Revise bladder & ureter(s),51565,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Revise bladder & ureter(s),51565,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Revise bladder & ureter(s),51565,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Removal of bladder,51570,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7280.77,,,,,,,fee schedule,5097,7280.77, Removal of bladder,51570,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7280.77, Removal of bladder,51570,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7280.77, Removal of bladder,51570,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7280.77, Removal of bladder & nodes,51575,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8987.74,,,,,,,fee schedule,5097,8987.74, Removal of bladder & nodes,51575,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8987.74, Removal of bladder & nodes,51575,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8987.74, Removal of bladder & nodes,51575,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8987.74, Remove bladder/revise tract,51580,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9395.19,,,,,,,fee schedule,5097,9395.19, Remove bladder/revise tract,51580,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,9395.19, Remove bladder/revise tract,51580,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,9395.19, Remove bladder/revise tract,51580,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,9395.19, Removal of bladder & nodes,51585,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10434.03,,,,,,,fee schedule,5097,10434.03, Removal of bladder & nodes,51585,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,10434.03, Removal of bladder & nodes,51585,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,10434.03, Removal of bladder & nodes,51585,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,10434.03, Remove bladder/revise tract,51590,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9575.63,,,,,,,fee schedule,5097,9575.63, Remove bladder/revise tract,51590,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,9575.63, Remove bladder/revise tract,51590,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,9575.63, Remove bladder/revise tract,51590,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,9575.63, Remove bladder/revise tract,51595,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10822.43,,,,,,,fee schedule,5097,10822.43, Remove bladder/revise tract,51595,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,10822.43, Remove bladder/revise tract,51595,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,10822.43, Remove bladder/revise tract,51595,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,10822.43, Remove bladder/create pouch,51596,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,11675.43,,,,,,,fee schedule,5097,11675.43, Remove bladder/create pouch,51596,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,11675.43, Remove bladder/create pouch,51596,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,11675.43, Remove bladder/create pouch,51596,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,11675.43, Removal of pelvic structures,51597,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,11420.47,,,,,,,fee schedule,5097,11420.47, Removal of pelvic structures,51597,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,11420.47, Removal of pelvic structures,51597,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,11420.47, Removal of pelvic structures,51597,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,11420.47, Injection for bladder x-ray,51600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,208.66,,,,,,,fee schedule,208.66,2782, Injection for bladder x-ray,51600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,208.66,2782, Injection for bladder x-ray,51600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,208.66,2782, Preparation for bladder xray,51605,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,192.75,,,,,,,fee schedule,192.75,2782, Preparation for bladder xray,51605,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,192.75,2782, Preparation for bladder xray,51605,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,192.75,2782, Injection for bladder x-ray,51610,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,317.99,,,,,,,fee schedule,317.99,2782, Injection for bladder x-ray,51610,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,317.99,2782, Injection for bladder x-ray,51610,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,317.99,2782, Irrigation of bladder,51700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,145.96,,,,,,,fee schedule,145.96,3195, Irrigation of bladder,51700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,145.96,3195, Irrigation of bladder,51700,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,145.96,3195, Irrigation of bladder,51700,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,145.96,3195, Insert bladder catheter,51701,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,124.49,,,,,,,fee schedule,124.49,3195, Insert bladder catheter,51701,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,124.49,3195, Insert bladder catheter,51701,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,124.49,3195, Insert bladder catheter,51701,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,124.49,3195, Insert temp bladder cath,51702,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,127.94,,,,,,,fee schedule,127.94,3195, Insert temp bladder cath,51702,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,127.94,3195, Insert temp bladder cath,51702,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,127.94,3195, Insert temp bladder cath,51702,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,127.94,3195, Insert bladder cath complex,51703,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,378.1,,,,,,,fee schedule,378.1,3195, Insert bladder cath complex,51703,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,378.1,3195, Insert bladder cath complex,51703,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,378.1,3195, Insert bladder cath complex,51703,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,378.1,3195, Change of bladder tube,51705,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,261.76,,,,,,,fee schedule,261.76,3195, Change of bladder tube,51705,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,261.76,3195, Change of bladder tube,51705,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,261.76,3195, Change of bladder tube,51705,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,261.76,3195, Change of bladder tube,51710,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,404.59,,,,,,,fee schedule,404.59,4497, Change of bladder tube,51710,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,404.59,4497, Change of bladder tube,51710,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,404.59,4497, Change of bladder tube,51710,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,404.59,4497, Endoscopic injection/implant,51715,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,990.87,,,,,,,fee schedule,990.87,12821, Endoscopic injection/implant,51715,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,990.87,12821, Endoscopic injection/implant,51715,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,990.87,12821, Endoscopic injection/implant,51715,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,990.87,12821, Treatment of bladder lesion,51720,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,214.01,,,,,,,fee schedule,214.01,3195, Treatment of bladder lesion,51720,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,214.01,3195, Treatment of bladder lesion,51720,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,214.01,3195, Treatment of bladder lesion,51720,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,214.01,3195, Ins trurl ablt trnsdc thr us,51721,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1070.35,,,,,,,fee schedule,1070.35,5664, Ins trurl ablt trnsdc thr us,51721,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1070.35,5664, Ins trurl ablt trnsdc thr us,51721,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1070.35,5664, Ins trurl ablt trnsdc thr us,51721,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1070.35,5664, Simple cystometrogram,51725,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,632.57,,,,,,,fee schedule,632.57,3195, Simple cystometrogram,51725,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,632.57,3195, Simple cystometrogram,51725,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,632.57,3195, Simple cystometrogram,51725,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,632.57,3195, Complex cystometrogram,51726,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,965.13,,,,,,,fee schedule,965.13,3195, Complex cystometrogram,51726,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,965.13,3195, Complex cystometrogram,51726,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,965.13,3195, Complex cystometrogram,51726,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,965.13,3195, Cystometrogram w/up,51727,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1163.27,,,,,,,fee schedule,1163.27,4497, Cystometrogram w/up,51727,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1163.27,4497, Cystometrogram w/up,51727,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,1163.27,4497, Cystometrogram w/up,51727,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,1163.27,4497, Cystometrogram w/vp,51728,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1201.2,,,,,,,fee schedule,1201.2,4497, Cystometrogram w/vp,51728,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1201.2,4497, Cystometrogram w/vp,51728,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,1201.2,4497, Cystometrogram w/vp,51728,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,1201.2,4497, Cystometrogram w/vp&up,51729,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1179.78,,,,,,,fee schedule,1179.78,4497, Cystometrogram w/vp&up,51729,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1179.78,4497, Cystometrogram w/vp&up,51729,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,1179.78,4497, Cystometrogram w/vp&up,51729,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,1179.78,4497, Urine flow measurement,51736,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,32,,,,,,,fee schedule,32,6979, Urine flow measurement,51736,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,32,6979, Urine flow measurement,51736,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,32,6979, Urine flow measurement,51736,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,32,6979, Electro-uroflowmetry first,51741,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,35.45,,,,,,,fee schedule,35.45,6979, Electro-uroflowmetry first,51741,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,35.45,6979, Electro-uroflowmetry first,51741,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,35.45,6979, Electro-uroflowmetry first,51741,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,35.45,6979, Anal/urinary muscle study,51784,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,152.6,,,,,,,fee schedule,152.6,6979, Anal/urinary muscle study,51784,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,152.6,6979, Anal/urinary muscle study,51784,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,152.6,6979, Anal/urinary muscle study,51784,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,152.6,6979, Anal/urinary muscle study,51785,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1545.04,,,,,,,fee schedule,1545.04,3195, Anal/urinary muscle study,51785,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1545.04,3195, Anal/urinary muscle study,51785,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1545.04,3195, Anal/urinary muscle study,51785,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1545.04,3195, Urinary reflex study,51792,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,988.49,,,,,,,fee schedule,988.49,6979, Urinary reflex study,51792,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,988.49,6979, Urinary reflex study,51792,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,988.49,6979, Urinary reflex study,51792,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,988.49,6979, Intraabdominal pressure test,51797,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,596.15,,,,,,,fee schedule,596.15,3195, Intraabdominal pressure test,51797,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,596.15,3195, Intraabdominal pressure test,51797,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,596.15,3195, Intraabdominal pressure test,51797,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,596.15,3195, Us urine capacity measure,51798,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,67.45,,,,,,,fee schedule,67.45,6979, Us urine capacity measure,51798,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,67.45,6979, Us urine capacity measure,51798,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,67.45,6979, Us urine capacity measure,51798,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,67.45,6979, Revision of bladder/urethra,51800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5183.45,,,,,,,fee schedule,5097,8406, Revision of bladder/urethra,51800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,5097,8406, Revision of bladder/urethra,51800,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8406, Revision of bladder/urethra,51800,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8406, Revision of urinary tract,51820,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5424.44,,,,,,,fee schedule,5097,8406, Revision of urinary tract,51820,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,5097,8406, Revision of urinary tract,51820,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8406, Revision of urinary tract,51820,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8406, Attach bladder/urethra,51840,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3458.51,,,,,,,fee schedule,3458.51,10940, Attach bladder/urethra,51840,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,3458.51,10940, Attach bladder/urethra,51840,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3458.51,10940, Attach bladder/urethra,51840,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3458.51,10940, Attach bladder/urethra,51841,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3980.58,,,,,,,fee schedule,3980.58,10940, Attach bladder/urethra,51841,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,3980.58,10940, Attach bladder/urethra,51841,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3980.58,10940, Attach bladder/urethra,51841,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3980.58,10940, Repair bladder neck,51845,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2940.82,,,,,,,fee schedule,2940.82,14456, Repair bladder neck,51845,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,2940.82,14456, Repair bladder neck,51845,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,2940.82,14456, Repair bladder neck,51845,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,2940.82,14456, Repair of bladder wound,51860,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3812.06,,,,,,,fee schedule,3812.06,10940, Repair of bladder wound,51860,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3812.06,10940, Repair of bladder wound,51860,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3812.06,10940, Repair of bladder wound,51860,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3812.06,10940, Repair of bladder wound,51865,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4518.39,,,,,,,fee schedule,4518.39,12821, Repair of bladder wound,51865,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4518.39,12821, Repair of bladder wound,51865,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4518.39,12821, Repair of bladder wound,51865,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4518.39,12821, Repair of bladder opening,51880,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2386.06,,,,,,,fee schedule,2386.06,10940, Repair of bladder opening,51880,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2386.06,10940, Repair of bladder opening,51880,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2386.06,10940, Repair of bladder opening,51880,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2386.06,10940, Repair bladder/vagina lesion,51900,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4137.54,,,,,,,fee schedule,4137.54,12821, Repair bladder/vagina lesion,51900,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4137.54,12821, Repair bladder/vagina lesion,51900,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4137.54,12821, Repair bladder/vagina lesion,51900,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4137.54,12821, Close bladder-uterus fistula,51920,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3842.82,,,,,,,fee schedule,3842.82,10940, Close bladder-uterus fistula,51920,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3842.82,10940, Close bladder-uterus fistula,51920,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3842.82,10940, Close bladder-uterus fistula,51920,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3842.82,10940, Hysterectomy/bladder repair,51925,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5309.12,,,,,,,fee schedule,5097,6979, Hysterectomy/bladder repair,51925,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Hysterectomy/bladder repair,51925,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Hysterectomy/bladder repair,51925,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Correction of bladder defect,51940,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8132.37,,,,,,,fee schedule,5097,8132.37, Correction of bladder defect,51940,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8132.37, Correction of bladder defect,51940,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8132.37, Correction of bladder defect,51940,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8132.37, Revision of bladder & bowel,51960,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6890.26,,,,,,,fee schedule,5097,6979, Revision of bladder & bowel,51960,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Revision of bladder & bowel,51960,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Revision of bladder & bowel,51960,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Construct bladder opening,51980,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3589.47,,,,,,,fee schedule,3589.47,10940, Construct bladder opening,51980,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3589.47,10940, Construct bladder opening,51980,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3589.47,10940, Construct bladder opening,51980,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3589.47,10940, Laparo urethral suspension,51990,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3733.44,,,,,,,fee schedule,3733.44,22111, Laparo urethral suspension,51990,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,3733.44,22111, Laparo urethral suspension,51990,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3733.44,22111, Laparo urethral suspension,51990,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3733.44,22111, Laparo sling operation,51992,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4200.57,,,,,,,fee schedule,4200.57,22111, Laparo sling operation,51992,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4200.57,22111, Laparo sling operation,51992,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4200.57,22111, Laparo sling operation,51992,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4200.57,22111, Laparoscope proc bla,51999,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,14456, Laparoscope proc bla,51999,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5248,14456, Laparoscope proc bla,51999,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5248,14456, Cystoscopy,52000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,398.55,,,,,,,fee schedule,398.55,4497, Cystoscopy,52000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,398.55,4497, Cystoscopy,52000,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,398.55,4497, Cystoscopy,52000,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,398.55,4497, Cystoscopy removal of clots,52001,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1413.37,,,,,,,fee schedule,1413.37,5664, Cystoscopy removal of clots,52001,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1413.37,5664, Cystoscopy removal of clots,52001,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1413.37,5664, Cystoscopy removal of clots,52001,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1413.37,5664, Cystoscopy & ureter catheter,52005,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,663.76,,,,,,,fee schedule,663.76,10940, Cystoscopy & ureter catheter,52005,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,663.76,10940, Cystoscopy & ureter catheter,52005,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,663.76,10940, Cystoscopy & ureter catheter,52005,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,663.76,10940, Cystoscopy and biopsy,52007,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,826.02,,,,,,,fee schedule,826.02,10940, Cystoscopy and biopsy,52007,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,826.02,10940, Cystoscopy and biopsy,52007,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,826.02,10940, Cystoscopy and biopsy,52007,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,826.02,10940, Cystoscopy & duct catheter,52010,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,820.62,,,,,,,fee schedule,820.62,4497, Cystoscopy & duct catheter,52010,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,820.62,4497, Cystoscopy & duct catheter,52010,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,820.62,4497, Cystoscopy & duct catheter,52010,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,820.62,4497, Cystoscopy w/biopsy(s),52204,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,708.33,,,,,,,fee schedule,708.33,10940, Cystoscopy w/biopsy(s),52204,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,708.33,10940, Cystoscopy w/biopsy(s),52204,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,708.33,10940, Cystoscopy w/biopsy(s),52204,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,708.33,10940, Cystoscopy and treatment,52214,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,853.38,,,,,,,fee schedule,853.38,10940, Cystoscopy and treatment,52214,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,853.38,10940, Cystoscopy and treatment,52214,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,853.38,10940, Cystoscopy and treatment,52214,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,853.38,10940, Cystoscopy and treatment,52224,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,985.96,,,,,,,fee schedule,985.96,10940, Cystoscopy and treatment,52224,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,985.96,10940, Cystoscopy and treatment,52224,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,985.96,10940, Cystoscopy and treatment,52224,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,985.96,10940, Cystoscopy and treatment,52234,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1210.11,,,,,,,fee schedule,1210.11,10940, Cystoscopy and treatment,52234,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1210.11,10940, Cystoscopy and treatment,52234,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1210.11,10940, Cystoscopy and treatment,52234,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1210.11,10940, Cystoscopy and treatment,52235,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1422.01,,,,,,,fee schedule,1422.01,10940, Cystoscopy and treatment,52235,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1422.01,10940, Cystoscopy and treatment,52235,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1422.01,10940, Cystoscopy and treatment,52235,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1422.01,10940, Cystoscopy and treatment,52240,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1928.04,,,,,,,fee schedule,1928.04,10940, Cystoscopy and treatment,52240,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1928.04,10940, Cystoscopy and treatment,52240,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1928.04,10940, Cystoscopy and treatment,52240,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1928.04,10940, Cystoscopy and radiotracer,52250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1182.32,,,,,,,fee schedule,1182.32,10940, Cystoscopy and radiotracer,52250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,1182.32,10940, Cystoscopy and radiotracer,52250,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1182.32,10940, Cystoscopy and radiotracer,52250,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1182.32,10940, Cystoscopy and treatment,52260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1038.46,,,,,,,fee schedule,1038.46,5664, Cystoscopy and treatment,52260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1038.46,5664, Cystoscopy and treatment,52260,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1038.46,5664, Cystoscopy and treatment,52260,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1038.46,5664, Cystoscopy and treatment,52265,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,808.48,,,,,,,fee schedule,808.48,4497, Cystoscopy and treatment,52265,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,808.48,4497, Cystoscopy and treatment,52265,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,808.48,4497, Cystoscopy and treatment,52265,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,808.48,4497, Cystoscopy & revise urethra,52270,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,904.05,,,,,,,fee schedule,904.05,5664, Cystoscopy & revise urethra,52270,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,904.05,5664, Cystoscopy & revise urethra,52270,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,904.05,5664, Cystoscopy & revise urethra,52270,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,904.05,5664, Cystoscopy & revise urethra,52275,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1223.7,,,,,,,fee schedule,1223.7,10940, Cystoscopy & revise urethra,52275,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1223.7,10940, Cystoscopy & revise urethra,52275,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1223.7,10940, Cystoscopy & revise urethra,52275,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1223.7,10940, Cystoscopy and treatment,52276,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1304.11,,,,,,,fee schedule,1304.11,10940, Cystoscopy and treatment,52276,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1304.11,10940, Cystoscopy and treatment,52276,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1304.11,10940, Cystoscopy and treatment,52276,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1304.11,10940, Cystoscopy and treatment,52277,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1597,,,,,,,fee schedule,1597,10940, Cystoscopy and treatment,52277,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1597,10940, Cystoscopy and treatment,52277,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1597,10940, Cystoscopy and treatment,52277,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1597,10940, Cystoscopy and treatment,52281,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,761.43,,,,,,,fee schedule,761.43,5664, Cystoscopy and treatment,52281,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,761.43,5664, Cystoscopy and treatment,52281,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,761.43,5664, Cystoscopy and treatment,52281,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,761.43,5664, Cystoscopy implant stent,52282,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1664.94,,,,,,,fee schedule,1664.94,10940, Cystoscopy implant stent,52282,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1664.94,10940, Cystoscopy implant stent,52282,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1664.94,10940, Cystoscopy implant stent,52282,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1664.94,10940, Cystoscopy and treatment,52283,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,997.02,,,,,,,fee schedule,997.02,10940, Cystoscopy and treatment,52283,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,997.02,10940, Cystoscopy and treatment,52283,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,997.02,10940, Cystoscopy and treatment,52283,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,997.02,10940, Cysto rx balo cath urtl strx,52284,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,815.34,,,,,,,fee schedule,815.34,10940, Cysto rx balo cath urtl strx,52284,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,815.34,10940, Cysto rx balo cath urtl strx,52284,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,815.34,10940, Cysto rx balo cath urtl strx,52284,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,815.34,10940, Cystoscopy and treatment,52285,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,970.36,,,,,,,fee schedule,970.36,5664, Cystoscopy and treatment,52285,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,970.36,5664, Cystoscopy and treatment,52285,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,970.36,5664, Cystoscopy and treatment,52285,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,970.36,5664, Cystoscopy chemodenervation,52287,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,835.57,,,,,,,fee schedule,835.57,5664, Cystoscopy chemodenervation,52287,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,835.57,5664, Cystoscopy chemodenervation,52287,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,835.57,5664, Cystoscopy chemodenervation,52287,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,835.57,5664, Cystoscopy and treatment,52290,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1202.98,,,,,,,fee schedule,1202.98,10940, Cystoscopy and treatment,52290,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1202.98,10940, Cystoscopy and treatment,52290,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1202.98,10940, Cystoscopy and treatment,52290,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1202.98,10940, Cystoscopy and treatment,52300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1381.11,,,,,,,fee schedule,1381.11,10940, Cystoscopy and treatment,52300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1381.11,10940, Cystoscopy and treatment,52300,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1381.11,10940, Cystoscopy and treatment,52300,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1381.11,10940, Cystoscopy and treatment,52301,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1425.95,,,,,,,fee schedule,1425.95,10940, Cystoscopy and treatment,52301,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1425.95,10940, Cystoscopy and treatment,52301,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1425.95,10940, Cystoscopy and treatment,52301,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1425.95,10940, Cystoscopy and treatment,52305,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1369.02,,,,,,,fee schedule,1369.02,10940, Cystoscopy and treatment,52305,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1369.02,10940, Cystoscopy and treatment,52305,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1369.02,10940, Cystoscopy and treatment,52305,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1369.02,10940, Cystoscopy and treatment,52310,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,751.61,,,,,,,fee schedule,751.61,5664, Cystoscopy and treatment,52310,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,751.61,5664, Cystoscopy and treatment,52310,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,751.61,5664, Cystoscopy and treatment,52310,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,751.61,5664, Cystoscopy and treatment,52315,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1357.15,,,,,,,fee schedule,1357.15,10940, Cystoscopy and treatment,52315,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1357.15,10940, Cystoscopy and treatment,52315,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1357.15,10940, Cystoscopy and treatment,52315,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1357.15,10940, Remove bladder stone,52317,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1705.3,,,,,,,fee schedule,1705.3,10940, Remove bladder stone,52317,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1705.3,10940, Remove bladder stone,52317,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1705.3,10940, Remove bladder stone,52317,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1705.3,10940, Remove bladder stone,52318,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2321.84,,,,,,,fee schedule,2321.84,10940, Remove bladder stone,52318,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2321.84,10940, Remove bladder stone,52318,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2321.84,10940, Remove bladder stone,52318,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2321.84,10940, Cystoscopy and treatment,52320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1209.95,,,,,,,fee schedule,1209.95,10940, Cystoscopy and treatment,52320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,1209.95,10940, Cystoscopy and treatment,52320,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1209.95,10940, Cystoscopy and treatment,52320,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1209.95,10940, Cystoscopy stone removal,52325,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1576.98,,,,,,,fee schedule,1576.98,10940, Cystoscopy stone removal,52325,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,1576.98,10940, Cystoscopy stone removal,52325,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1576.98,10940, Cystoscopy stone removal,52325,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1576.98,10940, Cystoscopy inject material,52327,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1264.44,,,,,,,fee schedule,1264.44,14456, Cystoscopy inject material,52327,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1264.44,14456, Cystoscopy inject material,52327,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,1264.44,14456, Cystoscopy inject material,52327,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,1264.44,14456, Cystoscopy and treatment,52330,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1292.29,,,,,,,fee schedule,1292.29,10940, Cystoscopy and treatment,52330,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1292.29,10940, Cystoscopy and treatment,52330,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1292.29,10940, Cystoscopy and treatment,52330,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1292.29,10940, Cystoscopy and treatment,52332,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,777.51,,,,,,,fee schedule,777.51,10940, Cystoscopy and treatment,52332,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,777.51,10940, Cystoscopy and treatment,52332,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,777.51,10940, Cystoscopy and treatment,52332,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,777.51,10940, Create passage to kidney,52334,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,911.06,,,,,,,fee schedule,911.06,10940, Create passage to kidney,52334,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,911.06,10940, Create passage to kidney,52334,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,911.06,10940, Create passage to kidney,52334,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,911.06,10940, Cysto W/Ureter Stricture Tx,52341,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1398.7,,,,,,,fee schedule,1398.7,10940, Cysto W/Ureter Stricture Tx,52341,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1398.7,10940, Cysto W/Ureter Stricture Tx,52341,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1398.7,10940, Cysto W/Ureter Stricture Tx,52341,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1398.7,10940, Cysto W/Up Stricture Tx,52342,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1521.4,,,,,,,fee schedule,1521.4,10940, Cysto W/Up Stricture Tx,52342,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1521.4,10940, Cysto W/Up Stricture Tx,52342,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1521.4,10940, Cysto W/Up Stricture Tx,52342,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1521.4,10940, Cysto W/Renal Stricture Tx,52343,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1692.56,,,,,,,fee schedule,1692.56,10940, Cysto W/Renal Stricture Tx,52343,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1692.56,10940, Cysto W/Renal Stricture Tx,52343,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1692.56,10940, Cysto W/Renal Stricture Tx,52343,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1692.56,10940, Cysto/uretero stricture tx,52344,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1817,,,,,,,fee schedule,1817,10940, Cysto/uretero stricture tx,52344,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1817,10940, Cysto/uretero stricture tx,52344,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1817,10940, Cysto/uretero stricture tx,52344,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1817,10940, Cysto/Uretero W/Up Stricture,52345,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1938.78,,,,,,,fee schedule,1938.78,10940, Cysto/Uretero W/Up Stricture,52345,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1938.78,10940, Cysto/Uretero W/Up Stricture,52345,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1938.78,10940, Cysto/Uretero W/Up Stricture,52345,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1938.78,10940, Cystouretero W/Renal Strict,52346,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2192.23,,,,,,,fee schedule,2192.23,10940, Cystouretero W/Renal Strict,52346,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2192.23,10940, Cystouretero W/Renal Strict,52346,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2192.23,10940, Cystouretero W/Renal Strict,52346,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2192.23,10940, Cystouretero & or pyeloscope,52351,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1489.46,,,,,,,fee schedule,1489.46,10940, Cystouretero & or pyeloscope,52351,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1489.46,10940, Cystouretero & or pyeloscope,52351,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1489.46,10940, Cystouretero & or pyeloscope,52351,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1489.46,10940, Cystouretero w/stone remove,52352,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1743.56,,,,,,,fee schedule,1743.56,10940, Cystouretero w/stone remove,52352,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,1743.56,10940, Cystouretero w/stone remove,52352,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1743.56,10940, Cystouretero w/stone remove,52352,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1743.56,10940, Cystouretero W/Lithotripsy,52353,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1922.65,,,,,,,fee schedule,1922.65,14456, Cystouretero W/Lithotripsy,52353,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,1922.65,14456, Cystouretero W/Lithotripsy,52353,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,1922.65,14456, Cystouretero W/Lithotripsy,52353,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,1922.65,14456, Cystouretero W/Biopsy,52354,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2052.53,,,,,,,fee schedule,2052.53,10940, Cystouretero W/Biopsy,52354,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2052.53,10940, Cystouretero W/Biopsy,52354,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2052.53,10940, Cystouretero W/Biopsy,52354,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2052.53,10940, Cystouretero W/Excise Tumor,52355,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2295.19,,,,,,,fee schedule,2295.19,10940, Cystouretero W/Excise Tumor,52355,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2295.19,10940, Cystouretero W/Excise Tumor,52355,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2295.19,10940, Cystouretero W/Excise Tumor,52355,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2295.19,10940, Cysto/uretero w/lithotripsy,52356,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2045.68,,,,,,,fee schedule,2045.68,14456, Cysto/uretero w/lithotripsy,52356,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2045.68,14456, Cysto/uretero w/lithotripsy,52356,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,2045.68,14456, Cysto/uretero w/lithotripsy,52356,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,2045.68,14456, Cystouretero W/Congen Repr,52400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2383.52,,,,,,,fee schedule,2383.52,10940, Cystouretero W/Congen Repr,52400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2383.52,10940, Cystouretero W/Congen Repr,52400,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2383.52,10940, Cystouretero W/Congen Repr,52400,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2383.52,10940, Cystourethro cut ejacul duct,52402,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1295.42,,,,,,,fee schedule,1295.42,10940, Cystourethro cut ejacul duct,52402,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1295.42,10940, Cystourethro cut ejacul duct,52402,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1295.42,10940, Cystourethro cut ejacul duct,52402,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1295.42,10940, Cystourethro w/implant,52441,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1027.61,,,,,,,fee schedule,1027.61,5248, Cystourethro w/implant,52441,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1027.61,5248, Cystourethro w/implant,52441,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1027.61,5248, Cystourethro w/implant,52441,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1027.61,5248, Cystourethro w/addl implant,52442,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,248,,,,,,,fee schedule,248,3195, Cystourethro w/addl implant,52442,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,248,3195, Cystourethro w/addl implant,52442,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,248,3195, Cystourethro w/addl implant,52442,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,248,3195, Cysto 1st trurl prst8 comis,52443,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,963.13,,,,,,,fee schedule,963.13,6979, Cysto 1st trurl prst8 comis,52443,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,963.13,6979, Incision of prostate,52450,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2416.65,,,,,,,fee schedule,2416.65,10940, Incision of prostate,52450,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2416.65,10940, Incision of prostate,52450,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2416.65,10940, Incision of prostate,52450,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2416.65,10940, Revision of bladder neck,52500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1939.11,,,,,,,fee schedule,1939.11,10940, Revision of bladder neck,52500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1939.11,10940, Revision of bladder neck,52500,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1939.11,10940, Revision of bladder neck,52500,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1939.11,10940, Trurl rbtc wtrjt rescj prst8,52597,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3040.59,,,,,,,fee schedule,3040.59,6979, Trurl rbtc wtrjt rescj prst8,52597,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3040.59,6979, Prostatectomy (TURP),52601,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2915.3,,,,,,,fee schedule,2915.3,14456, Prostatectomy (TURP),52601,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2915.3,14456, Prostatectomy (TURP),52601,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,2915.3,14456, Prostatectomy (TURP),52601,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,2915.3,14456, Remove prostate regrowth,52630,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2072.6,,,,,,,fee schedule,2072.6,14456, Remove prostate regrowth,52630,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2072.6,14456, Remove prostate regrowth,52630,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,2072.6,14456, Remove prostate regrowth,52630,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,2072.6,14456, Relieve bladder contracture,52640,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1654.52,,,,,,,fee schedule,1654.52,10940, Relieve bladder contracture,52640,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1654.52,10940, Relieve bladder contracture,52640,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1654.52,10940, Relieve bladder contracture,52640,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1654.52,10940, Laser surgery of prostate,52647,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,14456, Laser surgery of prostate,52647,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,6044,14456, Laser surgery of prostate,52647,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,6044,14456, Laser surgery of prostate,52648,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2928.73,,,,,,,fee schedule,2928.73,14456, Laser surgery of prostate,52648,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,2928.73,14456, Laser surgery of prostate,52648,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,2928.73,14456, Laser surgery of prostate,52648,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,2928.73,14456, Prostate laser enucleation,52649,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3650.39,,,,,,,fee schedule,3650.39,14456, Prostate laser enucleation,52649,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,3650.39,14456, Prostate laser enucleation,52649,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3650.39,14456, Prostate laser enucleation,52649,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3650.39,14456, Drainage of prostate abscess,52700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2241.34,,,,,,,fee schedule,2241.34,10940, Drainage of prostate abscess,52700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2241.34,10940, Drainage of prostate abscess,52700,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2241.34,10940, Drainage of prostate abscess,52700,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2241.34,10940, Incision of urethra,53000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,760.67,,,,,,,fee schedule,760.67,10940, Incision of urethra,53000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,760.67,10940, Incision of urethra,53000,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,760.67,10940, Incision of urethra,53000,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,760.67,10940, Incision of urethra,53010,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1541.37,,,,,,,fee schedule,1541.37,10940, Incision of urethra,53010,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1541.37,10940, Incision of urethra,53010,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1541.37,10940, Incision of urethra,53010,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1541.37,10940, Incision of urethra,53020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,478.95,,,,,,,fee schedule,478.95,10940, Incision of urethra,53020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,478.95,10940, Incision of urethra,53020,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,478.95,10940, Incision of urethra,53020,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,478.95,10940, Incision of urethra,53025,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,346.48,,,,,,,fee schedule,346.48,10940, Incision of urethra,53025,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,346.48,10940, Incision of urethra,53025,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,346.48,10940, Incision of urethra,53025,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,346.48,10940, Drainage of urethra abscess,53040,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2001,,,,,,,fee schedule,2001,10940, Drainage of urethra abscess,53040,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2001,10940, Drainage of urethra abscess,53040,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2001,10940, Drainage of urethra abscess,53040,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2001,10940, Drainage of urethra abscess,53060,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,833.52,,,,,,,fee schedule,833.52,10940, Drainage of urethra abscess,53060,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,833.52,10940, Drainage of urethra abscess,53060,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,833.52,10940, Drainage of urethra abscess,53060,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,833.52,10940, Drainage of urinary leakage,53080,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2148.31,,,,,,,fee schedule,2148.31,10940, Drainage of urinary leakage,53080,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2148.31,10940, Drainage of urinary leakage,53080,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2148.31,10940, Drainage of urinary leakage,53080,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2148.31,10940, Drainage of urinary leakage,53085,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3272.46,,,,,,,fee schedule,3272.46,10940, Drainage of urinary leakage,53085,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3272.46,10940, Drainage of urinary leakage,53085,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3272.46,10940, Drainage of urinary leakage,53085,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3272.46,10940, Biopsy of urethra,53200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,717.45,,,,,,,fee schedule,717.45,10940, Biopsy of urethra,53200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,717.45,10940, Biopsy of urethra,53200,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,717.45,10940, Biopsy of urethra,53200,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,717.45,10940, Removal of urethra,53210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3864.72,,,,,,,fee schedule,3864.72,12821, Removal of urethra,53210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,3864.72,12821, Removal of urethra,53210,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3864.72,12821, Removal of urethra,53210,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3864.72,12821, Removal of urethra,53215,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4635.76,,,,,,,fee schedule,4635.76,10940, Removal of urethra,53215,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4635.76,10940, Removal of urethra,53215,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,4635.76,10940, Removal of urethra,53215,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,4635.76,10940, Treatment of urethra lesion,53220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2298.8,,,,,,,fee schedule,2298.8,12821, Treatment of urethra lesion,53220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2298.8,12821, Treatment of urethra lesion,53220,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2298.8,12821, Treatment of urethra lesion,53220,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2298.8,12821, Removal of urethra lesion,53230,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3084.14,,,,,,,fee schedule,3084.14,12821, Removal of urethra lesion,53230,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3084.14,12821, Removal of urethra lesion,53230,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3084.14,12821, Removal of urethra lesion,53230,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3084.14,12821, Removal of urethra lesion,53235,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3198.16,,,,,,,fee schedule,3198.16,10940, Removal of urethra lesion,53235,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3198.16,10940, Removal of urethra lesion,53235,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3198.16,10940, Removal of urethra lesion,53235,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3198.16,10940, Surgery for urethra pouch,53240,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2165.25,,,,,,,fee schedule,2165.25,12821, Surgery for urethra pouch,53240,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2165.25,12821, Surgery for urethra pouch,53240,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2165.25,12821, Surgery for urethra pouch,53240,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2165.25,12821, Removal of urethra gland,53250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2026.58,,,,,,,fee schedule,2026.58,10940, Removal of urethra gland,53250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2026.58,10940, Removal of urethra gland,53250,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2026.58,10940, Removal of urethra gland,53250,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2026.58,10940, Treatment of urethra lesion,53260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,920.4,,,,,,,fee schedule,920.4,10940, Treatment of urethra lesion,53260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,920.4,10940, Treatment of urethra lesion,53260,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,920.4,10940, Treatment of urethra lesion,53260,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,920.4,10940, Treatment of urethra lesion,53265,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,948.56,,,,,,,fee schedule,948.56,10940, Treatment of urethra lesion,53265,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,948.56,10940, Treatment of urethra lesion,53265,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,948.56,10940, Treatment of urethra lesion,53265,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,948.56,10940, Removal of urethra gland,53270,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,937.29,,,,,,,fee schedule,937.29,10940, Removal of urethra gland,53270,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,937.29,10940, Removal of urethra gland,53270,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,937.29,10940, Removal of urethra gland,53270,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,937.29,10940, Repair of urethra defect,53275,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1326.71,,,,,,,fee schedule,1326.71,10940, Repair of urethra defect,53275,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1326.71,10940, Repair of urethra defect,53275,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1326.71,10940, Repair of urethra defect,53275,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1326.71,10940, Revise urethra stage 1,53400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4023.47,,,,,,,fee schedule,4023.47,12821, Revise urethra stage 1,53400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4023.47,12821, Revise urethra stage 1,53400,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4023.47,12821, Revise urethra stage 1,53400,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4023.47,12821, Revise urethra stage 2,53405,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4375.45,,,,,,,fee schedule,4108,12821, Revise urethra stage 2,53405,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,12821, Revise urethra stage 2,53405,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4108,12821, Revise urethra stage 2,53405,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4108,12821, Reconstruction of urethra,53410,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4892.28,,,,,,,fee schedule,4108,12821, Reconstruction of urethra,53410,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,12821, Reconstruction of urethra,53410,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4108,12821, Reconstruction of urethra,53410,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4108,12821, Reconstruction of urethra,53415,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5634.61,,,,,,,fee schedule,5634.61,14456, Reconstruction of urethra,53415,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5634.61,14456, Reconstruction of urethra,53415,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5634.61,14456, Reconstruction of urethra,53415,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5634.61,14456, Reconstruct urethra stage 1,53420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4213.36,,,,,,,fee schedule,4213.36,12821, Reconstruct urethra stage 1,53420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4213.36,12821, Reconstruct urethra stage 1,53420,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4213.36,12821, Reconstruct urethra stage 1,53420,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4213.36,12821, Reconstruct urethra stage 2,53425,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4674.61,,,,,,,fee schedule,4108,12821, Reconstruct urethra stage 2,53425,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,12821, Reconstruct urethra stage 2,53425,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4108,12821, Reconstruct urethra stage 2,53425,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4108,12821, Reconstruction of urethra,53430,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4879.23,,,,,,,fee schedule,4108,12821, Reconstruction of urethra,53430,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,12821, Reconstruction of urethra,53430,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4108,12821, Reconstruction of urethra,53430,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4108,12821, Reconstruct urethra/bladder,53431,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5740.48,,,,,,,fee schedule,4108,12821, Reconstruct urethra/bladder,53431,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,12821, Reconstruct urethra/bladder,53431,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4108,12821, Reconstruct urethra/bladder,53431,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4108,12821, Male sling procedure,53440,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3782.92,,,,,,,fee schedule,3782.92,25393, Male sling procedure,53440,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3782.92,25393, Male sling procedure,53440,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,3782.92,25393, Male sling procedure,53440,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,3782.92,25393, Remove/revise male sling,53442,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3966.76,,,,,,,fee schedule,3195,12821, Remove/revise male sling,53442,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,12821, Remove/revise male sling,53442,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3195,12821, Remove/revise male sling,53442,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3195,12821, Insert tandem cuff,53444,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3981.82,,,,,,,fee schedule,3981.82,25393, Insert tandem cuff,53444,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3981.82,25393, Insert tandem cuff,53444,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,3981.82,25393, Insert tandem cuff,53444,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,3981.82,25393, Insert uro/ves nck sphincter,53445,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3817.56,,,,,,,fee schedule,3195,34630, Insert uro/ves nck sphincter,53445,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,34630, Insert uro/ves nck sphincter,53445,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,34630,,,,,,,fee schedule,3195,34630, Insert uro/ves nck sphincter,53445,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,31168,,,,,,,fee schedule,3195,34630, Remove uro sphincter,53446,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3249.31,,,,,,,fee schedule,3195,22111, Remove uro sphincter,53446,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,22111, Remove uro sphincter,53446,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3195,22111, Remove uro sphincter,53446,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3195,22111, Remove/replace ur sphincter,53447,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4055.8,,,,,,,fee schedule,3195,34630, Remove/replace ur sphincter,53447,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,34630, Remove/replace ur sphincter,53447,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,34630,,,,,,,fee schedule,3195,34630, Remove/replace ur sphincter,53447,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,31168,,,,,,,fee schedule,3195,34630, Remov/replc ur sphinctr comp,53448,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6367.17,,,,,,,fee schedule,4047,6979, Remov/replc ur sphinctr comp,53448,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4047,6979, Remov/replc ur sphinctr comp,53448,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,4047,6979, Remov/replc ur sphinctr comp,53448,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,4047,6979, Repair uro sphincter,53449,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3098.87,,,,,,,fee schedule,3098.87,12821, Repair uro sphincter,53449,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3098.87,12821, Repair uro sphincter,53449,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3098.87,12821, Repair uro sphincter,53449,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3098.87,12821, Revision of urethra,53450,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2092.73,,,,,,,fee schedule,2092.73,12821, Revision of urethra,53450,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2092.73,12821, Revision of urethra,53450,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2092.73,12821, Revision of urethra,53450,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2092.73,12821, Tprnl balo cntnc dev bi,53451,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,25393, Tprnl balo cntnc dev bi,53451,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,5363,25393, Tprnl balo cntnc dev bi,53451,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,5363,25393, Tprnl balo cntnc dev uni,53452,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,10940, Tprnl balo cntnc dev uni,53452,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,5248,10940, Tprnl balo cntnc dev uni,53452,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,5248,10940, Tprnl balo cntnc dev rmvl ea,53453,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,10940, Tprnl balo cntnc dev rmvl ea,53453,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,4108,10940, Tprnl balo cntnc dev rmvl ea,53453,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,4108,10940, Tprnl balo cntnc dev adjmt,53454,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Tprnl balo cntnc dev adjmt,53454,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Tprnl balo cntnc dev adjmt,53454,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Revision of urethra,53460,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2331.99,,,,,,,fee schedule,2331.99,10940, Revision of urethra,53460,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2331.99,10940, Revision of urethra,53460,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2331.99,10940, Revision of urethra,53460,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2331.99,10940, Urethrlys transvag w/ scope,53500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3760.96,,,,,,,fee schedule,3760.96,12821, Urethrlys transvag w/ scope,53500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,3760.96,12821, Urethrlys transvag w/ scope,53500,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3760.96,12821, Urethrlys transvag w/ scope,53500,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3760.96,12821, Repair of urethra injury,53502,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2472.72,,,,,,,fee schedule,2472.72,10940, Repair of urethra injury,53502,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2472.72,10940, Repair of urethra injury,53502,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2472.72,10940, Repair of urethra injury,53502,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2472.72,10940, Repair of urethra injury,53505,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2471.04,,,,,,,fee schedule,2471.04,12821, Repair of urethra injury,53505,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2471.04,12821, Repair of urethra injury,53505,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2471.04,12821, Repair of urethra injury,53505,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2471.04,12821, Repair of urethra injury,53510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3191.03,,,,,,,fee schedule,3191.03,10940, Repair of urethra injury,53510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3191.03,10940, Repair of urethra injury,53510,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3191.03,10940, Repair of urethra injury,53510,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3191.03,10940, Repair of urethra injury,53515,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3987.16,,,,,,,fee schedule,3987.16,12821, Repair of urethra injury,53515,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3987.16,12821, Repair of urethra injury,53515,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3987.16,12821, Repair of urethra injury,53515,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3987.16,12821, Repair of urethra defect,53520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2834.68,,,,,,,fee schedule,2834.68,12821, Repair of urethra defect,53520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2834.68,12821, Repair of urethra defect,53520,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2834.68,12821, Repair of urethra defect,53520,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2834.68,12821, Dilate urethra stricture,53600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,313.62,,,,,,,fee schedule,313.62,3195, Dilate urethra stricture,53600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,313.62,3195, Dilate urethra stricture,53600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,313.62,3195, Dilate urethra stricture,53600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,313.62,3195, Dilate urethra stricture,53601,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,265.81,,,,,,,fee schedule,265.81,3195, Dilate urethra stricture,53601,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,265.81,3195, Dilate urethra stricture,53601,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,265.81,3195, Dilate urethra stricture,53601,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,265.81,3195, Dilate urethra stricture,53605,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,313.45,,,,,,,fee schedule,313.45,5664, Dilate urethra stricture,53605,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,313.45,5664, Dilate urethra stricture,53605,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,313.45,5664, Dilate urethra stricture,53605,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,313.45,5664, Dilate urethra stricture,53620,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,430.28,,,,,,,fee schedule,430.28,4497, Dilate urethra stricture,53620,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,430.28,4497, Dilate urethra stricture,53620,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,430.28,4497, Dilate urethra stricture,53620,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,430.28,4497, Dilate urethra stricture,53621,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,356.3,,,,,,,fee schedule,356.3,3195, Dilate urethra stricture,53621,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,356.3,3195, Dilate urethra stricture,53621,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,356.3,3195, Dilate urethra stricture,53621,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,356.3,3195, Description Not Available,53640,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Dilation of urethra,53660,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,206.34,,,,,,,fee schedule,206.34,3195, Dilation of urethra,53660,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,206.34,3195, Dilation of urethra,53660,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,206.34,3195, Dilation of urethra,53660,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,206.34,3195, Dilation of urethra,53661,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,199.54,,,,,,,fee schedule,199.54,6979, Dilation of urethra,53661,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,199.54,6979, Dilation of urethra,53661,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,199.54,6979, Dilation of urethra,53661,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,199.54,6979, Dilation of urethra,53665,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,185.3,,,,,,,fee schedule,185.3,10940, Dilation of urethra,53665,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,185.3,10940, Dilation of urethra,53665,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,185.3,10940, Dilation of urethra,53665,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,185.3,10940, Prostatic microwave thermotx,53850,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1815.43,,,,,,,fee schedule,1815.43,10675, Prostatic microwave thermotx,53850,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10675,,,,,,,fee schedule,1815.43,10675, Prostatic microwave thermotx,53850,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1815.43,10675, Prostatic microwave thermotx,53850,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1815.43,10675, Prostatic rf thermotx,53852,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1944.45,,,,,,,fee schedule,1944.45,14456, Prostatic rf thermotx,53852,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1944.45,14456, Prostatic rf thermotx,53852,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,1944.45,14456, Prostatic rf thermotx,53852,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,1944.45,14456, Trurl dstrj prst8 tiss rf wv,53854,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1946.18,,,,,,,fee schedule,1946.18,10940, Trurl dstrj prst8 tiss rf wv,53854,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1946.18,10940, Trurl dstrj prst8 tiss rf wv,53854,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1946.18,10940, Trurl dstrj prst8 tiss rf wv,53854,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1946.18,10940, Insert prost urethral stent,53855,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,403.84,,,,,,,fee schedule,403.84,4497, Insert prost urethral stent,53855,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,403.84,4497, Insert prost urethral stent,53855,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,403.84,4497, Insert prost urethral stent,53855,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,403.84,4497, Transurethral rf treatment,53860,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1118.7,,,,,,,fee schedule,1118.7,5664, Transurethral rf treatment,53860,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1118.7,5664, Transurethral rf treatment,53860,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1118.7,5664, Transurethral rf treatment,53860,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1118.7,5664, Cysto insj dev ischmc rmdlg,53865,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,813.61,,,,,,,fee schedule,813.61,10940, Cysto insj dev ischmc rmdlg,53865,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,813.61,10940, Cysto insj dev ischmc rmdlg,53865,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,813.61,10940, Cysto insj dev ischmc rmdlg,53865,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,813.61,10940, Cathj rmvl dev ischmc rmdlg,53866,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,410.96,,,,,,,fee schedule,410.96,3195, Cathj rmvl dev ischmc rmdlg,53866,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,410.96,3195, Cathj rmvl dev ischmc rmdlg,53866,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,410.96,3195, Cathj rmvl dev ischmc rmdlg,53866,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,410.96,3195, Urology surgery procedure,53899,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Urology surgery procedure,53899,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Urology surgery procedure,53899,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Slitting of prepuce,54000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,573.06,,,,,,,fee schedule,573.06,10940, Slitting of prepuce,54000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,573.06,10940, Slitting of prepuce,54000,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,573.06,10940, Slitting of prepuce,54000,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,573.06,10940, Slitting of prepuce,54001,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,712.43,,,,,,,fee schedule,712.43,10940, Slitting of prepuce,54001,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,712.43,10940, Slitting of prepuce,54001,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,712.43,10940, Slitting of prepuce,54001,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,712.43,10940, Drain penis lesion,54015,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1536.62,,,,,,,fee schedule,1536.62,5664, Drain penis lesion,54015,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,1536.62,5664, Drain penis lesion,54015,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1536.62,5664, Drain penis lesion,54015,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1536.62,5664, Destruction penis lesion(s),54050,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,523.47,,,,,,,fee schedule,523.47,6979, Destruction penis lesion(s),54050,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,523.47,6979, Destruction penis lesion(s),54050,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,523.47,6979, Destruction penis lesion(s),54050,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,523.47,6979, Destruction penis lesion(s),54055,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,471.45,,,,,,,fee schedule,471.45,6979, Destruction penis lesion(s),54055,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,471.45,6979, Destruction penis lesion(s),54055,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,471.45,6979, Destruction penis lesion(s),54055,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,471.45,6979, Cryosurgery penis lesion(s),54056,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,534.53,,,,,,,fee schedule,534.53,6979, Cryosurgery penis lesion(s),54056,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,534.53,6979, Cryosurgery penis lesion(s),54056,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,534.53,6979, Cryosurgery penis lesion(s),54056,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,534.53,6979, Laser surg penis lesion(s),54057,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,496.16,,,,,,,fee schedule,496.16,5664, Laser surg penis lesion(s),54057,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,496.16,5664, Laser surg penis lesion(s),54057,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,496.16,5664, Laser surg penis lesion(s),54057,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,496.16,5664, Excision of penis lesion(s),54060,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,671.32,,,,,,,fee schedule,671.32,5664, Excision of penis lesion(s),54060,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,671.32,5664, Excision of penis lesion(s),54060,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,671.32,5664, Excision of penis lesion(s),54060,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,671.32,5664, Destruction penis lesion(s),54065,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,820.84,,,,,,,fee schedule,820.84,5664, Destruction penis lesion(s),54065,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,820.84,5664, Destruction penis lesion(s),54065,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,820.84,5664, Destruction penis lesion(s),54065,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,820.84,5664, Biopsy of penis,54100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,570.25,,,,,,,fee schedule,570.25,5664, Biopsy of penis,54100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,570.25,5664, Biopsy of penis,54100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,570.25,5664, Biopsy of penis,54100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,570.25,5664, Biopsy of penis,54105,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1078.71,,,,,,,fee schedule,1078.71,10940, Biopsy of penis,54105,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1078.71,10940, Biopsy of penis,54105,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1078.71,10940, Biopsy of penis,54105,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1078.71,10940, Treatment of penis lesion,54110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3151.1,,,,,,,fee schedule,3151.1,14456, Treatment of penis lesion,54110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3151.1,14456, Treatment of penis lesion,54110,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3151.1,14456, Treatment of penis lesion,54110,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3151.1,14456, Treat penis lesion graft,54111,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4005.5,,,,,,,fee schedule,4005.5,14456, Treat penis lesion graft,54111,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4005.5,14456, Treat penis lesion graft,54111,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4005.5,14456, Treat penis lesion graft,54111,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4005.5,14456, Treat penis lesion graft,54112,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4691.93,,,,,,,fee schedule,4108,14456, Treat penis lesion graft,54112,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,14456, Treat penis lesion graft,54112,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4108,14456, Treat penis lesion graft,54112,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4108,14456, Treatment of penis lesion,54115,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2184.03,,,,,,,fee schedule,2184.03,10940, Treatment of penis lesion,54115,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2184.03,10940, Treatment of penis lesion,54115,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2184.03,10940, Treatment of penis lesion,54115,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2184.03,10940, Partial removal of penis,54120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3196.05,,,,,,,fee schedule,3196.05,12821, Partial removal of penis,54120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3196.05,12821, Partial removal of penis,54120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3196.05,12821, Partial removal of penis,54120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3196.05,12821, Removal of penis,54125,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4160.21,,,,,,,fee schedule,4108,5664, Removal of penis,54125,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,5664, Removal of penis,54125,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4108,5664, Removal of penis,54125,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4108,5664, Remove penis & nodes,54130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5950.87,,,,,,,fee schedule,5097,6979, Remove penis & nodes,54130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Remove penis & nodes,54130,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Remove penis & nodes,54130,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Remove penis & nodes,54135,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7501.95,,,,,,,fee schedule,5097,7501.95, Remove penis & nodes,54135,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7501.95, Remove penis & nodes,54135,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7501.95, Remove penis & nodes,54135,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7501.95, Circumcision w/regionl block,54150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,472.53,,,,,,,fee schedule,472.53,10940, Circumcision w/regionl block,54150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,472.53,10940, Circumcision w/regionl block,54150,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,472.53,10940, Circumcision w/regionl block,54150,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,472.53,10940, Circumcision neonate,54160,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,734.45,,,,,,,fee schedule,734.45,10940, Circumcision neonate,54160,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,734.45,10940, Circumcision neonate,54160,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,734.45,10940, Circumcision neonate,54160,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,734.45,10940, Circum 28 days or older,54161,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1000.96,,,,,,,fee schedule,1000.96,10940, Circum 28 days or older,54161,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1000.96,10940, Circum 28 days or older,54161,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1000.96,10940, Circum 28 days or older,54161,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1000.96,10940, Lysis penil circumic lesion,54162,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1018.23,,,,,,,fee schedule,1018.23,10940, Lysis penil circumic lesion,54162,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1018.23,10940, Lysis penil circumic lesion,54162,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1018.23,10940, Lysis penil circumic lesion,54162,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1018.23,10940, Repair of circumcision,54163,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1135.37,,,,,,,fee schedule,1135.37,10940, Repair of circumcision,54163,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1135.37,10940, Repair of circumcision,54163,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1135.37,10940, Repair of circumcision,54163,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1135.37,10940, Frenulotomy of penis,54164,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1013.58,,,,,,,fee schedule,1013.58,10940, Frenulotomy of penis,54164,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1013.58,10940, Frenulotomy of penis,54164,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1013.58,10940, Frenulotomy of penis,54164,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1013.58,10940, Treatment of penis lesion,54200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,453.1,,,,,,,fee schedule,453.1,6979, Treatment of penis lesion,54200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,453.1,6979, Treatment of penis lesion,54200,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,453.1,6979, Treatment of penis lesion,54200,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,453.1,6979, Treatment of penis lesion,54205,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2699.83,,,,,,,fee schedule,2699.83,12821, Treatment of penis lesion,54205,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2699.83,12821, Treatment of penis lesion,54205,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2699.83,12821, Treatment of penis lesion,54205,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2699.83,12821, Treatment of penis lesion,54220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,729.65,,,,,,,fee schedule,729.65,3195, Treatment of penis lesion,54220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,729.65,3195, Treatment of penis lesion,54220,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,729.65,3195, Treatment of penis lesion,54220,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,729.65,3195, Prepare penis study,54230,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,404.48,,,,,,,fee schedule,404.48,3195, Prepare penis study,54230,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,404.48,3195, Prepare penis study,54230,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,404.48,3195, Prepare penis study,54230,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,404.48,3195, Dynamic cavernosometry,54231,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,581.47,,,,,,,fee schedule,581.47,6979, Dynamic cavernosometry,54231,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,581.47,6979, Dynamic cavernosometry,54231,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,581.47,6979, Dynamic cavernosometry,54231,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,581.47,6979, Penile injection,54235,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,375.51,,,,,,,fee schedule,375.51,6979, Penile injection,54235,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,375.51,6979, Penile injection,54235,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,375.51,6979, Penile injection,54235,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,375.51,6979, Penis study,54240,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,243.2,,,,,,,fee schedule,243.2,3195, Penis study,54240,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,243.2,3195, Penis study,54240,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,243.2,3195, Penis study,54240,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,243.2,3195, Penis study,54250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,76.79,,,,,,,fee schedule,76.79,3195, Penis study,54250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,76.79,3195, Penis study,54250,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,76.79,3195, Penis study,54250,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,76.79,3195, Revision of penis,54300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3263.5,,,,,,,fee schedule,3263.5,14456, Revision of penis,54300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3263.5,14456, Revision of penis,54300,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3263.5,14456, Revision of penis,54300,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3263.5,14456, Revision of penis,54304,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3753.73,,,,,,,fee schedule,3753.73,14456, Revision of penis,54304,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3753.73,14456, Revision of penis,54304,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3753.73,14456, Revision of penis,54304,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3753.73,14456, Reconstruction of urethra,54308,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3601.13,,,,,,,fee schedule,3601.13,14456, Reconstruction of urethra,54308,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3601.13,14456, Reconstruction of urethra,54308,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3601.13,14456, Reconstruction of urethra,54308,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3601.13,14456, Reconstruction of urethra,54312,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4113.26,,,,,,,fee schedule,4113.26,12821, Reconstruction of urethra,54312,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4113.26,12821, Reconstruction of urethra,54312,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4113.26,12821, Reconstruction of urethra,54312,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4113.26,12821, Reconstruction of urethra,54316,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4967.99,,,,,,,fee schedule,4967.99,12821, Reconstruction of urethra,54316,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4967.99,12821, Reconstruction of urethra,54316,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4967.99,12821, Reconstruction of urethra,54316,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4967.99,12821, Reconstruction of urethra,54318,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3589.1,,,,,,,fee schedule,3589.1,12821, Reconstruction of urethra,54318,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3589.1,12821, Reconstruction of urethra,54318,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3589.1,12821, Reconstruction of urethra,54318,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3589.1,12821, Reconstruction of urethra,54322,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3916.15,,,,,,,fee schedule,3916.15,12821, Reconstruction of urethra,54322,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3916.15,12821, Reconstruction of urethra,54322,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3916.15,12821, Reconstruction of urethra,54322,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3916.15,12821, Reconstruction of urethra,54324,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4838.32,,,,,,,fee schedule,4838.32,14456, Reconstruction of urethra,54324,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4838.32,14456, Reconstruction of urethra,54324,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4838.32,14456, Reconstruction of urethra,54324,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4838.32,14456, Reconstruction of urethra,54326,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4714.54,,,,,,,fee schedule,4714.54,12821, Reconstruction of urethra,54326,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4714.54,12821, Reconstruction of urethra,54326,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4714.54,12821, Reconstruction of urethra,54326,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4714.54,12821, Revise penis/urethra,54328,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4686.75,,,,,,,fee schedule,4686.75,14456, Revise penis/urethra,54328,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4686.75,14456, Revise penis/urethra,54328,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4686.75,14456, Revise penis/urethra,54328,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4686.75,14456, Revise penis/urethra,54332,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5047.74,,,,,,,fee schedule,5047.74,12821, Revise penis/urethra,54332,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,5047.74,12821, Revise penis/urethra,54332,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5047.74,12821, Revise penis/urethra,54332,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5047.74,12821, Revise penis/urethra,54336,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5925.56,,,,,,,fee schedule,5925.56,12821, Revise penis/urethra,54336,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,5925.56,12821, Revise penis/urethra,54336,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5925.56,12821, Revise penis/urethra,54336,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5925.56,12821, Secondary urethral surgery,54340,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2881.57,,,,,,,fee schedule,2881.57,12821, Secondary urethral surgery,54340,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2881.57,12821, Secondary urethral surgery,54340,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2881.57,12821, Secondary urethral surgery,54340,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2881.57,12821, Secondary urethral surgery,54344,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4724.47,,,,,,,fee schedule,4724.47,12821, Secondary urethral surgery,54344,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4724.47,12821, Secondary urethral surgery,54344,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4724.47,12821, Secondary urethral surgery,54344,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4724.47,12821, Secondary urethral surgery,54348,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5052.49,,,,,,,fee schedule,5052.49,12821, Secondary urethral surgery,54348,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5052.49,12821, Secondary urethral surgery,54348,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5052.49,12821, Secondary urethral surgery,54348,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5052.49,12821, Reconstruct urethra/penis,54352,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7025.38,,,,,,,fee schedule,5248,14456, Reconstruct urethra/penis,54352,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,14456, Reconstruct urethra/penis,54352,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5248,14456, Reconstruct urethra/penis,54352,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5248,14456, Penis plastic surgery,54360,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3626,,,,,,,fee schedule,3626,14456, Penis plastic surgery,54360,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3626,14456, Penis plastic surgery,54360,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3626,14456, Penis plastic surgery,54360,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3626,14456, Repair penis,54380,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4016.19,,,,,,,fee schedule,4016.19,12821, Repair penis,54380,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4016.19,12821, Repair penis,54380,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4016.19,12821, Repair penis,54380,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4016.19,12821, Repair penis,54385,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4666.51,,,,,,,fee schedule,4666.51,12821, Repair penis,54385,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4666.51,12821, Repair penis,54385,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4666.51,12821, Repair penis,54385,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4666.51,12821, Repair penis and bladder,54390,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6185.27,,,,,,,fee schedule,6185.27,14456, Repair penis and bladder,54390,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6185.27,14456, Repair penis and bladder,54390,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,6185.27,14456, Repair penis and bladder,54390,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,6185.27,14456, Insert semi-rigid prosthesis,54400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2686.07,,,,,,,fee schedule,2686.07,25393, Insert semi-rigid prosthesis,54400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2686.07,25393, Insert semi-rigid prosthesis,54400,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,2686.07,25393, Insert semi-rigid prosthesis,54400,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,2686.07,25393, Insert self-contd prosthesis,54401,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3395.7,,,,,,,fee schedule,3395.7,34630, Insert self-contd prosthesis,54401,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3395.7,34630, Insert self-contd prosthesis,54401,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,34630,,,,,,,fee schedule,3395.7,34630, Insert self-contd prosthesis,54401,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,31168,,,,,,,fee schedule,3395.7,34630, Insert multi-comp penis pros,54405,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4051.32,,,,,,,fee schedule,4051.32,34630, Insert multi-comp penis pros,54405,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4051.32,34630, Insert multi-comp penis pros,54405,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,34630,,,,,,,fee schedule,4051.32,34630, Insert multi-comp penis pros,54405,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,31168,,,,,,,fee schedule,4051.32,34630, Remove muti-comp penis pros,54406,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3685.74,,,,,,,fee schedule,3685.74,12821, Remove muti-comp penis pros,54406,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3685.74,12821, Remove muti-comp penis pros,54406,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3685.74,12821, Remove muti-comp penis pros,54406,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3685.74,12821, Repair multi-comp penis pros,54408,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3984.51,,,,,,,fee schedule,3984.51,14456, Repair multi-comp penis pros,54408,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3984.51,14456, Repair multi-comp penis pros,54408,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3984.51,14456, Repair multi-comp penis pros,54408,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3984.51,14456, Remove/replace penis prosth,54410,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4340.97,,,,,,,fee schedule,4340.97,34630, Remove/replace penis prosth,54410,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4340.97,34630, Remove/replace penis prosth,54410,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,34630,,,,,,,fee schedule,4340.97,34630, Remove/replace penis prosth,54410,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,31168,,,,,,,fee schedule,4340.97,34630, Remov/replc penis pros comp,54411,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5159.6,,,,,,,fee schedule,2505,6044, Remov/replc penis pros comp,54411,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,2505,6044, Remov/replc penis pros comp,54411,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,6044, Remov/replc penis pros comp,54411,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,6044, Remove self-contd penis pros,54415,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2705.99,,,,,,,fee schedule,2705.99,12821, Remove self-contd penis pros,54415,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2705.99,12821, Remove self-contd penis pros,54415,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2705.99,12821, Remove self-contd penis pros,54415,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2705.99,12821, Remv/repl penis contain pros,54416,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3620.12,,,,,,,fee schedule,3620.12,34630, Remv/repl penis contain pros,54416,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3620.12,34630, Remv/repl penis contain pros,54416,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,34630,,,,,,,fee schedule,3620.12,34630, Remv/repl penis contain pros,54416,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,31168,,,,,,,fee schedule,3620.12,34630, Remv/replc penis pros compl,54417,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4510.57,,,,,,,fee schedule,4047,5363, Remv/replc penis pros compl,54417,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4047,5363, Remv/replc penis pros compl,54417,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,4047,5363, Remv/replc penis pros compl,54417,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,4047,5363, Revision of penis,54420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3529.96,,,,,,,fee schedule,3529.96,12821, Revision of penis,54420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3529.96,12821, Revision of penis,54420,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3529.96,12821, Revision of penis,54420,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3529.96,12821, Revision of penis,54430,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3220.33,,,,,,,fee schedule,3220.33,6979, Revision of penis,54430,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3220.33,6979, Revision of penis,54430,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3220.33,6979, Revision of penis,54430,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3220.33,6979, Revision of penis,54435,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2117.17,,,,,,,fee schedule,2117.17,12821, Revision of penis,54435,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2117.17,12821, Revision of penis,54435,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2117.17,12821, Revision of penis,54435,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2117.17,12821, Repair corporeal tear,54437,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3427.05,,,,,,,fee schedule,3427.05,10940, Repair corporeal tear,54437,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3427.05,10940, Repair corporeal tear,54437,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3427.05,10940, Repair corporeal tear,54437,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3427.05,10940, Replantation of penis,54438,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Repair of penis,54440,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,12821, Repair of penis,54440,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5363,12821, Repair of penis,54440,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5363,12821, Preputial stretching,54450,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,283.61,,,,,,,fee schedule,283.61,3195, Preputial stretching,54450,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,283.61,3195, Preputial stretching,54450,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,283.61,3195, Preputial stretching,54450,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,283.61,3195, Biopsy of testis,54500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,372.27,,,,,,,fee schedule,372.27,5664, Biopsy of testis,54500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,372.27,5664, Biopsy of testis,54500,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,372.27,5664, Biopsy of testis,54500,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,372.27,5664, Biopsy of testis,54505,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1065.33,,,,,,,fee schedule,1065.33,10940, Biopsy of testis,54505,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1065.33,10940, Biopsy of testis,54505,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1065.33,10940, Biopsy of testis,54505,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1065.33,10940, Excise Lesion Testis,54512,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2718.88,,,,,,,fee schedule,2718.88,10940, Excise Lesion Testis,54512,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2718.88,10940, Excise Lesion Testis,54512,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2718.88,10940, Excise Lesion Testis,54512,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2718.88,10940, Removal of testis,54520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1689.54,,,,,,,fee schedule,1689.54,12821, Removal of testis,54520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1689.54,12821, Removal of testis,54520,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,1689.54,12821, Removal of testis,54520,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,1689.54,12821, Orchiectomy partial,54522,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2966.67,,,,,,,fee schedule,2966.67,10940, Orchiectomy partial,54522,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2966.67,10940, Orchiectomy partial,54522,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2966.67,10940, Orchiectomy partial,54522,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2966.67,10940, Removal of testis,54530,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2595.69,,,,,,,fee schedule,2595.69,12821, Removal of testis,54530,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2595.69,12821, Removal of testis,54530,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2595.69,12821, Removal of testis,54530,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2595.69,12821, Extensive testis surgery,54535,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3739.97,,,,,,,fee schedule,3739.97,12821, Extensive testis surgery,54535,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3739.97,12821, Extensive testis surgery,54535,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3739.97,12821, Extensive testis surgery,54535,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3739.97,12821, Exploration for testis,54550,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2500.02,,,,,,,fee schedule,2500.02,12821, Exploration for testis,54550,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2500.02,12821, Exploration for testis,54550,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2500.02,12821, Exploration for testis,54550,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2500.02,12821, Exploration for testis,54560,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3456.57,,,,,,,fee schedule,3456.57,10940, Exploration for testis,54560,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3456.57,10940, Exploration for testis,54560,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3456.57,10940, Exploration for testis,54560,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3456.57,10940, Reduce testis torsion,54600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2305.76,,,,,,,fee schedule,2305.76,10940, Reduce testis torsion,54600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2305.76,10940, Reduce testis torsion,54600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2305.76,10940, Reduce testis torsion,54600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2305.76,10940, Suspension of testis,54620,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1510.34,,,,,,,fee schedule,1510.34,10940, Suspension of testis,54620,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1510.34,10940, Suspension of testis,54620,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1510.34,10940, Suspension of testis,54620,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1510.34,10940, Suspension of testis,54640,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2194.72,,,,,,,fee schedule,2194.72,12821, Suspension of testis,54640,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2194.72,12821, Suspension of testis,54640,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2194.72,12821, Suspension of testis,54640,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2194.72,12821, Orchiopexy (Fowler-Stephens),54650,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3590.28,,,,,,,fee schedule,3590.28,12821, Orchiopexy (Fowler-Stephens),54650,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3590.28,12821, Orchiopexy (Fowler-Stephens),54650,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3590.28,12821, Orchiopexy (Fowler-Stephens),54650,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3590.28,12821, Revision of testis,54660,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1839.12,,,,,,,fee schedule,1839.12,10940, Revision of testis,54660,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1839.12,10940, Revision of testis,54660,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1839.12,10940, Revision of testis,54660,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1839.12,10940, Repair testis injury,54670,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2088.09,,,,,,,fee schedule,2088.09,10940, Repair testis injury,54670,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2088.09,10940, Repair testis injury,54670,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2088.09,10940, Repair testis injury,54670,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2088.09,10940, Relocation of testis(es),54680,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3953.81,,,,,,,fee schedule,3953.81,10940, Relocation of testis(es),54680,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3953.81,10940, Relocation of testis(es),54680,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3953.81,10940, Relocation of testis(es),54680,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3953.81,10940, Laparoscopy orchiectomy,54690,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3294.47,,,,,,,fee schedule,3294.47,22111, Laparoscopy orchiectomy,54690,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3294.47,22111, Laparoscopy orchiectomy,54690,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3294.47,22111, Laparoscopy orchiectomy,54690,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3294.47,22111, Laparoscopy orchiopexy,54692,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3787.34,,,,,,,fee schedule,3787.34,22111, Laparoscopy orchiopexy,54692,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3787.34,22111, Laparoscopy orchiopexy,54692,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3787.34,22111, Laparoscopy orchiopexy,54692,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3787.34,22111, Laparoscope proc testis,54699,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,14456, Laparoscope proc testis,54699,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5248,14456, Laparoscope proc testis,54699,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5248,14456, Drainage of scrotum,54700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1106.23,,,,,,,fee schedule,1106.23,10940, Drainage of scrotum,54700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1106.23,10940, Drainage of scrotum,54700,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1106.23,10940, Drainage of scrotum,54700,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1106.23,10940, Biopsy of epididymis,54800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,619.35,,,,,,,fee schedule,619.35,4497, Biopsy of epididymis,54800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,619.35,4497, Biopsy of epididymis,54800,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,619.35,4497, Biopsy of epididymis,54800,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,619.35,4497, Remove epididymis lesion,54830,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1917.04,,,,,,,fee schedule,1917.04,10940, Remove epididymis lesion,54830,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1917.04,10940, Remove epididymis lesion,54830,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1917.04,10940, Remove epididymis lesion,54830,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1917.04,10940, Remove epididymis lesion,54840,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1646.21,,,,,,,fee schedule,1646.21,10940, Remove epididymis lesion,54840,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,1646.21,10940, Remove epididymis lesion,54840,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1646.21,10940, Remove epididymis lesion,54840,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1646.21,10940, Removal of epididymis,54860,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2140.92,,,,,,,fee schedule,2140.92,10940, Removal of epididymis,54860,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2140.92,10940, Removal of epididymis,54860,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2140.92,10940, Removal of epididymis,54860,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2140.92,10940, Removal of epididymis,54861,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2878.01,,,,,,,fee schedule,2878.01,10940, Removal of epididymis,54861,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2878.01,10940, Removal of epididymis,54861,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2878.01,10940, Removal of epididymis,54861,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2878.01,10940, Explore Epididymis,54865,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1848.99,,,,,,,fee schedule,1848.99,10940, Explore Epididymis,54865,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1848.99,10940, Explore Epididymis,54865,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1848.99,10940, Explore Epididymis,54865,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1848.99,10940, Fusion of spermatic ducts,54900,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4023.26,,,,,,,fee schedule,4023.26,10940, Fusion of spermatic ducts,54900,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4023.26,10940, Fusion of spermatic ducts,54900,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,4023.26,10940, Fusion of spermatic ducts,54900,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,4023.26,10940, Fusion of spermatic ducts,54901,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5291.43,,,,,,,fee schedule,5291.43,10940, Fusion of spermatic ducts,54901,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5291.43,10940, Fusion of spermatic ducts,54901,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,5291.43,10940, Fusion of spermatic ducts,54901,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,5291.43,10940, Drainage of hydrocele,55000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,426.77,,,,,,,fee schedule,426.77,6979, Drainage of hydrocele,55000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,426.77,6979, Drainage of hydrocele,55000,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,426.77,6979, Drainage of hydrocele,55000,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,426.77,6979, Removal of hydrocele,55040,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1736.92,,,,,,,fee schedule,1736.92,12821, Removal of hydrocele,55040,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1736.92,12821, Removal of hydrocele,55040,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,1736.92,12821, Removal of hydrocele,55040,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,1736.92,12821, Removal of hydroceles,55041,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2603.95,,,,,,,fee schedule,2603.95,12821, Removal of hydroceles,55041,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,2603.95,12821, Removal of hydroceles,55041,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2603.95,12821, Removal of hydroceles,55041,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2603.95,12821, Repair of hydrocele,55060,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1951.84,,,,,,,fee schedule,1951.84,10940, Repair of hydrocele,55060,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,1951.84,10940, Repair of hydrocele,55060,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1951.84,10940, Repair of hydrocele,55060,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1951.84,10940, Drainage of scrotum abscess,55100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,902.43,,,,,,,fee schedule,902.43,5664, Drainage of scrotum abscess,55100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,902.43,5664, Drainage of scrotum abscess,55100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,902.43,5664, Drainage of scrotum abscess,55100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,902.43,5664, Explore scrotum,55110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2006.61,,,,,,,fee schedule,2006.61,10940, Explore scrotum,55110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2006.61,10940, Explore scrotum,55110,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2006.61,10940, Explore scrotum,55110,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2006.61,10940, Removal of scrotum lesion,55120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1823.47,,,,,,,fee schedule,1823.47,10940, Removal of scrotum lesion,55120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1823.47,10940, Removal of scrotum lesion,55120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1823.47,10940, Removal of scrotum lesion,55120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1823.47,10940, Removal of scrotum,55150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2519.61,,,,,,,fee schedule,2519.61,10940, Removal of scrotum,55150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2519.61,10940, Removal of scrotum,55150,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2519.61,10940, Removal of scrotum,55150,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2519.61,10940, Revision of scrotum,55175,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1871.6,,,,,,,fee schedule,1871.6,14456, Revision of scrotum,55175,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1871.6,14456, Revision of scrotum,55175,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,1871.6,14456, Revision of scrotum,55175,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,1871.6,14456, Revision of scrotum,55180,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3457.59,,,,,,,fee schedule,3457.59,10940, Revision of scrotum,55180,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3457.59,10940, Revision of scrotum,55180,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3457.59,10940, Revision of scrotum,55180,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3457.59,10940, Incision of sperm duct,55200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1422.33,,,,,,,fee schedule,1422.33,10940, Incision of sperm duct,55200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1422.33,10940, Incision of sperm duct,55200,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1422.33,10940, Incision of sperm duct,55200,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1422.33,10940, Removal of sperm duct(s),55250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1192.62,,,,,,,fee schedule,1192.62,10940, Removal of sperm duct(s),55250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1192.62,10940, Removal of sperm duct(s),55250,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1192.62,10940, Removal of sperm duct(s),55250,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1192.62,10940, Prepare sperm duct x-ray,55300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,920.61,,,,,,,fee schedule,920.61,4108, Prepare sperm duct x-ray,55300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,920.61,4108, Prepare sperm duct x-ray,55300,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,920.61,4108, Prepare sperm duct x-ray,55300,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,920.61,4108, Repair of sperm duct,55400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2528.35,,,,,,,fee schedule,2528.35,10940, Repair of sperm duct,55400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2528.35,10940, Repair of sperm duct,55400,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2528.35,10940, Repair of sperm duct,55400,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2528.35,10940, Removal of hydrocele,55500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2036.77,,,,,,,fee schedule,2036.77,12821, Removal of hydrocele,55500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2036.77,12821, Removal of hydrocele,55500,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2036.77,12821, Removal of hydrocele,55500,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2036.77,12821, Removal of sperm cord lesion,55520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2532.34,,,,,,,fee schedule,2532.34,10940, Removal of sperm cord lesion,55520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2532.34,10940, Removal of sperm cord lesion,55520,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2532.34,10940, Removal of sperm cord lesion,55520,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2532.34,10940, Revise spermatic cord veins,55530,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1801.56,,,,,,,fee schedule,1801.56,10940, Revise spermatic cord veins,55530,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,1801.56,10940, Revise spermatic cord veins,55530,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1801.56,10940, Revise spermatic cord veins,55530,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1801.56,10940, Revise spermatic cord veins,55535,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2197.41,,,,,,,fee schedule,2197.41,12821, Revise spermatic cord veins,55535,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2197.41,12821, Revise spermatic cord veins,55535,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2197.41,12821, Revise spermatic cord veins,55535,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2197.41,12821, Revise hernia & sperm veins,55540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3063.2,,,,,,,fee schedule,3063.2,12821, Revise hernia & sperm veins,55540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,3063.2,12821, Revise hernia & sperm veins,55540,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3063.2,12821, Revise hernia & sperm veins,55540,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3063.2,12821, Laparo ligate spermatic vein,55550,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2192.34,,,,,,,fee schedule,2192.34,22111, Laparo ligate spermatic vein,55550,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2192.34,22111, Laparo ligate spermatic vein,55550,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,2192.34,22111, Laparo ligate spermatic vein,55550,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,2192.34,22111, Laparo proc spermatic cord,55559,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,14456, Laparo proc spermatic cord,55559,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5248,14456, Laparo proc spermatic cord,55559,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5248,14456, Incise sperm duct pouch,55600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2151.66,,,,,,,fee schedule,2151.66,10940, Incise sperm duct pouch,55600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2151.66,10940, Incise sperm duct pouch,55600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2151.66,10940, Incise sperm duct pouch,55600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2151.66,10940, Incise sperm duct pouch,55605,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2662.49,,,,,,,fee schedule,2662.49,4497, Incise sperm duct pouch,55605,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2662.49,4497, Incise sperm duct pouch,55605,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,2662.49,4497, Incise sperm duct pouch,55605,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,2662.49,4497, Remove sperm duct pouch,55650,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3616.13,,,,,,,fee schedule,3195,4497, Remove sperm duct pouch,55650,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,4497, Remove sperm duct pouch,55650,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,3195,4497, Remove sperm duct pouch,55650,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,3195,4497, Remove sperm pouch lesion,55680,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1773.83,,,,,,,fee schedule,1773.83,10940, Remove sperm pouch lesion,55680,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1773.83,10940, Remove sperm pouch lesion,55680,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1773.83,10940, Remove sperm pouch lesion,55680,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1773.83,10940, Biopsy of prostate,55700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,5664, Biopsy of prostate,55700,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4108,5664, Biopsy of prostate,55700,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4108,5664, Biopsy of prostate,55705,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,552.77,,,,,,,fee schedule,552.77,5664, Biopsy of prostate,55705,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,552.77,5664, Biopsy of prostate,55705,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,552.77,5664, Biopsy of prostate,55705,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,552.77,5664, Prostate saturation sampling,55706,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1134.56,,,,,,,fee schedule,1134.56,5664, Prostate saturation sampling,55706,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1134.56,5664, Prostate saturation sampling,55706,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1134.56,5664, Prostate saturation sampling,55706,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1134.56,5664, Bx prst8 trct us guided,55707,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,758.35,,,,,,,fee schedule,758.35,6979, Bx prst8 trct us guided,55707,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,758.35,6979, Bx prst8 trct us w/mri fus 1,55708,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,944.57,,,,,,,fee schedule,944.57,6979, Bx prst8 trct us w/mri fus 1,55708,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,944.57,6979, Bx prst8 tprnl us guided,55709,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,907.88,,,,,,,fee schedule,907.88,6979, Bx prst8 tprnl us guided,55709,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,907.88,6979, Bx prst8 tprn us w/mri fus 1,55710,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1049.31,,,,,,,fee schedule,1049.31,6979, Bx prst8 tprn us w/mri fus 1,55710,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1049.31,6979, Bx prst8 trct mri-us 1st,55711,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,754.74,,,,,,,fee schedule,754.74,6979, Bx prst8 trct mri-us 1st,55711,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,754.74,6979, Bx prst8 tprnl mri-us 1st,55712,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,879.98,,,,,,,fee schedule,879.98,6979, Bx prst8 tprnl mri-us 1st,55712,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,879.98,6979, Bx prst8 in-bore ct/mri bx 1,55713,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1039,,,,,,,fee schedule,1039,6979, Bx prst8 in-bore ct/mri bx 1,55713,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1039,6979, Bx prst8 in-bore ct/mri 1,55714,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,945.92,,,,,,,fee schedule,945.92,6979, Bx prst8 in-bore ct/mri 1,55714,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,945.92,6979, Bx prst8 ea add mri-us/ct/mr,55715,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,265.05,,,,,,,fee schedule,265.05,265.05, Drainage of prostate abscess,55720,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2298.1,,,,,,,fee schedule,2298.1,10940, Drainage of prostate abscess,55720,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2298.1,10940, Drainage of prostate abscess,55720,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2298.1,10940, Drainage of prostate abscess,55720,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2298.1,10940, Drainage of prostate abscess,55725,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3023.49,,,,,,,fee schedule,3023.49,10940, Drainage of prostate abscess,55725,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3023.49,10940, Drainage of prostate abscess,55725,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3023.49,10940, Drainage of prostate abscess,55725,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3023.49,10940, Removal of prostate,55801,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5470.2,,,,,,,fee schedule,5097,6979, Removal of prostate,55801,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Removal of prostate,55801,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Removal of prostate,55801,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Extensive prostate surgery,55810,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6497.38,,,,,,,fee schedule,5097,6979, Extensive prostate surgery,55810,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Extensive prostate surgery,55810,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Extensive prostate surgery,55810,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Extensive prostate surgery,55812,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7980.41,,,,,,,fee schedule,5097,7980.41, Extensive prostate surgery,55812,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7980.41, Extensive prostate surgery,55812,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7980.41, Extensive prostate surgery,55812,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7980.41, Extensive prostate surgery,55815,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8729.11,,,,,,,fee schedule,5097,8729.11, Extensive prostate surgery,55815,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8729.11, Extensive prostate surgery,55815,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8729.11, Extensive prostate surgery,55815,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8729.11, Removal of prostate,55821,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4201.38,,,,,,,fee schedule,4201.38,6979, Removal of prostate,55821,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4201.38,6979, Removal of prostate,55821,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4201.38,6979, Removal of prostate,55821,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4201.38,6979, Removal of prostate,55831,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4315.18,,,,,,,fee schedule,4315.18,6979, Removal of prostate,55831,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4315.18,6979, Removal of prostate,55831,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4315.18,6979, Removal of prostate,55831,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4315.18,6979, Extensive prostate surgery,55840,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5824.66,,,,,,,fee schedule,5097,6979, Extensive prostate surgery,55840,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Extensive prostate surgery,55840,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Extensive prostate surgery,55840,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Extensive prostate surgery,55842,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5808.63,,,,,,,fee schedule,5097,6979, Extensive prostate surgery,55842,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Extensive prostate surgery,55842,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Extensive prostate surgery,55842,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Extensive prostate surgery,55845,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6746.24,,,,,,,fee schedule,5097,8406, Extensive prostate surgery,55845,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,5097,8406, Extensive prostate surgery,55845,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8406, Extensive prostate surgery,55845,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8406, Surgical exposure prostate,55860,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4371.89,,,,,,,fee schedule,3195,10940, Surgical exposure prostate,55860,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,10940, Surgical exposure prostate,55860,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3195,10940, Surgical exposure prostate,55860,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3195,10940, Extensive prostate surgery,55862,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5464.64,,,,,,,fee schedule,5097,6979, Extensive prostate surgery,55862,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Extensive prostate surgery,55862,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Extensive prostate surgery,55862,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Extensive prostate surgery,55865,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6635.95,,,,,,,fee schedule,5097,6979, Extensive prostate surgery,55865,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Extensive prostate surgery,55865,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Extensive prostate surgery,55865,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Laparo radical prostatectomy,55866,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6033.48,,,,,,,fee schedule,6033.48,25393, Laparo radical prostatectomy,55866,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6033.48,25393, Laparo radical prostatectomy,55866,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,6033.48,25393, Laparo radical prostatectomy,55866,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,6033.48,25393, Laps surg prst8ect smpl stot,55867,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5273.08,,,,,,,fee schedule,5273.08,22111, Laps surg prst8ect smpl stot,55867,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,5273.08,22111, Laps surg prst8ect smpl stot,55867,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5273.08,22111, Laps surg prst8ect smpl stot,55867,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5273.08,22111, Lap srg prst8ct lymph nod bx,55868,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6178.53,,,,,,,fee schedule,6178.53,6979, Lap srg prst8ct lymph nod bx,55868,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6178.53,6979, Lap srg prst8ct bi pl lmphad,55869,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7421.5,,,,,,,fee schedule,6979,7421.5, Lap srg prst8ct bi pl lmphad,55869,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,7421.5, Electroejaculation,55870,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,710.71,,,,,,,fee schedule,710.71,4497, Electroejaculation,55870,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,710.71,4497, Electroejaculation,55870,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,710.71,4497, Electroejaculation,55870,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,710.71,4497, Cryoablate Prostate,55873,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3822.9,,,,,,,fee schedule,3822.9,25393, Cryoablate Prostate,55873,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3822.9,25393, Cryoablate Prostate,55873,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,3822.9,25393, Cryoablate Prostate,55873,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,3822.9,25393, Tprnl plmt biodegrdabl matrl,55874,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,791.65,,,,,,,fee schedule,791.65,22111, Tprnl plmt biodegrdabl matrl,55874,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,791.65,22111, Tprnl plmt biodegrdabl matrl,55874,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,791.65,22111, Tprnl plmt biodegrdabl matrl,55874,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,791.65,22111, Transperi needle place pros,55875,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3791.72,,,,,,,fee schedule,3791.72,14456, Transperi needle place pros,55875,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3791.72,14456, Transperi needle place pros,55875,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3791.72,14456, Transperi needle place pros,55875,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3791.72,14456, Place rt device/marker pros,55876,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,500.8,,,,,,,fee schedule,500.8,5664, Place rt device/marker pros,55876,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,500.8,5664, Place rt device/marker pros,55876,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,500.8,5664, Place rt device/marker pros,55876,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,500.8,5664, Abltj ire prst8 1+ tum perq,55877,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3729.01,,,,,,,fee schedule,3729.01,6979, Abltj ire prst8 1+ tum perq,55877,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3729.01,6979, Abltj mal prst8 tiss hifu,55880,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4891.69,,,,,,,fee schedule,4108,10940, Abltj mal prst8 tiss hifu,55880,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,10940, Abltj mal prst8 tiss hifu,55880,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,4108,10940, Abltj mal prst8 tiss hifu,55880,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,4108,10940, Ablt trurl prst8 tis thrm us,55881,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2413.85,,,,,,,fee schedule,2413.85,5664, Ablt trurl prst8 tis thrm us,55881,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2413.85,5664, Ablt trurl prst8 tis thrm us,55881,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2413.85,5664, Ablt trurl prst8 tis thrm us,55881,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2413.85,5664, Ablt trurl prst8 tis trnsdcr,55882,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2967.04,,,,,,,fee schedule,2967.04,25393, Ablt trurl prst8 tis trnsdcr,55882,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2967.04,25393, Ablt trurl prst8 tis trnsdcr,55882,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,2967.04,25393, Ablt trurl prst8 tis trnsdcr,55882,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,2967.04,25393, Genital surgery procedure,55899,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2505,4108, Genital surgery procedure,55899,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,4108, Genital surgery procedure,55899,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,4108, Place needles pelvic for rt,55920,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2113.72,,,,,,,fee schedule,2113.72,12821, Place needles pelvic for rt,55920,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2113.72,12821, Place needles pelvic for rt,55920,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2113.72,12821, Place needles pelvic for rt,55920,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2113.72,12821, Sex transformation m to f,55970,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Sex transformation f to m,55980,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Description Not Available,56300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Description Not Available,56301,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Description Not Available,56302,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Description Not Available,56303,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Description Not Available,56304,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Description Not Available,56305,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Description Not Available,56306,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Description Not Available,56307,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Description Not Available,56308,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Description Not Available,56309,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Description Not Available,56310,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Description Not Available,56311,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Description Not Available,56312,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Description Not Available,56313,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Description Not Available,56314,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Description Not Available,56315,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Description Not Available,56316,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Description Not Available,56317,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Description Not Available,56318,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Description Not Available,56320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Description Not Available,56322,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Description Not Available,56323,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Description Not Available,56324,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Description Not Available,56340,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Description Not Available,56341,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Description Not Available,56342,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Description Not Available,56343,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Description Not Available,56344,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Description Not Available,56345,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Description Not Available,56346,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Description Not Available,56347,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Description Not Available,56348,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Description Not Available,56349,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Description Not Available,56350,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Description Not Available,56351,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Description Not Available,56352,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Description Not Available,56353,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Description Not Available,56354,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Description Not Available,56355,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Description Not Available,56356,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Description Not Available,56360,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Description Not Available,56361,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Description Not Available,56362,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Description Not Available,56363,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Description Not Available,56399,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, I & D of vulva/perineum,56405,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,640.18,,,,,,,fee schedule,640.18,4108, I & D of vulva/perineum,56405,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,640.18,4108, I & D of vulva/perineum,56405,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,640.18,4108, I & D of vulva/perineum,56405,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,640.18,4108, Drainage of gland abscess,56420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,551.69,,,,,,,fee schedule,551.69,3195, Drainage of gland abscess,56420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,551.69,3195, Drainage of gland abscess,56420,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,551.69,3195, Drainage of gland abscess,56420,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,551.69,3195, Surgery for vulva lesion,56440,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,913.97,,,,,,,fee schedule,913.97,10940, Surgery for vulva lesion,56440,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,913.97,10940, Surgery for vulva lesion,56440,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,913.97,10940, Surgery for vulva lesion,56440,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,913.97,10940, Lysis of labial lesion(s),56441,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,774.54,,,,,,,fee schedule,774.54,10940, Lysis of labial lesion(s),56441,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,774.54,10940, Lysis of labial lesion(s),56441,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,774.54,10940, Lysis of labial lesion(s),56441,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,774.54,10940, Hymenotomy,56442,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,242.77,,,,,,,fee schedule,242.77,10940, Hymenotomy,56442,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,242.77,10940, Hymenotomy,56442,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,242.77,10940, Hymenotomy,56442,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,242.77,10940, Destroy vulva lesions sim,56501,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,655.4,,,,,,,fee schedule,655.4,5664, Destroy vulva lesions sim,56501,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,655.4,5664, Destroy vulva lesions sim,56501,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,655.4,5664, Destroy vulva lesions sim,56501,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,655.4,5664, Destroy vulva lesion/s compl,56515,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1054.49,,,,,,,fee schedule,1054.49,5664, Destroy vulva lesion/s compl,56515,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1054.49,5664, Destroy vulva lesion/s compl,56515,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1054.49,5664, Destroy vulva lesion/s compl,56515,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1054.49,5664, Biopsy of vulva/perineum,56605,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,294.3,,,,,,,fee schedule,294.3,4497, Biopsy of vulva/perineum,56605,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,294.3,4497, Biopsy of vulva/perineum,56605,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,294.3,4497, Biopsy of vulva/perineum,56605,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,294.3,4497, Biopsy of vulva/perineum,56606,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,144.13,,,,,,,fee schedule,144.13,3195, Biopsy of vulva/perineum,56606,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,144.13,3195, Biopsy of vulva/perineum,56606,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,144.13,3195, Biopsy of vulva/perineum,56606,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,144.13,3195, Partial removal of vulva,56620,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3027.64,,,,,,,fee schedule,3027.64,10940, Partial removal of vulva,56620,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,3027.64,10940, Partial removal of vulva,56620,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3027.64,10940, Partial removal of vulva,56620,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3027.64,10940, Complete removal of vulva,56625,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3474.86,,,,,,,fee schedule,3474.86,10940, Complete removal of vulva,56625,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3474.86,10940, Complete removal of vulva,56625,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3474.86,10940, Complete removal of vulva,56625,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3474.86,10940, Extensive vulva surgery,56630,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5059.4,,,,,,,fee schedule,5059.4,12821, Extensive vulva surgery,56630,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,5059.4,12821, Extensive vulva surgery,56630,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5059.4,12821, Extensive vulva surgery,56630,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5059.4,12821, Extensive vulva surgery,56631,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6269.99,,,,,,,fee schedule,6269.99,25393, Extensive vulva surgery,56631,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6269.99,25393, Extensive vulva surgery,56631,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,6269.99,25393, Extensive vulva surgery,56631,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,6269.99,25393, Extensive vulva surgery,56632,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7525.37,,,,,,,fee schedule,6979,25393, Extensive vulva surgery,56632,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,25393, Extensive vulva surgery,56632,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,6979,25393, Extensive vulva surgery,56632,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,6979,25393, Extensive vulva surgery,56633,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6500.56,,,,,,,fee schedule,6500.56,25393, Extensive vulva surgery,56633,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6500.56,25393, Extensive vulva surgery,56633,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,6500.56,25393, Extensive vulva surgery,56633,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,6500.56,25393, Extensive vulva surgery,56634,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6958.09,,,,,,,fee schedule,6958.09,25393, Extensive vulva surgery,56634,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6958.09,25393, Extensive vulva surgery,56634,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,6958.09,25393, Extensive vulva surgery,56634,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,6958.09,25393, Extensive vulva surgery,56637,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8130.75,,,,,,,fee schedule,6979,25393, Extensive vulva surgery,56637,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,25393, Extensive vulva surgery,56637,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,6979,25393, Extensive vulva surgery,56637,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,6979,25393, Extensive vulva surgery,56640,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8130.96,,,,,,,fee schedule,5097,8130.96, Extensive vulva surgery,56640,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8130.96, Extensive vulva surgery,56640,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8130.96, Extensive vulva surgery,56640,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8130.96, Partial removal of hymen,56700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1006.62,,,,,,,fee schedule,1006.62,10940, Partial removal of hymen,56700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1006.62,10940, Partial removal of hymen,56700,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1006.62,10940, Partial removal of hymen,56700,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1006.62,10940, Remove vagina gland lesion,56740,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1582.92,,,,,,,fee schedule,1582.92,10940, Remove vagina gland lesion,56740,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1582.92,10940, Remove vagina gland lesion,56740,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1582.92,10940, Remove vagina gland lesion,56740,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1582.92,10940, Repair of vagina,56800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1267.09,,,,,,,fee schedule,1267.09,10940, Repair of vagina,56800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1267.09,10940, Repair of vagina,56800,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1267.09,10940, Repair of vagina,56800,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1267.09,10940, Repair clitoris,56805,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5770.64,,,,,,,fee schedule,5770.64,10940, Repair clitoris,56805,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5770.64,10940, Repair clitoris,56805,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,5770.64,10940, Repair clitoris,56805,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,5770.64,10940, Repair of perineum,56810,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1347.17,,,,,,,fee schedule,1347.17,10940, Repair of perineum,56810,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,1347.17,10940, Repair of perineum,56810,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1347.17,10940, Repair of perineum,56810,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1347.17,10940, Exam of vulva w/scope,56820,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,427.58,,,,,,,fee schedule,427.58,3195, Exam of vulva w/scope,56820,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,427.58,3195, Exam of vulva w/scope,56820,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,427.58,3195, Exam of vulva w/scope,56820,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,427.58,3195, Exam/biopsy of vulva w/scope,56821,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,575.38,,,,,,,fee schedule,575.38,3195, Exam/biopsy of vulva w/scope,56821,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,575.38,3195, Exam/biopsy of vulva w/scope,56821,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,575.38,3195, Exam/biopsy of vulva w/scope,56821,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,575.38,3195, Exploration of vagina,57000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,992.7,,,,,,,fee schedule,992.7,10940, Exploration of vagina,57000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,992.7,10940, Exploration of vagina,57000,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,992.7,10940, Exploration of vagina,57000,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,992.7,10940, Drainage of pelvic abscess,57010,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2275.49,,,,,,,fee schedule,2275.49,10940, Drainage of pelvic abscess,57010,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2275.49,10940, Drainage of pelvic abscess,57010,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2275.49,10940, Drainage of pelvic abscess,57010,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2275.49,10940, Drainage of pelvic fluid,57020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,391.16,,,,,,,fee schedule,391.16,10940, Drainage of pelvic fluid,57020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,391.16,10940, Drainage of pelvic fluid,57020,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,391.16,10940, Drainage of pelvic fluid,57020,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,391.16,10940, I & d vaginal hematoma pp,57022,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,890.07,,,,,,,fee schedule,890.07,5664, I & d vaginal hematoma pp,57022,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,890.07,5664, I & d vaginal hematoma pp,57022,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,890.07,5664, I & d vaginal hematoma pp,57022,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,890.07,5664, I & d vag hematoma non-ob,57023,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1588.91,,,,,,,fee schedule,1588.91,10940, I & d vag hematoma non-ob,57023,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1588.91,10940, I & d vag hematoma non-ob,57023,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1588.91,10940, I & d vag hematoma non-ob,57023,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1588.91,10940, Destroy vag lesions simple,57061,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,576.24,,,,,,,fee schedule,576.24,10940, Destroy vag lesions simple,57061,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,576.24,10940, Destroy vag lesions simple,57061,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,576.24,10940, Destroy vag lesions simple,57061,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,576.24,10940, Destroy vag lesions complex,57065,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,921.26,,,,,,,fee schedule,921.26,10940, Destroy vag lesions complex,57065,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,921.26,10940, Destroy vag lesions complex,57065,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,921.26,10940, Destroy vag lesions complex,57065,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,921.26,10940, Biopsy of vagina,57100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,332.5,,,,,,,fee schedule,332.5,4497, Biopsy of vagina,57100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,332.5,4497, Biopsy of vagina,57100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,332.5,4497, Biopsy of vagina,57100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,332.5,4497, Biopsy of vagina,57105,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,745.57,,,,,,,fee schedule,745.57,10940, Biopsy of vagina,57105,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,745.57,10940, Biopsy of vagina,57105,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,745.57,10940, Biopsy of vagina,57105,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,745.57,10940, Remove vagina wall partial,57106,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2730.75,,,,,,,fee schedule,2730.75,10940, Remove vagina wall partial,57106,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2730.75,10940, Remove vagina wall partial,57106,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2730.75,10940, Remove vagina wall partial,57106,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2730.75,10940, Remove vagina tissue part,57107,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7466.82,,,,,,,fee schedule,4108,10940, Remove vagina tissue part,57107,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,10940, Remove vagina tissue part,57107,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,4108,10940, Remove vagina tissue part,57107,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,4108,10940, Description Not Available,57108,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Vaginectomy partial w/nodes,57109,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9234.98,,,,,,,fee schedule,3195,10940, Vaginectomy partial w/nodes,57109,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,10940, Vaginectomy partial w/nodes,57109,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3195,10940, Vaginectomy partial w/nodes,57109,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3195,10940, Remove vagina wall complete,57110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4487.31,,,,,,,fee schedule,4487.31,5664, Remove vagina wall complete,57110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4487.31,5664, Remove vagina wall complete,57110,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4487.31,5664, Remove vagina wall complete,57110,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4487.31,5664, Remove vagina tissue compl,57111,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9234.98,,,,,,,fee schedule,5248,12821, Remove vagina tissue compl,57111,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,12821, Remove vagina tissue compl,57111,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5248,12821, Remove vagina tissue compl,57111,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5248,12821, Closure of vagina,57120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2638.32,,,,,,,fee schedule,2638.32,12821, Closure of vagina,57120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,2638.32,12821, Closure of vagina,57120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2638.32,12821, Closure of vagina,57120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2638.32,12821, Remove vagina lesion,57130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,854.73,,,,,,,fee schedule,854.73,10940, Remove vagina lesion,57130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,854.73,10940, Remove vagina lesion,57130,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,854.73,10940, Remove vagina lesion,57130,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,854.73,10940, Remove vagina lesion,57135,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,934.59,,,,,,,fee schedule,934.59,10940, Remove vagina lesion,57135,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,934.59,10940, Remove vagina lesion,57135,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,934.59,10940, Remove vagina lesion,57135,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,934.59,10940, Treat vagina infection,57150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,126.21,,,,,,,fee schedule,126.21,6979, Treat vagina infection,57150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,126.21,6979, Treat vagina infection,57150,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,126.21,6979, Treat vagina infection,57150,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,126.21,6979, Insert uteri tandem/ovoids,57155,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1315.38,,,,,,,fee schedule,1315.38,4497, Insert uteri tandem/ovoids,57155,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1315.38,4497, Insert uteri tandem/ovoids,57155,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,1315.38,4497, Insert uteri tandem/ovoids,57155,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,1315.38,4497, Ins vag brachytx device,57156,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,696.25,,,,,,,fee schedule,696.25,4108, Ins vag brachytx device,57156,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,696.25,4108, Ins vag brachytx device,57156,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,696.25,4108, Ins vag brachytx device,57156,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,696.25,4108, Insert pessary/other device,57160,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,230.19,,,,,,,fee schedule,230.19,6979, Insert pessary/other device,57160,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,230.19,6979, Insert pessary/other device,57160,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,230.19,6979, Insert pessary/other device,57160,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,230.19,6979, Fitting of diaphragm/cap,57170,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,236.51,,,,,,,fee schedule,236.51,6979, Fitting of diaphragm/cap,57170,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,236.51,6979, Fitting of diaphragm/cap,57170,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,236.51,6979, Fitting of diaphragm/cap,57170,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,236.51,6979, Treat vaginal bleeding,57180,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,590.59,,,,,,,fee schedule,590.59,6979, Treat vaginal bleeding,57180,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,590.59,6979, Treat vaginal bleeding,57180,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,590.59,6979, Treat vaginal bleeding,57180,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,590.59,6979, Repair of vagina,57200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1684.42,,,,,,,fee schedule,1684.42,10940, Repair of vagina,57200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1684.42,10940, Repair of vagina,57200,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1684.42,10940, Repair of vagina,57200,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1684.42,10940, Repair vagina/perineum,57210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1975.31,,,,,,,fee schedule,1975.31,10940, Repair vagina/perineum,57210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1975.31,10940, Repair vagina/perineum,57210,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1975.31,10940, Repair vagina/perineum,57210,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1975.31,10940, Revision of urethra,57220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1724.94,,,,,,,fee schedule,1724.94,14456, Revision of urethra,57220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1724.94,14456, Revision of urethra,57220,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,1724.94,14456, Revision of urethra,57220,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,1724.94,14456, Repair of urethral lesion,57230,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2078.05,,,,,,,fee schedule,2078.05,10940, Repair of urethral lesion,57230,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2078.05,10940, Repair of urethral lesion,57230,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2078.05,10940, Repair of urethral lesion,57230,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2078.05,10940, Repair bladder & vagina,57240,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3048.63,,,,,,,fee schedule,3048.63,12821, Repair bladder & vagina,57240,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,3048.63,12821, Repair bladder & vagina,57240,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3048.63,12821, Repair bladder & vagina,57240,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3048.63,12821, Repair rectum & vagina,57250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3054.3,,,,,,,fee schedule,3054.3,12821, Repair rectum & vagina,57250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,3054.3,12821, Repair rectum & vagina,57250,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3054.3,12821, Repair rectum & vagina,57250,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3054.3,12821, Repair of vagina,57260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3862.35,,,,,,,fee schedule,3862.35,12821, Repair of vagina,57260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,3862.35,12821, Repair of vagina,57260,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3862.35,12821, Repair of vagina,57260,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3862.35,12821, Extensive repair of vagina,57265,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4323.44,,,,,,,fee schedule,4323.44,14456, Extensive repair of vagina,57265,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,4323.44,14456, Extensive repair of vagina,57265,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4323.44,14456, Extensive repair of vagina,57265,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4323.44,14456, Insert mesh/pelvic flr addon,57267,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1244.97,,,,,,,fee schedule,1244.97,8406, Insert mesh/pelvic flr addon,57267,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,1244.97,8406, Insert mesh/pelvic flr addon,57267,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1244.97,8406, Insert mesh/pelvic flr addon,57267,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1244.97,8406, Repair of bowel bulge,57268,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2539.09,,,,,,,fee schedule,2539.09,10940, Repair of bowel bulge,57268,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2539.09,10940, Repair of bowel bulge,57268,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2539.09,10940, Repair of bowel bulge,57268,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2539.09,10940, Repair of bowel pouch,57270,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4050.72,,,,,,,fee schedule,4050.72,10940, Repair of bowel pouch,57270,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4050.72,10940, Repair of bowel pouch,57270,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,4050.72,10940, Repair of bowel pouch,57270,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,4050.72,10940, Suspension of vagina,57280,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4813.99,,,,,,,fee schedule,4813.99,10940, Suspension of vagina,57280,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4813.99,10940, Suspension of vagina,57280,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,4813.99,10940, Suspension of vagina,57280,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,4813.99,10940, Colpopexy extraperitoneal,57282,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3448.04,,,,,,,fee schedule,3448.04,14456, Colpopexy extraperitoneal,57282,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,3448.04,14456, Colpopexy extraperitoneal,57282,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3448.04,14456, Colpopexy extraperitoneal,57282,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3448.04,14456, Colpopexy intraperitoneal,57283,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3475.13,,,,,,,fee schedule,3475.13,14456, Colpopexy intraperitoneal,57283,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,3475.13,14456, Colpopexy intraperitoneal,57283,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3475.13,14456, Colpopexy intraperitoneal,57283,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3475.13,14456, Repair paravag defect open,57284,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4161.18,,,,,,,fee schedule,4161.18,14456, Repair paravag defect open,57284,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4161.18,14456, Repair paravag defect open,57284,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4161.18,14456, Repair paravag defect open,57284,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4161.18,14456, Repair paravag defect vag,57285,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3449.07,,,,,,,fee schedule,3449.07,14456, Repair paravag defect vag,57285,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3449.07,14456, Repair paravag defect vag,57285,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3449.07,14456, Repair paravag defect vag,57285,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3449.07,14456, Revise/Remove Sling Repair,57287,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3660.43,,,,,,,fee schedule,3660.43,12821, Revise/Remove Sling Repair,57287,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,3660.43,12821, Revise/Remove Sling Repair,57287,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3660.43,12821, Revise/Remove Sling Repair,57287,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3660.43,12821, Repair bladder defect,57288,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3705.76,,,,,,,fee schedule,3705.76,14456, Repair bladder defect,57288,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,3705.76,14456, Repair bladder defect,57288,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3705.76,14456, Repair bladder defect,57288,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3705.76,14456, Repair bladder & vagina,57289,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3924.56,,,,,,,fee schedule,3924.56,12821, Repair bladder & vagina,57289,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,3924.56,12821, Repair bladder & vagina,57289,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3924.56,12821, Repair bladder & vagina,57289,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3924.56,12821, Construction of vagina,57291,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2730.75,,,,,,,fee schedule,2730.75,10940, Construction of vagina,57291,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,2730.75,10940, Construction of vagina,57291,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2730.75,10940, Construction of vagina,57291,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2730.75,10940, Construct vagina with graft,57292,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4117.36,,,,,,,fee schedule,4117.36,12821, Construct vagina with graft,57292,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4117.36,12821, Construct vagina with graft,57292,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4117.36,12821, Construct vagina with graft,57292,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4117.36,12821, Revise vag graft via vagina,57295,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2496.68,,,,,,,fee schedule,2496.68,10940, Revise vag graft via vagina,57295,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2496.68,10940, Revise vag graft via vagina,57295,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2496.68,10940, Revise vag graft via vagina,57295,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2496.68,10940, Revise vag graft open abd,57296,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4755.93,,,,,,,fee schedule,4755.93,6979, Revise vag graft open abd,57296,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4755.93,6979, Revise vag graft open abd,57296,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4755.93,6979, Revise vag graft open abd,57296,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4755.93,6979, Repair rectum-vagina fistula,57300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3136.21,,,,,,,fee schedule,3136.21,10940, Repair rectum-vagina fistula,57300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3136.21,10940, Repair rectum-vagina fistula,57300,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3136.21,10940, Repair rectum-vagina fistula,57300,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3136.21,10940, Repair rectum-vagina fistula,57305,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5049.85,,,,,,,fee schedule,5049.85,6044, Repair rectum-vagina fistula,57305,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,5049.85,6044, Repair rectum-vagina fistula,57305,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5049.85,6044, Repair rectum-vagina fistula,57305,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5049.85,6044, Fistula repair & colostomy,57307,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5520.43,,,,,,,fee schedule,5097,6979, Fistula repair & colostomy,57307,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Fistula repair & colostomy,57307,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Fistula repair & colostomy,57307,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Fistula repair transperine,57308,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3480.85,,,,,,,fee schedule,3480.85,10940, Fistula repair transperine,57308,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3480.85,10940, Fistula repair transperine,57308,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3480.85,10940, Fistula repair transperine,57308,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3480.85,10940, Repair urethrovaginal lesion,57310,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2469.53,,,,,,,fee schedule,2469.53,14456, Repair urethrovaginal lesion,57310,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2469.53,14456, Repair urethrovaginal lesion,57310,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,2469.53,14456, Repair urethrovaginal lesion,57310,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,2469.53,14456, Repair urethrovaginal lesion,57311,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2779.37,,,,,,,fee schedule,2779.37,12821, Repair urethrovaginal lesion,57311,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2779.37,12821, Repair urethrovaginal lesion,57311,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2779.37,12821, Repair urethrovaginal lesion,57311,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2779.37,12821, Repair bladder-vagina lesion,57320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2804.52,,,,,,,fee schedule,2804.52,12821, Repair bladder-vagina lesion,57320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2804.52,12821, Repair bladder-vagina lesion,57320,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2804.52,12821, Repair bladder-vagina lesion,57320,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2804.52,12821, Repair bladder-vagina lesion,57330,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3817.67,,,,,,,fee schedule,3817.67,12821, Repair bladder-vagina lesion,57330,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3817.67,12821, Repair bladder-vagina lesion,57330,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3817.67,12821, Repair bladder-vagina lesion,57330,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3817.67,12821, Repair vagina,57335,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5837.72,,,,,,,fee schedule,5248,10940, Repair vagina,57335,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,10940, Repair vagina,57335,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,5248,10940, Repair vagina,57335,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,5248,10940, Dilation of vagina,57400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,652.16,,,,,,,fee schedule,652.16,10940, Dilation of vagina,57400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,652.16,10940, Dilation of vagina,57400,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,652.16,10940, Dilation of vagina,57400,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,652.16,10940, Pelvic examination,57410,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,541.11,,,,,,,fee schedule,541.11,10940, Pelvic examination,57410,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,541.11,10940, Pelvic examination,57410,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,541.11,10940, Pelvic examination,57410,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,541.11,10940, Remove vaginal foreign body,57415,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,866.06,,,,,,,fee schedule,866.06,10940, Remove vaginal foreign body,57415,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,866.06,10940, Remove vaginal foreign body,57415,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,866.06,10940, Remove vaginal foreign body,57415,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,866.06,10940, Exam of vagina w/scope,57420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,460.66,,,,,,,fee schedule,460.66,3195, Exam of vagina w/scope,57420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,460.66,3195, Exam of vagina w/scope,57420,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,460.66,3195, Exam of vagina w/scope,57420,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,460.66,3195, Exam/biopsy of vag w/scope,57421,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,621.89,,,,,,,fee schedule,621.89,4497, Exam/biopsy of vag w/scope,57421,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,621.89,4497, Exam/biopsy of vag w/scope,57421,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,621.89,4497, Exam/biopsy of vag w/scope,57421,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,621.89,4497, Repair paravag defect lap,57423,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4622.75,,,,,,,fee schedule,4622.75,22111, Repair paravag defect lap,57423,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4622.75,22111, Repair paravag defect lap,57423,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4622.75,22111, Repair paravag defect lap,57423,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4622.75,22111, Laparoscopy surg colpopexy,57425,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4839.51,,,,,,,fee schedule,4839.51,22111, Laparoscopy surg colpopexy,57425,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4839.51,22111, Laparoscopy surg colpopexy,57425,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4839.51,22111, Laparoscopy surg colpopexy,57425,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4839.51,22111, Revise prosth vag graft lap,57426,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4342.81,,,,,,,fee schedule,4342.81,12821, Revise prosth vag graft lap,57426,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4342.81,12821, Revise prosth vag graft lap,57426,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4342.81,12821, Revise prosth vag graft lap,57426,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4342.81,12821, Exam of cervix w/scope,57452,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,462.81,,,,,,,fee schedule,462.81,4108, Exam of cervix w/scope,57452,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,462.81,4108, Exam of cervix w/scope,57452,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,462.81,4108, Exam of cervix w/scope,57452,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,462.81,4108, Bx/curett of cervix w/scope,57454,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,670.83,,,,,,,fee schedule,670.83,4108, Bx/curett of cervix w/scope,57454,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,670.83,4108, Bx/curett of cervix w/scope,57454,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,670.83,4108, Bx/curett of cervix w/scope,57454,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,670.83,4108, Biopsy of cervix w/scope,57455,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,548.83,,,,,,,fee schedule,548.83,3195, Biopsy of cervix w/scope,57455,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,548.83,3195, Biopsy of cervix w/scope,57455,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,548.83,3195, Biopsy of cervix w/scope,57455,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,548.83,3195, Endocerv curettage w/scope,57456,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,506.85,,,,,,,fee schedule,506.85,3195, Endocerv curettage w/scope,57456,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,506.85,3195, Endocerv curettage w/scope,57456,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,506.85,3195, Endocerv curettage w/scope,57456,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,506.85,3195, Bx of cervix w/scope leep,57460,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,799.74,,,,,,,fee schedule,799.74,10940, Bx of cervix w/scope leep,57460,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,799.74,10940, Bx of cervix w/scope leep,57460,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,799.74,10940, Bx of cervix w/scope leep,57460,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,799.74,10940, Conz of cervix w/scope leep,57461,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,919.59,,,,,,,fee schedule,919.59,10940, Conz of cervix w/scope leep,57461,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,919.59,10940, Conz of cervix w/scope leep,57461,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,919.59,10940, Conz of cervix w/scope leep,57461,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,919.59,10940, Cam cervix uteri drg colp,57465,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,209.58,,,,,,,fee schedule,209.58,2782, Cam cervix uteri drg colp,57465,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,209.58,2782, Cam cervix uteri drg colp,57465,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,209.58,2782, Biopsy of cervix,57500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,383.22,,,,,,,fee schedule,383.22,4497, Biopsy of cervix,57500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,383.22,4497, Biopsy of cervix,57500,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,383.22,4497, Biopsy of cervix,57500,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,383.22,4497, Endocervical curettage,57505,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,543.38,,,,,,,fee schedule,543.38,4497, Endocervical curettage,57505,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,543.38,4497, Endocervical curettage,57505,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,543.38,4497, Endocervical curettage,57505,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,543.38,4497, Cauterization of cervix,57510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,575.43,,,,,,,fee schedule,575.43,10940, Cauterization of cervix,57510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,575.43,10940, Cauterization of cervix,57510,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,575.43,10940, Cauterization of cervix,57510,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,575.43,10940, Cryocautery of cervix,57511,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,727.43,,,,,,,fee schedule,727.43,3195, Cryocautery of cervix,57511,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,727.43,3195, Cryocautery of cervix,57511,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,727.43,3195, Cryocautery of cervix,57511,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,727.43,3195, Laser surgery of cervix,57513,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,723.98,,,,,,,fee schedule,723.98,10940, Laser surgery of cervix,57513,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,723.98,10940, Laser surgery of cervix,57513,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,723.98,10940, Laser surgery of cervix,57513,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,723.98,10940, Conization of cervix,57520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1520.81,,,,,,,fee schedule,1520.81,10940, Conization of cervix,57520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1520.81,10940, Conization of cervix,57520,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1520.81,10940, Conization of cervix,57520,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1520.81,10940, Conization of cervix,57522,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1285.54,,,,,,,fee schedule,1285.54,10940, Conization of cervix,57522,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1285.54,10940, Conization of cervix,57522,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1285.54,10940, Conization of cervix,57522,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1285.54,10940, Removal of cervix,57530,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1886.71,,,,,,,fee schedule,1886.71,10940, Removal of cervix,57530,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1886.71,10940, Removal of cervix,57530,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1886.71,10940, Removal of cervix,57530,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1886.71,10940, Removal of cervix radical,57531,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9580.81,,,,,,,fee schedule,5097,9580.81, Removal of cervix radical,57531,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,9580.81, Removal of cervix radical,57531,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,9580.81, Removal of cervix radical,57531,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,9580.81, Removal of residual cervix,57540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3936.27,,,,,,,fee schedule,3936.27,6979, Removal of residual cervix,57540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3936.27,6979, Removal of residual cervix,57540,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3936.27,6979, Removal of residual cervix,57540,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3936.27,6979, Remove cervix/repair pelvis,57545,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4145.85,,,,,,,fee schedule,4145.85,6979, Remove cervix/repair pelvis,57545,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4145.85,6979, Remove cervix/repair pelvis,57545,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4145.85,6979, Remove cervix/repair pelvis,57545,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4145.85,6979, Removal of residual cervix,57550,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2148.26,,,,,,,fee schedule,2148.26,10940, Removal of residual cervix,57550,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2148.26,10940, Removal of residual cervix,57550,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2148.26,10940, Removal of residual cervix,57550,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2148.26,10940, Remove cervix/repair vagina,57555,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3080.52,,,,,,,fee schedule,3080.52,12821, Remove cervix/repair vagina,57555,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3080.52,12821, Remove cervix/repair vagina,57555,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3080.52,12821, Remove cervix/repair vagina,57555,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3080.52,12821, Remove cervix repair bowel,57556,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2927.65,,,,,,,fee schedule,2927.65,14456, Remove cervix repair bowel,57556,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,2927.65,14456, Remove cervix repair bowel,57556,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,2927.65,14456, Remove cervix repair bowel,57556,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,2927.65,14456, D&C oF Cervical Stump,57558,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,629.44,,,,,,,fee schedule,629.44,10940, D&C oF Cervical Stump,57558,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,629.44,10940, D&C oF Cervical Stump,57558,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,629.44,10940, D&C oF Cervical Stump,57558,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,629.44,10940, Revision of cervix,57700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1751.33,,,,,,,fee schedule,1751.33,10940, Revision of cervix,57700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1751.33,10940, Revision of cervix,57700,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1751.33,10940, Revision of cervix,57700,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1751.33,10940, Revision of cervix,57720,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1657.33,,,,,,,fee schedule,1657.33,10940, Revision of cervix,57720,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1657.33,10940, Revision of cervix,57720,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1657.33,10940, Revision of cervix,57720,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1657.33,10940, Dilation of cervical canal,57800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,243.74,,,,,,,fee schedule,243.74,10940, Dilation of cervical canal,57800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,243.74,10940, Dilation of cervical canal,57800,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,243.74,10940, Dilation of cervical canal,57800,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,243.74,10940, Biopsy of uterus lining,58100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,314.37,,,,,,,fee schedule,314.37,3195, Biopsy of uterus lining,58100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,314.37,3195, Biopsy of uterus lining,58100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,314.37,3195, Biopsy of uterus lining,58100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,314.37,3195, Bx done w/colposcopy add-on,58110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,202.4,,,,,,,fee schedule,202.4,3195, Bx done w/colposcopy add-on,58110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,202.4,3195, Bx done w/colposcopy add-on,58110,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,202.4,3195, Bx done w/colposcopy add-on,58110,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,202.4,3195, Dilation and curettage,58120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1173.9,,,,,,,fee schedule,1173.9,10940, Dilation and curettage,58120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1173.9,10940, Dilation and curettage,58120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1173.9,10940, Dilation and curettage,58120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1173.9,10940, Myomectomy abdom method,58140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4582.12,,,,,,,fee schedule,4582.12,12821, Myomectomy abdom method,58140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,4582.12,12821, Myomectomy abdom method,58140,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4582.12,12821, Myomectomy abdom method,58140,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4582.12,12821, Myomectomy vag method,58145,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2791.94,,,,,,,fee schedule,2791.94,10940, Myomectomy vag method,58145,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,2791.94,10940, Myomectomy vag method,58145,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2791.94,10940, Myomectomy vag method,58145,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2791.94,10940, Myomectomy abdom complex,58146,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5733.84,,,,,,,fee schedule,5733.84,12821, Myomectomy abdom complex,58146,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5733.84,12821, Myomectomy abdom complex,58146,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5733.84,12821, Myomectomy abdom complex,58146,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5733.84,12821, Total hysterectomy,58150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5284.14,,,,,,,fee schedule,5284.14,12821, Total hysterectomy,58150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,5284.14,12821, Total hysterectomy,58150,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5284.14,12821, Total hysterectomy,58150,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5284.14,12821, Total hysterectomy,58152,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6161.64,,,,,,,fee schedule,5097,8406, Total hysterectomy,58152,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,5097,8406, Total hysterectomy,58152,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8406, Total hysterectomy,58152,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8406, Partial hysterectomy,58180,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4898.33,,,,,,,fee schedule,4898.33,12821, Partial hysterectomy,58180,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,4898.33,12821, Partial hysterectomy,58180,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4898.33,12821, Partial hysterectomy,58180,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4898.33,12821, Extensive hysterectomy,58200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7145.6,,,,,,,fee schedule,5097,8406, Extensive hysterectomy,58200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,5097,8406, Extensive hysterectomy,58200,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8406, Extensive hysterectomy,58200,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8406, Extensive hysterectomy,58210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9537.48,,,,,,,fee schedule,5097,9537.48, Extensive hysterectomy,58210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,5097,9537.48, Extensive hysterectomy,58210,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,9537.48, Extensive hysterectomy,58210,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,9537.48, Removal of pelvis contents,58240,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,15162.92,,,,,,,fee schedule,5097,15162.92, Removal of pelvis contents,58240,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,15162.92, Removal of pelvis contents,58240,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,15162.92, Removal of pelvis contents,58240,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,15162.92, Vaginal hysterectomy,58260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4172.83,,,,,,,fee schedule,4172.83,12821, Vaginal hysterectomy,58260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4172.83,12821, Vaginal hysterectomy,58260,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4172.83,12821, Vaginal hysterectomy,58260,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4172.83,12821, Vag hyst including t/o,58262,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4610.56,,,,,,,fee schedule,4610.56,12821, Vag hyst including t/o,58262,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4610.56,12821, Vag hyst including t/o,58262,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4610.56,12821, Vag hyst including t/o,58262,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4610.56,12821, Vag hyst w/t/o & vag repair,58263,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4947.43,,,,,,,fee schedule,4947.43,12821, Vag hyst w/t/o & vag repair,58263,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4947.43,12821, Vag hyst w/t/o & vag repair,58263,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4947.43,12821, Vag hyst w/t/o & vag repair,58263,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4947.43,12821, Vag hyst w/urinary repair,58267,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5299.09,,,,,,,fee schedule,5299.09,12821, Vag hyst w/urinary repair,58267,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5299.09,12821, Vag hyst w/urinary repair,58267,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5299.09,12821, Vag hyst w/urinary repair,58267,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5299.09,12821, Vag hyst w/enterocele repair,58270,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4473.45,,,,,,,fee schedule,4473.45,12821, Vag hyst w/enterocele repair,58270,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4473.45,12821, Vag hyst w/enterocele repair,58270,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4473.45,12821, Vag hyst w/enterocele repair,58270,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4473.45,12821, Hysterectomy/revise vagina,58275,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4937.23,,,,,,,fee schedule,4937.23,12821, Hysterectomy/revise vagina,58275,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4937.23,12821, Hysterectomy/revise vagina,58275,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4937.23,12821, Hysterectomy/revise vagina,58275,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4937.23,12821, Hysterectomy/revise vagina,58280,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5260.94,,,,,,,fee schedule,5260.94,12821, Hysterectomy/revise vagina,58280,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5260.94,12821, Hysterectomy/revise vagina,58280,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5260.94,12821, Hysterectomy/revise vagina,58280,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5260.94,12821, Extensive hysterectomy,58285,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7554.51,,,,,,,fee schedule,5097,7554.51, Extensive hysterectomy,58285,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7554.51, Extensive hysterectomy,58285,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7554.51, Extensive hysterectomy,58285,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7554.51, Vag hyst complex,58290,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5717.82,,,,,,,fee schedule,5717.82,14456, Vag hyst complex,58290,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,5717.82,14456, Vag hyst complex,58290,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5717.82,14456, Vag hyst complex,58290,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5717.82,14456, Vag hyst incl t/o complex,58291,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6178.2,,,,,,,fee schedule,6044,14456, Vag hyst incl t/o complex,58291,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,14456, Vag hyst incl t/o complex,58291,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,6044,14456, Vag hyst incl t/o complex,58291,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,6044,14456, Vag hyst t/o & repair compl,58292,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6509.68,,,,,,,fee schedule,6044,14456, Vag hyst t/o & repair compl,58292,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,14456, Vag hyst t/o & repair compl,58292,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,6044,14456, Vag hyst t/o & repair compl,58292,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,6044,14456, Vag hyst w/enterocele compl,58294,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6046.49,,,,,,,fee schedule,6044,14456, Vag hyst w/enterocele compl,58294,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,14456, Vag hyst w/enterocele compl,58294,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,6044,14456, Vag hyst w/enterocele compl,58294,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,6044,14456, Insert intrauterine device,58300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Insert intrauterine device,58300,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Insert intrauterine device,58300,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Remove intrauterine device,58301,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,328.62,,,,,,,fee schedule,328.62,3195, Remove intrauterine device,58301,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,328.62,3195, Remove intrauterine device,58301,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,328.62,3195, Remove intrauterine device,58301,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,328.62,3195, Artificial insemination,58321,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,238.29,,,,,,,fee schedule,238.29,6979, Artificial insemination,58321,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,238.29,6979, Artificial insemination,58321,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,238.29,6979, Artificial insemination,58321,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,238.29,6979, Artificial insemination,58322,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,283.94,,,,,,,fee schedule,283.94,6979, Artificial insemination,58322,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,283.94,6979, Artificial insemination,58322,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,283.94,6979, Artificial insemination,58322,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,283.94,6979, Sperm washing,58323,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,59.09,,,,,,,fee schedule,59.09,6979, Sperm washing,58323,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,59.09,6979, Sperm washing,58323,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,59.09,6979, Sperm washing,58323,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,59.09,6979, Catheter for hysterography,58340,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,289.39,,,,,,,fee schedule,289.39,3195, Catheter for hysterography,58340,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,289.39,3195, Catheter for hysterography,58340,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,289.39,3195, Catheter for hysterography,58340,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,289.39,3195, Reopen fallopian tube,58345,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1432.53,,,,,,,fee schedule,1432.53,10940, Reopen fallopian tube,58345,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1432.53,10940, Reopen fallopian tube,58345,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1432.53,10940, Reopen fallopian tube,58345,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1432.53,10940, Insert heyman uteri capsule,58346,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2281.43,,,,,,,fee schedule,2281.43,10940, Insert heyman uteri capsule,58346,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2281.43,10940, Insert heyman uteri capsule,58346,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2281.43,10940, Insert heyman uteri capsule,58346,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2281.43,10940, Reopen fallopian tube,58350,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,458.39,,,,,,,fee schedule,458.39,12821, Reopen fallopian tube,58350,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,458.39,12821, Reopen fallopian tube,58350,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,458.39,12821, Reopen fallopian tube,58350,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,458.39,12821, Endometr ablate thermal,58353,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1138.99,,,,,,,fee schedule,1138.99,12821, Endometr ablate thermal,58353,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,1138.99,12821, Endometr ablate thermal,58353,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,1138.99,12821, Endometr ablate thermal,58353,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,1138.99,12821, Endometrial cryoablation,58356,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1734.54,,,,,,,fee schedule,1734.54,14456, Endometrial cryoablation,58356,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,1734.54,14456, Endometrial cryoablation,58356,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,1734.54,14456, Endometrial cryoablation,58356,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,1734.54,14456, Suspension of uterus,58400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2311.75,,,,,,,fee schedule,2311.75,12821, Suspension of uterus,58400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,2311.75,12821, Suspension of uterus,58400,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2311.75,12821, Suspension of uterus,58400,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2311.75,12821, Suspension of uterus,58410,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4055.96,,,,,,,fee schedule,4055.96,6979, Suspension of uterus,58410,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4055.96,6979, Suspension of uterus,58410,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4055.96,6979, Suspension of uterus,58410,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4055.96,6979, Repair of ruptured uterus,58520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3972.64,,,,,,,fee schedule,3972.64,6044, Repair of ruptured uterus,58520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,3972.64,6044, Repair of ruptured uterus,58520,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3972.64,6044, Repair of ruptured uterus,58520,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3972.64,6044, Revision of uterus,58540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4561.56,,,,,,,fee schedule,4561.56,8406, Revision of uterus,58540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,4561.56,8406, Revision of uterus,58540,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4561.56,8406, Revision of uterus,58540,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4561.56,8406, Lsh uterus 250 g or less,58541,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3634.31,,,,,,,fee schedule,3634.31,22111, Lsh uterus 250 g or less,58541,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,3634.31,22111, Lsh uterus 250 g or less,58541,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3634.31,22111, Lsh uterus 250 g or less,58541,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3634.31,22111, Lsh w/t/o ut 250 g or less,58542,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4125.89,,,,,,,fee schedule,4125.89,22111, Lsh w/t/o ut 250 g or less,58542,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4125.89,22111, Lsh w/t/o ut 250 g or less,58542,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4125.89,22111, Lsh w/t/o ut 250 g or less,58542,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4125.89,22111, LSH Uterus Above 250 g,58543,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4185.03,,,,,,,fee schedule,4185.03,22111, LSH Uterus Above 250 g,58543,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4185.03,22111, LSH Uterus Above 250 g,58543,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4185.03,22111, LSH Uterus Above 250 g,58543,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4185.03,22111, LSH w/t/o Uterus Above 250 g,58544,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4516.83,,,,,,,fee schedule,4516.83,22111, LSH w/t/o Uterus Above 250 g,58544,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4516.83,22111, LSH w/t/o Uterus Above 250 g,58544,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4516.83,22111, LSH w/t/o Uterus Above 250 g,58544,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4516.83,22111, Laparoscopic myomectomy,58545,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4570.14,,,,,,,fee schedule,4570.14,14456, Laparoscopic myomectomy,58545,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4570.14,14456, Laparoscopic myomectomy,58545,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4570.14,14456, Laparoscopic myomectomy,58545,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4570.14,14456, Laparo-myomectomy complex,58546,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5542.93,,,,,,,fee schedule,5542.93,22111, Laparo-myomectomy complex,58546,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,5542.93,22111, Laparo-myomectomy complex,58546,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5542.93,22111, Laparo-myomectomy complex,58546,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5542.93,22111, Lap Radical Hyst,58548,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9814.3,,,,,,,fee schedule,6979,14456, Lap Radical Hyst,58548,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,14456, Lap Radical Hyst,58548,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,6979,14456, Lap Radical Hyst,58548,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,6979,14456, Laparo-asst vag hysterectomy,58550,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4432.71,,,,,,,fee schedule,4432.71,22111, Laparo-asst vag hysterectomy,58550,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4432.71,22111, Laparo-asst vag hysterectomy,58550,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4432.71,22111, Laparo-asst vag hysterectomy,58550,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4432.71,22111, Laparo-vag hyst incl t/o,58552,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4954.82,,,,,,,fee schedule,4954.82,22111, Laparo-vag hyst incl t/o,58552,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,4954.82,22111, Laparo-vag hyst incl t/o,58552,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4954.82,22111, Laparo-vag hyst incl t/o,58552,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4954.82,22111, Laparo-vag hyst complex,58553,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5577.85,,,,,,,fee schedule,5577.85,22111, Laparo-vag hyst complex,58553,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,5577.85,22111, Laparo-vag hyst complex,58553,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5577.85,22111, Laparo-vag hyst complex,58553,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5577.85,22111, Laparo-vag hyst w/t/o compl,58554,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6577.45,,,,,,,fee schedule,6577.45,22111, Laparo-vag hyst w/t/o compl,58554,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,6577.45,22111, Laparo-vag hyst w/t/o compl,58554,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6577.45,22111, Laparo-vag hyst w/t/o compl,58554,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6577.45,22111, Hysteroscopy dx sep proc,58555,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,759.22,,,,,,,fee schedule,759.22,10940, Hysteroscopy dx sep proc,58555,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,759.22,10940, Hysteroscopy dx sep proc,58555,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,759.22,10940, Hysteroscopy dx sep proc,58555,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,759.22,10940, Hysteroscopy biopsy,58558,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1157.77,,,,,,,fee schedule,1157.77,10940, Hysteroscopy biopsy,58558,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1157.77,10940, Hysteroscopy biopsy,58558,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1157.77,10940, Hysteroscopy biopsy,58558,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1157.77,10940, Hysteroscopy lysis,58559,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1413.32,,,,,,,fee schedule,1413.32,10940, Hysteroscopy lysis,58559,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1413.32,10940, Hysteroscopy lysis,58559,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1413.32,10940, Hysteroscopy lysis,58559,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1413.32,10940, Hysteroscopy resect septum,58560,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1561.12,,,,,,,fee schedule,1561.12,12821, Hysteroscopy resect septum,58560,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1561.12,12821, Hysteroscopy resect septum,58560,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,1561.12,12821, Hysteroscopy resect septum,58560,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,1561.12,12821, Hysteroscopy remove myoma,58561,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1784.08,,,,,,,fee schedule,1784.08,12821, Hysteroscopy remove myoma,58561,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1784.08,12821, Hysteroscopy remove myoma,58561,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,1784.08,12821, Hysteroscopy remove myoma,58561,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,1784.08,12821, Hysteroscopy remove fb,58562,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1104.18,,,,,,,fee schedule,1104.18,10940, Hysteroscopy remove fb,58562,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1104.18,10940, Hysteroscopy remove fb,58562,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1104.18,10940, Hysteroscopy remove fb,58562,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1104.18,10940, Hysteroscopy ablation,58563,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1231.42,,,,,,,fee schedule,1231.42,12821, Hysteroscopy ablation,58563,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,1231.42,12821, Hysteroscopy ablation,58563,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,1231.42,12821, Hysteroscopy ablation,58563,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,1231.42,12821, Hysteroscopy sterilization,58565,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2260.17,,,,,,,fee schedule,2260.17,14456, Hysteroscopy sterilization,58565,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2260.17,14456, Hysteroscopy sterilization,58565,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,2260.17,14456, Hysteroscopy sterilization,58565,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,2260.17,14456, Tlh uterus 250 g or less,58570,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4098.8,,,,,,,fee schedule,4098.8,22111, Tlh uterus 250 g or less,58570,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4098.8,22111, Tlh uterus 250 g or less,58570,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4098.8,22111, Tlh uterus 250 g or less,58570,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4098.8,22111, Tlh w/t/o 250 g or less,58571,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4683.62,,,,,,,fee schedule,4683.62,22111, Tlh w/t/o 250 g or less,58571,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4683.62,22111, Tlh w/t/o 250 g or less,58571,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4683.62,22111, Tlh w/t/o 250 g or less,58571,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4683.62,22111, Tlh uterus over 250 g,58572,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5356.88,,,,,,,fee schedule,5356.88,22111, Tlh uterus over 250 g,58572,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5356.88,22111, Tlh uterus over 250 g,58572,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5356.88,22111, Tlh uterus over 250 g,58572,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5356.88,22111, Tlh w/t/o uterus over 250 g,58573,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6267.13,,,,,,,fee schedule,6267.13,22111, Tlh w/t/o uterus over 250 g,58573,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6267.13,22111, Tlh w/t/o uterus over 250 g,58573,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6267.13,22111, Tlh w/t/o uterus over 250 g,58573,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6267.13,22111, Laps tot hyst resj mal,58575,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10086.96,,,,,,,fee schedule,6979,12821, Laps tot hyst resj mal,58575,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,12821, Laps tot hyst resj mal,58575,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,6979,12821, Laps tot hyst resj mal,58575,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,6979,12821, Laparo proc uterus,58578,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,14456, Laparo proc uterus,58578,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5248,14456, Laparo proc uterus,58578,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5248,14456, Hysteroscope procedure,58579,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2505,5248, Hysteroscope procedure,58579,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,5248, Hysteroscope procedure,58579,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,5248, Transcrv abltj utrn fibrd rf,58580,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2038.82,,,,,,,fee schedule,2038.82,14456, Transcrv abltj utrn fibrd rf,58580,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,2038.82,14456, Transcrv abltj utrn fibrd rf,58580,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,2038.82,14456, Transcrv abltj utrn fibrd rf,58580,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,2038.82,14456, Division of fallopian tube,58600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1860.65,,,,,,,fee schedule,1860.65,10940, Division of fallopian tube,58600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1860.65,10940, Division of fallopian tube,58600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1860.65,10940, Division of fallopian tube,58600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1860.65,10940, Division of fallopian tube,58605,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1689.87,,,,,,,fee schedule,1689.87,5664, Division of fallopian tube,58605,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1689.87,5664, Division of fallopian tube,58605,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1689.87,5664, Division of fallopian tube,58605,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1689.87,5664, Ligate oviduct(s) add-on,58611,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,370.81,,,,,,,fee schedule,370.81,5664, Ligate oviduct(s) add-on,58611,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,370.81,5664, Ligate oviduct(s) add-on,58611,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,370.81,5664, Ligate oviduct(s) add-on,58611,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,370.81,5664, Occlude fallopian tube(s),58615,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1261.26,,,,,,,fee schedule,1261.26,10940, Occlude fallopian tube(s),58615,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1261.26,10940, Occlude fallopian tube(s),58615,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1261.26,10940, Occlude fallopian tube(s),58615,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1261.26,10940, Laparoscopy lysis,58660,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3560.82,,,,,,,fee schedule,3560.82,22111, Laparoscopy lysis,58660,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,3560.82,22111, Laparoscopy lysis,58660,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3560.82,22111, Laparoscopy lysis,58660,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3560.82,22111, Laparoscopy remove adnexa,58661,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3321.67,,,,,,,fee schedule,3321.67,22111, Laparoscopy remove adnexa,58661,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,3321.67,22111, Laparoscopy remove adnexa,58661,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3321.67,22111, Laparoscopy remove adnexa,58661,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3321.67,22111, Laparoscopy excise lesions,58662,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3656.49,,,,,,,fee schedule,3656.49,22111, Laparoscopy excise lesions,58662,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,3656.49,22111, Laparoscopy excise lesions,58662,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3656.49,22111, Laparoscopy excise lesions,58662,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3656.49,22111, Laparoscopy tubal cautery,58670,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1864.1,,,,,,,fee schedule,1864.1,22111, Laparoscopy tubal cautery,58670,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1864.1,22111, Laparoscopy tubal cautery,58670,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,1864.1,22111, Laparoscopy tubal cautery,58670,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,1864.1,22111, Laparoscopy tubal block,58671,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1864.1,,,,,,,fee schedule,1864.1,22111, Laparoscopy tubal block,58671,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1864.1,22111, Laparoscopy tubal block,58671,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,1864.1,22111, Laparoscopy tubal block,58671,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,1864.1,22111, Laparoscopy fimbrioplasty,58672,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3642.14,,,,,,,fee schedule,3642.14,22111, Laparoscopy fimbrioplasty,58672,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,3642.14,22111, Laparoscopy fimbrioplasty,58672,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3642.14,22111, Laparoscopy fimbrioplasty,58672,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3642.14,22111, Laparoscopy salpingostomy,58673,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3954.89,,,,,,,fee schedule,3954.89,22111, Laparoscopy salpingostomy,58673,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,3954.89,22111, Laparoscopy salpingostomy,58673,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3954.89,22111, Laparoscopy salpingostomy,58673,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3954.89,22111, Laps abltj uterine fibroids,58674,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4063.03,,,,,,,fee schedule,4063.03,22111, Laps abltj uterine fibroids,58674,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4063.03,22111, Laps abltj uterine fibroids,58674,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4063.03,22111, Laps abltj uterine fibroids,58674,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4063.03,22111, Laparo proc oviduct-ovary,58679,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,14456, Laparo proc oviduct-ovary,58679,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5248,14456, Laparo proc oviduct-ovary,58679,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5248,14456, Removal of fallopian tube,58700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4113.86,,,,,,,fee schedule,4113.86,12821, Removal of fallopian tube,58700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4113.86,12821, Removal of fallopian tube,58700,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4113.86,12821, Removal of fallopian tube,58700,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4113.86,12821, Removal of ovary/tube(s),58720,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3936.44,,,,,,,fee schedule,3936.44,14456, Removal of ovary/tube(s),58720,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,3936.44,14456, Removal of ovary/tube(s),58720,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3936.44,14456, Removal of ovary/tube(s),58720,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3936.44,14456, Adhesiolysis tube ovary,58740,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4658.96,,,,,,,fee schedule,4658.96,10940, Adhesiolysis tube ovary,58740,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4658.96,10940, Adhesiolysis tube ovary,58740,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,4658.96,10940, Adhesiolysis tube ovary,58740,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,4658.96,10940, Repair oviduct,58750,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4521.09,,,,,,,fee schedule,4521.09,12821, Repair oviduct,58750,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4521.09,12821, Repair oviduct,58750,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4521.09,12821, Repair oviduct,58750,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4521.09,12821, Revise ovarian tube(s),58752,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4507.33,,,,,,,fee schedule,4507.33,12821, Revise ovarian tube(s),58752,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4507.33,12821, Revise ovarian tube(s),58752,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4507.33,12821, Revise ovarian tube(s),58752,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4507.33,12821, Fimbrioplasty,58760,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4079.54,,,,,,,fee schedule,4079.54,12821, Fimbrioplasty,58760,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4079.54,12821, Fimbrioplasty,58760,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4079.54,12821, Fimbrioplasty,58760,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4079.54,12821, Create new tubal opening,58770,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4285.18,,,,,,,fee schedule,4285.18,10940, Create new tubal opening,58770,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4285.18,10940, Create new tubal opening,58770,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,4285.18,10940, Create new tubal opening,58770,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,4285.18,10940, Drainage of ovarian cyst(s),58800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1566.08,,,,,,,fee schedule,1566.08,10940, Drainage of ovarian cyst(s),58800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1566.08,10940, Drainage of ovarian cyst(s),58800,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1566.08,10940, Drainage of ovarian cyst(s),58800,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1566.08,10940, Drainage of ovarian cyst(s),58805,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2124.03,,,,,,,fee schedule,2124.03,10940, Drainage of ovarian cyst(s),58805,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2124.03,10940, Drainage of ovarian cyst(s),58805,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2124.03,10940, Drainage of ovarian cyst(s),58805,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2124.03,10940, Drain ovary abscess open,58820,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1682.42,,,,,,,fee schedule,1682.42,10940, Drain ovary abscess open,58820,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1682.42,10940, Drain ovary abscess open,58820,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1682.42,10940, Drain ovary abscess open,58820,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1682.42,10940, Drain ovary abscess percut,58822,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3553.81,,,,,,,fee schedule,3553.81,12821, Drain ovary abscess percut,58822,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3553.81,12821, Drain ovary abscess percut,58822,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3553.81,12821, Drain ovary abscess percut,58822,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3553.81,12821, Transposition ovary(s),58825,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3526.83,,,,,,,fee schedule,3526.83,12821, Transposition ovary(s),58825,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3526.83,12821, Transposition ovary(s),58825,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3526.83,12821, Transposition ovary(s),58825,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3526.83,12821, Biopsy of ovary(s),58900,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2169.68,,,,,,,fee schedule,2169.68,10940, Biopsy of ovary(s),58900,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2169.68,10940, Biopsy of ovary(s),58900,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2169.68,10940, Biopsy of ovary(s),58900,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2169.68,10940, Partial removal of ovary(s),58920,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3551,,,,,,,fee schedule,3551,12821, Partial removal of ovary(s),58920,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3551,12821, Partial removal of ovary(s),58920,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3551,12821, Partial removal of ovary(s),58920,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3551,12821, Removal of ovarian cyst(s),58925,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3934.82,,,,,,,fee schedule,3934.82,12821, Removal of ovarian cyst(s),58925,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,3934.82,12821, Removal of ovarian cyst(s),58925,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3934.82,12821, Removal of ovarian cyst(s),58925,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3934.82,12821, Removal of ovary(s),58940,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2886.75,,,,,,,fee schedule,2886.75,12821, Removal of ovary(s),58940,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,2886.75,12821, Removal of ovary(s),58940,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2886.75,12821, Removal of ovary(s),58940,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2886.75,12821, Removal of ovary(s),58943,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6411.9,,,,,,,fee schedule,6411.9,12821, Removal of ovary(s),58943,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6411.9,12821, Removal of ovary(s),58943,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,6411.9,12821, Removal of ovary(s),58943,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,6411.9,12821, Resect ovarian malignancy,58950,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6039.42,,,,,,,fee schedule,6039.42,12821, Resect ovarian malignancy,58950,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6039.42,12821, Resect ovarian malignancy,58950,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,6039.42,12821, Resect ovarian malignancy,58950,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,6039.42,12821, Resect ovarian malignancy,58951,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7556.77,,,,,,,fee schedule,5097,7556.77, Resect ovarian malignancy,58951,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7556.77, Resect ovarian malignancy,58951,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7556.77, Resect ovarian malignancy,58951,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7556.77, Resect ovarian malignancy,58952,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8624.48,,,,,,,fee schedule,5097,8624.48, Resect ovarian malignancy,58952,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8624.48, Resect ovarian malignancy,58952,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8624.48, Resect ovarian malignancy,58952,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8624.48, Tah rad dissect for debulk,58953,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10497.32,,,,,,,fee schedule,5097,10497.32, Tah rad dissect for debulk,58953,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,10497.32, Tah rad dissect for debulk,58953,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,10497.32, Tah rad dissect for debulk,58953,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,10497.32, Tah rad debulk/lymph remove,58954,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,11349.78,,,,,,,fee schedule,5097,11349.78, Tah rad debulk/lymph remove,58954,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,11349.78, Tah rad debulk/lymph remove,58954,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,11349.78, Tah rad debulk/lymph remove,58954,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,11349.78, Bso omentectomy w/tah,58956,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7148.19,,,,,,,fee schedule,5097,7148.19, Bso omentectomy w/tah,58956,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7148.19, Bso omentectomy w/tah,58956,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7148.19, Bso omentectomy w/tah,58956,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7148.19, Resect Recurrent Gyn Mal,58957,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Resect Recur Gyn Mal w/Lym,58958,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8214.71,,,,,,,fee schedule,5097,8214.71, Resect Recur Gyn Mal w/Lym,58958,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8214.71, Resect Recur Gyn Mal w/Lym,58958,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8214.71, Resect Recur Gyn Mal w/Lym,58958,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8214.71, Exploration of abdomen,58960,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5341.61,,,,,,,fee schedule,5341.61,22111, Exploration of abdomen,58960,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,5341.61,22111, Exploration of abdomen,58960,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5341.61,22111, Exploration of abdomen,58960,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5341.61,22111, Retrieval of oocyte,58970,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,976.14,,,,,,,fee schedule,976.14,4497, Retrieval of oocyte,58970,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,976.14,4497, Retrieval of oocyte,58970,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,976.14,4497, Retrieval of oocyte,58970,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,976.14,4497, Transfer of embryo,58974,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,4497, Transfer of embryo,58974,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,3195,4497, Transfer of embryo,58974,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,3195,4497, Transfer of embryo,58976,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1055.03,,,,,,,fee schedule,1055.03,3195, Transfer of embryo,58976,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1055.03,3195, Transfer of embryo,58976,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1055.03,3195, Transfer of embryo,58976,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1055.03,3195, Genital surgery procedure,58999,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Genital surgery procedure,58999,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Genital surgery procedure,58999,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Amniocentesis diagnostic,59000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,426.12,,,,,,,fee schedule,426.12,4497, Amniocentesis diagnostic,59000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,426.12,4497, Amniocentesis diagnostic,59000,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,426.12,4497, Amniocentesis diagnostic,59000,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,426.12,4497, Amniocentesis therapeutic,59001,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,938.53,,,,,,,fee schedule,938.53,3195, Amniocentesis therapeutic,59001,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,938.53,3195, Amniocentesis therapeutic,59001,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,938.53,3195, Amniocentesis therapeutic,59001,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,938.53,3195, Fetal cord puncture prenatal,59012,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1060.04,,,,,,,fee schedule,1060.04,6979, Fetal cord puncture prenatal,59012,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1060.04,6979, Fetal cord puncture prenatal,59012,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1060.04,6979, Fetal cord puncture prenatal,59012,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1060.04,6979, Chorion biopsy,59015,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,690.58,,,,,,,fee schedule,690.58,6979, Chorion biopsy,59015,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,690.58,6979, Chorion biopsy,59015,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,690.58,6979, Chorion biopsy,59015,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,690.58,6979, Fetal contract stress test,59020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,187.08,,,,,,,fee schedule,187.08,6979, Fetal contract stress test,59020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,187.08,6979, Fetal contract stress test,59020,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,187.08,6979, Fetal contract stress test,59020,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,187.08,6979, Fetal non-stress test,59025,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,109.54,,,,,,,fee schedule,109.54,6979, Fetal non-stress test,59025,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,109.54,6979, Fetal non-stress test,59025,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,109.54,6979, Fetal non-stress test,59025,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,109.54,6979, Fetal scalp blood sample,59030,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,585.52,,,,,,,fee schedule,585.52,6979, Fetal scalp blood sample,59030,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,585.52,6979, Fetal scalp blood sample,59030,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,585.52,6979, Fetal scalp blood sample,59030,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,585.52,6979, Fetal monitor w/report,59050,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,262.68,,,,,,,fee schedule,262.68,6979, Fetal monitor w/report,59050,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,262.68,6979, Fetal monitor w/report,59050,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,262.68,6979, Fetal monitor w/report,59050,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,262.68,6979, Fetal monitor/interpret only,59051,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,215.19,,,,,,,fee schedule,215.19,6979, Fetal monitor/interpret only,59051,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,215.19,6979, Fetal monitor/interpret only,59051,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,215.19,6979, Fetal monitor/interpret only,59051,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,215.19,6979, Transabdom amnioinfus w/us,59070,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1622.69,,,,,,,fee schedule,1622.69,3195, Transabdom amnioinfus w/us,59070,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1622.69,3195, Transabdom amnioinfus w/us,59070,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1622.69,3195, Transabdom amnioinfus w/us,59070,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1622.69,3195, Umbilical cord occlud w/us,59072,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2734.69,,,,,,,fee schedule,2505,3195, Umbilical cord occlud w/us,59072,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Umbilical cord occlud w/us,59072,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Umbilical cord occlud w/us,59072,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Fetal fluid drainage w/us,59074,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1622.69,,,,,,,fee schedule,1622.69,3195, Fetal fluid drainage w/us,59074,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1622.69,3195, Fetal fluid drainage w/us,59074,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1622.69,3195, Fetal fluid drainage w/us,59074,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1622.69,3195, Fetal shunt placement w/us,59076,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2734.69,,,,,,,fee schedule,2505,3195, Fetal shunt placement w/us,59076,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Fetal shunt placement w/us,59076,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Fetal shunt placement w/us,59076,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Remove uterus lesion,59100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4490.5,,,,,,,fee schedule,4490.5,10940, Remove uterus lesion,59100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4490.5,10940, Remove uterus lesion,59100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,4490.5,10940, Remove uterus lesion,59100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,4490.5,10940, Treat ectopic pregnancy,59120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4278,,,,,,,fee schedule,4278,12821, Treat ectopic pregnancy,59120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4278,12821, Treat ectopic pregnancy,59120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4278,12821, Treat ectopic pregnancy,59120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4278,12821, Treat ectopic pregnancy,59121,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4283.24,,,,,,,fee schedule,4283.24,12821, Treat ectopic pregnancy,59121,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4283.24,12821, Treat ectopic pregnancy,59121,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4283.24,12821, Treat ectopic pregnancy,59121,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4283.24,12821, Treat ectopic pregnancy,59130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4979.05,,,,,,,fee schedule,4979.05,6979, Treat ectopic pregnancy,59130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4979.05,6979, Treat ectopic pregnancy,59130,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4979.05,6979, Treat ectopic pregnancy,59130,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4979.05,6979, Treat ectopic pregnancy,59136,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4717.83,,,,,,,fee schedule,4717.83,6979, Treat ectopic pregnancy,59136,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4717.83,6979, Treat ectopic pregnancy,59136,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4717.83,6979, Treat ectopic pregnancy,59136,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4717.83,6979, Treat ectopic pregnancy,59140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2189.1,,,,,,,fee schedule,2189.1,6979, Treat ectopic pregnancy,59140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2189.1,6979, Treat ectopic pregnancy,59140,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2189.1,6979, Treat ectopic pregnancy,59140,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2189.1,6979, Treat ectopic pregnancy,59150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4152.22,,,,,,,fee schedule,4152.22,22111, Treat ectopic pregnancy,59150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4152.22,22111, Treat ectopic pregnancy,59150,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4152.22,22111, Treat ectopic pregnancy,59150,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4152.22,22111, Treat ectopic pregnancy,59151,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4048.46,,,,,,,fee schedule,4048.46,22111, Treat ectopic pregnancy,59151,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4048.46,22111, Treat ectopic pregnancy,59151,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4048.46,22111, Treat ectopic pregnancy,59151,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4048.46,22111, D & c after delivery,59160,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,972.04,,,,,,,fee schedule,972.04,10940, D & c after delivery,59160,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,972.04,10940, D & c after delivery,59160,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,972.04,10940, D & c after delivery,59160,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,972.04,10940, Insert cervical dilator,59200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,353.17,,,,,,,fee schedule,353.17,3195, Insert cervical dilator,59200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,353.17,3195, Insert cervical dilator,59200,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,353.17,3195, Insert cervical dilator,59200,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,353.17,3195, Episiotomy or vaginal repair,59300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,782.74,,,,,,,fee schedule,782.74,10940, Episiotomy or vaginal repair,59300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,782.74,10940, Episiotomy or vaginal repair,59300,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,782.74,10940, Episiotomy or vaginal repair,59300,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,782.74,10940, Revision of cervix,59320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,805.25,,,,,,,fee schedule,805.25,10940, Revision of cervix,59320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,805.25,10940, Revision of cervix,59320,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,805.25,10940, Revision of cervix,59320,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,805.25,10940, Revision of cervix,59325,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1267.95,,,,,,,fee schedule,1267.95,5664, Revision of cervix,59325,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,1267.95,5664, Revision of cervix,59325,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1267.95,5664, Revision of cervix,59325,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1267.95,5664, Repair of uterus,59350,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1458.92,,,,,,,fee schedule,1458.92,6979, Repair of uterus,59350,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1458.92,6979, Obstetrical care,59400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12756.09,,,,,,,fee schedule,6979,12756.09, Obstetrical care,59400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,12756.09, Obstetrical care,59409,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4233.7,,,,,,,fee schedule,3195,10940, Obstetrical care,59409,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,10940, Obstetrical care,59409,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3195,10940, Obstetrical care,59409,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3195,10940, Obstetrical care,59410,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5711.56,,,,,,,fee schedule,3195,5711.56, Obstetrical care,59410,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,5711.56, Antepartum manipulation,59412,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,552.71,,,,,,,fee schedule,552.71,10940, Antepartum manipulation,59412,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,552.71,10940, Antepartum manipulation,59412,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,552.71,10940, Antepartum manipulation,59412,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,552.71,10940, Deliver placenta,59414,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,485.91,,,,,,,fee schedule,485.91,10940, Deliver placenta,59414,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,485.91,10940, Deliver placenta,59414,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,485.91,10940, Deliver placenta,59414,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,485.91,10940, Antepartum care only,59425,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2302.8,,,,,,,fee schedule,2302.8,6979, Antepartum care only,59425,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2302.8,6979, Antepartum care only,59426,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4223.83,,,,,,,fee schedule,4223.83,6979, Antepartum care only,59426,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4223.83,6979, Care after delivery,59430,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,950.18,,,,,,,fee schedule,950.18,3195, Care after delivery,59430,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,950.18,3195, Cesarean delivery,59510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,14366.04,,,,,,,fee schedule,6979,14366.04, Cesarean delivery,59510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,14366.04, Cesarean delivery only,59514,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4870.75,,,,,,,fee schedule,4870.75,6979, Cesarean delivery only,59514,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4870.75,6979, Cesarean delivery,59515,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7214.72,,,,,,,fee schedule,6044,7214.72, Cesarean delivery,59515,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,7214.72, Remove uterus after cesarean,59525,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2527.76,,,,,,,fee schedule,2527.76,6979, Remove uterus after cesarean,59525,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2527.76,6979, Vbac delivery,59610,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,13556.59,,,,,,,fee schedule,6979,13556.59, Vbac delivery,59610,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,13556.59, Vbac delivery only,59612,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4882.52,,,,,,,fee schedule,4882.52,10940, Vbac delivery only,59612,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4882.52,10940, Vbac delivery only,59612,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,4882.52,10940, Vbac delivery only,59612,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,4882.52,10940, Vbac care after delivery,59614,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6311.7,,,,,,,fee schedule,6311.7,6979, Vbac care after delivery,59614,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6311.7,6979, Attempted vbac delivery,59618,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,14545.24,,,,,,,fee schedule,6979,14545.24, Attempted vbac delivery,59618,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,14545.24, Attempted vbac delivery only,59620,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5054.7,,,,,,,fee schedule,5054.7,6979, Attempted vbac delivery only,59620,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5054.7,6979, Attempted vbac after care,59622,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7437.79,,,,,,,fee schedule,6979,7437.79, Attempted vbac after care,59622,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,7437.79, Treatment of miscarriage,59812,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1611.57,,,,,,,fee schedule,1611.57,10940, Treatment of miscarriage,59812,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,1611.57,10940, Treatment of miscarriage,59812,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1611.57,10940, Treatment of miscarriage,59812,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1611.57,10940, Care of miscarriage,59820,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1997.92,,,,,,,fee schedule,1997.92,10940, Care of miscarriage,59820,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,1997.92,10940, Care of miscarriage,59820,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1997.92,10940, Care of miscarriage,59820,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1997.92,10940, Treatment of miscarriage,59821,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1970.78,,,,,,,fee schedule,1970.78,10940, Treatment of miscarriage,59821,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,1970.78,10940, Treatment of miscarriage,59821,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1970.78,10940, Treatment of miscarriage,59821,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1970.78,10940, Treat uterus infection,59830,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2416.44,,,,,,,fee schedule,2416.44,5664, Treat uterus infection,59830,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2416.44,5664, Treat uterus infection,59830,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2416.44,5664, Treat uterus infection,59830,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2416.44,5664, Abortion,59840,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1153.88,,,,,,,fee schedule,1153.88,10940, Abortion,59840,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,1153.88,10940, Abortion,59840,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1153.88,10940, Abortion,59840,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1153.88,10940, Abortion,59841,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1952.27,,,,,,,fee schedule,1952.27,10940, Abortion,59841,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,1952.27,10940, Abortion,59841,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1952.27,10940, Abortion,59841,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1952.27,10940, Abortion,59850,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2056.85,,,,,,,fee schedule,2056.85,5664, Abortion,59850,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2056.85,5664, Abortion,59850,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2056.85,5664, Abortion,59850,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2056.85,5664, Abortion,59851,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2223.37,,,,,,,fee schedule,2223.37,5664, Abortion,59851,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2223.37,5664, Abortion,59851,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2223.37,5664, Abortion,59851,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2223.37,5664, Abortion,59852,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3049.66,,,,,,,fee schedule,3049.66,5664, Abortion,59852,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3049.66,5664, Abortion,59852,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3049.66,5664, Abortion,59852,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3049.66,5664, Abortion,59855,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2237.94,,,,,,,fee schedule,2237.94,6979, Abortion,59855,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2237.94,6979, Abortion,59855,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2237.94,6979, Abortion,59855,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2237.94,6979, Abortion,59856,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2615.55,,,,,,,fee schedule,2615.55,5664, Abortion,59856,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2615.55,5664, Abortion,59856,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2615.55,5664, Abortion,59856,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2615.55,5664, Abortion,59857,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3053.11,,,,,,,fee schedule,3053.11,5664, Abortion,59857,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3053.11,5664, Abortion,59857,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3053.11,5664, Abortion,59857,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3053.11,5664, Abortion (mpr),59866,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1255.11,,,,,,,fee schedule,1255.11,6979, Abortion (mpr),59866,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1255.11,6979, Abortion (mpr),59866,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1255.11,6979, Abortion (mpr),59866,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1255.11,6979, Evacuate mole of uterus,59870,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2742.68,,,,,,,fee schedule,2742.68,10940, Evacuate mole of uterus,59870,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,2742.68,10940, Evacuate mole of uterus,59870,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2742.68,10940, Evacuate mole of uterus,59870,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2742.68,10940, Remove cerclage suture,59871,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,703.58,,,,,,,fee schedule,703.58,12821, Remove cerclage suture,59871,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,703.58,12821, Remove cerclage suture,59871,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,703.58,12821, Remove cerclage suture,59871,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,703.58,12821, Fetal invas px w/us,59897,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Fetal invas px w/us,59897,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Fetal invas px w/us,59897,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Laparo proc ob care/deliver,59898,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,14456, Laparo proc ob care/deliver,59898,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5248,14456, Laparo proc ob care/deliver,59898,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5248,14456, Maternity care procedure,59899,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2505,4108, Maternity care procedure,59899,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,4108, Maternity care procedure,59899,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,4108, Drain thyroid/tongue cyst,60000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,789.81,,,,,,,fee schedule,789.81,5664, Drain thyroid/tongue cyst,60000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,789.81,5664, Drain thyroid/tongue cyst,60000,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,789.81,5664, Drain thyroid/tongue cyst,60000,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,789.81,5664, Biopsy of thyroid,60100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,366.55,,,,,,,fee schedule,366.55,4497, Biopsy of thyroid,60100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,366.55,4497, Biopsy of thyroid,60100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,366.55,4497, Biopsy of thyroid,60100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,366.55,4497, Remove thyroid lesion,60200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3485.11,,,,,,,fee schedule,3485.11,22111, Remove thyroid lesion,60200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3485.11,22111, Remove thyroid lesion,60200,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3485.11,22111, Remove thyroid lesion,60200,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3485.11,22111, Partial thyroid excision,60210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3650.83,,,,,,,fee schedule,3650.83,22111, Partial thyroid excision,60210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3650.83,22111, Partial thyroid excision,60210,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3650.83,22111, Partial thyroid excision,60210,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3650.83,22111, Partial thyroid excision,60212,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5568.13,,,,,,,fee schedule,5363,22111, Partial thyroid excision,60212,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,22111, Partial thyroid excision,60212,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5363,22111, Partial thyroid excision,60212,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5363,22111, Partial removal of thyroid,60220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3599.51,,,,,,,fee schedule,3599.51,22111, Partial removal of thyroid,60220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3599.51,22111, Partial removal of thyroid,60220,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3599.51,22111, Partial removal of thyroid,60220,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3599.51,22111, Partial removal of thyroid,60225,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4781.88,,,,,,,fee schedule,4781.88,22111, Partial removal of thyroid,60225,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4781.88,22111, Partial removal of thyroid,60225,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4781.88,22111, Partial removal of thyroid,60225,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4781.88,22111, Removal of thyroid,60240,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4694.95,,,,,,,fee schedule,4694.95,22111, Removal of thyroid,60240,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,4694.95,22111, Removal of thyroid,60240,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4694.95,22111, Removal of thyroid,60240,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4694.95,22111, Removal of thyroid,60252,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6671.67,,,,,,,fee schedule,6671.67,14456, Removal of thyroid,60252,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,6671.67,14456, Removal of thyroid,60252,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,6671.67,14456, Removal of thyroid,60252,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,6671.67,14456, Extensive thyroid surgery,60254,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8407.24,,,,,,,fee schedule,8406,10940, Extensive thyroid surgery,60254,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,8406,10940, Extensive thyroid surgery,60254,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,8406,10940, Extensive thyroid surgery,60254,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,8406,10940, Repeat thyroid surgery,60260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5486.87,,,,,,,fee schedule,5486.87,14456, Repeat thyroid surgery,60260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,5486.87,14456, Repeat thyroid surgery,60260,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5486.87,14456, Repeat thyroid surgery,60260,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5486.87,14456, Removal of thyroid,60270,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6980.7,,,,,,,fee schedule,5097,6980.7, Removal of thyroid,60270,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6980.7, Removal of thyroid,60270,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6980.7, Removal of thyroid,60270,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6980.7, Removal of thyroid,60271,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5361.36,,,,,,,fee schedule,5361.36,14456, Removal of thyroid,60271,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5361.36,14456, Removal of thyroid,60271,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5361.36,14456, Removal of thyroid,60271,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5361.36,14456, Remove thyroid duct lesion,60280,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2253.48,,,,,,,fee schedule,2253.48,22111, Remove thyroid duct lesion,60280,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2253.48,22111, Remove thyroid duct lesion,60280,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,2253.48,22111, Remove thyroid duct lesion,60280,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,2253.48,22111, Remove thyroid duct lesion,60281,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2902.72,,,,,,,fee schedule,2902.72,22111, Remove thyroid duct lesion,60281,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2902.72,22111, Remove thyroid duct lesion,60281,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,2902.72,22111, Remove thyroid duct lesion,60281,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,2902.72,22111, Aspir/inj thyroid cyst,60300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,233.75,,,,,,,fee schedule,233.75,4497, Aspir/inj thyroid cyst,60300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,233.75,4497, Aspir/inj thyroid cyst,60300,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,233.75,4497, Aspir/inj thyroid cyst,60300,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,233.75,4497, Explore parathyroid glands,60500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5053.52,,,,,,,fee schedule,5053.52,14456, Explore parathyroid glands,60500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,5053.52,14456, Explore parathyroid glands,60500,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5053.52,14456, Explore parathyroid glands,60500,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5053.52,14456, Re-explore parathyroids,60502,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6848.17,,,,,,,fee schedule,6848.17,14456, Re-explore parathyroids,60502,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,6848.17,14456, Re-explore parathyroids,60502,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,6848.17,14456, Re-explore parathyroids,60502,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,6848.17,14456, Explore parathyroid glands,60505,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6691.42,,,,,,,fee schedule,5097,6979, Explore parathyroid glands,60505,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Explore parathyroid glands,60505,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Explore parathyroid glands,60505,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Autotransplant parathyroid,60512,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1213.02,,,,,,,fee schedule,1213.02,5248, Autotransplant parathyroid,60512,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1213.02,5248, Autotransplant parathyroid,60512,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1213.02,5248, Autotransplant parathyroid,60512,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1213.02,5248, Removal of thymus gland,60520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5604.72,,,,,,,fee schedule,5363,14456, Removal of thymus gland,60520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,14456, Removal of thymus gland,60520,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5363,14456, Removal of thymus gland,60520,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5363,14456, Removal of thymus gland,60521,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6187.05,,,,,,,fee schedule,5097,6979, Removal of thymus gland,60521,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Removal of thymus gland,60521,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Removal of thymus gland,60521,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Removal of thymus gland,60522,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7447.18,,,,,,,fee schedule,5097,7447.18, Removal of thymus gland,60522,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7447.18, Removal of thymus gland,60522,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7447.18, Removal of thymus gland,60522,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7447.18, Explore adrenal gland,60540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5747.28,,,,,,,fee schedule,5097,8406, Explore adrenal gland,60540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,5097,8406, Explore adrenal gland,60540,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8406, Explore adrenal gland,60540,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8406, Explore adrenal gland,60545,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6701.08,,,,,,,fee schedule,5097,6979, Explore adrenal gland,60545,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Explore adrenal gland,60545,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Explore adrenal gland,60545,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Remove carotid body lesion,60600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7060.88,,,,,,,fee schedule,5097,7060.88, Remove carotid body lesion,60600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7060.88, Remove carotid body lesion,60600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7060.88, Remove carotid body lesion,60600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7060.88, Remove carotid body lesion,60605,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8770.87,,,,,,,fee schedule,5097,8770.87, Remove carotid body lesion,60605,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8770.87, Remove carotid body lesion,60605,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8770.87, Remove carotid body lesion,60605,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8770.87, Laparoscopy adrenalectomy,60650,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6308.3,,,,,,,fee schedule,5363,14456, Laparoscopy adrenalectomy,60650,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,14456, Laparoscopy adrenalectomy,60650,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5363,14456, Laparoscopy adrenalectomy,60650,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5363,14456, Laparo proc endocrine,60659,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,14456, Laparo proc endocrine,60659,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5248,14456, Laparo proc endocrine,60659,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5248,14456, Abltj 1/+thyr ndul 1lobe prq,60660,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1575.15,,,,,,,fee schedule,1575.15,5664, Abltj 1/+thyr ndul 1lobe prq,60660,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1575.15,5664, Abltj 1/+thyr ndul 1lobe prq,60660,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1575.15,5664, Abltj 1/+thyr ndul 1lobe prq,60660,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1575.15,5664, Abltj 1/+thyr ndul addl prq,60661,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1082.98,,,,,,,fee schedule,1082.98,3195, Abltj 1/+thyr ndul addl prq,60661,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1082.98,3195, Abltj 1/+thyr ndul addl prq,60661,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1082.98,3195, Abltj 1/+thyr ndul addl prq,60661,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1082.98,3195, Endocrine surgery procedure,60699,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,22111, Endocrine surgery procedure,60699,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3195,22111, Endocrine surgery procedure,60699,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3195,22111, Remove cranial cavity fluid,61000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,649.08,,,,,,,fee schedule,649.08,4497, Remove cranial cavity fluid,61000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,649.08,4497, Remove cranial cavity fluid,61000,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,649.08,4497, Remove cranial cavity fluid,61000,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,649.08,4497, Remove cranial cavity fluid,61001,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,616.87,,,,,,,fee schedule,616.87,4497, Remove cranial cavity fluid,61001,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,616.87,4497, Remove cranial cavity fluid,61001,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,616.87,4497, Remove cranial cavity fluid,61001,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,616.87,4497, Remove brain cavity fluid,61020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,570.25,,,,,,,fee schedule,570.25,4497, Remove brain cavity fluid,61020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,570.25,4497, Remove brain cavity fluid,61020,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,570.25,4497, Remove brain cavity fluid,61020,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,570.25,4497, Injection into brain canal,61026,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,601.44,,,,,,,fee schedule,601.44,4497, Injection into brain canal,61026,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,601.44,4497, Injection into brain canal,61026,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,601.44,4497, Injection into brain canal,61026,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,601.44,4497, Remove brain canal fluid,61050,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,382.14,,,,,,,fee schedule,382.14,3195, Remove brain canal fluid,61050,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,382.14,3195, Remove brain canal fluid,61050,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,382.14,3195, Remove brain canal fluid,61050,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,382.14,3195, Injection into brain canal,61055,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,550.18,,,,,,,fee schedule,550.18,3195, Injection into brain canal,61055,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,550.18,3195, Injection into brain canal,61055,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,550.18,3195, Injection into brain canal,61055,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,550.18,3195, Brain canal shunt procedure,61070,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,287.01,,,,,,,fee schedule,287.01,4497, Brain canal shunt procedure,61070,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,287.01,4497, Brain canal shunt procedure,61070,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,287.01,4497, Brain canal shunt procedure,61070,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,287.01,4497, Twist drill hole,61105,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2832.68,,,,,,,fee schedule,2832.68,6979, Twist drill hole,61105,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2832.68,6979, Twist drill hole,61105,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2832.68,6979, Twist drill hole,61105,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2832.68,6979, Description Not Available,61106,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Drill skull for implantation,61107,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1723.27,,,,,,,fee schedule,1723.27,6979, Drill skull for implantation,61107,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1723.27,6979, Drill skull for implantation,61107,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1723.27,6979, Drill skull for implantation,61107,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1723.27,6979, Drill skull for drainage,61108,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5333.24,,,,,,,fee schedule,5097,6979, Drill skull for drainage,61108,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Drill skull for drainage,61108,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Drill skull for drainage,61108,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Burr hole for puncture,61120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4452.19,,,,,,,fee schedule,4452.19,6979, Burr hole for puncture,61120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4452.19,6979, Burr hole for puncture,61120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4452.19,6979, Burr hole for puncture,61120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4452.19,6979, Description Not Available,61130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Pierce skull for biopsy,61140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7365.86,,,,,,,fee schedule,5097,7365.86, Pierce skull for biopsy,61140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7365.86, Pierce skull for biopsy,61140,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7365.86, Pierce skull for biopsy,61140,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7365.86, Pierce skull for drainage,61150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7804.94,,,,,,,fee schedule,5097,7804.94, Pierce skull for drainage,61150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7804.94, Pierce skull for drainage,61150,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7804.94, Pierce skull for drainage,61150,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7804.94, Pierce skull for drainage,61151,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5800.54,,,,,,,fee schedule,5097,6979, Pierce skull for drainage,61151,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Pierce skull for drainage,61151,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Pierce skull for drainage,61151,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Pierce skull & remove clot,61154,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7458.14,,,,,,,fee schedule,5097,7458.14, Pierce skull & remove clot,61154,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7458.14, Pierce skull & remove clot,61154,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7458.14, Pierce skull & remove clot,61154,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7458.14, Pierce skull for drainage,61156,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7151.64,,,,,,,fee schedule,5097,7151.64, Pierce skull for drainage,61156,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7151.64, Pierce skull for drainage,61156,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7151.64, Pierce skull for drainage,61156,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7151.64, Pierce skull implant device,61210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2011.31,,,,,,,fee schedule,2011.31,6979, Pierce skull implant device,61210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2011.31,6979, Pierce skull implant device,61210,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2011.31,6979, Pierce skull implant device,61210,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2011.31,6979, Insert brain-fluid device,61215,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3157.52,,,,,,,fee schedule,3157.52,14456, Insert brain-fluid device,61215,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3157.52,14456, Insert brain-fluid device,61215,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3157.52,14456, Insert brain-fluid device,61215,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3157.52,14456, Pierce skull & explore,61250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5110.77,,,,,,,fee schedule,5097,6979, Pierce skull & explore,61250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Pierce skull & explore,61250,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Pierce skull & explore,61250,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Pierce skull & explore,61253,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5800.54,,,,,,,fee schedule,5097,6979, Pierce skull & explore,61253,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Pierce skull & explore,61253,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Pierce skull & explore,61253,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Open skull for exploration,61304,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9420.23,,,,,,,fee schedule,5097,9420.23, Open skull for exploration,61304,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,9420.23, Open skull for exploration,61304,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,9420.23, Open skull for exploration,61304,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,9420.23, Open skull for exploration,61305,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,11496.34,,,,,,,fee schedule,5097,11496.34, Open skull for exploration,61305,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,11496.34, Open skull for exploration,61305,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,11496.34, Open skull for exploration,61305,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,11496.34, Open skull for drainage,61312,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,11795.06,,,,,,,fee schedule,5097,11795.06, Open skull for drainage,61312,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,11795.06, Open skull for drainage,61312,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,11795.06, Open skull for drainage,61312,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,11795.06, Open skull for drainage,61313,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,11397.81,,,,,,,fee schedule,5097,11397.81, Open skull for drainage,61313,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,11397.81, Open skull for drainage,61313,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,11397.81, Open skull for drainage,61313,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,11397.81, Open skull for drainage,61314,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10475.69,,,,,,,fee schedule,5097,10475.69, Open skull for drainage,61314,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,10475.69, Open skull for drainage,61314,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,10475.69, Open skull for drainage,61314,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,10475.69, Open skull for drainage,61315,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,11839.26,,,,,,,fee schedule,5097,11839.26, Open skull for drainage,61315,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,11839.26, Open skull for drainage,61315,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,11839.26, Open skull for drainage,61315,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,11839.26, Implt cran bone flap to abdo,61316,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,477.82,,,,,,,fee schedule,477.82,5664, Implt cran bone flap to abdo,61316,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,477.82,5664, Implt cran bone flap to abdo,61316,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,477.82,5664, Implt cran bone flap to abdo,61316,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,477.82,5664, Open skull for drainage,61320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10789.52,,,,,,,fee schedule,5097,10789.52, Open skull for drainage,61320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,10789.52, Open skull for drainage,61320,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,10789.52, Open skull for drainage,61320,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,10789.52, Open skull for drainage,61321,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12150.34,,,,,,,fee schedule,5097,12150.34, Open skull for drainage,61321,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,12150.34, Open skull for drainage,61321,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,12150.34, Open skull for drainage,61321,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,12150.34, Decompressive craniotomy,61322,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,13532.63,,,,,,,fee schedule,5097,13532.63, Decompressive craniotomy,61322,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,13532.63, Decompressive craniotomy,61322,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,13532.63, Decompressive craniotomy,61322,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,13532.63, Decompressive lobectomy,61323,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,13550.44,,,,,,,fee schedule,5097,13550.44, Decompressive lobectomy,61323,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,13550.44, Decompressive lobectomy,61323,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,13550.44, Decompressive lobectomy,61323,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,13550.44, Decompress eye socket,61330,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10321.41,,,,,,,fee schedule,6979,14456, Decompress eye socket,61330,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,14456, Decompress eye socket,61330,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,6979,14456, Decompress eye socket,61330,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,6979,14456, Explore orbit/remove lesion,61333,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,11512.15,,,,,,,fee schedule,5097,11512.15, Explore orbit/remove lesion,61333,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,11512.15, Explore orbit/remove lesion,61333,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,11512.15, Explore orbit/remove lesion,61333,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,11512.15, Subtemporal decompression,61340,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8337.68,,,,,,,fee schedule,5097,8337.68, Subtemporal decompression,61340,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8337.68, Subtemporal decompression,61340,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8337.68, Subtemporal decompression,61340,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8337.68, Incise skull (press relief),61343,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12399.63,,,,,,,fee schedule,5097,12399.63, Incise skull (press relief),61343,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,12399.63, Incise skull (press relief),61343,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,12399.63, Incise skull (press relief),61343,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,12399.63, Relieve cranial pressure,61345,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,11676.94,,,,,,,fee schedule,5097,11676.94, Relieve cranial pressure,61345,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,11676.94, Relieve cranial pressure,61345,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,11676.94, Relieve cranial pressure,61345,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,11676.94, Incise skull for surgery,61450,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10963.7,,,,,,,fee schedule,5097,10963.7, Incise skull for surgery,61450,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,10963.7, Incise skull for surgery,61450,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,10963.7, Incise skull for surgery,61450,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,10963.7, Incise skull for brain wound,61458,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,11518.84,,,,,,,fee schedule,5097,11518.84, Incise skull for brain wound,61458,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,11518.84, Incise skull for brain wound,61458,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,11518.84, Incise skull for brain wound,61458,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,11518.84, Incise skull for surgery,61460,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12027.68,,,,,,,fee schedule,5097,12027.68, Incise skull for surgery,61460,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,12027.68, Incise skull for surgery,61460,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,12027.68, Incise skull for surgery,61460,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,12027.68, Removal of skull lesion,61500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6881.3,,,,,,,fee schedule,6881.3,22111, Removal of skull lesion,61500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8212,,,,,,,fee schedule,6881.3,22111, Removal of skull lesion,61500,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6881.3,22111, Removal of skull lesion,61500,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6881.3,22111, Remove infected skull bone,61501,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6036.94,,,,,,,fee schedule,5097,6979, Remove infected skull bone,61501,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Remove infected skull bone,61501,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Remove infected skull bone,61501,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Removal of brain lesion,61510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12634.14,,,,,,,fee schedule,5097,12634.14, Removal of brain lesion,61510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,12634.14, Removal of brain lesion,61510,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,12634.14, Removal of brain lesion,61510,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,12634.14, Remove brain lining lesion,61512,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,14495.6,,,,,,,fee schedule,5097,14495.6, Remove brain lining lesion,61512,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,14495.6, Remove brain lining lesion,61512,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,14495.6, Remove brain lining lesion,61512,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,14495.6, Removal of brain abscess,61514,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10881.57,,,,,,,fee schedule,5097,10881.57, Removal of brain abscess,61514,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,10881.57, Removal of brain abscess,61514,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,10881.57, Removal of brain abscess,61514,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,10881.57, Removal of brain lesion,61516,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10671.29,,,,,,,fee schedule,5097,10671.29, Removal of brain lesion,61516,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,10671.29, Removal of brain lesion,61516,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,10671.29, Removal of brain lesion,61516,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,10671.29, Implt brain chemotx add-on,61517,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,475.98,,,,,,,fee schedule,475.98,6979, Implt brain chemotx add-on,61517,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,475.98,6979, Implt brain chemotx add-on,61517,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,475.98,6979, Implt brain chemotx add-on,61517,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,475.98,6979, Removal of brain lesion,61518,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,15774.56,,,,,,,fee schedule,5097,15774.56, Removal of brain lesion,61518,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,15774.56, Removal of brain lesion,61518,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,15774.56, Removal of brain lesion,61518,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,15774.56, Remove brain lining lesion,61519,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,16643.15,,,,,,,fee schedule,5097,16643.15, Remove brain lining lesion,61519,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,16643.15, Remove brain lining lesion,61519,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,16643.15, Remove brain lining lesion,61519,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,16643.15, Removal of brain lesion,61520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,20578.73,,,,,,,fee schedule,5097,20578.73, Removal of brain lesion,61520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,20578.73, Removal of brain lesion,61520,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,20578.73, Removal of brain lesion,61520,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,20578.73, Removal of brain lesion,61521,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,17750.95,,,,,,,fee schedule,5097,17750.95, Removal of brain lesion,61521,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,17750.95, Removal of brain lesion,61521,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,17750.95, Removal of brain lesion,61521,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,17750.95, Removal of brain abscess,61522,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12473.23,,,,,,,fee schedule,5097,12473.23, Removal of brain abscess,61522,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,12473.23, Removal of brain abscess,61522,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,12473.23, Removal of brain abscess,61522,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,12473.23, Removal of brain lesion,61524,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,11907.78,,,,,,,fee schedule,5097,11907.78, Removal of brain lesion,61524,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,11907.78, Removal of brain lesion,61524,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,11907.78, Removal of brain lesion,61524,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,11907.78, Removal of brain lesion,61526,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,17573.48,,,,,,,fee schedule,5097,17573.48, Removal of brain lesion,61526,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,17573.48, Removal of brain lesion,61526,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,17573.48, Removal of brain lesion,61526,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,17573.48, Removal of brain lesion,61530,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,17331.52,,,,,,,fee schedule,5097,17331.52, Removal of brain lesion,61530,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,17331.52, Removal of brain lesion,61530,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,17331.52, Removal of brain lesion,61530,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,17331.52, Implant brain electrodes,61531,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7171.66,,,,,,,fee schedule,5097,7171.66, Implant brain electrodes,61531,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7171.66, Implant brain electrodes,61531,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7171.66, Implant brain electrodes,61531,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7171.66, Implant brain electrodes,61533,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8800.28,,,,,,,fee schedule,5097,8800.28, Implant brain electrodes,61533,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8800.28, Implant brain electrodes,61533,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8800.28, Implant brain electrodes,61533,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8800.28, Removal of brain lesion,61534,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9519.79,,,,,,,fee schedule,5097,9519.79, Removal of brain lesion,61534,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,9519.79, Removal of brain lesion,61534,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,9519.79, Removal of brain lesion,61534,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,9519.79, Remove brain electrodes,61535,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5921.95,,,,,,,fee schedule,5097,6979, Remove brain electrodes,61535,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Remove brain electrodes,61535,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Remove brain electrodes,61535,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Removal of brain lesion,61536,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,14616.09,,,,,,,fee schedule,5097,14616.09, Removal of brain lesion,61536,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,14616.09, Removal of brain lesion,61536,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,14616.09, Removal of brain lesion,61536,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,14616.09, Removal of brain tissue,61537,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,13910.56,,,,,,,fee schedule,5097,13910.56, Removal of brain tissue,61537,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,13910.56, Removal of brain tissue,61537,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,13910.56, Removal of brain tissue,61537,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,13910.56, Removal of brain tissue,61538,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,15030.23,,,,,,,fee schedule,5097,15030.23, Removal of brain tissue,61538,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,15030.23, Removal of brain tissue,61538,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,15030.23, Removal of brain tissue,61538,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,15030.23, Removal of brain tissue,61539,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,13425.25,,,,,,,fee schedule,5097,13425.25, Removal of brain tissue,61539,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,13425.25, Removal of brain tissue,61539,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,13425.25, Removal of brain tissue,61539,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,13425.25, Removal of brain tissue,61540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12424.61,,,,,,,fee schedule,5097,12424.61, Removal of brain tissue,61540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,12424.61, Removal of brain tissue,61540,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,12424.61, Removal of brain tissue,61540,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,12424.61, Incision of brain tissue,61541,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12269.21,,,,,,,fee schedule,5097,12269.21, Incision of brain tissue,61541,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,12269.21, Incision of brain tissue,61541,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,12269.21, Incision of brain tissue,61541,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,12269.21, Removal of brain tissue,61543,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12397.15,,,,,,,fee schedule,5097,12397.15, Removal of brain tissue,61543,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,12397.15, Removal of brain tissue,61543,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,12397.15, Removal of brain tissue,61543,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,12397.15, Remove & treat brain lesion,61544,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10850.17,,,,,,,fee schedule,5097,10850.17, Remove & treat brain lesion,61544,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,10850.17, Remove & treat brain lesion,61544,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,10850.17, Remove & treat brain lesion,61544,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,10850.17, Excision of brain tumor,61545,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,18071.31,,,,,,,fee schedule,5097,18071.31, Excision of brain tumor,61545,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,18071.31, Excision of brain tumor,61545,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,18071.31, Excision of brain tumor,61545,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,18071.31, Removal of pituitary gland,61546,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,13132.68,,,,,,,fee schedule,5097,13132.68, Removal of pituitary gland,61546,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,13132.68, Removal of pituitary gland,61546,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,13132.68, Removal of pituitary gland,61546,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,13132.68, Removal of pituitary gland,61548,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8651.08,,,,,,,fee schedule,5097,8651.08, Removal of pituitary gland,61548,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8651.08, Removal of pituitary gland,61548,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8651.08, Removal of pituitary gland,61548,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8651.08, Release of skull seams,61550,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7038,,,,,,,fee schedule,5097,7038, Release of skull seams,61550,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7038, Release of skull seams,61550,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7038, Release of skull seams,61550,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7038, Release of skull seams,61552,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8613.37,,,,,,,fee schedule,5097,8613.37, Release of skull seams,61552,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8613.37, Release of skull seams,61552,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8613.37, Release of skull seams,61552,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8613.37, Incise skull/sutures,61556,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9818.94,,,,,,,fee schedule,5097,9818.94, Incise skull/sutures,61556,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,9818.94, Incise skull/sutures,61556,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,9818.94, Incise skull/sutures,61556,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,9818.94, Incise skull/sutures,61557,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9757.26,,,,,,,fee schedule,5097,9757.26, Incise skull/sutures,61557,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,9757.26, Incise skull/sutures,61557,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,9757.26, Incise skull/sutures,61557,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,9757.26, Excision of skull/sutures,61558,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10821.79,,,,,,,fee schedule,5097,10821.79, Excision of skull/sutures,61558,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,10821.79, Excision of skull/sutures,61558,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,10821.79, Excision of skull/sutures,61558,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,10821.79, Excision of skull/sutures,61559,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,13733.63,,,,,,,fee schedule,5097,13733.63, Excision of skull/sutures,61559,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,13733.63, Excision of skull/sutures,61559,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,13733.63, Excision of skull/sutures,61559,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,13733.63, Excision of skull tumor,61563,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,11327.45,,,,,,,fee schedule,5097,11327.45, Excision of skull tumor,61563,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,11327.45, Excision of skull tumor,61563,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,11327.45, Excision of skull tumor,61563,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,11327.45, Excision of skull tumor,61564,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,13713.61,,,,,,,fee schedule,5097,13713.61, Excision of skull tumor,61564,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,13713.61, Excision of skull tumor,61564,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,13713.61, Excision of skull tumor,61564,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,13713.61, Removal of brain tissue,61566,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12777.19,,,,,,,fee schedule,5097,12777.19, Removal of brain tissue,61566,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,12777.19, Removal of brain tissue,61566,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,12777.19, Removal of brain tissue,61566,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,12777.19, Incision of brain tissue,61567,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,14548.21,,,,,,,fee schedule,5097,14548.21, Incision of brain tissue,61567,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,14548.21, Incision of brain tissue,61567,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,14548.21, Incision of brain tissue,61567,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,14548.21, Remove foreign body brain,61570,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10738.42,,,,,,,fee schedule,5097,10738.42, Remove foreign body brain,61570,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,10738.42, Remove foreign body brain,61570,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,10738.42, Remove foreign body brain,61570,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,10738.42, Incise skull for brain wound,61571,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,11401.37,,,,,,,fee schedule,5097,11401.37, Incise skull for brain wound,61571,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,11401.37, Incise skull for brain wound,61571,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,11401.37, Incise skull for brain wound,61571,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,11401.37, Skull base/brainstem surgery,61575,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,14213.44,,,,,,,fee schedule,5097,14213.44, Skull base/brainstem surgery,61575,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,14213.44, Skull base/brainstem surgery,61575,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,14213.44, Skull base/brainstem surgery,61575,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,14213.44, Skull base/brainstem surgery,61576,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,24308.06,,,,,,,fee schedule,5097,24308.06, Skull base/brainstem surgery,61576,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,24308.06, Skull base/brainstem surgery,61576,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,24308.06, Skull base/brainstem surgery,61576,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,24308.06, Craniofacial approach skull,61580,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12403.19,,,,,,,fee schedule,5097,12403.19, Craniofacial approach skull,61580,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,12403.19, Craniofacial approach skull,61580,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,12403.19, Craniofacial approach skull,61580,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,12403.19, Craniofacial approach skull,61581,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,13024.76,,,,,,,fee schedule,5097,13024.76, Craniofacial approach skull,61581,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,13024.76, Craniofacial approach skull,61581,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,13024.76, Craniofacial approach skull,61581,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,13024.76, Craniofacial approach skull,61582,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,17481.37,,,,,,,fee schedule,5097,17481.37, Craniofacial approach skull,61582,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,17481.37, Craniofacial approach skull,61582,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,17481.37, Craniofacial approach skull,61582,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,17481.37, Craniofacial approach skull,61583,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,16894.5,,,,,,,fee schedule,5097,16894.5, Craniofacial approach skull,61583,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,16894.5, Craniofacial approach skull,61583,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,16894.5, Craniofacial approach skull,61583,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,16894.5, Orbitocranial approach/skull,61584,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,16311.19,,,,,,,fee schedule,5097,16311.19, Orbitocranial approach/skull,61584,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,16311.19, Orbitocranial approach/skull,61584,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,16311.19, Orbitocranial approach/skull,61584,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,16311.19, Orbitocranial approach/skull,61585,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,18848.88,,,,,,,fee schedule,5097,18848.88, Orbitocranial approach/skull,61585,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,18848.88, Orbitocranial approach/skull,61585,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,18848.88, Orbitocranial approach/skull,61585,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,18848.88, Resect nasopharynx skull,61586,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,14943.68,,,,,,,fee schedule,5097,14943.68, Resect nasopharynx skull,61586,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,14943.68, Resect nasopharynx skull,61586,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,14943.68, Resect nasopharynx skull,61586,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,14943.68, Infratemporal approach/skull,61590,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,15019.06,,,,,,,fee schedule,5097,15019.06, Infratemporal approach/skull,61590,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,15019.06, Infratemporal approach/skull,61590,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,15019.06, Infratemporal approach/skull,61590,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,15019.06, Infratemporal approach/skull,61591,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,15809.79,,,,,,,fee schedule,5097,15809.79, Infratemporal approach/skull,61591,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,15809.79, Infratemporal approach/skull,61591,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,15809.79, Infratemporal approach/skull,61591,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,15809.79, Orbitocranial approach/skull,61592,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,17570.67,,,,,,,fee schedule,5097,17570.67, Orbitocranial approach/skull,61592,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,17570.67, Orbitocranial approach/skull,61592,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,17570.67, Orbitocranial approach/skull,61592,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,17570.67, Transtemporal approach/skull,61595,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12375.02,,,,,,,fee schedule,5097,12375.02, Transtemporal approach/skull,61595,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,12375.02, Transtemporal approach/skull,61595,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,12375.02, Transtemporal approach/skull,61595,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,12375.02, Transcochlear approach/skull,61596,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,11636.1,,,,,,,fee schedule,5097,11636.1, Transcochlear approach/skull,61596,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,11636.1, Transcochlear approach/skull,61596,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,11636.1, Transcochlear approach/skull,61596,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,11636.1, Transcondylar approach/skull,61597,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,17271.46,,,,,,,fee schedule,5097,17271.46, Transcondylar approach/skull,61597,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,17271.46, Transcondylar approach/skull,61597,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,17271.46, Transcondylar approach/skull,61597,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,17271.46, Transpetrosal approach/skull,61598,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,16455.59,,,,,,,fee schedule,5097,16455.59, Transpetrosal approach/skull,61598,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,16455.59, Transpetrosal approach/skull,61598,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,16455.59, Transpetrosal approach/skull,61598,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,16455.59, Resect/excise cranial lesion,61600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10749.91,,,,,,,fee schedule,5097,10749.91, Resect/excise cranial lesion,61600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,10749.91, Resect/excise cranial lesion,61600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,10749.91, Resect/excise cranial lesion,61600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,10749.91, Resect/excise cranial lesion,61601,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,13802.16,,,,,,,fee schedule,5097,13802.16, Resect/excise cranial lesion,61601,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,13802.16, Resect/excise cranial lesion,61601,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,13802.16, Resect/excise cranial lesion,61601,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,13802.16, Resect/excise cranial lesion,61605,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10666.97,,,,,,,fee schedule,5097,10666.97, Resect/excise cranial lesion,61605,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,10666.97, Resect/excise cranial lesion,61605,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,10666.97, Resect/excise cranial lesion,61605,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,10666.97, Resect/excise cranial lesion,61606,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,15785.78,,,,,,,fee schedule,5097,15785.78, Resect/excise cranial lesion,61606,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,15785.78, Resect/excise cranial lesion,61606,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,15785.78, Resect/excise cranial lesion,61606,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,15785.78, Resect/excise cranial lesion,61607,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,14287.15,,,,,,,fee schedule,5097,14287.15, Resect/excise cranial lesion,61607,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,14287.15, Resect/excise cranial lesion,61607,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,14287.15, Resect/excise cranial lesion,61607,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,14287.15, Resect/excise cranial lesion,61608,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,18443.85,,,,,,,fee schedule,5097,18443.85, Resect/excise cranial lesion,61608,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,18443.85, Resect/excise cranial lesion,61608,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,18443.85, Resect/excise cranial lesion,61608,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,18443.85, Transect artery sinus,61611,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2560.67,,,,,,,fee schedule,2560.67,6979, Transect artery sinus,61611,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2560.67,6979, Transect artery sinus,61611,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2560.67,6979, Transect artery sinus,61611,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2560.67,6979, Remove aneurysm sinus,61613,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,18728.87,,,,,,,fee schedule,5097,18728.87, Remove aneurysm sinus,61613,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,18728.87, Remove aneurysm sinus,61613,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,18728.87, Remove aneurysm sinus,61613,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,18728.87, Resect/excise lesion skull,61615,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,16268.51,,,,,,,fee schedule,5097,16268.51, Resect/excise lesion skull,61615,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,16268.51, Resect/excise lesion skull,61615,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,16268.51, Resect/excise lesion skull,61615,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,16268.51, Resect/excise lesion skull,61616,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,18286.02,,,,,,,fee schedule,5097,18286.02, Resect/excise lesion skull,61616,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,18286.02, Resect/excise lesion skull,61616,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,18286.02, Resect/excise lesion skull,61616,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,18286.02, Repair dura,61618,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7029.42,,,,,,,fee schedule,5097,7029.42, Repair dura,61618,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7029.42, Repair dura,61618,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7029.42, Repair dura,61618,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7029.42, Repair dura,61619,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9144.76,,,,,,,fee schedule,5097,9144.76, Repair dura,61619,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,9144.76, Repair dura,61619,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,9144.76, Repair dura,61619,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,9144.76, Endovasc tempory vessel occl,61623,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3041.89,,,,,,,fee schedule,3041.89,25393, Endovasc tempory vessel occl,61623,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3041.89,25393, Endovasc tempory vessel occl,61623,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,3041.89,25393, Endovasc tempory vessel occl,61623,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,3041.89,25393, Transcath occlusion cns,61624,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6172.21,,,,,,,fee schedule,6172.21,25393, Transcath occlusion cns,61624,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,6172.21,25393, Transcath occlusion cns,61624,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,6172.21,25393, Transcath occlusion cns,61624,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,6172.21,25393, Transcath occlusion non-cns,61626,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4408.21,,,,,,,fee schedule,4408.21,25393, Transcath occlusion non-cns,61626,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4408.21,25393, Transcath occlusion non-cns,61626,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,4408.21,25393, Transcath occlusion non-cns,61626,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,4408.21,25393, Intracranial angioplasty,61630,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7314.66,,,,,,,fee schedule,5097,7314.66, Intracranial angioplasty,61630,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7314.66, Intracranial angioplasty,61630,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7314.66, Intracranial angioplasty,61630,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7314.66, Intracran angioplsty w/stent,61635,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7902.55,,,,,,,fee schedule,5097,7902.55, Intracran angioplsty w/stent,61635,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7902.55, Intracran angioplsty w/stent,61635,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7902.55, Intracran angioplsty w/stent,61635,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7902.55, Dilate ic vasospasm init,61640,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Dilate ic vasospasm init,61640,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Dilate ic vasospasm init,61640,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Dilate ic vasospasm add-on,61641,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Dilate ic vasospasm add-on,61641,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Dilate ic vasospasm add-on,61641,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Dilate ic vasospasm add-on,61642,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Dilate ic vasospasm add-on,61642,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Dilate ic vasospasm add-on,61642,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Perq art m-thrombect &/nfs,61645,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4440.1,,,,,,,fee schedule,4440.1,6979, Perq art m-thrombect &/nfs,61645,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4440.1,6979, Perq art m-thrombect &/nfs,61645,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4440.1,6979, Perq art m-thrombect &/nfs,61645,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4440.1,6979, Evasc prlng admn rx agnt 1st,61650,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3091.75,,,,,,,fee schedule,3091.75,6979, Evasc prlng admn rx agnt 1st,61650,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3091.75,6979, Evasc prlng admn rx agnt 1st,61650,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3091.75,6979, Evasc prlng admn rx agnt 1st,61650,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3091.75,6979, Evasc prlng admn rx agnt add,61651,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1322.29,,,,,,,fee schedule,1322.29,6979, Evasc prlng admn rx agnt add,61651,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1322.29,6979, Evasc prlng admn rx agnt add,61651,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1322.29,6979, Evasc prlng admn rx agnt add,61651,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1322.29,6979, Intracranial vessel surgery,61680,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12962.11,,,,,,,fee schedule,5097,12962.11, Intracranial vessel surgery,61680,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,12962.11, Intracranial vessel surgery,61680,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,12962.11, Intracranial vessel surgery,61680,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,12962.11, Intracranial vessel surgery,61682,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,23038.17,,,,,,,fee schedule,5097,23038.17, Intracranial vessel surgery,61682,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,23038.17, Intracranial vessel surgery,61682,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,23038.17, Intracranial vessel surgery,61682,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,23038.17, Intracranial vessel surgery,61684,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,16099.83,,,,,,,fee schedule,5097,16099.83, Intracranial vessel surgery,61684,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,16099.83, Intracranial vessel surgery,61684,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,16099.83, Intracranial vessel surgery,61684,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,16099.83, Intracranial vessel surgery,61686,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,25177.3,,,,,,,fee schedule,5097,25177.3, Intracranial vessel surgery,61686,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,25177.3, Intracranial vessel surgery,61686,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,25177.3, Intracranial vessel surgery,61686,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,25177.3, Intracranial vessel surgery,61690,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12469.02,,,,,,,fee schedule,5097,12469.02, Intracranial vessel surgery,61690,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,12469.02, Intracranial vessel surgery,61690,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,12469.02, Intracranial vessel surgery,61690,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,12469.02, Intracranial vessel surgery,61692,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,20520.5,,,,,,,fee schedule,5097,20520.5, Intracranial vessel surgery,61692,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,20520.5, Intracranial vessel surgery,61692,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,20520.5, Intracranial vessel surgery,61692,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,20520.5, Brain aneurysm repr complx,61697,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,23712.61,,,,,,,fee schedule,5097,23712.61, Brain aneurysm repr complx,61697,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,23712.61, Brain aneurysm repr complx,61697,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,23712.61, Brain aneurysm repr complx,61697,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,23712.61, Brain aneurysm repr complx,61698,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,25916.34,,,,,,,fee schedule,5097,25916.34, Brain aneurysm repr complx,61698,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,25916.34, Brain aneurysm repr complx,61698,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,25916.34, Brain aneurysm repr complx,61698,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,25916.34, Brain aneurysm repr simple,61700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,18932.3,,,,,,,fee schedule,5097,18932.3, Brain aneurysm repr simple,61700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,18932.3, Brain aneurysm repr simple,61700,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,18932.3, Brain aneurysm repr simple,61700,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,18932.3, Inner skull vessel surgery,61702,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,22598.77,,,,,,,fee schedule,5097,22598.77, Inner skull vessel surgery,61702,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,22598.77, Inner skull vessel surgery,61702,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,22598.77, Inner skull vessel surgery,61702,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,22598.77, Clamp neck artery,61703,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7876,,,,,,,fee schedule,5097,7876, Clamp neck artery,61703,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7876, Clamp neck artery,61703,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7876, Clamp neck artery,61703,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7876, Revise circulation to head,61705,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,14743.06,,,,,,,fee schedule,5097,14743.06, Revise circulation to head,61705,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,14743.06, Revise circulation to head,61705,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,14743.06, Revise circulation to head,61705,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,14743.06, Revise circulation to head,61708,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,14437.97,,,,,,,fee schedule,5097,14437.97, Revise circulation to head,61708,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,14437.97, Revise circulation to head,61708,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,14437.97, Revise circulation to head,61708,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,14437.97, Revise circulation to head,61710,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12206.45,,,,,,,fee schedule,5097,12206.45, Revise circulation to head,61710,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,12206.45, Revise circulation to head,61710,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,12206.45, Revise circulation to head,61710,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,12206.45, Fusion of skull arteries,61711,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,14690.83,,,,,,,fee schedule,5097,14690.83, Fusion of skull arteries,61711,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,14690.83, Fusion of skull arteries,61711,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,14690.83, Fusion of skull arteries,61711,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,14690.83, Description Not Available,61712,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Mrgfus strtctc ablt trgt icr,61715,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,25393, Mrgfus strtctc ablt trgt icr,61715,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,5248,25393, Mrgfus strtctc ablt trgt icr,61715,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,5248,25393, Incise skull/brain surgery,61720,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7365.7,,,,,,,fee schedule,6979,14456, Incise skull/brain surgery,61720,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,14456, Incise skull/brain surgery,61720,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,6979,14456, Incise skull/brain surgery,61720,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,6979,14456, Incise skull/brain surgery,61735,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9183.83,,,,,,,fee schedule,5097,9183.83, Incise skull/brain surgery,61735,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,9183.83, Incise skull/brain surgery,61735,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,9183.83, Incise skull/brain surgery,61735,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,9183.83, Litt icr 1 traj 1 smpl les,61736,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6810.51,,,,,,,fee schedule,5097,6979, Litt icr 1 traj 1 smpl les,61736,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Litt icr 1 traj 1 smpl les,61736,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Litt icr 1 traj 1 smpl les,61736,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Litt icr mlt trj mlt/cplx ls,61737,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8059.47,,,,,,,fee schedule,5097,8059.47, Litt icr mlt trj mlt/cplx ls,61737,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8059.47, Litt icr mlt trj mlt/cplx ls,61737,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8059.47, Litt icr mlt trj mlt/cplx ls,61737,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8059.47, Incise skull/brain biopsy,61750,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8100.85,,,,,,,fee schedule,5097,8100.85, Incise skull/brain biopsy,61750,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8100.85, Incise skull/brain biopsy,61750,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8100.85, Incise skull/brain biopsy,61750,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8100.85, Brain biopsy w/ct/mr guide,61751,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8056.61,,,,,,,fee schedule,5097,8056.61, Brain biopsy w/ct/mr guide,61751,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8056.61, Brain biopsy w/ct/mr guide,61751,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8056.61, Brain biopsy w/ct/mr guide,61751,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8056.61, Implant brain electrodes,61760,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9098.25,,,,,,,fee schedule,5097,9098.25, Implant brain electrodes,61760,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,9098.25, Implant brain electrodes,61760,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,9098.25, Implant brain electrodes,61760,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,9098.25, Incise skull for treatment,61770,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9296.5,,,,,,,fee schedule,6979,14456, Incise skull for treatment,61770,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,14456, Incise skull for treatment,61770,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,6979,14456, Incise skull for treatment,61770,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,6979,14456, Scan proc cranial intra,61781,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1287.49,,,,,,,fee schedule,1287.49,3195, Scan proc cranial intra,61781,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1287.49,3195, Scan proc cranial intra,61781,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1287.49,3195, Scan proc cranial intra,61781,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1287.49,3195, Scan proc cranial extra,61782,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,814.26,,,,,,,fee schedule,814.26,3195, Scan proc cranial extra,61782,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,814.26,3195, Scan proc cranial extra,61782,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,814.26,3195, Scan proc cranial extra,61782,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,814.26,3195, Scan proc spinal,61783,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1228.18,,,,,,,fee schedule,1228.18,3195, Scan proc spinal,61783,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1228.18,3195, Scan proc spinal,61783,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1228.18,3195, Scan proc spinal,61783,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1228.18,3195, Treat trigeminal nerve,61790,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5182.53,,,,,,,fee schedule,5182.53,10940, Treat trigeminal nerve,61790,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5182.53,10940, Treat trigeminal nerve,61790,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,5182.53,10940, Treat trigeminal nerve,61790,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,5182.53,10940, Treat trigeminal tract,61791,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6554.9,,,,,,,fee schedule,5248,10940, Treat trigeminal tract,61791,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,10940, Treat trigeminal tract,61791,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,5248,10940, Treat trigeminal tract,61791,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,5248,10940, Srs cranial lesion simple,61796,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5891.84,,,,,,,fee schedule,5891.84,22111, Srs cranial lesion simple,61796,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5891.84,22111, Srs cranial lesion simple,61796,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5891.84,22111, Srs cranial lesion simple,61796,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5891.84,22111, Srs cran les simple addl,61797,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1198.94,,,,,,,fee schedule,1198.94,6979, Srs cran les simple addl,61797,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1198.94,6979, Srs cran les simple addl,61797,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1198.94,6979, Srs cran les simple addl,61797,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1198.94,6979, Srs cranial lesion complex,61798,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7842.28,,,,,,,fee schedule,6979,22111, Srs cranial lesion complex,61798,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,22111, Srs cranial lesion complex,61798,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6979,22111, Srs cranial lesion complex,61798,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6979,22111, Srs cran les complex addl,61799,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1648.96,,,,,,,fee schedule,1648.96,6979, Srs cran les complex addl,61799,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1648.96,6979, Srs cran les complex addl,61799,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1648.96,6979, Srs cran les complex addl,61799,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1648.96,6979, Apply srs headframe add-on,61800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,859.31,,,,,,,fee schedule,859.31,3195, Apply srs headframe add-on,61800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,859.31,3195, Apply srs headframe add-on,61800,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,859.31,3195, Apply srs headframe add-on,61800,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,859.31,3195, Implant neuroelectrodes,61850,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5750.41,,,,,,,fee schedule,5097,6979, Implant neuroelectrodes,61850,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Implant neuroelectrodes,61850,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Implant neuroelectrodes,61850,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Description Not Available,61855,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Implant neuroelectrodes,61860,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8974.41,,,,,,,fee schedule,5097,8974.41, Implant neuroelectrodes,61860,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8974.41, Implant neuroelectrodes,61860,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8974.41, Implant neuroelectrodes,61860,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8974.41, Implant neuroelectrode,61863,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8718.43,,,,,,,fee schedule,5097,8718.43, Implant neuroelectrode,61863,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8718.43, Implant neuroelectrode,61863,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8718.43, Implant neuroelectrode,61863,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8718.43, Implant neuroelectrde addl,61864,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1553.18,,,,,,,fee schedule,1553.18,6979, Implant neuroelectrde addl,61864,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1553.18,6979, Implant neuroelectrde addl,61864,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1553.18,6979, Implant neuroelectrde addl,61864,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1553.18,6979, Description Not Available,61865,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Implant neuroelectrode,61867,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12978.35,,,,,,,fee schedule,5097,12978.35, Implant neuroelectrode,61867,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,12978.35, Implant neuroelectrode,61867,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,12978.35, Implant neuroelectrode,61867,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,12978.35, Implant neuroelectrde addl,61868,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2732.48,,,,,,,fee schedule,2732.48,6979, Implant neuroelectrde addl,61868,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2732.48,6979, Implant neuroelectrde addl,61868,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2732.48,6979, Implant neuroelectrde addl,61868,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2732.48,6979, Revise/remove neuroelectrode,61880,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3529.96,,,,,,,fee schedule,3529.96,12821, Revise/remove neuroelectrode,61880,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3529.96,12821, Revise/remove neuroelectrode,61880,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3529.96,12821, Revise/remove neuroelectrode,61880,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3529.96,12821, Insrt/redo neurostim 1 array,61885,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3156.12,,,,,,,fee schedule,3156.12,39251, Insrt/redo neurostim 1 array,61885,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3156.12,39251, Insrt/redo neurostim 1 array,61885,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,39251,,,,,,,fee schedule,3156.12,39251, Insrt/redo neurostim 1 array,61885,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,35325,,,,,,,fee schedule,3156.12,39251, Implant neurostim arrays,61886,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5277.83,,,,,,,fee schedule,5248,46177, Implant neurostim arrays,61886,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,46177, Implant neurostim arrays,61886,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46177,,,,,,,fee schedule,5248,46177, Implant neurostim arrays,61886,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,41559,,,,,,,fee schedule,5248,46177, Revise/remove neuroreceiver,61888,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2321.25,,,,,,,fee schedule,2321.25,12821, Revise/remove neuroreceiver,61888,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2321.25,12821, Revise/remove neuroreceiver,61888,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2321.25,12821, Revise/remove neuroreceiver,61888,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2321.25,12821, Ins sk-mnt crnl nstm pg/rcvr,61889,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10273.71,,,,,,,fee schedule,5097,10273.71, Ins sk-mnt crnl nstm pg/rcvr,61889,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,10273.71, Ins sk-mnt crnl nstm pg/rcvr,61889,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,10273.71, Ins sk-mnt crnl nstm pg/rcvr,61889,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,10273.71, Rev/rplcmt sk-mnt crnl nstm,61891,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4826.56,,,,,,,fee schedule,4826.56,25393, Rev/rplcmt sk-mnt crnl nstm,61891,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4826.56,25393, Rev/rplcmt sk-mnt crnl nstm,61891,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,4826.56,25393, Rev/rplcmt sk-mnt crnl nstm,61891,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,4826.56,25393, Rmv sk-mnt crnl nstm pg/rcvr,61892,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6378.23,,,,,,,fee schedule,4108,12821, Rmv sk-mnt crnl nstm pg/rcvr,61892,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,12821, Rmv sk-mnt crnl nstm pg/rcvr,61892,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4108,12821, Rmv sk-mnt crnl nstm pg/rcvr,61892,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4108,12821, Treat skull fracture,62000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6040.5,,,,,,,fee schedule,6040.5,14456, Treat skull fracture,62000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6040.5,14456, Treat skull fracture,62000,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,6040.5,14456, Treat skull fracture,62000,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,6040.5,14456, Treat skull fracture,62005,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7370.23,,,,,,,fee schedule,5097,7370.23, Treat skull fracture,62005,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7370.23, Treat skull fracture,62005,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7370.23, Treat skull fracture,62005,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7370.23, Treatment of head injury,62010,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8863.58,,,,,,,fee schedule,5097,8863.58, Treatment of head injury,62010,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8863.58, Treatment of head injury,62010,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8863.58, Treatment of head injury,62010,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8863.58, Repair brain fluid leakage,62100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8426.72,,,,,,,fee schedule,5097,8426.72, Repair brain fluid leakage,62100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8426.72, Repair brain fluid leakage,62100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8426.72, Repair brain fluid leakage,62100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8426.72, Reduction of skull defect,62115,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9777.77,,,,,,,fee schedule,5097,9777.77, Reduction of skull defect,62115,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,9777.77, Reduction of skull defect,62115,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,9777.77, Reduction of skull defect,62115,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,9777.77, Reduction of skull defect,62117,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,11205.87,,,,,,,fee schedule,5097,11205.87, Reduction of skull defect,62117,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,11205.87, Reduction of skull defect,62117,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,11205.87, Reduction of skull defect,62117,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,11205.87, Repair skull cavity lesion,62120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12252.32,,,,,,,fee schedule,5097,12252.32, Repair skull cavity lesion,62120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,12252.32, Repair skull cavity lesion,62120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,12252.32, Repair skull cavity lesion,62120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,12252.32, Incise skull repair,62121,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8157.08,,,,,,,fee schedule,5097,8157.08, Incise skull repair,62121,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8157.08, Incise skull repair,62121,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8157.08, Incise skull repair,62121,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8157.08, Repair of skull defect,62140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5645.73,,,,,,,fee schedule,5097,6979, Repair of skull defect,62140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Repair of skull defect,62140,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Repair of skull defect,62140,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Repair of skull defect,62141,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6467.7,,,,,,,fee schedule,5097,6979, Repair of skull defect,62141,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Repair of skull defect,62141,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Repair of skull defect,62141,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Remove skull plate/flap,62142,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5197.54,,,,,,,fee schedule,5097,6979, Remove skull plate/flap,62142,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Remove skull plate/flap,62142,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Remove skull plate/flap,62142,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Replace skull plate/flap,62143,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6043.74,,,,,,,fee schedule,5097,6979, Replace skull plate/flap,62143,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Replace skull plate/flap,62143,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Replace skull plate/flap,62143,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Repair of skull & brain,62145,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7965.52,,,,,,,fee schedule,5097,7965.52, Repair of skull & brain,62145,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7965.52, Repair of skull & brain,62145,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7965.52, Repair of skull & brain,62145,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7965.52, Repair of skull with graft,62146,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7246.61,,,,,,,fee schedule,5097,7246.61, Repair of skull with graft,62146,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7246.61, Repair of skull with graft,62146,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7246.61, Repair of skull with graft,62146,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7246.61, Repair of skull with graft,62147,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7961.85,,,,,,,fee schedule,5097,7961.85, Repair of skull with graft,62147,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7961.85, Repair of skull with graft,62147,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7961.85, Repair of skull with graft,62147,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7961.85, Retr bone flap to fix skull,62148,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,690.74,,,,,,,fee schedule,690.74,5664, Retr bone flap to fix skull,62148,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,690.74,5664, Retr bone flap to fix skull,62148,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,690.74,5664, Neuroendoscopy add-on,62160,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1031.61,,,,,,,fee schedule,1031.61,3195, Neuroendoscopy add-on,62160,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1031.61,3195, Neuroendoscopy add-on,62160,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1031.61,3195, Neuroendoscopy add-on,62160,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1031.61,3195, Dissect brain w/scope,62161,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8767.74,,,,,,,fee schedule,5097,8767.74, Dissect brain w/scope,62161,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8767.74, Dissect brain w/scope,62161,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8767.74, Dissect brain w/scope,62161,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8767.74, Remove colloid cyst w/scope,62162,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10857.56,,,,,,,fee schedule,5097,10857.56, Remove colloid cyst w/scope,62162,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,10857.56, Remove colloid cyst w/scope,62162,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,10857.56, Remove colloid cyst w/scope,62162,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,10857.56, Remove brain tumor w/scope,62164,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12049.16,,,,,,,fee schedule,5097,12049.16, Remove brain tumor w/scope,62164,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,12049.16, Remove brain tumor w/scope,62164,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,12049.16, Remove brain tumor w/scope,62164,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,12049.16, Remove pituit tumor w/scope,62165,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8056.82,,,,,,,fee schedule,5097,8056.82, Remove pituit tumor w/scope,62165,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8056.82, Remove pituit tumor w/scope,62165,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8056.82, Remove pituit tumor w/scope,62165,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8056.82, Establish brain cavity shunt,62180,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9203.15,,,,,,,fee schedule,5097,9203.15, Establish brain cavity shunt,62180,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,9203.15, Establish brain cavity shunt,62180,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,9203.15, Establish brain cavity shunt,62180,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,9203.15, Establish brain cavity shunt,62190,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5474.24,,,,,,,fee schedule,5097,6979, Establish brain cavity shunt,62190,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Establish brain cavity shunt,62190,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Establish brain cavity shunt,62190,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Establish brain cavity shunt,62192,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5883.2,,,,,,,fee schedule,5097,6979, Establish brain cavity shunt,62192,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Establish brain cavity shunt,62192,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Establish brain cavity shunt,62192,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Replace/irrigate catheter,62194,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2993.59,,,,,,,fee schedule,2993.59,10940, Replace/irrigate catheter,62194,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2993.59,10940, Replace/irrigate catheter,62194,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2993.59,10940, Replace/irrigate catheter,62194,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2993.59,10940, Establish brain cavity shunt,62200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7943.61,,,,,,,fee schedule,5097,7943.61, Establish brain cavity shunt,62200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7943.61, Establish brain cavity shunt,62200,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7943.61, Establish brain cavity shunt,62200,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7943.61, Brain cavity shunt w/scope,62201,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7096.66,,,,,,,fee schedule,5097,7096.66, Brain cavity shunt w/scope,62201,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7096.66, Brain cavity shunt w/scope,62201,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7096.66, Brain cavity shunt w/scope,62201,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7096.66, Establish brain cavity shunt,62220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5635.42,,,,,,,fee schedule,5097,6979, Establish brain cavity shunt,62220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Establish brain cavity shunt,62220,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Establish brain cavity shunt,62220,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Establish brain cavity shunt,62223,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5887.79,,,,,,,fee schedule,5097,6979, Establish brain cavity shunt,62223,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Establish brain cavity shunt,62223,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Establish brain cavity shunt,62223,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Replace/irrigate catheter,62225,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3246.88,,,,,,,fee schedule,3195,5664, Replace/irrigate catheter,62225,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,5664, Replace/irrigate catheter,62225,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3195,5664, Replace/irrigate catheter,62225,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3195,5664, Replace/revise brain shunt,62230,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4848.09,,,,,,,fee schedule,4108,14456, Replace/revise brain shunt,62230,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,14456, Replace/revise brain shunt,62230,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4108,14456, Replace/revise brain shunt,62230,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4108,14456, Csf Shunt Reprogram,62252,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,281.83,,,,,,,fee schedule,281.83,6979, Csf Shunt Reprogram,62252,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,281.83,6979, Csf Shunt Reprogram,62252,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,281.83,6979, Csf Shunt Reprogram,62252,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,281.83,6979, Remove brain cavity shunt,62256,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3652.17,,,,,,,fee schedule,3652.17,5664, Remove brain cavity shunt,62256,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3652.17,5664, Remove brain cavity shunt,62256,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3652.17,5664, Remove brain cavity shunt,62256,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3652.17,5664, Replace brain cavity shunt,62258,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6420.81,,,,,,,fee schedule,5097,6979, Replace brain cavity shunt,62258,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Replace brain cavity shunt,62258,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Replace brain cavity shunt,62258,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Epidural lysis mult sessions,62263,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1622.69,,,,,,,fee schedule,1622.69,4497, Epidural lysis mult sessions,62263,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1622.69,4497, Epidural lysis mult sessions,62263,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,1622.69,4497, Epidural lysis mult sessions,62263,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,1622.69,4497, Epidural lysis on single day,62264,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1180.05,,,,,,,fee schedule,1180.05,4497, Epidural lysis on single day,62264,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1180.05,4497, Epidural lysis on single day,62264,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,1180.05,4497, Epidural lysis on single day,62264,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,1180.05,4497, Interdiscal perq aspir dx,62267,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,751.88,,,,,,,fee schedule,751.88,4497, Interdiscal perq aspir dx,62267,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,751.88,4497, Interdiscal perq aspir dx,62267,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,751.88,4497, Interdiscal perq aspir dx,62267,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,751.88,4497, Drain spinal cord cyst,62268,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1869.82,,,,,,,fee schedule,1869.82,4497, Drain spinal cord cyst,62268,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1869.82,4497, Drain spinal cord cyst,62268,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,1869.82,4497, Drain spinal cord cyst,62268,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,1869.82,4497, Needle biopsy spinal cord,62269,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1229.86,,,,,,,fee schedule,1229.86,5664, Needle biopsy spinal cord,62269,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1229.86,5664, Needle biopsy spinal cord,62269,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1229.86,5664, Needle biopsy spinal cord,62269,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1229.86,5664, Spinal fluid tap diagnostic,62270,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,341.3,,,,,,,fee schedule,341.3,4497, Spinal fluid tap diagnostic,62270,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,341.3,4497, Spinal fluid tap diagnostic,62270,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,341.3,4497, Spinal fluid tap diagnostic,62270,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,341.3,4497, Drain cerebro spinal fluid,62272,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,496.22,,,,,,,fee schedule,496.22,4497, Drain cerebro spinal fluid,62272,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,496.22,4497, Drain cerebro spinal fluid,62272,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,496.22,4497, Drain cerebro spinal fluid,62272,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,496.22,4497, Inject epidural patch,62273,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,564.58,,,,,,,fee schedule,564.58,4497, Inject epidural patch,62273,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,564.58,4497, Inject epidural patch,62273,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,564.58,4497, Inject epidural patch,62273,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,564.58,4497, Description Not Available,62274,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Description Not Available,62275,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Description Not Available,62276,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Description Not Available,62277,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Description Not Available,62278,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Description Not Available,62279,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Treat spinal cord lesion,62280,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,748.91,,,,,,,fee schedule,748.91,4497, Treat spinal cord lesion,62280,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,748.91,4497, Treat spinal cord lesion,62280,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,748.91,4497, Treat spinal cord lesion,62280,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,748.91,4497, Treat spinal cord lesion,62281,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,743.25,,,,,,,fee schedule,743.25,4497, Treat spinal cord lesion,62281,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,743.25,4497, Treat spinal cord lesion,62281,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,743.25,4497, Treat spinal cord lesion,62281,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,743.25,4497, Treat spinal canal lesion,62282,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,707.25,,,,,,,fee schedule,707.25,4497, Treat spinal canal lesion,62282,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,707.25,4497, Treat spinal canal lesion,62282,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,707.25,4497, Treat spinal canal lesion,62282,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,707.25,4497, Injection for myelogram,62284,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,398.12,,,,,,,fee schedule,398.12,3195, Injection for myelogram,62284,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,398.12,3195, Injection for myelogram,62284,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,398.12,3195, Injection for myelogram,62284,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,398.12,3195, Percutaneous diskectomy,62287,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2916.65,,,,,,,fee schedule,2916.65,12821, Percutaneous diskectomy,62287,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,2916.65,12821, Percutaneous diskectomy,62287,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2916.65,12821, Percutaneous diskectomy,62287,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2916.65,12821, Description Not Available,62288,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Description Not Available,62289,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Inject for spine disk x-ray,62290,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,784.58,,,,,,,fee schedule,784.58,3195, Inject for spine disk x-ray,62290,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,784.58,3195, Inject for spine disk x-ray,62290,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,784.58,3195, Inject for spine disk x-ray,62290,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,784.58,3195, Inject for spine disk x-ray,62291,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,735.37,,,,,,,fee schedule,735.37,3195, Inject for spine disk x-ray,62291,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,735.37,3195, Inject for spine disk x-ray,62291,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,735.37,3195, Inject for spine disk x-ray,62291,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,735.37,3195, Injection into disk lesion,62292,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2798.96,,,,,,,fee schedule,2798.96,10940, Injection into disk lesion,62292,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2798.96,10940, Injection into disk lesion,62292,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2798.96,10940, Injection into disk lesion,62292,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2798.96,10940, Injection into spinal artery,62294,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5548.87,,,,,,,fee schedule,4047,5548.87, Injection into spinal artery,62294,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4047,5548.87, Injection into spinal artery,62294,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,4047,5548.87, Injection into spinal artery,62294,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,4047,5548.87, Description Not Available,62298,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Myelography lumbar injection,62302,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,566.63,,,,,,,fee schedule,566.63,4497, Myelography lumbar injection,62302,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,566.63,4497, Myelography lumbar injection,62302,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,566.63,4497, Myelography lumbar injection,62302,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,566.63,4497, Myelography lumbar injection,62303,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,563.88,,,,,,,fee schedule,563.88,4497, Myelography lumbar injection,62303,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,563.88,4497, Myelography lumbar injection,62303,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,563.88,4497, Myelography lumbar injection,62303,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,563.88,4497, Myelography lumbar injection,62304,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,559.4,,,,,,,fee schedule,559.4,4497, Myelography lumbar injection,62304,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,559.4,4497, Myelography lumbar injection,62304,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,559.4,4497, Myelography lumbar injection,62304,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,559.4,4497, Myelography lumbar injection,62305,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,580.88,,,,,,,fee schedule,580.88,4497, Myelography lumbar injection,62305,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,580.88,4497, Myelography lumbar injection,62305,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,580.88,4497, Myelography lumbar injection,62305,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,580.88,4497, Njx interlaminar crv/thrc,62320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,487.8,,,,,,,fee schedule,487.8,4497, Njx interlaminar crv/thrc,62320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,487.8,4497, Njx interlaminar crv/thrc,62320,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,487.8,4497, Njx interlaminar crv/thrc,62320,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,487.8,4497, Njx interlaminar crv/thrc,62321,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,525.57,,,,,,,fee schedule,525.57,4497, Njx interlaminar crv/thrc,62321,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,525.57,4497, Njx interlaminar crv/thrc,62321,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,525.57,4497, Njx interlaminar crv/thrc,62321,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,525.57,4497, Njx interlaminar lmbr/sac,62322,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,409.29,,,,,,,fee schedule,409.29,4497, Njx interlaminar lmbr/sac,62322,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,409.29,4497, Njx interlaminar lmbr/sac,62322,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,409.29,4497, Njx interlaminar lmbr/sac,62322,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,409.29,4497, Njx interlaminar lmbr/sac,62323,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,490.77,,,,,,,fee schedule,490.77,4497, Njx interlaminar lmbr/sac,62323,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,490.77,4497, Njx interlaminar lmbr/sac,62323,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,490.77,4497, Njx interlaminar lmbr/sac,62323,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,490.77,4497, Njx interlaminar crv/thrc,62324,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,474.9,,,,,,,fee schedule,474.9,4497, Njx interlaminar crv/thrc,62324,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,474.9,4497, Njx interlaminar crv/thrc,62324,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,474.9,4497, Njx interlaminar crv/thrc,62324,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,474.9,4497, Njx interlaminar crv/thrc,62325,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,556.11,,,,,,,fee schedule,556.11,4497, Njx interlaminar crv/thrc,62325,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,556.11,4497, Njx interlaminar crv/thrc,62325,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,556.11,4497, Njx interlaminar crv/thrc,62325,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,556.11,4497, Njx interlaminar lmbr/sac,62326,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,452.45,,,,,,,fee schedule,452.45,4497, Njx interlaminar lmbr/sac,62326,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,452.45,4497, Njx interlaminar lmbr/sac,62326,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,452.45,4497, Njx interlaminar lmbr/sac,62326,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,452.45,4497, Njx interlaminar lmbr/sac,62327,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,514.13,,,,,,,fee schedule,514.13,4497, Njx interlaminar lmbr/sac,62327,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,514.13,4497, Njx interlaminar lmbr/sac,62327,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,514.13,4497, Njx interlaminar lmbr/sac,62327,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,514.13,4497, Dx lmbr spi pnxr w/fluor/ct,62328,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,410.2,,,,,,,fee schedule,410.2,4497, Dx lmbr spi pnxr w/fluor/ct,62328,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,410.2,4497, Dx lmbr spi pnxr w/fluor/ct,62328,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,410.2,4497, Dx lmbr spi pnxr w/fluor/ct,62328,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,410.2,4497, Ther spi pnxr csf fluor/ct,62329,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,529.19,,,,,,,fee schedule,529.19,4497, Ther spi pnxr csf fluor/ct,62329,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,529.19,4497, Ther spi pnxr csf fluor/ct,62329,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,529.19,4497, Ther spi pnxr csf fluor/ct,62329,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,529.19,4497, Dcmprn prq rmv lig flv 1lmbr,62330,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2605.94,,,,,,,fee schedule,2605.94,6979, Dcmprn prq rmv lig flv 1lmbr,62330,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2605.94,6979, Dcmprn prq rmv lig flv addl,62331,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1046.39,,,,,,,fee schedule,1046.39,1046.39, Implant spinal canal cath,62350,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2110.86,,,,,,,fee schedule,2110.86,14456, Implant spinal canal cath,62350,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2110.86,14456, Implant spinal canal cath,62350,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,2110.86,14456, Implant spinal canal cath,62350,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,2110.86,14456, Implant spinal canal cath,62351,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5215.18,,,,,,,fee schedule,4108,22111, Implant spinal canal cath,62351,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,22111, Implant spinal canal cath,62351,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4108,22111, Implant spinal canal cath,62351,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4108,22111, Remove spinal canal catheter,62355,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1561.28,,,,,,,fee schedule,1561.28,10940, Remove spinal canal catheter,62355,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1561.28,10940, Remove spinal canal catheter,62355,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1561.28,10940, Remove spinal canal catheter,62355,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1561.28,10940, Insert spine infusion device,62360,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1733.47,,,,,,,fee schedule,1733.47,14456, Insert spine infusion device,62360,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1733.47,14456, Insert spine infusion device,62360,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,1733.47,14456, Insert spine infusion device,62360,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,1733.47,14456, Implant spine infusion pump,62361,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2639.24,,,,,,,fee schedule,2639.24,39251, Implant spine infusion pump,62361,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2639.24,39251, Implant spine infusion pump,62361,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,39251,,,,,,,fee schedule,2639.24,39251, Implant spine infusion pump,62361,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,35325,,,,,,,fee schedule,2639.24,39251, Implant spine infusion pump,62362,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2085.23,,,,,,,fee schedule,2085.23,39251, Implant spine infusion pump,62362,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2085.23,39251, Implant spine infusion pump,62362,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,39251,,,,,,,fee schedule,2085.23,39251, Implant spine infusion pump,62362,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,35325,,,,,,,fee schedule,2085.23,39251, Remove spine infusion device,62365,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1653.55,,,,,,,fee schedule,1653.55,22111, Remove spine infusion device,62365,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1653.55,22111, Remove spine infusion device,62365,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,1653.55,22111, Remove spine infusion device,62365,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,1653.55,22111, Analyze spine infus pump,62367,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,118.93,,,,,,,fee schedule,118.93,4108, Analyze spine infus pump,62367,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,118.93,4108, Analyze spine infus pump,62367,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,118.93,4108, Analyze spine infus pump,62367,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,118.93,4108, Analyze sp inf pump w/reprog,62368,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,163.66,,,,,,,fee schedule,163.66,4108, Analyze sp inf pump w/reprog,62368,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,163.66,4108, Analyze sp inf pump w/reprog,62368,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,163.66,4108, Analyze sp inf pump w/reprog,62368,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,163.66,4108, Anal sp inf pmp w/reprg&fill,62369,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,165.39,,,,,,,fee schedule,165.39,6979, Anal sp inf pmp w/reprg&fill,62369,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,165.39,6979, Anal sp inf pmp w/reprg&fill,62369,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,165.39,6979, Anal sp inf pmp w/reprg&fill,62369,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,165.39,6979, Anl sp inf pmp w/mdreprg&fil,62370,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,218.16,,,,,,,fee schedule,218.16,4108, Anl sp inf pmp w/mdreprg&fil,62370,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,218.16,4108, Anl sp inf pmp w/mdreprg&fil,62370,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,218.16,4108, Anl sp inf pmp w/mdreprg&fil,62370,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,218.16,4108, Ndsc dcmprn 1 ntrspc lumbar,62380,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,22111, Ndsc dcmprn 1 ntrspc lumbar,62380,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6044,22111, Ndsc dcmprn 1 ntrspc lumbar,62380,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6044,22111, Remove spine lamina 1/2 crvl,63001,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6930.08,,,,,,,fee schedule,6930.08,22111, Remove spine lamina 1/2 crvl,63001,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6930.08,22111, Remove spine lamina 1/2 crvl,63001,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6930.08,22111, Remove spine lamina 1/2 crvl,63001,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6930.08,22111, Remove spine lamina 1/2 thrc,63003,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6954.53,,,,,,,fee schedule,6954.53,22111, Remove spine lamina 1/2 thrc,63003,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6954.53,22111, Remove spine lamina 1/2 thrc,63003,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6954.53,22111, Remove spine lamina 1/2 thrc,63003,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6954.53,22111, Remove spine lamina 1/2 lmbr,63005,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6881.52,,,,,,,fee schedule,6044,22111, Remove spine lamina 1/2 lmbr,63005,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,22111, Remove spine lamina 1/2 lmbr,63005,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6044,22111, Remove spine lamina 1/2 lmbr,63005,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6044,22111, Remove spine lamina 1/2 scrl,63011,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5734.11,,,,,,,fee schedule,5734.11,22111, Remove spine lamina 1/2 scrl,63011,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,5734.11,22111, Remove spine lamina 1/2 scrl,63011,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5734.11,22111, Remove spine lamina 1/2 scrl,63011,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5734.11,22111, Remove lamina/facets lumbar,63012,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6614.96,,,,,,,fee schedule,6044,22111, Remove lamina/facets lumbar,63012,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,22111, Remove lamina/facets lumbar,63012,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6044,22111, Remove lamina/facets lumbar,63012,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6044,22111, Remove spine lamina >2 crvcl,63015,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8386.14,,,,,,,fee schedule,6979,22111, Remove spine lamina >2 crvcl,63015,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,22111, Remove spine lamina >2 crvcl,63015,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6979,22111, Remove spine lamina >2 crvcl,63015,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6979,22111, Remove spine lamina >2 thrc,63016,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8501.61,,,,,,,fee schedule,6979,22111, Remove spine lamina >2 thrc,63016,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,22111, Remove spine lamina >2 thrc,63016,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6979,22111, Remove spine lamina >2 thrc,63016,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6979,22111, Remove spine lamina >2 lmbr,63017,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7197.24,,,,,,,fee schedule,5363,22111, Remove spine lamina >2 lmbr,63017,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,22111, Remove spine lamina >2 lmbr,63017,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5363,22111, Remove spine lamina >2 lmbr,63017,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5363,22111, Neck spine disk surgery,63020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6074.12,,,,,,,fee schedule,5248,22111, Neck spine disk surgery,63020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,22111, Neck spine disk surgery,63020,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5248,22111, Neck spine disk surgery,63020,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5248,22111, Low back disk surgery,63030,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5104.51,,,,,,,fee schedule,5104.51,22111, Low back disk surgery,63030,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,5104.51,22111, Low back disk surgery,63030,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5104.51,22111, Low back disk surgery,63030,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5104.51,22111, Lamot rpr anulr dfct 1 lmbr,63032,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,800.71,,,,,,,fee schedule,800.71,6979, Lamot rpr anulr dfct 1 lmbr,63032,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,800.71,6979, Spinal disk surgery add-on,63035,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1210,,,,,,,fee schedule,1210,6044, Spinal disk surgery add-on,63035,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,1210,6044, Spinal disk surgery add-on,63035,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1210,6044, Spinal disk surgery add-on,63035,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1210,6044, Laminotomy single cervical,63040,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7407.25,,,,,,,fee schedule,6044,22111, Laminotomy single cervical,63040,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,22111, Laminotomy single cervical,63040,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6044,22111, Laminotomy single cervical,63040,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6044,22111, Laminotomy single lumbar,63042,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979.73,,,,,,,fee schedule,6044,22111, Laminotomy single lumbar,63042,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,22111, Laminotomy single lumbar,63042,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6044,22111, Laminotomy single lumbar,63042,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6044,22111, Laminotomy addl cervical,63043,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,12821, Laminotomy addl cervical,63043,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3195,12821, Laminotomy addl cervical,63043,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3195,12821, Laminotomy addl lumbar,63044,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,12821, Laminotomy addl lumbar,63044,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3195,12821, Laminotomy addl lumbar,63044,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3195,12821, Remove spine lamina 1 crvl,63045,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7208.62,,,,,,,fee schedule,6044,22111, Remove spine lamina 1 crvl,63045,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,22111, Remove spine lamina 1 crvl,63045,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6044,22111, Remove spine lamina 1 crvl,63045,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6044,22111, Remove spine lamina 1 thrc,63046,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6809.05,,,,,,,fee schedule,6044,22111, Remove spine lamina 1 thrc,63046,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,22111, Remove spine lamina 1 thrc,63046,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6044,22111, Remove spine lamina 1 thrc,63046,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6044,22111, Remove spine lamina 1 lmbr,63047,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6096.4,,,,,,,fee schedule,6044,22111, Remove spine lamina 1 lmbr,63047,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,22111, Remove spine lamina 1 lmbr,63047,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6044,22111, Remove spine lamina 1 lmbr,63047,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6044,22111, Remove spinal lamina add-on,63048,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1101.86,,,,,,,fee schedule,1101.86,6044, Remove spinal lamina add-on,63048,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,1101.86,6044, Remove spinal lamina add-on,63048,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1101.86,6044, Remove spinal lamina add-on,63048,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1101.86,6044, Cervical laminoplsty 2/> seg,63050,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8073.55,,,,,,,fee schedule,5097,8073.55, Cervical laminoplsty 2/> seg,63050,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8073.55, Cervical laminoplsty 2/> seg,63050,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8073.55, Cervical laminoplsty 2/> seg,63050,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8073.55, C-laminoplasty w/graft/plate,63051,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9065.55,,,,,,,fee schedule,5097,9065.55, C-laminoplasty w/graft/plate,63051,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,9065.55, C-laminoplasty w/graft/plate,63051,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,9065.55, C-laminoplasty w/graft/plate,63051,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,9065.55, Lam facetc/frmt arthrd lum 1,63052,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1351.37,,,,,,,fee schedule,1351.37,3195, Lam facetc/frmt arthrd lum 1,63052,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1351.37,3195, Lam facetc/frmt arthrd lum 1,63052,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1351.37,3195, Lam facetc/frmt arthrd lum 1,63052,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1351.37,3195, Lam factc/frmt arthrd lum ea,63053,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1204.76,,,,,,,fee schedule,1204.76,3195, Lam factc/frmt arthrd lum ea,63053,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1204.76,3195, Lam factc/frmt arthrd lum ea,63053,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1204.76,3195, Lam factc/frmt arthrd lum ea,63053,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1204.76,3195, Decompress spinal cord thrc,63055,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9037.98,,,,,,,fee schedule,6044,22111, Decompress spinal cord thrc,63055,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,22111, Decompress spinal cord thrc,63055,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6044,22111, Decompress spinal cord thrc,63055,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6044,22111, Decompress spinal cord lmbr,63056,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8121.84,,,,,,,fee schedule,6979,22111, Decompress spinal cord lmbr,63056,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,22111, Decompress spinal cord lmbr,63056,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6979,22111, Decompress spinal cord lmbr,63056,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6979,22111, Decompress spine cord add-on,63057,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1697.64,,,,,,,fee schedule,1697.64,3195, Decompress spine cord add-on,63057,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1697.64,3195, Decompress spine cord add-on,63057,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1697.64,3195, Decompress spine cord add-on,63057,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1697.64,3195, Decompress spinal cord thrc,63064,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9810.63,,,,,,,fee schedule,6979,22111, Decompress spinal cord thrc,63064,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,22111, Decompress spinal cord thrc,63064,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6979,22111, Decompress spinal cord thrc,63064,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6979,22111, Decompress spine cord add-on,63066,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1124.69,,,,,,,fee schedule,1124.69,2782, Decompress spine cord add-on,63066,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1124.69,2782, Decompress spine cord add-on,63066,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1124.69,2782, Neck spine disk surgery,63075,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7422.25,,,,,,,fee schedule,6044,22111, Neck spine disk surgery,63075,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,22111, Neck spine disk surgery,63075,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6044,22111, Neck spine disk surgery,63075,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6044,22111, Neck spine disk surgery,63076,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1275.4,,,,,,,fee schedule,1275.4,5363, Neck spine disk surgery,63076,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,1275.4,5363, Neck spine disk surgery,63076,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1275.4,5363, Neck spine disk surgery,63076,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1275.4,5363, Spine disk surgery thorax,63077,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7411.46,,,,,,,fee schedule,5097,7411.46, Spine disk surgery thorax,63077,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7411.46, Spine disk surgery thorax,63077,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7411.46, Spine disk surgery thorax,63077,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7411.46, Spine disk surgery thorax,63078,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1129.98,,,,,,,fee schedule,1129.98,6979, Spine disk surgery thorax,63078,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1129.98,6979, Spine disk surgery thorax,63078,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1129.98,6979, Spine disk surgery thorax,63078,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1129.98,6979, Remove vert body dcmprn crvl,63081,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9616.97,,,,,,,fee schedule,6979,22111, Remove vert body dcmprn crvl,63081,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,22111, Remove vert body dcmprn crvl,63081,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6979,22111, Remove vert body dcmprn crvl,63081,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6979,22111, Remove vertebral body add-on,63082,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1399.72,,,,,,,fee schedule,1399.72,6979, Remove vertebral body add-on,63082,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1399.72,6979, Remove vertebral body add-on,63082,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1399.72,6979, Remove vertebral body add-on,63082,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1399.72,6979, Remove vert body dcmprn thrc,63085,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10565.91,,,,,,,fee schedule,5097,10565.91, Remove vert body dcmprn thrc,63085,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,10565.91, Remove vert body dcmprn thrc,63085,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,10565.91, Remove vert body dcmprn thrc,63085,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,10565.91, Remove vertebral body add-on,63086,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1008.4,,,,,,,fee schedule,1008.4,6979, Remove vertebral body add-on,63086,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1008.4,6979, Remove vertebral body add-on,63086,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1008.4,6979, Remove vertebral body add-on,63086,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1008.4,6979, Remov vertbr dcmprn thrclmbr,63087,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,13167.32,,,,,,,fee schedule,5097,13167.32, Remov vertbr dcmprn thrclmbr,63087,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,13167.32, Remov vertbr dcmprn thrclmbr,63087,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,13167.32, Remov vertbr dcmprn thrclmbr,63087,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,13167.32, Remove vertebral body add-on,63088,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1384.88,,,,,,,fee schedule,1384.88,6979, Remove vertebral body add-on,63088,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1384.88,6979, Remove vertebral body add-on,63088,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1384.88,6979, Remove vertebral body add-on,63088,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1384.88,6979, Remove vert body dcmprn lmbr,63090,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10498.84,,,,,,,fee schedule,5097,10498.84, Remove vert body dcmprn lmbr,63090,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,10498.84, Remove vert body dcmprn lmbr,63090,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,10498.84, Remove vert body dcmprn lmbr,63090,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,10498.84, Remove vertebral body add-on,63091,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,922.18,,,,,,,fee schedule,922.18,6979, Remove vertebral body add-on,63091,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,922.18,6979, Remove vertebral body add-on,63091,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,922.18,6979, Remove vertebral body add-on,63091,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,922.18,6979, Remove vert body dcmprn thrc,63101,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12907.45,,,,,,,fee schedule,5097,12907.45, Remove vert body dcmprn thrc,63101,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,12907.45, Remove vert body dcmprn thrc,63101,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,12907.45, Remove vert body dcmprn thrc,63101,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,12907.45, Remove vert body dcmprn lmbr,63102,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12618.44,,,,,,,fee schedule,5097,12618.44, Remove vert body dcmprn lmbr,63102,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,12618.44, Remove vert body dcmprn lmbr,63102,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,12618.44, Remove vert body dcmprn lmbr,63102,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,12618.44, Remove vertebral body add-on,63103,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1550.05,,,,,,,fee schedule,1550.05,6979, Remove vertebral body add-on,63103,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1550.05,6979, Remove vertebral body add-on,63103,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1550.05,6979, Remove vertebral body add-on,63103,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1550.05,6979, Incise spinal cord tract(s),63170,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9205.63,,,,,,,fee schedule,5097,9205.63, Incise spinal cord tract(s),63170,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,9205.63, Incise spinal cord tract(s),63170,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,9205.63, Incise spinal cord tract(s),63170,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,9205.63, Drainage of spinal cyst,63172,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8170.3,,,,,,,fee schedule,5097,8170.3, Drainage of spinal cyst,63172,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8170.3, Drainage of spinal cyst,63172,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8170.3, Drainage of spinal cyst,63172,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8170.3, Drainage of spinal cyst,63173,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9930.42,,,,,,,fee schedule,5097,9930.42, Drainage of spinal cyst,63173,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,9930.42, Drainage of spinal cyst,63173,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,9930.42, Drainage of spinal cyst,63173,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,9930.42, Incise spine nrv half segmnt,63185,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7173.55,,,,,,,fee schedule,6979,25393, Incise spine nrv half segmnt,63185,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,25393, Incise spine nrv half segmnt,63185,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,6979,25393, Incise spine nrv half segmnt,63185,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,6979,25393, Incise spine nrv >2 segmnts,63190,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6335.66,,,,,,,fee schedule,6335.66,25393, Incise spine nrv >2 segmnts,63190,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6335.66,25393, Incise spine nrv >2 segmnts,63190,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,6335.66,25393, Incise spine nrv >2 segmnts,63190,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,6335.66,25393, Incise spine accessory nerve,63191,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8014.57,,,,,,,fee schedule,6979,25393, Incise spine accessory nerve,63191,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,25393, Incise spine accessory nerve,63191,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,6979,25393, Incise spine accessory nerve,63191,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,6979,25393, Incise spine&cord 2 trx thrc,63197,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9849.86,,,,,,,fee schedule,5097,9849.86, Incise spine&cord 2 trx thrc,63197,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,9849.86, Incise spine&cord 2 trx thrc,63197,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,9849.86, Incise spine&cord 2 trx thrc,63197,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,9849.86, Release spinal cord lumbar,63200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8945.38,,,,,,,fee schedule,6979,25393, Release spinal cord lumbar,63200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,25393, Release spinal cord lumbar,63200,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,6979,25393, Release spinal cord lumbar,63200,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,6979,25393, Revise spinal cord vsls crvl,63250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,16740.06,,,,,,,fee schedule,5097,16740.06, Revise spinal cord vsls crvl,63250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,16740.06, Revise spinal cord vsls crvl,63250,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,16740.06, Revise spinal cord vsls crvl,63250,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,16740.06, Revise spinal cord vsls thrc,63251,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,17139.48,,,,,,,fee schedule,5097,17139.48, Revise spinal cord vsls thrc,63251,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,17139.48, Revise spinal cord vsls thrc,63251,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,17139.48, Revise spinal cord vsls thrc,63251,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,17139.48, Revise spine cord vsl thrlmb,63252,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,17135.92,,,,,,,fee schedule,6979,25393, Revise spine cord vsl thrlmb,63252,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,25393, Revise spine cord vsl thrlmb,63252,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,6979,25393, Revise spine cord vsl thrlmb,63252,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,6979,25393, Excise intraspinl lesion crv,63265,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9395.3,,,,,,,fee schedule,6044,22111, Excise intraspinl lesion crv,63265,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,22111, Excise intraspinl lesion crv,63265,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6044,22111, Excise intraspinl lesion crv,63265,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6044,22111, Excise intrspinl lesion thrc,63266,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9655.76,,,,,,,fee schedule,6044,22111, Excise intrspinl lesion thrc,63266,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,22111, Excise intrspinl lesion thrc,63266,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6044,22111, Excise intrspinl lesion thrc,63266,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6044,22111, Excise intrspinl lesion lmbr,63267,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7635.02,,,,,,,fee schedule,6044,10940, Excise intrspinl lesion lmbr,63267,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,10940, Excise intrspinl lesion lmbr,63267,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,6044,10940, Excise intrspinl lesion lmbr,63267,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,6044,10940, Excise intrspinl lesion scrl,63268,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8486.34,,,,,,,fee schedule,6044,22111, Excise intrspinl lesion scrl,63268,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,22111, Excise intrspinl lesion scrl,63268,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6044,22111, Excise intrspinl lesion scrl,63268,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6044,22111, Excise intrspinl lesion crvl,63270,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,11877.35,,,,,,,fee schedule,5097,11877.35, Excise intrspinl lesion crvl,63270,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,11877.35, Excise intrspinl lesion crvl,63270,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,11877.35, Excise intrspinl lesion crvl,63270,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,11877.35, Excise intrspinl lesion thrc,63271,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,11800.4,,,,,,,fee schedule,5097,11800.4, Excise intrspinl lesion thrc,63271,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,11800.4, Excise intrspinl lesion thrc,63271,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,11800.4, Excise intrspinl lesion thrc,63271,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,11800.4, Excise intrspinl lesion lmbr,63272,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10688.67,,,,,,,fee schedule,6979,25393, Excise intrspinl lesion lmbr,63272,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,25393, Excise intrspinl lesion lmbr,63272,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,6979,25393, Excise intrspinl lesion lmbr,63272,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,6979,25393, Excise intrspinl lesion scrl,63273,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10721.37,,,,,,,fee schedule,5097,10721.37, Excise intrspinl lesion scrl,63273,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,10721.37, Excise intrspinl lesion scrl,63273,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,10721.37, Excise intrspinl lesion scrl,63273,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,10721.37, Bx/exc xdrl spine lesn crvl,63275,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10097.91,,,,,,,fee schedule,5097,10097.91, Bx/exc xdrl spine lesn crvl,63275,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,10097.91, Bx/exc xdrl spine lesn crvl,63275,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,10097.91, Bx/exc xdrl spine lesn crvl,63275,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,10097.91, Bx/exc xdrl spine lesn thrc,63276,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10076.44,,,,,,,fee schedule,5097,10076.44, Bx/exc xdrl spine lesn thrc,63276,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,10076.44, Bx/exc xdrl spine lesn thrc,63276,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,10076.44, Bx/exc xdrl spine lesn thrc,63276,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,10076.44, Bx/exc xdrl spine lesn lmbr,63277,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8720.8,,,,,,,fee schedule,6979,25393, Bx/exc xdrl spine lesn lmbr,63277,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,25393, Bx/exc xdrl spine lesn lmbr,63277,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,6979,25393, Bx/exc xdrl spine lesn lmbr,63277,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,6979,25393, Bx/exc xdrl spine lesn scrl,63278,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9218.26,,,,,,,fee schedule,5097,9218.26, Bx/exc xdrl spine lesn scrl,63278,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,9218.26, Bx/exc xdrl spine lesn scrl,63278,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,9218.26, Bx/exc xdrl spine lesn scrl,63278,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,9218.26, Bx/exc idrl spine lesn crvl,63280,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12084.4,,,,,,,fee schedule,5097,12084.4, Bx/exc idrl spine lesn crvl,63280,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,12084.4, Bx/exc idrl spine lesn crvl,63280,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,12084.4, Bx/exc idrl spine lesn crvl,63280,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,12084.4, Bx/exc idrl spine lesn thrc,63281,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,11991.53,,,,,,,fee schedule,5097,11991.53, Bx/exc idrl spine lesn thrc,63281,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,11991.53, Bx/exc idrl spine lesn thrc,63281,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,11991.53, Bx/exc idrl spine lesn thrc,63281,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,11991.53, Bx/exc idrl spine lesn lmbr,63282,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,11339.48,,,,,,,fee schedule,6979,25393, Bx/exc idrl spine lesn lmbr,63282,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,25393, Bx/exc idrl spine lesn lmbr,63282,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,6979,25393, Bx/exc idrl spine lesn lmbr,63282,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,6979,25393, Bx/exc idrl spine lesn scrl,63283,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10952.53,,,,,,,fee schedule,5097,10952.53, Bx/exc idrl spine lesn scrl,63283,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,10952.53, Bx/exc idrl spine lesn scrl,63283,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,10952.53, Bx/exc idrl spine lesn scrl,63283,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,10952.53, Bx/exc idrl imed lesn cervl,63285,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,14858.86,,,,,,,fee schedule,5097,14858.86, Bx/exc idrl imed lesn cervl,63285,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,14858.86, Bx/exc idrl imed lesn cervl,63285,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,14858.86, Bx/exc idrl imed lesn cervl,63285,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,14858.86, Bx/exc idrl imed lesn thrc,63286,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,14675.56,,,,,,,fee schedule,5097,14675.56, Bx/exc idrl imed lesn thrc,63286,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,14675.56, Bx/exc idrl imed lesn thrc,63286,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,14675.56, Bx/exc idrl imed lesn thrc,63286,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,14675.56, Bx/exc idrl imed lesn thrlmb,63287,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,15559.47,,,,,,,fee schedule,6979,25393, Bx/exc idrl imed lesn thrlmb,63287,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,25393, Bx/exc idrl imed lesn thrlmb,63287,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,6979,25393, Bx/exc idrl imed lesn thrlmb,63287,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,6979,25393, Bx/exc xdrl/idrl lsn any lvl,63290,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,15820.69,,,,,,,fee schedule,6979,25393, Bx/exc xdrl/idrl lsn any lvl,63290,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,25393, Bx/exc xdrl/idrl lsn any lvl,63290,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,6979,25393, Bx/exc xdrl/idrl lsn any lvl,63290,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,6979,25393, Repair laminectomy defect,63295,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1813.6,,,,,,,fee schedule,1813.6,6979, Repair laminectomy defect,63295,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1813.6,6979, Repair laminectomy defect,63295,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1813.6,6979, Repair laminectomy defect,63295,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1813.6,6979, Remove vert xdrl body crvcl,63300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10128.78,,,,,,,fee schedule,5097,10128.78, Remove vert xdrl body crvcl,63300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,10128.78, Remove vert xdrl body crvcl,63300,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,10128.78, Remove vert xdrl body crvcl,63300,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,10128.78, Remove vert xdrl body thrc,63301,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12614.01,,,,,,,fee schedule,5097,12614.01, Remove vert xdrl body thrc,63301,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,12614.01, Remove vert xdrl body thrc,63301,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,12614.01, Remove vert xdrl body thrc,63301,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,12614.01, Remove vert xdrl body thrlmb,63302,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12472.69,,,,,,,fee schedule,5097,12472.69, Remove vert xdrl body thrlmb,63302,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,12472.69, Remove vert xdrl body thrlmb,63302,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,12472.69, Remove vert xdrl body thrlmb,63302,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,12472.69, Remov vert xdrl bdy lmbr/sac,63303,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,13172.93,,,,,,,fee schedule,5097,13172.93, Remov vert xdrl bdy lmbr/sac,63303,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,13172.93, Remov vert xdrl bdy lmbr/sac,63303,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,13172.93, Remov vert xdrl bdy lmbr/sac,63303,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,13172.93, Remove vert idrl body crvcl,63304,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,13403.18,,,,,,,fee schedule,5097,13403.18, Remove vert idrl body crvcl,63304,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,13403.18, Remove vert idrl body crvcl,63304,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,13403.18, Remove vert idrl body crvcl,63304,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,13403.18, Remove vert idrl body thrc,63305,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,14235.3,,,,,,,fee schedule,5097,14235.3, Remove vert idrl body thrc,63305,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,14235.3, Remove vert idrl body thrc,63305,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,14235.3, Remove vert idrl body thrc,63305,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,14235.3, Remov vert idrl bdy thrclmbr,63306,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,13994.63,,,,,,,fee schedule,5097,13994.63, Remov vert idrl bdy thrclmbr,63306,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,13994.63, Remov vert idrl bdy thrclmbr,63306,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,13994.63, Remov vert idrl bdy thrclmbr,63306,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,13994.63, Remov vert idrl bdy lmbr/sac,63307,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,13684.58,,,,,,,fee schedule,5097,13684.58, Remov vert idrl bdy lmbr/sac,63307,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,13684.58, Remov vert idrl bdy lmbr/sac,63307,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,13684.58, Remov vert idrl bdy lmbr/sac,63307,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,13684.58, Remove vertebral body add-on,63308,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1711.34,,,,,,,fee schedule,1711.34,6979, Remove vertebral body add-on,63308,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1711.34,6979, Remove vertebral body add-on,63308,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1711.34,6979, Remove vertebral body add-on,63308,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1711.34,6979, Remove spinal cord lesion,63600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6325.46,,,,,,,fee schedule,4108,10940, Remove spinal cord lesion,63600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,10940, Remove spinal cord lesion,63600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,4108,10940, Remove spinal cord lesion,63600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,4108,10940, Stimulation of spinal cord,63610,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3251.25,,,,,,,fee schedule,3195,5664, Stimulation of spinal cord,63610,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,5664, Stimulation of spinal cord,63610,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3195,5664, Stimulation of spinal cord,63610,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3195,5664, Srs spinal lesion,63620,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6494.36,,,,,,,fee schedule,6494.36,22111, Srs spinal lesion,63620,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6494.36,22111, Srs spinal lesion,63620,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6494.36,22111, Srs spinal lesion,63620,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6494.36,22111, Srs spinal lesion addl,63621,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1383.21,,,,,,,fee schedule,1383.21,6979, Srs spinal lesion addl,63621,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1383.21,6979, Srs spinal lesion addl,63621,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1383.21,6979, Srs spinal lesion addl,63621,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1383.21,6979, Implant neuroelectrodes,63650,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2069.8,,,,,,,fee schedule,2069.8,22111, Implant neuroelectrodes,63650,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2069.8,22111, Implant neuroelectrodes,63650,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,2069.8,22111, Implant neuroelectrodes,63650,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,2069.8,22111, Implant neuroelectrodes,63655,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4788.52,,,,,,,fee schedule,4788.52,25393, Implant neuroelectrodes,63655,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4788.52,25393, Implant neuroelectrodes,63655,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,4788.52,25393, Implant neuroelectrodes,63655,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,4788.52,25393, Remove spine eltrd perq aray,63661,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1729.63,,,,,,,fee schedule,1729.63,10940, Remove spine eltrd perq aray,63661,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1729.63,10940, Remove spine eltrd perq aray,63661,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1729.63,10940, Remove spine eltrd perq aray,63661,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1729.63,10940, Remove spine eltrd plate,63662,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4849.98,,,,,,,fee schedule,3195,12821, Remove spine eltrd plate,63662,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,12821, Remove spine eltrd plate,63662,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3195,12821, Remove spine eltrd plate,63662,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3195,12821, Revise spine eltrd perq aray,63663,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2278.84,,,,,,,fee schedule,2278.84,22111, Revise spine eltrd perq aray,63663,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2278.84,22111, Revise spine eltrd perq aray,63663,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,2278.84,22111, Revise spine eltrd perq aray,63663,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,2278.84,22111, Revise spine eltrd plate,63664,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5067.11,,,,,,,fee schedule,3195,22111, Revise spine eltrd plate,63664,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,22111, Revise spine eltrd plate,63664,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3195,22111, Revise spine eltrd plate,63664,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3195,22111, Insrt/redo spine n generator,63685,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1787.37,,,,,,,fee schedule,1787.37,39251, Insrt/redo spine n generator,63685,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1787.37,39251, Insrt/redo spine n generator,63685,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,39251,,,,,,,fee schedule,1787.37,39251, Insrt/redo spine n generator,63685,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,35325,,,,,,,fee schedule,1787.37,39251, Revise/remove neuroreceiver,63688,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1714.69,,,,,,,fee schedule,1714.69,12821, Revise/remove neuroreceiver,63688,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1714.69,12821, Revise/remove neuroreceiver,63688,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,1714.69,12821, Revise/remove neuroreceiver,63688,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,1714.69,12821, Description Not Available,63690,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Description Not Available,63691,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Repair of spinal herniation,63700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7670.47,,,,,,,fee schedule,5097,7670.47, Repair of spinal herniation,63700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7670.47, Repair of spinal herniation,63700,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7670.47, Repair of spinal herniation,63700,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7670.47, Repair of spinal herniation,63702,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8338.82,,,,,,,fee schedule,5097,8338.82, Repair of spinal herniation,63702,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8338.82, Repair of spinal herniation,63702,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8338.82, Repair of spinal herniation,63702,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8338.82, Repair of spinal herniation,63704,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9700.17,,,,,,,fee schedule,5097,9700.17, Repair of spinal herniation,63704,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,9700.17, Repair of spinal herniation,63704,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,9700.17, Repair of spinal herniation,63704,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,9700.17, Repair of spinal herniation,63706,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10713.92,,,,,,,fee schedule,5097,10713.92, Repair of spinal herniation,63706,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,10713.92, Repair of spinal herniation,63706,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,10713.92, Repair of spinal herniation,63706,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,10713.92, Repair spinal fluid leakage,63707,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5312.15,,,,,,,fee schedule,5097,6979, Repair spinal fluid leakage,63707,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Repair spinal fluid leakage,63707,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Repair spinal fluid leakage,63707,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Repair spinal fluid leakage,63709,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6232.97,,,,,,,fee schedule,5097,6979, Repair spinal fluid leakage,63709,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Repair spinal fluid leakage,63709,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Repair spinal fluid leakage,63709,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Graft repair of spine defect,63710,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5973.26,,,,,,,fee schedule,5097,6979, Graft repair of spine defect,63710,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Graft repair of spine defect,63710,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Graft repair of spine defect,63710,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Install spinal shunt,63740,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5812.52,,,,,,,fee schedule,5097,6979, Install spinal shunt,63740,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Install spinal shunt,63740,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Install spinal shunt,63740,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Install spinal shunt,63741,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4079.38,,,,,,,fee schedule,4079.38,14456, Install spinal shunt,63741,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4079.38,14456, Install spinal shunt,63741,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4079.38,14456, Install spinal shunt,63741,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4079.38,14456, Revision of spinal shunt,63744,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4228.47,,,,,,,fee schedule,4228.47,14456, Revision of spinal shunt,63744,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4228.47,14456, Revision of spinal shunt,63744,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4228.47,14456, Revision of spinal shunt,63744,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4228.47,14456, Removal of spinal shunt,63746,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3671.98,,,,,,,fee schedule,3671.98,10940, Removal of spinal shunt,63746,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3671.98,10940, Removal of spinal shunt,63746,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3671.98,10940, Removal of spinal shunt,63746,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3671.98,10940, N block inj trigeminal,64400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,271.15,,,,,,,fee schedule,271.15,3195, N block inj trigeminal,64400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,271.15,3195, N block inj trigeminal,64400,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,271.15,3195, N block inj trigeminal,64400,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,271.15,3195, N block inj occipital,64405,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,265.75,,,,,,,fee schedule,265.75,3195, N block inj occipital,64405,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,265.75,3195, N block inj occipital,64405,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,265.75,3195, N block inj occipital,64405,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,265.75,3195, N block inj vagus,64408,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,216.49,,,,,,,fee schedule,216.49,3195, N block inj vagus,64408,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,216.49,3195, N block inj vagus,64408,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,216.49,3195, N block inj vagus,64408,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,216.49,3195, N block inj brachial plexus,64415,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,366.28,,,,,,,fee schedule,366.28,4497, N block inj brachial plexus,64415,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,366.28,4497, N block inj brachial plexus,64415,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,366.28,4497, N block inj brachial plexus,64415,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,366.28,4497, N block cont infuse b plex,64416,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,402.65,,,,,,,fee schedule,402.65,4497, N block cont infuse b plex,64416,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,402.65,4497, N block cont infuse b plex,64416,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,402.65,4497, N block cont infuse b plex,64416,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,402.65,4497, N block inj axillary,64417,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,340,,,,,,,fee schedule,340,4497, N block inj axillary,64417,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,340,4497, N block inj axillary,64417,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,340,4497, N block inj axillary,64417,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,340,4497, N block inj suprascapular,64418,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,267.43,,,,,,,fee schedule,267.43,4497, N block inj suprascapular,64418,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,267.43,4497, N block inj suprascapular,64418,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,267.43,4497, N block inj suprascapular,64418,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,267.43,4497, N block inj intercost sng,64420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,287.71,,,,,,,fee schedule,287.71,4497, N block inj intercost sng,64420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,287.71,4497, N block inj intercost sng,64420,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,287.71,4497, N block inj intercost sng,64420,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,287.71,4497, N block inj intercost mlt,64421,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,120.82,,,,,,,fee schedule,120.82,4497, N block inj intercost mlt,64421,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,120.82,4497, N block inj intercost mlt,64421,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,120.82,4497, N block inj intercost mlt,64421,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,120.82,4497, N block inj ilio-ing/hypogi,64425,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,273.36,,,,,,,fee schedule,273.36,4497, N block inj ilio-ing/hypogi,64425,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,273.36,4497, N block inj ilio-ing/hypogi,64425,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,273.36,4497, N block inj ilio-ing/hypogi,64425,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,273.36,4497, N block inj pudendal,64430,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,270.18,,,,,,,fee schedule,270.18,4497, N block inj pudendal,64430,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,270.18,4497, N block inj pudendal,64430,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,270.18,4497, N block inj pudendal,64430,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,270.18,4497, N block inj paracervical,64435,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,218.48,,,,,,,fee schedule,218.48,4497, N block inj paracervical,64435,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,218.48,4497, N block inj paracervical,64435,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,218.48,4497, N block inj paracervical,64435,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,218.48,4497, Description Not Available,64440,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Description Not Available,64441,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Description Not Available,64442,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Description Not Available,64443,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, N block inj sciatic sng,64445,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,366.71,,,,,,,fee schedule,366.71,4497, N block inj sciatic sng,64445,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,366.71,4497, N block inj sciatic sng,64445,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,366.71,4497, N block inj sciatic sng,64445,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,366.71,4497, N blk inj sciatic cont inf,64446,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,393.64,,,,,,,fee schedule,393.64,6979, N blk inj sciatic cont inf,64446,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,393.64,6979, N blk inj sciatic cont inf,64446,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,393.64,6979, N blk inj sciatic cont inf,64446,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,393.64,6979, N block inj fem single,64447,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,335.79,,,,,,,fee schedule,335.79,6979, N block inj fem single,64447,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,335.79,6979, N block inj fem single,64447,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,335.79,6979, N block inj fem single,64447,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,335.79,6979, N block inj fem cont inf,64448,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,376.59,,,,,,,fee schedule,376.59,6979, N block inj fem cont inf,64448,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,376.59,6979, N block inj fem cont inf,64448,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,376.59,6979, N block inj fem cont inf,64448,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,376.59,6979, N block inj lumbar plexus,64449,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,335.52,,,,,,,fee schedule,335.52,4497, N block inj lumbar plexus,64449,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,335.52,4497, N block inj lumbar plexus,64449,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,335.52,4497, N block inj lumbar plexus,64449,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,335.52,4497, N block other peripheral,64450,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,210.82,,,,,,,fee schedule,210.82,4497, N block other peripheral,64450,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,210.82,4497, N block other peripheral,64450,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,210.82,4497, N block other peripheral,64450,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,210.82,4497, Njx aa&/strd nrv nrvtg si jt,64451,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,399.41,,,,,,,fee schedule,399.41,4497, Njx aa&/strd nrv nrvtg si jt,64451,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,399.41,4497, Njx aa&/strd nrv nrvtg si jt,64451,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,399.41,4497, Njx aa&/strd nrv nrvtg si jt,64451,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,399.41,4497, Njx aa&/strd gnclr nrv brnch,64454,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,401.89,,,,,,,fee schedule,401.89,4497, Njx aa&/strd gnclr nrv brnch,64454,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,401.89,4497, Njx aa&/strd gnclr nrv brnch,64454,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,401.89,4497, Njx aa&/strd gnclr nrv brnch,64454,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,401.89,4497, N block inj plantar digit,64455,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,167.76,,,,,,,fee schedule,167.76,3195, N block inj plantar digit,64455,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,167.76,3195, N block inj plantar digit,64455,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,167.76,3195, N block inj plantar digit,64455,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,167.76,3195, Pvb thoracic single inj site,64461,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,399.79,,,,,,,fee schedule,399.79,4497, Pvb thoracic single inj site,64461,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,399.79,4497, Pvb thoracic single inj site,64461,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,399.79,4497, Pvb thoracic single inj site,64461,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,399.79,4497, Pvb thoracic 2nd+ inj site,64462,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,245.52,,,,,,,fee schedule,245.52,3195, Pvb thoracic 2nd+ inj site,64462,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,245.52,3195, Pvb thoracic 2nd+ inj site,64462,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,245.52,3195, Pvb thoracic 2nd+ inj site,64462,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,245.52,3195, Pvb thoracic cont infusion,64463,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,424.99,,,,,,,fee schedule,424.99,4497, Pvb thoracic cont infusion,64463,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,424.99,4497, Pvb thoracic cont infusion,64463,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,424.99,4497, Pvb thoracic cont infusion,64463,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,424.99,4497, Thrc fascial pln blk uni njx,64466,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,342.43,,,,,,,fee schedule,342.43,3195, Thrc fascial pln blk uni njx,64466,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,342.43,3195, Thrc fascial pln blk uni njx,64466,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,342.43,3195, Thrc fascial pln blk uni njx,64466,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,342.43,3195, Thrc fascial pln blk uni nfs,64467,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,396.28,,,,,,,fee schedule,396.28,3195, Thrc fascial pln blk uni nfs,64467,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,396.28,3195, Thrc fascial pln blk uni nfs,64467,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,396.28,3195, Thrc fascial pln blk uni nfs,64467,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,396.28,3195, Thrc fascial pln blk bi njx,64468,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,379.23,,,,,,,fee schedule,379.23,3195, Thrc fascial pln blk bi njx,64468,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,379.23,3195, Thrc fascial pln blk bi njx,64468,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,379.23,3195, Thrc fascial pln blk bi njx,64468,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,379.23,3195, Thrc fascial pln blk bi nfs,64469,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,416.84,,,,,,,fee schedule,416.84,3195, Thrc fascial pln blk bi nfs,64469,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,416.84,3195, Thrc fascial pln blk bi nfs,64469,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,416.84,3195, Thrc fascial pln blk bi nfs,64469,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,416.84,3195, Lwr xtr fscl pln blk uni njx,64473,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,304.77,,,,,,,fee schedule,304.77,3195, Lwr xtr fscl pln blk uni njx,64473,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,304.77,3195, Lwr xtr fscl pln blk uni njx,64473,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,304.77,3195, Lwr xtr fscl pln blk uni njx,64473,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,304.77,3195, Lwr xtr fscl pln blk uni nfs,64474,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,379.23,,,,,,,fee schedule,379.23,3195, Lwr xtr fscl pln blk uni nfs,64474,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,379.23,3195, Lwr xtr fscl pln blk uni nfs,64474,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,379.23,3195, Lwr xtr fscl pln blk uni nfs,64474,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,379.23,3195, Inj foramen epidural c/t,64479,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,638.72,,,,,,,fee schedule,638.72,4497, Inj foramen epidural c/t,64479,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,638.72,4497, Inj foramen epidural c/t,64479,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,638.72,4497, Inj foramen epidural c/t,64479,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,638.72,4497, Inj foramen epidural add-on,64480,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,294.08,,,,,,,fee schedule,294.08,3195, Inj foramen epidural add-on,64480,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,294.08,3195, Inj foramen epidural add-on,64480,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,294.08,3195, Inj foramen epidural add-on,64480,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,294.08,3195, Inj foramen epidural l/s,64483,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,544.89,,,,,,,fee schedule,544.89,4497, Inj foramen epidural l/s,64483,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,544.89,4497, Inj foramen epidural l/s,64483,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,544.89,4497, Inj foramen epidural l/s,64483,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,544.89,4497, Inj foramen epidural add-on,64484,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,241.36,,,,,,,fee schedule,241.36,3195, Inj foramen epidural add-on,64484,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,241.36,3195, Inj foramen epidural add-on,64484,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,241.36,3195, Inj foramen epidural add-on,64484,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,241.36,3195, Tap block unil by injection,64486,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,267.97,,,,,,,fee schedule,267.97,4108, Tap block unil by injection,64486,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,267.97,4108, Tap block unil by injection,64486,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,267.97,4108, Tap block unil by injection,64486,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,267.97,4108, Tap block uni by infusion,64487,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,311.08,,,,,,,fee schedule,311.08,4108, Tap block uni by infusion,64487,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,311.08,4108, Tap block uni by infusion,64487,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,311.08,4108, Tap block uni by infusion,64487,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,311.08,4108, Tap block bi injection,64488,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,315.61,,,,,,,fee schedule,315.61,4108, Tap block bi injection,64488,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,315.61,4108, Tap block bi injection,64488,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,315.61,4108, Tap block bi injection,64488,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,315.61,4108, Tap block bi by infusion,64489,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,393.64,,,,,,,fee schedule,393.64,4108, Tap block bi by infusion,64489,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,393.64,4108, Tap block bi by infusion,64489,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,393.64,4108, Tap block bi by infusion,64489,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,393.64,4108, Inj paravert f jnt c/t 1 lev,64490,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,516.67,,,,,,,fee schedule,516.67,4497, Inj paravert f jnt c/t 1 lev,64490,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,516.67,4497, Inj paravert f jnt c/t 1 lev,64490,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,516.67,4497, Inj paravert f jnt c/t 1 lev,64490,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,516.67,4497, Inj paravert f jnt c/t 2 lev,64491,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,281.73,,,,,,,fee schedule,281.73,3195, Inj paravert f jnt c/t 2 lev,64491,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,281.73,3195, Inj paravert f jnt c/t 2 lev,64491,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,281.73,3195, Inj paravert f jnt c/t 2 lev,64491,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,281.73,3195, Inj paravert f jnt c/t 3 lev,64492,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,281.46,,,,,,,fee schedule,281.46,3195, Inj paravert f jnt c/t 3 lev,64492,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,281.46,3195, Inj paravert f jnt c/t 3 lev,64492,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,281.46,3195, Inj paravert f jnt c/t 3 lev,64492,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,281.46,3195, Inj paravert f jnt l/s 1 lev,64493,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,445.98,,,,,,,fee schedule,445.98,4497, Inj paravert f jnt l/s 1 lev,64493,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,445.98,4497, Inj paravert f jnt l/s 1 lev,64493,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,445.98,4497, Inj paravert f jnt l/s 1 lev,64493,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,445.98,4497, Inj paravert f jnt l/s 2 lev,64494,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,241.36,,,,,,,fee schedule,241.36,3195, Inj paravert f jnt l/s 2 lev,64494,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,241.36,3195, Inj paravert f jnt l/s 2 lev,64494,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,241.36,3195, Inj paravert f jnt l/s 2 lev,64494,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,241.36,3195, Inj paravert f jnt l/s 3 lev,64495,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,248.27,,,,,,,fee schedule,248.27,3195, Inj paravert f jnt l/s 3 lev,64495,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,248.27,3195, Inj paravert f jnt l/s 3 lev,64495,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,248.27,3195, Inj paravert f jnt l/s 3 lev,64495,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,248.27,3195, N block spenopalatine gangl,64505,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,551.15,,,,,,,fee schedule,551.15,3195, N block spenopalatine gangl,64505,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,551.15,3195, N block spenopalatine gangl,64505,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,551.15,3195, N block spenopalatine gangl,64505,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,551.15,3195, N block stellate ganglion,64510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,380.36,,,,,,,fee schedule,380.36,4497, N block stellate ganglion,64510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,380.36,4497, N block stellate ganglion,64510,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,380.36,4497, N block stellate ganglion,64510,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,380.36,4497, N block inj hypogas plxs,64517,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,624.32,,,,,,,fee schedule,624.32,4497, N block inj hypogas plxs,64517,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,624.32,4497, N block inj hypogas plxs,64517,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,624.32,4497, N block inj hypogas plxs,64517,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,624.32,4497, N block lumbar/thoracic,64520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,418.57,,,,,,,fee schedule,418.57,4497, N block lumbar/thoracic,64520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,418.57,4497, N block lumbar/thoracic,64520,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,418.57,4497, N block lumbar/thoracic,64520,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,418.57,4497, N block inj celiac pelus,64530,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,468.1,,,,,,,fee schedule,468.1,4497, N block inj celiac pelus,64530,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,468.1,4497, N block inj celiac pelus,64530,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,468.1,4497, N block inj celiac pelus,64530,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,468.1,4497, Implant neuroelectrodes,64553,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2621.92,,,,,,,fee schedule,2621.92,22111, Implant neuroelectrodes,64553,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2621.92,22111, Implant neuroelectrodes,64553,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,2621.92,22111, Implant neuroelectrodes,64553,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,2621.92,22111, Implant neuroelectrodes,64555,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1617.99,,,,,,,fee schedule,1617.99,22111, Implant neuroelectrodes,64555,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1617.99,22111, Implant neuroelectrodes,64555,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,1617.99,22111, Implant neuroelectrodes,64555,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,1617.99,22111, Implant neuroelectrodes,64561,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1515.03,,,,,,,fee schedule,1515.03,22111, Implant neuroelectrodes,64561,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1515.03,22111, Implant neuroelectrodes,64561,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,1515.03,22111, Implant neuroelectrodes,64561,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,1515.03,22111, Neuroeltrd stim post tibial,64566,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,145.96,,,,,,,fee schedule,145.96,3195, Neuroeltrd stim post tibial,64566,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,145.96,3195, Neuroeltrd stim post tibial,64566,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,145.96,3195, Neuroeltrd stim post tibial,64566,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,145.96,3195, Perq elec nrv field stimj cn,64567,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,370.54,,,,,,,fee schedule,370.54,6979, Perq elec nrv field stimj cn,64567,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,370.54,6979, Inc for vagus n elect impl,64568,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3779.9,,,,,,,fee schedule,3779.9,46177, Inc for vagus n elect impl,64568,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3779.9,46177, Inc for vagus n elect impl,64568,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46177,,,,,,,fee schedule,3779.9,46177, Inc for vagus n elect impl,64568,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,41559,,,,,,,fee schedule,3779.9,46177, Revise/repl vagus n eltrd,64569,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4301.04,,,,,,,fee schedule,4108,22111, Revise/repl vagus n eltrd,64569,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,22111, Revise/repl vagus n eltrd,64569,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,4108,22111, Revise/repl vagus n eltrd,64569,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,4108,22111, Remove vagus n eltrd,64570,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4391.64,,,,,,,fee schedule,3195,22111, Remove vagus n eltrd,64570,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,22111, Remove vagus n eltrd,64570,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3195,22111, Remove vagus n eltrd,64570,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3195,22111, Implant neuroelectrodes,64575,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1616.75,,,,,,,fee schedule,1616.75,25393, Implant neuroelectrodes,64575,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1616.75,25393, Implant neuroelectrodes,64575,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,1616.75,25393, Implant neuroelectrodes,64575,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,1616.75,25393, Implant neuroelectrodes,64580,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1765.68,,,,,,,fee schedule,1765.68,25393, Implant neuroelectrodes,64580,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1765.68,25393, Implant neuroelectrodes,64580,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,1765.68,25393, Implant neuroelectrodes,64580,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,1765.68,25393, Implant neuroelectrodes,64581,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3297.44,,,,,,,fee schedule,3297.44,25393, Implant neuroelectrodes,64581,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3297.44,25393, Implant neuroelectrodes,64581,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,3297.44,25393, Implant neuroelectrodes,64581,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,3297.44,25393, Opn mpltj hpglsl nstm ary pg,64582,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4033.02,,,,,,,fee schedule,4033.02,39251, Opn mpltj hpglsl nstm ary pg,64582,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4033.02,39251, Opn mpltj hpglsl nstm ary pg,64582,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,39251,,,,,,,fee schedule,4033.02,39251, Opn mpltj hpglsl nstm ary pg,64582,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,35325,,,,,,,fee schedule,4033.02,39251, Rev/rplct hpglsl nstm ary pg,64583,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4159.24,,,,,,,fee schedule,4108,25393, Rev/rplct hpglsl nstm ary pg,64583,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,25393, Rev/rplct hpglsl nstm ary pg,64583,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,4108,25393, Rev/rplct hpglsl nstm ary pg,64583,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,4108,25393, Rmvl hpglsl nstim ary pg,64584,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3518.57,,,,,,,fee schedule,3195,22111, Rmvl hpglsl nstim ary pg,64584,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,22111, Rmvl hpglsl nstim ary pg,64584,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3195,22111, Rmvl hpglsl nstim ary pg,64584,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3195,22111, Revise/remove neuroelectrode,64585,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,746.21,,,,,,,fee schedule,746.21,12821, Revise/remove neuroelectrode,64585,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,746.21,12821, Revise/remove neuroelectrode,64585,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,746.21,12821, Revise/remove neuroelectrode,64585,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,746.21,12821, Insrt/redo pn/gastr stimul,64590,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1488.05,,,,,,,fee schedule,1488.05,39251, Insrt/redo pn/gastr stimul,64590,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1488.05,39251, Insrt/redo pn/gastr stimul,64590,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,39251,,,,,,,fee schedule,1488.05,39251, Insrt/redo pn/gastr stimul,64590,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,35325,,,,,,,fee schedule,1488.05,39251, Revise/rmv pn/gastr stimul,64595,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1165.59,,,,,,,fee schedule,1165.59,12821, Revise/rmv pn/gastr stimul,64595,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1165.59,12821, Revise/rmv pn/gastr stimul,64595,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,1165.59,12821, Revise/rmv pn/gastr stimul,64595,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,1165.59,12821, Ins/rplcmt prq eltrd ra pn 1,64596,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,25393, Ins/rplcmt prq eltrd ra pn 1,64596,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,4108,25393, Ins/rplcmt prq eltrd ra pn 1,64596,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,4108,25393, Ins/rplcm prq eltrd ra pn ea,64597,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Ins/rplcm prq eltrd ra pn ea,64597,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Ins/rplcm prq eltrd ra pn ea,64597,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Revj/rmvl nea pn w/int nstim,64598,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,12821, Revj/rmvl nea pn w/int nstim,64598,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3195,12821, Revj/rmvl nea pn w/int nstim,64598,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3195,12821, Injection treatment of nerve,64600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1289.32,,,,,,,fee schedule,1289.32,4497, Injection treatment of nerve,64600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1289.32,4497, Injection treatment of nerve,64600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,1289.32,4497, Injection treatment of nerve,64600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,1289.32,4497, Injection treatment of nerve,64605,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2459.93,,,,,,,fee schedule,2459.93,10940, Injection treatment of nerve,64605,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2459.93,10940, Injection treatment of nerve,64605,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2459.93,10940, Injection treatment of nerve,64605,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2459.93,10940, Injection treatment of nerve,64610,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2590.03,,,,,,,fee schedule,2590.03,10940, Injection treatment of nerve,64610,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2590.03,10940, Injection treatment of nerve,64610,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2590.03,10940, Injection treatment of nerve,64610,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2590.03,10940, Chemodenerv saliv glands,64611,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,604.62,,,,,,,fee schedule,604.62,3195, Chemodenerv saliv glands,64611,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,604.62,3195, Chemodenerv saliv glands,64611,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,604.62,3195, Chemodenerv saliv glands,64611,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,604.62,3195, Destroy nerve face muscle,64612,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,597.71,,,,,,,fee schedule,597.71,3195, Destroy nerve face muscle,64612,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,597.71,3195, Destroy nerve face muscle,64612,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,597.71,3195, Destroy nerve face muscle,64612,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,597.71,3195, Chemodenerv musc migraine,64615,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,638.83,,,,,,,fee schedule,638.83,3195, Chemodenerv musc migraine,64615,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,638.83,3195, Chemodenerv musc migraine,64615,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,638.83,3195, Chemodenerv musc migraine,64615,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,638.83,3195, Chemodenerv musc neck dyston,64616,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,574.57,,,,,,,fee schedule,574.57,3195, Chemodenerv musc neck dyston,64616,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,574.57,3195, Chemodenerv musc neck dyston,64616,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,574.57,3195, Chemodenerv musc neck dyston,64616,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,574.57,3195, Chemodener muscle larynx emg,64617,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,514.13,,,,,,,fee schedule,514.13,4497, Chemodener muscle larynx emg,64617,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,514.13,4497, Chemodener muscle larynx emg,64617,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,514.13,4497, Chemodener muscle larynx emg,64617,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,514.13,4497, Injection treatment of nerve,64620,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,921.1,,,,,,,fee schedule,921.1,4497, Injection treatment of nerve,64620,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,921.1,4497, Injection treatment of nerve,64620,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,921.1,4497, Injection treatment of nerve,64620,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,921.1,4497, Dstrj nulyt agt gnclr nrv,64624,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,728.51,,,,,,,fee schedule,728.51,10940, Dstrj nulyt agt gnclr nrv,64624,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,728.51,10940, Dstrj nulyt agt gnclr nrv,64624,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,728.51,10940, Dstrj nulyt agt gnclr nrv,64624,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,728.51,10940, Rf abltj nrv nrvtg si jt,64625,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,970.25,,,,,,,fee schedule,970.25,10940, Rf abltj nrv nrvtg si jt,64625,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,970.25,10940, Rf abltj nrv nrvtg si jt,64625,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,970.25,10940, Rf abltj nrv nrvtg si jt,64625,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,970.25,10940, Trml dstrj ios bvn 1st 2 l/s,64628,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2007.8,,,,,,,fee schedule,2007.8,22111, Trml dstrj ios bvn 1st 2 l/s,64628,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,2007.8,22111, Trml dstrj ios bvn 1st 2 l/s,64628,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,2007.8,22111, Trml dstrj ios bvn 1st 2 l/s,64628,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,2007.8,22111, Trml dstrj ios bvn ea addl,64629,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,930.86,,,,,,,fee schedule,930.86,3195, Trml dstrj ios bvn ea addl,64629,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,930.86,3195, Trml dstrj ios bvn ea addl,64629,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,930.86,3195, Trml dstrj ios bvn ea addl,64629,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,930.86,3195, Injection treatment of nerve,64630,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1025.46,,,,,,,fee schedule,1025.46,4497, Injection treatment of nerve,64630,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1025.46,4497, Injection treatment of nerve,64630,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,1025.46,4497, Injection treatment of nerve,64630,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,1025.46,4497, N block inj common digit,64632,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,337.14,,,,,,,fee schedule,337.14,3195, N block inj common digit,64632,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,337.14,3195, N block inj common digit,64632,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,337.14,3195, N block inj common digit,64632,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,337.14,3195, Destroy cerv/thor facet jnt,64633,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,946.08,,,,,,,fee schedule,946.08,10940, Destroy cerv/thor facet jnt,64633,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,946.08,10940, Destroy cerv/thor facet jnt,64633,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,946.08,10940, Destroy cerv/thor facet jnt,64633,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,946.08,10940, Destroy c/th facet jnt addl,64634,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,320.14,,,,,,,fee schedule,320.14,3195, Destroy c/th facet jnt addl,64634,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,320.14,3195, Destroy c/th facet jnt addl,64634,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,320.14,3195, Destroy c/th facet jnt addl,64634,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,320.14,3195, Destroy lumb/sac facet jnt,64635,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,946.78,,,,,,,fee schedule,946.78,10940, Destroy lumb/sac facet jnt,64635,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,946.78,10940, Destroy lumb/sac facet jnt,64635,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,946.78,10940, Destroy lumb/sac facet jnt,64635,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,946.78,10940, Destroy l/s facet jnt addl,64636,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,281.73,,,,,,,fee schedule,281.73,3195, Destroy l/s facet jnt addl,64636,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,281.73,3195, Destroy l/s facet jnt addl,64636,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,281.73,3195, Destroy l/s facet jnt addl,64636,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,281.73,3195, Injection treatment of nerve,64640,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,612.5,,,,,,,fee schedule,612.5,4497, Injection treatment of nerve,64640,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,612.5,4497, Injection treatment of nerve,64640,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,612.5,4497, Injection treatment of nerve,64640,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,612.5,4497, Chemodenerv 1 extremity 1-4,64642,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,547.42,,,,,,,fee schedule,547.42,4497, Chemodenerv 1 extremity 1-4,64642,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,547.42,4497, Chemodenerv 1 extremity 1-4,64642,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,547.42,4497, Chemodenerv 1 extremity 1-4,64642,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,547.42,4497, Chemodenerv 1 extrem 1-4 ea,64643,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,340.54,,,,,,,fee schedule,340.54,3195, Chemodenerv 1 extrem 1-4 ea,64643,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,340.54,3195, Chemodenerv 1 extrem 1-4 ea,64643,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,340.54,3195, Chemodenerv 1 extrem 1-4 ea,64643,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,340.54,3195, Chemodenerv 1 extrem 5/> mus,64644,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,587.62,,,,,,,fee schedule,587.62,4497, Chemodenerv 1 extrem 5/> mus,64644,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,587.62,4497, Chemodenerv 1 extrem 5/> mus,64644,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,587.62,4497, Chemodenerv 1 extrem 5/> mus,64644,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,587.62,4497, Chemodenerv 1 extrem 5/> ea,64645,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,407.88,,,,,,,fee schedule,407.88,3195, Chemodenerv 1 extrem 5/> ea,64645,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,407.88,3195, Chemodenerv 1 extrem 5/> ea,64645,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,407.88,3195, Chemodenerv 1 extrem 5/> ea,64645,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,407.88,3195, Chemodenerv trunk musc 1-5,64646,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,597.12,,,,,,,fee schedule,597.12,4497, Chemodenerv trunk musc 1-5,64646,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,597.12,4497, Chemodenerv trunk musc 1-5,64646,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,597.12,4497, Chemodenerv trunk musc 1-5,64646,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,597.12,4497, Chemodenerv trunk musc 6/>,64647,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,665.22,,,,,,,fee schedule,665.22,4497, Chemodenerv trunk musc 6/>,64647,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,665.22,4497, Chemodenerv trunk musc 6/>,64647,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,665.22,4497, Chemodenerv trunk musc 6/>,64647,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,665.22,4497, Chemodenerv eccrine glands,64650,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,188.54,,,,,,,fee schedule,188.54,3195, Chemodenerv eccrine glands,64650,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,188.54,3195, Chemodenerv eccrine glands,64650,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,188.54,3195, Chemodenerv eccrine glands,64650,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,188.54,3195, Chemodenerv eccrine glands,64653,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,245.84,,,,,,,fee schedule,245.84,3195, Chemodenerv eccrine glands,64653,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,245.84,3195, Chemodenerv eccrine glands,64653,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,245.84,3195, Chemodenerv eccrine glands,64653,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,245.84,3195, 1st opn implt bat modulj sys,64654,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3248.34,,,,,,,fee schedule,3248.34,6979, 1st opn implt bat modulj sys,64654,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3248.34,6979, Revj/rplcmt bat mod sys lead,64655,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3668.63,,,,,,,fee schedule,3668.63,6979, Revj/rplcmt bat mod sys lead,64655,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3668.63,6979, Revj/rplcmt bat mod sys pg,64656,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2462.46,,,,,,,fee schedule,2462.46,6979, Revj/rplcmt bat mod sys pg,64656,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2462.46,6979, Rmvl bat modulj sys tot sys,64657,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3657.57,,,,,,,fee schedule,3657.57,6979, Rmvl bat modulj sys tot sys,64657,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3657.57,6979, Rmvl bat modul sys lead only,64658,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2750.07,,,,,,,fee schedule,2750.07,6979, Rmvl bat modul sys lead only,64658,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2750.07,6979, Rmvl bat modulj sys pg only,64659,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2549.12,,,,,,,fee schedule,2549.12,6979, Rmvl bat modulj sys pg only,64659,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2549.12,6979, Injection treatment of nerve,64680,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,802.66,,,,,,,fee schedule,802.66,4497, Injection treatment of nerve,64680,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,802.66,4497, Injection treatment of nerve,64680,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,802.66,4497, Injection treatment of nerve,64680,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,802.66,4497, Injection treatment of nerve,64681,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1054.76,,,,,,,fee schedule,1054.76,4497, Injection treatment of nerve,64681,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1054.76,4497, Injection treatment of nerve,64681,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,1054.76,4497, Injection treatment of nerve,64681,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,1054.76,4497, Revise finger/toe nerve,64702,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2676.58,,,,,,,fee schedule,2676.58,10940, Revise finger/toe nerve,64702,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2676.58,10940, Revise finger/toe nerve,64702,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2676.58,10940, Revise finger/toe nerve,64702,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2676.58,10940, Revise hand/foot nerve,64704,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1681.77,,,,,,,fee schedule,1681.77,10940, Revise hand/foot nerve,64704,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1681.77,10940, Revise hand/foot nerve,64704,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1681.77,10940, Revise hand/foot nerve,64704,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1681.77,10940, Revise arm/leg nerve,64708,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2527.97,,,,,,,fee schedule,2527.97,10940, Revise arm/leg nerve,64708,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2527.97,10940, Revise arm/leg nerve,64708,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2527.97,10940, Revise arm/leg nerve,64708,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2527.97,10940, Revision of sciatic nerve,64712,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3103.73,,,,,,,fee schedule,3103.73,10940, Revision of sciatic nerve,64712,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3103.73,10940, Revision of sciatic nerve,64712,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3103.73,10940, Revision of sciatic nerve,64712,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3103.73,10940, Revision of arm nerve(s),64713,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4186.59,,,,,,,fee schedule,4108,10940, Revision of arm nerve(s),64713,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,10940, Revision of arm nerve(s),64713,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,4108,10940, Revision of arm nerve(s),64713,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,4108,10940, Revise low back nerve(s),64714,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4011.6,,,,,,,fee schedule,4011.6,10940, Revise low back nerve(s),64714,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4011.6,10940, Revise low back nerve(s),64714,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,4011.6,10940, Revise low back nerve(s),64714,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,4011.6,10940, Revision of cranial nerve,64716,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2591.75,,,,,,,fee schedule,2591.75,10940, Revision of cranial nerve,64716,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2591.75,10940, Revision of cranial nerve,64716,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2591.75,10940, Revision of cranial nerve,64716,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2591.75,10940, Revise ulnar nerve at elbow,64718,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3164.16,,,,,,,fee schedule,3164.16,10940, Revise ulnar nerve at elbow,64718,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3164.16,10940, Revise ulnar nerve at elbow,64718,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3164.16,10940, Revise ulnar nerve at elbow,64718,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3164.16,10940, Revise ulnar nerve at wrist,64719,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2133.52,,,,,,,fee schedule,2133.52,10940, Revise ulnar nerve at wrist,64719,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2133.52,10940, Revise ulnar nerve at wrist,64719,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2133.52,10940, Revise ulnar nerve at wrist,64719,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2133.52,10940, Carpal tunnel surgery,64721,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2319.09,,,,,,,fee schedule,2319.09,10940, Carpal tunnel surgery,64721,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2319.09,10940, Carpal tunnel surgery,64721,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2319.09,10940, Carpal tunnel surgery,64721,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2319.09,10940, Relieve pressure on nerve(s),64722,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2071.31,,,,,,,fee schedule,2071.31,10940, Relieve pressure on nerve(s),64722,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2071.31,10940, Relieve pressure on nerve(s),64722,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2071.31,10940, Relieve pressure on nerve(s),64722,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2071.31,10940, Release foot/toe nerve,64726,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1407.28,,,,,,,fee schedule,1407.28,10940, Release foot/toe nerve,64726,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1407.28,10940, Release foot/toe nerve,64726,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1407.28,10940, Release foot/toe nerve,64726,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1407.28,10940, Internal nerve revision,64727,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,797.37,,,,,,,fee schedule,797.37,3195, Internal nerve revision,64727,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,797.37,3195, Internal nerve revision,64727,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,797.37,3195, Internal nerve revision,64727,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,797.37,3195, Dcmprn median nrv carpl tunl,64728,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,677.41,,,,,,,fee schedule,677.41,6979, Dcmprn median nrv carpl tunl,64728,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,677.41,6979, Incision of brow nerve,64732,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2786.06,,,,,,,fee schedule,2786.06,5664, Incision of brow nerve,64732,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2786.06,5664, Incision of brow nerve,64732,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2786.06,5664, Incision of brow nerve,64732,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2786.06,5664, Incision of cheek nerve,64734,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3141.66,,,,,,,fee schedule,3141.66,5664, Incision of cheek nerve,64734,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3141.66,5664, Incision of cheek nerve,64734,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3141.66,5664, Incision of cheek nerve,64734,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3141.66,5664, Incision of chin nerve,64736,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1671.46,,,,,,,fee schedule,1671.46,5664, Incision of chin nerve,64736,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1671.46,5664, Incision of chin nerve,64736,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1671.46,5664, Incision of chin nerve,64736,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1671.46,5664, Incision of jaw nerve,64738,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2284.77,,,,,,,fee schedule,2284.77,5664, Incision of jaw nerve,64738,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2284.77,5664, Incision of jaw nerve,64738,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2284.77,5664, Incision of jaw nerve,64738,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2284.77,5664, Incision of tongue nerve,64740,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2355.79,,,,,,,fee schedule,2355.79,10940, Incision of tongue nerve,64740,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2355.79,10940, Incision of tongue nerve,64740,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2355.79,10940, Incision of tongue nerve,64740,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2355.79,10940, Incision of facial nerve,64742,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2298.37,,,,,,,fee schedule,2298.37,10940, Incision of facial nerve,64742,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2298.37,10940, Incision of facial nerve,64742,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2298.37,10940, Incision of facial nerve,64742,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2298.37,10940, Incise nerve back of head,64744,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3072.37,,,,,,,fee schedule,3072.37,10940, Incise nerve back of head,64744,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3072.37,10940, Incise nerve back of head,64744,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3072.37,10940, Incise nerve back of head,64744,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3072.37,10940, Incise diaphragm nerve,64746,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2448.65,,,,,,,fee schedule,2448.65,5664, Incise diaphragm nerve,64746,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2448.65,5664, Incise diaphragm nerve,64746,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2448.65,5664, Incise diaphragm nerve,64746,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2448.65,5664, Incision of stomach nerves,64755,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4991.25,,,,,,,fee schedule,4991.25,6979, Incision of stomach nerves,64755,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4991.25,6979, Incision of stomach nerves,64755,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4991.25,6979, Incision of stomach nerves,64755,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4991.25,6979, Incision of vagus nerve,64760,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2888.37,,,,,,,fee schedule,2888.37,6979, Incision of vagus nerve,64760,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2888.37,6979, Incision of vagus nerve,64760,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2888.37,6979, Incision of vagus nerve,64760,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2888.37,6979, Incise hip/thigh nerve,64763,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2854.43,,,,,,,fee schedule,2854.43,6979, Incise hip/thigh nerve,64763,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2854.43,6979, Incise hip/thigh nerve,64763,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2854.43,6979, Incise hip/thigh nerve,64763,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2854.43,6979, Incise hip/thigh nerve,64766,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3508.7,,,,,,,fee schedule,3508.7,12821, Incise hip/thigh nerve,64766,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3508.7,12821, Incise hip/thigh nerve,64766,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3508.7,12821, Incise hip/thigh nerve,64766,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3508.7,12821, Sever cranial nerve,64771,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3090.56,,,,,,,fee schedule,3090.56,10940, Sever cranial nerve,64771,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3090.56,10940, Sever cranial nerve,64771,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3090.56,10940, Sever cranial nerve,64771,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3090.56,10940, Incision of spinal nerve,64772,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2865.33,,,,,,,fee schedule,2865.33,10940, Incision of spinal nerve,64772,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2865.33,10940, Incision of spinal nerve,64772,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2865.33,10940, Incision of spinal nerve,64772,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2865.33,10940, Remove skin nerve lesion,64774,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2286.66,,,,,,,fee schedule,2286.66,10940, Remove skin nerve lesion,64774,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2286.66,10940, Remove skin nerve lesion,64774,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2286.66,10940, Remove skin nerve lesion,64774,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2286.66,10940, Remove digit nerve lesion,64776,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2064.51,,,,,,,fee schedule,2064.51,10940, Remove digit nerve lesion,64776,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2064.51,10940, Remove digit nerve lesion,64776,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2064.51,10940, Remove digit nerve lesion,64776,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2064.51,10940, Digit nerve surgery add-on,64778,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,886.62,,,,,,,fee schedule,886.62,4108, Digit nerve surgery add-on,64778,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,886.62,4108, Digit nerve surgery add-on,64778,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,886.62,4108, Digit nerve surgery add-on,64778,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,886.62,4108, Remove limb nerve lesion,64782,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2407.8,,,,,,,fee schedule,2407.8,10940, Remove limb nerve lesion,64782,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2407.8,10940, Remove limb nerve lesion,64782,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2407.8,10940, Remove limb nerve lesion,64782,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2407.8,10940, Limb nerve surgery add-on,64783,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1061.88,,,,,,,fee schedule,1061.88,4108, Limb nerve surgery add-on,64783,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1061.88,4108, Limb nerve surgery add-on,64783,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1061.88,4108, Limb nerve surgery add-on,64783,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1061.88,4108, Remove nerve lesion,64784,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3759.02,,,,,,,fee schedule,3759.02,10940, Remove nerve lesion,64784,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3759.02,10940, Remove nerve lesion,64784,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3759.02,10940, Remove nerve lesion,64784,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3759.02,10940, Remove sciatic nerve lesion,64786,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5449.74,,,,,,,fee schedule,5248,14456, Remove sciatic nerve lesion,64786,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,14456, Remove sciatic nerve lesion,64786,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5248,14456, Remove sciatic nerve lesion,64786,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5248,14456, Implant nerve end,64787,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1158.14,,,,,,,fee schedule,1158.14,4108, Implant nerve end,64787,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1158.14,4108, Implant nerve end,64787,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1158.14,4108, Implant nerve end,64787,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1158.14,4108, Remove skin nerve lesion,64788,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2163.63,,,,,,,fee schedule,2163.63,10940, Remove skin nerve lesion,64788,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2163.63,10940, Remove skin nerve lesion,64788,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2163.63,10940, Remove skin nerve lesion,64788,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2163.63,10940, Removal of nerve lesion,64790,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4547.48,,,,,,,fee schedule,4547.48,10940, Removal of nerve lesion,64790,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4547.48,10940, Removal of nerve lesion,64790,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,4547.48,10940, Removal of nerve lesion,64790,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,4547.48,10940, Removal of nerve lesion,64792,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7023.38,,,,,,,fee schedule,5248,14456, Removal of nerve lesion,64792,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,14456, Removal of nerve lesion,64792,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5248,14456, Removal of nerve lesion,64792,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5248,14456, Biopsy of nerve,64795,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1071.43,,,,,,,fee schedule,1071.43,10940, Biopsy of nerve,64795,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1071.43,10940, Biopsy of nerve,64795,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1071.43,10940, Biopsy of nerve,64795,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1071.43,10940, Sympathectomy cervical,64802,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5035.12,,,,,,,fee schedule,4108,5664, Sympathectomy cervical,64802,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,5664, Sympathectomy cervical,64802,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4108,5664, Sympathectomy cervical,64802,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4108,5664, Remove sympathetic nerves,64804,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6957.82,,,,,,,fee schedule,5097,6979, Remove sympathetic nerves,64804,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Remove sympathetic nerves,64804,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Remove sympathetic nerves,64804,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Remove sympathetic nerves,64809,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6353.79,,,,,,,fee schedule,5097,6979, Remove sympathetic nerves,64809,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Remove sympathetic nerves,64809,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Remove sympathetic nerves,64809,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Remove sympathetic nerves,64818,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4030,,,,,,,fee schedule,4030,6979, Remove sympathetic nerves,64818,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4030,6979, Remove sympathetic nerves,64818,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4030,6979, Remove sympathetic nerves,64818,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4030,6979, Sympathectomy digital artery,64820,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3892.13,,,,,,,fee schedule,3892.13,10940, Sympathectomy digital artery,64820,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3892.13,10940, Sympathectomy digital artery,64820,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3892.13,10940, Sympathectomy digital artery,64820,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3892.13,10940, Remove sympathetic nerves,64821,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3669.82,,,,,,,fee schedule,3669.82,12821, Remove sympathetic nerves,64821,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3669.82,12821, Remove sympathetic nerves,64821,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3669.82,12821, Remove sympathetic nerves,64821,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3669.82,12821, Remove sympathetic nerves,64822,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3669.82,,,,,,,fee schedule,3669.82,12821, Remove sympathetic nerves,64822,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3669.82,12821, Remove sympathetic nerves,64822,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3669.82,12821, Remove sympathetic nerves,64822,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3669.82,12821, Sympathectomy supfc palmar,64823,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4126.59,,,,,,,fee schedule,4108,12821, Sympathectomy supfc palmar,64823,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,12821, Sympathectomy supfc palmar,64823,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4108,12821, Sympathectomy supfc palmar,64823,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4108,12821, Description Not Available,64830,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Repair of digit nerve,64831,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3558.66,,,,,,,fee schedule,3558.66,12821, Repair of digit nerve,64831,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3558.66,12821, Repair of digit nerve,64831,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3558.66,12821, Repair of digit nerve,64831,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3558.66,12821, Repair nerve add-on,64832,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1601.69,,,,,,,fee schedule,1601.69,3195, Repair nerve add-on,64832,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1601.69,3195, Repair nerve add-on,64832,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1601.69,3195, Repair nerve add-on,64832,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1601.69,3195, Repair of hand or foot nerve,64834,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3668.15,,,,,,,fee schedule,3668.15,14456, Repair of hand or foot nerve,64834,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3668.15,14456, Repair of hand or foot nerve,64834,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3668.15,14456, Repair of hand or foot nerve,64834,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3668.15,14456, Repair of hand or foot nerve,64835,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4227.01,,,,,,,fee schedule,4227.01,14456, Repair of hand or foot nerve,64835,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4227.01,14456, Repair of hand or foot nerve,64835,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4227.01,14456, Repair of hand or foot nerve,64835,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4227.01,14456, Repair of hand or foot nerve,64836,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4227.01,,,,,,,fee schedule,4227.01,14456, Repair of hand or foot nerve,64836,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4227.01,14456, Repair of hand or foot nerve,64836,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4227.01,14456, Repair of hand or foot nerve,64836,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4227.01,14456, Repair nerve add-on,64837,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1784.03,,,,,,,fee schedule,1784.03,3195, Repair nerve add-on,64837,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1784.03,3195, Repair nerve add-on,64837,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1784.03,3195, Repair nerve add-on,64837,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1784.03,3195, Repair of leg nerve,64840,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4959.57,,,,,,,fee schedule,4108,14456, Repair of leg nerve,64840,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,14456, Repair of leg nerve,64840,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4108,14456, Repair of leg nerve,64840,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4108,14456, Repair/transpose nerve,64856,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5202.01,,,,,,,fee schedule,4108,14456, Repair/transpose nerve,64856,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,14456, Repair/transpose nerve,64856,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4108,14456, Repair/transpose nerve,64856,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4108,14456, Repair arm/leg nerve,64857,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5317.11,,,,,,,fee schedule,4108,14456, Repair arm/leg nerve,64857,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,14456, Repair arm/leg nerve,64857,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4108,14456, Repair arm/leg nerve,64857,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4108,14456, Repair sciatic nerve,64858,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5990.32,,,,,,,fee schedule,4108,12821, Repair sciatic nerve,64858,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,12821, Repair sciatic nerve,64858,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4108,12821, Repair sciatic nerve,64858,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4108,12821, Nerve surgery,64859,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1214.69,,,,,,,fee schedule,1214.69,3195, Nerve surgery,64859,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1214.69,3195, Nerve surgery,64859,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1214.69,3195, Nerve surgery,64859,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1214.69,3195, Repair of arm nerves,64861,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8808.48,,,,,,,fee schedule,5248,12821, Repair of arm nerves,64861,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,12821, Repair of arm nerves,64861,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5248,12821, Repair of arm nerves,64861,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5248,12821, Repair of low back nerves,64862,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6978.59,,,,,,,fee schedule,5248,14456, Repair of low back nerves,64862,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,14456, Repair of low back nerves,64862,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5248,14456, Repair of low back nerves,64862,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5248,14456, Repair of facial nerve,64864,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4215.3,,,,,,,fee schedule,4215.3,14456, Repair of facial nerve,64864,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4215.3,14456, Repair of facial nerve,64864,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4215.3,14456, Repair of facial nerve,64864,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4215.3,14456, Repair of facial nerve,64865,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5241.08,,,,,,,fee schedule,5241.08,14456, Repair of facial nerve,64865,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5241.08,14456, Repair of facial nerve,64865,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5241.08,14456, Repair of facial nerve,64865,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5241.08,14456, Fusion of facial/other nerve,64866,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6243.28,,,,,,,fee schedule,5097,6979, Fusion of facial/other nerve,64866,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Fusion of facial/other nerve,64866,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Fusion of facial/other nerve,64866,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Fusion of facial/other nerve,64868,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4802.33,,,,,,,fee schedule,4802.33,6979, Fusion of facial/other nerve,64868,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4802.33,6979, Fusion of facial/other nerve,64868,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4802.33,6979, Fusion of facial/other nerve,64868,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4802.33,6979, Subsequent repair of nerve,64872,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,570.25,,,,,,,fee schedule,570.25,4108, Subsequent repair of nerve,64872,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,570.25,4108, Subsequent repair of nerve,64872,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,570.25,4108, Subsequent repair of nerve,64872,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,570.25,4108, Repair & revise nerve add-on,64874,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,849.98,,,,,,,fee schedule,849.98,5248, Repair & revise nerve add-on,64874,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,849.98,5248, Repair & revise nerve add-on,64874,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,849.98,5248, Repair & revise nerve add-on,64874,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,849.98,5248, Repair nerve/shorten bone,64876,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,960.81,,,,,,,fee schedule,960.81,5248, Repair nerve/shorten bone,64876,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,960.81,5248, Repair nerve/shorten bone,64876,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,960.81,5248, Repair nerve/shorten bone,64876,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,960.81,5248, Nerve graft head/neck <=4 cm,64885,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5174.22,,,,,,,fee schedule,4108,14456, Nerve graft head/neck <=4 cm,64885,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,14456, Nerve graft head/neck <=4 cm,64885,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4108,14456, Nerve graft head/neck <=4 cm,64885,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4108,14456, Nerve graft head/neck >4 cm,64886,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6245.33,,,,,,,fee schedule,4108,14456, Nerve graft head/neck >4 cm,64886,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,14456, Nerve graft head/neck >4 cm,64886,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4108,14456, Nerve graft head/neck >4 cm,64886,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4108,14456, Nerve graft hand/foot <=4 cm,64890,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5511.37,,,,,,,fee schedule,4108,14456, Nerve graft hand/foot <=4 cm,64890,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,14456, Nerve graft hand/foot <=4 cm,64890,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4108,14456, Nerve graft hand/foot <=4 cm,64890,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4108,14456, Nerve graft hand/foot >4 cm,64891,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5858.98,,,,,,,fee schedule,4108,14456, Nerve graft hand/foot >4 cm,64891,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,14456, Nerve graft hand/foot >4 cm,64891,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4108,14456, Nerve graft hand/foot >4 cm,64891,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4108,14456, Nerve graft arm/leg <4 cm,64892,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5369.18,,,,,,,fee schedule,4108,14456, Nerve graft arm/leg <4 cm,64892,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,14456, Nerve graft arm/leg <4 cm,64892,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4108,14456, Nerve graft arm/leg <4 cm,64892,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4108,14456, Nerve graft arm/leg >4 cm,64893,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5718.63,,,,,,,fee schedule,4108,14456, Nerve graft arm/leg >4 cm,64893,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,14456, Nerve graft arm/leg >4 cm,64893,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4108,14456, Nerve graft arm/leg >4 cm,64893,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4108,14456, Nerve graft hand/foot <=4 cm,64895,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6724.12,,,,,,,fee schedule,5248,14456, Nerve graft hand/foot <=4 cm,64895,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,14456, Nerve graft hand/foot <=4 cm,64895,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5248,14456, Nerve graft hand/foot <=4 cm,64895,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5248,14456, Nerve graft hand/foot >4 cm,64896,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7254.65,,,,,,,fee schedule,5248,14456, Nerve graft hand/foot >4 cm,64896,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,14456, Nerve graft hand/foot >4 cm,64896,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5248,14456, Nerve graft hand/foot >4 cm,64896,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5248,14456, Nerve graft arm/leg <=4 cm,64897,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6435.43,,,,,,,fee schedule,5248,14456, Nerve graft arm/leg <=4 cm,64897,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,14456, Nerve graft arm/leg <=4 cm,64897,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5248,14456, Nerve graft arm/leg <=4 cm,64897,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5248,14456, Nerve graft arm/leg >4 cm,64898,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6968.61,,,,,,,fee schedule,5248,14456, Nerve graft arm/leg >4 cm,64898,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,14456, Nerve graft arm/leg >4 cm,64898,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5248,14456, Nerve graft arm/leg >4 cm,64898,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5248,14456, Nerve graft add-on,64901,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2913.79,,,,,,,fee schedule,2505,4108, Nerve graft add-on,64901,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2505,4108, Nerve graft add-on,64901,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,4108, Nerve graft add-on,64901,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,4108, Nerve graft add-on,64902,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3373.2,,,,,,,fee schedule,2505,4108, Nerve graft add-on,64902,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2505,4108, Nerve graft add-on,64902,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,4108, Nerve graft add-on,64902,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,4108, Nerve pedicle transfer,64905,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5016.23,,,,,,,fee schedule,4108,14456, Nerve pedicle transfer,64905,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,14456, Nerve pedicle transfer,64905,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4108,14456, Nerve pedicle transfer,64905,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4108,14456, Nerve pedicle transfer,64907,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6598.23,,,,,,,fee schedule,3195,14456, Nerve pedicle transfer,64907,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,14456, Nerve pedicle transfer,64907,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3195,14456, Nerve pedicle transfer,64907,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3195,14456, Nerve repair w/allograft,64910,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3850.8,,,,,,,fee schedule,3850.8,14456, Nerve repair w/allograft,64910,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3850.8,14456, Nerve repair w/allograft,64910,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3850.8,14456, Nerve repair w/allograft,64910,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3850.8,14456, Neurorraphy w/vein autograft,64911,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5297.09,,,,,,,fee schedule,4108,14456, Neurorraphy w/vein autograft,64911,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,14456, Neurorraphy w/vein autograft,64911,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4108,14456, Neurorraphy w/vein autograft,64911,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4108,14456, Nrv rpr w/nrv algrft 1st,64912,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4540.41,,,,,,,fee schedule,4108,14456, Nrv rpr w/nrv algrft 1st,64912,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,14456, Nrv rpr w/nrv algrft 1st,64912,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4108,14456, Nrv rpr w/nrv algrft 1st,64912,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4108,14456, Nrv rpr w/nrv algrft ea addl,64913,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,832.87,,,,,,,fee schedule,832.87,3195, Nrv rpr w/nrv algrft ea addl,64913,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,832.87,3195, Nrv rpr w/nrv algrft ea addl,64913,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,832.87,3195, Nrv rpr w/nrv algrft ea addl,64913,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,832.87,3195, Nervous system surgery,64999,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Nervous system surgery,64999,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Nervous system surgery,64999,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Revise eye,65091,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3529.79,,,,,,,fee schedule,3529.79,12821, Revise eye,65091,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3529.79,12821, Revise eye,65091,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3529.79,12821, Revise eye,65091,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3529.79,12821, Revise eye with implant,65093,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3511.55,,,,,,,fee schedule,3511.55,12821, Revise eye with implant,65093,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3511.55,12821, Revise eye with implant,65093,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3511.55,12821, Revise eye with implant,65093,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3511.55,12821, Removal of eye,65101,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4045.38,,,,,,,fee schedule,4045.38,12821, Removal of eye,65101,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4045.38,12821, Removal of eye,65101,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4045.38,12821, Removal of eye,65101,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4045.38,12821, Remove eye/insert implant,65103,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4162.1,,,,,,,fee schedule,4162.1,12821, Remove eye/insert implant,65103,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4162.1,12821, Remove eye/insert implant,65103,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4162.1,12821, Remove eye/insert implant,65103,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4162.1,12821, Remove eye/attach implant,65105,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4527.68,,,,,,,fee schedule,4527.68,12821, Remove eye/attach implant,65105,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4527.68,12821, Remove eye/attach implant,65105,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4527.68,12821, Remove eye/attach implant,65105,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4527.68,12821, Removal of eye,65110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6154.3,,,,,,,fee schedule,6044,12821, Removal of eye,65110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,12821, Removal of eye,65110,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,6044,12821, Removal of eye,65110,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,6044,12821, Remove eye/revise socket,65112,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7025.54,,,,,,,fee schedule,7025.54,12821, Remove eye/revise socket,65112,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,7025.54,12821, Remove eye/revise socket,65112,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,7025.54,12821, Remove eye/revise socket,65112,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,7025.54,12821, Remove eye/revise socket,65114,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7311.74,,,,,,,fee schedule,7311.74,12821, Remove eye/revise socket,65114,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,7311.74,12821, Remove eye/revise socket,65114,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,7311.74,12821, Remove eye/revise socket,65114,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,7311.74,12821, Revise ocular implant,65125,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1395.62,,,,,,,fee schedule,1395.62,10940, Revise ocular implant,65125,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1395.62,10940, Revise ocular implant,65125,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1395.62,10940, Revise ocular implant,65125,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1395.62,10940, Insert ocular implant,65130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4057.63,,,,,,,fee schedule,4057.63,12821, Insert ocular implant,65130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4057.63,12821, Insert ocular implant,65130,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4057.63,12821, Insert ocular implant,65130,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4057.63,12821, Insert ocular implant,65135,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4104.85,,,,,,,fee schedule,4104.85,12821, Insert ocular implant,65135,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4104.85,12821, Insert ocular implant,65135,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4104.85,12821, Insert ocular implant,65135,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4104.85,12821, Attach ocular implant,65140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4399.2,,,,,,,fee schedule,4399.2,12821, Attach ocular implant,65140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4399.2,12821, Attach ocular implant,65140,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4399.2,12821, Attach ocular implant,65140,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4399.2,12821, Revise ocular implant,65150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3346.65,,,,,,,fee schedule,3346.65,12821, Revise ocular implant,65150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3346.65,12821, Revise ocular implant,65150,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3346.65,12821, Revise ocular implant,65150,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3346.65,12821, Reinsert ocular implant,65155,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4566.9,,,,,,,fee schedule,4566.9,12821, Reinsert ocular implant,65155,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4566.9,12821, Reinsert ocular implant,65155,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4566.9,12821, Reinsert ocular implant,65155,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4566.9,12821, Removal of ocular implant,65175,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3721.46,,,,,,,fee schedule,3195,12821, Removal of ocular implant,65175,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,12821, Removal of ocular implant,65175,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3195,12821, Removal of ocular implant,65175,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3195,12821, Remove foreign body from eye,65205,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,131.55,,,,,,,fee schedule,131.55,6979, Remove foreign body from eye,65205,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,131.55,6979, Remove foreign body from eye,65205,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,131.55,6979, Remove foreign body from eye,65205,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,131.55,6979, Remove foreign body from eye,65210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,162.69,,,,,,,fee schedule,162.69,6979, Remove foreign body from eye,65210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,162.69,6979, Remove foreign body from eye,65210,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,162.69,6979, Remove foreign body from eye,65210,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,162.69,6979, Remove foreign body from eye,65220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,209.04,,,,,,,fee schedule,209.04,6979, Remove foreign body from eye,65220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,209.04,6979, Remove foreign body from eye,65220,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,209.04,6979, Remove foreign body from eye,65220,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,209.04,6979, Remove foreign body from eye,65222,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,225.82,,,,,,,fee schedule,225.82,6979, Remove foreign body from eye,65222,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,225.82,6979, Remove foreign body from eye,65222,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,225.82,6979, Remove foreign body from eye,65222,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,225.82,6979, Remove foreign body from eye,65235,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3418.53,,,,,,,fee schedule,3418.53,10940, Remove foreign body from eye,65235,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3418.53,10940, Remove foreign body from eye,65235,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3418.53,10940, Remove foreign body from eye,65235,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3418.53,10940, Remove foreign body from eye,65260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4527.95,,,,,,,fee schedule,2505,5248, Remove foreign body from eye,65260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2505,5248, Remove foreign body from eye,65260,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,5248, Remove foreign body from eye,65260,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,5248, Remove foreign body from eye,65265,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5080.17,,,,,,,fee schedule,5080.17,10940, Remove foreign body from eye,65265,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5080.17,10940, Remove foreign body from eye,65265,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,5080.17,10940, Remove foreign body from eye,65265,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,5080.17,10940, Repair of eye wound,65270,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,641.53,,,,,,,fee schedule,641.53,10940, Repair of eye wound,65270,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,641.53,10940, Repair of eye wound,65270,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,641.53,10940, Repair of eye wound,65270,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,641.53,10940, Repair of eye wound,65272,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1616.7,,,,,,,fee schedule,1616.7,10940, Repair of eye wound,65272,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1616.7,10940, Repair of eye wound,65272,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1616.7,10940, Repair of eye wound,65272,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1616.7,10940, Repair of eye wound,65273,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1735.14,,,,,,,fee schedule,1735.14,5664, Repair of eye wound,65273,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1735.14,5664, Repair of eye wound,65273,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1735.14,5664, Repair of eye wound,65273,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1735.14,5664, Repair of eye wound,65275,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2101.53,,,,,,,fee schedule,2101.53,12821, Repair of eye wound,65275,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2101.53,12821, Repair of eye wound,65275,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2101.53,12821, Repair of eye wound,65275,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2101.53,12821, Repair of eye wound,65280,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3058.13,,,,,,,fee schedule,3058.13,10940, Repair of eye wound,65280,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3058.13,10940, Repair of eye wound,65280,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3058.13,10940, Repair of eye wound,65280,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3058.13,10940, Repair of eye wound,65285,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5031.5,,,,,,,fee schedule,5031.5,10940, Repair of eye wound,65285,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5031.5,10940, Repair of eye wound,65285,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,5031.5,10940, Repair of eye wound,65285,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,5031.5,10940, Repair of eye wound,65286,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2266.32,,,,,,,fee schedule,2266.32,5664, Repair of eye wound,65286,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2266.32,5664, Repair of eye wound,65286,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2266.32,5664, Repair of eye wound,65286,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2266.32,5664, Repair of eye socket wound,65290,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2240.53,,,,,,,fee schedule,2240.53,12821, Repair of eye socket wound,65290,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2240.53,12821, Repair of eye socket wound,65290,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2240.53,12821, Repair of eye socket wound,65290,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2240.53,12821, Removal of eye lesion,65400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2817.09,,,,,,,fee schedule,2817.09,5664, Removal of eye lesion,65400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2817.09,5664, Removal of eye lesion,65400,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2817.09,5664, Removal of eye lesion,65400,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2817.09,5664, Biopsy of cornea,65410,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,468.43,,,,,,,fee schedule,468.43,4497, Biopsy of cornea,65410,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,468.43,4497, Biopsy of cornea,65410,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,468.43,4497, Biopsy of cornea,65410,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,468.43,4497, Removal of eye lesion,65420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1794.66,,,,,,,fee schedule,1794.66,10940, Removal of eye lesion,65420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1794.66,10940, Removal of eye lesion,65420,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1794.66,10940, Removal of eye lesion,65420,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1794.66,10940, Removal of eye lesion,65426,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2223.48,,,,,,,fee schedule,2223.48,10940, Removal of eye lesion,65426,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,2223.48,10940, Removal of eye lesion,65426,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2223.48,10940, Removal of eye lesion,65426,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2223.48,10940, Corneal smear,65430,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,463.3,,,,,,,fee schedule,463.3,6979, Corneal smear,65430,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,463.3,6979, Corneal smear,65430,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,463.3,6979, Corneal smear,65430,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,463.3,6979, Curette/treat cornea,65435,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,325.92,,,,,,,fee schedule,325.92,5664, Curette/treat cornea,65435,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,325.92,5664, Curette/treat cornea,65435,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,325.92,5664, Curette/treat cornea,65435,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,325.92,5664, Curette/treat cornea,65436,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1715.06,,,,,,,fee schedule,1715.06,10940, Curette/treat cornea,65436,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1715.06,10940, Curette/treat cornea,65436,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1715.06,10940, Curette/treat cornea,65436,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1715.06,10940, Treatment of corneal lesion,65450,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1542.82,,,,,,,fee schedule,1542.82,3195, Treatment of corneal lesion,65450,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1542.82,3195, Treatment of corneal lesion,65450,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1542.82,3195, Treatment of corneal lesion,65450,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1542.82,3195, Revision of cornea,65600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1612.32,,,,,,,fee schedule,1612.32,10940, Revision of cornea,65600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1612.32,10940, Revision of cornea,65600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1612.32,10940, Revision of cornea,65600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1612.32,10940, Corneal transplant,65710,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5293.96,,,,,,,fee schedule,5293.96,14456, Corneal transplant,65710,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,5293.96,14456, Corneal transplant,65710,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5293.96,14456, Corneal transplant,65710,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5293.96,14456, Corneal transplant,65730,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5761.04,,,,,,,fee schedule,5761.04,14456, Corneal transplant,65730,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,5761.04,14456, Corneal transplant,65730,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5761.04,14456, Corneal transplant,65730,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5761.04,14456, Corneal transplant,65750,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5778.63,,,,,,,fee schedule,5778.63,14456, Corneal transplant,65750,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,5778.63,14456, Corneal transplant,65750,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5778.63,14456, Corneal transplant,65750,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5778.63,14456, Corneal transplant,65755,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5751.92,,,,,,,fee schedule,5751.92,14456, Corneal transplant,65755,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,5751.92,14456, Corneal transplant,65755,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5751.92,14456, Corneal transplant,65755,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5751.92,14456, Corneal trnspl endothelial,65756,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5374.96,,,,,,,fee schedule,5374.96,14456, Corneal trnspl endothelial,65756,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,5374.96,14456, Corneal trnspl endothelial,65756,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5374.96,14456, Corneal trnspl endothelial,65756,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5374.96,14456, Prep corneal endo allograft,65757,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,2782, Prep corneal endo allograft,65757,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,2782, Revision of cornea,65760,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,8406,10940, Revision of cornea,65760,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,8406,10940, Revision of cornea,65760,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,8406,10940, Revision of cornea,65765,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,8406,10940, Revision of cornea,65765,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,8406,10940, Revision of cornea,65765,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,8406,10940, Corneal tissue transplant,65767,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,8406,10940, Corneal tissue transplant,65767,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,8406,10940, Corneal tissue transplant,65767,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,8406,10940, Revise cornea with implant,65770,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6402.95,,,,,,,fee schedule,6402.95,22111, Revise cornea with implant,65770,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,6402.95,22111, Revise cornea with implant,65770,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6402.95,22111, Revise cornea with implant,65770,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6402.95,22111, Radial keratotomy,65771,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,8406,10940, Radial keratotomy,65771,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,8406,10940, Radial keratotomy,65771,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,8406,10940, Correction of astigmatism,65772,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1889.68,,,,,,,fee schedule,1889.68,5664, Correction of astigmatism,65772,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,1889.68,5664, Correction of astigmatism,65772,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1889.68,5664, Correction of astigmatism,65772,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1889.68,5664, Correction of astigmatism,65775,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2679.87,,,,,,,fee schedule,2679.87,10940, Correction of astigmatism,65775,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2679.87,10940, Correction of astigmatism,65775,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2679.87,10940, Correction of astigmatism,65775,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2679.87,10940, Cover eye w/membrane,65778,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,194.8,,,,,,,fee schedule,194.8,5664, Cover eye w/membrane,65778,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,194.8,5664, Cover eye w/membrane,65778,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,194.8,5664, Cover eye w/membrane,65778,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,194.8,5664, Cover eye w/membrane suture,65779,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,465.03,,,,,,,fee schedule,465.03,12821, Cover eye w/membrane suture,65779,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,465.03,12821, Cover eye w/membrane suture,65779,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,465.03,12821, Cover eye w/membrane suture,65779,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,465.03,12821, Ocular reconst transplant,65780,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2769.6,,,,,,,fee schedule,2769.6,12821, Ocular reconst transplant,65780,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,2769.6,12821, Ocular reconst transplant,65780,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2769.6,12821, Ocular reconst transplant,65780,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2769.6,12821, Ocular reconst transplant,65781,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6072.06,,,,,,,fee schedule,6044,14456, Ocular reconst transplant,65781,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,14456, Ocular reconst transplant,65781,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,6044,14456, Ocular reconst transplant,65781,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,6044,14456, Ocular reconst transplant,65782,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5261.15,,,,,,,fee schedule,5261.15,12821, Ocular reconst transplant,65782,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,5261.15,12821, Ocular reconst transplant,65782,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5261.15,12821, Ocular reconst transplant,65782,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5261.15,12821, Impltj ntrstrml crnl rng seg,65785,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2074.92,,,,,,,fee schedule,2074.92,14456, Impltj ntrstrml crnl rng seg,65785,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2074.92,14456, Impltj ntrstrml crnl rng seg,65785,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,2074.92,14456, Impltj ntrstrml crnl rng seg,65785,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,2074.92,14456, Drainage of eye,65800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,390.67,,,,,,,fee schedule,390.67,3195, Drainage of eye,65800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,390.67,3195, Drainage of eye,65800,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,390.67,3195, Drainage of eye,65800,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,390.67,3195, Drainage of eye,65810,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2155.97,,,,,,,fee schedule,2155.97,10940, Drainage of eye,65810,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2155.97,10940, Drainage of eye,65810,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2155.97,10940, Drainage of eye,65810,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2155.97,10940, Drainage of eye,65815,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2214.46,,,,,,,fee schedule,2214.46,10940, Drainage of eye,65815,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2214.46,10940, Drainage of eye,65815,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2214.46,10940, Drainage of eye,65815,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2214.46,10940, Relieve inner eye pressure,65820,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3868.01,,,,,,,fee schedule,3195,10940, Relieve inner eye pressure,65820,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,10940, Relieve inner eye pressure,65820,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3195,10940, Relieve inner eye pressure,65820,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3195,10940, Incision of eye,65850,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3858.68,,,,,,,fee schedule,3858.68,10940, Incision of eye,65850,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3858.68,10940, Incision of eye,65850,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3858.68,10940, Incision of eye,65850,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3858.68,10940, Trabeculoplasty laser surg,65855,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,928.81,,,,,,,fee schedule,928.81,4497, Trabeculoplasty laser surg,65855,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,928.81,4497, Trabeculoplasty laser surg,65855,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,928.81,4497, Trabeculoplasty laser surg,65855,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,928.81,4497, Incise inner eye adhesions,65860,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1133,,,,,,,fee schedule,1133,5363, Incise inner eye adhesions,65860,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,1133,5363, Incise inner eye adhesions,65860,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,1133,5363, Incise inner eye adhesions,65860,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,1133,5363, Incise inner eye adhesions,65865,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2222.83,,,,,,,fee schedule,2222.83,10940, Incise inner eye adhesions,65865,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2222.83,10940, Incise inner eye adhesions,65865,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2222.83,10940, Incise inner eye adhesions,65865,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2222.83,10940, Incise inner eye adhesions,65870,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2759.89,,,,,,,fee schedule,2759.89,10940, Incise inner eye adhesions,65870,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2759.89,10940, Incise inner eye adhesions,65870,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2759.89,10940, Incise inner eye adhesions,65870,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2759.89,10940, Incise inner eye adhesions,65875,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2946.97,,,,,,,fee schedule,2946.97,10940, Incise inner eye adhesions,65875,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2946.97,10940, Incise inner eye adhesions,65875,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2946.97,10940, Incise inner eye adhesions,65875,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2946.97,10940, Incise inner eye adhesions,65880,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3086.13,,,,,,,fee schedule,3086.13,10940, Incise inner eye adhesions,65880,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3086.13,10940, Incise inner eye adhesions,65880,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3086.13,10940, Incise inner eye adhesions,65880,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3086.13,10940, Remove eye lesion,65900,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4577.7,,,,,,,fee schedule,4577.7,10940, Remove eye lesion,65900,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4577.7,10940, Remove eye lesion,65900,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,4577.7,10940, Remove eye lesion,65900,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,4577.7,10940, Remove implant of eye,65920,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3668.36,,,,,,,fee schedule,3668.36,10940, Remove implant of eye,65920,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,3668.36,10940, Remove implant of eye,65920,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3668.36,10940, Remove implant of eye,65920,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3668.36,10940, Remove blood clot from eye,65930,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2953.72,,,,,,,fee schedule,2953.72,10940, Remove blood clot from eye,65930,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,2953.72,10940, Remove blood clot from eye,65930,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2953.72,10940, Remove blood clot from eye,65930,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2953.72,10940, Injection treatment of eye,66020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,613.04,,,,,,,fee schedule,613.04,5664, Injection treatment of eye,66020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,613.04,5664, Injection treatment of eye,66020,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,613.04,5664, Injection treatment of eye,66020,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,613.04,5664, Injection treatment of eye,66030,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,522.06,,,,,,,fee schedule,522.06,5664, Injection treatment of eye,66030,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,522.06,5664, Injection treatment of eye,66030,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,522.06,5664, Injection treatment of eye,66030,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,522.06,5664, Remove eye lesion,66130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2580.37,,,,,,,fee schedule,2580.37,10940, Remove eye lesion,66130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,2580.37,10940, Remove eye lesion,66130,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2580.37,10940, Remove eye lesion,66130,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2580.37,10940, Glaucoma surgery,66150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4089.03,,,,,,,fee schedule,4089.03,10940, Glaucoma surgery,66150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4089.03,10940, Glaucoma surgery,66150,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,4089.03,10940, Glaucoma surgery,66150,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,4089.03,10940, Glaucoma surgery,66155,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4087.2,,,,,,,fee schedule,4087.2,10940, Glaucoma surgery,66155,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4087.2,10940, Glaucoma surgery,66155,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,4087.2,10940, Glaucoma surgery,66155,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,4087.2,10940, Glaucoma surgery,66160,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4568.85,,,,,,,fee schedule,4108,10940, Glaucoma surgery,66160,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,10940, Glaucoma surgery,66160,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,4108,10940, Glaucoma surgery,66160,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,4108,10940, Glaucoma surgery,66170,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5055.19,,,,,,,fee schedule,5055.19,10940, Glaucoma surgery,66170,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5055.19,10940, Glaucoma surgery,66170,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,5055.19,10940, Glaucoma surgery,66170,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,5055.19,10940, Incision of eye,66172,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5537.7,,,,,,,fee schedule,5363,10940, Incision of eye,66172,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,10940, Incision of eye,66172,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,5363,10940, Incision of eye,66172,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,5363,10940, Translum dil eye canal,66174,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2903.91,,,,,,,fee schedule,2903.91,14456, Translum dil eye canal,66174,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,2903.91,14456, Translum dil eye canal,66174,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,2903.91,14456, Translum dil eye canal,66174,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,2903.91,14456, Trnslum dil eye canal w/stnt,66175,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3342.88,,,,,,,fee schedule,3342.88,14456, Trnslum dil eye canal w/stnt,66175,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,3342.88,14456, Trnslum dil eye canal w/stnt,66175,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3342.88,14456, Trnslum dil eye canal w/stnt,66175,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3342.88,14456, Aqueous shunt eye w/o graft,66179,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4979.81,,,,,,,fee schedule,4979.81,14456, Aqueous shunt eye w/o graft,66179,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4979.81,14456, Aqueous shunt eye w/o graft,66179,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4979.81,14456, Aqueous shunt eye w/o graft,66179,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4979.81,14456, Aqueous shunt eye w/graft,66180,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5238.44,,,,,,,fee schedule,5238.44,14456, Aqueous shunt eye w/graft,66180,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,5238.44,14456, Aqueous shunt eye w/graft,66180,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5238.44,14456, Aqueous shunt eye w/graft,66180,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5238.44,14456, Insert ant drainage device,66183,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4751.61,,,,,,,fee schedule,4751.61,14456, Insert ant drainage device,66183,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4751.61,14456, Insert ant drainage device,66183,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4751.61,14456, Insert ant drainage device,66183,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4751.61,14456, Revision of aqueous shunt,66184,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3690.54,,,,,,,fee schedule,3690.54,10940, Revision of aqueous shunt,66184,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3690.54,10940, Revision of aqueous shunt,66184,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3690.54,10940, Revision of aqueous shunt,66184,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3690.54,10940, Revise aqueous shunt eye,66185,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3947.39,,,,,,,fee schedule,3947.39,10940, Revise aqueous shunt eye,66185,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3947.39,10940, Revise aqueous shunt eye,66185,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3947.39,10940, Revise aqueous shunt eye,66185,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3947.39,10940, Repair/graft eye lesion,66225,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4288.36,,,,,,,fee schedule,4288.36,10940, Repair/graft eye lesion,66225,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4288.36,10940, Repair/graft eye lesion,66225,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,4288.36,10940, Repair/graft eye lesion,66225,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,4288.36,10940, Follow-up surgery of eye,66250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2574.7,,,,,,,fee schedule,2574.7,10940, Follow-up surgery of eye,66250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2574.7,10940, Follow-up surgery of eye,66250,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2574.7,10940, Follow-up surgery of eye,66250,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2574.7,10940, Incision of iris,66500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1875.92,,,,,,,fee schedule,1875.92,3195, Incision of iris,66500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1875.92,3195, Incision of iris,66500,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1875.92,3195, Incision of iris,66500,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1875.92,3195, Incision of iris,66505,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2040.66,,,,,,,fee schedule,2040.66,5664, Incision of iris,66505,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2040.66,5664, Incision of iris,66505,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2040.66,5664, Incision of iris,66505,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2040.66,5664, Remove iris and lesion,66600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4237.96,,,,,,,fee schedule,4237.96,10940, Remove iris and lesion,66600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4237.96,10940, Remove iris and lesion,66600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,4237.96,10940, Remove iris and lesion,66600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,4237.96,10940, Removal of iris,66605,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4998.96,,,,,,,fee schedule,4998.96,14456, Removal of iris,66605,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4998.96,14456, Removal of iris,66605,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4998.96,14456, Removal of iris,66605,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4998.96,14456, Removal of iris,66625,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1993.98,,,,,,,fee schedule,1993.98,5664, Removal of iris,66625,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1993.98,5664, Removal of iris,66625,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1993.98,5664, Removal of iris,66625,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1993.98,5664, Removal of iris,66630,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2620.19,,,,,,,fee schedule,2620.19,5664, Removal of iris,66630,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2620.19,5664, Removal of iris,66630,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,2620.19,5664, Removal of iris,66630,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,2620.19,5664, Removal of iris,66635,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2644.31,,,,,,,fee schedule,2644.31,10940, Removal of iris,66635,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2644.31,10940, Removal of iris,66635,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2644.31,10940, Removal of iris,66635,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2644.31,10940, Repair iris & ciliary body,66680,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2739.01,,,,,,,fee schedule,2739.01,10940, Repair iris & ciliary body,66680,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2739.01,10940, Repair iris & ciliary body,66680,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2739.01,10940, Repair iris & ciliary body,66680,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2739.01,10940, Repair iris & ciliary body,66682,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3055.86,,,,,,,fee schedule,3055.86,10940, Repair iris & ciliary body,66682,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3055.86,10940, Repair iris & ciliary body,66682,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3055.86,10940, Repair iris & ciliary body,66682,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3055.86,10940, Implantation iris prosthesis,66683,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3574.15,,,,,,,fee schedule,3574.15,14456, Implantation iris prosthesis,66683,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,3574.15,14456, Implantation iris prosthesis,66683,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3574.15,14456, Implantation iris prosthesis,66683,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3574.15,14456, Destruction ciliary body,66700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1809.06,,,,,,,fee schedule,1809.06,5664, Destruction ciliary body,66700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1809.06,5664, Destruction ciliary body,66700,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1809.06,5664, Destruction ciliary body,66700,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1809.06,5664, Ciliary transsleral therapy,66710,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1809.06,,,,,,,fee schedule,1809.06,10940, Ciliary transsleral therapy,66710,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1809.06,10940, Ciliary transsleral therapy,66710,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1809.06,10940, Ciliary transsleral therapy,66710,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1809.06,10940, Ciliary endoscopic ablation,66711,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2387.78,,,,,,,fee schedule,2387.78,10940, Ciliary endoscopic ablation,66711,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2387.78,10940, Ciliary endoscopic ablation,66711,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2387.78,10940, Ciliary endoscopic ablation,66711,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2387.78,10940, Destruction ciliary body,66720,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1939.21,,,,,,,fee schedule,1939.21,10940, Destruction ciliary body,66720,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1939.21,10940, Destruction ciliary body,66720,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1939.21,10940, Destruction ciliary body,66720,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1939.21,10940, Destruction ciliary body,66740,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1809.06,,,,,,,fee schedule,1809.06,10940, Destruction ciliary body,66740,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1809.06,10940, Destruction ciliary body,66740,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1809.06,10940, Destruction ciliary body,66740,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1809.06,10940, Revision of iris,66761,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1087.35,,,,,,,fee schedule,1087.35,4497, Revision of iris,66761,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1087.35,4497, Revision of iris,66761,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,1087.35,4497, Revision of iris,66761,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,1087.35,4497, Revision of iris,66762,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1976.61,,,,,,,fee schedule,1976.61,4497, Revision of iris,66762,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1976.61,4497, Revision of iris,66762,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,1976.61,4497, Revision of iris,66762,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,1976.61,4497, Removal of inner eye lesion,66770,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2237.18,,,,,,,fee schedule,2237.18,4497, Removal of inner eye lesion,66770,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2237.18,4497, Removal of inner eye lesion,66770,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,2237.18,4497, Removal of inner eye lesion,66770,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,2237.18,4497, Incision secondary cataract,66820,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2232.33,,,,,,,fee schedule,2232.33,3195, Incision secondary cataract,66820,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2232.33,3195, Incision secondary cataract,66820,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2232.33,3195, Incision secondary cataract,66820,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2232.33,3195, After cataract laser surgery,66821,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1470.84,,,,,,,fee schedule,1470.84,4497, After cataract laser surgery,66821,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1470.84,4497, After cataract laser surgery,66821,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,1470.84,4497, After cataract laser surgery,66821,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,1470.84,4497, Reposition intraocular lens,66825,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3904.17,,,,,,,fee schedule,3904.17,10940, Reposition intraocular lens,66825,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3904.17,10940, Reposition intraocular lens,66825,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3904.17,10940, Reposition intraocular lens,66825,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3904.17,10940, Removal of lens lesion,66830,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3255.95,,,,,,,fee schedule,3255.95,10940, Removal of lens lesion,66830,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3255.95,10940, Removal of lens lesion,66830,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3255.95,10940, Removal of lens lesion,66830,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3255.95,10940, Removal of lens material,66840,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3187.26,,,,,,,fee schedule,3187.26,10940, Removal of lens material,66840,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3187.26,10940, Removal of lens material,66840,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3187.26,10940, Removal of lens material,66840,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3187.26,10940, Removal of lens material,66850,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3618.83,,,,,,,fee schedule,3618.83,10940, Removal of lens material,66850,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,3618.83,10940, Removal of lens material,66850,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3618.83,10940, Removal of lens material,66850,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3618.83,10940, Removal of lens material,66852,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3839.04,,,,,,,fee schedule,3839.04,14456, Removal of lens material,66852,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3839.04,14456, Removal of lens material,66852,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3839.04,14456, Removal of lens material,66852,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3839.04,14456, Extraction of lens,66920,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3431.69,,,,,,,fee schedule,3431.69,10940, Extraction of lens,66920,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3431.69,10940, Extraction of lens,66920,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3431.69,10940, Extraction of lens,66920,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3431.69,10940, Extraction of lens,66930,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3925.32,,,,,,,fee schedule,3925.32,10940, Extraction of lens,66930,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,3925.32,10940, Extraction of lens,66930,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3925.32,10940, Extraction of lens,66930,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3925.32,10940, Extraction of lens,66940,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3606.04,,,,,,,fee schedule,3606.04,6044, Extraction of lens,66940,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,3606.04,6044, Extraction of lens,66940,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3606.04,6044, Extraction of lens,66940,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3606.04,6044, Cataract surgery complex,66982,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3410.16,,,,,,,fee schedule,3410.16,10940, Cataract surgery complex,66982,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,3410.16,10940, Cataract surgery complex,66982,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3410.16,10940, Cataract surgery complex,66982,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3410.16,10940, Cataract surg w/iol 1 stage,66983,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,10940, Cataract surg w/iol 1 stage,66983,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,6044,10940, Cataract surg w/iol 1 stage,66983,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,6044,10940, Cataract surg w/iol 1 stage,66984,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2496.46,,,,,,,fee schedule,2496.46,10940, Cataract surg w/iol 1 stage,66984,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,2496.46,10940, Cataract surg w/iol 1 stage,66984,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2496.46,10940, Cataract surg w/iol 1 stage,66984,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2496.46,10940, Insert lens prosthesis,66985,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3552.83,,,,,,,fee schedule,3552.83,10940, Insert lens prosthesis,66985,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3552.83,10940, Insert lens prosthesis,66985,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3552.83,10940, Insert lens prosthesis,66985,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3552.83,10940, Exchange lens prosthesis,66986,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4130.69,,,,,,,fee schedule,4130.69,10940, Exchange lens prosthesis,66986,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4130.69,10940, Exchange lens prosthesis,66986,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,4130.69,10940, Exchange lens prosthesis,66986,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,4130.69,10940, Xcapsl ctrc rmvl cplx w/ecp,66987,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,14456, Xcapsl ctrc rmvl cplx w/ecp,66987,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,6979,14456, Xcapsl ctrc rmvl cplx w/ecp,66987,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,6979,14456, Xcapsl ctrc rmvl w/ecp,66988,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,14456, Xcapsl ctrc rmvl w/ecp,66988,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,6979,14456, Xcapsl ctrc rmvl w/ecp,66988,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,6979,14456, Xcpsl ctrc rmvl cplx insj 1+,66989,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3892.46,,,,,,,fee schedule,3892.46,14456, Xcpsl ctrc rmvl cplx insj 1+,66989,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3892.46,14456, Xcpsl ctrc rmvl cplx insj 1+,66989,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3892.46,14456, Xcpsl ctrc rmvl cplx insj 1+,66989,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3892.46,14456, Ophthalmic endoscope add-on,66990,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,387.06,,,,,,,fee schedule,387.06,3195, Ophthalmic endoscope add-on,66990,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,387.06,3195, Ophthalmic endoscope add-on,66990,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,387.06,3195, Ophthalmic endoscope add-on,66990,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,387.06,3195, Xcapsl ctrc rmvl insj 1+,66991,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3142.63,,,,,,,fee schedule,3142.63,14456, Xcapsl ctrc rmvl insj 1+,66991,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3142.63,14456, Xcapsl ctrc rmvl insj 1+,66991,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3142.63,14456, Xcapsl ctrc rmvl insj 1+,66991,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3142.63,14456, Eye surgery procedure,66999,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,5664, Eye surgery procedure,66999,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3195,5664, Eye surgery procedure,66999,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3195,5664, Partial removal of eye fluid,67005,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2222.99,,,,,,,fee schedule,2222.99,10940, Partial removal of eye fluid,67005,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2222.99,10940, Partial removal of eye fluid,67005,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2222.99,10940, Partial removal of eye fluid,67005,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2222.99,10940, Partial removal of eye fluid,67010,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2523.44,,,,,,,fee schedule,2523.44,10940, Partial removal of eye fluid,67010,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2523.44,10940, Partial removal of eye fluid,67010,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2523.44,10940, Partial removal of eye fluid,67010,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2523.44,10940, Release of eye fluid,67015,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2814.55,,,,,,,fee schedule,2814.55,10940, Release of eye fluid,67015,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2814.55,10940, Release of eye fluid,67015,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2814.55,10940, Release of eye fluid,67015,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2814.55,10940, Replace eye fluid,67025,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2909.95,,,,,,,fee schedule,2909.95,10940, Replace eye fluid,67025,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2909.95,10940, Replace eye fluid,67025,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2909.95,10940, Replace eye fluid,67025,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2909.95,10940, Implant eye drug system,67027,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3868.55,,,,,,,fee schedule,3868.55,14456, Implant eye drug system,67027,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3868.55,14456, Implant eye drug system,67027,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3868.55,14456, Implant eye drug system,67027,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3868.55,14456, Injection eye drug,67028,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,411.34,,,,,,,fee schedule,411.34,3195, Injection eye drug,67028,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,411.34,3195, Injection eye drug,67028,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,411.34,3195, Injection eye drug,67028,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,411.34,3195, Incise inner eye strands,67030,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2626.45,,,,,,,fee schedule,2626.45,10940, Incise inner eye strands,67030,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2626.45,10940, Incise inner eye strands,67030,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2626.45,10940, Incise inner eye strands,67030,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2626.45,10940, Laser surgery eye strands,67031,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1645.62,,,,,,,fee schedule,1645.62,4497, Laser surgery eye strands,67031,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1645.62,4497, Laser surgery eye strands,67031,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,1645.62,4497, Laser surgery eye strands,67031,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,1645.62,4497, Removal of inner eye fluid,67036,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4103.87,,,,,,,fee schedule,4103.87,14456, Removal of inner eye fluid,67036,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4103.87,14456, Removal of inner eye fluid,67036,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4103.87,14456, Removal of inner eye fluid,67036,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4103.87,14456, Laser treatment of retina,67039,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4379.45,,,,,,,fee schedule,4379.45,14456, Laser treatment of retina,67039,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,4379.45,14456, Laser treatment of retina,67039,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4379.45,14456, Laser treatment of retina,67039,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4379.45,14456, Laser treatment of retina,67040,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4710.28,,,,,,,fee schedule,4710.28,14456, Laser treatment of retina,67040,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,4710.28,14456, Laser treatment of retina,67040,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4710.28,14456, Laser treatment of retina,67040,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4710.28,14456, Vit for macular pucker,67041,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5177.52,,,,,,,fee schedule,5177.52,14456, Vit for macular pucker,67041,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,5177.52,14456, Vit for macular pucker,67041,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5177.52,14456, Vit for macular pucker,67041,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5177.52,14456, Vit for macular hole,67042,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5175.84,,,,,,,fee schedule,5175.84,14456, Vit for macular hole,67042,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,5175.84,14456, Vit for macular hole,67042,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5175.84,14456, Vit for macular hole,67042,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5175.84,14456, Vit for membrane dissect,67043,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5449.47,,,,,,,fee schedule,5449.47,14456, Vit for membrane dissect,67043,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,5449.47,14456, Vit for membrane dissect,67043,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5449.47,14456, Vit for membrane dissect,67043,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5449.47,14456, Repair detached retina crtx,67101,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1320.83,,,,,,,fee schedule,1320.83,10940, Repair detached retina crtx,67101,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,1320.83,10940, Repair detached retina crtx,67101,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1320.83,10940, Repair detached retina crtx,67101,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1320.83,10940, Repair detached retina pc,67105,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1274.21,,,,,,,fee schedule,1274.21,6044, Repair detached retina pc,67105,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,1274.21,6044, Repair detached retina pc,67105,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,1274.21,6044, Repair detached retina pc,67105,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,1274.21,6044, Repair detached retina,67107,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5093.77,,,,,,,fee schedule,5093.77,14456, Repair detached retina,67107,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,5093.77,14456, Repair detached retina,67107,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5093.77,14456, Repair detached retina,67107,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5093.77,14456, Repair detached retina,67108,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5380.89,,,,,,,fee schedule,5380.89,14456, Repair detached retina,67108,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,5380.89,14456, Repair detached retina,67108,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5380.89,14456, Repair detached retina,67108,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5380.89,14456, Repair detached retina,67110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3760.9,,,,,,,fee schedule,3760.9,10940, Repair detached retina,67110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3760.9,10940, Repair detached retina,67110,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3760.9,10940, Repair detached retina,67110,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3760.9,10940, Repair retinal detach cplx,67113,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6019.13,,,,,,,fee schedule,6019.13,14456, Repair retinal detach cplx,67113,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6019.13,14456, Repair retinal detach cplx,67113,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,6019.13,14456, Repair retinal detach cplx,67113,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,6019.13,14456, Release encircling material,67115,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2323.19,,,,,,,fee schedule,2323.19,10940, Release encircling material,67115,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2323.19,10940, Release encircling material,67115,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2323.19,10940, Release encircling material,67115,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2323.19,10940, Remove eye implant material,67120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2563.42,,,,,,,fee schedule,2563.42,10940, Remove eye implant material,67120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2563.42,10940, Remove eye implant material,67120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2563.42,10940, Remove eye implant material,67120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2563.42,10940, Remove eye implant material,67121,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4133.28,,,,,,,fee schedule,4108,12821, Remove eye implant material,67121,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,12821, Remove eye implant material,67121,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4108,12821, Remove eye implant material,67121,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4108,12821, Treatment of retina,67141,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1012.83,,,,,,,fee schedule,1012.83,4108, Treatment of retina,67141,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1012.83,4108, Treatment of retina,67141,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1012.83,4108, Treatment of retina,67141,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1012.83,4108, Treatment of retina,67145,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1012.83,,,,,,,fee schedule,1012.83,4497, Treatment of retina,67145,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1012.83,4497, Treatment of retina,67145,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,1012.83,4497, Treatment of retina,67145,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,1012.83,4497, Treatment of retinal lesion,67208,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2653.59,,,,,,,fee schedule,2505,6044, Treatment of retinal lesion,67208,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,2505,6044, Treatment of retinal lesion,67208,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,6044, Treatment of retinal lesion,67208,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,6044, Treatment of retinal lesion,67210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2306.36,,,,,,,fee schedule,2306.36,6044, Treatment of retinal lesion,67210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,2306.36,6044, Treatment of retinal lesion,67210,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,2306.36,6044, Treatment of retinal lesion,67210,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,2306.36,6044, Treatment of retinal lesion,67218,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6271.34,,,,,,,fee schedule,6044,12821, Treatment of retinal lesion,67218,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,12821, Treatment of retinal lesion,67218,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,6044,12821, Treatment of retinal lesion,67218,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,6044,12821, Treatment of choroid lesion,67220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2303.66,,,,,,,fee schedule,2303.66,4497, Treatment of choroid lesion,67220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2303.66,4497, Treatment of choroid lesion,67220,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,2303.66,4497, Treatment of choroid lesion,67220,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,2303.66,4497, Ocular Photodynamic Ther,67221,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,920.67,,,,,,,fee schedule,920.67,4497, Ocular Photodynamic Ther,67221,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,920.67,4497, Ocular Photodynamic Ther,67221,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,920.67,4497, Ocular Photodynamic Ther,67221,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,920.67,4497, Eye photodynamic ther add-on,67225,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,121.3,,,,,,,fee schedule,121.3,3195, Eye photodynamic ther add-on,67225,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,121.3,3195, Eye photodynamic ther add-on,67225,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,121.3,3195, Eye photodynamic ther add-on,67225,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,121.3,3195, Dstrj extensive retinopathy,67227,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1162.3,,,,,,,fee schedule,1162.3,12821, Dstrj extensive retinopathy,67227,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1162.3,12821, Dstrj extensive retinopathy,67227,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,1162.3,12821, Dstrj extensive retinopathy,67227,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,1162.3,12821, Treatment x10sv retinopathy,67228,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1377.92,,,,,,,fee schedule,1377.92,4497, Treatment x10sv retinopathy,67228,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1377.92,4497, Treatment x10sv retinopathy,67228,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,1377.92,4497, Treatment x10sv retinopathy,67228,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,1377.92,4497, Tr retinal les preterm inf,67229,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5254.84,,,,,,,fee schedule,4047,5254.84, Tr retinal les preterm inf,67229,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4047,5254.84, Tr retinal les preterm inf,67229,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,4047,5254.84, Tr retinal les preterm inf,67229,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,4047,5254.84, Reinforce eye wall,67250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4252.48,,,,,,,fee schedule,4252.48,10940, Reinforce eye wall,67250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4252.48,10940, Reinforce eye wall,67250,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,4252.48,10940, Reinforce eye wall,67250,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,4252.48,10940, Reinforce/graft eye wall,67255,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3206.14,,,,,,,fee schedule,3206.14,10940, Reinforce/graft eye wall,67255,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3206.14,10940, Reinforce/graft eye wall,67255,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3206.14,10940, Reinforce/graft eye wall,67255,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3206.14,10940, Eye surgery procedure,67299,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Eye surgery procedure,67299,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Eye surgery procedure,67299,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Revise eye muscle,67311,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2107.84,,,,,,,fee schedule,2107.84,10940, Revise eye muscle,67311,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2107.84,10940, Revise eye muscle,67311,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2107.84,10940, Revise eye muscle,67311,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2107.84,10940, Revise two eye muscles,67312,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3024.57,,,,,,,fee schedule,3024.57,12821, Revise two eye muscles,67312,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3024.57,12821, Revise two eye muscles,67312,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3024.57,12821, Revise two eye muscles,67312,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3024.57,12821, Revise eye muscle,67314,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2107.84,,,,,,,fee schedule,2107.84,10940, Revise eye muscle,67314,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2107.84,10940, Revise eye muscle,67314,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2107.84,10940, Revise eye muscle,67314,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2107.84,10940, Revise two eye muscles,67316,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3235.12,,,,,,,fee schedule,3235.12,10940, Revise two eye muscles,67316,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3235.12,10940, Revise two eye muscles,67316,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3235.12,10940, Revise two eye muscles,67316,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3235.12,10940, Revise eye muscle(s),67318,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3136.69,,,,,,,fee schedule,3136.69,10940, Revise eye muscle(s),67318,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3136.69,10940, Revise eye muscle(s),67318,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3136.69,10940, Revise eye muscle(s),67318,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3136.69,10940, Revise eye muscle(s) add-on,67320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,765.15,,,,,,,fee schedule,765.15,5363, Revise eye muscle(s) add-on,67320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,765.15,5363, Revise eye muscle(s) add-on,67320,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,765.15,5363, Revise eye muscle(s) add-on,67320,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,765.15,5363, Eye surgery follow-up add-on,67331,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,551.58,,,,,,,fee schedule,551.58,5363, Eye surgery follow-up add-on,67331,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,551.58,5363, Eye surgery follow-up add-on,67331,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,551.58,5363, Eye surgery follow-up add-on,67331,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,551.58,5363, Rerevise eye muscles add-on,67332,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,890.07,,,,,,,fee schedule,890.07,5363, Rerevise eye muscles add-on,67332,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,890.07,5363, Rerevise eye muscles add-on,67332,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,890.07,5363, Rerevise eye muscles add-on,67332,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,890.07,5363, Revise eye muscle w/suture,67334,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,545.16,,,,,,,fee schedule,545.16,5363, Revise eye muscle w/suture,67334,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,545.16,5363, Revise eye muscle w/suture,67334,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,545.16,5363, Revise eye muscle w/suture,67334,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,545.16,5363, Eye suture during surgery,67335,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,820.57,,,,,,,fee schedule,820.57,5363, Eye suture during surgery,67335,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,820.57,5363, Eye suture during surgery,67335,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,820.57,5363, Eye suture during surgery,67335,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,820.57,5363, Revise eye muscle add-on,67340,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1281.55,,,,,,,fee schedule,1281.55,5363, Revise eye muscle add-on,67340,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,1281.55,5363, Revise eye muscle add-on,67340,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1281.55,5363, Revise eye muscle add-on,67340,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1281.55,5363, Release eye tissue,67343,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3138.21,,,,,,,fee schedule,3138.21,10940, Release eye tissue,67343,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,3138.21,10940, Release eye tissue,67343,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3138.21,10940, Release eye tissue,67343,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3138.21,10940, Destroy nerve of eye muscle,67345,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1059.34,,,,,,,fee schedule,1059.34,3195, Destroy nerve of eye muscle,67345,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1059.34,3195, Destroy nerve of eye muscle,67345,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1059.34,3195, Destroy nerve of eye muscle,67345,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1059.34,3195, Biopsy eye muscle,67346,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,873.4,,,,,,,fee schedule,873.4,12821, Biopsy eye muscle,67346,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,873.4,12821, Biopsy eye muscle,67346,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,873.4,12821, Biopsy eye muscle,67346,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,873.4,12821, Unlisted px extraocular musc,67399,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2505,6979, Unlisted px extraocular musc,67399,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,6979, Unlisted px extraocular musc,67399,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,6979, Explore/biopsy eye socket,67400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4874.69,,,,,,,fee schedule,4874.69,12821, Explore/biopsy eye socket,67400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4874.69,12821, Explore/biopsy eye socket,67400,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4874.69,12821, Explore/biopsy eye socket,67400,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4874.69,12821, Explore/drain eye socket,67405,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4276.33,,,,,,,fee schedule,4276.33,10940, Explore/drain eye socket,67405,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4276.33,10940, Explore/drain eye socket,67405,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,4276.33,10940, Explore/drain eye socket,67405,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,4276.33,10940, Explore/treat eye socket,67412,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4669.81,,,,,,,fee schedule,4669.81,10940, Explore/treat eye socket,67412,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4669.81,10940, Explore/treat eye socket,67412,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,4669.81,10940, Explore/treat eye socket,67412,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,4669.81,10940, Explore/treat eye socket,67413,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4527.57,,,,,,,fee schedule,4527.57,10940, Explore/treat eye socket,67413,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4527.57,10940, Explore/treat eye socket,67413,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,4527.57,10940, Explore/treat eye socket,67413,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,4527.57,10940, Explr/decompress eye socket,67414,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6736.53,,,,,,,fee schedule,6044,12821, Explr/decompress eye socket,67414,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,12821, Explr/decompress eye socket,67414,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,6044,12821, Explr/decompress eye socket,67414,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,6044,12821, Aspiration orbital contents,67415,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,451.32,,,,,,,fee schedule,451.32,10940, Aspiration orbital contents,67415,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,451.32,10940, Aspiration orbital contents,67415,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,451.32,10940, Aspiration orbital contents,67415,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,451.32,10940, Explore/treat eye socket,67420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8129.88,,,,,,,fee schedule,6044,12821, Explore/treat eye socket,67420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,12821, Explore/treat eye socket,67420,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,6044,12821, Explore/treat eye socket,67420,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,6044,12821, Explore/treat eye socket,67430,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6492.79,,,,,,,fee schedule,6044,12821, Explore/treat eye socket,67430,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,12821, Explore/treat eye socket,67430,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,6044,12821, Explore/treat eye socket,67430,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,6044,12821, Explore/drain eye socket,67440,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6295.84,,,,,,,fee schedule,6044,12821, Explore/drain eye socket,67440,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,12821, Explore/drain eye socket,67440,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,6044,12821, Explore/drain eye socket,67440,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,6044,12821, Explr/decompress eye socket,67445,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7069.84,,,,,,,fee schedule,6044,12821, Explr/decompress eye socket,67445,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,12821, Explr/decompress eye socket,67445,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,6044,12821, Explr/decompress eye socket,67445,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,6044,12821, Explore/biopsy eye socket,67450,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6522.2,,,,,,,fee schedule,6044,12821, Explore/biopsy eye socket,67450,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,12821, Explore/biopsy eye socket,67450,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,6044,12821, Explore/biopsy eye socket,67450,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,6044,12821, Inject/treat eye socket,67500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,301.31,,,,,,,fee schedule,301.31,6979, Inject/treat eye socket,67500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,301.31,6979, Inject/treat eye socket,67500,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,301.31,6979, Inject/treat eye socket,67500,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,301.31,6979, Inject/treat eye socket,67505,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,316.8,,,,,,,fee schedule,316.8,3195, Inject/treat eye socket,67505,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,316.8,3195, Inject/treat eye socket,67505,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,316.8,3195, Inject/treat eye socket,67505,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,316.8,3195, Inject/treat eye socket,67515,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,209.85,,,,,,,fee schedule,209.85,3195, Inject/treat eye socket,67515,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,209.85,3195, Inject/treat eye socket,67515,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,209.85,3195, Inject/treat eye socket,67515,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,209.85,3195, Sprchoroidal spc njx rx agt,67516,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,435.46,,,,,,,fee schedule,435.46,6979, Sprchoroidal spc njx rx agt,67516,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,435.46,6979, Sprchoroidal spc njx rx agt,67516,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,435.46,6979, Sprchoroidal spc njx rx agt,67516,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,435.46,6979, Insert eye socket implant,67550,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5118.92,,,,,,,fee schedule,5118.92,12821, Insert eye socket implant,67550,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5118.92,12821, Insert eye socket implant,67550,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5118.92,12821, Insert eye socket implant,67550,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5118.92,12821, Revise eye socket implant,67560,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5231.64,,,,,,,fee schedule,4108,12821, Revise eye socket implant,67560,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,12821, Revise eye socket implant,67560,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4108,12821, Revise eye socket implant,67560,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4108,12821, Decompress optic nerve,67570,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5938.73,,,,,,,fee schedule,5363,12821, Decompress optic nerve,67570,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,12821, Decompress optic nerve,67570,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5363,12821, Decompress optic nerve,67570,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5363,12821, Orbit surgery procedure,67599,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2505,6979, Orbit surgery procedure,67599,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,6979, Orbit surgery procedure,67599,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,6979, Drainage of eyelid abscess,67700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,550.66,,,,,,,fee schedule,550.66,3195, Drainage of eyelid abscess,67700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,550.66,3195, Drainage of eyelid abscess,67700,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,550.66,3195, Drainage of eyelid abscess,67700,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,550.66,3195, Incision of eyelid,67710,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,464.11,,,,,,,fee schedule,464.11,5664, Incision of eyelid,67710,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,464.11,5664, Incision of eyelid,67710,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,464.11,5664, Incision of eyelid,67710,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,464.11,5664, Incision of eyelid fold,67715,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,554.82,,,,,,,fee schedule,554.82,10940, Incision of eyelid fold,67715,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,554.82,10940, Incision of eyelid fold,67715,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,554.82,10940, Incision of eyelid fold,67715,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,554.82,10940, Remove eyelid lesion,67800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,469.67,,,,,,,fee schedule,469.67,3195, Remove eyelid lesion,67800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,469.67,3195, Remove eyelid lesion,67800,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,469.67,3195, Remove eyelid lesion,67800,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,469.67,3195, Remove eyelid lesions,67801,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,598.15,,,,,,,fee schedule,598.15,5664, Remove eyelid lesions,67801,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,598.15,5664, Remove eyelid lesions,67801,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,598.15,5664, Remove eyelid lesions,67801,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,598.15,5664, Remove eyelid lesions,67805,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,750.31,,,,,,,fee schedule,750.31,3195, Remove eyelid lesions,67805,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,750.31,3195, Remove eyelid lesions,67805,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,750.31,3195, Remove eyelid lesions,67805,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,750.31,3195, Remove eyelid lesion(s),67808,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1719.27,,,,,,,fee schedule,1719.27,10940, Remove eyelid lesion(s),67808,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1719.27,10940, Remove eyelid lesion(s),67808,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1719.27,10940, Remove eyelid lesion(s),67808,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1719.27,10940, Biopsy eyelid & lid margin,67810,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,304.28,,,,,,,fee schedule,304.28,3195, Biopsy eyelid & lid margin,67810,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,304.28,3195, Biopsy eyelid & lid margin,67810,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,304.28,3195, Biopsy eyelid & lid margin,67810,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,304.28,3195, Revise eyelashes,67820,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,102.63,,,,,,,fee schedule,102.63,6979, Revise eyelashes,67820,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,102.63,6979, Revise eyelashes,67820,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,102.63,6979, Revise eyelashes,67820,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,102.63,6979, Revise eyelashes,67825,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,576.67,,,,,,,fee schedule,576.67,6979, Revise eyelashes,67825,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,576.67,6979, Revise eyelashes,67825,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,576.67,6979, Revise eyelashes,67825,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,576.67,6979, Revise eyelashes,67830,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,642.5,,,,,,,fee schedule,642.5,5664, Revise eyelashes,67830,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,642.5,5664, Revise eyelashes,67830,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,642.5,5664, Revise eyelashes,67830,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,642.5,5664, Revise eyelashes,67835,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2043.84,,,,,,,fee schedule,2043.84,10940, Revise eyelashes,67835,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2043.84,10940, Revise eyelashes,67835,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2043.84,10940, Revise eyelashes,67835,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2043.84,10940, Remove eyelid lesion,67840,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,725.6,,,,,,,fee schedule,725.6,5664, Remove eyelid lesion,67840,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,725.6,5664, Remove eyelid lesion,67840,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,725.6,5664, Remove eyelid lesion,67840,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,725.6,5664, Treat eyelid lesion,67850,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,608.94,,,,,,,fee schedule,608.94,5664, Treat eyelid lesion,67850,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,608.94,5664, Treat eyelid lesion,67850,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,608.94,5664, Treat eyelid lesion,67850,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,608.94,5664, Closure of eyelid by suture,67875,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,439.99,,,,,,,fee schedule,439.99,5664, Closure of eyelid by suture,67875,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,439.99,5664, Closure of eyelid by suture,67875,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,439.99,5664, Closure of eyelid by suture,67875,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,439.99,5664, Revision of eyelid,67880,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1721.97,,,,,,,fee schedule,1721.97,10940, Revision of eyelid,67880,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1721.97,10940, Revision of eyelid,67880,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1721.97,10940, Revision of eyelid,67880,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1721.97,10940, Revision of eyelid,67882,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2185.38,,,,,,,fee schedule,2185.38,10940, Revision of eyelid,67882,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2185.38,10940, Revision of eyelid,67882,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2185.38,10940, Revision of eyelid,67882,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2185.38,10940, Repair brow defect,67900,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2344.89,,,,,,,fee schedule,2344.89,10940, Repair brow defect,67900,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2344.89,10940, Repair brow defect,67900,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2344.89,10940, Repair brow defect,67900,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2344.89,10940, Repair eyelid defect,67901,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2711.22,,,,,,,fee schedule,2711.22,10940, Repair eyelid defect,67901,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,2711.22,10940, Repair eyelid defect,67901,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2711.22,10940, Repair eyelid defect,67901,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2711.22,10940, Repair eyelid defect,67902,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3326.58,,,,,,,fee schedule,3326.58,12821, Repair eyelid defect,67902,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,3326.58,12821, Repair eyelid defect,67902,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3326.58,12821, Repair eyelid defect,67902,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3326.58,12821, Repair eyelid defect,67903,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2206.91,,,,,,,fee schedule,2206.91,10940, Repair eyelid defect,67903,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2206.91,10940, Repair eyelid defect,67903,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2206.91,10940, Repair eyelid defect,67903,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2206.91,10940, Repair eyelid defect,67904,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2746.4,,,,,,,fee schedule,2746.4,10940, Repair eyelid defect,67904,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2746.4,10940, Repair eyelid defect,67904,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2746.4,10940, Repair eyelid defect,67904,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2746.4,10940, Repair eyelid defect,67906,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2311.32,,,,,,,fee schedule,2311.32,12821, Repair eyelid defect,67906,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,2311.32,12821, Repair eyelid defect,67906,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2311.32,12821, Repair eyelid defect,67906,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2311.32,12821, Repair eyelid defect,67908,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2017.35,,,,,,,fee schedule,2017.35,10940, Repair eyelid defect,67908,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2017.35,10940, Repair eyelid defect,67908,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2017.35,10940, Repair eyelid defect,67908,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2017.35,10940, Revise eyelid defect,67909,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2044.27,,,,,,,fee schedule,2044.27,10940, Revise eyelid defect,67909,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2044.27,10940, Revise eyelid defect,67909,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2044.27,10940, Revise eyelid defect,67909,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2044.27,10940, Revise eyelid defect,67911,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2579.29,,,,,,,fee schedule,2579.29,10940, Revise eyelid defect,67911,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2579.29,10940, Revise eyelid defect,67911,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2579.29,10940, Revise eyelid defect,67911,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2579.29,10940, Correction eyelid w/implant,67912,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2302.69,,,,,,,fee schedule,2302.69,10940, Correction eyelid w/implant,67912,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2302.69,10940, Correction eyelid w/implant,67912,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2302.69,10940, Correction eyelid w/implant,67912,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2302.69,10940, Repair eyelid defect,67914,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1566.73,,,,,,,fee schedule,1566.73,10940, Repair eyelid defect,67914,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1566.73,10940, Repair eyelid defect,67914,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1566.73,10940, Repair eyelid defect,67914,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1566.73,10940, Repair eyelid defect,67915,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,960.16,,,,,,,fee schedule,960.16,10940, Repair eyelid defect,67915,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,960.16,10940, Repair eyelid defect,67915,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,960.16,10940, Repair eyelid defect,67915,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,960.16,10940, Repair eyelid defect,67916,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2004.4,,,,,,,fee schedule,2004.4,10940, Repair eyelid defect,67916,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2004.4,10940, Repair eyelid defect,67916,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2004.4,10940, Repair eyelid defect,67916,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2004.4,10940, Repair eyelid defect,67917,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2115.99,,,,,,,fee schedule,2115.99,10940, Repair eyelid defect,67917,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2115.99,10940, Repair eyelid defect,67917,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2115.99,10940, Repair eyelid defect,67917,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2115.99,10940, Repair eyelid defect,67921,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1479.1,,,,,,,fee schedule,1479.1,10940, Repair eyelid defect,67921,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1479.1,10940, Repair eyelid defect,67921,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1479.1,10940, Repair eyelid defect,67921,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1479.1,10940, Repair eyelid defect,67922,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,960.16,,,,,,,fee schedule,960.16,10940, Repair eyelid defect,67922,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,960.16,10940, Repair eyelid defect,67922,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,960.16,10940, Repair eyelid defect,67922,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,960.16,10940, Repair eyelid defect,67923,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1999,,,,,,,fee schedule,1999,10940, Repair eyelid defect,67923,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,1999,10940, Repair eyelid defect,67923,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1999,10940, Repair eyelid defect,67923,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1999,10940, Repair eyelid defect,67924,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2114.96,,,,,,,fee schedule,2114.96,10940, Repair eyelid defect,67924,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2114.96,10940, Repair eyelid defect,67924,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2114.96,10940, Repair eyelid defect,67924,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2114.96,10940, Repair eyelid wound,67930,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1075.64,,,,,,,fee schedule,1075.64,10940, Repair eyelid wound,67930,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1075.64,10940, Repair eyelid wound,67930,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1075.64,10940, Repair eyelid wound,67930,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1075.64,10940, Repair eyelid wound,67935,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2005.86,,,,,,,fee schedule,2005.86,10940, Repair eyelid wound,67935,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2005.86,10940, Repair eyelid wound,67935,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2005.86,10940, Repair eyelid wound,67935,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2005.86,10940, Remove eyelid foreign body,67938,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,533.5,,,,,,,fee schedule,533.5,3195, Remove eyelid foreign body,67938,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,533.5,3195, Remove eyelid foreign body,67938,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,533.5,3195, Remove eyelid foreign body,67938,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,533.5,3195, Revision of eyelid,67950,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2145.99,,,,,,,fee schedule,2145.99,10940, Revision of eyelid,67950,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2145.99,10940, Revision of eyelid,67950,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2145.99,10940, Revision of eyelid,67950,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2145.99,10940, Revision of eyelid,67961,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2105.84,,,,,,,fee schedule,2105.84,10940, Revision of eyelid,67961,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2105.84,10940, Revision of eyelid,67961,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2105.84,10940, Revision of eyelid,67961,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2105.84,10940, Revision of eyelid,67966,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3003.25,,,,,,,fee schedule,3003.25,10940, Revision of eyelid,67966,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3003.25,10940, Revision of eyelid,67966,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3003.25,10940, Revision of eyelid,67966,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3003.25,10940, Reconstruction of eyelid,67971,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3291.4,,,,,,,fee schedule,3291.4,10940, Reconstruction of eyelid,67971,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3291.4,10940, Reconstruction of eyelid,67971,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3291.4,10940, Reconstruction of eyelid,67971,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3291.4,10940, Reconstruction of eyelid,67973,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4214.71,,,,,,,fee schedule,4214.71,10940, Reconstruction of eyelid,67973,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4214.71,10940, Reconstruction of eyelid,67973,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,4214.71,10940, Reconstruction of eyelid,67973,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,4214.71,10940, Reconstruction of eyelid,67974,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4204.89,,,,,,,fee schedule,4204.89,12821, Reconstruction of eyelid,67974,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4204.89,12821, Reconstruction of eyelid,67974,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4204.89,12821, Reconstruction of eyelid,67974,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4204.89,12821, Reconstruction of eyelid,67975,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3134.48,,,,,,,fee schedule,3134.48,10940, Reconstruction of eyelid,67975,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3134.48,10940, Reconstruction of eyelid,67975,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3134.48,10940, Reconstruction of eyelid,67975,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3134.48,10940, Revision of eyelid,67999,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2505,6979, Revision of eyelid,67999,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,6979, Revision of eyelid,67999,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,6979, Incise/drain eyelid lining,68020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,509.17,,,,,,,fee schedule,509.17,5664, Incise/drain eyelid lining,68020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,509.17,5664, Incise/drain eyelid lining,68020,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,509.17,5664, Incise/drain eyelid lining,68020,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,509.17,5664, Treatment of eyelid lesions,68040,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,215.57,,,,,,,fee schedule,215.57,6979, Treatment of eyelid lesions,68040,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,215.57,6979, Treatment of eyelid lesions,68040,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,215.57,6979, Treatment of eyelid lesions,68040,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,215.57,6979, Biopsy of eyelid lining,68100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,439.99,,,,,,,fee schedule,439.99,4497, Biopsy of eyelid lining,68100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,439.99,4497, Biopsy of eyelid lining,68100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,439.99,4497, Biopsy of eyelid lining,68100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,439.99,4497, Remove eyelid lining lesion,68110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,692.9,,,,,,,fee schedule,692.9,10940, Remove eyelid lining lesion,68110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,692.9,10940, Remove eyelid lining lesion,68110,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,692.9,10940, Remove eyelid lining lesion,68110,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,692.9,10940, Remove eyelid lining lesion,68115,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,847.17,,,,,,,fee schedule,847.17,10940, Remove eyelid lining lesion,68115,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,847.17,10940, Remove eyelid lining lesion,68115,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,847.17,10940, Remove eyelid lining lesion,68115,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,847.17,10940, Remove eyelid lining lesion,68130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1924.21,,,,,,,fee schedule,1924.21,10940, Remove eyelid lining lesion,68130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1924.21,10940, Remove eyelid lining lesion,68130,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1924.21,10940, Remove eyelid lining lesion,68130,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1924.21,10940, Remove eyelid lining lesion,68135,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,699.65,,,,,,,fee schedule,699.65,10940, Remove eyelid lining lesion,68135,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,699.65,10940, Remove eyelid lining lesion,68135,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,699.65,10940, Remove eyelid lining lesion,68135,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,699.65,10940, Treat eyelid by injection,68200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,157.67,,,,,,,fee schedule,157.67,6979, Treat eyelid by injection,68200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,157.67,6979, Treat eyelid by injection,68200,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,157.67,6979, Treat eyelid by injection,68200,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,157.67,6979, Revise/graft eyelid lining,68320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2517.23,,,,,,,fee schedule,2517.23,10940, Revise/graft eyelid lining,68320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2517.23,10940, Revise/graft eyelid lining,68320,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2517.23,10940, Revise/graft eyelid lining,68320,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2517.23,10940, Revise/graft eyelid lining,68325,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3022.95,,,,,,,fee schedule,3022.95,12821, Revise/graft eyelid lining,68325,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3022.95,12821, Revise/graft eyelid lining,68325,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3022.95,12821, Revise/graft eyelid lining,68325,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3022.95,12821, Revise/graft eyelid lining,68326,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2979.29,,,,,,,fee schedule,2979.29,12821, Revise/graft eyelid lining,68326,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2979.29,12821, Revise/graft eyelid lining,68326,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2979.29,12821, Revise/graft eyelid lining,68326,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2979.29,12821, Revise/graft eyelid lining,68328,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3234.36,,,,,,,fee schedule,3234.36,10940, Revise/graft eyelid lining,68328,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3234.36,10940, Revise/graft eyelid lining,68328,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3234.36,10940, Revise/graft eyelid lining,68328,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3234.36,10940, Revise eyelid lining,68330,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2138.49,,,,,,,fee schedule,2138.49,10940, Revise eyelid lining,68330,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2138.49,10940, Revise eyelid lining,68330,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2138.49,10940, Revise eyelid lining,68330,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2138.49,10940, Revise/graft eyelid lining,68335,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2986.52,,,,,,,fee schedule,2986.52,12821, Revise/graft eyelid lining,68335,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2986.52,12821, Revise/graft eyelid lining,68335,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2986.52,12821, Revise/graft eyelid lining,68335,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2986.52,12821, Separate eyelid adhesions,68340,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1941.97,,,,,,,fee schedule,1941.97,10940, Separate eyelid adhesions,68340,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,1941.97,10940, Separate eyelid adhesions,68340,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1941.97,10940, Separate eyelid adhesions,68340,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1941.97,10940, Revise eyelid lining,68360,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1910.94,,,,,,,fee schedule,1910.94,12821, Revise eyelid lining,68360,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1910.94,12821, Revise eyelid lining,68360,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,1910.94,12821, Revise eyelid lining,68360,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,1910.94,12821, Revise eyelid lining,68362,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3017.66,,,,,,,fee schedule,3017.66,10940, Revise eyelid lining,68362,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,3017.66,10940, Revise eyelid lining,68362,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3017.66,10940, Revise eyelid lining,68362,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3017.66,10940, Harvest eye tissue alograft,68371,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1929.29,,,,,,,fee schedule,1929.29,10940, Harvest eye tissue alograft,68371,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1929.29,10940, Harvest eye tissue alograft,68371,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1929.29,10940, Harvest eye tissue alograft,68371,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1929.29,10940, Eyelid lining surgery,68399,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2505,6979, Eyelid lining surgery,68399,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,6979, Eyelid lining surgery,68399,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,6979, Incise/drain tear gland,68400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,609.64,,,,,,,fee schedule,609.64,5664, Incise/drain tear gland,68400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,609.64,5664, Incise/drain tear gland,68400,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,609.64,5664, Incise/drain tear gland,68400,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,609.64,5664, Incise/drain tear sac,68420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,762.99,,,,,,,fee schedule,762.99,4497, Incise/drain tear sac,68420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,762.99,4497, Incise/drain tear sac,68420,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,762.99,4497, Incise/drain tear sac,68420,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,762.99,4497, Incise tear duct opening,68440,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,483.27,,,,,,,fee schedule,483.27,3195, Incise tear duct opening,68440,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,483.27,3195, Incise tear duct opening,68440,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,483.27,3195, Incise tear duct opening,68440,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,483.27,3195, Removal of tear gland,68500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4950.34,,,,,,,fee schedule,4950.34,12821, Removal of tear gland,68500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4950.34,12821, Removal of tear gland,68500,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4950.34,12821, Removal of tear gland,68500,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4950.34,12821, Partial removal tear gland,68505,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4929.79,,,,,,,fee schedule,4929.79,12821, Partial removal tear gland,68505,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4929.79,12821, Partial removal tear gland,68505,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4929.79,12821, Partial removal tear gland,68505,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4929.79,12821, Biopsy of tear gland,68510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1282.36,,,,,,,fee schedule,1282.36,10940, Biopsy of tear gland,68510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1282.36,10940, Biopsy of tear gland,68510,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1282.36,10940, Biopsy of tear gland,68510,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1282.36,10940, Removal of tear sac,68520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3458.13,,,,,,,fee schedule,3458.13,12821, Removal of tear sac,68520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3458.13,12821, Removal of tear sac,68520,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3458.13,12821, Removal of tear sac,68520,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3458.13,12821, Biopsy of tear sac,68525,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1134.51,,,,,,,fee schedule,1134.51,10940, Biopsy of tear sac,68525,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1134.51,10940, Biopsy of tear sac,68525,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1134.51,10940, Biopsy of tear sac,68525,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1134.51,10940, Clearance of tear duct,68530,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1153.77,,,,,,,fee schedule,1153.77,3195, Clearance of tear duct,68530,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1153.77,3195, Clearance of tear duct,68530,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1153.77,3195, Clearance of tear duct,68530,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1153.77,3195, Remove tear gland lesion,68540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4559.13,,,,,,,fee schedule,4559.13,10940, Remove tear gland lesion,68540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4559.13,10940, Remove tear gland lesion,68540,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,4559.13,10940, Remove tear gland lesion,68540,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,4559.13,10940, Remove tear gland lesion,68550,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5668.88,,,,,,,fee schedule,5248,12821, Remove tear gland lesion,68550,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,12821, Remove tear gland lesion,68550,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5248,12821, Remove tear gland lesion,68550,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5248,12821, Repair tear ducts,68700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2785.74,,,,,,,fee schedule,2785.74,10940, Repair tear ducts,68700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2785.74,10940, Repair tear ducts,68700,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2785.74,10940, Repair tear ducts,68700,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2785.74,10940, Revise tear duct opening,68705,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,772.28,,,,,,,fee schedule,772.28,3195, Revise tear duct opening,68705,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,772.28,3195, Revise tear duct opening,68705,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,772.28,3195, Revise tear duct opening,68705,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,772.28,3195, Create tear sac drain,68720,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3783.08,,,,,,,fee schedule,3783.08,12821, Create tear sac drain,68720,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3783.08,12821, Create tear sac drain,68720,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3783.08,12821, Create tear sac drain,68720,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3783.08,12821, Create tear duct drain,68745,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3795.87,,,,,,,fee schedule,3795.87,12821, Create tear duct drain,68745,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3795.87,12821, Create tear duct drain,68745,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,3795.87,12821, Create tear duct drain,68745,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,3795.87,12821, Create tear duct drain,68750,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4021.96,,,,,,,fee schedule,4021.96,12821, Create tear duct drain,68750,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,4021.96,12821, Create tear duct drain,68750,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4021.96,12821, Create tear duct drain,68750,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4021.96,12821, Close tear duct opening,68760,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,685.78,,,,,,,fee schedule,685.78,3195, Close tear duct opening,68760,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,685.78,3195, Close tear duct opening,68760,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,685.78,3195, Close tear duct opening,68760,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,685.78,3195, Close tear duct opening,68761,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,551.9,,,,,,,fee schedule,551.9,3195, Close tear duct opening,68761,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,551.9,3195, Close tear duct opening,68761,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,551.9,3195, Close tear duct opening,68761,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,551.9,3195, Close tear system fistula,68770,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2889.18,,,,,,,fee schedule,2889.18,5363, Close tear system fistula,68770,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,2889.18,5363, Close tear system fistula,68770,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,2889.18,5363, Close tear system fistula,68770,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,2889.18,5363, Description Not Available,68800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Dilate tear duct opening,68801,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,381.71,,,,,,,fee schedule,381.71,6979, Dilate tear duct opening,68801,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,381.71,6979, Dilate tear duct opening,68801,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,381.71,6979, Dilate tear duct opening,68801,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,381.71,6979, Probe nasolacrimal duct,68810,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,602.68,,,,,,,fee schedule,602.68,3195, Probe nasolacrimal duct,68810,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,602.68,3195, Probe nasolacrimal duct,68810,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,602.68,3195, Probe nasolacrimal duct,68810,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,602.68,3195, Probe nasolacrimal duct,68811,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,634.79,,,,,,,fee schedule,634.79,10940, Probe nasolacrimal duct,68811,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,634.79,10940, Probe nasolacrimal duct,68811,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,634.79,10940, Probe nasolacrimal duct,68811,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,634.79,10940, Probe nasolacrimal duct,68815,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1037.43,,,,,,,fee schedule,1037.43,10940, Probe nasolacrimal duct,68815,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1037.43,10940, Probe nasolacrimal duct,68815,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1037.43,10940, Probe nasolacrimal duct,68815,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1037.43,10940, Probe nl duct w/balloon,68816,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,722.96,,,,,,,fee schedule,722.96,10940, Probe nl duct w/balloon,68816,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,722.96,10940, Probe nl duct w/balloon,68816,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,722.96,10940, Probe nl duct w/balloon,68816,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,722.96,10940, Description Not Available,68820,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Description Not Available,68825,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Description Not Available,68830,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Explore/irrigate tear ducts,68840,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,558.27,,,,,,,fee schedule,558.27,3195, Explore/irrigate tear ducts,68840,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,558.27,3195, Explore/irrigate tear ducts,68840,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,558.27,3195, Explore/irrigate tear ducts,68840,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,558.27,3195, Insj rx elut implt lac canal,68841,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,149.04,,,,,,,fee schedule,149.04,10940, Insj rx elut implt lac canal,68841,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,149.04,10940, Insj rx elut implt lac canal,68841,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,149.04,10940, Insj rx elut implt lac canal,68841,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,149.04,10940, Injection for tear sac x-ray,68850,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,249.13,,,,,,,fee schedule,249.13,3195, Injection for tear sac x-ray,68850,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,249.13,3195, Injection for tear sac x-ray,68850,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,249.13,3195, Injection for tear sac x-ray,68850,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,249.13,3195, Tear duct system surgery,68899,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2505,6979, Tear duct system surgery,68899,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,6979, Tear duct system surgery,68899,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,6979, Drain external ear lesion,69000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,640.78,,,,,,,fee schedule,640.78,4497, Drain external ear lesion,69000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,640.78,4497, Drain external ear lesion,69000,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,640.78,4497, Drain external ear lesion,69000,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,640.78,4497, Drain external ear lesion,69005,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,803.95,,,,,,,fee schedule,803.95,5664, Drain external ear lesion,69005,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,803.95,5664, Drain external ear lesion,69005,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,803.95,5664, Drain external ear lesion,69005,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,803.95,5664, Drain outer ear canal lesion,69020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,718.26,,,,,,,fee schedule,718.26,4497, Drain outer ear canal lesion,69020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,718.26,4497, Drain outer ear canal lesion,69020,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,718.26,4497, Drain outer ear canal lesion,69020,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,718.26,4497, Pierce earlobes,69090,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Pierce earlobes,69090,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Pierce earlobes,69090,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Biopsy of external ear,69100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,206.13,,,,,,,fee schedule,206.13,6979, Biopsy of external ear,69100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,206.13,6979, Biopsy of external ear,69100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,206.13,6979, Biopsy of external ear,69100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,206.13,6979, Biopsy of external ear canal,69105,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,313.78,,,,,,,fee schedule,313.78,6979, Biopsy of external ear canal,69105,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,313.78,6979, Biopsy of external ear canal,69105,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,313.78,6979, Biopsy of external ear canal,69105,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,313.78,6979, Remove external ear partial,69110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1627.27,,,,,,,fee schedule,1627.27,5664, Remove external ear partial,69110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1627.27,5664, Remove external ear partial,69110,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1627.27,5664, Remove external ear partial,69110,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1627.27,5664, Removal of external ear,69120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1949.09,,,,,,,fee schedule,1949.09,10940, Removal of external ear,69120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1949.09,10940, Removal of external ear,69120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1949.09,10940, Removal of external ear,69120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1949.09,10940, Remove ear canal lesion(s),69140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4524.49,,,,,,,fee schedule,4108,10940, Remove ear canal lesion(s),69140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,10940, Remove ear canal lesion(s),69140,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,4108,10940, Remove ear canal lesion(s),69140,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,4108,10940, Remove ear canal lesion(s),69145,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1282.63,,,,,,,fee schedule,1282.63,5664, Remove ear canal lesion(s),69145,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1282.63,5664, Remove ear canal lesion(s),69145,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,1282.63,5664, Remove ear canal lesion(s),69145,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,1282.63,5664, Extensive ear canal surgery,69150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4951.86,,,,,,,fee schedule,4951.86,10940, Extensive ear canal surgery,69150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4951.86,10940, Extensive ear canal surgery,69150,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,4951.86,10940, Extensive ear canal surgery,69150,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,4951.86,10940, Extensive ear/neck surgery,69155,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7891,,,,,,,fee schedule,5097,7891, Extensive ear/neck surgery,69155,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,7891, Extensive ear/neck surgery,69155,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,7891, Extensive ear/neck surgery,69155,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,7891, Clear outer ear canal,69200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,232.19,,,,,,,fee schedule,232.19,6979, Clear outer ear canal,69200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,232.19,6979, Clear outer ear canal,69200,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,232.19,6979, Clear outer ear canal,69200,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,232.19,6979, Clear outer ear canal,69205,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,477.55,,,,,,,fee schedule,477.55,5664, Clear outer ear canal,69205,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,477.55,5664, Clear outer ear canal,69205,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,477.55,5664, Clear outer ear canal,69205,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,477.55,5664, Remove impacted ear wax uni,69209,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,88.87,,,,,,,fee schedule,88.87,3195, Remove impacted ear wax uni,69209,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,88.87,3195, Remove impacted ear wax uni,69209,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,88.87,3195, Remove impacted ear wax uni,69209,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,88.87,3195, Remove impacted ear wax uni,69210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,151.14,,,,,,,fee schedule,151.14,3195, Remove impacted ear wax uni,69210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,151.14,3195, Remove impacted ear wax uni,69210,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,151.14,3195, Remove impacted ear wax uni,69210,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,151.14,3195, Clean out mastoid cavity,69220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,247.41,,,,,,,fee schedule,247.41,6979, Clean out mastoid cavity,69220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,247.41,6979, Clean out mastoid cavity,69220,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,247.41,6979, Clean out mastoid cavity,69220,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,247.41,6979, Clean out mastoid cavity,69222,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,681.46,,,,,,,fee schedule,681.46,4108, Clean out mastoid cavity,69222,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,681.46,4108, Clean out mastoid cavity,69222,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,681.46,4108, Clean out mastoid cavity,69222,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,681.46,4108, Revise external ear,69300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2346.5,,,,,,,fee schedule,2346.5,10940, Revise external ear,69300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,2346.5,10940, Revise external ear,69300,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2346.5,10940, Revise external ear,69300,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2346.5,10940, Rebuild outer ear canal,69310,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5595.49,,,,,,,fee schedule,5248,14456, Rebuild outer ear canal,69310,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,14456, Rebuild outer ear canal,69310,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5248,14456, Rebuild outer ear canal,69310,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5248,14456, Rebuild outer ear canal,69320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7732.36,,,,,,,fee schedule,7732.36,14456, Rebuild outer ear canal,69320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,7732.36,14456, Rebuild outer ear canal,69320,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,7732.36,14456, Rebuild outer ear canal,69320,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,7732.36,14456, Outer ear surgery procedure,69399,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2505,6979, Outer ear surgery procedure,69399,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,6979, Outer ear surgery procedure,69399,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,6979, Incision of eardrum,69420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,600.74,,,,,,,fee schedule,600.74,5248, Incision of eardrum,69420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,600.74,5248, Incision of eardrum,69420,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,600.74,5248, Incision of eardrum,69420,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,600.74,5248, Incision of eardrum,69421,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,750.04,,,,,,,fee schedule,750.04,5664, Incision of eardrum,69421,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,750.04,5664, Incision of eardrum,69421,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,750.04,5664, Incision of eardrum,69421,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,750.04,5664, Remove ventilating tube,69424,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,301.47,,,,,,,fee schedule,301.47,12821, Remove ventilating tube,69424,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,301.47,12821, Remove ventilating tube,69424,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,301.47,12821, Remove ventilating tube,69424,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,301.47,12821, Create eardrum opening,69433,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,649.68,,,,,,,fee schedule,649.68,5248, Create eardrum opening,69433,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,649.68,5248, Create eardrum opening,69433,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,649.68,5248, Create eardrum opening,69433,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,649.68,5248, Create eardrum opening,69436,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,789.22,,,,,,,fee schedule,789.22,5664, Create eardrum opening,69436,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,789.22,5664, Create eardrum opening,69436,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,789.22,5664, Create eardrum opening,69436,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,789.22,5664, Exploration of middle ear,69440,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3389.39,,,,,,,fee schedule,3389.39,10940, Exploration of middle ear,69440,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3389.39,10940, Exploration of middle ear,69440,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3389.39,10940, Exploration of middle ear,69440,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3389.39,10940, Eardrum revision,69450,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2687.69,,,,,,,fee schedule,2687.69,14456, Eardrum revision,69450,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2687.69,14456, Eardrum revision,69450,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,2687.69,14456, Eardrum revision,69450,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,2687.69,14456, Mastoidectomy,69501,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3479.23,,,,,,,fee schedule,3479.23,14456, Mastoidectomy,69501,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,3479.23,14456, Mastoidectomy,69501,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3479.23,14456, Mastoidectomy,69501,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3479.23,14456, Mastoidectomy,69502,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4609.69,,,,,,,fee schedule,4609.69,10940, Mastoidectomy,69502,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,4609.69,10940, Mastoidectomy,69502,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,4609.69,10940, Mastoidectomy,69502,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,4609.69,10940, Remove mastoid structures,69505,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6106.49,,,,,,,fee schedule,6106.49,14456, Remove mastoid structures,69505,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,6106.49,14456, Remove mastoid structures,69505,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,6106.49,14456, Remove mastoid structures,69505,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,6106.49,14456, Extensive mastoid surgery,69511,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6244.31,,,,,,,fee schedule,6244.31,14456, Extensive mastoid surgery,69511,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,6244.31,14456, Extensive mastoid surgery,69511,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,6244.31,14456, Extensive mastoid surgery,69511,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,6244.31,14456, Extensive mastoid surgery,69530,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8310.76,,,,,,,fee schedule,8310.76,14456, Extensive mastoid surgery,69530,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,8310.76,14456, Extensive mastoid surgery,69530,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,8310.76,14456, Extensive mastoid surgery,69530,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,8310.76,14456, Remove part of temporal bone,69535,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,13006.52,,,,,,,fee schedule,5097,13006.52, Remove part of temporal bone,69535,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,13006.52, Remove part of temporal bone,69535,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,13006.52, Remove part of temporal bone,69535,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,13006.52, Remove ear lesion,69540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,647.68,,,,,,,fee schedule,647.68,5664, Remove ear lesion,69540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,647.68,5664, Remove ear lesion,69540,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,647.68,5664, Remove ear lesion,69540,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,647.68,5664, Remove ear lesion,69550,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5292.13,,,,,,,fee schedule,5292.13,14456, Remove ear lesion,69550,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,5292.13,14456, Remove ear lesion,69550,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5292.13,14456, Remove ear lesion,69550,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5292.13,14456, Remove ear lesion,69552,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7802.18,,,,,,,fee schedule,7802.18,14456, Remove ear lesion,69552,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,7802.18,14456, Remove ear lesion,69552,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,7802.18,14456, Remove ear lesion,69552,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,7802.18,14456, Remove ear lesion,69554,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12312.27,,,,,,,fee schedule,5097,12312.27, Remove ear lesion,69554,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,12312.27, Remove ear lesion,69554,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,12312.27, Remove ear lesion,69554,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,12312.27, Mastoid surgery revision,69601,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4961.62,,,,,,,fee schedule,4961.62,14456, Mastoid surgery revision,69601,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,4961.62,14456, Mastoid surgery revision,69601,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4961.62,14456, Mastoid surgery revision,69601,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4961.62,14456, Mastoid surgery revision,69602,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5284.3,,,,,,,fee schedule,5284.3,14456, Mastoid surgery revision,69602,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,5284.3,14456, Mastoid surgery revision,69602,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5284.3,14456, Mastoid surgery revision,69602,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5284.3,14456, Mastoid surgery revision,69603,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6372.24,,,,,,,fee schedule,6372.24,14456, Mastoid surgery revision,69603,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,6372.24,14456, Mastoid surgery revision,69603,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,6372.24,14456, Mastoid surgery revision,69603,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,6372.24,14456, Mastoid surgery revision,69604,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5397.03,,,,,,,fee schedule,5397.03,14456, Mastoid surgery revision,69604,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,5397.03,14456, Mastoid surgery revision,69604,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5397.03,14456, Mastoid surgery revision,69604,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5397.03,14456, Repair of eardrum,69610,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1382.78,,,,,,,fee schedule,1382.78,10940, Repair of eardrum,69610,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,1382.78,10940, Repair of eardrum,69610,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,1382.78,10940, Repair of eardrum,69610,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,1382.78,10940, Repair of eardrum,69620,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2463.65,,,,,,,fee schedule,2463.65,10940, Repair of eardrum,69620,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2463.65,10940, Repair of eardrum,69620,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,2463.65,10940, Repair of eardrum,69620,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,2463.65,10940, Repair eardrum structures,69631,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4342.86,,,,,,,fee schedule,4342.86,14456, Repair eardrum structures,69631,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4342.86,14456, Repair eardrum structures,69631,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4342.86,14456, Repair eardrum structures,69631,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4342.86,14456, Rebuild eardrum structures,69632,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5288.73,,,,,,,fee schedule,5288.73,14456, Rebuild eardrum structures,69632,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,5288.73,14456, Rebuild eardrum structures,69632,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5288.73,14456, Rebuild eardrum structures,69632,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5288.73,14456, Rebuild eardrum structures,69633,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5144.33,,,,,,,fee schedule,5144.33,14456, Rebuild eardrum structures,69633,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,5144.33,14456, Rebuild eardrum structures,69633,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5144.33,14456, Rebuild eardrum structures,69633,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5144.33,14456, Repair eardrum structures,69635,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6400.84,,,,,,,fee schedule,6400.84,14456, Repair eardrum structures,69635,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,6400.84,14456, Repair eardrum structures,69635,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,6400.84,14456, Repair eardrum structures,69635,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,6400.84,14456, Rebuild eardrum structures,69636,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6985.99,,,,,,,fee schedule,6985.99,14456, Rebuild eardrum structures,69636,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,6985.99,14456, Rebuild eardrum structures,69636,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,6985.99,14456, Rebuild eardrum structures,69636,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,6985.99,14456, Rebuild eardrum structures,69637,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6960.08,,,,,,,fee schedule,6960.08,14456, Rebuild eardrum structures,69637,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,6960.08,14456, Rebuild eardrum structures,69637,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,6960.08,14456, Rebuild eardrum structures,69637,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,6960.08,14456, Revise middle ear & mastoid,69641,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5070.3,,,,,,,fee schedule,5070.3,14456, Revise middle ear & mastoid,69641,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,5070.3,14456, Revise middle ear & mastoid,69641,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5070.3,14456, Revise middle ear & mastoid,69641,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5070.3,14456, Revise middle ear & mastoid,69642,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6482.97,,,,,,,fee schedule,6482.97,14456, Revise middle ear & mastoid,69642,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,6482.97,14456, Revise middle ear & mastoid,69642,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,6482.97,14456, Revise middle ear & mastoid,69642,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,6482.97,14456, Revise middle ear & mastoid,69643,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5954.43,,,,,,,fee schedule,5954.43,14456, Revise middle ear & mastoid,69643,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,5954.43,14456, Revise middle ear & mastoid,69643,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5954.43,14456, Revise middle ear & mastoid,69643,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5954.43,14456, Revise middle ear & mastoid,69644,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7450.42,,,,,,,fee schedule,7450.42,14456, Revise middle ear & mastoid,69644,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,7450.42,14456, Revise middle ear & mastoid,69644,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,7450.42,14456, Revise middle ear & mastoid,69644,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,7450.42,14456, Revise middle ear & mastoid,69645,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7335.59,,,,,,,fee schedule,7335.59,14456, Revise middle ear & mastoid,69645,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,7335.59,14456, Revise middle ear & mastoid,69645,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,7335.59,14456, Revise middle ear & mastoid,69645,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,7335.59,14456, Revise middle ear & mastoid,69646,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7794.25,,,,,,,fee schedule,7794.25,14456, Revise middle ear & mastoid,69646,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,7794.25,14456, Revise middle ear & mastoid,69646,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,7794.25,14456, Revise middle ear & mastoid,69646,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,7794.25,14456, Release middle ear bone,69650,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3913.88,,,,,,,fee schedule,3913.88,10940, Release middle ear bone,69650,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,3913.88,10940, Release middle ear bone,69650,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3913.88,10940, Release middle ear bone,69650,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3913.88,10940, Revise middle ear bone,69660,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4487.42,,,,,,,fee schedule,4487.42,14456, Revise middle ear bone,69660,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,4487.42,14456, Revise middle ear bone,69660,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4487.42,14456, Revise middle ear bone,69660,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4487.42,14456, Revise middle ear bone,69661,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5837.12,,,,,,,fee schedule,5837.12,14456, Revise middle ear bone,69661,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,5837.12,14456, Revise middle ear bone,69661,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5837.12,14456, Revise middle ear bone,69661,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5837.12,14456, Revise middle ear bone,69662,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5613.14,,,,,,,fee schedule,5613.14,14456, Revise middle ear bone,69662,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,5613.14,14456, Revise middle ear bone,69662,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5613.14,14456, Revise middle ear bone,69662,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5613.14,14456, Repair middle ear structures,69666,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3934.44,,,,,,,fee schedule,3934.44,10940, Repair middle ear structures,69666,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3934.44,10940, Repair middle ear structures,69666,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3934.44,10940, Repair middle ear structures,69666,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3934.44,10940, Repair middle ear structures,69667,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3952.25,,,,,,,fee schedule,3952.25,10940, Repair middle ear structures,69667,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,3952.25,10940, Repair middle ear structures,69667,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3952.25,10940, Repair middle ear structures,69667,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3952.25,10940, Remove mastoid air cells,69670,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4588.76,,,,,,,fee schedule,4588.76,14456, Remove mastoid air cells,69670,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4588.76,14456, Remove mastoid air cells,69670,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4588.76,14456, Remove mastoid air cells,69670,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4588.76,14456, Remove middle ear nerve,69676,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4061.68,,,,,,,fee schedule,4061.68,10940, Remove middle ear nerve,69676,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,4061.68,10940, Remove middle ear nerve,69676,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,4061.68,10940, Remove middle ear nerve,69676,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,4061.68,10940, Close mastoid fistula,69700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3269.92,,,,,,,fee schedule,3269.92,5664, Close mastoid fistula,69700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,3269.92,5664, Close mastoid fistula,69700,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3269.92,5664, Close mastoid fistula,69700,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3269.92,5664, Nps surg dilat eust tube uni,69705,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,830.66,,,,,,,fee schedule,830.66,14456, Nps surg dilat eust tube uni,69705,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,830.66,14456, Nps surg dilat eust tube uni,69705,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,830.66,14456, Nps surg dilat eust tube uni,69705,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,830.66,14456, Nps surg dilat eust tube bi,69706,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1151.78,,,,,,,fee schedule,1151.78,14456, Nps surg dilat eust tube bi,69706,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,1151.78,14456, Nps surg dilat eust tube bi,69706,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,1151.78,14456, Nps surg dilat eust tube bi,69706,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,1151.78,14456, Implant/replace hearing aid,69710,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,14456, Implant/replace hearing aid,69710,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5248,14456, Implant/replace hearing aid,69710,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5248,14456, Remove/repair hearing aid,69711,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4098.1,,,,,,,fee schedule,3195,14456, Remove/repair hearing aid,69711,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,14456, Remove/repair hearing aid,69711,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3195,14456, Remove/repair hearing aid,69711,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3195,14456, Implant Temple Bone W/Stimul,69714,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2403.43,,,,,,,fee schedule,2403.43,25393, Implant Temple Bone W/Stimul,69714,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10675,,,,,,,fee schedule,2403.43,25393, Implant Temple Bone W/Stimul,69714,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,2403.43,25393, Implant Temple Bone W/Stimul,69714,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,2403.43,25393, Impltj oi implt skl tc esp,69716,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3007.46,,,,,,,fee schedule,3007.46,22111, Impltj oi implt skl tc esp,69716,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10675,,,,,,,fee schedule,3007.46,22111, Impltj oi implt skl tc esp,69716,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3007.46,22111, Impltj oi implt skl tc esp,69716,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3007.46,22111, Temple Bone Implant Revision,69717,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2713.97,,,,,,,fee schedule,2713.97,14456, Temple Bone Implant Revision,69717,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10675,,,,,,,fee schedule,2713.97,14456, Temple Bone Implant Revision,69717,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,2713.97,14456, Temple Bone Implant Revision,69717,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,2713.97,14456, Revj/rplcmt oi implt tc esp,69719,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3104.05,,,,,,,fee schedule,3104.05,22111, Revj/rplcmt oi implt tc esp,69719,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10675,,,,,,,fee schedule,3104.05,22111, Revj/rplcmt oi implt tc esp,69719,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3104.05,22111, Revj/rplcmt oi implt tc esp,69719,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3104.05,22111, Release facial nerve,69720,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5805.61,,,,,,,fee schedule,5805.61,14456, Release facial nerve,69720,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,5805.61,14456, Release facial nerve,69720,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5805.61,14456, Release facial nerve,69720,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5805.61,14456, Release facial nerve,69725,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8988.76,,,,,,,fee schedule,6044,14456, Release facial nerve,69725,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,14456, Release facial nerve,69725,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,6044,14456, Release facial nerve,69725,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,6044,14456, Rmvl oi implt skl perq esp,69726,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2318.5,,,,,,,fee schedule,2318.5,12821, Rmvl oi implt skl perq esp,69726,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2318.5,12821, Rmvl oi implt skl perq esp,69726,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2318.5,12821, Rmvl oi implt skl perq esp,69726,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2318.5,12821, Rmvl oi implt skl tc esp,69727,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2582.42,,,,,,,fee schedule,2582.42,12821, Rmvl oi implt skl tc esp,69727,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2582.42,12821, Rmvl oi implt skl tc esp,69727,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2582.42,12821, Rmvl oi implt skl tc esp,69727,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2582.42,12821, Rmv ntr oi imp sktc esp>=100,69728,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2866.03,,,,,,,fee schedule,2866.03,12821, Rmv ntr oi imp sktc esp>=100,69728,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2866.03,12821, Rmv ntr oi imp sktc esp>=100,69728,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2866.03,12821, Rmv ntr oi imp sktc esp>=100,69728,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2866.03,12821, Impl oi implt sk tc esp>=100,69729,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3257.94,,,,,,,fee schedule,3257.94,22111, Impl oi implt sk tc esp>=100,69729,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10675,,,,,,,fee schedule,3257.94,22111, Impl oi implt sk tc esp>=100,69729,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3257.94,22111, Impl oi implt sk tc esp>=100,69729,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3257.94,22111, Rplc oi implt sk tc esp>=100,69730,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3308.07,,,,,,,fee schedule,3308.07,22111, Rplc oi implt sk tc esp>=100,69730,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10675,,,,,,,fee schedule,3308.07,22111, Rplc oi implt sk tc esp>=100,69730,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3308.07,22111, Rplc oi implt sk tc esp>=100,69730,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3308.07,22111, Repair facial nerve,69740,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5611.41,,,,,,,fee schedule,5611.41,14456, Repair facial nerve,69740,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,5611.41,14456, Repair facial nerve,69740,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5611.41,14456, Repair facial nerve,69740,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5611.41,14456, Repair facial nerve,69745,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5980.28,,,,,,,fee schedule,5980.28,14456, Repair facial nerve,69745,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,5980.28,14456, Repair facial nerve,69745,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5980.28,14456, Repair facial nerve,69745,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5980.28,14456, Middle ear surgery procedure,69799,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Middle ear surgery procedure,69799,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Middle ear surgery procedure,69799,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Incise inner ear,69801,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,599.33,,,,,,,fee schedule,599.33,6044, Incise inner ear,69801,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,599.33,6044, Incise inner ear,69801,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,599.33,6044, Incise inner ear,69801,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,599.33,6044, Explore inner ear,69805,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4997.72,,,,,,,fee schedule,4997.72,14456, Explore inner ear,69805,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,4997.72,14456, Explore inner ear,69805,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4997.72,14456, Explore inner ear,69805,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4997.72,14456, Explore inner ear,69806,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4480.68,,,,,,,fee schedule,4480.68,14456, Explore inner ear,69806,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,4480.68,14456, Explore inner ear,69806,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4480.68,14456, Explore inner ear,69806,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4480.68,14456, Remove inner ear,69905,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4468.91,,,,,,,fee schedule,4468.91,14456, Remove inner ear,69905,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,4468.91,14456, Remove inner ear,69905,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4468.91,14456, Remove inner ear,69905,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4468.91,14456, Remove inner ear & mastoid,69910,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4811.83,,,,,,,fee schedule,4811.83,14456, Remove inner ear & mastoid,69910,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,4811.83,14456, Remove inner ear & mastoid,69910,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4811.83,14456, Remove inner ear & mastoid,69910,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4811.83,14456, Incise inner ear nerve,69915,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7245.26,,,,,,,fee schedule,7245.26,14456, Incise inner ear nerve,69915,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,7245.26,14456, Incise inner ear nerve,69915,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,7245.26,14456, Incise inner ear nerve,69915,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,7245.26,14456, Implant cochlear device,69930,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5854.66,,,,,,,fee schedule,5854.66,97285, Implant cochlear device,69930,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,5854.66,97285, Implant cochlear device,69930,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,97285,,,,,,,fee schedule,5854.66,97285, Implant cochlear device,69930,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,87557,,,,,,,fee schedule,5854.66,97285, Inner ear surgery procedure,69949,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Inner ear surgery procedure,69949,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Inner ear surgery procedure,69949,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Incise inner ear nerve,69950,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8395.96,,,,,,,fee schedule,5097,8395.96, Incise inner ear nerve,69950,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,8395.96, Incise inner ear nerve,69950,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8395.96, Incise inner ear nerve,69950,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8395.96, Release facial nerve,69955,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9447.59,,,,,,,fee schedule,5363,14456, Release facial nerve,69955,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,14456, Release facial nerve,69955,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5363,14456, Release facial nerve,69955,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5363,14456, Release inner ear canal,69960,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9061.61,,,,,,,fee schedule,6979,14456, Release inner ear canal,69960,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,14456, Release inner ear canal,69960,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,6979,14456, Release inner ear canal,69960,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,6979,14456, Remove inner ear lesion,69970,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10209.18,,,,,,,fee schedule,5363,14456, Remove inner ear lesion,69970,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,14456, Remove inner ear lesion,69970,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,5363,14456, Remove inner ear lesion,69970,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,5363,14456, Temporal bone surgery,69979,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Temporal bone surgery,69979,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Temporal bone surgery,69979,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Microsurgery add-on,69990,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1185.5,,,,,,,fee schedule,1185.5,3195, Microsurgery add-on,69990,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1185.5,3195, Microsurgery add-on,69990,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1185.5,3195, Microsurgery add-on,69990,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1185.5,3195, Contrast x-ray of brain,70010,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,275.03,,,,,,,fee schedule,275.03,859.16, Contrast x-ray of brain,70010,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,859.16,,,,,,,fee schedule,275.03,859.16, Contrast x-ray of brain,70010,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,859.16,,,,,,,fee schedule,275.03,859.16, Contrast x-ray of brain,70015,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,545.48,,,,,,,fee schedule,545.48,1531.85, Contrast x-ray of brain,70015,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1531.85,,,,,,,fee schedule,545.48,1531.85, Contrast x-ray of brain,70015,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1531.85,,,,,,,fee schedule,545.48,1531.85, X-ray eye for foreign body,70030,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,125.03,,,,,,,fee schedule,125.03,179.57, X-ray eye for foreign body,70030,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,179.57,,,,,,,fee schedule,125.03,179.57, X-ray eye for foreign body,70030,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,179.57,,,,,,,fee schedule,125.03,179.57, X-ray exam of jaw <4views,70100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,162.96,,,,,,,fee schedule,162.96,179.57, X-ray exam of jaw <4views,70100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,179.57,,,,,,,fee schedule,162.96,179.57, X-ray exam of jaw <4views,70100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,179.57,,,,,,,fee schedule,162.96,179.57, X-ray exam of jaw 4/> views,70110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,162.96,,,,,,,fee schedule,162.96,252.18, X-ray exam of jaw 4/> views,70110,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,162.96,252.18, X-ray exam of jaw 4/> views,70110,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,162.96,252.18, X-ray exam of mastoids,70120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,156.05,,,,,,,fee schedule,156.05,252.18, X-ray exam of mastoids,70120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,156.05,252.18, X-ray exam of mastoids,70120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,156.05,252.18, X-ray exam of mastoids,70130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,233.59,,,,,,,fee schedule,233.59,252.18, X-ray exam of mastoids,70130,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,233.59,252.18, X-ray exam of mastoids,70130,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,233.59,252.18, X-ray exam of middle ear,70134,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,230.14,,,,,,,fee schedule,230.14,1083.56, X-ray exam of middle ear,70134,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.56,,,,,,,fee schedule,230.14,1083.56, X-ray exam of middle ear,70134,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1083.56,,,,,,,fee schedule,230.14,1083.56, X-ray exam of facial bones,70140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,114.72,,,,,,,fee schedule,114.72,179.57, X-ray exam of facial bones,70140,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,179.57,,,,,,,fee schedule,114.72,179.57, X-ray exam of facial bones,70140,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,179.57,,,,,,,fee schedule,114.72,179.57, X-ray exam of facial bones,70150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,178.45,,,,,,,fee schedule,178.45,252.18, X-ray exam of facial bones,70150,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,178.45,252.18, X-ray exam of facial bones,70150,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,178.45,252.18, X-ray exam of nasal bones,70160,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,150.87,,,,,,,fee schedule,150.87,179.57, X-ray exam of nasal bones,70160,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,179.57,,,,,,,fee schedule,150.87,179.57, X-ray exam of nasal bones,70160,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,179.57,,,,,,,fee schedule,150.87,179.57, X-ray exam of tear duct,70170,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,524.34,,,,,,,fee schedule,524.34,524.34, X-ray exam of tear duct,70170,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,524.34,,,,,,,fee schedule,524.34,524.34, X-ray exam of eye sockets,70190,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,137.11,,,,,,,fee schedule,137.11,179.57, X-ray exam of eye sockets,70190,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,179.57,,,,,,,fee schedule,137.11,179.57, X-ray exam of eye sockets,70190,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,179.57,,,,,,,fee schedule,137.11,179.57, X-ray exam of eye sockets,70200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,174.99,,,,,,,fee schedule,174.99,252.18, X-ray exam of eye sockets,70200,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,174.99,252.18, X-ray exam of eye sockets,70200,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,174.99,252.18, X-ray exam of sinuses,70210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,125.03,,,,,,,fee schedule,125.03,179.57, X-ray exam of sinuses,70210,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,179.57,,,,,,,fee schedule,125.03,179.57, X-ray exam of sinuses,70210,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,179.57,,,,,,,fee schedule,125.03,179.57, X-ray exam of sinuses,70220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,142.29,,,,,,,fee schedule,142.29,179.57, X-ray exam of sinuses,70220,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,179.57,,,,,,,fee schedule,142.29,179.57, X-ray exam of sinuses,70220,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,179.57,,,,,,,fee schedule,142.29,179.57, X-ray exam pituitary saddle,70240,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,119.9,,,,,,,fee schedule,119.9,179.57, X-ray exam pituitary saddle,70240,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,179.57,,,,,,,fee schedule,119.9,179.57, X-ray exam pituitary saddle,70240,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,179.57,,,,,,,fee schedule,119.9,179.57, X-ray exam of skull,70250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,140.57,,,,,,,fee schedule,140.57,252.18, X-ray exam of skull,70250,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,140.57,252.18, X-ray exam of skull,70250,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,140.57,252.18, X-ray exam of skull,70260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,159.51,,,,,,,fee schedule,159.51,252.18, X-ray exam of skull,70260,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,159.51,252.18, X-ray exam of skull,70260,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,159.51,252.18, X-ray exam of teeth,70300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,47.48,,,,,,,fee schedule,47.48,179.57, X-ray exam of teeth,70300,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,179.57,,,,,,,fee schedule,47.48,179.57, X-ray exam of teeth,70300,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,179.57,,,,,,,fee schedule,47.48,179.57, X-ray exam of teeth,70310,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,180.17,,,,,,,fee schedule,180.17,524.34, X-ray exam of teeth,70310,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,524.34,,,,,,,fee schedule,180.17,524.34, X-ray exam of teeth,70310,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,524.34,,,,,,,fee schedule,180.17,524.34, Full mouth x-ray of teeth,70320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,235.32,,,,,,,fee schedule,235.32,524.34, Full mouth x-ray of teeth,70320,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,524.34,,,,,,,fee schedule,235.32,524.34, Full mouth x-ray of teeth,70320,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,524.34,,,,,,,fee schedule,235.32,524.34, X-ray exam of jaw joint,70328,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,131.93,,,,,,,fee schedule,131.93,179.57, X-ray exam of jaw joint,70328,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,179.57,,,,,,,fee schedule,131.93,179.57, X-ray exam of jaw joint,70328,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,179.57,,,,,,,fee schedule,131.93,179.57, X-ray exam of jaw joints,70330,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,218.11,,,,,,,fee schedule,179.57,218.11, X-ray exam of jaw joints,70330,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,179.57,,,,,,,fee schedule,179.57,218.11, X-ray exam of jaw joints,70330,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,179.57,,,,,,,fee schedule,179.57,218.11, X-ray exam of jaw joint,70332,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,283.56,,,,,,,fee schedule,283.56,524.34, X-ray exam of jaw joint,70332,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,524.34,,,,,,,fee schedule,283.56,524.34, X-ray exam of jaw joint,70332,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,524.34,,,,,,,fee schedule,283.56,524.34, Magnetic image jaw joint,70336,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,994.43,,,,,,,fee schedule,524.34,994.43, Magnetic image jaw joint,70336,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,524.34,,,,,,,fee schedule,524.34,994.43, Magnetic image jaw joint,70336,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,524.34,,,,,,,fee schedule,524.34,994.43, X-ray head for orthodontia,70350,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,50.94,,,,,,,fee schedule,50.94,179.57, X-ray head for orthodontia,70350,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,179.57,,,,,,,fee schedule,50.94,179.57, X-ray head for orthodontia,70350,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,179.57,,,,,,,fee schedule,50.94,179.57, Panoramic x-ray of jaws,70355,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,49.21,,,,,,,fee schedule,49.21,179.57, Panoramic x-ray of jaws,70355,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,179.57,,,,,,,fee schedule,49.21,179.57, Panoramic x-ray of jaws,70355,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,179.57,,,,,,,fee schedule,49.21,179.57, X-ray exam of neck,70360,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,116.45,,,,,,,fee schedule,116.45,179.57, X-ray exam of neck,70360,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,179.57,,,,,,,fee schedule,116.45,179.57, X-ray exam of neck,70360,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,179.57,,,,,,,fee schedule,116.45,179.57, Throat x-ray & fluoroscopy,70370,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,438.64,,,,,,,fee schedule,179.57,438.64, Throat x-ray & fluoroscopy,70370,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,179.57,,,,,,,fee schedule,179.57,438.64, Throat x-ray & fluoroscopy,70370,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,179.57,,,,,,,fee schedule,179.57,438.64, Speech evaluation complex,70371,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,362.83,,,,,,,fee schedule,362.83,524.34, Speech evaluation complex,70371,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,524.34,,,,,,,fee schedule,362.83,524.34, Speech evaluation complex,70371,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,524.34,,,,,,,fee schedule,362.83,524.34, X-ray exam of salivary gland,70380,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,149.15,,,,,,,fee schedule,149.15,179.57, X-ray exam of salivary gland,70380,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,179.57,,,,,,,fee schedule,149.15,179.57, X-ray exam of salivary gland,70380,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,179.57,,,,,,,fee schedule,149.15,179.57, X-ray exam of salivary duct,70390,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,481.7,,,,,,,fee schedule,481.7,524.34, X-ray exam of salivary duct,70390,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,524.34,,,,,,,fee schedule,481.7,524.34, X-ray exam of salivary duct,70390,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,524.34,,,,,,,fee schedule,481.7,524.34, Ct head/brain w/o dye,70450,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,347.29,,,,,,,fee schedule,252.18,347.29, Ct head/brain w/o dye,70450,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,252.18,347.29, Ct head/brain w/o dye,70450,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,252.18,347.29, Ct head/brain w/dye,70460,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,498.21,,,,,,,fee schedule,410,498.21, Ct head/brain w/dye,70460,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,410,,,,,,,fee schedule,410,498.21, Ct head/brain w/dye,70460,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,410,,,,,,,fee schedule,410,498.21, Ct head/brain w/o & w/dye,70470,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,592.97,,,,,,,fee schedule,410,592.97, Ct head/brain w/o & w/dye,70470,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,410,,,,,,,fee schedule,410,592.97, Ct head/brain w/o & w/dye,70470,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,410,,,,,,,fee schedule,410,592.97, Cta h&n c+ w/noncontrast img,70471,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1336.59,,,,,,,fee schedule,1336.59,1336.59, Ct cere prfu alys c+w/ct/cta,70472,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,619.57,,,,,,,fee schedule,619.57,619.57, Ct cere prfu aly c+wo ct/cta,70473,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1002.31,,,,,,,fee schedule,1002.31,1002.31, Ct orbit/ear/fossa w/o dye,70480,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,513.7,,,,,,,fee schedule,252.18,513.7, Ct orbit/ear/fossa w/o dye,70480,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,252.18,513.7, Ct orbit/ear/fossa w/o dye,70480,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,252.18,513.7, Ct orbit/ear/fossa w/dye,70481,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,660.15,,,,,,,fee schedule,410,660.15, Ct orbit/ear/fossa w/dye,70481,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,410,,,,,,,fee schedule,410,660.15, Ct orbit/ear/fossa w/dye,70481,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,410,,,,,,,fee schedule,410,660.15, Ct orbit/ear/fossa w/o&w/dye,70482,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,780.75,,,,,,,fee schedule,410,780.75, Ct orbit/ear/fossa w/o&w/dye,70482,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,410,,,,,,,fee schedule,410,780.75, Ct orbit/ear/fossa w/o&w/dye,70482,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,410,,,,,,,fee schedule,410,780.75, Ct maxillofacial w/o dye,70486,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,457.58,,,,,,,fee schedule,252.18,457.58, Ct maxillofacial w/o dye,70486,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,252.18,457.58, Ct maxillofacial w/o dye,70486,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,252.18,457.58, Ct maxillofacial w/dye,70487,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,515.43,,,,,,,fee schedule,410,515.43, Ct maxillofacial w/dye,70487,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,410,,,,,,,fee schedule,410,515.43, Ct maxillofacial w/dye,70487,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,410,,,,,,,fee schedule,410,515.43, Ct maxillofacial w/o & w/dye,70488,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,649.84,,,,,,,fee schedule,410,649.84, Ct maxillofacial w/o & w/dye,70488,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,410,,,,,,,fee schedule,410,649.84, Ct maxillofacial w/o & w/dye,70488,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,410,,,,,,,fee schedule,410,649.84, Ct soft tissue neck w/o dye,70490,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,467.94,,,,,,,fee schedule,252.18,467.94, Ct soft tissue neck w/o dye,70490,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,252.18,467.94, Ct soft tissue neck w/o dye,70490,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,252.18,467.94, Ct soft tissue neck w/dye,70491,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,620.54,,,,,,,fee schedule,410,620.54, Ct soft tissue neck w/dye,70491,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,410,,,,,,,fee schedule,410,620.54, Ct soft tissue neck w/dye,70491,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,410,,,,,,,fee schedule,410,620.54, Ct sft tsue nck w/o & w/dye,70492,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,754.95,,,,,,,fee schedule,410,754.95, Ct sft tsue nck w/o & w/dye,70492,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,410,,,,,,,fee schedule,410,754.95, Ct sft tsue nck w/o & w/dye,70492,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,410,,,,,,,fee schedule,410,754.95, Ct angiography head,70496,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1002.31,,,,,,,fee schedule,410,1002.31, Ct angiography head,70496,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,410,,,,,,,fee schedule,410,1002.31, Ct angiography head,70496,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,410,,,,,,,fee schedule,410,1002.31, Ct angiography neck,70498,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1002.31,,,,,,,fee schedule,410,1002.31, Ct angiography neck,70498,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,410,,,,,,,fee schedule,410,1002.31, Ct angiography neck,70498,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,410,,,,,,,fee schedule,410,1002.31, Mri orbit/face/neck w/o dye,70540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,841.07,,,,,,,fee schedule,524.34,841.07, Mri orbit/face/neck w/o dye,70540,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,524.34,,,,,,,fee schedule,524.34,841.07, Mri orbit/face/neck w/o dye,70540,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,524.34,,,,,,,fee schedule,524.34,841.07, Mri Orbit/Face/Neck W/Dye,70542,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,993.67,,,,,,,fee schedule,859.16,993.67, Mri Orbit/Face/Neck W/Dye,70542,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,859.16,,,,,,,fee schedule,859.16,993.67, Mri Orbit/Face/Neck W/Dye,70542,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,859.16,,,,,,,fee schedule,859.16,993.67, Mri orbt/fac/nck w/o &w/dye,70543,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1231.48,,,,,,,fee schedule,859.16,1231.48, Mri orbt/fac/nck w/o &w/dye,70543,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,859.16,,,,,,,fee schedule,859.16,1231.48, Mri orbt/fac/nck w/o &w/dye,70543,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,859.16,,,,,,,fee schedule,859.16,1231.48, Mr Angiography Head W/O Dye,70544,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,826.56,,,,,,,fee schedule,524.34,826.56, Mr Angiography Head W/O Dye,70544,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,524.34,,,,,,,fee schedule,524.34,826.56, Mr Angiography Head W/O Dye,70544,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,524.34,,,,,,,fee schedule,524.34,826.56, Mr Angiography Head W/Dye,70545,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,886.89,,,,,,,fee schedule,859.16,886.89, Mr Angiography Head W/Dye,70545,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,859.16,,,,,,,fee schedule,859.16,886.89, Mr Angiography Head W/Dye,70545,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,859.16,,,,,,,fee schedule,859.16,886.89, Mr angiograph head w/o&w/dye,70546,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1344.47,,,,,,,fee schedule,859.16,1344.47, Mr angiograph head w/o&w/dye,70546,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,859.16,,,,,,,fee schedule,859.16,1344.47, Mr angiograph head w/o&w/dye,70546,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,859.16,,,,,,,fee schedule,859.16,1344.47, Mr Angiography Neck W/O Dye,70547,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,826.56,,,,,,,fee schedule,524.34,826.56, Mr Angiography Neck W/O Dye,70547,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,524.34,,,,,,,fee schedule,524.34,826.56, Mr Angiography Neck W/O Dye,70547,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,524.34,,,,,,,fee schedule,524.34,826.56, Mr Angiography Neck W/Dye,70548,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,914.41,,,,,,,fee schedule,859.16,914.41, Mr Angiography Neck W/Dye,70548,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,859.16,,,,,,,fee schedule,859.16,914.41, Mr Angiography Neck W/Dye,70548,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,859.16,,,,,,,fee schedule,859.16,914.41, Mr angiograph neck w/o&w/dye,70549,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1349.59,,,,,,,fee schedule,859.16,1349.59, Mr angiograph neck w/o&w/dye,70549,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,859.16,,,,,,,fee schedule,859.16,1349.59, Mr angiograph neck w/o&w/dye,70549,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,859.16,,,,,,,fee schedule,859.16,1349.59, Mri brain stem w/o dye,70551,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,660.15,,,,,,,fee schedule,524.34,660.15, Mri brain stem w/o dye,70551,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,524.34,,,,,,,fee schedule,524.34,660.15, Mri brain stem w/o dye,70551,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,524.34,,,,,,,fee schedule,524.34,660.15, Mri brain stem w/dye,70552,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,967.83,,,,,,,fee schedule,859.16,967.83, Mri brain stem w/dye,70552,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,859.16,,,,,,,fee schedule,859.16,967.83, Mri brain stem w/dye,70552,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,859.16,,,,,,,fee schedule,859.16,967.83, Mri brain stem w/o & w/dye,70553,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1095.33,,,,,,,fee schedule,859.16,1095.33, Mri brain stem w/o & w/dye,70553,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,859.16,,,,,,,fee schedule,859.16,1095.33, Mri brain stem w/o & w/dye,70553,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,859.16,,,,,,,fee schedule,859.16,1095.33, Fmri brain by tech,70554,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1447.8,,,,,,,fee schedule,524.34,1447.8, Fmri brain by tech,70554,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,524.34,,,,,,,fee schedule,524.34,1447.8, Fmri brain by tech,70554,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,524.34,,,,,,,fee schedule,524.34,1447.8, Fmri brain by phys/psych,70555,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,524.34,,,,,,,fee schedule,524.34,524.34, Fmri brain by phys/psych,70555,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,524.34,,,,,,,fee schedule,524.34,524.34, Mri brain w/o dye,70557,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.56,,,,,,,fee schedule,1083.56,1083.56, Mri brain w/o dye,70557,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1083.56,,,,,,,fee schedule,1083.56,1083.56, Mri brain w/dye,70558,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,410,,,,,,,fee schedule,410,410, Mri brain w/dye,70558,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,410,,,,,,,fee schedule,410,410, Mri brain w/o & w/dye,70559,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,410,,,,,,,fee schedule,410,410, Mri brain w/o & w/dye,70559,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,410,,,,,,,fee schedule,410,410, X-ray exam chest 1 view,71045,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,88.87,,,,,,,fee schedule,88.87,179.57, X-ray exam chest 1 view,71045,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,179.57,,,,,,,fee schedule,88.87,179.57, X-ray exam chest 1 view,71045,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,179.57,,,,,,,fee schedule,88.87,179.57, X-ray exam chest 2 views,71046,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,119.9,,,,,,,fee schedule,119.9,179.57, X-ray exam chest 2 views,71046,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,179.57,,,,,,,fee schedule,119.9,179.57, X-ray exam chest 2 views,71046,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,179.57,,,,,,,fee schedule,119.9,179.57, X-ray exam chest 3 views,71047,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,147.42,,,,,,,fee schedule,147.42,179.57, X-ray exam chest 3 views,71047,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,179.57,,,,,,,fee schedule,147.42,179.57, X-ray exam chest 3 views,71047,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,179.57,,,,,,,fee schedule,147.42,179.57, X-ray exam chest 4+ views,71048,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,157.78,,,,,,,fee schedule,157.78,252.18, X-ray exam chest 4+ views,71048,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,157.78,252.18, X-ray exam chest 4+ views,71048,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,157.78,252.18, X-ray exam ribs uni 2 views,71100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,133.66,,,,,,,fee schedule,133.66,179.57, X-ray exam ribs uni 2 views,71100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,179.57,,,,,,,fee schedule,133.66,179.57, X-ray exam ribs uni 2 views,71100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,179.57,,,,,,,fee schedule,133.66,179.57, X-ray exam unilat ribs/chest,71101,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,150.87,,,,,,,fee schedule,150.87,252.18, X-ray exam unilat ribs/chest,71101,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,150.87,252.18, X-ray exam unilat ribs/chest,71101,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,150.87,252.18, X-ray exam ribs bil 3 views,71110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,152.6,,,,,,,fee schedule,152.6,252.18, X-ray exam ribs bil 3 views,71110,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,152.6,252.18, X-ray exam ribs bil 3 views,71110,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,152.6,252.18, X-ray exam ribs/chest4/> vws,71111,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,188.81,,,,,,,fee schedule,188.81,252.18, X-ray exam ribs/chest4/> vws,71111,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,188.81,252.18, X-ray exam ribs/chest4/> vws,71111,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,188.81,252.18, X-ray exam breastbone 2/>vws,71120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,123.3,,,,,,,fee schedule,123.3,179.57, X-ray exam breastbone 2/>vws,71120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,179.57,,,,,,,fee schedule,123.3,179.57, X-ray exam breastbone 2/>vws,71120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,179.57,,,,,,,fee schedule,123.3,179.57, X-ray strenoclavic jt 3/>vws,71130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,161.23,,,,,,,fee schedule,161.23,179.57, X-ray strenoclavic jt 3/>vws,71130,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,179.57,,,,,,,fee schedule,161.23,179.57, X-ray strenoclavic jt 3/>vws,71130,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,179.57,,,,,,,fee schedule,161.23,179.57, Ct thorax w/o dye,71250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,430.01,,,,,,,fee schedule,252.18,430.01, Ct thorax w/o dye,71250,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,252.18,430.01, Ct thorax w/o dye,71250,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,252.18,430.01, Ct thorax w/dye,71260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,584.33,,,,,,,fee schedule,410,584.33, Ct thorax w/dye,71260,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,410,,,,,,,fee schedule,410,584.33, Ct thorax w/dye,71260,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,410,,,,,,,fee schedule,410,584.33, Ct thorax w/o & w/dye,71270,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,715.29,,,,,,,fee schedule,410,715.29, Ct thorax w/o & w/dye,71270,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,410,,,,,,,fee schedule,410,715.29, Ct thorax w/o & w/dye,71270,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,410,,,,,,,fee schedule,410,715.29, Ct thorax lung cancer scr c-,71271,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,449.97,,,,,,,fee schedule,182.03,449.97, Ct thorax lung cancer scr c-,71271,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,182.03,,,,,,,fee schedule,182.03,449.97, Ct thorax lung cancer scr c-,71271,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,182.03,,,,,,,fee schedule,182.03,449.97, Ct angiography chest,71275,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1019.52,,,,,,,fee schedule,410,1019.52, Ct angiography chest,71275,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,410,,,,,,,fee schedule,410,1019.52, Ct angiography chest,71275,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,410,,,,,,,fee schedule,410,1019.52, Mri chest w/o dye,71550,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1377.92,,,,,,,fee schedule,524.34,1377.92, Mri chest w/o dye,71550,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,524.34,,,,,,,fee schedule,524.34,1377.92, Mri chest w/o dye,71550,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,524.34,,,,,,,fee schedule,524.34,1377.92, Mri Chest W/Dye,71551,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1508.88,,,,,,,fee schedule,1508.88,1531.85, Mri Chest W/Dye,71551,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1531.85,,,,,,,fee schedule,1508.88,1531.85, Mri Chest W/Dye,71551,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1531.85,,,,,,,fee schedule,1508.88,1531.85, Mri chest w/o & w/dye,71552,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1871.71,,,,,,,fee schedule,859.16,1871.71, Mri chest w/o & w/dye,71552,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,859.16,,,,,,,fee schedule,859.16,1871.71, Mri chest w/o & w/dye,71552,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,859.16,,,,,,,fee schedule,859.16,1871.71, Mri angio chest w or w/o dye,71555,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1303.08,,,,,,,fee schedule,671.54,1303.08, Mri angio chest w or w/o dye,71555,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,671.54,,,,,,,fee schedule,671.54,1303.08, Mri angio chest w or w/o dye,71555,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,671.54,,,,,,,fee schedule,671.54,1303.08, X-ray exam of spine 1 view,72020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,83.69,,,,,,,fee schedule,83.69,179.57, X-ray exam of spine 1 view,72020,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,179.57,,,,,,,fee schedule,83.69,179.57, X-ray exam of spine 1 view,72020,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,179.57,,,,,,,fee schedule,83.69,179.57, X-ray exam neck spine 2-3 vw,72040,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,152.6,,,,,,,fee schedule,152.6,179.57, X-ray exam neck spine 2-3 vw,72040,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,179.57,,,,,,,fee schedule,152.6,179.57, X-ray exam neck spine 2-3 vw,72040,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,179.57,,,,,,,fee schedule,152.6,179.57, X-ray exam neck spine 4/5vws,72050,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,218.11,,,,,,,fee schedule,218.11,252.18, X-ray exam neck spine 4/5vws,72050,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,218.11,252.18, X-ray exam neck spine 4/5vws,72050,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,218.11,252.18, X-ray exam neck spine 6/>vws,72052,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,250.81,,,,,,,fee schedule,250.81,252.18, X-ray exam neck spine 6/>vws,72052,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,250.81,252.18, X-ray exam neck spine 6/>vws,72052,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,250.81,252.18, X-ray exam thorac spine 2vws,72070,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,121.57,,,,,,,fee schedule,121.57,252.18, X-ray exam thorac spine 2vws,72070,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,121.57,252.18, X-ray exam thorac spine 2vws,72070,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,121.57,252.18, X-ray exam thorac spine 3vws,72072,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,147.42,,,,,,,fee schedule,147.42,252.18, X-ray exam thorac spine 3vws,72072,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,147.42,252.18, X-ray exam thorac spine 3vws,72072,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,147.42,252.18, X-ray exam thorac spine4/>vw,72074,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,169.87,,,,,,,fee schedule,169.87,252.18, X-ray exam thorac spine4/>vw,72074,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,169.87,252.18, X-ray exam thorac spine4/>vw,72074,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,169.87,252.18, X-ray exam thoracolmb 2/> vw,72080,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,130.21,,,,,,,fee schedule,130.21,179.57, X-ray exam thoracolmb 2/> vw,72080,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,179.57,,,,,,,fee schedule,130.21,179.57, X-ray exam thoracolmb 2/> vw,72080,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,179.57,,,,,,,fee schedule,130.21,179.57, X-ray exam entire spi 1 vw,72081,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,162.96,,,,,,,fee schedule,162.96,179.57, X-ray exam entire spi 1 vw,72081,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,179.57,,,,,,,fee schedule,162.96,179.57, X-ray exam entire spi 1 vw,72081,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,179.57,,,,,,,fee schedule,162.96,179.57, X-ray exam entire spi 2/3 vw,72082,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,293.92,,,,,,,fee schedule,252.18,293.92, X-ray exam entire spi 2/3 vw,72082,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,252.18,293.92, X-ray exam entire spi 2/3 vw,72082,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,252.18,293.92, X-ray exam entire spi 4/5 vw,72083,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,324.89,,,,,,,fee schedule,252.18,324.89, X-ray exam entire spi 4/5 vw,72083,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,252.18,324.89, X-ray exam entire spi 4/5 vw,72083,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,252.18,324.89, X-ray exam entire spi 6/> vw,72084,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,408.59,,,,,,,fee schedule,252.18,408.59, X-ray exam entire spi 6/> vw,72084,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,252.18,408.59, X-ray exam entire spi 6/> vw,72084,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,252.18,408.59, X-ray exam l-s spine 2/3 vws,72100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,154.33,,,,,,,fee schedule,154.33,252.18, X-ray exam l-s spine 2/3 vws,72100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,154.33,252.18, X-ray exam l-s spine 2/3 vws,72100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,154.33,252.18, X-ray exam l-2 spine 4/>vws,72110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,211.2,,,,,,,fee schedule,211.2,252.18, X-ray exam l-2 spine 4/>vws,72110,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,211.2,252.18, X-ray exam l-2 spine 4/>vws,72110,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,211.2,252.18, X-ray exam l-s spine bending,72114,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,245.68,,,,,,,fee schedule,245.68,252.18, X-ray exam l-s spine bending,72114,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,245.68,252.18, X-ray exam l-s spine bending,72114,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,245.68,252.18, X-ray bend only l-s spine,72120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,162.96,,,,,,,fee schedule,162.96,252.18, X-ray bend only l-s spine,72120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,162.96,252.18, X-ray bend only l-s spine,72120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,162.96,252.18, Ct neck spine w/o dye,72125,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,435.19,,,,,,,fee schedule,252.18,435.19, Ct neck spine w/o dye,72125,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,252.18,435.19, Ct neck spine w/o dye,72125,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,252.18,435.19, Ct neck spine w/dye,72126,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,580.88,,,,,,,fee schedule,580.88,859.16, Ct neck spine w/dye,72126,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,859.16,,,,,,,fee schedule,580.88,859.16, Ct neck spine w/dye,72126,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,859.16,,,,,,,fee schedule,580.88,859.16, Ct neck spine w/o & w/dye,72127,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,713.57,,,,,,,fee schedule,410,713.57, Ct neck spine w/o & w/dye,72127,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,410,,,,,,,fee schedule,410,713.57, Ct neck spine w/o & w/dye,72127,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,410,,,,,,,fee schedule,410,713.57, Ct chest spine w/o dye,72128,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,433.46,,,,,,,fee schedule,252.18,433.46, Ct chest spine w/o dye,72128,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,252.18,433.46, Ct chest spine w/o dye,72128,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,252.18,433.46, Ct chest spine w/dye,72129,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,586.06,,,,,,,fee schedule,410,586.06, Ct chest spine w/dye,72129,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,410,,,,,,,fee schedule,410,586.06, Ct chest spine w/dye,72129,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,410,,,,,,,fee schedule,410,586.06, Ct chest spine w/o & w/dye,72130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,722.2,,,,,,,fee schedule,410,722.2, Ct chest spine w/o & w/dye,72130,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,410,,,,,,,fee schedule,410,722.2, Ct chest spine w/o & w/dye,72130,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,410,,,,,,,fee schedule,410,722.2, Ct lumbar spine w/o dye,72131,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,431.73,,,,,,,fee schedule,252.18,431.73, Ct lumbar spine w/o dye,72131,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,252.18,431.73, Ct lumbar spine w/o dye,72131,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,252.18,431.73, Ct lumbar spine w/dye,72132,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,582.61,,,,,,,fee schedule,582.61,859.16, Ct lumbar spine w/dye,72132,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,859.16,,,,,,,fee schedule,582.61,859.16, Ct lumbar spine w/dye,72132,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,859.16,,,,,,,fee schedule,582.61,859.16, Ct lumbar spine w/o & w/dye,72133,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,715.29,,,,,,,fee schedule,410,715.29, Ct lumbar spine w/o & w/dye,72133,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,410,,,,,,,fee schedule,410,715.29, Ct lumbar spine w/o & w/dye,72133,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,410,,,,,,,fee schedule,410,715.29, Mri neck spine w/o dye,72141,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,634.3,,,,,,,fee schedule,524.34,634.3, Mri neck spine w/o dye,72141,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,524.34,,,,,,,fee schedule,524.34,634.3, Mri neck spine w/o dye,72141,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,524.34,,,,,,,fee schedule,524.34,634.3, Mri neck spine w/dye,72142,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,988.49,,,,,,,fee schedule,859.16,988.49, Mri neck spine w/dye,72142,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,859.16,,,,,,,fee schedule,859.16,988.49, Mri neck spine w/dye,72142,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,859.16,,,,,,,fee schedule,859.16,988.49, Mri chest spine w/o dye,72146,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,632.57,,,,,,,fee schedule,524.34,632.57, Mri chest spine w/o dye,72146,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,524.34,,,,,,,fee schedule,524.34,632.57, Mri chest spine w/o dye,72146,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,524.34,,,,,,,fee schedule,524.34,632.57, Mri chest spine w/dye,72147,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,978.19,,,,,,,fee schedule,859.16,978.19, Mri chest spine w/dye,72147,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,859.16,,,,,,,fee schedule,859.16,978.19, Mri chest spine w/dye,72147,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,859.16,,,,,,,fee schedule,859.16,978.19, Mri lumbar spine w/o dye,72148,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,637.75,,,,,,,fee schedule,524.34,637.75, Mri lumbar spine w/o dye,72148,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,524.34,,,,,,,fee schedule,524.34,637.75, Mri lumbar spine w/o dye,72148,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,524.34,,,,,,,fee schedule,524.34,637.75, Mri lumbar spine w/dye,72149,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,969.55,,,,,,,fee schedule,859.16,969.55, Mri lumbar spine w/dye,72149,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,859.16,,,,,,,fee schedule,859.16,969.55, Mri lumbar spine w/dye,72149,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,859.16,,,,,,,fee schedule,859.16,969.55, Mri neck spine w/o & w/dye,72156,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1098.79,,,,,,,fee schedule,859.16,1098.79, Mri neck spine w/o & w/dye,72156,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,859.16,,,,,,,fee schedule,859.16,1098.79, Mri neck spine w/o & w/dye,72156,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,859.16,,,,,,,fee schedule,859.16,1098.79, Mri chest spine w/o & w/dye,72157,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1102.24,,,,,,,fee schedule,859.16,1102.24, Mri chest spine w/o & w/dye,72157,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,859.16,,,,,,,fee schedule,859.16,1102.24, Mri chest spine w/o & w/dye,72157,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,859.16,,,,,,,fee schedule,859.16,1102.24, Mri lumbar spine w/o & w/dye,72158,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1100.51,,,,,,,fee schedule,859.16,1100.51, Mri lumbar spine w/o & w/dye,72158,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,859.16,,,,,,,fee schedule,859.16,1100.51, Mri lumbar spine w/o & w/dye,72158,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,859.16,,,,,,,fee schedule,859.16,1100.51, Mr angio spine w/o&w/dye,72159,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1318.62,,,,,,,fee schedule,703.22,1318.62, Mr angio spine w/o&w/dye,72159,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,703.22,,,,,,,fee schedule,703.22,1318.62, Mr angio spine w/o&w/dye,72159,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,703.22,,,,,,,fee schedule,703.22,1318.62, X-ray exam of pelvis,72170,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,102.63,,,,,,,fee schedule,102.63,252.18, X-ray exam of pelvis,72170,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,102.63,252.18, X-ray exam of pelvis,72170,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,102.63,252.18, X-ray exam of pelvis,72190,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,161.23,,,,,,,fee schedule,161.23,252.18, X-ray exam of pelvis,72190,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,161.23,252.18, X-ray exam of pelvis,72190,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,161.23,252.18, Ct angiograph pelv w/o&w/dye,72191,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1145.3,,,,,,,fee schedule,410,1145.3, Ct angiograph pelv w/o&w/dye,72191,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,410,,,,,,,fee schedule,410,1145.3, Ct angiograph pelv w/o&w/dye,72191,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,410,,,,,,,fee schedule,410,1145.3, Ct pelvis w/o dye,72192,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,428.28,,,,,,,fee schedule,252.18,428.28, Ct pelvis w/o dye,72192,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,252.18,428.28, Ct pelvis w/o dye,72192,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,252.18,428.28, Ct pelvis w/dye,72193,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,891.04,,,,,,,fee schedule,410,891.04, Ct pelvis w/dye,72193,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,410,,,,,,,fee schedule,410,891.04, Ct pelvis w/dye,72193,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,410,,,,,,,fee schedule,410,891.04, Ct pelvis w/o & w/dye,72194,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1004.79,,,,,,,fee schedule,410,1004.79, Ct pelvis w/o & w/dye,72194,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,410,,,,,,,fee schedule,410,1004.79, Ct pelvis w/o & w/dye,72194,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,410,,,,,,,fee schedule,410,1004.79, Mri Pelvis W/O Dye,72195,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,830.71,,,,,,,fee schedule,524.34,830.71, Mri Pelvis W/O Dye,72195,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,524.34,,,,,,,fee schedule,524.34,830.71, Mri Pelvis W/O Dye,72195,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,524.34,,,,,,,fee schedule,524.34,830.71, Mri pelvis w/dye,72196,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,976.46,,,,,,,fee schedule,859.16,976.46, Mri pelvis w/dye,72196,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,859.16,,,,,,,fee schedule,859.16,976.46, Mri pelvis w/dye,72196,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,859.16,,,,,,,fee schedule,859.16,976.46, Mri pelvis w/o & w/dye,72197,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1203.9,,,,,,,fee schedule,859.16,1203.9, Mri pelvis w/o & w/dye,72197,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,859.16,,,,,,,fee schedule,859.16,1203.9, Mri pelvis w/o & w/dye,72197,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,859.16,,,,,,,fee schedule,859.16,1203.9, Mr angio pelvis w/o & w/dye,72198,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1315.17,,,,,,,fee schedule,677.23,1315.17, Mr angio pelvis w/o & w/dye,72198,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,677.23,,,,,,,fee schedule,677.23,1315.17, Mr angio pelvis w/o & w/dye,72198,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,677.23,,,,,,,fee schedule,677.23,1315.17, X-ray exam si joints,72200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,131.93,,,,,,,fee schedule,131.93,252.18, X-ray exam si joints,72200,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,131.93,252.18, X-ray exam si joints,72200,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,131.93,252.18, X-ray exam si joints 3/> vws,72202,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,147.42,,,,,,,fee schedule,147.42,252.18, X-ray exam si joints 3/> vws,72202,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,147.42,252.18, X-ray exam si joints 3/> vws,72202,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,147.42,252.18, X-ray exam sacrum tailbone,72220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,123.3,,,,,,,fee schedule,123.3,179.57, X-ray exam sacrum tailbone,72220,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,179.57,,,,,,,fee schedule,123.3,179.57, X-ray exam sacrum tailbone,72220,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,179.57,,,,,,,fee schedule,123.3,179.57, Myelography neck spine,72240,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,355.92,,,,,,,fee schedule,355.92,1531.85, Myelography neck spine,72240,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1531.85,,,,,,,fee schedule,355.92,1531.85, Myelography neck spine,72240,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1531.85,,,,,,,fee schedule,355.92,1531.85, Myelography thoracic spine,72255,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,321.44,,,,,,,fee schedule,321.44,1531.85, Myelography thoracic spine,72255,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1531.85,,,,,,,fee schedule,321.44,1531.85, Myelography thoracic spine,72255,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1531.85,,,,,,,fee schedule,321.44,1531.85, Myelography l-s spine,72265,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,362.83,,,,,,,fee schedule,362.83,1531.85, Myelography l-s spine,72265,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1531.85,,,,,,,fee schedule,362.83,1531.85, Myelography l-s spine,72265,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1531.85,,,,,,,fee schedule,362.83,1531.85, Myelogphy 2/> spine regions,72270,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,380.04,,,,,,,fee schedule,380.04,1531.85, Myelogphy 2/> spine regions,72270,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1531.85,,,,,,,fee schedule,380.04,1531.85, Myelogphy 2/> spine regions,72270,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1531.85,,,,,,,fee schedule,380.04,1531.85, Discography cerv/thor spine,72285,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,454.13,,,,,,,fee schedule,454.13,3868.54, Discography cerv/thor spine,72285,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3868.54,,,,,,,fee schedule,454.13,3868.54, Discography cerv/thor spine,72285,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3868.54,,,,,,,fee schedule,454.13,3868.54, X-ray of lower spine disk,72295,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,423.1,,,,,,,fee schedule,423.1,3868.54, X-ray of lower spine disk,72295,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3868.54,,,,,,,fee schedule,423.1,3868.54, X-ray of lower spine disk,72295,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3868.54,,,,,,,fee schedule,423.1,3868.54, X-ray exam of collar bone,73000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,131.93,,,,,,,fee schedule,131.93,179.57, X-ray exam of collar bone,73000,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,179.57,,,,,,,fee schedule,131.93,179.57, X-ray exam of collar bone,73000,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,179.57,,,,,,,fee schedule,131.93,179.57, X-ray exam of shoulder blade,73010,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,83.69,,,,,,,fee schedule,83.69,252.18, X-ray exam of shoulder blade,73010,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,83.69,252.18, X-ray exam of shoulder blade,73010,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,83.69,252.18, X-ray exam of shoulder,73020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,75.06,,,,,,,fee schedule,75.06,179.57, X-ray exam of shoulder,73020,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,179.57,,,,,,,fee schedule,75.06,179.57, X-ray exam of shoulder,73020,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,179.57,,,,,,,fee schedule,75.06,179.57, X-ray exam of shoulder,73030,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,138.84,,,,,,,fee schedule,138.84,179.57, X-ray exam of shoulder,73030,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,179.57,,,,,,,fee schedule,138.84,179.57, X-ray exam of shoulder,73030,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,179.57,,,,,,,fee schedule,138.84,179.57, Contrast x-ray of shoulder,73040,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,557.51,,,,,,,fee schedule,557.51,859.16, Contrast x-ray of shoulder,73040,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,859.16,,,,,,,fee schedule,557.51,859.16, Contrast x-ray of shoulder,73040,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,859.16,,,,,,,fee schedule,557.51,859.16, X-ray exam of shoulders,73050,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,109.54,,,,,,,fee schedule,109.54,179.57, X-ray exam of shoulders,73050,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,179.57,,,,,,,fee schedule,109.54,179.57, X-ray exam of shoulders,73050,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,179.57,,,,,,,fee schedule,109.54,179.57, X-ray exam of humerus,73060,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,125.03,,,,,,,fee schedule,125.03,179.57, X-ray exam of humerus,73060,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,179.57,,,,,,,fee schedule,125.03,179.57, X-ray exam of humerus,73060,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,179.57,,,,,,,fee schedule,125.03,179.57, X-ray exam of elbow,73070,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,111.27,,,,,,,fee schedule,111.27,179.57, X-ray exam of elbow,73070,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,179.57,,,,,,,fee schedule,111.27,179.57, X-ray exam of elbow,73070,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,179.57,,,,,,,fee schedule,111.27,179.57, X-ray exam of elbow,73080,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,128.48,,,,,,,fee schedule,128.48,179.57, X-ray exam of elbow,73080,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,179.57,,,,,,,fee schedule,128.48,179.57, X-ray exam of elbow,73080,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,179.57,,,,,,,fee schedule,128.48,179.57, Contrast x-ray of elbow,73085,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,368.01,,,,,,,fee schedule,368.01,859.16, Contrast x-ray of elbow,73085,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,859.16,,,,,,,fee schedule,368.01,859.16, Contrast x-ray of elbow,73085,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,859.16,,,,,,,fee schedule,368.01,859.16, X-ray exam of forearm,73090,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,111.27,,,,,,,fee schedule,111.27,179.57, X-ray exam of forearm,73090,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,179.57,,,,,,,fee schedule,111.27,179.57, X-ray exam of forearm,73090,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,179.57,,,,,,,fee schedule,111.27,179.57, X-ray exam of arm infant,73092,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,119.9,,,,,,,fee schedule,119.9,252.18, X-ray exam of arm infant,73092,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,119.9,252.18, X-ray exam of arm infant,73092,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,119.9,252.18, X-ray exam of wrist,73100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,135.39,,,,,,,fee schedule,135.39,179.57, X-ray exam of wrist,73100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,179.57,,,,,,,fee schedule,135.39,179.57, X-ray exam of wrist,73100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,179.57,,,,,,,fee schedule,135.39,179.57, X-ray exam of wrist,73110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,176.72,,,,,,,fee schedule,176.72,179.57, X-ray exam of wrist,73110,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,179.57,,,,,,,fee schedule,176.72,179.57, X-ray exam of wrist,73110,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,179.57,,,,,,,fee schedule,176.72,179.57, Contrast x-ray of wrist,73115,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,548.88,,,,,,,fee schedule,548.88,859.16, Contrast x-ray of wrist,73115,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,859.16,,,,,,,fee schedule,548.88,859.16, Contrast x-ray of wrist,73115,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,859.16,,,,,,,fee schedule,548.88,859.16, X-ray exam of hand,73120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,121.57,,,,,,,fee schedule,121.57,252.18, X-ray exam of hand,73120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,121.57,252.18, X-ray exam of hand,73120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,121.57,252.18, X-ray exam of hand,73130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,152.6,,,,,,,fee schedule,152.6,179.57, X-ray exam of hand,73130,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,179.57,,,,,,,fee schedule,152.6,179.57, X-ray exam of hand,73130,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,179.57,,,,,,,fee schedule,152.6,179.57, X-ray exam of finger(s),73140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,169.87,,,,,,,fee schedule,169.87,179.57, X-ray exam of finger(s),73140,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,179.57,,,,,,,fee schedule,169.87,179.57, X-ray exam of finger(s),73140,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,179.57,,,,,,,fee schedule,169.87,179.57, Ct upper extremity w/o dye,73200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,591.24,,,,,,,fee schedule,252.18,591.24, Ct upper extremity w/o dye,73200,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,252.18,591.24, Ct upper extremity w/o dye,73200,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,252.18,591.24, Ct upper extremity w/dye,73201,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,754.95,,,,,,,fee schedule,754.95,859.16, Ct upper extremity w/dye,73201,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,859.16,,,,,,,fee schedule,754.95,859.16, Ct upper extremity w/dye,73201,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,859.16,,,,,,,fee schedule,754.95,859.16, Ct uppr extremity w/o&w/dye,73202,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,984.07,,,,,,,fee schedule,410,984.07, Ct uppr extremity w/o&w/dye,73202,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,410,,,,,,,fee schedule,410,984.07, Ct uppr extremity w/o&w/dye,73202,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,410,,,,,,,fee schedule,410,984.07, Ct angio upr extrm w/o&w/dye,73206,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1102.24,,,,,,,fee schedule,410,1102.24, Ct angio upr extrm w/o&w/dye,73206,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,410,,,,,,,fee schedule,410,1102.24, Ct angio upr extrm w/o&w/dye,73206,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,410,,,,,,,fee schedule,410,1102.24, Mri Upper Extremity W/O Dye,73218,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1243.51,,,,,,,fee schedule,524.34,1243.51, Mri Upper Extremity W/O Dye,73218,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,524.34,,,,,,,fee schedule,524.34,1243.51, Mri Upper Extremity W/O Dye,73218,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,524.34,,,,,,,fee schedule,524.34,1243.51, Mri Upper Extremity W/Dye,73219,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1317.6,,,,,,,fee schedule,859.16,1317.6, Mri Upper Extremity W/Dye,73219,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,859.16,,,,,,,fee schedule,859.16,1317.6, Mri Upper Extremity W/Dye,73219,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,859.16,,,,,,,fee schedule,859.16,1317.6, Mri uppr extremity w/o&w/dye,73220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1589.12,,,,,,,fee schedule,859.16,1589.12, Mri uppr extremity w/o&w/dye,73220,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,859.16,,,,,,,fee schedule,859.16,1589.12, Mri uppr extremity w/o&w/dye,73220,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,859.16,,,,,,,fee schedule,859.16,1589.12, Mri joint upr extrem w/o dye,73221,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,734.23,,,,,,,fee schedule,524.34,734.23, Mri joint upr extrem w/o dye,73221,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,524.34,,,,,,,fee schedule,524.34,734.23, Mri joint upr extrem w/o dye,73221,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,524.34,,,,,,,fee schedule,524.34,734.23, Mri joint upr extrem w/dye,73222,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1228.02,,,,,,,fee schedule,1228.02,1531.85, Mri joint upr extrem w/dye,73222,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1531.85,,,,,,,fee schedule,1228.02,1531.85, Mri joint upr extrem w/dye,73222,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1531.85,,,,,,,fee schedule,1228.02,1531.85, Mri joint upr extr w/o&w/dye,73223,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1465.77,,,,,,,fee schedule,859.16,1465.77, Mri joint upr extr w/o&w/dye,73223,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,859.16,,,,,,,fee schedule,859.16,1465.77, Mri joint upr extr w/o&w/dye,73223,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,859.16,,,,,,,fee schedule,859.16,1465.77, Mr angio upr extr w/o&w/dye,73225,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1270.38,,,,,,,fee schedule,703.22,1270.38, Mr angio upr extr w/o&w/dye,73225,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,703.22,,,,,,,fee schedule,703.22,1270.38, Mr angio upr extr w/o&w/dye,73225,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,703.22,,,,,,,fee schedule,703.22,1270.38, X-ray exam hip uni 1 view,73501,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,128.48,,,,,,,fee schedule,128.48,179.57, X-ray exam hip uni 1 view,73501,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,179.57,,,,,,,fee schedule,128.48,179.57, X-ray exam hip uni 1 view,73501,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,179.57,,,,,,,fee schedule,128.48,179.57, X-ray exam hip uni 2-3 views,73502,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,197.39,,,,,,,fee schedule,179.57,197.39, X-ray exam hip uni 2-3 views,73502,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,179.57,,,,,,,fee schedule,179.57,197.39, X-ray exam hip uni 2-3 views,73502,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,179.57,,,,,,,fee schedule,179.57,197.39, X-ray exam hip uni 4/> views,73503,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,255.99,,,,,,,fee schedule,252.18,255.99, X-ray exam hip uni 4/> views,73503,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,252.18,255.99, X-ray exam hip uni 4/> views,73503,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,252.18,255.99, X-ray exam hips bi 2 views,73521,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,161.23,,,,,,,fee schedule,161.23,252.18, X-ray exam hips bi 2 views,73521,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,161.23,252.18, X-ray exam hips bi 2 views,73521,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,161.23,252.18, X-ray exam hips bi 3-4 views,73522,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,209.47,,,,,,,fee schedule,209.47,252.18, X-ray exam hips bi 3-4 views,73522,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,209.47,252.18, X-ray exam hips bi 3-4 views,73522,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,209.47,252.18, X-ray exam hips bi 5/> views,73523,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,242.23,,,,,,,fee schedule,242.23,252.18, X-ray exam hips bi 5/> views,73523,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,242.23,252.18, X-ray exam hips bi 5/> views,73523,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,242.23,252.18, Contrast x-ray of hip,73525,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,542.03,,,,,,,fee schedule,542.03,859.16, Contrast x-ray of hip,73525,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,859.16,,,,,,,fee schedule,542.03,859.16, Contrast x-ray of hip,73525,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,859.16,,,,,,,fee schedule,542.03,859.16, X-ray exam of femur 1,73551,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,111.27,,,,,,,fee schedule,111.27,179.57, X-ray exam of femur 1,73551,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,179.57,,,,,,,fee schedule,111.27,179.57, X-ray exam of femur 1,73551,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,179.57,,,,,,,fee schedule,111.27,179.57, X-ray exam of femur 2/>,73552,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,140.57,,,,,,,fee schedule,140.57,179.57, X-ray exam of femur 2/>,73552,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,179.57,,,,,,,fee schedule,140.57,179.57, X-ray exam of femur 2/>,73552,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,179.57,,,,,,,fee schedule,140.57,179.57, X-ray exam of knee 1 or 2,73560,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,137.11,,,,,,,fee schedule,137.11,179.57, X-ray exam of knee 1 or 2,73560,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,179.57,,,,,,,fee schedule,137.11,179.57, X-ray exam of knee 1 or 2,73560,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,179.57,,,,,,,fee schedule,137.11,179.57, X-ray exam of knee 3,73562,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,171.54,,,,,,,fee schedule,171.54,179.57, X-ray exam of knee 3,73562,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,179.57,,,,,,,fee schedule,171.54,179.57, X-ray exam of knee 3,73562,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,179.57,,,,,,,fee schedule,171.54,179.57, X-ray exam knee 4 or more,73564,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,199.11,,,,,,,fee schedule,199.11,252.18, X-ray exam knee 4 or more,73564,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,199.11,252.18, X-ray exam knee 4 or more,73564,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,199.11,252.18, X-ray exam of knees,73565,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,174.99,,,,,,,fee schedule,174.99,179.57, X-ray exam of knees,73565,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,179.57,,,,,,,fee schedule,174.99,179.57, X-ray exam of knees,73565,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,179.57,,,,,,,fee schedule,174.99,179.57, Contrast x-ray of knee joint,73580,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,442.09,,,,,,,fee schedule,442.09,859.16, Contrast x-ray of knee joint,73580,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,859.16,,,,,,,fee schedule,442.09,859.16, Contrast x-ray of knee joint,73580,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,859.16,,,,,,,fee schedule,442.09,859.16, X-ray exam of lower leg,73590,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,123.3,,,,,,,fee schedule,123.3,179.57, X-ray exam of lower leg,73590,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,179.57,,,,,,,fee schedule,123.3,179.57, X-ray exam of lower leg,73590,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,179.57,,,,,,,fee schedule,123.3,179.57, X-ray exam of leg infant,73592,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,119.9,,,,,,,fee schedule,119.9,179.57, X-ray exam of leg infant,73592,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,179.57,,,,,,,fee schedule,119.9,179.57, X-ray exam of leg infant,73592,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,179.57,,,,,,,fee schedule,119.9,179.57, X-ray exam of ankle,73600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,126.75,,,,,,,fee schedule,126.75,179.57, X-ray exam of ankle,73600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,179.57,,,,,,,fee schedule,126.75,179.57, X-ray exam of ankle,73600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,179.57,,,,,,,fee schedule,126.75,179.57, X-ray exam of ankle,73610,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,149.15,,,,,,,fee schedule,149.15,179.57, X-ray exam of ankle,73610,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,179.57,,,,,,,fee schedule,149.15,179.57, X-ray exam of ankle,73610,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,179.57,,,,,,,fee schedule,149.15,179.57, Contrast x-ray of ankle,73615,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,542.03,,,,,,,fee schedule,542.03,859.16, Contrast x-ray of ankle,73615,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,859.16,,,,,,,fee schedule,542.03,859.16, Contrast x-ray of ankle,73615,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,859.16,,,,,,,fee schedule,542.03,859.16, X-ray exam of foot,73620,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,109.54,,,,,,,fee schedule,109.54,179.57, X-ray exam of foot,73620,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,179.57,,,,,,,fee schedule,109.54,179.57, X-ray exam of foot,73620,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,179.57,,,,,,,fee schedule,109.54,179.57, X-ray exam of foot,73630,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,135.39,,,,,,,fee schedule,135.39,179.57, X-ray exam of foot,73630,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,179.57,,,,,,,fee schedule,135.39,179.57, X-ray exam of foot,73630,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,179.57,,,,,,,fee schedule,135.39,179.57, X-ray exam of heel,73650,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,107.81,,,,,,,fee schedule,107.81,179.57, X-ray exam of heel,73650,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,179.57,,,,,,,fee schedule,107.81,179.57, X-ray exam of heel,73650,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,179.57,,,,,,,fee schedule,107.81,179.57, X-ray exam of toe(s),73660,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,116.45,,,,,,,fee schedule,116.45,179.57, X-ray exam of toe(s),73660,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,179.57,,,,,,,fee schedule,116.45,179.57, X-ray exam of toe(s),73660,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,179.57,,,,,,,fee schedule,116.45,179.57, Ct lower extremity w/o dye,73700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,433.46,,,,,,,fee schedule,252.18,433.46, Ct lower extremity w/o dye,73700,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,252.18,433.46, Ct lower extremity w/o dye,73700,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,252.18,433.46, Ct lower extremity w/dye,73701,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,582.61,,,,,,,fee schedule,410,582.61, Ct lower extremity w/dye,73701,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,410,,,,,,,fee schedule,410,582.61, Ct lower extremity w/dye,73701,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,410,,,,,,,fee schedule,410,582.61, Ct lwr extremity w/o&w/dye,73702,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,718.75,,,,,,,fee schedule,410,718.75, Ct lwr extremity w/o&w/dye,73702,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,410,,,,,,,fee schedule,410,718.75, Ct lwr extremity w/o&w/dye,73702,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,410,,,,,,,fee schedule,410,718.75, Ct angio lwr extr w/o&w/dye,73706,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1215.23,,,,,,,fee schedule,410,1215.23, Ct angio lwr extr w/o&w/dye,73706,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,410,,,,,,,fee schedule,410,1215.23, Ct angio lwr extr w/o&w/dye,73706,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,410,,,,,,,fee schedule,410,1215.23, Mri Lower Extremity W/O Dye,73718,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,829.04,,,,,,,fee schedule,524.34,829.04, Mri Lower Extremity W/O Dye,73718,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,524.34,,,,,,,fee schedule,524.34,829.04, Mri Lower Extremity W/O Dye,73718,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,524.34,,,,,,,fee schedule,524.34,829.04, Mri Lower Extremity W/Dye,73719,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,967.83,,,,,,,fee schedule,859.16,967.83, Mri Lower Extremity W/Dye,73719,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,859.16,,,,,,,fee schedule,859.16,967.83, Mri Lower Extremity W/Dye,73719,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,859.16,,,,,,,fee schedule,859.16,967.83, Mri lwr extremity w/o&w/dye,73720,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1219.39,,,,,,,fee schedule,859.16,1219.39, Mri lwr extremity w/o&w/dye,73720,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,859.16,,,,,,,fee schedule,859.16,1219.39, Mri lwr extremity w/o&w/dye,73720,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,859.16,,,,,,,fee schedule,859.16,1219.39, Mri jnt of lwr extre w/o dye,73721,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,732.51,,,,,,,fee schedule,524.34,732.51, Mri jnt of lwr extre w/o dye,73721,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,524.34,,,,,,,fee schedule,524.34,732.51, Mri jnt of lwr extre w/o dye,73721,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,524.34,,,,,,,fee schedule,524.34,732.51, Mri Joint Of Lwr Extr W/Dye,73722,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1240.05,,,,,,,fee schedule,1240.05,1531.85, Mri Joint Of Lwr Extr W/Dye,73722,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1531.85,,,,,,,fee schedule,1240.05,1531.85, Mri Joint Of Lwr Extr W/Dye,73722,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1531.85,,,,,,,fee schedule,1240.05,1531.85, Mri joint lwr extr w/o&w/dye,73723,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1458.92,,,,,,,fee schedule,859.16,1458.92, Mri joint lwr extr w/o&w/dye,73723,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,859.16,,,,,,,fee schedule,859.16,1458.92, Mri joint lwr extr w/o&w/dye,73723,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,859.16,,,,,,,fee schedule,859.16,1458.92, Mr ang lwr ext w or w/o dye,73725,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1315.17,,,,,,,fee schedule,676.42,1315.17, Mr ang lwr ext w or w/o dye,73725,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,676.42,,,,,,,fee schedule,676.42,1315.17, Mr ang lwr ext w or w/o dye,73725,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,676.42,,,,,,,fee schedule,676.42,1315.17, X-ray exam abdomen 1 view,74018,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,109.54,,,,,,,fee schedule,109.54,179.57, X-ray exam abdomen 1 view,74018,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,179.57,,,,,,,fee schedule,109.54,179.57, X-ray exam abdomen 1 view,74018,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,179.57,,,,,,,fee schedule,109.54,179.57, X-ray exam abdomen 2 views,74019,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,131.93,,,,,,,fee schedule,131.93,252.18, X-ray exam abdomen 2 views,74019,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,131.93,252.18, X-ray exam abdomen 2 views,74019,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,131.93,252.18, X-ray exam abdomen 3+ views,74021,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,154.33,,,,,,,fee schedule,154.33,252.18, X-ray exam abdomen 3+ views,74021,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,154.33,252.18, X-ray exam abdomen 3+ views,74021,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,154.33,252.18, X-ray exam series abdomen,74022,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,178.45,,,,,,,fee schedule,178.45,252.18, X-ray exam series abdomen,74022,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,178.45,252.18, X-ray exam series abdomen,74022,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,178.45,252.18, Ct abdomen w/o dye,74150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,421.37,,,,,,,fee schedule,252.18,421.37, Ct abdomen w/o dye,74150,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,252.18,421.37, Ct abdomen w/o dye,74150,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,252.18,421.37, Ct abdomen w/dye,74160,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,887.59,,,,,,,fee schedule,410,887.59, Ct abdomen w/dye,74160,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,410,,,,,,,fee schedule,410,887.59, Ct abdomen w/dye,74160,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,410,,,,,,,fee schedule,410,887.59, Ct abdomen w/o & w/dye,74170,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1006.46,,,,,,,fee schedule,410,1006.46, Ct abdomen w/o & w/dye,74170,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,410,,,,,,,fee schedule,410,1006.46, Ct abdomen w/o & w/dye,74170,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,410,,,,,,,fee schedule,410,1006.46, Ct angio abd&pelv w/o&w/dye,74174,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1435.77,,,,,,,fee schedule,859.16,1435.77, Ct angio abd&pelv w/o&w/dye,74174,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,859.16,,,,,,,fee schedule,859.16,1435.77, Ct angio abd&pelv w/o&w/dye,74174,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,859.16,,,,,,,fee schedule,859.16,1435.77, Ct angio abdom w/o & w/dye,74175,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1143.57,,,,,,,fee schedule,410,1143.57, Ct angio abdom w/o & w/dye,74175,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,410,,,,,,,fee schedule,410,1143.57, Ct angio abdom w/o & w/dye,74175,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,410,,,,,,,fee schedule,410,1143.57, Ct abd & pelvis w/o contrast,74176,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,534.37,,,,,,,fee schedule,524.34,534.37, Ct abd & pelvis w/o contrast,74176,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,524.34,,,,,,,fee schedule,524.34,534.37, Ct abd & pelvis w/o contrast,74176,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,524.34,,,,,,,fee schedule,524.34,534.37, Ct abd & pelv w/contrast,74177,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1118.48,,,,,,,fee schedule,859.16,1118.48, Ct abd & pelv w/contrast,74177,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,859.16,,,,,,,fee schedule,859.16,1118.48, Ct abd & pelv w/contrast,74177,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,859.16,,,,,,,fee schedule,859.16,1118.48, Ct abd & pelv 1/> regns,74178,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1267.63,,,,,,,fee schedule,859.16,1267.63, Ct abd & pelv 1/> regns,74178,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,859.16,,,,,,,fee schedule,859.16,1267.63, Ct abd & pelv 1/> regns,74178,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,859.16,,,,,,,fee schedule,859.16,1267.63, Mri abdomen w/o dye,74181,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,658.42,,,,,,,fee schedule,524.34,658.42, Mri abdomen w/o dye,74181,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,524.34,,,,,,,fee schedule,524.34,658.42, Mri abdomen w/o dye,74181,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,524.34,,,,,,,fee schedule,524.34,658.42, Mri Abdomen W/Dye,74182,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1143.57,,,,,,,fee schedule,859.16,1143.57, Mri Abdomen W/Dye,74182,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,859.16,,,,,,,fee schedule,859.16,1143.57, Mri Abdomen W/Dye,74182,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,859.16,,,,,,,fee schedule,859.16,1143.57, Mri abdomen w/o & w/dye,74183,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1212.54,,,,,,,fee schedule,859.16,1212.54, Mri abdomen w/o & w/dye,74183,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,859.16,,,,,,,fee schedule,859.16,1212.54, Mri abdomen w/o & w/dye,74183,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,859.16,,,,,,,fee schedule,859.16,1212.54, Mri angio abdom w orw/o dye,74185,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1309.99,,,,,,,fee schedule,680.47,1309.99, Mri angio abdom w orw/o dye,74185,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,680.47,,,,,,,fee schedule,680.47,1309.99, Mri angio abdom w orw/o dye,74185,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,680.47,,,,,,,fee schedule,680.47,1309.99, X-ray exam of peritoneum,74190,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.56,,,,,,,fee schedule,1083.56,1083.56, X-ray exam of peritoneum,74190,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1083.56,,,,,,,fee schedule,1083.56,1083.56, Contrst x-ray exam of throat,74210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,331.8,,,,,,,fee schedule,331.8,410, Contrst x-ray exam of throat,74210,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,410,,,,,,,fee schedule,331.8,410, Contrst x-ray exam of throat,74210,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,410,,,,,,,fee schedule,331.8,410, Contrast x-ray esophagus,74220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,343.89,,,,,,,fee schedule,343.89,410, Contrast x-ray esophagus,74220,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,410,,,,,,,fee schedule,343.89,410, Contrast x-ray esophagus,74220,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,410,,,,,,,fee schedule,343.89,410, X-ray xm esophagus 2cntrst,74221,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,380.04,,,,,,,fee schedule,380.04,410, X-ray xm esophagus 2cntrst,74221,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,410,,,,,,,fee schedule,380.04,410, X-ray xm esophagus 2cntrst,74221,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,410,,,,,,,fee schedule,380.04,410, Cine/vid x-ray throat/esoph,74230,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,493.79,,,,,,,fee schedule,410,493.79, Cine/vid x-ray throat/esoph,74230,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,410,,,,,,,fee schedule,410,493.79, Cine/vid x-ray throat/esoph,74230,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,410,,,,,,,fee schedule,410,493.79, X-ray upper gi delay w/o kub,74240,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,435.19,,,,,,,fee schedule,410,435.19, X-ray upper gi delay w/o kub,74240,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,410,,,,,,,fee schedule,410,435.19, X-ray upper gi delay w/o kub,74240,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,410,,,,,,,fee schedule,410,435.19, Contrst x-ray uppr gi tract,74246,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,479.97,,,,,,,fee schedule,410,479.97, Contrst x-ray uppr gi tract,74246,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,410,,,,,,,fee schedule,410,479.97, Contrst x-ray uppr gi tract,74246,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,410,,,,,,,fee schedule,410,479.97, X-ray sm int f-thru std,74248,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,245.68,,,,,,,fee schedule,245.68,245.68, X-ray exam of small bowel,74250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,417.97,,,,,,,fee schedule,410,417.97, X-ray exam of small bowel,74250,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,410,,,,,,,fee schedule,410,417.97, X-ray exam of small bowel,74250,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,410,,,,,,,fee schedule,410,417.97, X-ray exam of small bowel,74251,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1496.58,,,,,,,fee schedule,410,1496.58, X-ray exam of small bowel,74251,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,410,,,,,,,fee schedule,410,1496.58, X-ray exam of small bowel,74251,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,410,,,,,,,fee schedule,410,1496.58, Ct colonography dx,74261,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1541.58,,,,,,,fee schedule,252.18,1541.58, Ct colonography dx,74261,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,252.18,1541.58, Ct colonography dx,74261,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,252.18,1541.58, Ct colonography dx w/dye,74262,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1777.66,,,,,,,fee schedule,410,1777.66, Ct colonography dx w/dye,74262,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,410,,,,,,,fee schedule,410,1777.66, Ct colonography dx w/dye,74262,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,410,,,,,,,fee schedule,410,1777.66, Ct colonography screening,74263,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3690.22,,,,,,,fee schedule,1453.5,3690.22, Ct colonography screening,74263,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1453.5,,,,,,,fee schedule,1453.5,3690.22, Ct colonography screening,74263,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1453.5,,,,,,,fee schedule,1453.5,3690.22, Contrast x-ray exam of colon,74270,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,521.36,,,,,,,fee schedule,410,521.36, Contrast x-ray exam of colon,74270,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,410,,,,,,,fee schedule,410,521.36, Contrast x-ray exam of colon,74270,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,410,,,,,,,fee schedule,410,521.36, Contrast x-ray exam of colon,74280,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,794.56,,,,,,,fee schedule,410,794.56, Contrast x-ray exam of colon,74280,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,410,,,,,,,fee schedule,410,794.56, Contrast x-ray exam of colon,74280,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,410,,,,,,,fee schedule,410,794.56, Contrast x-ray exam of colon,74283,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,915.92,,,,,,,fee schedule,410,915.92, Contrast x-ray exam of colon,74283,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,410,,,,,,,fee schedule,410,915.92, Contrast x-ray exam of colon,74283,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,410,,,,,,,fee schedule,410,915.92, Contrast x-ray gallbladder,74290,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,343.89,,,,,,,fee schedule,343.89,410, Contrast x-ray gallbladder,74290,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,410,,,,,,,fee schedule,343.89,410, Contrast x-ray gallbladder,74290,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,410,,,,,,,fee schedule,343.89,410, Contrst x-ray urinary tract,74400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,565.39,,,,,,,fee schedule,410,565.39, Contrst x-ray urinary tract,74400,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,410,,,,,,,fee schedule,410,565.39, Contrst x-ray urinary tract,74400,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,410,,,,,,,fee schedule,410,565.39, Contrst x-ray urinary tract,74410,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,629.17,,,,,,,fee schedule,410,629.17, Contrst x-ray urinary tract,74410,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,410,,,,,,,fee schedule,410,629.17, Contrst x-ray urinary tract,74410,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,410,,,,,,,fee schedule,410,629.17, Contrst x-ray urinary tract,74415,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,667.05,,,,,,,fee schedule,410,667.05, Contrst x-ray urinary tract,74415,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,410,,,,,,,fee schedule,410,667.05, Contrst x-ray urinary tract,74415,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,410,,,,,,,fee schedule,410,667.05, Contrst x-ray urinary tract,74420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,292.19,,,,,,,fee schedule,292.19,859.16, Contrst x-ray urinary tract,74420,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,859.16,,,,,,,fee schedule,292.19,859.16, Contrst x-ray urinary tract,74420,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,859.16,,,,,,,fee schedule,292.19,859.16, Contrst x-ray urinary tract,74425,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,569.6,,,,,,,fee schedule,569.6,859.16, Contrst x-ray urinary tract,74425,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,859.16,,,,,,,fee schedule,569.6,859.16, Contrst x-ray urinary tract,74425,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,859.16,,,,,,,fee schedule,569.6,859.16, Contrast x-ray bladder,74430,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,138.84,,,,,,,fee schedule,138.84,859.16, Contrast x-ray bladder,74430,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,859.16,,,,,,,fee schedule,138.84,859.16, Contrast x-ray bladder,74430,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,859.16,,,,,,,fee schedule,138.84,859.16, X-ray male genital tract,74440,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,428.28,,,,,,,fee schedule,428.28,524.34, X-ray male genital tract,74440,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,524.34,,,,,,,fee schedule,428.28,524.34, X-ray male genital tract,74440,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,524.34,,,,,,,fee schedule,428.28,524.34, X-ray exam of penis,74445,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,252.18,252.18, X-ray exam of penis,74445,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,252.18,252.18, X-ray urethra/bladder,74450,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,524.34,,,,,,,fee schedule,524.34,524.34, X-ray urethra/bladder,74450,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,524.34,,,,,,,fee schedule,524.34,524.34, X-ray urethra/bladder,74455,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,464.49,,,,,,,fee schedule,464.49,524.34, X-ray urethra/bladder,74455,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,524.34,,,,,,,fee schedule,464.49,524.34, X-ray urethra/bladder,74455,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,524.34,,,,,,,fee schedule,464.49,524.34, X-ray exam of kidney lesion,74470,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.56,,,,,,,fee schedule,1083.56,1083.56, X-ray exam of kidney lesion,74470,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1083.56,,,,,,,fee schedule,1083.56,1083.56, X-ray guide gu dilation,74485,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,435.19,,,,,,,fee schedule,435.19,3985.99, X-ray guide gu dilation,74485,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3985.99,,,,,,,fee schedule,435.19,3985.99, X-ray guide gu dilation,74485,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3985.99,,,,,,,fee schedule,435.19,3985.99, Mri fetal sngl/1st gestation,74712,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1381.38,,,,,,,fee schedule,524.34,1381.38, Mri fetal sngl/1st gestation,74712,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,524.34,,,,,,,fee schedule,524.34,1381.38, Mri fetal sngl/1st gestation,74712,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,524.34,,,,,,,fee schedule,524.34,1381.38, Mri fetal ea addl gestation,74713,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,576.45,,,,,,,fee schedule,576.45,576.45, X-ray female genital tract,74740,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,374.86,,,,,,,fee schedule,374.86,524.34, X-ray female genital tract,74740,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,524.34,,,,,,,fee schedule,374.86,524.34, X-ray female genital tract,74740,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,524.34,,,,,,,fee schedule,374.86,524.34, X-ray exam of perineum,74775,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,524.34,,,,,,,fee schedule,524.34,524.34, X-ray exam of perineum,74775,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,524.34,,,,,,,fee schedule,524.34,524.34, Cardiac mri for morph,75557,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,889.31,,,,,,,fee schedule,524.34,889.31, Cardiac mri for morph,75557,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,524.34,,,,,,,fee schedule,524.34,889.31, Cardiac mri for morph,75557,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,524.34,,,,,,,fee schedule,524.34,889.31, Cardiac mri w/stress img,75559,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1264.93,,,,,,,fee schedule,1083.56,1264.93, Cardiac mri w/stress img,75559,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.56,,,,,,,fee schedule,1083.56,1264.93, Cardiac mri w/stress img,75559,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1083.56,,,,,,,fee schedule,1083.56,1264.93, Cardiac mri for morph w/dye,75561,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1267.63,,,,,,,fee schedule,859.16,1267.63, Cardiac mri for morph w/dye,75561,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,859.16,,,,,,,fee schedule,859.16,1267.63, Cardiac mri for morph w/dye,75561,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,859.16,,,,,,,fee schedule,859.16,1267.63, Card mri w/stress img & dye,75563,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1508.88,,,,,,,fee schedule,1508.88,1531.85, Card mri w/stress img & dye,75563,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1531.85,,,,,,,fee schedule,1508.88,1531.85, Card mri w/stress img & dye,75563,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1531.85,,,,,,,fee schedule,1508.88,1531.85, Card mri veloc flow mapping,75565,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,175.75,,,,,,,fee schedule,175.75,175.75, Ct hrt w/o dye w/ca test,75571,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,377.61,,,,,,,fee schedule,179.57,377.61, Ct hrt w/o dye w/ca test,75571,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,179.57,,,,,,,fee schedule,179.57,377.61, Ct hrt w/o dye w/ca test,75571,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,179.57,,,,,,,fee schedule,179.57,377.61, Ct hrt w/3d image,75572,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,773.14,,,,,,,fee schedule,410,773.14, Ct hrt w/3d image,75572,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,410,,,,,,,fee schedule,410,773.14, Ct hrt w/3d image,75572,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,410,,,,,,,fee schedule,410,773.14, Ct hrt w/3d image congen,75573,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,989.52,,,,,,,fee schedule,410,989.52, Ct hrt w/3d image congen,75573,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,410,,,,,,,fee schedule,410,989.52, Ct hrt w/3d image congen,75573,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,410,,,,,,,fee schedule,410,989.52, Ct angio hrt w/3d image,75574,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1113.57,,,,,,,fee schedule,410,1113.57, Ct angio hrt w/3d image,75574,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,410,,,,,,,fee schedule,410,1113.57, Ct angio hrt w/3d image,75574,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,410,,,,,,,fee schedule,410,1113.57, Quan&char c athrosclrtc plaq,75577,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5008.08,,,,,,,fee schedule,5008.08,5008.08, N-invas est c ffr sw aly cta,75580,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4403.03,,,,,,,fee schedule,2241.41,4403.03, N-invas est c ffr sw aly cta,75580,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2241.41,,,,,,,fee schedule,2241.41,4403.03, N-invas est c ffr sw aly cta,75580,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2241.41,,,,,,,fee schedule,2241.41,4403.03, Contrast exam thoracic aorta,75600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,794.56,,,,,,,fee schedule,794.56,6235.38, Contrast exam thoracic aorta,75600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6235.38,,,,,,,fee schedule,794.56,6235.38, Contrast exam thoracic aorta,75600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,6235.38,,,,,,,fee schedule,794.56,6235.38, Contrast exam thoracic aorta,75605,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,356.89,,,,,,,fee schedule,356.89,10341.43, Contrast exam thoracic aorta,75605,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10341.43,,,,,,,fee schedule,356.89,10341.43, Contrast exam thoracic aorta,75605,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,10341.43,,,,,,,fee schedule,356.89,10341.43, Contrast exam abdominl aorta,75625,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,307.68,,,,,,,fee schedule,307.68,6235.38, Contrast exam abdominl aorta,75625,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6235.38,,,,,,,fee schedule,307.68,6235.38, Contrast exam abdominl aorta,75625,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,6235.38,,,,,,,fee schedule,307.68,6235.38, X-ray aorta leg arteries,75630,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,334.5,,,,,,,fee schedule,334.5,6235.38, X-ray aorta leg arteries,75630,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6235.38,,,,,,,fee schedule,334.5,6235.38, X-ray aorta leg arteries,75630,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,6235.38,,,,,,,fee schedule,334.5,6235.38, Ct Angio Abdominal Arteries,75635,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1560.79,,,,,,,fee schedule,410,1560.79, Ct Angio Abdominal Arteries,75635,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,410,,,,,,,fee schedule,410,1560.79, Ct Angio Abdominal Arteries,75635,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,410,,,,,,,fee schedule,410,1560.79, Artery x-rays spine,75705,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,869.62,,,,,,,fee schedule,869.62,10341.43, Artery x-rays spine,75705,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10341.43,,,,,,,fee schedule,869.62,10341.43, Artery x-rays spine,75705,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,10341.43,,,,,,,fee schedule,869.62,10341.43, Artery x-rays arm/leg,75710,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,356.89,,,,,,,fee schedule,356.89,6235.38, Artery x-rays arm/leg,75710,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6235.38,,,,,,,fee schedule,356.89,6235.38, Artery x-rays arm/leg,75710,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,6235.38,,,,,,,fee schedule,356.89,6235.38, Artery x-rays arms/legs,75716,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,375.89,,,,,,,fee schedule,375.89,6235.38, Artery x-rays arms/legs,75716,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6235.38,,,,,,,fee schedule,375.89,6235.38, Artery x-rays arms/legs,75716,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,6235.38,,,,,,,fee schedule,375.89,6235.38, Artery x-rays abdomen,75726,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,398.28,,,,,,,fee schedule,398.28,10341.43, Artery x-rays abdomen,75726,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10341.43,,,,,,,fee schedule,398.28,10341.43, Artery x-rays abdomen,75726,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,10341.43,,,,,,,fee schedule,398.28,10341.43, Artery x-rays adrenal gland,75731,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,511.27,,,,,,,fee schedule,511.27,3670.04, Artery x-rays adrenal gland,75731,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3670.04,,,,,,,fee schedule,511.27,3670.04, Artery x-rays adrenal gland,75731,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3670.04,,,,,,,fee schedule,511.27,3670.04, Artery x-rays adrenals,75733,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,598.36,,,,,,,fee schedule,598.36,6235.38, Artery x-rays adrenals,75733,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6235.38,,,,,,,fee schedule,598.36,6235.38, Artery x-rays adrenals,75733,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,6235.38,,,,,,,fee schedule,598.36,6235.38, Artery x-rays pelvis,75736,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,483.7,,,,,,,fee schedule,483.7,10341.43, Artery x-rays pelvis,75736,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10341.43,,,,,,,fee schedule,483.7,10341.43, Artery x-rays pelvis,75736,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,10341.43,,,,,,,fee schedule,483.7,10341.43, Artery x-rays lung,75741,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,360.34,,,,,,,fee schedule,360.34,6235.38, Artery x-rays lung,75741,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6235.38,,,,,,,fee schedule,360.34,6235.38, Artery x-rays lung,75741,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,6235.38,,,,,,,fee schedule,360.34,6235.38, Artery x-rays lungs,75743,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,370.71,,,,,,,fee schedule,370.71,6235.38, Artery x-rays lungs,75743,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6235.38,,,,,,,fee schedule,370.71,6235.38, Artery x-rays lungs,75743,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,6235.38,,,,,,,fee schedule,370.71,6235.38, Artery x-rays lung,75746,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,430.98,,,,,,,fee schedule,430.98,3670.04, Artery x-rays lung,75746,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3670.04,,,,,,,fee schedule,430.98,3670.04, Artery x-rays lung,75746,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3670.04,,,,,,,fee schedule,430.98,3670.04, Artery x-rays chest,75756,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,587.08,,,,,,,fee schedule,587.08,6235.38, Artery x-rays chest,75756,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6235.38,,,,,,,fee schedule,587.08,6235.38, Artery x-rays chest,75756,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,6235.38,,,,,,,fee schedule,587.08,6235.38, Artery x-ray each vessel,75774,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,262.89,,,,,,,fee schedule,262.89,262.89, Lymph vessel x-ray arm/leg,75801,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1418.65,,,,,,,fee schedule,1418.65,1418.65, Lymph vessel x-ray arm/leg,75801,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1418.65,,,,,,,fee schedule,1418.65,1418.65, Lymph vessel x-ray arms/legs,75803,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3670.04,,,,,,,fee schedule,3670.04,3670.04, Lymph vessel x-ray arms/legs,75803,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3670.04,,,,,,,fee schedule,3670.04,3670.04, Lymph vessel x-ray trunk,75805,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3670.04,,,,,,,fee schedule,3670.04,3670.04, Lymph vessel x-ray trunk,75805,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3670.04,,,,,,,fee schedule,3670.04,3670.04, Lymph vessel x-ray trunk,75807,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6235.38,,,,,,,fee schedule,6235.38,6235.38, Lymph vessel x-ray trunk,75807,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,6235.38,,,,,,,fee schedule,6235.38,6235.38, Nonvascular shunt x-ray,75809,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,319.77,,,,,,,fee schedule,252.18,319.77, Nonvascular shunt x-ray,75809,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,252.18,319.77, Nonvascular shunt x-ray,75809,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,252.18,319.77, Vein x-ray spleen/liver,75810,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3670.04,,,,,,,fee schedule,3670.04,3670.04, Vein x-ray spleen/liver,75810,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3670.04,,,,,,,fee schedule,3670.04,3670.04, Vein x-ray arm/leg,75820,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,305.95,,,,,,,fee schedule,305.95,1418.65, Vein x-ray arm/leg,75820,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1418.65,,,,,,,fee schedule,305.95,1418.65, Vein x-ray arm/leg,75820,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1418.65,,,,,,,fee schedule,305.95,1418.65, Vein x-ray arms/legs,75822,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,340.43,,,,,,,fee schedule,340.43,3670.04, Vein x-ray arms/legs,75822,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3670.04,,,,,,,fee schedule,340.43,3670.04, Vein x-ray arms/legs,75822,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3670.04,,,,,,,fee schedule,340.43,3670.04, Vein x-ray trunk,75825,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,318.04,,,,,,,fee schedule,318.04,6235.38, Vein x-ray trunk,75825,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6235.38,,,,,,,fee schedule,318.04,6235.38, Vein x-ray trunk,75825,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,6235.38,,,,,,,fee schedule,318.04,6235.38, Vein x-ray chest,75827,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,342.16,,,,,,,fee schedule,342.16,1418.65, Vein x-ray chest,75827,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1418.65,,,,,,,fee schedule,342.16,1418.65, Vein x-ray chest,75827,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1418.65,,,,,,,fee schedule,342.16,1418.65, Vein x-ray kidney,75831,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,356.89,,,,,,,fee schedule,356.89,6235.38, Vein x-ray kidney,75831,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6235.38,,,,,,,fee schedule,356.89,6235.38, Vein x-ray kidney,75831,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,6235.38,,,,,,,fee schedule,356.89,6235.38, Vein x-ray kidneys,75833,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,439.61,,,,,,,fee schedule,439.61,6235.38, Vein x-ray kidneys,75833,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6235.38,,,,,,,fee schedule,439.61,6235.38, Vein x-ray kidneys,75833,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,6235.38,,,,,,,fee schedule,439.61,6235.38, Vein x-ray adrenal gland,75840,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,379.28,,,,,,,fee schedule,379.28,6235.38, Vein x-ray adrenal gland,75840,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6235.38,,,,,,,fee schedule,379.28,6235.38, Vein x-ray adrenal gland,75840,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,6235.38,,,,,,,fee schedule,379.28,6235.38, Vein x-ray adrenal glands,75842,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10341.43,,,,,,,fee schedule,10341.43,10341.43, Vein x-ray adrenal glands,75842,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,10341.43,,,,,,,fee schedule,10341.43,10341.43, Vein x-ray neck,75860,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,394.83,,,,,,,fee schedule,394.83,6235.38, Vein x-ray neck,75860,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6235.38,,,,,,,fee schedule,394.83,6235.38, Vein x-ray neck,75860,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,6235.38,,,,,,,fee schedule,394.83,6235.38, Vein x-ray skull,75870,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,629.17,,,,,,,fee schedule,629.17,3670.04, Vein x-ray skull,75870,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3670.04,,,,,,,fee schedule,629.17,3670.04, Vein x-ray skull,75870,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3670.04,,,,,,,fee schedule,629.17,3670.04, Vein x-ray skull epidural,75872,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,379.28,,,,,,,fee schedule,379.28,1418.65, Vein x-ray skull epidural,75872,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1418.65,,,,,,,fee schedule,379.28,1418.65, Vein x-ray skull epidural,75872,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1418.65,,,,,,,fee schedule,379.28,1418.65, Vein x-ray eye socket,75880,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,377.61,,,,,,,fee schedule,377.61,1418.65, Vein x-ray eye socket,75880,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1418.65,,,,,,,fee schedule,377.61,1418.65, Vein x-ray eye socket,75880,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1418.65,,,,,,,fee schedule,377.61,1418.65, Vein x-ray liver w/hemodynam,75885,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,372.43,,,,,,,fee schedule,372.43,6235.38, Vein x-ray liver w/hemodynam,75885,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6235.38,,,,,,,fee schedule,372.43,6235.38, Vein x-ray liver w/hemodynam,75885,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,6235.38,,,,,,,fee schedule,372.43,6235.38, Vein x-ray liver w/o hemodyn,75887,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,374.16,,,,,,,fee schedule,374.16,3670.04, Vein x-ray liver w/o hemodyn,75887,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3670.04,,,,,,,fee schedule,374.16,3670.04, Vein x-ray liver w/o hemodyn,75887,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3670.04,,,,,,,fee schedule,374.16,3670.04, Vein x-ray liver w/hemodynam,75889,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,374.16,,,,,,,fee schedule,374.16,6235.38, Vein x-ray liver w/hemodynam,75889,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6235.38,,,,,,,fee schedule,374.16,6235.38, Vein x-ray liver w/hemodynam,75889,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,6235.38,,,,,,,fee schedule,374.16,6235.38, Vein x-ray liver,75891,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,375.89,,,,,,,fee schedule,375.89,6235.38, Vein x-ray liver,75891,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6235.38,,,,,,,fee schedule,375.89,6235.38, Vein x-ray liver,75891,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,6235.38,,,,,,,fee schedule,375.89,6235.38, Venous sampling by catheter,75893,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,437.89,,,,,,,fee schedule,437.89,10341.43, Venous sampling by catheter,75893,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10341.43,,,,,,,fee schedule,437.89,10341.43, Venous sampling by catheter,75893,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,10341.43,,,,,,,fee schedule,437.89,10341.43, X-rays transcath therapy,75894,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,978.19,,,,,,,fee schedule,978.19,978.19, Follow-up angiography,75898,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,861.74,,,,,,,fee schedule,861.74,3670.04, Follow-up angiography,75898,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3670.04,,,,,,,fee schedule,861.74,3670.04, Follow-up angiography,75898,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3670.04,,,,,,,fee schedule,861.74,3670.04, Remove cva device obstruct,75901,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1061.61,,,,,,,fee schedule,1061.61,1061.61, Remove cva lumen obstruct,75902,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,352.47,,,,,,,fee schedule,352.47,352.47, Xray control catheter change,75984,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,293.92,,,,,,,fee schedule,293.92,293.92, Abscess drainage under x-ray,75989,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,300.77,,,,,,,fee schedule,300.77,300.77, Fluoroscope examination,76000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,149.15,,,,,,,fee schedule,149.15,524.34, Fluoroscope examination,76000,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,524.34,,,,,,,fee schedule,149.15,524.34, Fluoroscope examination,76000,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,524.34,,,,,,,fee schedule,149.15,524.34, X-ray nose to rectum,76010,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,106.09,,,,,,,fee schedule,106.09,179.57, X-ray nose to rectum,76010,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,179.57,,,,,,,fee schedule,106.09,179.57, X-ray nose to rectum,76010,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,179.57,,,,,,,fee schedule,106.09,179.57, Mr sfty implt&/fb asmt stf 1,76014,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,57.85,,,,,,,fee schedule,55.1,57.85, Mr sfty implt&/fb asmt stf 1,76014,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,55.1,,,,,,,fee schedule,55.1,57.85, Mr sfty implt&/fb asmt stf 1,76014,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,55.1,,,,,,,fee schedule,55.1,57.85, Mr sfty mplt&/fb asmt stf ea,76015,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,279.89,,,,,,,fee schedule,279.89,279.89, Mr safety deter phys/qhp,76016,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,229.38,,,,,,,fee schedule,198.11,229.38, Mr safety deter phys/qhp,76016,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,198.11,,,,,,,fee schedule,198.11,229.38, Mr safety deter phys/qhp,76016,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,198.11,,,,,,,fee schedule,198.11,229.38, Mr sfty med physics xm cstmz,76017,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,971.77,,,,,,,fee schedule,543.87,971.77, Mr sfty med physics xm cstmz,76017,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,543.87,,,,,,,fee schedule,543.87,971.77, Mr sfty med physics xm cstmz,76017,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,543.87,,,,,,,fee schedule,543.87,971.77, Mr safety implant elec prepj,76018,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,416.25,,,,,,,fee schedule,206.53,416.25, Mr safety implant elec prepj,76018,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,206.53,,,,,,,fee schedule,206.53,416.25, Mr safety implant elec prepj,76018,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,206.53,,,,,,,fee schedule,206.53,416.25, Mr safety implt pos&/immoblj,76019,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,647.09,,,,,,,fee schedule,133.65,647.09, Mr safety implt pos&/immoblj,76019,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,133.65,,,,,,,fee schedule,133.65,647.09, Mr safety implt pos&/immoblj,76019,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,133.65,,,,,,,fee schedule,133.65,647.09, X-ray exam of fistula,76080,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,180.17,,,,,,,fee schedule,180.17,1083.56, X-ray exam of fistula,76080,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.56,,,,,,,fee schedule,180.17,1083.56, X-ray exam of fistula,76080,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1083.56,,,,,,,fee schedule,180.17,1083.56, X-ray exam breast specimen,76098,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,147.42,,,,,,,fee schedule,147.42,1083.56, X-ray exam breast specimen,76098,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.56,,,,,,,fee schedule,147.42,1083.56, X-ray exam breast specimen,76098,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1083.56,,,,,,,fee schedule,147.42,1083.56, X-ray exam of body section,76100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,305.95,,,,,,,fee schedule,252.18,305.95, X-ray exam of body section,76100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,252.18,305.95, X-ray exam of body section,76100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,252.18,305.95, Cine/video x-rays,76120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,490.33,,,,,,,fee schedule,252.18,490.33, Cine/video x-rays,76120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,252.18,490.33, Cine/video x-rays,76120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,252.18,490.33, Med physic dos eval rad exps,76145,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5410.57,,,,,,,fee schedule,285.46,5410.57, Med physic dos eval rad exps,76145,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,285.46,,,,,,,fee schedule,285.46,5410.57, Med physic dos eval rad exps,76145,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,285.46,,,,,,,fee schedule,285.46,5410.57, 3d render w/intrp postproces,76376,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,83.69,,,,,,,fee schedule,83.69,83.69, 3d render w/intrp postproces,76377,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,217.35,,,,,,,fee schedule,217.35,217.35, CAT scan follow-up study,76380,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,452.4,,,,,,,fee schedule,179.57,452.4, CAT scan follow-up study,76380,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,179.57,,,,,,,fee schedule,179.57,452.4, CAT scan follow-up study,76380,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,179.57,,,,,,,fee schedule,179.57,452.4, Mr spectroscopy,76390,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,810.38,,,,,,,fee schedule,810.38,810.38, Mr spectroscopy,76390,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,810.38,,,,,,,fee schedule,810.38,810.38, Mr elastography,76391,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,761.81,,,,,,,fee schedule,524.34,761.81, Mr elastography,76391,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,524.34,,,,,,,fee schedule,524.34,761.81, Mr elastography,76391,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,524.34,,,,,,,fee schedule,524.34,761.81, Fluoroscopic procedure,76496,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,179.57,,,,,,,fee schedule,179.57,179.57, Fluoroscopic procedure,76496,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,179.57,,,,,,,fee schedule,179.57,179.57, Ct procedure,76497,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,179.57,,,,,,,fee schedule,179.57,179.57, Ct procedure,76497,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,179.57,,,,,,,fee schedule,179.57,179.57, Mri procedure,76498,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,179.57,,,,,,,fee schedule,179.57,179.57, Mri procedure,76498,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,179.57,,,,,,,fee schedule,179.57,179.57, Radiographic procedure,76499,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,179.57,,,,,,,fee schedule,179.57,179.57, Radiographic procedure,76499,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,179.57,,,,,,,fee schedule,179.57,179.57, Echo exam of head,76506,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,411.07,,,,,,,fee schedule,252.18,411.07, Echo exam of head,76506,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,252.18,411.07, Echo exam of head,76506,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,252.18,411.07, Ophth us b & quant a,76510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,157.78,,,,,,,fee schedule,157.78,245.32, Ophth us b & quant a,76510,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,245.32,,,,,,,fee schedule,157.78,245.32, Ophth us b & quant a,76510,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,245.32,,,,,,,fee schedule,157.78,245.32, Ophth us quant a only,76511,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,116.45,,,,,,,fee schedule,116.45,252.18, Ophth us quant a only,76511,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,116.45,252.18, Ophth us quant a only,76511,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,116.45,252.18, Ophth us b w/non-quant a,76512,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,95.73,,,,,,,fee schedule,95.73,252.18, Ophth us b w/non-quant a,76512,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,95.73,252.18, Ophth us b w/non-quant a,76512,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,95.73,252.18, Echo exam of eye water bath,76513,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,228.41,,,,,,,fee schedule,228.41,252.18, Echo exam of eye water bath,76513,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,228.41,252.18, Echo exam of eye water bath,76513,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,228.41,252.18, Echo exam of eye thickness,76514,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,21.64,,,,,,,fee schedule,21.64,51.73, Echo exam of eye thickness,76514,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,51.73,,,,,,,fee schedule,21.64,51.73, Echo exam of eye thickness,76514,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,51.73,,,,,,,fee schedule,21.64,51.73, Echo exam of eye,76516,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,131.93,,,,,,,fee schedule,131.93,252.18, Echo exam of eye,76516,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,131.93,252.18, Echo exam of eye,76516,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,131.93,252.18, Echo exam of eye,76519,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,204.29,,,,,,,fee schedule,204.29,252.18, Echo exam of eye,76519,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,204.29,252.18, Echo exam of eye,76519,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,204.29,252.18, Echo exam of eye,76529,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,285.29,,,,,,,fee schedule,179.57,285.29, Echo exam of eye,76529,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,179.57,,,,,,,fee schedule,179.57,285.29, Echo exam of eye,76529,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,179.57,,,,,,,fee schedule,179.57,285.29, Us exam of head and neck,76536,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,424.83,,,,,,,fee schedule,252.18,424.83, Us exam of head and neck,76536,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,252.18,424.83, Us exam of head and neck,76536,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,252.18,424.83, Us exam chest,76604,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,173.27,,,,,,,fee schedule,173.27,252.18, Us exam chest,76604,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,173.27,252.18, Us exam chest,76604,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,173.27,252.18, Ultrasound breast complete,76641,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,343.89,,,,,,,fee schedule,252.18,343.89, Ultrasound breast complete,76641,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,252.18,343.89, Ultrasound breast complete,76641,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,252.18,343.89, Ultrasound breast limited,76642,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,269.8,,,,,,,fee schedule,179.57,269.8, Ultrasound breast limited,76642,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,179.57,,,,,,,fee schedule,179.57,269.8, Ultrasound breast limited,76642,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,179.57,,,,,,,fee schedule,179.57,269.8, Us exam abdom complete,76700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,398.28,,,,,,,fee schedule,252.18,398.28, Us exam abdom complete,76700,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,252.18,398.28, Us exam abdom complete,76700,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,252.18,398.28, Echo exam of abdomen,76705,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,304.23,,,,,,,fee schedule,252.18,304.23, Echo exam of abdomen,76705,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,252.18,304.23, Echo exam of abdomen,76705,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,252.18,304.23, Us abdl aorta screen aaa,76706,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,414.52,,,,,,,fee schedule,252.18,414.52, Us abdl aorta screen aaa,76706,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,252.18,414.52, Us abdl aorta screen aaa,76706,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,252.18,414.52, Us exam abdo back wall comp,76770,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,373.13,,,,,,,fee schedule,252.18,373.13, Us exam abdo back wall comp,76770,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,252.18,373.13, Us exam abdo back wall comp,76770,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,252.18,373.13, Us exam abdo back wall lim,76775,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,174.99,,,,,,,fee schedule,174.99,252.18, Us exam abdo back wall lim,76775,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,174.99,252.18, Us exam abdo back wall lim,76775,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,174.99,252.18, Us exam k transpl w/doppler,76776,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,561.94,,,,,,,fee schedule,252.18,561.94, Us exam k transpl w/doppler,76776,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,252.18,561.94, Us exam k transpl w/doppler,76776,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,252.18,561.94, Us exam spinal canal,76800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,650.54,,,,,,,fee schedule,252.18,650.54, Us exam spinal canal,76800,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,252.18,650.54, Us exam spinal canal,76800,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,252.18,650.54, Ob us < 14 wks single fetus,76801,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,364.55,,,,,,,fee schedule,252.18,364.55, Ob us < 14 wks single fetus,76801,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,252.18,364.55, Ob us < 14 wks single fetus,76801,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,252.18,364.55, Ob us < 14 wks addl fetus,76802,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,108.57,,,,,,,fee schedule,108.57,108.57, Ob us >/= 14 wks sngl fetus,76805,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,460.28,,,,,,,fee schedule,252.18,460.28, Ob us >/= 14 wks sngl fetus,76805,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,252.18,460.28, Ob us >/= 14 wks sngl fetus,76805,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,252.18,460.28, Ob us >/= 14 wks addl fetus,76810,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,214.65,,,,,,,fee schedule,214.65,214.65, Ob us detailed sngl fetus,76811,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,475.06,,,,,,,fee schedule,475.06,524.34, Ob us detailed sngl fetus,76811,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,524.34,,,,,,,fee schedule,475.06,524.34, Ob us detailed sngl fetus,76811,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,524.34,,,,,,,fee schedule,475.06,524.34, Ob us detailed addl fetus,76812,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,563.67,,,,,,,fee schedule,563.67,563.67, Ob us nuchal meas 1 gest,76813,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,305.95,,,,,,,fee schedule,252.18,305.95, Ob us nuchal meas 1 gest,76813,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,252.18,305.95, Ob us nuchal meas 1 gest,76813,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,252.18,305.95, Ob us nuchal meas add-on,76814,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,141.27,,,,,,,fee schedule,141.27,141.27, Ob us limited fetus(s),76815,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,262.89,,,,,,,fee schedule,252.18,262.89, Ob us limited fetus(s),76815,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,252.18,262.89, Ob us limited fetus(s),76815,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,252.18,262.89, Ob us follow-up per fetus,76816,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,364.55,,,,,,,fee schedule,252.18,364.55, Ob us follow-up per fetus,76816,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,252.18,364.55, Ob us follow-up per fetus,76816,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,252.18,364.55, Transvaginal us obstetric,76817,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,297.32,,,,,,,fee schedule,252.18,297.32, Transvaginal us obstetric,76817,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,252.18,297.32, Transvaginal us obstetric,76817,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,252.18,297.32, Fetal biophys profile w/nst,76818,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,372.43,,,,,,,fee schedule,252.18,372.43, Fetal biophys profile w/nst,76818,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,252.18,372.43, Fetal biophys profile w/nst,76818,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,252.18,372.43, Fetal biophys profil w/o nst,76819,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,265.59,,,,,,,fee schedule,252.18,265.59, Fetal biophys profil w/o nst,76819,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,252.18,265.59, Fetal biophys profil w/o nst,76819,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,252.18,265.59, Umbilical artery echo,76820,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,109.54,,,,,,,fee schedule,109.54,252.18, Umbilical artery echo,76820,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,109.54,252.18, Umbilical artery echo,76820,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,109.54,252.18, Middle cerebral artery echo,76821,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,293.92,,,,,,,fee schedule,252.18,293.92, Middle cerebral artery echo,76821,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,252.18,293.92, Middle cerebral artery echo,76821,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,252.18,293.92, Echo exam of fetal heart,76825,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,947.16,,,,,,,fee schedule,947.16,1083.56, Echo exam of fetal heart,76825,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.56,,,,,,,fee schedule,947.16,1083.56, Echo exam of fetal heart,76825,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1083.56,,,,,,,fee schedule,947.16,1083.56, Echo exam of fetal heart,76826,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,615.36,,,,,,,fee schedule,524.34,615.36, Echo exam of fetal heart,76826,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,524.34,,,,,,,fee schedule,524.34,615.36, Echo exam of fetal heart,76826,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,524.34,,,,,,,fee schedule,524.34,615.36, Echo exam of fetal heart,76827,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,219.83,,,,,,,fee schedule,219.83,252.18, Echo exam of fetal heart,76827,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,219.83,252.18, Echo exam of fetal heart,76827,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,219.83,252.18, Echo exam of fetal heart,76828,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,118.17,,,,,,,fee schedule,118.17,252.18, Echo exam of fetal heart,76828,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,118.17,252.18, Echo exam of fetal heart,76828,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,118.17,252.18, Transvaginal us non-ob,76830,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,441.34,,,,,,,fee schedule,252.18,441.34, Transvaginal us non-ob,76830,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,252.18,441.34, Transvaginal us non-ob,76830,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,252.18,441.34, Echo exam uterus,76831,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,426.55,,,,,,,fee schedule,426.55,524.34, Echo exam uterus,76831,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,524.34,,,,,,,fee schedule,426.55,524.34, Echo exam uterus,76831,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,524.34,,,,,,,fee schedule,426.55,524.34, Us exam pelvic complete,76856,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,376.59,,,,,,,fee schedule,252.18,376.59, Us exam pelvic complete,76856,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,252.18,376.59, Us exam pelvic complete,76856,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,252.18,376.59, Us exam pelvic limited,76857,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,142.29,,,,,,,fee schedule,142.29,252.18, Us exam pelvic limited,76857,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,142.29,252.18, Us exam pelvic limited,76857,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,142.29,252.18, Us exam scrotum,76870,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,355.92,,,,,,,fee schedule,252.18,355.92, Us exam scrotum,76870,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,252.18,355.92, Us exam scrotum,76870,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,252.18,355.92, Us transrectal,76872,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,458.55,,,,,,,fee schedule,252.18,458.55, Us transrectal,76872,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,252.18,458.55, Us transrectal,76872,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,252.18,458.55, Echograp trans r pros study,76873,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,530.91,,,,,,,fee schedule,252.18,530.91, Echograp trans r pros study,76873,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,252.18,530.91, Echograp trans r pros study,76873,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,252.18,530.91, Us xtr non-vasc complete,76881,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,57.85,,,,,,,fee schedule,57.85,252.18, Us xtr non-vasc complete,76881,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,57.85,252.18, Us xtr non-vasc complete,76881,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,57.85,252.18, Us xtr non-vasc lmtd,76882,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,166.41,,,,,,,fee schedule,166.41,252.18, Us xtr non-vasc lmtd,76882,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,166.41,252.18, Us xtr non-vasc lmtd,76882,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,166.41,252.18, Us nrv&acc strux 1xtr compre,76883,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,85.42,,,,,,,fee schedule,85.42,240.48, Us nrv&acc strux 1xtr compre,76883,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,240.48,,,,,,,fee schedule,85.42,240.48, Us nrv&acc strux 1xtr compre,76883,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,240.48,,,,,,,fee schedule,85.42,240.48, Us exam infant hips dynamic,76885,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,505.07,,,,,,,fee schedule,179.57,505.07, Us exam infant hips dynamic,76885,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,179.57,,,,,,,fee schedule,179.57,505.07, Us exam infant hips dynamic,76885,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,179.57,,,,,,,fee schedule,179.57,505.07, Us exam infant hips static,76886,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,354.19,,,,,,,fee schedule,179.57,354.19, Us exam infant hips static,76886,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,179.57,,,,,,,fee schedule,179.57,354.19, Us exam infant hips static,76886,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,179.57,,,,,,,fee schedule,179.57,354.19, Echo guide for artery repair,76936,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,890.29,,,,,,,fee schedule,569.48,890.29, Echo guide for artery repair,76936,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,569.48,,,,,,,fee schedule,569.48,890.29, Echo guide for artery repair,76936,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,569.48,,,,,,,fee schedule,569.48,890.29, Us guide vascular access,76937,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,138.84,,,,,,,fee schedule,138.84,138.84, Echo guide for biopsy,76942,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,169.87,,,,,,,fee schedule,169.87,169.87, Echo guide for amniocentesis,76946,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,81.97,,,,,,,fee schedule,81.97,81.97, Echo guide ova aspiration,76948,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,259.44,,,,,,,fee schedule,259.44,259.44, Echo guidance radiotherapy,76965,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,149.15,,,,,,,fee schedule,149.15,149.15, GI endoscopic ultrasound,76975,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,524.34,,,,,,,fee schedule,524.34,524.34, GI endoscopic ultrasound,76975,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,524.34,,,,,,,fee schedule,524.34,524.34, Us bone density measure,76977,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,26.82,,,,,,,fee schedule,26.82,252.18, Us bone density measure,76977,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,26.82,252.18, Us bone density measure,76977,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,26.82,252.18, Us trgt dyn mbubb 1st les,76978,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,501.67,,,,,,,fee schedule,410,501.67, Us trgt dyn mbubb 1st les,76978,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,410,,,,,,,fee schedule,410,501.67, Us trgt dyn mbubb 1st les,76978,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,410,,,,,,,fee schedule,410,501.67, Us trgt dyn mbubb ea addl,76979,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,349.01,,,,,,,fee schedule,349.01,349.01, Use parenchyma,76981,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,431.73,,,,,,,fee schedule,252.18,431.73, Use parenchyma,76981,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,252.18,431.73, Use parenchyma,76981,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,252.18,431.73, Use 1st target lesion,76982,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,333.53,,,,,,,fee schedule,252.18,333.53, Use 1st target lesion,76982,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,252.18,333.53, Use 1st target lesion,76982,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,252.18,333.53, Use ea addl target lesion,76983,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,190.53,,,,,,,fee schedule,190.53,190.53, Echo examination procedure,76999,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,179.57,,,,,,,fee schedule,179.57,179.57, Echo examination procedure,76999,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,179.57,,,,,,,fee schedule,179.57,179.57, Fluoroguide for Vein Device,77001,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,417.97,,,,,,,fee schedule,417.97,417.97, Needle localization by xray,77002,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,486.88,,,,,,,fee schedule,486.88,486.88, Fluoroguide for Spine Inject,77003,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,393.85,,,,,,,fee schedule,393.85,393.85, CT Scan for Localization,77011,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,833.2,,,,,,,fee schedule,833.2,833.2, Ct scan for needle biopsy,77012,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,288.74,,,,,,,fee schedule,288.74,288.74, MR Guidance for Needle Place,77021,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1842.14,,,,,,,fee schedule,1842.14,1842.14, Mri breast c- unilateral,77046,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,760.08,,,,,,,fee schedule,524.34,760.08, Mri breast c- unilateral,77046,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,524.34,,,,,,,fee schedule,524.34,760.08, Mri breast c- unilateral,77046,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,524.34,,,,,,,fee schedule,524.34,760.08, Mri breast c- bilateral,77047,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,741.14,,,,,,,fee schedule,524.34,741.14, Mri breast c- bilateral,77047,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,524.34,,,,,,,fee schedule,524.34,741.14, Mri breast c- bilateral,77047,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,524.34,,,,,,,fee schedule,524.34,741.14, Mri breast c-+ w/cad uni,77048,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1226.29,,,,,,,fee schedule,646.36,1226.29, Mri breast c-+ w/cad uni,77048,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,646.36,,,,,,,fee schedule,646.36,1226.29, Mri breast c-+ w/cad uni,77048,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,646.36,,,,,,,fee schedule,646.36,1226.29, Mri breast c-+ w/cad bi,77049,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1209.08,,,,,,,fee schedule,643.93,1209.08, Mri breast c-+ w/cad bi,77049,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,643.93,,,,,,,fee schedule,643.93,1209.08, Mri breast c-+ w/cad bi,77049,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,643.93,,,,,,,fee schedule,643.93,1209.08, X-Ray of Mammary Duct,77053,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,188.81,,,,,,,fee schedule,188.81,524.34, X-Ray of Mammary Duct,77053,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,524.34,,,,,,,fee schedule,188.81,524.34, X-Ray of Mammary Duct,77053,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,524.34,,,,,,,fee schedule,188.81,524.34, X-ray of mammary ducts,77054,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,245.68,,,,,,,fee schedule,245.68,524.34, X-ray of mammary ducts,77054,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,524.34,,,,,,,fee schedule,245.68,524.34, X-ray of mammary ducts,77054,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,524.34,,,,,,,fee schedule,245.68,524.34, Breast tomosynthesis uni,77061,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,212.74,,,,,,,fee schedule,212.74,212.74, Breast tomosynthesis uni,77061,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,212.74,,,,,,,fee schedule,212.74,212.74, Breast tomosynthesis bi,77062,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,271.22,,,,,,,fee schedule,271.22,271.22, Breast tomosynthesis bi,77062,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,271.22,,,,,,,fee schedule,271.22,271.22, Breast tomosynthesis bi,77063,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,120.6,,,,,,,fee schedule,56.84,120.6, Breast tomosynthesis bi,77063,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56.84,,,,,,,fee schedule,56.84,120.6, Breast tomosynthesis bi,77063,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,56.84,,,,,,,fee schedule,56.84,120.6, Dx mammo incl cad uni,77065,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,445.55,,,,,,,fee schedule,212.74,445.55, Dx mammo incl cad uni,77065,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,212.74,,,,,,,fee schedule,212.74,445.55, Dx mammo incl cad uni,77065,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,212.74,,,,,,,fee schedule,212.74,445.55, Dx mammo incl cad bi,77066,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,572.3,,,,,,,fee schedule,271.22,572.3, Dx mammo incl cad bi,77066,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,271.22,,,,,,,fee schedule,271.22,572.3, Dx mammo incl cad bi,77066,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,271.22,,,,,,,fee schedule,271.22,572.3, Scr mammo bi incl cad,77067,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,471.39,,,,,,,fee schedule,224.93,471.39, Scr mammo bi incl cad,77067,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,224.93,,,,,,,fee schedule,224.93,471.39, Scr mammo bi incl cad,77067,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,224.93,,,,,,,fee schedule,224.93,471.39, X-Ray Stress View,77071,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,311.62,,,,,,,fee schedule,179.57,311.62, X-Ray Stress View,77071,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,179.57,,,,,,,fee schedule,179.57,311.62, X-Ray Stress View,77071,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,179.57,,,,,,,fee schedule,179.57,311.62, X-Rays for Bone Age,77072,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,85.42,,,,,,,fee schedule,85.42,252.18, X-Rays for Bone Age,77072,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,85.42,252.18, X-Rays for Bone Age,77072,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,85.42,252.18, X-rays bone length studies,77073,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,173.27,,,,,,,fee schedule,173.27,252.18, X-rays bone length studies,77073,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,173.27,252.18, X-rays bone length studies,77073,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,173.27,252.18, X-rays bone survey limited,77074,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,228.41,,,,,,,fee schedule,228.41,252.18, X-rays bone survey limited,77074,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,228.41,252.18, X-rays bone survey limited,77074,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,228.41,252.18, X-rays bone survey complete,77075,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,374.16,,,,,,,fee schedule,252.18,374.16, X-rays bone survey complete,77075,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,252.18,374.16, X-rays bone survey complete,77075,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,252.18,374.16, X-rays bone survey infant,77076,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,375.89,,,,,,,fee schedule,252.18,375.89, X-rays bone survey infant,77076,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,252.18,375.89, X-rays bone survey infant,77076,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,252.18,375.89, Joint survey single view,77077,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,161.23,,,,,,,fee schedule,161.23,252.18, Joint survey single view,77077,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,161.23,252.18, Joint survey single view,77077,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,161.23,252.18, Ct bone density axial,77078,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,452.4,,,,,,,fee schedule,179.57,452.4, Ct bone density axial,77078,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,179.57,,,,,,,fee schedule,179.57,452.4, Ct bone density axial,77078,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,179.57,,,,,,,fee schedule,179.57,452.4, Dxa bone density axial,77080,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,156.05,,,,,,,fee schedule,156.05,252.18, Dxa bone density axial,77080,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,156.05,252.18, Dxa bone density axial,77080,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,156.05,252.18, Dxa bone density/peripheral,77081,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,116.45,,,,,,,fee schedule,116.45,179.57, Dxa bone density/peripheral,77081,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,179.57,,,,,,,fee schedule,116.45,179.57, Dxa bone density/peripheral,77081,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,179.57,,,,,,,fee schedule,116.45,179.57, Magnetic image bone marrow,77084,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1241.78,,,,,,,fee schedule,524.34,1241.78, Magnetic image bone marrow,77084,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,524.34,,,,,,,fee schedule,524.34,1241.78, Magnetic image bone marrow,77084,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,524.34,,,,,,,fee schedule,524.34,1241.78, Dxa bone density study,77085,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,208.72,,,,,,,fee schedule,208.72,252.18, Dxa bone density study,77085,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,208.72,252.18, Dxa bone density study,77085,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,208.72,252.18, Fracture assessment via dxa,77086,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,138.84,,,,,,,fee schedule,138.84,179.57, Fracture assessment via dxa,77086,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,179.57,,,,,,,fee schedule,138.84,179.57, Fracture assessment via dxa,77086,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,179.57,,,,,,,fee schedule,138.84,179.57, Tbs dxa cal w/i&r fx risk,77089,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,209.58,,,,,,,fee schedule,93.44,209.58, Tbs dxa cal w/i&r fx risk,77089,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,93.44,,,,,,,fee schedule,93.44,209.58, Tbs dxa cal w/i&r fx risk,77089,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,93.44,,,,,,,fee schedule,93.44,209.58, Tbs techl prep&transmis data,77090,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,16.51,,,,,,,fee schedule,16.51,185.87, Tbs techl prep&transmis data,77090,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,185.87,,,,,,,fee schedule,16.51,185.87, Tbs techl prep&transmis data,77090,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,185.87,,,,,,,fee schedule,16.51,185.87, Tbs techl calculation only,77091,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,138.84,,,,,,,fee schedule,138.84,185.87, Tbs techl calculation only,77091,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,185.87,,,,,,,fee schedule,138.84,185.87, Tbs techl calculation only,77091,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,185.87,,,,,,,fee schedule,138.84,185.87, Tbs i&r fx rsk qhp,77092,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,54.28,,,,,,,fee schedule,23.36,54.28, Tbs i&r fx rsk qhp,77092,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23.36,,,,,,,fee schedule,23.36,54.28, Tbs i&r fx rsk qhp,77092,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,23.36,,,,,,,fee schedule,23.36,54.28, Radiation therapy planning,77261,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,377.07,,,,,,,fee schedule,377.07,377.07, Radiation therapy planning,77262,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,580.39,,,,,,,fee schedule,580.39,580.39, Radiation therapy planning,77263,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,916.35,,,,,,,fee schedule,916.35,916.35, Set radiation therapy field,77280,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1200.18,,,,,,,fee schedule,1200.18,1200.18, Set radiation therapy field,77285,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2050.64,,,,,,,fee schedule,2050.64,2050.64, Set radiation therapy field,77290,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1858.65,,,,,,,fee schedule,1858.65,1858.65, Respirator motion mgmt simul,77293,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1538.18,,,,,,,fee schedule,1538.18,1538.18, 3-d radiotherapy plan,77295,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1350.83,,,,,,,fee schedule,1350.83,1350.83, Radiation therapy dose plan,77300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,178.45,,,,,,,fee schedule,178.45,178.45, Radiotherapy dose plan imrt,77301,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7985.49,,,,,,,fee schedule,7985.49,7985.49, Telethx isodose plan simple,77306,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,396.55,,,,,,,fee schedule,396.55,396.55, Telethx isodose plan cplx,77307,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,717.29,,,,,,,fee schedule,717.29,717.29, Brachytx isodose plan simple,77316,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,909.5,,,,,,,fee schedule,909.5,909.5, Brachytx isodose intermed,77317,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1193.06,,,,,,,fee schedule,1193.06,1193.06, Brachytx isodose complex,77318,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1611.03,,,,,,,fee schedule,1611.03,1611.03, Special teletx port plan,77321,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,231.87,,,,,,,fee schedule,231.87,231.87, Special radiation dosimetry,77331,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,100.91,,,,,,,fee schedule,100.91,100.91, Radiation treatment aid(s),77332,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,88.87,,,,,,,fee schedule,88.87,88.87, Radiation treatment aid(s),77333,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,509.27,,,,,,,fee schedule,509.27,509.27, Radiation treatment aid(s),77334,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,342.16,,,,,,,fee schedule,342.16,342.16, Radiation physics consult,77336,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,482.46,,,,,,,fee schedule,482.46,482.46, Design mlc device for imrt,77338,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1295.69,,,,,,,fee schedule,1295.69,1295.69, Radiation physics consult,77370,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,793.59,,,,,,,fee schedule,793.59,793.59, Srs linear based,77372,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4838.22,,,,,,,fee schedule,4838.22,4838.22, SBRT Delivery,77373,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5073.05,,,,,,,fee schedule,5073.05,5073.05, Guidance for radiaj tx dlvr,77387,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,196.14,,,,,,,fee schedule,196.14,196.14, Radiation treatment delivery,77402,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,425.85,,,,,,,fee schedule,425.85,425.85, Radiation treatment delivery,77407,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1604.88,,,,,,,fee schedule,1604.88,1604.88, Radiation treatment delivery,77412,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2295.08,,,,,,,fee schedule,2295.08,2295.08, Radiation tx management x5,77427,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1060.31,,,,,,,fee schedule,1060.31,1060.31, Radiation therapy management,77431,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,577.43,,,,,,,fee schedule,577.43,577.43, Stereotactic radiation trmt,77432,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2309.6,,,,,,,fee schedule,2309.6,2309.6, SBRT Management,77435,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3490.62,,,,,,,fee schedule,3490.62,3490.62, Surf radj ther tx planning,77436,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,190.53,,,,,,,fee schedule,190.53,190.53, Surf radj ther supfc<=150kv,77437,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,566.15,,,,,,,fee schedule,566.15,566.15, Surf rad thr orthvlt>150-500,77438,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,571.33,,,,,,,fee schedule,571.33,571.33, Surf rad thr img gdn us plmt,77439,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,85.09,,,,,,,fee schedule,85.09,85.09, Io radiation tx management,77469,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1462.86,,,,,,,fee schedule,1462.86,1462.86, Special radiation treatment,77470,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,201.86,,,,,,,fee schedule,201.86,201.86, Hyperthermia treatment,77600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2472.56,,,,,,,fee schedule,2472.56,2472.56, Hyperthermia treatment,77605,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4810.64,,,,,,,fee schedule,4810.64,4810.64, Hyperthermia treatment,77610,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3127.25,,,,,,,fee schedule,3127.25,3127.25, Hyperthermia treatment,77615,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4996.75,,,,,,,fee schedule,4996.75,4996.75, Hyperthermia treatment,77620,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3330.57,,,,,,,fee schedule,3330.57,3330.57, Infuse radioactive materials,77750,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,690.69,,,,,,,fee schedule,690.69,690.69, Apply intrcav radiat simple,77761,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1154.42,,,,,,,fee schedule,1154.42,1154.42, Apply intrcav radiat interm,77762,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1329.41,,,,,,,fee schedule,1329.41,1329.41, Apply intrcav radiat compl,77763,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1756.51,,,,,,,fee schedule,1756.51,1756.51, Hdr rdncl skn surf brachytx,77767,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1016.34,,,,,,,fee schedule,1016.34,1016.34, Hdr rdncl skn surf brachytx,77768,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1530.04,,,,,,,fee schedule,1530.04,1530.04, Hdr rdncl ntrstl/icav brchtx,77770,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1282.68,,,,,,,fee schedule,1282.68,1282.68, Hdr rdncl ntrstl/icav brchtx,77771,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2133.58,,,,,,,fee schedule,2133.58,2133.58, Hdr rdncl ntrstl/icav brchtx,77772,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3287.03,,,,,,,fee schedule,3287.03,3287.03, Apply interstit radiat compl,77778,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2455.56,,,,,,,fee schedule,2455.56,2455.56, Apply surf ldr radionuclide,77789,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,379.28,,,,,,,fee schedule,379.28,379.28, Radiation handling,77790,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,98.48,,,,,,,fee schedule,98.48,98.48, Thyroid uptake measurement,78012,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,371.68,,,,,,,fee schedule,371.68,828.29, Thyroid uptake measurement,78012,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,828.29,,,,,,,fee schedule,371.68,828.29, Thyroid uptake measurement,78012,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,828.29,,,,,,,fee schedule,371.68,828.29, Thyroid imaging w/blood flow,78013,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,773.14,,,,,,,fee schedule,773.14,828.29, Thyroid imaging w/blood flow,78013,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,828.29,,,,,,,fee schedule,773.14,828.29, Thyroid imaging w/blood flow,78013,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,828.29,,,,,,,fee schedule,773.14,828.29, Thyroid imaging w/blood flow,78014,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,973.98,,,,,,,fee schedule,828.29,973.98, Thyroid imaging w/blood flow,78014,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,828.29,,,,,,,fee schedule,828.29,973.98, Thyroid imaging w/blood flow,78014,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,828.29,,,,,,,fee schedule,828.29,973.98, Thyroid met imaging,78015,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,896.44,,,,,,,fee schedule,828.29,896.44, Thyroid met imaging,78015,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,828.29,,,,,,,fee schedule,828.29,896.44, Thyroid met imaging,78015,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,828.29,,,,,,,fee schedule,828.29,896.44, Thyroid met imaging/studies,78016,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1137.91,,,,,,,fee schedule,828.29,1137.91, Thyroid met imaging/studies,78016,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,828.29,,,,,,,fee schedule,828.29,1137.91, Thyroid met imaging/studies,78016,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,828.29,,,,,,,fee schedule,828.29,1137.91, Thyroid met imaging body,78018,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1229.96,,,,,,,fee schedule,1061.96,1229.96, Thyroid met imaging body,78018,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1061.96,,,,,,,fee schedule,1061.96,1229.96, Thyroid met imaging body,78018,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1061.96,,,,,,,fee schedule,1061.96,1229.96, Thyroid met uptake,78020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,275.95,,,,,,,fee schedule,275.95,275.95, Parathyroid planar imaging,78070,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1161.81,,,,,,,fee schedule,828.29,1161.81, Parathyroid planar imaging,78070,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,828.29,,,,,,,fee schedule,828.29,1161.81, Parathyroid planar imaging,78070,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,828.29,,,,,,,fee schedule,828.29,1161.81, Parathyrd planar w/wo subtrj,78071,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1323.05,,,,,,,fee schedule,828.29,1323.05, Parathyrd planar w/wo subtrj,78071,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,828.29,,,,,,,fee schedule,828.29,1323.05, Parathyrd planar w/wo subtrj,78071,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,828.29,,,,,,,fee schedule,828.29,1323.05, Parathyrd planar w/spect&ct,78072,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1615.94,,,,,,,fee schedule,1061.96,1615.94, Parathyrd planar w/spect&ct,78072,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1061.96,,,,,,,fee schedule,1061.96,1615.94, Parathyrd planar w/spect&ct,78072,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1061.96,,,,,,,fee schedule,1061.96,1615.94, Adrenal cortex & medulla img,78075,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1829.84,,,,,,,fee schedule,1829.84,2862.43, Adrenal cortex & medulla img,78075,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2862.43,,,,,,,fee schedule,1829.84,2862.43, Adrenal cortex & medulla img,78075,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2862.43,,,,,,,fee schedule,1829.84,2862.43, Endocrine nuclear procedure,78099,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,828.29,,,,,,,fee schedule,828.29,828.29, Endocrine nuclear procedure,78099,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,828.29,,,,,,,fee schedule,828.29,828.29, Bone marrow imaging ltd,78102,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,687.99,,,,,,,fee schedule,687.99,828.29, Bone marrow imaging ltd,78102,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,828.29,,,,,,,fee schedule,687.99,828.29, Bone marrow imaging ltd,78102,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,828.29,,,,,,,fee schedule,687.99,828.29, Bone marrow imaging mult,78103,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,732.78,,,,,,,fee schedule,732.78,828.29, Bone marrow imaging mult,78103,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,828.29,,,,,,,fee schedule,732.78,828.29, Bone marrow imaging mult,78103,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,828.29,,,,,,,fee schedule,732.78,828.29, Bone marrow imaging body,78104,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,960.22,,,,,,,fee schedule,828.29,960.22, Bone marrow imaging body,78104,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,828.29,,,,,,,fee schedule,828.29,960.22, Bone marrow imaging body,78104,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,828.29,,,,,,,fee schedule,828.29,960.22, Plasma volume single,78110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,331.31,,,,,,,fee schedule,331.31,2862.43, Plasma volume single,78110,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2862.43,,,,,,,fee schedule,331.31,2862.43, Plasma volume single,78110,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2862.43,,,,,,,fee schedule,331.31,2862.43, Plasma volume multiple,78111,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,450.19,,,,,,,fee schedule,450.19,2862.43, Plasma volume multiple,78111,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2862.43,,,,,,,fee schedule,450.19,2862.43, Plasma volume multiple,78111,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2862.43,,,,,,,fee schedule,450.19,2862.43, Red cell mass single,78120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,331.31,,,,,,,fee schedule,331.31,828.29, Red cell mass single,78120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,828.29,,,,,,,fee schedule,331.31,828.29, Red cell mass single,78120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,828.29,,,,,,,fee schedule,331.31,828.29, Red cell mass multiple,78121,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,431.25,,,,,,,fee schedule,431.25,1061.96, Red cell mass multiple,78121,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1061.96,,,,,,,fee schedule,431.25,1061.96, Red cell mass multiple,78121,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1061.96,,,,,,,fee schedule,431.25,1061.96, Blood volume,78122,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,419.22,,,,,,,fee schedule,419.22,1061.96, Blood volume,78122,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1061.96,,,,,,,fee schedule,419.22,1061.96, Blood volume,78122,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1061.96,,,,,,,fee schedule,419.22,1061.96, Red cell survival study,78130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,538.3,,,,,,,fee schedule,538.3,828.29, Red cell survival study,78130,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,828.29,,,,,,,fee schedule,538.3,828.29, Red cell survival study,78130,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,828.29,,,,,,,fee schedule,538.3,828.29, Red cell sequestration,78140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,448.46,,,,,,,fee schedule,448.46,828.29, Red cell sequestration,78140,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,828.29,,,,,,,fee schedule,448.46,828.29, Red cell sequestration,78140,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,828.29,,,,,,,fee schedule,448.46,828.29, Spleen imaging,78185,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,719.02,,,,,,,fee schedule,719.02,828.29, Spleen imaging,78185,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,828.29,,,,,,,fee schedule,719.02,828.29, Spleen imaging,78185,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,828.29,,,,,,,fee schedule,719.02,828.29, Platelet survival,78191,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,538.3,,,,,,,fee schedule,538.3,828.29, Platelet survival,78191,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,828.29,,,,,,,fee schedule,538.3,828.29, Platelet survival,78191,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,828.29,,,,,,,fee schedule,538.3,828.29, Lymph system imaging,78195,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1336.81,,,,,,,fee schedule,1061.96,1336.81, Lymph system imaging,78195,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1061.96,,,,,,,fee schedule,1061.96,1336.81, Lymph system imaging,78195,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1061.96,,,,,,,fee schedule,1061.96,1336.81, Blood/lymph nuclear exam,78199,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,828.29,,,,,,,fee schedule,828.29,828.29, Blood/lymph nuclear exam,78199,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,828.29,,,,,,,fee schedule,828.29,828.29, Liver imaging,78201,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,787.92,,,,,,,fee schedule,787.92,2862.43, Liver imaging,78201,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2862.43,,,,,,,fee schedule,787.92,2862.43, Liver imaging,78201,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2862.43,,,,,,,fee schedule,787.92,2862.43, Liver imaging with flow,78202,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,875.77,,,,,,,fee schedule,875.77,2862.43, Liver imaging with flow,78202,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2862.43,,,,,,,fee schedule,875.77,2862.43, Liver imaging with flow,78202,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2862.43,,,,,,,fee schedule,875.77,2862.43, Liver and spleen imaging,78215,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,806.86,,,,,,,fee schedule,806.86,828.29, Liver and spleen imaging,78215,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,828.29,,,,,,,fee schedule,806.86,828.29, Liver and spleen imaging,78215,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,828.29,,,,,,,fee schedule,806.86,828.29, Liver & spleen image/flow,78216,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,548.4,,,,,,,fee schedule,548.4,828.29, Liver & spleen image/flow,78216,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,828.29,,,,,,,fee schedule,548.4,828.29, Liver & spleen image/flow,78216,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,828.29,,,,,,,fee schedule,548.4,828.29, Hepatobiliary system imaging,78226,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1300.65,,,,,,,fee schedule,828.29,1300.65, Hepatobiliary system imaging,78226,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,828.29,,,,,,,fee schedule,828.29,1300.65, Hepatobiliary system imaging,78226,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,828.29,,,,,,,fee schedule,828.29,1300.65, Hepatobil syst image w/drug,78227,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1769.56,,,,,,,fee schedule,1061.96,1769.56, Hepatobil syst image w/drug,78227,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1061.96,,,,,,,fee schedule,1061.96,1769.56, Hepatobil syst image w/drug,78227,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1061.96,,,,,,,fee schedule,1061.96,1769.56, Salivary gland imaging,78230,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,710.38,,,,,,,fee schedule,710.38,828.29, Salivary gland imaging,78230,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,828.29,,,,,,,fee schedule,710.38,828.29, Salivary gland imaging,78230,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,828.29,,,,,,,fee schedule,710.38,828.29, Serial salivary imaging,78231,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,439.88,,,,,,,fee schedule,439.88,828.29, Serial salivary imaging,78231,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,828.29,,,,,,,fee schedule,439.88,828.29, Serial salivary imaging,78231,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,828.29,,,,,,,fee schedule,439.88,828.29, Salivary gland function exam,78232,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,441.61,,,,,,,fee schedule,441.61,828.29, Salivary gland function exam,78232,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,828.29,,,,,,,fee schedule,441.61,828.29, Salivary gland function exam,78232,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,828.29,,,,,,,fee schedule,441.61,828.29, Esophageal motility study,78258,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,889.58,,,,,,,fee schedule,828.29,889.58, Esophageal motility study,78258,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,828.29,,,,,,,fee schedule,828.29,889.58, Esophageal motility study,78258,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,828.29,,,,,,,fee schedule,828.29,889.58, Gastric mucosa imaging,78261,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,813.77,,,,,,,fee schedule,813.77,828.29, Gastric mucosa imaging,78261,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,828.29,,,,,,,fee schedule,813.77,828.29, Gastric mucosa imaging,78261,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,828.29,,,,,,,fee schedule,813.77,828.29, Gastroesophageal reflux exam,78262,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,963.67,,,,,,,fee schedule,828.29,963.67, Gastroesophageal reflux exam,78262,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,828.29,,,,,,,fee schedule,828.29,963.67, Gastroesophageal reflux exam,78262,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,828.29,,,,,,,fee schedule,828.29,963.67, Gastric emptying imag study,78264,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1316.14,,,,,,,fee schedule,828.29,1316.14, Gastric emptying imag study,78264,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,828.29,,,,,,,fee schedule,828.29,1316.14, Gastric emptying imag study,78264,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,828.29,,,,,,,fee schedule,828.29,1316.14, Gastric emptying imag study,78265,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1568.67,,,,,,,fee schedule,828.29,1568.67, Gastric emptying imag study,78265,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,828.29,,,,,,,fee schedule,828.29,1568.67, Gastric emptying imag study,78265,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,828.29,,,,,,,fee schedule,828.29,1568.67, Gastric emptying imag study,78266,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1798.81,,,,,,,fee schedule,1061.96,1798.81, Gastric emptying imag study,78266,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1061.96,,,,,,,fee schedule,1061.96,1798.81, Gastric emptying imag study,78266,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1061.96,,,,,,,fee schedule,1061.96,1798.81, Breath tst attain/anal c-14,78267,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,46.14,,,,,,,fee schedule,24.89,46.14, Breath tst attain/anal c-14,78267,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24.89,,,,,,,fee schedule,24.89,46.14, Breath tst attain/anal c-14,78267,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,24.89,,,,,,,fee schedule,24.89,46.14, Breath test analysis c-14,78268,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,393.88,,,,,,,fee schedule,212.42,393.88, Breath test analysis c-14,78268,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,212.42,,,,,,,fee schedule,212.42,393.88, Breath test analysis c-14,78268,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,212.42,,,,,,,fee schedule,212.42,393.88, Acute GI blood loss imaging,78278,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1348.89,,,,,,,fee schedule,828.29,1348.89, Acute GI blood loss imaging,78278,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,828.29,,,,,,,fee schedule,828.29,1348.89, Acute GI blood loss imaging,78278,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,828.29,,,,,,,fee schedule,828.29,1348.89, GI protein loss exam,78282,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,828.29,,,,,,,fee schedule,828.29,828.29, GI protein loss exam,78282,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,828.29,,,,,,,fee schedule,828.29,828.29, Meckels divert exam,78290,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1345.44,,,,,,,fee schedule,828.29,1345.44, Meckels divert exam,78290,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,828.29,,,,,,,fee schedule,828.29,1345.44, Meckels divert exam,78290,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,828.29,,,,,,,fee schedule,828.29,1345.44, Leveen/shunt patency exam,78291,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,994.7,,,,,,,fee schedule,828.29,994.7, Leveen/shunt patency exam,78291,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,828.29,,,,,,,fee schedule,828.29,994.7, Leveen/shunt patency exam,78291,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,828.29,,,,,,,fee schedule,828.29,994.7, GI nuclear procedure,78299,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,828.29,,,,,,,fee schedule,828.29,828.29, GI nuclear procedure,78299,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,828.29,,,,,,,fee schedule,828.29,828.29, Bone imaging limited area,78300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,886.89,,,,,,,fee schedule,828.29,886.89, Bone imaging limited area,78300,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,828.29,,,,,,,fee schedule,828.29,886.89, Bone imaging limited area,78300,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,828.29,,,,,,,fee schedule,828.29,886.89, Bone imaging multiple areas,78305,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1060.15,,,,,,,fee schedule,828.29,1060.15, Bone imaging multiple areas,78305,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,828.29,,,,,,,fee schedule,828.29,1060.15, Bone imaging multiple areas,78305,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,828.29,,,,,,,fee schedule,828.29,1060.15, Bone imaging whole body,78306,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1141.15,,,,,,,fee schedule,828.29,1141.15, Bone imaging whole body,78306,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,828.29,,,,,,,fee schedule,828.29,1141.15, Bone imaging whole body,78306,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,828.29,,,,,,,fee schedule,828.29,1141.15, Bone imaging 3 phase,78315,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1331.62,,,,,,,fee schedule,828.29,1331.62, Bone imaging 3 phase,78315,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,828.29,,,,,,,fee schedule,828.29,1331.62, Bone imaging 3 phase,78315,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,828.29,,,,,,,fee schedule,828.29,1331.62, Bone mineral single photon,78350,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,48.71,,,,,,,fee schedule,48.71,48.71, Bone mineral single photon,78350,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,48.71,,,,,,,fee schedule,48.71,48.71, Bone mineral dual photon,78351,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,35.73,,,,,,,fee schedule,35.73,35.73, Bone mineral dual photon,78351,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,35.73,,,,,,,fee schedule,35.73,35.73, Musculoskeletal nuclear exam,78399,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,828.29,,,,,,,fee schedule,828.29,828.29, Musculoskeletal nuclear exam,78399,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,828.29,,,,,,,fee schedule,828.29,828.29, Non-imaging heart function,78414,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1061.96,,,,,,,fee schedule,1061.96,1061.96, Non-imaging heart function,78414,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1061.96,,,,,,,fee schedule,1061.96,1061.96, Cardiac shunt imaging,78428,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,705.2,,,,,,,fee schedule,705.2,828.29, Cardiac shunt imaging,78428,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,828.29,,,,,,,fee schedule,705.2,828.29, Cardiac shunt imaging,78428,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,828.29,,,,,,,fee schedule,705.2,828.29, Myocrd img pet 1 std w/ct,78429,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3246.95,,,,,,,fee schedule,3246.95,3246.95, Myocrd img pet 1 std w/ct,78429,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3246.95,,,,,,,fee schedule,3246.95,3246.95, Myocrd img pet rst/strs w/ct,78430,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3246.95,,,,,,,fee schedule,3246.95,3246.95, Myocrd img pet rst/strs w/ct,78430,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3246.95,,,,,,,fee schedule,3246.95,3246.95, Myocrd img pet rst&strs ct,78431,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5063.63,,,,,,,fee schedule,5063.63,5063.63, Myocrd img pet rst&strs ct,78431,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5063.63,,,,,,,fee schedule,5063.63,5063.63, Myocrd img pet 2rtracer,78432,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6188.63,,,,,,,fee schedule,6188.63,6188.63, Myocrd img pet 2rtracer,78432,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,6188.63,,,,,,,fee schedule,6188.63,6188.63, Myocrd img pet 2rtracer ct,78433,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6188.63,,,,,,,fee schedule,6188.63,6188.63, Myocrd img pet 2rtracer ct,78433,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,6188.63,,,,,,,fee schedule,6188.63,6188.63, Vascular flow imaging,78445,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,748.26,,,,,,,fee schedule,748.26,828.29, Vascular flow imaging,78445,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,828.29,,,,,,,fee schedule,748.26,828.29, Vascular flow imaging,78445,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,828.29,,,,,,,fee schedule,748.26,828.29, Ht muscle image spect sing,78451,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1285.11,,,,,,,fee schedule,1285.11,2862.43, Ht muscle image spect sing,78451,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2862.43,,,,,,,fee schedule,1285.11,2862.43, Ht muscle image spect sing,78451,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2862.43,,,,,,,fee schedule,1285.11,2862.43, Ht muscle image spect mult,78452,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1829.84,,,,,,,fee schedule,1829.84,2862.43, Ht muscle image spect mult,78452,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2862.43,,,,,,,fee schedule,1829.84,2862.43, Ht muscle image spect mult,78452,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2862.43,,,,,,,fee schedule,1829.84,2862.43, Ht muscle image planar sing,78453,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1126.63,,,,,,,fee schedule,1126.63,2862.43, Ht muscle image planar sing,78453,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2862.43,,,,,,,fee schedule,1126.63,2862.43, Ht muscle image planar sing,78453,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2862.43,,,,,,,fee schedule,1126.63,2862.43, Ht musc image planar mult,78454,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1662.72,,,,,,,fee schedule,1662.72,2862.43, Ht musc image planar mult,78454,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2862.43,,,,,,,fee schedule,1662.72,2862.43, Ht musc image planar mult,78454,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2862.43,,,,,,,fee schedule,1662.72,2862.43, Acute venous thrombus image,78456,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1235.14,,,,,,,fee schedule,1235.14,2862.43, Acute venous thrombus image,78456,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2862.43,,,,,,,fee schedule,1235.14,2862.43, Acute venous thrombus image,78456,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2862.43,,,,,,,fee schedule,1235.14,2862.43, Venous thrombosis imaging,78457,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,684.54,,,,,,,fee schedule,684.54,2862.43, Venous thrombosis imaging,78457,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2862.43,,,,,,,fee schedule,684.54,2862.43, Venous thrombosis imaging,78457,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2862.43,,,,,,,fee schedule,684.54,2862.43, Ven thrombosis images bilat,78458,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,748.26,,,,,,,fee schedule,748.26,828.29, Ven thrombosis images bilat,78458,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,828.29,,,,,,,fee schedule,748.26,828.29, Ven thrombosis images bilat,78458,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,828.29,,,,,,,fee schedule,748.26,828.29, Heart muscle imaging (PET),78459,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2862.43,,,,,,,fee schedule,2862.43,2862.43, Heart muscle imaging (PET),78459,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2862.43,,,,,,,fee schedule,2862.43,2862.43, Heart infarct image,78466,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,662.14,,,,,,,fee schedule,662.14,828.29, Heart infarct image,78466,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,828.29,,,,,,,fee schedule,662.14,828.29, Heart infarct image,78466,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,828.29,,,,,,,fee schedule,662.14,828.29, Heart infarct image (ef),78468,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,758.62,,,,,,,fee schedule,758.62,1061.96, Heart infarct image (ef),78468,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1061.96,,,,,,,fee schedule,758.62,1061.96, Heart infarct image (ef),78468,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1061.96,,,,,,,fee schedule,758.62,1061.96, Heart infarct image (3D),78469,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,836.16,,,,,,,fee schedule,836.16,2862.43, Heart infarct image (3D),78469,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2862.43,,,,,,,fee schedule,836.16,2862.43, Heart infarct image (3D),78469,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2862.43,,,,,,,fee schedule,836.16,2862.43, Gated heart planar single,78472,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,843.07,,,,,,,fee schedule,828.29,843.07, Gated heart planar single,78472,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,828.29,,,,,,,fee schedule,828.29,843.07, Gated heart planar single,78472,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,828.29,,,,,,,fee schedule,828.29,843.07, Gated heart multiple,78473,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1031.82,,,,,,,fee schedule,828.29,1031.82, Gated heart multiple,78473,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,828.29,,,,,,,fee schedule,828.29,1031.82, Gated heart multiple,78473,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,828.29,,,,,,,fee schedule,828.29,1031.82, Heart first pass single,78481,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,611.2,,,,,,,fee schedule,611.2,1061.96, Heart first pass single,78481,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1061.96,,,,,,,fee schedule,611.2,1061.96, Heart first pass single,78481,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1061.96,,,,,,,fee schedule,611.2,1061.96, Heart first pass multiple,78483,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,788.63,,,,,,,fee schedule,788.63,1061.96, Heart first pass multiple,78483,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1061.96,,,,,,,fee schedule,788.63,1061.96, Heart first pass multiple,78483,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1061.96,,,,,,,fee schedule,788.63,1061.96, Heart image (pet) single,78491,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3246.95,,,,,,,fee schedule,3246.95,3246.95, Heart image (pet) single,78491,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3246.95,,,,,,,fee schedule,3246.95,3246.95, Heart image (pet) multiple,78492,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3246.95,,,,,,,fee schedule,3246.95,3246.95, Heart image (pet) multiple,78492,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3246.95,,,,,,,fee schedule,3246.95,3246.95, Heart image spect,78494,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,812.04,,,,,,,fee schedule,812.04,828.29, Heart image spect,78494,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,828.29,,,,,,,fee schedule,812.04,828.29, Heart image spect,78494,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,828.29,,,,,,,fee schedule,812.04,828.29, Heart first pass add-on,78496,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,100.91,,,,,,,fee schedule,100.91,100.91, Cardiovascular nuclear exam,78499,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,828.29,,,,,,,fee schedule,828.29,828.29, Cardiovascular nuclear exam,78499,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,828.29,,,,,,,fee schedule,828.29,828.29, Lung ventilation imaging,78579,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,745.57,,,,,,,fee schedule,745.57,828.29, Lung ventilation imaging,78579,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,828.29,,,,,,,fee schedule,745.57,828.29, Lung ventilation imaging,78579,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,828.29,,,,,,,fee schedule,745.57,828.29, Lung perfusion imaging,78580,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,910.25,,,,,,,fee schedule,828.29,910.25, Lung perfusion imaging,78580,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,828.29,,,,,,,fee schedule,828.29,910.25, Lung perfusion imaging,78580,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,828.29,,,,,,,fee schedule,828.29,910.25, Lung ventilat&perfus imaging,78582,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1254.14,,,,,,,fee schedule,1061.96,1254.14, Lung ventilat&perfus imaging,78582,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1061.96,,,,,,,fee schedule,1061.96,1254.14, Lung ventilat&perfus imaging,78582,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1061.96,,,,,,,fee schedule,1061.96,1254.14, Lung perfusion differential,78597,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,761.11,,,,,,,fee schedule,761.11,828.29, Lung perfusion differential,78597,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,828.29,,,,,,,fee schedule,761.11,828.29, Lung perfusion differential,78597,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,828.29,,,,,,,fee schedule,761.11,828.29, Lung perf&ventilat diferentl,78598,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1176.6,,,,,,,fee schedule,1061.96,1176.6, Lung perf&ventilat diferentl,78598,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1061.96,,,,,,,fee schedule,1061.96,1176.6, Lung perf&ventilat diferentl,78598,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1061.96,,,,,,,fee schedule,1061.96,1176.6, Respiratory nuclear exam,78599,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,828.29,,,,,,,fee schedule,828.29,828.29, Respiratory nuclear exam,78599,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,828.29,,,,,,,fee schedule,828.29,828.29, Brain image < 4 views,78600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,760.35,,,,,,,fee schedule,760.35,828.29, Brain image < 4 views,78600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,828.29,,,,,,,fee schedule,760.35,828.29, Brain image < 4 views,78600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,828.29,,,,,,,fee schedule,760.35,828.29, Brain image w/flow < 4 views,78601,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,877.5,,,,,,,fee schedule,828.29,877.5, Brain image w/flow < 4 views,78601,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,828.29,,,,,,,fee schedule,828.29,877.5, Brain image w/flow < 4 views,78601,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,828.29,,,,,,,fee schedule,828.29,877.5, Brain image 4+ views,78605,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,801.68,,,,,,,fee schedule,801.68,1061.96, Brain image 4+ views,78605,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1061.96,,,,,,,fee schedule,801.68,1061.96, Brain image 4+ views,78605,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1061.96,,,,,,,fee schedule,801.68,1061.96, Brain image w/flow 4 + views,78606,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1341.99,,,,,,,fee schedule,1061.96,1341.99, Brain image w/flow 4 + views,78606,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1061.96,,,,,,,fee schedule,1061.96,1341.99, Brain image w/flow 4 + views,78606,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1061.96,,,,,,,fee schedule,1061.96,1341.99, Brain imaging (PET),78608,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3246.95,,,,,,,fee schedule,3246.95,3246.95, Brain imaging (PET),78608,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3246.95,,,,,,,fee schedule,3246.95,3246.95, Brain flow imaging only,78610,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,741.41,,,,,,,fee schedule,741.41,1061.96, Brain flow imaging only,78610,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1061.96,,,,,,,fee schedule,741.41,1061.96, Brain flow imaging only,78610,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1061.96,,,,,,,fee schedule,741.41,1061.96, Cerebrospinal fluid scan,78630,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1367.08,,,,,,,fee schedule,1061.96,1367.08, Cerebrospinal fluid scan,78630,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1061.96,,,,,,,fee schedule,1061.96,1367.08, Cerebrospinal fluid scan,78630,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1061.96,,,,,,,fee schedule,1061.96,1367.08, CSF ventriculography,78635,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1379.87,,,,,,,fee schedule,1061.96,1379.87, CSF ventriculography,78635,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1061.96,,,,,,,fee schedule,1061.96,1379.87, CSF ventriculography,78635,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1061.96,,,,,,,fee schedule,1061.96,1379.87, CSF shunt evaluation,78645,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1343.71,,,,,,,fee schedule,1061.96,1343.71, CSF shunt evaluation,78645,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1061.96,,,,,,,fee schedule,1061.96,1343.71, CSF shunt evaluation,78645,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1061.96,,,,,,,fee schedule,1061.96,1343.71, CSF leakage imaging,78650,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1148.27,,,,,,,fee schedule,1148.27,2862.43, CSF leakage imaging,78650,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2862.43,,,,,,,fee schedule,1148.27,2862.43, CSF leakage imaging,78650,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2862.43,,,,,,,fee schedule,1148.27,2862.43, Nuclear exam of tear flow,78660,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,581.15,,,,,,,fee schedule,581.15,828.29, Nuclear exam of tear flow,78660,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,828.29,,,,,,,fee schedule,581.15,828.29, Nuclear exam of tear flow,78660,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,828.29,,,,,,,fee schedule,581.15,828.29, Nervous system nuclear exam,78699,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,828.29,,,,,,,fee schedule,828.29,828.29, Nervous system nuclear exam,78699,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,828.29,,,,,,,fee schedule,828.29,828.29, Kidney imaging morphol,78700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,691.44,,,,,,,fee schedule,691.44,828.29, Kidney imaging morphol,78700,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,828.29,,,,,,,fee schedule,691.44,828.29, Kidney imaging morphol,78700,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,828.29,,,,,,,fee schedule,691.44,828.29, Kidney imaging with flow,78701,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,932.64,,,,,,,fee schedule,828.29,932.64, Kidney imaging with flow,78701,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,828.29,,,,,,,fee schedule,828.29,932.64, Kidney imaging with flow,78701,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,828.29,,,,,,,fee schedule,828.29,932.64, K flow/funct image w/o drug,78707,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,860.28,,,,,,,fee schedule,860.28,1061.96, K flow/funct image w/o drug,78707,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1061.96,,,,,,,fee schedule,860.28,1061.96, K flow/funct image w/o drug,78707,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1061.96,,,,,,,fee schedule,860.28,1061.96, K flow/funct image w/drug,78708,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,614.87,,,,,,,fee schedule,614.87,1061.96, K flow/funct image w/drug,78708,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1061.96,,,,,,,fee schedule,614.87,1061.96, K flow/funct image w/drug,78708,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1061.96,,,,,,,fee schedule,614.87,1061.96, K flow/funct image multiple,78709,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1363.62,,,,,,,fee schedule,1061.96,1363.62, K flow/funct image multiple,78709,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1061.96,,,,,,,fee schedule,1061.96,1363.62, K flow/funct image multiple,78709,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1061.96,,,,,,,fee schedule,1061.96,1363.62, Kidney function study,78725,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,429.52,,,,,,,fee schedule,429.52,828.29, Kidney function study,78725,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,828.29,,,,,,,fee schedule,429.52,828.29, Kidney function study,78725,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,828.29,,,,,,,fee schedule,429.52,828.29, Urinary bladder retention,78730,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,338.71,,,,,,,fee schedule,338.71,338.71, Ureteral reflux study,78740,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1003.28,,,,,,,fee schedule,828.29,1003.28, Ureteral reflux study,78740,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,828.29,,,,,,,fee schedule,828.29,1003.28, Ureteral reflux study,78740,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,828.29,,,,,,,fee schedule,828.29,1003.28, Testicular imaging w/flow,78761,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,815.5,,,,,,,fee schedule,815.5,828.29, Testicular imaging w/flow,78761,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,828.29,,,,,,,fee schedule,815.5,828.29, Testicular imaging w/flow,78761,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,828.29,,,,,,,fee schedule,815.5,828.29, Genitourinary nuclear exam,78799,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,828.29,,,,,,,fee schedule,828.29,828.29, Genitourinary nuclear exam,78799,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,828.29,,,,,,,fee schedule,828.29,828.29, Tumor imaging limited area,78800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1040.19,,,,,,,fee schedule,828.29,1040.19, Tumor imaging limited area,78800,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,828.29,,,,,,,fee schedule,828.29,1040.19, Tumor imaging limited area,78800,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,828.29,,,,,,,fee schedule,828.29,1040.19, Tumor imaging mult areas,78801,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1072.19,,,,,,,fee schedule,828.29,1072.19, Tumor imaging mult areas,78801,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,828.29,,,,,,,fee schedule,828.29,1072.19, Tumor imaging mult areas,78801,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,828.29,,,,,,,fee schedule,828.29,1072.19, Tumor imaging whole body,78802,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1213.51,,,,,,,fee schedule,1213.51,2862.43, Tumor imaging whole body,78802,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2862.43,,,,,,,fee schedule,1213.51,2862.43, Tumor imaging whole body,78802,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2862.43,,,,,,,fee schedule,1213.51,2862.43, Tumor imaging (3D),78803,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1483.25,,,,,,,fee schedule,1483.25,2862.43, Tumor imaging (3D),78803,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2862.43,,,,,,,fee schedule,1483.25,2862.43, Tumor imaging (3D),78803,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2862.43,,,,,,,fee schedule,1483.25,2862.43, Tumor imaging whole body,78804,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2669.94,,,,,,,fee schedule,2669.94,2862.43, Tumor imaging whole body,78804,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2862.43,,,,,,,fee schedule,2669.94,2862.43, Tumor imaging whole body,78804,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2862.43,,,,,,,fee schedule,2669.94,2862.43, Iv inj ra drug dx study,78808,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,216.33,,,,,,,fee schedule,216.33,828.29, Iv inj ra drug dx study,78808,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,828.29,,,,,,,fee schedule,216.33,828.29, Iv inj ra drug dx study,78808,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,828.29,,,,,,,fee schedule,216.33,828.29, Pet image ltd area,78811,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2862.43,,,,,,,fee schedule,2862.43,2862.43, Pet image ltd area,78811,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2862.43,,,,,,,fee schedule,2862.43,2862.43, Pet image skull-thigh,78812,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3246.95,,,,,,,fee schedule,3246.95,3246.95, Pet image skull-thigh,78812,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3246.95,,,,,,,fee schedule,3246.95,3246.95, Pet image full body,78813,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3246.95,,,,,,,fee schedule,3246.95,3246.95, Pet image full body,78813,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3246.95,,,,,,,fee schedule,3246.95,3246.95, Pet image w/ct lmtd,78814,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3246.95,,,,,,,fee schedule,3246.95,3246.95, Pet image w/ct lmtd,78814,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3246.95,,,,,,,fee schedule,3246.95,3246.95, Pet image w/ct skull-thigh,78815,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3246.95,,,,,,,fee schedule,3246.95,3246.95, Pet image w/ct skull-thigh,78815,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3246.95,,,,,,,fee schedule,3246.95,3246.95, Pet image w/ct full body,78816,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3246.95,,,,,,,fee schedule,3246.95,3246.95, Pet image w/ct full body,78816,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3246.95,,,,,,,fee schedule,3246.95,3246.95, Rp loclzj tum spect w/ct 1,78830,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1840.9,,,,,,,fee schedule,1840.9,2862.43, Rp loclzj tum spect w/ct 1,78830,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2862.43,,,,,,,fee schedule,1840.9,2862.43, Rp loclzj tum spect w/ct 1,78830,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2862.43,,,,,,,fee schedule,1840.9,2862.43, Rp loclzj tum spect 2 areas,78831,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2804.36,,,,,,,fee schedule,2804.36,2862.43, Rp loclzj tum spect 2 areas,78831,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2862.43,,,,,,,fee schedule,2804.36,2862.43, Rp loclzj tum spect 2 areas,78831,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2862.43,,,,,,,fee schedule,2804.36,2862.43, Rp loclzj tum spect w/ct 2,78832,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3604.8,,,,,,,fee schedule,3246.95,3604.8, Rp loclzj tum spect w/ct 2,78832,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3246.95,,,,,,,fee schedule,3246.95,3604.8, Rp loclzj tum spect w/ct 2,78832,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3246.95,,,,,,,fee schedule,3246.95,3604.8, Rp quan meas single area,78835,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,354.19,,,,,,,fee schedule,354.19,354.19, Nuclear diagnostic exam,78999,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,828.29,,,,,,,fee schedule,828.29,828.29, Nuclear diagnostic exam,78999,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,828.29,,,,,,,fee schedule,828.29,828.29, Nuclear rx oral admin,79005,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,263.86,,,,,,,fee schedule,263.86,534.15, Nuclear rx oral admin,79005,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,534.15,,,,,,,fee schedule,263.86,534.15, Nuclear rx oral admin,79005,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,534.15,,,,,,,fee schedule,263.86,534.15, Nuclear rx iv admin,79101,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,275.95,,,,,,,fee schedule,275.95,534.15, Nuclear rx iv admin,79101,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,534.15,,,,,,,fee schedule,275.95,534.15, Nuclear rx iv admin,79101,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,534.15,,,,,,,fee schedule,275.95,534.15, Nuclear rx intracav admin,79200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,275.95,,,,,,,fee schedule,275.95,534.15, Nuclear rx intracav admin,79200,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,534.15,,,,,,,fee schedule,275.95,534.15, Nuclear rx intracav admin,79200,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,534.15,,,,,,,fee schedule,275.95,534.15, Nuclr rx interstit colloid,79300,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,534.15,,,,,,,fee schedule,534.15,534.15, Nuclr rx interstit colloid,79300,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,534.15,,,,,,,fee schedule,534.15,534.15, Hematopoietic nuclear tx,79403,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,362.34,,,,,,,fee schedule,362.34,534.15, Hematopoietic nuclear tx,79403,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,534.15,,,,,,,fee schedule,362.34,534.15, Hematopoietic nuclear tx,79403,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,534.15,,,,,,,fee schedule,362.34,534.15, Nuclear rx intra-articular,79440,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,206.99,,,,,,,fee schedule,206.99,534.15, Nuclear rx intra-articular,79440,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,534.15,,,,,,,fee schedule,206.99,534.15, Nuclear rx intra-articular,79440,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,534.15,,,,,,,fee schedule,206.99,534.15, Nuclear rx intra-arterial,79445,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,534.15,,,,,,,fee schedule,534.15,534.15, Nuclear rx intra-arterial,79445,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,534.15,,,,,,,fee schedule,534.15,534.15, Nuclear medicine therapy,79999,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,534.15,,,,,,,fee schedule,534.15,534.15, Nuclear medicine therapy,79999,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,534.15,,,,,,,fee schedule,534.15,534.15, Metabolic panel ionized ca,80047,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,57.28,,,,,,,fee schedule,20.6,57.28, Metabolic panel ionized ca,80047,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,20.6,,,,,,,fee schedule,20.6,57.28, Metabolic panel ionized ca,80047,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,20.6,,,,,,,fee schedule,20.6,57.28, Metabolic panel total ca,80048,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,35.3,,,,,,,fee schedule,12.69,35.3, Metabolic panel total ca,80048,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.69,,,,,,,fee schedule,12.69,35.3, Metabolic panel total ca,80048,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,12.69,,,,,,,fee schedule,12.69,35.3, General health panel,80050,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,70.92,,,,,,,fee schedule,70.92,70.92, General health panel,80050,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,70.92,,,,,,,fee schedule,70.92,70.92, Electrolyte panel,80051,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,29.25,,,,,,,fee schedule,10.52,29.25, Electrolyte panel,80051,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.52,,,,,,,fee schedule,10.52,29.25, Electrolyte panel,80051,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,10.52,,,,,,,fee schedule,10.52,29.25, Comprehen metabolic panel,80053,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,44.06,,,,,,,fee schedule,15.84,44.06, Comprehen metabolic panel,80053,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.84,,,,,,,fee schedule,15.84,44.06, Comprehen metabolic panel,80053,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,15.84,,,,,,,fee schedule,15.84,44.06, Obstetric panel,80055,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,199.46,,,,,,,fee schedule,71.72,199.46, Obstetric panel,80055,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,71.72,,,,,,,fee schedule,71.72,199.46, Obstetric panel,80055,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,71.72,,,,,,,fee schedule,71.72,199.46, Lipid panel,80061,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,55.86,,,,,,,fee schedule,20.09,55.86, Lipid panel,80061,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,20.09,,,,,,,fee schedule,20.09,55.86, Lipid panel,80061,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,20.09,,,,,,,fee schedule,20.09,55.86, Renal function panel,80069,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,36.21,,,,,,,fee schedule,13.02,36.21, Renal function panel,80069,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13.02,,,,,,,fee schedule,13.02,36.21, Renal function panel,80069,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13.02,,,,,,,fee schedule,13.02,36.21, Acute hepatitis panel,80074,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,198.71,,,,,,,fee schedule,71.45,198.71, Acute hepatitis panel,80074,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,71.45,,,,,,,fee schedule,71.45,198.71, Acute hepatitis panel,80074,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,71.45,,,,,,,fee schedule,71.45,198.71, Hepatic function panel,80076,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,34.09,,,,,,,fee schedule,12.26,34.09, Hepatic function panel,80076,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.26,,,,,,,fee schedule,12.26,34.09, Hepatic function panel,80076,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,12.26,,,,,,,fee schedule,12.26,34.09, Obstetric panel,80081,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,312.32,,,,,,,fee schedule,112.29,312.32, Obstetric panel,80081,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,112.29,,,,,,,fee schedule,112.29,312.32, Obstetric panel,80081,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,112.29,,,,,,,fee schedule,112.29,312.32, Drug assay acetaminophen,80143,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,77.77,,,,,,,fee schedule,27.96,77.77, Drug assay acetaminophen,80143,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,27.96,,,,,,,fee schedule,27.96,77.77, Drug assay acetaminophen,80143,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,27.96,,,,,,,fee schedule,27.96,77.77, Drug assay adalimumab,80145,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,160.91,,,,,,,fee schedule,57.86,160.91, Drug assay adalimumab,80145,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,57.86,,,,,,,fee schedule,57.86,160.91, Drug assay adalimumab,80145,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,57.86,,,,,,,fee schedule,57.86,160.91, Assay of amikacin,80150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,62.91,,,,,,,fee schedule,22.62,62.91, Assay of amikacin,80150,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22.62,,,,,,,fee schedule,22.62,62.91, Assay of amikacin,80150,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22.62,,,,,,,fee schedule,22.62,62.91, Drug assay amiodarone,80151,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,77.77,,,,,,,fee schedule,27.96,77.77, Drug assay amiodarone,80151,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,27.96,,,,,,,fee schedule,27.96,77.77, Drug assay amiodarone,80151,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,27.96,,,,,,,fee schedule,27.96,77.77, Drug assay caffeine,80155,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,160.91,,,,,,,fee schedule,57.86,160.91, Drug assay caffeine,80155,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,57.86,,,,,,,fee schedule,57.86,160.91, Drug assay caffeine,80155,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,57.86,,,,,,,fee schedule,57.86,160.91, Assay carbamazepine total,80156,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,60.79,,,,,,,fee schedule,21.86,60.79, Assay carbamazepine total,80156,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21.86,,,,,,,fee schedule,21.86,60.79, Assay carbamazepine total,80156,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,21.86,,,,,,,fee schedule,21.86,60.79, Assay carbamazepine free,80157,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,55.28,,,,,,,fee schedule,19.88,55.28, Assay carbamazepine free,80157,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.88,,,,,,,fee schedule,19.88,55.28, Assay carbamazepine free,80157,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19.88,,,,,,,fee schedule,19.88,55.28, Drug assay cyclosporine,80158,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,75.3,,,,,,,fee schedule,27.08,75.3, Drug assay cyclosporine,80158,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,27.08,,,,,,,fee schedule,27.08,75.3, Drug assay cyclosporine,80158,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,27.08,,,,,,,fee schedule,27.08,75.3, Drug assay clozapine,80159,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,84.07,,,,,,,fee schedule,30.23,84.07, Drug assay clozapine,80159,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,30.23,,,,,,,fee schedule,30.23,84.07, Drug assay clozapine,80159,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,30.23,,,,,,,fee schedule,30.23,84.07, "Asy carbamazepin 10,11-epxid",80161,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,77.77,,,,,,,fee schedule,27.96,77.77, "Asy carbamazepin 10,11-epxid",80161,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,27.96,,,,,,,fee schedule,27.96,77.77, "Asy carbamazepin 10,11-epxid",80161,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,27.96,,,,,,,fee schedule,27.96,77.77, Assay of digoxin total,80162,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,55.4,,,,,,,fee schedule,19.92,55.4, Assay of digoxin total,80162,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.92,,,,,,,fee schedule,19.92,55.4, Assay of digoxin total,80162,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19.92,,,,,,,fee schedule,19.92,55.4, Assay of digoxin free,80163,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,55.4,,,,,,,fee schedule,19.92,55.4, Assay of digoxin free,80163,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.92,,,,,,,fee schedule,19.92,55.4, Assay of digoxin free,80163,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19.92,,,,,,,fee schedule,19.92,55.4, Assay dipropylacetic acd tot,80164,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,56.49,,,,,,,fee schedule,20.31,56.49, Assay dipropylacetic acd tot,80164,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,20.31,,,,,,,fee schedule,20.31,56.49, Assay dipropylacetic acd tot,80164,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,20.31,,,,,,,fee schedule,20.31,56.49, Dipropylacetic acid free,80165,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,56.49,,,,,,,fee schedule,20.31,56.49, Dipropylacetic acid free,80165,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,20.31,,,,,,,fee schedule,20.31,56.49, Dipropylacetic acid free,80165,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,20.31,,,,,,,fee schedule,20.31,56.49, Drug assay felbamate,80167,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,77.77,,,,,,,fee schedule,27.96,77.77, Drug assay felbamate,80167,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,27.96,,,,,,,fee schedule,27.96,77.77, Drug assay felbamate,80167,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,27.96,,,,,,,fee schedule,27.96,77.77, Assay of ethosuximide,80168,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,68.17,,,,,,,fee schedule,24.51,68.17, Assay of ethosuximide,80168,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24.51,,,,,,,fee schedule,24.51,68.17, Assay of ethosuximide,80168,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,24.51,,,,,,,fee schedule,24.51,68.17, Drug assay everolimus,80169,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,57.28,,,,,,,fee schedule,20.6,57.28, Drug assay everolimus,80169,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,20.6,,,,,,,fee schedule,20.6,57.28, Drug assay everolimus,80169,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,20.6,,,,,,,fee schedule,20.6,57.28, Assay of gentamicin,80170,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,68.34,,,,,,,fee schedule,24.57,68.34, Assay of gentamicin,80170,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24.57,,,,,,,fee schedule,24.57,68.34, Assay of gentamicin,80170,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,24.57,,,,,,,fee schedule,24.57,68.34, Drug screen quant gabapentin,80171,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,90.41,,,,,,,fee schedule,32.51,90.41, Drug screen quant gabapentin,80171,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,32.51,,,,,,,fee schedule,32.51,90.41, Drug screen quant gabapentin,80171,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,32.51,,,,,,,fee schedule,32.51,90.41, Assay Of Haloperidol,80173,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,65.83,,,,,,,fee schedule,23.67,65.83, Assay Of Haloperidol,80173,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23.67,,,,,,,fee schedule,23.67,65.83, Assay Of Haloperidol,80173,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,23.67,,,,,,,fee schedule,23.67,65.83, Drug screen quan lamotrigine,80175,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,55.28,,,,,,,fee schedule,19.88,55.28, Drug screen quan lamotrigine,80175,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.88,,,,,,,fee schedule,19.88,55.28, Drug screen quan lamotrigine,80175,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19.88,,,,,,,fee schedule,19.88,55.28, Assay of lidocaine,80176,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,61.29,,,,,,,fee schedule,22.04,61.29, Assay of lidocaine,80176,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22.04,,,,,,,fee schedule,22.04,61.29, Assay of lidocaine,80176,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22.04,,,,,,,fee schedule,22.04,61.29, Drug scrn quan levetiracetam,80177,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,55.28,,,,,,,fee schedule,19.88,55.28, Drug scrn quan levetiracetam,80177,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.88,,,,,,,fee schedule,19.88,55.28, Drug scrn quan levetiracetam,80177,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19.88,,,,,,,fee schedule,19.88,55.28, Assay of lithium,80178,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,27.58,,,,,,,fee schedule,9.92,27.58, Assay of lithium,80178,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.92,,,,,,,fee schedule,9.92,27.58, Assay of lithium,80178,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9.92,,,,,,,fee schedule,9.92,27.58, Drug assay salicylate,80179,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,77.77,,,,,,,fee schedule,27.96,77.77, Drug assay salicylate,80179,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,27.96,,,,,,,fee schedule,27.96,77.77, Drug assay salicylate,80179,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,27.96,,,,,,,fee schedule,27.96,77.77, Drug scrn quan mycophenolate,80180,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,75.3,,,,,,,fee schedule,27.08,75.3, Drug scrn quan mycophenolate,80180,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,27.08,,,,,,,fee schedule,27.08,75.3, Drug scrn quan mycophenolate,80180,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,27.08,,,,,,,fee schedule,27.08,75.3, Drug assay flecainide,80181,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,77.77,,,,,,,fee schedule,27.96,77.77, Drug assay flecainide,80181,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,27.96,,,,,,,fee schedule,27.96,77.77, Drug assay flecainide,80181,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,27.96,,,,,,,fee schedule,27.96,77.77, Drug scrn quant oxcarbazepin,80183,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,55.28,,,,,,,fee schedule,19.88,55.28, Drug scrn quant oxcarbazepin,80183,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.88,,,,,,,fee schedule,19.88,55.28, Drug scrn quant oxcarbazepin,80183,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19.88,,,,,,,fee schedule,19.88,55.28, Assay of phenobarbital,80184,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,63.83,,,,,,,fee schedule,22.95,63.83, Assay of phenobarbital,80184,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22.95,,,,,,,fee schedule,22.95,63.83, Assay of phenobarbital,80184,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22.95,,,,,,,fee schedule,22.95,63.83, Assay of phenytoin total,80185,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,55.28,,,,,,,fee schedule,19.88,55.28, Assay of phenytoin total,80185,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.88,,,,,,,fee schedule,19.88,55.28, Assay of phenytoin total,80185,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19.88,,,,,,,fee schedule,19.88,55.28, Assay of phenytoin free,80186,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,57.41,,,,,,,fee schedule,20.64,57.41, Assay of phenytoin free,80186,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,20.64,,,,,,,fee schedule,20.64,57.41, Assay of phenytoin free,80186,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,20.64,,,,,,,fee schedule,20.64,57.41, Drug assay posaconazole,80187,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,113.1,,,,,,,fee schedule,40.67,113.1, Drug assay posaconazole,80187,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,40.67,,,,,,,fee schedule,40.67,113.1, Drug assay posaconazole,80187,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,40.67,,,,,,,fee schedule,40.67,113.1, Assay of primidone,80188,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,69.21,,,,,,,fee schedule,24.89,69.21, Assay of primidone,80188,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24.89,,,,,,,fee schedule,24.89,69.21, Assay of primidone,80188,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,24.89,,,,,,,fee schedule,24.89,69.21, Drug assay itraconzaole,80189,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,113.1,,,,,,,fee schedule,40.67,113.1, Drug assay itraconzaole,80189,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,40.67,,,,,,,fee schedule,40.67,113.1, Drug assay itraconzaole,80189,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,40.67,,,,,,,fee schedule,40.67,113.1, Assay of procainamide,80190,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,250.32,,,,,,,fee schedule,90,250.32, Assay of procainamide,80190,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,90,,,,,,,fee schedule,90,250.32, Assay of procainamide,80190,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,90,,,,,,,fee schedule,90,250.32, Assay of procainamide,80192,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,69.88,,,,,,,fee schedule,25.13,69.88, Assay of procainamide,80192,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25.13,,,,,,,fee schedule,25.13,69.88, Assay of procainamide,80192,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,25.13,,,,,,,fee schedule,25.13,69.88, Drug assay leflunomide,80193,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,160.91,,,,,,,fee schedule,57.86,160.91, Drug assay leflunomide,80193,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,57.86,,,,,,,fee schedule,57.86,160.91, Drug assay leflunomide,80193,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,57.86,,,,,,,fee schedule,57.86,160.91, Assay of quinidine,80194,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,60.91,,,,,,,fee schedule,21.9,60.91, Assay of quinidine,80194,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21.9,,,,,,,fee schedule,21.9,60.91, Assay of quinidine,80194,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,21.9,,,,,,,fee schedule,21.9,60.91, Assay of sirolimus,80195,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,57.28,,,,,,,fee schedule,20.6,57.28, Assay of sirolimus,80195,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,20.6,,,,,,,fee schedule,20.6,57.28, Assay of sirolimus,80195,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,20.6,,,,,,,fee schedule,20.6,57.28, Assay of tacrolimus,80197,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,57.28,,,,,,,fee schedule,20.6,57.28, Assay of tacrolimus,80197,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,20.6,,,,,,,fee schedule,20.6,57.28, Assay of tacrolimus,80197,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,20.6,,,,,,,fee schedule,20.6,57.28, Assay of theophylline,80198,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,58.99,,,,,,,fee schedule,21.21,58.99, Assay of theophylline,80198,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21.21,,,,,,,fee schedule,21.21,58.99, Assay of theophylline,80198,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,21.21,,,,,,,fee schedule,21.21,58.99, Drug screen quant tiagabine,80199,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,113.1,,,,,,,fee schedule,40.67,113.1, Drug screen quant tiagabine,80199,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,40.67,,,,,,,fee schedule,40.67,113.1, Drug screen quant tiagabine,80199,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,40.67,,,,,,,fee schedule,40.67,113.1, Assay of tobramycin,80200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,67.29,,,,,,,fee schedule,24.2,67.29, Assay of tobramycin,80200,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24.2,,,,,,,fee schedule,24.2,67.29, Assay of tobramycin,80200,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,24.2,,,,,,,fee schedule,24.2,67.29, Assay of topiramate,80201,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,49.73,,,,,,,fee schedule,17.88,49.73, Assay of topiramate,80201,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.88,,,,,,,fee schedule,17.88,49.73, Assay of topiramate,80201,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,17.88,,,,,,,fee schedule,17.88,49.73, Assay of vancomycin,80202,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,56.49,,,,,,,fee schedule,20.31,56.49, Assay of vancomycin,80202,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,20.31,,,,,,,fee schedule,20.31,56.49, Assay of vancomycin,80202,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,20.31,,,,,,,fee schedule,20.31,56.49, Drug screen quant zonisamide,80203,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,55.28,,,,,,,fee schedule,19.88,55.28, Drug screen quant zonisamide,80203,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.88,,,,,,,fee schedule,19.88,55.28, Drug screen quant zonisamide,80203,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19.88,,,,,,,fee schedule,19.88,55.28, Drug assay methotrexate,80204,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,160.91,,,,,,,fee schedule,57.86,160.91, Drug assay methotrexate,80204,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,57.86,,,,,,,fee schedule,57.86,160.91, Drug assay methotrexate,80204,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,57.86,,,,,,,fee schedule,57.86,160.91, Drug assay rufinamide,80210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,113.1,,,,,,,fee schedule,40.67,113.1, Drug assay rufinamide,80210,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,40.67,,,,,,,fee schedule,40.67,113.1, Drug assay rufinamide,80210,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,40.67,,,,,,,fee schedule,40.67,113.1, Drug asy hydroxychloroquine,80220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,77.77,,,,,,,fee schedule,27.96,77.77, Drug asy hydroxychloroquine,80220,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,27.96,,,,,,,fee schedule,27.96,77.77, Drug asy hydroxychloroquine,80220,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,27.96,,,,,,,fee schedule,27.96,77.77, Drug assay infliximab,80230,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,160.91,,,,,,,fee schedule,57.86,160.91, Drug assay infliximab,80230,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,57.86,,,,,,,fee schedule,57.86,160.91, Drug assay infliximab,80230,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,57.86,,,,,,,fee schedule,57.86,160.91, Drug assay lacosamide,80235,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,113.1,,,,,,,fee schedule,40.67,113.1, Drug assay lacosamide,80235,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,40.67,,,,,,,fee schedule,40.67,113.1, Drug assay lacosamide,80235,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,40.67,,,,,,,fee schedule,40.67,113.1, Drug assay vedolizumab,80280,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,160.91,,,,,,,fee schedule,57.86,160.91, Drug assay vedolizumab,80280,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,57.86,,,,,,,fee schedule,57.86,160.91, Drug assay vedolizumab,80280,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,57.86,,,,,,,fee schedule,57.86,160.91, Drug assay voriconazole,80285,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,113.1,,,,,,,fee schedule,40.67,113.1, Drug assay voriconazole,80285,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,40.67,,,,,,,fee schedule,40.67,113.1, Drug assay voriconazole,80285,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,40.67,,,,,,,fee schedule,40.67,113.1, Quantitative assay drug,80299,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,77.77,,,,,,,fee schedule,27.96,77.77, Quantitative assay drug,80299,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,27.96,,,,,,,fee schedule,27.96,77.77, Quantitative assay drug,80299,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,27.96,,,,,,,fee schedule,27.96,77.77, Drug test prsmv dir opt obs,80305,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,52.57,,,,,,,fee schedule,18.9,52.57, Drug test prsmv dir opt obs,80305,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.9,,,,,,,fee schedule,18.9,52.57, Drug test prsmv dir opt obs,80305,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,18.9,,,,,,,fee schedule,18.9,52.57, Drug test prsmv instrmnt,80306,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,71.51,,,,,,,fee schedule,25.71,71.51, Drug test prsmv instrmnt,80306,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25.71,,,,,,,fee schedule,25.71,71.51, Drug test prsmv instrmnt,80306,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,25.71,,,,,,,fee schedule,25.71,71.51, Drug test prsmv chem anlyzr,80307,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,259.25,,,,,,,fee schedule,93.21,259.25, Drug test prsmv chem anlyzr,80307,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,93.21,,,,,,,fee schedule,93.21,259.25, Drug test prsmv chem anlyzr,80307,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,93.21,,,,,,,fee schedule,93.21,259.25, Acth stimulation panel,80400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,136.09,,,,,,,fee schedule,48.93,136.09, Acth stimulation panel,80400,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,48.93,,,,,,,fee schedule,48.93,136.09, Acth stimulation panel,80400,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,48.93,,,,,,,fee schedule,48.93,136.09, Acth stimulation panel,80402,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,362.8,,,,,,,fee schedule,130.44,362.8, Acth stimulation panel,80402,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,130.44,,,,,,,fee schedule,130.44,362.8, Acth stimulation panel,80402,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,130.44,,,,,,,fee schedule,130.44,362.8, Acth stimulation panel,80406,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,326.5,,,,,,,fee schedule,117.39,326.5, Acth stimulation panel,80406,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,117.39,,,,,,,fee schedule,117.39,326.5, Acth stimulation panel,80406,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,117.39,,,,,,,fee schedule,117.39,326.5, Aldosterone suppression eval,80408,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,523.59,,,,,,,fee schedule,188.25,523.59, Aldosterone suppression eval,80408,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,188.25,,,,,,,fee schedule,188.25,523.59, Aldosterone suppression eval,80408,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,188.25,,,,,,,fee schedule,188.25,523.59, Calcitonin stimul panel,80410,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,335.3,,,,,,,fee schedule,120.56,335.3, Calcitonin stimul panel,80410,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,120.56,,,,,,,fee schedule,120.56,335.3, Calcitonin stimul panel,80410,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,120.56,,,,,,,fee schedule,120.56,335.3, CRH stimulation panel,80412,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3344.36,,,,,,,fee schedule,1202.43,3344.36, CRH stimulation panel,80412,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1202.43,,,,,,,fee schedule,1202.43,3344.36, CRH stimulation panel,80412,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1202.43,,,,,,,fee schedule,1202.43,3344.36, Testosterone response,80414,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,215.44,,,,,,,fee schedule,77.46,215.44, Testosterone response,80414,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,77.46,,,,,,,fee schedule,77.46,215.44, Testosterone response,80414,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,77.46,,,,,,,fee schedule,77.46,215.44, Estradiol response panel,80415,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,233.17,,,,,,,fee schedule,83.84,233.17, Estradiol response panel,80415,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,83.84,,,,,,,fee schedule,83.84,233.17, Estradiol response panel,80415,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,83.84,,,,,,,fee schedule,83.84,233.17, Renin stimulation panel,80416,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,873.28,,,,,,,fee schedule,313.98,873.28, Renin stimulation panel,80416,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,313.98,,,,,,,fee schedule,313.98,873.28, Renin stimulation panel,80416,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,313.98,,,,,,,fee schedule,313.98,873.28, Renin stimulation panel,80417,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,183.53,,,,,,,fee schedule,65.99,183.53, Renin stimulation panel,80417,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,65.99,,,,,,,fee schedule,65.99,183.53, Renin stimulation panel,80417,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,65.99,,,,,,,fee schedule,65.99,183.53, Pituitary evaluation panel,80418,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2417.59,,,,,,,fee schedule,869.22,2417.59, Pituitary evaluation panel,80418,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,869.22,,,,,,,fee schedule,869.22,2417.59, Pituitary evaluation panel,80418,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,869.22,,,,,,,fee schedule,869.22,2417.59, Dexamethasone panel,80420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,675.36,,,,,,,fee schedule,242.82,675.36, Dexamethasone panel,80420,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,242.82,,,,,,,fee schedule,242.82,675.36, Dexamethasone panel,80420,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,242.82,,,,,,,fee schedule,242.82,675.36, Glucagon tolerance panel,80422,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,192.2,,,,,,,fee schedule,69.11,192.2, Glucagon tolerance panel,80422,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,69.11,,,,,,,fee schedule,69.11,192.2, Glucagon tolerance panel,80422,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,69.11,,,,,,,fee schedule,69.11,192.2, Glucagon tolerance panel,80424,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,210.69,,,,,,,fee schedule,75.75,210.69, Glucagon tolerance panel,80424,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,75.75,,,,,,,fee schedule,75.75,210.69, Glucagon tolerance panel,80424,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,75.75,,,,,,,fee schedule,75.75,210.69, Gonadotropin hormone panel,80426,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,619.17,,,,,,,fee schedule,222.62,619.17, Gonadotropin hormone panel,80426,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,222.62,,,,,,,fee schedule,222.62,619.17, Gonadotropin hormone panel,80426,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,222.62,,,,,,,fee schedule,222.62,619.17, Growth hormone panel,80428,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,278.27,,,,,,,fee schedule,100.05,278.27, Growth hormone panel,80428,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,100.05,,,,,,,fee schedule,100.05,278.27, Growth hormone panel,80428,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,100.05,,,,,,,fee schedule,100.05,278.27, Growth hormone panel,80430,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,539.56,,,,,,,fee schedule,194,539.56, Growth hormone panel,80430,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,194,,,,,,,fee schedule,194,539.56, Growth hormone panel,80430,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,194,,,,,,,fee schedule,194,539.56, Insulin suppression panel,80432,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,690.92,,,,,,,fee schedule,248.42,690.92, Insulin suppression panel,80432,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,248.42,,,,,,,fee schedule,248.42,690.92, Insulin suppression panel,80432,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,248.42,,,,,,,fee schedule,248.42,690.92, Insulin tolerance panel,80434,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1189.15,,,,,,,fee schedule,427.55,1189.15, Insulin tolerance panel,80434,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,427.55,,,,,,,fee schedule,427.55,1189.15, Insulin tolerance panel,80434,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,427.55,,,,,,,fee schedule,427.55,1189.15, Insulin tolerance panel,80435,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,429.72,,,,,,,fee schedule,154.5,429.72, Insulin tolerance panel,80435,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,154.5,,,,,,,fee schedule,154.5,429.72, Insulin tolerance panel,80435,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,154.5,,,,,,,fee schedule,154.5,429.72, Metyrapone panel,80436,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,380.32,,,,,,,fee schedule,136.74,380.32, Metyrapone panel,80436,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,136.74,,,,,,,fee schedule,136.74,380.32, Metyrapone panel,80436,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,136.74,,,,,,,fee schedule,136.74,380.32, TRH stimulation panel,80438,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,210.31,,,,,,,fee schedule,75.62,210.31, TRH stimulation panel,80438,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,75.62,,,,,,,fee schedule,75.62,210.31, TRH stimulation panel,80438,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,75.62,,,,,,,fee schedule,75.62,210.31, TRH stimulation panel,80439,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,280.4,,,,,,,fee schedule,100.82,280.4, TRH stimulation panel,80439,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,100.82,,,,,,,fee schedule,100.82,280.4, TRH stimulation panel,80439,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,100.82,,,,,,,fee schedule,100.82,280.4, Path clin consltj sf 5-20,80503,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,100.15,,,,,,,fee schedule,76.13,100.15, Path clin consltj sf 5-20,80503,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,77.43,,,,,,,fee schedule,76.13,100.15, Path clin consltj sf 5-20,80503,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,76.13,,,,,,,fee schedule,76.13,100.15, Path clin consltj sf 5-20,80503,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,76.13,,,,,,,fee schedule,76.13,100.15, Path clin consltj mod 21-40,80504,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,212.01,,,,,,,fee schedule,163.92,228.48, Path clin consltj mod 21-40,80504,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,163.92,,,,,,,fee schedule,163.92,228.48, Path clin consltj mod 21-40,80504,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,228.48,,,,,,,fee schedule,163.92,228.48, Path clin consltj mod 21-40,80504,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,228.48,,,,,,,fee schedule,163.92,228.48, Path clin consltj high 41-60,80505,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,401.52,,,,,,,fee schedule,228.48,401.52, Path clin consltj high 41-60,80505,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,310.44,,,,,,,fee schedule,228.48,401.52, Path clin consltj high 41-60,80505,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,228.48,,,,,,,fee schedule,228.48,401.52, Path clin consltj high 41-60,80505,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,228.48,,,,,,,fee schedule,228.48,401.52, Path clin consltj prolng svc,80506,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,226.63,,,,,,,fee schedule,64.89,226.63, Path clin consltj prolng svc,80506,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,175.22,,,,,,,fee schedule,64.89,226.63, Path clin consltj prolng svc,80506,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,64.89,,,,,,,fee schedule,64.89,226.63, Path clin consltj prolng svc,80506,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,64.89,,,,,,,fee schedule,64.89,226.63, Urinalysis nonauto w/scope,81000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,16.77,,,,,,,fee schedule,6.03,16.77, Urinalysis nonauto w/scope,81000,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.03,,,,,,,fee schedule,6.03,16.77, Urinalysis nonauto w/scope,81000,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,6.03,,,,,,,fee schedule,6.03,16.77, Urinalysis auto w/scope,81001,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,13.23,,,,,,,fee schedule,4.76,13.23, Urinalysis auto w/scope,81001,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.76,,,,,,,fee schedule,4.76,13.23, Urinalysis auto w/scope,81001,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4.76,,,,,,,fee schedule,4.76,13.23, Urinalysis nonauto w/o scope,81002,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,14.52,,,,,,,fee schedule,5.22,14.52, Urinalysis nonauto w/o scope,81002,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.22,,,,,,,fee schedule,5.22,14.52, Urinalysis nonauto w/o scope,81002,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5.22,,,,,,,fee schedule,5.22,14.52, Urinalysis auto w/o scope,81003,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9.39,,,,,,,fee schedule,3.38,9.39, Urinalysis auto w/o scope,81003,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3.38,,,,,,,fee schedule,3.38,9.39, Urinalysis auto w/o scope,81003,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3.38,,,,,,,fee schedule,3.38,9.39, Urinalysis,81005,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9.05,,,,,,,fee schedule,3.26,9.05, Urinalysis,81005,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3.26,,,,,,,fee schedule,3.26,9.05, Urinalysis,81005,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3.26,,,,,,,fee schedule,3.26,9.05, Urine screen for bacteria,81007,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,125.08,,,,,,,fee schedule,44.97,125.08, Urine screen for bacteria,81007,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,44.97,,,,,,,fee schedule,44.97,125.08, Urine screen for bacteria,81007,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,44.97,,,,,,,fee schedule,44.97,125.08, Microscopic exam of urine,81015,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12.72,,,,,,,fee schedule,4.58,12.72, Microscopic exam of urine,81015,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.58,,,,,,,fee schedule,4.58,12.72, Microscopic exam of urine,81015,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4.58,,,,,,,fee schedule,4.58,12.72, Urinalysis glass test,81020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,19.61,,,,,,,fee schedule,7.05,19.61, Urinalysis glass test,81020,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.05,,,,,,,fee schedule,7.05,19.61, Urinalysis glass test,81020,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,7.05,,,,,,,fee schedule,7.05,19.61, Urine pregnancy test,81025,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,35.92,,,,,,,fee schedule,12.92,35.92, Urine pregnancy test,81025,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.92,,,,,,,fee schedule,12.92,35.92, Urine pregnancy test,81025,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,12.92,,,,,,,fee schedule,12.92,35.92, Urinalysis volume measure,81050,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,15.19,,,,,,,fee schedule,5.46,15.19, Urinalysis volume measure,81050,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.46,,,,,,,fee schedule,5.46,15.19, Urinalysis volume measure,81050,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5.46,,,,,,,fee schedule,5.46,15.19, Hpa-1 genotyping,81105,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,509.9,,,,,,,fee schedule,183.33,509.9, Hpa-1 genotyping,81105,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,183.33,,,,,,,fee schedule,183.33,509.9, Hpa-1 genotyping,81105,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,183.33,,,,,,,fee schedule,183.33,509.9, Hpa-2 genotyping,81106,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,509.9,,,,,,,fee schedule,183.33,509.9, Hpa-2 genotyping,81106,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,183.33,,,,,,,fee schedule,183.33,509.9, Hpa-2 genotyping,81106,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,183.33,,,,,,,fee schedule,183.33,509.9, Hpa-3 genotyping,81107,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,509.9,,,,,,,fee schedule,183.33,509.9, Hpa-3 genotyping,81107,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,183.33,,,,,,,fee schedule,183.33,509.9, Hpa-3 genotyping,81107,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,183.33,,,,,,,fee schedule,183.33,509.9, Hpa-4 genotyping,81108,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,509.9,,,,,,,fee schedule,183.33,509.9, Hpa-4 genotyping,81108,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,183.33,,,,,,,fee schedule,183.33,509.9, Hpa-4 genotyping,81108,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,183.33,,,,,,,fee schedule,183.33,509.9, Hpa-5 genotyping,81109,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,509.9,,,,,,,fee schedule,183.33,509.9, Hpa-5 genotyping,81109,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,183.33,,,,,,,fee schedule,183.33,509.9, Hpa-5 genotyping,81109,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,183.33,,,,,,,fee schedule,183.33,509.9, Hpa-6 genotyping,81110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,509.9,,,,,,,fee schedule,183.33,509.9, Hpa-6 genotyping,81110,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,183.33,,,,,,,fee schedule,183.33,509.9, Hpa-6 genotyping,81110,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,183.33,,,,,,,fee schedule,183.33,509.9, Hpa-9 genotyping,81111,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,509.9,,,,,,,fee schedule,183.33,509.9, Hpa-9 genotyping,81111,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,183.33,,,,,,,fee schedule,183.33,509.9, Hpa-9 genotyping,81111,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,183.33,,,,,,,fee schedule,183.33,509.9, Hpa-15 genotyping,81112,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,509.9,,,,,,,fee schedule,183.33,509.9, Hpa-15 genotyping,81112,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,183.33,,,,,,,fee schedule,183.33,509.9, Hpa-15 genotyping,81112,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,183.33,,,,,,,fee schedule,183.33,509.9, Idh1 common variants,81120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,806.24,,,,,,,fee schedule,289.88,806.24, Idh1 common variants,81120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,289.88,,,,,,,fee schedule,289.88,806.24, Idh1 common variants,81120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,289.88,,,,,,,fee schedule,289.88,806.24, Idh2 common variants,81121,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1234.04,,,,,,,fee schedule,443.69,1234.04, Idh2 common variants,81121,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,443.69,,,,,,,fee schedule,443.69,1234.04, Idh2 common variants,81121,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,443.69,,,,,,,fee schedule,443.69,1234.04, DMD dup/delet analysis,81161,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1163.99,,,,,,,fee schedule,418.5,1163.99, DMD dup/delet analysis,81161,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,418.5,,,,,,,fee schedule,418.5,1163.99, DMD dup/delet analysis,81161,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,418.5,,,,,,,fee schedule,418.5,1163.99, Brca1&2 seq & full dup/del,81162,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7613.4,,,,,,,fee schedule,2737.32,7613.4, Brca1&2 seq & full dup/del,81162,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2737.32,,,,,,,fee schedule,2737.32,7613.4, Brca1&2 seq & full dup/del,81162,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2737.32,,,,,,,fee schedule,2737.32,7613.4, Brca1&2 gene full seq alys,81163,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1952.5,,,,,,,fee schedule,1404,1952.5, Brca1&2 gene full seq alys,81163,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1404,,,,,,,fee schedule,1404,1952.5, Brca1&2 gene full seq alys,81163,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1404,,,,,,,fee schedule,1404,1952.5, Brca1&2 gen ful dup/del alys,81164,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2437.41,,,,,,,fee schedule,876.35,2437.41, Brca1&2 gen ful dup/del alys,81164,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,876.35,,,,,,,fee schedule,876.35,2437.41, Brca1&2 gen ful dup/del alys,81164,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,876.35,,,,,,,fee schedule,876.35,2437.41, Brca1 gene full seq alys,81165,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1180.18,,,,,,,fee schedule,848.64,1180.18, Brca1 gene full seq alys,81165,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,848.64,,,,,,,fee schedule,848.64,1180.18, Brca1 gene full seq alys,81165,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,848.64,,,,,,,fee schedule,848.64,1180.18, Brca1 gene full dup/del alys,81166,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1257.23,,,,,,,fee schedule,452.03,1257.23, Brca1 gene full dup/del alys,81166,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,452.03,,,,,,,fee schedule,452.03,1257.23, Brca1 gene full dup/del alys,81166,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,452.03,,,,,,,fee schedule,452.03,1257.23, Brca2 gene full dup/del alys,81167,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1180.18,,,,,,,fee schedule,424.32,1180.18, Brca2 gene full dup/del alys,81167,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,424.32,,,,,,,fee schedule,424.32,1180.18, Brca2 gene full dup/del alys,81167,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,424.32,,,,,,,fee schedule,424.32,1180.18, Ccnd1/igh translocation alys,81168,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,864.9,,,,,,,fee schedule,310.97,864.9, Ccnd1/igh translocation alys,81168,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,310.97,,,,,,,fee schedule,310.97,864.9, Ccnd1/igh translocation alys,81168,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,310.97,,,,,,,fee schedule,310.97,864.9, Abl1 gene,81170,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1251.6,,,,,,,fee schedule,450,1251.6, Abl1 gene,81170,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,450,,,,,,,fee schedule,450,1251.6, Abl1 gene,81170,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,450,,,,,,,fee schedule,450,1251.6, Aff2 gene detc abnor alleles,81171,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,571.56,,,,,,,fee schedule,205.5,571.56, Aff2 gene detc abnor alleles,81171,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,205.5,,,,,,,fee schedule,205.5,571.56, Aff2 gene detc abnor alleles,81171,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,205.5,,,,,,,fee schedule,205.5,571.56, Aff2 gene charac alleles,81172,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1146.59,,,,,,,fee schedule,412.25,1146.59, Aff2 gene charac alleles,81172,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,412.25,,,,,,,fee schedule,412.25,1146.59, Aff2 gene charac alleles,81172,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,412.25,,,,,,,fee schedule,412.25,1146.59, Ar gene full gene sequence,81173,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1257.23,,,,,,,fee schedule,452.03,1257.23, Ar gene full gene sequence,81173,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,452.03,,,,,,,fee schedule,452.03,1257.23, Ar gene full gene sequence,81173,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,452.03,,,,,,,fee schedule,452.03,1257.23, Ar gene known famil variant,81174,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,772.65,,,,,,,fee schedule,277.8,772.65, Ar gene known famil variant,81174,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,277.8,,,,,,,fee schedule,277.8,772.65, Ar gene known famil variant,81174,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,277.8,,,,,,,fee schedule,277.8,772.65, Asxl1 full gene sequence,81175,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2822.36,,,,,,,fee schedule,1014.75,2822.36, Asxl1 full gene sequence,81175,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1014.75,,,,,,,fee schedule,1014.75,2822.36, Asxl1 full gene sequence,81175,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1014.75,,,,,,,fee schedule,1014.75,2822.36, Asxl1 gene target seq alys,81176,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1009.21,,,,,,,fee schedule,362.85,1009.21, Asxl1 gene target seq alys,81176,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,362.85,,,,,,,fee schedule,362.85,1009.21, Asxl1 gene target seq alys,81176,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,362.85,,,,,,,fee schedule,362.85,1009.21, Atn1 gene detc abnor alleles,81177,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,571.56,,,,,,,fee schedule,205.5,571.56, Atn1 gene detc abnor alleles,81177,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,205.5,,,,,,,fee schedule,205.5,571.56, Atn1 gene detc abnor alleles,81177,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,205.5,,,,,,,fee schedule,205.5,571.56, Atxn1 gene detc abnor allele,81178,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,571.56,,,,,,,fee schedule,205.5,571.56, Atxn1 gene detc abnor allele,81178,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,205.5,,,,,,,fee schedule,205.5,571.56, Atxn1 gene detc abnor allele,81178,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,205.5,,,,,,,fee schedule,205.5,571.56, Atxn2 gene detc abnor allele,81179,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,571.56,,,,,,,fee schedule,205.5,571.56, Atxn2 gene detc abnor allele,81179,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,205.5,,,,,,,fee schedule,205.5,571.56, Atxn2 gene detc abnor allele,81179,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,205.5,,,,,,,fee schedule,205.5,571.56, Atxn3 gene detc abnor allele,81180,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,571.56,,,,,,,fee schedule,205.5,571.56, Atxn3 gene detc abnor allele,81180,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,205.5,,,,,,,fee schedule,205.5,571.56, Atxn3 gene detc abnor allele,81180,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,205.5,,,,,,,fee schedule,205.5,571.56, Atxn7 gene detc abnor allele,81181,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,571.56,,,,,,,fee schedule,205.5,571.56, Atxn7 gene detc abnor allele,81181,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,205.5,,,,,,,fee schedule,205.5,571.56, Atxn7 gene detc abnor allele,81181,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,205.5,,,,,,,fee schedule,205.5,571.56, Atxn8os gen detc abnor allel,81182,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,571.56,,,,,,,fee schedule,205.5,571.56, Atxn8os gen detc abnor allel,81182,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,205.5,,,,,,,fee schedule,205.5,571.56, Atxn8os gen detc abnor allel,81182,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,205.5,,,,,,,fee schedule,205.5,571.56, Atxn10 gene detc abnor allel,81183,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,571.56,,,,,,,fee schedule,205.5,571.56, Atxn10 gene detc abnor allel,81183,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,205.5,,,,,,,fee schedule,205.5,571.56, Atxn10 gene detc abnor allel,81183,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,205.5,,,,,,,fee schedule,205.5,571.56, Cacna1a gen detc abnor allel,81184,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,571.56,,,,,,,fee schedule,205.5,571.56, Cacna1a gen detc abnor allel,81184,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,205.5,,,,,,,fee schedule,205.5,571.56, Cacna1a gen detc abnor allel,81184,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,205.5,,,,,,,fee schedule,205.5,571.56, Cacna1a gene full gene seq,81185,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3530.64,,,,,,,fee schedule,1269.41,3530.64, Cacna1a gene full gene seq,81185,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1269.41,,,,,,,fee schedule,1269.41,3530.64, Cacna1a gene full gene seq,81185,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1269.41,,,,,,,fee schedule,1269.41,3530.64, Cacna1a gen known famil vrnt,81186,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,772.65,,,,,,,fee schedule,277.8,772.65, Cacna1a gen known famil vrnt,81186,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,277.8,,,,,,,fee schedule,277.8,772.65, Cacna1a gen known famil vrnt,81186,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,277.8,,,,,,,fee schedule,277.8,772.65, Cnbp gene detc abnor allele,81187,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,571.56,,,,,,,fee schedule,205.5,571.56, Cnbp gene detc abnor allele,81187,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,205.5,,,,,,,fee schedule,205.5,571.56, Cnbp gene detc abnor allele,81187,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,205.5,,,,,,,fee schedule,205.5,571.56, Cstb gene detc abnor allele,81188,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,571.56,,,,,,,fee schedule,205.5,571.56, Cstb gene detc abnor allele,81188,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,205.5,,,,,,,fee schedule,205.5,571.56, Cstb gene detc abnor allele,81188,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,205.5,,,,,,,fee schedule,205.5,571.56, Cstb gene full gene sequence,81189,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1146.59,,,,,,,fee schedule,412.25,1146.59, Cstb gene full gene sequence,81189,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,412.25,,,,,,,fee schedule,412.25,1146.59, Cstb gene full gene sequence,81189,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,412.25,,,,,,,fee schedule,412.25,1146.59, Cstb gene known famil vrnt,81190,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,772.65,,,,,,,fee schedule,277.8,772.65, Cstb gene known famil vrnt,81190,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,277.8,,,,,,,fee schedule,277.8,772.65, Cstb gene known famil vrnt,81190,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,277.8,,,,,,,fee schedule,277.8,772.65, Ntrk1 translocation analysis,81191,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,864.9,,,,,,,fee schedule,310.97,864.9, Ntrk1 translocation analysis,81191,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,310.97,,,,,,,fee schedule,310.97,864.9, Ntrk1 translocation analysis,81191,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,310.97,,,,,,,fee schedule,310.97,864.9, Ntrk2 translocation analysis,81192,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,864.9,,,,,,,fee schedule,310.97,864.9, Ntrk2 translocation analysis,81192,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,310.97,,,,,,,fee schedule,310.97,864.9, Ntrk2 translocation analysis,81192,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,310.97,,,,,,,fee schedule,310.97,864.9, Ntrk3 translocation analysis,81193,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,864.9,,,,,,,fee schedule,310.97,864.9, Ntrk3 translocation analysis,81193,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,310.97,,,,,,,fee schedule,310.97,864.9, Ntrk3 translocation analysis,81193,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,310.97,,,,,,,fee schedule,310.97,864.9, Ntrk translocation analysis,81194,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2162.26,,,,,,,fee schedule,777.42,2162.26, Ntrk translocation analysis,81194,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,777.42,,,,,,,fee schedule,777.42,2162.26, Ntrk translocation analysis,81194,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,777.42,,,,,,,fee schedule,777.42,2162.26, Cytog genom-wid alys hem mal,81195,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,7773.35,,,,,,,fee schedule,1895.3,7773.35, Cytog genom-wid alys hem mal,81195,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1895.3,,,,,,,fee schedule,1895.3,7773.35, Cytog genom-wid alys hem mal,81195,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1895.3,,,,,,,fee schedule,1895.3,7773.35, Aspa gene,81200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,197.13,,,,,,,fee schedule,70.88,197.13, Aspa gene,81200,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,70.88,,,,,,,fee schedule,70.88,197.13, Aspa gene,81200,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,70.88,,,,,,,fee schedule,70.88,197.13, Apc gene full sequence,81201,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3254.16,,,,,,,fee schedule,1170,3254.16, Apc gene full sequence,81201,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1170,,,,,,,fee schedule,1170,3254.16, Apc gene full sequence,81201,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1170,,,,,,,fee schedule,1170,3254.16, Apc gene known fam variants,81202,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1168.16,,,,,,,fee schedule,420,1168.16, Apc gene known fam variants,81202,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,420,,,,,,,fee schedule,420,1168.16, Apc gene known fam variants,81202,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,420,,,,,,,fee schedule,420,1168.16, Apc gene dup/delet variants,81203,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,834.4,,,,,,,fee schedule,300,834.4, Apc gene dup/delet variants,81203,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,300,,,,,,,fee schedule,300,834.4, Apc gene dup/delet variants,81203,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,300,,,,,,,fee schedule,300,834.4, Ar gene charac alleles,81204,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,571.56,,,,,,,fee schedule,205.5,571.56, Ar gene charac alleles,81204,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,205.5,,,,,,,fee schedule,205.5,571.56, Ar gene charac alleles,81204,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,205.5,,,,,,,fee schedule,205.5,571.56, Bckdhb gene,81205,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,396.3,,,,,,,fee schedule,142.49,396.3, Bckdhb gene,81205,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,142.49,,,,,,,fee schedule,142.49,396.3, Bckdhb gene,81205,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,142.49,,,,,,,fee schedule,142.49,396.3, Bcr/abl1 gene major bp,81206,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,684.04,,,,,,,fee schedule,245.94,684.04, Bcr/abl1 gene major bp,81206,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,245.94,,,,,,,fee schedule,245.94,684.04, Bcr/abl1 gene major bp,81206,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,245.94,,,,,,,fee schedule,245.94,684.04, Bcr/abl1 gene minor bp,81207,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,604.27,,,,,,,fee schedule,217.26,604.27, Bcr/abl1 gene minor bp,81207,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,217.26,,,,,,,fee schedule,217.26,604.27, Bcr/abl1 gene minor bp,81207,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,217.26,,,,,,,fee schedule,217.26,604.27, Bcr/abl1 gene other bp,81208,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,895.39,,,,,,,fee schedule,321.93,895.39, Bcr/abl1 gene other bp,81208,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,321.93,,,,,,,fee schedule,321.93,895.39, Bcr/abl1 gene other bp,81208,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,321.93,,,,,,,fee schedule,321.93,895.39, Blm gene,81209,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,164,,,,,,,fee schedule,58.97,164, Blm gene,81209,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,58.97,,,,,,,fee schedule,58.97,164, Blm gene,81209,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,58.97,,,,,,,fee schedule,58.97,164, Braf gene,81210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,731.77,,,,,,,fee schedule,263.1,731.77, Braf gene,81210,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,263.1,,,,,,,fee schedule,263.1,731.77, Braf gene,81210,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,263.1,,,,,,,fee schedule,263.1,731.77, Brca1&2 185&5385&6174 var,81212,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1835.68,,,,,,,fee schedule,660,1835.68, Brca1&2 185&5385&6174 var,81212,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,660,,,,,,,fee schedule,660,1835.68, Brca1&2 185&5385&6174 var,81212,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,660,,,,,,,fee schedule,660,1835.68, Brca1 gene known fam variant,81215,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1565.54,,,,,,,fee schedule,562.88,1565.54, Brca1 gene known fam variant,81215,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,562.88,,,,,,,fee schedule,562.88,1565.54, Brca1 gene known fam variant,81215,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,562.88,,,,,,,fee schedule,562.88,1565.54, Brca2 gene full sequence,81216,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,772.32,,,,,,,fee schedule,277.68,772.32, Brca2 gene full sequence,81216,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,277.68,,,,,,,fee schedule,277.68,772.32, Brca2 gene full sequence,81216,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,277.68,,,,,,,fee schedule,277.68,772.32, Brca2 gene known fam variant,81217,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1565.54,,,,,,,fee schedule,562.88,1565.54, Brca2 gene known fam variant,81217,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,562.88,,,,,,,fee schedule,562.88,1565.54, Brca2 gene known fam variant,81217,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,562.88,,,,,,,fee schedule,562.88,1565.54, Cebpa gene full sequence,81218,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1009.21,,,,,,,fee schedule,362.85,1009.21, Cebpa gene full sequence,81218,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,362.85,,,,,,,fee schedule,362.85,1009.21, Cebpa gene full sequence,81218,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,362.85,,,,,,,fee schedule,362.85,1009.21, Calr gene com variants,81219,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,507.44,,,,,,,fee schedule,182.45,507.44, Calr gene com variants,81219,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,182.45,,,,,,,fee schedule,182.45,507.44, Calr gene com variants,81219,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,182.45,,,,,,,fee schedule,182.45,507.44, Cftr gene com variants,81220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2322.14,,,,,,,fee schedule,834.9,2322.14, Cftr gene com variants,81220,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,834.9,,,,,,,fee schedule,834.9,2322.14, Cftr gene com variants,81220,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,834.9,,,,,,,fee schedule,834.9,2322.14, Cftr gene known fam variants,81221,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,405.6,,,,,,,fee schedule,145.83,405.6, Cftr gene known fam variants,81221,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,145.83,,,,,,,fee schedule,145.83,405.6, Cftr gene known fam variants,81221,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,145.83,,,,,,,fee schedule,145.83,405.6, Cftr gene dup/delet variants,81222,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1815.11,,,,,,,fee schedule,652.61,1815.11, Cftr gene dup/delet variants,81222,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,652.61,,,,,,,fee schedule,652.61,1815.11, Cftr gene dup/delet variants,81222,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,652.61,,,,,,,fee schedule,652.61,1815.11, Cftr gene full sequence,81223,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2081.83,,,,,,,fee schedule,748.5,2081.83, Cftr gene full sequence,81223,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,748.5,,,,,,,fee schedule,748.5,2081.83, Cftr gene full sequence,81223,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,748.5,,,,,,,fee schedule,748.5,2081.83, Cftr gene intron poly t,81224,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,704.03,,,,,,,fee schedule,253.13,704.03, Cftr gene intron poly t,81224,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,253.13,,,,,,,fee schedule,253.13,704.03, Cftr gene intron poly t,81224,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,253.13,,,,,,,fee schedule,253.13,704.03, Cyp2c19 gene com variants,81225,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1215.55,,,,,,,fee schedule,437.04,1215.55, Cyp2c19 gene com variants,81225,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,437.04,,,,,,,fee schedule,437.04,1215.55, Cyp2c19 gene com variants,81225,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,437.04,,,,,,,fee schedule,437.04,1215.55, Cyp2d6 gene com variants,81226,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1881.2,,,,,,,fee schedule,676.37,1881.2, Cyp2d6 gene com variants,81226,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,676.37,,,,,,,fee schedule,676.37,1881.2, Cyp2d6 gene com variants,81226,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,676.37,,,,,,,fee schedule,676.37,1881.2, Cyp2c9 gene com variants,81227,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,729.31,,,,,,,fee schedule,262.22,729.31, Cyp2c9 gene com variants,81227,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,262.22,,,,,,,fee schedule,262.22,729.31, Cyp2c9 gene com variants,81227,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,262.22,,,,,,,fee schedule,262.22,729.31, Cytogen micrarray copy nmbr,81228,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3754.8,,,,,,,fee schedule,1350,3754.8, Cytogen micrarray copy nmbr,81228,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1350,,,,,,,fee schedule,1350,3754.8, Cytogen micrarray copy nmbr,81228,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1350,,,,,,,fee schedule,1350,3754.8, Cytogen m array copy no&snp,81229,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4839.52,,,,,,,fee schedule,1740,4839.52, Cytogen m array copy no&snp,81229,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1740,,,,,,,fee schedule,1740,4839.52, Cytogen m array copy no&snp,81229,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1740,,,,,,,fee schedule,1740,4839.52, Cyp3a4 gene common variants,81230,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,729.31,,,,,,,fee schedule,262.22,729.31, Cyp3a4 gene common variants,81230,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,262.22,,,,,,,fee schedule,262.22,729.31, Cyp3a4 gene common variants,81230,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,262.22,,,,,,,fee schedule,262.22,729.31, Cyp3a5 gene common variants,81231,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,729.31,,,,,,,fee schedule,262.22,729.31, Cyp3a5 gene common variants,81231,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,262.22,,,,,,,fee schedule,262.22,729.31, Cyp3a5 gene common variants,81231,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,262.22,,,,,,,fee schedule,262.22,729.31, Dpyd gene common variants,81232,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,729.31,,,,,,,fee schedule,262.22,729.31, Dpyd gene common variants,81232,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,262.22,,,,,,,fee schedule,262.22,729.31, Dpyd gene common variants,81232,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,262.22,,,,,,,fee schedule,262.22,729.31, Btk gene common variants,81233,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,731.77,,,,,,,fee schedule,263.1,731.77, Btk gene common variants,81233,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,263.1,,,,,,,fee schedule,263.1,731.77, Btk gene common variants,81233,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,263.1,,,,,,,fee schedule,263.1,731.77, Dmpk gene detc abnor allele,81234,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,571.56,,,,,,,fee schedule,205.5,571.56, Dmpk gene detc abnor allele,81234,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,205.5,,,,,,,fee schedule,205.5,571.56, Dmpk gene detc abnor allele,81234,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,205.5,,,,,,,fee schedule,205.5,571.56, Egfr gene com variants,81235,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1354.15,,,,,,,fee schedule,486.87,1354.15, Egfr gene com variants,81235,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,486.87,,,,,,,fee schedule,486.87,1354.15, Egfr gene com variants,81235,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,486.87,,,,,,,fee schedule,486.87,1354.15, Ezh2 gene full gene sequence,81236,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1180.18,,,,,,,fee schedule,424.32,1180.18, Ezh2 gene full gene sequence,81236,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,424.32,,,,,,,fee schedule,424.32,1180.18, Ezh2 gene full gene sequence,81236,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,424.32,,,,,,,fee schedule,424.32,1180.18, Ezh2 gene common variants,81237,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,731.77,,,,,,,fee schedule,263.1,731.77, Ezh2 gene common variants,81237,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,263.1,,,,,,,fee schedule,263.1,731.77, Ezh2 gene common variants,81237,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,263.1,,,,,,,fee schedule,263.1,731.77, F9 full gene sequence,81238,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2503.2,,,,,,,fee schedule,900,2503.2, F9 full gene sequence,81238,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,900,,,,,,,fee schedule,900,2503.2, F9 full gene sequence,81238,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,900,,,,,,,fee schedule,900,2503.2, Dmpk gene charac alleles,81239,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1146.59,,,,,,,fee schedule,412.25,1146.59, Dmpk gene charac alleles,81239,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,412.25,,,,,,,fee schedule,412.25,1146.59, Dmpk gene charac alleles,81239,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,412.25,,,,,,,fee schedule,412.25,1146.59, F2 gene,81240,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,274.06,,,,,,,fee schedule,98.54,274.06, F2 gene,81240,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,98.54,,,,,,,fee schedule,98.54,274.06, F2 gene,81240,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,98.54,,,,,,,fee schedule,98.54,274.06, F5 gene,81241,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,306.1,,,,,,,fee schedule,110.06,306.1, F5 gene,81241,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,110.06,,,,,,,fee schedule,110.06,306.1, F5 gene,81241,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,110.06,,,,,,,fee schedule,110.06,306.1, Fancc gene,81242,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,152.78,,,,,,,fee schedule,54.93,152.78, Fancc gene,81242,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,54.93,,,,,,,fee schedule,54.93,152.78, Fancc gene,81242,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,54.93,,,,,,,fee schedule,54.93,152.78, Fmr1 gene detection,81243,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,237.97,,,,,,,fee schedule,85.56,237.97, Fmr1 gene detection,81243,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,85.56,,,,,,,fee schedule,85.56,237.97, Fmr1 gene detection,81243,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,85.56,,,,,,,fee schedule,85.56,237.97, Fmr1 gene characterization,81244,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,187.28,,,,,,,fee schedule,67.34,187.28, Fmr1 gene characterization,81244,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,67.34,,,,,,,fee schedule,67.34,187.28, Fmr1 gene characterization,81244,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,67.34,,,,,,,fee schedule,67.34,187.28, Flt3 gene,81245,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,690.51,,,,,,,fee schedule,248.27,690.51, Flt3 gene,81245,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,248.27,,,,,,,fee schedule,248.27,690.51, Flt3 gene,81245,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,248.27,,,,,,,fee schedule,248.27,690.51, Flt3 gene analysis,81246,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,346.28,,,,,,,fee schedule,124.5,346.28, Flt3 gene analysis,81246,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,124.5,,,,,,,fee schedule,124.5,346.28, Flt3 gene analysis,81246,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,124.5,,,,,,,fee schedule,124.5,346.28, G6pd gene alys cmn variant,81247,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,729.31,,,,,,,fee schedule,262.22,729.31, G6pd gene alys cmn variant,81247,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,262.22,,,,,,,fee schedule,262.22,729.31, G6pd gene alys cmn variant,81247,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,262.22,,,,,,,fee schedule,262.22,729.31, G6pd known familial variant,81248,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1565.54,,,,,,,fee schedule,562.88,1565.54, G6pd known familial variant,81248,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,562.88,,,,,,,fee schedule,562.88,1565.54, G6pd known familial variant,81248,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,562.88,,,,,,,fee schedule,562.88,1565.54, G6pd full gene sequence,81249,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2503.2,,,,,,,fee schedule,900,2503.2, G6pd full gene sequence,81249,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,900,,,,,,,fee schedule,900,2503.2, G6pd full gene sequence,81249,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,900,,,,,,,fee schedule,900,2503.2, G6pc gene,81250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,244.02,,,,,,,fee schedule,87.74,244.02, G6pc gene,81250,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,87.74,,,,,,,fee schedule,87.74,244.02, G6pc gene,81250,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,87.74,,,,,,,fee schedule,87.74,244.02, Gba gene,81251,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,197.13,,,,,,,fee schedule,70.88,197.13, Gba gene,81251,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,70.88,,,,,,,fee schedule,70.88,197.13, Gba gene,81251,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,70.88,,,,,,,fee schedule,70.88,197.13, Gjb2 gene full sequence,81252,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,421.87,,,,,,,fee schedule,151.68,421.87, Gjb2 gene full sequence,81252,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,151.68,,,,,,,fee schedule,151.68,421.87, Gjb2 gene full sequence,81252,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,151.68,,,,,,,fee schedule,151.68,421.87, Gjb2 gene known fam variants,81253,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,256.66,,,,,,,fee schedule,92.28,256.66, Gjb2 gene known fam variants,81253,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,92.28,,,,,,,fee schedule,92.28,256.66, Gjb2 gene known fam variants,81253,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,92.28,,,,,,,fee schedule,92.28,256.66, Gjb6 gene com variants,81254,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,146.02,,,,,,,fee schedule,52.5,146.02, Gjb6 gene com variants,81254,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,52.5,,,,,,,fee schedule,52.5,146.02, Gjb6 gene com variants,81254,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,52.5,,,,,,,fee schedule,52.5,146.02, Hexa gene,81255,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,214.65,,,,,,,fee schedule,77.18,214.65, Hexa gene,81255,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,77.18,,,,,,,fee schedule,77.18,214.65, Hexa gene,81255,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,77.18,,,,,,,fee schedule,77.18,214.65, Hfe gene,81256,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,272.68,,,,,,,fee schedule,98.04,272.68, Hfe gene,81256,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,98.04,,,,,,,fee schedule,98.04,272.68, Hfe gene,81256,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,98.04,,,,,,,fee schedule,98.04,272.68, Hba1/hba2 gene,81257,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,426.63,,,,,,,fee schedule,153.39,426.63, Hba1/hba2 gene,81257,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,153.39,,,,,,,fee schedule,153.39,426.63, Hba1/hba2 gene,81257,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,153.39,,,,,,,fee schedule,153.39,426.63, Hba1/hba2 gene fam vrnt,81258,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1565.54,,,,,,,fee schedule,562.88,1565.54, Hba1/hba2 gene fam vrnt,81258,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,562.88,,,,,,,fee schedule,562.88,1565.54, Hba1/hba2 gene fam vrnt,81258,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,562.88,,,,,,,fee schedule,562.88,1565.54, Hba1/hba2 full gene sequence,81259,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2503.2,,,,,,,fee schedule,900,2503.2, Hba1/hba2 full gene sequence,81259,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,900,,,,,,,fee schedule,900,2503.2, Hba1/hba2 full gene sequence,81259,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,900,,,,,,,fee schedule,900,2503.2, Ikbkap gene,81260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,164,,,,,,,fee schedule,58.97,164, Ikbkap gene,81260,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,58.97,,,,,,,fee schedule,58.97,164, Ikbkap gene,81260,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,58.97,,,,,,,fee schedule,58.97,164, Igh gene rearrange amp meth,81261,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,826.01,,,,,,,fee schedule,296.99,826.01, Igh gene rearrange amp meth,81261,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,296.99,,,,,,,fee schedule,296.99,826.01, Igh gene rearrange amp meth,81261,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,296.99,,,,,,,fee schedule,296.99,826.01, Igh gene rearrang dir probe,81262,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,285.99,,,,,,,fee schedule,102.83,285.99, Igh gene rearrang dir probe,81262,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,102.83,,,,,,,fee schedule,102.83,285.99, Igh gene rearrang dir probe,81262,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,102.83,,,,,,,fee schedule,102.83,285.99, Igh vari regional mutation,81263,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1228.74,,,,,,,fee schedule,441.78,1228.74, Igh vari regional mutation,81263,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,441.78,,,,,,,fee schedule,441.78,1228.74, Igh vari regional mutation,81263,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,441.78,,,,,,,fee schedule,441.78,1228.74, Igk rearrangeabn clonal pop,81264,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,720.63,,,,,,,fee schedule,259.1,720.63, Igk rearrangeabn clonal pop,81264,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,259.1,,,,,,,fee schedule,259.1,720.63, Igk rearrangeabn clonal pop,81264,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,259.1,,,,,,,fee schedule,259.1,720.63, Str markers specimen anal,81265,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,972.37,,,,,,,fee schedule,349.61,972.37, Str markers specimen anal,81265,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,349.61,,,,,,,fee schedule,349.61,972.37, Str markers specimen anal,81265,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,349.61,,,,,,,fee schedule,349.61,972.37, Str markers spec anal addl,81266,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1271.67,,,,,,,fee schedule,457.22,1271.67, Str markers spec anal addl,81266,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,457.22,,,,,,,fee schedule,457.22,1271.67, Str markers spec anal addl,81266,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,457.22,,,,,,,fee schedule,457.22,1271.67, Chimerism anal no cell selec,81267,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,865.52,,,,,,,fee schedule,311.19,865.52, Chimerism anal no cell selec,81267,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,311.19,,,,,,,fee schedule,311.19,865.52, Chimerism anal no cell selec,81267,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,311.19,,,,,,,fee schedule,311.19,865.52, Chimerism anal w/cell select,81268,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1088.02,,,,,,,fee schedule,391.19,1088.02, Chimerism anal w/cell select,81268,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,391.19,,,,,,,fee schedule,391.19,1088.02, Chimerism anal w/cell select,81268,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,391.19,,,,,,,fee schedule,391.19,1088.02, Hba1/hba2 gene dup/del vrnts,81269,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,844.41,,,,,,,fee schedule,303.6,844.41, Hba1/hba2 gene dup/del vrnts,81269,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,303.6,,,,,,,fee schedule,303.6,844.41, Hba1/hba2 gene dup/del vrnts,81269,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,303.6,,,,,,,fee schedule,303.6,844.41, Jak2 gene,81270,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,382.41,,,,,,,fee schedule,137.49,382.41, Jak2 gene,81270,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,137.49,,,,,,,fee schedule,137.49,382.41, Jak2 gene,81270,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,137.49,,,,,,,fee schedule,137.49,382.41, Htt gene detc abnor alleles,81271,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,571.56,,,,,,,fee schedule,205.5,571.56, Htt gene detc abnor alleles,81271,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,205.5,,,,,,,fee schedule,205.5,571.56, Htt gene detc abnor alleles,81271,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,205.5,,,,,,,fee schedule,205.5,571.56, Kit gene targeted seq analys,81272,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1374.72,,,,,,,fee schedule,494.27,1374.72, Kit gene targeted seq analys,81272,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,494.27,,,,,,,fee schedule,494.27,1374.72, Kit gene targeted seq analys,81272,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,494.27,,,,,,,fee schedule,494.27,1374.72, Kit gene analys d816 variant,81273,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,520.96,,,,,,,fee schedule,187.31,520.96, Kit gene analys d816 variant,81273,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,187.31,,,,,,,fee schedule,187.31,520.96, Kit gene analys d816 variant,81273,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,187.31,,,,,,,fee schedule,187.31,520.96, Htt gene charac alleles,81274,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1146.59,,,,,,,fee schedule,412.25,1146.59, Htt gene charac alleles,81274,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,412.25,,,,,,,fee schedule,412.25,1146.59, Htt gene charac alleles,81274,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,412.25,,,,,,,fee schedule,412.25,1146.59, Kras gene variants exon 2,81275,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,806.24,,,,,,,fee schedule,289.88,806.24, Kras gene variants exon 2,81275,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,289.88,,,,,,,fee schedule,289.88,806.24, Kras gene variants exon 2,81275,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,289.88,,,,,,,fee schedule,289.88,806.24, Kras gene addl variants,81276,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,806.24,,,,,,,fee schedule,289.88,806.24, Kras gene addl variants,81276,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,289.88,,,,,,,fee schedule,289.88,806.24, Kras gene addl variants,81276,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,289.88,,,,,,,fee schedule,289.88,806.24, Cytogenomic neo microra alys,81277,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4839.52,,,,,,,fee schedule,1740,4839.52, Cytogenomic neo microra alys,81277,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1740,,,,,,,fee schedule,1740,4839.52, Cytogenomic neo microra alys,81277,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1740,,,,,,,fee schedule,1740,4839.52, Igh@/bcl2 translocation alys,81278,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,864.9,,,,,,,fee schedule,310.97,864.9, Igh@/bcl2 translocation alys,81278,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,310.97,,,,,,,fee schedule,310.97,864.9, Igh@/bcl2 translocation alys,81278,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,310.97,,,,,,,fee schedule,310.97,864.9, Jak2 gene trgt sequence alys,81279,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,772.65,,,,,,,fee schedule,277.8,772.65, Jak2 gene trgt sequence alys,81279,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,277.8,,,,,,,fee schedule,277.8,772.65, Jak2 gene trgt sequence alys,81279,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,277.8,,,,,,,fee schedule,277.8,772.65, Ifnl3 gene,81283,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,306.1,,,,,,,fee schedule,110.06,306.1, Ifnl3 gene,81283,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,110.06,,,,,,,fee schedule,110.06,306.1, Ifnl3 gene,81283,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,110.06,,,,,,,fee schedule,110.06,306.1, Fxn gene detc abnor alleles,81284,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,571.56,,,,,,,fee schedule,205.5,571.56, Fxn gene detc abnor alleles,81284,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,205.5,,,,,,,fee schedule,205.5,571.56, Fxn gene detc abnor alleles,81284,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,205.5,,,,,,,fee schedule,205.5,571.56, Fxn gene charac alleles,81285,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1146.59,,,,,,,fee schedule,412.25,1146.59, Fxn gene charac alleles,81285,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,412.25,,,,,,,fee schedule,412.25,1146.59, Fxn gene charac alleles,81285,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,412.25,,,,,,,fee schedule,412.25,1146.59, Fxn gene full gene sequence,81286,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1146.59,,,,,,,fee schedule,412.25,1146.59, Fxn gene full gene sequence,81286,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,412.25,,,,,,,fee schedule,412.25,1146.59, Fxn gene full gene sequence,81286,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,412.25,,,,,,,fee schedule,412.25,1146.59, Mgmt gene methylation anal,81287,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,520,,,,,,,fee schedule,186.96,520, Mgmt gene methylation anal,81287,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,186.96,,,,,,,fee schedule,186.96,520, Mgmt gene methylation anal,81287,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,186.96,,,,,,,fee schedule,186.96,520, Mlh1 gene,81288,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,802.36,,,,,,,fee schedule,288.48,802.36, Mlh1 gene,81288,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,288.48,,,,,,,fee schedule,288.48,802.36, Mlh1 gene,81288,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,288.48,,,,,,,fee schedule,288.48,802.36, Fxn gene known famil variant,81289,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,772.65,,,,,,,fee schedule,277.8,772.65, Fxn gene known famil variant,81289,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,277.8,,,,,,,fee schedule,277.8,772.65, Fxn gene known famil variant,81289,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,277.8,,,,,,,fee schedule,277.8,772.65, Mcoln1 gene,81290,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,164,,,,,,,fee schedule,58.97,164, Mcoln1 gene,81290,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,58.97,,,,,,,fee schedule,58.97,164, Mcoln1 gene,81290,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,58.97,,,,,,,fee schedule,58.97,164, Mthfr gene,81291,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,272.6,,,,,,,fee schedule,98.01,272.6, Mthfr gene,81291,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,98.01,,,,,,,fee schedule,98.01,272.6, Mthfr gene,81291,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,98.01,,,,,,,fee schedule,98.01,272.6, Mlh1 gene full seq,81292,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2817.77,,,,,,,fee schedule,1013.1,2817.77, Mlh1 gene full seq,81292,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1013.1,,,,,,,fee schedule,1013.1,2817.77, Mlh1 gene full seq,81292,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1013.1,,,,,,,fee schedule,1013.1,2817.77, Mlh1 gene known variants,81293,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1380.93,,,,,,,fee schedule,496.5,1380.93, Mlh1 gene known variants,81293,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,496.5,,,,,,,fee schedule,496.5,1380.93, Mlh1 gene known variants,81293,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,496.5,,,,,,,fee schedule,496.5,1380.93, Mlh1 gene dup/delete variant,81294,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,844.41,,,,,,,fee schedule,303.6,844.41, Mlh1 gene dup/delete variant,81294,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,303.6,,,,,,,fee schedule,303.6,844.41, Mlh1 gene dup/delete variant,81294,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,303.6,,,,,,,fee schedule,303.6,844.41, Msh2 gene full seq,81295,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1592.45,,,,,,,fee schedule,572.55,1592.45, Msh2 gene full seq,81295,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,572.55,,,,,,,fee schedule,572.55,1592.45, Msh2 gene full seq,81295,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,572.55,,,,,,,fee schedule,572.55,1592.45, Msh2 gene known variants,81296,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1409.01,,,,,,,fee schedule,506.6,1409.01, Msh2 gene known variants,81296,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,506.6,,,,,,,fee schedule,506.6,1409.01, Msh2 gene known variants,81296,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,506.6,,,,,,,fee schedule,506.6,1409.01, Msh2 gene dup/delete variant,81297,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,889.89,,,,,,,fee schedule,319.95,889.89, Msh2 gene dup/delete variant,81297,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,319.95,,,,,,,fee schedule,319.95,889.89, Msh2 gene dup/delete variant,81297,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,319.95,,,,,,,fee schedule,319.95,889.89, Msh6 gene full seq,81298,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2677.8,,,,,,,fee schedule,962.78,2677.8, Msh6 gene full seq,81298,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,962.78,,,,,,,fee schedule,962.78,2677.8, Msh6 gene full seq,81298,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,962.78,,,,,,,fee schedule,962.78,2677.8, Msh6 gene known variants,81299,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1284.98,,,,,,,fee schedule,462,1284.98, Msh6 gene known variants,81299,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,462,,,,,,,fee schedule,462,1284.98, Msh6 gene known variants,81299,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,462,,,,,,,fee schedule,462,1284.98, Msh6 gene dup/delete variant,81300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,992.94,,,,,,,fee schedule,357,992.94, Msh6 gene dup/delete variant,81300,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,357,,,,,,,fee schedule,357,992.94, Msh6 gene dup/delete variant,81300,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,357,,,,,,,fee schedule,357,992.94, Microsatellite instability,81301,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1454.19,,,,,,,fee schedule,522.84,1454.19, Microsatellite instability,81301,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,522.84,,,,,,,fee schedule,522.84,1454.19, Microsatellite instability,81301,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,522.84,,,,,,,fee schedule,522.84,1454.19, Mecp2 gene full seq,81302,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2202.27,,,,,,,fee schedule,791.81,2202.27, Mecp2 gene full seq,81302,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,791.81,,,,,,,fee schedule,791.81,2202.27, Mecp2 gene full seq,81302,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,791.81,,,,,,,fee schedule,791.81,2202.27, Mecp2 gene known variant,81303,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,500.64,,,,,,,fee schedule,180,500.64, Mecp2 gene known variant,81303,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,180,,,,,,,fee schedule,180,500.64, Mecp2 gene known variant,81303,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,180,,,,,,,fee schedule,180,500.64, Mecp2 gene dup/delet variant,81304,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,625.8,,,,,,,fee schedule,225,625.8, Mecp2 gene dup/delet variant,81304,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,225,,,,,,,fee schedule,225,625.8, Mecp2 gene dup/delet variant,81304,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,225,,,,,,,fee schedule,225,625.8, Myd88 gene p.leu265pro vrnt,81305,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,731.77,,,,,,,fee schedule,263.1,731.77, Myd88 gene p.leu265pro vrnt,81305,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,263.1,,,,,,,fee schedule,263.1,731.77, Myd88 gene p.leu265pro vrnt,81305,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,263.1,,,,,,,fee schedule,263.1,731.77, Nudt15 gene common variants,81306,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1215.55,,,,,,,fee schedule,437.04,1215.55, Nudt15 gene common variants,81306,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,437.04,,,,,,,fee schedule,437.04,1215.55, Nudt15 gene common variants,81306,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,437.04,,,,,,,fee schedule,437.04,1215.55, Palb2 gene full gene seq,81307,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2822.36,,,,,,,fee schedule,424.32,2822.36, Palb2 gene full gene seq,81307,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,424.32,,,,,,,fee schedule,424.32,2822.36, Palb2 gene full gene seq,81307,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,424.32,,,,,,,fee schedule,424.32,2822.36, Palb2 gene known famil vrnt,81308,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1257.23,,,,,,,fee schedule,452.03,1257.23, Palb2 gene known famil vrnt,81308,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,452.03,,,,,,,fee schedule,452.03,1257.23, Palb2 gene known famil vrnt,81308,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,452.03,,,,,,,fee schedule,452.03,1257.23, Pik3ca gene trgt seq alys,81309,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1146.59,,,,,,,fee schedule,412.25,1146.59, Pik3ca gene trgt seq alys,81309,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,412.25,,,,,,,fee schedule,412.25,1146.59, Pik3ca gene trgt seq alys,81309,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,412.25,,,,,,,fee schedule,412.25,1146.59, Npm1 gene,81310,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1028.48,,,,,,,fee schedule,369.78,1028.48, Npm1 gene,81310,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,369.78,,,,,,,fee schedule,369.78,1028.48, Npm1 gene,81310,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,369.78,,,,,,,fee schedule,369.78,1028.48, Nras gene variants exon 2&3,81311,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1234.04,,,,,,,fee schedule,443.69,1234.04, Nras gene variants exon 2&3,81311,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,443.69,,,,,,,fee schedule,443.69,1234.04, Nras gene variants exon 2&3,81311,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,443.69,,,,,,,fee schedule,443.69,1234.04, Pabpn1 gene detc abnor allel,81312,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,571.56,,,,,,,fee schedule,205.5,571.56, Pabpn1 gene detc abnor allel,81312,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,205.5,,,,,,,fee schedule,205.5,571.56, Pabpn1 gene detc abnor allel,81312,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,205.5,,,,,,,fee schedule,205.5,571.56, Pca3/klk3 antigen,81313,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1064.07,,,,,,,fee schedule,382.58,1064.07, Pca3/klk3 antigen,81313,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.58,,,,,,,fee schedule,382.58,1064.07, Pca3/klk3 antigen,81313,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,382.58,,,,,,,fee schedule,382.58,1064.07, Pdgfra gene,81314,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1374.72,,,,,,,fee schedule,494.27,1374.72, Pdgfra gene,81314,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,494.27,,,,,,,fee schedule,494.27,1374.72, Pdgfra gene,81314,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,494.27,,,,,,,fee schedule,494.27,1374.72, Pml/raralpha com breakpoints,81315,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,864.9,,,,,,,fee schedule,310.97,864.9, Pml/raralpha com breakpoints,81315,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,310.97,,,,,,,fee schedule,310.97,864.9, Pml/raralpha com breakpoints,81315,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,310.97,,,,,,,fee schedule,310.97,864.9, Pml/raralpha 1 breakpoint,81316,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,864.9,,,,,,,fee schedule,310.97,864.9, Pml/raralpha 1 breakpoint,81316,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,310.97,,,,,,,fee schedule,310.97,864.9, Pml/raralpha 1 breakpoint,81316,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,310.97,,,,,,,fee schedule,310.97,864.9, Pms2 gene full seq analysis,81317,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2822.36,,,,,,,fee schedule,1014.75,2822.36, Pms2 gene full seq analysis,81317,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1014.75,,,,,,,fee schedule,1014.75,2822.36, Pms2 gene full seq analysis,81317,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1014.75,,,,,,,fee schedule,1014.75,2822.36, Pms2 known familial variants,81318,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1380.93,,,,,,,fee schedule,496.5,1380.93, Pms2 known familial variants,81318,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,496.5,,,,,,,fee schedule,496.5,1380.93, Pms2 known familial variants,81318,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,496.5,,,,,,,fee schedule,496.5,1380.93, Pms2 gene dup/delet variants,81319,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,849,,,,,,,fee schedule,305.25,849, Pms2 gene dup/delet variants,81319,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,305.25,,,,,,,fee schedule,305.25,849, Pms2 gene dup/delet variants,81319,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,305.25,,,,,,,fee schedule,305.25,849, Plcg2 gene common variants,81320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1215.55,,,,,,,fee schedule,437.04,1215.55, Plcg2 gene common variants,81320,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,437.04,,,,,,,fee schedule,437.04,1215.55, Plcg2 gene common variants,81320,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,437.04,,,,,,,fee schedule,437.04,1215.55, Pten gene full sequence,81321,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2503.2,,,,,,,fee schedule,900,2503.2, Pten gene full sequence,81321,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,900,,,,,,,fee schedule,900,2503.2, Pten gene full sequence,81321,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,900,,,,,,,fee schedule,900,2503.2, Pten gene known fam variant,81322,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,194.42,,,,,,,fee schedule,69.9,194.42, Pten gene known fam variant,81322,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,69.9,,,,,,,fee schedule,69.9,194.42, Pten gene known fam variant,81322,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,69.9,,,,,,,fee schedule,69.9,194.42, Pten gene dup/delet variant,81323,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1251.6,,,,,,,fee schedule,450,1251.6, Pten gene dup/delet variant,81323,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,450,,,,,,,fee schedule,450,1251.6, Pten gene dup/delet variant,81323,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,450,,,,,,,fee schedule,450,1251.6, Pmp22 gene dup/delet,81324,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3163.88,,,,,,,fee schedule,1137.54,3163.88, Pmp22 gene dup/delet,81324,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1137.54,,,,,,,fee schedule,1137.54,3163.88, Pmp22 gene dup/delet,81324,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1137.54,,,,,,,fee schedule,1137.54,3163.88, Pmp22 gene full sequence,81325,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3210.69,,,,,,,fee schedule,1154.37,3210.69, Pmp22 gene full sequence,81325,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1154.37,,,,,,,fee schedule,1154.37,3210.69, Pmp22 gene full sequence,81325,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1154.37,,,,,,,fee schedule,1154.37,3210.69, Pmp22 gene known fam variant,81326,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,194.42,,,,,,,fee schedule,69.9,194.42, Pmp22 gene known fam variant,81326,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,69.9,,,,,,,fee schedule,69.9,194.42, Pmp22 gene known fam variant,81326,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,69.9,,,,,,,fee schedule,69.9,194.42, Sept9 methylation analysis,81327,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,801.02,,,,,,,fee schedule,288,801.02, Sept9 methylation analysis,81327,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,288,,,,,,,fee schedule,288,801.02, Sept9 methylation analysis,81327,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,288,,,,,,,fee schedule,288,801.02, Slco1b1 gene com variants,81328,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,729.31,,,,,,,fee schedule,262.22,729.31, Slco1b1 gene com variants,81328,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,262.22,,,,,,,fee schedule,262.22,729.31, Slco1b1 gene com variants,81328,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,262.22,,,,,,,fee schedule,262.22,729.31, Smn1 gene dos/deletion alys,81329,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,571.56,,,,,,,fee schedule,205.5,571.56, Smn1 gene dos/deletion alys,81329,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,205.5,,,,,,,fee schedule,205.5,571.56, Smn1 gene dos/deletion alys,81329,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,205.5,,,,,,,fee schedule,205.5,571.56, Smpd1 gene common variants,81330,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,196.08,,,,,,,fee schedule,70.5,196.08, Smpd1 gene common variants,81330,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,70.5,,,,,,,fee schedule,70.5,196.08, Smpd1 gene common variants,81330,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,70.5,,,,,,,fee schedule,70.5,196.08, Snrpn/ube3a gene,81331,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,213.06,,,,,,,fee schedule,76.61,213.06, Snrpn/ube3a gene,81331,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,76.61,,,,,,,fee schedule,76.61,213.06, Snrpn/ube3a gene,81331,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,76.61,,,,,,,fee schedule,76.61,213.06, Serpina1 gene,81332,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,182.11,,,,,,,fee schedule,65.48,182.11, Serpina1 gene,81332,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,65.48,,,,,,,fee schedule,65.48,182.11, Serpina1 gene,81332,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,65.48,,,,,,,fee schedule,65.48,182.11, Tgfbi gene common variants,81333,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,571.56,,,,,,,fee schedule,205.5,571.56, Tgfbi gene common variants,81333,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,205.5,,,,,,,fee schedule,205.5,571.56, Tgfbi gene common variants,81333,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,205.5,,,,,,,fee schedule,205.5,571.56, Runx1 gene targeted seq alys,81334,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1374.72,,,,,,,fee schedule,494.27,1374.72, Runx1 gene targeted seq alys,81334,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,494.27,,,,,,,fee schedule,494.27,1374.72, Runx1 gene targeted seq alys,81334,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,494.27,,,,,,,fee schedule,494.27,1374.72, Tpmt gene com variants,81335,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,729.31,,,,,,,fee schedule,262.22,729.31, Tpmt gene com variants,81335,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,262.22,,,,,,,fee schedule,262.22,729.31, Tpmt gene com variants,81335,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,262.22,,,,,,,fee schedule,262.22,729.31, Smn1 gene full gene sequence,81336,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1257.23,,,,,,,fee schedule,452.03,1257.23, Smn1 gene full gene sequence,81336,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,452.03,,,,,,,fee schedule,452.03,1257.23, Smn1 gene full gene sequence,81336,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,452.03,,,,,,,fee schedule,452.03,1257.23, Smn1 gen nown famil seq vrnt,81337,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,772.65,,,,,,,fee schedule,277.8,772.65, Smn1 gen nown famil seq vrnt,81337,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,277.8,,,,,,,fee schedule,277.8,772.65, Smn1 gen nown famil seq vrnt,81337,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,277.8,,,,,,,fee schedule,277.8,772.65, Mpl gene common variants,81338,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,627.18,,,,,,,fee schedule,225.5,627.18, Mpl gene common variants,81338,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,225.5,,,,,,,fee schedule,225.5,627.18, Mpl gene common variants,81338,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,225.5,,,,,,,fee schedule,225.5,627.18, Mpl gene seq alys exon 10,81339,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,772.65,,,,,,,fee schedule,277.8,772.65, Mpl gene seq alys exon 10,81339,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,277.8,,,,,,,fee schedule,277.8,772.65, Mpl gene seq alys exon 10,81339,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,277.8,,,,,,,fee schedule,277.8,772.65, Trb@ gene rearrange amplify,81340,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,871.61,,,,,,,fee schedule,313.38,871.61, Trb@ gene rearrange amplify,81340,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,313.38,,,,,,,fee schedule,313.38,871.61, Trb@ gene rearrange amplify,81340,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,313.38,,,,,,,fee schedule,313.38,871.61, Trb@ gene rearrange dirprobe,81341,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,206.89,,,,,,,fee schedule,74.39,206.89, Trb@ gene rearrange dirprobe,81341,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,74.39,,,,,,,fee schedule,74.39,206.89, Trb@ gene rearrange dirprobe,81341,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,74.39,,,,,,,fee schedule,74.39,206.89, Trg gene rearrangement anal,81342,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,840.66,,,,,,,fee schedule,302.25,840.66, Trg gene rearrangement anal,81342,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,302.25,,,,,,,fee schedule,302.25,840.66, Trg gene rearrangement anal,81342,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,302.25,,,,,,,fee schedule,302.25,840.66, Ppp2r2b gen detc abnor allel,81343,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,571.56,,,,,,,fee schedule,205.5,571.56, Ppp2r2b gen detc abnor allel,81343,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,205.5,,,,,,,fee schedule,205.5,571.56, Ppp2r2b gen detc abnor allel,81343,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,205.5,,,,,,,fee schedule,205.5,571.56, Tbp gene detc abnor alleles,81344,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,571.56,,,,,,,fee schedule,205.5,571.56, Tbp gene detc abnor alleles,81344,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,205.5,,,,,,,fee schedule,205.5,571.56, Tbp gene detc abnor alleles,81344,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,205.5,,,,,,,fee schedule,205.5,571.56, Tert gene targeted seq alys,81345,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,772.65,,,,,,,fee schedule,277.8,772.65, Tert gene targeted seq alys,81345,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,277.8,,,,,,,fee schedule,277.8,772.65, Tert gene targeted seq alys,81345,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,277.8,,,,,,,fee schedule,277.8,772.65, Tyms gene com variants,81346,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,729.31,,,,,,,fee schedule,262.22,729.31, Tyms gene com variants,81346,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,262.22,,,,,,,fee schedule,262.22,729.31, Tyms gene com variants,81346,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,262.22,,,,,,,fee schedule,262.22,729.31, Sf3b1 gene common variants,81347,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,806.24,,,,,,,fee schedule,289.88,806.24, Sf3b1 gene common variants,81347,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,289.88,,,,,,,fee schedule,289.88,806.24, Sf3b1 gene common variants,81347,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,289.88,,,,,,,fee schedule,289.88,806.24, Srsf2 gene common variants,81348,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,731.77,,,,,,,fee schedule,263.1,731.77, Srsf2 gene common variants,81348,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,263.1,,,,,,,fee schedule,263.1,731.77, Srsf2 gene common variants,81348,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,263.1,,,,,,,fee schedule,263.1,731.77, Cytog alys chrml abnr lw-ps,81349,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4997.81,,,,,,,fee schedule,1740,4997.81, Cytog alys chrml abnr lw-ps,81349,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1740,,,,,,,fee schedule,1740,4997.81, Cytog alys chrml abnr lw-ps,81349,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1740,,,,,,,fee schedule,1740,4997.81, Ugt1a1 gene,81350,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,976.25,,,,,,,fee schedule,351,976.25, Ugt1a1 gene,81350,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,351,,,,,,,fee schedule,351,976.25, Ugt1a1 gene,81350,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,351,,,,,,,fee schedule,351,976.25, Tp53 gene full gene sequence,81351,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2677.8,,,,,,,fee schedule,962.78,2677.8, Tp53 gene full gene sequence,81351,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,962.78,,,,,,,fee schedule,962.78,2677.8, Tp53 gene full gene sequence,81351,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,962.78,,,,,,,fee schedule,962.78,2677.8, Tp53 gene trgt sequence alys,81352,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1374.72,,,,,,,fee schedule,494.27,1374.72, Tp53 gene trgt sequence alys,81352,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,494.27,,,,,,,fee schedule,494.27,1374.72, Tp53 gene trgt sequence alys,81352,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,494.27,,,,,,,fee schedule,494.27,1374.72, Tp53 gene known famil vrnt,81353,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1284.98,,,,,,,fee schedule,462,1284.98, Tp53 gene known famil vrnt,81353,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,462,,,,,,,fee schedule,462,1284.98, Tp53 gene known famil vrnt,81353,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,462,,,,,,,fee schedule,462,1284.98, Cytog alys chrml abnor ogm,81354,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5271.45,,,,,,,fee schedule,5271.45,5271.45, Vkorc1 gene,81355,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,367.97,,,,,,,fee schedule,132.3,367.97, Vkorc1 gene,81355,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,132.3,,,,,,,fee schedule,132.3,367.97, Vkorc1 gene,81355,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,132.3,,,,,,,fee schedule,132.3,367.97, U2af1 gene common variants,81357,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,806.24,,,,,,,fee schedule,289.88,806.24, U2af1 gene common variants,81357,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,289.88,,,,,,,fee schedule,289.88,806.24, U2af1 gene common variants,81357,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,289.88,,,,,,,fee schedule,289.88,806.24, Zrsr2 gene common variants,81360,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,806.24,,,,,,,fee schedule,289.88,806.24, Zrsr2 gene common variants,81360,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,289.88,,,,,,,fee schedule,289.88,806.24, Zrsr2 gene common variants,81360,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,289.88,,,,,,,fee schedule,289.88,806.24, Hbb gene com variants,81361,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,729.31,,,,,,,fee schedule,262.22,729.31, Hbb gene com variants,81361,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,262.22,,,,,,,fee schedule,262.22,729.31, Hbb gene com variants,81361,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,262.22,,,,,,,fee schedule,262.22,729.31, Hbb gene known fam variant,81362,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1565.54,,,,,,,fee schedule,562.88,1565.54, Hbb gene known fam variant,81362,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,562.88,,,,,,,fee schedule,562.88,1565.54, Hbb gene known fam variant,81362,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,562.88,,,,,,,fee schedule,562.88,1565.54, Hbb gene dup/del variants,81363,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,844.41,,,,,,,fee schedule,303.6,844.41, Hbb gene dup/del variants,81363,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,303.6,,,,,,,fee schedule,303.6,844.41, Hbb gene dup/del variants,81363,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,303.6,,,,,,,fee schedule,303.6,844.41, Hbb full gene sequence,81364,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1354.15,,,,,,,fee schedule,486.87,1354.15, Hbb full gene sequence,81364,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,486.87,,,,,,,fee schedule,486.87,1354.15, Hbb full gene sequence,81364,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,486.87,,,,,,,fee schedule,486.87,1354.15, Hla i & ii typing lr,81370,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1677.64,,,,,,,fee schedule,603.18,1677.64, Hla i & ii typing lr,81370,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,603.18,,,,,,,fee schedule,603.18,1677.64, Hla i & ii typing lr,81370,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,603.18,,,,,,,fee schedule,603.18,1677.64, Hla i & ii type verify lr,81371,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1687.66,,,,,,,fee schedule,606.78,1687.66, Hla i & ii type verify lr,81371,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,606.78,,,,,,,fee schedule,606.78,1687.66, Hla i & ii type verify lr,81371,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,606.78,,,,,,,fee schedule,606.78,1687.66, Hla i typing complete lr,81372,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1683.78,,,,,,,fee schedule,605.39,1683.78, Hla i typing complete lr,81372,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,605.39,,,,,,,fee schedule,605.39,1683.78, Hla i typing complete lr,81372,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,605.39,,,,,,,fee schedule,605.39,1683.78, Hla i typing 1 locus lr,81373,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,531.64,,,,,,,fee schedule,191.15,531.64, Hla i typing 1 locus lr,81373,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,191.15,,,,,,,fee schedule,191.15,531.64, Hla i typing 1 locus lr,81373,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,191.15,,,,,,,fee schedule,191.15,531.64, Hla i typing 1 antigen lr,81374,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,310.1,,,,,,,fee schedule,111.5,310.1, Hla i typing 1 antigen lr,81374,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,111.5,,,,,,,fee schedule,111.5,310.1, Hla i typing 1 antigen lr,81374,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,111.5,,,,,,,fee schedule,111.5,310.1, Hla ii typing ag equiv lr,81375,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,920.93,,,,,,,fee schedule,331.11,920.93, Hla ii typing ag equiv lr,81375,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,331.11,,,,,,,fee schedule,331.11,920.93, Hla ii typing ag equiv lr,81375,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,331.11,,,,,,,fee schedule,331.11,920.93, Hla ii typing 1 locus lr,81376,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,509.9,,,,,,,fee schedule,183.33,509.9, Hla ii typing 1 locus lr,81376,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,183.33,,,,,,,fee schedule,183.33,509.9, Hla ii typing 1 locus lr,81376,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,183.33,,,,,,,fee schedule,183.33,509.9, Hla ii type 1 ag equiv lr,81377,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,395.26,,,,,,,fee schedule,142.11,395.26, Hla ii type 1 ag equiv lr,81377,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,142.11,,,,,,,fee schedule,142.11,395.26, Hla ii type 1 ag equiv lr,81377,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,142.11,,,,,,,fee schedule,142.11,395.26, Hla i & ii typing hr,81378,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1441.72,,,,,,,fee schedule,518.36,1441.72, Hla i & ii typing hr,81378,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,518.36,,,,,,,fee schedule,518.36,1441.72, Hla i & ii typing hr,81378,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,518.36,,,,,,,fee schedule,518.36,1441.72, Hla i typing complete hr,81379,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1399.21,,,,,,,fee schedule,503.07,1399.21, Hla i typing complete hr,81379,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,503.07,,,,,,,fee schedule,503.07,1399.21, Hla i typing complete hr,81379,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,503.07,,,,,,,fee schedule,503.07,1399.21, Hla i typing 1 locus hr,81380,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,739.49,,,,,,,fee schedule,265.88,739.49, Hla i typing 1 locus hr,81380,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,265.88,,,,,,,fee schedule,265.88,739.49, Hla i typing 1 locus hr,81380,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,265.88,,,,,,,fee schedule,265.88,739.49, Hla i typing 1 allele hr,81381,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,708.82,,,,,,,fee schedule,254.85,708.82, Hla i typing 1 allele hr,81381,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,254.85,,,,,,,fee schedule,254.85,708.82, Hla i typing 1 allele hr,81381,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,254.85,,,,,,,fee schedule,254.85,708.82, Hla ii typing 1 loc hr,81382,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,515.99,,,,,,,fee schedule,185.52,515.99, Hla ii typing 1 loc hr,81382,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,185.52,,,,,,,fee schedule,185.52,515.99, Hla ii typing 1 loc hr,81382,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,185.52,,,,,,,fee schedule,185.52,515.99, Hla ii typing 1 allele hr,81383,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,455.29,,,,,,,fee schedule,163.7,455.29, Hla ii typing 1 allele hr,81383,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,163.7,,,,,,,fee schedule,163.7,455.29, Hla ii typing 1 allele hr,81383,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,163.7,,,,,,,fee schedule,163.7,455.29, Mopath procedure level 1,81400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,266.84,,,,,,,fee schedule,95.94,266.84, Mopath procedure level 1,81400,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,95.94,,,,,,,fee schedule,95.94,266.84, Mopath procedure level 1,81400,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,95.94,,,,,,,fee schedule,95.94,266.84, Mopath procedure level 2,81401,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,571.56,,,,,,,fee schedule,205.5,571.56, Mopath procedure level 2,81401,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,205.5,,,,,,,fee schedule,205.5,571.56, Mopath procedure level 2,81401,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,205.5,,,,,,,fee schedule,205.5,571.56, Mopath procedure level 3,81402,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,627.18,,,,,,,fee schedule,225.5,627.18, Mopath procedure level 3,81402,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,225.5,,,,,,,fee schedule,225.5,627.18, Mopath procedure level 3,81402,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,225.5,,,,,,,fee schedule,225.5,627.18, Mopath procedure level 4,81403,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,772.65,,,,,,,fee schedule,277.8,772.65, Mopath procedure level 4,81403,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,277.8,,,,,,,fee schedule,277.8,772.65, Mopath procedure level 4,81403,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,277.8,,,,,,,fee schedule,277.8,772.65, Mopath procedure level 5,81404,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1146.59,,,,,,,fee schedule,412.25,1146.59, Mopath procedure level 5,81404,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,412.25,,,,,,,fee schedule,412.25,1146.59, Mopath procedure level 5,81404,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,412.25,,,,,,,fee schedule,412.25,1146.59, Mopath procedure level 6,81405,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1257.23,,,,,,,fee schedule,452.03,1257.23, Mopath procedure level 6,81405,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,452.03,,,,,,,fee schedule,452.03,1257.23, Mopath procedure level 6,81405,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,452.03,,,,,,,fee schedule,452.03,1257.23, Mopath procedure level 7,81406,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1180.18,,,,,,,fee schedule,424.32,1180.18, Mopath procedure level 7,81406,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,424.32,,,,,,,fee schedule,424.32,1180.18, Mopath procedure level 7,81406,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,424.32,,,,,,,fee schedule,424.32,1180.18, Mopath procedure level 8,81407,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3530.64,,,,,,,fee schedule,1269.41,3530.64, Mopath procedure level 8,81407,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1269.41,,,,,,,fee schedule,1269.41,3530.64, Mopath procedure level 8,81407,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1269.41,,,,,,,fee schedule,1269.41,3530.64, Mopath procedure level 9,81408,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8344,,,,,,,fee schedule,3000,8344, Mopath procedure level 9,81408,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3000,,,,,,,fee schedule,3000,8344, Mopath procedure level 9,81408,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3000,,,,,,,fee schedule,3000,8344, Aortic dysfunction/dilation,81410,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2102.69,,,,,,,fee schedule,756,2102.69, Aortic dysfunction/dilation,81410,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,756,,,,,,,fee schedule,756,2102.69, Aortic dysfunction/dilation,81410,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,756,,,,,,,fee schedule,756,2102.69, Aortic dysfunction/dilation,81411,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5632.99,,,,,,,fee schedule,2025.29,5632.99, Aortic dysfunction/dilation,81411,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2025.29,,,,,,,fee schedule,2025.29,5632.99, Aortic dysfunction/dilation,81411,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2025.29,,,,,,,fee schedule,2025.29,5632.99, Ashkenazi jewish assoc dis,81412,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10215.39,,,,,,,fee schedule,3672.84,10215.39, Ashkenazi jewish assoc dis,81412,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3672.84,,,,,,,fee schedule,3672.84,10215.39, Ashkenazi jewish assoc dis,81412,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3672.84,,,,,,,fee schedule,3672.84,10215.39, Car ion chnnlpath inc 10 gns,81413,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2440.2,,,,,,,fee schedule,877.35,2440.2, Car ion chnnlpath inc 10 gns,81413,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,877.35,,,,,,,fee schedule,877.35,2440.2, Car ion chnnlpath inc 10 gns,81413,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,877.35,,,,,,,fee schedule,877.35,2440.2, Car ion chnnlpath inc 2 gns,81414,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2440.2,,,,,,,fee schedule,877.35,2440.2, Car ion chnnlpath inc 2 gns,81414,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,877.35,,,,,,,fee schedule,877.35,2440.2, Car ion chnnlpath inc 2 gns,81414,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,877.35,,,,,,,fee schedule,877.35,2440.2, Exome sequence analysis,81415,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,19942.16,,,,,,,fee schedule,7170,19942.16, Exome sequence analysis,81415,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7170,,,,,,,fee schedule,7170,19942.16, Exome sequence analysis,81415,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,7170,,,,,,,fee schedule,7170,19942.16, Exome sequence analysis,81416,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,50064,,,,,,,fee schedule,18000,50064, Exome sequence analysis,81416,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18000,,,,,,,fee schedule,18000,50064, Exome sequence analysis,81416,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,18000,,,,,,,fee schedule,18000,50064, Exome re-evaluation,81417,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1335.04,,,,,,,fee schedule,480,1335.04, Exome re-evaluation,81417,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,480,,,,,,,fee schedule,480,1335.04, Exome re-evaluation,81417,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,480,,,,,,,fee schedule,480,1335.04, Rx metab gen seq alys pnl 6,81418,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3826.06,,,,,,,fee schedule,1375.62,3826.06, Rx metab gen seq alys pnl 6,81418,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1375.62,,,,,,,fee schedule,1375.62,3826.06, Rx metab gen seq alys pnl 6,81418,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1375.62,,,,,,,fee schedule,1375.62,3826.06, Epilepsy gen seq alys panel,81419,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10215.39,,,,,,,fee schedule,3672.84,10215.39, Epilepsy gen seq alys panel,81419,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3672.84,,,,,,,fee schedule,3672.84,10215.39, Epilepsy gen seq alys panel,81419,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3672.84,,,,,,,fee schedule,3672.84,10215.39, Fetal chrmoml aneuploidy,81420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3166.76,,,,,,,fee schedule,1138.58,3166.76, Fetal chrmoml aneuploidy,81420,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1138.58,,,,,,,fee schedule,1138.58,3166.76, Fetal chrmoml aneuploidy,81420,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1138.58,,,,,,,fee schedule,1138.58,3166.76, Fetal chrmoml microdeltj,81422,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3166.76,,,,,,,fee schedule,1138.58,3166.76, Fetal chrmoml microdeltj,81422,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1138.58,,,,,,,fee schedule,1138.58,3166.76, Fetal chrmoml microdeltj,81422,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1138.58,,,,,,,fee schedule,1138.58,3166.76, Genome sequence analysis,81425,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,20990.17,,,,,,,fee schedule,7546.8,20990.17, Genome sequence analysis,81425,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7546.8,,,,,,,fee schedule,7546.8,20990.17, Genome sequence analysis,81425,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,7546.8,,,,,,,fee schedule,7546.8,20990.17, Genome sequence analysis,81426,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,11305.91,,,,,,,fee schedule,4064.93,11305.91, Genome sequence analysis,81426,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4064.93,,,,,,,fee schedule,4064.93,11305.91, Genome sequence analysis,81426,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4064.93,,,,,,,fee schedule,4064.93,11305.91, Genome re-evaluation,81427,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9752.68,,,,,,,fee schedule,3506.48,9752.68, Genome re-evaluation,81427,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3506.48,,,,,,,fee schedule,3506.48,9752.68, Genome re-evaluation,81427,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3506.48,,,,,,,fee schedule,3506.48,9752.68, Hearing loss sequence analys,81430,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6779.5,,,,,,,fee schedule,2437.5,6779.5, Hearing loss sequence analys,81430,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2437.5,,,,,,,fee schedule,2437.5,6779.5, Hearing loss sequence analys,81430,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2437.5,,,,,,,fee schedule,2437.5,6779.5, Hearing loss dup/del analys,81431,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2835.17,,,,,,,fee schedule,1019.36,2835.17, Hearing loss dup/del analys,81431,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1019.36,,,,,,,fee schedule,1019.36,2835.17, Hearing loss dup/del analys,81431,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1019.36,,,,,,,fee schedule,1019.36,2835.17, Hrdtry brst ca-rlatd dsordrs,81432,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5440.08,,,,,,,fee schedule,1018.58,5440.08, Hrdtry brst ca-rlatd dsordrs,81432,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1018.58,,,,,,,fee schedule,1018.58,5440.08, Hrdtry brst ca-rlatd dsordrs,81432,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1018.58,,,,,,,fee schedule,1018.58,5440.08, Hereditary retinal disorders,81434,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2494.48,,,,,,,fee schedule,896.87,2494.48, Hereditary retinal disorders,81434,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,896.87,,,,,,,fee schedule,896.87,2494.48, Hereditary retinal disorders,81434,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,896.87,,,,,,,fee schedule,896.87,2494.48, Hereditary colon ca dsordrs,81435,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5440.08,,,,,,,fee schedule,877.35,5440.08, Hereditary colon ca dsordrs,81435,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,877.35,,,,,,,fee schedule,877.35,5440.08, Hereditary colon ca dsordrs,81435,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,877.35,,,,,,,fee schedule,877.35,5440.08, Heredtry nurondcrn tum dsrdr,81437,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5440.08,,,,,,,fee schedule,658.4,5440.08, Heredtry nurondcrn tum dsrdr,81437,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,658.4,,,,,,,fee schedule,658.4,5440.08, Heredtry nurondcrn tum dsrdr,81437,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,658.4,,,,,,,fee schedule,658.4,5440.08, Inherited cardmypthy 5 gns,81439,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2440.2,,,,,,,fee schedule,877.35,2440.2, Inherited cardmypthy 5 gns,81439,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,877.35,,,,,,,fee schedule,877.35,2440.2, Inherited cardmypthy 5 gns,81439,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,877.35,,,,,,,fee schedule,877.35,2440.2, Mitochondrial gene,81440,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,13867.73,,,,,,,fee schedule,4986,13867.73, Mitochondrial gene,81440,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4986,,,,,,,fee schedule,4986,13867.73, Mitochondrial gene,81440,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4986,,,,,,,fee schedule,4986,13867.73, Ibmfs seq alys pnl 30 genes,81441,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10215.39,,,,,,,fee schedule,3672.84,10215.39, Ibmfs seq alys pnl 30 genes,81441,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3672.84,,,,,,,fee schedule,3672.84,10215.39, Ibmfs seq alys pnl 30 genes,81441,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3672.84,,,,,,,fee schedule,3672.84,10215.39, Noonan spectrum disorders,81442,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8943.1,,,,,,,fee schedule,3215.4,8943.1, Noonan spectrum disorders,81442,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3215.4,,,,,,,fee schedule,3215.4,8943.1, Noonan spectrum disorders,81442,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3215.4,,,,,,,fee schedule,3215.4,8943.1, Genetic tstg severe inh cond,81443,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10215.39,,,,,,,fee schedule,3672.84,10215.39, Genetic tstg severe inh cond,81443,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3672.84,,,,,,,fee schedule,3672.84,10215.39, Genetic tstg severe inh cond,81443,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3672.84,,,,,,,fee schedule,3672.84,10215.39, Targeted genomic seq analys,81445,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2494.48,,,,,,,fee schedule,896.87,2494.48, Targeted genomic seq analys,81445,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,896.87,,,,,,,fee schedule,896.87,2494.48, Targeted genomic seq analys,81445,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,896.87,,,,,,,fee schedule,896.87,2494.48, Hrdtry perph neurphy panel,81448,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2440.2,,,,,,,fee schedule,877.35,2440.2, Hrdtry perph neurphy panel,81448,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,877.35,,,,,,,fee schedule,877.35,2440.2, Hrdtry perph neurphy panel,81448,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,877.35,,,,,,,fee schedule,877.35,2440.2, Tgsap so neo 5-50 rna alys,81449,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2494.48,,,,,,,fee schedule,896.87,2494.48, Tgsap so neo 5-50 rna alys,81449,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,896.87,,,,,,,fee schedule,896.87,2494.48, Tgsap so neo 5-50 rna alys,81449,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,896.87,,,,,,,fee schedule,896.87,2494.48, Targeted genomic seq analys,81450,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3168.76,,,,,,,fee schedule,1139.3,3168.76, Targeted genomic seq analys,81450,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1139.3,,,,,,,fee schedule,1139.3,3168.76, Targeted genomic seq analys,81450,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1139.3,,,,,,,fee schedule,1139.3,3168.76, Tgsap hl neo 5-50 rna alys,81451,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3168.76,,,,,,,fee schedule,1139.3,3168.76, Tgsap hl neo 5-50 rna alys,81451,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1139.3,,,,,,,fee schedule,1139.3,3168.76, Tgsap hl neo 5-50 rna alys,81451,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1139.3,,,,,,,fee schedule,1139.3,3168.76, Targeted genomic seq analys,81455,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12180.57,,,,,,,fee schedule,4379.4,12180.57, Targeted genomic seq analys,81455,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4379.4,,,,,,,fee schedule,4379.4,12180.57, Targeted genomic seq analys,81455,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4379.4,,,,,,,fee schedule,4379.4,12180.57, Tgsap so/hl 51/< rna alys,81456,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12180.57,,,,,,,fee schedule,4379.4,12180.57, Tgsap so/hl 51/< rna alys,81456,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4379.4,,,,,,,fee schedule,4379.4,12180.57, Tgsap so/hl 51/< rna alys,81456,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4379.4,,,,,,,fee schedule,4379.4,12180.57, So neo gsap dna mcrstl ins,81457,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3741.74,,,,,,,fee schedule,1345.31,3741.74, So neo gsap dna mcrstl ins,81457,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1345.31,,,,,,,fee schedule,1345.31,3741.74, So neo gsap dna mcrstl ins,81457,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1345.31,,,,,,,fee schedule,1345.31,3741.74, So gsap dna cpy nmbr&mcrstl,81458,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4365.37,,,,,,,fee schedule,1569.53,4365.37, So gsap dna cpy nmbr&mcrstl,81458,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1569.53,,,,,,,fee schedule,1569.53,4365.37, So gsap dna cpy nmbr&mcrstl,81458,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1569.53,,,,,,,fee schedule,1569.53,4365.37, So neo gsap dna/dna&rna,81459,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12472.4,,,,,,,fee schedule,4484.33,12472.4, So neo gsap dna/dna&rna,81459,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4484.33,,,,,,,fee schedule,4484.33,12472.4, So neo gsap dna/dna&rna,81459,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4484.33,,,,,,,fee schedule,4484.33,12472.4, Whole mitochondrial genome,81460,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5369.36,,,,,,,fee schedule,1930.5,5369.36, Whole mitochondrial genome,81460,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1930.5,,,,,,,fee schedule,1930.5,5369.36, Whole mitochondrial genome,81460,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1930.5,,,,,,,fee schedule,1930.5,5369.36, So gsap cll fr dna/dna&rna,81462,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4989,,,,,,,fee schedule,1793.75,4989, So gsap cll fr dna/dna&rna,81462,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1793.75,,,,,,,fee schedule,1793.75,4989, So gsap cll fr dna/dna&rna,81462,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1793.75,,,,,,,fee schedule,1793.75,4989, So gsap cl fr cpy nmbr&mcrst,81463,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5612.63,,,,,,,fee schedule,2017.97,5612.63, So gsap cl fr cpy nmbr&mcrst,81463,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2017.97,,,,,,,fee schedule,2017.97,5612.63, So gsap cl fr cpy nmbr&mcrst,81463,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2017.97,,,,,,,fee schedule,2017.97,5612.63, So gsap cll fr mcrstl ins,81464,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,13719.66,,,,,,,fee schedule,4932.77,13719.66, So gsap cll fr mcrstl ins,81464,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4932.77,,,,,,,fee schedule,4932.77,13719.66, So gsap cll fr mcrstl ins,81464,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4932.77,,,,,,,fee schedule,4932.77,13719.66, Whole mitochondrial genome,81465,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3904.99,,,,,,,fee schedule,1404,3904.99, Whole mitochondrial genome,81465,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1404,,,,,,,fee schedule,1404,3904.99, Whole mitochondrial genome,81465,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1404,,,,,,,fee schedule,1404,3904.99, X-linked intellectual dblt,81470,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3813.21,,,,,,,fee schedule,1371,3813.21, X-linked intellectual dblt,81470,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1371,,,,,,,fee schedule,1371,3813.21, X-linked intellectual dblt,81470,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1371,,,,,,,fee schedule,1371,3813.21, X-linked intellectual dblt,81471,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3813.21,,,,,,,fee schedule,1371,3813.21, X-linked intellectual dblt,81471,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1371,,,,,,,fee schedule,1371,3813.21, X-linked intellectual dblt,81471,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1371,,,,,,,fee schedule,1371,3813.21, Autoimmune rheumatoid arthr,81490,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3507.19,,,,,,,fee schedule,1260.98,3507.19, Autoimmune rheumatoid arthr,81490,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1260.98,,,,,,,fee schedule,1260.98,3507.19, Autoimmune rheumatoid arthr,81490,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1260.98,,,,,,,fee schedule,1260.98,3507.19, Cor artery disease mrna,81493,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4380.6,,,,,,,fee schedule,1575,4380.6, Cor artery disease mrna,81493,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1575,,,,,,,fee schedule,1575,4380.6, Cor artery disease mrna,81493,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1575,,,,,,,fee schedule,1575,4380.6, Onco (ovar) two proteins,81500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1086.81,,,,,,,fee schedule,390.75,1086.81, Onco (ovar) two proteins,81500,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,390.75,,,,,,,fee schedule,390.75,1086.81, Onco (ovar) two proteins,81500,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,390.75,,,,,,,fee schedule,390.75,1086.81, Onco (ovar) five proteins,81503,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3742.28,,,,,,,fee schedule,1345.5,3742.28, Onco (ovar) five proteins,81503,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1345.5,,,,,,,fee schedule,1345.5,3742.28, Onco (ovar) five proteins,81503,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1345.5,,,,,,,fee schedule,1345.5,3742.28, Oncology tissue of origin,81504,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2169.44,,,,,,,fee schedule,780,2169.44, Oncology tissue of origin,81504,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,780,,,,,,,fee schedule,780,2169.44, Oncology tissue of origin,81504,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,780,,,,,,,fee schedule,780,2169.44, Endo assay seven anal,81506,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,287.53,,,,,,,fee schedule,103.38,287.53, Endo assay seven anal,81506,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,103.38,,,,,,,fee schedule,103.38,287.53, Endo assay seven anal,81506,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,103.38,,,,,,,fee schedule,103.38,287.53, Fetal aneuploidy trisom risk,81507,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3316.74,,,,,,,fee schedule,1192.5,3316.74, Fetal aneuploidy trisom risk,81507,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1192.5,,,,,,,fee schedule,1192.5,3316.74, Fetal aneuploidy trisom risk,81507,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1192.5,,,,,,,fee schedule,1192.5,3316.74, Ftl cgen abnor two proteins,81508,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,226.54,,,,,,,fee schedule,81.45,226.54, Ftl cgen abnor two proteins,81508,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,81.45,,,,,,,fee schedule,81.45,226.54, Ftl cgen abnor two proteins,81508,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,81.45,,,,,,,fee schedule,81.45,226.54, Ftl cgen abnor 3 proteins,81509,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6205.31,,,,,,,fee schedule,2231.06,6205.31, Ftl cgen abnor 3 proteins,81509,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2231.06,,,,,,,fee schedule,2231.06,6205.31, Ftl cgen abnor 3 proteins,81509,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2231.06,,,,,,,fee schedule,2231.06,6205.31, Ftl cgen abnor three anal,81510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,231.71,,,,,,,fee schedule,83.31,231.71, Ftl cgen abnor three anal,81510,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,83.31,,,,,,,fee schedule,83.31,231.71, Ftl cgen abnor three anal,81510,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,83.31,,,,,,,fee schedule,83.31,231.71, Ftl cgen abnor four anal,81511,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,640.4,,,,,,,fee schedule,230.25,640.4, Ftl cgen abnor four anal,81511,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,230.25,,,,,,,fee schedule,230.25,640.4, Ftl cgen abnor four anal,81511,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,230.25,,,,,,,fee schedule,230.25,640.4, Ftl cgen abnor five anal,81512,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,290.04,,,,,,,fee schedule,104.28,290.04, Ftl cgen abnor five anal,81512,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,104.28,,,,,,,fee schedule,104.28,290.04, Ftl cgen abnor five anal,81512,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,104.28,,,,,,,fee schedule,104.28,290.04, Nfct ds bv rna vag flu alg,81513,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,595.05,,,,,,,fee schedule,213.95,595.05, Nfct ds bv rna vag flu alg,81513,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,213.95,,,,,,,fee schedule,213.95,595.05, Nfct ds bv rna vag flu alg,81513,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,213.95,,,,,,,fee schedule,213.95,595.05, Nfct ds bv&vaginitis dna alg,81514,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1097.19,,,,,,,fee schedule,394.49,1097.19, Nfct ds bv&vaginitis dna alg,81514,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,394.49,,,,,,,fee schedule,394.49,1097.19, Nfct ds bv&vaginitis dna alg,81514,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,394.49,,,,,,,fee schedule,394.49,1097.19, Nfct ds bv&vaginitis dna alg,81515,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1097.19,,,,,,,fee schedule,394.49,1097.19, Nfct ds bv&vaginitis dna alg,81515,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,394.49,,,,,,,fee schedule,394.49,1097.19, Nfct ds bv&vaginitis dna alg,81515,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,394.49,,,,,,,fee schedule,394.49,1097.19, Liver ds alys 3 bmrk srm alg,81517,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,735.06,,,,,,,fee schedule,264.29,735.06, Liver ds alys 3 bmrk srm alg,81517,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,264.29,,,,,,,fee schedule,264.29,735.06, Liver ds alys 3 bmrk srm alg,81517,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,264.29,,,,,,,fee schedule,264.29,735.06, Onc brst mrna 11 genes,81518,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,16158.16,,,,,,,fee schedule,5809.5,16158.16, Onc brst mrna 11 genes,81518,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5809.5,,,,,,,fee schedule,5809.5,16158.16, Onc brst mrna 11 genes,81518,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5809.5,,,,,,,fee schedule,5809.5,16158.16, Oncology breast mrna,81519,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,16158.16,,,,,,,fee schedule,5809.5,16158.16, Oncology breast mrna,81519,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5809.5,,,,,,,fee schedule,5809.5,16158.16, Oncology breast mrna,81519,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5809.5,,,,,,,fee schedule,5809.5,16158.16, Onc breast mrna 58 genes,81520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10472.6,,,,,,,fee schedule,3765.32,10472.6, Onc breast mrna 58 genes,81520,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3765.32,,,,,,,fee schedule,3765.32,10472.6, Onc breast mrna 58 genes,81520,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3765.32,,,,,,,fee schedule,3765.32,10472.6, Onc breast mrna 70 genes,81521,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,16158.16,,,,,,,fee schedule,5809.5,16158.16, Onc breast mrna 70 genes,81521,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5809.5,,,,,,,fee schedule,5809.5,16158.16, Onc breast mrna 70 genes,81521,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5809.5,,,,,,,fee schedule,5809.5,16158.16, Onc breast mrna 12 genes,81522,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,16158.16,,,,,,,fee schedule,5809.5,16158.16, Onc breast mrna 12 genes,81522,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5809.5,,,,,,,fee schedule,5809.5,16158.16, Onc breast mrna 12 genes,81522,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5809.5,,,,,,,fee schedule,5809.5,16158.16, Onc brst mrna 70 cnt 31 gene,81523,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,16158.16,,,,,,,fee schedule,5809.5,16158.16, Onc brst mrna 70 cnt 31 gene,81523,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5809.5,,,,,,,fee schedule,5809.5,16158.16, Onc brst mrna 70 cnt 31 gene,81523,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5809.5,,,,,,,fee schedule,5809.5,16158.16, Oncology colon mrna,81525,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12999.95,,,,,,,fee schedule,4674,12999.95, Oncology colon mrna,81525,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4674,,,,,,,fee schedule,4674,12999.95, Oncology colon mrna,81525,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4674,,,,,,,fee schedule,4674,12999.95, Oncology colorectal scr,81528,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2123.01,,,,,,,fee schedule,763.31,2123.01, Oncology colorectal scr,81528,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,763.31,,,,,,,fee schedule,763.31,2123.01, Oncology colorectal scr,81528,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,763.31,,,,,,,fee schedule,763.31,2123.01, Onc cutan mlnma mrna 31 gene,81529,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,30009.2,,,,,,,fee schedule,10789.5,30009.2, Onc cutan mlnma mrna 31 gene,81529,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10789.5,,,,,,,fee schedule,10789.5,30009.2, Onc cutan mlnma mrna 31 gene,81529,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,10789.5,,,,,,,fee schedule,10789.5,30009.2, Oncology gynecologic,81535,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2417.51,,,,,,,fee schedule,869.19,2417.51, Oncology gynecologic,81535,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,869.19,,,,,,,fee schedule,869.19,2417.51, Oncology gynecologic,81535,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,869.19,,,,,,,fee schedule,869.19,2417.51, Oncology gynecologic,81536,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,740.78,,,,,,,fee schedule,266.34,740.78, Oncology gynecologic,81536,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,266.34,,,,,,,fee schedule,266.34,740.78, Oncology gynecologic,81536,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,266.34,,,,,,,fee schedule,266.34,740.78, Oncology lung,81538,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,11977.81,,,,,,,fee schedule,4306.5,11977.81, Oncology lung,81538,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4306.5,,,,,,,fee schedule,4306.5,11977.81, Oncology lung,81538,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4306.5,,,,,,,fee schedule,4306.5,11977.81, Oncology prostate prob score,81539,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3170.72,,,,,,,fee schedule,1140,3170.72, Oncology prostate prob score,81539,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1140,,,,,,,fee schedule,1140,3170.72, Oncology prostate prob score,81539,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1140,,,,,,,fee schedule,1140,3170.72, Oncology tum unknown origin,81540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,15645,,,,,,,fee schedule,5625,15645, Oncology tum unknown origin,81540,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5625,,,,,,,fee schedule,5625,15645, Oncology tum unknown origin,81540,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5625,,,,,,,fee schedule,5625,15645, Onc prostate mrna 46 genes,81541,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,16158.16,,,,,,,fee schedule,5809.5,16158.16, Onc prostate mrna 46 genes,81541,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5809.5,,,,,,,fee schedule,5809.5,16158.16, Onc prostate mrna 46 genes,81541,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5809.5,,,,,,,fee schedule,5809.5,16158.16, Onc prostate mrna 22 cnt gen,81542,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,16158.16,,,,,,,fee schedule,5809.5,16158.16, Onc prostate mrna 22 cnt gen,81542,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5809.5,,,,,,,fee schedule,5809.5,16158.16, Onc prostate mrna 22 cnt gen,81542,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5809.5,,,,,,,fee schedule,5809.5,16158.16, "Onc thyr mrna 10,196 gen alg",81546,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,15019.2,,,,,,,fee schedule,5400,15019.2, "Onc thyr mrna 10,196 gen alg",81546,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5400,,,,,,,fee schedule,5400,15019.2, "Onc thyr mrna 10,196 gen alg",81546,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5400,,,,,,,fee schedule,5400,15019.2, Onc prostate 3 genes,81551,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8469.16,,,,,,,fee schedule,3045,8469.16, Onc prostate 3 genes,81551,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3045,,,,,,,fee schedule,3045,8469.16, Onc prostate 3 genes,81551,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3045,,,,,,,fee schedule,3045,8469.16, Onc uveal mlnma mrna 15 gene,81552,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,32441.47,,,,,,,fee schedule,11664,32441.47, Onc uveal mlnma mrna 15 gene,81552,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11664,,,,,,,fee schedule,11664,32441.47, Onc uveal mlnma mrna 15 gene,81552,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11664,,,,,,,fee schedule,11664,32441.47, Pulm ds ipf mrna 190 gen alg,81554,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,22568.85,,,,,,,fee schedule,8250,22568.85, Pulm ds ipf mrna 190 gen alg,81554,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8250,,,,,,,fee schedule,8250,22568.85, Pulm ds ipf mrna 190 gen alg,81554,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,8250,,,,,,,fee schedule,8250,22568.85, Trnspl rej kdn mrna qpcr 139,81558,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,13517.28,,,,,,,fee schedule,4860,13517.28, Trnspl rej kdn mrna qpcr 139,81558,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4860,,,,,,,fee schedule,4860,13517.28, Trnspl rej kdn mrna qpcr 139,81558,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4860,,,,,,,fee schedule,4860,13517.28, Trnsplj pd lvr&bwl cd154+cll,81560,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2673.13,,,,,,,fee schedule,961.1,2673.13, Trnsplj pd lvr&bwl cd154+cll,81560,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,961.1,,,,,,,fee schedule,961.1,2673.13, Trnsplj pd lvr&bwl cd154+cll,81560,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,961.1,,,,,,,fee schedule,961.1,2673.13, Cardiology hrt trnspl mrna,81595,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,13517.28,,,,,,,fee schedule,4860,13517.28, Cardiology hrt trnspl mrna,81595,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4860,,,,,,,fee schedule,4860,13517.28, Cardiology hrt trnspl mrna,81595,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4860,,,,,,,fee schedule,4860,13517.28, Nfct ds chrnc hcv 6 assays,81596,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,301.18,,,,,,,fee schedule,108.29,301.18, Nfct ds chrnc hcv 6 assays,81596,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,108.29,,,,,,,fee schedule,108.29,301.18, Nfct ds chrnc hcv 6 assays,81596,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,108.29,,,,,,,fee schedule,108.29,301.18, Test for acetone/ketones,82009,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,18.86,,,,,,,fee schedule,6.78,18.86, Test for acetone/ketones,82009,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.78,,,,,,,fee schedule,6.78,18.86, Test for acetone/ketones,82009,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,6.78,,,,,,,fee schedule,6.78,18.86, Acetone assay,82010,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,34.09,,,,,,,fee schedule,12.26,34.09, Acetone assay,82010,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.26,,,,,,,fee schedule,12.26,34.09, Acetone assay,82010,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,12.26,,,,,,,fee schedule,12.26,34.09, Acetylcholinesterase assay,82013,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,51.27,,,,,,,fee schedule,18.44,51.27, Acetylcholinesterase assay,82013,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.44,,,,,,,fee schedule,18.44,51.27, Acetylcholinesterase assay,82013,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,18.44,,,,,,,fee schedule,18.44,51.27, Acylcarnitines qual,82016,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,68.8,,,,,,,fee schedule,24.74,68.8, Acylcarnitines qual,82016,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24.74,,,,,,,fee schedule,24.74,68.8, Acylcarnitines qual,82016,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,24.74,,,,,,,fee schedule,24.74,68.8, Acylcarnitines quant,82017,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,70.38,,,,,,,fee schedule,25.31,70.38, Acylcarnitines quant,82017,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25.31,,,,,,,fee schedule,25.31,70.38, Acylcarnitines quant,82017,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,25.31,,,,,,,fee schedule,25.31,70.38, Assay of acth,82024,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,161.12,,,,,,,fee schedule,57.93,161.12, Assay of acth,82024,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,57.93,,,,,,,fee schedule,57.93,161.12, Assay of acth,82024,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,57.93,,,,,,,fee schedule,57.93,161.12, Assay of adp & amp,82030,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,107.64,,,,,,,fee schedule,38.7,107.64, Assay of adp & amp,82030,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,38.7,,,,,,,fee schedule,38.7,107.64, Assay of adp & amp,82030,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,38.7,,,,,,,fee schedule,38.7,107.64, Assay of serum albumin,82040,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,20.65,,,,,,,fee schedule,7.43,20.65, Assay of serum albumin,82040,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.43,,,,,,,fee schedule,7.43,20.65, Assay of serum albumin,82040,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,7.43,,,,,,,fee schedule,7.43,20.65, Assay of urine albumin,82042,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,32.46,,,,,,,fee schedule,11.67,32.46, Assay of urine albumin,82042,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.67,,,,,,,fee schedule,11.67,32.46, Assay of urine albumin,82042,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11.67,,,,,,,fee schedule,11.67,32.46, Microalbumin quantitative,82043,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,24.11,,,,,,,fee schedule,8.67,24.11, Microalbumin quantitative,82043,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.67,,,,,,,fee schedule,8.67,24.11, Microalbumin quantitative,82043,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,8.67,,,,,,,fee schedule,8.67,24.11, Microalbumin semiquant,82044,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,25.99,,,,,,,fee schedule,9.35,25.99, Microalbumin semiquant,82044,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.35,,,,,,,fee schedule,9.35,25.99, Microalbumin semiquant,82044,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9.35,,,,,,,fee schedule,9.35,25.99, Albumin ischemia modified,82045,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,141.6,,,,,,,fee schedule,50.91,141.6, Albumin ischemia modified,82045,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,50.91,,,,,,,fee schedule,50.91,141.6, Albumin ischemia modified,82045,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,50.91,,,,,,,fee schedule,50.91,141.6, Assay of breath ethanol,82075,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,125.16,,,,,,,fee schedule,45,125.16, Assay of breath ethanol,82075,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,45,,,,,,,fee schedule,45,125.16, Assay of breath ethanol,82075,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,45,,,,,,,fee schedule,45,125.16, Assay spec xcp ur&breath ia,82077,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,72.05,,,,,,,fee schedule,25.91,72.05, Assay spec xcp ur&breath ia,82077,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25.91,,,,,,,fee schedule,25.91,72.05, Assay spec xcp ur&breath ia,82077,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,25.91,,,,,,,fee schedule,25.91,72.05, Assay of aldolase,82085,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,40.51,,,,,,,fee schedule,14.57,40.51, Assay of aldolase,82085,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.57,,,,,,,fee schedule,14.57,40.51, Assay of aldolase,82085,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,14.57,,,,,,,fee schedule,14.57,40.51, Assay of aldosterone,82088,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,170.01,,,,,,,fee schedule,61.13,170.01, Assay of aldosterone,82088,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,61.13,,,,,,,fee schedule,61.13,170.01, Assay of aldosterone,82088,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,61.13,,,,,,,fee schedule,61.13,170.01, Alpha-1-antitrypsin total,82103,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,56.07,,,,,,,fee schedule,20.16,56.07, Alpha-1-antitrypsin total,82103,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,20.16,,,,,,,fee schedule,20.16,56.07, Alpha-1-antitrypsin total,82103,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,20.16,,,,,,,fee schedule,20.16,56.07, Alpha-1-antitrypsin pheno,82104,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,60.33,,,,,,,fee schedule,21.69,60.33, Alpha-1-antitrypsin pheno,82104,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21.69,,,,,,,fee schedule,21.69,60.33, Alpha-1-antitrypsin pheno,82104,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,21.69,,,,,,,fee schedule,21.69,60.33, Alpha-fetoprotein serum,82105,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,69.96,,,,,,,fee schedule,25.16,69.96, Alpha-fetoprotein serum,82105,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25.16,,,,,,,fee schedule,25.16,69.96, Alpha-fetoprotein serum,82105,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,25.16,,,,,,,fee schedule,25.16,69.96, Alpha-fetoprotein amniotic,82106,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,70.92,,,,,,,fee schedule,25.5,70.92, Alpha-fetoprotein amniotic,82106,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25.5,,,,,,,fee schedule,25.5,70.92, Alpha-fetoprotein amniotic,82106,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,25.5,,,,,,,fee schedule,25.5,70.92, Alpha-Fetoprotein L3,82107,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,268.72,,,,,,,fee schedule,96.62,268.72, Alpha-Fetoprotein L3,82107,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,96.62,,,,,,,fee schedule,96.62,268.72, Alpha-Fetoprotein L3,82107,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,96.62,,,,,,,fee schedule,96.62,268.72, Assay of aluminum,82108,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,106.3,,,,,,,fee schedule,38.22,106.3, Assay of aluminum,82108,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,38.22,,,,,,,fee schedule,38.22,106.3, Assay of aluminum,82108,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,38.22,,,,,,,fee schedule,38.22,106.3, Amines vaginal fluid qual,82120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,24.99,,,,,,,fee schedule,8.99,24.99, Amines vaginal fluid qual,82120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.99,,,,,,,fee schedule,8.99,24.99, Amines vaginal fluid qual,82120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,8.99,,,,,,,fee schedule,8.99,24.99, Amino acid single qual,82127,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,59.16,,,,,,,fee schedule,21.27,59.16, Amino acid single qual,82127,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21.27,,,,,,,fee schedule,21.27,59.16, Amino acid single qual,82127,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,21.27,,,,,,,fee schedule,21.27,59.16, Amino acids mult qual,82128,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,57.87,,,,,,,fee schedule,20.81,57.87, Amino acids mult qual,82128,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,20.81,,,,,,,fee schedule,20.81,57.87, Amino acids mult qual,82128,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,20.81,,,,,,,fee schedule,20.81,57.87, Amino acids single quant,82131,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,95.87,,,,,,,fee schedule,34.47,95.87, Amino acids single quant,82131,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,34.47,,,,,,,fee schedule,34.47,95.87, Amino acids single quant,82131,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,34.47,,,,,,,fee schedule,34.47,95.87, Assay aminolevulinic acid,82135,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,68.63,,,,,,,fee schedule,24.68,68.63, Assay aminolevulinic acid,82135,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24.68,,,,,,,fee schedule,24.68,68.63, Assay aminolevulinic acid,82135,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,24.68,,,,,,,fee schedule,24.68,68.63, Amino acids quant 2-5,82136,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,81.81,,,,,,,fee schedule,29.42,81.81, Amino acids quant 2-5,82136,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,29.42,,,,,,,fee schedule,29.42,81.81, Amino acids quant 2-5,82136,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,29.42,,,,,,,fee schedule,29.42,81.81, Amino acids quan 6 or more,82139,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,70.38,,,,,,,fee schedule,25.31,70.38, Amino acids quan 6 or more,82139,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25.31,,,,,,,fee schedule,25.31,70.38, Amino acids quan 6 or more,82139,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,25.31,,,,,,,fee schedule,25.31,70.38, Assay of ammonia,82140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,60.79,,,,,,,fee schedule,21.86,60.79, Assay of ammonia,82140,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21.86,,,,,,,fee schedule,21.86,60.79, Assay of ammonia,82140,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,21.86,,,,,,,fee schedule,21.86,60.79, Amniotic fluid scan,82143,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,39.01,,,,,,,fee schedule,14.03,39.01, Amniotic fluid scan,82143,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.03,,,,,,,fee schedule,14.03,39.01, Amniotic fluid scan,82143,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,14.03,,,,,,,fee schedule,14.03,39.01, Assay of amylase,82150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,27.03,,,,,,,fee schedule,9.72,27.03, Assay of amylase,82150,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.72,,,,,,,fee schedule,9.72,27.03, Assay of amylase,82150,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9.72,,,,,,,fee schedule,9.72,27.03, Androstanediol glucuronide,82154,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,120.28,,,,,,,fee schedule,43.25,120.28, Androstanediol glucuronide,82154,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,43.25,,,,,,,fee schedule,43.25,120.28, Androstanediol glucuronide,82154,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,43.25,,,,,,,fee schedule,43.25,120.28, Assay of androstenedione,82157,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,122.16,,,,,,,fee schedule,43.92,122.16, Assay of androstenedione,82157,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,43.92,,,,,,,fee schedule,43.92,122.16, Assay of androstenedione,82157,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,43.92,,,,,,,fee schedule,43.92,122.16, Assay of androsterone,82160,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,106.59,,,,,,,fee schedule,38.33,106.59, Assay of androsterone,82160,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,38.33,,,,,,,fee schedule,38.33,106.59, Assay of androsterone,82160,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,38.33,,,,,,,fee schedule,38.33,106.59, Assay of angiotensin II,82163,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,85.61,,,,,,,fee schedule,30.78,85.61, Assay of angiotensin II,82163,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,30.78,,,,,,,fee schedule,30.78,85.61, Assay of angiotensin II,82163,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,30.78,,,,,,,fee schedule,30.78,85.61, Angiotensin I enzyme test,82164,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,60.91,,,,,,,fee schedule,21.9,60.91, Angiotensin I enzyme test,82164,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21.9,,,,,,,fee schedule,21.9,60.91, Angiotensin I enzyme test,82164,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,21.9,,,,,,,fee schedule,21.9,60.91, Assay anti-mullerian horm,82166,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,161.12,,,,,,,fee schedule,57.93,161.12, Assay anti-mullerian horm,82166,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,57.93,,,,,,,fee schedule,57.93,161.12, Assay anti-mullerian horm,82166,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,57.93,,,,,,,fee schedule,57.93,161.12, Assay of apolipoprotein,82172,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,87.99,,,,,,,fee schedule,31.64,87.99, Assay of apolipoprotein,82172,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31.64,,,,,,,fee schedule,31.64,87.99, Assay of apolipoprotein,82172,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,31.64,,,,,,,fee schedule,31.64,87.99, Assay of arsenic,82175,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,79.14,,,,,,,fee schedule,28.46,79.14, Assay of arsenic,82175,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,28.46,,,,,,,fee schedule,28.46,79.14, Assay of arsenic,82175,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,28.46,,,,,,,fee schedule,28.46,79.14, Assay of ascorbic acid,82180,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,41.26,,,,,,,fee schedule,14.84,41.26, Assay of ascorbic acid,82180,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.84,,,,,,,fee schedule,14.84,41.26, Assay of ascorbic acid,82180,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,14.84,,,,,,,fee schedule,14.84,41.26, Atomic absorption,82190,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,66.33,,,,,,,fee schedule,23.85,66.33, Atomic absorption,82190,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23.85,,,,,,,fee schedule,23.85,66.33, Atomic absorption,82190,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,23.85,,,,,,,fee schedule,23.85,66.33, Assay of beta-2 protein,82232,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,67.5,,,,,,,fee schedule,24.27,67.5, Assay of beta-2 protein,82232,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24.27,,,,,,,fee schedule,24.27,67.5, Assay of beta-2 protein,82232,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,24.27,,,,,,,fee schedule,24.27,67.5, Beta-amyloid 1-40 (abeta 40),82233,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,537.85,,,,,,,fee schedule,537.85,537.85, Beta-amyloid 1-42 (abeta 42),82234,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,537.85,,,,,,,fee schedule,537.85,537.85, Bile acids total,82239,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,71.42,,,,,,,fee schedule,25.68,71.42, Bile acids total,82239,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25.68,,,,,,,fee schedule,25.68,71.42, Bile acids total,82239,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,25.68,,,,,,,fee schedule,25.68,71.42, Bile acids cholylglycine,82240,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,110.89,,,,,,,fee schedule,39.87,110.89, Bile acids cholylglycine,82240,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,39.87,,,,,,,fee schedule,39.87,110.89, Bile acids cholylglycine,82240,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,39.87,,,,,,,fee schedule,39.87,110.89, Bilirubin total,82247,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,20.94,,,,,,,fee schedule,7.53,20.94, Bilirubin total,82247,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.53,,,,,,,fee schedule,7.53,20.94, Bilirubin total,82247,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,7.53,,,,,,,fee schedule,7.53,20.94, Bilirubin direct,82248,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,20.94,,,,,,,fee schedule,7.53,20.94, Bilirubin direct,82248,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.53,,,,,,,fee schedule,7.53,20.94, Bilirubin direct,82248,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,7.53,,,,,,,fee schedule,7.53,20.94, Fecal bilirubin test,82252,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,19.02,,,,,,,fee schedule,6.84,19.02, Fecal bilirubin test,82252,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.84,,,,,,,fee schedule,6.84,19.02, Fecal bilirubin test,82252,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,6.84,,,,,,,fee schedule,6.84,19.02, Assay of biotinidase,82261,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,70.38,,,,,,,fee schedule,25.31,70.38, Assay of biotinidase,82261,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25.31,,,,,,,fee schedule,25.31,70.38, Assay of biotinidase,82261,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,25.31,,,,,,,fee schedule,25.31,70.38, Occult blood feces,82270,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,18.27,,,,,,,fee schedule,6.57,18.27, Occult blood feces,82270,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.57,,,,,,,fee schedule,6.57,18.27, Occult blood feces,82270,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,6.57,,,,,,,fee schedule,6.57,18.27, Occult blood other sources,82271,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,22.2,,,,,,,fee schedule,7.98,22.2, Occult blood other sources,82271,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.98,,,,,,,fee schedule,7.98,22.2, Occult blood other sources,82271,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,7.98,,,,,,,fee schedule,7.98,22.2, Occult bld feces 1-3 tests,82272,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,17.65,,,,,,,fee schedule,6.35,17.65, Occult bld feces 1-3 tests,82272,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.35,,,,,,,fee schedule,6.35,17.65, Occult bld feces 1-3 tests,82272,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,6.35,,,,,,,fee schedule,6.35,17.65, Assay test for blood fecal,82274,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,66.42,,,,,,,fee schedule,23.88,66.42, Assay test for blood fecal,82274,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23.88,,,,,,,fee schedule,23.88,66.42, Assay test for blood fecal,82274,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,23.88,,,,,,,fee schedule,23.88,66.42, Assay of bradykinin,82286,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,21.53,,,,,,,fee schedule,7.74,21.53, Assay of bradykinin,82286,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.74,,,,,,,fee schedule,7.74,21.53, Assay of bradykinin,82286,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,7.74,,,,,,,fee schedule,7.74,21.53, Assay of cadmium,82300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,98.63,,,,,,,fee schedule,35.46,98.63, Assay of cadmium,82300,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,35.46,,,,,,,fee schedule,35.46,98.63, Assay of cadmium,82300,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,35.46,,,,,,,fee schedule,35.46,98.63, Vitamin d 25 hydroxy,82306,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,123.49,,,,,,,fee schedule,44.4,123.49, Vitamin d 25 hydroxy,82306,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,44.4,,,,,,,fee schedule,44.4,123.49, Vitamin d 25 hydroxy,82306,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,44.4,,,,,,,fee schedule,44.4,123.49, Assay of calcitonin,82308,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,111.77,,,,,,,fee schedule,40.19,111.77, Assay of calcitonin,82308,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,40.19,,,,,,,fee schedule,40.19,111.77, Assay of calcitonin,82308,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,40.19,,,,,,,fee schedule,40.19,111.77, Assay of calcium,82310,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,21.53,,,,,,,fee schedule,7.74,21.53, Assay of calcium,82310,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.74,,,,,,,fee schedule,7.74,21.53, Assay of calcium,82310,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,7.74,,,,,,,fee schedule,7.74,21.53, Assay of calcium,82330,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,57.07,,,,,,,fee schedule,20.52,57.07, Assay of calcium,82330,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,20.52,,,,,,,fee schedule,20.52,57.07, Assay of calcium,82330,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,20.52,,,,,,,fee schedule,20.52,57.07, Calcium infusion test,82331,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,55.65,,,,,,,fee schedule,20.01,55.65, Calcium infusion test,82331,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,20.01,,,,,,,fee schedule,20.01,55.65, Calcium infusion test,82331,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,20.01,,,,,,,fee schedule,20.01,55.65, Assay of calcium in urine,82340,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,25.16,,,,,,,fee schedule,9.05,25.16, Assay of calcium in urine,82340,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.05,,,,,,,fee schedule,9.05,25.16, Assay of calcium in urine,82340,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9.05,,,,,,,fee schedule,9.05,25.16, Calculus analysis qual,82355,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,48.31,,,,,,,fee schedule,17.37,48.31, Calculus analysis qual,82355,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.37,,,,,,,fee schedule,17.37,48.31, Calculus analysis qual,82355,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,17.37,,,,,,,fee schedule,17.37,48.31, Calculus assay quant,82360,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,53.69,,,,,,,fee schedule,19.31,53.69, Calculus assay quant,82360,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.31,,,,,,,fee schedule,19.31,53.69, Calculus assay quant,82360,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19.31,,,,,,,fee schedule,19.31,53.69, Calculus spectroscopy,82365,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,53.82,,,,,,,fee schedule,19.35,53.82, Calculus spectroscopy,82365,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.35,,,,,,,fee schedule,19.35,53.82, Calculus spectroscopy,82365,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19.35,,,,,,,fee schedule,19.35,53.82, X-ray assay calculus,82370,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,52.23,,,,,,,fee schedule,18.78,52.23, X-ray assay calculus,82370,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.78,,,,,,,fee schedule,18.78,52.23, X-ray assay calculus,82370,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,18.78,,,,,,,fee schedule,18.78,52.23, Assay c-d transfer measure,82373,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,75.35,,,,,,,fee schedule,27.09,75.35, Assay c-d transfer measure,82373,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,27.09,,,,,,,fee schedule,27.09,75.35, Assay c-d transfer measure,82373,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,27.09,,,,,,,fee schedule,27.09,75.35, Assay blood carbon dioxide,82374,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,20.36,,,,,,,fee schedule,7.32,20.36, Assay blood carbon dioxide,82374,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.32,,,,,,,fee schedule,7.32,20.36, Assay blood carbon dioxide,82374,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,7.32,,,,,,,fee schedule,7.32,20.36, Assay carboxyhb quant,82375,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,51.4,,,,,,,fee schedule,18.48,51.4, Assay carboxyhb quant,82375,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.48,,,,,,,fee schedule,18.48,51.4, Assay carboxyhb quant,82375,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,18.48,,,,,,,fee schedule,18.48,51.4, Assay carboxyhb qual,82376,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,58.7,,,,,,,fee schedule,21.11,58.7, Assay carboxyhb qual,82376,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21.11,,,,,,,fee schedule,21.11,58.7, Assay carboxyhb qual,82376,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,21.11,,,,,,,fee schedule,21.11,58.7, Carcinoembryonic antigen,82378,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,79.1,,,,,,,fee schedule,28.44,79.1, Carcinoembryonic antigen,82378,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,28.44,,,,,,,fee schedule,28.44,79.1, Carcinoembryonic antigen,82378,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,28.44,,,,,,,fee schedule,28.44,79.1, Assay of carnitine,82379,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,70.38,,,,,,,fee schedule,25.31,70.38, Assay of carnitine,82379,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25.31,,,,,,,fee schedule,25.31,70.38, Assay of carnitine,82379,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,25.31,,,,,,,fee schedule,25.31,70.38, Assay of carotene,82380,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,38.47,,,,,,,fee schedule,13.83,38.47, Assay of carotene,82380,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13.83,,,,,,,fee schedule,13.83,38.47, Assay of carotene,82380,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13.83,,,,,,,fee schedule,13.83,38.47, Assay urine catecholamines,82382,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,113.9,,,,,,,fee schedule,40.95,113.9, Assay urine catecholamines,82382,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,40.95,,,,,,,fee schedule,40.95,113.9, Assay urine catecholamines,82382,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,40.95,,,,,,,fee schedule,40.95,113.9, Assay blood catecholamines,82383,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,121.32,,,,,,,fee schedule,43.62,121.32, Assay blood catecholamines,82383,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,43.62,,,,,,,fee schedule,43.62,121.32, Assay blood catecholamines,82383,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,43.62,,,,,,,fee schedule,43.62,121.32, Assay three catecholamines,82384,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,105.34,,,,,,,fee schedule,37.88,105.34, Assay three catecholamines,82384,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,37.88,,,,,,,fee schedule,37.88,105.34, Assay three catecholamines,82384,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,37.88,,,,,,,fee schedule,37.88,105.34, Assay of cathepsin-d,82387,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,75.35,,,,,,,fee schedule,27.09,75.35, Assay of cathepsin-d,82387,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,27.09,,,,,,,fee schedule,27.09,75.35, Assay of cathepsin-d,82387,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,27.09,,,,,,,fee schedule,27.09,75.35, Assay of ceruloplasmin,82390,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,44.81,,,,,,,fee schedule,16.11,44.81, Assay of ceruloplasmin,82390,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.11,,,,,,,fee schedule,16.11,44.81, Assay of ceruloplasmin,82390,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,16.11,,,,,,,fee schedule,16.11,44.81, Chemiluminescent assay,82397,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,58.91,,,,,,,fee schedule,21.18,58.91, Chemiluminescent assay,82397,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21.18,,,,,,,fee schedule,21.18,58.91, Chemiluminescent assay,82397,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,21.18,,,,,,,fee schedule,21.18,58.91, Assay of chloramphenicol,82415,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,52.86,,,,,,,fee schedule,19.01,52.86, Assay of chloramphenicol,82415,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.01,,,,,,,fee schedule,19.01,52.86, Assay of chloramphenicol,82415,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19.01,,,,,,,fee schedule,19.01,52.86, Assay of blood chloride,82435,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,19.19,,,,,,,fee schedule,6.9,19.19, Assay of blood chloride,82435,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.9,,,,,,,fee schedule,6.9,19.19, Assay of blood chloride,82435,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,6.9,,,,,,,fee schedule,6.9,19.19, Assay of urine chloride,82436,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,23.99,,,,,,,fee schedule,8.63,23.99, Assay of urine chloride,82436,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.63,,,,,,,fee schedule,8.63,23.99, Assay of urine chloride,82436,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,8.63,,,,,,,fee schedule,8.63,23.99, Assay other fluid chlorides,82438,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,20.86,,,,,,,fee schedule,7.5,20.86, Assay other fluid chlorides,82438,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.5,,,,,,,fee schedule,7.5,20.86, Assay other fluid chlorides,82438,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,7.5,,,,,,,fee schedule,7.5,20.86, Test for chlorohydrocarbons,82441,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,25.07,,,,,,,fee schedule,9.02,25.07, Test for chlorohydrocarbons,82441,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.02,,,,,,,fee schedule,9.02,25.07, Test for chlorohydrocarbons,82441,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9.02,,,,,,,fee schedule,9.02,25.07, Assay bld/serum cholesterol,82465,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,18.15,,,,,,,fee schedule,6.53,18.15, Assay bld/serum cholesterol,82465,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.53,,,,,,,fee schedule,6.53,18.15, Assay bld/serum cholesterol,82465,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,6.53,,,,,,,fee schedule,6.53,18.15, Assay serum cholinesterase,82480,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,32.83,,,,,,,fee schedule,11.81,32.83, Assay serum cholinesterase,82480,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.81,,,,,,,fee schedule,11.81,32.83, Assay serum cholinesterase,82480,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11.81,,,,,,,fee schedule,11.81,32.83, Assay rbc cholinesterase,82482,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,40.93,,,,,,,fee schedule,14.72,40.93, Assay rbc cholinesterase,82482,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.72,,,,,,,fee schedule,14.72,40.93, Assay rbc cholinesterase,82482,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,14.72,,,,,,,fee schedule,14.72,40.93, Assay chondroitin sulfate,82485,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,86.15,,,,,,,fee schedule,30.98,86.15, Assay chondroitin sulfate,82485,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,30.98,,,,,,,fee schedule,30.98,86.15, Assay chondroitin sulfate,82485,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,30.98,,,,,,,fee schedule,30.98,86.15, Assay of chromium,82495,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,84.61,,,,,,,fee schedule,30.42,84.61, Assay of chromium,82495,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,30.42,,,,,,,fee schedule,30.42,84.61, Assay of chromium,82495,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,30.42,,,,,,,fee schedule,30.42,84.61, Assay of citrate,82507,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,115.98,,,,,,,fee schedule,41.7,115.98, Assay of citrate,82507,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,41.7,,,,,,,fee schedule,41.7,115.98, Assay of citrate,82507,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,41.7,,,,,,,fee schedule,41.7,115.98, Collagen crosslinks,82523,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,77.93,,,,,,,fee schedule,28.02,77.93, Collagen crosslinks,82523,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,28.02,,,,,,,fee schedule,28.02,77.93, Collagen crosslinks,82523,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,28.02,,,,,,,fee schedule,28.02,77.93, Assay of copper,82525,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,51.77,,,,,,,fee schedule,18.62,51.77, Assay of copper,82525,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.62,,,,,,,fee schedule,18.62,51.77, Assay of copper,82525,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,18.62,,,,,,,fee schedule,18.62,51.77, Assay of corticosterone,82528,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,93.95,,,,,,,fee schedule,33.78,93.95, Assay of corticosterone,82528,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,33.78,,,,,,,fee schedule,33.78,93.95, Assay of corticosterone,82528,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,33.78,,,,,,,fee schedule,33.78,93.95, Cortisol free,82530,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,69.71,,,,,,,fee schedule,25.07,69.71, Cortisol free,82530,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25.07,,,,,,,fee schedule,25.07,69.71, Cortisol free,82530,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,25.07,,,,,,,fee schedule,25.07,69.71, Total cortisol,82533,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,68,,,,,,,fee schedule,24.45,68, Total cortisol,82533,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24.45,,,,,,,fee schedule,24.45,68, Total cortisol,82533,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,24.45,,,,,,,fee schedule,24.45,68, Assay of creatine,82540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,19.36,,,,,,,fee schedule,6.96,19.36, Assay of creatine,82540,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.96,,,,,,,fee schedule,6.96,19.36, Assay of creatine,82540,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,6.96,,,,,,,fee schedule,6.96,19.36, Col chromotography qual/quan,82542,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,100.5,,,,,,,fee schedule,36.14,100.5, Col chromotography qual/quan,82542,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,36.14,,,,,,,fee schedule,36.14,100.5, Col chromotography qual/quan,82542,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,36.14,,,,,,,fee schedule,36.14,100.5, Assay of ck (cpk),82550,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,27.16,,,,,,,fee schedule,9.77,27.16, Assay of ck (cpk),82550,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.77,,,,,,,fee schedule,9.77,27.16, Assay of ck (cpk),82550,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9.77,,,,,,,fee schedule,9.77,27.16, Assay of cpk in blood,82552,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,55.86,,,,,,,fee schedule,20.09,55.86, Assay of cpk in blood,82552,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,20.09,,,,,,,fee schedule,20.09,55.86, Assay of cpk in blood,82552,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,20.09,,,,,,,fee schedule,20.09,55.86, Creatine mb fraction,82553,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,48.19,,,,,,,fee schedule,17.33,48.19, Creatine mb fraction,82553,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.33,,,,,,,fee schedule,17.33,48.19, Creatine mb fraction,82553,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,17.33,,,,,,,fee schedule,17.33,48.19, Creatine isoforms,82554,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,49.52,,,,,,,fee schedule,17.81,49.52, Creatine isoforms,82554,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.81,,,,,,,fee schedule,17.81,49.52, Creatine isoforms,82554,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,17.81,,,,,,,fee schedule,17.81,49.52, Assay of creatinine,82565,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,21.36,,,,,,,fee schedule,7.68,21.36, Assay of creatinine,82565,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.68,,,,,,,fee schedule,7.68,21.36, Assay of creatinine,82565,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,7.68,,,,,,,fee schedule,7.68,21.36, Assay of urine creatinine,82570,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,21.61,,,,,,,fee schedule,7.77,21.61, Assay of urine creatinine,82570,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.77,,,,,,,fee schedule,7.77,21.61, Assay of urine creatinine,82570,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,7.77,,,,,,,fee schedule,7.77,21.61, Creatinine clearance test,82575,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,39.47,,,,,,,fee schedule,14.19,39.47, Creatinine clearance test,82575,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.19,,,,,,,fee schedule,14.19,39.47, Creatinine clearance test,82575,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,14.19,,,,,,,fee schedule,14.19,39.47, Assay of cryofibrinogen,82585,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,58.99,,,,,,,fee schedule,21.21,58.99, Assay of cryofibrinogen,82585,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21.21,,,,,,,fee schedule,21.21,58.99, Assay of cryofibrinogen,82585,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,21.21,,,,,,,fee schedule,21.21,58.99, Assay of cryoglobulin,82595,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,26.99,,,,,,,fee schedule,9.71,26.99, Assay of cryoglobulin,82595,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.71,,,,,,,fee schedule,9.71,26.99, Assay of cryoglobulin,82595,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9.71,,,,,,,fee schedule,9.71,26.99, Assay of cyanide,82600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,80.94,,,,,,,fee schedule,29.1,80.94, Assay of cyanide,82600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,29.1,,,,,,,fee schedule,29.1,80.94, Assay of cyanide,82600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,29.1,,,,,,,fee schedule,29.1,80.94, Vitamin B-12,82607,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,62.91,,,,,,,fee schedule,22.62,62.91, Vitamin B-12,82607,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22.62,,,,,,,fee schedule,22.62,62.91, Vitamin B-12,82607,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22.62,,,,,,,fee schedule,22.62,62.91, B-12 binding capacity,82608,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,59.74,,,,,,,fee schedule,21.48,59.74, B-12 binding capacity,82608,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21.48,,,,,,,fee schedule,21.48,59.74, B-12 binding capacity,82608,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,21.48,,,,,,,fee schedule,21.48,59.74, Cystatin c,82610,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,77.27,,,,,,,fee schedule,27.78,77.27, Cystatin c,82610,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,27.78,,,,,,,fee schedule,27.78,77.27, Cystatin c,82610,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,27.78,,,,,,,fee schedule,27.78,77.27, Test for urine cystines,82615,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,39.84,,,,,,,fee schedule,14.33,39.84, Test for urine cystines,82615,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.33,,,,,,,fee schedule,14.33,39.84, Test for urine cystines,82615,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,14.33,,,,,,,fee schedule,14.33,39.84, Dehydroepiandrosterone,82626,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,105.43,,,,,,,fee schedule,37.91,105.43, Dehydroepiandrosterone,82626,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,37.91,,,,,,,fee schedule,37.91,105.43, Dehydroepiandrosterone,82626,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,37.91,,,,,,,fee schedule,37.91,105.43, Dehydroepiandrosterone,82627,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,92.74,,,,,,,fee schedule,33.35,92.74, Dehydroepiandrosterone,82627,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,33.35,,,,,,,fee schedule,33.35,92.74, Dehydroepiandrosterone,82627,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,33.35,,,,,,,fee schedule,33.35,92.74, Desoxycorticosterone,82633,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,129.25,,,,,,,fee schedule,46.47,129.25, Desoxycorticosterone,82633,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46.47,,,,,,,fee schedule,46.47,129.25, Desoxycorticosterone,82633,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,46.47,,,,,,,fee schedule,46.47,129.25, Deoxycortisol,82634,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,122.16,,,,,,,fee schedule,43.92,122.16, Deoxycortisol,82634,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,43.92,,,,,,,fee schedule,43.92,122.16, Deoxycortisol,82634,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,43.92,,,,,,,fee schedule,43.92,122.16, Assay of dibucaine number,82638,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,51.11,,,,,,,fee schedule,18.38,51.11, Assay of dibucaine number,82638,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.38,,,,,,,fee schedule,18.38,51.11, Assay of dibucaine number,82638,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,18.38,,,,,,,fee schedule,18.38,51.11, Dihydrotestosterone,82642,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,122.16,,,,,,,fee schedule,43.92,122.16, Dihydrotestosterone,82642,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,43.92,,,,,,,fee schedule,43.92,122.16, Dihydrotestosterone,82642,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,43.92,,,,,,,fee schedule,43.92,122.16, Vit d 1 25-dihydroxy,82652,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,160.62,,,,,,,fee schedule,57.75,160.62, Vit d 1 25-dihydroxy,82652,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,57.75,,,,,,,fee schedule,57.75,160.62, Vit d 1 25-dihydroxy,82652,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,57.75,,,,,,,fee schedule,57.75,160.62, El-1 fecal quantitative,82653,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,95.83,,,,,,,fee schedule,34.46,95.83, El-1 fecal quantitative,82653,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,34.46,,,,,,,fee schedule,34.46,95.83, El-1 fecal quantitative,82653,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,34.46,,,,,,,fee schedule,34.46,95.83, Pancreatic elastase fecal,82656,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,48.1,,,,,,,fee schedule,17.3,48.1, Pancreatic elastase fecal,82656,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.3,,,,,,,fee schedule,17.3,48.1, Pancreatic elastase fecal,82656,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,17.3,,,,,,,fee schedule,17.3,48.1, Enzyme cell activity,82657,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,92.49,,,,,,,fee schedule,33.26,92.49, Enzyme cell activity,82657,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,33.26,,,,,,,fee schedule,33.26,92.49, Enzyme cell activity,82657,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,33.26,,,,,,,fee schedule,33.26,92.49, Enzyme cell activity ra,82658,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,183.69,,,,,,,fee schedule,66.05,183.69, Enzyme cell activity ra,82658,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,66.05,,,,,,,fee schedule,66.05,183.69, Enzyme cell activity ra,82658,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,66.05,,,,,,,fee schedule,66.05,183.69, Electrophoretic test,82664,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,256.58,,,,,,,fee schedule,92.25,256.58, Electrophoretic test,82664,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,92.25,,,,,,,fee schedule,92.25,256.58, Electrophoretic test,82664,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,92.25,,,,,,,fee schedule,92.25,256.58, Assay of erythropoietin,82668,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,78.39,,,,,,,fee schedule,28.19,78.39, Assay of erythropoietin,82668,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,28.19,,,,,,,fee schedule,28.19,78.39, Assay of erythropoietin,82668,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,28.19,,,,,,,fee schedule,28.19,78.39, Assay of estradiol,82670,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,116.57,,,,,,,fee schedule,41.91,116.57, Assay of estradiol,82670,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,41.91,,,,,,,fee schedule,41.91,116.57, Assay of estradiol,82670,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,41.91,,,,,,,fee schedule,41.91,116.57, Assay of estrogens,82671,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,134.76,,,,,,,fee schedule,48.45,134.76, Assay of estrogens,82671,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,48.45,,,,,,,fee schedule,48.45,134.76, Assay of estrogens,82671,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,48.45,,,,,,,fee schedule,48.45,134.76, Assay of estrogen,82672,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,90.53,,,,,,,fee schedule,32.55,90.53, Assay of estrogen,82672,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,32.55,,,,,,,fee schedule,32.55,90.53, Assay of estrogen,82672,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,32.55,,,,,,,fee schedule,32.55,90.53, Assay of estriol,82677,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,100.88,,,,,,,fee schedule,36.27,100.88, Assay of estriol,82677,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,36.27,,,,,,,fee schedule,36.27,100.88, Assay of estriol,82677,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,36.27,,,,,,,fee schedule,36.27,100.88, Assay of estrone,82679,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,104.09,,,,,,,fee schedule,37.43,104.09, Assay of estrone,82679,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,37.43,,,,,,,fee schedule,37.43,104.09, Assay of estrone,82679,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,37.43,,,,,,,fee schedule,37.43,104.09, Assay dir meas fr estradiol,82681,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,116.57,,,,,,,fee schedule,41.91,116.57, Assay dir meas fr estradiol,82681,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,41.91,,,,,,,fee schedule,41.91,116.57, Assay dir meas fr estradiol,82681,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,41.91,,,,,,,fee schedule,41.91,116.57, Assay of ethylene glycol,82693,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,62.16,,,,,,,fee schedule,22.35,62.16, Assay of ethylene glycol,82693,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22.35,,,,,,,fee schedule,22.35,62.16, Assay of ethylene glycol,82693,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22.35,,,,,,,fee schedule,22.35,62.16, Assay of etiocholanolone,82696,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,109.47,,,,,,,fee schedule,39.36,109.47, Assay of etiocholanolone,82696,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,39.36,,,,,,,fee schedule,39.36,109.47, Assay of etiocholanolone,82696,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,39.36,,,,,,,fee schedule,39.36,109.47, Fats/lipids feces qual,82705,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,21.28,,,,,,,fee schedule,7.65,21.28, Fats/lipids feces qual,82705,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.65,,,,,,,fee schedule,7.65,21.28, Fats/lipids feces qual,82705,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,7.65,,,,,,,fee schedule,7.65,21.28, Fats/lipids feces quant,82710,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,70.09,,,,,,,fee schedule,25.2,70.09, Fats/lipids feces quant,82710,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25.2,,,,,,,fee schedule,25.2,70.09, Fats/lipids feces quant,82710,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,25.2,,,,,,,fee schedule,25.2,70.09, Assay of fecal fat,82715,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,95.83,,,,,,,fee schedule,34.46,95.83, Assay of fecal fat,82715,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,34.46,,,,,,,fee schedule,34.46,95.83, Assay of fecal fat,82715,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,34.46,,,,,,,fee schedule,34.46,95.83, Assay of blood fatty acids,82725,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,78.31,,,,,,,fee schedule,28.16,78.31, Assay of blood fatty acids,82725,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,28.16,,,,,,,fee schedule,28.16,78.31, Assay of blood fatty acids,82725,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,28.16,,,,,,,fee schedule,28.16,78.31, Long chain fatty acids,82726,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,82.4,,,,,,,fee schedule,29.63,82.4, Long chain fatty acids,82726,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,29.63,,,,,,,fee schedule,29.63,82.4, Long chain fatty acids,82726,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,29.63,,,,,,,fee schedule,29.63,82.4, Assay of ferritin,82728,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,56.86,,,,,,,fee schedule,20.45,56.86, Assay of ferritin,82728,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,20.45,,,,,,,fee schedule,20.45,56.86, Assay of ferritin,82728,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,20.45,,,,,,,fee schedule,20.45,56.86, Assay of fetal fibronectin,82731,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,268.72,,,,,,,fee schedule,96.62,268.72, Assay of fetal fibronectin,82731,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,96.62,,,,,,,fee schedule,96.62,268.72, Assay of fetal fibronectin,82731,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,96.62,,,,,,,fee schedule,96.62,268.72, Assay of fluoride,82735,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,77.35,,,,,,,fee schedule,27.81,77.35, Assay of fluoride,82735,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,27.81,,,,,,,fee schedule,27.81,77.35, Assay of fluoride,82735,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,27.81,,,,,,,fee schedule,27.81,77.35, Assay of folic acid serum,82746,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,61.33,,,,,,,fee schedule,22.05,61.33, Assay of folic acid serum,82746,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22.05,,,,,,,fee schedule,22.05,61.33, Assay of folic acid serum,82746,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22.05,,,,,,,fee schedule,22.05,61.33, Assay of folic acid rbc,82747,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,73.64,,,,,,,fee schedule,26.48,73.64, Assay of folic acid rbc,82747,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26.48,,,,,,,fee schedule,26.48,73.64, Assay of folic acid rbc,82747,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,26.48,,,,,,,fee schedule,26.48,73.64, Assay of semen fructose,82757,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,72.34,,,,,,,fee schedule,26.01,72.34, Assay of semen fructose,82757,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26.01,,,,,,,fee schedule,26.01,72.34, Assay of semen fructose,82757,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,26.01,,,,,,,fee schedule,26.01,72.34, Assay of rbc galactokinase,82759,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,89.61,,,,,,,fee schedule,32.22,89.61, Assay of rbc galactokinase,82759,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,32.22,,,,,,,fee schedule,32.22,89.61, Assay of rbc galactokinase,82759,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,32.22,,,,,,,fee schedule,32.22,89.61, Assay of galactose,82760,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,46.73,,,,,,,fee schedule,16.8,46.73, Assay of galactose,82760,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.8,,,,,,,fee schedule,16.8,46.73, Assay of galactose,82760,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,16.8,,,,,,,fee schedule,16.8,46.73, Assay galactose transferase,82775,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,87.9,,,,,,,fee schedule,31.61,87.9, Assay galactose transferase,82775,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31.61,,,,,,,fee schedule,31.61,87.9, Assay galactose transferase,82775,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,31.61,,,,,,,fee schedule,31.61,87.9, Galactose transferase test,82776,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,48.98,,,,,,,fee schedule,17.61,48.98, Galactose transferase test,82776,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.61,,,,,,,fee schedule,17.61,48.98, Galactose transferase test,82776,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,17.61,,,,,,,fee schedule,17.61,48.98, Galectin-3,82777,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,184.61,,,,,,,fee schedule,66.38,184.61, Galectin-3,82777,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,66.38,,,,,,,fee schedule,66.38,184.61, Galectin-3,82777,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,66.38,,,,,,,fee schedule,66.38,184.61, Assay iga/igd/igg/igm each,82784,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,38.8,,,,,,,fee schedule,13.95,38.8, Assay iga/igd/igg/igm each,82784,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13.95,,,,,,,fee schedule,13.95,38.8, Assay iga/igd/igg/igm each,82784,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13.95,,,,,,,fee schedule,13.95,38.8, Assay of ige,82785,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,68.67,,,,,,,fee schedule,24.69,68.67, Assay of ige,82785,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24.69,,,,,,,fee schedule,24.69,68.67, Assay of ige,82785,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,24.69,,,,,,,fee schedule,24.69,68.67, Igg 1 2 3 or 4 each,82787,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,33.46,,,,,,,fee schedule,12.03,33.46, Igg 1 2 3 or 4 each,82787,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.03,,,,,,,fee schedule,12.03,33.46, Igg 1 2 3 or 4 each,82787,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,12.03,,,,,,,fee schedule,12.03,33.46, Blood pH,82800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,45.89,,,,,,,fee schedule,16.5,45.89, Blood pH,82800,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.5,,,,,,,fee schedule,16.5,45.89, Blood pH,82800,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,16.5,,,,,,,fee schedule,16.5,45.89, Blood gases any combination,82803,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,108.76,,,,,,,fee schedule,39.11,108.76, Blood gases any combination,82803,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,39.11,,,,,,,fee schedule,39.11,108.76, Blood gases any combination,82803,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,39.11,,,,,,,fee schedule,39.11,108.76, Blood gases w/o2 saturation,82805,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,328.63,,,,,,,fee schedule,118.16,328.63, Blood gases w/o2 saturation,82805,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,118.16,,,,,,,fee schedule,118.16,328.63, Blood gases w/o2 saturation,82805,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,118.16,,,,,,,fee schedule,118.16,328.63, Blood gases o2 sat only,82810,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,40.76,,,,,,,fee schedule,14.66,40.76, Blood gases o2 sat only,82810,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.66,,,,,,,fee schedule,14.66,40.76, Blood gases o2 sat only,82810,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,14.66,,,,,,,fee schedule,14.66,40.76, Hemoglobin-oxygen affinity,82820,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,55.65,,,,,,,fee schedule,20.01,55.65, Hemoglobin-oxygen affinity,82820,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,20.01,,,,,,,fee schedule,20.01,55.65, Hemoglobin-oxygen affinity,82820,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,20.01,,,,,,,fee schedule,20.01,55.65, Gastric analy w/ph ea spec,82930,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,27.99,,,,,,,fee schedule,10.07,27.99, Gastric analy w/ph ea spec,82930,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.07,,,,,,,fee schedule,10.07,27.99, Gastric analy w/ph ea spec,82930,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,10.07,,,,,,,fee schedule,10.07,27.99, Gastrin test,82938,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,73.8,,,,,,,fee schedule,26.54,73.8, Gastrin test,82938,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26.54,,,,,,,fee schedule,26.54,73.8, Gastrin test,82938,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,26.54,,,,,,,fee schedule,26.54,73.8, Assay of gastrin,82941,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,73.55,,,,,,,fee schedule,26.45,73.55, Assay of gastrin,82941,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26.45,,,,,,,fee schedule,26.45,73.55, Assay of gastrin,82941,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,26.45,,,,,,,fee schedule,26.45,73.55, Assay of glucagon,82943,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,59.62,,,,,,,fee schedule,21.44,59.62, Assay of glucagon,82943,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21.44,,,,,,,fee schedule,21.44,59.62, Assay of glucagon,82943,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,21.44,,,,,,,fee schedule,21.44,59.62, Glucose Other Fluid,82945,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,16.4,,,,,,,fee schedule,5.9,16.4, Glucose Other Fluid,82945,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.9,,,,,,,fee schedule,5.9,16.4, Glucose Other Fluid,82945,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5.9,,,,,,,fee schedule,5.9,16.4, Glucagon tolerance test,82946,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,74.14,,,,,,,fee schedule,26.66,74.14, Glucagon tolerance test,82946,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26.66,,,,,,,fee schedule,26.66,74.14, Glucagon tolerance test,82946,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,26.66,,,,,,,fee schedule,26.66,74.14, Assay glucose blood quant,82947,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,16.4,,,,,,,fee schedule,5.9,16.4, Assay glucose blood quant,82947,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.9,,,,,,,fee schedule,5.9,16.4, Assay glucose blood quant,82947,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5.9,,,,,,,fee schedule,5.9,16.4, Reagent strip/blood glucose,82948,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,21.03,,,,,,,fee schedule,7.56,21.03, Reagent strip/blood glucose,82948,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.56,,,,,,,fee schedule,7.56,21.03, Reagent strip/blood glucose,82948,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,7.56,,,,,,,fee schedule,7.56,21.03, Glucose test,82950,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,19.82,,,,,,,fee schedule,7.13,19.82, Glucose test,82950,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.13,,,,,,,fee schedule,7.13,19.82, Glucose test,82950,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,7.13,,,,,,,fee schedule,7.13,19.82, Glucose tolerance test (GTT),82951,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,53.69,,,,,,,fee schedule,19.31,53.69, Glucose tolerance test (GTT),82951,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.31,,,,,,,fee schedule,19.31,53.69, Glucose tolerance test (GTT),82951,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19.31,,,,,,,fee schedule,19.31,53.69, GTT-added samples,82952,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,16.35,,,,,,,fee schedule,5.88,16.35, GTT-added samples,82952,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.88,,,,,,,fee schedule,5.88,16.35, GTT-added samples,82952,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5.88,,,,,,,fee schedule,5.88,16.35, Assay of g6pd enzyme,82955,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,40.47,,,,,,,fee schedule,14.55,40.47, Assay of g6pd enzyme,82955,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.55,,,,,,,fee schedule,14.55,40.47, Assay of g6pd enzyme,82955,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,14.55,,,,,,,fee schedule,14.55,40.47, Test for G6PD enzyme,82960,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,25.24,,,,,,,fee schedule,9.08,25.24, Test for G6PD enzyme,82960,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.08,,,,,,,fee schedule,9.08,25.24, Test for G6PD enzyme,82960,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9.08,,,,,,,fee schedule,9.08,25.24, Glucose blood test,82962,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,13.68,,,,,,,fee schedule,4.92,13.68, Glucose blood test,82962,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.92,,,,,,,fee schedule,4.92,13.68, Glucose blood test,82962,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4.92,,,,,,,fee schedule,4.92,13.68, Assay of glucosidase,82963,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,89.61,,,,,,,fee schedule,32.22,89.61, Assay of glucosidase,82963,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,32.22,,,,,,,fee schedule,32.22,89.61, Assay of glucosidase,82963,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,32.22,,,,,,,fee schedule,32.22,89.61, Assay of gdh enzyme,82965,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,54.86,,,,,,,fee schedule,19.73,54.86, Assay of gdh enzyme,82965,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.73,,,,,,,fee schedule,19.73,54.86, Assay of gdh enzyme,82965,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19.73,,,,,,,fee schedule,19.73,54.86, Assay of GGT,82977,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,30.04,,,,,,,fee schedule,10.8,30.04, Assay of GGT,82977,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.8,,,,,,,fee schedule,10.8,30.04, Assay of GGT,82977,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,10.8,,,,,,,fee schedule,10.8,30.04, Assay of glutathione,82978,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,64.46,,,,,,,fee schedule,23.18,64.46, Assay of glutathione,82978,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23.18,,,,,,,fee schedule,23.18,64.46, Assay of glutathione,82978,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,23.18,,,,,,,fee schedule,23.18,64.46, Assay rbc glutathione,82979,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,39.38,,,,,,,fee schedule,14.16,39.38, Assay rbc glutathione,82979,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.16,,,,,,,fee schedule,14.16,39.38, Assay rbc glutathione,82979,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,14.16,,,,,,,fee schedule,14.16,39.38, Assay of glycated protein,82985,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,69.92,,,,,,,fee schedule,25.14,69.92, Assay of glycated protein,82985,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25.14,,,,,,,fee schedule,25.14,69.92, Assay of glycated protein,82985,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,25.14,,,,,,,fee schedule,25.14,69.92, Assay of gonadotropin (fsh),83001,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,77.52,,,,,,,fee schedule,27.87,77.52, Assay of gonadotropin (fsh),83001,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,27.87,,,,,,,fee schedule,27.87,77.52, Assay of gonadotropin (fsh),83001,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,27.87,,,,,,,fee schedule,27.87,77.52, Assay of gonadotropin (lh),83002,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,77.27,,,,,,,fee schedule,27.78,77.27, Assay of gonadotropin (lh),83002,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,27.78,,,,,,,fee schedule,27.78,77.27, Assay of gonadotropin (lh),83002,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,27.78,,,,,,,fee schedule,27.78,77.27, Assay growth hormone (hgh),83003,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,69.55,,,,,,,fee schedule,25.01,69.55, Assay growth hormone (hgh),83003,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25.01,,,,,,,fee schedule,25.01,69.55, Assay growth hormone (hgh),83003,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,25.01,,,,,,,fee schedule,25.01,69.55, Growth stimulation gene 2,83006,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,315.4,,,,,,,fee schedule,113.4,315.4, Growth stimulation gene 2,83006,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,113.4,,,,,,,fee schedule,113.4,315.4, Growth stimulation gene 2,83006,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,113.4,,,,,,,fee schedule,113.4,315.4, H pylori (c-13) blood,83009,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,281.03,,,,,,,fee schedule,101.04,281.03, H pylori (c-13) blood,83009,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,101.04,,,,,,,fee schedule,101.04,281.03, H pylori (c-13) blood,83009,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,101.04,,,,,,,fee schedule,101.04,281.03, Assay of haptoglobin quant,83010,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,52.48,,,,,,,fee schedule,18.87,52.48, Assay of haptoglobin quant,83010,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.87,,,,,,,fee schedule,18.87,52.48, Assay of haptoglobin quant,83010,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,18.87,,,,,,,fee schedule,18.87,52.48, Assay of haptoglobins,83012,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,112.19,,,,,,,fee schedule,40.34,112.19, Assay of haptoglobins,83012,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,40.34,,,,,,,fee schedule,40.34,112.19, Assay of haptoglobins,83012,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,40.34,,,,,,,fee schedule,40.34,112.19, H pylori (c-13) breath,83013,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,281.03,,,,,,,fee schedule,101.04,281.03, H pylori (c-13) breath,83013,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,101.04,,,,,,,fee schedule,101.04,281.03, H pylori (c-13) breath,83013,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,101.04,,,,,,,fee schedule,101.04,281.03, H pylori drug admin,83014,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,32.79,,,,,,,fee schedule,11.79,32.79, H pylori drug admin,83014,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.79,,,,,,,fee schedule,11.79,32.79, H pylori drug admin,83014,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11.79,,,,,,,fee schedule,11.79,32.79, Heavy metal qual any anal,83015,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,87.36,,,,,,,fee schedule,31.41,87.36, Heavy metal qual any anal,83015,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31.41,,,,,,,fee schedule,31.41,87.36, Heavy metal qual any anal,83015,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,31.41,,,,,,,fee schedule,31.41,87.36, Heavy metal quant each nes,83018,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,91.62,,,,,,,fee schedule,32.94,91.62, Heavy metal quant each nes,83018,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,32.94,,,,,,,fee schedule,32.94,91.62, Heavy metal quant each nes,83018,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,32.94,,,,,,,fee schedule,32.94,91.62, Hemoglobin electrophoresis,83020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,53.69,,,,,,,fee schedule,19.31,53.69, Hemoglobin electrophoresis,83020,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.31,,,,,,,fee schedule,19.31,53.69, Hemoglobin electrophoresis,83020,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19.31,,,,,,,fee schedule,19.31,53.69, Hemoglobin chromotography,83021,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,75.35,,,,,,,fee schedule,27.09,75.35, Hemoglobin chromotography,83021,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,27.09,,,,,,,fee schedule,27.09,75.35, Hemoglobin chromotography,83021,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,27.09,,,,,,,fee schedule,27.09,75.35, Hemoglobin copper sulfate,83026,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,16.73,,,,,,,fee schedule,6.02,16.73, Hemoglobin copper sulfate,83026,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.02,,,,,,,fee schedule,6.02,16.73, Hemoglobin copper sulfate,83026,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,6.02,,,,,,,fee schedule,6.02,16.73, Fetal hemoglobin chemical,83030,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,44.81,,,,,,,fee schedule,16.11,44.81, Fetal hemoglobin chemical,83030,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.11,,,,,,,fee schedule,16.11,44.81, Fetal hemoglobin chemical,83030,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,16.11,,,,,,,fee schedule,16.11,44.81, Fetal hemoglobin assay qual,83033,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,33.38,,,,,,,fee schedule,12,33.38, Fetal hemoglobin assay qual,83033,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12,,,,,,,fee schedule,12,33.38, Fetal hemoglobin assay qual,83033,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,12,,,,,,,fee schedule,12,33.38, Glycosylated hemoglobin test,83036,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,40.51,,,,,,,fee schedule,14.57,40.51, Glycosylated hemoglobin test,83036,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.57,,,,,,,fee schedule,14.57,40.51, Glycosylated hemoglobin test,83036,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,14.57,,,,,,,fee schedule,14.57,40.51, Glycosylated hb home device,83037,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,40.51,,,,,,,fee schedule,14.57,40.51, Glycosylated hb home device,83037,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.57,,,,,,,fee schedule,14.57,40.51, Glycosylated hb home device,83037,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,14.57,,,,,,,fee schedule,14.57,40.51, Blood methemoglobin test,83045,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,27.08,,,,,,,fee schedule,9.74,27.08, Blood methemoglobin test,83045,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.74,,,,,,,fee schedule,9.74,27.08, Blood methemoglobin test,83045,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9.74,,,,,,,fee schedule,9.74,27.08, Blood methemoglobin assay,83050,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,34.21,,,,,,,fee schedule,12.3,34.21, Blood methemoglobin assay,83050,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.3,,,,,,,fee schedule,12.3,34.21, Blood methemoglobin assay,83050,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,12.3,,,,,,,fee schedule,12.3,34.21, Assay of plasma hemoglobin,83051,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,30.5,,,,,,,fee schedule,10.97,30.5, Assay of plasma hemoglobin,83051,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.97,,,,,,,fee schedule,10.97,30.5, Assay of plasma hemoglobin,83051,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,10.97,,,,,,,fee schedule,10.97,30.5, Blood sulfhemoglobin assay,83060,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,36.71,,,,,,,fee schedule,13.2,36.71, Blood sulfhemoglobin assay,83060,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13.2,,,,,,,fee schedule,13.2,36.71, Blood sulfhemoglobin assay,83060,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13.2,,,,,,,fee schedule,13.2,36.71, Assay of hemoglobin heat,83065,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,37.55,,,,,,,fee schedule,13.5,37.55, Assay of hemoglobin heat,83065,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13.5,,,,,,,fee schedule,13.5,37.55, Assay of hemoglobin heat,83065,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13.5,,,,,,,fee schedule,13.5,37.55, Hemoglobin stability screen,83068,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,39.51,,,,,,,fee schedule,14.21,39.51, Hemoglobin stability screen,83068,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.21,,,,,,,fee schedule,14.21,39.51, Hemoglobin stability screen,83068,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,14.21,,,,,,,fee schedule,14.21,39.51, Assay of urine hemoglobin,83069,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,16.48,,,,,,,fee schedule,5.93,16.48, Assay of urine hemoglobin,83069,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.93,,,,,,,fee schedule,5.93,16.48, Assay of urine hemoglobin,83069,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5.93,,,,,,,fee schedule,5.93,16.48, Assay of hemosiderin qual,83070,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,19.82,,,,,,,fee schedule,7.13,19.82, Assay of hemosiderin qual,83070,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.13,,,,,,,fee schedule,7.13,19.82, Assay of hemosiderin qual,83070,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,7.13,,,,,,,fee schedule,7.13,19.82, Assay of b hexosaminidase,83080,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,70.38,,,,,,,fee schedule,25.31,70.38, Assay of b hexosaminidase,83080,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25.31,,,,,,,fee schedule,25.31,70.38, Assay of b hexosaminidase,83080,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,25.31,,,,,,,fee schedule,25.31,70.38, Assay of histamine,83088,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,123.2,,,,,,,fee schedule,44.3,123.2, Assay of histamine,83088,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,44.3,,,,,,,fee schedule,44.3,123.2, Assay of histamine,83088,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,44.3,,,,,,,fee schedule,44.3,123.2, Assay Of Homocystine,83090,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,74.76,,,,,,,fee schedule,26.88,74.76, Assay Of Homocystine,83090,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26.88,,,,,,,fee schedule,26.88,74.76, Assay Of Homocystine,83090,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,26.88,,,,,,,fee schedule,26.88,74.76, Assay of homovanillic acid,83150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,93.49,,,,,,,fee schedule,33.62,93.49, Assay of homovanillic acid,83150,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,33.62,,,,,,,fee schedule,33.62,93.49, Assay of homovanillic acid,83150,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,33.62,,,,,,,fee schedule,33.62,93.49, Assay of corticosteroids 17,83491,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,74.68,,,,,,,fee schedule,26.85,74.68, Assay of corticosteroids 17,83491,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26.85,,,,,,,fee schedule,26.85,74.68, Assay of corticosteroids 17,83491,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,26.85,,,,,,,fee schedule,26.85,74.68, Assay of 5-hiaa,83497,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,53.82,,,,,,,fee schedule,19.35,53.82, Assay of 5-hiaa,83497,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.35,,,,,,,fee schedule,19.35,53.82, Assay of 5-hiaa,83497,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19.35,,,,,,,fee schedule,19.35,53.82, Assay of progesterone 17-d,83498,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,113.35,,,,,,,fee schedule,40.76,113.35, Assay of progesterone 17-d,83498,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,40.76,,,,,,,fee schedule,40.76,113.35, Assay of progesterone 17-d,83498,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,40.76,,,,,,,fee schedule,40.76,113.35, Assay free hydroxyproline,83500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,94.5,,,,,,,fee schedule,33.98,94.5, Assay free hydroxyproline,83500,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,33.98,,,,,,,fee schedule,33.98,94.5, Assay free hydroxyproline,83500,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,33.98,,,,,,,fee schedule,33.98,94.5, Assay total hydroxyproline,83505,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,101.38,,,,,,,fee schedule,36.45,101.38, Assay total hydroxyproline,83505,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,36.45,,,,,,,fee schedule,36.45,101.38, Assay total hydroxyproline,83505,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,36.45,,,,,,,fee schedule,36.45,101.38, Immunoassay nonantibody,83516,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,48.1,,,,,,,fee schedule,17.3,48.1, Immunoassay nonantibody,83516,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.3,,,,,,,fee schedule,17.3,48.1, Immunoassay nonantibody,83516,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,17.3,,,,,,,fee schedule,17.3,48.1, Immunoassay dipstick,83518,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,40.22,,,,,,,fee schedule,14.46,40.22, Immunoassay dipstick,83518,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.46,,,,,,,fee schedule,14.46,40.22, Immunoassay dipstick,83518,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,14.46,,,,,,,fee schedule,14.46,40.22, Ria nonantibody,83519,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,76.76,,,,,,,fee schedule,27.6,76.76, Ria nonantibody,83519,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,27.6,,,,,,,fee schedule,27.6,76.76, Ria nonantibody,83519,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,27.6,,,,,,,fee schedule,27.6,76.76, Immunoassay quant nos nonab,83520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,72.05,,,,,,,fee schedule,25.91,72.05, Immunoassay quant nos nonab,83520,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25.91,,,,,,,fee schedule,25.91,72.05, Immunoassay quant nos nonab,83520,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,25.91,,,,,,,fee schedule,25.91,72.05, Ig light chains free each,83521,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,72.05,,,,,,,fee schedule,25.91,72.05, Ig light chains free each,83521,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25.91,,,,,,,fee schedule,25.91,72.05, Ig light chains free each,83521,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,25.91,,,,,,,fee schedule,25.91,72.05, Assay of insulin,83525,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,47.69,,,,,,,fee schedule,17.15,47.69, Assay of insulin,83525,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.15,,,,,,,fee schedule,17.15,47.69, Assay of insulin,83525,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,17.15,,,,,,,fee schedule,17.15,47.69, Assay of insulin,83527,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,54.03,,,,,,,fee schedule,19.43,54.03, Assay of insulin,83527,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.43,,,,,,,fee schedule,19.43,54.03, Assay of insulin,83527,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19.43,,,,,,,fee schedule,19.43,54.03, Assay of intrinsic factor,83528,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,82.69,,,,,,,fee schedule,29.73,82.69, Assay of intrinsic factor,83528,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,29.73,,,,,,,fee schedule,29.73,82.69, Assay of intrinsic factor,83528,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,29.73,,,,,,,fee schedule,29.73,82.69, Asay of interleukin-6 (il-6),83529,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,72.05,,,,,,,fee schedule,25.91,72.05, Asay of interleukin-6 (il-6),83529,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25.91,,,,,,,fee schedule,25.91,72.05, Asay of interleukin-6 (il-6),83529,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,25.91,,,,,,,fee schedule,25.91,72.05, Assay of iron,83540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,26.99,,,,,,,fee schedule,9.71,26.99, Assay of iron,83540,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.71,,,,,,,fee schedule,9.71,26.99, Assay of iron,83540,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9.71,,,,,,,fee schedule,9.71,26.99, Iron binding test,83550,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,36.46,,,,,,,fee schedule,13.11,36.46, Iron binding test,83550,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13.11,,,,,,,fee schedule,13.11,36.46, Iron binding test,83550,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13.11,,,,,,,fee schedule,13.11,36.46, Assay of idh enzyme,83570,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,36.92,,,,,,,fee schedule,13.28,36.92, Assay of idh enzyme,83570,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13.28,,,,,,,fee schedule,13.28,36.92, Assay of idh enzyme,83570,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13.28,,,,,,,fee schedule,13.28,36.92, Assay of ketogenic steroids,83582,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,64.54,,,,,,,fee schedule,23.21,64.54, Assay of ketogenic steroids,83582,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23.21,,,,,,,fee schedule,23.21,64.54, Assay of ketogenic steroids,83582,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,23.21,,,,,,,fee schedule,23.21,64.54, Assay 17- ketosteroids,83586,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,53.4,,,,,,,fee schedule,19.2,53.4, Assay 17- ketosteroids,83586,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.2,,,,,,,fee schedule,19.2,53.4, Assay 17- ketosteroids,83586,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19.2,,,,,,,fee schedule,19.2,53.4, Fractionation ketosteroids,83593,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,118.9,,,,,,,fee schedule,42.75,118.9, Fractionation ketosteroids,83593,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,42.75,,,,,,,fee schedule,42.75,118.9, Fractionation ketosteroids,83593,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,42.75,,,,,,,fee schedule,42.75,118.9, Assay of lactic acid,83605,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,48.27,,,,,,,fee schedule,17.36,48.27, Assay of lactic acid,83605,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.36,,,,,,,fee schedule,17.36,48.27, Assay of lactic acid,83605,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,17.36,,,,,,,fee schedule,17.36,48.27, Lactate (LD) (LDH) enzyme,83615,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,25.2,,,,,,,fee schedule,9.06,25.2, Lactate (LD) (LDH) enzyme,83615,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.06,,,,,,,fee schedule,9.06,25.2, Lactate (LD) (LDH) enzyme,83615,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9.06,,,,,,,fee schedule,9.06,25.2, Assay of ldh enzymes,83625,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,53.36,,,,,,,fee schedule,19.19,53.36, Assay of ldh enzymes,83625,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.19,,,,,,,fee schedule,19.19,53.36, Assay of ldh enzymes,83625,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19.19,,,,,,,fee schedule,19.19,53.36, Lactoferrin fecal (qual),83630,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,82.19,,,,,,,fee schedule,29.55,82.19, Lactoferrin fecal (qual),83630,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,29.55,,,,,,,fee schedule,29.55,82.19, Lactoferrin fecal (qual),83630,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,29.55,,,,,,,fee schedule,29.55,82.19, Lactoferrin fecal (quant),83631,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,81.9,,,,,,,fee schedule,29.45,81.9, Lactoferrin fecal (quant),83631,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,29.45,,,,,,,fee schedule,29.45,81.9, Lactoferrin fecal (quant),83631,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,29.45,,,,,,,fee schedule,29.45,81.9, Placental lactogen,83632,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,84.36,,,,,,,fee schedule,30.33,84.36, Placental lactogen,83632,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,30.33,,,,,,,fee schedule,30.33,84.36, Placental lactogen,83632,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,30.33,,,,,,,fee schedule,30.33,84.36, Test urine for lactose,83633,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,46.94,,,,,,,fee schedule,16.88,46.94, Test urine for lactose,83633,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.88,,,,,,,fee schedule,16.88,46.94, Test urine for lactose,83633,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,16.88,,,,,,,fee schedule,16.88,46.94, Assay of lead,83655,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,50.52,,,,,,,fee schedule,18.17,50.52, Assay of lead,83655,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.17,,,,,,,fee schedule,18.17,50.52, Assay of lead,83655,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,18.17,,,,,,,fee schedule,18.17,50.52, L/s ratio fetal lung,83661,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,91.74,,,,,,,fee schedule,32.99,91.74, L/s ratio fetal lung,83661,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,32.99,,,,,,,fee schedule,32.99,91.74, L/s ratio fetal lung,83661,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,32.99,,,,,,,fee schedule,32.99,91.74, Foam stability fetal lung,83662,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,78.89,,,,,,,fee schedule,28.37,78.89, Foam stability fetal lung,83662,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,28.37,,,,,,,fee schedule,28.37,78.89, Foam stability fetal lung,83662,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,28.37,,,,,,,fee schedule,28.37,78.89, Fluoro polarize fetal lung,83663,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,78.89,,,,,,,fee schedule,28.37,78.89, Fluoro polarize fetal lung,83663,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,28.37,,,,,,,fee schedule,28.37,78.89, Fluoro polarize fetal lung,83663,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,28.37,,,,,,,fee schedule,28.37,78.89, Lamellar bdy fetal lung,83664,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,80.6,,,,,,,fee schedule,28.98,80.6, Lamellar bdy fetal lung,83664,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,28.98,,,,,,,fee schedule,28.98,80.6, Lamellar bdy fetal lung,83664,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,28.98,,,,,,,fee schedule,28.98,80.6, Assay of lap enzyme,83670,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,40.93,,,,,,,fee schedule,14.72,40.93, Assay of lap enzyme,83670,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.72,,,,,,,fee schedule,14.72,40.93, Assay of lap enzyme,83670,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,14.72,,,,,,,fee schedule,14.72,40.93, Assay of lipase,83690,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,28.75,,,,,,,fee schedule,10.34,28.75, Assay of lipase,83690,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.34,,,,,,,fee schedule,10.34,28.75, Assay of lipase,83690,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,10.34,,,,,,,fee schedule,10.34,28.75, Assay of lipoprotein(a),83695,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,59.74,,,,,,,fee schedule,21.48,59.74, Assay of lipoprotein(a),83695,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21.48,,,,,,,fee schedule,21.48,59.74, Assay of lipoprotein(a),83695,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,21.48,,,,,,,fee schedule,21.48,59.74, Assay Lipoprotein Pla2,83698,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,193.21,,,,,,,fee schedule,69.47,193.21, Assay Lipoprotein Pla2,83698,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,69.47,,,,,,,fee schedule,69.47,193.21, Assay Lipoprotein Pla2,83698,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,69.47,,,,,,,fee schedule,69.47,193.21, Lipopro bld electrophoretic,83700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,46.98,,,,,,,fee schedule,16.89,46.98, Lipopro bld electrophoretic,83700,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.89,,,,,,,fee schedule,16.89,46.98, Lipopro bld electrophoretic,83700,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,16.89,,,,,,,fee schedule,16.89,46.98, Lipoprotein bld hr fraction,83701,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,141.26,,,,,,,fee schedule,50.79,141.26, Lipoprotein bld hr fraction,83701,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,50.79,,,,,,,fee schedule,50.79,141.26, Lipoprotein bld hr fraction,83701,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,50.79,,,,,,,fee schedule,50.79,141.26, Lipoprotein bld quan part,83704,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,142.64,,,,,,,fee schedule,51.29,142.64, Lipoprotein bld quan part,83704,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,51.29,,,,,,,fee schedule,51.29,142.64, Lipoprotein bld quan part,83704,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,51.29,,,,,,,fee schedule,51.29,142.64, Assay of lipoprotein,83718,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,34.17,,,,,,,fee schedule,12.29,34.17, Assay of lipoprotein,83718,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.29,,,,,,,fee schedule,12.29,34.17, Assay of lipoprotein,83718,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,12.29,,,,,,,fee schedule,12.29,34.17, Assay of blood lipoprotein,83719,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,53.19,,,,,,,fee schedule,19.13,53.19, Assay of blood lipoprotein,83719,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.13,,,,,,,fee schedule,19.13,53.19, Assay of blood lipoprotein,83719,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19.13,,,,,,,fee schedule,19.13,53.19, Assay of blood lipoprotein,83721,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,43.81,,,,,,,fee schedule,15.75,43.81, Assay of blood lipoprotein,83721,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.75,,,,,,,fee schedule,15.75,43.81, Assay of blood lipoprotein,83721,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,15.75,,,,,,,fee schedule,15.75,43.81, Lipoprtn dir meas sd ldl chl,83722,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,142.64,,,,,,,fee schedule,51.29,142.64, Lipoprtn dir meas sd ldl chl,83722,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,51.29,,,,,,,fee schedule,51.29,142.64, Lipoprtn dir meas sd ldl chl,83722,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,51.29,,,,,,,fee schedule,51.29,142.64, Assay of lrh hormone,83727,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,71.72,,,,,,,fee schedule,25.79,71.72, Assay of lrh hormone,83727,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25.79,,,,,,,fee schedule,25.79,71.72, Assay of lrh hormone,83727,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,25.79,,,,,,,fee schedule,25.79,71.72, Assay of magnesium,83735,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,27.95,,,,,,,fee schedule,10.05,27.95, Assay of magnesium,83735,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.05,,,,,,,fee schedule,10.05,27.95, Assay of magnesium,83735,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,10.05,,,,,,,fee schedule,10.05,27.95, Assay malate dehydrogenase,83775,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,30.75,,,,,,,fee schedule,11.06,30.75, Assay malate dehydrogenase,83775,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.06,,,,,,,fee schedule,11.06,30.75, Assay malate dehydrogenase,83775,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11.06,,,,,,,fee schedule,11.06,30.75, Assay of manganese,83785,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,111.18,,,,,,,fee schedule,39.98,111.18, Assay of manganese,83785,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,39.98,,,,,,,fee schedule,39.98,111.18, Assay of manganese,83785,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,39.98,,,,,,,fee schedule,39.98,111.18, Mass spectrometry qual/quan,83789,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,100.59,,,,,,,fee schedule,36.17,100.59, Mass spectrometry qual/quan,83789,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,36.17,,,,,,,fee schedule,36.17,100.59, Mass spectrometry qual/quan,83789,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,36.17,,,,,,,fee schedule,36.17,100.59, Assay of mercury,83825,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,67.84,,,,,,,fee schedule,24.39,67.84, Assay of mercury,83825,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24.39,,,,,,,fee schedule,24.39,67.84, Assay of mercury,83825,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,24.39,,,,,,,fee schedule,24.39,67.84, Assay of metanephrines,83835,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,70.67,,,,,,,fee schedule,25.41,70.67, Assay of metanephrines,83835,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25.41,,,,,,,fee schedule,25.41,70.67, Assay of metanephrines,83835,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,25.41,,,,,,,fee schedule,25.41,70.67, Assay of methemalbumin,83857,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,44.81,,,,,,,fee schedule,16.11,44.81, Assay of methemalbumin,83857,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.11,,,,,,,fee schedule,16.11,44.81, Assay of methemalbumin,83857,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,16.11,,,,,,,fee schedule,16.11,44.81, Microfluid analy tears,83861,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,93.79,,,,,,,fee schedule,33.72,93.79, Microfluid analy tears,83861,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,33.72,,,,,,,fee schedule,33.72,93.79, Microfluid analy tears,83861,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,33.72,,,,,,,fee schedule,33.72,93.79, Mucopolysaccharides,83864,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,118.9,,,,,,,fee schedule,42.75,118.9, Mucopolysaccharides,83864,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,42.75,,,,,,,fee schedule,42.75,118.9, Mucopolysaccharides,83864,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,42.75,,,,,,,fee schedule,42.75,118.9, Assay synovial fluid mucin,83872,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,24.45,,,,,,,fee schedule,8.79,24.45, Assay synovial fluid mucin,83872,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.79,,,,,,,fee schedule,8.79,24.45, Assay synovial fluid mucin,83872,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,8.79,,,,,,,fee schedule,8.79,24.45, Assay of csf protein,83873,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,71.76,,,,,,,fee schedule,25.8,71.76, Assay of csf protein,83873,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25.8,,,,,,,fee schedule,25.8,71.76, Assay of csf protein,83873,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,25.8,,,,,,,fee schedule,25.8,71.76, Assay of myoglobin,83874,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,53.9,,,,,,,fee schedule,19.38,53.9, Assay of myoglobin,83874,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.38,,,,,,,fee schedule,19.38,53.9, Assay of myoglobin,83874,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19.38,,,,,,,fee schedule,19.38,53.9, Assay myeloperoxidase,83876,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,212.19,,,,,,,fee schedule,76.29,212.19, Assay myeloperoxidase,83876,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,76.29,,,,,,,fee schedule,76.29,212.19, Assay myeloperoxidase,83876,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,76.29,,,,,,,fee schedule,76.29,212.19, Assay of natriuretic peptide,83880,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,163.79,,,,,,,fee schedule,58.89,163.79, Assay of natriuretic peptide,83880,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,58.89,,,,,,,fee schedule,58.89,163.79, Assay of natriuretic peptide,83880,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,58.89,,,,,,,fee schedule,58.89,163.79, Assay nephelometry not spec,83883,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,56.74,,,,,,,fee schedule,20.4,56.74, Assay nephelometry not spec,83883,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,20.4,,,,,,,fee schedule,20.4,56.74, Assay nephelometry not spec,83883,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,20.4,,,,,,,fee schedule,20.4,56.74, Assay neurflmnt light chain,83884,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,484.91,,,,,,,fee schedule,484.91,484.91, Assay of nickel,83885,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,102.26,,,,,,,fee schedule,36.77,102.26, Assay of nickel,83885,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,36.77,,,,,,,fee schedule,36.77,102.26, Assay of nickel,83885,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,36.77,,,,,,,fee schedule,36.77,102.26, Assay of nucleotidase,83915,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,46.52,,,,,,,fee schedule,16.73,46.52, Assay of nucleotidase,83915,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.73,,,,,,,fee schedule,16.73,46.52, Assay of nucleotidase,83915,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,16.73,,,,,,,fee schedule,16.73,46.52, Oligoclonal bands,83916,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,114.27,,,,,,,fee schedule,41.09,114.27, Oligoclonal bands,83916,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,41.09,,,,,,,fee schedule,41.09,114.27, Oligoclonal bands,83916,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,41.09,,,,,,,fee schedule,41.09,114.27, Organic acids total quant,83918,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,98.46,,,,,,,fee schedule,35.4,98.46, Organic acids total quant,83918,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,35.4,,,,,,,fee schedule,35.4,98.46, Organic acids total quant,83918,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,35.4,,,,,,,fee schedule,35.4,98.46, Organic acids qual each,83919,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,68.63,,,,,,,fee schedule,24.68,68.63, Organic acids qual each,83919,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24.68,,,,,,,fee schedule,24.68,68.63, Organic acids qual each,83919,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,24.68,,,,,,,fee schedule,24.68,68.63, Organic acid single quant,83921,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,88.49,,,,,,,fee schedule,31.82,88.49, Organic acid single quant,83921,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31.82,,,,,,,fee schedule,31.82,88.49, Organic acid single quant,83921,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,31.82,,,,,,,fee schedule,31.82,88.49, Assay of blood osmolality,83930,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,27.58,,,,,,,fee schedule,9.92,27.58, Assay of blood osmolality,83930,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.92,,,,,,,fee schedule,9.92,27.58, Assay of blood osmolality,83930,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9.92,,,,,,,fee schedule,9.92,27.58, Assay of urine osmolality,83935,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,28.45,,,,,,,fee schedule,10.23,28.45, Assay of urine osmolality,83935,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.23,,,,,,,fee schedule,10.23,28.45, Assay of urine osmolality,83935,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,10.23,,,,,,,fee schedule,10.23,28.45, Assay of osteocalcin,83937,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,124.53,,,,,,,fee schedule,44.78,124.53, Assay of osteocalcin,83937,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,44.78,,,,,,,fee schedule,44.78,124.53, Assay of osteocalcin,83937,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,44.78,,,,,,,fee schedule,44.78,124.53, Assay of oxalate,83945,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,60.29,,,,,,,fee schedule,21.68,60.29, Assay of oxalate,83945,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21.68,,,,,,,fee schedule,21.68,60.29, Assay of oxalate,83945,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,21.68,,,,,,,fee schedule,21.68,60.29, Oncoprotein her-2/neu,83950,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,268.72,,,,,,,fee schedule,96.62,268.72, Oncoprotein her-2/neu,83950,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,96.62,,,,,,,fee schedule,96.62,268.72, Oncoprotein her-2/neu,83950,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,96.62,,,,,,,fee schedule,96.62,268.72, Oncoprotein dcp,83951,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,268.72,,,,,,,fee schedule,96.62,268.72, Oncoprotein dcp,83951,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,96.62,,,,,,,fee schedule,96.62,268.72, Oncoprotein dcp,83951,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,96.62,,,,,,,fee schedule,96.62,268.72, Assay of parathormone,83970,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,172.22,,,,,,,fee schedule,61.92,172.22, Assay of parathormone,83970,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,61.92,,,,,,,fee schedule,61.92,172.22, Assay of parathormone,83970,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,61.92,,,,,,,fee schedule,61.92,172.22, Assay ph body fluid nos,83986,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,14.94,,,,,,,fee schedule,5.37,14.94, Assay ph body fluid nos,83986,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.37,,,,,,,fee schedule,5.37,14.94, Assay ph body fluid nos,83986,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5.37,,,,,,,fee schedule,5.37,14.94, Exhaled breath condensate,83987,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,14.94,,,,,,,fee schedule,5.37,14.94, Exhaled breath condensate,83987,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.37,,,,,,,fee schedule,5.37,14.94, Exhaled breath condensate,83987,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5.37,,,,,,,fee schedule,5.37,14.94, Assay for phencyclidine,83992,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,64.97,,,,,,,fee schedule,64.97,64.97, Assay for phencyclidine,83992,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,64.97,,,,,,,fee schedule,64.97,64.97, Assay for calprotectin fecal,83993,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,81.9,,,,,,,fee schedule,29.45,81.9, Assay for calprotectin fecal,83993,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,29.45,,,,,,,fee schedule,29.45,81.9, Assay for calprotectin fecal,83993,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,29.45,,,,,,,fee schedule,29.45,81.9, Assay of blood pku,84030,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,22.95,,,,,,,fee schedule,8.25,22.95, Assay of blood pku,84030,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.25,,,,,,,fee schedule,8.25,22.95, Assay of blood pku,84030,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,8.25,,,,,,,fee schedule,8.25,22.95, Assay of phenylketones,84035,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,16.6,,,,,,,fee schedule,5.97,16.6, Assay of phenylketones,84035,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.97,,,,,,,fee schedule,5.97,16.6, Assay of phenylketones,84035,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5.97,,,,,,,fee schedule,5.97,16.6, Assay acid phosphatase,84060,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,31.87,,,,,,,fee schedule,11.46,31.87, Assay acid phosphatase,84060,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.46,,,,,,,fee schedule,11.46,31.87, Assay acid phosphatase,84060,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11.46,,,,,,,fee schedule,11.46,31.87, Assay prostate phosphatase,84066,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,40.3,,,,,,,fee schedule,14.49,40.3, Assay prostate phosphatase,84066,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.49,,,,,,,fee schedule,14.49,40.3, Assay prostate phosphatase,84066,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,14.49,,,,,,,fee schedule,14.49,40.3, Assay alkaline phosphatase,84075,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,21.61,,,,,,,fee schedule,7.77,21.61, Assay alkaline phosphatase,84075,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.77,,,,,,,fee schedule,7.77,21.61, Assay alkaline phosphatase,84075,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,7.77,,,,,,,fee schedule,7.77,21.61, Assay alkaline phosphatase,84078,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,34.46,,,,,,,fee schedule,12.39,34.46, Assay alkaline phosphatase,84078,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.39,,,,,,,fee schedule,12.39,34.46, Assay alkaline phosphatase,84078,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,12.39,,,,,,,fee schedule,12.39,34.46, Assay alkaline phosphatases,84080,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,61.66,,,,,,,fee schedule,22.17,61.66, Assay alkaline phosphatases,84080,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22.17,,,,,,,fee schedule,22.17,61.66, Assay alkaline phosphatases,84080,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22.17,,,,,,,fee schedule,22.17,61.66, Assay phosphatidylglycerol,84081,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,68.92,,,,,,,fee schedule,24.78,68.92, Assay phosphatidylglycerol,84081,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24.78,,,,,,,fee schedule,24.78,68.92, Assay phosphatidylglycerol,84081,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,24.78,,,,,,,fee schedule,24.78,68.92, Assay of rbc pg6d enzyme,84085,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,39.38,,,,,,,fee schedule,14.16,39.38, Assay of rbc pg6d enzyme,84085,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.16,,,,,,,fee schedule,14.16,39.38, Assay of rbc pg6d enzyme,84085,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,14.16,,,,,,,fee schedule,14.16,39.38, Assay phosphohexose enzymes,84087,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,44.77,,,,,,,fee schedule,16.1,44.77, Assay phosphohexose enzymes,84087,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.1,,,,,,,fee schedule,16.1,44.77, Assay phosphohexose enzymes,84087,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,16.1,,,,,,,fee schedule,16.1,44.77, Assay of phosphorus,84100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,19.78,,,,,,,fee schedule,7.11,19.78, Assay of phosphorus,84100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.11,,,,,,,fee schedule,7.11,19.78, Assay of phosphorus,84100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,7.11,,,,,,,fee schedule,7.11,19.78, Assay of urine phosphorus,84105,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,24.11,,,,,,,fee schedule,8.67,24.11, Assay of urine phosphorus,84105,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.67,,,,,,,fee schedule,8.67,24.11, Assay of urine phosphorus,84105,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,8.67,,,,,,,fee schedule,8.67,24.11, Test for porphobilinogen,84106,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,24.28,,,,,,,fee schedule,8.73,24.28, Test for porphobilinogen,84106,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.73,,,,,,,fee schedule,8.73,24.28, Test for porphobilinogen,84106,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,8.73,,,,,,,fee schedule,8.73,24.28, Assay of porphobilinogen,84110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,35.21,,,,,,,fee schedule,12.66,35.21, Assay of porphobilinogen,84110,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.66,,,,,,,fee schedule,12.66,35.21, Assay of porphobilinogen,84110,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,12.66,,,,,,,fee schedule,12.66,35.21, Eval amniotic fluid protein,84112,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,409.31,,,,,,,fee schedule,147.17,409.31, Eval amniotic fluid protein,84112,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,147.17,,,,,,,fee schedule,147.17,409.31, Eval amniotic fluid protein,84112,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,147.17,,,,,,,fee schedule,147.17,409.31, Test urine for porphyrins,84119,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,55.74,,,,,,,fee schedule,20.04,55.74, Test urine for porphyrins,84119,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,20.04,,,,,,,fee schedule,20.04,55.74, Test urine for porphyrins,84119,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,20.04,,,,,,,fee schedule,20.04,55.74, Assay of urine porphyrins,84120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,61.37,,,,,,,fee schedule,22.07,61.37, Assay of urine porphyrins,84120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22.07,,,,,,,fee schedule,22.07,61.37, Assay of urine porphyrins,84120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22.07,,,,,,,fee schedule,22.07,61.37, Assay of feces porphyrins,84126,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,163.17,,,,,,,fee schedule,58.67,163.17, Assay of feces porphyrins,84126,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,58.67,,,,,,,fee schedule,58.67,163.17, Assay of feces porphyrins,84126,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,58.67,,,,,,,fee schedule,58.67,163.17, Assay of serum potassium,84132,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,19.86,,,,,,,fee schedule,7.14,19.86, Assay of serum potassium,84132,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.14,,,,,,,fee schedule,7.14,19.86, Assay of serum potassium,84132,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,7.14,,,,,,,fee schedule,7.14,19.86, Assay of urine potassium,84133,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,19.73,,,,,,,fee schedule,7.1,19.73, Assay of urine potassium,84133,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.1,,,,,,,fee schedule,7.1,19.73, Assay of urine potassium,84133,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,7.1,,,,,,,fee schedule,7.1,19.73, Assay of prealbumin,84134,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,60.87,,,,,,,fee schedule,21.89,60.87, Assay of prealbumin,84134,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21.89,,,,,,,fee schedule,21.89,60.87, Assay of prealbumin,84134,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,21.89,,,,,,,fee schedule,21.89,60.87, Assay of pregnanediol,84135,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,88.74,,,,,,,fee schedule,31.91,88.74, Assay of pregnanediol,84135,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31.91,,,,,,,fee schedule,31.91,88.74, Assay of pregnanediol,84135,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,31.91,,,,,,,fee schedule,31.91,88.74, Assay of pregnanetriol,84138,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,87.82,,,,,,,fee schedule,31.58,87.82, Assay of pregnanetriol,84138,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31.58,,,,,,,fee schedule,31.58,87.82, Assay of pregnanetriol,84138,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,31.58,,,,,,,fee schedule,31.58,87.82, Assay of pregnenolone,84140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,86.24,,,,,,,fee schedule,31.01,86.24, Assay of pregnenolone,84140,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31.01,,,,,,,fee schedule,31.01,86.24, Assay of pregnenolone,84140,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,31.01,,,,,,,fee schedule,31.01,86.24, Assay of 17-hydroxypregneno,84143,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,95.16,,,,,,,fee schedule,34.22,95.16, Assay of 17-hydroxypregneno,84143,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,34.22,,,,,,,fee schedule,34.22,95.16, Assay of 17-hydroxypregneno,84143,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,34.22,,,,,,,fee schedule,34.22,95.16, Assay of progesterone,84144,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,87.03,,,,,,,fee schedule,31.29,87.03, Assay of progesterone,84144,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31.29,,,,,,,fee schedule,31.29,87.03, Assay of progesterone,84144,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,31.29,,,,,,,fee schedule,31.29,87.03, Procalcitonin (PCT),84145,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,113.56,,,,,,,fee schedule,40.83,113.56, Procalcitonin (PCT),84145,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,40.83,,,,,,,fee schedule,40.83,113.56, Procalcitonin (PCT),84145,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,40.83,,,,,,,fee schedule,40.83,113.56, Assay of prolactin,84146,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,80.85,,,,,,,fee schedule,29.07,80.85, Assay of prolactin,84146,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,29.07,,,,,,,fee schedule,29.07,80.85, Assay of prolactin,84146,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,29.07,,,,,,,fee schedule,29.07,80.85, Assay of prostaglandin,84150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,174.26,,,,,,,fee schedule,62.66,174.26, Assay of prostaglandin,84150,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,62.66,,,,,,,fee schedule,62.66,174.26, Assay of prostaglandin,84150,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,62.66,,,,,,,fee schedule,62.66,174.26, Assay of psa complexed,84152,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,76.72,,,,,,,fee schedule,27.59,76.72, Assay of psa complexed,84152,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,27.59,,,,,,,fee schedule,27.59,76.72, Assay of psa complexed,84152,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,27.59,,,,,,,fee schedule,27.59,76.72, Assay of psa total,84153,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,76.72,,,,,,,fee schedule,27.59,76.72, Assay of psa total,84153,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,27.59,,,,,,,fee schedule,27.59,76.72, Assay of psa total,84153,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,27.59,,,,,,,fee schedule,27.59,76.72, Assay of psa free,84154,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,76.72,,,,,,,fee schedule,27.59,76.72, Assay of psa free,84154,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,27.59,,,,,,,fee schedule,27.59,76.72, Assay of psa free,84154,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,27.59,,,,,,,fee schedule,27.59,76.72, Assay of protein serum,84155,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,15.31,,,,,,,fee schedule,5.51,15.31, Assay of protein serum,84155,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.51,,,,,,,fee schedule,5.51,15.31, Assay of protein serum,84155,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5.51,,,,,,,fee schedule,5.51,15.31, Assay of protein urine,84156,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,15.31,,,,,,,fee schedule,5.51,15.31, Assay of protein urine,84156,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.51,,,,,,,fee schedule,5.51,15.31, Assay of protein urine,84156,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5.51,,,,,,,fee schedule,5.51,15.31, Assay of protein other,84157,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,16.69,,,,,,,fee schedule,6,16.69, Assay of protein other,84157,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6,,,,,,,fee schedule,6,16.69, Assay of protein other,84157,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,6,,,,,,,fee schedule,6,16.69, Assay of protein any source,84160,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,23.4,,,,,,,fee schedule,8.42,23.4, Assay of protein any source,84160,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.42,,,,,,,fee schedule,8.42,23.4, Assay of protein any source,84160,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,8.42,,,,,,,fee schedule,8.42,23.4, Pappa serum,84163,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,62.79,,,,,,,fee schedule,22.58,62.79, Pappa serum,84163,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22.58,,,,,,,fee schedule,22.58,62.79, Pappa serum,84163,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22.58,,,,,,,fee schedule,22.58,62.79, Protein e-phoresis serum,84165,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,44.81,,,,,,,fee schedule,16.11,44.81, Protein e-phoresis serum,84165,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.11,,,,,,,fee schedule,16.11,44.81, Protein e-phoresis serum,84165,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,16.11,,,,,,,fee schedule,16.11,44.81, Protein e-phoresis/urine/csf,84166,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,74.39,,,,,,,fee schedule,26.75,74.39, Protein e-phoresis/urine/csf,84166,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26.75,,,,,,,fee schedule,26.75,74.39, Protein e-phoresis/urine/csf,84166,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,26.75,,,,,,,fee schedule,26.75,74.39, Western blot test,84181,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,71.05,,,,,,,fee schedule,25.55,71.05, Western blot test,84181,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25.55,,,,,,,fee schedule,25.55,71.05, Western blot test,84181,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,25.55,,,,,,,fee schedule,25.55,71.05, Protein western blot test,84182,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,121.86,,,,,,,fee schedule,43.82,121.86, Protein western blot test,84182,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,43.82,,,,,,,fee schedule,43.82,121.86, Protein western blot test,84182,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,43.82,,,,,,,fee schedule,43.82,121.86, Assay RBC protoporphyrin,84202,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,59.87,,,,,,,fee schedule,21.53,59.87, Assay RBC protoporphyrin,84202,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21.53,,,,,,,fee schedule,21.53,59.87, Assay RBC protoporphyrin,84202,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,21.53,,,,,,,fee schedule,21.53,59.87, Test RBC protoporphyrin,84203,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,40.64,,,,,,,fee schedule,14.61,40.64, Test RBC protoporphyrin,84203,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.61,,,,,,,fee schedule,14.61,40.64, Test RBC protoporphyrin,84203,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,14.61,,,,,,,fee schedule,14.61,40.64, Assay of proinsulin,84206,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,111.35,,,,,,,fee schedule,40.04,111.35, Assay of proinsulin,84206,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,40.04,,,,,,,fee schedule,40.04,111.35, Assay of proinsulin,84206,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,40.04,,,,,,,fee schedule,40.04,111.35, Assay of vitamin b-6,84207,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,117.23,,,,,,,fee schedule,42.15,117.23, Assay of vitamin b-6,84207,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,42.15,,,,,,,fee schedule,42.15,117.23, Assay of vitamin b-6,84207,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,42.15,,,,,,,fee schedule,42.15,117.23, Assay of pyruvate,84210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,60.41,,,,,,,fee schedule,21.72,60.41, Assay of pyruvate,84210,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21.72,,,,,,,fee schedule,21.72,60.41, Assay of pyruvate,84210,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,21.72,,,,,,,fee schedule,21.72,60.41, Assay of pyruvate kinase,84220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,39.38,,,,,,,fee schedule,14.16,39.38, Assay of pyruvate kinase,84220,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.16,,,,,,,fee schedule,14.16,39.38, Assay of pyruvate kinase,84220,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,14.16,,,,,,,fee schedule,14.16,39.38, Assay of quinine,84228,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,48.52,,,,,,,fee schedule,17.45,48.52, Assay of quinine,84228,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.45,,,,,,,fee schedule,17.45,48.52, Assay of quinine,84228,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,17.45,,,,,,,fee schedule,17.45,48.52, Assay of estrogen,84233,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,366.64,,,,,,,fee schedule,131.82,366.64, Assay of estrogen,84233,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,131.82,,,,,,,fee schedule,131.82,366.64, Assay of estrogen,84233,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,131.82,,,,,,,fee schedule,131.82,366.64, Assay of progesterone,84234,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,270.68,,,,,,,fee schedule,97.32,270.68, Assay of progesterone,84234,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,97.32,,,,,,,fee schedule,97.32,270.68, Assay of progesterone,84234,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,97.32,,,,,,,fee schedule,97.32,270.68, Assay of endocrine hormone,84235,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,297.17,,,,,,,fee schedule,106.85,297.17, Assay of endocrine hormone,84235,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,106.85,,,,,,,fee schedule,106.85,297.17, Assay of endocrine hormone,84235,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,106.85,,,,,,,fee schedule,106.85,297.17, Assay nonendocrine receptor,84238,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,152.57,,,,,,,fee schedule,54.86,152.57, Assay nonendocrine receptor,84238,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,54.86,,,,,,,fee schedule,54.86,152.57, Assay nonendocrine receptor,84238,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,54.86,,,,,,,fee schedule,54.86,152.57, Assay of renin,84244,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,91.74,,,,,,,fee schedule,32.99,91.74, Assay of renin,84244,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,32.99,,,,,,,fee schedule,32.99,91.74, Assay of renin,84244,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,32.99,,,,,,,fee schedule,32.99,91.74, Assay of vitamin b-2,84252,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,84.44,,,,,,,fee schedule,30.36,84.44, Assay of vitamin b-2,84252,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,30.36,,,,,,,fee schedule,30.36,84.44, Assay of vitamin b-2,84252,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,30.36,,,,,,,fee schedule,30.36,84.44, Assay of selenium,84255,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,106.51,,,,,,,fee schedule,38.3,106.51, Assay of selenium,84255,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,38.3,,,,,,,fee schedule,38.3,106.51, Assay of selenium,84255,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,38.3,,,,,,,fee schedule,38.3,106.51, Assay of serotonin,84260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,129.25,,,,,,,fee schedule,46.47,129.25, Assay of serotonin,84260,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46.47,,,,,,,fee schedule,46.47,129.25, Assay of serotonin,84260,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,46.47,,,,,,,fee schedule,46.47,129.25, Assay of sex hormone globul,84270,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,90.66,,,,,,,fee schedule,32.6,90.66, Assay of sex hormone globul,84270,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,32.6,,,,,,,fee schedule,32.6,90.66, Assay of sex hormone globul,84270,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,32.6,,,,,,,fee schedule,32.6,90.66, Assay of sialic acid,84275,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,56.07,,,,,,,fee schedule,20.16,56.07, Assay of sialic acid,84275,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,20.16,,,,,,,fee schedule,20.16,56.07, Assay of sialic acid,84275,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,20.16,,,,,,,fee schedule,20.16,56.07, Assay of silica,84285,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,105.18,,,,,,,fee schedule,37.82,105.18, Assay of silica,84285,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,37.82,,,,,,,fee schedule,37.82,105.18, Assay of silica,84285,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,37.82,,,,,,,fee schedule,37.82,105.18, Assay of serum sodium,84295,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,20.07,,,,,,,fee schedule,7.22,20.07, Assay of serum sodium,84295,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.22,,,,,,,fee schedule,7.22,20.07, Assay of serum sodium,84295,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,7.22,,,,,,,fee schedule,7.22,20.07, Assay of urine sodium,84300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,21.11,,,,,,,fee schedule,7.59,21.11, Assay of urine sodium,84300,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.59,,,,,,,fee schedule,7.59,21.11, Assay of urine sodium,84300,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,7.59,,,,,,,fee schedule,7.59,21.11, Assay of sweat sodium,84302,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,20.28,,,,,,,fee schedule,7.29,20.28, Assay of sweat sodium,84302,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.29,,,,,,,fee schedule,7.29,20.28, Assay of sweat sodium,84302,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,7.29,,,,,,,fee schedule,7.29,20.28, Assay of somatomedin,84305,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,88.7,,,,,,,fee schedule,31.89,88.7, Assay of somatomedin,84305,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31.89,,,,,,,fee schedule,31.89,88.7, Assay of somatomedin,84305,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,31.89,,,,,,,fee schedule,31.89,88.7, Assay of somatostatin,84307,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,76.26,,,,,,,fee schedule,27.42,76.26, Assay of somatostatin,84307,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,27.42,,,,,,,fee schedule,27.42,76.26, Assay of somatostatin,84307,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,27.42,,,,,,,fee schedule,27.42,76.26, Spectrophotometry,84311,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,33.79,,,,,,,fee schedule,12.15,33.79, Spectrophotometry,84311,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.15,,,,,,,fee schedule,12.15,33.79, Spectrophotometry,84311,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,12.15,,,,,,,fee schedule,12.15,33.79, Body fluid specific gravity,84315,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,13.68,,,,,,,fee schedule,4.92,13.68, Body fluid specific gravity,84315,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.92,,,,,,,fee schedule,4.92,13.68, Body fluid specific gravity,84315,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4.92,,,,,,,fee schedule,4.92,13.68, Chromatogram assay sugars,84375,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,162.71,,,,,,,fee schedule,58.5,162.71, Chromatogram assay sugars,84375,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,58.5,,,,,,,fee schedule,58.5,162.71, Chromatogram assay sugars,84375,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,58.5,,,,,,,fee schedule,58.5,162.71, Sugars single qual,84376,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,22.95,,,,,,,fee schedule,8.25,22.95, Sugars single qual,84376,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.25,,,,,,,fee schedule,8.25,22.95, Sugars single qual,84376,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,8.25,,,,,,,fee schedule,8.25,22.95, Sugars multiple qual,84377,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,22.95,,,,,,,fee schedule,8.25,22.95, Sugars multiple qual,84377,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.25,,,,,,,fee schedule,8.25,22.95, Sugars multiple qual,84377,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,8.25,,,,,,,fee schedule,8.25,22.95, Sugars single quant,84378,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,48.1,,,,,,,fee schedule,17.3,48.1, Sugars single quant,84378,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.3,,,,,,,fee schedule,17.3,48.1, Sugars single quant,84378,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,17.3,,,,,,,fee schedule,17.3,48.1, Sugars multiple quant,84379,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,48.1,,,,,,,fee schedule,17.3,48.1, Sugars multiple quant,84379,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.3,,,,,,,fee schedule,17.3,48.1, Sugars multiple quant,84379,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,17.3,,,,,,,fee schedule,17.3,48.1, Assay of urine sulfate,84392,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,22.9,,,,,,,fee schedule,8.24,22.9, Assay of urine sulfate,84392,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.24,,,,,,,fee schedule,8.24,22.9, Assay of urine sulfate,84392,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,8.24,,,,,,,fee schedule,8.24,22.9, Tau phosphorylated ea,84393,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,537.85,,,,,,,fee schedule,537.85,537.85, Total tau,84394,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,537.85,,,,,,,fee schedule,537.85,537.85, Assay of free testosterone,84402,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,106.26,,,,,,,fee schedule,38.21,106.26, Assay of free testosterone,84402,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,38.21,,,,,,,fee schedule,38.21,106.26, Assay of free testosterone,84402,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,38.21,,,,,,,fee schedule,38.21,106.26, Assay of total testosterone,84403,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,107.68,,,,,,,fee schedule,38.72,107.68, Assay of total testosterone,84403,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,38.72,,,,,,,fee schedule,38.72,107.68, Assay of total testosterone,84403,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,38.72,,,,,,,fee schedule,38.72,107.68, Testosterone bioavailable,84410,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,213.94,,,,,,,fee schedule,76.92,213.94, Testosterone bioavailable,84410,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,76.92,,,,,,,fee schedule,76.92,213.94, Testosterone bioavailable,84410,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,76.92,,,,,,,fee schedule,76.92,213.94, Assay of vitamin b-1,84425,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,88.57,,,,,,,fee schedule,31.85,88.57, Assay of vitamin b-1,84425,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31.85,,,,,,,fee schedule,31.85,88.57, Assay of vitamin b-1,84425,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,31.85,,,,,,,fee schedule,31.85,88.57, Assay of thiocyanate,84430,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,48.52,,,,,,,fee schedule,17.45,48.52, Assay of thiocyanate,84430,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.45,,,,,,,fee schedule,17.45,48.52, Assay of thiocyanate,84430,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,17.45,,,,,,,fee schedule,17.45,48.52, Thromboxane urine,84431,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,146.48,,,,,,,fee schedule,52.67,146.48, Thromboxane urine,84431,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,52.67,,,,,,,fee schedule,52.67,146.48, Thromboxane urine,84431,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,52.67,,,,,,,fee schedule,52.67,146.48, Assay of thyroglobulin,84432,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,67,,,,,,,fee schedule,24.09,67, Assay of thyroglobulin,84432,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24.09,,,,,,,fee schedule,24.09,67, Assay of thyroglobulin,84432,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,24.09,,,,,,,fee schedule,24.09,67, Asy thiopurin s-mthyltrnsfrs,84433,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,92.49,,,,,,,fee schedule,33.26,92.49, Asy thiopurin s-mthyltrnsfrs,84433,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,33.26,,,,,,,fee schedule,33.26,92.49, Asy thiopurin s-mthyltrnsfrs,84433,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,33.26,,,,,,,fee schedule,33.26,92.49, Assay of total thyroxine,84436,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,28.66,,,,,,,fee schedule,10.31,28.66, Assay of total thyroxine,84436,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.31,,,,,,,fee schedule,10.31,28.66, Assay of total thyroxine,84436,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,10.31,,,,,,,fee schedule,10.31,28.66, Assay of neonatal thyroxine,84437,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,26.99,,,,,,,fee schedule,9.71,26.99, Assay of neonatal thyroxine,84437,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.71,,,,,,,fee schedule,9.71,26.99, Assay of neonatal thyroxine,84437,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9.71,,,,,,,fee schedule,9.71,26.99, Assay of free thyroxine,84439,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,37.63,,,,,,,fee schedule,13.53,37.63, Assay of free thyroxine,84439,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13.53,,,,,,,fee schedule,13.53,37.63, Assay of free thyroxine,84439,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13.53,,,,,,,fee schedule,13.53,37.63, Assay of thyroid activity,84442,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,61.66,,,,,,,fee schedule,22.17,61.66, Assay of thyroid activity,84442,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22.17,,,,,,,fee schedule,22.17,61.66, Assay of thyroid activity,84442,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22.17,,,,,,,fee schedule,22.17,61.66, Assay thyroid stim hormone,84443,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,70.09,,,,,,,fee schedule,25.2,70.09, Assay thyroid stim hormone,84443,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25.2,,,,,,,fee schedule,25.2,70.09, Assay thyroid stim hormone,84443,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,25.2,,,,,,,fee schedule,25.2,70.09, Assay of tsi globulin,84445,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,212.19,,,,,,,fee schedule,76.29,212.19, Assay of tsi globulin,84445,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,76.29,,,,,,,fee schedule,76.29,212.19, Assay of tsi globulin,84445,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,76.29,,,,,,,fee schedule,76.29,212.19, Assay of vitamin e,84446,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,59.16,,,,,,,fee schedule,21.27,59.16, Assay of vitamin e,84446,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21.27,,,,,,,fee schedule,21.27,59.16, Assay of vitamin e,84446,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,21.27,,,,,,,fee schedule,21.27,59.16, Assay of transcortin,84449,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,75.1,,,,,,,fee schedule,27,75.1, Assay of transcortin,84449,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,27,,,,,,,fee schedule,27,75.1, Assay of transcortin,84449,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,27,,,,,,,fee schedule,27,75.1, Transferase (AST) (SGOT),84450,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,21.61,,,,,,,fee schedule,7.77,21.61, Transferase (AST) (SGOT),84450,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.77,,,,,,,fee schedule,7.77,21.61, Transferase (AST) (SGOT),84450,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,7.77,,,,,,,fee schedule,7.77,21.61, Alanine amino (ALT) (SGPT),84460,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,22.11,,,,,,,fee schedule,7.95,22.11, Alanine amino (ALT) (SGPT),84460,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.95,,,,,,,fee schedule,7.95,22.11, Alanine amino (ALT) (SGPT),84460,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,7.95,,,,,,,fee schedule,7.95,22.11, Assay of transferrin,84466,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,53.23,,,,,,,fee schedule,19.14,53.23, Assay of transferrin,84466,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.14,,,,,,,fee schedule,19.14,53.23, Assay of transferrin,84466,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19.14,,,,,,,fee schedule,19.14,53.23, Assay of triglycerides,84478,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,23.95,,,,,,,fee schedule,8.61,23.95, Assay of triglycerides,84478,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.61,,,,,,,fee schedule,8.61,23.95, Assay of triglycerides,84478,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,8.61,,,,,,,fee schedule,8.61,23.95, Assay of thyroid (t3 or t4),84479,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,26.99,,,,,,,fee schedule,9.71,26.99, Assay of thyroid (t3 or t4),84479,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.71,,,,,,,fee schedule,9.71,26.99, Assay of thyroid (t3 or t4),84479,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9.71,,,,,,,fee schedule,9.71,26.99, Assay triiodothyronine (t3),84480,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,59.16,,,,,,,fee schedule,21.27,59.16, Assay triiodothyronine (t3),84480,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21.27,,,,,,,fee schedule,21.27,59.16, Assay triiodothyronine (t3),84480,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,21.27,,,,,,,fee schedule,21.27,59.16, Free assay (FT-3),84481,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,70.67,,,,,,,fee schedule,25.41,70.67, Free assay (FT-3),84481,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25.41,,,,,,,fee schedule,25.41,70.67, Free assay (FT-3),84481,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,25.41,,,,,,,fee schedule,25.41,70.67, T3 reverse,84482,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,65.75,,,,,,,fee schedule,23.64,65.75, T3 reverse,84482,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23.64,,,,,,,fee schedule,23.64,65.75, T3 reverse,84482,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,23.64,,,,,,,fee schedule,23.64,65.75, Assay of troponin quant,84484,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,52.02,,,,,,,fee schedule,18.71,52.02, Assay of troponin quant,84484,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.71,,,,,,,fee schedule,18.71,52.02, Assay of troponin quant,84484,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,18.71,,,,,,,fee schedule,18.71,52.02, Assay duodenal fluid trypsin,84485,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,30.04,,,,,,,fee schedule,10.8,30.04, Assay duodenal fluid trypsin,84485,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.8,,,,,,,fee schedule,10.8,30.04, Assay duodenal fluid trypsin,84485,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,10.8,,,,,,,fee schedule,10.8,30.04, Test feces for trypsin,84488,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,30.46,,,,,,,fee schedule,10.95,30.46, Test feces for trypsin,84488,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.95,,,,,,,fee schedule,10.95,30.46, Test feces for trypsin,84488,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,10.95,,,,,,,fee schedule,10.95,30.46, Assay of feces for trypsin,84490,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,41.43,,,,,,,fee schedule,14.9,41.43, Assay of feces for trypsin,84490,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.9,,,,,,,fee schedule,14.9,41.43, Assay of feces for trypsin,84490,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,14.9,,,,,,,fee schedule,14.9,41.43, Assay of tyrosine,84510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,44.35,,,,,,,fee schedule,15.95,44.35, Assay of tyrosine,84510,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.95,,,,,,,fee schedule,15.95,44.35, Assay of tyrosine,84510,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,15.95,,,,,,,fee schedule,15.95,44.35, Assay of troponin qual,84512,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,42.1,,,,,,,fee schedule,15.14,42.1, Assay of troponin qual,84512,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.14,,,,,,,fee schedule,15.14,42.1, Assay of troponin qual,84512,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,15.14,,,,,,,fee schedule,15.14,42.1, Assay of urea nitrogen,84520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,16.48,,,,,,,fee schedule,5.93,16.48, Assay of urea nitrogen,84520,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.93,,,,,,,fee schedule,5.93,16.48, Assay of urea nitrogen,84520,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5.93,,,,,,,fee schedule,5.93,16.48, Urea nitrogen semi-quant,84525,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,21.4,,,,,,,fee schedule,7.7,21.4, Urea nitrogen semi-quant,84525,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.7,,,,,,,fee schedule,7.7,21.4, Urea nitrogen semi-quant,84525,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,7.7,,,,,,,fee schedule,7.7,21.4, Assay of urine/urea-n,84540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,23.2,,,,,,,fee schedule,8.34,23.2, Assay of urine/urea-n,84540,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.34,,,,,,,fee schedule,8.34,23.2, Assay of urine/urea-n,84540,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,8.34,,,,,,,fee schedule,8.34,23.2, Urea-N clearance test,84545,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,30.04,,,,,,,fee schedule,10.8,30.04, Urea-N clearance test,84545,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.8,,,,,,,fee schedule,10.8,30.04, Urea-N clearance test,84545,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,10.8,,,,,,,fee schedule,10.8,30.04, Assay of blood/uric acid,84550,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,18.86,,,,,,,fee schedule,6.78,18.86, Assay of blood/uric acid,84550,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.78,,,,,,,fee schedule,6.78,18.86, Assay of blood/uric acid,84550,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,6.78,,,,,,,fee schedule,6.78,18.86, Assay of urine/uric acid,84560,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,21.19,,,,,,,fee schedule,7.62,21.19, Assay of urine/uric acid,84560,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.62,,,,,,,fee schedule,7.62,21.19, Assay of urine/uric acid,84560,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,7.62,,,,,,,fee schedule,7.62,21.19, Assay of feces/urobilinogen,84577,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,70.09,,,,,,,fee schedule,25.2,70.09, Assay of feces/urobilinogen,84577,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25.2,,,,,,,fee schedule,25.2,70.09, Assay of feces/urobilinogen,84577,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,25.2,,,,,,,fee schedule,25.2,70.09, Test urine urobilinogen,84578,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,18.65,,,,,,,fee schedule,6.71,18.65, Test urine urobilinogen,84578,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.71,,,,,,,fee schedule,6.71,18.65, Test urine urobilinogen,84578,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,6.71,,,,,,,fee schedule,6.71,18.65, Assay of urine urobilinogen,84580,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,39.84,,,,,,,fee schedule,14.33,39.84, Assay of urine urobilinogen,84580,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.33,,,,,,,fee schedule,14.33,39.84, Assay of urine urobilinogen,84580,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,14.33,,,,,,,fee schedule,14.33,39.84, Assay of urine urobilinogen,84583,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,25.24,,,,,,,fee schedule,9.08,25.24, Assay of urine urobilinogen,84583,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.08,,,,,,,fee schedule,9.08,25.24, Assay of urine urobilinogen,84583,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9.08,,,,,,,fee schedule,9.08,25.24, Assay of urine vma,84585,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,64.67,,,,,,,fee schedule,23.25,64.67, Assay of urine vma,84585,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23.25,,,,,,,fee schedule,23.25,64.67, Assay of urine vma,84585,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,23.25,,,,,,,fee schedule,23.25,64.67, Assay of vip,84586,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,147.4,,,,,,,fee schedule,53,147.4, Assay of vip,84586,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,53,,,,,,,fee schedule,53,147.4, Assay of vip,84586,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,53,,,,,,,fee schedule,53,147.4, Assay of vasopressin,84588,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,141.6,,,,,,,fee schedule,50.91,141.6, Assay of vasopressin,84588,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,50.91,,,,,,,fee schedule,50.91,141.6, Assay of vasopressin,84588,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,50.91,,,,,,,fee schedule,50.91,141.6, Assay of vitamin a,84590,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,48.44,,,,,,,fee schedule,17.42,48.44, Assay of vitamin a,84590,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.42,,,,,,,fee schedule,17.42,48.44, Assay of vitamin a,84590,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,17.42,,,,,,,fee schedule,17.42,48.44, Assay Of Nos Vitamin,84591,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,71.17,,,,,,,fee schedule,25.59,71.17, Assay Of Nos Vitamin,84591,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25.59,,,,,,,fee schedule,25.59,71.17, Assay Of Nos Vitamin,84591,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,25.59,,,,,,,fee schedule,25.59,71.17, Assay of vitamin k,84597,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,57.24,,,,,,,fee schedule,20.58,57.24, Assay of vitamin k,84597,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,20.58,,,,,,,fee schedule,20.58,57.24, Assay of vitamin k,84597,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,20.58,,,,,,,fee schedule,20.58,57.24, Assay of volatiles,84600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,71.38,,,,,,,fee schedule,25.67,71.38, Assay of volatiles,84600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25.67,,,,,,,fee schedule,25.67,71.38, Assay of volatiles,84600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,25.67,,,,,,,fee schedule,25.67,71.38, Xylose tolerance test,84620,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,53.86,,,,,,,fee schedule,19.37,53.86, Xylose tolerance test,84620,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.37,,,,,,,fee schedule,19.37,53.86, Xylose tolerance test,84620,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19.37,,,,,,,fee schedule,19.37,53.86, Assay of zinc,84630,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,47.52,,,,,,,fee schedule,17.09,47.52, Assay of zinc,84630,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.09,,,,,,,fee schedule,17.09,47.52, Assay of zinc,84630,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,17.09,,,,,,,fee schedule,17.09,47.52, Assay of c-peptide,84681,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,86.82,,,,,,,fee schedule,31.22,86.82, Assay of c-peptide,84681,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31.22,,,,,,,fee schedule,31.22,86.82, Assay of c-peptide,84681,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,31.22,,,,,,,fee schedule,31.22,86.82, Chorionic gonadotropin test,84702,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,62.79,,,,,,,fee schedule,22.58,62.79, Chorionic gonadotropin test,84702,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22.58,,,,,,,fee schedule,22.58,62.79, Chorionic gonadotropin test,84702,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22.58,,,,,,,fee schedule,22.58,62.79, Chorionic gonadotropin assay,84703,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,31.37,,,,,,,fee schedule,11.28,31.37, Chorionic gonadotropin assay,84703,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.28,,,,,,,fee schedule,11.28,31.37, Chorionic gonadotropin assay,84703,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11.28,,,,,,,fee schedule,11.28,31.37, Hcg free betachain test,84704,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,63.79,,,,,,,fee schedule,22.94,63.79, Hcg free betachain test,84704,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22.94,,,,,,,fee schedule,22.94,63.79, Hcg free betachain test,84704,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22.94,,,,,,,fee schedule,22.94,63.79, Ovulation tests,84830,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,52.98,,,,,,,fee schedule,19.05,52.98, Ovulation tests,84830,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.05,,,,,,,fee schedule,19.05,52.98, Ovulation tests,84830,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19.05,,,,,,,fee schedule,19.05,52.98, Bleeding time test,85002,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,20.11,,,,,,,fee schedule,7.23,20.11, Bleeding time test,85002,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.23,,,,,,,fee schedule,7.23,20.11, Bleeding time test,85002,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,7.23,,,,,,,fee schedule,7.23,20.11, Automated diff wbc count,85004,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,26.99,,,,,,,fee schedule,9.71,26.99, Automated diff wbc count,85004,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.71,,,,,,,fee schedule,9.71,26.99, Automated diff wbc count,85004,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9.71,,,,,,,fee schedule,9.71,26.99, Bl smear w/diff wbc count,85007,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,15.85,,,,,,,fee schedule,5.7,15.85, Bl smear w/diff wbc count,85007,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.7,,,,,,,fee schedule,5.7,15.85, Bl smear w/diff wbc count,85007,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5.7,,,,,,,fee schedule,5.7,15.85, Bl smear w/o diff wbc count,85008,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,14.31,,,,,,,fee schedule,5.15,14.31, Bl smear w/o diff wbc count,85008,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.15,,,,,,,fee schedule,5.15,14.31, Bl smear w/o diff wbc count,85008,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5.15,,,,,,,fee schedule,5.15,14.31, Manual diff wbc count b-coat,85009,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,21.15,,,,,,,fee schedule,7.61,21.15, Manual diff wbc count b-coat,85009,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.61,,,,,,,fee schedule,7.61,21.15, Manual diff wbc count b-coat,85009,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,7.61,,,,,,,fee schedule,7.61,21.15, Spun microhematocrit,85013,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,29.2,,,,,,,fee schedule,10.5,29.2, Spun microhematocrit,85013,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.5,,,,,,,fee schedule,10.5,29.2, Spun microhematocrit,85013,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,10.5,,,,,,,fee schedule,10.5,29.2, Hematocrit,85014,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9.89,,,,,,,fee schedule,3.56,9.89, Hematocrit,85014,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3.56,,,,,,,fee schedule,3.56,9.89, Hematocrit,85014,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3.56,,,,,,,fee schedule,3.56,9.89, Hemoglobin,85018,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,9.89,,,,,,,fee schedule,3.56,9.89, Hemoglobin,85018,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3.56,,,,,,,fee schedule,3.56,9.89, Hemoglobin,85018,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3.56,,,,,,,fee schedule,3.56,9.89, Complete cbc w/auto diff wbc,85025,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,32.42,,,,,,,fee schedule,11.66,32.42, Complete cbc w/auto diff wbc,85025,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.66,,,,,,,fee schedule,11.66,32.42, Complete cbc w/auto diff wbc,85025,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11.66,,,,,,,fee schedule,11.66,32.42, Complete cbc automated,85027,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,26.99,,,,,,,fee schedule,9.71,26.99, Complete cbc automated,85027,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.71,,,,,,,fee schedule,9.71,26.99, Complete cbc automated,85027,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9.71,,,,,,,fee schedule,9.71,26.99, Manual cell count each,85032,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,17.98,,,,,,,fee schedule,6.47,17.98, Manual cell count each,85032,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.47,,,,,,,fee schedule,6.47,17.98, Manual cell count each,85032,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,6.47,,,,,,,fee schedule,6.47,17.98, Automated rbc count,85041,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12.6,,,,,,,fee schedule,4.53,12.6, Automated rbc count,85041,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.53,,,,,,,fee schedule,4.53,12.6, Automated rbc count,85041,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4.53,,,,,,,fee schedule,4.53,12.6, Manual reticulocyte count,85044,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,17.98,,,,,,,fee schedule,6.47,17.98, Manual reticulocyte count,85044,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.47,,,,,,,fee schedule,6.47,17.98, Manual reticulocyte count,85044,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,6.47,,,,,,,fee schedule,6.47,17.98, Automated reticulocyte count,85045,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,16.65,,,,,,,fee schedule,5.99,16.65, Automated reticulocyte count,85045,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.99,,,,,,,fee schedule,5.99,16.65, Automated reticulocyte count,85045,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5.99,,,,,,,fee schedule,5.99,16.65, Reticyte/hgb concentrate,85046,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,23.24,,,,,,,fee schedule,8.36,23.24, Reticyte/hgb concentrate,85046,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.36,,,,,,,fee schedule,8.36,23.24, Reticyte/hgb concentrate,85046,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,8.36,,,,,,,fee schedule,8.36,23.24, Automated leukocyte count,85048,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,10.6,,,,,,,fee schedule,3.81,10.6, Automated leukocyte count,85048,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3.81,,,,,,,fee schedule,3.81,10.6, Automated leukocyte count,85048,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3.81,,,,,,,fee schedule,3.81,10.6, Automated platelet count,85049,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,18.69,,,,,,,fee schedule,6.72,18.69, Automated platelet count,85049,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.72,,,,,,,fee schedule,6.72,18.69, Automated platelet count,85049,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,6.72,,,,,,,fee schedule,6.72,18.69, Reticulated platelet assay,85055,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,149.11,,,,,,,fee schedule,53.61,149.11, Reticulated platelet assay,85055,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,53.61,,,,,,,fee schedule,53.61,149.11, Reticulated platelet assay,85055,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,53.61,,,,,,,fee schedule,53.61,149.11, Blood smear interpretation,85060,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,103.66,,,,,,,fee schedule,37.89,103.66, Blood smear interpretation,85060,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,80.14,,,,,,,fee schedule,37.89,103.66, Blood smear interpretation,85060,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,37.89,,,,,,,fee schedule,37.89,103.66, Blood smear interpretation,85060,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,37.89,,,,,,,fee schedule,37.89,103.66, Bone marrow interpretation,85097,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,213.84,,,,,,,fee schedule,165.34,942.3, Bone marrow interpretation,85097,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,165.34,,,,,,,fee schedule,165.34,942.3, Bone marrow interpretation,85097,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,942.3,,,,,,,fee schedule,165.34,942.3, Bone marrow interpretation,85097,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,942.3,,,,,,,fee schedule,165.34,942.3, Chromogenic substrate assay,85130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,49.61,,,,,,,fee schedule,17.84,49.61, Chromogenic substrate assay,85130,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.84,,,,,,,fee schedule,17.84,49.61, Chromogenic substrate assay,85130,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,17.84,,,,,,,fee schedule,17.84,49.61, Blood clot retraction,85170,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,68,,,,,,,fee schedule,24.45,68, Blood clot retraction,85170,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24.45,,,,,,,fee schedule,24.45,68, Blood clot retraction,85170,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,24.45,,,,,,,fee schedule,24.45,68, Blood clot lysis time,85175,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,84.98,,,,,,,fee schedule,30.56,84.98, Blood clot lysis time,85175,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,30.56,,,,,,,fee schedule,30.56,84.98, Blood clot lysis time,85175,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,30.56,,,,,,,fee schedule,30.56,84.98, Clot factor ii prothrom spec,85210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,54.15,,,,,,,fee schedule,19.47,54.15, Clot factor ii prothrom spec,85210,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.47,,,,,,,fee schedule,19.47,54.15, Clot factor ii prothrom spec,85210,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19.47,,,,,,,fee schedule,19.47,54.15, Blooc clot factor v test,85220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,73.64,,,,,,,fee schedule,26.48,73.64, Blooc clot factor v test,85220,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26.48,,,,,,,fee schedule,26.48,73.64, Blooc clot factor v test,85220,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,26.48,,,,,,,fee schedule,26.48,73.64, Clot factor vii proconvertin,85230,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,74.68,,,,,,,fee schedule,26.85,74.68, Clot factor vii proconvertin,85230,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26.85,,,,,,,fee schedule,26.85,74.68, Clot factor vii proconvertin,85230,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,26.85,,,,,,,fee schedule,26.85,74.68, Clot factor viii ahg 1 stage,85240,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,74.68,,,,,,,fee schedule,26.85,74.68, Clot factor viii ahg 1 stage,85240,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26.85,,,,,,,fee schedule,26.85,74.68, Clot factor viii ahg 1 stage,85240,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,26.85,,,,,,,fee schedule,26.85,74.68, Clot factor viii reltd antgn,85244,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,85.19,,,,,,,fee schedule,30.63,85.19, Clot factor viii reltd antgn,85244,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,30.63,,,,,,,fee schedule,30.63,85.19, Clot factor viii reltd antgn,85244,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,30.63,,,,,,,fee schedule,30.63,85.19, Clot factor viii vw ristoctn,85245,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,95.71,,,,,,,fee schedule,34.41,95.71, Clot factor viii vw ristoctn,85245,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,34.41,,,,,,,fee schedule,34.41,95.71, Clot factor viii vw ristoctn,85245,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,34.41,,,,,,,fee schedule,34.41,95.71, Clot factor viii vw antigen,85246,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,95.71,,,,,,,fee schedule,34.41,95.71, Clot factor viii vw antigen,85246,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,34.41,,,,,,,fee schedule,34.41,95.71, Clot factor viii vw antigen,85246,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,34.41,,,,,,,fee schedule,34.41,95.71, Clot factor viii multimetric,85247,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,95.71,,,,,,,fee schedule,34.41,95.71, Clot factor viii multimetric,85247,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,34.41,,,,,,,fee schedule,34.41,95.71, Clot factor viii multimetric,85247,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,34.41,,,,,,,fee schedule,34.41,95.71, Clot factor ix ptc/chrstmas,85250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,79.43,,,,,,,fee schedule,28.56,79.43, Clot factor ix ptc/chrstmas,85250,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,28.56,,,,,,,fee schedule,28.56,79.43, Clot factor ix ptc/chrstmas,85250,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,28.56,,,,,,,fee schedule,28.56,79.43, Clot factor x stuart-power,85260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,74.68,,,,,,,fee schedule,26.85,74.68, Clot factor x stuart-power,85260,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26.85,,,,,,,fee schedule,26.85,74.68, Clot factor x stuart-power,85260,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,26.85,,,,,,,fee schedule,26.85,74.68, Clot factor xi pta,85270,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,74.68,,,,,,,fee schedule,26.85,74.68, Clot factor xi pta,85270,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26.85,,,,,,,fee schedule,26.85,74.68, Clot factor xi pta,85270,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,26.85,,,,,,,fee schedule,26.85,74.68, Clot factor xii hageman,85280,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,80.73,,,,,,,fee schedule,29.03,80.73, Clot factor xii hageman,85280,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,29.03,,,,,,,fee schedule,29.03,80.73, Clot factor xii hageman,85280,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,29.03,,,,,,,fee schedule,29.03,80.73, Clot factor xiii fibrin stab,85290,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,68.17,,,,,,,fee schedule,24.51,68.17, Clot factor xiii fibrin stab,85290,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24.51,,,,,,,fee schedule,24.51,68.17, Clot factor xiii fibrin stab,85290,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,24.51,,,,,,,fee schedule,24.51,68.17, Clot factor xiii fibrin scrn,85291,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,38.01,,,,,,,fee schedule,13.67,38.01, Clot factor xiii fibrin scrn,85291,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13.67,,,,,,,fee schedule,13.67,38.01, Clot factor xiii fibrin scrn,85291,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13.67,,,,,,,fee schedule,13.67,38.01, Clot factor fletcher fact,85292,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,78.98,,,,,,,fee schedule,28.4,78.98, Clot factor fletcher fact,85292,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,28.4,,,,,,,fee schedule,28.4,78.98, Clot factor fletcher fact,85292,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,28.4,,,,,,,fee schedule,28.4,78.98, Clot factor wght kininogen,85293,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,78.98,,,,,,,fee schedule,28.4,78.98, Clot factor wght kininogen,85293,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,28.4,,,,,,,fee schedule,28.4,78.98, Clot factor wght kininogen,85293,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,28.4,,,,,,,fee schedule,28.4,78.98, Antithrombin iii activity,85300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,49.44,,,,,,,fee schedule,17.78,49.44, Antithrombin iii activity,85300,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.78,,,,,,,fee schedule,17.78,49.44, Antithrombin iii activity,85300,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,17.78,,,,,,,fee schedule,17.78,49.44, Antithrombin iii antigen,85301,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,45.1,,,,,,,fee schedule,16.22,45.1, Antithrombin iii antigen,85301,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.22,,,,,,,fee schedule,16.22,45.1, Antithrombin iii antigen,85301,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,16.22,,,,,,,fee schedule,16.22,45.1, Clot inhibit prot c antigen,85302,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,50.11,,,,,,,fee schedule,18.02,50.11, Clot inhibit prot c antigen,85302,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.02,,,,,,,fee schedule,18.02,50.11, Clot inhibit prot c antigen,85302,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,18.02,,,,,,,fee schedule,18.02,50.11, Clot inhibit prot c activity,85303,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,57.74,,,,,,,fee schedule,20.76,57.74, Clot inhibit prot c activity,85303,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,20.76,,,,,,,fee schedule,20.76,57.74, Clot inhibit prot c activity,85303,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,20.76,,,,,,,fee schedule,20.76,57.74, Clot inhibit prot s total,85305,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,48.44,,,,,,,fee schedule,17.42,48.44, Clot inhibit prot s total,85305,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.42,,,,,,,fee schedule,17.42,48.44, Clot inhibit prot s total,85305,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,17.42,,,,,,,fee schedule,17.42,48.44, Clot inhibit prot s free,85306,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,63.92,,,,,,,fee schedule,22.98,63.92, Clot inhibit prot s free,85306,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22.98,,,,,,,fee schedule,22.98,63.92, Clot inhibit prot s free,85306,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22.98,,,,,,,fee schedule,22.98,63.92, Assay Activated Protein C,85307,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,63.92,,,,,,,fee schedule,22.98,63.92, Assay Activated Protein C,85307,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22.98,,,,,,,fee schedule,22.98,63.92, Assay Activated Protein C,85307,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22.98,,,,,,,fee schedule,22.98,63.92, Factor inhibitor test,85335,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,53.69,,,,,,,fee schedule,19.31,53.69, Factor inhibitor test,85335,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.31,,,,,,,fee schedule,19.31,53.69, Factor inhibitor test,85335,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19.31,,,,,,,fee schedule,19.31,53.69, Thrombomodulin,85337,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,72.05,,,,,,,fee schedule,25.91,72.05, Thrombomodulin,85337,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25.91,,,,,,,fee schedule,25.91,72.05, Thrombomodulin,85337,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,25.91,,,,,,,fee schedule,25.91,72.05, Coagulation time lee & white,85345,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,19.57,,,,,,,fee schedule,7.04,19.57, Coagulation time lee & white,85345,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.04,,,,,,,fee schedule,7.04,19.57, Coagulation time lee & white,85345,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,7.04,,,,,,,fee schedule,7.04,19.57, Coagulation time activated,85347,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,17.86,,,,,,,fee schedule,6.42,17.86, Coagulation time activated,85347,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.42,,,,,,,fee schedule,6.42,17.86, Coagulation time activated,85347,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,6.42,,,,,,,fee schedule,6.42,17.86, Coagulation time otr method,85348,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,18.73,,,,,,,fee schedule,6.74,18.73, Coagulation time otr method,85348,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.74,,,,,,,fee schedule,6.74,18.73, Coagulation time otr method,85348,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,6.74,,,,,,,fee schedule,6.74,18.73, Euglobulin lysis,85360,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,35.09,,,,,,,fee schedule,12.62,35.09, Euglobulin lysis,85360,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.62,,,,,,,fee schedule,12.62,35.09, Euglobulin lysis,85360,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,12.62,,,,,,,fee schedule,12.62,35.09, Fibrin degradation products,85362,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,28.75,,,,,,,fee schedule,10.34,28.75, Fibrin degradation products,85362,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.34,,,,,,,fee schedule,10.34,28.75, Fibrin degradation products,85362,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,10.34,,,,,,,fee schedule,10.34,28.75, Fibrinogen test,85366,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,335.68,,,,,,,fee schedule,120.69,335.68, Fibrinogen test,85366,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,120.69,,,,,,,fee schedule,120.69,335.68, Fibrinogen test,85366,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,120.69,,,,,,,fee schedule,120.69,335.68, Fibrinogen test,85370,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,51.86,,,,,,,fee schedule,18.65,51.86, Fibrinogen test,85370,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.65,,,,,,,fee schedule,18.65,51.86, Fibrinogen test,85370,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,18.65,,,,,,,fee schedule,18.65,51.86, Fibrin degrade semiquant,85378,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,40.55,,,,,,,fee schedule,14.58,40.55, Fibrin degrade semiquant,85378,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.58,,,,,,,fee schedule,14.58,40.55, Fibrin degrade semiquant,85378,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,14.58,,,,,,,fee schedule,14.58,40.55, Fibrin degradation quant,85379,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,42.47,,,,,,,fee schedule,15.27,42.47, Fibrin degradation quant,85379,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.27,,,,,,,fee schedule,15.27,42.47, Fibrin degradation quant,85379,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,15.27,,,,,,,fee schedule,15.27,42.47, Fibrin degradj d-dimer,85380,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,42.47,,,,,,,fee schedule,15.27,42.47, Fibrin degradj d-dimer,85380,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.27,,,,,,,fee schedule,15.27,42.47, Fibrin degradj d-dimer,85380,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,15.27,,,,,,,fee schedule,15.27,42.47, Fibrinogen activity,85384,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,40.55,,,,,,,fee schedule,14.58,40.55, Fibrinogen activity,85384,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.58,,,,,,,fee schedule,14.58,40.55, Fibrinogen activity,85384,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,14.58,,,,,,,fee schedule,14.58,40.55, Fibrinogen antigen,85385,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,60.33,,,,,,,fee schedule,21.69,60.33, Fibrinogen antigen,85385,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21.69,,,,,,,fee schedule,21.69,60.33, Fibrinogen antigen,85385,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,21.69,,,,,,,fee schedule,21.69,60.33, Fibrinolysins screen i&r,85390,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,64.58,,,,,,,fee schedule,23.22,64.58, Fibrinolysins screen i&r,85390,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23.22,,,,,,,fee schedule,23.22,64.58, Fibrinolysins screen i&r,85390,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,23.22,,,,,,,fee schedule,23.22,64.58, Clotting assay whole blood,85396,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,85.8,,,,,,,fee schedule,31.4,85.8, Clotting assay whole blood,85396,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,66.33,,,,,,,fee schedule,31.4,85.8, Clotting assay whole blood,85396,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31.4,,,,,,,fee schedule,31.4,85.8, Clotting assay whole blood,85396,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,31.4,,,,,,,fee schedule,31.4,85.8, Clotting funct activity,85397,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,128.75,,,,,,,fee schedule,46.29,128.75, Clotting funct activity,85397,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46.29,,,,,,,fee schedule,46.29,128.75, Clotting funct activity,85397,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,46.29,,,,,,,fee schedule,46.29,128.75, Fibrinolytic plasmin,85400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,32.17,,,,,,,fee schedule,11.57,32.17, Fibrinolytic plasmin,85400,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.57,,,,,,,fee schedule,11.57,32.17, Fibrinolytic plasmin,85400,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11.57,,,,,,,fee schedule,11.57,32.17, Fibrinolytic antiplasmin,85410,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,32.17,,,,,,,fee schedule,11.57,32.17, Fibrinolytic antiplasmin,85410,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.57,,,,,,,fee schedule,11.57,32.17, Fibrinolytic antiplasmin,85410,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11.57,,,,,,,fee schedule,11.57,32.17, Fibrinolytic plasminogen,85415,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,71.72,,,,,,,fee schedule,25.79,71.72, Fibrinolytic plasminogen,85415,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25.79,,,,,,,fee schedule,25.79,71.72, Fibrinolytic plasminogen,85415,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,25.79,,,,,,,fee schedule,25.79,71.72, Fibrinolytic plasminogen,85420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,27.24,,,,,,,fee schedule,9.8,27.24, Fibrinolytic plasminogen,85420,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.8,,,,,,,fee schedule,9.8,27.24, Fibrinolytic plasminogen,85420,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9.8,,,,,,,fee schedule,9.8,27.24, Fibrinolytic plasminogen,85421,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,42.47,,,,,,,fee schedule,15.27,42.47, Fibrinolytic plasminogen,85421,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.27,,,,,,,fee schedule,15.27,42.47, Fibrinolytic plasminogen,85421,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,15.27,,,,,,,fee schedule,15.27,42.47, Heinz bodies direct,85441,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,17.52,,,,,,,fee schedule,6.3,17.52, Heinz bodies direct,85441,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.3,,,,,,,fee schedule,6.3,17.52, Heinz bodies direct,85441,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,6.3,,,,,,,fee schedule,6.3,17.52, Heinz bodies induced,85445,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,28.45,,,,,,,fee schedule,10.23,28.45, Heinz bodies induced,85445,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.23,,,,,,,fee schedule,10.23,28.45, Heinz bodies induced,85445,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,10.23,,,,,,,fee schedule,10.23,28.45, Hemoglobin fetal,85460,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,32.25,,,,,,,fee schedule,11.6,32.25, Hemoglobin fetal,85460,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.6,,,,,,,fee schedule,11.6,32.25, Hemoglobin fetal,85460,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11.6,,,,,,,fee schedule,11.6,32.25, Hemoglobin fetal,85461,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,39.05,,,,,,,fee schedule,14.04,39.05, Hemoglobin fetal,85461,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.04,,,,,,,fee schedule,14.04,39.05, Hemoglobin fetal,85461,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,14.04,,,,,,,fee schedule,14.04,39.05, Hemolysin acid,85475,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,37.01,,,,,,,fee schedule,13.31,37.01, Hemolysin acid,85475,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13.31,,,,,,,fee schedule,13.31,37.01, Hemolysin acid,85475,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13.31,,,,,,,fee schedule,13.31,37.01, Heparin assay,85520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,54.61,,,,,,,fee schedule,19.64,54.61, Heparin assay,85520,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.64,,,,,,,fee schedule,19.64,54.61, Heparin assay,85520,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19.64,,,,,,,fee schedule,19.64,54.61, Heparin neutralization,85525,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,49.4,,,,,,,fee schedule,17.76,49.4, Heparin neutralization,85525,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.76,,,,,,,fee schedule,17.76,49.4, Heparin neutralization,85525,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,17.76,,,,,,,fee schedule,17.76,49.4, Heparin-protamine tolerance,85530,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,54.61,,,,,,,fee schedule,19.64,54.61, Heparin-protamine tolerance,85530,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.64,,,,,,,fee schedule,19.64,54.61, Heparin-protamine tolerance,85530,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19.64,,,,,,,fee schedule,19.64,54.61, Iron Stain Peripheral Blood,85536,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,28.7,,,,,,,fee schedule,10.32,28.7, Iron Stain Peripheral Blood,85536,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.32,,,,,,,fee schedule,10.32,28.7, Iron Stain Peripheral Blood,85536,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,10.32,,,,,,,fee schedule,10.32,28.7, Wbc alkaline phosphatase,85540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,35.88,,,,,,,fee schedule,12.9,35.88, Wbc alkaline phosphatase,85540,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.9,,,,,,,fee schedule,12.9,35.88, Wbc alkaline phosphatase,85540,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,12.9,,,,,,,fee schedule,12.9,35.88, RBC mechanical fragility,85547,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,35.88,,,,,,,fee schedule,12.9,35.88, RBC mechanical fragility,85547,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.9,,,,,,,fee schedule,12.9,35.88, RBC mechanical fragility,85547,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,12.9,,,,,,,fee schedule,12.9,35.88, Muramidase,85549,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,78.23,,,,,,,fee schedule,28.13,78.23, Muramidase,85549,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,28.13,,,,,,,fee schedule,28.13,78.23, Muramidase,85549,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,28.13,,,,,,,fee schedule,28.13,78.23, RBC osmotic fragility,85555,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,31.16,,,,,,,fee schedule,11.21,31.16, RBC osmotic fragility,85555,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.21,,,,,,,fee schedule,11.21,31.16, RBC osmotic fragility,85555,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11.21,,,,,,,fee schedule,11.21,31.16, RBC osmotic fragility,85557,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,55.74,,,,,,,fee schedule,20.04,55.74, RBC osmotic fragility,85557,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,20.04,,,,,,,fee schedule,20.04,55.74, RBC osmotic fragility,85557,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,20.04,,,,,,,fee schedule,20.04,55.74, Blood platelet aggregation,85576,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,103.92,,,,,,,fee schedule,37.37,103.92, Blood platelet aggregation,85576,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,37.37,,,,,,,fee schedule,37.37,103.92, Blood platelet aggregation,85576,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,37.37,,,,,,,fee schedule,37.37,103.92, Phospholipid pltlt neutraliz,85597,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,75.01,,,,,,,fee schedule,26.97,75.01, Phospholipid pltlt neutraliz,85597,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26.97,,,,,,,fee schedule,26.97,75.01, Phospholipid pltlt neutraliz,85597,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,26.97,,,,,,,fee schedule,26.97,75.01, Hexagnal phosph pltlt neutrl,85598,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,75.01,,,,,,,fee schedule,26.97,75.01, Hexagnal phosph pltlt neutrl,85598,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26.97,,,,,,,fee schedule,26.97,75.01, Hexagnal phosph pltlt neutrl,85598,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,26.97,,,,,,,fee schedule,26.97,75.01, Prothrombin time,85610,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,17.9,,,,,,,fee schedule,6.44,17.9, Prothrombin time,85610,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.44,,,,,,,fee schedule,6.44,17.9, Prothrombin time,85610,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,6.44,,,,,,,fee schedule,6.44,17.9, Prothrombin test,85611,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,16.44,,,,,,,fee schedule,5.91,16.44, Prothrombin test,85611,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.91,,,,,,,fee schedule,5.91,16.44, Prothrombin test,85611,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5.91,,,,,,,fee schedule,5.91,16.44, Viper venom prothrombin time,85612,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,72.97,,,,,,,fee schedule,26.24,72.97, Viper venom prothrombin time,85612,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26.24,,,,,,,fee schedule,26.24,72.97, Viper venom prothrombin time,85612,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,26.24,,,,,,,fee schedule,26.24,72.97, Russell viper venom diluted,85613,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,39.97,,,,,,,fee schedule,14.37,39.97, Russell viper venom diluted,85613,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.37,,,,,,,fee schedule,14.37,39.97, Russell viper venom diluted,85613,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,14.37,,,,,,,fee schedule,14.37,39.97, Reptilase test,85635,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,41.09,,,,,,,fee schedule,14.78,41.09, Reptilase test,85635,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.78,,,,,,,fee schedule,14.78,41.09, Reptilase test,85635,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,14.78,,,,,,,fee schedule,14.78,41.09, Rbc sed rate nonautomated,85651,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,17.81,,,,,,,fee schedule,6.41,17.81, Rbc sed rate nonautomated,85651,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.41,,,,,,,fee schedule,6.41,17.81, Rbc sed rate nonautomated,85651,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,6.41,,,,,,,fee schedule,6.41,17.81, Rbc sed rate automated,85652,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,11.26,,,,,,,fee schedule,4.05,11.26, Rbc sed rate automated,85652,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.05,,,,,,,fee schedule,4.05,11.26, Rbc sed rate automated,85652,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4.05,,,,,,,fee schedule,4.05,11.26, RBC sickle cell test,85660,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,22.99,,,,,,,fee schedule,8.27,22.99, RBC sickle cell test,85660,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.27,,,,,,,fee schedule,8.27,22.99, RBC sickle cell test,85660,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,8.27,,,,,,,fee schedule,8.27,22.99, Thrombin time plasma,85670,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,24.07,,,,,,,fee schedule,8.66,24.07, Thrombin time plasma,85670,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.66,,,,,,,fee schedule,8.66,24.07, Thrombin time plasma,85670,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,8.66,,,,,,,fee schedule,8.66,24.07, Thrombin time titer,85675,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,28.58,,,,,,,fee schedule,10.28,28.58, Thrombin time titer,85675,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.28,,,,,,,fee schedule,10.28,28.58, Thrombin time titer,85675,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,10.28,,,,,,,fee schedule,10.28,28.58, Thromboplastin inhibition,85705,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,40.18,,,,,,,fee schedule,14.45,40.18, Thromboplastin inhibition,85705,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.45,,,,,,,fee schedule,14.45,40.18, Thromboplastin inhibition,85705,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,14.45,,,,,,,fee schedule,14.45,40.18, Thromboplastin time partial,85730,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,25.07,,,,,,,fee schedule,9.02,25.07, Thromboplastin time partial,85730,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.02,,,,,,,fee schedule,9.02,25.07, Thromboplastin time partial,85730,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9.02,,,,,,,fee schedule,9.02,25.07, Thromboplastin time partial,85732,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,26.99,,,,,,,fee schedule,9.71,26.99, Thromboplastin time partial,85732,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.71,,,,,,,fee schedule,9.71,26.99, Thromboplastin time partial,85732,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9.71,,,,,,,fee schedule,9.71,26.99, Blood viscosity examination,85810,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,48.69,,,,,,,fee schedule,17.51,48.69, Blood viscosity examination,85810,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.51,,,,,,,fee schedule,17.51,48.69, Blood viscosity examination,85810,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,17.51,,,,,,,fee schedule,17.51,48.69, Agglutinins febrile antigen,86000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,29.12,,,,,,,fee schedule,10.47,29.12, Agglutinins febrile antigen,86000,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.47,,,,,,,fee schedule,10.47,29.12, Agglutinins febrile antigen,86000,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,10.47,,,,,,,fee schedule,10.47,29.12, Allergen Specific Igg,86001,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,32.63,,,,,,,fee schedule,11.73,32.63, Allergen Specific Igg,86001,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.73,,,,,,,fee schedule,11.73,32.63, Allergen Specific Igg,86001,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11.73,,,,,,,fee schedule,11.73,32.63, Allergen specific IgE,86003,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,21.78,,,,,,,fee schedule,7.83,21.78, Allergen specific IgE,86003,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.83,,,,,,,fee schedule,7.83,21.78, Allergen specific IgE,86003,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,7.83,,,,,,,fee schedule,7.83,21.78, Allergen specific IgE,86005,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,33.25,,,,,,,fee schedule,11.96,33.25, Allergen specific IgE,86005,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.96,,,,,,,fee schedule,11.96,33.25, Allergen specific IgE,86005,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11.96,,,,,,,fee schedule,11.96,33.25, Allg spec ige recomb ea,86008,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,74.8,,,,,,,fee schedule,26.9,74.8, Allg spec ige recomb ea,86008,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26.9,,,,,,,fee schedule,26.9,74.8, Allg spec ige recomb ea,86008,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,26.9,,,,,,,fee schedule,26.9,74.8, Actin antibody each,86015,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,50.27,,,,,,,fee schedule,17.3,50.27, Actin antibody each,86015,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.3,,,,,,,fee schedule,17.3,50.27, Actin antibody each,86015,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,17.3,,,,,,,fee schedule,17.3,50.27, WBC antibody identification,86021,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,62.79,,,,,,,fee schedule,22.58,62.79, WBC antibody identification,86021,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22.58,,,,,,,fee schedule,22.58,62.79, WBC antibody identification,86021,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22.58,,,,,,,fee schedule,22.58,62.79, Platelet antibodies,86022,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,76.64,,,,,,,fee schedule,27.56,76.64, Platelet antibodies,86022,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,27.56,,,,,,,fee schedule,27.56,76.64, Platelet antibodies,86022,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,27.56,,,,,,,fee schedule,27.56,76.64, Immunoglobulin assay,86023,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,51.98,,,,,,,fee schedule,18.69,51.98, Immunoglobulin assay,86023,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.69,,,,,,,fee schedule,18.69,51.98, Immunoglobulin assay,86023,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,18.69,,,,,,,fee schedule,18.69,51.98, Anca screen each antibody,86036,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,50.27,,,,,,,fee schedule,18.08,50.27, Anca screen each antibody,86036,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.08,,,,,,,fee schedule,18.08,50.27, Anca screen each antibody,86036,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,18.08,,,,,,,fee schedule,18.08,50.27, Anca titer each antibody,86037,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,50.27,,,,,,,fee schedule,18.08,50.27, Anca titer each antibody,86037,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.08,,,,,,,fee schedule,18.08,50.27, Anca titer each antibody,86037,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,18.08,,,,,,,fee schedule,18.08,50.27, Antinuclear antibodies,86038,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,50.44,,,,,,,fee schedule,18.14,50.44, Antinuclear antibodies,86038,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.14,,,,,,,fee schedule,18.14,50.44, Antinuclear antibodies,86038,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,18.14,,,,,,,fee schedule,18.14,50.44, Antinuclear antibodies (ANA),86039,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,46.56,,,,,,,fee schedule,16.74,46.56, Antinuclear antibodies (ANA),86039,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.74,,,,,,,fee schedule,16.74,46.56, Antinuclear antibodies (ANA),86039,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,16.74,,,,,,,fee schedule,16.74,46.56, Acetylcholn rcptr bndng antb,86041,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,76.76,,,,,,,fee schedule,27.6,76.76, Acetylcholn rcptr bndng antb,86041,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,27.6,,,,,,,fee schedule,27.6,76.76, Acetylcholn rcptr bndng antb,86041,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,27.6,,,,,,,fee schedule,27.6,76.76, Acetylcholn rcptr blckg antb,86042,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,76.76,,,,,,,fee schedule,27.6,76.76, Acetylcholn rcptr blckg antb,86042,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,27.6,,,,,,,fee schedule,27.6,76.76, Acetylcholn rcptr blckg antb,86042,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,27.6,,,,,,,fee schedule,27.6,76.76, Acetylcholn rcptr modlg antb,86043,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,50.27,,,,,,,fee schedule,18.08,50.27, Acetylcholn rcptr modlg antb,86043,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.08,,,,,,,fee schedule,18.08,50.27, Acetylcholn rcptr modlg antb,86043,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,18.08,,,,,,,fee schedule,18.08,50.27, Aquaporin-4 antb elisa,86051,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,48.1,,,,,,,fee schedule,17.3,48.1, Aquaporin-4 antb elisa,86051,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.3,,,,,,,fee schedule,17.3,48.1, Aquaporin-4 antb elisa,86051,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,17.3,,,,,,,fee schedule,17.3,48.1, Aquaporin-4 antb cba each,86052,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,50.27,,,,,,,fee schedule,18.08,50.27, Aquaporin-4 antb cba each,86052,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.08,,,,,,,fee schedule,18.08,50.27, Aquaporin-4 antb cba each,86052,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,18.08,,,,,,,fee schedule,18.08,50.27, Aqaprn-4 antb flo cytmtry ea,86053,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,157.41,,,,,,,fee schedule,18.08,157.41, Aqaprn-4 antb flo cytmtry ea,86053,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.08,,,,,,,fee schedule,18.08,157.41, Aqaprn-4 antb flo cytmtry ea,86053,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,18.08,,,,,,,fee schedule,18.08,157.41, Antistreptolysin o titer,86060,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,30.46,,,,,,,fee schedule,10.95,30.46, Antistreptolysin o titer,86060,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.95,,,,,,,fee schedule,10.95,30.46, Antistreptolysin o titer,86060,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,10.95,,,,,,,fee schedule,10.95,30.46, Antistreptolysin o screen,86063,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,24.07,,,,,,,fee schedule,8.66,24.07, Antistreptolysin o screen,86063,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.66,,,,,,,fee schedule,8.66,24.07, Antistreptolysin o screen,86063,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,8.66,,,,,,,fee schedule,8.66,24.07, Phys blood bank serv xmatch,86077,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,217.24,,,,,,,fee schedule,34.49,217.24, Phys blood bank serv xmatch,86077,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,167.96,,,,,,,fee schedule,34.49,217.24, Phys blood bank serv xmatch,86077,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,34.49,,,,,,,fee schedule,34.49,217.24, Phys blood bank serv xmatch,86077,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,34.49,,,,,,,fee schedule,34.49,217.24, Phys blood bank serv reactj,86078,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,217.24,,,,,,,fee schedule,167.96,217.24, Phys blood bank serv reactj,86078,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,167.96,,,,,,,fee schedule,167.96,217.24, Phys blood bank serv reactj,86078,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,215.25,,,,,,,fee schedule,167.96,217.24, Phys blood bank serv reactj,86078,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,215.25,,,,,,,fee schedule,167.96,217.24, Phys blood bank serv authrj,86079,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,215.52,,,,,,,fee schedule,74.21,215.52, Phys blood bank serv authrj,86079,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,166.63,,,,,,,fee schedule,74.21,215.52, Phys blood bank serv authrj,86079,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,74.21,,,,,,,fee schedule,74.21,215.52, Phys blood bank serv authrj,86079,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,74.21,,,,,,,fee schedule,74.21,215.52, C-reactive protein,86140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,21.61,,,,,,,fee schedule,7.77,21.61, C-reactive protein,86140,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.77,,,,,,,fee schedule,7.77,21.61, C-reactive protein,86140,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,7.77,,,,,,,fee schedule,7.77,21.61, C-reactive protein hs,86141,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,54.03,,,,,,,fee schedule,19.43,54.03, C-reactive protein hs,86141,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.43,,,,,,,fee schedule,19.43,54.03, C-reactive protein hs,86141,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19.43,,,,,,,fee schedule,19.43,54.03, Beta-2 glycoprotein antibody,86146,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,106.18,,,,,,,fee schedule,38.18,106.18, Beta-2 glycoprotein antibody,86146,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,38.18,,,,,,,fee schedule,38.18,106.18, Beta-2 glycoprotein antibody,86146,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,38.18,,,,,,,fee schedule,38.18,106.18, Cardiolipin antibody ea ig,86147,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,106.18,,,,,,,fee schedule,38.18,106.18, Cardiolipin antibody ea ig,86147,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,38.18,,,,,,,fee schedule,38.18,106.18, Cardiolipin antibody ea ig,86147,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,38.18,,,,,,,fee schedule,38.18,106.18, Anti-phospholipid antibody,86148,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,67.04,,,,,,,fee schedule,24.11,67.04, Anti-phospholipid antibody,86148,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24.11,,,,,,,fee schedule,24.11,67.04, Anti-phospholipid antibody,86148,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,24.11,,,,,,,fee schedule,24.11,67.04, Cell enumeration & id,86152,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1046.25,,,,,,,fee schedule,376.17,1046.25, Cell enumeration & id,86152,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,376.17,,,,,,,fee schedule,376.17,1046.25, Cell enumeration & id,86152,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,376.17,,,,,,,fee schedule,376.17,1046.25, Chemotaxis assay,86155,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,66.71,,,,,,,fee schedule,23.99,66.71, Chemotaxis assay,86155,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23.99,,,,,,,fee schedule,23.99,66.71, Chemotaxis assay,86155,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,23.99,,,,,,,fee schedule,23.99,66.71, Cold agglutinin screen,86156,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,33.67,,,,,,,fee schedule,12.11,33.67, Cold agglutinin screen,86156,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.11,,,,,,,fee schedule,12.11,33.67, Cold agglutinin screen,86156,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,12.11,,,,,,,fee schedule,12.11,33.67, Cold agglutinin titer,86157,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,33.63,,,,,,,fee schedule,12.09,33.63, Cold agglutinin titer,86157,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.09,,,,,,,fee schedule,12.09,33.63, Cold agglutinin titer,86157,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,12.09,,,,,,,fee schedule,12.09,33.63, Complement antigen,86160,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,50.06,,,,,,,fee schedule,18,50.06, Complement antigen,86160,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18,,,,,,,fee schedule,18,50.06, Complement antigen,86160,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,18,,,,,,,fee schedule,18,50.06, Complement/function activity,86161,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,50.06,,,,,,,fee schedule,18,50.06, Complement/function activity,86161,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18,,,,,,,fee schedule,18,50.06, Complement/function activity,86161,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,18,,,,,,,fee schedule,18,50.06, Complement total (ch50),86162,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,84.78,,,,,,,fee schedule,30.48,84.78, Complement total (ch50),86162,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,30.48,,,,,,,fee schedule,30.48,84.78, Complement total (ch50),86162,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,30.48,,,,,,,fee schedule,30.48,84.78, Complement fixation each,86171,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,41.76,,,,,,,fee schedule,15.02,41.76, Complement fixation each,86171,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.02,,,,,,,fee schedule,15.02,41.76, Complement fixation each,86171,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,15.02,,,,,,,fee schedule,15.02,41.76, Ccp antibody,86200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,54.03,,,,,,,fee schedule,19.43,54.03, Ccp antibody,86200,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.43,,,,,,,fee schedule,19.43,54.03, Ccp antibody,86200,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19.43,,,,,,,fee schedule,19.43,54.03, Deoxyribonuclease antibody,86215,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,55.28,,,,,,,fee schedule,19.88,55.28, Deoxyribonuclease antibody,86215,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.88,,,,,,,fee schedule,19.88,55.28, Deoxyribonuclease antibody,86215,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19.88,,,,,,,fee schedule,19.88,55.28, Dna antibody native,86225,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,57.32,,,,,,,fee schedule,20.61,57.32, Dna antibody native,86225,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,20.61,,,,,,,fee schedule,20.61,57.32, Dna antibody native,86225,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,20.61,,,,,,,fee schedule,20.61,57.32, Dna antibody single strand,86226,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,50.52,,,,,,,fee schedule,18.17,50.52, Dna antibody single strand,86226,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.17,,,,,,,fee schedule,18.17,50.52, Dna antibody single strand,86226,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,18.17,,,,,,,fee schedule,18.17,50.52, Ema each ig class,86231,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,50.44,,,,,,,fee schedule,18.14,50.44, Ema each ig class,86231,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.14,,,,,,,fee schedule,18.14,50.44, Ema each ig class,86231,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,18.14,,,,,,,fee schedule,18.14,50.44, Nuclear antigen antibody,86235,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,74.8,,,,,,,fee schedule,26.9,74.8, Nuclear antigen antibody,86235,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26.9,,,,,,,fee schedule,26.9,74.8, Nuclear antigen antibody,86235,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,26.9,,,,,,,fee schedule,26.9,74.8, Fluorescent antibody screen,86255,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,50.27,,,,,,,fee schedule,18.08,50.27, Fluorescent antibody screen,86255,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.08,,,,,,,fee schedule,18.08,50.27, Fluorescent antibody screen,86255,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,18.08,,,,,,,fee schedule,18.08,50.27, Fluorescent antibody titer,86256,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,50.27,,,,,,,fee schedule,18.08,50.27, Fluorescent antibody titer,86256,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.08,,,,,,,fee schedule,18.08,50.27, Fluorescent antibody titer,86256,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,18.08,,,,,,,fee schedule,18.08,50.27, Dgp antibody each ig class,86258,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,50.27,,,,,,,fee schedule,17.3,50.27, Dgp antibody each ig class,86258,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.3,,,,,,,fee schedule,17.3,50.27, Dgp antibody each ig class,86258,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,17.3,,,,,,,fee schedule,17.3,50.27, Growth hormone antibody,86277,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,65.67,,,,,,,fee schedule,23.61,65.67, Growth hormone antibody,86277,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23.61,,,,,,,fee schedule,23.61,65.67, Growth hormone antibody,86277,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,23.61,,,,,,,fee schedule,23.61,65.67, Hemagglutination inhibition,86280,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,34.17,,,,,,,fee schedule,12.29,34.17, Hemagglutination inhibition,86280,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.29,,,,,,,fee schedule,12.29,34.17, Hemagglutination inhibition,86280,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,12.29,,,,,,,fee schedule,12.29,34.17, Immunoassay tumor qual,86294,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,106.68,,,,,,,fee schedule,38.36,106.68, Immunoassay tumor qual,86294,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,38.36,,,,,,,fee schedule,38.36,106.68, Immunoassay tumor qual,86294,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,38.36,,,,,,,fee schedule,38.36,106.68, Immunoassay tumor ca 15-3,86300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,86.82,,,,,,,fee schedule,31.22,86.82, Immunoassay tumor ca 15-3,86300,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31.22,,,,,,,fee schedule,31.22,86.82, Immunoassay tumor ca 15-3,86300,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,31.22,,,,,,,fee schedule,31.22,86.82, Immunoassay tumor ca 19-9,86301,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,86.82,,,,,,,fee schedule,31.22,86.82, Immunoassay tumor ca 19-9,86301,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31.22,,,,,,,fee schedule,31.22,86.82, Immunoassay tumor ca 19-9,86301,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,31.22,,,,,,,fee schedule,31.22,86.82, Immunoassay tumor ca 125,86304,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,86.82,,,,,,,fee schedule,31.22,86.82, Immunoassay tumor ca 125,86304,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31.22,,,,,,,fee schedule,31.22,86.82, Immunoassay tumor ca 125,86304,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,31.22,,,,,,,fee schedule,31.22,86.82, Human epididymis protein 4,86305,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,86.82,,,,,,,fee schedule,31.22,86.82, Human epididymis protein 4,86305,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31.22,,,,,,,fee schedule,31.22,86.82, Human epididymis protein 4,86305,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,31.22,,,,,,,fee schedule,31.22,86.82, Heterophile antibody screen,86308,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,21.61,,,,,,,fee schedule,7.77,21.61, Heterophile antibody screen,86308,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.77,,,,,,,fee schedule,7.77,21.61, Heterophile antibody screen,86308,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,7.77,,,,,,,fee schedule,7.77,21.61, Heterophile antibody titer,86309,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,26.99,,,,,,,fee schedule,9.71,26.99, Heterophile antibody titer,86309,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.71,,,,,,,fee schedule,9.71,26.99, Heterophile antibody titer,86309,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9.71,,,,,,,fee schedule,9.71,26.99, Heterophile antibody absrbj,86310,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,30.75,,,,,,,fee schedule,11.06,30.75, Heterophile antibody absrbj,86310,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.06,,,,,,,fee schedule,11.06,30.75, Heterophile antibody absrbj,86310,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11.06,,,,,,,fee schedule,11.06,30.75, Immunoassay tumor other,86316,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,86.82,,,,,,,fee schedule,31.22,86.82, Immunoassay tumor other,86316,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31.22,,,,,,,fee schedule,31.22,86.82, Immunoassay tumor other,86316,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,31.22,,,,,,,fee schedule,31.22,86.82, Immunoassay infectious agent,86317,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,62.54,,,,,,,fee schedule,22.49,62.54, Immunoassay infectious agent,86317,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22.49,,,,,,,fee schedule,22.49,62.54, Immunoassay infectious agent,86317,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22.49,,,,,,,fee schedule,22.49,62.54, Immunoassay infectious agent,86318,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,75.47,,,,,,,fee schedule,27.14,75.47, Immunoassay infectious agent,86318,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,27.14,,,,,,,fee schedule,27.14,75.47, Immunoassay infectious agent,86318,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,27.14,,,,,,,fee schedule,27.14,75.47, Serum immunoelectrophoresis,86320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,124.83,,,,,,,fee schedule,44.88,124.83, Serum immunoelectrophoresis,86320,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,44.88,,,,,,,fee schedule,44.88,124.83, Serum immunoelectrophoresis,86320,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,44.88,,,,,,,fee schedule,44.88,124.83, Other immunoelectrophoresis,86325,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,96.5,,,,,,,fee schedule,34.7,96.5, Other immunoelectrophoresis,86325,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,34.7,,,,,,,fee schedule,34.7,96.5, Other immunoelectrophoresis,86325,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,34.7,,,,,,,fee schedule,34.7,96.5, Ia nfct ab sarscov2 covid19,86328,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,188.91,,,,,,,fee schedule,67.92,188.91, Ia nfct ab sarscov2 covid19,86328,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,67.92,,,,,,,fee schedule,67.92,188.91, Ia nfct ab sarscov2 covid19,86328,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,67.92,,,,,,,fee schedule,67.92,188.91, Immunodiffusion nes,86329,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,58.62,,,,,,,fee schedule,21.08,58.62, Immunodiffusion nes,86329,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21.08,,,,,,,fee schedule,21.08,58.62, Immunodiffusion nes,86329,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,21.08,,,,,,,fee schedule,21.08,58.62, Immunodiffusion ouchterlony,86331,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,49.98,,,,,,,fee schedule,17.97,49.98, Immunodiffusion ouchterlony,86331,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.97,,,,,,,fee schedule,17.97,49.98, Immunodiffusion ouchterlony,86331,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,17.97,,,,,,,fee schedule,17.97,49.98, Immune complex assay,86332,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,101.67,,,,,,,fee schedule,36.56,101.67, Immune complex assay,86332,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,36.56,,,,,,,fee schedule,36.56,101.67, Immune complex assay,86332,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,36.56,,,,,,,fee schedule,36.56,101.67, Immunofix e-phoresis serum,86334,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,93.2,,,,,,,fee schedule,33.51,93.2, Immunofix e-phoresis serum,86334,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,33.51,,,,,,,fee schedule,33.51,93.2, Immunofix e-phoresis serum,86334,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,33.51,,,,,,,fee schedule,33.51,93.2, Immunfix e-phorsis/urine/csf,86335,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,122.45,,,,,,,fee schedule,44.03,122.45, Immunfix e-phorsis/urine/csf,86335,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,44.03,,,,,,,fee schedule,44.03,122.45, Immunfix e-phorsis/urine/csf,86335,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,44.03,,,,,,,fee schedule,44.03,122.45, Inhibin A,86336,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,65.04,,,,,,,fee schedule,23.39,65.04, Inhibin A,86336,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23.39,,,,,,,fee schedule,23.39,65.04, Inhibin A,86336,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,23.39,,,,,,,fee schedule,23.39,65.04, Insulin antibodies,86337,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,89.32,,,,,,,fee schedule,32.12,89.32, Insulin antibodies,86337,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,32.12,,,,,,,fee schedule,32.12,89.32, Insulin antibodies,86337,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,32.12,,,,,,,fee schedule,32.12,89.32, Intrinsic factor antibody,86340,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,62.91,,,,,,,fee schedule,22.62,62.91, Intrinsic factor antibody,86340,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22.62,,,,,,,fee schedule,22.62,62.91, Intrinsic factor antibody,86340,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22.62,,,,,,,fee schedule,22.62,62.91, Islet cell antibody,86341,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,98.33,,,,,,,fee schedule,35.36,98.33, Islet cell antibody,86341,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,35.36,,,,,,,fee schedule,35.36,98.33, Islet cell antibody,86341,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,35.36,,,,,,,fee schedule,35.36,98.33, Leukocyte histamine release,86343,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,51.98,,,,,,,fee schedule,18.69,51.98, Leukocyte histamine release,86343,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.69,,,,,,,fee schedule,18.69,51.98, Leukocyte histamine release,86343,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,18.69,,,,,,,fee schedule,18.69,51.98, Leukocyte phagocytosis,86344,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,43.35,,,,,,,fee schedule,15.59,43.35, Leukocyte phagocytosis,86344,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.59,,,,,,,fee schedule,15.59,43.35, Leukocyte phagocytosis,86344,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,15.59,,,,,,,fee schedule,15.59,43.35, Cell function assay w/stim,86352,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,566.81,,,,,,,fee schedule,203.79,566.81, Cell function assay w/stim,86352,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,203.79,,,,,,,fee schedule,203.79,566.81, Cell function assay w/stim,86352,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,203.79,,,,,,,fee schedule,203.79,566.81, Lymphocyte transformation,86353,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,204.55,,,,,,,fee schedule,73.55,204.55, Lymphocyte transformation,86353,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,73.55,,,,,,,fee schedule,73.55,204.55, Lymphocyte transformation,86353,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,73.55,,,,,,,fee schedule,73.55,204.55, B cells total count,86355,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,157.41,,,,,,,fee schedule,56.6,157.41, B cells total count,86355,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56.6,,,,,,,fee schedule,56.6,157.41, B cells total count,86355,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,56.6,,,,,,,fee schedule,56.6,157.41, Mononuclear cell antigen,86356,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,111.73,,,,,,,fee schedule,40.17,111.73, Mononuclear cell antigen,86356,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,40.17,,,,,,,fee schedule,40.17,111.73, Mononuclear cell antigen,86356,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,40.17,,,,,,,fee schedule,40.17,111.73, Nk cells total count,86357,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,157.41,,,,,,,fee schedule,56.6,157.41, Nk cells total count,86357,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56.6,,,,,,,fee schedule,56.6,157.41, Nk cells total count,86357,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,56.6,,,,,,,fee schedule,56.6,157.41, T cells total count,86359,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,157.41,,,,,,,fee schedule,56.6,157.41, T cells total count,86359,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56.6,,,,,,,fee schedule,56.6,157.41, T cells total count,86359,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,56.6,,,,,,,fee schedule,56.6,157.41, T cell absolute count/ratio,86360,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,196,,,,,,,fee schedule,70.47,196, T cell absolute count/ratio,86360,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,70.47,,,,,,,fee schedule,70.47,196, T cell absolute count/ratio,86360,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,70.47,,,,,,,fee schedule,70.47,196, T cell absolute count,86361,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,111.73,,,,,,,fee schedule,40.17,111.73, T cell absolute count,86361,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,40.17,,,,,,,fee schedule,40.17,111.73, T cell absolute count,86361,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,40.17,,,,,,,fee schedule,40.17,111.73, Mog-igg1 antb cba each,86362,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,50.27,,,,,,,fee schedule,18.08,50.27, Mog-igg1 antb cba each,86362,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.08,,,,,,,fee schedule,18.08,50.27, Mog-igg1 antb cba each,86362,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,18.08,,,,,,,fee schedule,18.08,50.27, Mog-igg1 antb flo cytmtry ea,86363,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,157.41,,,,,,,fee schedule,18.08,157.41, Mog-igg1 antb flo cytmtry ea,86363,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.08,,,,,,,fee schedule,18.08,157.41, Mog-igg1 antb flo cytmtry ea,86363,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,18.08,,,,,,,fee schedule,18.08,157.41, Tiss trnsgltmnase ea ig clas,86364,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,48.1,,,,,,,fee schedule,17.3,48.1, Tiss trnsgltmnase ea ig clas,86364,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.3,,,,,,,fee schedule,17.3,48.1, Tiss trnsgltmnase ea ig clas,86364,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,17.3,,,,,,,fee schedule,17.3,48.1, Muscle-specific kinase antb,86366,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,76.76,,,,,,,fee schedule,27.6,76.76, Muscle-specific kinase antb,86366,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,27.6,,,,,,,fee schedule,27.6,76.76, Muscle-specific kinase antb,86366,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,27.6,,,,,,,fee schedule,27.6,76.76, Stem cells total count,86367,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,324.5,,,,,,,fee schedule,116.67,324.5, Stem cells total count,86367,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,116.67,,,,,,,fee schedule,116.67,324.5, Stem cells total count,86367,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,116.67,,,,,,,fee schedule,116.67,324.5, Microsomal antibody each,86376,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,60.7,,,,,,,fee schedule,21.83,60.7, Microsomal antibody each,86376,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21.83,,,,,,,fee schedule,21.83,60.7, Microsomal antibody each,86376,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,21.83,,,,,,,fee schedule,21.83,60.7, Mitochondrial antibody each,86381,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,106.18,,,,,,,fee schedule,38.18,106.18, Mitochondrial antibody each,86381,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,38.18,,,,,,,fee schedule,38.18,106.18, Mitochondrial antibody each,86381,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,38.18,,,,,,,fee schedule,38.18,106.18, Neutralization test viral,86382,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,70.55,,,,,,,fee schedule,25.37,70.55, Neutralization test viral,86382,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25.37,,,,,,,fee schedule,25.37,70.55, Neutralization test viral,86382,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,25.37,,,,,,,fee schedule,25.37,70.55, Nitroblue tetrazolium dye,86384,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,56.78,,,,,,,fee schedule,20.42,56.78, Nitroblue tetrazolium dye,86384,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,20.42,,,,,,,fee schedule,20.42,56.78, Nitroblue tetrazolium dye,86384,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,20.42,,,,,,,fee schedule,20.42,56.78, Nuclear matrix protein 22,86386,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,90.87,,,,,,,fee schedule,32.67,90.87, Nuclear matrix protein 22,86386,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,32.67,,,,,,,fee schedule,32.67,90.87, Nuclear matrix protein 22,86386,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,32.67,,,,,,,fee schedule,32.67,90.87, Particle agglut antbdy scrn,86403,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,48.14,,,,,,,fee schedule,17.31,48.14, Particle agglut antbdy scrn,86403,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.31,,,,,,,fee schedule,17.31,48.14, Particle agglut antbdy scrn,86403,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,17.31,,,,,,,fee schedule,17.31,48.14, Particle agglut antbdy titr,86406,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,44.39,,,,,,,fee schedule,15.96,44.39, Particle agglut antbdy titr,86406,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.96,,,,,,,fee schedule,15.96,44.39, Particle agglut antbdy titr,86406,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,15.96,,,,,,,fee schedule,15.96,44.39, Neutrlzg antb sarscov2 scr,86408,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,175.77,,,,,,,fee schedule,63.2,175.77, Neutrlzg antb sarscov2 scr,86408,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,63.2,,,,,,,fee schedule,63.2,175.77, Neutrlzg antb sarscov2 scr,86408,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,63.2,,,,,,,fee schedule,63.2,175.77, Neutrlzg antb sarscov2 titer,86409,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,332.13,,,,,,,fee schedule,158,332.13, Neutrlzg antb sarscov2 titer,86409,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,158,,,,,,,fee schedule,158,332.13, Neutrlzg antb sarscov2 titer,86409,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,158,,,,,,,fee schedule,158,332.13, Sars-cov-2 antb quantitative,86413,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,214.57,,,,,,,fee schedule,63.2,214.57, Sars-cov-2 antb quantitative,86413,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,63.2,,,,,,,fee schedule,63.2,214.57, Sars-cov-2 antb quantitative,86413,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,63.2,,,,,,,fee schedule,63.2,214.57, Rheumatoid factor test qual,86430,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,25.62,,,,,,,fee schedule,9.21,25.62, Rheumatoid factor test qual,86430,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.21,,,,,,,fee schedule,9.21,25.62, Rheumatoid factor test qual,86430,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9.21,,,,,,,fee schedule,9.21,25.62, Rheumatoid factor quant,86431,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,23.66,,,,,,,fee schedule,8.51,23.66, Rheumatoid factor quant,86431,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.51,,,,,,,fee schedule,8.51,23.66, Rheumatoid factor quant,86431,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,8.51,,,,,,,fee schedule,8.51,23.66, Tb test cell immun measure,86480,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,258.58,,,,,,,fee schedule,92.97,258.58, Tb test cell immun measure,86480,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,92.97,,,,,,,fee schedule,92.97,258.58, Tb test cell immun measure,86480,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,92.97,,,,,,,fee schedule,92.97,258.58, Tb ag response t-cell susp,86481,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,417.2,,,,,,,fee schedule,150,417.2, Tb ag response t-cell susp,86481,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,150,,,,,,,fee schedule,150,417.2, Tb ag response t-cell susp,86481,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,150,,,,,,,fee schedule,150,417.2, Skin test candida,86485,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,34.49,,,,,,,fee schedule,34.49,34.49, Skin test candida,86485,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,34.49,,,,,,,fee schedule,34.49,34.49, Skin test nos antigen,86486,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,35.45,,,,,,,fee schedule,27.41,35.45, Skin test nos antigen,86486,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,27.41,,,,,,,fee schedule,27.41,35.45, Skin test nos antigen,86486,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,34.49,,,,,,,fee schedule,27.41,35.45, Skin test nos antigen,86486,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,34.49,,,,,,,fee schedule,27.41,35.45, Histoplasmosis skin test,86510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,44.09,,,,,,,fee schedule,34.09,82.52, Histoplasmosis skin test,86510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,34.09,,,,,,,fee schedule,34.09,82.52, Histoplasmosis skin test,86510,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,82.52,,,,,,,fee schedule,34.09,82.52, Histoplasmosis skin test,86510,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,82.52,,,,,,,fee schedule,34.09,82.52, TB intradermal test,86580,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,57.85,,,,,,,fee schedule,34.49,57.85, TB intradermal test,86580,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,44.72,,,,,,,fee schedule,34.49,57.85, TB intradermal test,86580,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,34.49,,,,,,,fee schedule,34.49,57.85, TB intradermal test,86580,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,34.49,,,,,,,fee schedule,34.49,57.85, Strptcs pneum antb serot ia,86581,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,383.95,,,,,,,fee schedule,383.95,383.95, Streptokinase antibody,86590,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,52.82,,,,,,,fee schedule,18.99,52.82, Streptokinase antibody,86590,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.99,,,,,,,fee schedule,18.99,52.82, Streptokinase antibody,86590,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,18.99,,,,,,,fee schedule,18.99,52.82, Syphilis test non-trep qual,86592,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,17.81,,,,,,,fee schedule,6.41,17.81, Syphilis test non-trep qual,86592,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.41,,,,,,,fee schedule,6.41,17.81, Syphilis test non-trep qual,86592,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,6.41,,,,,,,fee schedule,6.41,17.81, Syphilis test non-trep quant,86593,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,18.36,,,,,,,fee schedule,6.6,18.36, Syphilis test non-trep quant,86593,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.6,,,,,,,fee schedule,6.6,18.36, Syphilis test non-trep quant,86593,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,6.6,,,,,,,fee schedule,6.6,18.36, Voltage-gtd ca chnl antb ea,86596,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,50.27,,,,,,,fee schedule,27.6,50.27, Voltage-gtd ca chnl antb ea,86596,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,27.6,,,,,,,fee schedule,27.6,50.27, Voltage-gtd ca chnl antb ea,86596,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,27.6,,,,,,,fee schedule,27.6,50.27, Antinomyces antibody,86602,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,42.47,,,,,,,fee schedule,15.27,42.47, Antinomyces antibody,86602,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.27,,,,,,,fee schedule,15.27,42.47, Antinomyces antibody,86602,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,15.27,,,,,,,fee schedule,15.27,42.47, Adenovirus antibody,86603,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,53.69,,,,,,,fee schedule,19.31,53.69, Adenovirus antibody,86603,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.31,,,,,,,fee schedule,19.31,53.69, Adenovirus antibody,86603,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19.31,,,,,,,fee schedule,19.31,53.69, Aspergillus antibody,86606,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,62.79,,,,,,,fee schedule,22.58,62.79, Aspergillus antibody,86606,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22.58,,,,,,,fee schedule,22.58,62.79, Aspergillus antibody,86606,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22.58,,,,,,,fee schedule,22.58,62.79, Bacterium antibody,86609,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,53.74,,,,,,,fee schedule,19.32,53.74, Bacterium antibody,86609,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.32,,,,,,,fee schedule,19.32,53.74, Bacterium antibody,86609,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19.32,,,,,,,fee schedule,19.32,53.74, Bartonella Antibody,86611,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,42.47,,,,,,,fee schedule,15.27,42.47, Bartonella Antibody,86611,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.27,,,,,,,fee schedule,15.27,42.47, Bartonella Antibody,86611,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,15.27,,,,,,,fee schedule,15.27,42.47, Blastomyces antibody,86612,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,53.82,,,,,,,fee schedule,19.35,53.82, Blastomyces antibody,86612,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.35,,,,,,,fee schedule,19.35,53.82, Blastomyces antibody,86612,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19.35,,,,,,,fee schedule,19.35,53.82, Bordetella antibody,86615,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,55.03,,,,,,,fee schedule,19.79,55.03, Bordetella antibody,86615,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.79,,,,,,,fee schedule,19.79,55.03, Bordetella antibody,86615,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19.79,,,,,,,fee schedule,19.79,55.03, Lyme disease antibody,86617,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,64.62,,,,,,,fee schedule,23.24,64.62, Lyme disease antibody,86617,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23.24,,,,,,,fee schedule,23.24,64.62, Lyme disease antibody,86617,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,23.24,,,,,,,fee schedule,23.24,64.62, Lyme disease antibody,86618,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,71.05,,,,,,,fee schedule,25.55,71.05, Lyme disease antibody,86618,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25.55,,,,,,,fee schedule,25.55,71.05, Lyme disease antibody,86618,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,25.55,,,,,,,fee schedule,25.55,71.05, Borrelia antibody,86619,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,55.82,,,,,,,fee schedule,20.07,55.82, Borrelia antibody,86619,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,20.07,,,,,,,fee schedule,20.07,55.82, Borrelia antibody,86619,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,20.07,,,,,,,fee schedule,20.07,55.82, Brucella antibody,86622,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,37.26,,,,,,,fee schedule,13.4,37.26, Brucella antibody,86622,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13.4,,,,,,,fee schedule,13.4,37.26, Brucella antibody,86622,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13.4,,,,,,,fee schedule,13.4,37.26, Campylobacter antibody,86625,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,54.74,,,,,,,fee schedule,19.68,54.74, Campylobacter antibody,86625,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.68,,,,,,,fee schedule,19.68,54.74, Campylobacter antibody,86625,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19.68,,,,,,,fee schedule,19.68,54.74, Candida antibody,86628,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,50.11,,,,,,,fee schedule,18.02,50.11, Candida antibody,86628,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.02,,,,,,,fee schedule,18.02,50.11, Candida antibody,86628,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,18.02,,,,,,,fee schedule,18.02,50.11, Chlamydia antibody,86631,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,49.31,,,,,,,fee schedule,17.73,49.31, Chlamydia antibody,86631,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.73,,,,,,,fee schedule,17.73,49.31, Chlamydia antibody,86631,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,17.73,,,,,,,fee schedule,17.73,49.31, Chlamydia igm antibody,86632,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,52.9,,,,,,,fee schedule,19.02,52.9, Chlamydia igm antibody,86632,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.02,,,,,,,fee schedule,19.02,52.9, Chlamydia igm antibody,86632,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19.02,,,,,,,fee schedule,19.02,52.9, Coccidioides antibody,86635,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,47.85,,,,,,,fee schedule,17.21,47.85, Coccidioides antibody,86635,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.21,,,,,,,fee schedule,17.21,47.85, Coccidioides antibody,86635,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,17.21,,,,,,,fee schedule,17.21,47.85, Q fever antibody,86638,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,50.56,,,,,,,fee schedule,18.18,50.56, Q fever antibody,86638,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.18,,,,,,,fee schedule,18.18,50.56, Q fever antibody,86638,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,18.18,,,,,,,fee schedule,18.18,50.56, Cryptococcus antibody,86641,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,60.12,,,,,,,fee schedule,21.62,60.12, Cryptococcus antibody,86641,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21.62,,,,,,,fee schedule,21.62,60.12, Cryptococcus antibody,86641,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,21.62,,,,,,,fee schedule,21.62,60.12, CMV antibody,86644,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,60.04,,,,,,,fee schedule,21.59,60.04, CMV antibody,86644,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21.59,,,,,,,fee schedule,21.59,60.04, CMV antibody,86644,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,21.59,,,,,,,fee schedule,21.59,60.04, Cmv antibody igm,86645,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,70.3,,,,,,,fee schedule,25.28,70.3, Cmv antibody igm,86645,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25.28,,,,,,,fee schedule,25.28,70.3, Cmv antibody igm,86645,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,25.28,,,,,,,fee schedule,25.28,70.3, Diphtheria antibody,86648,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,63.46,,,,,,,fee schedule,22.82,63.46, Diphtheria antibody,86648,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22.82,,,,,,,fee schedule,22.82,63.46, Diphtheria antibody,86648,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22.82,,,,,,,fee schedule,22.82,63.46, Encephalitis californ antbdy,86651,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,55.03,,,,,,,fee schedule,19.79,55.03, Encephalitis californ antbdy,86651,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.79,,,,,,,fee schedule,19.79,55.03, Encephalitis californ antbdy,86651,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19.79,,,,,,,fee schedule,19.79,55.03, Encephaltis east eqne anbdy,86652,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,55.03,,,,,,,fee schedule,19.79,55.03, Encephaltis east eqne anbdy,86652,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.79,,,,,,,fee schedule,19.79,55.03, Encephaltis east eqne anbdy,86652,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19.79,,,,,,,fee schedule,19.79,55.03, Encephaltis st louis antbody,86653,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,55.03,,,,,,,fee schedule,19.79,55.03, Encephaltis st louis antbody,86653,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.79,,,,,,,fee schedule,19.79,55.03, Encephaltis st louis antbody,86653,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19.79,,,,,,,fee schedule,19.79,55.03, Encephaltis west eqne antbdy,86654,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,55.03,,,,,,,fee schedule,19.79,55.03, Encephaltis west eqne antbdy,86654,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.79,,,,,,,fee schedule,19.79,55.03, Encephaltis west eqne antbdy,86654,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19.79,,,,,,,fee schedule,19.79,55.03, Enterovirus antibody,86658,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,54.36,,,,,,,fee schedule,19.55,54.36, Enterovirus antibody,86658,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.55,,,,,,,fee schedule,19.55,54.36, Enterovirus antibody,86658,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19.55,,,,,,,fee schedule,19.55,54.36, Epstein-barr antibody,86663,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,54.74,,,,,,,fee schedule,19.68,54.74, Epstein-barr antibody,86663,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.68,,,,,,,fee schedule,19.68,54.74, Epstein-barr antibody,86663,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19.68,,,,,,,fee schedule,19.68,54.74, Epstein-barr nuclear antigen,86664,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,63.79,,,,,,,fee schedule,22.94,63.79, Epstein-barr nuclear antigen,86664,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22.94,,,,,,,fee schedule,22.94,63.79, Epstein-barr nuclear antigen,86664,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22.94,,,,,,,fee schedule,22.94,63.79, Epstein-barr capsid vca,86665,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,75.68,,,,,,,fee schedule,27.21,75.68, Epstein-barr capsid vca,86665,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,27.21,,,,,,,fee schedule,27.21,75.68, Epstein-barr capsid vca,86665,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,27.21,,,,,,,fee schedule,27.21,75.68, Ehrlichia Antibody,86666,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,42.47,,,,,,,fee schedule,15.27,42.47, Ehrlichia Antibody,86666,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.27,,,,,,,fee schedule,15.27,42.47, Ehrlichia Antibody,86666,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,15.27,,,,,,,fee schedule,15.27,42.47, Francisella tularensis,86668,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,59.08,,,,,,,fee schedule,21.24,59.08, Francisella tularensis,86668,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21.24,,,,,,,fee schedule,21.24,59.08, Francisella tularensis,86668,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,21.24,,,,,,,fee schedule,21.24,59.08, Fungus nes antibody,86671,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,51.11,,,,,,,fee schedule,18.38,51.11, Fungus nes antibody,86671,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.38,,,,,,,fee schedule,18.38,51.11, Fungus nes antibody,86671,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,18.38,,,,,,,fee schedule,18.38,51.11, Giardia lamblia antibody,86674,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,61.41,,,,,,,fee schedule,22.08,61.41, Giardia lamblia antibody,86674,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22.08,,,,,,,fee schedule,22.08,61.41, Giardia lamblia antibody,86674,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22.08,,,,,,,fee schedule,22.08,61.41, Helicobacter pylori antibody,86677,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,70.3,,,,,,,fee schedule,25.28,70.3, Helicobacter pylori antibody,86677,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25.28,,,,,,,fee schedule,25.28,70.3, Helicobacter pylori antibody,86677,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,25.28,,,,,,,fee schedule,25.28,70.3, Helminth antibody,86682,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,54.28,,,,,,,fee schedule,19.52,54.28, Helminth antibody,86682,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.52,,,,,,,fee schedule,19.52,54.28, Helminth antibody,86682,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19.52,,,,,,,fee schedule,19.52,54.28, Hemophilus influenza antibdy,86684,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,66.08,,,,,,,fee schedule,23.76,66.08, Hemophilus influenza antibdy,86684,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23.76,,,,,,,fee schedule,23.76,66.08, Hemophilus influenza antibdy,86684,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,23.76,,,,,,,fee schedule,23.76,66.08, Htlv-i antibody,86687,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,37.92,,,,,,,fee schedule,13.64,37.92, Htlv-i antibody,86687,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13.64,,,,,,,fee schedule,13.64,37.92, Htlv-i antibody,86687,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13.64,,,,,,,fee schedule,13.64,37.92, Htlv-ii antibody,86688,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,58.41,,,,,,,fee schedule,21,58.41, Htlv-ii antibody,86688,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21,,,,,,,fee schedule,21,58.41, Htlv-ii antibody,86688,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,21,,,,,,,fee schedule,21,58.41, Htlv/hiv confirmj antibody,86689,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,80.73,,,,,,,fee schedule,29.03,80.73, Htlv/hiv confirmj antibody,86689,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,29.03,,,,,,,fee schedule,29.03,80.73, Htlv/hiv confirmj antibody,86689,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,29.03,,,,,,,fee schedule,29.03,80.73, Hepatitis delta agent antbdy,86692,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,71.59,,,,,,,fee schedule,25.74,71.59, Hepatitis delta agent antbdy,86692,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25.74,,,,,,,fee schedule,25.74,71.59, Hepatitis delta agent antbdy,86692,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,25.74,,,,,,,fee schedule,25.74,71.59, Herpes simplex nes antbdy,86694,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,60.04,,,,,,,fee schedule,21.59,60.04, Herpes simplex nes antbdy,86694,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21.59,,,,,,,fee schedule,21.59,60.04, Herpes simplex nes antbdy,86694,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,21.59,,,,,,,fee schedule,21.59,60.04, Herpes simplex type 1 test,86695,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,55.03,,,,,,,fee schedule,19.79,55.03, Herpes simplex type 1 test,86695,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.79,,,,,,,fee schedule,19.79,55.03, Herpes simplex type 1 test,86695,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19.79,,,,,,,fee schedule,19.79,55.03, Herpes simplex type 2 test,86696,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,80.73,,,,,,,fee schedule,29.03,80.73, Herpes simplex type 2 test,86696,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,29.03,,,,,,,fee schedule,29.03,80.73, Herpes simplex type 2 test,86696,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,29.03,,,,,,,fee schedule,29.03,80.73, Histoplasma antibody,86698,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,57.53,,,,,,,fee schedule,20.69,57.53, Histoplasma antibody,86698,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,20.69,,,,,,,fee schedule,20.69,57.53, Histoplasma antibody,86698,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,20.69,,,,,,,fee schedule,20.69,57.53, Hiv-1antibody,86701,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,37.09,,,,,,,fee schedule,13.34,37.09, Hiv-1antibody,86701,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13.34,,,,,,,fee schedule,13.34,37.09, Hiv-1antibody,86701,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13.34,,,,,,,fee schedule,13.34,37.09, Hiv-2 antibody,86702,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,56.41,,,,,,,fee schedule,20.28,56.41, Hiv-2 antibody,86702,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,20.28,,,,,,,fee schedule,20.28,56.41, Hiv-2 antibody,86702,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,20.28,,,,,,,fee schedule,20.28,56.41, Hiv-1/hiv-2 1 result antbdy,86703,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,57.2,,,,,,,fee schedule,20.57,57.2, Hiv-1/hiv-2 1 result antbdy,86703,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,20.57,,,,,,,fee schedule,20.57,57.2, Hiv-1/hiv-2 1 result antbdy,86703,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,20.57,,,,,,,fee schedule,20.57,57.2, Hep b core antibody total,86704,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,50.27,,,,,,,fee schedule,18.08,50.27, Hep b core antibody total,86704,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.08,,,,,,,fee schedule,18.08,50.27, Hep b core antibody total,86704,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,18.08,,,,,,,fee schedule,18.08,50.27, Hep b core antibody igm,86705,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,49.1,,,,,,,fee schedule,17.66,49.1, Hep b core antibody igm,86705,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.66,,,,,,,fee schedule,17.66,49.1, Hep b core antibody igm,86705,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,17.66,,,,,,,fee schedule,17.66,49.1, Hep b surface antibody,86706,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,44.81,,,,,,,fee schedule,16.11,44.81, Hep b surface antibody,86706,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.11,,,,,,,fee schedule,16.11,44.81, Hep b surface antibody,86706,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,16.11,,,,,,,fee schedule,16.11,44.81, Hepatitis be antibody,86707,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,48.27,,,,,,,fee schedule,17.36,48.27, Hepatitis be antibody,86707,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.36,,,,,,,fee schedule,17.36,48.27, Hepatitis be antibody,86707,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,17.36,,,,,,,fee schedule,17.36,48.27, Hepatitis a antibody,86708,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,51.69,,,,,,,fee schedule,18.59,51.69, Hepatitis a antibody,86708,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.59,,,,,,,fee schedule,18.59,51.69, Hepatitis a antibody,86708,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,18.59,,,,,,,fee schedule,18.59,51.69, Hepatitis a igm antibody,86709,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,46.98,,,,,,,fee schedule,16.89,46.98, Hepatitis a igm antibody,86709,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.89,,,,,,,fee schedule,16.89,46.98, Hepatitis a igm antibody,86709,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,16.89,,,,,,,fee schedule,16.89,46.98, Influenza virus antibody,86710,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,56.53,,,,,,,fee schedule,20.33,56.53, Influenza virus antibody,86710,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,20.33,,,,,,,fee schedule,20.33,56.53, Influenza virus antibody,86710,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,20.33,,,,,,,fee schedule,20.33,56.53, John cunningham antibody,86711,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,70.47,,,,,,,fee schedule,25.34,70.47, John cunningham antibody,86711,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25.34,,,,,,,fee schedule,25.34,70.47, John cunningham antibody,86711,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,25.34,,,,,,,fee schedule,25.34,70.47, Legionella antibody,86713,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,63.83,,,,,,,fee schedule,22.95,63.83, Legionella antibody,86713,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22.95,,,,,,,fee schedule,22.95,63.83, Legionella antibody,86713,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22.95,,,,,,,fee schedule,22.95,63.83, Leishmania antibody,86717,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,51.11,,,,,,,fee schedule,18.38,51.11, Leishmania antibody,86717,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.38,,,,,,,fee schedule,18.38,51.11, Leishmania antibody,86717,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,18.38,,,,,,,fee schedule,18.38,51.11, Leptospira antibody,86720,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,67.59,,,,,,,fee schedule,24.3,67.59, Leptospira antibody,86720,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24.3,,,,,,,fee schedule,24.3,67.59, Leptospira antibody,86720,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,24.3,,,,,,,fee schedule,24.3,67.59, Listeria monocytogenes,86723,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,55.03,,,,,,,fee schedule,19.79,55.03, Listeria monocytogenes,86723,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.79,,,,,,,fee schedule,19.79,55.03, Listeria monocytogenes,86723,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19.79,,,,,,,fee schedule,19.79,55.03, Lymph choriomeningitis ab,86727,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,53.69,,,,,,,fee schedule,19.31,53.69, Lymph choriomeningitis ab,86727,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.31,,,,,,,fee schedule,19.31,53.69, Lymph choriomeningitis ab,86727,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19.31,,,,,,,fee schedule,19.31,53.69, Mucormycosis antibody,86732,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,62.58,,,,,,,fee schedule,22.5,62.58, Mucormycosis antibody,86732,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22.5,,,,,,,fee schedule,22.5,62.58, Mucormycosis antibody,86732,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22.5,,,,,,,fee schedule,22.5,62.58, Mumps antibody,86735,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,54.44,,,,,,,fee schedule,19.58,54.44, Mumps antibody,86735,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.58,,,,,,,fee schedule,19.58,54.44, Mumps antibody,86735,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19.58,,,,,,,fee schedule,19.58,54.44, Mycoplasma antibody,86738,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,55.24,,,,,,,fee schedule,19.86,55.24, Mycoplasma antibody,86738,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.86,,,,,,,fee schedule,19.86,55.24, Mycoplasma antibody,86738,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19.86,,,,,,,fee schedule,19.86,55.24, Neisseria meningitidis,86741,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,55.03,,,,,,,fee schedule,19.79,55.03, Neisseria meningitidis,86741,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.79,,,,,,,fee schedule,19.79,55.03, Neisseria meningitidis,86741,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19.79,,,,,,,fee schedule,19.79,55.03, Nocardia antibody,86744,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,66.71,,,,,,,fee schedule,23.99,66.71, Nocardia antibody,86744,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23.99,,,,,,,fee schedule,23.99,66.71, Nocardia antibody,86744,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,23.99,,,,,,,fee schedule,23.99,66.71, Parvovirus antibody,86747,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,62.71,,,,,,,fee schedule,22.55,62.71, Parvovirus antibody,86747,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22.55,,,,,,,fee schedule,22.55,62.71, Parvovirus antibody,86747,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22.55,,,,,,,fee schedule,22.55,62.71, Malaria antibody,86750,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,55.03,,,,,,,fee schedule,19.79,55.03, Malaria antibody,86750,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.79,,,,,,,fee schedule,19.79,55.03, Malaria antibody,86750,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19.79,,,,,,,fee schedule,19.79,55.03, Protozoa antibody nos,86753,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,51.69,,,,,,,fee schedule,18.59,51.69, Protozoa antibody nos,86753,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.59,,,,,,,fee schedule,18.59,51.69, Protozoa antibody nos,86753,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,18.59,,,,,,,fee schedule,18.59,51.69, Respiratory virus antibody,86756,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,66.29,,,,,,,fee schedule,23.84,66.29, Respiratory virus antibody,86756,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23.84,,,,,,,fee schedule,23.84,66.29, Respiratory virus antibody,86756,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,23.84,,,,,,,fee schedule,23.84,66.29, Rickettsia Antibody,86757,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,80.73,,,,,,,fee schedule,29.03,80.73, Rickettsia Antibody,86757,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,29.03,,,,,,,fee schedule,29.03,80.73, Rickettsia Antibody,86757,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,29.03,,,,,,,fee schedule,29.03,80.73, Rotavirus antibody,86759,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,76.06,,,,,,,fee schedule,27.35,76.06, Rotavirus antibody,86759,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,27.35,,,,,,,fee schedule,27.35,76.06, Rotavirus antibody,86759,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,27.35,,,,,,,fee schedule,27.35,76.06, Rubella antibody,86762,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,60.04,,,,,,,fee schedule,21.59,60.04, Rubella antibody,86762,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21.59,,,,,,,fee schedule,21.59,60.04, Rubella antibody,86762,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,21.59,,,,,,,fee schedule,21.59,60.04, Rubeola antibody,86765,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,53.74,,,,,,,fee schedule,19.32,53.74, Rubeola antibody,86765,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.32,,,,,,,fee schedule,19.32,53.74, Rubeola antibody,86765,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19.32,,,,,,,fee schedule,19.32,53.74, Salmonella antibody,86768,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,55.03,,,,,,,fee schedule,19.79,55.03, Salmonella antibody,86768,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.79,,,,,,,fee schedule,19.79,55.03, Salmonella antibody,86768,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19.79,,,,,,,fee schedule,19.79,55.03, Sars-cov-2 covid-19 antibody,86769,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,175.77,,,,,,,fee schedule,63.2,175.77, Sars-cov-2 covid-19 antibody,86769,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,63.2,,,,,,,fee schedule,63.2,175.77, Sars-cov-2 covid-19 antibody,86769,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,63.2,,,,,,,fee schedule,63.2,175.77, Shigella antibody,86771,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,102.13,,,,,,,fee schedule,36.72,102.13, Shigella antibody,86771,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,36.72,,,,,,,fee schedule,36.72,102.13, Shigella antibody,86771,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,36.72,,,,,,,fee schedule,36.72,102.13, Tetanus antibody,86774,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,61.75,,,,,,,fee schedule,22.2,61.75, Tetanus antibody,86774,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22.2,,,,,,,fee schedule,22.2,61.75, Tetanus antibody,86774,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22.2,,,,,,,fee schedule,22.2,61.75, Toxoplasma antibody,86777,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,60.04,,,,,,,fee schedule,21.59,60.04, Toxoplasma antibody,86777,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21.59,,,,,,,fee schedule,21.59,60.04, Toxoplasma antibody,86777,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,21.59,,,,,,,fee schedule,21.59,60.04, Toxoplasma antibody igm,86778,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,60.12,,,,,,,fee schedule,21.62,60.12, Toxoplasma antibody igm,86778,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21.62,,,,,,,fee schedule,21.62,60.12, Toxoplasma antibody igm,86778,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,21.62,,,,,,,fee schedule,21.62,60.12, Treponema pallidum,86780,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,55.24,,,,,,,fee schedule,19.86,55.24, Treponema pallidum,86780,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.86,,,,,,,fee schedule,19.86,55.24, Treponema pallidum,86780,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19.86,,,,,,,fee schedule,19.86,55.24, Trichinella antibody,86784,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,52.4,,,,,,,fee schedule,18.84,52.4, Trichinella antibody,86784,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.84,,,,,,,fee schedule,18.84,52.4, Trichinella antibody,86784,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,18.84,,,,,,,fee schedule,18.84,52.4, Varicella-zoster antibody,86787,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,53.74,,,,,,,fee schedule,19.32,53.74, Varicella-zoster antibody,86787,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.32,,,,,,,fee schedule,19.32,53.74, Varicella-zoster antibody,86787,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19.32,,,,,,,fee schedule,19.32,53.74, West nile virus ab igm,86788,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,70.3,,,,,,,fee schedule,25.28,70.3, West nile virus ab igm,86788,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25.28,,,,,,,fee schedule,25.28,70.3, West nile virus ab igm,86788,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,25.28,,,,,,,fee schedule,25.28,70.3, West Nile Virus Antibody,86789,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,60.04,,,,,,,fee schedule,21.59,60.04, West Nile Virus Antibody,86789,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21.59,,,,,,,fee schedule,21.59,60.04, West Nile Virus Antibody,86789,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,21.59,,,,,,,fee schedule,21.59,60.04, Virus antibody nos,86790,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,53.74,,,,,,,fee schedule,19.32,53.74, Virus antibody nos,86790,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.32,,,,,,,fee schedule,19.32,53.74, Virus antibody nos,86790,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19.32,,,,,,,fee schedule,19.32,53.74, Yersinia antibody,86793,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,55.03,,,,,,,fee schedule,19.79,55.03, Yersinia antibody,86793,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.79,,,,,,,fee schedule,19.79,55.03, Yersinia antibody,86793,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19.79,,,,,,,fee schedule,19.79,55.03, Zika virus igm antibody,86794,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,70.3,,,,,,,fee schedule,25.28,70.3, Zika virus igm antibody,86794,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25.28,,,,,,,fee schedule,25.28,70.3, Zika virus igm antibody,86794,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,25.28,,,,,,,fee schedule,25.28,70.3, Thyroglobulin antibody,86800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,66.38,,,,,,,fee schedule,23.87,66.38, Thyroglobulin antibody,86800,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23.87,,,,,,,fee schedule,23.87,66.38, Thyroglobulin antibody,86800,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,23.87,,,,,,,fee schedule,23.87,66.38, Hepatitis c ab test,86803,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,59.53,,,,,,,fee schedule,21.41,59.53, Hepatitis c ab test,86803,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21.41,,,,,,,fee schedule,21.41,59.53, Hepatitis c ab test,86803,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,21.41,,,,,,,fee schedule,21.41,59.53, Hep c ab test confirm,86804,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,64.62,,,,,,,fee schedule,23.24,64.62, Hep c ab test confirm,86804,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23.24,,,,,,,fee schedule,23.24,64.62, Hep c ab test confirm,86804,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,23.24,,,,,,,fee schedule,23.24,64.62, Lymphocytotoxicity assay,86805,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,790.64,,,,,,,fee schedule,284.27,790.64, Lymphocytotoxicity assay,86805,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,284.27,,,,,,,fee schedule,284.27,790.64, Lymphocytotoxicity assay,86805,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,284.27,,,,,,,fee schedule,284.27,790.64, Lymphocytotoxicity assay,86806,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,198.55,,,,,,,fee schedule,71.39,198.55, Lymphocytotoxicity assay,86806,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,71.39,,,,,,,fee schedule,71.39,198.55, Lymphocytotoxicity assay,86806,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,71.39,,,,,,,fee schedule,71.39,198.55, Cytotoxic antibody screening,86807,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,328.13,,,,,,,fee schedule,117.98,328.13, Cytotoxic antibody screening,86807,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,117.98,,,,,,,fee schedule,117.98,328.13, Cytotoxic antibody screening,86807,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,117.98,,,,,,,fee schedule,117.98,328.13, Cytotoxic antibody screening,86808,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,123.82,,,,,,,fee schedule,44.52,123.82, Cytotoxic antibody screening,86808,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,44.52,,,,,,,fee schedule,44.52,123.82, Cytotoxic antibody screening,86808,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,44.52,,,,,,,fee schedule,44.52,123.82, Hla typing a b or c,86812,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,107.68,,,,,,,fee schedule,38.72,107.68, Hla typing a b or c,86812,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,38.72,,,,,,,fee schedule,38.72,107.68, Hla typing a b or c,86812,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,38.72,,,,,,,fee schedule,38.72,107.68, Hla typing a b or c,86813,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,241.98,,,,,,,fee schedule,87,241.98, Hla typing a b or c,86813,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,87,,,,,,,fee schedule,87,241.98, Hla typing a b or c,86813,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,87,,,,,,,fee schedule,87,241.98, Hla typing dr/dq,86816,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,125.87,,,,,,,fee schedule,45.26,125.87, Hla typing dr/dq,86816,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,45.26,,,,,,,fee schedule,45.26,125.87, Hla typing dr/dq,86816,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,45.26,,,,,,,fee schedule,45.26,125.87, Hla typing dr/dq,86817,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,442.82,,,,,,,fee schedule,159.21,442.82, Hla typing dr/dq,86817,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,159.21,,,,,,,fee schedule,159.21,442.82, Hla typing dr/dq,86817,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,159.21,,,,,,,fee schedule,159.21,442.82, Lymphocyte culture mixed,86821,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,152.53,,,,,,,fee schedule,54.84,152.53, Lymphocyte culture mixed,86821,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,54.84,,,,,,,fee schedule,54.84,152.53, Lymphocyte culture mixed,86821,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,54.84,,,,,,,fee schedule,54.84,152.53, Hla x-math non-cytotoxic,86825,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,456.79,,,,,,,fee schedule,164.24,456.79, Hla x-math non-cytotoxic,86825,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,164.24,,,,,,,fee schedule,164.24,456.79, Hla x-math non-cytotoxic,86825,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,164.24,,,,,,,fee schedule,164.24,456.79, Hla x-match noncytotoxc addl,86826,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,152.4,,,,,,,fee schedule,54.8,152.4, Hla x-match noncytotoxc addl,86826,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,54.8,,,,,,,fee schedule,54.8,152.4, Hla x-match noncytotoxc addl,86826,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,54.8,,,,,,,fee schedule,54.8,152.4, Hla class i&ii antibody qual,86828,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,267.8,,,,,,,fee schedule,96.29,267.8, Hla class i&ii antibody qual,86828,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,96.29,,,,,,,fee schedule,96.29,267.8, Hla class i&ii antibody qual,86828,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,96.29,,,,,,,fee schedule,96.29,267.8, Hla class i/ii antibody qual,86829,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,267.8,,,,,,,fee schedule,96.29,267.8, Hla class i/ii antibody qual,86829,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,96.29,,,,,,,fee schedule,96.29,267.8, Hla class i/ii antibody qual,86829,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,96.29,,,,,,,fee schedule,96.29,267.8, Hla class i phenotype qual,86830,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,398.51,,,,,,,fee schedule,143.28,398.51, Hla class i phenotype qual,86830,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,143.28,,,,,,,fee schedule,143.28,398.51, Hla class i phenotype qual,86830,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,143.28,,,,,,,fee schedule,143.28,398.51, Hla class ii phenotype qual,86831,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,341.6,,,,,,,fee schedule,122.82,341.6, Hla class ii phenotype qual,86831,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,122.82,,,,,,,fee schedule,122.82,341.6, Hla class ii phenotype qual,86831,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,122.82,,,,,,,fee schedule,122.82,341.6, Hla class i high defin qual,86832,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1350.69,,,,,,,fee schedule,485.63,1350.69, Hla class i high defin qual,86832,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,485.63,,,,,,,fee schedule,485.63,1350.69, Hla class i high defin qual,86832,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,485.63,,,,,,,fee schedule,485.63,1350.69, Hla class ii high defin qual,86833,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1359.24,,,,,,,fee schedule,488.7,1359.24, Hla class ii high defin qual,86833,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,488.7,,,,,,,fee schedule,488.7,1359.24, Hla class ii high defin qual,86833,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,488.7,,,,,,,fee schedule,488.7,1359.24, Hla class i semiquant panel,86834,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1491.74,,,,,,,fee schedule,536.34,1491.74, Hla class i semiquant panel,86834,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,536.34,,,,,,,fee schedule,536.34,1491.74, Hla class i semiquant panel,86834,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,536.34,,,,,,,fee schedule,536.34,1491.74, Hla class ii semiquant panel,86835,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1347.39,,,,,,,fee schedule,484.44,1347.39, Hla class ii semiquant panel,86835,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,484.44,,,,,,,fee schedule,484.44,1347.39, Hla class ii semiquant panel,86835,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,484.44,,,,,,,fee schedule,484.44,1347.39, RBC antibody screen,86850,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,40.76,,,,,,,fee schedule,14.66,40.76, RBC antibody screen,86850,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.66,,,,,,,fee schedule,14.66,40.76, RBC antibody screen,86850,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,14.66,,,,,,,fee schedule,14.66,40.76, RBC antibody elution,86860,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,215.25,,,,,,,fee schedule,215.25,215.25, RBC antibody elution,86860,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,215.25,,,,,,,fee schedule,215.25,215.25, RBC antibody identification,86870,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,425.12,,,,,,,fee schedule,425.12,425.12, RBC antibody identification,86870,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,425.12,,,,,,,fee schedule,425.12,425.12, Coombs test direct,86880,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,22.49,,,,,,,fee schedule,8.09,22.49, Coombs test direct,86880,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.09,,,,,,,fee schedule,8.09,22.49, Coombs test direct,86880,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,8.09,,,,,,,fee schedule,8.09,22.49, Coombs test indirect qual,86885,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,23.86,,,,,,,fee schedule,8.58,23.86, Coombs test indirect qual,86885,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.58,,,,,,,fee schedule,8.58,23.86, Coombs test indirect qual,86885,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,8.58,,,,,,,fee schedule,8.58,23.86, Coombs test indirect titer,86886,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,21.61,,,,,,,fee schedule,7.77,21.61, Coombs test indirect titer,86886,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.77,,,,,,,fee schedule,7.77,21.61, Coombs test indirect titer,86886,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,7.77,,,,,,,fee schedule,7.77,21.61, Autologous blood process,86890,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,215.25,,,,,,,fee schedule,215.25,215.25, Autologous blood process,86890,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,215.25,,,,,,,fee schedule,215.25,215.25, Autologous blood op salvage,86891,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,942.3,,,,,,,fee schedule,942.3,942.3, Autologous blood op salvage,86891,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,942.3,,,,,,,fee schedule,942.3,942.3, Blood typing serologic abo,86900,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12.47,,,,,,,fee schedule,4.49,12.47, Blood typing serologic abo,86900,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.49,,,,,,,fee schedule,4.49,12.47, Blood typing serologic abo,86900,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4.49,,,,,,,fee schedule,4.49,12.47, Blood typing serologic rh(d),86901,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12.47,,,,,,,fee schedule,4.49,12.47, Blood typing serologic rh(d),86901,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.49,,,,,,,fee schedule,4.49,12.47, Blood typing serologic rh(d),86901,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4.49,,,,,,,fee schedule,4.49,12.47, Blood type antigen donor ea,86902,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,26.49,,,,,,,fee schedule,9.53,26.49, Blood type antigen donor ea,86902,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.53,,,,,,,fee schedule,9.53,26.49, Blood type antigen donor ea,86902,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9.53,,,,,,,fee schedule,9.53,26.49, Blood typing patient serum,86904,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,68.17,,,,,,,fee schedule,24.51,68.17, Blood typing patient serum,86904,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24.51,,,,,,,fee schedule,24.51,68.17, Blood typing patient serum,86904,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,24.51,,,,,,,fee schedule,24.51,68.17, Blood typing rbc antigens,86905,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,15.98,,,,,,,fee schedule,5.75,15.98, Blood typing rbc antigens,86905,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.75,,,,,,,fee schedule,5.75,15.98, Blood typing rbc antigens,86905,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5.75,,,,,,,fee schedule,5.75,15.98, Bld typing serologic rh phnt,86906,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,32.33,,,,,,,fee schedule,11.63,32.33, Bld typing serologic rh phnt,86906,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.63,,,,,,,fee schedule,11.63,32.33, Bld typing serologic rh phnt,86906,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11.63,,,,,,,fee schedule,11.63,32.33, Blood typing paternity test,86910,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,40.07,,,,,,,fee schedule,40.07,40.07, Blood typing paternity test,86910,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,40.07,,,,,,,fee schedule,40.07,40.07, Blood typing antigen system,86911,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,34.65,,,,,,,fee schedule,34.65,34.65, Blood typing antigen system,86911,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,34.65,,,,,,,fee schedule,34.65,34.65, Compatibility test spin,86920,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,215.25,,,,,,,fee schedule,215.25,215.25, Compatibility test spin,86920,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,215.25,,,,,,,fee schedule,215.25,215.25, Compatibility test incubate,86921,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,215.25,,,,,,,fee schedule,215.25,215.25, Compatibility test incubate,86921,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,215.25,,,,,,,fee schedule,215.25,215.25, Compatibility test antiglob,86922,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,215.25,,,,,,,fee schedule,215.25,215.25, Compatibility test antiglob,86922,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,215.25,,,,,,,fee schedule,215.25,215.25, Compatibility test electric,86923,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,215.25,,,,,,,fee schedule,215.25,215.25, Compatibility test electric,86923,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,215.25,,,,,,,fee schedule,215.25,215.25, Plasma fresh frozen,86927,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,215.25,,,,,,,fee schedule,215.25,215.25, Plasma fresh frozen,86927,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,215.25,,,,,,,fee schedule,215.25,215.25, Frozen blood prep,86930,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,425.12,,,,,,,fee schedule,425.12,425.12, Frozen blood prep,86930,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,425.12,,,,,,,fee schedule,425.12,425.12, Frozen blood thaw,86931,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,425.12,,,,,,,fee schedule,425.12,425.12, Frozen blood thaw,86931,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,425.12,,,,,,,fee schedule,425.12,425.12, Frozen blood freeze/thaw,86932,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,50.15,,,,,,,fee schedule,50.15,50.15, Frozen blood freeze/thaw,86932,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,50.15,,,,,,,fee schedule,50.15,50.15, Hemolysins/agglutinins auto,86940,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,36.59,,,,,,,fee schedule,13.16,36.59, Hemolysins/agglutinins auto,86940,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13.16,,,,,,,fee schedule,13.16,36.59, Hemolysins/agglutinins auto,86940,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13.16,,,,,,,fee schedule,13.16,36.59, Hemolysins/agglutinins,86941,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,50.52,,,,,,,fee schedule,18.17,50.52, Hemolysins/agglutinins,86941,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.17,,,,,,,fee schedule,18.17,50.52, Hemolysins/agglutinins,86941,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,18.17,,,,,,,fee schedule,18.17,50.52, Blood product/irradiation,86945,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,50.15,,,,,,,fee schedule,50.15,50.15, Blood product/irradiation,86945,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,50.15,,,,,,,fee schedule,50.15,50.15, Leukacyte transfusion,86950,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,215.25,,,,,,,fee schedule,215.25,215.25, Leukacyte transfusion,86950,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,215.25,,,,,,,fee schedule,215.25,215.25, Vol reduction of blood/prod,86960,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,215.25,,,,,,,fee schedule,215.25,215.25, Vol reduction of blood/prod,86960,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,215.25,,,,,,,fee schedule,215.25,215.25, Pooling blood platelets,86965,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,215.25,,,,,,,fee schedule,215.25,215.25, Pooling blood platelets,86965,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,215.25,,,,,,,fee schedule,215.25,215.25, Rbc pretx incubatj w/chemicl,86970,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,50.15,,,,,,,fee schedule,50.15,50.15, Rbc pretx incubatj w/chemicl,86970,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,50.15,,,,,,,fee schedule,50.15,50.15, Rbc pretx incubatj w/enzymes,86971,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,425.12,,,,,,,fee schedule,425.12,425.12, Rbc pretx incubatj w/enzymes,86971,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,425.12,,,,,,,fee schedule,425.12,425.12, Rbc pretx incubatj w/density,86972,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,215.25,,,,,,,fee schedule,215.25,215.25, Rbc pretx incubatj w/density,86972,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,215.25,,,,,,,fee schedule,215.25,215.25, Rbc serum pretx incubj drugs,86975,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,163.55,,,,,,,fee schedule,163.55,163.55, Rbc serum pretx incubj drugs,86975,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,163.55,,,,,,,fee schedule,163.55,163.55, Rbc serum pretx id dilution,86976,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,34.49,,,,,,,fee schedule,34.49,34.49, Rbc serum pretx id dilution,86976,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,34.49,,,,,,,fee schedule,34.49,34.49, Rbc serum pretx incubj/inhib,86977,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,215.25,,,,,,,fee schedule,215.25,215.25, Rbc serum pretx incubj/inhib,86977,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,215.25,,,,,,,fee schedule,215.25,215.25, Rbc pretreatment serum,86978,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,50.15,,,,,,,fee schedule,50.15,50.15, Rbc pretreatment serum,86978,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,50.15,,,,,,,fee schedule,50.15,50.15, Split blood or products,86985,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,215.25,,,,,,,fee schedule,215.25,215.25, Split blood or products,86985,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,215.25,,,,,,,fee schedule,215.25,215.25, Transfusion procedure,86999,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,34.49,,,,,,,fee schedule,34.49,34.49, Transfusion procedure,86999,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,34.49,,,,,,,fee schedule,34.49,34.49, Small animal inoculation,87003,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,70.26,,,,,,,fee schedule,25.26,70.26, Small animal inoculation,87003,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25.26,,,,,,,fee schedule,25.26,70.26, Small animal inoculation,87003,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,25.26,,,,,,,fee schedule,25.26,70.26, Specimen infect agnt concntj,87015,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,27.87,,,,,,,fee schedule,10.02,27.87, Specimen infect agnt concntj,87015,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.02,,,,,,,fee schedule,10.02,27.87, Specimen infect agnt concntj,87015,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,10.02,,,,,,,fee schedule,10.02,27.87, Blood culture for bacteria,87040,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,43.06,,,,,,,fee schedule,15.48,43.06, Blood culture for bacteria,87040,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.48,,,,,,,fee schedule,15.48,43.06, Blood culture for bacteria,87040,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,15.48,,,,,,,fee schedule,15.48,43.06, Feces culture aerobic bact,87045,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,39.38,,,,,,,fee schedule,14.16,39.38, Feces culture aerobic bact,87045,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.16,,,,,,,fee schedule,14.16,39.38, Feces culture aerobic bact,87045,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,14.16,,,,,,,fee schedule,14.16,39.38, Stool cultr aerobic bact ea,87046,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,39.38,,,,,,,fee schedule,14.16,39.38, Stool cultr aerobic bact ea,87046,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.16,,,,,,,fee schedule,14.16,39.38, Stool cultr aerobic bact ea,87046,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,14.16,,,,,,,fee schedule,14.16,39.38, Culture othr specimn aerobic,87070,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,35.96,,,,,,,fee schedule,12.93,35.96, Culture othr specimn aerobic,87070,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.93,,,,,,,fee schedule,12.93,35.96, Culture othr specimn aerobic,87070,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,12.93,,,,,,,fee schedule,12.93,35.96, Culture aerobic quant other,87071,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,41.26,,,,,,,fee schedule,14.84,41.26, Culture aerobic quant other,87071,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.84,,,,,,,fee schedule,14.84,41.26, Culture aerobic quant other,87071,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,14.84,,,,,,,fee schedule,14.84,41.26, Culture Bacteria Anaerobic,87073,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,40.3,,,,,,,fee schedule,14.49,40.3, Culture Bacteria Anaerobic,87073,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.49,,,,,,,fee schedule,14.49,40.3, Culture Bacteria Anaerobic,87073,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,14.49,,,,,,,fee schedule,14.49,40.3, Cultr bacteria except blood,87075,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,39.51,,,,,,,fee schedule,14.21,39.51, Cultr bacteria except blood,87075,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.21,,,,,,,fee schedule,14.21,39.51, Cultr bacteria except blood,87075,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,14.21,,,,,,,fee schedule,14.21,39.51, Culture anaerobe ident each,87076,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,33.71,,,,,,,fee schedule,12.12,33.71, Culture anaerobe ident each,87076,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.12,,,,,,,fee schedule,12.12,33.71, Culture anaerobe ident each,87076,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,12.12,,,,,,,fee schedule,12.12,33.71, Culture Aerobic Identify,87077,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,33.71,,,,,,,fee schedule,12.12,33.71, Culture Aerobic Identify,87077,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.12,,,,,,,fee schedule,12.12,33.71, Culture Aerobic Identify,87077,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,12.12,,,,,,,fee schedule,12.12,33.71, Culture screen only,87081,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,27.66,,,,,,,fee schedule,9.95,27.66, Culture screen only,87081,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.95,,,,,,,fee schedule,9.95,27.66, Culture screen only,87081,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9.95,,,,,,,fee schedule,9.95,27.66, Culture of specimen by kit,87084,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,112.94,,,,,,,fee schedule,40.61,112.94, Culture of specimen by kit,87084,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,40.61,,,,,,,fee schedule,40.61,112.94, Culture of specimen by kit,87084,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,40.61,,,,,,,fee schedule,40.61,112.94, Urine culture/colony count,87086,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,33.67,,,,,,,fee schedule,12.11,33.67, Urine culture/colony count,87086,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.11,,,,,,,fee schedule,12.11,33.67, Urine culture/colony count,87086,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,12.11,,,,,,,fee schedule,12.11,33.67, Urine bacteria culture,87088,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,33.75,,,,,,,fee schedule,12.14,33.75, Urine bacteria culture,87088,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.14,,,,,,,fee schedule,12.14,33.75, Urine bacteria culture,87088,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,12.14,,,,,,,fee schedule,12.14,33.75, Skin fungi culture,87101,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,32.17,,,,,,,fee schedule,11.57,32.17, Skin fungi culture,87101,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.57,,,,,,,fee schedule,11.57,32.17, Skin fungi culture,87101,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11.57,,,,,,,fee schedule,11.57,32.17, Fungus isolation culture,87102,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,35.09,,,,,,,fee schedule,12.62,35.09, Fungus isolation culture,87102,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.62,,,,,,,fee schedule,12.62,35.09, Fungus isolation culture,87102,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,12.62,,,,,,,fee schedule,12.62,35.09, Blood fungus culture,87103,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,85.36,,,,,,,fee schedule,30.69,85.36, Blood fungus culture,87103,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,30.69,,,,,,,fee schedule,30.69,85.36, Blood fungus culture,87103,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,30.69,,,,,,,fee schedule,30.69,85.36, Fungi identification yeast,87106,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,43.06,,,,,,,fee schedule,15.48,43.06, Fungi identification yeast,87106,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.48,,,,,,,fee schedule,15.48,43.06, Fungi identification yeast,87106,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,15.48,,,,,,,fee schedule,15.48,43.06, Fungi identification mold,87107,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,43.06,,,,,,,fee schedule,15.48,43.06, Fungi identification mold,87107,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.48,,,,,,,fee schedule,15.48,43.06, Fungi identification mold,87107,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,15.48,,,,,,,fee schedule,15.48,43.06, Mycoplasma,87109,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,64.21,,,,,,,fee schedule,23.09,64.21, Mycoplasma,87109,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23.09,,,,,,,fee schedule,23.09,64.21, Mycoplasma,87109,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,23.09,,,,,,,fee schedule,23.09,64.21, Chlamydia culture,87110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,81.77,,,,,,,fee schedule,29.4,81.77, Chlamydia culture,87110,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,29.4,,,,,,,fee schedule,29.4,81.77, Chlamydia culture,87110,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,29.4,,,,,,,fee schedule,29.4,81.77, Mycobacteria culture,87116,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,45.06,,,,,,,fee schedule,16.2,45.06, Mycobacteria culture,87116,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.2,,,,,,,fee schedule,16.2,45.06, Mycobacteria culture,87116,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,16.2,,,,,,,fee schedule,16.2,45.06, Mycobacteric identification,87118,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,60.95,,,,,,,fee schedule,21.92,60.95, Mycobacteric identification,87118,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21.92,,,,,,,fee schedule,21.92,60.95, Mycobacteric identification,87118,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,21.92,,,,,,,fee schedule,21.92,60.95, Culture type immunofluoresc,87140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,23.24,,,,,,,fee schedule,8.36,23.24, Culture type immunofluoresc,87140,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.36,,,,,,,fee schedule,8.36,23.24, Culture type immunofluoresc,87140,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,8.36,,,,,,,fee schedule,8.36,23.24, Culture typing glc/hplc,87143,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,52.23,,,,,,,fee schedule,18.78,52.23, Culture typing glc/hplc,87143,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.78,,,,,,,fee schedule,18.78,52.23, Culture typing glc/hplc,87143,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,18.78,,,,,,,fee schedule,18.78,52.23, Culture type immunologic,87147,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,21.61,,,,,,,fee schedule,7.77,21.61, Culture type immunologic,87147,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.77,,,,,,,fee schedule,7.77,21.61, Culture type immunologic,87147,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,7.77,,,,,,,fee schedule,7.77,21.61, Dna/rna direct probe,87149,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,83.65,,,,,,,fee schedule,30.08,83.65, Dna/rna direct probe,87149,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,30.08,,,,,,,fee schedule,30.08,83.65, Dna/rna direct probe,87149,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,30.08,,,,,,,fee schedule,30.08,83.65, Dna/rna amplified probe,87150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,146.4,,,,,,,fee schedule,52.64,146.4, Dna/rna amplified probe,87150,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,52.64,,,,,,,fee schedule,52.64,146.4, Dna/rna amplified probe,87150,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,52.64,,,,,,,fee schedule,52.64,146.4, Culture Type Pulse Field Gel,87152,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,32.29,,,,,,,fee schedule,11.61,32.29, Culture Type Pulse Field Gel,87152,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.61,,,,,,,fee schedule,11.61,32.29, Culture Type Pulse Field Gel,87152,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11.61,,,,,,,fee schedule,11.61,32.29, Dna/rna sequencing,87153,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,481.28,,,,,,,fee schedule,173.04,481.28, Dna/rna sequencing,87153,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,173.04,,,,,,,fee schedule,173.04,481.28, Dna/rna sequencing,87153,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,173.04,,,,,,,fee schedule,173.04,481.28, Cul typ id bld pthgn 6+ trgt,87154,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,909.75,,,,,,,fee schedule,327.09,909.75, Cul typ id bld pthgn 6+ trgt,87154,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,327.09,,,,,,,fee schedule,327.09,909.75, Cul typ id bld pthgn 6+ trgt,87154,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,327.09,,,,,,,fee schedule,327.09,909.75, Culture typing added method,87158,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,32.29,,,,,,,fee schedule,11.61,32.29, Culture typing added method,87158,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.61,,,,,,,fee schedule,11.61,32.29, Culture typing added method,87158,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11.61,,,,,,,fee schedule,11.61,32.29, Dark field examination,87164,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,44.81,,,,,,,fee schedule,16.11,44.81, Dark field examination,87164,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.11,,,,,,,fee schedule,16.11,44.81, Dark field examination,87164,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,16.11,,,,,,,fee schedule,16.11,44.81, Dark field examination,87166,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,47.14,,,,,,,fee schedule,16.95,47.14, Dark field examination,87166,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.95,,,,,,,fee schedule,16.95,47.14, Dark field examination,87166,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,16.95,,,,,,,fee schedule,16.95,47.14, Macroscopic Exam Arthropod,87168,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,17.81,,,,,,,fee schedule,6.41,17.81, Macroscopic Exam Arthropod,87168,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.41,,,,,,,fee schedule,6.41,17.81, Macroscopic Exam Arthropod,87168,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,6.41,,,,,,,fee schedule,6.41,17.81, Macroscopic exam parasite,87169,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,17.98,,,,,,,fee schedule,6.47,17.98, Macroscopic exam parasite,87169,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.47,,,,,,,fee schedule,6.47,17.98, Macroscopic exam parasite,87169,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,6.47,,,,,,,fee schedule,6.47,17.98, Pinworm Exam,87172,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,17.81,,,,,,,fee schedule,6.41,17.81, Pinworm Exam,87172,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.41,,,,,,,fee schedule,6.41,17.81, Pinworm Exam,87172,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,6.41,,,,,,,fee schedule,6.41,17.81, Tissue homogenization cultr,87176,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,24.53,,,,,,,fee schedule,8.82,24.53, Tissue homogenization cultr,87176,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.82,,,,,,,fee schedule,8.82,24.53, Tissue homogenization cultr,87176,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,8.82,,,,,,,fee schedule,8.82,24.53, Ova and parasites smears,87177,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,37.13,,,,,,,fee schedule,13.35,37.13, Ova and parasites smears,87177,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13.35,,,,,,,fee schedule,13.35,37.13, Ova and parasites smears,87177,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13.35,,,,,,,fee schedule,13.35,37.13, Microbe susceptible diffuse,87181,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,19.82,,,,,,,fee schedule,7.13,19.82, Microbe susceptible diffuse,87181,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.13,,,,,,,fee schedule,7.13,19.82, Microbe susceptible diffuse,87181,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,7.13,,,,,,,fee schedule,7.13,19.82, Sc std carbapenem resist gen,87183,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,146.4,,,,,,,fee schedule,146.4,146.4, Microbe susceptible disk,87184,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,31.21,,,,,,,fee schedule,11.22,31.21, Microbe susceptible disk,87184,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.22,,,,,,,fee schedule,11.22,31.21, Microbe susceptible disk,87184,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11.22,,,,,,,fee schedule,11.22,31.21, Microbe susceptible enzyme,87185,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,19.82,,,,,,,fee schedule,7.13,19.82, Microbe susceptible enzyme,87185,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.13,,,,,,,fee schedule,7.13,19.82, Microbe susceptible enzyme,87185,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,7.13,,,,,,,fee schedule,7.13,19.82, Microbe susceptible mic,87186,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,36.09,,,,,,,fee schedule,12.98,36.09, Microbe susceptible mic,87186,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.98,,,,,,,fee schedule,12.98,36.09, Microbe susceptible mic,87186,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,12.98,,,,,,,fee schedule,12.98,36.09, Microbe susceptible mlc,87187,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,167.59,,,,,,,fee schedule,60.26,167.59, Microbe susceptible mlc,87187,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,60.26,,,,,,,fee schedule,60.26,167.59, Microbe susceptible mlc,87187,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,60.26,,,,,,,fee schedule,60.26,167.59, Microbe suscept macrobroth,87188,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,27.7,,,,,,,fee schedule,9.96,27.7, Microbe suscept macrobroth,87188,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.96,,,,,,,fee schedule,9.96,27.7, Microbe suscept macrobroth,87188,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9.96,,,,,,,fee schedule,9.96,27.7, Microbe suscept mycobacteri,87190,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,30.5,,,,,,,fee schedule,10.97,30.5, Microbe suscept mycobacteri,87190,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.97,,,,,,,fee schedule,10.97,30.5, Microbe suscept mycobacteri,87190,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,10.97,,,,,,,fee schedule,10.97,30.5, Bactericidal level serum,87197,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,62.66,,,,,,,fee schedule,22.53,62.66, Bactericidal level serum,87197,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22.53,,,,,,,fee schedule,22.53,62.66, Bactericidal level serum,87197,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22.53,,,,,,,fee schedule,22.53,62.66, Smear gram stain,87205,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,17.81,,,,,,,fee schedule,6.41,17.81, Smear gram stain,87205,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.41,,,,,,,fee schedule,6.41,17.81, Smear gram stain,87205,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,6.41,,,,,,,fee schedule,6.41,17.81, Smear fluorescent/acid stai,87206,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,22.49,,,,,,,fee schedule,8.09,22.49, Smear fluorescent/acid stai,87206,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.09,,,,,,,fee schedule,8.09,22.49, Smear fluorescent/acid stai,87206,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,8.09,,,,,,,fee schedule,8.09,22.49, Smear special stain,87207,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,24.99,,,,,,,fee schedule,8.99,24.99, Smear special stain,87207,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.99,,,,,,,fee schedule,8.99,24.99, Smear special stain,87207,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,8.99,,,,,,,fee schedule,8.99,24.99, Smear complex stain,87209,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,75.01,,,,,,,fee schedule,26.97,75.01, Smear complex stain,87209,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26.97,,,,,,,fee schedule,26.97,75.01, Smear complex stain,87209,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,26.97,,,,,,,fee schedule,26.97,75.01, Smear wet mount saline/ink,87210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,24.28,,,,,,,fee schedule,8.73,24.28, Smear wet mount saline/ink,87210,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.73,,,,,,,fee schedule,8.73,24.28, Smear wet mount saline/ink,87210,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,8.73,,,,,,,fee schedule,8.73,24.28, Tissue exam for fungi,87220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,17.81,,,,,,,fee schedule,6.41,17.81, Tissue exam for fungi,87220,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.41,,,,,,,fee schedule,6.41,17.81, Tissue exam for fungi,87220,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,6.41,,,,,,,fee schedule,6.41,17.81, Assay toxin or antitoxin,87230,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,82.36,,,,,,,fee schedule,29.61,82.36, Assay toxin or antitoxin,87230,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,29.61,,,,,,,fee schedule,29.61,82.36, Assay toxin or antitoxin,87230,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,29.61,,,,,,,fee schedule,29.61,82.36, Virus inoculate eggs/animal,87250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,81.6,,,,,,,fee schedule,29.34,81.6, Virus inoculate eggs/animal,87250,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,29.34,,,,,,,fee schedule,29.34,81.6, Virus inoculate eggs/animal,87250,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,29.34,,,,,,,fee schedule,29.34,81.6, Virus inoculation tissue,87252,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,108.76,,,,,,,fee schedule,39.11,108.76, Virus inoculation tissue,87252,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,39.11,,,,,,,fee schedule,39.11,108.76, Virus inoculation tissue,87252,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,39.11,,,,,,,fee schedule,39.11,108.76, Virus inoculate tissue addl,87253,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,84.27,,,,,,,fee schedule,30.3,84.27, Virus inoculate tissue addl,87253,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,30.3,,,,,,,fee schedule,30.3,84.27, Virus inoculate tissue addl,87253,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,30.3,,,,,,,fee schedule,30.3,84.27, Virus inoculation shell via,87254,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,81.6,,,,,,,fee schedule,29.34,81.6, Virus inoculation shell via,87254,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,29.34,,,,,,,fee schedule,29.34,81.6, Virus inoculation shell via,87254,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,29.34,,,,,,,fee schedule,29.34,81.6, Genet virus isolate hsv,87255,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,141.26,,,,,,,fee schedule,50.79,141.26, Genet virus isolate hsv,87255,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,50.79,,,,,,,fee schedule,50.79,141.26, Genet virus isolate hsv,87255,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,50.79,,,,,,,fee schedule,50.79,141.26, Adenovirus ag if,87260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,60.2,,,,,,,fee schedule,21.65,60.2, Adenovirus ag if,87260,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21.65,,,,,,,fee schedule,21.65,60.2, Adenovirus ag if,87260,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,21.65,,,,,,,fee schedule,21.65,60.2, Pertussis ag if,87265,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,49.98,,,,,,,fee schedule,17.97,49.98, Pertussis ag if,87265,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.97,,,,,,,fee schedule,17.97,49.98, Pertussis ag if,87265,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,17.97,,,,,,,fee schedule,17.97,49.98, Enterovirus antibody dfa,87267,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,55.99,,,,,,,fee schedule,20.13,55.99, Enterovirus antibody dfa,87267,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,20.13,,,,,,,fee schedule,20.13,55.99, Enterovirus antibody dfa,87267,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,20.13,,,,,,,fee schedule,20.13,55.99, Giardia ag if,87269,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,56.78,,,,,,,fee schedule,20.42,56.78, Giardia ag if,87269,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,20.42,,,,,,,fee schedule,20.42,56.78, Giardia ag if,87269,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,20.42,,,,,,,fee schedule,20.42,56.78, Chlamydia trachomatis ag if,87270,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,49.98,,,,,,,fee schedule,17.97,49.98, Chlamydia trachomatis ag if,87270,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.97,,,,,,,fee schedule,17.97,49.98, Chlamydia trachomatis ag if,87270,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,17.97,,,,,,,fee schedule,17.97,49.98, Cytomegalovirus dfa,87271,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,55.99,,,,,,,fee schedule,20.13,55.99, Cytomegalovirus dfa,87271,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,20.13,,,,,,,fee schedule,20.13,55.99, Cytomegalovirus dfa,87271,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,20.13,,,,,,,fee schedule,20.13,55.99, Cryptosporidium ag if,87272,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,49.98,,,,,,,fee schedule,17.97,49.98, Cryptosporidium ag if,87272,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.97,,,,,,,fee schedule,17.97,49.98, Cryptosporidium ag if,87272,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,17.97,,,,,,,fee schedule,17.97,49.98, Herpes simplex 2 ag if,87273,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,49.98,,,,,,,fee schedule,17.97,49.98, Herpes simplex 2 ag if,87273,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.97,,,,,,,fee schedule,17.97,49.98, Herpes simplex 2 ag if,87273,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,17.97,,,,,,,fee schedule,17.97,49.98, Herpes simplex 1 ag if,87274,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,49.98,,,,,,,fee schedule,17.97,49.98, Herpes simplex 1 ag if,87274,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.97,,,,,,,fee schedule,17.97,49.98, Herpes simplex 1 ag if,87274,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,17.97,,,,,,,fee schedule,17.97,49.98, Influenza b ag if,87275,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,51.11,,,,,,,fee schedule,18.38,51.11, Influenza b ag if,87275,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.38,,,,,,,fee schedule,18.38,51.11, Influenza b ag if,87275,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,18.38,,,,,,,fee schedule,18.38,51.11, Influenza a ag if,87276,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,67.04,,,,,,,fee schedule,24.11,67.04, Influenza a ag if,87276,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24.11,,,,,,,fee schedule,24.11,67.04, Influenza a ag if,87276,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,24.11,,,,,,,fee schedule,24.11,67.04, Legion pneumophilia ag if,87278,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,65.08,,,,,,,fee schedule,23.4,65.08, Legion pneumophilia ag if,87278,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23.4,,,,,,,fee schedule,23.4,65.08, Legion pneumophilia ag if,87278,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,23.4,,,,,,,fee schedule,23.4,65.08, Parainfluenza ag if,87279,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,68.55,,,,,,,fee schedule,24.65,68.55, Parainfluenza ag if,87279,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24.65,,,,,,,fee schedule,24.65,68.55, Parainfluenza ag if,87279,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,24.65,,,,,,,fee schedule,24.65,68.55, Respiratory syncytial ag if,87280,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,55.99,,,,,,,fee schedule,20.13,55.99, Respiratory syncytial ag if,87280,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,20.13,,,,,,,fee schedule,20.13,55.99, Respiratory syncytial ag if,87280,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,20.13,,,,,,,fee schedule,20.13,55.99, Pneumocystis carinii ag if,87281,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,49.98,,,,,,,fee schedule,17.97,49.98, Pneumocystis carinii ag if,87281,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.97,,,,,,,fee schedule,17.97,49.98, Pneumocystis carinii ag if,87281,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,17.97,,,,,,,fee schedule,17.97,49.98, Rubeola ag if,87283,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,253.66,,,,,,,fee schedule,91.2,253.66, Rubeola ag if,87283,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,91.2,,,,,,,fee schedule,91.2,253.66, Rubeola ag if,87283,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,91.2,,,,,,,fee schedule,91.2,253.66, Treponema pallidum ag if,87285,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,50.81,,,,,,,fee schedule,18.27,50.81, Treponema pallidum ag if,87285,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.27,,,,,,,fee schedule,18.27,50.81, Treponema pallidum ag if,87285,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,18.27,,,,,,,fee schedule,18.27,50.81, Varicella zoster ag if,87290,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,55.99,,,,,,,fee schedule,20.13,55.99, Varicella zoster ag if,87290,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,20.13,,,,,,,fee schedule,20.13,55.99, Varicella zoster ag if,87290,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,20.13,,,,,,,fee schedule,20.13,55.99, Antibody detection nos if,87299,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,67.17,,,,,,,fee schedule,24.15,67.17, Antibody detection nos if,87299,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24.15,,,,,,,fee schedule,24.15,67.17, Antibody detection nos if,87299,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,24.15,,,,,,,fee schedule,24.15,67.17, Ag detection polyval if,87300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,49.98,,,,,,,fee schedule,17.97,49.98, Ag detection polyval if,87300,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.97,,,,,,,fee schedule,17.97,49.98, Ag detection polyval if,87300,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,17.97,,,,,,,fee schedule,17.97,49.98, Adenovirus ag ia,87301,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,49.98,,,,,,,fee schedule,17.97,49.98, Adenovirus ag ia,87301,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.97,,,,,,,fee schedule,17.97,49.98, Adenovirus ag ia,87301,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,17.97,,,,,,,fee schedule,17.97,49.98, Aspergillus ag ia,87305,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,49.98,,,,,,,fee schedule,17.97,49.98, Aspergillus ag ia,87305,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.97,,,,,,,fee schedule,17.97,49.98, Aspergillus ag ia,87305,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,17.97,,,,,,,fee schedule,17.97,49.98, Chylmd trach ag ia,87320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,62.58,,,,,,,fee schedule,22.5,62.58, Chylmd trach ag ia,87320,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22.5,,,,,,,fee schedule,22.5,62.58, Chylmd trach ag ia,87320,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22.5,,,,,,,fee schedule,22.5,62.58, Clostridium ag ia,87324,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,49.98,,,,,,,fee schedule,17.97,49.98, Clostridium ag ia,87324,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.97,,,,,,,fee schedule,17.97,49.98, Clostridium ag ia,87324,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,17.97,,,,,,,fee schedule,17.97,49.98, Cryptococcus neoform ag ia,87327,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,55.99,,,,,,,fee schedule,20.13,55.99, Cryptococcus neoform ag ia,87327,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,20.13,,,,,,,fee schedule,20.13,55.99, Cryptococcus neoform ag ia,87327,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,20.13,,,,,,,fee schedule,20.13,55.99, Cryptosporidium ag ia,87328,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,57.66,,,,,,,fee schedule,20.73,57.66, Cryptosporidium ag ia,87328,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,20.73,,,,,,,fee schedule,20.73,57.66, Cryptosporidium ag ia,87328,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,20.73,,,,,,,fee schedule,20.73,57.66, Giardia ag ia,87329,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,49.98,,,,,,,fee schedule,17.97,49.98, Giardia ag ia,87329,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.97,,,,,,,fee schedule,17.97,49.98, Giardia ag ia,87329,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,17.97,,,,,,,fee schedule,17.97,49.98, Cytomegalovirus ag ia,87332,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,49.98,,,,,,,fee schedule,17.97,49.98, Cytomegalovirus ag ia,87332,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.97,,,,,,,fee schedule,17.97,49.98, Cytomegalovirus ag ia,87332,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,17.97,,,,,,,fee schedule,17.97,49.98, E coli 0157 ag ia,87335,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,52.82,,,,,,,fee schedule,18.99,52.82, E coli 0157 ag ia,87335,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.99,,,,,,,fee schedule,18.99,52.82, E coli 0157 ag ia,87335,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,18.99,,,,,,,fee schedule,18.99,52.82, Entamoeb hist dispr ag ia,87336,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,66.75,,,,,,,fee schedule,24,66.75, Entamoeb hist dispr ag ia,87336,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24,,,,,,,fee schedule,24,66.75, Entamoeb hist dispr ag ia,87336,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,24,,,,,,,fee schedule,24,66.75, Entamoeb hist group ag ia,87337,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,49.98,,,,,,,fee schedule,17.97,49.98, Entamoeb hist group ag ia,87337,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.97,,,,,,,fee schedule,17.97,49.98, Entamoeb hist group ag ia,87337,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,17.97,,,,,,,fee schedule,17.97,49.98, Hpylori stool ia,87338,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,59.99,,,,,,,fee schedule,21.57,59.99, Hpylori stool ia,87338,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21.57,,,,,,,fee schedule,21.57,59.99, Hpylori stool ia,87338,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,21.57,,,,,,,fee schedule,21.57,59.99, H pylori ag ia,87339,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,66.75,,,,,,,fee schedule,24,66.75, H pylori ag ia,87339,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24,,,,,,,fee schedule,24,66.75, H pylori ag ia,87339,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,24,,,,,,,fee schedule,24,66.75, Hepatitis b surface ag ia,87340,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,43.1,,,,,,,fee schedule,15.5,43.1, Hepatitis b surface ag ia,87340,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.5,,,,,,,fee schedule,15.5,43.1, Hepatitis b surface ag ia,87340,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,15.5,,,,,,,fee schedule,15.5,43.1, Hepatitis b surface ag ia,87341,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,43.1,,,,,,,fee schedule,15.5,43.1, Hepatitis b surface ag ia,87341,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.5,,,,,,,fee schedule,15.5,43.1, Hepatitis b surface ag ia,87341,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,15.5,,,,,,,fee schedule,15.5,43.1, Hepatitis be ag ia,87350,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,48.1,,,,,,,fee schedule,17.3,48.1, Hepatitis be ag ia,87350,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.3,,,,,,,fee schedule,17.3,48.1, Hepatitis be ag ia,87350,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,17.3,,,,,,,fee schedule,17.3,48.1, Hepatitis delta ag ia,87380,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,76.6,,,,,,,fee schedule,27.54,76.6, Hepatitis delta ag ia,87380,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,27.54,,,,,,,fee schedule,27.54,76.6, Hepatitis delta ag ia,87380,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,27.54,,,,,,,fee schedule,27.54,76.6, Histoplasma capsul ag ia,87385,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,55.28,,,,,,,fee schedule,19.88,55.28, Histoplasma capsul ag ia,87385,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.88,,,,,,,fee schedule,19.88,55.28, Histoplasma capsul ag ia,87385,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19.88,,,,,,,fee schedule,19.88,55.28, Hiv-1 ag w/hiv-1 & hiv-2 ab,87389,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,100.46,,,,,,,fee schedule,36.12,100.46, Hiv-1 ag w/hiv-1 & hiv-2 ab,87389,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,36.12,,,,,,,fee schedule,36.12,100.46, Hiv-1 ag w/hiv-1 & hiv-2 ab,87389,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,36.12,,,,,,,fee schedule,36.12,100.46, Hiv-1 ag ia,87390,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,100.38,,,,,,,fee schedule,36.09,100.38, Hiv-1 ag ia,87390,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,36.09,,,,,,,fee schedule,36.09,100.38, Hiv-1 ag ia,87390,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,36.09,,,,,,,fee schedule,36.09,100.38, Hiv-2 ag ia,87391,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,91.37,,,,,,,fee schedule,32.85,91.37, Hiv-2 ag ia,87391,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,32.85,,,,,,,fee schedule,32.85,91.37, Hiv-2 ag ia,87391,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,32.85,,,,,,,fee schedule,32.85,91.37, Influenza a/b ag ia,87400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,58.95,,,,,,,fee schedule,21.2,58.95, Influenza a/b ag ia,87400,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21.2,,,,,,,fee schedule,21.2,58.95, Influenza a/b ag ia,87400,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,21.2,,,,,,,fee schedule,21.2,58.95, Resp syncytial ag ia,87420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,58.03,,,,,,,fee schedule,20.87,58.03, Resp syncytial ag ia,87420,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,20.87,,,,,,,fee schedule,20.87,58.03, Resp syncytial ag ia,87420,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,20.87,,,,,,,fee schedule,20.87,58.03, Rotavirus ag ia,87425,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,49.98,,,,,,,fee schedule,17.97,49.98, Rotavirus ag ia,87425,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.97,,,,,,,fee schedule,17.97,49.98, Rotavirus ag ia,87425,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,17.97,,,,,,,fee schedule,17.97,49.98, Coronavirus ag ia,87426,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,147.4,,,,,,,fee schedule,68.06,147.4, Coronavirus ag ia,87426,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,68.06,,,,,,,fee schedule,68.06,147.4, Coronavirus ag ia,87426,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,68.06,,,,,,,fee schedule,68.06,147.4, Shiga-like toxin ag ia,87427,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,49.98,,,,,,,fee schedule,17.97,49.98, Shiga-like toxin ag ia,87427,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.97,,,,,,,fee schedule,17.97,49.98, Shiga-like toxin ag ia,87427,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,17.97,,,,,,,fee schedule,17.97,49.98, Sarscov & inf vir a&b ag ia,87428,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,293.25,,,,,,,fee schedule,110.36,293.25, Sarscov & inf vir a&b ag ia,87428,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,110.36,,,,,,,fee schedule,110.36,293.25, Sarscov & inf vir a&b ag ia,87428,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,110.36,,,,,,,fee schedule,110.36,293.25, Strep a ag ia,87430,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,70.13,,,,,,,fee schedule,25.22,70.13, Strep a ag ia,87430,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25.22,,,,,,,fee schedule,25.22,70.13, Strep a ag ia,87430,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,25.22,,,,,,,fee schedule,25.22,70.13, Ag detect nos ia mult,87449,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,49.98,,,,,,,fee schedule,17.97,49.98, Ag detect nos ia mult,87449,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.97,,,,,,,fee schedule,17.97,49.98, Ag detect nos ia mult,87449,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,17.97,,,,,,,fee schedule,17.97,49.98, Ag detect polyval ia mult,87451,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,43.85,,,,,,,fee schedule,15.77,43.85, Ag detect polyval ia mult,87451,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.77,,,,,,,fee schedule,15.77,43.85, Ag detect polyval ia mult,87451,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,15.77,,,,,,,fee schedule,15.77,43.85, Hepatitis b surface ag quan,87467,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,105.64,,,,,,,fee schedule,22.58,105.64, Hepatitis b surface ag quan,87467,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22.58,,,,,,,fee schedule,22.58,105.64, Hepatitis b surface ag quan,87467,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22.58,,,,,,,fee schedule,22.58,105.64, Anaplsma phgcytophlm amp prb,87468,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,146.4,,,,,,,fee schedule,52.64,146.4, Anaplsma phgcytophlm amp prb,87468,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,52.64,,,,,,,fee schedule,52.64,146.4, Anaplsma phgcytophlm amp prb,87468,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,52.64,,,,,,,fee schedule,52.64,146.4, Babesia microti amp prb,87469,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,146.4,,,,,,,fee schedule,52.64,146.4, Babesia microti amp prb,87469,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,52.64,,,,,,,fee schedule,52.64,146.4, Babesia microti amp prb,87469,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,52.64,,,,,,,fee schedule,52.64,146.4, Bartonella dna amp probe,87471,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,146.4,,,,,,,fee schedule,52.64,146.4, Bartonella dna amp probe,87471,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,52.64,,,,,,,fee schedule,52.64,146.4, Bartonella dna amp probe,87471,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,52.64,,,,,,,fee schedule,52.64,146.4, Bartonella dna quant,87472,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,178.73,,,,,,,fee schedule,64.26,178.73, Bartonella dna quant,87472,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,64.26,,,,,,,fee schedule,64.26,178.73, Bartonella dna quant,87472,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,64.26,,,,,,,fee schedule,64.26,178.73, Lyme dis dna dir probe,87475,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,83.65,,,,,,,fee schedule,30.08,83.65, Lyme dis dna dir probe,87475,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,30.08,,,,,,,fee schedule,30.08,83.65, Lyme dis dna dir probe,87475,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,30.08,,,,,,,fee schedule,30.08,83.65, Lyme dis dna amp probe,87476,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,146.4,,,,,,,fee schedule,52.64,146.4, Lyme dis dna amp probe,87476,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,52.64,,,,,,,fee schedule,52.64,146.4, Lyme dis dna amp probe,87476,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,52.64,,,,,,,fee schedule,52.64,146.4, Borrelia miyamotoi amp prb,87478,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,146.4,,,,,,,fee schedule,52.64,146.4, Borrelia miyamotoi amp prb,87478,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,52.64,,,,,,,fee schedule,52.64,146.4, Borrelia miyamotoi amp prb,87478,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,52.64,,,,,,,fee schedule,52.64,146.4, Candida dna dir probe,87480,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,83.65,,,,,,,fee schedule,30.08,83.65, Candida dna dir probe,87480,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,30.08,,,,,,,fee schedule,30.08,83.65, Candida dna dir probe,87480,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,30.08,,,,,,,fee schedule,30.08,83.65, Candida dna amp probe,87481,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,146.4,,,,,,,fee schedule,52.64,146.4, Candida dna amp probe,87481,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,52.64,,,,,,,fee schedule,52.64,146.4, Candida dna amp probe,87481,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,52.64,,,,,,,fee schedule,52.64,146.4, Candida dna quant,87482,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,232.55,,,,,,,fee schedule,83.61,232.55, Candida dna quant,87482,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,83.61,,,,,,,fee schedule,83.61,232.55, Candida dna quant,87482,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,83.61,,,,,,,fee schedule,83.61,232.55, Cns dna amp probe type 12-25,87483,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1738.81,,,,,,,fee schedule,625.17,1738.81, Cns dna amp probe type 12-25,87483,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,625.17,,,,,,,fee schedule,625.17,1738.81, Cns dna amp probe type 12-25,87483,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,625.17,,,,,,,fee schedule,625.17,1738.81, Ehrlicha chaffeensis amp prb,87484,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,146.4,,,,,,,fee schedule,52.64,146.4, Ehrlicha chaffeensis amp prb,87484,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,52.64,,,,,,,fee schedule,52.64,146.4, Ehrlicha chaffeensis amp prb,87484,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,52.64,,,,,,,fee schedule,52.64,146.4, Chylmd pneum dna dir probe,87485,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,83.65,,,,,,,fee schedule,30.08,83.65, Chylmd pneum dna dir probe,87485,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,30.08,,,,,,,fee schedule,30.08,83.65, Chylmd pneum dna dir probe,87485,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,30.08,,,,,,,fee schedule,30.08,83.65, Chylmd pneum dna amp probe,87486,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,146.4,,,,,,,fee schedule,52.64,146.4, Chylmd pneum dna amp probe,87486,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,52.64,,,,,,,fee schedule,52.64,146.4, Chylmd pneum dna amp probe,87486,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,52.64,,,,,,,fee schedule,52.64,146.4, Chylmd pneum dna quant,87487,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,178.73,,,,,,,fee schedule,64.26,178.73, Chylmd pneum dna quant,87487,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,64.26,,,,,,,fee schedule,64.26,178.73, Chylmd pneum dna quant,87487,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,64.26,,,,,,,fee schedule,64.26,178.73, Chylmd trach dna dir probe,87490,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,94.91,,,,,,,fee schedule,34.13,94.91, Chylmd trach dna dir probe,87490,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,34.13,,,,,,,fee schedule,34.13,94.91, Chylmd trach dna dir probe,87490,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,34.13,,,,,,,fee schedule,34.13,94.91, Chylmd trach dna amp probe,87491,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,146.4,,,,,,,fee schedule,52.64,146.4, Chylmd trach dna amp probe,87491,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,52.64,,,,,,,fee schedule,52.64,146.4, Chylmd trach dna amp probe,87491,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,52.64,,,,,,,fee schedule,52.64,146.4, Chylmd trach dna quant,87492,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,223.08,,,,,,,fee schedule,80.21,223.08, Chylmd trach dna quant,87492,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,80.21,,,,,,,fee schedule,80.21,223.08, Chylmd trach dna quant,87492,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,80.21,,,,,,,fee schedule,80.21,223.08, C diff amplified probe,87493,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,155.49,,,,,,,fee schedule,55.91,155.49, C diff amplified probe,87493,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,55.91,,,,,,,fee schedule,55.91,155.49, C diff amplified probe,87493,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,55.91,,,,,,,fee schedule,55.91,155.49, Chlmy trch&neisra gonor mult,87494,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,292.79,,,,,,,fee schedule,292.79,292.79, Cytomeg dna dir probe,87495,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,125.29,,,,,,,fee schedule,45.05,125.29, Cytomeg dna dir probe,87495,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,45.05,,,,,,,fee schedule,45.05,125.29, Cytomeg dna dir probe,87495,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,45.05,,,,,,,fee schedule,45.05,125.29, Cytomeg dna amp probe,87496,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,146.4,,,,,,,fee schedule,52.64,146.4, Cytomeg dna amp probe,87496,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,52.64,,,,,,,fee schedule,52.64,146.4, Cytomeg dna amp probe,87496,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,52.64,,,,,,,fee schedule,52.64,146.4, Cytomeg dna quant,87497,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,178.73,,,,,,,fee schedule,64.26,178.73, Cytomeg dna quant,87497,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,64.26,,,,,,,fee schedule,64.26,178.73, Cytomeg dna quant,87497,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,64.26,,,,,,,fee schedule,64.26,178.73, Enterovirus probe&revrs trns,87498,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,146.4,,,,,,,fee schedule,52.64,146.4, Enterovirus probe&revrs trns,87498,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,52.64,,,,,,,fee schedule,52.64,146.4, Enterovirus probe&revrs trns,87498,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,52.64,,,,,,,fee schedule,52.64,146.4, Vanomycin dna amp probe,87500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,146.4,,,,,,,fee schedule,52.64,146.4, Vanomycin dna amp probe,87500,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,52.64,,,,,,,fee schedule,52.64,146.4, Vanomycin dna amp probe,87500,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,52.64,,,,,,,fee schedule,52.64,146.4, Influenza dna amp prob 1+,87501,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,214.07,,,,,,,fee schedule,76.97,214.07, Influenza dna amp prob 1+,87501,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,76.97,,,,,,,fee schedule,76.97,214.07, Influenza dna amp prob 1+,87501,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,76.97,,,,,,,fee schedule,76.97,214.07, Influenza dna amp probe,87502,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,399.68,,,,,,,fee schedule,143.7,399.68, Influenza dna amp probe,87502,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,143.7,,,,,,,fee schedule,143.7,399.68, Influenza dna amp probe,87502,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,143.7,,,,,,,fee schedule,143.7,399.68, Influenza dna amp prob addl,87503,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,121.91,,,,,,,fee schedule,43.83,121.91, Influenza dna amp prob addl,87503,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,43.83,,,,,,,fee schedule,43.83,121.91, Influenza dna amp prob addl,87503,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,43.83,,,,,,,fee schedule,43.83,121.91, Nfct agent detection gi,87505,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,535.23,,,,,,,fee schedule,192.44,535.23, Nfct agent detection gi,87505,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,192.44,,,,,,,fee schedule,192.44,535.23, Nfct agent detection gi,87505,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,192.44,,,,,,,fee schedule,192.44,535.23, Iadna-dna/rna probe tq 6-11,87506,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1097.19,,,,,,,fee schedule,394.49,1097.19, Iadna-dna/rna probe tq 6-11,87506,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,394.49,,,,,,,fee schedule,394.49,1097.19, Iadna-dna/rna probe tq 6-11,87506,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,394.49,,,,,,,fee schedule,394.49,1097.19, Iadna-dna/rna probe tq 12-25,87507,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1738.81,,,,,,,fee schedule,625.17,1738.81, Iadna-dna/rna probe tq 12-25,87507,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,625.17,,,,,,,fee schedule,625.17,1738.81, Iadna-dna/rna probe tq 12-25,87507,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,625.17,,,,,,,fee schedule,625.17,1738.81, Gardner vag dna dir probe,87510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,83.65,,,,,,,fee schedule,30.08,83.65, Gardner vag dna dir probe,87510,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,30.08,,,,,,,fee schedule,30.08,83.65, Gardner vag dna dir probe,87510,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,30.08,,,,,,,fee schedule,30.08,83.65, Gardner vag dna amp probe,87511,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,146.4,,,,,,,fee schedule,52.64,146.4, Gardner vag dna amp probe,87511,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,52.64,,,,,,,fee schedule,52.64,146.4, Gardner vag dna amp probe,87511,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,52.64,,,,,,,fee schedule,52.64,146.4, Gardner vag dna quant,87512,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,174.22,,,,,,,fee schedule,62.64,174.22, Gardner vag dna quant,87512,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,62.64,,,,,,,fee schedule,62.64,174.22, Gardner vag dna quant,87512,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,62.64,,,,,,,fee schedule,62.64,174.22, H pylri clrthmcn rst amp prb,87513,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,146.4,,,,,,,fee schedule,52.64,146.4, H pylri clrthmcn rst amp prb,87513,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,52.64,,,,,,,fee schedule,52.64,146.4, H pylri clrthmcn rst amp prb,87513,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,52.64,,,,,,,fee schedule,52.64,146.4, Hepatitis b dna amp probe,87516,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,146.4,,,,,,,fee schedule,52.64,146.4, Hepatitis b dna amp probe,87516,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,52.64,,,,,,,fee schedule,52.64,146.4, Hepatitis b dna amp probe,87516,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,52.64,,,,,,,fee schedule,52.64,146.4, Hepatitis b dna quant,87517,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,178.73,,,,,,,fee schedule,64.26,178.73, Hepatitis b dna quant,87517,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,64.26,,,,,,,fee schedule,64.26,178.73, Hepatitis b dna quant,87517,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,64.26,,,,,,,fee schedule,64.26,178.73, Hepatitis c rna dir probe,87520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,130.25,,,,,,,fee schedule,46.83,130.25, Hepatitis c rna dir probe,87520,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46.83,,,,,,,fee schedule,46.83,130.25, Hepatitis c rna dir probe,87520,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,46.83,,,,,,,fee schedule,46.83,130.25, Hepatitis c probe&rvrs trnsc,87521,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,146.4,,,,,,,fee schedule,52.64,146.4, Hepatitis c probe&rvrs trnsc,87521,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,52.64,,,,,,,fee schedule,52.64,146.4, Hepatitis c probe&rvrs trnsc,87521,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,52.64,,,,,,,fee schedule,52.64,146.4, Hepatitis c revrs trnscrpj,87522,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,178.73,,,,,,,fee schedule,64.26,178.73, Hepatitis c revrs trnscrpj,87522,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,64.26,,,,,,,fee schedule,64.26,178.73, Hepatitis c revrs trnscrpj,87522,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,64.26,,,,,,,fee schedule,64.26,178.73, Hepatitis d quantification,87523,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,178.73,,,,,,,fee schedule,64.26,178.73, Hepatitis d quantification,87523,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,64.26,,,,,,,fee schedule,64.26,178.73, Hepatitis d quantification,87523,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,64.26,,,,,,,fee schedule,64.26,178.73, Hepatitis g dna dir probe,87525,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,124.33,,,,,,,fee schedule,44.7,124.33, Hepatitis g dna dir probe,87525,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,44.7,,,,,,,fee schedule,44.7,124.33, Hepatitis g dna dir probe,87525,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,44.7,,,,,,,fee schedule,44.7,124.33, Hepatitis g dna amp probe,87526,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,163.79,,,,,,,fee schedule,58.89,163.79, Hepatitis g dna amp probe,87526,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,58.89,,,,,,,fee schedule,58.89,163.79, Hepatitis g dna amp probe,87526,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,58.89,,,,,,,fee schedule,58.89,163.79, Hepatitis g dna quant,87527,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,174.22,,,,,,,fee schedule,62.64,174.22, Hepatitis g dna quant,87527,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,62.64,,,,,,,fee schedule,62.64,174.22, Hepatitis g dna quant,87527,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,62.64,,,,,,,fee schedule,62.64,174.22, Hsv dna dir probe,87528,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,83.65,,,,,,,fee schedule,30.08,83.65, Hsv dna dir probe,87528,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,30.08,,,,,,,fee schedule,30.08,83.65, Hsv dna dir probe,87528,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,30.08,,,,,,,fee schedule,30.08,83.65, Hsv dna amp probe,87529,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,146.4,,,,,,,fee schedule,52.64,146.4, Hsv dna amp probe,87529,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,52.64,,,,,,,fee schedule,52.64,146.4, Hsv dna amp probe,87529,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,52.64,,,,,,,fee schedule,52.64,146.4, Hsv dna quant,87530,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,178.73,,,,,,,fee schedule,64.26,178.73, Hsv dna quant,87530,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,64.26,,,,,,,fee schedule,64.26,178.73, Hsv dna quant,87530,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,64.26,,,,,,,fee schedule,64.26,178.73, Hhv-6 dna dir probe,87531,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,241.98,,,,,,,fee schedule,87,241.98, Hhv-6 dna dir probe,87531,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,87,,,,,,,fee schedule,87,241.98, Hhv-6 dna dir probe,87531,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,87,,,,,,,fee schedule,87,241.98, Hhv-6 dna amp probe,87532,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,146.4,,,,,,,fee schedule,52.64,146.4, Hhv-6 dna amp probe,87532,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,52.64,,,,,,,fee schedule,52.64,146.4, Hhv-6 dna amp probe,87532,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,52.64,,,,,,,fee schedule,52.64,146.4, Hhv-6 dna quant,87533,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,174.22,,,,,,,fee schedule,62.64,174.22, Hhv-6 dna quant,87533,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,62.64,,,,,,,fee schedule,62.64,174.22, Hhv-6 dna quant,87533,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,62.64,,,,,,,fee schedule,62.64,174.22, Hiv-1 dna dir probe,87534,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,91.45,,,,,,,fee schedule,32.88,91.45, Hiv-1 dna dir probe,87534,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,32.88,,,,,,,fee schedule,32.88,91.45, Hiv-1 dna dir probe,87534,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,32.88,,,,,,,fee schedule,32.88,91.45, Hiv-1 probe&reverse trnscrpj,87535,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,146.4,,,,,,,fee schedule,52.64,146.4, Hiv-1 probe&reverse trnscrpj,87535,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,52.64,,,,,,,fee schedule,52.64,146.4, Hiv-1 probe&reverse trnscrpj,87535,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,52.64,,,,,,,fee schedule,52.64,146.4, Hiv-1 quant&revrse trnscrpj,87536,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,355.04,,,,,,,fee schedule,127.65,355.04, Hiv-1 quant&revrse trnscrpj,87536,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,127.65,,,,,,,fee schedule,127.65,355.04, Hiv-1 quant&revrse trnscrpj,87536,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,127.65,,,,,,,fee schedule,127.65,355.04, Hiv-2 dna dir probe,87537,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,91.45,,,,,,,fee schedule,32.88,91.45, Hiv-2 dna dir probe,87537,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,32.88,,,,,,,fee schedule,32.88,91.45, Hiv-2 dna dir probe,87537,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,32.88,,,,,,,fee schedule,32.88,91.45, Hiv-2 probe&revrse trnscripj,87538,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,146.4,,,,,,,fee schedule,52.64,146.4, Hiv-2 probe&revrse trnscripj,87538,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,52.64,,,,,,,fee schedule,52.64,146.4, Hiv-2 probe&revrse trnscripj,87538,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,52.64,,,,,,,fee schedule,52.64,146.4, Hiv-2 quant&revrse trnscripj,87539,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,244.56,,,,,,,fee schedule,87.93,244.56, Hiv-2 quant&revrse trnscripj,87539,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,87.93,,,,,,,fee schedule,87.93,244.56, Hiv-2 quant&revrse trnscripj,87539,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,87.93,,,,,,,fee schedule,87.93,244.56, Legion pneumo dna dir prob,87540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,83.65,,,,,,,fee schedule,30.08,83.65, Legion pneumo dna dir prob,87540,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,30.08,,,,,,,fee schedule,30.08,83.65, Legion pneumo dna dir prob,87540,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,30.08,,,,,,,fee schedule,30.08,83.65, Legion pneumo dna amp prob,87541,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,146.4,,,,,,,fee schedule,52.64,146.4, Legion pneumo dna amp prob,87541,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,52.64,,,,,,,fee schedule,52.64,146.4, Legion pneumo dna amp prob,87541,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,52.64,,,,,,,fee schedule,52.64,146.4, Legion pneumo dna quant,87542,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,174.22,,,,,,,fee schedule,62.64,174.22, Legion pneumo dna quant,87542,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,62.64,,,,,,,fee schedule,62.64,174.22, Legion pneumo dna quant,87542,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,62.64,,,,,,,fee schedule,62.64,174.22, Mycobacteria dna dir probe,87550,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,83.65,,,,,,,fee schedule,30.08,83.65, Mycobacteria dna dir probe,87550,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,30.08,,,,,,,fee schedule,30.08,83.65, Mycobacteria dna dir probe,87550,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,30.08,,,,,,,fee schedule,30.08,83.65, Mycobacteria dna amp probe,87551,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,201.26,,,,,,,fee schedule,72.36,201.26, Mycobacteria dna amp probe,87551,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,72.36,,,,,,,fee schedule,72.36,201.26, Mycobacteria dna amp probe,87551,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,72.36,,,,,,,fee schedule,72.36,201.26, Mycobacteria dna quant,87552,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,178.73,,,,,,,fee schedule,64.26,178.73, Mycobacteria dna quant,87552,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,64.26,,,,,,,fee schedule,64.26,178.73, Mycobacteria dna quant,87552,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,64.26,,,,,,,fee schedule,64.26,178.73, M.tuberculo dna dir probe,87555,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,112.14,,,,,,,fee schedule,40.32,112.14, M.tuberculo dna dir probe,87555,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,40.32,,,,,,,fee schedule,40.32,112.14, M.tuberculo dna dir probe,87555,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,40.32,,,,,,,fee schedule,40.32,112.14, M.tuberculo dna amp probe,87556,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,173.89,,,,,,,fee schedule,62.52,173.89, M.tuberculo dna amp probe,87556,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,62.52,,,,,,,fee schedule,62.52,173.89, M.tuberculo dna amp probe,87556,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,62.52,,,,,,,fee schedule,62.52,173.89, M.tuberculo dna quant,87557,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,178.73,,,,,,,fee schedule,64.26,178.73, M.tuberculo dna quant,87557,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,64.26,,,,,,,fee schedule,64.26,178.73, M.tuberculo dna quant,87557,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,64.26,,,,,,,fee schedule,64.26,178.73, M.avium-intra dna dir prob,87560,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,113.85,,,,,,,fee schedule,40.94,113.85, M.avium-intra dna dir prob,87560,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,40.94,,,,,,,fee schedule,40.94,113.85, M.avium-intra dna dir prob,87560,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,40.94,,,,,,,fee schedule,40.94,113.85, M.avium-intra dna amp prob,87561,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,146.4,,,,,,,fee schedule,52.64,146.4, M.avium-intra dna amp prob,87561,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,52.64,,,,,,,fee schedule,52.64,146.4, M.avium-intra dna amp prob,87561,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,52.64,,,,,,,fee schedule,52.64,146.4, M.avium-intra dna quant,87562,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,178.73,,,,,,,fee schedule,64.26,178.73, M.avium-intra dna quant,87562,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,64.26,,,,,,,fee schedule,64.26,178.73, M.avium-intra dna quant,87562,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,64.26,,,,,,,fee schedule,64.26,178.73, M. genitalium amp probe,87563,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,146.4,,,,,,,fee schedule,52.64,146.4, M. genitalium amp probe,87563,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,52.64,,,,,,,fee schedule,52.64,146.4, M. genitalium amp probe,87563,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,52.64,,,,,,,fee schedule,52.64,146.4, Mtb rifampin rst amp prb tq,87564,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,320.28,,,,,,,fee schedule,115.16,320.28, Mtb rifampin rst amp prb tq,87564,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,115.16,,,,,,,fee schedule,115.16,320.28, Mtb rifampin rst amp prb tq,87564,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,115.16,,,,,,,fee schedule,115.16,320.28, M.pneumon dna dir probe,87580,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,83.65,,,,,,,fee schedule,30.08,83.65, M.pneumon dna dir probe,87580,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,30.08,,,,,,,fee schedule,30.08,83.65, M.pneumon dna dir probe,87580,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,30.08,,,,,,,fee schedule,30.08,83.65, M.pneumon dna amp probe,87581,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,146.4,,,,,,,fee schedule,52.64,146.4, M.pneumon dna amp probe,87581,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,52.64,,,,,,,fee schedule,52.64,146.4, M.pneumon dna amp probe,87581,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,52.64,,,,,,,fee schedule,52.64,146.4, M.pneumon dna quant,87582,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1262.53,,,,,,,fee schedule,453.93,1262.53, M.pneumon dna quant,87582,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,453.93,,,,,,,fee schedule,453.93,1262.53, M.pneumon dna quant,87582,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,453.93,,,,,,,fee schedule,453.93,1262.53, N.gonorrhoeae dna dir prob,87590,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,112.14,,,,,,,fee schedule,40.32,112.14, N.gonorrhoeae dna dir prob,87590,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,40.32,,,,,,,fee schedule,40.32,112.14, N.gonorrhoeae dna dir prob,87590,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,40.32,,,,,,,fee schedule,40.32,112.14, N.gonorrhoeae dna amp prob,87591,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,146.4,,,,,,,fee schedule,52.64,146.4, N.gonorrhoeae dna amp prob,87591,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,52.64,,,,,,,fee schedule,52.64,146.4, N.gonorrhoeae dna amp prob,87591,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,52.64,,,,,,,fee schedule,52.64,146.4, N.gonorrhoeae dna quant,87592,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,178.73,,,,,,,fee schedule,64.26,178.73, N.gonorrhoeae dna quant,87592,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,64.26,,,,,,,fee schedule,64.26,178.73, N.gonorrhoeae dna quant,87592,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,64.26,,,,,,,fee schedule,64.26,178.73, Orthopoxvirus amp prb each,87593,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,214.07,,,,,,,fee schedule,76.76,214.07, Orthopoxvirus amp prb each,87593,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,76.76,,,,,,,fee schedule,76.76,214.07, Orthopoxvirus amp prb each,87593,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,76.76,,,,,,,fee schedule,76.76,214.07, Pneumcysts jirovecii amp prb,87594,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,146.4,,,,,,,fee schedule,52.64,146.4, Pneumcysts jirovecii amp prb,87594,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,52.64,,,,,,,fee schedule,52.64,146.4, Pneumcysts jirovecii amp prb,87594,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,52.64,,,,,,,fee schedule,52.64,146.4, Hpv low-risk types,87623,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,146.4,,,,,,,fee schedule,52.64,146.4, Hpv low-risk types,87623,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,52.64,,,,,,,fee schedule,52.64,146.4, Hpv low-risk types,87623,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,52.64,,,,,,,fee schedule,52.64,146.4, Hpv high-risk types,87624,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,146.4,,,,,,,fee schedule,52.64,146.4, Hpv high-risk types,87624,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,52.64,,,,,,,fee schedule,52.64,146.4, Hpv high-risk types,87624,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,52.64,,,,,,,fee schedule,52.64,146.4, Hpv types 16 & 18 only,87625,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,169.17,,,,,,,fee schedule,60.83,169.17, Hpv types 16 & 18 only,87625,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,60.83,,,,,,,fee schedule,60.83,169.17, Hpv types 16 & 18 only,87625,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,60.83,,,,,,,fee schedule,60.83,169.17, Hpv sep hi-rsk typ&pool rslt,87626,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,292.87,,,,,,,fee schedule,105.3,292.87, Hpv sep hi-rsk typ&pool rslt,87626,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,105.3,,,,,,,fee schedule,105.3,292.87, Hpv sep hi-rsk typ&pool rslt,87626,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,105.3,,,,,,,fee schedule,105.3,292.87, Jt spc pthgn&rx rsist gen26+,87627,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2836,,,,,,,fee schedule,2836,2836, Resp virus 3-5 targets,87631,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,595.05,,,,,,,fee schedule,213.95,595.05, Resp virus 3-5 targets,87631,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,213.95,,,,,,,fee schedule,213.95,595.05, Resp virus 3-5 targets,87631,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,213.95,,,,,,,fee schedule,213.95,595.05, Resp virus 6-11 targets,87632,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,909.75,,,,,,,fee schedule,327.09,909.75, Resp virus 6-11 targets,87632,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,327.09,,,,,,,fee schedule,327.09,909.75, Resp virus 6-11 targets,87632,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,327.09,,,,,,,fee schedule,327.09,909.75, Resp virus 12-25 targets,87633,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1738.81,,,,,,,fee schedule,625.17,1738.81, Resp virus 12-25 targets,87633,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,625.17,,,,,,,fee schedule,625.17,1738.81, Resp virus 12-25 targets,87633,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,625.17,,,,,,,fee schedule,625.17,1738.81, Rsv dna/rna amp probe,87634,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,292.87,,,,,,,fee schedule,105.3,292.87, Rsv dna/rna amp probe,87634,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,105.3,,,,,,,fee schedule,105.3,292.87, Rsv dna/rna amp probe,87634,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,105.3,,,,,,,fee schedule,105.3,292.87, Sars-cov-2 covid-19 amp prb,87635,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,214.07,,,,,,,fee schedule,76.97,214.07, Sars-cov-2 covid-19 amp prb,87635,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,76.97,,,,,,,fee schedule,76.97,214.07, Sars-cov-2 covid-19 amp prb,87635,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,76.97,,,,,,,fee schedule,76.97,214.07, Sarscov2 & inf a&b amp prb,87636,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,595.05,,,,,,,fee schedule,213.9,595.05, Sarscov2 & inf a&b amp prb,87636,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,213.9,,,,,,,fee schedule,213.9,595.05, Sarscov2 & inf a&b amp prb,87636,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,213.9,,,,,,,fee schedule,213.9,595.05, Sarscov2&inf a&b&rsv amp prb,87637,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,595.05,,,,,,,fee schedule,213.9,595.05, Sarscov2&inf a&b&rsv amp prb,87637,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,213.9,,,,,,,fee schedule,213.9,595.05, Sarscov2&inf a&b&rsv amp prb,87637,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,213.9,,,,,,,fee schedule,213.9,595.05, Staph a dna amp probe,87640,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,146.4,,,,,,,fee schedule,52.64,146.4, Staph a dna amp probe,87640,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,52.64,,,,,,,fee schedule,52.64,146.4, Staph a dna amp probe,87640,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,52.64,,,,,,,fee schedule,52.64,146.4, Mr-staph dna amp probe,87641,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,146.4,,,,,,,fee schedule,52.64,146.4, Mr-staph dna amp probe,87641,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,52.64,,,,,,,fee schedule,52.64,146.4, Mr-staph dna amp probe,87641,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,52.64,,,,,,,fee schedule,52.64,146.4, Strep a dna dir probe,87650,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,83.65,,,,,,,fee schedule,30.08,83.65, Strep a dna dir probe,87650,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,30.08,,,,,,,fee schedule,30.08,83.65, Strep a dna dir probe,87650,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,30.08,,,,,,,fee schedule,30.08,83.65, Strep a dna amp probe,87651,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,146.4,,,,,,,fee schedule,52.64,146.4, Strep a dna amp probe,87651,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,52.64,,,,,,,fee schedule,52.64,146.4, Strep a dna amp probe,87651,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,52.64,,,,,,,fee schedule,52.64,146.4, Strep a dna quant,87652,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,174.22,,,,,,,fee schedule,62.64,174.22, Strep a dna quant,87652,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,62.64,,,,,,,fee schedule,62.64,174.22, Strep a dna quant,87652,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,62.64,,,,,,,fee schedule,62.64,174.22, Strep b dna amp probe,87653,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,146.4,,,,,,,fee schedule,52.64,146.4, Strep b dna amp probe,87653,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,52.64,,,,,,,fee schedule,52.64,146.4, Strep b dna amp probe,87653,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,52.64,,,,,,,fee schedule,52.64,146.4, Trichomonas vagin dir probe,87660,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,83.65,,,,,,,fee schedule,30.08,83.65, Trichomonas vagin dir probe,87660,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,30.08,,,,,,,fee schedule,30.08,83.65, Trichomonas vagin dir probe,87660,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,30.08,,,,,,,fee schedule,30.08,83.65, Trichomonas vaginalis amplif,87661,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,146.4,,,,,,,fee schedule,52.64,146.4, Trichomonas vaginalis amplif,87661,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,52.64,,,,,,,fee schedule,52.64,146.4, Trichomonas vaginalis amplif,87661,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,52.64,,,,,,,fee schedule,52.64,146.4, Zika virus dna/rna amp probe,87662,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,214.07,,,,,,,fee schedule,76.97,214.07, Zika virus dna/rna amp probe,87662,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,76.97,,,,,,,fee schedule,76.97,214.07, Zika virus dna/rna amp probe,87662,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,76.97,,,,,,,fee schedule,76.97,214.07, Detect agent nos dna dir,87797,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,125.29,,,,,,,fee schedule,45.05,125.29, Detect agent nos dna dir,87797,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,45.05,,,,,,,fee schedule,45.05,125.29, Detect agent nos dna dir,87797,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,45.05,,,,,,,fee schedule,45.05,125.29, Detect agent nos dna amp,87798,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,146.4,,,,,,,fee schedule,52.64,146.4, Detect agent nos dna amp,87798,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,52.64,,,,,,,fee schedule,52.64,146.4, Detect agent nos dna amp,87798,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,52.64,,,,,,,fee schedule,52.64,146.4, Detect agent nos dna quant,87799,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,178.73,,,,,,,fee schedule,64.26,178.73, Detect agent nos dna quant,87799,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,64.26,,,,,,,fee schedule,64.26,178.73, Detect agent nos dna quant,87799,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,64.26,,,,,,,fee schedule,64.26,178.73, Detect agnt mult dna direc,87800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,182.19,,,,,,,fee schedule,65.51,182.19, Detect agnt mult dna direc,87800,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,65.51,,,,,,,fee schedule,65.51,182.19, Detect agnt mult dna direc,87800,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,65.51,,,,,,,fee schedule,65.51,182.19, Detect agnt mult dna ampli,87801,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,292.87,,,,,,,fee schedule,105.3,292.87, Detect agnt mult dna ampli,87801,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,105.3,,,,,,,fee schedule,105.3,292.87, Detect agnt mult dna ampli,87801,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,105.3,,,,,,,fee schedule,105.3,292.87, Strep b assay w/optic,87802,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,53.11,,,,,,,fee schedule,19.1,53.11, Strep b assay w/optic,87802,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.1,,,,,,,fee schedule,19.1,53.11, Strep b assay w/optic,87802,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19.1,,,,,,,fee schedule,19.1,53.11, Clostridium toxin a w/optic,87803,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,66.75,,,,,,,fee schedule,24,66.75, Clostridium toxin a w/optic,87803,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24,,,,,,,fee schedule,24,66.75, Clostridium toxin a w/optic,87803,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,24,,,,,,,fee schedule,24,66.75, Influenza assay w/optic,87804,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,69.05,,,,,,,fee schedule,24.83,69.05, Influenza assay w/optic,87804,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24.83,,,,,,,fee schedule,24.83,69.05, Influenza assay w/optic,87804,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,24.83,,,,,,,fee schedule,24.83,69.05, Hiv antigen w/hiv antibodies,87806,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,136.72,,,,,,,fee schedule,49.16,136.72, Hiv antigen w/hiv antibodies,87806,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,49.16,,,,,,,fee schedule,49.16,136.72, Hiv antigen w/hiv antibodies,87806,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,49.16,,,,,,,fee schedule,49.16,136.72, Rsv assay w/optic,87807,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,54.65,,,,,,,fee schedule,19.65,54.65, Rsv assay w/optic,87807,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.65,,,,,,,fee schedule,19.65,54.65, Rsv assay w/optic,87807,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19.65,,,,,,,fee schedule,19.65,54.65, Trichomonas assay w/optic,87808,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,63.79,,,,,,,fee schedule,22.94,63.79, Trichomonas assay w/optic,87808,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22.94,,,,,,,fee schedule,22.94,63.79, Trichomonas assay w/optic,87808,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22.94,,,,,,,fee schedule,22.94,63.79, Adenovirus assay w/optic,87809,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,90.78,,,,,,,fee schedule,32.64,90.78, Adenovirus assay w/optic,87809,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,32.64,,,,,,,fee schedule,32.64,90.78, Adenovirus assay w/optic,87809,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,32.64,,,,,,,fee schedule,32.64,90.78, Chylmd trach assay w/optic,87810,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,147.23,,,,,,,fee schedule,52.94,147.23, Chylmd trach assay w/optic,87810,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,52.94,,,,,,,fee schedule,52.94,147.23, Chylmd trach assay w/optic,87810,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,52.94,,,,,,,fee schedule,52.94,147.23, Sars-cov-2 covid19 w/optic,87811,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,172.64,,,,,,,fee schedule,62.22,172.64, Sars-cov-2 covid19 w/optic,87811,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,62.22,,,,,,,fee schedule,62.22,172.64, Sars-cov-2 covid19 w/optic,87811,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,62.22,,,,,,,fee schedule,62.22,172.64, Sarscov2&inf typ a&b w/optic,87812,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,310.73,,,,,,,fee schedule,310.73,310.73, N. gonorrhoeae assay w/optic,87850,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,102.46,,,,,,,fee schedule,36.84,102.46, N. gonorrhoeae assay w/optic,87850,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,36.84,,,,,,,fee schedule,36.84,102.46, N. gonorrhoeae assay w/optic,87850,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,36.84,,,,,,,fee schedule,36.84,102.46, Strep a assay w/optic,87880,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,68.96,,,,,,,fee schedule,24.8,68.96, Strep a assay w/optic,87880,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24.8,,,,,,,fee schedule,24.8,68.96, Strep a assay w/optic,87880,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,24.8,,,,,,,fee schedule,24.8,68.96, Agent nos assay w/optic,87899,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,67.04,,,,,,,fee schedule,24.11,67.04, Agent nos assay w/optic,87899,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24.11,,,,,,,fee schedule,24.11,67.04, Agent nos assay w/optic,87899,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,24.11,,,,,,,fee schedule,24.11,67.04, Phenotype infect agent drug,87900,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,543.82,,,,,,,fee schedule,195.53,543.82, Phenotype infect agent drug,87900,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,195.53,,,,,,,fee schedule,195.53,543.82, Phenotype infect agent drug,87900,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,195.53,,,,,,,fee schedule,195.53,543.82, Genotype dna hiv reverse t,87901,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1074.08,,,,,,,fee schedule,386.18,1074.08, Genotype dna hiv reverse t,87901,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,386.18,,,,,,,fee schedule,386.18,1074.08, Genotype dna hiv reverse t,87901,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,386.18,,,,,,,fee schedule,386.18,1074.08, Genotype dna/rna hep c,87902,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1074.08,,,,,,,fee schedule,386.18,1074.08, Genotype dna/rna hep c,87902,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,386.18,,,,,,,fee schedule,386.18,1074.08, Genotype dna/rna hep c,87902,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,386.18,,,,,,,fee schedule,386.18,1074.08, Phenotype dna hiv w/culture,87903,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2038.69,,,,,,,fee schedule,732.99,2038.69, Phenotype dna hiv w/culture,87903,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,732.99,,,,,,,fee schedule,732.99,2038.69, Phenotype dna hiv w/culture,87903,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,732.99,,,,,,,fee schedule,732.99,2038.69, Phenotype dna hiv w/clt add,87904,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,108.76,,,,,,,fee schedule,39.11,108.76, Phenotype dna hiv w/clt add,87904,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,39.11,,,,,,,fee schedule,39.11,108.76, Phenotype dna hiv w/clt add,87904,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,39.11,,,,,,,fee schedule,39.11,108.76, Sialidase enzyme assay,87905,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,50.98,,,,,,,fee schedule,18.33,50.98, Sialidase enzyme assay,87905,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.33,,,,,,,fee schedule,18.33,50.98, Sialidase enzyme assay,87905,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,18.33,,,,,,,fee schedule,18.33,50.98, Genotype dna/rna hiv,87906,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,537.06,,,,,,,fee schedule,193.1,537.06, Genotype dna/rna hiv,87906,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,193.1,,,,,,,fee schedule,193.1,537.06, Genotype dna/rna hiv,87906,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,193.1,,,,,,,fee schedule,193.1,537.06, Genotype cytomegalovirus,87910,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1074.08,,,,,,,fee schedule,386.18,1074.08, Genotype cytomegalovirus,87910,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,386.18,,,,,,,fee schedule,386.18,1074.08, Genotype cytomegalovirus,87910,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,386.18,,,,,,,fee schedule,386.18,1074.08, Genotype dna hepatitis b,87912,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1074.08,,,,,,,fee schedule,386.18,1074.08, Genotype dna hepatitis b,87912,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,386.18,,,,,,,fee schedule,386.18,1074.08, Genotype dna hepatitis b,87912,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,386.18,,,,,,,fee schedule,386.18,1074.08, Nfct agt gntyp alys sarscov2,87913,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1074.08,,,,,,,fee schedule,386.18,1074.08, Nfct agt gntyp alys sarscov2,87913,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,386.18,,,,,,,fee schedule,386.18,1074.08, Nfct agt gntyp alys sarscov2,87913,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,386.18,,,,,,,fee schedule,386.18,1074.08, Autopsy (necropsy) gross,88000,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,310.73,,,,,,,fee schedule,310.73,310.73, Autopsy (necropsy) gross,88000,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,310.73,,,,,,,fee schedule,310.73,310.73, Autopsy (necropsy) gross,88005,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,362.7,,,,,,,fee schedule,362.7,362.7, Autopsy (necropsy) gross,88005,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,362.7,,,,,,,fee schedule,362.7,362.7, Autopsy (necropsy) gross,88007,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,380.03,,,,,,,fee schedule,380.03,380.03, Autopsy (necropsy) gross,88007,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,380.03,,,,,,,fee schedule,380.03,380.03, Autopsy (necropsy) gross,88012,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,310.73,,,,,,,fee schedule,310.73,310.73, Autopsy (necropsy) gross,88012,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,310.73,,,,,,,fee schedule,310.73,310.73, Autopsy (necropsy) gross,88014,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,284.75,,,,,,,fee schedule,284.75,284.75, Autopsy (necropsy) gross,88014,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,284.75,,,,,,,fee schedule,284.75,284.75, Autopsy (necropsy) gross,88016,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,397.35,,,,,,,fee schedule,397.35,397.35, Autopsy (necropsy) gross,88016,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,397.35,,,,,,,fee schedule,397.35,397.35, Autopsy (necropsy) complete,88020,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,535.4,,,,,,,fee schedule,535.4,535.4, Autopsy (necropsy) complete,88020,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,535.4,,,,,,,fee schedule,535.4,535.4, Autopsy (necropsy) complete,88025,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,518.07,,,,,,,fee schedule,518.07,518.07, Autopsy (necropsy) complete,88025,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,518.07,,,,,,,fee schedule,518.07,518.07, Autopsy (necropsy) complete,88027,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,552.71,,,,,,,fee schedule,552.71,552.71, Autopsy (necropsy) complete,88027,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,552.71,,,,,,,fee schedule,552.71,552.71, Autopsy (necropsy) complete,88028,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,310.73,,,,,,,fee schedule,310.73,310.73, Autopsy (necropsy) complete,88028,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,310.73,,,,,,,fee schedule,310.73,310.73, Autopsy (necropsy) complete,88029,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,310.73,,,,,,,fee schedule,310.73,310.73, Autopsy (necropsy) complete,88029,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,310.73,,,,,,,fee schedule,310.73,310.73, Limited autopsy,88036,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,155.37,,,,,,,fee schedule,155.37,155.37, Limited autopsy,88036,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,155.37,,,,,,,fee schedule,155.37,155.37, Limited autopsy,88037,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,138.05,,,,,,,fee schedule,138.05,138.05, Limited autopsy,88037,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,138.05,,,,,,,fee schedule,138.05,138.05, Forensic autopsy (necropsy),88040,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,863.45,,,,,,,fee schedule,863.45,863.45, Forensic autopsy (necropsy),88040,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,863.45,,,,,,,fee schedule,863.45,863.45, Coroners autopsy (necropsy),88045,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,86.61,,,,,,,fee schedule,86.61,86.61, Coroners autopsy (necropsy),88045,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,86.61,,,,,,,fee schedule,86.61,86.61, Cytopath fl nongyn smears,88104,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,298.34,,,,,,,fee schedule,50.15,298.34, Cytopath fl nongyn smears,88104,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,230.67,,,,,,,fee schedule,50.15,298.34, Cytopath fl nongyn smears,88104,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,50.15,,,,,,,fee schedule,50.15,298.34, Cytopath fl nongyn smears,88104,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,50.15,,,,,,,fee schedule,50.15,298.34, Cytopath fl nongyn filter,88106,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,258.68,,,,,,,fee schedule,34.49,258.68, Cytopath fl nongyn filter,88106,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,200.01,,,,,,,fee schedule,34.49,258.68, Cytopath fl nongyn filter,88106,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,34.49,,,,,,,fee schedule,34.49,258.68, Cytopath fl nongyn filter,88106,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,34.49,,,,,,,fee schedule,34.49,258.68, Cytopath concentrate tech,88108,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,245.68,,,,,,,fee schedule,50.15,245.68, Cytopath concentrate tech,88108,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,189.95,,,,,,,fee schedule,50.15,245.68, Cytopath concentrate tech,88108,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,50.15,,,,,,,fee schedule,50.15,245.68, Cytopath concentrate tech,88108,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,50.15,,,,,,,fee schedule,50.15,245.68, Cytopath cell enhance tech,88112,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,204.29,,,,,,,fee schedule,74.21,204.29, Cytopath cell enhance tech,88112,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,157.95,,,,,,,fee schedule,74.21,204.29, Cytopath cell enhance tech,88112,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,74.21,,,,,,,fee schedule,74.21,204.29, Cytopath cell enhance tech,88112,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,74.21,,,,,,,fee schedule,74.21,204.29, Cytp urne 3-5 probes ea spec,88120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2518.53,,,,,,,fee schedule,215.25,2518.53, Cytp urne 3-5 probes ea spec,88120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1947.24,,,,,,,fee schedule,215.25,2518.53, Cytp urne 3-5 probes ea spec,88120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,215.25,,,,,,,fee schedule,215.25,2518.53, Cytp urne 3-5 probes ea spec,88120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,215.25,,,,,,,fee schedule,215.25,2518.53, Cytp urine 3-5 probes cmptr,88121,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1799.08,,,,,,,fee schedule,425.12,1799.08, Cytp urine 3-5 probes cmptr,88121,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1390.99,,,,,,,fee schedule,425.12,1799.08, Cytp urine 3-5 probes cmptr,88121,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,425.12,,,,,,,fee schedule,425.12,1799.08, Cytp urine 3-5 probes cmptr,88121,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,425.12,,,,,,,fee schedule,425.12,1799.08, Forensic cytopathology,88125,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,78.51,,,,,,,fee schedule,60.7,78.51, Forensic cytopathology,88125,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,60.7,,,,,,,fee schedule,60.7,78.51, Forensic cytopathology,88125,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,74.21,,,,,,,fee schedule,60.7,78.51, Forensic cytopathology,88125,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,74.21,,,,,,,fee schedule,60.7,78.51, Sex chromatin identification,88130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,75.01,,,,,,,fee schedule,26.97,75.01, Sex chromatin identification,88130,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26.97,,,,,,,fee schedule,26.97,75.01, Sex chromatin identification,88130,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,26.97,,,,,,,fee schedule,26.97,75.01, Sex chromatin identification,88140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,33.33,,,,,,,fee schedule,11.99,33.33, Sex chromatin identification,88140,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.99,,,,,,,fee schedule,11.99,33.33, Sex chromatin identification,88140,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11.99,,,,,,,fee schedule,11.99,33.33, Cytopath c/v interpret,88141,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,127.02,,,,,,,fee schedule,39.53,127.02, Cytopath c/v interpret,88141,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,98.21,,,,,,,fee schedule,39.53,127.02, Cytopath c/v interpret,88141,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,39.53,,,,,,,fee schedule,39.53,127.02, Cytopath c/v interpret,88141,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,39.53,,,,,,,fee schedule,39.53,127.02, Cytopath c/v thin layer,88142,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,84.52,,,,,,,fee schedule,30.39,84.52, Cytopath c/v thin layer,88142,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,30.39,,,,,,,fee schedule,30.39,84.52, Cytopath c/v thin layer,88142,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,30.39,,,,,,,fee schedule,30.39,84.52, Cytopath c/v thin layer redo,88143,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,96.12,,,,,,,fee schedule,34.56,96.12, Cytopath c/v thin layer redo,88143,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,34.56,,,,,,,fee schedule,34.56,96.12, Cytopath c/v thin layer redo,88143,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,34.56,,,,,,,fee schedule,34.56,96.12, Cytopath c/v automated,88147,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,210.94,,,,,,,fee schedule,75.84,210.94, Cytopath c/v automated,88147,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,75.84,,,,,,,fee schedule,75.84,210.94, Cytopath c/v automated,88147,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,75.84,,,,,,,fee schedule,75.84,210.94, Cytopath c/v auto rescreen,88148,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,77.35,,,,,,,fee schedule,24,77.35, Cytopath c/v auto rescreen,88148,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24,,,,,,,fee schedule,24,77.35, Cytopath c/v auto rescreen,88148,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,24,,,,,,,fee schedule,24,77.35, Cytopath c/v manual,88150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,77.35,,,,,,,fee schedule,22.68,77.35, Cytopath c/v manual,88150,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22.68,,,,,,,fee schedule,22.68,77.35, Cytopath c/v manual,88150,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22.68,,,,,,,fee schedule,22.68,77.35, Cytopath c/v auto redo,88152,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,115.31,,,,,,,fee schedule,41.46,115.31, Cytopath c/v auto redo,88152,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,41.46,,,,,,,fee schedule,41.46,115.31, Cytopath c/v auto redo,88152,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,41.46,,,,,,,fee schedule,41.46,115.31, Cytopath c/v redo,88153,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,100.25,,,,,,,fee schedule,36.05,100.25, Cytopath c/v redo,88153,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,36.05,,,,,,,fee schedule,36.05,100.25, Cytopath c/v redo,88153,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,36.05,,,,,,,fee schedule,36.05,100.25, Cytopath c/v index add-on,88155,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,61.12,,,,,,,fee schedule,21.98,61.12, Cytopath c/v index add-on,88155,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21.98,,,,,,,fee schedule,21.98,61.12, Cytopath c/v index add-on,88155,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,21.98,,,,,,,fee schedule,21.98,61.12, Cytopath smear other source,88160,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,298.34,,,,,,,fee schedule,34.49,298.34, Cytopath smear other source,88160,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,230.67,,,,,,,fee schedule,34.49,298.34, Cytopath smear other source,88160,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,34.49,,,,,,,fee schedule,34.49,298.34, Cytopath smear other source,88160,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,34.49,,,,,,,fee schedule,34.49,298.34, Cytopath smear other source,88161,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,305.2,,,,,,,fee schedule,34.49,305.2, Cytopath smear other source,88161,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,235.97,,,,,,,fee schedule,34.49,305.2, Cytopath smear other source,88161,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,34.49,,,,,,,fee schedule,34.49,305.2, Cytopath smear other source,88161,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,34.49,,,,,,,fee schedule,34.49,305.2, Cytopath smear other source,88162,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,471.61,,,,,,,fee schedule,74.21,471.61, Cytopath smear other source,88162,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,364.63,,,,,,,fee schedule,74.21,471.61, Cytopath smear other source,88162,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,74.21,,,,,,,fee schedule,74.21,471.61, Cytopath smear other source,88162,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,74.21,,,,,,,fee schedule,74.21,471.61, Cytopath tbs c/v manual,88164,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,77.35,,,,,,,fee schedule,22.68,77.35, Cytopath tbs c/v manual,88164,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22.68,,,,,,,fee schedule,22.68,77.35, Cytopath tbs c/v manual,88164,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22.68,,,,,,,fee schedule,22.68,77.35, Cytopath tbs c/v redo,88165,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,176.14,,,,,,,fee schedule,63.33,176.14, Cytopath tbs c/v redo,88165,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,63.33,,,,,,,fee schedule,63.33,176.14, Cytopath tbs c/v redo,88165,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,63.33,,,,,,,fee schedule,63.33,176.14, Cytopath tbs c/v auto redo,88166,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,77.35,,,,,,,fee schedule,22.68,77.35, Cytopath tbs c/v auto redo,88166,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22.68,,,,,,,fee schedule,22.68,77.35, Cytopath tbs c/v auto redo,88166,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22.68,,,,,,,fee schedule,22.68,77.35, Cytopath tbs c/v select,88167,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,77.35,,,,,,,fee schedule,22.68,77.35, Cytopath tbs c/v select,88167,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22.68,,,,,,,fee schedule,22.68,77.35, Cytopath tbs c/v select,88167,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22.68,,,,,,,fee schedule,22.68,77.35, Cytp dx eval fna 1st ea site,88172,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,109.54,,,,,,,fee schedule,84.69,215.25, Cytp dx eval fna 1st ea site,88172,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,84.69,,,,,,,fee schedule,84.69,215.25, Cytp dx eval fna 1st ea site,88172,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,215.25,,,,,,,fee schedule,84.69,215.25, Cytp dx eval fna 1st ea site,88172,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,215.25,,,,,,,fee schedule,84.69,215.25, Cytopath eval fna report,88173,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,525.03,,,,,,,fee schedule,74.21,525.03, Cytopath eval fna report,88173,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,405.94,,,,,,,fee schedule,74.21,525.03, Cytopath eval fna report,88173,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,74.21,,,,,,,fee schedule,74.21,525.03, Cytopath eval fna report,88173,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,74.21,,,,,,,fee schedule,74.21,525.03, Cytopath c/v auto in fluid,88174,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,105.84,,,,,,,fee schedule,38.06,105.84, Cytopath c/v auto in fluid,88174,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,38.06,,,,,,,fee schedule,38.06,105.84, Cytopath c/v auto in fluid,88174,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,38.06,,,,,,,fee schedule,38.06,105.84, Cytopath c/v auto fluid redo,88175,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,111.02,,,,,,,fee schedule,39.92,111.02, Cytopath c/v auto fluid redo,88175,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,39.92,,,,,,,fee schedule,39.92,111.02, Cytopath c/v auto fluid redo,88175,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,39.92,,,,,,,fee schedule,39.92,111.02, Cytp fna eval ea addl,88177,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,44.79,,,,,,,fee schedule,10.83,44.79, Cytp fna eval ea addl,88177,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,34.63,,,,,,,fee schedule,10.83,44.79, Cytp fna eval ea addl,88177,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.83,,,,,,,fee schedule,10.83,44.79, Cytp fna eval ea addl,88177,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,10.83,,,,,,,fee schedule,10.83,44.79, Cell marker study,88182,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,592.48,,,,,,,fee schedule,74.21,592.48, Cell marker study,88182,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,458.09,,,,,,,fee schedule,74.21,592.48, Cell marker study,88182,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,74.21,,,,,,,fee schedule,74.21,592.48, Cell marker study,88182,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,74.21,,,,,,,fee schedule,74.21,592.48, Flowcytometry/ tc 1 marker,88184,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,420.67,,,,,,,fee schedule,325.25,425.12, Flowcytometry/ tc 1 marker,88184,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,325.25,,,,,,,fee schedule,325.25,425.12, Flowcytometry/ tc 1 marker,88184,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,425.12,,,,,,,fee schedule,325.25,425.12, Flowcytometry/ tc 1 marker,88184,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,425.12,,,,,,,fee schedule,325.25,425.12, Flowcytometry/tc add-on,88185,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,118.87,,,,,,,fee schedule,33.57,118.87, Flowcytometry/tc add-on,88185,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,91.91,,,,,,,fee schedule,33.57,118.87, Flowcytometry/tc add-on,88185,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,33.57,,,,,,,fee schedule,33.57,118.87, Flowcytometry/tc add-on,88185,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,33.57,,,,,,,fee schedule,33.57,118.87, Flowcytometry/read 2-8,88187,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,189.56,,,,,,,fee schedule,59.01,189.56, Flowcytometry/read 2-8,88187,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,146.56,,,,,,,fee schedule,59.01,189.56, Flowcytometry/read 2-8,88187,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,59.01,,,,,,,fee schedule,59.01,189.56, Flowcytometry/read 2-8,88187,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,59.01,,,,,,,fee schedule,59.01,189.56, Flowcytometry/read 9-15,88188,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,316.75,,,,,,,fee schedule,99.06,316.75, Flowcytometry/read 9-15,88188,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,244.9,,,,,,,fee schedule,99.06,316.75, Flowcytometry/read 9-15,88188,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,99.06,,,,,,,fee schedule,99.06,316.75, Flowcytometry/read 9-15,88188,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,99.06,,,,,,,fee schedule,99.06,316.75, Flowcytometry/read 16 & >,88189,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,428.44,,,,,,,fee schedule,133.17,428.44, Flowcytometry/read 16 & >,88189,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,331.26,,,,,,,fee schedule,133.17,428.44, Flowcytometry/read 16 & >,88189,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,133.17,,,,,,,fee schedule,133.17,428.44, Flowcytometry/read 16 & >,88189,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,133.17,,,,,,,fee schedule,133.17,428.44, Cytopathology procedure,88199,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,74.21,,,,,,,fee schedule,74.21,74.21, Cytopathology procedure,88199,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,74.21,,,,,,,fee schedule,74.21,74.21, Tissue culture lymphocyte,88230,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,486,,,,,,,fee schedule,174.74,486, Tissue culture lymphocyte,88230,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,174.74,,,,,,,fee schedule,174.74,486, Tissue culture lymphocyte,88230,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,174.74,,,,,,,fee schedule,174.74,486, Tissue culture skin/biopsy,88233,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,587.13,,,,,,,fee schedule,211.1,587.13, Tissue culture skin/biopsy,88233,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,211.1,,,,,,,fee schedule,211.1,587.13, Tissue culture skin/biopsy,88233,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,211.1,,,,,,,fee schedule,211.1,587.13, Tissue culture placenta,88235,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,627.05,,,,,,,fee schedule,225.45,627.05, Tissue culture placenta,88235,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,225.45,,,,,,,fee schedule,225.45,627.05, Tissue culture placenta,88235,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,225.45,,,,,,,fee schedule,225.45,627.05, Tissue culture bone marrow,88237,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,599.73,,,,,,,fee schedule,215.63,599.73, Tissue culture bone marrow,88237,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,215.63,,,,,,,fee schedule,215.63,599.73, Tissue culture bone marrow,88237,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,215.63,,,,,,,fee schedule,215.63,599.73, Tissue culture tumor,88239,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,615.45,,,,,,,fee schedule,221.28,615.45, Tissue culture tumor,88239,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,221.28,,,,,,,fee schedule,221.28,615.45, Tissue culture tumor,88239,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,221.28,,,,,,,fee schedule,221.28,615.45, Cell cryopreserve/storage,88240,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,54.53,,,,,,,fee schedule,19.61,54.53, Cell cryopreserve/storage,88240,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.61,,,,,,,fee schedule,19.61,54.53, Cell cryopreserve/storage,88240,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19.61,,,,,,,fee schedule,19.61,54.53, Frozen cell preparation,88241,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,50.44,,,,,,,fee schedule,18.14,50.44, Frozen cell preparation,88241,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.14,,,,,,,fee schedule,18.14,50.44, Frozen cell preparation,88241,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,18.14,,,,,,,fee schedule,18.14,50.44, Chromosome analysis 20-25,88245,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,722.47,,,,,,,fee schedule,259.76,722.47, Chromosome analysis 20-25,88245,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,259.76,,,,,,,fee schedule,259.76,722.47, Chromosome analysis 20-25,88245,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,259.76,,,,,,,fee schedule,259.76,722.47, Chromosome analysis 50-100,88248,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,722.47,,,,,,,fee schedule,259.76,722.47, Chromosome analysis 50-100,88248,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,259.76,,,,,,,fee schedule,259.76,722.47, Chromosome analysis 50-100,88248,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,259.76,,,,,,,fee schedule,259.76,722.47, Chromosome analysis 100,88249,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,722.47,,,,,,,fee schedule,259.76,722.47, Chromosome analysis 100,88249,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,259.76,,,,,,,fee schedule,259.76,722.47, Chromosome analysis 100,88249,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,259.76,,,,,,,fee schedule,259.76,722.47, Chromosome analysis 5,88261,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1102.83,,,,,,,fee schedule,396.51,1102.83, Chromosome analysis 5,88261,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,396.51,,,,,,,fee schedule,396.51,1102.83, Chromosome analysis 5,88261,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,396.51,,,,,,,fee schedule,396.51,1102.83, Chromosome analysis 15-20,88262,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,523.54,,,,,,,fee schedule,188.24,523.54, Chromosome analysis 15-20,88262,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,188.24,,,,,,,fee schedule,188.24,523.54, Chromosome analysis 15-20,88262,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,188.24,,,,,,,fee schedule,188.24,523.54, Chromosome analysis 45,88263,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,627.01,,,,,,,fee schedule,225.44,627.01, Chromosome analysis 45,88263,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,225.44,,,,,,,fee schedule,225.44,627.01, Chromosome analysis 45,88263,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,225.44,,,,,,,fee schedule,225.44,627.01, Chromosome analysis 20-25,88264,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,603.31,,,,,,,fee schedule,216.92,603.31, Chromosome analysis 20-25,88264,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,216.92,,,,,,,fee schedule,216.92,603.31, Chromosome analysis 20-25,88264,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,216.92,,,,,,,fee schedule,216.92,603.31, Chromosome analys placenta,88267,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,786.71,,,,,,,fee schedule,282.86,786.71, Chromosome analys placenta,88267,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,282.86,,,,,,,fee schedule,282.86,786.71, Chromosome analys placenta,88267,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,282.86,,,,,,,fee schedule,282.86,786.71, Chromosome analys amniotic,88269,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,724.51,,,,,,,fee schedule,260.49,724.51, Chromosome analys amniotic,88269,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,260.49,,,,,,,fee schedule,260.49,724.51, Chromosome analys amniotic,88269,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,260.49,,,,,,,fee schedule,260.49,724.51, Cytogenetics dna probe,88271,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,89.36,,,,,,,fee schedule,32.13,89.36, Cytogenetics dna probe,88271,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,32.13,,,,,,,fee schedule,32.13,89.36, Cytogenetics dna probe,88271,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,32.13,,,,,,,fee schedule,32.13,89.36, Cytogenetics 3-5,88272,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,169.8,,,,,,,fee schedule,61.05,169.8, Cytogenetics 3-5,88272,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,61.05,,,,,,,fee schedule,61.05,169.8, Cytogenetics 3-5,88272,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,61.05,,,,,,,fee schedule,61.05,169.8, Cytogenetics 10-30,88273,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,145.23,,,,,,,fee schedule,52.22,145.23, Cytogenetics 10-30,88273,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,52.22,,,,,,,fee schedule,52.22,145.23, Cytogenetics 10-30,88273,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,52.22,,,,,,,fee schedule,52.22,145.23, Cytogenetics 25-99,88274,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,176.81,,,,,,,fee schedule,63.57,176.81, Cytogenetics 25-99,88274,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,63.57,,,,,,,fee schedule,63.57,176.81, Cytogenetics 25-99,88274,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,63.57,,,,,,,fee schedule,63.57,176.81, Cytogenetics 100-300,88275,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,213.56,,,,,,,fee schedule,76.79,213.56, Cytogenetics 100-300,88275,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,76.79,,,,,,,fee schedule,76.79,213.56, Cytogenetics 100-300,88275,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,76.79,,,,,,,fee schedule,76.79,213.56, Chromosome karyotype study,88280,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,139.64,,,,,,,fee schedule,50.21,139.64, Chromosome karyotype study,88280,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,50.21,,,,,,,fee schedule,50.21,139.64, Chromosome karyotype study,88280,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,50.21,,,,,,,fee schedule,50.21,139.64, Chromosome banding study,88283,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,286.2,,,,,,,fee schedule,102.9,286.2, Chromosome banding study,88283,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,102.9,,,,,,,fee schedule,102.9,286.2, Chromosome banding study,88283,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,102.9,,,,,,,fee schedule,102.9,286.2, Chromosome count additional,88285,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,112.27,,,,,,,fee schedule,40.37,112.27, Chromosome count additional,88285,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,40.37,,,,,,,fee schedule,40.37,112.27, Chromosome count additional,88285,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,40.37,,,,,,,fee schedule,40.37,112.27, Chromosome study additional,88289,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,143.64,,,,,,,fee schedule,51.65,143.64, Chromosome study additional,88289,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,51.65,,,,,,,fee schedule,51.65,143.64, Chromosome study additional,88289,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,51.65,,,,,,,fee schedule,51.65,143.64, Cyto/molecular report,88291,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,176.61,,,,,,,fee schedule,51.98,176.61, Cyto/molecular report,88291,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,136.55,,,,,,,fee schedule,51.98,176.61, Cyto/molecular report,88291,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,51.98,,,,,,,fee schedule,51.98,176.61, Cyto/molecular report,88291,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,51.98,,,,,,,fee schedule,51.98,176.61, Cytogenetic study,88299,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,74.21,,,,,,,fee schedule,74.21,74.21, Cytogenetic study,88299,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,74.21,,,,,,,fee schedule,74.21,74.21, Surgical path gross,88300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,63.03,,,,,,,fee schedule,34.49,63.03, Surgical path gross,88300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,48.73,,,,,,,fee schedule,34.49,63.03, Surgical path gross,88300,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,34.49,,,,,,,fee schedule,34.49,63.03, Surgical path gross,88300,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,34.49,,,,,,,fee schedule,34.49,63.03, Tissue exam by pathologist,88302,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,133.66,,,,,,,fee schedule,34.49,133.66, Tissue exam by pathologist,88302,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,103.34,,,,,,,fee schedule,34.49,133.66, Tissue exam by pathologist,88302,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,34.49,,,,,,,fee schedule,34.49,133.66, Tissue exam by pathologist,88302,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,34.49,,,,,,,fee schedule,34.49,133.66, Tissue exam by pathologist,88304,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,159.51,,,,,,,fee schedule,74.21,159.51, Tissue exam by pathologist,88304,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,123.32,,,,,,,fee schedule,74.21,159.51, Tissue exam by pathologist,88304,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,74.21,,,,,,,fee schedule,74.21,159.51, Tissue exam by pathologist,88304,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,74.21,,,,,,,fee schedule,74.21,159.51, Tissue exam by pathologist,88305,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,181.9,,,,,,,fee schedule,74.21,181.9, Tissue exam by pathologist,88305,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,140.64,,,,,,,fee schedule,74.21,181.9, Tissue exam by pathologist,88305,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,74.21,,,,,,,fee schedule,74.21,181.9, Tissue exam by pathologist,88305,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,74.21,,,,,,,fee schedule,74.21,181.9, Tissue exam by pathologist,88307,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1042.94,,,,,,,fee schedule,425.12,1042.94, Tissue exam by pathologist,88307,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,806.36,,,,,,,fee schedule,425.12,1042.94, Tissue exam by pathologist,88307,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,425.12,,,,,,,fee schedule,425.12,1042.94, Tissue exam by pathologist,88307,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,425.12,,,,,,,fee schedule,425.12,1042.94, Tissue exam by pathologist,88309,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1443.65,,,,,,,fee schedule,942.3,1443.65, Tissue exam by pathologist,88309,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1116.18,,,,,,,fee schedule,942.3,1443.65, Tissue exam by pathologist,88309,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,942.3,,,,,,,fee schedule,942.3,1443.65, Tissue exam by pathologist,88309,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,942.3,,,,,,,fee schedule,942.3,1443.65, Decalcify tissue,88311,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,44.09,,,,,,,fee schedule,13.53,44.09, Decalcify tissue,88311,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,34.09,,,,,,,fee schedule,13.53,44.09, Decalcify tissue,88311,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13.53,,,,,,,fee schedule,13.53,44.09, Decalcify tissue,88311,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13.53,,,,,,,fee schedule,13.53,44.09, Special stains group 1,88312,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,437.89,,,,,,,fee schedule,74.21,437.89, Special stains group 1,88312,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,338.56,,,,,,,fee schedule,74.21,437.89, Special stains group 1,88312,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,74.21,,,,,,,fee schedule,74.21,437.89, Special stains group 1,88312,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,74.21,,,,,,,fee schedule,74.21,437.89, Special stains group 2,88313,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,359.37,,,,,,,fee schedule,50.15,359.37, Special stains group 2,88313,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,277.86,,,,,,,fee schedule,50.15,359.37, Special stains group 2,88313,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,50.15,,,,,,,fee schedule,50.15,359.37, Special stains group 2,88313,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,50.15,,,,,,,fee schedule,50.15,359.37, Histochemical stains add-on,88314,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,327.65,,,,,,,fee schedule,113.15,327.65, Histochemical stains add-on,88314,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,253.32,,,,,,,fee schedule,113.15,327.65, Histochemical stains add-on,88314,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,113.15,,,,,,,fee schedule,113.15,327.65, Histochemical stains add-on,88314,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,113.15,,,,,,,fee schedule,113.15,327.65, Enzyme histochemistry,88319,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,551.63,,,,,,,fee schedule,426.5,942.3, Enzyme histochemistry,88319,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,426.5,,,,,,,fee schedule,426.5,942.3, Enzyme histochemistry,88319,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,942.3,,,,,,,fee schedule,426.5,942.3, Enzyme histochemistry,88319,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,942.3,,,,,,,fee schedule,426.5,942.3, Microslide consultation,88321,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,367.58,,,,,,,fee schedule,50.15,367.58, Microslide consultation,88321,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,284.2,,,,,,,fee schedule,50.15,367.58, Microslide consultation,88321,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,50.15,,,,,,,fee schedule,50.15,367.58, Microslide consultation,88321,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,50.15,,,,,,,fee schedule,50.15,367.58, Microslide consultation,88323,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,154.33,,,,,,,fee schedule,74.21,154.33, Microslide consultation,88323,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,119.32,,,,,,,fee schedule,74.21,154.33, Microslide consultation,88323,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,74.21,,,,,,,fee schedule,74.21,154.33, Microslide consultation,88323,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,74.21,,,,,,,fee schedule,74.21,154.33, Comprehensive review of data,88325,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,613.53,,,,,,,fee schedule,74.21,613.53, Comprehensive review of data,88325,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,474.36,,,,,,,fee schedule,74.21,613.53, Comprehensive review of data,88325,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,74.21,,,,,,,fee schedule,74.21,613.53, Comprehensive review of data,88325,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,74.21,,,,,,,fee schedule,74.21,613.53, Path consult introp,88329,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,153.84,,,,,,,fee schedule,50.15,153.84, Path consult introp,88329,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,118.94,,,,,,,fee schedule,50.15,153.84, Path consult introp,88329,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,50.15,,,,,,,fee schedule,50.15,153.84, Path consult introp,88329,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,50.15,,,,,,,fee schedule,50.15,153.84, Path consult intraop 1 bloc,88331,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,204.29,,,,,,,fee schedule,157.95,215.25, Path consult intraop 1 bloc,88331,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,157.95,,,,,,,fee schedule,157.95,215.25, Path consult intraop 1 bloc,88331,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,215.25,,,,,,,fee schedule,157.95,215.25, Path consult intraop 1 bloc,88331,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,215.25,,,,,,,fee schedule,157.95,215.25, Path consult intraop addl,88332,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,126.75,,,,,,,fee schedule,34.65,126.75, Path consult intraop addl,88332,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,98,,,,,,,fee schedule,34.65,126.75, Path consult intraop addl,88332,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,34.65,,,,,,,fee schedule,34.65,126.75, Path consult intraop addl,88332,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,34.65,,,,,,,fee schedule,34.65,126.75, Intraop cyto path consult 1,88333,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,159.51,,,,,,,fee schedule,123.32,942.3, Intraop cyto path consult 1,88333,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,123.32,,,,,,,fee schedule,123.32,942.3, Intraop cyto path consult 1,88333,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,942.3,,,,,,,fee schedule,123.32,942.3, Intraop cyto path consult 1,88333,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,942.3,,,,,,,fee schedule,123.32,942.3, Intraop cyto path consult 2,88334,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,96.48,,,,,,,fee schedule,27.06,96.48, Intraop cyto path consult 2,88334,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,74.6,,,,,,,fee schedule,27.06,96.48, Intraop cyto path consult 2,88334,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,27.06,,,,,,,fee schedule,27.06,96.48, Intraop cyto path consult 2,88334,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,27.06,,,,,,,fee schedule,27.06,96.48, Immunohisto antb addl slide,88341,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,348.04,,,,,,,fee schedule,96.9,348.04, Immunohisto antb addl slide,88341,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,269.09,,,,,,,fee schedule,96.9,348.04, Immunohisto antb addl slide,88341,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,96.9,,,,,,,fee schedule,96.9,348.04, Immunohisto antb addl slide,88341,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,96.9,,,,,,,fee schedule,96.9,348.04, Immunohisto antb 1st stain,88342,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,400.71,,,,,,,fee schedule,215.25,400.71, Immunohisto antb 1st stain,88342,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,309.81,,,,,,,fee schedule,215.25,400.71, Immunohisto antb 1st stain,88342,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,215.25,,,,,,,fee schedule,215.25,400.71, Immunohisto antb 1st stain,88342,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,215.25,,,,,,,fee schedule,215.25,400.71, Immunohisto antibody slide,88344,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,709.14,,,,,,,fee schedule,425.12,709.14, Immunohisto antibody slide,88344,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,548.28,,,,,,,fee schedule,425.12,709.14, Immunohisto antibody slide,88344,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,425.12,,,,,,,fee schedule,425.12,709.14, Immunohisto antibody slide,88344,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,425.12,,,,,,,fee schedule,425.12,709.14, Immunofluor antb 1st stain,88346,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,536.09,,,,,,,fee schedule,414.49,536.09, Immunofluor antb 1st stain,88346,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,414.49,,,,,,,fee schedule,414.49,536.09, Immunofluor antb 1st stain,88346,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,425.12,,,,,,,fee schedule,414.49,536.09, Immunofluor antb 1st stain,88346,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,425.12,,,,,,,fee schedule,414.49,536.09, Electron microscopy,88348,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2102.34,,,,,,,fee schedule,942.3,2102.34, Electron microscopy,88348,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1625.45,,,,,,,fee schedule,942.3,2102.34, Electron microscopy,88348,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,942.3,,,,,,,fee schedule,942.3,2102.34, Electron microscopy,88348,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,942.3,,,,,,,fee schedule,942.3,2102.34, Immunofluor antb addl stain,88350,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,411.07,,,,,,,fee schedule,95.82,411.07, Immunofluor antb addl stain,88350,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,317.82,,,,,,,fee schedule,95.82,411.07, Immunofluor antb addl stain,88350,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,95.82,,,,,,,fee schedule,95.82,411.07, Immunofluor antb addl stain,88350,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,95.82,,,,,,,fee schedule,95.82,411.07, Analysis skeletal muscle,88355,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,320.74,,,,,,,fee schedule,215.25,320.74, Analysis skeletal muscle,88355,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,247.98,,,,,,,fee schedule,215.25,320.74, Analysis skeletal muscle,88355,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,215.25,,,,,,,fee schedule,215.25,320.74, Analysis skeletal muscle,88355,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,215.25,,,,,,,fee schedule,215.25,320.74, Analysis nerve,88356,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,579.69,,,,,,,fee schedule,74.21,579.69, Analysis nerve,88356,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,448.2,,,,,,,fee schedule,74.21,579.69, Analysis nerve,88356,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,74.21,,,,,,,fee schedule,74.21,579.69, Analysis nerve,88356,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,74.21,,,,,,,fee schedule,74.21,579.69, Analysis tumor,88358,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,435.19,,,,,,,fee schedule,215.25,435.19, Analysis tumor,88358,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,336.47,,,,,,,fee schedule,215.25,435.19, Analysis tumor,88358,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,215.25,,,,,,,fee schedule,215.25,435.19, Analysis tumor,88358,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,215.25,,,,,,,fee schedule,215.25,435.19, Tumor immunohistochem/manual,88360,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,419.7,,,,,,,fee schedule,215.25,419.7, Tumor immunohistochem/manual,88360,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,324.5,,,,,,,fee schedule,215.25,419.7, Tumor immunohistochem/manual,88360,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,215.25,,,,,,,fee schedule,215.25,419.7, Tumor immunohistochem/manual,88360,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,215.25,,,,,,,fee schedule,215.25,419.7, Tumor immunohistochem/comput,88361,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,383.49,,,,,,,fee schedule,296.5,425.12, Tumor immunohistochem/comput,88361,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,296.5,,,,,,,fee schedule,296.5,425.12, Tumor immunohistochem/comput,88361,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,425.12,,,,,,,fee schedule,296.5,425.12, Tumor immunohistochem/comput,88361,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,425.12,,,,,,,fee schedule,296.5,425.12, Nerve teasing preparations,88362,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,587.08,,,,,,,fee schedule,453.91,942.3, Nerve teasing preparations,88362,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,453.91,,,,,,,fee schedule,453.91,942.3, Nerve teasing preparations,88362,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,942.3,,,,,,,fee schedule,453.91,942.3, Nerve teasing preparations,88362,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,942.3,,,,,,,fee schedule,453.91,942.3, Xm archive tissue molec anal,88363,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,84.07,,,,,,,fee schedule,34.49,84.07, Xm archive tissue molec anal,88363,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,65,,,,,,,fee schedule,34.49,84.07, Xm archive tissue molec anal,88363,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,34.49,,,,,,,fee schedule,34.49,84.07, Xm archive tissue molec anal,88363,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,34.49,,,,,,,fee schedule,34.49,84.07, Insitu hybridization (fish),88364,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,490.33,,,,,,,fee schedule,156.45,490.33, Insitu hybridization (fish),88364,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,379.11,,,,,,,fee schedule,156.45,490.33, Insitu hybridization (fish),88364,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,156.45,,,,,,,fee schedule,156.45,490.33, Insitu hybridization (fish),88364,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,156.45,,,,,,,fee schedule,156.45,490.33, Insitu hybridization (fish),88365,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,665.33,,,,,,,fee schedule,215.25,665.33, Insitu hybridization (fish),88365,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,514.41,,,,,,,fee schedule,215.25,665.33, Insitu hybridization (fish),88365,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,215.25,,,,,,,fee schedule,215.25,665.33, Insitu hybridization (fish),88365,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,215.25,,,,,,,fee schedule,215.25,665.33, Insitu hybridization (fish),88366,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1071.97,,,,,,,fee schedule,425.12,1071.97, Insitu hybridization (fish),88366,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,828.81,,,,,,,fee schedule,425.12,1071.97, Insitu hybridization (fish),88366,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,425.12,,,,,,,fee schedule,425.12,1071.97, Insitu hybridization (fish),88366,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,425.12,,,,,,,fee schedule,425.12,1071.97, Insitu hybridization auto,88367,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,381.77,,,,,,,fee schedule,295.17,425.12, Insitu hybridization auto,88367,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,295.17,,,,,,,fee schedule,295.17,425.12, Insitu hybridization auto,88367,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,425.12,,,,,,,fee schedule,295.17,425.12, Insitu hybridization auto,88367,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,425.12,,,,,,,fee schedule,295.17,425.12, Insitu hybridization manual,88368,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,548.18,,,,,,,fee schedule,423.83,548.18, Insitu hybridization manual,88368,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,423.83,,,,,,,fee schedule,423.83,548.18, Insitu hybridization manual,88368,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,425.12,,,,,,,fee schedule,423.83,548.18, Insitu hybridization manual,88368,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,425.12,,,,,,,fee schedule,423.83,548.18, M/phmtrc alysishquant/semiq,88369,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,500.64,,,,,,,fee schedule,123.98,500.64, M/phmtrc alysishquant/semiq,88369,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,387.08,,,,,,,fee schedule,123.98,500.64, M/phmtrc alysishquant/semiq,88369,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,123.98,,,,,,,fee schedule,123.98,500.64, M/phmtrc alysishquant/semiq,88369,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,123.98,,,,,,,fee schedule,123.98,500.64, Protein western blot tissue,88371,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,92.74,,,,,,,fee schedule,33.35,92.74, Protein western blot tissue,88371,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,33.35,,,,,,,fee schedule,33.35,92.74, Protein western blot tissue,88371,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,33.35,,,,,,,fee schedule,33.35,92.74, Protein analysis w/probe,88372,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,109.39,,,,,,,fee schedule,39.33,109.39, Protein analysis w/probe,88372,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,39.33,,,,,,,fee schedule,39.33,109.39, Protein analysis w/probe,88372,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,39.33,,,,,,,fee schedule,39.33,109.39, M/phmtrc alys ishquant/semiq,88373,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,206.02,,,,,,,fee schedule,70.92,206.02, M/phmtrc alys ishquant/semiq,88373,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,159.29,,,,,,,fee schedule,70.92,206.02, M/phmtrc alys ishquant/semiq,88373,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,70.92,,,,,,,fee schedule,70.92,206.02, M/phmtrc alys ishquant/semiq,88373,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,70.92,,,,,,,fee schedule,70.92,206.02, M/phmtrc alys ishquant/semiq,88374,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1170.93,,,,,,,fee schedule,215.25,1170.93, M/phmtrc alys ishquant/semiq,88374,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,905.32,,,,,,,fee schedule,215.25,1170.93, M/phmtrc alys ishquant/semiq,88374,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,215.25,,,,,,,fee schedule,215.25,1170.93, M/phmtrc alys ishquant/semiq,88374,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,215.25,,,,,,,fee schedule,215.25,1170.93, Optical endomicroscpy interp,88375,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,244.6,,,,,,,fee schedule,76.88,244.6, Optical endomicroscpy interp,88375,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,189.12,,,,,,,fee schedule,76.88,244.6, Optical endomicroscpy interp,88375,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,76.88,,,,,,,fee schedule,76.88,244.6, Optical endomicroscpy interp,88375,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,76.88,,,,,,,fee schedule,76.88,244.6, M/phmtrc alys ishquant/semiq,88377,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1670.82,,,,,,,fee schedule,215.25,1670.82, M/phmtrc alys ishquant/semiq,88377,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1291.82,,,,,,,fee schedule,215.25,1670.82, M/phmtrc alys ishquant/semiq,88377,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,215.25,,,,,,,fee schedule,215.25,1670.82, M/phmtrc alys ishquant/semiq,88377,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,215.25,,,,,,,fee schedule,215.25,1670.82, Microdissection laser,88380,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,359.64,,,,,,,fee schedule,120.18,359.64, Microdissection laser,88380,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,278.06,,,,,,,fee schedule,120.18,359.64, Microdissection laser,88380,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,120.18,,,,,,,fee schedule,120.18,359.64, Microdissection laser,88380,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,120.18,,,,,,,fee schedule,120.18,359.64, Microdissection manual,88381,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,858.56,,,,,,,fee schedule,235.49,858.56, Microdissection manual,88381,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,663.81,,,,,,,fee schedule,235.49,858.56, Microdissection manual,88381,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,235.49,,,,,,,fee schedule,235.49,858.56, Microdissection manual,88381,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,235.49,,,,,,,fee schedule,235.49,858.56, Tiss exam molecular study,88387,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,38.91,,,,,,,fee schedule,10.83,38.91, Tiss exam molecular study,88387,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,30.08,,,,,,,fee schedule,10.83,38.91, Tiss exam molecular study,88387,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.83,,,,,,,fee schedule,10.83,38.91, Tiss exam molecular study,88387,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,10.83,,,,,,,fee schedule,10.83,38.91, Surgical pathology procedure,88399,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,74.21,,,,,,,fee schedule,74.21,74.21, Surgical pathology procedure,88399,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,74.21,,,,,,,fee schedule,74.21,74.21, Bilirubin total transcut,88720,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,20.94,,,,,,,fee schedule,7.53,20.94, Bilirubin total transcut,88720,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.53,,,,,,,fee schedule,7.53,20.94, Bilirubin total transcut,88720,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,7.53,,,,,,,fee schedule,7.53,20.94, Hgb quant transcutaneous,88738,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,20.94,,,,,,,fee schedule,7.53,20.94, Hgb quant transcutaneous,88738,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.53,,,,,,,fee schedule,7.53,20.94, Hgb quant transcutaneous,88738,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,7.53,,,,,,,fee schedule,7.53,20.94, Transcutaneous carboxyhb,88740,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,39.09,,,,,,,fee schedule,14.06,39.09, Transcutaneous carboxyhb,88740,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.06,,,,,,,fee schedule,14.06,39.09, Transcutaneous carboxyhb,88740,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,14.06,,,,,,,fee schedule,14.06,39.09, Transcutaneous methb,88741,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,39.09,,,,,,,fee schedule,14.06,39.09, Transcutaneous methb,88741,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.06,,,,,,,fee schedule,14.06,39.09, Transcutaneous methb,88741,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,14.06,,,,,,,fee schedule,14.06,39.09, Chct for mal hyperthermia,89049,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,330.13,,,,,,,fee schedule,215.25,330.13, Chct for mal hyperthermia,89049,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,255.24,,,,,,,fee schedule,215.25,330.13, Chct for mal hyperthermia,89049,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,215.25,,,,,,,fee schedule,215.25,330.13, Chct for mal hyperthermia,89049,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,215.25,,,,,,,fee schedule,215.25,330.13, Body fluid cell count,89050,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,19.69,,,,,,,fee schedule,7.08,19.69, Body fluid cell count,89050,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.08,,,,,,,fee schedule,7.08,19.69, Body fluid cell count,89050,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,7.08,,,,,,,fee schedule,7.08,19.69, Body fluid cell count,89051,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,23.36,,,,,,,fee schedule,8.4,23.36, Body fluid cell count,89051,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.4,,,,,,,fee schedule,8.4,23.36, Body fluid cell count,89051,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,8.4,,,,,,,fee schedule,8.4,23.36, Leukocyte assessment fecal,89055,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,17.81,,,,,,,fee schedule,6.41,17.81, Leukocyte assessment fecal,89055,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.41,,,,,,,fee schedule,6.41,17.81, Leukocyte assessment fecal,89055,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,6.41,,,,,,,fee schedule,6.41,17.81, Exam synovial fluid crystals,89060,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,30.58,,,,,,,fee schedule,11,30.58, Exam synovial fluid crystals,89060,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11,,,,,,,fee schedule,11,30.58, Exam synovial fluid crystals,89060,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11,,,,,,,fee schedule,11,30.58, Specimen fat stain,89125,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,24.53,,,,,,,fee schedule,8.82,24.53, Specimen fat stain,89125,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.82,,,,,,,fee schedule,8.82,24.53, Specimen fat stain,89125,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,8.82,,,,,,,fee schedule,8.82,24.53, Exam feces for meat fibers,89160,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,20.23,,,,,,,fee schedule,7.28,20.23, Exam feces for meat fibers,89160,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.28,,,,,,,fee schedule,7.28,20.23, Exam feces for meat fibers,89160,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,7.28,,,,,,,fee schedule,7.28,20.23, Nasal smear for eosinophils,89190,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,24.16,,,,,,,fee schedule,8.69,24.16, Nasal smear for eosinophils,89190,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.69,,,,,,,fee schedule,8.69,24.16, Nasal smear for eosinophils,89190,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,8.69,,,,,,,fee schedule,8.69,24.16, Sputum specimen collection,89220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,109.54,,,,,,,fee schedule,84.69,215.25, Sputum specimen collection,89220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,84.69,,,,,,,fee schedule,84.69,215.25, Sputum specimen collection,89220,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,215.25,,,,,,,fee schedule,84.69,215.25, Sputum specimen collection,89220,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,215.25,,,,,,,fee schedule,84.69,215.25, Collect sweat for test,89230,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,16.51,,,,,,,fee schedule,12.77,74.21, Collect sweat for test,89230,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,12.77,,,,,,,fee schedule,12.77,74.21, Collect sweat for test,89230,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,74.21,,,,,,,fee schedule,12.77,74.21, Collect sweat for test,89230,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,74.21,,,,,,,fee schedule,12.77,74.21, Pathology lab procedure,89240,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,74.21,,,,,,,fee schedule,74.21,74.21, Pathology lab procedure,89240,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,74.21,,,,,,,fee schedule,74.21,74.21, Cultr oocyte/embryo <4 days,89250,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,215.25,,,,,,,fee schedule,215.25,215.25, Cultr oocyte/embryo <4 days,89250,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,215.25,,,,,,,fee schedule,215.25,215.25, Cultr oocyte/embryo <4 days,89251,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,215.25,,,,,,,fee schedule,215.25,215.25, Cultr oocyte/embryo <4 days,89251,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,215.25,,,,,,,fee schedule,215.25,215.25, Embryo hatching,89253,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,215.25,,,,,,,fee schedule,215.25,215.25, Embryo hatching,89253,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,215.25,,,,,,,fee schedule,215.25,215.25, Oocyte identification,89254,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,215.25,,,,,,,fee schedule,215.25,215.25, Oocyte identification,89254,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,215.25,,,,,,,fee schedule,215.25,215.25, Prepare embryo for transfer,89255,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,74.21,,,,,,,fee schedule,74.21,74.21, Prepare embryo for transfer,89255,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,74.21,,,,,,,fee schedule,74.21,74.21, Sperm identification,89257,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,74.21,,,,,,,fee schedule,74.21,74.21, Sperm identification,89257,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,74.21,,,,,,,fee schedule,74.21,74.21, Cryopreservation embryo(s),89258,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,942.3,,,,,,,fee schedule,942.3,942.3, Cryopreservation embryo(s),89258,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,942.3,,,,,,,fee schedule,942.3,942.3, Cryopreservation sperm,89259,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,215.25,,,,,,,fee schedule,215.25,215.25, Cryopreservation sperm,89259,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,215.25,,,,,,,fee schedule,215.25,215.25, Sperm isolation simple,89260,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,74.21,,,,,,,fee schedule,74.21,74.21, Sperm isolation simple,89260,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,74.21,,,,,,,fee schedule,74.21,74.21, Sperm isolation complex,89261,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,74.21,,,,,,,fee schedule,74.21,74.21, Sperm isolation complex,89261,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,74.21,,,,,,,fee schedule,74.21,74.21, Identify sperm tissue,89264,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,74.21,,,,,,,fee schedule,74.21,74.21, Identify sperm tissue,89264,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,74.21,,,,,,,fee schedule,74.21,74.21, Insemination of oocytes,89268,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,215.25,,,,,,,fee schedule,215.25,215.25, Insemination of oocytes,89268,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,215.25,,,,,,,fee schedule,215.25,215.25, Extended culture of oocytes,89272,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,942.3,,,,,,,fee schedule,942.3,942.3, Extended culture of oocytes,89272,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,942.3,,,,,,,fee schedule,942.3,942.3, Assist oocyte fertilization,89280,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,942.3,,,,,,,fee schedule,942.3,942.3, Assist oocyte fertilization,89280,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,942.3,,,,,,,fee schedule,942.3,942.3, Assist oocyte fertilization,89281,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,215.25,,,,,,,fee schedule,215.25,215.25, Assist oocyte fertilization,89281,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,215.25,,,,,,,fee schedule,215.25,215.25, Biopsy oocyte polar body,89290,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,215.25,,,,,,,fee schedule,215.25,215.25, Biopsy oocyte polar body,89290,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,215.25,,,,,,,fee schedule,215.25,215.25, Biopsy oocyte polar body,89291,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,215.25,,,,,,,fee schedule,215.25,215.25, Biopsy oocyte polar body,89291,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,215.25,,,,,,,fee schedule,215.25,215.25, Semen analysis w/huhner,89300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,41.05,,,,,,,fee schedule,14.76,41.05, Semen analysis w/huhner,89300,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.76,,,,,,,fee schedule,14.76,41.05, Semen analysis w/huhner,89300,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,14.76,,,,,,,fee schedule,14.76,41.05, Semen analysis w/count,89310,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,35.92,,,,,,,fee schedule,12.92,35.92, Semen analysis w/count,89310,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.92,,,,,,,fee schedule,12.92,35.92, Semen analysis w/count,89310,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,12.92,,,,,,,fee schedule,12.92,35.92, Semen anal vol/count/mot,89320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,51.36,,,,,,,fee schedule,18.47,51.36, Semen anal vol/count/mot,89320,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.47,,,,,,,fee schedule,18.47,51.36, Semen anal vol/count/mot,89320,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,18.47,,,,,,,fee schedule,18.47,51.36, Semen anal sperm detection,89321,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,50.27,,,,,,,fee schedule,18.08,50.27, Semen anal sperm detection,89321,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.08,,,,,,,fee schedule,18.08,50.27, Semen anal sperm detection,89321,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,18.08,,,,,,,fee schedule,18.08,50.27, Semen anal strict criteria,89322,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,64.67,,,,,,,fee schedule,23.25,64.67, Semen anal strict criteria,89322,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23.25,,,,,,,fee schedule,23.25,64.67, Semen anal strict criteria,89322,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,23.25,,,,,,,fee schedule,23.25,64.67, Sperm antibody test,89325,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,44.52,,,,,,,fee schedule,16.01,44.52, Sperm antibody test,89325,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.01,,,,,,,fee schedule,16.01,44.52, Sperm antibody test,89325,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,16.01,,,,,,,fee schedule,16.01,44.52, Sperm evaluation test,89329,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,81.73,,,,,,,fee schedule,29.39,81.73, Sperm evaluation test,89329,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,29.39,,,,,,,fee schedule,29.39,81.73, Sperm evaluation test,89329,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,29.39,,,,,,,fee schedule,29.39,81.73, Evaluation cervical mucus,89330,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,43.31,,,,,,,fee schedule,15.57,43.31, Evaluation cervical mucus,89330,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.57,,,,,,,fee schedule,15.57,43.31, Evaluation cervical mucus,89330,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,15.57,,,,,,,fee schedule,15.57,43.31, Retrograde ejaculation anal,89331,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,81.73,,,,,,,fee schedule,29.39,81.73, Retrograde ejaculation anal,89331,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,29.39,,,,,,,fee schedule,29.39,81.73, Retrograde ejaculation anal,89331,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,29.39,,,,,,,fee schedule,29.39,81.73, Cryopreserve testicular tiss,89335,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,74.21,,,,,,,fee schedule,74.21,74.21, Cryopreserve testicular tiss,89335,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,74.21,,,,,,,fee schedule,74.21,74.21, Cryopreservation oocyte(s),89337,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,215.25,,,,,,,fee schedule,215.25,215.25, Cryopreservation oocyte(s),89337,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,215.25,,,,,,,fee schedule,215.25,215.25, Storage/year embryo(s),89342,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,215.25,,,,,,,fee schedule,215.25,215.25, Storage/year embryo(s),89342,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,215.25,,,,,,,fee schedule,215.25,215.25, Storage/year sperm/semen,89343,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,215.25,,,,,,,fee schedule,215.25,215.25, Storage/year sperm/semen,89343,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,215.25,,,,,,,fee schedule,215.25,215.25, Storage/year reprod tissue,89344,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,215.25,,,,,,,fee schedule,215.25,215.25, Storage/year reprod tissue,89344,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,215.25,,,,,,,fee schedule,215.25,215.25, Storage/year oocyte(s),89346,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,425.12,,,,,,,fee schedule,425.12,425.12, Storage/year oocyte(s),89346,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,425.12,,,,,,,fee schedule,425.12,425.12, Thawing cryopresrved embryo,89352,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,215.25,,,,,,,fee schedule,215.25,215.25, Thawing cryopresrved embryo,89352,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,215.25,,,,,,,fee schedule,215.25,215.25, Thawing cryopresrved sperm,89353,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,74.21,,,,,,,fee schedule,74.21,74.21, Thawing cryopresrved sperm,89353,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,74.21,,,,,,,fee schedule,74.21,74.21, Thaw cryoprsvrd reprod tiss,89354,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,215.25,,,,,,,fee schedule,215.25,215.25, Thaw cryoprsvrd reprod tiss,89354,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,215.25,,,,,,,fee schedule,215.25,215.25, Thawing cryopresrved oocyte,89356,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,215.25,,,,,,,fee schedule,215.25,215.25, Thawing cryopresrved oocyte,89356,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,215.25,,,,,,,fee schedule,215.25,215.25, Unlisted reprod med lab proc,89398,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,74.21,,,,,,,fee schedule,74.21,74.21, Unlisted reprod med lab proc,89398,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,74.21,,,,,,,fee schedule,74.21,74.21, Human ig im,90281,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,145.75,,,,,,,fee schedule,145.75,145.75, Human ig im,90281,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,145.75,,,,,,,fee schedule,145.75,145.75, Human ig iv,90283,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,113.31,,,,,,,fee schedule,113.31,113.31, Human ig iv,90283,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,113.31,,,,,,,fee schedule,113.31,113.31, Human ig sc,90284,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,28.79,,,,,,,fee schedule,28.79,28.79, Human ig sc,90284,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,28.79,,,,,,,fee schedule,28.79,28.79, Cmv ig iv,90291,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2572.03,,,,,,,fee schedule,2572.03,2572.03, Cmv ig iv,90291,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2572.03,,,,,,,fee schedule,2572.03,2572.03, Hep b ig im,90371,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,293.99,,,,,,,fee schedule,159.41,317.5, Hep b ig im,90371,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,317.5,,,,,,,fee schedule,159.41,317.5, Hep b ig im,90371,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,159.41,,,,,,,fee schedule,159.41,317.5, Hep b ig im,90371,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,159.41,,,,,,,fee schedule,159.41,317.5, Rabies ig im/sc,90375,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,599.49,,,,,,,fee schedule,325.06,647.45, Rabies ig im/sc,90375,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,647.45,,,,,,,fee schedule,325.06,647.45, Rabies ig im/sc,90375,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,325.06,,,,,,,fee schedule,325.06,647.45, Rabies ig im/sc,90375,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,325.06,,,,,,,fee schedule,325.06,647.45, Rabies ig heat treated,90376,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,423.73,,,,,,,fee schedule,423.73,423.73, Rabies ig heat treated,90376,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,423.73,,,,,,,fee schedule,423.73,423.73, Rabies ig ht&sol human im/sc,90377,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,533.48,,,,,,,fee schedule,289.26,576.15, Rabies ig ht&sol human im/sc,90377,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,576.15,,,,,,,fee schedule,289.26,576.15, Rabies ig ht&sol human im/sc,90377,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,289.26,,,,,,,fee schedule,289.26,576.15, Rabies ig ht&sol human im/sc,90377,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,289.26,,,,,,,fee schedule,289.26,576.15, Rsv mab im 50mg,90378,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,791.86,,,,,,,fee schedule,791.86,791.86, Rsv mab im 50mg,90378,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,791.86,,,,,,,fee schedule,791.86,791.86, Rsv monoc antb seasn .5ml im,90380,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,814.18,,,,,,,fee schedule,814.18,814.18, Rsv monoc antb seasn .5ml im,90380,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,814.18,,,,,,,fee schedule,814.18,814.18, Rsv monoc antb seasnl 1ml im,90381,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,814.18,,,,,,,fee schedule,814.18,814.18, Rsv monoc antb seasnl 1ml im,90381,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,814.18,,,,,,,fee schedule,814.18,814.18, Rh ig full-dose im,90384,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,159.25,,,,,,,fee schedule,159.25,159.25, Rh ig full-dose im,90384,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,159.25,,,,,,,fee schedule,159.25,159.25, Rh ig minidose im,90385,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,73.52,,,,,,,fee schedule,73.52,73.52, Rh ig minidose im,90385,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,73.52,,,,,,,fee schedule,73.52,73.52, Rh ig iv,90386,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,808.53,,,,,,,fee schedule,808.53,808.53, Rh ig iv,90386,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,808.53,,,,,,,fee schedule,808.53,808.53, Tetanus ig im,90389,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,950.38,,,,,,,fee schedule,950.38,950.38, Tetanus ig im,90389,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,950.38,,,,,,,fee schedule,950.38,950.38, Varicella-zoster ig im,90396,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2879.08,,,,,,,fee schedule,2879.08,2879.08, Varicella-zoster ig im,90396,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2879.08,,,,,,,fee schedule,2879.08,2879.08, Immune globulin,90399,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,522.03,,,,,,,fee schedule,522.03,522.03, Immune globulin,90399,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,522.03,,,,,,,fee schedule,522.03,522.03, Im admin 1st/only component,90460,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,124.43,,,,,,,fee schedule,124.43,124.43, Im admin each addl component,90461,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,47.22,,,,,,,fee schedule,47.22,47.22, Immunization admin,90471,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,116.07,,,,,,,fee schedule,116.07,116.07, Immunization admin each add,90472,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,84.88,,,,,,,fee schedule,84.88,84.88, Immune admin oral/nasal,90473,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,91.95,,,,,,,fee schedule,91.95,91.95, Immune admin oral/nasal addl,90474,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,65.94,,,,,,,fee schedule,65.94,65.94, Anthrax vaccine sc or im,90581,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,141.59,,,,,,,fee schedule,141.59,141.59, Anthrax vaccine sc or im,90581,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,141.59,,,,,,,fee schedule,141.59,141.59, Bcg vaccine percut,90585,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,258.64,,,,,,,fee schedule,258.64,258.64, Bcg vaccine percut,90585,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,258.64,,,,,,,fee schedule,258.64,258.64, Bcg vaccine intravesical,90586,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,351.36,,,,,,,fee schedule,190.52,379.47, Bcg vaccine intravesical,90586,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,379.47,,,,,,,fee schedule,190.52,379.47, Bcg vaccine intravesical,90586,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,190.52,,,,,,,fee schedule,190.52,379.47, Bcg vaccine intravesical,90586,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,190.52,,,,,,,fee schedule,190.52,379.47, Dengue vacc quad 3 dose subq,90587,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,96.62,,,,,,,fee schedule,96.62,96.62, Dengue vacc quad 3 dose subq,90587,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,96.62,,,,,,,fee schedule,96.62,96.62, Chikungunya vacc recomb im,90593,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,503.25,,,,,,,fee schedule,503.25,503.25, Chikungunya vacc recomb im,90593,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,503.25,,,,,,,fee schedule,503.25,503.25, Smallpox&monkeypox vac 0.5ml,90611,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.01,,,,,,,fee schedule,0.01,0.01, Smallpox&monkeypox vac 0.5ml,90611,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.01,,,,,,,fee schedule,0.01,0.01, Menacwy-tt vaccine im,90619,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,251.58,,,,,,,fee schedule,251.58,251.58, Menacwy-tt vaccine im,90619,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,251.58,,,,,,,fee schedule,251.58,251.58, Menb rp w/omv vaccine im,90620,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,346.97,,,,,,,fee schedule,346.97,346.97, Menb rp w/omv vaccine im,90620,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,346.97,,,,,,,fee schedule,346.97,346.97, Menb rlp vaccine im,90621,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,303.33,,,,,,,fee schedule,303.33,303.33, Menb rlp vaccine im,90621,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,303.33,,,,,,,fee schedule,303.33,303.33, Vaccinia vrs vac 0.3 ml perq,90622,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.01,,,,,,,fee schedule,0.01,0.01, Vaccinia vrs vac 0.3 ml perq,90622,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.01,,,,,,,fee schedule,0.01,0.01, Menacwy-tt menb-fhbp vacc im,90623,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,346.82,,,,,,,fee schedule,346.82,346.82, Menacwy-tt menb-fhbp vacc im,90623,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,346.82,,,,,,,fee schedule,346.82,346.82, Menb-4c&menacwy vacc im,90624,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,366.92,,,,,,,fee schedule,366.92,366.92, Menb-4c&menacwy vacc im,90624,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,366.92,,,,,,,fee schedule,366.92,366.92, Hepa vaccine adult im,90632,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,163.53,,,,,,,fee schedule,88.67,176.61, Hepa vaccine adult im,90632,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,176.61,,,,,,,fee schedule,88.67,176.61, Hepa vaccine adult im,90632,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,88.67,,,,,,,fee schedule,88.67,176.61, Hepa vaccine adult im,90632,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,88.67,,,,,,,fee schedule,88.67,176.61, Hepa vacc ped/adol 2 dose im,90633,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,51.63,,,,,,,fee schedule,51.63,51.63, Hepa vacc ped/adol 2 dose im,90633,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,51.63,,,,,,,fee schedule,51.63,51.63, Hepa vacc ped/adol 3 dose,90634,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,35.51,,,,,,,fee schedule,35.51,35.51, Hepa vacc ped/adol 3 dose,90634,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,35.51,,,,,,,fee schedule,35.51,35.51, Hep a/hep b vacc adult im,90636,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,193.52,,,,,,,fee schedule,193.52,193.52, Hep a/hep b vacc adult im,90636,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,193.52,,,,,,,fee schedule,193.52,193.52, Hib-mency vacc 6wk-18m0 im,90644,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26.84,,,,,,,fee schedule,26.84,26.84, Hib-mency vacc 6wk-18m0 im,90644,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,26.84,,,,,,,fee schedule,26.84,26.84, Hib prp-omp vacc 3 dose im,90647,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,44.58,,,,,,,fee schedule,44.58,44.58, Hib prp-omp vacc 3 dose im,90647,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,44.58,,,,,,,fee schedule,44.58,44.58, Hib prp-t vaccine 4 dose im,90648,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.26,,,,,,,fee schedule,19.26,19.26, Hib prp-t vaccine 4 dose im,90648,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19.26,,,,,,,fee schedule,19.26,19.26, 4vhpv vaccine 3 dose im,90649,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,128.26,,,,,,,fee schedule,128.26,128.26, 4vhpv vaccine 3 dose im,90649,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,128.26,,,,,,,fee schedule,128.26,128.26, 9vhpv vaccine 3 dose im,90651,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,450.16,,,,,,,fee schedule,450.16,450.16, 9vhpv vaccine 3 dose im,90651,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,450.16,,,,,,,fee schedule,450.16,450.16, Iiv adjuvant vaccine im,90653,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,187.85,,,,,,,fee schedule,101.86,202.88, Iiv adjuvant vaccine im,90653,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,202.88,,,,,,,fee schedule,101.86,202.88, Iiv adjuvant vaccine im,90653,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,101.86,,,,,,,fee schedule,101.86,202.88, Iiv adjuvant vaccine im,90653,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,101.86,,,,,,,fee schedule,101.86,202.88, Iiv3 vacc no prsv 0.25 ml im,90655,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.32,,,,,,,fee schedule,16.32,16.32, Iiv3 vacc no prsv 0.25 ml im,90655,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,16.32,,,,,,,fee schedule,16.32,16.32, Iiv3 vacc no prsv 0.5 ml im,90656,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,50.29,,,,,,,fee schedule,27.27,54.31, Iiv3 vacc no prsv 0.5 ml im,90656,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,54.31,,,,,,,fee schedule,27.27,54.31, Iiv3 vacc no prsv 0.5 ml im,90656,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,27.27,,,,,,,fee schedule,27.27,54.31, Iiv3 vacc no prsv 0.5 ml im,90656,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,27.27,,,,,,,fee schedule,27.27,54.31, Iiv3 vaccine splt 0.25 ml im,90657,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,24.59,,,,,,,fee schedule,13.33,26.56, Iiv3 vaccine splt 0.25 ml im,90657,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,26.56,,,,,,,fee schedule,13.33,26.56, Iiv3 vaccine splt 0.25 ml im,90657,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13.33,,,,,,,fee schedule,13.33,26.56, Iiv3 vaccine splt 0.25 ml im,90657,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13.33,,,,,,,fee schedule,13.33,26.56, Iiv3 vaccine splt 0.5 ml im,90658,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,49.19,,,,,,,fee schedule,26.67,53.12, Iiv3 vaccine splt 0.5 ml im,90658,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,53.12,,,,,,,fee schedule,26.67,53.12, Iiv3 vaccine splt 0.5 ml im,90658,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26.67,,,,,,,fee schedule,26.67,53.12, Iiv3 vaccine splt 0.5 ml im,90658,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,26.67,,,,,,,fee schedule,26.67,53.12, Laiv3 vaccine intranasal,90660,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,64.96,,,,,,,fee schedule,35.22,70.15, Laiv3 vaccine intranasal,90660,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,70.15,,,,,,,fee schedule,35.22,70.15, Laiv3 vaccine intranasal,90660,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,35.22,,,,,,,fee schedule,35.22,70.15, Laiv3 vaccine intranasal,90660,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,35.22,,,,,,,fee schedule,35.22,70.15, Cciiv3 vac no prsv 0.5 ml im,90661,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,82.91,,,,,,,fee schedule,44.96,89.55, Cciiv3 vac no prsv 0.5 ml im,90661,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,89.55,,,,,,,fee schedule,44.96,89.55, Cciiv3 vac no prsv 0.5 ml im,90661,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,44.96,,,,,,,fee schedule,44.96,89.55, Cciiv3 vac no prsv 0.5 ml im,90661,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,44.96,,,,,,,fee schedule,44.96,89.55, Iiv no prsv increased ag im,90662,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,187.85,,,,,,,fee schedule,101.86,202.88, Iiv no prsv increased ag im,90662,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,202.88,,,,,,,fee schedule,101.86,202.88, Iiv no prsv increased ag im,90662,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,101.86,,,,,,,fee schedule,101.86,202.88, Iiv no prsv increased ag im,90662,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,101.86,,,,,,,fee schedule,101.86,202.88, Pcv13 vaccine im,90670,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,580.48,,,,,,,fee schedule,314.75,626.92, Pcv13 vaccine im,90670,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,626.92,,,,,,,fee schedule,314.75,626.92, Pcv13 vaccine im,90670,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,314.75,,,,,,,fee schedule,314.75,626.92, Pcv13 vaccine im,90670,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,314.75,,,,,,,fee schedule,314.75,626.92, Pcv15 vaccine im,90671,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,587.59,,,,,,,fee schedule,318.6,634.59, Pcv15 vaccine im,90671,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,634.59,,,,,,,fee schedule,318.6,634.59, Pcv15 vaccine im,90671,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,318.6,,,,,,,fee schedule,318.6,634.59, Pcv15 vaccine im,90671,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,318.6,,,,,,,fee schedule,318.6,634.59, Riv3 vaccine no preserv im,90673,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,187.85,,,,,,,fee schedule,101.86,202.88, Riv3 vaccine no preserv im,90673,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,202.88,,,,,,,fee schedule,101.86,202.88, Riv3 vaccine no preserv im,90673,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,101.86,,,,,,,fee schedule,101.86,202.88, Riv3 vaccine no preserv im,90673,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,101.86,,,,,,,fee schedule,101.86,202.88, Rabies vaccine im,90675,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,702.07,,,,,,,fee schedule,380.68,758.23, Rabies vaccine im,90675,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,758.23,,,,,,,fee schedule,380.68,758.23, Rabies vaccine im,90675,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,380.68,,,,,,,fee schedule,380.68,758.23, Rabies vaccine im,90675,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,380.68,,,,,,,fee schedule,380.68,758.23, Rabies vaccine id,90676,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,322.65,,,,,,,fee schedule,322.65,322.65, Rabies vaccine id,90676,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,322.65,,,,,,,fee schedule,322.65,322.65, Pcv20 vaccine im,90677,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,704.03,,,,,,,fee schedule,381.74,760.35, Pcv20 vaccine im,90677,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,760.35,,,,,,,fee schedule,381.74,760.35, Pcv20 vaccine im,90677,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,381.74,,,,,,,fee schedule,381.74,760.35, Pcv20 vaccine im,90677,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,381.74,,,,,,,fee schedule,381.74,760.35, Rsv vacc pref bivalent im,90678,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,449.16,,,,,,,fee schedule,449.16,449.16, Rsv vacc pref bivalent im,90678,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,449.16,,,,,,,fee schedule,449.16,449.16, Rsv vacc pref recomb adjt im,90679,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,448.5,,,,,,,fee schedule,448.5,448.5, Rsv vacc pref recomb adjt im,90679,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,448.5,,,,,,,fee schedule,448.5,448.5, Rv5 vacc 3 dose live oral,90680,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,144.48,,,,,,,fee schedule,144.48,144.48, Rv5 vacc 3 dose live oral,90680,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,144.48,,,,,,,fee schedule,144.48,144.48, Rv1 vacc 2 dose live oral,90681,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,215.05,,,,,,,fee schedule,215.05,215.05, Rv1 vacc 2 dose live oral,90681,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,215.05,,,,,,,fee schedule,215.05,215.05, Rsv vacc mrna lipid nano im,90683,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,424.56,,,,,,,fee schedule,424.56,424.56, Rsv vacc mrna lipid nano im,90683,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,424.56,,,,,,,fee schedule,424.56,424.56, Pcv21 vaccine im,90684,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,737.75,,,,,,,fee schedule,400.03,796.77, Pcv21 vaccine im,90684,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,796.77,,,,,,,fee schedule,400.03,796.77, Pcv21 vaccine im,90684,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,400.03,,,,,,,fee schedule,400.03,796.77, Pcv21 vaccine im,90684,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,400.03,,,,,,,fee schedule,400.03,796.77, Typhoid vaccine oral,90690,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,171.7,,,,,,,fee schedule,171.7,171.7, Typhoid vaccine oral,90690,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,171.7,,,,,,,fee schedule,171.7,171.7, Typhoid vaccine im,90691,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,182.55,,,,,,,fee schedule,182.55,182.55, Typhoid vaccine im,90691,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,182.55,,,,,,,fee schedule,182.55,182.55, Dtap-ipv vaccine 4-6 yrs im,90696,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,93.43,,,,,,,fee schedule,93.43,93.43, Dtap-ipv vaccine 4-6 yrs im,90696,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,93.43,,,,,,,fee schedule,93.43,93.43, Dtap-ipv-hib-hepb vaccine im,90697,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,228.25,,,,,,,fee schedule,228.25,228.25, Dtap-ipv-hib-hepb vaccine im,90697,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,228.25,,,,,,,fee schedule,228.25,228.25, Dtap-ipv/hib vaccine im,90698,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,164.69,,,,,,,fee schedule,164.69,164.69, Dtap-ipv/hib vaccine im,90698,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,164.69,,,,,,,fee schedule,164.69,164.69, Dtap vaccine < 7 yrs im,90700,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,43.55,,,,,,,fee schedule,43.55,43.55, Dtap vaccine < 7 yrs im,90700,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,43.55,,,,,,,fee schedule,43.55,43.55, Dt vaccine under 7 yrs im,90702,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,20.52,,,,,,,fee schedule,20.52,20.52, Dt vaccine under 7 yrs im,90702,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,20.52,,,,,,,fee schedule,20.52,20.52, Mmr vaccine sc,90707,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,138.82,,,,,,,fee schedule,138.82,138.82, Mmr vaccine sc,90707,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,138.82,,,,,,,fee schedule,138.82,138.82, Mmrv vaccine sc,90710,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,406.49,,,,,,,fee schedule,406.49,406.49, Mmrv vaccine sc,90710,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,406.49,,,,,,,fee schedule,406.49,406.49, Poliovirus ipv sc/im,90713,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,65.31,,,,,,,fee schedule,65.31,65.31, Poliovirus ipv sc/im,90713,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,65.31,,,,,,,fee schedule,65.31,65.31, Td vacc no presv 7 yrs+ im,90714,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,81.81,,,,,,,fee schedule,44.37,88.35, Td vacc no presv 7 yrs+ im,90714,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,88.35,,,,,,,fee schedule,44.37,88.35, Td vacc no presv 7 yrs+ im,90714,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,44.37,,,,,,,fee schedule,44.37,88.35, Td vacc no presv 7 yrs+ im,90714,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,44.37,,,,,,,fee schedule,44.37,88.35, Tdap vaccine 7 yrs/> im,90715,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,89.35,,,,,,,fee schedule,48.45,96.5, Tdap vaccine 7 yrs/> im,90715,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,96.5,,,,,,,fee schedule,48.45,96.5, Tdap vaccine 7 yrs/> im,90715,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,48.45,,,,,,,fee schedule,48.45,96.5, Tdap vaccine 7 yrs/> im,90715,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,48.45,,,,,,,fee schedule,48.45,96.5, Var vaccine live subq,90716,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,267.73,,,,,,,fee schedule,267.73,267.73, Var vaccine live subq,90716,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,267.73,,,,,,,fee schedule,267.73,267.73, Yellow fever vaccine subq,90717,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,344.27,,,,,,,fee schedule,344.27,344.27, Yellow fever vaccine subq,90717,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,344.27,,,,,,,fee schedule,344.27,344.27, Dtap-hep b-ipv vaccine im,90723,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,150.78,,,,,,,fee schedule,150.78,150.78, Dtap-hep b-ipv vaccine im,90723,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,150.78,,,,,,,fee schedule,150.78,150.78, Ppsv23 vacc 2 yrs+ subq/im,90732,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,300.31,,,,,,,fee schedule,162.83,324.33, Ppsv23 vacc 2 yrs+ subq/im,90732,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,324.33,,,,,,,fee schedule,162.83,324.33, Ppsv23 vacc 2 yrs+ subq/im,90732,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,162.83,,,,,,,fee schedule,162.83,324.33, Ppsv23 vacc 2 yrs+ subq/im,90732,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,162.83,,,,,,,fee schedule,162.83,324.33, Mpsv4 vaccine subq,90733,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,101.42,,,,,,,fee schedule,101.42,101.42, Mpsv4 vaccine subq,90733,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,101.42,,,,,,,fee schedule,101.42,101.42, Mcv4 menacwy vaccine im,90734,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,243.94,,,,,,,fee schedule,243.94,243.94, Mcv4 menacwy vaccine im,90734,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,243.94,,,,,,,fee schedule,243.94,243.94, Hzv vaccine live subq,90736,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,162.19,,,,,,,fee schedule,162.19,162.19, Hzv vaccine live subq,90736,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,162.19,,,,,,,fee schedule,162.19,162.19, Inactivated je vacc im,90738,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,372.97,,,,,,,fee schedule,372.97,372.97, Inactivated je vacc im,90738,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,372.97,,,,,,,fee schedule,372.97,372.97, Hepb vacc 2 dose adult im,90739,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,399.51,,,,,,,fee schedule,216.62,431.47, Hepb vacc 2 dose adult im,90739,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,431.47,,,,,,,fee schedule,216.62,431.47, Hepb vacc 2 dose adult im,90739,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,216.62,,,,,,,fee schedule,216.62,431.47, Hepb vacc 2 dose adult im,90739,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,216.62,,,,,,,fee schedule,216.62,431.47, Hepb vacc 3 dose immunsup im,90740,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,369.95,,,,,,,fee schedule,200.59,399.54, Hepb vacc 3 dose immunsup im,90740,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,399.54,,,,,,,fee schedule,200.59,399.54, Hepb vacc 3 dose immunsup im,90740,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,200.59,,,,,,,fee schedule,200.59,399.54, Hepb vacc 3 dose immunsup im,90740,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,200.59,,,,,,,fee schedule,200.59,399.54, Hepb vacc 2 dose adolesc im,90743,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,169.07,,,,,,,fee schedule,91.68,182.59, Hepb vacc 2 dose adolesc im,90743,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,182.59,,,,,,,fee schedule,91.68,182.59, Hepb vacc 2 dose adolesc im,90743,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,91.68,,,,,,,fee schedule,91.68,182.59, Hepb vacc 2 dose adolesc im,90743,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,91.68,,,,,,,fee schedule,91.68,182.59, Hepb vacc 3 dose ped/adol im,90744,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,71.26,,,,,,,fee schedule,38.64,76.96, Hepb vacc 3 dose ped/adol im,90744,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,76.96,,,,,,,fee schedule,38.64,76.96, Hepb vacc 3 dose ped/adol im,90744,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,38.64,,,,,,,fee schedule,38.64,76.96, Hepb vacc 3 dose ped/adol im,90744,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,38.64,,,,,,,fee schedule,38.64,76.96, Hepb vaccine 3 dose adult im,90746,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,158.36,,,,,,,fee schedule,85.86,171.02, Hepb vaccine 3 dose adult im,90746,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,171.02,,,,,,,fee schedule,85.86,171.02, Hepb vaccine 3 dose adult im,90746,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,85.86,,,,,,,fee schedule,85.86,171.02, Hepb vaccine 3 dose adult im,90746,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,85.86,,,,,,,fee schedule,85.86,171.02, Hepb vacc 4 dose immunsup im,90747,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,316.69,,,,,,,fee schedule,171.72,342.02, Hepb vacc 4 dose immunsup im,90747,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,342.02,,,,,,,fee schedule,171.72,342.02, Hepb vacc 4 dose immunsup im,90747,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,171.72,,,,,,,fee schedule,171.72,342.02, Hepb vacc 4 dose immunsup im,90747,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,171.72,,,,,,,fee schedule,171.72,342.02, Hib-hepb vaccine im,90748,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56.44,,,,,,,fee schedule,56.44,56.44, Hib-hepb vaccine im,90748,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,56.44,,,,,,,fee schedule,56.44,56.44, Hep b vac 3ag 10mcg 3 dos im,90759,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,166.1,,,,,,,fee schedule,90.06,179.38, Hep b vac 3ag 10mcg 3 dos im,90759,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,179.38,,,,,,,fee schedule,90.06,179.38, Hep b vac 3ag 10mcg 3 dos im,90759,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,90.06,,,,,,,fee schedule,90.06,179.38, Hep b vac 3ag 10mcg 3 dos im,90759,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,90.06,,,,,,,fee schedule,90.06,179.38, Psytx complex interactive,90785,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,62.92,,,,,,,fee schedule,62.92,62.92, Psych diagnostic evaluation,90791,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,740.6,,,,,,,fee schedule,740.6,740.6, Psych diag eval w/med srvcs,90792,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,871.62,,,,,,,fee schedule,871.62,871.62, Psytx w pt 30 minutes,90832,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,374.75,,,,,,,fee schedule,374.75,374.75, Psytx w pt w e/m 30 min,90833,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,359.91,,,,,,,fee schedule,359.91,359.91, Psytx w pt 45 minutes,90834,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,496.11,,,,,,,fee schedule,496.11,496.11, Psytx w pt w e/m 45 min,90836,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,454.13,,,,,,,fee schedule,454.13,454.13, Psytx w pt 60 minutes,90837,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,729.76,,,,,,,fee schedule,729.76,729.76, Psytx w pt w e/m 60 min,90838,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,603.11,,,,,,,fee schedule,603.11,603.11, Psytx crisis initial 60 min,90839,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,699.86,,,,,,,fee schedule,699.86,699.86, Psytx crisis ea addl 30 min,90840,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,337.74,,,,,,,fee schedule,337.74,337.74, Psychoanalysis,90845,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,477.87,,,,,,,fee schedule,477.87,477.87, Family psytx w/o pt 50 min,90846,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,536.42,,,,,,,fee schedule,536.42,536.42, Family psytx w/pt 50 min,90847,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,555.36,,,,,,,fee schedule,555.36,555.36, Multiple family group psytx,90849,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,162.37,,,,,,,fee schedule,162.37,162.37, Group psychotherapy,90853,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,132.09,,,,,,,fee schedule,132.09,132.09, Narcosynthesis,90865,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,626.31,,,,,,,fee schedule,626.31,626.31, Electroconvulsive therapy,90870,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,537.01,,,,,,,fee schedule,537.01,537.01, Hypnotherapy,90880,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,429.41,,,,,,,fee schedule,429.41,429.41, Biofeedback train any meth,90901,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,88.66,,,,,,,fee schedule,88.66,88.66, Bfb training 1st 15 min,90912,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,205.05,,,,,,,fee schedule,205.05,205.05, Bfb training ea addl 15 min,90913,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,115.47,,,,,,,fee schedule,115.47,115.47, Hemodialysis one evaluation,90935,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,336.33,,,,,,,fee schedule,336.33,336.33, Hemodialysis repeated eval,90937,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,485.75,,,,,,,fee schedule,485.75,485.75, Dialysis one evaluation,90945,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,418.95,,,,,,,fee schedule,418.95,418.95, Dialysis repeated eval,90947,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,584.17,,,,,,,fee schedule,584.17,584.17, Esrd serv 4 visits p mo <2yr,90951,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6439.96,,,,,,,fee schedule,6439.96,6439.96, Esrd serv 4 vsts p mo 2-11,90954,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5630.73,,,,,,,fee schedule,5630.73,5630.73, Esrd srv 2-3 vsts p mo 2-11,90955,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2922.42,,,,,,,fee schedule,2922.42,2922.42, Esrd srv 1 visit p mo 2-11,90956,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1984.92,,,,,,,fee schedule,1984.92,1984.92, Esrd srv 4 vsts p mo 12-19,90957,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4330.34,,,,,,,fee schedule,4330.34,4330.34, Esrd srv 2-3 vsts p mo 12-19,90958,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2814.23,,,,,,,fee schedule,2814.23,2814.23, Esrd serv 1 vst p mo 12-19,90959,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1836.37,,,,,,,fee schedule,1836.37,1836.37, Esrd srv 4 visits p mo 20+,90960,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2018.97,,,,,,,fee schedule,2018.97,2018.97, Esrd srv 2-3 vsts p mo 20+,90961,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1681.66,,,,,,,fee schedule,1681.66,1681.66, Esrd serv 1 visit p mo 20+,90962,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1159.6,,,,,,,fee schedule,1159.6,1159.6, Esrd home pt serv p mo <2yrs,90963,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3400.45,,,,,,,fee schedule,3400.45,3400.45, Esrd home pt serv p mo 2-11,90964,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2897.49,,,,,,,fee schedule,2897.49,2897.49, Esrd home pt serv p mo 12-19,90965,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2798.91,,,,,,,fee schedule,2798.91,2798.91, Esrd home pt serv p mo 20+,90966,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1679.94,,,,,,,fee schedule,1679.94,1679.94, Esrd home pt serv p day <2,90967,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,99.5,,,,,,,fee schedule,99.5,99.5, Esrd home pt srv p day 2-11,90968,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,95.99,,,,,,,fee schedule,95.99,95.99, Esrd home pt srv p day 12-19,90969,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,94.16,,,,,,,fee schedule,94.16,94.16, Esrd home pt serv p day 20+,90970,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,54.12,,,,,,,fee schedule,54.12,54.12, Hemoperfusion,90997,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,417.87,,,,,,,fee schedule,417.87,417.87, Esophagus motility study,91010,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,920.34,,,,,,,fee schedule,920.34,3195, Esophagus motility study,91010,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,920.34,3195, Esophagus motility study,91010,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,920.34,3195, Esophagus motility study,91010,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,920.34,3195, Esophgl motil w/stim/perfus,91013,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,96.48,,,,,,,fee schedule,96.48,2782, Esophgl motil w/stim/perfus,91013,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,96.48,2782, Esophgl motil w/stim/perfus,91013,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,96.48,2782, Gastric motility studies,91020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1202.17,,,,,,,fee schedule,1202.17,3195, Gastric motility studies,91020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1202.17,3195, Gastric motility studies,91020,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1202.17,3195, Gastric motility studies,91020,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1202.17,3195, Duodenal motility study,91022,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,610.18,,,,,,,fee schedule,610.18,3195, Duodenal motility study,91022,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,610.18,3195, Duodenal motility study,91022,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,610.18,3195, Duodenal motility study,91022,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,610.18,3195, Acid perfusion of esophagus,91030,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,592.97,,,,,,,fee schedule,592.97,2782, Acid perfusion of esophagus,91030,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,592.97,2782, Acid perfusion of esophagus,91030,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,592.97,2782, Gastroesophageal reflux test,91034,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,785.93,,,,,,,fee schedule,785.93,2782, Gastroesophageal reflux test,91034,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,785.93,2782, Gastroesophageal reflux test,91034,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,785.93,2782, G-esoph reflx tst w/electrod,91035,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2154.03,,,,,,,fee schedule,2154.03,2782, G-esoph reflx tst w/electrod,91035,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2154.03,2782, G-esoph reflx tst w/electrod,91035,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2154.03,2782, Esoph imped function test,91037,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,703.26,,,,,,,fee schedule,703.26,2782, Esoph imped function test,91037,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,703.26,2782, Esoph imped function test,91037,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,703.26,2782, Esoph imped funct test > 1hr,91038,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1993.77,,,,,,,fee schedule,1993.77,2782, Esoph imped funct test > 1hr,91038,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1993.77,2782, Esoph imped funct test > 1hr,91038,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1993.77,2782, Esoph balloon distension tst,91040,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2711.27,,,,,,,fee schedule,2505,2782, Esoph balloon distension tst,91040,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,2782, Esoph balloon distension tst,91040,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,2782, Breath hydrogen/methane test,91065,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,283.56,,,,,,,fee schedule,283.56,2782, Breath hydrogen/methane test,91065,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,283.56,2782, Breath hydrogen/methane test,91065,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,283.56,2782, Gi tract capsule endoscopy,91110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3531.41,,,,,,,fee schedule,3531.41,5664, Gi tract capsule endoscopy,91110,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3531.41,5664, Gi tract capsule endoscopy,91110,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3531.41,5664, Esophageal Capsule Endoscopy,91111,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4691.01,,,,,,,fee schedule,4691.01,5664, Esophageal Capsule Endoscopy,91111,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4691.01,5664, Esophageal Capsule Endoscopy,91111,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4691.01,5664, Gi wireless capsule measure,91112,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8546.4,,,,,,,fee schedule,5097,8546.4, Gi wireless capsule measure,91112,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8546.4, Gi wireless capsule measure,91112,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8546.4, Gi trc img intral colon i&r,91113,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4428.39,,,,,,,fee schedule,4428.39,4428.39, Colon motility 6 hr study,91117,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,665.6,,,,,,,fee schedule,665.6,2782, Colon motility 6 hr study,91117,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,665.6,2782, Colon motility 6 hr study,91117,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,665.6,2782, Rectal sensation test,91120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,2782, Rectal sensation test,91120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,2782, Anal pressure record,91122,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,2782, Anal pressure record,91122,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,2782, Rct snsatn tone&cmplianc std,91124,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3124.34,,,,,,,fee schedule,3124.34,3124.34, Anrct mano rct snsatn&balo,91125,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1059.88,,,,,,,fee schedule,1059.88,1059.88, Electrogastrography,91132,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2363.23,,,,,,,fee schedule,2363.23,2782, Electrogastrography,91132,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2363.23,2782, Electrogastrography,91132,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2363.23,2782, Electrogastrography W/Test,91133,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2445.95,,,,,,,fee schedule,2445.95,2782, Electrogastrography W/Test,91133,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2445.95,2782, Electrogastrography W/Test,91133,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2445.95,2782, Liver elastography,91200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,118.17,,,,,,,fee schedule,118.17,118.17, Gastroenterology procedure,91299,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,2782, Gastroenterology procedure,91299,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,2782, Coronavirus vaccine 5,91304,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,363.47,,,,,,,fee schedule,197.08,392.54, Coronavirus vaccine 5,91304,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,392.54,,,,,,,fee schedule,197.08,392.54, Coronavirus vaccine 5,91304,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,197.08,,,,,,,fee schedule,197.08,392.54, Coronavirus vaccine 5,91304,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,197.08,,,,,,,fee schedule,197.08,392.54, Sarscov2 vac 3mcg trs-suc im,91318,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,147.49,,,,,,,fee schedule,79.97,159.29, Sarscov2 vac 3mcg trs-suc im,91318,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,159.29,,,,,,,fee schedule,79.97,159.29, Sarscov2 vac 3mcg trs-suc im,91318,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,79.97,,,,,,,fee schedule,79.97,159.29, Sarscov2 vac 3mcg trs-suc im,91318,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,79.97,,,,,,,fee schedule,79.97,159.29, Sarscv2 vac 10mcg trs-suc im,91319,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,197.51,,,,,,,fee schedule,107.09,213.31, Sarscv2 vac 10mcg trs-suc im,91319,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,213.31,,,,,,,fee schedule,107.09,213.31, Sarscv2 vac 10mcg trs-suc im,91319,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,107.09,,,,,,,fee schedule,107.09,213.31, Sarscv2 vac 10mcg trs-suc im,91319,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,107.09,,,,,,,fee schedule,107.09,213.31, Sarscv2 vac 30mcg trs-suc im,91320,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,350.78,,,,,,,fee schedule,190.2,378.84, Sarscv2 vac 30mcg trs-suc im,91320,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,378.84,,,,,,,fee schedule,190.2,378.84, Sarscv2 vac 30mcg trs-suc im,91320,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,190.2,,,,,,,fee schedule,190.2,378.84, Sarscv2 vac 30mcg trs-suc im,91320,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,190.2,,,,,,,fee schedule,190.2,378.84, Sarscov2 vac 25 mcg/.25ml im,91321,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,330.89,,,,,,,fee schedule,179.41,357.36, Sarscov2 vac 25 mcg/.25ml im,91321,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,357.36,,,,,,,fee schedule,179.41,357.36, Sarscov2 vac 25 mcg/.25ml im,91321,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,179.41,,,,,,,fee schedule,179.41,357.36, Sarscov2 vac 25 mcg/.25ml im,91321,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,179.41,,,,,,,fee schedule,179.41,357.36, Sarscov2 vac 50 mcg/0.5ml im,91322,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,363.71,,,,,,,fee schedule,197.21,392.81, Sarscov2 vac 50 mcg/0.5ml im,91322,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,392.81,,,,,,,fee schedule,197.21,392.81, Sarscov2 vac 50 mcg/0.5ml im,91322,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,197.21,,,,,,,fee schedule,197.21,392.81, Sarscov2 vac 50 mcg/0.5ml im,91322,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,197.21,,,,,,,fee schedule,197.21,392.81, Eye exam new patient,92002,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,203.65,,,,,,,fee schedule,203.65,203.65, Eye exam new patient,92004,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,419.86,,,,,,,fee schedule,419.86,419.86, Eye exam establish patient,92012,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,223.88,,,,,,,fee schedule,223.88,223.88, Eye exam&tx estab pt 1/>vst,92014,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,335.69,,,,,,,fee schedule,335.69,335.69, New eye exam & treatment,92018,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,614.28,,,,,,,fee schedule,614.28,10940, New eye exam & treatment,92018,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,614.28,10940, New eye exam & treatment,92018,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,614.28,10940, Eye exam & treatment,92019,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,319.34,,,,,,,fee schedule,319.34,10940, Eye exam & treatment,92019,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,319.34,10940, Eye exam & treatment,92019,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,319.34,10940, Special eye evaluation,92020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,88.28,,,,,,,fee schedule,88.28,88.28, Corneal Topography,92025,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,92.33,,,,,,,fee schedule,92.33,92.33, Special eye evaluation,92060,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,145.69,,,,,,,fee schedule,145.69,145.69, Orthoptic/pleoptic training,92065,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,147.74,,,,,,,fee schedule,147.74,147.74, Orthop traing supvj phys/qhp,92066,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,135.39,,,,,,,fee schedule,135.39,135.39, Contact lens fitting for tx,92071,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,141.05,,,,,,,fee schedule,141.05,141.05, Fit contac lens for managmnt,92072,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,410.8,,,,,,,fee schedule,410.8,410.8, Visual field examination(s),92081,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,94.05,,,,,,,fee schedule,94.05,94.05, Visual field examination(s),92082,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,140.57,,,,,,,fee schedule,140.57,140.57, Visual field examination(s),92083,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,193.99,,,,,,,fee schedule,193.99,193.99, Serial tonometry exam(s),92100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,141.05,,,,,,,fee schedule,141.05,141.05, Cmptr ophth dx img ant segmt,92132,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,75.06,,,,,,,fee schedule,75.06,75.06, Cmptr ophth img optic nerve,92133,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,75.06,,,,,,,fee schedule,75.06,75.06, Cptr ophth dx img post segmt,92134,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,78.51,,,,,,,fee schedule,78.51,78.51, Ophthalmic biometry,92136,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,94.05,,,,,,,fee schedule,94.05,94.05, Cptrz oph img pst sg rta oct,92137,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,130.21,,,,,,,fee schedule,130.21,700.65, Cptrz oph img pst sg rta oct,92137,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,700.65,,,,,,,fee schedule,130.21,700.65, Cptrz oph img pst sg rta oct,92137,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,700.65,,,,,,,fee schedule,130.21,700.65, Corneal hysteresis deter,92145,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,42.36,,,,,,,fee schedule,42.36,42.36, Opscpy extnd rta draw uni/bi,92201,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,99.83,,,,,,,fee schedule,99.83,99.83, Opscpy extnd on/mac draw,92202,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,63.3,,,,,,,fee schedule,63.3,63.3, Remote dx retinal imaging,92227,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,97.45,,,,,,,fee schedule,97.45,97.45, Remote retinal imaging mgmt,92228,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,73.33,,,,,,,fee schedule,73.33,73.33, Img rta detc/mntr ds poc aly,92229,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,242.23,,,,,,,fee schedule,242.23,242.23, Eye exam with photos,92230,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,146.45,,,,,,,fee schedule,146.45,146.45, Fluorescein angrph uni/bi,92235,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,622.97,,,,,,,fee schedule,622.97,622.97, Icg angiography uni/bi,92240,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1026.16,,,,,,,fee schedule,1026.16,1026.16, Fluorescein icg angiography,92242,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1458.65,,,,,,,fee schedule,1458.65,1458.65, Eye exam with photos,92250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,87.15,,,,,,,fee schedule,87.15,87.15, Ophthalmoscopy/dynamometry,92260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,49.1,,,,,,,fee schedule,49.1,49.1, Eye muscle evaluation,92265,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,223.23,,,,,,,fee schedule,223.23,223.23, Electro-oculography,92270,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,434.43,,,,,,,fee schedule,434.43,434.43, Full field erg w/i&r,92273,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,460.28,,,,,,,fee schedule,460.28,460.28, Multifocal erg w/i&r,92274,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,307.68,,,,,,,fee schedule,307.68,307.68, Color vision examination,92283,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,240.5,,,,,,,fee schedule,240.5,240.5, Dark adaptation eye exam,92284,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,100.91,,,,,,,fee schedule,100.91,100.91, Eye photography,92285,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,107.81,,,,,,,fee schedule,107.81,107.81, Internal eye photography,92286,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,95.73,,,,,,,fee schedule,95.73,95.73, Internal eye photography,92287,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,583.36,,,,,,,fee schedule,583.36,583.36, Contact lens fitting,92311,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,226.42,,,,,,,fee schedule,226.42,226.42, Contact lens fitting,92312,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,264.03,,,,,,,fee schedule,264.03,264.03, Contact lens fitting,92313,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,192.48,,,,,,,fee schedule,192.48,192.48, Rx cntact lens aphakia 1 eye,92315,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,95.78,,,,,,,fee schedule,95.78,95.78, Rx cntact lens aphakia 2 eye,92316,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,142.35,,,,,,,fee schedule,142.35,142.35, Rx corneoscleral cntact lens,92317,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,95.78,,,,,,,fee schedule,95.78,95.78, Modification of contact lens,92325,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,242.23,,,,,,,fee schedule,242.23,242.23, Replacement of contact lens,92326,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,202.57,,,,,,,fee schedule,202.57,202.57, Ear and throat examination,92502,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,468.75,,,,,,,fee schedule,468.75,2782, Ear and throat examination,92502,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,468.75,2782, Ear and throat examination,92502,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,468.75,2782, Ear microscopy examination,92504,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,42.03,,,,,,,fee schedule,42.03,42.03, Speech/hearing therapy,92507,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,404.16,,,,,,,fee schedule,404.16,404.16, Speech/hearing therapy,92508,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,127.67,,,,,,,fee schedule,127.67,127.67, Nasopharyngoscopy,92511,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,177.47,,,,,,,fee schedule,177.47,3195, Nasopharyngoscopy,92511,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,177.47,3195, Nasal function studies,92512,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,128.86,,,,,,,fee schedule,128.86,128.86, Facial nerve function test,92516,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,102.79,,,,,,,fee schedule,102.79,102.79, Vemp test i&r cervical,92517,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,182.17,,,,,,,fee schedule,182.17,182.17, Vemp test i&r ocular,92518,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,189.35,,,,,,,fee schedule,189.35,189.35, Vemp tst i&r cervical&ocular,92519,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,275.84,,,,,,,fee schedule,275.84,275.84, Laryngeal function studies,92520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,174.88,,,,,,,fee schedule,174.88,174.88, Evaluation of speech fluency,92521,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,706.23,,,,,,,fee schedule,706.23,706.23, Evaluate speech production,92522,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,596.37,,,,,,,fee schedule,596.37,596.37, Speech sound lang comprehen,92523,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1199.64,,,,,,,fee schedule,1199.64,1199.64, Behavral qualit analys voice,92524,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,583.31,,,,,,,fee schedule,583.31,583.31, Oral function therapy,92526,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,445.82,,,,,,,fee schedule,445.82,445.82, Caloric vstblr test w/rec,92537,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,47.48,,,,,,,fee schedule,47.48,47.48, Caloric vstblr test w/rec,92538,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,33.73,,,,,,,fee schedule,33.73,33.73, Basic vestibular evaluation,92540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,150.87,,,,,,,fee schedule,150.87,150.87, Spontaneous nystagmus test,92541,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,23.36,,,,,,,fee schedule,23.36,23.36, Positional nystagmus test,92542,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,21.64,,,,,,,fee schedule,21.64,21.64, Optokinetic nystagmus test,92544,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,19.97,,,,,,,fee schedule,19.97,19.97, Oscillating tracking test,92545,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,19.97,,,,,,,fee schedule,19.97,19.97, Sinusoidal rotational test,92546,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,620.54,,,,,,,fee schedule,620.54,620.54, Supplemental electrical test,92547,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,56.87,,,,,,,fee schedule,56.87,56.87, Posturography,92548,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,75.06,,,,,,,fee schedule,75.06,75.06, Cdp-sot 6 cond w/i&r mct&adt,92549,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,100.91,,,,,,,fee schedule,100.91,100.91, Tympanometry & reflex thresh,92550,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,115.74,,,,,,,fee schedule,115.74,115.74, Pure tone audiometry air,92552,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,209.47,,,,,,,fee schedule,209.47,209.47, Audiometry air & bone,92553,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,254.26,,,,,,,fee schedule,254.26,254.26, Speech threshold audiometry,92555,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,154.33,,,,,,,fee schedule,154.33,154.33, Speech audiometry complete,92556,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,240.5,,,,,,,fee schedule,240.5,240.5, Comprehensive hearing test,92557,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,138.41,,,,,,,fee schedule,138.41,138.41, Loudness balance test,92562,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,254.26,,,,,,,fee schedule,254.26,254.26, Tone decay hearing test,92563,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,185.35,,,,,,,fee schedule,185.35,185.35, Stenger test pure tone,92565,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,116.45,,,,,,,fee schedule,116.45,116.45, Tympanometry,92567,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,47.38,,,,,,,fee schedule,47.38,47.38, Acoustic refl threshold tst,92568,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,68.75,,,,,,,fee schedule,68.75,68.75, Acoustic immitance testing,92570,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,127.67,,,,,,,fee schedule,127.67,127.67, Filtered speech hearing test,92571,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,161.23,,,,,,,fee schedule,161.23,161.23, Staggered spondaic word test,92572,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,312.86,,,,,,,fee schedule,312.86,312.86, Sensorineural acuity test,92575,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,382.74,,,,,,,fee schedule,382.74,382.74, Synthetic sentence test,92576,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,219.83,,,,,,,fee schedule,219.83,219.83, Stenger test speech,92577,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,118.17,,,,,,,fee schedule,118.17,118.17, Visual audiometry (vra),92579,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,159.72,,,,,,,fee schedule,159.72,159.72, Conditioning play audiometry,92582,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,448.95,,,,,,,fee schedule,448.95,448.95, Select picture audiometry,92583,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,318.04,,,,,,,fee schedule,318.04,318.04, Electrocochleography,92584,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,553.47,,,,,,,fee schedule,553.47,553.47, Evoked auditory test limited,92587,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,19.97,,,,,,,fee schedule,19.97,19.97, Evoked auditory tst complete,92588,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,26.82,,,,,,,fee schedule,26.82,26.82, Ear protector evaluation,92596,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,404.16,,,,,,,fee schedule,404.16,404.16, Oral speech device eval,92597,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,378.75,,,,,,,fee schedule,378.75,378.75, Cochlear implt f/up exam <7,92601,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,525.79,,,,,,,fee schedule,525.79,525.79, Reprogram cochlear implt 7/>,92602,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,299.05,,,,,,,fee schedule,299.05,299.05, Cochlear implt f/up exam 7/>,92603,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,513.32,,,,,,,fee schedule,513.32,513.32, Reprogram cochlear implt 7/>,92604,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,286.58,,,,,,,fee schedule,286.58,286.58, Ex for speech device rx 1hr,92607,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,646.28,,,,,,,fee schedule,646.28,646.28, Ex for speech device rx addl,92608,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,251.94,,,,,,,fee schedule,251.94,251.94, Use of speech device service,92609,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,541.87,,,,,,,fee schedule,541.87,541.87, Evaluate swallowing function,92610,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,309.35,,,,,,,fee schedule,309.35,309.35, Motion fluoroscopy/swallow,92611,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,487.42,,,,,,,fee schedule,487.42,487.42, Endoscopy swallow (fees) vid,92612,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,293.87,,,,,,,fee schedule,293.87,293.87, Endoscopy swallow (fees) i&r,92613,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,164.47,,,,,,,fee schedule,164.47,164.47, Laryngoscopic sensory vid,92614,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,294.89,,,,,,,fee schedule,294.89,294.89, Laryngoscopic sensory i&r,92615,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,146.61,,,,,,,fee schedule,146.61,146.61, Fees w/laryngeal sense test,92616,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,433.19,,,,,,,fee schedule,433.19,433.19, Fees w/laryngeal sense i&r,92617,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,185.08,,,,,,,fee schedule,185.08,185.08, Auditory function 60 min,92620,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,343.73,,,,,,,fee schedule,343.73,343.73, Auditory function + 15 min,92621,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,80.29,,,,,,,fee schedule,80.29,80.29, Dx aly aud oi snd prcsr 1st,92622,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,288.31,,,,,,,fee schedule,288.31,288.31, Dx aly aud oi snd prcsr each,92623,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,75,,,,,,,fee schedule,75,75, Tinnitus assessment,92625,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,266.08,,,,,,,fee schedule,266.08,266.08, Eval aud rehab status,92626,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,320.52,,,,,,,fee schedule,320.52,320.52, Eval aud status rehab add-on,92627,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,75,,,,,,,fee schedule,75,75, Aud brainstem implt programg,92640,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,402.6,,,,,,,fee schedule,402.6,402.6, Aep hearing status deter i&r,92651,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,425.26,,,,,,,fee schedule,425.26,425.26, Aep thrshld est mlt freq i&r,92652,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,575,,,,,,,fee schedule,575,575, Aep neurodiagnostic i&r,92653,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,426.55,,,,,,,fee schedule,426.55,426.55, Prq cardiac angioplast 1 art,92920,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2249.81,,,,,,,fee schedule,2249.81,22111, Prq cardiac angioplast 1 art,92920,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,2249.81,22111, Prq cardiac angioplast 1 art,92920,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,2249.81,22111, Prq cardiac angioplast 1 art,92920,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,2249.81,22111, Prq cardiac angio addl art,92921,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,22111, Prq cardiac angio addl art,92921,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3195,22111, Prq cardiac angio addl art,92921,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3195,22111, Prq card angio/athrect 1 art,92924,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2726.92,,,,,,,fee schedule,2726.92,25393, Prq card angio/athrect 1 art,92924,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,2726.92,25393, Prq card angio/athrect 1 art,92924,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,2726.92,25393, Prq card angio/athrect 1 art,92924,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,2726.92,25393, Prq card angio/athrect addl,92925,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,25393, Prq card angio/athrect addl,92925,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,3195,25393, Prq card angio/athrect addl,92925,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,3195,25393, Prq card stent w/angio 1 vsl,92928,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2697.35,,,,,,,fee schedule,2697.35,22111, Prq card stent w/angio 1 vsl,92928,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8212,,,,,,,fee schedule,2697.35,22111, Prq card stent w/angio 1 vsl,92928,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,2697.35,22111, Prq card stent w/angio 1 vsl,92928,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,2697.35,22111, Prq card stent w/angio addl,92929,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,22111, Prq card stent w/angio addl,92929,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3195,22111, Prq card stent w/angio addl,92929,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3195,22111, Prq tcat plmt ntrac st 2+les,92930,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2786.87,,,,,,,fee schedule,2786.87,6979, Prq tcat plmt ntrac st 2+les,92930,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,2786.87,6979, Prq card stent/ath/angio,92933,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3216.5,,,,,,,fee schedule,3216.5,22111, Prq card stent/ath/angio,92933,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8212,,,,,,,fee schedule,3216.5,22111, Prq card stent/ath/angio,92933,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3216.5,22111, Prq card stent/ath/angio,92933,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3216.5,22111, Prq card stent/ath/angio,92934,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,22111, Prq card stent/ath/angio,92934,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3195,22111, Prq card stent/ath/angio,92934,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3195,22111, Prq revasc byp graft 1 vsl,92937,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3044.42,,,,,,,fee schedule,3044.42,22111, Prq revasc byp graft 1 vsl,92937,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8212,,,,,,,fee schedule,3044.42,22111, Prq revasc byp graft 1 vsl,92937,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3044.42,22111, Prq revasc byp graft 1 vsl,92937,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3044.42,22111, Prq revasc byp graft addl,92938,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,22111, Prq revasc byp graft addl,92938,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3195,22111, Prq revasc byp graft addl,92938,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3195,22111, Prq card revasc mi 1 vsl,92941,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3425.33,,,,,,,fee schedule,3425.33,22111, Prq card revasc mi 1 vsl,92941,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3425.33,22111, Prq card revasc mi 1 vsl,92941,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3425.33,22111, Prq card revasc chronic 1vsl,92943,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3683.74,,,,,,,fee schedule,3683.74,22111, Prq card revasc chronic 1vsl,92943,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8212,,,,,,,fee schedule,3683.74,22111, Prq card revasc chronic 1vsl,92943,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3683.74,22111, Prq card revasc chronic 1vsl,92943,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3683.74,22111, Prq card revasc chronic addl,92944,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,22111, Prq card revasc chronic addl,92944,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3195,22111, Prq card revasc chronic addl,92944,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3195,22111, Prq trl rvs ch occ ant&rtrgr,92945,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3485.38,,,,,,,fee schedule,3485.38,6979, Prq trl rvs ch occ ant&rtrgr,92945,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,3485.38,6979, Heart/lung resuscitation cpr,92950,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,953.04,,,,,,,fee schedule,953.04,2782, Heart/lung resuscitation cpr,92950,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,953.04,2782, Heart/lung resuscitation cpr,92950,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,953.04,2782, Temporary external pacing,92953,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6.26,,,,,,,fee schedule,6.26,4497, Temporary external pacing,92953,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,6.26,4497, Temporary external pacing,92953,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,6.26,4497, Cardioversion electric ext,92960,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,519.58,,,,,,,fee schedule,519.58,4497, Cardioversion electric ext,92960,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,519.58,4497, Cardioversion electric ext,92960,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,519.58,4497, Cardioversion electric int,92961,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1241.51,,,,,,,fee schedule,1241.51,4497, Cardioversion electric int,92961,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,1241.51,4497, Cardioversion electric int,92961,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,1241.51,4497, Cardioassist internal,92970,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,948.78,,,,,,,fee schedule,948.78,5664, Cardioassist internal,92970,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,948.78,5664, Cardioassist internal,92970,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,948.78,5664, Cardioassist external,92971,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,505.55,,,,,,,fee schedule,505.55,5664, Cardioassist external,92971,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,505.55,5664, Cardioassist external,92971,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,505.55,5664, Perq trluml coronry lithotrp,92972,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,674.34,,,,,,,fee schedule,674.34,3195, Perq trluml coronry lithotrp,92972,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,674.34,3195, Prq coronary mech thrombect,92973,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,473.39,,,,,,,fee schedule,473.39,2782, Prq coronary mech thrombect,92973,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,473.39,2782, Prq coronary mech thrombect,92973,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,473.39,2782, Cath place cardio brachytx,92974,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,804.33,,,,,,,fee schedule,804.33,2782, Cath place cardio brachytx,92974,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,804.33,2782, Cath place cardio brachytx,92974,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,804.33,2782, Dissolve clot heart vessel,92975,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Dissolve clot heart vessel,92975,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Dissolve clot heart vessel,92977,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,2782, Dissolve clot heart vessel,92977,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,2782, Endoluminl ivus oct c 1st,92978,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,2782, Endoluminl ivus oct c 1st,92978,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,2782, Endoluminl ivus oct c ea,92979,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,2782, Endoluminl ivus oct c ea,92979,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,2782, Revision of aortic valve,92986,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6709.82,,,,,,,fee schedule,6709.82,22111, Revision of aortic valve,92986,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,6709.82,22111, Revision of aortic valve,92986,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6709.82,22111, Revision of aortic valve,92986,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6709.82,22111, Revision of mitral valve,92987,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6919.94,,,,,,,fee schedule,6919.94,22111, Revision of mitral valve,92987,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,6919.94,22111, Revision of mitral valve,92987,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6919.94,22111, Revision of mitral valve,92987,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6919.94,22111, Revision of pulmonary valve,92990,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5544.17,,,,,,,fee schedule,5544.17,22111, Revision of pulmonary valve,92990,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,5544.17,22111, Revision of pulmonary valve,92990,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5544.17,22111, Revision of pulmonary valve,92990,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5544.17,22111, Pul art balloon repr percut,92997,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3148.3,,,,,,,fee schedule,3148.3,22111, Pul art balloon repr percut,92997,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,3148.3,22111, Pul art balloon repr percut,92997,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3148.3,22111, Pul art balloon repr percut,92997,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3148.3,22111, Pul art balloon repr percut,92998,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1593.49,,,,,,,fee schedule,1593.49,22111, Pul art balloon repr percut,92998,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,1593.49,22111, Pul art balloon repr percut,92998,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,1593.49,22111, Electrocardiogram complete,93000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,82.56,,,,,,,fee schedule,82.56,82.56, Electrocardiogram tracing,93005,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,37.18,,,,,,,fee schedule,37.18,37.18, Electrocardiogram report,93010,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,45.43,,,,,,,fee schedule,45.43,45.43, Cardiovascular stress test,93015,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,388.78,,,,,,,fee schedule,388.78,388.78, Cardiovascular stress test,93016,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,111.32,,,,,,,fee schedule,111.32,111.32, Cardiovascular stress test,93017,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,203.54,,,,,,,fee schedule,203.54,203.54, Cardiovascular stress test,93018,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,73.93,,,,,,,fee schedule,73.93,73.93, Cardiac drug stress test,93024,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,318.26,,,,,,,fee schedule,318.26,318.26, Microvolt t-wave assess,93025,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,510.25,,,,,,,fee schedule,510.25,510.25, Rhythm ECG with report,93040,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,80.67,,,,,,,fee schedule,80.67,80.67, Rhythm ecg tracing,93041,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,42.36,,,,,,,fee schedule,42.36,42.36, Rhythm ecg report,93042,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,38.37,,,,,,,fee schedule,38.37,38.37, Art pressure waveform analys,93050,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,45.76,,,,,,,fee schedule,45.76,45.76, Interrog crtd sins bat ip wo,93145,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,153.08,,,,,,,fee schedule,153.08,153.08, Interrog crtd sins bat ip w/,93146,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,214.65,,,,,,,fee schedule,214.65,214.65, Therapy activation ipnss,93150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,201.27,,,,,,,fee schedule,201.27,201.27, Interrog&prgrmg ipnss,93151,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,189.56,,,,,,,fee schedule,189.56,189.56, Interrog&prgrmg ipnss polysm,93152,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,418.95,,,,,,,fee schedule,418.95,418.95, Interrog w/o prgrmg ipnss,93153,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,102.79,,,,,,,fee schedule,102.79,102.79, Ecg monit/reprt up to 48 hrs,93224,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,369.52,,,,,,,fee schedule,369.52,369.52, Ecg monit/reprt up to 48 hrs,93225,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,94.05,,,,,,,fee schedule,94.05,94.05, Ecg monit/reprt up to 48 hrs,93226,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,180.17,,,,,,,fee schedule,180.17,180.17, Ecg monit/reprt up to 48 hrs,93227,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,95.29,,,,,,,fee schedule,95.29,95.29, Remote 30 day ecg rev/report,93228,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,135.93,,,,,,,fee schedule,135.93,135.93, Remote 30 day ecg tech supp,93229,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3919.87,,,,,,,fee schedule,3919.87,3919.87, Ext ecg>48hr<7d rec scan a/r,93241,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1448.29,,,,,,,fee schedule,1448.29,1448.29, Ext ecg>48hr<7d recording,93242,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,61.3,,,,,,,fee schedule,61.3,61.3, Ext ecg>48hr<7d scan a/r,93243,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1263.96,,,,,,,fee schedule,1263.96,1263.96, Ext ecg>48hr<7d rev&interpj,93244,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,123.03,,,,,,,fee schedule,123.03,123.03, Ext ecg>7d<15d rec scan a/r,93245,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1502.08,,,,,,,fee schedule,1502.08,1502.08, Ext ecg>7d<15d recording,93246,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,61.3,,,,,,,fee schedule,61.3,61.3, Ext ecg>7d<15d scan a/r,93247,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1307.02,,,,,,,fee schedule,1307.02,1307.02, Ext ecg>7d<15d rev&interpj,93248,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,133.77,,,,,,,fee schedule,133.77,133.77, Prgrmg dev eval impltbl sys,93260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,180.17,,,,,,,fee schedule,180.17,180.17, Interrogate subq defib,93261,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,178.45,,,,,,,fee schedule,178.45,178.45, Rem mntr wrls p-art prs snr,93264,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,163.66,,,,,,,fee schedule,163.66,163.66, ECG record/review,93268,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,883.27,,,,,,,fee schedule,883.27,883.27, Remote 30 day ecg rev/report,93270,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,44.09,,,,,,,fee schedule,44.09,44.09, Ecg/monitoring and analysis,93271,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,710.87,,,,,,,fee schedule,710.87,710.87, Ecg/review interpret only,93272,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,128.37,,,,,,,fee schedule,128.37,128.37, ECG/signal-averaged,93278,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,107.81,,,,,,,fee schedule,107.81,107.81, Pm device progr eval sngl,93279,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,187.08,,,,,,,fee schedule,187.08,187.08, Pm device progr eval dual,93280,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,216.38,,,,,,,fee schedule,216.38,216.38, Pm device progr eval multi,93281,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,218.11,,,,,,,fee schedule,218.11,218.11, Prgrmg eval implantable dfb,93282,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,197.39,,,,,,,fee schedule,197.39,197.39, Prgrmg eval implantable dfb,93283,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,218.11,,,,,,,fee schedule,218.11,218.11, Prgrmg eval implantable dfb,93284,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,233.59,,,,,,,fee schedule,233.59,233.59, Ilr device eval progr,93285,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,178.45,,,,,,,fee schedule,178.45,178.45, Peri-px pacemaker device evl,93286,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,156.05,,,,,,,fee schedule,156.05,156.05, Peri-px device eval & prgr,93287,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,156.05,,,,,,,fee schedule,156.05,156.05, Pm device eval in person,93288,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,183.63,,,,,,,fee schedule,183.63,183.63, Interrog device eval heart,93289,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,185.35,,,,,,,fee schedule,185.35,185.35, Icm device eval,93290,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,166.41,,,,,,,fee schedule,166.41,166.41, Ilr device interrogate,93291,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,159.51,,,,,,,fee schedule,159.51,159.51, Wcd device interrogate,93292,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,161.23,,,,,,,fee schedule,161.23,161.23, Pm phone r-strip device eval,93293,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,137.11,,,,,,,fee schedule,137.11,137.11, Pm device interrogate remote,93294,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,160.26,,,,,,,fee schedule,160.26,160.26, Dev interrog remote 1/2/mlt,93295,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,196.74,,,,,,,fee schedule,196.74,196.74, Pm/icd remote tech serv,93296,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,164.69,,,,,,,fee schedule,164.69,164.69, Icm device interrogat remote,93297,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,188.81,,,,,,,fee schedule,188.81,188.81, Ilr device interrogat remote,93298,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,408.59,,,,,,,fee schedule,408.59,408.59, Echo transthoracic,93303,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,830.01,,,,,,,fee schedule,830.01,830.01, Echo transthoracic,93304,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,615.36,,,,,,,fee schedule,615.36,615.36, Tte w/doppler complete,93306,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,669.75,,,,,,,fee schedule,669.75,669.75, Tte w/o doppler complete,93307,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,491.31,,,,,,,fee schedule,491.31,491.31, Tte f-up or lmtd,93308,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,396.55,,,,,,,fee schedule,396.55,396.55, Echo transesophageal,93312,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,695.6,,,,,,,fee schedule,695.6,695.6, Echo transesophageal,93313,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,57.36,,,,,,,fee schedule,57.36,57.36, Echo transesophageal,93314,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,740.39,,,,,,,fee schedule,740.39,740.39, Echo transesophageal,93316,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,135.39,,,,,,,fee schedule,135.39,135.39, 3d echo img cgen car anomal,93319,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,114.67,,,,,,,fee schedule,114.67,114.67, Doppler echo exam heart,93320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,176.72,,,,,,,fee schedule,176.72,176.72, Doppler echo exam heart,93321,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,93.03,,,,,,,fee schedule,93.03,93.03, Doppler color flow add-on,93325,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,105.11,,,,,,,fee schedule,105.11,105.11, Stress tte only,93350,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,610.18,,,,,,,fee schedule,610.18,610.18, Stress tte complete,93351,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,789.65,,,,,,,fee schedule,789.65,789.65, Admin ecg contrast agent,93352,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,187.83,,,,,,,fee schedule,187.83,187.83, Echo transesophageal (tee),93355,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1060.26,,,,,,,fee schedule,1060.26,1060.26, Myocrd strain img spckl trck,93356,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,55.47,,,,,,,fee schedule,55.47,55.47, Right heart cath,93451,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3735,,,,,,,fee schedule,3195,14456, Right heart cath,93451,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,14456, Right heart cath,93451,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3195,14456, Right heart cath,93451,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3195,14456, Left hrt cath w/ventrclgrphy,93452,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3332.08,,,,,,,fee schedule,3332.08,14456, Left hrt cath w/ventrclgrphy,93452,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,3332.08,14456, Left hrt cath w/ventrclgrphy,93452,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3332.08,14456, Left hrt cath w/ventrclgrphy,93452,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3332.08,14456, R&l hrt cath w/ventriclgrphy,93453,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4167.71,,,,,,,fee schedule,4167.71,14456, R&l hrt cath w/ventriclgrphy,93453,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,4167.71,14456, R&l hrt cath w/ventriclgrphy,93453,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4167.71,14456, R&l hrt cath w/ventriclgrphy,93453,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4167.71,14456, Coronary artery angio s&i,93454,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3330.36,,,,,,,fee schedule,3330.36,14456, Coronary artery angio s&i,93454,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,3330.36,14456, Coronary artery angio s&i,93454,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3330.36,14456, Coronary artery angio s&i,93454,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3330.36,14456, Coronary art/grft angio s&i,93455,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3654.28,,,,,,,fee schedule,3654.28,14456, Coronary art/grft angio s&i,93455,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,3654.28,14456, Coronary art/grft angio s&i,93455,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3654.28,14456, Coronary art/grft angio s&i,93455,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3654.28,14456, R hrt coronary artery angio,93456,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4083.32,,,,,,,fee schedule,4083.32,14456, R hrt coronary artery angio,93456,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,4083.32,14456, R hrt coronary artery angio,93456,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4083.32,14456, R hrt coronary artery angio,93456,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4083.32,14456, R hrt art/grft angio,93457,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4403.03,,,,,,,fee schedule,4403.03,14456, R hrt art/grft angio,93457,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,4403.03,14456, R hrt art/grft angio,93457,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4403.03,14456, R hrt art/grft angio,93457,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4403.03,14456, L hrt artery/ventricle angio,93458,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3733.55,,,,,,,fee schedule,3733.55,14456, L hrt artery/ventricle angio,93458,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,3733.55,14456, L hrt artery/ventricle angio,93458,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3733.55,14456, L hrt artery/ventricle angio,93458,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3733.55,14456, L hrt art/grft angio,93459,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3934.39,,,,,,,fee schedule,3934.39,14456, L hrt art/grft angio,93459,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,3934.39,14456, L hrt art/grft angio,93459,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,3934.39,14456, L hrt art/grft angio,93459,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,3934.39,14456, R&l hrt art/ventricle angio,93460,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4349.61,,,,,,,fee schedule,4349.61,14456, R&l hrt art/ventricle angio,93460,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,4349.61,14456, R&l hrt art/ventricle angio,93460,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4349.61,14456, R&l hrt art/ventricle angio,93460,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4349.61,14456, R&l hrt art/ventricle angio,93461,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4789.98,,,,,,,fee schedule,4789.98,14456, R&l hrt art/ventricle angio,93461,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,4789.98,14456, R&l hrt art/ventricle angio,93461,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,4789.98,14456, R&l hrt art/ventricle angio,93461,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,4789.98,14456, L hrt cath trnsptl puncture,93462,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1026.86,,,,,,,fee schedule,1026.86,3195, L hrt cath trnsptl puncture,93462,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1026.86,3195, L hrt cath trnsptl puncture,93462,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1026.86,3195, L hrt cath trnsptl puncture,93462,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1026.86,3195, Drug admin & hemodynmic meas,93463,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,456.56,,,,,,,fee schedule,456.56,2782, Drug admin & hemodynmic meas,93463,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,456.56,2782, Drug admin & hemodynmic meas,93463,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,456.56,2782, Exercise w/hemodynamic meas,93464,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,700.51,,,,,,,fee schedule,700.51,2782, Exercise w/hemodynamic meas,93464,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,700.51,2782, Exercise w/hemodynamic meas,93464,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,700.51,2782, Insert/place heart catheter,93503,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,453.64,,,,,,,fee schedule,453.64,4497, Insert/place heart catheter,93503,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,453.64,4497, Insert/place heart catheter,93503,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,453.64,4497, Insert/place heart catheter,93503,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,453.64,4497, Biopsy of heart lining,93505,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2219.48,,,,,,,fee schedule,2219.48,12821, Biopsy of heart lining,93505,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2219.48,12821, Biopsy of heart lining,93505,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,2219.48,12821, Biopsy of heart lining,93505,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,2219.48,12821, Inject congenital card cath,93563,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,252.69,,,,,,,fee schedule,252.69,2782, Inject congenital card cath,93563,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,252.69,2782, Inject congenital card cath,93563,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,252.69,2782, Inject hrt congntl art/grft,93564,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,275.25,,,,,,,fee schedule,275.25,2782, Inject hrt congntl art/grft,93564,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,275.25,2782, Inject hrt congntl art/grft,93564,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,275.25,2782, Inject l ventr/atrial angio,93565,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,136.3,,,,,,,fee schedule,136.3,2782, Inject l ventr/atrial angio,93565,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,136.3,2782, Inject l ventr/atrial angio,93565,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,136.3,2782, Inject r ventr/atrial angio,93566,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,127.24,,,,,,,fee schedule,127.24,2782, Inject r ventr/atrial angio,93566,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,127.24,2782, Inject r ventr/atrial angio,93566,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,127.24,2782, Inject suprvlv aortography,93567,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,188.32,,,,,,,fee schedule,188.32,2782, Inject suprvlv aortography,93567,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,188.32,2782, Inject suprvlv aortography,93567,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,188.32,2782, Inject pulm art hrt cath,93568,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,233.05,,,,,,,fee schedule,233.05,2782, Inject pulm art hrt cath,93568,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,233.05,2782, Inject pulm art hrt cath,93568,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,233.05,2782, Njx cth slct p-art angrp uni,93569,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,179.09,,,,,,,fee schedule,179.09,2782, Njx cth slct p-art angrp uni,93569,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,179.09,2782, Njx cth slct p-art angrp uni,93569,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,179.09,2782, Heart flow reserve measure,93571,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,2782, Heart flow reserve measure,93571,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,2782, Heart flow reserve measure,93572,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,2782, Heart flow reserve measure,93572,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,2782, Njx cath slct p-art angrp bi,93573,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,291.92,,,,,,,fee schedule,291.92,2782, Njx cath slct p-art angrp bi,93573,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,291.92,2782, Njx cath slct p-art angrp bi,93573,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,291.92,2782, Njx cath slct pulm vn angrph,93574,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,323.22,,,,,,,fee schedule,323.22,2782, Njx cath slct pulm vn angrph,93574,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,323.22,2782, Njx cath slct pulm vn angrph,93574,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,323.22,2782, Njx cath slct p angrph mapca,93575,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,432.54,,,,,,,fee schedule,432.54,2782, Njx cath slct p angrph mapca,93575,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,432.54,2782, Njx cath slct p angrph mapca,93575,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,432.54,2782, Transcath closure of asd,93580,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4893.25,,,,,,,fee schedule,4893.25,34630, Transcath closure of asd,93580,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8212,,,,,,,fee schedule,4893.25,34630, Transcath closure of asd,93580,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,34630,,,,,,,fee schedule,4893.25,34630, Transcath closure of asd,93580,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,31168,,,,,,,fee schedule,4893.25,34630, Transcath closure of vsd,93581,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6660.44,,,,,,,fee schedule,6660.44,34630, Transcath closure of vsd,93581,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8212,,,,,,,fee schedule,6660.44,34630, Transcath closure of vsd,93581,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,34630,,,,,,,fee schedule,6660.44,34630, Transcath closure of vsd,93581,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,31168,,,,,,,fee schedule,6660.44,34630, Perq transcath closure pda,93582,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3326.2,,,,,,,fee schedule,3326.2,34630, Perq transcath closure pda,93582,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8212,,,,,,,fee schedule,3326.2,34630, Perq transcath closure pda,93582,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,34630,,,,,,,fee schedule,3326.2,34630, Perq transcath closure pda,93582,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,31168,,,,,,,fee schedule,3326.2,34630, Perq transcath septal reduxn,93583,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3728.26,,,,,,,fee schedule,3728.26,8212, Perq transcath septal reduxn,93583,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8212,,,,,,,fee schedule,3728.26,8212, Perq transcath septal reduxn,93583,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,3728.26,8212, Perq transcath septal reduxn,93583,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,3728.26,8212, Vngrph chd anom/persist svc,93584,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,267.75,,,,,,,fee schedule,267.75,3195, Vngrph chd anom/persist svc,93584,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,267.75,3195, Vngrph chd azygs/hemiazygs,93585,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,253.4,,,,,,,fee schedule,253.4,3195, Vngrph chd azygs/hemiazygs,93585,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,253.4,3195, Vngrph chd coronary sinus,93586,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,325.59,,,,,,,fee schedule,325.59,3195, Vngrph chd coronary sinus,93586,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,325.59,3195, Vngrph chd vnvn cltrl at/abv,93587,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,477.38,,,,,,,fee schedule,477.38,3195, Vngrph chd vnvn cltrl at/abv,93587,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,477.38,3195, Vngrph chd vnvn cltrl below,93588,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,481,,,,,,,fee schedule,481,3195, Vngrph chd vnvn cltrl below,93588,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,481,3195, Perq transcath cls mitral,93590,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5048.61,,,,,,,fee schedule,5048.61,39251, Perq transcath cls mitral,93590,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8212,,,,,,,fee schedule,5048.61,39251, Perq transcath cls mitral,93590,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,39251,,,,,,,fee schedule,5048.61,39251, Perq transcath cls mitral,93590,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,35325,,,,,,,fee schedule,5048.61,39251, Perq transcath cls aortic,93591,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4151.52,,,,,,,fee schedule,4151.52,39251, Perq transcath cls aortic,93591,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8212,,,,,,,fee schedule,4151.52,39251, Perq transcath cls aortic,93591,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,39251,,,,,,,fee schedule,4151.52,39251, Perq transcath cls aortic,93591,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,35325,,,,,,,fee schedule,4151.52,39251, Perq transcath closure each,93592,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1801.94,,,,,,,fee schedule,1801.94,3195, Perq transcath closure each,93592,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1801.94,3195, Perq transcath closure each,93592,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1801.94,3195, Perq transcath closure each,93592,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1801.94,3195, R hrt cath chd nml nt cnj,93593,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,8406,14456, R hrt cath chd nml nt cnj,93593,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,8406,14456, R hrt cath chd nml nt cnj,93593,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,8406,14456, R hrt cath chd abnl nt cnj,93594,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,8406,14456, R hrt cath chd abnl nt cnj,93594,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,8406,14456, R hrt cath chd abnl nt cnj,93594,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,8406,14456, L hrt cath chd nm/abn nt cnj,93595,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,8406,14456, L hrt cath chd nm/abn nt cnj,93595,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,8406,14456, L hrt cath chd nm/abn nt cnj,93595,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,8406,14456, R&l hrt cath chd nml nt cnj,93596,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,8406,14456, R&l hrt cath chd nml nt cnj,93596,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,8406,14456, R&l hrt cath chd nml nt cnj,93596,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,8406,14456, R&l hrt cath chd abnl nt cnj,93597,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,8406,14456, R&l hrt cath chd abnl nt cnj,93597,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,8406,14456, R&l hrt cath chd abnl nt cnj,93597,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,8406,14456, Car outp meas drg cath chd,93598,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,2782, Car outp meas drg cath chd,93598,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,2782, Bundle of His recording,93600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,8406,12864, Bundle of His recording,93600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12864,,,,,,,fee schedule,8406,12864, Bundle of His recording,93600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11577,,,,,,,fee schedule,8406,12864, Intra-atrial recording,93602,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12864,,,,,,,fee schedule,11577,12864, Intra-atrial recording,93602,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11577,,,,,,,fee schedule,11577,12864, Right ventricular recording,93603,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12864,,,,,,,fee schedule,11577,12864, Right ventricular recording,93603,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11577,,,,,,,fee schedule,11577,12864, Map tachycardia add-on,93609,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,8406,12864, Map tachycardia add-on,93609,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12864,,,,,,,fee schedule,8406,12864, Map tachycardia add-on,93609,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11577,,,,,,,fee schedule,8406,12864, Intra-atrial pacing,93610,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12864,,,,,,,fee schedule,11577,12864, Intra-atrial pacing,93610,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11577,,,,,,,fee schedule,11577,12864, Intraventricular pacing,93612,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12864,,,,,,,fee schedule,11577,12864, Intraventricular pacing,93612,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11577,,,,,,,fee schedule,11577,12864, Electrophys map 3d add-on,93613,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1438.2,,,,,,,fee schedule,1438.2,12864, Electrophys map 3d add-on,93613,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12864,,,,,,,fee schedule,1438.2,12864, Electrophys map 3d add-on,93613,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11577,,,,,,,fee schedule,1438.2,12864, Esophageal recording,93615,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12864,,,,,,,fee schedule,11577,12864, Esophageal recording,93615,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11577,,,,,,,fee schedule,11577,12864, Esophageal recording,93616,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12864,,,,,,,fee schedule,11577,12864, Esophageal recording,93616,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11577,,,,,,,fee schedule,11577,12864, Heart rhythm pacing,93618,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,8406,12864, Heart rhythm pacing,93618,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12864,,,,,,,fee schedule,8406,12864, Heart rhythm pacing,93618,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11577,,,,,,,fee schedule,8406,12864, Electrophysiology evaluation,93619,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,8406,22111, Electrophysiology evaluation,93619,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,8406,22111, Electrophysiology evaluation,93619,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,8406,22111, Electrophysiology evaluation,93620,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,8406,22111, Electrophysiology evaluation,93620,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,8406,22111, Electrophysiology evaluation,93620,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,8406,22111, Electrophysiology evaluation,93621,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,8406,12864, Electrophysiology evaluation,93621,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12864,,,,,,,fee schedule,8406,12864, Electrophysiology evaluation,93621,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11577,,,,,,,fee schedule,8406,12864, Electrophysiology evaluation,93622,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,8406,12864, Electrophysiology evaluation,93622,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12864,,,,,,,fee schedule,8406,12864, Electrophysiology evaluation,93622,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11577,,,,,,,fee schedule,8406,12864, Stimulation pacing heart,93623,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12864,,,,,,,fee schedule,11577,12864, Stimulation pacing heart,93623,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11577,,,,,,,fee schedule,11577,12864, Electrophysiologic study,93624,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,19899,22111, Electrophysiologic study,93624,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,19899,22111, Heart pacing mapping,93631,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12864,,,,,,,fee schedule,11577,12864, Heart pacing mapping,93631,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11577,,,,,,,fee schedule,11577,12864, Evaluation heart device,93640,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,8406,12864, Evaluation heart device,93640,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12864,,,,,,,fee schedule,8406,12864, Evaluation heart device,93640,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11577,,,,,,,fee schedule,8406,12864, Electrophysiology evaluation,93641,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,8406,12864, Electrophysiology evaluation,93641,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12864,,,,,,,fee schedule,8406,12864, Electrophysiology evaluation,93641,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11577,,,,,,,fee schedule,8406,12864, Electrophysiology evaluation,93642,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,433.73,,,,,,,fee schedule,433.73,12864, Electrophysiology evaluation,93642,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,433.73,12864, Electrophysiology evaluation,93642,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12864,,,,,,,fee schedule,433.73,12864, Electrophysiology evaluation,93642,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11577,,,,,,,fee schedule,433.73,12864, Electrophysiology evaluation,93644,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,261.17,,,,,,,fee schedule,261.17,12864, Electrophysiology evaluation,93644,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12864,,,,,,,fee schedule,261.17,12864, Electrophysiology evaluation,93644,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11577,,,,,,,fee schedule,261.17,12864, Ablate heart dysrhythm focus,93650,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2874.67,,,,,,,fee schedule,2874.67,53655, Ablate heart dysrhythm focus,93650,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,2874.67,53655, Ablate heart dysrhythm focus,93650,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,53655,,,,,,,fee schedule,2874.67,53655, Ablate heart dysrhythm focus,93650,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,48290,,,,,,,fee schedule,2874.67,53655, Ep & ablate supravent arrhyt,93653,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4126.16,,,,,,,fee schedule,4126.16,53655, Ep & ablate supravent arrhyt,93653,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,4126.16,53655, Ep & ablate supravent arrhyt,93653,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,53655,,,,,,,fee schedule,4126.16,53655, Ep & ablate supravent arrhyt,93653,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,48290,,,,,,,fee schedule,4126.16,53655, Ep & ablate ventric tachy,93654,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4972.09,,,,,,,fee schedule,4972.09,53655, Ep & ablate ventric tachy,93654,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,4972.09,53655, Ep & ablate ventric tachy,93654,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,53655,,,,,,,fee schedule,4972.09,53655, Ep & ablate ventric tachy,93654,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,48290,,,,,,,fee schedule,4972.09,53655, Ablate arrhythmia add on,93655,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1513.36,,,,,,,fee schedule,1513.36,53655, Ablate arrhythmia add on,93655,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1513.36,53655, Ablate arrhythmia add on,93655,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,53655,,,,,,,fee schedule,1513.36,53655, Ablate arrhythmia add on,93655,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,48290,,,,,,,fee schedule,1513.36,53655, Tx atrial fib pulm vein isol,93656,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4678.01,,,,,,,fee schedule,4678.01,53655, Tx atrial fib pulm vein isol,93656,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,4678.01,53655, Tx atrial fib pulm vein isol,93656,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,53655,,,,,,,fee schedule,4678.01,53655, Tx atrial fib pulm vein isol,93656,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,48290,,,,,,,fee schedule,4678.01,53655, Tx l/r atrial fib addl,93657,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1513.36,,,,,,,fee schedule,1513.36,53655, Tx l/r atrial fib addl,93657,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1513.36,53655, Tx l/r atrial fib addl,93657,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,53655,,,,,,,fee schedule,1513.36,53655, Tx l/r atrial fib addl,93657,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,48290,,,,,,,fee schedule,1513.36,53655, Tilt table evaluation,93660,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,407.88,,,,,,,fee schedule,407.88,2782, Tilt table evaluation,93660,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,407.88,2782, Tilt table evaluation,93660,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,407.88,2782, Intracardiac Ecg (Ice),93662,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,2782, Intracardiac Ecg (Ice),93662,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,2782, Peripheral Vascular Rehab,93668,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,80.24,,,,,,,fee schedule,80.24,80.24, Bioimpedance cv analysis,93701,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,140.57,,,,,,,fee schedule,140.57,140.57, Bis xtracell fluid analysis,93702,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,685.99,,,,,,,fee schedule,685.99,685.99, Analyze pacemaker system,93724,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,240.5,,,,,,,fee schedule,240.5,240.5, Set-up cardiovert-defibrill,93745,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,2782, Set-up cardiovert-defibrill,93745,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,2782, Interrogation vad in person,93750,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,188.59,,,,,,,fee schedule,188.59,2782, Interrogation vad in person,93750,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,188.59,2782, Interrogation vad in person,93750,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,188.59,2782, Ambulatory BP monitoring,93784,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,252.26,,,,,,,fee schedule,252.26,252.26, Ambulatory BP recording,93786,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,123.3,,,,,,,fee schedule,123.3,123.3, Ambulatory BP analysis,93788,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,32,,,,,,,fee schedule,32,32, Review/report BP recording,93790,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,96.97,,,,,,,fee schedule,96.97,96.97, Pt/caregiver trainj home inr,93792,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,376.86,,,,,,,fee schedule,376.86,376.86, Anticoag mgmt pt warfarin,93793,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,62.7,,,,,,,fee schedule,62.7,62.7, Cardiac rehab,93797,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,42.03,,,,,,,fee schedule,42.03,42.03, Cardiac rehab/monitor,93798,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,66.21,,,,,,,fee schedule,66.21,66.21, Cardiovascular procedure,93799,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,2782, Cardiovascular procedure,93799,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,2782, Extracranial bilat study,93880,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,785.23,,,,,,,fee schedule,785.23,785.23, Extracranial uni/ltd study,93882,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,520.61,,,,,,,fee schedule,520.61,520.61, Intracranial complete study,93886,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1160.84,,,,,,,fee schedule,1160.84,1160.84, Intracranial limited study,93888,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,694.63,,,,,,,fee schedule,694.63,694.63, Tcd emboli detect w/o inj,93892,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1282.41,,,,,,,fee schedule,1282.41,1282.41, Tcd emboli detect w/inj,93893,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1582.97,,,,,,,fee schedule,1582.97,1582.97, Vsrctv std tcd icr art compl,93896,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,756.63,,,,,,,fee schedule,756.63,756.63, Emboli detcj wo iv mbubb njx,93897,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1035.06,,,,,,,fee schedule,1035.06,1035.06, Ven-artl shunt det mbubb njx,93898,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1128.84,,,,,,,fee schedule,1128.84,1128.84, Upr/l xtremity art 2 levels,93922,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,370.71,,,,,,,fee schedule,370.71,370.71, Upr/lxtr art stdy 3+ lvls,93923,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,581.9,,,,,,,fee schedule,581.9,581.9, Lwr xtr vasc stdy bilat,93924,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,733.53,,,,,,,fee schedule,733.53,733.53, Lower extremity study,93925,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1039.49,,,,,,,fee schedule,1039.49,1039.49, Lower extremity study,93926,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,609.48,,,,,,,fee schedule,609.48,609.48, Upper extremity study,93930,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,836.92,,,,,,,fee schedule,836.92,836.92, Upper extremity study,93931,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,508.52,,,,,,,fee schedule,508.52,508.52, Extremity study,93970,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,786.95,,,,,,,fee schedule,786.95,786.95, Extremity study,93971,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,496.49,,,,,,,fee schedule,496.49,496.49, Vascular study,93975,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1067.06,,,,,,,fee schedule,1067.06,1067.06, Vascular study,93976,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,615.36,,,,,,,fee schedule,615.36,615.36, Vascular study,93978,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,740.39,,,,,,,fee schedule,740.39,740.39, Vascular study,93979,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,484.4,,,,,,,fee schedule,484.4,484.4, Penile vascular study,93980,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,316.31,,,,,,,fee schedule,316.31,316.31, Penile vascular study,93981,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,271.47,,,,,,,fee schedule,271.47,271.47, Dup-scan hemo compl bi std,93985,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1099.06,,,,,,,fee schedule,1099.06,1099.06, Dup-scan hemo compl uni std,93986,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,649.08,,,,,,,fee schedule,649.08,649.08, Doppler flow testing,93990,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,631.87,,,,,,,fee schedule,631.87,631.87, Vent mgmt inpat init day,94002,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,476.36,,,,,,,fee schedule,476.36,476.36, Vent mgmt inpat subq day,94003,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,327.65,,,,,,,fee schedule,327.65,327.65, Vent Mgmt NF per day,94004,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,240.55,,,,,,,fee schedule,240.55,240.55, Breathing capacity test,94010,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,111.27,,,,,,,fee schedule,111.27,111.27, Spirometry up to 2 yrs old,94011,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,392.88,,,,,,,fee schedule,392.88,392.88, Spirmtry w/brnchdil inf-2 yr,94012,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,643.58,,,,,,,fee schedule,643.58,643.58, Meas lung vol thru 2 yrs,94013,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,92.27,,,,,,,fee schedule,92.27,92.27, Patient recorded spirometry,94014,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,315.4,,,,,,,fee schedule,315.4,315.4, Patient recorded spirometry,94015,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,181.9,,,,,,,fee schedule,181.9,181.9, Review patient spirometry,94016,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,133.5,,,,,,,fee schedule,133.5,133.5, Evaluation of wheezing,94060,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,171.54,,,,,,,fee schedule,171.54,171.54, Evaluation of wheezing,94070,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,213.9,,,,,,,fee schedule,213.9,213.9, Lung function test (MBC/MVV),94200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,71.6,,,,,,,fee schedule,71.6,71.6, Respiratory flow volume loop,94375,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,144.02,,,,,,,fee schedule,144.02,144.02, Hypoxia response curve,94450,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,470.64,,,,,,,fee schedule,470.64,470.64, Hast w/report,94452,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,221.51,,,,,,,fee schedule,221.51,221.51, Hast w/oxygen titrate,94453,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,294.89,,,,,,,fee schedule,294.89,294.89, Surfactant Admin Thru Tube,94610,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,262.25,,,,,,,fee schedule,262.25,262.25, Exercise tst brncspsm,94617,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,321.71,,,,,,,fee schedule,321.71,321.71, Pulmonary stress testing,94618,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,75.06,,,,,,,fee schedule,75.06,75.06, Exercise tst brncspsm wo ecg,94619,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,236.29,,,,,,,fee schedule,236.29,236.29, Pulm stress test/complex,94621,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,507.82,,,,,,,fee schedule,507.82,507.82, Phy/qhp op pulm rhb w/o mntr,94625,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,92.22,,,,,,,fee schedule,92.22,92.22, Phy/qhp op pulm rhb w/mntr,94626,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,137.11,,,,,,,fee schedule,137.11,137.11, Airway inhalation treatment,94640,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,45.76,,,,,,,fee schedule,45.76,45.76, Cbt 1st hour,94644,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,324.19,,,,,,,fee schedule,324.19,324.19, Cbt each addl hour,94645,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,87.15,,,,,,,fee schedule,87.15,87.15, Pos airway pressure cpap,94660,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,178.93,,,,,,,fee schedule,178.93,178.93, Evaluate pt use of inhaler,94664,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,105.33,,,,,,,fee schedule,105.33,105.33, Chest wall manipulation,94667,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,143.26,,,,,,,fee schedule,143.26,143.26, Chest wall manipulation,94668,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,203.54,,,,,,,fee schedule,203.54,203.54, Mechanical chest wall oscill,94669,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,134.63,,,,,,,fee schedule,134.63,134.63, Exhaled air analysis o2,94680,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,236.29,,,,,,,fee schedule,236.29,236.29, Exhaled air analysis o2/co2,94681,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,210.44,,,,,,,fee schedule,210.44,210.44, Exhaled air analysis,94690,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,252.53,,,,,,,fee schedule,252.53,252.53, Pulm funct tst plethysmograp,94726,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,269.04,,,,,,,fee schedule,269.04,269.04, Pulm function test by gas,94727,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,195.71,,,,,,,fee schedule,195.71,195.71, Pulm funct test oscillometry,94728,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,185.35,,,,,,,fee schedule,185.35,185.35, Co/membane diffuse capacity,94729,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,280.11,,,,,,,fee schedule,280.11,280.11, Measure blood oxygen level,94760,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,21.64,,,,,,,fee schedule,21.64,21.64, Measure blood oxygen level,94761,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,23.36,,,,,,,fee schedule,23.36,23.36, Measure blood oxygen level,94762,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,125.03,,,,,,,fee schedule,125.03,125.03, Car seat/bed test 60 min,94780,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,111.86,,,,,,,fee schedule,111.86,111.86, Car seat/bed test + 30 min,94781,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,38.53,,,,,,,fee schedule,38.53,38.53, Percut allergy skin tests,95004,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,20.02,,,,,,,fee schedule,20.02,20.02, Exhaled Nitric Oxide Meas,95012,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,102.63,,,,,,,fee schedule,102.63,102.63, Perq & icut allg test venoms,95017,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,17.05,,,,,,,fee schedule,17.05,17.05, Perq&ic allg test drugs/biol,95018,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,33.13,,,,,,,fee schedule,33.13,33.13, Icut allergy test drug/bug,95024,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6.26,,,,,,,fee schedule,6.26,6.26, Icut allergy titrate-airborn,95027,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,25.2,,,,,,,fee schedule,25.2,25.2, Icut allergy test-delayed,95028,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,64.75,,,,,,,fee schedule,64.75,64.75, Allergy patch tests,95044,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,26.82,,,,,,,fee schedule,26.82,26.82, Photo patch test,95052,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,32,,,,,,,fee schedule,32,32, Photosensitivity tests,95056,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,269.04,,,,,,,fee schedule,269.04,269.04, Eye allergy tests,95060,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,211.2,,,,,,,fee schedule,211.2,211.2, Nose allergy test,95065,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,145.69,,,,,,,fee schedule,145.69,145.69, Bronchial allergy tests,95070,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,208.02,,,,,,,fee schedule,208.02,208.02, Ingest challenge ini 120 min,95076,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,340,,,,,,,fee schedule,340,340, Ingest challenge addl 60 min,95079,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,312.21,,,,,,,fee schedule,312.21,312.21, Immunotherapy one injection,95115,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,54.39,,,,,,,fee schedule,54.39,54.39, Immunotherapy injections,95117,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,64.75,,,,,,,fee schedule,64.75,64.75, Antigen therapy services,95144,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,15.27,,,,,,,fee schedule,15.27,15.27, Antigen therapy services,95145,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,15.27,,,,,,,fee schedule,15.27,15.27, Antigen therapy services,95146,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,15.27,,,,,,,fee schedule,15.27,15.27, Antigen therapy services,95147,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,15.27,,,,,,,fee schedule,15.27,15.27, Antigen therapy services,95148,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,15.27,,,,,,,fee schedule,15.27,15.27, Antigen therapy services,95149,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,15.27,,,,,,,fee schedule,15.27,15.27, Antigen therapy services,95165,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,15.27,,,,,,,fee schedule,15.27,15.27, Antigen therapy services,95170,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,15.27,,,,,,,fee schedule,15.27,15.27, Rapid desensitization,95180,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,470.8,,,,,,,fee schedule,470.8,470.8, Cont gluc mntr pt prov eqp,95249,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,364.07,,,,,,,fee schedule,364.07,364.07, Glucose monitoring cont,95250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,792.35,,,,,,,fee schedule,792.35,792.35, Gluc monitor cont phys i&r,95251,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,191.23,,,,,,,fee schedule,191.23,191.23, Eeg phys/qhp 2-12 hr w/o vid,95717,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,491.31,,,,,,,fee schedule,491.31,491.31, Eeg phys/qhp 2-12 hr w/veeg,95718,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,614.55,,,,,,,fee schedule,614.55,614.55, Eeg phys/qhp ea incr w/o vid,95719,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,736.82,,,,,,,fee schedule,736.82,736.82, Eeg phy/qhp ea incr w/veeg,95720,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,945,,,,,,,fee schedule,945,945, Eeg phy/qhp>36<60 hr w/o vid,95721,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,974.63,,,,,,,fee schedule,974.63,974.63, Eeg phy/qhp>36<60 hr w/veeg,95722,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1179.19,,,,,,,fee schedule,1179.19,1179.19, Eeg phy/qhp>60<84 hr w/o vid,95723,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1182.8,,,,,,,fee schedule,1182.8,1182.8, Eeg phy/qhp>60<84 hr w/veeg,95724,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1495.45,,,,,,,fee schedule,1495.45,1495.45, Eeg phy/qhp>84 hr w/o vid,95725,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1358.5,,,,,,,fee schedule,1358.5,1358.5, Eeg phy/qhp>84 hr w/veeg,95726,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1902.58,,,,,,,fee schedule,1902.58,1902.58, Polysom <6 yrs 4/> paramtrs,95782,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4611.53,,,,,,,fee schedule,4611.53,4611.53, Polysom <6 yrs cpap/bilvl,95783,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4865.84,,,,,,,fee schedule,4865.84,4865.84, Slp stdy unattended,95800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,530.91,,,,,,,fee schedule,530.91,530.91, Slp stdy unatnd w/anal,95801,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,325.92,,,,,,,fee schedule,325.92,325.92, Actigraphy testing,95803,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,478.25,,,,,,,fee schedule,478.25,478.25, Multiple sleep latency test,95805,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2187.97,,,,,,,fee schedule,2187.97,2187.97, Sleep study unatt&resp efft,95806,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,303.53,,,,,,,fee schedule,303.53,303.53, Sleep study attended,95807,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1992.31,,,,,,,fee schedule,1992.31,1992.31, Polysom any age 1-3> param,95808,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2235.51,,,,,,,fee schedule,2235.51,2235.51, Polysom 6/> yrs 4/> param,95810,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2873.26,,,,,,,fee schedule,2873.26,2873.26, Polysom 6/>yrs cpap 4/> parm,95811,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3028.56,,,,,,,fee schedule,3028.56,3028.56, Eeg 41-60 minutes,95812,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1678.7,,,,,,,fee schedule,1678.7,1678.7, Eeg over 1 hour,95813,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2024.31,,,,,,,fee schedule,2024.31,2024.31, Eeg awake and drowsy,95816,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1846.83,,,,,,,fee schedule,1846.83,1846.83, Eeg awake and asleep,95819,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2201.03,,,,,,,fee schedule,2201.03,2201.03, Eeg coma or sleep only,95822,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2017.4,,,,,,,fee schedule,2017.4,2017.4, Surgery electrocorticogram,95829,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8448.19,,,,,,,fee schedule,8448.19,8448.19, Insert electrodes for EEG,95830,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,419.81,,,,,,,fee schedule,419.81,419.81, Ecog impltd brn npgt <=30 d,95836,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,487.69,,,,,,,fee schedule,487.69,487.69, Range of motion measurements,95851,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,36.69,,,,,,,fee schedule,36.69,36.69, Range of motion measurements,95852,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,27.68,,,,,,,fee schedule,27.68,27.68, Cholinesterase challenge,95857,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,130.42,,,,,,,fee schedule,130.42,130.42, Muscle test one limb,95860,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,352.47,,,,,,,fee schedule,352.47,352.47, Muscle test 2 limbs,95861,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,417.97,,,,,,,fee schedule,417.97,417.97, Muscle test 3 limbs,95863,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,628.15,,,,,,,fee schedule,628.15,628.15, Muscle test 4 limbs,95864,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,700.51,,,,,,,fee schedule,700.51,700.51, Muscle test larynx,95865,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,364.55,,,,,,,fee schedule,364.55,364.55, Muscle test hemidiaphragm,95866,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,361.1,,,,,,,fee schedule,361.1,361.1, Muscle test cran nerv unilat,95867,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,342.16,,,,,,,fee schedule,342.16,342.16, Muscle test cran nerve bilat,95868,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,349.01,,,,,,,fee schedule,349.01,349.01, Muscle test thor paraspinal,95869,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,390.4,,,,,,,fee schedule,390.4,390.4, Muscle test nonparaspinal,95870,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,345.61,,,,,,,fee schedule,345.61,345.61, Muscle test one fiber,95872,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,319.77,,,,,,,fee schedule,319.77,319.77, Guide nerv destr elec stim,95873,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,289.44,,,,,,,fee schedule,289.44,289.44, Guide nerv destr needle emg,95874,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,313.56,,,,,,,fee schedule,313.56,313.56, Limb exercise test,95875,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,355.92,,,,,,,fee schedule,355.92,355.92, Musc tst done w/nerv tst lim,95885,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,237.8,,,,,,,fee schedule,237.8,237.8, Musc test done w/n test comp,95886,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,280.86,,,,,,,fee schedule,280.86,280.86, Musc tst done w/n tst nonext,95887,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,263.59,,,,,,,fee schedule,263.59,263.59, Motor &/ sens nrve cndj test,95905,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,159.51,,,,,,,fee schedule,159.51,159.51, Nvr cndj tst 1-2 studies,95907,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,211.2,,,,,,,fee schedule,211.2,211.2, Nrv cndj tst 3-4 studies,95908,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,264.62,,,,,,,fee schedule,264.62,264.62, Nrv cndj tst 5-6 studies,95909,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,319.77,,,,,,,fee schedule,319.77,319.77, Nrv cndj test 7-8 studies,95910,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,405.89,,,,,,,fee schedule,405.89,405.89, Nrv cndj test 9-10 studies,95911,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,452.4,,,,,,,fee schedule,452.4,452.4, Nrv cndj test 11-12 studies,95912,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,499.94,,,,,,,fee schedule,499.94,499.94, Nrv cndj test 13/> studies,95913,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,580.88,,,,,,,fee schedule,580.88,580.88, Quan puplmtry phy/qhp uni/bi,95919,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,35.45,,,,,,,fee schedule,35.45,35.45, Autonomic nrv parasym inervj,95921,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,238.77,,,,,,,fee schedule,238.77,238.77, Autonomic nrv adrenrg inervj,95922,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,235.32,,,,,,,fee schedule,235.32,235.32, Autonomic nrv syst funj test,95923,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,407.61,,,,,,,fee schedule,407.61,407.61, Ans parasymp & symp w/tilt,95924,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,346.59,,,,,,,fee schedule,346.59,346.59, Somatosensory testing,95925,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,643.9,,,,,,,fee schedule,643.9,643.9, Somatosensory testing,95926,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,569.82,,,,,,,fee schedule,569.82,569.82, Somatosensory testing,95927,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,741.41,,,,,,,fee schedule,741.41,741.41, C motor evoked uppr limbs,95928,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,915.16,,,,,,,fee schedule,915.16,915.16, C motor evoked lwr limbs,95929,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,887.59,,,,,,,fee schedule,887.59,887.59, Visual evoked potential test,95930,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,257.71,,,,,,,fee schedule,257.71,257.71, Blink reflex test,95933,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,278.38,,,,,,,fee schedule,278.38,278.38, Neuromuscular junction test,95937,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,374.86,,,,,,,fee schedule,374.86,374.86, Somatosensory testing,95938,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1836.47,,,,,,,fee schedule,1836.47,1836.47, C motor evoked upr&lwr limbs,95939,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2438.83,,,,,,,fee schedule,2438.83,2438.83, Ionm in operatng room 15 min,95940,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,145.53,,,,,,,fee schedule,145.53,145.53, EEG monitoring/giving drugs,95954,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1416.34,,,,,,,fee schedule,1416.34,1416.34, EEG during surgery,95955,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,747.08,,,,,,,fee schedule,747.08,747.08, EEG digital analysis,95957,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1079.09,,,,,,,fee schedule,1079.09,1079.09, EEG monitoring/function test,95958,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2790.54,,,,,,,fee schedule,2790.54,2790.54, Electrode stimulation brain,95961,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1009.92,,,,,,,fee schedule,1009.92,1009.92, Electrode stim brain add-on,95962,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,653.29,,,,,,,fee schedule,653.29,653.29, Analyze neurostim no prog,95970,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,88.44,,,,,,,fee schedule,88.44,88.44, Analyze neurostim simple,95971,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,190.53,,,,,,,fee schedule,190.53,190.53, Analyze neurostim complex,95972,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,194.15,,,,,,,fee schedule,194.15,194.15, Alys smpl cn npgt prgrmg,95976,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,175.21,,,,,,,fee schedule,175.21,175.21, Alys cplx cn npgt prgrmg,95977,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,234.24,,,,,,,fee schedule,234.24,234.24, Io anal gast n-stim init,95980,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,238.56,,,,,,,fee schedule,238.56,238.56, Io anal gast n-stim subsq,95981,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,94.38,,,,,,,fee schedule,94.38,94.38, Io ga n-stim subsq w/reprog,95982,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,188.37,,,,,,,fee schedule,188.37,188.37, Alys brn npgt prgrmg 15 min,95983,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,232.19,,,,,,,fee schedule,232.19,232.19, Alys brn npgt prgrmg addl 15,95984,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,204.51,,,,,,,fee schedule,204.51,204.51, Spin/brain pump refil & main,95990,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,511.49,,,,,,,fee schedule,511.49,2782, Spin/brain pump refil & main,95990,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,511.49,2782, Spin/brain pump refil & main,95990,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,511.49,2782, Spin/brain pump refil & main,95991,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,186.86,,,,,,,fee schedule,186.86,2782, Spin/brain pump refil & main,95991,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,186.86,2782, Spin/brain pump refil & main,95991,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,186.86,2782, Canalith repositioning proc,95992,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,161.12,,,,,,,fee schedule,161.12,161.12, Motion analysis video/3d,96000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,382.47,,,,,,,fee schedule,382.47,382.47, Motion test w/ft press meas,96001,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,473.5,,,,,,,fee schedule,473.5,473.5, Dynamic surface emg,96002,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,99.18,,,,,,,fee schedule,99.18,99.18, Phys review of motion tests,96004,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,578.29,,,,,,,fee schedule,578.29,578.29, Assessment of aphasia,96105,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,520.23,,,,,,,fee schedule,520.23,520.23, Devel tst phys/qhp 1st hr,96112,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,585.47,,,,,,,fee schedule,585.47,585.47, Devel tst phys/qhp ea addl,96113,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,244.76,,,,,,,fee schedule,244.76,244.76, Neurobehavioral status exam,96116,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,392.83,,,,,,,fee schedule,392.83,392.83, Nubhvl xm phy/qhp ea addl hr,96121,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,331.58,,,,,,,fee schedule,331.58,331.58, Cognitive test by hc pro,96125,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,548.13,,,,,,,fee schedule,548.13,548.13, Brief emotional/behav assmt,96127,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,26.82,,,,,,,fee schedule,26.82,26.82, Psycl tst eval phys/qhp 1st,96130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,542.62,,,,,,,fee schedule,542.62,542.62, Psycl tst eval phys/qhp ea,96131,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,378.37,,,,,,,fee schedule,378.37,378.37, Nrpsyc tst eval phys/qhp 1st,96132,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,535.5,,,,,,,fee schedule,535.5,535.5, Nrpsyc tst eval phys/qhp ea,96133,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,381.07,,,,,,,fee schedule,381.07,381.07, Psycl/nrpsyc tst phy/qhp 1st,96136,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,116.61,,,,,,,fee schedule,116.61,116.61, Psycl/nrpsyc tst phy/qhp ea,96137,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,88.06,,,,,,,fee schedule,88.06,88.06, Psycl/nrpsyc tech 1st,96138,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,195.71,,,,,,,fee schedule,195.71,195.71, Psycl/nrpsyc tst tech ea,96139,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,182.65,,,,,,,fee schedule,182.65,182.65, Psycl/nrpsyc tst auto result,96146,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,13.06,,,,,,,fee schedule,13.06,13.06, Hlth bhv assmt/reassessment,96156,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,468.97,,,,,,,fee schedule,468.97,468.97, Hlth bhv ivntj indiv 1st 30,96158,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,322.57,,,,,,,fee schedule,322.57,322.57, Hlth bhv ivntj indiv ea addl,96159,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,109.65,,,,,,,fee schedule,109.65,109.65, Pt-focused hlth risk assmt,96160,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,15.49,,,,,,,fee schedule,15.49,15.49, Caregiver health risk assmt,96161,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,17.21,,,,,,,fee schedule,17.21,17.21, Hlth bhv ivntj grp 1st 30,96164,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,51.15,,,,,,,fee schedule,51.15,51.15, Hlth bhv ivntj grp ea addl,96165,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,21.53,,,,,,,fee schedule,21.53,21.53, Hlth bhv ivntj fam 1st 30,96167,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,340.65,,,,,,,fee schedule,340.65,340.65, Hlth bhv ivntj fam ea addl,96168,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,123.14,,,,,,,fee schedule,123.14,123.14, Mlt fam grp bhv train 1st 60,96202,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,94,,,,,,,fee schedule,94,94, Mlt fam grp bhv train ea add,96203,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,27.79,,,,,,,fee schedule,27.79,27.79, Hydration iv infusion init,96360,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,174.61,,,,,,,fee schedule,174.61,257.04, Hydration iv infusion init,96360,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,257.04,,,,,,,fee schedule,174.61,257.04, Hydration iv infusion init,96360,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,257.04,,,,,,,fee schedule,174.61,257.04, Hydrate iv infusion add-on,96361,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,68.91,,,,,,,fee schedule,56.29,68.91, Hydrate iv infusion add-on,96361,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56.29,,,,,,,fee schedule,56.29,68.91, Hydrate iv infusion add-on,96361,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,56.29,,,,,,,fee schedule,56.29,68.91, Ther/proph/diag iv inf init,96365,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,351.93,,,,,,,fee schedule,351.93,351.93, Ther/proph/diag iv inf addon,96366,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,112.67,,,,,,,fee schedule,112.67,112.67, Tx/proph/dg addl seq iv inf,96367,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,155.84,,,,,,,fee schedule,155.84,155.84, Ther/diag concurrent inf,96368,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,109.16,,,,,,,fee schedule,109.16,109.16, Sc ther infusion up to 1 hr,96369,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,752.42,,,,,,,fee schedule,752.42,752.42, Sc ther infusion addl hr,96370,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,90.28,,,,,,,fee schedule,90.28,90.28, Sc ther infusion reset pump,96371,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,291.17,,,,,,,fee schedule,291.17,291.17, Ther/proph/diag inj sc/im,96372,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,81.59,,,,,,,fee schedule,81.59,81.59, Ther/proph/diag inj ia,96373,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,103.98,,,,,,,fee schedule,103.98,103.98, Ther/proph/diag inj iv push,96374,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,198.09,,,,,,,fee schedule,198.09,198.09, Tx/pro/dx inj new drug addon,96375,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,82.77,,,,,,,fee schedule,82.77,82.77, Applicaton on-body injector,96377,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,100.53,,,,,,,fee schedule,100.53,3195, Applicaton on-body injector,96377,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,100.53,3195, Admn rsv monoc antb im cnsl,96380,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,159.29,,,,,,,fee schedule,159.29,159.29, 1 admn rsv monoc antb im njx,96381,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,128.1,,,,,,,fee schedule,128.1,128.1, Chemo anti-neopl sq/im,96401,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,376.05,,,,,,,fee schedule,376.05,376.05, Chemo hormon antineopl sq/im,96402,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,203.32,,,,,,,fee schedule,203.32,203.32, Chemo intralesional up to 7,96405,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,129.4,,,,,,,fee schedule,129.4,129.4, Chemo intralesional over 7,96406,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,205.21,,,,,,,fee schedule,205.21,205.21, Chemo iv push sngl drug,96409,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,547.1,,,,,,,fee schedule,547.1,547.1, Chemo iv push addl drug,96411,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,299.15,,,,,,,fee schedule,299.15,299.15, Chemo iv infusion 1 hr,96413,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,696.62,,,,,,,fee schedule,696.62,696.62, Chemo iv infusion addl hr,96415,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,149.95,,,,,,,fee schedule,149.95,149.95, Chemo prolong infuse w/pump,96416,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,696.03,,,,,,,fee schedule,696.03,696.03, Chemo iv infus each addl seq,96417,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,347.5,,,,,,,fee schedule,347.5,347.5, Chemo ia push tecnique,96420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,550.01,,,,,,,fee schedule,550.01,550.01, Chemo ia infusion up to 1 hr,96422,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,731.91,,,,,,,fee schedule,731.91,731.91, Chemo ia infuse each addl hr,96423,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,395.69,,,,,,,fee schedule,395.69,395.69, Chemotherapy infusion method,96425,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,909.87,,,,,,,fee schedule,909.87,909.87, Chemotherapy intracavitary,96440,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,630.2,,,,,,,fee schedule,630.2,630.2, Chemotx admn prtl cavity,96446,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,112.99,,,,,,,fee schedule,112.99,112.99, Chemotherapy into cns,96450,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,368.82,,,,,,,fee schedule,368.82,368.82, Refill/maint portable pump,96521,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,749.45,,,,,,,fee schedule,749.45,749.45, Refill/maint pump/resvr syst,96522,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,654.7,,,,,,,fee schedule,654.7,654.7, Irrig drug delivery device,96523,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,135.71,,,,,,,fee schedule,135.71,135.71, Chemotherapy injection,96542,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,196.2,,,,,,,fee schedule,196.2,196.2, Intraop hipec px 1st 60 min,96547,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1902.25,,,,,,,fee schedule,1902.25,2782, Intraop hipec px 1st 60 min,96547,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1902.25,2782, Intraop hipec px 1st 60 min,96547,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1902.25,2782, Ntraop hipec px ea add 30min,96548,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,874.04,,,,,,,fee schedule,874.04,2782, Ntraop hipec px ea add 30min,96548,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,874.04,2782, Ntraop hipec px ea add 30min,96548,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,874.04,2782, Photodynamic tx skin,96567,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,667.81,,,,,,,fee schedule,667.81,2782, Photodynamic tx skin,96567,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,667.81,2782, Photodynamic tx skin,96567,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,667.81,2782, Photodynmc tx 30 min add-on,96570,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,254.37,,,,,,,fee schedule,254.37,2782, Photodynmc tx 30 min add-on,96570,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,254.37,2782, Photodynmc tx 30 min add-on,96570,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,254.37,2782, Photodynamic tx addl 15 min,96571,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,129.88,,,,,,,fee schedule,129.88,2782, Photodynamic tx addl 15 min,96571,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,129.88,2782, Photodynamic tx addl 15 min,96571,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,129.88,2782, Pdt dstr prmlg les phys/qhp,96573,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1127.39,,,,,,,fee schedule,1127.39,2782, Pdt dstr prmlg les phys/qhp,96573,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1127.39,2782, Pdt dstr prmlg les phys/qhp,96573,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1127.39,2782, Dbrdmt prmlg les w/pdt,96574,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1388.39,,,,,,,fee schedule,1388.39,3195, Dbrdmt prmlg les w/pdt,96574,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,1388.39,3195, Dbrdmt prmlg les w/pdt,96574,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,1388.39,3195, Dbrdmt prmlg les w/pdt,96574,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,1388.39,3195, Ultraviolet light therapy,96900,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,123.3,,,,,,,fee schedule,123.3,123.3, Whole Body Photography,96904,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,342.16,,,,,,,fee schedule,342.16,342.16, Photochemotherapy with UV-B,96910,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,594.69,,,,,,,fee schedule,594.69,594.69, Photochemotherapy with UV-A,96912,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,503.39,,,,,,,fee schedule,503.39,503.39, Photochemotherapy uv-a or b,96913,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,762.78,,,,,,,fee schedule,762.78,762.78, Laser tx skin < 250 sq cm,96920,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,222.32,,,,,,,fee schedule,222.32,3195, Laser tx skin < 250 sq cm,96920,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,222.32,3195, Laser tx skin 250-500 sq cm,96921,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,252.16,,,,,,,fee schedule,252.16,3195, Laser tx skin 250-500 sq cm,96921,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,252.16,3195, Laser tx skin >500 sq cm,96922,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,401.46,,,,,,,fee schedule,401.46,3195, Laser tx skin >500 sq cm,96922,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,401.46,3195, Rcm celulr subcelulr img skn,96931,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,859.58,,,,,,,fee schedule,859.58,859.58, Rcm celulr subcelulr img skn,96932,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,633.33,,,,,,,fee schedule,633.33,633.33, Rcm celulr subcelulr img skn,96933,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,226.25,,,,,,,fee schedule,226.25,226.25, Rcm celulr subcelulr img skn,96934,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,605,,,,,,,fee schedule,605,605, Rcm celulr subcelulr img skn,96935,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,392.83,,,,,,,fee schedule,392.83,392.83, Rcm celulr subcelulr img skn,96936,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,212.12,,,,,,,fee schedule,212.12,212.12, Mchnl sclp cool meas fitg,97007,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8747.24,,,,,,,fee schedule,8747.24,8747.24, Mchnl sclp cool prep plmt,97008,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,52.66,,,,,,,fee schedule,52.66,52.66, Mchnl sclp cool after chemo,97009,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,32.75,,,,,,,fee schedule,32.75,32.75, Mechanical traction therapy,97012,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,77,,,,,,,fee schedule,77,77, Vasopneumatic device therapy,97016,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,64.43,,,,,,,fee schedule,64.43,64.43, Paraffin bath therapy,97018,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,32.48,,,,,,,fee schedule,32.48,32.48, Whirlpool therapy,97022,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,83.31,,,,,,,fee schedule,83.31,83.31, Diathermy eg microwave,97024,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,39.39,,,,,,,fee schedule,39.39,39.39, Infrared therapy,97026,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,35.94,,,,,,,fee schedule,35.94,35.94, Ultraviolet therapy,97028,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,44.68,,,,,,,fee schedule,44.68,44.68, Electrical stimulation,97032,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,78.78,,,,,,,fee schedule,78.78,78.78, Electric current therapy,97033,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,101.28,,,,,,,fee schedule,101.28,101.28, Contrast bath therapy,97034,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,75,,,,,,,fee schedule,75,75, Ultrasound therapy,97035,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,76.73,,,,,,,fee schedule,76.73,76.73, Hydrotherapy,97036,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,182.38,,,,,,,fee schedule,182.38,182.38, Therapeutic exercises,97110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,154.43,,,,,,,fee schedule,154.43,154.43, Neuromuscular reeducation,97112,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,173.81,,,,,,,fee schedule,173.81,173.81, Aquatic therapy/exercises,97113,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,196.04,,,,,,,fee schedule,196.04,196.04, Gait training therapy,97116,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,154.43,,,,,,,fee schedule,154.43,154.43, Massage therapy,97124,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,157.13,,,,,,,fee schedule,157.13,157.13, Ther ivntj 1st 15 min,97129,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,106.62,,,,,,,fee schedule,106.62,106.62, Ther ivntj ea addl 15 min,97130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,98.58,,,,,,,fee schedule,98.58,98.58, Manual therapy 1/> regions,97140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,147.42,,,,,,,fee schedule,147.42,147.42, Group therapeutic procedures,97150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,96.32,,,,,,,fee schedule,96.32,96.32, Pt eval low complex 20 min,97161,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,518.02,,,,,,,fee schedule,518.02,518.02, Pt eval mod complex 30 min,97162,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,518.02,,,,,,,fee schedule,518.02,518.02, Pt eval high complex 45 min,97163,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,518.02,,,,,,,fee schedule,518.02,518.02, Pt re-eval est plan care,97164,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,356.62,,,,,,,fee schedule,356.62,356.62, Ot eval low complex 30 min,97165,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,531.83,,,,,,,fee schedule,531.83,531.83, Ot eval mod complex 45 min,97166,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,531.83,,,,,,,fee schedule,531.83,531.83, Ot eval high complex 60 min,97167,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,531.83,,,,,,,fee schedule,531.83,531.83, Ot re-eval est plan care,97168,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,361.8,,,,,,,fee schedule,361.8,361.8, Therapeutic activities,97530,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,185.41,,,,,,,fee schedule,185.41,185.41, Sensory Integration,97533,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,318.36,,,,,,,fee schedule,318.36,318.36, Self care mngment training,97535,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,171.7,,,,,,,fee schedule,171.7,171.7, Community/work reintegration,97537,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,170.19,,,,,,,fee schedule,170.19,170.19, Wheelchair mngment training,97542,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,165.01,,,,,,,fee schedule,165.01,165.01, Caregiver traing 1st 30 min,97550,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,213.95,,,,,,,fee schedule,213.95,213.95, Caregiver traing ea addl 15,97551,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,112.83,,,,,,,fee schedule,112.83,112.83, Group caregiver training,97552,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,51.05,,,,,,,fee schedule,51.05,51.05, Rmvl devital tis 20 cm/<,97597,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,171.11,,,,,,,fee schedule,171.11,3195, Rmvl devital tis 20 cm/<,97597,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,171.11,3195, Rmvl devital tis 20 cm/<,97597,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,171.11,3195, Rmvl devital tis 20 cm/<,97597,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,171.11,3195, Rmvl devital tis addl 20cm/<,97598,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,121.79,,,,,,,fee schedule,121.79,3195, Rmvl devital tis addl 20cm/<,97598,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,121.79,3195, Rmvl devital tis addl 20cm/<,97598,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,121.79,3195, Rmvl devital tis addl 20cm/<,97598,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,121.79,3195, Neg press wound tx <=50 cm,97605,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,113.8,,,,,,,fee schedule,113.8,113.8, Neg press wound tx >50 cm,97606,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,124.54,,,,,,,fee schedule,124.54,124.54, Neg press wnd tx <=50 sq cm,97607,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,105.6,,,,,,,fee schedule,105.6,105.6, Neg press wound tx >50 cm,97608,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,123.46,,,,,,,fee schedule,123.46,123.46, Low frequency non-thermal us,97610,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,83.31,,,,,,,fee schedule,83.31,83.31, Physical performance test,97750,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,178.55,,,,,,,fee schedule,178.55,178.55, Assistive technology assess,97755,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,200.62,,,,,,,fee schedule,200.62,200.62, Orthotic mgmt and training,97760,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,242.71,,,,,,,fee schedule,242.71,242.71, Prosthetic training,97761,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,213.41,,,,,,,fee schedule,213.41,213.41, Orthc/prostc mgmt sbsq enc,97763,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,263.27,,,,,,,fee schedule,263.27,263.27, Medical nutrition indiv in,97802,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,141.32,,,,,,,fee schedule,141.32,141.32, Med nutrition indiv subseq,97803,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,118.28,,,,,,,fee schedule,118.28,118.28, Medical nutrition group,97804,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,66.69,,,,,,,fee schedule,66.69,66.69, Acupunct w/o stimul 15 min,97810,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,150.06,,,,,,,fee schedule,150.06,150.06, Acupunct w/o stimul addl 15m,97811,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,113.42,,,,,,,fee schedule,113.42,113.42, Acupunct w/stimul 15 min,97813,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,183.09,,,,,,,fee schedule,183.09,183.09, Acupunct w/stimul addl 15m,97814,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,115.26,,,,,,,fee schedule,115.26,115.26, Brief comunicaj tech-bsd svc,98016,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,71.55,,,,,,,fee schedule,71.55,71.55, Osteopath manj 1-2 regions,98925,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,108.19,,,,,,,fee schedule,108.19,108.19, Osteopath manj 3-4 regions,98926,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,162.74,,,,,,,fee schedule,162.74,162.74, Osteopath manj 5-6 regions,98927,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,220.16,,,,,,,fee schedule,220.16,220.16, Osteopath manj 7-8 regions,98928,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,274.71,,,,,,,fee schedule,274.71,274.71, Osteopath manj 9-10 regions,98929,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,324.84,,,,,,,fee schedule,324.84,324.84, Chiropract manj 1-2 regions,98940,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,99.34,,,,,,,fee schedule,99.34,99.34, Chiropract manj 3-4 regions,98941,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,151.2,,,,,,,fee schedule,151.2,151.2, Chiropractic manj 5 regions,98942,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,204.89,,,,,,,fee schedule,204.89,204.89, Hc pro phone call 5-10 min,98966,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,56.39,,,,,,,fee schedule,56.39,56.39, Hc pro phone call 11-20 min,98967,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,109.32,,,,,,,fee schedule,109.32,109.32, Hc pro phone call 21-30 min,98968,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,157.83,,,,,,,fee schedule,157.83,157.83, Qnhp ol dig e/m svc 5-10min,98970,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,56.39,,,,,,,fee schedule,56.39,56.39, Qnhp ol dig em svc 11-20min,98971,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,103.66,,,,,,,fee schedule,103.66,103.66, Qnhp ol dig e/m svc 21+ min,98972,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,158.32,,,,,,,fee schedule,158.32,158.32, Rem ther mntr 1st setup&edu,98975,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,113.96,,,,,,,fee schedule,113.96,113.96, Rem ther mntr dev sply resp,98976,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,269.8,,,,,,,fee schedule,269.8,269.8, Rem ther mntr dv sply mscskl,98977,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,266.35,,,,,,,fee schedule,266.35,266.35, Rtm tx mgmt 1st 10 min,98979,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,62,,,,,,,fee schedule,62,62, Rem ther mntr 1st 20 min,98980,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,140.57,,,,,,,fee schedule,140.57,140.57, Rem ther mntr ea addl 20 min,98981,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,138.73,,,,,,,fee schedule,138.73,138.73, Rtm dev sply resp sys 2-15 d,98984,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,269.8,,,,,,,fee schedule,269.8,269.8, Rtm dev sply mscsk sys 2-15d,98985,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,266.35,,,,,,,fee schedule,266.35,266.35, Specimen handling office-lab,99000,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.66,,,,,,,fee schedule,8.66,8.66, Specimen handling office-lab,99000,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,8.66,,,,,,,fee schedule,8.66,8.66, Specimen handling pt-lab,99001,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.21,,,,,,,fee schedule,9.21,9.21, Specimen handling pt-lab,99001,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9.21,,,,,,,fee schedule,9.21,9.21, Collect/review data from pt,99091,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,260.3,,,,,,,fee schedule,260.3,260.3, Mod sed same phys/qhp <5 yrs,99151,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,115.47,,,,,,,fee schedule,115.47,115.47, Mod sed same phys/qhp 5/>yrs,99152,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,61.78,,,,,,,fee schedule,61.78,61.78, Mod sed same phys/qhp ea,99153,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,65.72,,,,,,,fee schedule,65.72,65.72, Mod sed oth phys/qhp <5 yrs,99155,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,459.15,,,,,,,fee schedule,459.15,459.15, Mod sed oth phys/qhp 5/>yrs,99156,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,398.82,,,,,,,fee schedule,398.82,398.82, Mod sed other phys/qhp ea,99157,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,302.82,,,,,,,fee schedule,302.82,302.82, Anogenital exam child w imag,99170,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,392.88,,,,,,,fee schedule,392.88,392.88, Induction of vomiting,99175,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,237.05,,,,,,,fee schedule,237.05,237.05, Hyperbaric oxygen therapy,99183,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,607.1,,,,,,,fee schedule,607.1,607.1, Hypothermia ill neonate,99184,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1013.75,,,,,,,fee schedule,1013.75,1013.75, Phlebotomy,99195,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,511.49,,,,,,,fee schedule,511.49,511.49, Office/outpatient visit new,99202,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,226.2,,,,,,,fee schedule,226.2,226.2, Office/outpatient visit new,99203,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,397.2,,,,,,,fee schedule,397.2,397.2, Office/outpatient visit new,99204,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,647.36,,,,,,,fee schedule,647.36,647.36, Office/outpatient visit new,99205,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,890.29,,,,,,,fee schedule,890.29,890.29, Office/outpatient visit est,99211,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,42.03,,,,,,,fee schedule,42.03,42.03, Office/outpatient visit est,99212,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,171.7,,,,,,,fee schedule,171.7,171.7, Office/outpatient visit est,99213,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,315.56,,,,,,,fee schedule,315.56,315.56, Office/outpatient visit est,99214,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,464.97,,,,,,,fee schedule,464.97,464.97, Office/outpatient visit est,99215,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,690.74,,,,,,,fee schedule,690.74,690.74, Initial hospital care,99221,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,415.87,,,,,,,fee schedule,415.87,415.87, Initial hospital care,99222,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,646.33,,,,,,,fee schedule,646.33,646.33, Initial hospital care,99223,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,861.74,,,,,,,fee schedule,861.74,861.74, Subsequent hospital care,99231,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,243.25,,,,,,,fee schedule,243.25,243.25, Subsequent hospital care,99232,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,387.97,,,,,,,fee schedule,387.97,387.97, Subsequent hospital care,99233,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,588.16,,,,,,,fee schedule,588.16,588.16, Observ/hosp same date,99234,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,488.5,,,,,,,fee schedule,488.5,488.5, Observ/hosp same date,99235,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,787.76,,,,,,,fee schedule,787.76,787.76, Observ/hosp same date,99236,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1048.28,,,,,,,fee schedule,1048.28,1048.28, Hospital discharge day,99238,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,409.66,,,,,,,fee schedule,409.66,409.66, Hospital discharge day,99239,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,582.44,,,,,,,fee schedule,582.44,582.44, Emergency dept visit,99281,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,61.78,,,,,,,fee schedule,61.78,61.78, Emergency dept visit,99282,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,226.69,,,,,,,fee schedule,226.69,226.69, Emergency dept visit,99283,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,390.78,,,,,,,fee schedule,390.78,390.78, Emergency dept visit,99284,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,666.19,,,,,,,fee schedule,666.19,666.19, Emergency dept visit,99285,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,962.97,,,,,,,fee schedule,962.97,962.97, Critical care first hour,99291,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1107.96,,,,,,,fee schedule,1107.96,1107.96, Critical care addl 30 min,99292,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,557.41,,,,,,,fee schedule,557.41,557.41, Nursing facility care init,99304,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,387.76,,,,,,,fee schedule,387.76,387.76, Nursing facility care init,99305,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.15,,,,,,,fee schedule,656.15,656.15, Nursing facility care init,99306,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,892.98,,,,,,,fee schedule,892.98,892.98, Nursing fac care subseq,99307,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,201.76,,,,,,,fee schedule,201.76,201.76, Nursing fac care subseq,99308,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,367.95,,,,,,,fee schedule,367.95,367.95, Nursing fac care subseq,99309,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,537.33,,,,,,,fee schedule,537.33,537.33, Nursing fac care subseq,99310,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,766.56,,,,,,,fee schedule,766.56,766.56, Nursing fac discharge day,99315,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,398.12,,,,,,,fee schedule,398.12,398.12, Nursing fac discharge day,99316,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,643.1,,,,,,,fee schedule,643.1,643.1, Home visit new patient,99341,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,265.16,,,,,,,fee schedule,265.16,265.16, Home visit new patient,99342,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,426.61,,,,,,,fee schedule,426.61,426.61, Home visit new patient,99344,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,794.94,,,,,,,fee schedule,794.94,794.94, Home visit new patient,99345,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1139.2,,,,,,,fee schedule,1139.2,1139.2, Home visit est patient,99347,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,248.86,,,,,,,fee schedule,248.86,248.86, Home visit est patient,99348,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,425.42,,,,,,,fee schedule,425.42,425.42, Home visit est patient,99349,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,717.45,,,,,,,fee schedule,717.45,717.45, Home visit est patient,99350,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1048.12,,,,,,,fee schedule,1048.12,1048.12, Behav chng smoking 3-10 min,99406,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,59.03,,,,,,,fee schedule,59.03,59.03, Behav chng smoking > 10 min,99407,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,121.63,,,,,,,fee schedule,121.63,121.63, Prolong clincl staff svc,99415,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,119.9,,,,,,,fee schedule,119.9,119.9, Prolong clincl staff svc add,99416,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,66.48,,,,,,,fee schedule,66.48,66.48, Ol dig e/m svc 5-10 min,99421,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,60.81,,,,,,,fee schedule,60.81,60.81, Ol dig e/m svc 11-20 min,99422,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,123.35,,,,,,,fee schedule,123.35,123.35, Ol dig e/m svc 21+ min,99423,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,192.21,,,,,,,fee schedule,192.21,192.21, Prin care mgmt phys 1st 30,99424,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,356.62,,,,,,,fee schedule,356.62,356.62, Prin care mgmt phys ea addl,99425,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,242.28,,,,,,,fee schedule,242.28,242.28, Prin care mgmt staff 1st 30,99426,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,242.28,,,,,,,fee schedule,242.28,242.28, Prin care mgmt staff ea addl,99427,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,172.51,,,,,,,fee schedule,172.51,172.51, Chrnc care mgmt phys ea addl,99437,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,240.55,,,,,,,fee schedule,240.55,240.55, Chrnc care mgmt svc ea addl,99439,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,169,,,,,,,fee schedule,169,169, Rem mntr physiol param 2-15,99445,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,269.8,,,,,,,fee schedule,269.8,269.8, Interprof phone/online 5-10,99446,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,89.41,,,,,,,fee schedule,89.41,89.41, Interprof phone/online 11-20,99447,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,177.85,,,,,,,fee schedule,177.85,177.85, Interprof phone/online 21-30,99448,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,263.59,,,,,,,fee schedule,263.59,263.59, Interprof phone/online 31/>,99449,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,350.31,,,,,,,fee schedule,350.31,350.31, Ntrprof ph1/ntrnet/ehr 5/>,99451,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,165.55,,,,,,,fee schedule,165.55,165.55, Ntrprof ph1/ntrnet/ehr rfrl,99452,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,170.73,,,,,,,fee schedule,170.73,170.73, Rem mntr physiol param setup,99453,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,113.96,,,,,,,fee schedule,113.96,113.96, Rem mntr physiol param dev,99454,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,269.8,,,,,,,fee schedule,269.8,269.8, Rem physiol mntr 20 min mo,99457,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,144.88,,,,,,,fee schedule,144.88,144.88, Rem physiol mntr ea addl 20,99458,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,144.88,,,,,,,fee schedule,144.88,144.88, Pelvic examination,99459,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,89.57,,,,,,,fee schedule,89.57,89.57, Init nb em per day hosp,99460,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,444.04,,,,,,,fee schedule,444.04,444.04, Init nb em per day non-fac,99461,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,290.84,,,,,,,fee schedule,290.84,290.84, Sbsq nb em per day hosp,99462,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,194.26,,,,,,,fee schedule,194.26,194.26, Same day nb discharge,99463,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,519.04,,,,,,,fee schedule,519.04,519.04, Attendance at delivery,99464,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,345.45,,,,,,,fee schedule,345.45,345.45, Nb resuscitation,99465,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,678.49,,,,,,,fee schedule,678.49,678.49, Ped crit care transport,99466,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1106.29,,,,,,,fee schedule,1106.29,1106.29, Ped crit care transport addl,99467,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,555.9,,,,,,,fee schedule,555.9,555.9, Neonate crit care initial,99468,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4275.14,,,,,,,fee schedule,4275.14,4275.14, Neonate crit care subsq,99469,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1847.48,,,,,,,fee schedule,1847.48,1847.48, Rpm tx mgmt 1st 10 min,99470,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,73.33,,,,,,,fee schedule,73.33,73.33, Ped critical care initial,99471,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3703.06,,,,,,,fee schedule,3703.06,3703.06, Ped critical care subsq,99472,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1934.9,,,,,,,fee schedule,1934.9,1934.9, Self-meas bp pt educaj/train,99473,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,80.24,,,,,,,fee schedule,80.24,80.24, Self-meas bp 2 readg bid 30d,99474,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,43.76,,,,,,,fee schedule,43.76,43.76, Ped crit care age 2-5 init,99475,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,2601.2,,,,,,,fee schedule,2601.2,2601.2, Ped crit care age 2-5 subsq,99476,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1687.76,,,,,,,fee schedule,1687.76,1687.76, Init day hosp neonate care,99477,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1621.07,,,,,,,fee schedule,1621.07,1621.07, Ic lbw inf < 1500 gm subsq,99478,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,636.46,,,,,,,fee schedule,636.46,636.46, Ic lbw inf 1500-2500 g subsq,99479,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,577.37,,,,,,,fee schedule,577.37,577.37, Ic inf pbw 2501-5000 g subsq,99480,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,555.9,,,,,,,fee schedule,555.9,555.9, Assmt & care pln pt cog imp,99483,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,932.37,,,,,,,fee schedule,932.37,932.37, Care mgmt svc bhvl hlth cond,99484,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,213.14,,,,,,,fee schedule,213.14,213.14, Cmplx chron care w/o pt vsit,99487,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,435.51,,,,,,,fee schedule,435.51,435.51, Cmplx chron care addl 30 min,99489,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,240.55,,,,,,,fee schedule,240.55,240.55, Chron care mgmt srvc 20 min,99490,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,240.55,,,,,,,fee schedule,240.55,240.55, Chrnc care mgmt svc 30 min,99491,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,358.46,,,,,,,fee schedule,358.46,358.46, 1st psyc collab care mgmt,99492,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,452.56,,,,,,,fee schedule,452.56,452.56, Sbsq psyc collab care mgmt,99493,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,491.85,,,,,,,fee schedule,491.85,491.85, 1st/sbsq psyc collab care,99494,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,198.52,,,,,,,fee schedule,198.52,198.52, Trans care mgmt 14 day disch,99495,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,671.42,,,,,,,fee schedule,671.42,671.42, Trans care mgmt 7 day disch,99496,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,911.76,,,,,,,fee schedule,911.76,911.76, Advncd care plan 30 min,99497,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,360.18,,,,,,,fee schedule,360.18,360.18, Advncd care plan addl 30 min,99498,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,347.34,,,,,,,fee schedule,347.34,347.34, Miscellaneous M >=66.50,A2001,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,1561.93, Miscellaneous M >=66.50,A2001,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1561.93,,,,,,,fee schedule,656.48,1561.93, Miscellaneous M >=66.50,A2001,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1561.93,,,,,,,fee schedule,656.48,1561.93, Miscellaneous M >=55.50 and M <66.50,A2002,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,418.3,656.48, Miscellaneous M >=55.50 and M <66.50,A2002,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,418.3,,,,,,,fee schedule,418.3,656.48, Miscellaneous M >=55.50 and M <66.50,A2002,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,418.3,,,,,,,fee schedule,418.3,656.48, Miscellaneous M <46.50 and A >=77.50,A2004,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.03,,,,,,,fee schedule,19.03,19.03, Miscellaneous M <46.50 and A >=77.50,A2004,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19.03,,,,,,,fee schedule,19.03,19.03, Miscellaneous M <46.50 and A <77.50,A2005,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,310.58,656.48, Miscellaneous M <46.50 and A <77.50,A2005,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,310.58,,,,,,,fee schedule,310.58,656.48, Miscellaneous M <46.50 and A <77.50,A2005,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,310.58,,,,,,,fee schedule,310.58,656.48, Novosorb synpath per sq cm,A2006,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, "Restrata, per sq cm",A2007,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,98.26,656.48, "Restrata, per sq cm",A2007,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,98.26,,,,,,,fee schedule,98.26,656.48, "Restrata, per sq cm",A2007,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,98.26,,,,,,,fee schedule,98.26,656.48, "Theragenesis, per sq cm",A2008,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,109.7,656.48, "Theragenesis, per sq cm",A2008,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,109.7,,,,,,,fee schedule,109.7,656.48, "Theragenesis, per sq cm",A2008,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,109.7,,,,,,,fee schedule,109.7,656.48, "Symphony, per sq cm",A2009,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,152.71,656.48, "Symphony, per sq cm",A2009,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,152.71,,,,,,,fee schedule,152.71,656.48, "Symphony, per sq cm",A2009,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,152.71,,,,,,,fee schedule,152.71,656.48, "Apis, per square centimeter",A2010,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, "Supra sdrm, per sq cm",A2011,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, "Suprathel, per sq cm",A2012,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, "Innovamatrix fs, per sq cm",A2013,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,1687.03, "Innovamatrix fs, per sq cm",A2013,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1687.03,,,,,,,fee schedule,656.48,1687.03, "Innovamatrix fs, per sq cm",A2013,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1687.03,,,,,,,fee schedule,656.48,1687.03, Omeza collag per 100 mg,A2014,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,187.58,,,,,,,fee schedule,187.58,187.58, Omeza collag per 100 mg,A2014,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,187.58,,,,,,,fee schedule,187.58,187.58, "Phoenix wnd mtrx, per sq cm",A2015,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,1755.17, "Phoenix wnd mtrx, per sq cm",A2015,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1755.17,,,,,,,fee schedule,656.48,1755.17, "Phoenix wnd mtrx, per sq cm",A2015,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1755.17,,,,,,,fee schedule,656.48,1755.17, "Permeaderm b, per sq cm",A2016,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, "Permeaderm c, per sq cm",A2018,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, Kerecis marigen shld sq cm,A2019,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,860.89, Kerecis marigen shld sq cm,A2019,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,860.89,,,,,,,fee schedule,656.48,860.89, Kerecis marigen shld sq cm,A2019,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,860.89,,,,,,,fee schedule,656.48,860.89, Neomatrix per sq cm,A2021,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,1636.13, Neomatrix per sq cm,A2021,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1636.13,,,,,,,fee schedule,656.48,1636.13, Neomatrix per sq cm,A2021,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1636.13,,,,,,,fee schedule,656.48,1636.13, Innovabrn/innovamatx xl sqcm,A2022,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,1780.55, Innovabrn/innovamatx xl sqcm,A2022,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1780.55,,,,,,,fee schedule,656.48,1780.55, Innovabrn/innovamatx xl sqcm,A2022,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1780.55,,,,,,,fee schedule,656.48,1780.55, "Innovamatrix pd, 1 mg",A2023,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,20.13,,,,,,,fee schedule,20.13,20.13, "Innovamatrix pd, 1 mg",A2023,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,20.13,,,,,,,fee schedule,20.13,20.13, Resolve matrix per sq cm,A2024,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,2367.76, Resolve matrix per sq cm,A2024,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2367.76,,,,,,,fee schedule,656.48,2367.76, Resolve matrix per sq cm,A2024,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2367.76,,,,,,,fee schedule,656.48,2367.76, Miro3d per cubic cm,A2025,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,366.15,656.48, Miro3d per cubic cm,A2025,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,366.15,,,,,,,fee schedule,366.15,656.48, Miro3d per cubic cm,A2025,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,366.15,,,,,,,fee schedule,366.15,656.48, Matriderm per sq cm,A2027,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, Mirotract matrix sheet,A2029,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,624.7,656.48, Mirotract matrix sheet,A2029,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,624.7,,,,,,,fee schedule,624.7,656.48, Mirotract matrix sheet,A2029,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,624.7,,,,,,,fee schedule,624.7,656.48, "Miro3d fibers, per mg",A2030,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.67,,,,,,,fee schedule,6.67,6.67, "Miro3d fibers, per mg",A2030,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,6.67,,,,,,,fee schedule,6.67,6.67, "Mirodry, per sq cm",A2031,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,732.13, "Mirodry, per sq cm",A2031,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,732.13,,,,,,,fee schedule,656.48,732.13, "Mirodry, per sq cm",A2031,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,732.13,,,,,,,fee schedule,656.48,732.13, "Myriad matrix, per sq cm",A2032,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,28.71,656.48, "Myriad matrix, per sq cm",A2032,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,28.71,,,,,,,fee schedule,28.71,656.48, "Myriad matrix, per sq cm",A2032,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,28.71,,,,,,,fee schedule,28.71,656.48, "Myriad morcells, 4 mg",A2033,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.1,,,,,,,fee schedule,16.1,16.1, "Myriad morcells, 4 mg",A2033,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,16.1,,,,,,,fee schedule,16.1,16.1, "Found drs solo, per sq cm",A2034,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,1876.87, "Found drs solo, per sq cm",A2034,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1876.87,,,,,,,fee schedule,656.48,1876.87, "Found drs solo, per sq cm",A2034,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1876.87,,,,,,,fee schedule,656.48,1876.87, Corpl p therac p allac p mg,A2035,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,139.68,,,,,,,fee schedule,139.68,139.68, Corpl p therac p allac p mg,A2035,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,139.68,,,,,,,fee schedule,139.68,139.68, Cohealyx col dml mx pr sq cm,A2036,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, "Marigen pacto, per sq cm",A2038,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, "Innovamatrix fd, per sq cm",A2039,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, Skin sub fda clrd as dev nos,A4100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, Ces system monthly supp,A4596,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,58.9,,,,,,,fee schedule,58.9,58.9, Ces system monthly supp,A4596,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,58.9,,,,,,,fee schedule,58.9,58.9, In111 satumomab,A4642,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1980.63,,,,,,,fee schedule,1980.63,1980.63, In111 satumomab,A4642,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1980.63,,,,,,,fee schedule,1980.63,1980.63, Tc99m sestamibi,A9500,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,549.71,,,,,,,fee schedule,549.71,549.71, Tc99m sestamibi,A9500,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,549.71,,,,,,,fee schedule,549.71,549.71, Tc99m tetrofosmin,A9502,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,138.12,,,,,,,fee schedule,138.12,138.12, Tc99m tetrofosmin,A9502,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,138.12,,,,,,,fee schedule,138.12,138.12, Tc99m medronate,A9503,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,72.21,,,,,,,fee schedule,72.21,72.21, Tc99m medronate,A9503,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,72.21,,,,,,,fee schedule,72.21,72.21, Tc99m apcitide,A9504,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,621.14,,,,,,,fee schedule,621.14,621.14, Tc99m apcitide,A9504,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,621.14,,,,,,,fee schedule,621.14,621.14, Tl201 thallium,A9505,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,59.58,,,,,,,fee schedule,59.58,59.58, Tl201 thallium,A9505,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,59.58,,,,,,,fee schedule,59.58,59.58, Tc-99m graphite crucible,A9506,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,400.89,,,,,,,fee schedule,400.89,400.89, Tc-99m graphite crucible,A9506,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,400.89,,,,,,,fee schedule,400.89,400.89, In111 capromab,A9507,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1602.58,,,,,,,fee schedule,1602.58,1602.58, In111 capromab,A9507,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1602.58,,,,,,,fee schedule,1602.58,1602.58, "I131 iodobenguate, dx",A9508,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1257.28,,,,,,,fee schedule,1257.28,1257.28, "I131 iodobenguate, dx",A9508,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1257.28,,,,,,,fee schedule,1257.28,1257.28, Iodine I-123 sod iodide mil,A9509,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,205.61,,,,,,,fee schedule,205.61,205.61, Iodine I-123 sod iodide mil,A9509,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,205.61,,,,,,,fee schedule,205.61,205.61, Tc99m disofenin,A9510,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,73,,,,,,,fee schedule,73,73, Tc99m disofenin,A9510,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,73,,,,,,,fee schedule,73,73, Tc99m pertechnetate,A9512,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13.02,,,,,,,fee schedule,13.02,13.02, Tc99m pertechnetate,A9512,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13.02,,,,,,,fee schedule,13.02,13.02, Lutetium lu 177 dotatat ther,A9513,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,381.48,,,,,,,fee schedule,381.48,381.48, Lutetium lu 177 dotatat ther,A9513,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,381.48,,,,,,,fee schedule,381.48,381.48, Choline c-11,A9515,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2516.79,,,,,,,fee schedule,2516.79,2516.79, Choline c-11,A9515,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2516.79,,,,,,,fee schedule,2516.79,2516.79, Iodine I-123 sod iodide mic,A9516,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,142.85,,,,,,,fee schedule,142.85,142.85, Iodine I-123 sod iodide mic,A9516,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,142.85,,,,,,,fee schedule,142.85,142.85, "I131 iodide cap, rx",A9517,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,28.22,,,,,,,fee schedule,28.22,28.22, "I131 iodide cap, rx",A9517,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,28.22,,,,,,,fee schedule,28.22,28.22, Tc99m exametazime,A9521,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,978.85,,,,,,,fee schedule,978.85,978.85, Tc99m exametazime,A9521,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,978.85,,,,,,,fee schedule,978.85,978.85, "I131 serum albumin, dx",A9524,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,594.7,,,,,,,fee schedule,594.7,594.7, "I131 serum albumin, dx",A9524,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,594.7,,,,,,,fee schedule,594.7,594.7, Nitrogen n-13 ammonia,A9526,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,897.38,,,,,,,fee schedule,897.38,897.38, Nitrogen n-13 ammonia,A9526,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,897.38,,,,,,,fee schedule,897.38,897.38, Iodine I-125 sodium iodide,A9527,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,254.47,,,,,,,fee schedule,254.47,254.47, Iodine I-125 sodium iodide,A9527,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,254.47,,,,,,,fee schedule,254.47,254.47, "Iodine i-131 iodide cap, dx",A9528,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,115.23,,,,,,,fee schedule,115.23,115.23, "Iodine i-131 iodide cap, dx",A9528,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,115.23,,,,,,,fee schedule,115.23,115.23, "I131 iodide sol, rx",A9530,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25.47,,,,,,,fee schedule,25.47,25.47, "I131 iodide sol, rx",A9530,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,25.47,,,,,,,fee schedule,25.47,25.47, I131 max 100uci,A9531,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.14,,,,,,,fee schedule,5.14,5.14, I131 max 100uci,A9531,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5.14,,,,,,,fee schedule,5.14,5.14, "I125 serum albumin, dx",A9532,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,250.2,,,,,,,fee schedule,250.2,250.2, "I125 serum albumin, dx",A9532,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,250.2,,,,,,,fee schedule,250.2,250.2, Tc99m depreotide,A9536,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,945.93,,,,,,,fee schedule,945.93,945.93, Tc99m depreotide,A9536,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,945.93,,,,,,,fee schedule,945.93,945.93, Tc99m mebrofenin,A9537,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,138.42,,,,,,,fee schedule,138.42,138.42, Tc99m mebrofenin,A9537,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,138.42,,,,,,,fee schedule,138.42,138.42, Tc99m pyrophosphate,A9538,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,49.73,,,,,,,fee schedule,49.73,49.73, Tc99m pyrophosphate,A9538,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,49.73,,,,,,,fee schedule,49.73,49.73, Tc99m pentetate,A9539,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,33.94,,,,,,,fee schedule,33.94,33.94, Tc99m pentetate,A9539,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,33.94,,,,,,,fee schedule,33.94,33.94, Tc99m maa,A9540,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,35.92,,,,,,,fee schedule,35.92,35.92, Tc99m maa,A9540,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,35.92,,,,,,,fee schedule,35.92,35.92, Tc99m sulfur colloid,A9541,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,916.71,,,,,,,fee schedule,916.71,916.71, Tc99m sulfur colloid,A9541,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,916.71,,,,,,,fee schedule,916.71,916.71, "In111 ibritumomab, dx",A9542,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,973.58,,,,,,,fee schedule,973.58,973.58, "In111 ibritumomab, dx",A9542,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,973.58,,,,,,,fee schedule,973.58,973.58, "Y90 ibritumomab, rx",A9543,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,69325.95,,,,,,,fee schedule,69325.95,69325.95, "Y90 ibritumomab, rx",A9543,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,69325.95,,,,,,,fee schedule,69325.95,69325.95, Co57/58,A9546,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.57,,,,,,,fee schedule,1.57,1.57, Co57/58,A9546,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.57,,,,,,,fee schedule,1.57,1.57, In111 oxyquinoline,A9547,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,942.62,,,,,,,fee schedule,942.62,942.62, In111 oxyquinoline,A9547,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,942.62,,,,,,,fee schedule,942.62,942.62, In111 pentetate,A9548,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,872.65,,,,,,,fee schedule,872.65,872.65, In111 pentetate,A9548,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,872.65,,,,,,,fee schedule,872.65,872.65, Tc99m succimer,A9551,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,597.47,,,,,,,fee schedule,597.47,597.47, Tc99m succimer,A9551,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,597.47,,,,,,,fee schedule,597.47,597.47, F18 fdg,A9552,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,509.46,,,,,,,fee schedule,509.46,509.46, F18 fdg,A9552,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,509.46,,,,,,,fee schedule,509.46,509.46, Cr51 chromate,A9553,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,514.19,,,,,,,fee schedule,514.19,514.19, Cr51 chromate,A9553,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,514.19,,,,,,,fee schedule,514.19,514.19, "I125 iothalamate, dx",A9554,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,47.36,,,,,,,fee schedule,47.36,47.36, "I125 iothalamate, dx",A9554,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,47.36,,,,,,,fee schedule,47.36,47.36, Rb82 rubidium,A9555,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,632.19,,,,,,,fee schedule,632.19,632.19, Rb82 rubidium,A9555,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,632.19,,,,,,,fee schedule,632.19,632.19, Ga67 gallium,A9556,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26.84,,,,,,,fee schedule,26.84,26.84, Ga67 gallium,A9556,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,26.84,,,,,,,fee schedule,26.84,26.84, Tc99m bicisate,A9557,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,834.24,,,,,,,fee schedule,834.24,834.24, Tc99m bicisate,A9557,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,834.24,,,,,,,fee schedule,834.24,834.24, Xe133 xenon 10mci,A9558,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,361.88,,,,,,,fee schedule,361.88,361.88, Xe133 xenon 10mci,A9558,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,361.88,,,,,,,fee schedule,361.88,361.88, Co57 cyano,A9559,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,196.53,,,,,,,fee schedule,196.53,196.53, Co57 cyano,A9559,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,196.53,,,,,,,fee schedule,196.53,196.53, Tc99m labeled rbc,A9560,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,128.65,,,,,,,fee schedule,128.65,128.65, Tc99m labeled rbc,A9560,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,128.65,,,,,,,fee schedule,128.65,128.65, Tc99m oxidronate,A9561,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,61.56,,,,,,,fee schedule,61.56,61.56, Tc99m oxidronate,A9561,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,61.56,,,,,,,fee schedule,61.56,61.56, Tc99m mertiatide,A9562,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,937.24,,,,,,,fee schedule,937.24,937.24, Tc99m mertiatide,A9562,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,937.24,,,,,,,fee schedule,937.24,937.24, P32 na phosphate,A9563,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,218.53,,,,,,,fee schedule,218.53,218.53, P32 na phosphate,A9563,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,218.53,,,,,,,fee schedule,218.53,218.53, P32 chromic phosphate,A9564,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,184.68,,,,,,,fee schedule,184.68,184.68, P32 chromic phosphate,A9564,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,184.68,,,,,,,fee schedule,184.68,184.68, Technetium tc-99m aerosol,A9567,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24.86,,,,,,,fee schedule,24.86,24.86, Technetium tc-99m aerosol,A9567,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,24.86,,,,,,,fee schedule,24.86,24.86, Technetium tc99m arcitumomab,A9568,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,987.6,,,,,,,fee schedule,987.6,987.6, Technetium tc99m arcitumomab,A9568,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,987.6,,,,,,,fee schedule,987.6,987.6, Technetium TC-99m auto WBC,A9569,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1269.19,,,,,,,fee schedule,1269.19,1269.19, Technetium TC-99m auto WBC,A9569,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1269.19,,,,,,,fee schedule,1269.19,1269.19, Indium In-111 auto WBC,A9570,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1258.3,,,,,,,fee schedule,1258.3,1258.3, Indium In-111 auto WBC,A9570,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1258.3,,,,,,,fee schedule,1258.3,1258.3, Indium IN-111 auto platelet,A9571,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5668.03,,,,,,,fee schedule,5668.03,5668.03, Indium IN-111 auto platelet,A9571,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5668.03,,,,,,,fee schedule,5668.03,5668.03, Indium In-111 pentetreotide,A9572,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2335.82,,,,,,,fee schedule,2335.82,2335.82, Indium In-111 pentetreotide,A9572,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2335.82,,,,,,,fee schedule,2335.82,2335.82, "Inj, gadopiclenol, 1 ml",A9573,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.16,,,,,,,fee schedule,4.16,4.16, "Inj, gadopiclenol, 1 ml",A9573,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4.16,,,,,,,fee schedule,4.16,4.16, Inj gadoterate meglumi 0.1ml,A9575,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.15,,,,,,,fee schedule,0.15,0.15, Inj gadoterate meglumi 0.1ml,A9575,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.15,,,,,,,fee schedule,0.15,0.15, Inj prohance multipack,A9576,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.73,,,,,,,fee schedule,1.73,1.73, Inj prohance multipack,A9576,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.73,,,,,,,fee schedule,1.73,1.73, Inj multihance,A9577,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2.12,,,,,,,fee schedule,2.12,2.12, Inj multihance,A9577,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2.12,,,,,,,fee schedule,2.12,2.12, Inj multihance multipack,A9578,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2.09,,,,,,,fee schedule,2.09,2.09, Inj multihance multipack,A9578,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2.09,,,,,,,fee schedule,2.09,2.09, "Gad-base MR contrast NOS,1ml",A9579,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.79,,,,,,,fee schedule,1.79,1.79, "Gad-base MR contrast NOS,1ml",A9579,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.79,,,,,,,fee schedule,1.79,1.79, Sodium fluoride F-18,A9580,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,319.65,,,,,,,fee schedule,319.65,319.65, Sodium fluoride F-18,A9580,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,319.65,,,,,,,fee schedule,319.65,319.65, Gadoxetate disodium inj,A9581,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.93,,,,,,,fee schedule,17.93,17.93, Gadoxetate disodium inj,A9581,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,17.93,,,,,,,fee schedule,17.93,17.93, Iodine I-123 iobenguane,A9582,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2531.27,,,,,,,fee schedule,2531.27,2531.27, Iodine I-123 iobenguane,A9582,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2531.27,,,,,,,fee schedule,2531.27,2531.27, Iodine i-123 ioflupane,A9584,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1693.38,,,,,,,fee schedule,1693.38,1693.38, Iodine i-123 ioflupane,A9584,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1693.38,,,,,,,fee schedule,1693.38,1693.38, Gadobutrol injection,A9585,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.32,,,,,,,fee schedule,0.32,0.32, Gadobutrol injection,A9585,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.32,,,,,,,fee schedule,0.32,0.32, Florbetapir F18,A9586,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2677.44,,,,,,,fee schedule,2677.44,2677.44, Florbetapir F18,A9586,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2677.44,,,,,,,fee schedule,2677.44,2677.44, Gallium ga-68,A9587,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,62.33,,,,,,,fee schedule,62.33,62.33, Gallium ga-68,A9587,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,62.33,,,,,,,fee schedule,62.33,62.33, Fluciclovine f-18,A9588,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,327.47,,,,,,,fee schedule,327.47,327.47, Fluciclovine f-18,A9588,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,327.47,,,,,,,fee schedule,327.47,327.47, Insti hexaminolevulinate hcl,A9589,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1737.68,,,,,,,fee schedule,1737.68,1737.68, Insti hexaminolevulinate hcl,A9589,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1737.68,,,,,,,fee schedule,1737.68,1737.68, Fluoroestradiol f 18,A9591,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,608.38,,,,,,,fee schedule,608.38,608.38, Fluoroestradiol f 18,A9591,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,608.38,,,,,,,fee schedule,608.38,608.38, Copper cu 64 dotatate diag,A9592,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,726.02,,,,,,,fee schedule,726.02,726.02, Copper cu 64 dotatate diag,A9592,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,726.02,,,,,,,fee schedule,726.02,726.02, Gallium ga-68 psma-11 ucsf,A9593,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,652.59,,,,,,,fee schedule,652.59,652.59, Gallium ga-68 psma-11 ucsf,A9593,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,652.59,,,,,,,fee schedule,652.59,652.59, "Gallium ga-68 psma-11, ucla",A9594,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,454.05,,,,,,,fee schedule,454.05,454.05, "Gallium ga-68 psma-11, ucla",A9594,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,454.05,,,,,,,fee schedule,454.05,454.05, "Piflu f-18, dia 1 millicurie",A9595,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,405.58,,,,,,,fee schedule,405.58,405.58, "Piflu f-18, dia 1 millicurie",A9595,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,405.58,,,,,,,fee schedule,405.58,405.58, Gallium illuccix 1 millicure,A9596,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,624.09,,,,,,,fee schedule,624.09,624.09, Gallium illuccix 1 millicure,A9596,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,624.09,,,,,,,fee schedule,624.09,624.09, Sr89 strontium,A9600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5058.53,,,,,,,fee schedule,5058.53,5058.53, Sr89 strontium,A9600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5058.53,,,,,,,fee schedule,5058.53,5058.53, Flortaucipir inj 1 millicuri,A9601,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4526.2,,,,,,,fee schedule,4526.2,4526.2, Flortaucipir inj 1 millicuri,A9601,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4526.2,,,,,,,fee schedule,4526.2,4526.2, Fluorodopa f-18 diag per mci,A9602,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,608.32,,,,,,,fee schedule,608.32,608.32, Fluorodopa f-18 diag per mci,A9602,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,608.32,,,,,,,fee schedule,608.32,608.32, Sm 153 lexidronam,A9604,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5264.19,,,,,,,fee schedule,5264.19,5264.19, Sm 153 lexidronam,A9604,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5264.19,,,,,,,fee schedule,5264.19,5264.19, Radium ra223 dichloride ther,A9606,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,209.57,,,,,,,fee schedule,209.57,209.57, Radium ra223 dichloride ther,A9606,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,209.57,,,,,,,fee schedule,209.57,209.57, Lutetium lu 177 vipivotide,A9607,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,308.88,,,,,,,fee schedule,308.88,308.88, Lutetium lu 177 vipivotide,A9607,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,308.88,,,,,,,fee schedule,308.88,308.88, Flotufolastat f18 diag 1 mci,A9608,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,818.89,,,,,,,fee schedule,818.89,818.89, Flotufolastat f18 diag 1 mci,A9608,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,818.89,,,,,,,fee schedule,818.89,818.89, "Flurpiridaz f18, diag, 1 mci",A9611,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,646.6,,,,,,,fee schedule,646.6,646.6, "Flurpiridaz f18, diag, 1 mci",A9611,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,646.6,,,,,,,fee schedule,646.6,646.6, "Inj, pegulicianine, 1 mg",A9615,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,44.47,,,,,,,fee schedule,44.47,44.47, "Inj, pegulicianine, 1 mg",A9615,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,44.47,,,,,,,fee schedule,44.47,44.47, "Inj, magtrace per study dose",A9697,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1388.35,,,,,,,fee schedule,1388.35,1388.35, "Inj, magtrace per study dose",A9697,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1388.35,,,,,,,fee schedule,1388.35,1388.35, Radiopharm rx agent noc,A9699,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,55169.68,,,,,,,fee schedule,55169.68,55169.68, Radiopharm rx agent noc,A9699,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,55169.68,,,,,,,fee schedule,55169.68,55169.68, Gallium locametz 1 millicuri,A9800,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1065.6,,,,,,,fee schedule,1065.6,1065.6, Gallium locametz 1 millicuri,A9800,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1065.6,,,,,,,fee schedule,1065.6,1065.6, Low cost skin substitute app,C5271,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2505,4108, Low cost skin substitute app,C5271,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,4108, Low cost skin substitute app,C5271,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,4108, Low cost skin substitute app,C5272,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Low cost skin substitute app,C5272,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Low cost skin substitute app,C5272,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Low cost skin substitute app,C5273,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,5664, Low cost skin substitute app,C5273,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4108,5664, Low cost skin substitute app,C5273,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4108,5664, Low cost skin substitute app,C5274,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Low cost skin substitute app,C5274,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Low cost skin substitute app,C5274,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Low cost skin substitute app,C5275,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2505,4108, Low cost skin substitute app,C5275,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,4108, Low cost skin substitute app,C5275,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,4108, Low cost skin substitute app,C5276,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Low cost skin substitute app,C5276,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Low cost skin substitute app,C5276,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Low cost skin substitute app,C5277,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,2505,4108, Low cost skin substitute app,C5277,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,4108, Low cost skin substitute app,C5277,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,4108, Low cost skin substitute app,C5278,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Low cost skin substitute app,C5278,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Low cost skin substitute app,C5278,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Deb bone 20 cm2 w/drug dev,C7500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,5664, Deb bone 20 cm2 w/drug dev,C7500,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4108,5664, Deb bone 20 cm2 w/drug dev,C7500,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4108,5664, Perc bx breast lesions stero,C7501,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,5664, Perc bx breast lesions stero,C7501,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4108,5664, Perc bx breast lesions stero,C7501,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4108,5664, Perc bx breast lesions mr,C7502,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5097,5664, Perc bx breast lesions mr,C7502,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Perc bx breast lesions mr,C7502,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Open exc cerv node(s) w/ id,C7503,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,5664, Open exc cerv node(s) w/ id,C7503,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4108,5664, Open exc cerv node(s) w/ id,C7503,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4108,5664, Perq cvt&ls inj vert bodies,C7504,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5097,5664, Perq cvt&ls inj vert bodies,C7504,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Perq cvt&ls inj vert bodies,C7504,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Perq ls&cvt inj vert bodies,C7505,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5097,5664, Perq ls&cvt inj vert bodies,C7505,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Perq ls&cvt inj vert bodies,C7505,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Fusion of finger joints,C7506,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5097,5664, Fusion of finger joints,C7506,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Fusion of finger joints,C7506,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Perq thor&lumb vert aug,C7507,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,5097,6044, Perq thor&lumb vert aug,C7507,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6044, Perq thor&lumb vert aug,C7507,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6044, Perq lumb&thor vert aug,C7508,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,5097,6044, Perq lumb&thor vert aug,C7508,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6044, Perq lumb&thor vert aug,C7508,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6044, Dx bronch w/ navigation,C7509,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5097,5664, Dx bronch w/ navigation,C7509,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Dx bronch w/ navigation,C7509,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Bronch/lavag w/ navigation,C7510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5097,5664, Bronch/lavag w/ navigation,C7510,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Bronch/lavag w/ navigation,C7510,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Bronch/bpsy(s) w/ navigation,C7511,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5097,5664, Bronch/bpsy(s) w/ navigation,C7511,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Bronch/bpsy(s) w/ navigation,C7511,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Bronch/bpsy(s) w/ ebus,C7512,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5097,5664, Bronch/bpsy(s) w/ ebus,C7512,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Bronch/bpsy(s) w/ ebus,C7512,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Cath/angio dialcir w/aplasty,C7513,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,5097,8406, Cath/angio dialcir w/aplasty,C7513,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8406, Cath/angio dialcir w/aplasty,C7513,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8406, Cath/angio dial cir w/stents,C7514,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,5097,8406, Cath/angio dial cir w/stents,C7514,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8406, Cath/angio dial cir w/stents,C7514,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8406, Cath/angio dial cir w/embol,C7515,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,5097,8406, Cath/angio dial cir w/embol,C7515,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8406, Cath/angio dial cir w/embol,C7515,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8406, Cor angio w/ ivus or oct,C7516,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8212,,,,,,,fee schedule,5097,8212, Cor angio w/ ivus or oct,C7516,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8212, Cor angio w/ ivus or oct,C7516,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8212, Cor angio w/ilic/fem angio,C7517,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,5097,8406, Cor angio w/ilic/fem angio,C7517,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8406, Cor angio w/ilic/fem angio,C7517,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8406, Cor/gft angio w/ ivus or oct,C7518,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8212,,,,,,,fee schedule,5097,8212, Cor/gft angio w/ ivus or oct,C7518,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8212, Cor/gft angio w/ ivus or oct,C7518,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8212, Cor/gft angio w/ flow resrv,C7519,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,5097,8406, Cor/gft angio w/ flow resrv,C7519,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8406, Cor/gft angio w/ flow resrv,C7519,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8406, Cor/gft angio w/ilic/fem ang,C7520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,5097,8406, Cor/gft angio w/ilic/fem ang,C7520,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8406, Cor/gft angio w/ilic/fem ang,C7520,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8406, R hrt angio w/ ivus or oct,C7521,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8212,,,,,,,fee schedule,5097,8212, R hrt angio w/ ivus or oct,C7521,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8212, R hrt angio w/ ivus or oct,C7521,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8212, R hrt angio w/flow resrv,C7522,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,5097,8406, R hrt angio w/flow resrv,C7522,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8406, R hrt angio w/flow resrv,C7522,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8406, L hrt angio w/ ivus or oct,C7523,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8212,,,,,,,fee schedule,5097,8212, L hrt angio w/ ivus or oct,C7523,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8212, L hrt angio w/ ivus or oct,C7523,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8212, L hrt angio w/flow resrv,C7524,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,5097,8406, L hrt angio w/flow resrv,C7524,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8406, L hrt angio w/flow resrv,C7524,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8406, L hrt gft ang w/ ivus or oct,C7525,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8212,,,,,,,fee schedule,5097,8212, L hrt gft ang w/ ivus or oct,C7525,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8212, L hrt gft ang w/ ivus or oct,C7525,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8212, L hrt gft ang w/flow resrv,C7526,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,5097,8406, L hrt gft ang w/flow resrv,C7526,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8406, L hrt gft ang w/flow resrv,C7526,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8406, R&l hrt angio w/ ivus or oct,C7527,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8212,,,,,,,fee schedule,5097,8212, R&l hrt angio w/ ivus or oct,C7527,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8212, R&l hrt angio w/ ivus or oct,C7527,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8212, R&l hrt angio w/flow resrv,C7528,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,5097,8406, R&l hrt angio w/flow resrv,C7528,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8406, R&l hrt angio w/flow resrv,C7528,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8406, R&l hrt gft ang w/flow resrv,C7529,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,5097,8406, R&l hrt gft ang w/flow resrv,C7529,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8406, R&l hrt gft ang w/flow resrv,C7529,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8406, Cath/aplasty dial cir w/stnt,C7530,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,5097,8406, Cath/aplasty dial cir w/stnt,C7530,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8406, Cath/aplasty dial cir w/stnt,C7530,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8406, Angio fem/pop w/ us,C7531,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,5097,6044, Angio fem/pop w/ us,C7531,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6044, Angio fem/pop w/ us,C7531,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6044, Angio w/ us non-coronary,C7532,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,5097,8406, Angio w/ us non-coronary,C7532,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8406, Angio w/ us non-coronary,C7532,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8406, Ptca w/ plcmt brachytx dev,C7533,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Ptca w/ plcmt brachytx dev,C7533,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Fem/pop revasc w/arthr & us,C7534,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,5097,6044, Fem/pop revasc w/arthr & us,C7534,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6044, Fem/pop revasc w/arthr & us,C7534,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6044, Fem/pop revasc w/stent & us,C7535,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,5097,6044, Fem/pop revasc w/stent & us,C7535,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6044, Fem/pop revasc w/stent & us,C7535,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6044, Insrt atril pm w/l vent lead,C7537,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,5097,8406, Insrt atril pm w/l vent lead,C7537,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8406, Insrt atril pm w/l vent lead,C7537,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8406, Insrt vent pm w/l vent lead,C7538,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,5097,8406, Insrt vent pm w/l vent lead,C7538,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8406, Insrt vent pm w/l vent lead,C7538,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8406, Insrt a & v pm w/l vent lead,C7539,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,5097,8406, Insrt a & v pm w/l vent lead,C7539,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8406, Insrt a & v pm w/l vent lead,C7539,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8406, Rmv&rplc pm dul w/l vnt lead,C7540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,5097,8406, Rmv&rplc pm dul w/l vnt lead,C7540,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8406, Rmv&rplc pm dul w/l vnt lead,C7540,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8406, Ercp w/ pancreatoscopy,C7541,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5097,5664, Ercp w/ pancreatoscopy,C7541,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Ercp w/ pancreatoscopy,C7541,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Ercp w/bx & pancreatoscopy,C7542,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5097,5664, Ercp w/bx & pancreatoscopy,C7542,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Ercp w/bx & pancreatoscopy,C7542,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, "Ercp w/otomy, pancreatoscopy",C7543,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5097,5664, "Ercp w/otomy, pancreatoscopy",C7543,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, "Ercp w/otomy, pancreatoscopy",C7543,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Ercp rmv calc pancreatoscopy,C7544,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5097,5664, Ercp rmv calc pancreatoscopy,C7544,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Ercp rmv calc pancreatoscopy,C7544,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Exch bil cath w/ rmv calculi,C7545,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5097,5664, Exch bil cath w/ rmv calculi,C7545,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Exch bil cath w/ rmv calculi,C7545,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Rep nph/urt cath w/dil stric,C7546,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,5664, Rep nph/urt cath w/dil stric,C7546,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4108,5664, Rep nph/urt cath w/dil stric,C7546,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4108,5664, Cnvrt neph cath w/ dil stric,C7547,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,5664, Cnvrt neph cath w/ dil stric,C7547,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4108,5664, Cnvrt neph cath w/ dil stric,C7547,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4108,5664, Exch neph cath w/ dil stric,C7548,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,5664, Exch neph cath w/ dil stric,C7548,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4108,5664, Exch neph cath w/ dil stric,C7548,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4108,5664, Chge urtr stent w/ dil stric,C7549,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,5664, Chge urtr stent w/ dil stric,C7549,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4108,5664, Chge urtr stent w/ dil stric,C7549,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4108,5664, Cysto w/ bx(s) w/ blue light,C7550,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,5664, Cysto w/ bx(s) w/ blue light,C7550,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4108,5664, Cysto w/ bx(s) w/ blue light,C7550,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4108,5664, Exc neuroma w/ implnt nv end,C7551,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5097,5664, Exc neuroma w/ implnt nv end,C7551,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Exc neuroma w/ implnt nv end,C7551,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, R hrt art/grft ang hrt flow,C7552,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,5097,8406, R hrt art/grft ang hrt flow,C7552,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8406, R hrt art/grft ang hrt flow,C7552,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8406, R&l hrt art/vent ang drg ad,C7553,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,5097,8406, R&l hrt art/vent ang drg ad,C7553,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8406, R&l hrt art/vent ang drg ad,C7553,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8406, Cystureth blu li cyst fl img,C7554,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,5664, Cystureth blu li cyst fl img,C7554,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,4108,5664, Cystureth blu li cyst fl img,C7554,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,4108,5664, Rmvl thyrd w/autotran parath,C7555,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,5097,8406, Rmvl thyrd w/autotran parath,C7555,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8406, Rmvl thyrd w/autotran parath,C7555,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8406, Bronch lavage w/ebus,C7556,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,4108, Cor angio/vent w/ffr,C7557,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8212,,,,,,,fee schedule,5097,8212, Cor angio/vent w/ffr,C7557,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8212, Cor angio/vent w/ffr,C7557,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8212, Ercp remove forgn body&endo,C7560,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5097,5664, Ercp remove forgn body&endo,C7560,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Ercp remove forgn body&endo,C7560,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, R&l hrt angio w/ffr & 3d map,C7562,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8212,,,,,,,fee schedule,5097,8212, R&l hrt angio w/ffr & 3d map,C7562,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8212, R&l hrt angio w/ffr & 3d map,C7562,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8212, Trluml ballo angiop all art,C7563,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,5097,8406, Trluml ballo angiop all art,C7563,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8406, Trluml ballo angiop all art,C7563,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8406, Vein mech throm w/intrvas us,C7564,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,5097,8406, Vein mech throm w/intrvas us,C7564,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,8406, Vein mech throm w/intrvas us,C7564,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,8406, Rpr aa hrn < 3 rdc w/ rmvl,C7565,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5097,5664, Rpr aa hrn < 3 rdc w/ rmvl,C7565,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Rpr aa hrn < 3 rdc w/ rmvl,C7565,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Fuse finger joints w/grafts,C7566,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Bronch/needle bx(s) w/ nav,C7567,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Cor angio w/flow resrv,C7568,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Ptca w/ ivus or oct,C7569,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Cor angio w/ffr & 3d map,C7570,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Pcta w/ cor lithotrip,C7571,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, 3d anat seg imaging preop,C8001,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,198.11,,,,,,,fee schedule,198.11,198.11, 3d anat seg imaging preop,C8001,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,198.11,,,,,,,fee schedule,198.11,198.11, Imp extar knee shck absrb,C8003,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,25393, Imp extar knee shck absrb,C8003,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,5363,25393, Imp extar knee shck absrb,C8003,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,5363,25393, "Mra w/cont, abd",C8900,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,859.16,,,,,,,fee schedule,859.16,859.16, "Mra w/cont, abd",C8900,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,859.16,,,,,,,fee schedule,859.16,859.16, "Mra w/o cont, abd",C8901,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,524.34,,,,,,,fee schedule,524.34,524.34, "Mra w/o cont, abd",C8901,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,524.34,,,,,,,fee schedule,524.34,524.34, "Mra w/o fol w/cont, abd",C8902,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,859.16,,,,,,,fee schedule,859.16,859.16, "Mra w/o fol w/cont, abd",C8902,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,859.16,,,,,,,fee schedule,859.16,859.16, "Mri w/cont, breast, uni",C8903,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,410,,,,,,,fee schedule,410,410, "Mri w/cont, breast, uni",C8903,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,410,,,,,,,fee schedule,410,410, "Mri w/o fol w/cont, brst, un",C8905,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,859.16,,,,,,,fee schedule,859.16,859.16, "Mri w/o fol w/cont, brst, un",C8905,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,859.16,,,,,,,fee schedule,859.16,859.16, "Mri w/cont, breast, bi",C8906,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,859.16,,,,,,,fee schedule,859.16,859.16, "Mri w/cont, breast, bi",C8906,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,859.16,,,,,,,fee schedule,859.16,859.16, "Mri w/o fol w/cont, breast,",C8908,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,859.16,,,,,,,fee schedule,859.16,859.16, "Mri w/o fol w/cont, breast,",C8908,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,859.16,,,,,,,fee schedule,859.16,859.16, "MRA w/cont, chest",C8909,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,859.16,,,,,,,fee schedule,859.16,859.16, "MRA w/cont, chest",C8909,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,859.16,,,,,,,fee schedule,859.16,859.16, "MRA w/o cont, chest",C8910,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,524.34,,,,,,,fee schedule,524.34,524.34, "MRA w/o cont, chest",C8910,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,524.34,,,,,,,fee schedule,524.34,524.34, "MRA w/o fol w/cont, chest",C8911,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,859.16,,,,,,,fee schedule,859.16,859.16, "MRA w/o fol w/cont, chest",C8911,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,859.16,,,,,,,fee schedule,859.16,859.16, "Mra w/cont, lwr ext",C8912,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,859.16,,,,,,,fee schedule,859.16,859.16, "Mra w/cont, lwr ext",C8912,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,859.16,,,,,,,fee schedule,859.16,859.16, "Mra w/o cont, lwr ext",C8913,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,524.34,,,,,,,fee schedule,524.34,524.34, "Mra w/o cont, lwr ext",C8913,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,524.34,,,,,,,fee schedule,524.34,524.34, "Mra w/o fol w/cont, lwr ext",C8914,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,859.16,,,,,,,fee schedule,859.16,859.16, "Mra w/o fol w/cont, lwr ext",C8914,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,859.16,,,,,,,fee schedule,859.16,859.16, "MRA w/cont, pelvis",C8918,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,859.16,,,,,,,fee schedule,859.16,859.16, "MRA w/cont, pelvis",C8918,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,859.16,,,,,,,fee schedule,859.16,859.16, "MRA w/o cont, pelvis",C8919,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,524.34,,,,,,,fee schedule,524.34,524.34, "MRA w/o cont, pelvis",C8919,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,524.34,,,,,,,fee schedule,524.34,524.34, "Mra w/o fol w/cont, pelvis",C8920,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,859.16,,,,,,,fee schedule,859.16,859.16, "Mra w/o fol w/cont, pelvis",C8920,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,859.16,,,,,,,fee schedule,859.16,859.16, "MRA, w/dye, spinal canal",C8931,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,859.16,,,,,,,fee schedule,859.16,859.16, "MRA, w/dye, spinal canal",C8931,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,859.16,,,,,,,fee schedule,859.16,859.16, "MRA, w/o dye, spinal canal",C8932,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,524.34,,,,,,,fee schedule,524.34,524.34, "MRA, w/o dye, spinal canal",C8932,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,524.34,,,,,,,fee schedule,524.34,524.34, "MRA, w/o&w/dye, spinal canal",C8933,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,859.16,,,,,,,fee schedule,859.16,859.16, "MRA, w/o&w/dye, spinal canal",C8933,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,859.16,,,,,,,fee schedule,859.16,859.16, "MRA, w/dye, upper extremity",C8934,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,859.16,,,,,,,fee schedule,859.16,859.16, "MRA, w/dye, upper extremity",C8934,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,859.16,,,,,,,fee schedule,859.16,859.16, "MRA, w/o dye, upper extr",C8935,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,524.34,,,,,,,fee schedule,524.34,524.34, "MRA, w/o dye, upper extr",C8935,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,524.34,,,,,,,fee schedule,524.34,524.34, "MRA, w/o&w/dye, upper extr",C8936,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,859.16,,,,,,,fee schedule,859.16,859.16, "MRA, w/o&w/dye, upper extr",C8936,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,859.16,,,,,,,fee schedule,859.16,859.16, Gallium ga-68 dotatoc,C9067,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.94,,,,,,,fee schedule,4.94,4.94, Gallium ga-68 dotatoc,C9067,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4.94,,,,,,,fee schedule,4.94,4.94, "Instill, bupivac and meloxic",C9088,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.99,,,,,,,fee schedule,0.99,0.99, "Instill, bupivac and meloxic",C9088,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.99,,,,,,,fee schedule,0.99,0.99, "Inj, oliceridine 0.1 mg",C9101,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.59,,,,,,,fee schedule,1.59,1.59, "Inj, oliceridine 0.1 mg",C9101,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.59,,,,,,,fee schedule,1.59,1.59, "Inj, bupivacaine (posimir)",C9144,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.62,,,,,,,fee schedule,0.62,0.62, "Inj, bupivacaine (posimir)",C9144,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.62,,,,,,,fee schedule,0.62,0.62, "Inj, aponvie, 1 mg",C9145,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2.34,,,,,,,fee schedule,2.34,2.34, "Inj, aponvie, 1 mg",C9145,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2.34,,,,,,,fee schedule,2.34,2.34, "Datopotamab deruxtecan, 1 mg",C9174,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,61.46,,,,,,,fee schedule,61.46,61.46, "Datopotamab deruxtecan, 1 mg",C9174,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,61.46,,,,,,,fee schedule,61.46,61.46, "Inj, treosulfan, 50 mg",C9175,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,38.33,,,,,,,fee schedule,38.33,38.33, "Inj, treosulfan, 50 mg",C9175,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,38.33,,,,,,,fee schedule,38.33,38.33, "Inj, clevidipine butyrate",C9248,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3.51,,,,,,,fee schedule,3.51,3.51, "Inj, clevidipine butyrate",C9248,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3.51,,,,,,,fee schedule,3.51,3.51, Artiss fibrin sealant,C9250,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,173.33,,,,,,,fee schedule,173.33,173.33, Artiss fibrin sealant,C9250,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,173.33,,,,,,,fee schedule,173.33,173.33, Bevacizumab injection,C9257,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2.23,,,,,,,fee schedule,2.23,2.23, Bevacizumab injection,C9257,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2.23,,,,,,,fee schedule,2.23,2.23, "Injection, cangrelor",C9460,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24.17,,,,,,,fee schedule,24.17,24.17, "Injection, cangrelor",C9460,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,24.17,,,,,,,fee schedule,24.17,24.17, Sotalol hydrochloride IV,C9482,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,30.56,,,,,,,fee schedule,30.56,30.56, Sotalol hydrochloride IV,C9482,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,30.56,,,,,,,fee schedule,30.56,30.56, Perc drug-el cor stent sing,C9600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8212,,,,,,,fee schedule,8212,25393, Perc drug-el cor stent sing,C9600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,8212,25393, Perc drug-el cor stent sing,C9600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,8212,25393, Perc drug-el cor stent bran,C9601,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Perc drug-el cor stent bran,C9601,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Perc drug-el cor stent bran,C9601,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Perc d-e cor stent ather s,C9602,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8212,,,,,,,fee schedule,8212,25393, Perc d-e cor stent ather s,C9602,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,8212,25393, Perc d-e cor stent ather s,C9602,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,8212,25393, Perc d-e cor stent ather br,C9603,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,2782, Perc d-e cor stent ather br,C9603,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,2782, Perc d-e cor revasc t cabg s,C9604,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8212,,,,,,,fee schedule,8212,25393, Perc d-e cor revasc t cabg s,C9604,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,8212,25393, Perc d-e cor revasc t cabg s,C9604,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,8212,25393, Perc d-e cor revasc t cabg b,C9605,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,2782, Perc d-e cor revasc t cabg b,C9605,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,2782, Perc d-e cor revasc w AMI s,C9606,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Perc d-e cor revasc w AMI s,C9606,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Perc d-e cor revasc w AMI s,C9606,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Perc d-e cor revasc chro sin,C9607,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8212,,,,,,,fee schedule,8212,25393, Perc d-e cor revasc chro sin,C9607,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,8212,25393, Perc d-e cor revasc chro sin,C9607,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,8212,25393, Perc d-e cor revasc chro add,C9608,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,2782, Perc d-e cor revasc chro add,C9608,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,2782, Place endorectal app,C9725,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4047,6979, Place endorectal app,C9725,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,4047,6979, Place endorectal app,C9725,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,4047,6979, Rxt breast appl place/remov,C9726,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,2782, Rxt breast appl place/remov,C9726,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,2782, Insert palate implants,C9727,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Insert palate implants,C9727,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Insert palate implants,C9727,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, "Place device/marker, non pro",C9728,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Non-ophthalmic FVA,C9733,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,859.16,,,,,,,fee schedule,859.16,859.16, Non-ophthalmic FVA,C9733,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,859.16,,,,,,,fee schedule,859.16,859.16, Blue light cysto imag agent,C9738,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Blue light cysto imag agent,C9738,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Blue light cysto imag agent,C9738,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Cystoscopy prostatic imp 1-3,C9739,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,10940, Cystoscopy prostatic imp 1-3,C9739,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,5363,10940, Cystoscopy prostatic imp 1-3,C9739,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,5363,10940, Cysto impl 4 or more,C9740,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,22111, Cysto impl 4 or more,C9740,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6044,22111, Cysto impl 4 or more,C9740,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6044,22111, "Microwave bronch, 3d, ebus",C9751,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,8406,12821, "Microwave bronch, 3d, ebus",C9751,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,8406,12821, "Microwave bronch, 3d, ebus",C9751,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,8406,12821, Fluorescence lymph map w/ICG,C9756,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Fluorescence lymph map w/ICG,C9756,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Fluorescence lymph map w/ICG,C9756,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Spine/lumbar disk surgery,C9757,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,22111, Spine/lumbar disk surgery,C9757,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6044,22111, Spine/lumbar disk surgery,C9757,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6044,22111, Interatrial shunt IDE,C9758,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,39251,,,,,,,fee schedule,35325,39251, Interatrial shunt IDE,C9758,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,35325,,,,,,,fee schedule,35325,39251, Transcath intraop microinf,C9759,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,2782, Transcath intraop microinf,C9759,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,2782, Non-blind interatrial shunt,C9760,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,46177, Non-blind interatrial shunt,C9760,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46177,,,,,,,fee schedule,6979,46177, Non-blind interatrial shunt,C9760,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,41559,,,,,,,fee schedule,6979,46177, "Cysto, litho, vacuum kidney",C9761,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,10940, "Cysto, litho, vacuum kidney",C9761,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,5363,10940, "Cysto, litho, vacuum kidney",C9761,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,5363,10940, Cardiac MRI seg dys strain,C9762,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.56,,,,,,,fee schedule,1083.56,1083.56, Cardiac MRI seg dys strain,C9762,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1083.56,,,,,,,fee schedule,1083.56,1083.56, Cardiac MRI seg dys stress,C9763,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.56,,,,,,,fee schedule,1083.56,1083.56, Cardiac MRI seg dys stress,C9763,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1083.56,,,,,,,fee schedule,1083.56,1083.56, Revasc intravasc lithotripsy,C9764,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,22111, Revasc intravasc lithotripsy,C9764,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5363,22111, Revasc intravasc lithotripsy,C9764,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5363,22111, Revasc intra lithotrip-stent,C9765,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,25393, Revasc intra lithotrip-stent,C9765,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,5363,25393, Revasc intra lithotrip-stent,C9765,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,5363,25393, Revasc intra lithotrip-ather,C9766,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,25393, Revasc intra lithotrip-ather,C9766,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,6044,25393, Revasc intra lithotrip-ather,C9766,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,6044,25393, Revasc lithotrip-stent-ather,C9767,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,25393, Revasc lithotrip-stent-ather,C9767,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,6044,25393, Revasc lithotrip-stent-ather,C9767,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,6044,25393, Endo us-guide hep porto grad,C9768,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,3195, Cysto w/temp pros implant,C9769,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,5248, Revasc lithotrip tibi/perone,C9772,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,25393, Revasc lithotrip tibi/perone,C9772,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,5363,25393, Revasc lithotrip tibi/perone,C9772,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,5363,25393, Revasc lithotr-stent tib/per,C9773,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,25393, Revasc lithotr-stent tib/per,C9773,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,5363,25393, Revasc lithotr-stent tib/per,C9773,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,5363,25393, Revasc lithotr-ather tib/per,C9774,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,25393, Revasc lithotr-ather tib/per,C9774,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,5363,25393, Revasc lithotr-ather tib/per,C9774,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,5363,25393, Revasc lith-sten-ath tib/per,C9775,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,25393, Revasc lith-sten-ath tib/per,C9775,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,5363,25393, Revasc lith-sten-ath tib/per,C9775,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,5363,25393, Esophag mucosal integ add-on,C9777,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,10940, Esophag mucosal integ add-on,C9777,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,3195,10940, Esophag mucosal integ add-on,C9777,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,3195,10940, "Colpopexy, min/inv, ex-perit",C9778,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,10940, "Colpopexy, min/inv, ex-perit",C9778,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,6044,10940, "Colpopexy, min/inv, ex-perit",C9778,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,6044,10940, ESD endoscopy or colonoscopy,C9779,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,10940, ESD endoscopy or colonoscopy,C9779,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,5248,10940, ESD endoscopy or colonoscopy,C9779,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,5248,10940, Insert cv cath inf & sup app,C9780,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,25393, Insert cv cath inf & sup app,C9780,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,5248,25393, Insert cv cath inf & sup app,C9780,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,5248,25393, Arthro/shoul surg; w/spacer,C9781,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,6044,22111, Arthro/shoul surg; w/spacer,C9781,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6044,22111, Arthro/shoul surg; w/spacer,C9781,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6044,22111, Blind myocar trpl bon marrow,C9782,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,39251, Blind myocar trpl bon marrow,C9782,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,39251,,,,,,,fee schedule,6979,39251, Blind myocar trpl bon marrow,C9782,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,35325,,,,,,,fee schedule,6979,39251, Blind cor sinus reducer impl,C9783,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,8406,25393, Blind cor sinus reducer impl,C9783,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,8406,25393, Blind cor sinus reducer impl,C9783,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,8406,25393, Endo sleeve gastro w/tube,C9784,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,22111, Endo sleeve gastro w/tube,C9784,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5248,22111, Endo sleeve gastro w/tube,C9784,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5248,22111, Endo outlet restrict w/tube,C9785,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,22111, Endo outlet restrict w/tube,C9785,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5248,22111, Endo outlet restrict w/tube,C9785,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5248,22111, Instill pharm renal pelvis,C9789,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,10940, Instill pharm renal pelvis,C9789,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,4108,10940, Instill pharm renal pelvis,C9789,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,4108,10940, Kidney histotripsy w/image,C9790,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5363,,,,,,,fee schedule,5363,5363, Mri hyperpolarized xenon129,C9791,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2813.63,,,,,,,fee schedule,2813.63,2813.63, Mri hyperpolarized xenon129,C9791,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2813.63,,,,,,,fee schedule,2813.63,2813.63, Blind/nonblind trans atrial,C9792,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,8406,,,,,,,fee schedule,8406,25393, Blind/nonblind trans atrial,C9792,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,8406,25393, Blind/nonblind trans atrial,C9792,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,8406,25393, Rpr intst excl anrect fist,C9796,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,10940, Rpr intst excl anrect fist,C9796,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10940,,,,,,,fee schedule,4108,10940, Rpr intst excl anrect fist,C9796,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9846,,,,,,,fee schedule,4108,10940, Vasc emb/occ w/prs cath,C9797,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,25393, Vasc emb/occ w/prs cath,C9797,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25393,,,,,,,fee schedule,5248,25393, Vasc emb/occ w/prs cath,C9797,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22854,,,,,,,fee schedule,5248,25393, Endo defect closure GI tract,C9901,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,22111, Endo defect closure GI tract,C9901,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5248,22111, Endo defect closure GI tract,C9901,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5248,22111, Indirect rest remov,D2956,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Indirect rest remov,D2956,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Excavate tooth non-restorabl,D2989,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Excavate tooth non-restorabl,D2989,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Apicoectomy - anterior,D3410,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Root surgery bicuspid,D3421,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Root surgery molar,D3425,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Bone graft peri per tooth,D3428,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Guided tissue regeneration,D3432,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Root amputation,D3450,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Surg rep root res anterior,D3471,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Surg rep root res anterior,D3471,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Surg rep root res premolar,D3472,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Surg rep root res premolar,D3472,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Surg rep root res molar,D3473,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Surg rep root res molar,D3473,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Surg exp root surf anterior,D3501,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Surg exp root surf anterior,D3501,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Surg exp root surf premolar,D3502,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Surg exp root surf premolar,D3502,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Surg exp root surf molar,D3503,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Surg exp root surf molar,D3503,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Isolation- tooth w rubb dam,D3910,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Tooth splitting,D3920,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, D?cor or submerg erupt tooth,D3921,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, D?cor or submerg erupt tooth,D3921,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Endodontic procedure,D3999,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Gingivectomy/plasty 4 or mor,D4210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Gingivectomy/plasty 1 to 3,D4211,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Gingivectomy/plasty rest,D4212,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Ana crown exp 4 or> per quad,D4230,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Ana crown exp 1-3 per quad,D4231,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Gingival flap proc w/ planin,D4240,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Gngvl flap w rootplan 1-3 th,D4241,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Apically positioned flap,D4245,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Crown lengthen hard tissue,D4249,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Osseous surgery 4 or more,D4260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Osseous surg 1 to 3 teeth,D4261,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Bone replce graft first site,D4263,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Guided tiss regen resorble,D4266,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Guided tiss regen nonresorb,D4267,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Surgical revision procedure,D4268,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Pedicle soft tissue graft pr,D4270,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Auto tissue graft 1st tooth,D4273,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Mesial/distal wedge proc,D4274,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Non-auto graft 1st tooth,D4275,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Con tissue w dble ped graft,D4276,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Soft tissue graft firsttooth,D4277,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Remove non-resorb barrier,D4286,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Remove non-resorb barrier,D4286,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, "Peri medicament w/seal, max",D5995,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, "Peri medicament w/seal, max",D5995,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, "Peri medicament w/seal, mand",D5996,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, "Peri medicament w/seal, mand",D5996,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Odontics endosteal implant,D6010,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Second stage implant surgery,D6011,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Endosteal implant,D6012,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Surgical place mini implant,D6013,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Odontics eposteal implant,D6040,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Odontics transosteal implnt,D6050,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Interim abutment,D6051,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Access/retorq implant screw,D6089,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Access/retorq implant screw,D6089,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Bone graft repair perimplant,D6103,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Bone graft time of implant,D6104,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Remove implant body,D6105,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Remove implant body,D6105,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Tissue regen resorbable,D6106,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Tissue regen resorbable,D6106,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Tissue regen non-resorbable,D6107,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Tissue regen non-resorbable,D6107,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Semi precision abutment,D6191,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Semi precision abutment,D6191,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Semi precision attachment,D6192,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Semi precision attachment,D6192,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Replace implnt screw,D6193,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Replace implnt screw,D6193,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Replace material prosthesis,D6197,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Replace material prosthesis,D6197,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Remove interim implant,D6198,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Remove interim implant,D6198,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Extraction coronal remnants,D7111,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Extraction erupted tooth/exr,D7140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Rem imp tooth w mucoper flp,D7210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Impact tooth remov soft tiss,D7220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Impact tooth remov part bony,D7230,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Impact tooth remov comp bony,D7240,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Impact tooth rem bony w/comp,D7241,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Tooth root removal,D7250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Coronectomy,D7251,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Part extract for implant,D7252,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Part extract for implant,D7252,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Nerve dissection,D7259,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Nerve dissection,D7259,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Oral antral fistula closure,D7260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Primary closure sinus perf,D7261,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Tooth reimplantation,D7270,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Tooth transplantation,D7272,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Exposure of unerupted tooth,D7280,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Mobilize erupted/malpos toot,D7282,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Place device impacted tooth,D7283,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Exc biopsy of saliv glands,D7284,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Exc biopsy of saliv glands,D7284,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Biopsy of oral tissue hard,D7285,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Biopsy of oral tissue soft,D7286,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Exfoliative cytolog collect,D7287,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Brush biopsy,D7288,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Repositioning of teeth,D7290,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Transseptal fiberotomy,D7291,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Screw retained plate,D7292,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Temp anchorage dev w flap,D7293,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Temp anchorage dev w/o flap,D7294,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, "Bone harvest,auto graft proc",D7295,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Remove screw retained plate,D7298,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Remove screw retained plate,D7298,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Rem anchorage device w/flap,D7299,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Rem anchorage device w/flap,D7299,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Rem anchorage dev w/o flap,D7300,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Rem anchorage dev w/o flap,D7300,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Alveoplasty w/ extraction,D7310,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Alveoloplasty w/extract 1-3,D7311,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Alveoplasty w/o extraction,D7320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Alveoloplasty not w/extracts,D7321,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Vestibuloplasty ridge extens,D7340,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Vestibuloplasty exten graft,D7350,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Rad exc lesion up to 1.25 cm,D7410,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Excision benign lesion>1.25c,D7411,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Excision benign lesion compl,D7412,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Excision malig lesion<=1.25c,D7413,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Excision malig lesion>1.25cm,D7414,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Excision malig les complicat,D7415,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Malig tumor exc to 1.25 cm,D7440,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Malig tumor > 1.25 cm,D7441,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Rem odontogen cyst to 1.25cm,D7450,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Rem odontogen cyst > 1.25 cm,D7451,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Rem nonodonto cyst to 1.25cm,D7460,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Rem nonodonto cyst > 1.25 cm,D7461,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Lesion destruction,D7465,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Rem exostosis any site,D7471,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Removal of torus palatinus,D7472,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Remove torus mandibularis,D7473,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Surg reduct osseoustuberosit,D7485,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Maxilla or mandible resectio,D7490,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Marsupialization odon cyst,D7509,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Marsupialization odon cyst,D7509,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, I&d absc intraoral soft tiss,D7510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Incision/drain abscess intra,D7511,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, I&d abscess extraoral,D7520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Incision/drain abscess extra,D7521,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Removal fb skin/areolar tiss,D7530,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Removal of fb reaction,D7540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Removal of sloughed off bone,D7550,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Maxillary sinusotomy,D7560,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Maxilla open reduct simple,D7610,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Open red simpl mandible fx,D7630,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Open red simp malar/zygom fx,D7650,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Alveolus open reduction,D7671,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Reduct simple facial bone fx,D7680,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Maxilla open reduct compound,D7710,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Open reduct compd mandble fx,D7730,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Open red comp malar/zygma fx,D7750,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Open reduc compd alveolus fx,D7770,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Reduct compnd facial bone fx,D7780,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Tmj open reduct-dislocation,D7810,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Tmj manipulation under anest,D7830,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Removal of tmj condyle,D7840,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Tmj meniscectomy,D7850,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Tmj repair of joint disc,D7852,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Tmj excisn of joint membrane,D7854,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Tmj cutting of a muscle,D7856,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Tmj reconstruction,D7858,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Tmj cutting into joint,D7860,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Tmj reshaping components,D7865,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Tmj aspiration joint fluid,D7870,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Lysis + lavage w catheters,D7871,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Tmj diagnostic arthroscopy,D7872,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Tmj arthroscopy lysis adhesn,D7873,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Tmj arthroscopy disc reposit,D7874,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Tmj arthroscopy synovectomy,D7875,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Tmj arthroscopy discectomy,D7876,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Tmj arthroscopy debridement,D7877,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Dent sutur recent wnd to 5cm,D7910,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Dental suture wound to 5 cm,D7911,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Suture complicate wnd > 5 cm,D7912,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Dental skin graft,D7920,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Collect & appl blood product,D7921,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Indexing for osteotomy,D7939,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Indexing for osteotomy,D7939,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Reshaping bone orthognathic,D7940,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Bone cutting ramus closed,D7941,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Cutting ramus open w/graft,D7943,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Bone cutting segmented,D7944,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Bone cutting body mandible,D7945,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Reconstruction maxilla total,D7946,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Reconstruct maxilla segment,D7947,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Reconstruct midface no graft,D7948,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Reconstruct midface w/graft,D7949,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Mandible graft,D7950,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Sinus aug w bone or bone sub,D7951,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Sinus augmentation vertical,D7952,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Bone replacement graft,D7953,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Repair maxillofacial defects,D7955,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Tiss regen edent resorb,D7956,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Tiss regen edent resorb,D7956,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Tiss regen edent nonresorb,D7957,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Tiss regen edent nonresorb,D7957,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Buccal/labial frenectomy,D7961,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Buccal/labial frenectomy,D7961,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Lingual frenectomy,D7962,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Lingual frenectomy,D7962,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Frenuloplasty,D7963,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Excision hyperplastic tissue,D7970,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Excision pericoronal gingiva,D7971,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Surg redct fibrous tuberosit,D7972,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Sialolithotomy,D7980,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Excision of salivary gland,D7981,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Sialodochoplasty,D7982,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Closure of salivary fistula,D7983,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Emergency tracheotomy,D7990,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Dental coronoidectomy,D7991,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Surg place craniofacial impl,D7993,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Surg place craniofacial impl,D7993,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Surg place zygomatic impl,D7994,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Surg place zygomatic impl,D7994,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Synthetic graft facial bones,D7995,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Implant mandible for augment,D7996,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Appliance removal,D7997,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Intraoral place of fix dev,D7998,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Oral surgery procedure,D7999,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Repair sleep apnea appliance,D9949,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Repair sleep apnea appliance,D9949,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, "Hiv prep counsel, md 15-30m",G0011,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,119.52,,,,,,,fee schedule,119.52,119.52, Injection of hiv prep drug,G0012,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,81.59,,,,,,,fee schedule,81.59,81.59, "Hiv prep counsel, clin staff",G0013,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,42.03,,,,,,,fee schedule,42.03,42.03, Crisis psychotherapy 60m,G0017,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,929.57,,,,,,,fee schedule,929.57,929.57, Crisis psychotherapy add 30m,G0018,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,449.81,,,,,,,fee schedule,449.81,449.81, Comm hlth intg svs sdoh 60mn,G0019,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,242.28,,,,,,,fee schedule,242.28,242.28, Comm hlth intg svs add 30 m,G0022,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,169,,,,,,,fee schedule,169,169, Pin service 60m per month,G0023,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,244.01,,,,,,,fee schedule,244.01,244.01, Pin srv add 30 min pr m,G0024,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,170.73,,,,,,,fee schedule,170.73,170.73, Semen analysis,G0027,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,27.12,,,,,,,fee schedule,9.75,27.12, Semen analysis,G0027,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.75,,,,,,,fee schedule,9.75,27.12, Semen analysis,G0027,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9.75,,,,,,,fee schedule,9.75,27.12, Care manag h vst new pt 20 m,G0076,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,266.94,,,,,,,fee schedule,266.94,266.94, Care manag h vst new pt 30 m,G0077,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,403.19,,,,,,,fee schedule,403.19,403.19, Care manag h vst new pt 45 m,G0078,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,652.16,,,,,,,fee schedule,652.16,652.16, Care manag h vst new pt 60 m,G0079,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,886.83,,,,,,,fee schedule,886.83,886.83, Care manag h vst new pt 75 m,G0080,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1177.03,,,,,,,fee schedule,1177.03,1177.03, Care man h v ext pt 20 mi,G0081,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,266.89,,,,,,,fee schedule,266.89,266.89, Care man h v ext pt 30 m,G0082,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,436.27,,,,,,,fee schedule,436.27,436.27, Care man h v ext pt 45 m,G0083,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,697.59,,,,,,,fee schedule,697.59,697.59, Care man h v ext pt 60 m,G0084,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,990.44,,,,,,,fee schedule,990.44,990.44, Care man h v ext pt 75 m,G0085,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1177.03,,,,,,,fee schedule,1177.03,1177.03, Care man home care plan 30 m,G0086,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,400.55,,,,,,,fee schedule,400.55,400.55, Care man home care plan 60 m,G0087,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,560.48,,,,,,,fee schedule,560.48,560.48, CA screen;pelvic/breast exam,G0101,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,137.87,,,,,,,fee schedule,137.87,137.87, Prostate ca screening; dre,G0102,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,42.03,,,,,,,fee schedule,42.03,42.03, PSA Screening,G0103,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,80.56,,,,,,,fee schedule,28.97,80.56, PSA Screening,G0103,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,28.97,,,,,,,fee schedule,28.97,80.56, PSA Screening,G0103,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,28.97,,,,,,,fee schedule,28.97,80.56, CA screen;flexi sigmoidscope,G0104,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,293,,,,,,,fee schedule,293,4497, CA screen;flexi sigmoidscope,G0104,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,293,4497, CA screen;flexi sigmoidscope,G0104,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,293,4497, CA screen;flexi sigmoidscope,G0104,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,293,4497, Colorectal scrn; hi risk ind,G0105,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,456.18,,,,,,,fee schedule,456.18,4497, Colorectal scrn; hi risk ind,G0105,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,915.11,,,,,,,fee schedule,456.18,4497, Colorectal scrn; hi risk ind,G0105,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,456.18,4497, Colorectal scrn; hi risk ind,G0105,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,456.18,4497, Colorectal scrn; hi risk ind,G0105,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,456.18,4497, Colon CA screen;barium enema,G0106,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Diab manage trn per indiv,G0108,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,298.83,,,,,,,fee schedule,298.83,298.83, Diab manage trn ind/group,G0109,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,85.69,,,,,,,fee schedule,85.69,85.69, Glaucoma scrn hgh risk direc,G0117,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,338.01,,,,,,,fee schedule,338.01,338.01, Glaucoma scrn hgh risk direc,G0118,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,210.82,,,,,,,fee schedule,210.82,210.82, Colon ca scrn; barium enema,G0120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Colon ca scrn not hi rsk ind,G0121,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,458.88,,,,,,,fee schedule,458.88,4497, Colon ca scrn not hi rsk ind,G0121,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,917.81,,,,,,,fee schedule,458.88,4497, Colon ca scrn not hi rsk ind,G0121,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,458.88,4497, Colon ca scrn not hi rsk ind,G0121,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,458.88,4497, Colon ca scrn not hi rsk ind,G0121,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,458.88,4497, Screen cerv/vag thin layer,G0123,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,84.52,,,,,,,fee schedule,30.39,84.52, Screen cerv/vag thin layer,G0123,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,30.39,,,,,,,fee schedule,30.39,84.52, Screen cerv/vag thin layer,G0123,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,30.39,,,,,,,fee schedule,30.39,84.52, Screen c/v thin layer by MD,G0124,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,127.02,,,,,,,fee schedule,39.53,127.02, Screen c/v thin layer by MD,G0124,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,39.53,,,,,,,fee schedule,39.53,127.02, Screen c/v thin layer by MD,G0124,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,39.53,,,,,,,fee schedule,39.53,127.02, Trim nail(s),G0127,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,36.8,,,,,,,fee schedule,36.8,2782, Trim nail(s),G0127,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,36.8,2782, Trim nail(s),G0127,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,36.8,2782, CORF skilled nursing service,G0128,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,57.85,,,,,,,fee schedule,57.85,57.85, Single energy x-ray study,G0130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,149.15,,,,,,,fee schedule,149.15,252.18, Single energy x-ray study,G0130,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.18,,,,,,,fee schedule,149.15,252.18, Single energy x-ray study,G0130,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.18,,,,,,,fee schedule,149.15,252.18, Adm of soc dtr assess 5-15 m,G0136,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,43.76,,,,,,,fee schedule,43.76,43.76, Iv cipaglucosidase alfa-atga,G0138,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1019.74,,,,,,,fee schedule,1019.74,1019.74, Nav srv peer sup 60 min pr m,G0140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,244.01,,,,,,,fee schedule,244.01,244.01, "Scr c/v cyto,autosys and md",G0141,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,127.02,,,,,,,fee schedule,39.53,127.02, "Scr c/v cyto,autosys and md",G0141,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,39.53,,,,,,,fee schedule,39.53,127.02, "Scr c/v cyto,autosys and md",G0141,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,39.53,,,,,,,fee schedule,39.53,127.02, "Scr c/v cyto,thinlayer,rescr",G0143,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,112.85,,,,,,,fee schedule,40.58,112.85, "Scr c/v cyto,thinlayer,rescr",G0143,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,40.58,,,,,,,fee schedule,40.58,112.85, "Scr c/v cyto,thinlayer,rescr",G0143,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,40.58,,,,,,,fee schedule,40.58,112.85, "Scr c/v cyto,thinlayer,rescr",G0144,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,183.44,,,,,,,fee schedule,65.96,183.44, "Scr c/v cyto,thinlayer,rescr",G0144,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,65.96,,,,,,,fee schedule,65.96,183.44, "Scr c/v cyto,thinlayer,rescr",G0144,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,65.96,,,,,,,fee schedule,65.96,183.44, "Scr c/v cyto,thinlayer,rescr",G0145,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,110.52,,,,,,,fee schedule,39.74,110.52, "Scr c/v cyto,thinlayer,rescr",G0145,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,39.74,,,,,,,fee schedule,39.74,110.52, "Scr c/v cyto,thinlayer,rescr",G0145,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,39.74,,,,,,,fee schedule,39.74,110.52, Nav srv peer sup add 30 pr m,G0146,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,166.3,,,,,,,fee schedule,166.3,166.3, "Scr c/v cyto, automated sys",G0147,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,77.35,,,,,,,fee schedule,22.68,77.35, "Scr c/v cyto, automated sys",G0147,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22.68,,,,,,,fee schedule,22.68,77.35, "Scr c/v cyto, automated sys",G0147,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22.68,,,,,,,fee schedule,22.68,77.35, "Scr c/v cyto, autosys, rescr",G0148,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,133.25,,,,,,,fee schedule,47.91,133.25, "Scr c/v cyto, autosys, rescr",G0148,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,47.91,,,,,,,fee schedule,47.91,133.25, "Scr c/v cyto, autosys, rescr",G0148,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,47.91,,,,,,,fee schedule,47.91,133.25, "Extrnl counterpulse, per tx",G0166,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,534.64,,,,,,,fee schedule,534.64,534.64, Wound closure by adhesive,G0168,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,81.64,,,,,,,fee schedule,81.64,2782, Wound closure by adhesive,G0168,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,81.64,2782, Wound closure by adhesive,G0168,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,81.64,2782, MD recertification HHA PT,G0179,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,235.59,,,,,,,fee schedule,235.59,235.59, MD certification HHA patient,G0180,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,302.99,,,,,,,fee schedule,302.99,302.99, Home health care supervision,G0181,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,592.43,,,,,,,fee schedule,592.43,592.43, Hospice care supervision,G0182,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,585.52,,,,,,,fee schedule,585.52,585.52, "Dstry eye lesn,fdr vssl tech",G0186,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,4497, "Dstry eye lesn,fdr vssl tech",G0186,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,3195,4497, "Dstry eye lesn,fdr vssl tech",G0186,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,3195,4497, PET not otherwise specified,G0235,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,848.52,,,,,,,fee schedule,848.52,848.52, PET not otherwise specified,G0235,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,848.52,,,,,,,fee schedule,848.52,848.52, Therapeutic procd strg endur,G0237,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,66.48,,,,,,,fee schedule,66.48,66.48, "Oth resp proc, indiv",G0238,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,59.57,,,,,,,fee schedule,59.57,59.57, "Oth resp proc, group",G0239,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,75.06,,,,,,,fee schedule,75.06,75.06, Initial foot exam pt lops,G0245,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,189.94,,,,,,,fee schedule,189.94,189.94, Followup eval of foot pt lop,G0246,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,95.08,,,,,,,fee schedule,95.08,95.08, Routine footcare pt w lops,G0247,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,104.09,,,,,,,fee schedule,104.09,104.09, Demonstrate use home inr mon,G0248,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,549.42,,,,,,,fee schedule,549.42,549.42, Provide INR test mater/equip,G0249,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,340.43,,,,,,,fee schedule,340.43,340.43, MD INR test revie inter mgmt,G0250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,48.94,,,,,,,fee schedule,48.94,48.94, Inject for sacroiliac joint,G0259,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, Inject for sacroiliac joint,G0259,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, Inject for sacroiliac joint,G0259,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, Inj for sacroiliac jt anesth,G0260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,4497, Inj for sacroiliac jt anesth,G0260,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4497,,,,,,,fee schedule,3195,4497, Inj for sacroiliac jt anesth,G0260,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4047,,,,,,,fee schedule,3195,4497, Removal of impacted wax md,G0268,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,153.84,,,,,,,fee schedule,153.84,2782, Removal of impacted wax md,G0268,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,153.84,2782, Removal of impacted wax md,G0268,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,153.84,2782, Occlusive device in vein art,G0269,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,2782, Occlusive device in vein art,G0269,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,2782, MNT subs tx for change dx,G0270,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,118.28,,,,,,,fee schedule,118.28,118.28, Group MNT 2 or more 30 mins,G0271,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,66.69,,,,,,,fee schedule,66.69,66.69, Pild/placebo control clin tr,G0276,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1976.93,,,,,,,fee schedule,1976.93,22111, Pild/placebo control clin tr,G0276,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1976.93,22111, Pild/placebo control clin tr,G0276,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,1976.93,22111, Pild/placebo control clin tr,G0276,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,1976.93,22111, "Hbot, full body chamber, 30m",G0277,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1003.28,,,,,,,fee schedule,1003.28,1003.28, "Iliac art angio,cardiac cath",G0278,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,68.1,,,,,,,fee schedule,68.1,68.1, "Tomosynthesis, mammo",G0279,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,65.45,,,,,,,fee schedule,56.84,65.45, "Tomosynthesis, mammo",G0279,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56.84,,,,,,,fee schedule,56.84,65.45, "Tomosynthesis, mammo",G0279,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,56.84,,,,,,,fee schedule,56.84,65.45, Elec stim unattend for press,G0281,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,62.7,,,,,,,fee schedule,62.7,62.7, Elec stim other than wound,G0283,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,67.88,,,,,,,fee schedule,67.88,67.88, "Recon, CTA for surg plan",G0288,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,244.65,,,,,,,fee schedule,244.65,244.65, "Arthro, loose body + chondro",G0289,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,415.6,,,,,,,fee schedule,415.6,2782, "Arthro, loose body + chondro",G0289,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,415.6,2782, "Arthro, loose body + chondro",G0289,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,415.6,2782, Visit to determ ldct elig,G0296,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,122.54,,,,,,,fee schedule,122.54,122.54, CBC/diffwbc w/o platelet,G0306,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,32.42,,,,,,,fee schedule,11.66,32.42, CBC/diffwbc w/o platelet,G0306,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.66,,,,,,,fee schedule,11.66,32.42, CBC/diffwbc w/o platelet,G0306,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11.66,,,,,,,fee schedule,11.66,32.42, CBC without platelet,G0307,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,26.99,,,,,,,fee schedule,9.71,26.99, CBC without platelet,G0307,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.71,,,,,,,fee schedule,9.71,26.99, CBC without platelet,G0307,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9.71,,,,,,,fee schedule,9.71,26.99, Prolong inpt eval add15 m,G0316,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,152.76,,,,,,,fee schedule,152.76,152.76, Prolong nursin fac eval 15m,G0317,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,148.34,,,,,,,fee schedule,148.34,148.34, Prolong home eval add 15m,G0318,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,151.03,,,,,,,fee schedule,151.03,151.03, Care manage beh svs 20mins,G0323,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,206.02,,,,,,,fee schedule,206.02,206.02, Fecal blood scrn immunoassay,G0328,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,75.3,,,,,,,fee schedule,27.08,75.3, Fecal blood scrn immunoassay,G0328,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,27.08,,,,,,,fee schedule,27.08,75.3, Fecal blood scrn immunoassay,G0328,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,27.08,,,,,,,fee schedule,27.08,75.3, Electromagntic tx for ulcers,G0329,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,56.6,,,,,,,fee schedule,56.6,56.6, Facility svs dental rehab,G0330,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Facility svs dental rehab,G0330,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, "Robot lin-radsurg com, first",G0339,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14456,,,,,,,fee schedule,13011,14456, "Robot lin-radsurg com, first",G0339,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13011,,,,,,,fee schedule,13011,14456, Robt lin-radsurg fractx 2-5,G0340,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,11539,12821, Robt lin-radsurg fractx 2-5,G0340,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,11539,12821, Percutaneous islet celltrans,G0341,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1606.28,,,,,,,fee schedule,1606.28,6979, Percutaneous islet celltrans,G0341,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,1606.28,6979, Laparoscopy islet cell trans,G0342,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4103.98,,,,,,,fee schedule,4103.98,6979, Laparoscopy islet cell trans,G0342,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,4103.98,6979, Laparotomy islet cell transp,G0343,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6671.02,,,,,,,fee schedule,6671.02,6979, Laparotomy islet cell transp,G0343,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6671.02,6979, Md service required for pmd,G0372,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,41.98,,,,,,,fee schedule,41.98,41.98, Alcohol/subs interv 15-30mn,G0396,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,160.96,,,,,,,fee schedule,160.96,160.96, Alcohol/subs interv >30 min,G0397,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,301.53,,,,,,,fee schedule,301.53,301.53, Initial preventive exam,G0402,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,626.64,,,,,,,fee schedule,626.64,626.64, EKG for initial prevent exam,G0403,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,82.56,,,,,,,fee schedule,82.56,82.56, EKG tracing for initial prev,G0404,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,37.18,,,,,,,fee schedule,37.18,37.18, EKG interpret & report preve,G0405,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,45.43,,,,,,,fee schedule,45.43,45.43, Inpt/tele follow up 15,G0406,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,199.98,,,,,,,fee schedule,199.98,199.98, Inpt/tele follow up 25,G0407,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,351.93,,,,,,,fee schedule,351.93,351.93, Inpt/tele follow up 35,G0408,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,516.07,,,,,,,fee schedule,516.07,516.07, CORF related serv 15 mins ea,G0409,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,125.03,,,,,,,fee schedule,125.03,125.03, Open tx iliac spine uni/bil,G0412,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3745.96,,,,,,,fee schedule,3745.96,22111, Open tx iliac spine uni/bil,G0412,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,3745.96,22111, Open tx iliac spine uni/bil,G0412,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,3745.96,22111, Open tx iliac spine uni/bil,G0412,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,3745.96,22111, Pelvic ring fracture uni/bil,G0413,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5488,,,,,,,fee schedule,5488,12821, Pelvic ring fracture uni/bil,G0413,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6044,,,,,,,fee schedule,5488,12821, Pelvic ring fracture uni/bil,G0413,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,5488,12821, Pelvic ring fracture uni/bil,G0413,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,5488,12821, Pelvic ring fx treat int fix,G0414,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5180.54,,,,,,,fee schedule,5180.54,22111, Pelvic ring fx treat int fix,G0414,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5180.54,22111, Pelvic ring fx treat int fix,G0414,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,5180.54,22111, Pelvic ring fx treat int fix,G0414,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,5180.54,22111, Open tx post pelvic fxcture,G0415,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6990.95,,,,,,,fee schedule,6979,22111, Open tx post pelvic fxcture,G0415,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,22111, Open tx post pelvic fxcture,G0415,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22111,,,,,,,fee schedule,6979,22111, Open tx post pelvic fxcture,G0415,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19899,,,,,,,fee schedule,6979,22111, "Prostate biopsy, any mthd",G0416,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,981.86,,,,,,,fee schedule,425.12,981.86, "Prostate biopsy, any mthd",G0416,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,425.12,,,,,,,fee schedule,425.12,981.86, "Prostate biopsy, any mthd",G0416,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,425.12,,,,,,,fee schedule,425.12,981.86, Ed svc CKD ind per session,G0420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,615.47,,,,,,,fee schedule,615.47,615.47, Ed svc CKD grp per session,G0421,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,148.23,,,,,,,fee schedule,148.23,148.23, Intens cardiac rehab w/exerc,G0422,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,706.93,,,,,,,fee schedule,706.93,706.93, Intens cardiac rehab no exer,G0423,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,706.93,,,,,,,fee schedule,706.93,706.93, Inpt/ed teleconsult30,G0425,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,468.16,,,,,,,fee schedule,468.16,468.16, Inpt/ed teleconsult50,G0426,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,648.17,,,,,,,fee schedule,648.17,648.17, Inpt/ed teleconsult70,G0427,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,926.6,,,,,,,fee schedule,926.6,926.6, Collagen Meniscus Implant,G0428,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,5097,6979, Collagen Meniscus Implant,G0428,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,6979, Collagen Meniscus Implant,G0428,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,6979, Dermal filler injection(s),G0429,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,311.46,,,,,,,fee schedule,311.46,6979, Dermal filler injection(s),G0429,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,311.46,6979, EIA HIV-1/HIV-2 screen,G0432,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,81.65,,,,,,,fee schedule,29.36,81.65, EIA HIV-1/HIV-2 screen,G0432,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,29.36,,,,,,,fee schedule,29.36,81.65, EIA HIV-1/HIV-2 screen,G0432,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,29.36,,,,,,,fee schedule,29.36,81.65, ELISA HIV-1/HIV-2 screen,G0433,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,76.31,,,,,,,fee schedule,27.44,76.31, ELISA HIV-1/HIV-2 screen,G0433,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,27.44,,,,,,,fee schedule,27.44,76.31, ELISA HIV-1/HIV-2 screen,G0433,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,27.44,,,,,,,fee schedule,27.44,76.31, Oral hiv-1/hiv-2 screen,G0435,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,49.98,,,,,,,fee schedule,17.97,49.98, Oral hiv-1/hiv-2 screen,G0435,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.97,,,,,,,fee schedule,17.97,49.98, Oral hiv-1/hiv-2 screen,G0435,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,17.97,,,,,,,fee schedule,17.97,49.98, "PPPS, initial visit",G0438,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,936.8,,,,,,,fee schedule,936.8,936.8, "PPPS, subseq visit",G0439,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,737.9,,,,,,,fee schedule,737.9,737.9, Annual alcohol screen 15 min,G0442,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,43.76,,,,,,,fee schedule,43.76,43.76, Brief alcohol misuse counsel,G0443,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,144.83,,,,,,,fee schedule,144.83,144.83, Depression Screen annual,G0444,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,43.76,,,,,,,fee schedule,43.76,43.76, High inten beh couns STD 30m,G0445,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,146.56,,,,,,,fee schedule,146.56,146.56, Intens behave ther cardio dx,G0446,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,144.83,,,,,,,fee schedule,144.83,144.83, Behavior counsel obesity 15m,G0447,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,144.83,,,,,,,fee schedule,144.83,144.83, Place perm pacing cardiovert,G0448,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5097,5664, Place perm pacing cardiovert,G0448,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5664,,,,,,,fee schedule,5097,5664, Place perm pacing cardiovert,G0448,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5097,,,,,,,fee schedule,5097,5664, Devlopment test interpt&rep,G0451,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,64.75,,,,,,,fee schedule,64.75,64.75, Molecular pathology interpr,G0452,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,16.51,,,,,,,fee schedule,4.38,16.51, Molecular pathology interpr,G0452,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.38,,,,,,,fee schedule,4.38,16.51, Molecular pathology interpr,G0452,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4.38,,,,,,,fee schedule,4.38,16.51, Cont intraop neuro monitor,G0453,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,150.98,,,,,,,fee schedule,150.98,2782, Cont intraop neuro monitor,G0453,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,150.98,2782, Cont intraop neuro monitor,G0453,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,150.98,2782, MD document visit by NPP,G0454,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,42.03,,,,,,,fee schedule,42.03,42.03, Fecal microbiota prep instil,G0455,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,341.24,,,,,,,fee schedule,341.24,3195, Fecal microbiota prep instil,G0455,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,341.24,3195, Telehealth inpt pharm mgmt,G0459,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,218.48,,,,,,,fee schedule,218.48,218.48, Autolog prp diab wound ulcer,G0465,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,461.36,,,,,,,fee schedule,461.36,461.36, Ven blood coll snf/hha,G0471,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,47.31,,,,,,,fee schedule,47.31,47.31, Hep c screen high risk/other,G0472,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,193.37,,,,,,,fee schedule,69.53,193.37, Hep c screen high risk/other,G0472,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,69.53,,,,,,,fee schedule,69.53,193.37, Hep c screen high risk/other,G0472,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,69.53,,,,,,,fee schedule,69.53,193.37, Group behave couns 2-10,G0473,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,54.5,,,,,,,fee schedule,54.5,54.5, Hiv combination assay,G0475,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,100.46,,,,,,,fee schedule,36.12,100.46, Hiv combination assay,G0475,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,36.12,,,,,,,fee schedule,36.12,100.46, Hiv combination assay,G0475,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,36.12,,,,,,,fee schedule,36.12,100.46, Hpv combo assay ca screen,G0476,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,146.4,,,,,,,fee schedule,52.64,146.4, Hpv combo assay ca screen,G0476,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,52.64,,,,,,,fee schedule,52.64,146.4, Hpv combo assay ca screen,G0476,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,52.64,,,,,,,fee schedule,52.64,146.4, Drug test def 1-7 classes,G0480,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,477.4,,,,,,,fee schedule,171.65,477.4, Drug test def 1-7 classes,G0480,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,171.65,,,,,,,fee schedule,171.65,477.4, Drug test def 1-7 classes,G0480,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,171.65,,,,,,,fee schedule,171.65,477.4, Drug test def 8-14 classes,G0481,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,653.29,,,,,,,fee schedule,234.89,653.29, Drug test def 8-14 classes,G0481,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,234.89,,,,,,,fee schedule,234.89,653.29, Drug test def 8-14 classes,G0481,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,234.89,,,,,,,fee schedule,234.89,653.29, Drug test def 15-21 classes,G0482,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,829.14,,,,,,,fee schedule,298.11,829.14, Drug test def 15-21 classes,G0482,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,298.11,,,,,,,fee schedule,298.11,829.14, Drug test def 15-21 classes,G0482,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,298.11,,,,,,,fee schedule,298.11,829.14, Drug test def 22+ classes,G0483,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1030.15,,,,,,,fee schedule,370.38,1030.15, Drug test def 22+ classes,G0483,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,370.38,,,,,,,fee schedule,370.38,1030.15, Drug test def 22+ classes,G0483,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,370.38,,,,,,,fee schedule,370.38,1030.15, Hepb screen high risk indiv,G0499,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,117.94,,,,,,,fee schedule,42.41,117.94, Hepb screen high risk indiv,G0499,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,42.41,,,,,,,fee schedule,42.41,117.94, Hepb screen high risk indiv,G0499,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,42.41,,,,,,,fee schedule,42.41,117.94, Mod sedat endo service >5yrs,G0500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,31.3,,,,,,,fee schedule,31.3,31.3, Comp asses care plan ccm svc,G0506,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,210.98,,,,,,,fee schedule,210.98,210.98, Crit care telehea consult 60,G0508,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1020.06,,,,,,,fee schedule,1020.06,1020.06, Crit care telehea consult 50,G0509,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,975.87,,,,,,,fee schedule,975.87,975.87, "Prolong prev svcs, first 30m",G0513,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,278.06,,,,,,,fee schedule,278.06,278.06, "Prolong prev svcs, addl 30m",G0514,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,278.06,,,,,,,fee schedule,278.06,278.06, "Insert drug del implant, >4",G0516,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,466.48,,,,,,,fee schedule,466.48,3195, "Insert drug del implant, >4",G0516,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,466.48,3195, "Insert drug del implant, >4",G0516,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,466.48,3195, "Insert drug del implant, >4",G0516,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,466.48,3195, Remove drug implant,G0517,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,535.39,,,,,,,fee schedule,535.39,3195, Remove drug implant,G0517,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,535.39,3195, Remove drug implant,G0517,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,535.39,3195, Remove drug implant,G0517,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,535.39,3195, Remove w insert drug implant,G0518,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,871.02,,,,,,,fee schedule,871.02,3195, Remove w insert drug implant,G0518,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,871.02,3195, Remove w insert drug implant,G0518,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,871.02,3195, Remove w insert drug implant,G0518,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,871.02,3195, Risk ascvd tst once pr 12 mo,G0537,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,43.76,,,,,,,fee schedule,43.76,43.76, Ascvd rsk mng clin stf pr mo,G0538,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,43.76,,,,,,,fee schedule,43.76,43.76, Initial care training 30 m,G0539,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,213.95,,,,,,,fee schedule,213.95,213.95, Train for caregiver add 15,G0540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,112.83,,,,,,,fee schedule,112.83,112.83, No pt prsnt train initial 30,G0541,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,213.95,,,,,,,fee schedule,213.95,213.95, No pt prsnt train add 15,G0542,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,112.83,,,,,,,fee schedule,112.83,112.83, Group train w/o patient,G0543,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,51.05,,,,,,,fee schedule,51.05,51.05, Post d/c phone follow up,G0544,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,236.94,,,,,,,fee schedule,236.94,236.94, Inherent visit to inpt,G0545,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,222.42,,,,,,,fee schedule,222.42,222.42, Phone/internet ehr assess,G0546,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,89.41,,,,,,,fee schedule,89.41,89.41, Phone/internet svs 11-20 m,G0547,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,177.85,,,,,,,fee schedule,177.85,177.85, Phone/inter svs 21-30 m,G0548,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,263.59,,,,,,,fee schedule,263.59,263.59, Phone/inter for treat>31m,G0549,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,350.31,,,,,,,fee schedule,350.31,350.31, Phone/inter for dx/treat >5m,G0550,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,165.55,,,,,,,fee schedule,165.55,165.55, Phn/intr svs fr dx treat 30m,G0551,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,170.73,,,,,,,fee schedule,170.73,170.73, Monthly tx for dmht 20mins,G0553,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,142.29,,,,,,,fee schedule,142.29,142.29, Add 20 m of monthly tx,G0554,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,138.73,,,,,,,fee schedule,138.73,138.73, Adv prim care mgmt lvl 1,G0556,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,60.81,,,,,,,fee schedule,60.81,60.81, Adv prim care mgmt lvl 2,G0557,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,185.08,,,,,,,fee schedule,185.08,185.08, Adv prim care mgmt lvl 3,G0558,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,400.71,,,,,,,fee schedule,400.71,400.71, Unrelat prac follow up visit,G0559,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,45.6,,,,,,,fee schedule,45.6,45.6, Safety plan interven,G0560,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,212.93,,,,,,,fee schedule,212.93,212.93, "Temp tube delivery, unil",G0561,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,2505,3195, "Temp tube delivery, unil",G0561,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2782,,,,,,,fee schedule,2505,3195, "Temp tube delivery, unil",G0561,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2505,,,,,,,fee schedule,2505,3195, 365 d implant glucose sensor,G0564,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,12821, 365 d implant glucose sensor,G0564,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4108,12821, 365 d implant glucose sensor,G0564,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4108,12821, Rem/ins glu snsr 365 dif sit,G0565,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,4108,,,,,,,fee schedule,4108,12821, Rem/ins glu snsr 365 dif sit,G0565,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12821,,,,,,,fee schedule,4108,12821, Rem/ins glu snsr 365 dif sit,G0565,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11539,,,,,,,fee schedule,4108,12821, 3d bn img algor drvd fr mri,G0566,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,352.04,,,,,,,fee schedule,352.04,352.04, 3d bn img algor drvd fr mri,G0566,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,352.04,,,,,,,fee schedule,352.04,352.04, Screening Hep C detect,G0567,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,146.4,,,,,,,fee schedule,146.4,146.4, "Int psych care mng, 1 cal mo",G0568,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,451.86,,,,,,,fee schedule,451.86,451.86, "Subs psych care mng, subs mo",G0569,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,494.54,,,,,,,fee schedule,494.54,494.54, "Care manage serv, pr cal mo",G0570,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,213.14,,,,,,,fee schedule,213.14,213.14, Intraop nerve cryoablation,G0571,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,335.47,,,,,,,fee schedule,335.47,335.47, Drug test def simple all cl,G0659,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,259.25,,,,,,,fee schedule,93.21,259.25, Drug test def simple all cl,G0659,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,93.21,,,,,,,fee schedule,93.21,259.25, Drug test def simple all cl,G0659,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,93.21,,,,,,,fee schedule,93.21,259.25, Post d/c h vst new pt 20 m,G2001,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,266.94,,,,,,,fee schedule,266.94,266.94, Post-d/c h vst new pt 30 m,G2002,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,403.19,,,,,,,fee schedule,403.19,403.19, Post-d/c h vst new pt 45 m,G2003,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,652.16,,,,,,,fee schedule,652.16,652.16, Post-d/c h vst new pt 60 m,G2004,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,886.83,,,,,,,fee schedule,886.83,886.83, Post-d/c h vst new pt 75 m,G2005,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1177.03,,,,,,,fee schedule,1177.03,1177.03, Post-d/c h vst ext pt 20 m,G2006,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,266.89,,,,,,,fee schedule,266.89,266.89, Post-d/c h vst ext pt 30 m,G2007,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,436.27,,,,,,,fee schedule,436.27,436.27, Post-d/c h vst ext pt 45 m,G2008,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,697.59,,,,,,,fee schedule,697.59,697.59, Post-d/c h vst ext pt 60 m,G2009,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,990.44,,,,,,,fee schedule,990.44,990.44, Remot image submit by pt,G2010,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,43.76,,,,,,,fee schedule,43.76,43.76, Alcohol/sub abuse assess,G2011,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,81.37,,,,,,,fee schedule,81.37,81.37, Post-d/c h vst ext pt 75 m,G2013,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1177.03,,,,,,,fee schedule,1177.03,1177.03, Post-d/c care plan overs 30m,G2014,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,400.55,,,,,,,fee schedule,400.55,400.55, Post-d/c care plan overs 60m,G2015,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,560.48,,,,,,,fee schedule,560.48,560.48, Visit esketamine 56m or less,G2082,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,172.67,,,,,,,fee schedule,172.67,172.67, "Visit esketamine, > 56m",G2083,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,172.67,,,,,,,fee schedule,172.67,172.67, Off base opioid tx 70min,G2086,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1998.62,,,,,,,fee schedule,1998.62,1998.62, "Off base opioid tx, 60 m",G2087,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,1899.01,,,,,,,fee schedule,1899.01,1899.01, "Off base opioid tx, add30",G2088,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,187.19,,,,,,,fee schedule,187.19,187.19, Complex e/m visit add on,G2211,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,78.67,,,,,,,fee schedule,78.67,78.67, Prolong outpt/office vis,G2212,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,151.03,,,,,,,fee schedule,151.03,151.03, Initiat med assist tx in er,G2213,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,304.71,,,,,,,fee schedule,304.71,304.71, Init/sub psych care m 1st 30,G2214,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,186.05,,,,,,,fee schedule,186.05,186.05, "Remot img sub by pt, non e/m",G2250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,43.76,,,,,,,fee schedule,43.76,43.76, "Brief chkin, 5-10, non-e/m",G2251,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,58.11,,,,,,,fee schedule,58.11,58.11, "Brief chkin by md/qhp, 11-20",G2252,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,123.35,,,,,,,fee schedule,123.35,123.35, Chronic pain mgmt 30 mins,G3002,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,355.87,,,,,,,fee schedule,355.87,355.87, Chronic pain mgmt addl 15m,G3003,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,126.05,,,,,,,fee schedule,126.05,126.05, Warfarin respon genetic test,G9143,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,503.64,,,,,,,fee schedule,181.08,503.64, Warfarin respon genetic test,G9143,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,181.08,,,,,,,fee schedule,181.08,503.64, Warfarin respon genetic test,G9143,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,181.08,,,,,,,fee schedule,181.08,503.64, Transesoph doppl cardiac mon,G9157,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,491.41,,,,,,,fee schedule,491.41,491.41, BPCI home visit,G9187,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,268.02,,,,,,,fee schedule,268.02,268.02, Remote E/M new pt 10mins,G9481,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,102.74,,,,,,,fee schedule,102.74,102.74, Remote E/M new pt 20mins,G9482,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,186.59,,,,,,,fee schedule,186.59,186.59, Remote E/M new pt 30mins,G9483,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,299.26,,,,,,,fee schedule,299.26,299.26, Remote E/M new pt 45mins,G9484,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,502.96,,,,,,,fee schedule,502.96,502.96, Remote E/M new pt 60mins,G9485,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,668.83,,,,,,,fee schedule,668.83,668.83, Remote E/M est. pt 10mins,G9486,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,102.74,,,,,,,fee schedule,102.74,102.74, Remote E/M est. pt 15mins,G9487,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,199.22,,,,,,,fee schedule,199.22,199.22, Remote E/M est. pt 25mins,G9488,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,308.27,,,,,,,fee schedule,308.27,308.27, Remote E/M est. pt 40mins,G9489,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,437.18,,,,,,,fee schedule,437.18,437.18, Joint replac mod home visit,G9490,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,268.02,,,,,,,fee schedule,268.02,268.02, Acute Nursing Facility Care,G9685,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,864.44,,,,,,,fee schedule,864.44,864.44, Next Gen ACO model <10min,G9868,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,144.18,,,,,,,fee schedule,144.18,144.18, Next Gen ACO model 10-20min,G9869,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,192.85,,,,,,,fee schedule,192.85,192.85, Next Gen ACO model >20min,G9870,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,241.52,,,,,,,fee schedule,241.52,241.52, Remote E/M new pt 10mins,G9978,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,132.04,,,,,,,fee schedule,132.04,132.04, Remote E/M new pt 20mins,G9979,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,226.2,,,,,,,fee schedule,226.2,226.2, Remote E/M new pt 30 mins,G9980,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,364.77,,,,,,,fee schedule,364.77,364.77, Remote E/M new pt 45mins,G9981,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,616.71,,,,,,,fee schedule,616.71,616.71, Remote E/M new pt 60mins,G9982,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,830.82,,,,,,,fee schedule,830.82,830.82, Remote E/M est. pt 10mins,G9983,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,132.04,,,,,,,fee schedule,132.04,132.04, Remote E/M est. pt 15mins,G9984,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,256.04,,,,,,,fee schedule,256.04,256.04, Remote E/M est. pt 25mins,G9985,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,389.27,,,,,,,fee schedule,389.27,389.27, Remote E/M est. pt 40mins,G9986,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,566.42,,,,,,,fee schedule,566.42,566.42, BPCI Advanced In home visit,G9987,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,268.02,,,,,,,fee schedule,268.02,268.02, "Inj., omadacycline, 1 mg",J0121,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,9.02,,,,,,,fee schedule,4.89,9.74, "Inj., omadacycline, 1 mg",J0121,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,9.74,,,,,,,fee schedule,4.89,9.74, "Inj., omadacycline, 1 mg",J0121,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.89,,,,,,,fee schedule,4.89,9.74, "Inj., omadacycline, 1 mg",J0121,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4.89,,,,,,,fee schedule,4.89,9.74, "Inj., eravacycline, 1 mg",J0122,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,2.9,,,,,,,fee schedule,1.57,3.13, "Inj., eravacycline, 1 mg",J0122,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,3.13,,,,,,,fee schedule,1.57,3.13, "Inj., eravacycline, 1 mg",J0122,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.57,,,,,,,fee schedule,1.57,3.13, "Inj., eravacycline, 1 mg",J0122,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.57,,,,,,,fee schedule,1.57,3.13, Abatacept injection,J0129,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,100.1,,,,,,,fee schedule,54.28,108.11, Abatacept injection,J0129,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,108.11,,,,,,,fee schedule,54.28,108.11, Abatacept injection,J0129,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,54.28,,,,,,,fee schedule,54.28,108.11, Abatacept injection,J0129,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,54.28,,,,,,,fee schedule,54.28,108.11, Abciximab injection,J0130,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,681.52,,,,,,,fee schedule,681.52,681.52, Abciximab injection,J0130,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,681.52,,,,,,,fee schedule,681.52,681.52, Acetaminophen injection,J0131,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.11,,,,,,,fee schedule,0.06,0.12, Acetaminophen injection,J0131,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.12,,,,,,,fee schedule,0.06,0.12, Acetaminophen injection,J0131,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.06,,,,,,,fee schedule,0.06,0.12, Acetaminophen injection,J0131,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.06,,,,,,,fee schedule,0.06,0.12, Acetylcysteine injection,J0132,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.83,,,,,,,fee schedule,0.45,0.9, Acetylcysteine injection,J0132,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.9,,,,,,,fee schedule,0.45,0.9, Acetylcysteine injection,J0132,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.45,,,,,,,fee schedule,0.45,0.9, Acetylcysteine injection,J0132,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.45,,,,,,,fee schedule,0.45,0.9, Acyclovir injection,J0133,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.07,,,,,,,fee schedule,0.04,0.07, Acyclovir injection,J0133,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.07,,,,,,,fee schedule,0.04,0.07, Acyclovir injection,J0133,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.04,,,,,,,fee schedule,0.04,0.07, Acyclovir injection,J0133,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.04,,,,,,,fee schedule,0.04,0.07, Inj acetaminophen -fresenius,J0134,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.14,,,,,,,fee schedule,0.07,0.15, Inj acetaminophen -fresenius,J0134,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.15,,,,,,,fee schedule,0.07,0.15, Inj acetaminophen -fresenius,J0134,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.07,,,,,,,fee schedule,0.07,0.15, Inj acetaminophen -fresenius,J0134,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.07,,,,,,,fee schedule,0.07,0.15, "Inj, acetaminophen (b braun)",J0136,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.11,,,,,,,fee schedule,0.06,0.12, "Inj, acetaminophen (b braun)",J0136,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.12,,,,,,,fee schedule,0.06,0.12, "Inj, acetaminophen (b braun)",J0136,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.06,,,,,,,fee schedule,0.06,0.12, "Inj, acetaminophen (b braun)",J0136,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.06,,,,,,,fee schedule,0.06,0.12, "Inj, acetaminophen (hikma)",J0137,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.11,,,,,,,fee schedule,0.06,0.12, "Inj, acetaminophen (hikma)",J0137,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.12,,,,,,,fee schedule,0.06,0.12, "Inj, acetaminophen (hikma)",J0137,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.06,,,,,,,fee schedule,0.06,0.12, "Inj, acetaminophen (hikma)",J0137,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.06,,,,,,,fee schedule,0.06,0.12, "Injection, acetaminoph 10 mg",J0138,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.5,,,,,,,fee schedule,0.27,0.53, "Injection, acetaminoph 10 mg",J0138,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.53,,,,,,,fee schedule,0.27,0.53, "Injection, acetaminoph 10 mg",J0138,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.27,,,,,,,fee schedule,0.27,0.53, "Injection, acetaminoph 10 mg",J0138,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.27,,,,,,,fee schedule,0.27,0.53, "Inj, adalimumab, 1 mg",J0139,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,111.91,,,,,,,fee schedule,111.91,111.91, "Inj, adalimumab, 1 mg",J0139,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,111.91,,,,,,,fee schedule,111.91,111.91, Adenosine inj 1mg,J0153,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,1.04,,,,,,,fee schedule,0.56,1.12, Adenosine inj 1mg,J0153,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,1.12,,,,,,,fee schedule,0.56,1.12, Adenosine inj 1mg,J0153,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.56,,,,,,,fee schedule,0.56,1.12, Adenosine inj 1mg,J0153,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.56,,,,,,,fee schedule,0.56,1.12, Inj epinephrine nos 0.1 mg,J0165,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,1.31,,,,,,,fee schedule,0.71,1.41, Inj epinephrine nos 0.1 mg,J0165,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,1.41,,,,,,,fee schedule,0.71,1.41, Inj epinephrine nos 0.1 mg,J0165,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.71,,,,,,,fee schedule,0.71,1.41, Inj epinephrine nos 0.1 mg,J0165,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.71,,,,,,,fee schedule,0.71,1.41, Inj epinephrine (bpi),J0166,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,5.13,,,,,,,fee schedule,2.78,5.54, Inj epinephrine (bpi),J0166,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,5.54,,,,,,,fee schedule,2.78,5.54, Inj epinephrine (bpi),J0166,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2.78,,,,,,,fee schedule,2.78,5.54, Inj epinephrine (bpi),J0166,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2.78,,,,,,,fee schedule,2.78,5.54, Inj epinephrine (hospira),J0167,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,1.67,,,,,,,fee schedule,0.9,1.8, Inj epinephrine (hospira),J0167,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,1.8,,,,,,,fee schedule,0.9,1.8, Inj epinephrine (hospira),J0167,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.9,,,,,,,fee schedule,0.9,1.8, Inj epinephrine (hospira),J0167,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.9,,,,,,,fee schedule,0.9,1.8, Epinephrine (intl med sys),J0168,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,4.91,,,,,,,fee schedule,2.66,5.3, Epinephrine (intl med sys),J0168,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,5.3,,,,,,,fee schedule,2.66,5.3, Epinephrine (intl med sys),J0168,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2.66,,,,,,,fee schedule,2.66,5.3, Epinephrine (intl med sys),J0168,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2.66,,,,,,,fee schedule,2.66,5.3, Inj epinephrine (adrenalin),J0169,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,2.97,,,,,,,fee schedule,1.61,3.21, Inj epinephrine (adrenalin),J0169,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,3.21,,,,,,,fee schedule,1.61,3.21, Inj epinephrine (adrenalin),J0169,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.61,,,,,,,fee schedule,1.61,3.21, Inj epinephrine (adrenalin),J0169,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.61,,,,,,,fee schedule,1.61,3.21, "Inj, aducanumab-avwa, 2 mg",J0172,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,13.46,,,,,,,fee schedule,7.3,14.53, "Inj, aducanumab-avwa, 2 mg",J0172,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,14.53,,,,,,,fee schedule,7.3,14.53, "Inj, aducanumab-avwa, 2 mg",J0172,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.3,,,,,,,fee schedule,7.3,14.53, "Inj, aducanumab-avwa, 2 mg",J0172,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,7.3,,,,,,,fee schedule,7.3,14.53, "Inj, lecanemab-irmb",J0174,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,2.99,,,,,,,fee schedule,1.62,3.23, "Inj, lecanemab-irmb",J0174,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,3.23,,,,,,,fee schedule,1.62,3.23, "Inj, lecanemab-irmb",J0174,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.62,,,,,,,fee schedule,1.62,3.23, "Inj, lecanemab-irmb",J0174,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.62,,,,,,,fee schedule,1.62,3.23, "Inj, donanemab-azbt, 2 mg",J0175,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,9.32,,,,,,,fee schedule,5.05,10.06, "Inj, donanemab-azbt, 2 mg",J0175,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,10.06,,,,,,,fee schedule,5.05,10.06, "Inj, donanemab-azbt, 2 mg",J0175,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.05,,,,,,,fee schedule,5.05,10.06, "Inj, donanemab-azbt, 2 mg",J0175,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5.05,,,,,,,fee schedule,5.05,10.06, "Inj, aflibercept hd, 1 mg",J0177,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,719.42,,,,,,,fee schedule,390.08,776.97, "Inj, aflibercept hd, 1 mg",J0177,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,776.97,,,,,,,fee schedule,390.08,776.97, "Inj, aflibercept hd, 1 mg",J0177,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,390.08,,,,,,,fee schedule,390.08,776.97, "Inj, aflibercept hd, 1 mg",J0177,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,390.08,,,,,,,fee schedule,390.08,776.97, Aflibercept injection,J0178,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,1777.59,,,,,,,fee schedule,963.85,1919.8, Aflibercept injection,J0178,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,1919.8,,,,,,,fee schedule,963.85,1919.8, Aflibercept injection,J0178,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,963.85,,,,,,,fee schedule,963.85,1919.8, Aflibercept injection,J0178,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,963.85,,,,,,,fee schedule,963.85,1919.8, "Inj, brolucizumab-dbll, 1 mg",J0179,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,778.93,,,,,,,fee schedule,422.35,841.24, "Inj, brolucizumab-dbll, 1 mg",J0179,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,841.24,,,,,,,fee schedule,422.35,841.24, "Inj, brolucizumab-dbll, 1 mg",J0179,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,422.35,,,,,,,fee schedule,422.35,841.24, "Inj, brolucizumab-dbll, 1 mg",J0179,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,422.35,,,,,,,fee schedule,422.35,841.24, Agalsidase beta injection,J0180,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,518.09,,,,,,,fee schedule,280.92,559.53, Agalsidase beta injection,J0180,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,559.53,,,,,,,fee schedule,280.92,559.53, Agalsidase beta injection,J0180,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,280.92,,,,,,,fee schedule,280.92,559.53, Agalsidase beta injection,J0180,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,280.92,,,,,,,fee schedule,280.92,559.53, "Inj, amisulpride, 1 mg",J0184,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.79,,,,,,,fee schedule,11.79,11.79, "Inj, amisulpride, 1 mg",J0184,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11.79,,,,,,,fee schedule,11.79,11.79, "Inj., aprepitant, 1 mg",J0185,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,3.98,,,,,,,fee schedule,2.16,4.3, "Inj., aprepitant, 1 mg",J0185,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,4.3,,,,,,,fee schedule,2.16,4.3, "Inj., aprepitant, 1 mg",J0185,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2.16,,,,,,,fee schedule,2.16,4.3, "Inj., aprepitant, 1 mg",J0185,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2.16,,,,,,,fee schedule,2.16,4.3, "Injection, alemtuzumab",J0202,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,5491.58,,,,,,,fee schedule,2977.65,5930.9, "Injection, alemtuzumab",J0202,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,5930.9,,,,,,,fee schedule,2977.65,5930.9, "Injection, alemtuzumab",J0202,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2977.65,,,,,,,fee schedule,2977.65,5930.9, "Injection, alemtuzumab",J0202,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2977.65,,,,,,,fee schedule,2977.65,5930.9, Alglucerase injection,J0205,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,36.7,,,,,,,fee schedule,36.7,36.7, Alglucerase injection,J0205,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,36.7,,,,,,,fee schedule,36.7,36.7, Inj allopurinol sodium 1 mg,J0206,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,10.22,,,,,,,fee schedule,5.54,11.03, Inj allopurinol sodium 1 mg,J0206,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,11.03,,,,,,,fee schedule,5.54,11.03, Inj allopurinol sodium 1 mg,J0206,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.54,,,,,,,fee schedule,5.54,11.03, Inj allopurinol sodium 1 mg,J0206,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5.54,,,,,,,fee schedule,5.54,11.03, Amifostine,J0207,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,993.21,,,,,,,fee schedule,993.21,993.21, Amifostine,J0207,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,993.21,,,,,,,fee schedule,993.21,993.21, Inj sodium thiosulfate 100mg,J0208,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,116.07,,,,,,,fee schedule,116.07,116.07, Inj sodium thiosulfate 100mg,J0208,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,116.07,,,,,,,fee schedule,116.07,116.07, "Inj, sod thiosulfate (hope)",J0209,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.13,,,,,,,fee schedule,1.13,1.13, "Inj, sod thiosulfate (hope)",J0209,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.13,,,,,,,fee schedule,1.13,1.13, Methyldopate hcl injection,J0210,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,61,,,,,,,fee schedule,61,61, Methyldopate hcl injection,J0210,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,61,,,,,,,fee schedule,61,61, "Inj, nithiodote, 3mg / 125mg",J0211,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2.65,,,,,,,fee schedule,2.65,2.65, "Inj, nithiodote, 3mg / 125mg",J0211,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2.65,,,,,,,fee schedule,2.65,2.65, Alefacept,J0215,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,30.78,,,,,,,fee schedule,30.78,30.78, Alefacept,J0215,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,30.78,,,,,,,fee schedule,30.78,30.78, Inj velmanase alfa-tycv 1 mg,J0217,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,1046.36,,,,,,,fee schedule,567.36,1130.07, Inj velmanase alfa-tycv 1 mg,J0217,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,1130.07,,,,,,,fee schedule,567.36,1130.07, Inj velmanase alfa-tycv 1 mg,J0217,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,567.36,,,,,,,fee schedule,567.36,1130.07, Inj velmanase alfa-tycv 1 mg,J0217,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,567.36,,,,,,,fee schedule,567.36,1130.07, Inj olipudase alfa-rpcp 1mg,J0218,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,886.1,,,,,,,fee schedule,480.46,956.98, Inj olipudase alfa-rpcp 1mg,J0218,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,956.98,,,,,,,fee schedule,480.46,956.98, Inj olipudase alfa-rpcp 1mg,J0218,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,480.46,,,,,,,fee schedule,480.46,956.98, Inj olipudase alfa-rpcp 1mg,J0218,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,480.46,,,,,,,fee schedule,480.46,956.98, Inj aval alfa-nqpt 4mg,J0219,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,181.69,,,,,,,fee schedule,98.52,196.22, Inj aval alfa-nqpt 4mg,J0219,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,196.22,,,,,,,fee schedule,98.52,196.22, Inj aval alfa-nqpt 4mg,J0219,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,98.52,,,,,,,fee schedule,98.52,196.22, Inj aval alfa-nqpt 4mg,J0219,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,98.52,,,,,,,fee schedule,98.52,196.22, Lumizyme injection,J0221,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,464.9,,,,,,,fee schedule,252.08,502.09, Lumizyme injection,J0221,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,502.09,,,,,,,fee schedule,252.08,502.09, Lumizyme injection,J0221,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252.08,,,,,,,fee schedule,252.08,502.09, Lumizyme injection,J0221,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,252.08,,,,,,,fee schedule,252.08,502.09, "Inj., patisiran, 0.1 mg",J0222,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,224.6,,,,,,,fee schedule,121.78,242.56, "Inj., patisiran, 0.1 mg",J0222,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,242.56,,,,,,,fee schedule,121.78,242.56, "Inj., patisiran, 0.1 mg",J0222,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,121.78,,,,,,,fee schedule,121.78,242.56, "Inj., patisiran, 0.1 mg",J0222,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,121.78,,,,,,,fee schedule,121.78,242.56, Inj givosiran 0.5 mg,J0223,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,263.68,,,,,,,fee schedule,142.97,284.77, Inj givosiran 0.5 mg,J0223,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,284.77,,,,,,,fee schedule,142.97,284.77, Inj givosiran 0.5 mg,J0223,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,142.97,,,,,,,fee schedule,142.97,284.77, Inj givosiran 0.5 mg,J0223,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,142.97,,,,,,,fee schedule,142.97,284.77, "Inj. lumasiran, 0.5 mg",J0224,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,740.48,,,,,,,fee schedule,401.5,799.71, "Inj. lumasiran, 0.5 mg",J0224,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,799.71,,,,,,,fee schedule,401.5,799.71, "Inj. lumasiran, 0.5 mg",J0224,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,401.5,,,,,,,fee schedule,401.5,799.71, "Inj. lumasiran, 0.5 mg",J0224,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,401.5,,,,,,,fee schedule,401.5,799.71, "Inj, vutrisiran, 1 mg",J0225,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,11213.69,,,,,,,fee schedule,6080.31,12110.78, "Inj, vutrisiran, 1 mg",J0225,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,12110.78,,,,,,,fee schedule,6080.31,12110.78, "Inj, vutrisiran, 1 mg",J0225,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6080.31,,,,,,,fee schedule,6080.31,12110.78, "Inj, vutrisiran, 1 mg",J0225,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,6080.31,,,,,,,fee schedule,6080.31,12110.78, "Inj, remdesivir, 1 mg?",J0248,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,15.14,,,,,,,fee schedule,8.21,16.35, "Inj, remdesivir, 1 mg?",J0248,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,16.35,,,,,,,fee schedule,8.21,16.35, "Inj, remdesivir, 1 mg?",J0248,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.21,,,,,,,fee schedule,8.21,16.35, "Inj, remdesivir, 1 mg?",J0248,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,8.21,,,,,,,fee schedule,8.21,16.35, Alpha 1 proteinase inhibitor,J0256,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,11.66,,,,,,,fee schedule,6.33,12.59, Alpha 1 proteinase inhibitor,J0256,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,12.59,,,,,,,fee schedule,6.33,12.59, Alpha 1 proteinase inhibitor,J0256,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.33,,,,,,,fee schedule,6.33,12.59, Alpha 1 proteinase inhibitor,J0256,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,6.33,,,,,,,fee schedule,6.33,12.59, Glassia injection,J0257,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,12.85,,,,,,,fee schedule,6.97,13.88, Glassia injection,J0257,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,13.88,,,,,,,fee schedule,6.97,13.88, Glassia injection,J0257,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.97,,,,,,,fee schedule,6.97,13.88, Glassia injection,J0257,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,6.97,,,,,,,fee schedule,6.97,13.88, Alprostadil for injection,J0270,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.59,,,,,,,fee schedule,0.59,0.59, Alprostadil for injection,J0270,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.59,,,,,,,fee schedule,0.59,0.59, Amikacin sulfate injection,J0278,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,1.4,,,,,,,fee schedule,0.76,1.51, Amikacin sulfate injection,J0278,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,1.51,,,,,,,fee schedule,0.76,1.51, Amikacin sulfate injection,J0278,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.76,,,,,,,fee schedule,0.76,1.51, Amikacin sulfate injection,J0278,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.76,,,,,,,fee schedule,0.76,1.51, Aminophyllin 250 MG inj,J0280,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,18.68,,,,,,,fee schedule,10.13,20.17, Aminophyllin 250 MG inj,J0280,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,20.17,,,,,,,fee schedule,10.13,20.17, Aminophyllin 250 MG inj,J0280,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.13,,,,,,,fee schedule,10.13,20.17, Aminophyllin 250 MG inj,J0280,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,10.13,,,,,,,fee schedule,10.13,20.17, Inj aminocaproic acid 1 gram,J0281,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,3.38,,,,,,,fee schedule,1.83,3.65, Inj aminocaproic acid 1 gram,J0281,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,3.65,,,,,,,fee schedule,1.83,3.65, Inj aminocaproic acid 1 gram,J0281,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.83,,,,,,,fee schedule,1.83,3.65, Inj aminocaproic acid 1 gram,J0281,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.83,,,,,,,fee schedule,1.83,3.65, Amiodarone HCl,J0282,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,1.15,,,,,,,fee schedule,0.62,1.24, Amiodarone HCl,J0282,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,1.24,,,,,,,fee schedule,0.62,1.24, Amiodarone HCl,J0282,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.62,,,,,,,fee schedule,0.62,1.24, Amiodarone HCl,J0282,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.62,,,,,,,fee schedule,0.62,1.24, "Inj, amiodarone (nexterone)",J0283,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,5.87,,,,,,,fee schedule,3.18,6.34, "Inj, amiodarone (nexterone)",J0283,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,6.34,,,,,,,fee schedule,3.18,6.34, "Inj, amiodarone (nexterone)",J0283,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3.18,,,,,,,fee schedule,3.18,6.34, "Inj, amiodarone (nexterone)",J0283,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3.18,,,,,,,fee schedule,3.18,6.34, Amphotericin B,J0285,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,76.77,,,,,,,fee schedule,41.63,82.91, Amphotericin B,J0285,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,82.91,,,,,,,fee schedule,41.63,82.91, Amphotericin B,J0285,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,41.63,,,,,,,fee schedule,41.63,82.91, Amphotericin B,J0285,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,41.63,,,,,,,fee schedule,41.63,82.91, Amphotericin b lipid complex,J0287,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,23.18,,,,,,,fee schedule,12.57,25.03, Amphotericin b lipid complex,J0287,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,25.03,,,,,,,fee schedule,12.57,25.03, Amphotericin b lipid complex,J0287,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.57,,,,,,,fee schedule,12.57,25.03, Amphotericin b lipid complex,J0287,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,12.57,,,,,,,fee schedule,12.57,25.03, Ampho b cholesteryl sulfate,J0288,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,86.42,,,,,,,fee schedule,86.42,86.42, Ampho b cholesteryl sulfate,J0288,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,86.42,,,,,,,fee schedule,86.42,86.42, Amphotericin b liposome inj,J0289,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,50.9,,,,,,,fee schedule,27.6,54.97, Amphotericin b liposome inj,J0289,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,54.97,,,,,,,fee schedule,27.6,54.97, Amphotericin b liposome inj,J0289,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,27.6,,,,,,,fee schedule,27.6,54.97, Amphotericin b liposome inj,J0289,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,27.6,,,,,,,fee schedule,27.6,54.97, Ampicillin 500 MG inj,J0290,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,1.1,,,,,,,fee schedule,0.6,1.19, Ampicillin 500 MG inj,J0290,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,1.19,,,,,,,fee schedule,0.6,1.19, Ampicillin 500 MG inj,J0290,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.6,,,,,,,fee schedule,0.6,1.19, Ampicillin 500 MG inj,J0290,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.6,,,,,,,fee schedule,0.6,1.19, "Inj., plazomicin, 5 mg",J0291,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,8.03,,,,,,,fee schedule,4.36,8.68, "Inj., plazomicin, 5 mg",J0291,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,8.68,,,,,,,fee schedule,4.36,8.68, "Inj., plazomicin, 5 mg",J0291,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.36,,,,,,,fee schedule,4.36,8.68, "Inj., plazomicin, 5 mg",J0291,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4.36,,,,,,,fee schedule,4.36,8.68, Ampicillin sodium per 1.5 gm,J0295,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,3.35,,,,,,,fee schedule,1.82,3.62, Ampicillin sodium per 1.5 gm,J0295,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,3.62,,,,,,,fee schedule,1.82,3.62, Ampicillin sodium per 1.5 gm,J0295,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.82,,,,,,,fee schedule,1.82,3.62, Ampicillin sodium per 1.5 gm,J0295,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.82,,,,,,,fee schedule,1.82,3.62, Amobarbital 125 MG inj,J0300,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13.81,,,,,,,fee schedule,13.81,13.81, Amobarbital 125 MG inj,J0300,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13.81,,,,,,,fee schedule,13.81,13.81, Succinycholine chloride inj,J0330,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.9,,,,,,,fee schedule,1.9,1.9, Succinycholine chloride inj,J0330,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.9,,,,,,,fee schedule,1.9,1.9, Anidulafungin injection,J0348,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,1.08,,,,,,,fee schedule,0.59,1.17, Anidulafungin injection,J0348,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,1.17,,,,,,,fee schedule,0.59,1.17, Anidulafungin injection,J0348,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.59,,,,,,,fee schedule,0.59,1.17, Anidulafungin injection,J0348,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.59,,,,,,,fee schedule,0.59,1.17, "Inj, rezafungin, 1 mg",J0349,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,23.9,,,,,,,fee schedule,12.96,25.81, "Inj, rezafungin, 1 mg",J0349,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,25.81,,,,,,,fee schedule,12.96,25.81, "Inj, rezafungin, 1 mg",J0349,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.96,,,,,,,fee schedule,12.96,25.81, "Inj, rezafungin, 1 mg",J0349,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,12.96,,,,,,,fee schedule,12.96,25.81, Hydralazine hcl injection,J0360,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,11.68,,,,,,,fee schedule,6.33,12.61, Hydralazine hcl injection,J0360,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,12.61,,,,,,,fee schedule,6.33,12.61, Hydralazine hcl injection,J0360,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.33,,,,,,,fee schedule,6.33,12.61, Hydralazine hcl injection,J0360,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,6.33,,,,,,,fee schedule,6.33,12.61, Apomorphine hydrochloride,J0364,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,64.7,,,,,,,fee schedule,64.7,64.7, Apomorphine hydrochloride,J0364,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,64.7,,,,,,,fee schedule,64.7,64.7, "Aprotonin, 10,000 kiu",J0365,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3.16,,,,,,,fee schedule,3.16,3.16, "Aprotonin, 10,000 kiu",J0365,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3.16,,,,,,,fee schedule,3.16,3.16, Inj metaraminol bitartrate,J0380,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.18,,,,,,,fee schedule,1.18,1.18, Inj metaraminol bitartrate,J0380,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.18,,,,,,,fee schedule,1.18,1.18, "Inj, artesunate, 1mg",J0391,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,63.23,,,,,,,fee schedule,63.23,63.23, "Inj, artesunate, 1mg",J0391,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,63.23,,,,,,,fee schedule,63.23,63.23, Aripiprazole injection,J0400,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.39,,,,,,,fee schedule,0.39,0.39, Aripiprazole injection,J0400,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.39,,,,,,,fee schedule,0.39,0.39, Inj aripiprazole ext rel 1mg,J0401,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,16.29,,,,,,,fee schedule,8.83,17.59, Inj aripiprazole ext rel 1mg,J0401,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,17.59,,,,,,,fee schedule,8.83,17.59, Inj aripiprazole ext rel 1mg,J0401,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.83,,,,,,,fee schedule,8.83,17.59, Inj aripiprazole ext rel 1mg,J0401,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,8.83,,,,,,,fee schedule,8.83,17.59, "Inj, abilify asimtufii, 1 mg",J0402,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,13.57,,,,,,,fee schedule,7.36,14.65, "Inj, abilify asimtufii, 1 mg",J0402,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,14.65,,,,,,,fee schedule,7.36,14.65, "Inj, abilify asimtufii, 1 mg",J0402,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.36,,,,,,,fee schedule,7.36,14.65, "Inj, abilify asimtufii, 1 mg",J0402,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,7.36,,,,,,,fee schedule,7.36,14.65, Azithromycin,J0456,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,5.87,,,,,,,fee schedule,3.18,6.34, Azithromycin,J0456,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,6.34,,,,,,,fee schedule,3.18,6.34, Azithromycin,J0456,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3.18,,,,,,,fee schedule,3.18,6.34, Azithromycin,J0456,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3.18,,,,,,,fee schedule,3.18,6.34, "Injection, aztreonam, 100 mg",J0457,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,5.99,,,,,,,fee schedule,3.26,6.46, "Injection, aztreonam, 100 mg",J0457,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,6.46,,,,,,,fee schedule,3.26,6.46, "Injection, aztreonam, 100 mg",J0457,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3.26,,,,,,,fee schedule,3.26,6.46, "Injection, aztreonam, 100 mg",J0457,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3.26,,,,,,,fee schedule,3.26,6.46, Atropine sulfate injection,J0461,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.16,,,,,,,fee schedule,0.09,0.17, Atropine sulfate injection,J0461,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.17,,,,,,,fee schedule,0.09,0.17, Atropine sulfate injection,J0461,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.09,,,,,,,fee schedule,0.09,0.17, Atropine sulfate injection,J0461,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.09,,,,,,,fee schedule,0.09,0.17, Baclofen 10 mg injection,J0475,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,395.6,,,,,,,fee schedule,214.5,427.24, Baclofen 10 mg injection,J0475,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,427.24,,,,,,,fee schedule,214.5,427.24, Baclofen 10 mg injection,J0475,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,214.5,,,,,,,fee schedule,214.5,427.24, Baclofen 10 mg injection,J0475,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,214.5,,,,,,,fee schedule,214.5,427.24, Baclofen intrathecal trial,J0476,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,151.2,,,,,,,fee schedule,81.98,163.3, Baclofen intrathecal trial,J0476,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,163.3,,,,,,,fee schedule,81.98,163.3, Baclofen intrathecal trial,J0476,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,81.98,,,,,,,fee schedule,81.98,163.3, Baclofen intrathecal trial,J0476,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,81.98,,,,,,,fee schedule,81.98,163.3, Basiliximab,J0480,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,10513.06,,,,,,,fee schedule,5700.41,11354.1, Basiliximab,J0480,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,11354.1,,,,,,,fee schedule,5700.41,11354.1, Basiliximab,J0480,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5700.41,,,,,,,fee schedule,5700.41,11354.1, Basiliximab,J0480,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5700.41,,,,,,,fee schedule,5700.41,11354.1, Belatacept injection,J0485,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,8.75,,,,,,,fee schedule,4.75,9.45, Belatacept injection,J0485,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,9.45,,,,,,,fee schedule,4.75,9.45, Belatacept injection,J0485,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.75,,,,,,,fee schedule,4.75,9.45, Belatacept injection,J0485,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4.75,,,,,,,fee schedule,4.75,9.45, Belimumab injection,J0490,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,126.02,,,,,,,fee schedule,68.33,136.1, Belimumab injection,J0490,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,136.1,,,,,,,fee schedule,68.33,136.1, Belimumab injection,J0490,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,68.33,,,,,,,fee schedule,68.33,136.1, Belimumab injection,J0490,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,68.33,,,,,,,fee schedule,68.33,136.1, Inj anifrolumab-fnia 1mg,J0491,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,40.73,,,,,,,fee schedule,22.08,43.98, Inj anifrolumab-fnia 1mg,J0491,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,43.98,,,,,,,fee schedule,22.08,43.98, Inj anifrolumab-fnia 1mg,J0491,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22.08,,,,,,,fee schedule,22.08,43.98, Inj anifrolumab-fnia 1mg,J0491,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22.08,,,,,,,fee schedule,22.08,43.98, Dicyclomine injection,J0500,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,26.28,,,,,,,fee schedule,14.25,28.38, Dicyclomine injection,J0500,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,28.38,,,,,,,fee schedule,14.25,28.38, Dicyclomine injection,J0500,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.25,,,,,,,fee schedule,14.25,28.38, Dicyclomine injection,J0500,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,14.25,,,,,,,fee schedule,14.25,28.38, Inj benztropine mesylate,J0515,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,38.86,,,,,,,fee schedule,21.07,41.97, Inj benztropine mesylate,J0515,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,41.97,,,,,,,fee schedule,21.07,41.97, Inj benztropine mesylate,J0515,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21.07,,,,,,,fee schedule,21.07,41.97, Inj benztropine mesylate,J0515,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,21.07,,,,,,,fee schedule,21.07,41.97, "Inj., benralizumab, 1 mg",J0517,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,378.29,,,,,,,fee schedule,205.12,408.56, "Inj., benralizumab, 1 mg",J0517,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,408.56,,,,,,,fee schedule,205.12,408.56, "Inj., benralizumab, 1 mg",J0517,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,205.12,,,,,,,fee schedule,205.12,408.56, "Inj., benralizumab, 1 mg",J0517,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,205.12,,,,,,,fee schedule,205.12,408.56, PenG benzathine/procaine inj,J0558,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,39.08,,,,,,,fee schedule,21.19,42.21, PenG benzathine/procaine inj,J0558,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,42.21,,,,,,,fee schedule,21.19,42.21, PenG benzathine/procaine inj,J0558,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21.19,,,,,,,fee schedule,21.19,42.21, PenG benzathine/procaine inj,J0558,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,21.19,,,,,,,fee schedule,21.19,42.21, Penicillin g benzathine inj,J0561,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,65.93,,,,,,,fee schedule,35.75,71.2, Penicillin g benzathine inj,J0561,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,71.2,,,,,,,fee schedule,35.75,71.2, Penicillin g benzathine inj,J0561,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,35.75,,,,,,,fee schedule,35.75,71.2, Penicillin g benzathine inj,J0561,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,35.75,,,,,,,fee schedule,35.75,71.2, "Inj, bezlotoxumab, 10 mg",J0565,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,89.6,,,,,,,fee schedule,48.59,96.76, "Inj, bezlotoxumab, 10 mg",J0565,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,96.76,,,,,,,fee schedule,48.59,96.76, "Inj, bezlotoxumab, 10 mg",J0565,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,48.59,,,,,,,fee schedule,48.59,96.76, "Inj, bezlotoxumab, 10 mg",J0565,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,48.59,,,,,,,fee schedule,48.59,96.76, "Inj., cerliponase alfa 1 mg",J0567,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,114.9,,,,,,,fee schedule,114.9,114.9, "Inj., cerliponase alfa 1 mg",J0567,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,114.9,,,,,,,fee schedule,114.9,114.9, Buprenorphine oral 1mg,J0571,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.54,,,,,,,fee schedule,1.54,1.54, Buprenorphine oral 1mg,J0571,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.54,,,,,,,fee schedule,1.54,1.54, Bupren/nal up to 3mg bupreno,J0572,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.94,,,,,,,fee schedule,7.94,7.94, Bupren/nal up to 3mg bupreno,J0572,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,7.94,,,,,,,fee schedule,7.94,7.94, Bupren/nal 3.1 to 6mg bupren,J0573,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13.38,,,,,,,fee schedule,13.38,13.38, Bupren/nal 3.1 to 6mg bupren,J0573,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13.38,,,,,,,fee schedule,13.38,13.38, Bupren/nal 6.1 to 10mg bupre,J0574,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.13,,,,,,,fee schedule,12.13,12.13, Bupren/nal 6.1 to 10mg bupre,J0574,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,12.13,,,,,,,fee schedule,12.13,12.13, Bupren/nal over 10mg bupreno,J0575,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22.57,,,,,,,fee schedule,22.57,22.57, Bupren/nal over 10mg bupreno,J0575,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22.57,,,,,,,fee schedule,22.57,22.57, "Inj, brixadi, 7 days or less",J0577,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,951.37,,,,,,,fee schedule,515.85,1027.48, "Inj, brixadi, 7 days or less",J0577,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,1027.48,,,,,,,fee schedule,515.85,1027.48, "Inj, brixadi, 7 days or less",J0577,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,515.85,,,,,,,fee schedule,515.85,1027.48, "Inj, brixadi, 7 days or less",J0577,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,515.85,,,,,,,fee schedule,515.85,1027.48, "Inj brixadi, more than 7 day",J0578,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,3805.45,,,,,,,fee schedule,2063.4,4109.88, "Inj brixadi, more than 7 day",J0578,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,4109.88,,,,,,,fee schedule,2063.4,4109.88, "Inj brixadi, more than 7 day",J0578,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2063.4,,,,,,,fee schedule,2063.4,4109.88, "Inj brixadi, more than 7 day",J0578,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2063.4,,,,,,,fee schedule,2063.4,4109.88, Bivalirudin,J0583,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.38,,,,,,,fee schedule,0.21,0.41, Bivalirudin,J0583,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.41,,,,,,,fee schedule,0.21,0.41, Bivalirudin,J0583,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.21,,,,,,,fee schedule,0.21,0.41, Bivalirudin,J0583,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.21,,,,,,,fee schedule,0.21,0.41, "Injection, burosumab-twza 1m",J0584,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,1083.53,,,,,,,fee schedule,587.52,1170.22, "Injection, burosumab-twza 1m",J0584,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,1170.22,,,,,,,fee schedule,587.52,1170.22, "Injection, burosumab-twza 1m",J0584,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,587.52,,,,,,,fee schedule,587.52,1170.22, "Injection, burosumab-twza 1m",J0584,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,587.52,,,,,,,fee schedule,587.52,1170.22, "Injection,onabotulinumtoxina",J0585,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,14.63,,,,,,,fee schedule,7.15,15.8, "Injection,onabotulinumtoxina",J0585,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,15.8,,,,,,,fee schedule,7.15,15.8, "Injection,onabotulinumtoxina",J0585,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.15,,,,,,,fee schedule,7.15,15.8, "Injection,onabotulinumtoxina",J0585,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,7.15,,,,,,,fee schedule,7.15,15.8, Abobotulinumtoxina,J0586,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,20.63,,,,,,,fee schedule,10.09,22.28, Abobotulinumtoxina,J0586,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,22.28,,,,,,,fee schedule,10.09,22.28, Abobotulinumtoxina,J0586,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.09,,,,,,,fee schedule,10.09,22.28, Abobotulinumtoxina,J0586,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,10.09,,,,,,,fee schedule,10.09,22.28, "Inj, rimabotulinumtoxinb",J0587,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,30.02,,,,,,,fee schedule,14.67,32.42, "Inj, rimabotulinumtoxinb",J0587,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,32.42,,,,,,,fee schedule,14.67,32.42, "Inj, rimabotulinumtoxinb",J0587,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.67,,,,,,,fee schedule,14.67,32.42, "Inj, rimabotulinumtoxinb",J0587,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,14.67,,,,,,,fee schedule,14.67,32.42, Incobotulinumtoxin a,J0588,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,11.95,,,,,,,fee schedule,5.84,12.9, Incobotulinumtoxin a,J0588,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,12.9,,,,,,,fee schedule,5.84,12.9, Incobotulinumtoxin a,J0588,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.84,,,,,,,fee schedule,5.84,12.9, Incobotulinumtoxin a,J0588,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5.84,,,,,,,fee schedule,5.84,12.9, Inj daxibotulinumtoxina-lanm,J0589,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,7,,,,,,,fee schedule,3.79,7.56, Inj daxibotulinumtoxina-lanm,J0589,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,7.56,,,,,,,fee schedule,3.79,7.56, Inj daxibotulinumtoxina-lanm,J0589,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3.79,,,,,,,fee schedule,3.79,7.56, Inj daxibotulinumtoxina-lanm,J0589,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3.79,,,,,,,fee schedule,3.79,7.56, Buprenorphine hydrochloride,J0592,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,9.29,,,,,,,fee schedule,5.04,10.04, Buprenorphine hydrochloride,J0592,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,10.04,,,,,,,fee schedule,5.04,10.04, Buprenorphine hydrochloride,J0592,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.04,,,,,,,fee schedule,5.04,10.04, Buprenorphine hydrochloride,J0592,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5.04,,,,,,,fee schedule,5.04,10.04, "Inj., lanadelumab-flyo, 1 mg",J0593,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,195.62,,,,,,,fee schedule,106.07,211.26, "Inj., lanadelumab-flyo, 1 mg",J0593,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,211.26,,,,,,,fee schedule,106.07,211.26, "Inj., lanadelumab-flyo, 1 mg",J0593,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,106.07,,,,,,,fee schedule,106.07,211.26, "Inj., lanadelumab-flyo, 1 mg",J0593,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,106.07,,,,,,,fee schedule,106.07,211.26, Busulfan injection,J0594,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,4.14,,,,,,,fee schedule,2.24,4.47, Busulfan injection,J0594,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,4.47,,,,,,,fee schedule,2.24,4.47, Busulfan injection,J0594,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2.24,,,,,,,fee schedule,2.24,4.47, Busulfan injection,J0594,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2.24,,,,,,,fee schedule,2.24,4.47, Butorphanol tartrate 1 mg,J0595,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,11.36,,,,,,,fee schedule,6.16,12.27, Butorphanol tartrate 1 mg,J0595,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,12.27,,,,,,,fee schedule,6.16,12.27, Butorphanol tartrate 1 mg,J0595,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.16,,,,,,,fee schedule,6.16,12.27, Butorphanol tartrate 1 mg,J0595,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,6.16,,,,,,,fee schedule,6.16,12.27, "Injection, ruconest",J0596,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,82.67,,,,,,,fee schedule,44.82,89.28, "Injection, ruconest",J0596,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,89.28,,,,,,,fee schedule,44.82,89.28, "Injection, ruconest",J0596,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,44.82,,,,,,,fee schedule,44.82,89.28, "Injection, ruconest",J0596,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,44.82,,,,,,,fee schedule,44.82,89.28, "C-1 esterase, berinert",J0597,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,170.69,,,,,,,fee schedule,92.55,184.34, "C-1 esterase, berinert",J0597,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,184.34,,,,,,,fee schedule,92.55,184.34, "C-1 esterase, berinert",J0597,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,92.55,,,,,,,fee schedule,92.55,184.34, "C-1 esterase, berinert",J0597,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,92.55,,,,,,,fee schedule,92.55,184.34, "C-1 esterase, cinryze",J0598,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,147.87,,,,,,,fee schedule,80.19,159.7, "C-1 esterase, cinryze",J0598,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,159.7,,,,,,,fee schedule,80.19,159.7, "C-1 esterase, cinryze",J0598,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,80.19,,,,,,,fee schedule,80.19,159.7, "C-1 esterase, cinryze",J0598,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,80.19,,,,,,,fee schedule,80.19,159.7, "Inj., haegarda 10 units",J0599,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.63,,,,,,,fee schedule,17.63,17.63, "Inj., haegarda 10 units",J0599,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,17.63,,,,,,,fee schedule,17.63,17.63, Edetate calcium disodium inj,J0600,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,14522.78,,,,,,,fee schedule,7874.58,15684.61, Edetate calcium disodium inj,J0600,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,15684.61,,,,,,,fee schedule,7874.58,15684.61, Edetate calcium disodium inj,J0600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7874.58,,,,,,,fee schedule,7874.58,15684.61, Edetate calcium disodium inj,J0600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,7874.58,,,,,,,fee schedule,7874.58,15684.61, Sevelamer carbonate 20 mg,J0601,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.13,,,,,,,fee schedule,0.13,0.13, Sevelamer carbonate 20 mg,J0601,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.13,,,,,,,fee schedule,0.13,0.13, Sevelamer carbonate pdr 20mg,J0602,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.38,,,,,,,fee schedule,0.38,0.38, Sevelamer carbonate pdr 20mg,J0602,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.38,,,,,,,fee schedule,0.38,0.38, Sevelamer hydrochloride 20mg,J0603,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.24,,,,,,,fee schedule,0.24,0.24, Sevelamer hydrochloride 20mg,J0603,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.24,,,,,,,fee schedule,0.24,0.24, "Cinacalcet, esrd on dialysis",J0604,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.21,,,,,,,fee schedule,1.21,1.21, "Cinacalcet, esrd on dialysis",J0604,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.21,,,,,,,fee schedule,1.21,1.21, Sucroferric oxyhydroxide 5mg,J0605,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.26,,,,,,,fee schedule,0.26,0.26, Sucroferric oxyhydroxide 5mg,J0605,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.26,,,,,,,fee schedule,0.26,0.26, "Inj, etelcalcetide, 0.1 mg",J0606,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.04,,,,,,,fee schedule,6.04,6.04, "Inj, etelcalcetide, 0.1 mg",J0606,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,6.04,,,,,,,fee schedule,6.04,6.04, Lanthanum carbonate oral 5mg,J0607,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.11,,,,,,,fee schedule,0.11,0.11, Lanthanum carbonate oral 5mg,J0607,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.11,,,,,,,fee schedule,0.11,0.11, Lanthanum carbonate pwdr 5mg,J0608,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.1,,,,,,,fee schedule,0.1,0.1, Lanthanum carbonate pwdr 5mg,J0608,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.1,,,,,,,fee schedule,0.1,0.1, Ferric citrate orl 3 mg iron,J0609,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.04,,,,,,,fee schedule,0.04,0.04, Ferric citrate orl 3 mg iron,J0609,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.04,,,,,,,fee schedule,0.04,0.04, Calcium glucon (fresenius),J0612,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.09,,,,,,,fee schedule,0.05,0.1, Calcium glucon (fresenius),J0612,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.1,,,,,,,fee schedule,0.05,0.1, Calcium glucon (fresenius),J0612,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.05,,,,,,,fee schedule,0.05,0.1, Calcium glucon (fresenius),J0612,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.05,,,,,,,fee schedule,0.05,0.1, Calcium glucon (wg critical),J0613,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.18,,,,,,,fee schedule,0.1,0.19, Calcium glucon (wg critical),J0613,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.19,,,,,,,fee schedule,0.1,0.19, Calcium glucon (wg critical),J0613,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.1,,,,,,,fee schedule,0.1,0.19, Calcium glucon (wg critical),J0613,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.1,,,,,,,fee schedule,0.1,0.19, "Calcium acetate, oral, 23 mg",J0615,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.04,,,,,,,fee schedule,0.04,0.04, "Calcium acetate, oral, 23 mg",J0615,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.04,,,,,,,fee schedule,0.04,0.04, Inj metoprolol tartrate 1 mg,J0616,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.29,,,,,,,fee schedule,0.16,0.32, Inj metoprolol tartrate 1 mg,J0616,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.32,,,,,,,fee schedule,0.16,0.32, Inj metoprolol tartrate 1 mg,J0616,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.16,,,,,,,fee schedule,0.16,0.32, Inj metoprolol tartrate 1 mg,J0616,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.16,,,,,,,fee schedule,0.16,0.32, "Inj, calcium chloride, 2 mg",J0618,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.05,,,,,,,fee schedule,0.05,0.05, "Inj, calcium chloride, 2 mg",J0618,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.05,,,,,,,fee schedule,0.05,0.05, Calcium glycer & lact/10 ML,J0620,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13.42,,,,,,,fee schedule,13.42,13.42, Calcium glycer & lact/10 ML,J0620,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13.42,,,,,,,fee schedule,13.42,13.42, Calcitonin salmon injection,J0630,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1019.68,,,,,,,fee schedule,1019.68,1019.68, Calcitonin salmon injection,J0630,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1019.68,,,,,,,fee schedule,1019.68,1019.68, Inj calcitriol per 0.1 mcg,J0636,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.45,,,,,,,fee schedule,1.45,1.45, Inj calcitriol per 0.1 mcg,J0636,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.45,,,,,,,fee schedule,1.45,1.45, Caspofungin acetate,J0637,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,5.11,,,,,,,fee schedule,2.77,5.52, Caspofungin acetate,J0637,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,5.52,,,,,,,fee schedule,2.77,5.52, Caspofungin acetate,J0637,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2.77,,,,,,,fee schedule,2.77,5.52, Caspofungin acetate,J0637,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2.77,,,,,,,fee schedule,2.77,5.52, Canakinumab injection,J0638,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,317.25,,,,,,,fee schedule,172.02,342.63, Canakinumab injection,J0638,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,342.63,,,,,,,fee schedule,172.02,342.63, Canakinumab injection,J0638,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,172.02,,,,,,,fee schedule,172.02,342.63, Canakinumab injection,J0638,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,172.02,,,,,,,fee schedule,172.02,342.63, Leucovorin calcium injection,J0640,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,8.89,,,,,,,fee schedule,4.82,9.6, Leucovorin calcium injection,J0640,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,9.6,,,,,,,fee schedule,4.82,9.6, Leucovorin calcium injection,J0640,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.82,,,,,,,fee schedule,4.82,9.6, Leucovorin calcium injection,J0640,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4.82,,,,,,,fee schedule,4.82,9.6, Levoleucovorin injection,J0641,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.09,,,,,,,fee schedule,0.05,0.1, Levoleucovorin injection,J0641,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.1,,,,,,,fee schedule,0.05,0.1, Levoleucovorin injection,J0641,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.05,,,,,,,fee schedule,0.05,0.1, Levoleucovorin injection,J0641,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.05,,,,,,,fee schedule,0.05,0.1, "Injection, khapzory, 0.5 mg",J0642,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,2.52,,,,,,,fee schedule,1.37,2.72, "Injection, khapzory, 0.5 mg",J0642,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,2.72,,,,,,,fee schedule,1.37,2.72, "Injection, khapzory, 0.5 mg",J0642,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.37,,,,,,,fee schedule,1.37,2.72, "Injection, khapzory, 0.5 mg",J0642,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.37,,,,,,,fee schedule,1.37,2.72, "Inj, levothyroxine nos 10mcg",J0650,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,17.33,,,,,,,fee schedule,9.39,18.71, "Inj, levothyroxine nos 10mcg",J0650,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,18.71,,,,,,,fee schedule,9.39,18.71, "Inj, levothyroxine nos 10mcg",J0650,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.39,,,,,,,fee schedule,9.39,18.71, "Inj, levothyroxine nos 10mcg",J0650,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9.39,,,,,,,fee schedule,9.39,18.71, "Inj, levothyroxine, freskabi",J0651,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,15.98,,,,,,,fee schedule,8.66,17.25, "Inj, levothyroxine, freskabi",J0651,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,17.25,,,,,,,fee schedule,8.66,17.25, "Inj, levothyroxine, freskabi",J0651,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.66,,,,,,,fee schedule,8.66,17.25, "Inj, levothyroxine, freskabi",J0651,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,8.66,,,,,,,fee schedule,8.66,17.25, "Inj, levothyroxine, hikma",J0652,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,11.57,,,,,,,fee schedule,6.27,12.49, "Inj, levothyroxine, hikma",J0652,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,12.49,,,,,,,fee schedule,6.27,12.49, "Inj, levothyroxine, hikma",J0652,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.27,,,,,,,fee schedule,6.27,12.49, "Inj, levothyroxine, hikma",J0652,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,6.27,,,,,,,fee schedule,6.27,12.49, "Inj, bupivacaine, nos, 0.5mg",J0665,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.02,,,,,,,fee schedule,0.01,0.02, "Inj, bupivacaine, nos, 0.5mg",J0665,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.02,,,,,,,fee schedule,0.01,0.02, "Inj, bupivacaine, nos, 0.5mg",J0665,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.01,,,,,,,fee schedule,0.01,0.02, "Inj, bupivacaine, nos, 0.5mg",J0665,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.01,,,,,,,fee schedule,0.01,0.02, "Inj, bupivacaine liposome",J0666,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,3.35,,,,,,,fee schedule,1.82,3.62, "Inj, bupivacaine liposome",J0666,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,3.62,,,,,,,fee schedule,1.82,3.62, "Inj, bupivacaine liposome",J0666,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.82,,,,,,,fee schedule,1.82,3.62, "Inj, bupivacaine liposome",J0666,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.82,,,,,,,fee schedule,1.82,3.62, Inj mepivacaine HCL/10 ml,J0670,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,8.6,,,,,,,fee schedule,4.66,9.28, Inj mepivacaine HCL/10 ml,J0670,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,9.28,,,,,,,fee schedule,4.66,9.28, Inj mepivacaine HCL/10 ml,J0670,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.66,,,,,,,fee schedule,4.66,9.28, Inj mepivacaine HCL/10 ml,J0670,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4.66,,,,,,,fee schedule,4.66,9.28, Inj cefazolin (wg crit care),J0687,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,2.25,,,,,,,fee schedule,1.22,2.43, Inj cefazolin (wg crit care),J0687,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,2.43,,,,,,,fee schedule,1.22,2.43, Inj cefazolin (wg crit care),J0687,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.22,,,,,,,fee schedule,1.22,2.43, Inj cefazolin (wg crit care),J0687,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.22,,,,,,,fee schedule,1.22,2.43, "Inj cefazolin sodium, hikma",J0688,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,2.05,,,,,,,fee schedule,1.11,2.21, "Inj cefazolin sodium, hikma",J0688,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,2.21,,,,,,,fee schedule,1.11,2.21, "Inj cefazolin sodium, hikma",J0688,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.11,,,,,,,fee schedule,1.11,2.21, "Inj cefazolin sodium, hikma",J0688,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.11,,,,,,,fee schedule,1.11,2.21, "Inj cefazolin sodium, baxter",J0689,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,2.99,,,,,,,fee schedule,1.62,3.23, "Inj cefazolin sodium, baxter",J0689,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,3.23,,,,,,,fee schedule,1.62,3.23, "Inj cefazolin sodium, baxter",J0689,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.62,,,,,,,fee schedule,1.62,3.23, "Inj cefazolin sodium, baxter",J0689,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.62,,,,,,,fee schedule,1.62,3.23, Cefazolin sodium injection,J0690,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,1.89,,,,,,,fee schedule,1.02,2.04, Cefazolin sodium injection,J0690,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,2.04,,,,,,,fee schedule,1.02,2.04, Cefazolin sodium injection,J0690,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.02,,,,,,,fee schedule,1.02,2.04, Cefazolin sodium injection,J0690,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.02,,,,,,,fee schedule,1.02,2.04, Inj lefamulin 1 mg,J0691,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1,,,,,,,fee schedule,1,1, Inj lefamulin 1 mg,J0691,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1,,,,,,,fee schedule,1,1, Cefepime hcl for injection,J0692,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,2.77,,,,,,,fee schedule,1.5,2.99, Cefepime hcl for injection,J0692,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,2.99,,,,,,,fee schedule,1.5,2.99, Cefepime hcl for injection,J0692,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.5,,,,,,,fee schedule,1.5,2.99, Cefepime hcl for injection,J0692,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.5,,,,,,,fee schedule,1.5,2.99, Cefoxitin sodium injection,J0694,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,11.54,,,,,,,fee schedule,6.26,12.47, Cefoxitin sodium injection,J0694,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,12.47,,,,,,,fee schedule,6.26,12.47, Cefoxitin sodium injection,J0694,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.26,,,,,,,fee schedule,6.26,12.47, Cefoxitin sodium injection,J0694,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,6.26,,,,,,,fee schedule,6.26,12.47, Inj ceftolozane tazobactam,J0695,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,20.54,,,,,,,fee schedule,11.14,22.19, Inj ceftolozane tazobactam,J0695,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,22.19,,,,,,,fee schedule,11.14,22.19, Inj ceftolozane tazobactam,J0695,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.14,,,,,,,fee schedule,11.14,22.19, Inj ceftolozane tazobactam,J0695,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11.14,,,,,,,fee schedule,11.14,22.19, Ceftriaxone sodium injection,J0696,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,1.08,,,,,,,fee schedule,0.59,1.17, Ceftriaxone sodium injection,J0696,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,1.17,,,,,,,fee schedule,0.59,1.17, Ceftriaxone sodium injection,J0696,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.59,,,,,,,fee schedule,0.59,1.17, Ceftriaxone sodium injection,J0696,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.59,,,,,,,fee schedule,0.59,1.17, Sterile cefuroxime injection,J0697,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,5.15,,,,,,,fee schedule,2.79,5.56, Sterile cefuroxime injection,J0697,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,5.56,,,,,,,fee schedule,2.79,5.56, Sterile cefuroxime injection,J0697,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2.79,,,,,,,fee schedule,2.79,5.56, Sterile cefuroxime injection,J0697,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2.79,,,,,,,fee schedule,2.79,5.56, Cefotaxime sodium injection,J0698,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.69,,,,,,,fee schedule,8.69,8.69, Cefotaxime sodium injection,J0698,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,8.69,,,,,,,fee schedule,8.69,8.69, "Inj, cefiderocol, 10 mg",J0699,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,5.4,,,,,,,fee schedule,2.93,5.83, "Inj, cefiderocol, 10 mg",J0699,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,5.83,,,,,,,fee schedule,2.93,5.83, "Inj, cefiderocol, 10 mg",J0699,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2.93,,,,,,,fee schedule,2.93,5.83, "Inj, cefiderocol, 10 mg",J0699,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2.93,,,,,,,fee schedule,2.93,5.83, Inj. cefepime hcl (baxter),J0701,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,13.21,,,,,,,fee schedule,7.16,14.26, Inj. cefepime hcl (baxter),J0701,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,14.26,,,,,,,fee schedule,7.16,14.26, Inj. cefepime hcl (baxter),J0701,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.16,,,,,,,fee schedule,7.16,14.26, Inj. cefepime hcl (baxter),J0701,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,7.16,,,,,,,fee schedule,7.16,14.26, Betamethasone acet&sod phosp,J0702,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,15.5,,,,,,,fee schedule,8.41,16.74, Betamethasone acet&sod phosp,J0702,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,16.74,,,,,,,fee schedule,8.41,16.74, Betamethasone acet&sod phosp,J0702,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.41,,,,,,,fee schedule,8.41,16.74, Betamethasone acet&sod phosp,J0702,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,8.41,,,,,,,fee schedule,8.41,16.74, "Inj, cefepime hcl (b braun)",J0703,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,11.41,,,,,,,fee schedule,6.19,12.32, "Inj, cefepime hcl (b braun)",J0703,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,12.32,,,,,,,fee schedule,6.19,12.32, "Inj, cefepime hcl (b braun)",J0703,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.19,,,,,,,fee schedule,6.19,12.32, "Inj, cefepime hcl (b braun)",J0703,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,6.19,,,,,,,fee schedule,6.19,12.32, Caffeine citrate injection,J0706,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2.48,,,,,,,fee schedule,2.48,2.48, Caffeine citrate injection,J0706,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2.48,,,,,,,fee schedule,2.48,2.48, Ceftaroline fosamil inj,J0712,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,9.54,,,,,,,fee schedule,5.17,10.3, Ceftaroline fosamil inj,J0712,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,10.3,,,,,,,fee schedule,5.17,10.3, Ceftaroline fosamil inj,J0712,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.17,,,,,,,fee schedule,5.17,10.3, Ceftaroline fosamil inj,J0712,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5.17,,,,,,,fee schedule,5.17,10.3, Inj ceftazidime per 500 mg,J0713,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,3.69,,,,,,,fee schedule,2,3.99, Inj ceftazidime per 500 mg,J0713,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,3.99,,,,,,,fee schedule,2,3.99, Inj ceftazidime per 500 mg,J0713,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2,,,,,,,fee schedule,2,3.99, Inj ceftazidime per 500 mg,J0713,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2,,,,,,,fee schedule,2,3.99, Ceftazidime and avibactam,J0714,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,236.14,,,,,,,fee schedule,128.04,255.03, Ceftazidime and avibactam,J0714,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,255.03,,,,,,,fee schedule,128.04,255.03, Ceftazidime and avibactam,J0714,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,128.04,,,,,,,fee schedule,128.04,255.03, Ceftazidime and avibactam,J0714,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,128.04,,,,,,,fee schedule,128.04,255.03, Centruroides immune f(ab),J0716,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5927.99,,,,,,,fee schedule,5927.99,5927.99, Centruroides immune f(ab),J0716,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5927.99,,,,,,,fee schedule,5927.99,5927.99, Certolizumab pegol inj 1mg,J0717,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,10.1,,,,,,,fee schedule,5.48,10.91, Certolizumab pegol inj 1mg,J0717,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,10.91,,,,,,,fee schedule,5.48,10.91, Certolizumab pegol inj 1mg,J0717,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.48,,,,,,,fee schedule,5.48,10.91, Certolizumab pegol inj 1mg,J0717,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5.48,,,,,,,fee schedule,5.48,10.91, Chloramphenicol sodium injec,J0720,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,71.22,,,,,,,fee schedule,71.22,71.22, Chloramphenicol sodium injec,J0720,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,71.22,,,,,,,fee schedule,71.22,71.22, Chorionic gonadotropin/1000u,J0725,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,39.4,,,,,,,fee schedule,21.36,42.55, Chorionic gonadotropin/1000u,J0725,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,42.55,,,,,,,fee schedule,21.36,42.55, Chorionic gonadotropin/1000u,J0725,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21.36,,,,,,,fee schedule,21.36,42.55, Chorionic gonadotropin/1000u,J0725,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,21.36,,,,,,,fee schedule,21.36,42.55, Clonidine hydrochloride,J0735,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,39.76,,,,,,,fee schedule,21.56,42.94, Clonidine hydrochloride,J0735,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,42.94,,,,,,,fee schedule,21.56,42.94, Clonidine hydrochloride,J0735,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21.56,,,,,,,fee schedule,21.56,42.94, Clonidine hydrochloride,J0735,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,21.56,,,,,,,fee schedule,21.56,42.94, "Inj, clindamycin phosp 300mg",J0736,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,3.76,,,,,,,fee schedule,2.04,4.06, "Inj, clindamycin phosp 300mg",J0736,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,4.06,,,,,,,fee schedule,2.04,4.06, "Inj, clindamycin phosp 300mg",J0736,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2.04,,,,,,,fee schedule,2.04,4.06, "Inj, clindamycin phosp 300mg",J0736,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2.04,,,,,,,fee schedule,2.04,4.06, "Inj, clindamycin (baxter)",J0737,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,3.87,,,,,,,fee schedule,2.1,4.18, "Inj, clindamycin (baxter)",J0737,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,4.18,,,,,,,fee schedule,2.1,4.18, "Inj, clindamycin (baxter)",J0737,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2.1,,,,,,,fee schedule,2.1,4.18, "Inj, clindamycin (baxter)",J0737,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2.1,,,,,,,fee schedule,2.1,4.18, "Injection, cabotegravir 1 mg",J0739,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,15.82,,,,,,,fee schedule,8.58,17.08, "Injection, cabotegravir 1 mg",J0739,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,17.08,,,,,,,fee schedule,8.58,17.08, "Injection, cabotegravir 1 mg",J0739,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.58,,,,,,,fee schedule,8.58,17.08, "Injection, cabotegravir 1 mg",J0739,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,8.58,,,,,,,fee schedule,8.58,17.08, Cidofovir injection,J0740,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,1191.11,,,,,,,fee schedule,645.84,1286.39, Cidofovir injection,J0740,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,1286.39,,,,,,,fee schedule,645.84,1286.39, Cidofovir injection,J0740,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,645.84,,,,,,,fee schedule,645.84,1286.39, Cidofovir injection,J0740,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,645.84,,,,,,,fee schedule,645.84,1286.39, "Inj, cabote rilpivir 2mg 3mg",J0741,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,53.17,,,,,,,fee schedule,28.83,57.42, "Inj, cabote rilpivir 2mg 3mg",J0741,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,57.42,,,,,,,fee schedule,28.83,57.42, "Inj, cabote rilpivir 2mg 3mg",J0741,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,28.83,,,,,,,fee schedule,28.83,57.42, "Inj, cabote rilpivir 2mg 3mg",J0741,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,28.83,,,,,,,fee schedule,28.83,57.42, Inj imip 4 cilas 4 releb 2mg,J0742,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,5.87,,,,,,,fee schedule,3.18,6.34, Inj imip 4 cilas 4 releb 2mg,J0742,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,6.34,,,,,,,fee schedule,3.18,6.34, Inj imip 4 cilas 4 releb 2mg,J0742,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3.18,,,,,,,fee schedule,3.18,6.34, Inj imip 4 cilas 4 releb 2mg,J0742,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3.18,,,,,,,fee schedule,3.18,6.34, Cilastatin sodium injection,J0743,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,15.68,,,,,,,fee schedule,8.5,16.94, Cilastatin sodium injection,J0743,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,16.94,,,,,,,fee schedule,8.5,16.94, Cilastatin sodium injection,J0743,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.5,,,,,,,fee schedule,8.5,16.94, Cilastatin sodium injection,J0743,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,8.5,,,,,,,fee schedule,8.5,16.94, Ciprofloxacin iv,J0744,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,5.22,,,,,,,fee schedule,2.83,5.64, Ciprofloxacin iv,J0744,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,5.64,,,,,,,fee schedule,2.83,5.64, Ciprofloxacin iv,J0744,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2.83,,,,,,,fee schedule,2.83,5.64, Ciprofloxacin iv,J0744,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2.83,,,,,,,fee schedule,2.83,5.64, Inj codeine phosphate /30 MG,J0745,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.18,,,,,,,fee schedule,1.18,1.18, Inj codeine phosphate /30 MG,J0745,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.18,,,,,,,fee schedule,1.18,1.18, "Hiv prep, ftc/tdf 200/300mg",J0750,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,3.92,,,,,,,fee schedule,2.12,4.23, "Hiv prep, ftc/tdf 200/300mg",J0750,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,4.23,,,,,,,fee schedule,2.12,4.23, "Hiv prep, ftc/tdf 200/300mg",J0750,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2.12,,,,,,,fee schedule,2.12,4.23, "Hiv prep, ftc/tdf 200/300mg",J0750,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2.12,,,,,,,fee schedule,2.12,4.23, "Hiv prep, ftc/taf 200/25mg",J0751,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,160.36,,,,,,,fee schedule,86.95,173.19, "Hiv prep, ftc/taf 200/25mg",J0751,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,173.19,,,,,,,fee schedule,86.95,173.19, "Hiv prep, ftc/taf 200/25mg",J0751,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,86.95,,,,,,,fee schedule,86.95,173.19, "Hiv prep, ftc/taf 200/25mg",J0751,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,86.95,,,,,,,fee schedule,86.95,173.19, Colistimethate sodium inj,J0770,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,25.63,,,,,,,fee schedule,13.9,27.68, Colistimethate sodium inj,J0770,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,27.68,,,,,,,fee schedule,13.9,27.68, Colistimethate sodium inj,J0770,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13.9,,,,,,,fee schedule,13.9,27.68, Colistimethate sodium inj,J0770,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13.9,,,,,,,fee schedule,13.9,27.68, "Collagenase, clost hist inj",J0775,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,164.61,,,,,,,fee schedule,80.48,177.78, "Collagenase, clost hist inj",J0775,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,177.78,,,,,,,fee schedule,80.48,177.78, "Collagenase, clost hist inj",J0775,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,80.48,,,,,,,fee schedule,80.48,177.78, "Collagenase, clost hist inj",J0775,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,80.48,,,,,,,fee schedule,80.48,177.78, Prochlorperazine injection,J0780,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,5.67,,,,,,,fee schedule,3.07,6.12, Prochlorperazine injection,J0780,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,6.12,,,,,,,fee schedule,3.07,6.12, Prochlorperazine injection,J0780,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3.07,,,,,,,fee schedule,3.07,6.12, Prochlorperazine injection,J0780,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3.07,,,,,,,fee schedule,3.07,6.12, Inj crizanlizumab-tmca 5mg,J0791,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,291.56,,,,,,,fee schedule,158.09,314.88, Inj crizanlizumab-tmca 5mg,J0791,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,314.88,,,,,,,fee schedule,158.09,314.88, Inj crizanlizumab-tmca 5mg,J0791,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,158.09,,,,,,,fee schedule,158.09,314.88, Inj crizanlizumab-tmca 5mg,J0791,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,158.09,,,,,,,fee schedule,158.09,314.88, Corticorelin ovine triflutal,J0795,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.14,,,,,,,fee schedule,5.14,5.14, Corticorelin ovine triflutal,J0795,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5.14,,,,,,,fee schedule,5.14,5.14, Inj. acthar gel to 40 units,J0801,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,9421.72,,,,,,,fee schedule,5108.66,10175.45, Inj. acthar gel to 40 units,J0801,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,10175.45,,,,,,,fee schedule,5108.66,10175.45, Inj. acthar gel to 40 units,J0801,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5108.66,,,,,,,fee schedule,5108.66,10175.45, Inj. acthar gel to 40 units,J0801,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5108.66,,,,,,,fee schedule,5108.66,10175.45, "Inj. (ani), up to 40 units",J0802,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,7981.47,,,,,,,fee schedule,4327.73,8619.99, "Inj. (ani), up to 40 units",J0802,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,8619.99,,,,,,,fee schedule,4327.73,8619.99, "Inj. (ani), up to 40 units",J0802,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4327.73,,,,,,,fee schedule,4327.73,8619.99, "Inj. (ani), up to 40 units",J0802,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4327.73,,,,,,,fee schedule,4327.73,8619.99, Cosyntropin cortrosyn inj,J0834,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,63.05,,,,,,,fee schedule,34.18,68.09, Cosyntropin cortrosyn inj,J0834,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,68.09,,,,,,,fee schedule,34.18,68.09, Cosyntropin cortrosyn inj,J0834,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,34.18,,,,,,,fee schedule,34.18,68.09, Cosyntropin cortrosyn inj,J0834,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,34.18,,,,,,,fee schedule,34.18,68.09, Crotalidae poly immune fab,J0840,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,4187.54,,,,,,,fee schedule,2270.58,4522.55, Crotalidae poly immune fab,J0840,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,4522.55,,,,,,,fee schedule,2270.58,4522.55, Crotalidae poly immune fab,J0840,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2270.58,,,,,,,fee schedule,2270.58,4522.55, Crotalidae poly immune fab,J0840,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2270.58,,,,,,,fee schedule,2270.58,4522.55, Inj crotalidae im f(ab')2 eq,J0841,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,2349.32,,,,,,,fee schedule,1273.85,2537.26, Inj crotalidae im f(ab')2 eq,J0841,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,2537.26,,,,,,,fee schedule,1273.85,2537.26, Inj crotalidae im f(ab')2 eq,J0841,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1273.85,,,,,,,fee schedule,1273.85,2537.26, Inj crotalidae im f(ab')2 eq,J0841,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1273.85,,,,,,,fee schedule,1273.85,2537.26, Cytomegalovirus imm IV /vial,J0850,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,4071.24,,,,,,,fee schedule,2207.52,4396.94, Cytomegalovirus imm IV /vial,J0850,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,4396.94,,,,,,,fee schedule,2207.52,4396.94, Cytomegalovirus imm IV /vial,J0850,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2207.52,,,,,,,fee schedule,2207.52,4396.94, Cytomegalovirus imm IV /vial,J0850,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2207.52,,,,,,,fee schedule,2207.52,4396.94, "Injection, imetelstat, 1 mg",J0870,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,128.3,,,,,,,fee schedule,69.56,138.56, "Injection, imetelstat, 1 mg",J0870,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,138.56,,,,,,,fee schedule,69.56,138.56, "Injection, imetelstat, 1 mg",J0870,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,69.56,,,,,,,fee schedule,69.56,138.56, "Injection, imetelstat, 1 mg",J0870,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,69.56,,,,,,,fee schedule,69.56,138.56, Daptomycin (xellia) unrefrig,J0872,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.11,,,,,,,fee schedule,0.06,0.12, Daptomycin (xellia) unrefrig,J0872,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.12,,,,,,,fee schedule,0.06,0.12, Daptomycin (xellia) unrefrig,J0872,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.06,,,,,,,fee schedule,0.06,0.12, Daptomycin (xellia) unrefrig,J0872,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.06,,,,,,,fee schedule,0.06,0.12, "Inj, daptomycin (xellia)",J0873,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.09,,,,,,,fee schedule,0.05,0.1, "Inj, daptomycin (xellia)",J0873,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.1,,,,,,,fee schedule,0.05,0.1, "Inj, daptomycin (xellia)",J0873,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.05,,,,,,,fee schedule,0.05,0.1, "Inj, daptomycin (xellia)",J0873,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.05,,,,,,,fee schedule,0.05,0.1, "Inj, daptomycin (baxter)",J0874,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.14,,,,,,,fee schedule,0.07,0.15, "Inj, daptomycin (baxter)",J0874,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.15,,,,,,,fee schedule,0.07,0.15, "Inj, daptomycin (baxter)",J0874,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.07,,,,,,,fee schedule,0.07,0.15, "Inj, daptomycin (baxter)",J0874,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.07,,,,,,,fee schedule,0.07,0.15, "Injection, dalbavancin",J0875,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,34.99,,,,,,,fee schedule,18.97,37.79, "Injection, dalbavancin",J0875,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,37.79,,,,,,,fee schedule,18.97,37.79, "Injection, dalbavancin",J0875,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.97,,,,,,,fee schedule,18.97,37.79, "Injection, dalbavancin",J0875,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,18.97,,,,,,,fee schedule,18.97,37.79, "Inj, daptomycin (hospira)",J0877,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.14,,,,,,,fee schedule,0.07,0.15, "Inj, daptomycin (hospira)",J0877,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.15,,,,,,,fee schedule,0.07,0.15, "Inj, daptomycin (hospira)",J0877,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.07,,,,,,,fee schedule,0.07,0.15, "Inj, daptomycin (hospira)",J0877,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.07,,,,,,,fee schedule,0.07,0.15, Daptomycin injection,J0878,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.07,,,,,,,fee schedule,0.04,0.07, Daptomycin injection,J0878,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.07,,,,,,,fee schedule,0.04,0.07, Daptomycin injection,J0878,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.04,,,,,,,fee schedule,0.04,0.07, Daptomycin injection,J0878,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.04,,,,,,,fee schedule,0.04,0.07, "Difelikefalin, esrd on dialy",J0879,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.1,,,,,,,fee schedule,0.1,0.1, "Difelikefalin, esrd on dialy",J0879,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.1,,,,,,,fee schedule,0.1,0.1, "Darbepoetin alfa, non-esrd",J0881,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,6.75,,,,,,,fee schedule,3.66,7.29, "Darbepoetin alfa, non-esrd",J0881,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,7.29,,,,,,,fee schedule,3.66,7.29, "Darbepoetin alfa, non-esrd",J0881,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3.66,,,,,,,fee schedule,3.66,7.29, "Darbepoetin alfa, non-esrd",J0881,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3.66,,,,,,,fee schedule,3.66,7.29, "Darbepoetin alfa, esrd use",J0882,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,6.75,,,,,,,fee schedule,3.66,7.29, "Darbepoetin alfa, esrd use",J0882,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,7.29,,,,,,,fee schedule,3.66,7.29, "Darbepoetin alfa, esrd use",J0882,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3.66,,,,,,,fee schedule,3.66,7.29, "Darbepoetin alfa, esrd use",J0882,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3.66,,,,,,,fee schedule,3.66,7.29, Argatroban nonesrd use 1mg,J0883,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,1.67,,,,,,,fee schedule,0.9,1.8, Argatroban nonesrd use 1mg,J0883,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,1.8,,,,,,,fee schedule,0.9,1.8, Argatroban nonesrd use 1mg,J0883,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.9,,,,,,,fee schedule,0.9,1.8, Argatroban nonesrd use 1mg,J0883,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.9,,,,,,,fee schedule,0.9,1.8, Argatroban esrd dialysis 1mg,J0884,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,1.67,,,,,,,fee schedule,0.9,1.8, Argatroban esrd dialysis 1mg,J0884,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,1.8,,,,,,,fee schedule,0.9,1.8, Argatroban esrd dialysis 1mg,J0884,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.9,,,,,,,fee schedule,0.9,1.8, Argatroban esrd dialysis 1mg,J0884,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.9,,,,,,,fee schedule,0.9,1.8, "Epoetin alfa, non-esrd",J0885,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,17.28,,,,,,,fee schedule,9.37,18.66, "Epoetin alfa, non-esrd",J0885,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,18.66,,,,,,,fee schedule,9.37,18.66, "Epoetin alfa, non-esrd",J0885,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.37,,,,,,,fee schedule,9.37,18.66, "Epoetin alfa, non-esrd",J0885,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9.37,,,,,,,fee schedule,9.37,18.66, Epoetin beta esrd use,J0887,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,3.17,,,,,,,fee schedule,1.72,3.43, Epoetin beta esrd use,J0887,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,3.43,,,,,,,fee schedule,1.72,3.43, Epoetin beta esrd use,J0887,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.72,,,,,,,fee schedule,1.72,3.43, Epoetin beta esrd use,J0887,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.72,,,,,,,fee schedule,1.72,3.43, Epoetin beta non esrd,J0888,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,3.17,,,,,,,fee schedule,1.72,3.43, Epoetin beta non esrd,J0888,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,3.43,,,,,,,fee schedule,1.72,3.43, Epoetin beta non esrd,J0888,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.72,,,,,,,fee schedule,1.72,3.43, Epoetin beta non esrd,J0888,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.72,,,,,,,fee schedule,1.72,3.43, Argatroban nonesrd (accord),J0891,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2.22,,,,,,,fee schedule,2.22,2.22, Argatroban nonesrd (accord),J0891,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2.22,,,,,,,fee schedule,2.22,2.22, Argatroban dialysis (accord),J0892,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.8,,,,,,,fee schedule,5.8,5.8, Argatroban dialysis (accord),J0892,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5.8,,,,,,,fee schedule,5.8,5.8, "Inj, decitabine (sun pharma)",J0893,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,1.76,,,,,,,fee schedule,0.95,1.9, "Inj, decitabine (sun pharma)",J0893,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,1.9,,,,,,,fee schedule,0.95,1.9, "Inj, decitabine (sun pharma)",J0893,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.95,,,,,,,fee schedule,0.95,1.9, "Inj, decitabine (sun pharma)",J0893,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.95,,,,,,,fee schedule,0.95,1.9, Decitabine injection,J0894,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,3.58,,,,,,,fee schedule,1.94,3.86, Decitabine injection,J0894,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,3.86,,,,,,,fee schedule,1.94,3.86, Decitabine injection,J0894,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.94,,,,,,,fee schedule,1.94,3.86, Decitabine injection,J0894,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.94,,,,,,,fee schedule,1.94,3.86, Deferoxamine mesylate inj,J0895,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,20.3,,,,,,,fee schedule,11,21.92, Deferoxamine mesylate inj,J0895,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,21.92,,,,,,,fee schedule,11,21.92, Deferoxamine mesylate inj,J0895,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11,,,,,,,fee schedule,11,21.92, Deferoxamine mesylate inj,J0895,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11,,,,,,,fee schedule,11,21.92, Inj luspatercept-aamt 0.25mg,J0896,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,94.41,,,,,,,fee schedule,51.19,101.96, Inj luspatercept-aamt 0.25mg,J0896,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,101.96,,,,,,,fee schedule,51.19,101.96, Inj luspatercept-aamt 0.25mg,J0896,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,51.19,,,,,,,fee schedule,51.19,101.96, Inj luspatercept-aamt 0.25mg,J0896,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,51.19,,,,,,,fee schedule,51.19,101.96, Denosumab injection,J0897,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,65.79,,,,,,,fee schedule,35.67,71.05, Denosumab injection,J0897,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,71.05,,,,,,,fee schedule,35.67,71.05, Denosumab injection,J0897,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,35.67,,,,,,,fee schedule,35.67,71.05, Denosumab injection,J0897,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,35.67,,,,,,,fee schedule,35.67,71.05, Argatroban nonesrd (auromed),J0898,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,3.26,,,,,,,fee schedule,1.77,3.52, Argatroban nonesrd (auromed),J0898,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,3.52,,,,,,,fee schedule,1.77,3.52, Argatroban nonesrd (auromed),J0898,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.77,,,,,,,fee schedule,1.77,3.52, Argatroban nonesrd (auromed),J0898,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.77,,,,,,,fee schedule,1.77,3.52, "Argatroban dialysis, auromed",J0899,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,3.26,,,,,,,fee schedule,1.77,3.52, "Argatroban dialysis, auromed",J0899,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,3.52,,,,,,,fee schedule,1.77,3.52, "Argatroban dialysis, auromed",J0899,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.77,,,,,,,fee schedule,1.77,3.52, "Argatroban dialysis, auromed",J0899,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.77,,,,,,,fee schedule,1.77,3.52, Vadadustat oral 1mg for esrd,J0901,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.21,,,,,,,fee schedule,0.21,0.21, Vadadustat oral 1mg for esrd,J0901,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.21,,,,,,,fee schedule,0.21,0.21, Inst tauro 1.35mg/hep 100u,J0911,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.37,,,,,,,fee schedule,9.37,9.37, Inst tauro 1.35mg/hep 100u,J0911,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9.37,,,,,,,fee schedule,9.37,9.37, Brompheniramine maleate inj,J0945,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.39,,,,,,,fee schedule,0.39,0.39, Brompheniramine maleate inj,J0945,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.39,,,,,,,fee schedule,0.39,0.39, Depo-estradiol cypionate inj,J1000,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,105.55,,,,,,,fee schedule,57.23,113.99, Depo-estradiol cypionate inj,J1000,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,113.99,,,,,,,fee schedule,57.23,113.99, Depo-estradiol cypionate inj,J1000,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,57.23,,,,,,,fee schedule,57.23,113.99, Depo-estradiol cypionate inj,J1000,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,57.23,,,,,,,fee schedule,57.23,113.99, "Inj, methylpred acetate 1 mg",J1010,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.27,,,,,,,fee schedule,0.15,0.29, "Inj, methylpred acetate 1 mg",J1010,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.29,,,,,,,fee schedule,0.15,0.29, "Inj, methylpred acetate 1 mg",J1010,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.15,,,,,,,fee schedule,0.15,0.29, "Inj, methylpred acetate 1 mg",J1010,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.15,,,,,,,fee schedule,0.15,0.29, Medroxyprogesterone acetate,J1050,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.66,,,,,,,fee schedule,0.66,0.66, Medroxyprogesterone acetate,J1050,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.66,,,,,,,fee schedule,0.66,0.66, Inj testosterone cypionate,J1071,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.07,,,,,,,fee schedule,0.04,0.07, Inj testosterone cypionate,J1071,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.07,,,,,,,fee schedule,0.04,0.07, Inj testosterone cypionate,J1071,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.04,,,,,,,fee schedule,0.04,0.07, Inj testosterone cypionate,J1071,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.04,,,,,,,fee schedule,0.04,0.07, "Inj, testosterone, azmiro",J1072,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,2.97,,,,,,,fee schedule,1.62,3.21, "Inj, testosterone, azmiro",J1072,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,3.21,,,,,,,fee schedule,1.62,3.21, "Inj, testosterone, azmiro",J1072,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.62,,,,,,,fee schedule,1.62,3.21, "Inj, testosterone, azmiro",J1072,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.62,,,,,,,fee schedule,1.62,3.21, "Injection, dexamethasone 9%",J1095,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3.31,,,,,,,fee schedule,3.31,3.31, "Injection, dexamethasone 9%",J1095,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3.31,,,,,,,fee schedule,3.31,3.31, Dexametha opth insert 0.1 mg,J1096,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,228.35,,,,,,,fee schedule,123.82,246.62, Dexametha opth insert 0.1 mg,J1096,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,246.62,,,,,,,fee schedule,123.82,246.62, Dexametha opth insert 0.1 mg,J1096,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,123.82,,,,,,,fee schedule,123.82,246.62, Dexametha opth insert 0.1 mg,J1096,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,123.82,,,,,,,fee schedule,123.82,246.62, Phenylep ketorolac opth soln,J1097,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,118.85,,,,,,,fee schedule,118.85,118.85, Phenylep ketorolac opth soln,J1097,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,118.85,,,,,,,fee schedule,118.85,118.85, Dexamethasone sodium phos,J1100,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.27,,,,,,,fee schedule,0.15,0.29, Dexamethasone sodium phos,J1100,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.29,,,,,,,fee schedule,0.15,0.29, Dexamethasone sodium phos,J1100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.15,,,,,,,fee schedule,0.15,0.29, Dexamethasone sodium phos,J1100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.15,,,,,,,fee schedule,0.15,0.29, "Dexmedetomidine film, 1 mcg",J1105,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.78,,,,,,,fee schedule,0.78,0.78, "Dexmedetomidine film, 1 mcg",J1105,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.78,,,,,,,fee schedule,0.78,0.78, Inj dihydroergotamine mesylt,J1110,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,218.41,,,,,,,fee schedule,118.43,235.88, Inj dihydroergotamine mesylt,J1110,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,235.88,,,,,,,fee schedule,118.43,235.88, Inj dihydroergotamine mesylt,J1110,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,118.43,,,,,,,fee schedule,118.43,235.88, Inj dihydroergotamine mesylt,J1110,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,118.43,,,,,,,fee schedule,118.43,235.88, Acetazolamid sodium injectio,J1120,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,38.77,,,,,,,fee schedule,21.02,41.87, Acetazolamid sodium injectio,J1120,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,41.87,,,,,,,fee schedule,21.02,41.87, Acetazolamid sodium injectio,J1120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21.02,,,,,,,fee schedule,21.02,41.87, Acetazolamid sodium injectio,J1120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,21.02,,,,,,,fee schedule,21.02,41.87, Digoxin injection,J1160,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,9,,,,,,,fee schedule,4.88,9.72, Digoxin injection,J1160,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,9.72,,,,,,,fee schedule,4.88,9.72, Digoxin injection,J1160,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.88,,,,,,,fee schedule,4.88,9.72, Digoxin injection,J1160,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4.88,,,,,,,fee schedule,4.88,9.72, Digoxin immune fab (ovine),J1162,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,11179.31,,,,,,,fee schedule,6061.67,12073.65, Digoxin immune fab (ovine),J1162,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,12073.65,,,,,,,fee schedule,6061.67,12073.65, Digoxin immune fab (ovine),J1162,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6061.67,,,,,,,fee schedule,6061.67,12073.65, Digoxin immune fab (ovine),J1162,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,6061.67,,,,,,,fee schedule,6061.67,12073.65, "Inj, diltiazem hcl, 0.5 mg",J1163,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.09,,,,,,,fee schedule,0.05,0.1, "Inj, diltiazem hcl, 0.5 mg",J1163,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.1,,,,,,,fee schedule,0.05,0.1, "Inj, diltiazem hcl, 0.5 mg",J1163,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.05,,,,,,,fee schedule,0.05,0.1, "Inj, diltiazem hcl, 0.5 mg",J1163,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.05,,,,,,,fee schedule,0.05,0.1, Phenytoin sodium injection,J1165,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,1.49,,,,,,,fee schedule,0.81,1.6, Phenytoin sodium injection,J1165,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,1.6,,,,,,,fee schedule,0.81,1.6, Phenytoin sodium injection,J1165,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.81,,,,,,,fee schedule,0.81,1.6, Phenytoin sodium injection,J1165,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.81,,,,,,,fee schedule,0.81,1.6, "Inj, hydromorphone, 0.1 mg",J1171,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.18,,,,,,,fee schedule,0.11,0.19, "Inj, hydromorphone, 0.1 mg",J1171,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.19,,,,,,,fee schedule,0.11,0.19, "Inj, hydromorphone, 0.1 mg",J1171,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.11,,,,,,,fee schedule,0.11,0.19, "Inj, hydromorphone, 0.1 mg",J1171,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.11,,,,,,,fee schedule,0.11,0.19, Dexrazoxane hcl injection,J1190,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,72.18,,,,,,,fee schedule,39.15,77.95, Dexrazoxane hcl injection,J1190,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,77.95,,,,,,,fee schedule,39.15,77.95, Dexrazoxane hcl injection,J1190,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,39.15,,,,,,,fee schedule,39.15,77.95, Dexrazoxane hcl injection,J1190,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,39.15,,,,,,,fee schedule,39.15,77.95, Diphenhydramine hcl injectio,J1200,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,2.03,,,,,,,fee schedule,1.1,2.19, Diphenhydramine hcl injectio,J1200,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,2.19,,,,,,,fee schedule,1.1,2.19, Diphenhydramine hcl injectio,J1200,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.1,,,,,,,fee schedule,1.1,2.19, Diphenhydramine hcl injectio,J1200,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.1,,,,,,,fee schedule,1.1,2.19, Inj. cetirizine hcl 0.5mg,J1201,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,36.9,,,,,,,fee schedule,20.01,39.85, Inj. cetirizine hcl 0.5mg,J1201,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,39.85,,,,,,,fee schedule,20.01,39.85, Inj. cetirizine hcl 0.5mg,J1201,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,20.01,,,,,,,fee schedule,20.01,39.85, Inj. cetirizine hcl 0.5mg,J1201,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,20.01,,,,,,,fee schedule,20.01,39.85, Miglustat oral 65 mg,J1202,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,49.07,,,,,,,fee schedule,49.07,49.07, Miglustat oral 65 mg,J1202,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,49.07,,,,,,,fee schedule,49.07,49.07, "Inj, cipaglucosidase, 5 mg",J1203,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,202.05,,,,,,,fee schedule,109.56,218.21, "Inj, cipaglucosidase, 5 mg",J1203,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,218.21,,,,,,,fee schedule,109.56,218.21, "Inj, cipaglucosidase, 5 mg",J1203,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,109.56,,,,,,,fee schedule,109.56,218.21, "Inj, cipaglucosidase, 5 mg",J1203,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,109.56,,,,,,,fee schedule,109.56,218.21, Chlorothiazide sodium inj,J1205,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,90.86,,,,,,,fee schedule,49.26,98.12, Chlorothiazide sodium inj,J1205,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,98.12,,,,,,,fee schedule,49.26,98.12, Chlorothiazide sodium inj,J1205,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,49.26,,,,,,,fee schedule,49.26,98.12, Chlorothiazide sodium inj,J1205,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,49.26,,,,,,,fee schedule,49.26,98.12, Dimethyl sulfoxide 50% 50 ML,J1212,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,1671.53,,,,,,,fee schedule,906.34,1805.25, Dimethyl sulfoxide 50% 50 ML,J1212,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,1805.25,,,,,,,fee schedule,906.34,1805.25, Dimethyl sulfoxide 50% 50 ML,J1212,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,906.34,,,,,,,fee schedule,906.34,1805.25, Dimethyl sulfoxide 50% 50 ML,J1212,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,906.34,,,,,,,fee schedule,906.34,1805.25, Methadone injection,J1230,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,51.55,,,,,,,fee schedule,27.95,55.67, Methadone injection,J1230,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,55.67,,,,,,,fee schedule,27.95,55.67, Methadone injection,J1230,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,27.95,,,,,,,fee schedule,27.95,55.67, Methadone injection,J1230,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,27.95,,,,,,,fee schedule,27.95,55.67, Dimenhydrinate injection,J1240,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,17.42,,,,,,,fee schedule,9.44,18.81, Dimenhydrinate injection,J1240,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,18.81,,,,,,,fee schedule,9.44,18.81, Dimenhydrinate injection,J1240,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.44,,,,,,,fee schedule,9.44,18.81, Dimenhydrinate injection,J1240,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9.44,,,,,,,fee schedule,9.44,18.81, Dipyridamole injection,J1245,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,8.69,,,,,,,fee schedule,4.71,9.38, Dipyridamole injection,J1245,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,9.38,,,,,,,fee schedule,4.71,9.38, Dipyridamole injection,J1245,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.71,,,,,,,fee schedule,4.71,9.38, Dipyridamole injection,J1245,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4.71,,,,,,,fee schedule,4.71,9.38, Inj dobutamine HCL/250 mg,J1250,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,17.96,,,,,,,fee schedule,9.74,19.39, Inj dobutamine HCL/250 mg,J1250,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,19.39,,,,,,,fee schedule,9.74,19.39, Inj dobutamine HCL/250 mg,J1250,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.74,,,,,,,fee schedule,9.74,19.39, Inj dobutamine HCL/250 mg,J1250,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9.74,,,,,,,fee schedule,9.74,19.39, Dolasetron mesylate,J1260,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.34,,,,,,,fee schedule,4.34,4.34, Dolasetron mesylate,J1260,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4.34,,,,,,,fee schedule,4.34,4.34, Dopamine injection,J1265,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,1.49,,,,,,,fee schedule,0.81,1.6, Dopamine injection,J1265,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,1.6,,,,,,,fee schedule,0.81,1.6, Dopamine injection,J1265,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.81,,,,,,,fee schedule,0.81,1.6, Dopamine injection,J1265,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.81,,,,,,,fee schedule,0.81,1.6, Doripenem injection,J1267,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.79,,,,,,,fee schedule,0.79,0.79, Doripenem injection,J1267,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.79,,,,,,,fee schedule,0.79,0.79, "Injection, doxercalciferol",J1270,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.83,,,,,,,fee schedule,0.45,0.9, "Injection, doxercalciferol",J1270,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.9,,,,,,,fee schedule,0.45,0.9, "Injection, doxercalciferol",J1270,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.45,,,,,,,fee schedule,0.45,0.9, "Injection, doxercalciferol",J1270,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.45,,,,,,,fee schedule,0.45,0.9, Inj doxycycline hyclate 1 mg,J1271,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.27,,,,,,,fee schedule,0.15,0.29, Inj doxycycline hyclate 1 mg,J1271,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.29,,,,,,,fee schedule,0.15,0.29, Inj doxycycline hyclate 1 mg,J1271,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.15,,,,,,,fee schedule,0.15,0.29, Inj doxycycline hyclate 1 mg,J1271,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.15,,,,,,,fee schedule,0.15,0.29, Ecallantide injection,J1290,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,1304.98,,,,,,,fee schedule,707.59,1409.38, Ecallantide injection,J1290,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,1409.38,,,,,,,fee schedule,707.59,1409.38, Ecallantide injection,J1290,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,707.59,,,,,,,fee schedule,707.59,1409.38, Ecallantide injection,J1290,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,707.59,,,,,,,fee schedule,707.59,1409.38, "Inj, eculizumab, 2 mg",J1299,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,100.73,,,,,,,fee schedule,54.62,108.79, "Inj, eculizumab, 2 mg",J1299,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,108.79,,,,,,,fee schedule,54.62,108.79, "Inj, eculizumab, 2 mg",J1299,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,54.62,,,,,,,fee schedule,54.62,108.79, "Inj, eculizumab, 2 mg",J1299,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,54.62,,,,,,,fee schedule,54.62,108.79, "Injection, edaravone, 1 mg",J1301,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,42.39,,,,,,,fee schedule,22.98,45.78, "Injection, edaravone, 1 mg",J1301,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,45.78,,,,,,,fee schedule,22.98,45.78, "Injection, edaravone, 1 mg",J1301,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22.98,,,,,,,fee schedule,22.98,45.78, "Injection, edaravone, 1 mg",J1301,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22.98,,,,,,,fee schedule,22.98,45.78, "Inj, sutimlimab-jome, 10 mg",J1302,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,40.75,,,,,,,fee schedule,22.09,44.01, "Inj, sutimlimab-jome, 10 mg",J1302,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,44.01,,,,,,,fee schedule,22.09,44.01, "Inj, sutimlimab-jome, 10 mg",J1302,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22.09,,,,,,,fee schedule,22.09,44.01, "Inj, sutimlimab-jome, 10 mg",J1302,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22.09,,,,,,,fee schedule,22.09,44.01, "Inj., ravulizumab-cwvz 10 mg",J1303,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,506.68,,,,,,,fee schedule,274.73,547.21, "Inj., ravulizumab-cwvz 10 mg",J1303,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,547.21,,,,,,,fee schedule,274.73,547.21, "Inj., ravulizumab-cwvz 10 mg",J1303,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,274.73,,,,,,,fee schedule,274.73,547.21, "Inj., ravulizumab-cwvz 10 mg",J1303,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,274.73,,,,,,,fee schedule,274.73,547.21, Inj tofersen intrathec 1 mg,J1304,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,349.52,,,,,,,fee schedule,189.51,377.48, Inj tofersen intrathec 1 mg,J1304,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,377.48,,,,,,,fee schedule,189.51,377.48, Inj tofersen intrathec 1 mg,J1304,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,189.51,,,,,,,fee schedule,189.51,377.48, Inj tofersen intrathec 1 mg,J1304,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,189.51,,,,,,,fee schedule,189.51,377.48, "Inj, evinacumab-dgnb, 5mg",J1305,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,426.94,,,,,,,fee schedule,231.5,461.09, "Inj, evinacumab-dgnb, 5mg",J1305,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,461.09,,,,,,,fee schedule,231.5,461.09, "Inj, evinacumab-dgnb, 5mg",J1305,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,231.5,,,,,,,fee schedule,231.5,461.09, "Inj, evinacumab-dgnb, 5mg",J1305,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,231.5,,,,,,,fee schedule,231.5,461.09, "Injection, inclisiran, 1 mg",J1306,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,27.79,,,,,,,fee schedule,15.07,30.01, "Injection, inclisiran, 1 mg",J1306,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,30.01,,,,,,,fee schedule,15.07,30.01, "Injection, inclisiran, 1 mg",J1306,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.07,,,,,,,fee schedule,15.07,30.01, "Injection, inclisiran, 1 mg",J1306,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,15.07,,,,,,,fee schedule,15.07,30.01, "Inj, crovalimab-akkz, 10 mg",J1307,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,672.84,,,,,,,fee schedule,672.84,672.84, "Inj, crovalimab-akkz, 10 mg",J1307,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,672.84,,,,,,,fee schedule,672.84,672.84, "Inj, famotidine, 0.25 mg",J1308,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.02,,,,,,,fee schedule,0.01,0.02, "Inj, famotidine, 0.25 mg",J1308,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.02,,,,,,,fee schedule,0.01,0.02, "Inj, famotidine, 0.25 mg",J1308,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.01,,,,,,,fee schedule,0.01,0.02, "Inj, famotidine, 0.25 mg",J1308,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.01,,,,,,,fee schedule,0.01,0.02, "Elosulfase alfa, injection",J1322,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,690.3,,,,,,,fee schedule,374.3,745.52, "Elosulfase alfa, injection",J1322,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,745.52,,,,,,,fee schedule,374.3,745.52, "Elosulfase alfa, injection",J1322,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,374.3,,,,,,,fee schedule,374.3,745.52, "Elosulfase alfa, injection",J1322,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,374.3,,,,,,,fee schedule,374.3,745.52, "Inj, elranatamab-bcmm, 1 mg",J1323,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,416.95,,,,,,,fee schedule,226.08,450.3, "Inj, elranatamab-bcmm, 1 mg",J1323,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,450.3,,,,,,,fee schedule,226.08,450.3, "Inj, elranatamab-bcmm, 1 mg",J1323,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,226.08,,,,,,,fee schedule,226.08,450.3, "Inj, elranatamab-bcmm, 1 mg",J1323,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,226.08,,,,,,,fee schedule,226.08,450.3, Enfuvirtide injection,J1324,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.98,,,,,,,fee schedule,0.98,0.98, Enfuvirtide injection,J1324,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.98,,,,,,,fee schedule,0.98,0.98, Epoprostenol injection,J1325,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,36.45,,,,,,,fee schedule,19.76,39.37, Epoprostenol injection,J1325,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,39.37,,,,,,,fee schedule,19.76,39.37, Epoprostenol injection,J1325,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.76,,,,,,,fee schedule,19.76,39.37, Epoprostenol injection,J1325,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19.76,,,,,,,fee schedule,19.76,39.37, "Inj, zolbetuximab-clzb, 2 mg",J1326,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,75.51,,,,,,,fee schedule,40.94,81.55, "Inj, zolbetuximab-clzb, 2 mg",J1326,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,81.55,,,,,,,fee schedule,40.94,81.55, "Inj, zolbetuximab-clzb, 2 mg",J1326,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,40.94,,,,,,,fee schedule,40.94,81.55, "Inj, zolbetuximab-clzb, 2 mg",J1326,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,40.94,,,,,,,fee schedule,40.94,81.55, Eptifibatide injection,J1327,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,27.83,,,,,,,fee schedule,27.83,27.83, Eptifibatide injection,J1327,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,27.83,,,,,,,fee schedule,27.83,27.83, Ertapenem injection,J1335,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,20.3,,,,,,,fee schedule,11,21.92, Ertapenem injection,J1335,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,21.92,,,,,,,fee schedule,11,21.92, Ertapenem injection,J1335,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11,,,,,,,fee schedule,11,21.92, Ertapenem injection,J1335,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11,,,,,,,fee schedule,11,21.92, Erythro lactobionate /500 MG,J1364,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,168.86,,,,,,,fee schedule,91.56,182.37, Erythro lactobionate /500 MG,J1364,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,182.37,,,,,,,fee schedule,91.56,182.37, Erythro lactobionate /500 MG,J1364,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,91.56,,,,,,,fee schedule,91.56,182.37, Erythro lactobionate /500 MG,J1364,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,91.56,,,,,,,fee schedule,91.56,182.37, Estradiol valerate 10 MG inj,J1380,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,17.35,,,,,,,fee schedule,9.41,18.74, Estradiol valerate 10 MG inj,J1380,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,18.74,,,,,,,fee schedule,9.41,18.74, Estradiol valerate 10 MG inj,J1380,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.41,,,,,,,fee schedule,9.41,18.74, Estradiol valerate 10 MG inj,J1380,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9.41,,,,,,,fee schedule,9.41,18.74, Inj estrogen conjugate 25 MG,J1410,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,879.17,,,,,,,fee schedule,476.7,949.5, Inj estrogen conjugate 25 MG,J1410,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,949.5,,,,,,,fee schedule,476.7,949.5, Inj estrogen conjugate 25 MG,J1410,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,476.7,,,,,,,fee schedule,476.7,949.5, Inj estrogen conjugate 25 MG,J1410,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,476.7,,,,,,,fee schedule,476.7,949.5, "Inj, hemgenix, per tx dose",J1411,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4496025.34,,,,,,,fee schedule,4496025.34,4496025.34, "Inj, hemgenix, per tx dose",J1411,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4496025.34,,,,,,,fee schedule,4496025.34,4496025.34, Inj roctavian ml 2x10^13vc g,J1412,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15089.22,,,,,,,fee schedule,15089.22,15089.22, Inj roctavian ml 2x10^13vc g,J1412,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,15089.22,,,,,,,fee schedule,15089.22,15089.22, Inj delandistrogene mox rokl,J1413,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4055977.72,,,,,,,fee schedule,4055977.72,4055977.72, Inj delandistrogene mox rokl,J1413,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4055977.72,,,,,,,fee schedule,4055977.72,4055977.72, "Inj, beqvez, per tx dose",J1414,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4526200,,,,,,,fee schedule,4526200,4526200, "Inj, beqvez, per tx dose",J1414,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4526200,,,,,,,fee schedule,4526200,4526200, "Injection, casimersen, 10 mg",J1426,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,234.24,,,,,,,fee schedule,234.24,234.24, "Injection, casimersen, 10 mg",J1426,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,234.24,,,,,,,fee schedule,234.24,234.24, Inj. viltolarsen,J1427,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,82.57,,,,,,,fee schedule,82.57,82.57, Inj. viltolarsen,J1427,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,82.57,,,,,,,fee schedule,82.57,82.57, "Inj, eteplirsen, 10 mg",J1428,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,234.24,,,,,,,fee schedule,234.24,234.24, "Inj, eteplirsen, 10 mg",J1428,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,234.24,,,,,,,fee schedule,234.24,234.24, Inj golodirsen 10 mg,J1429,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,234.24,,,,,,,fee schedule,234.24,234.24, Inj golodirsen 10 mg,J1429,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,234.24,,,,,,,fee schedule,234.24,234.24, Ethanolamine oleate 100 mg,J1430,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,1168.92,,,,,,,fee schedule,633.81,1262.43, Ethanolamine oleate 100 mg,J1430,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,1262.43,,,,,,,fee schedule,633.81,1262.43, Ethanolamine oleate 100 mg,J1430,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,633.81,,,,,,,fee schedule,633.81,1262.43, Ethanolamine oleate 100 mg,J1430,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,633.81,,,,,,,fee schedule,633.81,1262.43, "Inj, focinvez, 1mg",J1434,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,6.46,,,,,,,fee schedule,3.5,6.97, "Inj, focinvez, 1mg",J1434,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,6.97,,,,,,,fee schedule,3.5,6.97, "Inj, focinvez, 1mg",J1434,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3.5,,,,,,,fee schedule,3.5,6.97, "Inj, focinvez, 1mg",J1434,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3.5,,,,,,,fee schedule,3.5,6.97, Injection estrone per 1 MG,J1435,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.39,,,,,,,fee schedule,0.39,0.39, Injection estrone per 1 MG,J1435,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.39,,,,,,,fee schedule,0.39,0.39, Inj. fe derisomaltose 10 mg,J1437,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,42.64,,,,,,,fee schedule,23.12,46.05, Inj. fe derisomaltose 10 mg,J1437,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,46.05,,,,,,,fee schedule,23.12,46.05, Inj. fe derisomaltose 10 mg,J1437,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23.12,,,,,,,fee schedule,23.12,46.05, Inj. fe derisomaltose 10 mg,J1437,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,23.12,,,,,,,fee schedule,23.12,46.05, Etanercept injection,J1438,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1318.67,,,,,,,fee schedule,1318.67,1318.67, Etanercept injection,J1438,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1318.67,,,,,,,fee schedule,1318.67,1318.67, Inj ferric carboxymaltos 1mg,J1439,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,2.57,,,,,,,fee schedule,1.39,2.77, Inj ferric carboxymaltos 1mg,J1439,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,2.77,,,,,,,fee schedule,1.39,2.77, Inj ferric carboxymaltos 1mg,J1439,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.39,,,,,,,fee schedule,1.39,2.77, Inj ferric carboxymaltos 1mg,J1439,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.39,,,,,,,fee schedule,1.39,2.77, Fecal?microbiota jslm 1 ml,J1440,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,144.07,,,,,,,fee schedule,78.12,155.59, Fecal?microbiota jslm 1 ml,J1440,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,155.59,,,,,,,fee schedule,78.12,155.59, Fecal?microbiota jslm 1 ml,J1440,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,78.12,,,,,,,fee schedule,78.12,155.59, Fecal?microbiota jslm 1 ml,J1440,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,78.12,,,,,,,fee schedule,78.12,155.59, Inj filgrastim excl biosimil,J1442,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,2.21,,,,,,,fee schedule,1.21,2.38, Inj filgrastim excl biosimil,J1442,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,2.38,,,,,,,fee schedule,1.21,2.38, Inj filgrastim excl biosimil,J1442,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.21,,,,,,,fee schedule,1.21,2.38, Inj filgrastim excl biosimil,J1442,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.21,,,,,,,fee schedule,1.21,2.38, Inj tbo filgrastim 1 microg,J1447,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.68,,,,,,,fee schedule,0.37,0.73, Inj tbo filgrastim 1 microg,J1447,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.73,,,,,,,fee schedule,0.37,0.73, Inj tbo filgrastim 1 microg,J1447,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.37,,,,,,,fee schedule,0.37,0.73, Inj tbo filgrastim 1 microg,J1447,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.37,,,,,,,fee schedule,0.37,0.73, "Injection, trilaciclib, 1mg",J1448,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,12.13,,,,,,,fee schedule,6.58,13.1, "Injection, trilaciclib, 1mg",J1448,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,13.1,,,,,,,fee schedule,6.58,13.1, "Injection, trilaciclib, 1mg",J1448,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.58,,,,,,,fee schedule,6.58,13.1, "Injection, trilaciclib, 1mg",J1448,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,6.58,,,,,,,fee schedule,6.58,13.1, Inj eflapegrastim-xnst 0.1mg,J1449,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,47.52,,,,,,,fee schedule,25.77,51.32, Inj eflapegrastim-xnst 0.1mg,J1449,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,51.32,,,,,,,fee schedule,25.77,51.32, Inj eflapegrastim-xnst 0.1mg,J1449,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25.77,,,,,,,fee schedule,25.77,51.32, Inj eflapegrastim-xnst 0.1mg,J1449,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,25.77,,,,,,,fee schedule,25.77,51.32, Fluconazole,J1450,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,5.09,,,,,,,fee schedule,2.76,5.49, Fluconazole,J1450,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,5.49,,,,,,,fee schedule,2.76,5.49, Fluconazole,J1450,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2.76,,,,,,,fee schedule,2.76,5.49, Fluconazole,J1450,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2.76,,,,,,,fee schedule,2.76,5.49, "Fomepizole, 15 mg",J1451,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.36,,,,,,,fee schedule,7.36,7.36, "Fomepizole, 15 mg",J1451,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,7.36,,,,,,,fee schedule,7.36,7.36, Fosaprepitant injection,J1453,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.25,,,,,,,fee schedule,0.13,0.27, Fosaprepitant injection,J1453,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.27,,,,,,,fee schedule,0.13,0.27, Fosaprepitant injection,J1453,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.13,,,,,,,fee schedule,0.13,0.27, Fosaprepitant injection,J1453,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.13,,,,,,,fee schedule,0.13,0.27, "Inj fosnetupitant, palonoset",J1454,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,1364.29,,,,,,,fee schedule,739.75,1473.43, "Inj fosnetupitant, palonoset",J1454,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,1473.43,,,,,,,fee schedule,739.75,1473.43, "Inj fosnetupitant, palonoset",J1454,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,739.75,,,,,,,fee schedule,739.75,1473.43, "Inj fosnetupitant, palonoset",J1454,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,739.75,,,,,,,fee schedule,739.75,1473.43, Foscarnet sodium injection,J1455,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,35.06,,,,,,,fee schedule,19.01,37.86, Foscarnet sodium injection,J1455,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,37.86,,,,,,,fee schedule,19.01,37.86, Foscarnet sodium injection,J1455,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.01,,,,,,,fee schedule,19.01,37.86, Foscarnet sodium injection,J1455,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19.01,,,,,,,fee schedule,19.01,37.86, "Inj, fosaprepitant (teva)",J1456,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,2.54,,,,,,,fee schedule,1.38,2.75, "Inj, fosaprepitant (teva)",J1456,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,2.75,,,,,,,fee schedule,1.38,2.75, "Inj, fosaprepitant (teva)",J1456,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.38,,,,,,,fee schedule,1.38,2.75, "Inj, fosaprepitant (teva)",J1456,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.38,,,,,,,fee schedule,1.38,2.75, Gallium nitrate injection,J1457,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.57,,,,,,,fee schedule,1.57,1.57, Gallium nitrate injection,J1457,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.57,,,,,,,fee schedule,1.57,1.57, Galsulfase injection,J1458,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,1137.38,,,,,,,fee schedule,616.72,1228.37, Galsulfase injection,J1458,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,1228.37,,,,,,,fee schedule,616.72,1228.37, Galsulfase injection,J1458,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,616.72,,,,,,,fee schedule,616.72,1228.37, Galsulfase injection,J1458,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,616.72,,,,,,,fee schedule,616.72,1228.37, Inj IVIG privigen 500 mg,J1459,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,113.47,,,,,,,fee schedule,61.52,122.54, Inj IVIG privigen 500 mg,J1459,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,122.54,,,,,,,fee schedule,61.52,122.54, Inj IVIG privigen 500 mg,J1459,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,61.52,,,,,,,fee schedule,61.52,122.54, Inj IVIG privigen 500 mg,J1459,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,61.52,,,,,,,fee schedule,61.52,122.54, Gamma globulin 1 CC inj,J1460,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,108.95,,,,,,,fee schedule,59.07,117.66, Gamma globulin 1 CC inj,J1460,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,117.66,,,,,,,fee schedule,59.07,117.66, Gamma globulin 1 CC inj,J1460,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,59.07,,,,,,,fee schedule,59.07,117.66, Gamma globulin 1 CC inj,J1460,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,59.07,,,,,,,fee schedule,59.07,117.66, Inj cutaquig 100 mg,J1551,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,31.97,,,,,,,fee schedule,17.34,34.53, Inj cutaquig 100 mg,J1551,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,34.53,,,,,,,fee schedule,17.34,34.53, Inj cutaquig 100 mg,J1551,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.34,,,,,,,fee schedule,17.34,34.53, Inj cutaquig 100 mg,J1551,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,17.34,,,,,,,fee schedule,17.34,34.53, "Inj, alyglo, 500 mg",J1552,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,295.02,,,,,,,fee schedule,159.97,318.62, "Inj, alyglo, 500 mg",J1552,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,318.62,,,,,,,fee schedule,159.97,318.62, "Inj, alyglo, 500 mg",J1552,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,159.97,,,,,,,fee schedule,159.97,318.62, "Inj, alyglo, 500 mg",J1552,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,159.97,,,,,,,fee schedule,159.97,318.62, Inj. asceniv,J1554,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,1117.13,,,,,,,fee schedule,605.74,1206.5, Inj. asceniv,J1554,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,1206.5,,,,,,,fee schedule,605.74,1206.5, Inj. asceniv,J1554,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,605.74,,,,,,,fee schedule,605.74,1206.5, Inj. asceniv,J1554,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,605.74,,,,,,,fee schedule,605.74,1206.5, "Inj cuvitru, 100 mg",J1555,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,39.58,,,,,,,fee schedule,21.46,42.74, "Inj cuvitru, 100 mg",J1555,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,42.74,,,,,,,fee schedule,21.46,42.74, "Inj cuvitru, 100 mg",J1555,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21.46,,,,,,,fee schedule,21.46,42.74, "Inj cuvitru, 100 mg",J1555,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,21.46,,,,,,,fee schedule,21.46,42.74, "Inj, imm glob bivigam, 500mg",J1556,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,173.86,,,,,,,fee schedule,94.27,187.77, "Inj, imm glob bivigam, 500mg",J1556,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,187.77,,,,,,,fee schedule,94.27,187.77, "Inj, imm glob bivigam, 500mg",J1556,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,94.27,,,,,,,fee schedule,94.27,187.77, "Inj, imm glob bivigam, 500mg",J1556,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,94.27,,,,,,,fee schedule,94.27,187.77, Gammaplex injection,J1557,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,140.56,,,,,,,fee schedule,76.21,151.8, Gammaplex injection,J1557,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,151.8,,,,,,,fee schedule,76.21,151.8, Gammaplex injection,J1557,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,76.21,,,,,,,fee schedule,76.21,151.8, Gammaplex injection,J1557,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,76.21,,,,,,,fee schedule,76.21,151.8, "Inj. xembify, 100 mg",J1558,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,33.55,,,,,,,fee schedule,18.19,36.23, "Inj. xembify, 100 mg",J1558,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,36.23,,,,,,,fee schedule,18.19,36.23, "Inj. xembify, 100 mg",J1558,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.19,,,,,,,fee schedule,18.19,36.23, "Inj. xembify, 100 mg",J1558,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,18.19,,,,,,,fee schedule,18.19,36.23, Hizentra injection,J1559,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,31.77,,,,,,,fee schedule,17.23,34.31, Hizentra injection,J1559,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,34.31,,,,,,,fee schedule,17.23,34.31, Hizentra injection,J1559,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.23,,,,,,,fee schedule,17.23,34.31, Hizentra injection,J1559,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,17.23,,,,,,,fee schedule,17.23,34.31, Gamma globulin > 10 CC inj,J1560,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,375.89,,,,,,,fee schedule,203.81,405.96, Gamma globulin > 10 CC inj,J1560,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,405.96,,,,,,,fee schedule,203.81,405.96, Gamma globulin > 10 CC inj,J1560,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,203.81,,,,,,,fee schedule,203.81,405.96, Gamma globulin > 10 CC inj,J1560,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,203.81,,,,,,,fee schedule,203.81,405.96, Gamunex-c/gammaked,J1561,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,108.07,,,,,,,fee schedule,58.6,116.71, Gamunex-c/gammaked,J1561,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,116.71,,,,,,,fee schedule,58.6,116.71, Gamunex-c/gammaked,J1561,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,58.6,,,,,,,fee schedule,58.6,116.71, Gamunex-c/gammaked,J1561,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,58.6,,,,,,,fee schedule,58.6,116.71, "Vivaglobin, inj",J1562,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.05,,,,,,,fee schedule,11.05,11.05, "Vivaglobin, inj",J1562,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11.05,,,,,,,fee schedule,11.05,11.05, "Immune globulin, powder",J1566,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,183.83,,,,,,,fee schedule,99.67,198.53, "Immune globulin, powder",J1566,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,198.53,,,,,,,fee schedule,99.67,198.53, "Immune globulin, powder",J1566,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,99.67,,,,,,,fee schedule,99.67,198.53, "Immune globulin, powder",J1566,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,99.67,,,,,,,fee schedule,99.67,198.53, Octagam injection,J1568,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,108.86,,,,,,,fee schedule,59.02,117.56, Octagam injection,J1568,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,117.56,,,,,,,fee schedule,59.02,117.56, Octagam injection,J1568,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,59.02,,,,,,,fee schedule,59.02,117.56, Octagam injection,J1568,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,59.02,,,,,,,fee schedule,59.02,117.56, Gammagard liquid injection,J1569,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,107.55,,,,,,,fee schedule,58.32,116.15, Gammagard liquid injection,J1569,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,116.15,,,,,,,fee schedule,58.32,116.15, Gammagard liquid injection,J1569,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,58.32,,,,,,,fee schedule,58.32,116.15, Gammagard liquid injection,J1569,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,58.32,,,,,,,fee schedule,58.32,116.15, Ganciclovir sodium injection,J1570,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,89.15,,,,,,,fee schedule,48.34,96.28, Ganciclovir sodium injection,J1570,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,96.28,,,,,,,fee schedule,48.34,96.28, Ganciclovir sodium injection,J1570,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,48.34,,,,,,,fee schedule,48.34,96.28, Ganciclovir sodium injection,J1570,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,48.34,,,,,,,fee schedule,48.34,96.28, HepaGam B IM injection,J1571,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,161.24,,,,,,,fee schedule,87.43,174.13, HepaGam B IM injection,J1571,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,174.13,,,,,,,fee schedule,87.43,174.13, HepaGam B IM injection,J1571,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,87.43,,,,,,,fee schedule,87.43,174.13, HepaGam B IM injection,J1571,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,87.43,,,,,,,fee schedule,87.43,174.13, Flebogamma injection,J1572,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,68.03,,,,,,,fee schedule,68.03,68.03, Flebogamma injection,J1572,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,68.03,,,,,,,fee schedule,68.03,68.03, "Hepagam B intravenous, inj",J1573,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,161.24,,,,,,,fee schedule,87.43,174.13, "Hepagam B intravenous, inj",J1573,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,174.13,,,,,,,fee schedule,87.43,174.13, "Hepagam B intravenous, inj",J1573,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,87.43,,,,,,,fee schedule,87.43,174.13, "Hepagam B intravenous, inj",J1573,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,87.43,,,,,,,fee schedule,87.43,174.13, "Inj, ganciclovir (exela)",J1574,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,73.2,,,,,,,fee schedule,73.2,73.2, "Inj, ganciclovir (exela)",J1574,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,73.2,,,,,,,fee schedule,73.2,73.2, Hyqvia 100mg immuneglobulin,J1575,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,41.38,,,,,,,fee schedule,22.44,44.69, Hyqvia 100mg immuneglobulin,J1575,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,44.69,,,,,,,fee schedule,22.44,44.69, Hyqvia 100mg immuneglobulin,J1575,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22.44,,,,,,,fee schedule,22.44,44.69, Hyqvia 100mg immuneglobulin,J1575,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22.44,,,,,,,fee schedule,22.44,44.69, "Inj, panzyga, 500 mg",J1576,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,167.54,,,,,,,fee schedule,90.84,180.94, "Inj, panzyga, 500 mg",J1576,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,180.94,,,,,,,fee schedule,90.84,180.94, "Inj, panzyga, 500 mg",J1576,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,90.84,,,,,,,fee schedule,90.84,180.94, "Inj, panzyga, 500 mg",J1576,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,90.84,,,,,,,fee schedule,90.84,180.94, Garamycin gentamicin inj,J1580,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,5.9,,,,,,,fee schedule,3.2,6.37, Garamycin gentamicin inj,J1580,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,6.37,,,,,,,fee schedule,3.2,6.37, Garamycin gentamicin inj,J1580,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3.2,,,,,,,fee schedule,3.2,6.37, Garamycin gentamicin inj,J1580,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3.2,,,,,,,fee schedule,3.2,6.37, Injection glatiramer acetate,J1595,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,195.68,,,,,,,fee schedule,195.68,195.68, Injection glatiramer acetate,J1595,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,195.68,,,,,,,fee schedule,195.68,195.68, "Inj, glycopyrrolate, 0.1 mg",J1596,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.97,,,,,,,fee schedule,0.52,1.04, "Inj, glycopyrrolate, 0.1 mg",J1596,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,1.04,,,,,,,fee schedule,0.52,1.04, "Inj, glycopyrrolate, 0.1 mg",J1596,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.52,,,,,,,fee schedule,0.52,1.04, "Inj, glycopyrrolate, 0.1 mg",J1596,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.52,,,,,,,fee schedule,0.52,1.04, "Inj glycopyrrolate, glyrx-pf",J1597,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2.39,,,,,,,fee schedule,2.39,2.39, "Inj glycopyrrolate, glyrx-pf",J1597,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2.39,,,,,,,fee schedule,2.39,2.39, Inj glycopyrrolate fres kabi,J1598,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,4.16,,,,,,,fee schedule,2.26,4.5, Inj glycopyrrolate fres kabi,J1598,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,4.5,,,,,,,fee schedule,2.26,4.5, Inj glycopyrrolate fres kabi,J1598,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2.26,,,,,,,fee schedule,2.26,4.5, Inj glycopyrrolate fres kabi,J1598,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2.26,,,,,,,fee schedule,2.26,4.5, Gold sodium thiomaleate inj,J1600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.18,,,,,,,fee schedule,16.18,16.18, Gold sodium thiomaleate inj,J1600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,16.18,,,,,,,fee schedule,16.18,16.18, Golimumab for iv use 1mg,J1602,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,24.82,,,,,,,fee schedule,13.46,26.8, Golimumab for iv use 1mg,J1602,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,26.8,,,,,,,fee schedule,13.46,26.8, Golimumab for iv use 1mg,J1602,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13.46,,,,,,,fee schedule,13.46,26.8, Golimumab for iv use 1mg,J1602,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13.46,,,,,,,fee schedule,13.46,26.8, Glucagon hydrochloride/1 mg,J1610,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,440.53,,,,,,,fee schedule,238.86,475.77, Glucagon hydrochloride/1 mg,J1610,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,475.77,,,,,,,fee schedule,238.86,475.77, Glucagon hydrochloride/1 mg,J1610,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,238.86,,,,,,,fee schedule,238.86,475.77, Glucagon hydrochloride/1 mg,J1610,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,238.86,,,,,,,fee schedule,238.86,475.77, "Inj glucagon hcl, fresenius",J1611,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,325.98,,,,,,,fee schedule,176.75,352.06, "Inj glucagon hcl, fresenius",J1611,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,352.06,,,,,,,fee schedule,176.75,352.06, "Inj glucagon hcl, fresenius",J1611,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,176.75,,,,,,,fee schedule,176.75,352.06, "Inj glucagon hcl, fresenius",J1611,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,176.75,,,,,,,fee schedule,176.75,352.06, Granisetron hcl injection,J1626,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.52,,,,,,,fee schedule,0.28,0.56, Granisetron hcl injection,J1626,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.56,,,,,,,fee schedule,0.28,0.56, Granisetron hcl injection,J1626,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.28,,,,,,,fee schedule,0.28,0.56, Granisetron hcl injection,J1626,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.28,,,,,,,fee schedule,0.28,0.56, "Inj, granisetron, xr, 0.1 mg",J1627,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,11.16,,,,,,,fee schedule,6.05,12.05, "Inj, granisetron, xr, 0.1 mg",J1627,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,12.05,,,,,,,fee schedule,6.05,12.05, "Inj, granisetron, xr, 0.1 mg",J1627,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.05,,,,,,,fee schedule,6.05,12.05, "Inj, granisetron, xr, 0.1 mg",J1627,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,6.05,,,,,,,fee schedule,6.05,12.05, "Inj., guselkumab, 1 mg",J1628,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,168.44,,,,,,,fee schedule,91.33,181.91, "Inj., guselkumab, 1 mg",J1628,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,181.91,,,,,,,fee schedule,91.33,181.91, "Inj., guselkumab, 1 mg",J1628,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,91.33,,,,,,,fee schedule,91.33,181.91, "Inj., guselkumab, 1 mg",J1628,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,91.33,,,,,,,fee schedule,91.33,181.91, Haloperidol injection,J1630,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,1.89,,,,,,,fee schedule,1.02,2.04, Haloperidol injection,J1630,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,2.04,,,,,,,fee schedule,1.02,2.04, Haloperidol injection,J1630,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.02,,,,,,,fee schedule,1.02,2.04, Haloperidol injection,J1630,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.02,,,,,,,fee schedule,1.02,2.04, Haloperidol decanoate inj,J1631,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,10.53,,,,,,,fee schedule,5.71,11.37, Haloperidol decanoate inj,J1631,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,11.37,,,,,,,fee schedule,5.71,11.37, Haloperidol decanoate inj,J1631,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.71,,,,,,,fee schedule,5.71,11.37, Haloperidol decanoate inj,J1631,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5.71,,,,,,,fee schedule,5.71,11.37, "Hemin, 1 mg",J1640,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,76.86,,,,,,,fee schedule,41.69,83.01, "Hemin, 1 mg",J1640,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,83.01,,,,,,,fee schedule,41.69,83.01, "Hemin, 1 mg",J1640,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,41.69,,,,,,,fee schedule,41.69,83.01, "Hemin, 1 mg",J1640,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,41.69,,,,,,,fee schedule,41.69,83.01, Inj heparin sodium per 10 u,J1642,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.05,,,,,,,fee schedule,0.02,0.05, Inj heparin sodium per 10 u,J1642,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.05,,,,,,,fee schedule,0.02,0.05, Inj heparin sodium per 10 u,J1642,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.02,,,,,,,fee schedule,0.02,0.05, Inj heparin sodium per 10 u,J1642,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.02,,,,,,,fee schedule,0.02,0.05, "Inj heparin, pfizer, 1000u",J1643,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,6.77,,,,,,,fee schedule,3.67,7.31, "Inj heparin, pfizer, 1000u",J1643,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,7.31,,,,,,,fee schedule,3.67,7.31, "Inj heparin, pfizer, 1000u",J1643,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3.67,,,,,,,fee schedule,3.67,7.31, "Inj heparin, pfizer, 1000u",J1643,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3.67,,,,,,,fee schedule,3.67,7.31, Inj heparin sodium per 1000u,J1644,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.5,,,,,,,fee schedule,0.27,0.53, Inj heparin sodium per 1000u,J1644,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.53,,,,,,,fee schedule,0.27,0.53, Inj heparin sodium per 1000u,J1644,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.27,,,,,,,fee schedule,0.27,0.53, Inj heparin sodium per 1000u,J1644,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.27,,,,,,,fee schedule,0.27,0.53, Dalteparin sodium,J1645,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,40.59,,,,,,,fee schedule,22.01,43.84, Dalteparin sodium,J1645,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,43.84,,,,,,,fee schedule,22.01,43.84, Dalteparin sodium,J1645,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22.01,,,,,,,fee schedule,22.01,43.84, Dalteparin sodium,J1645,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22.01,,,,,,,fee schedule,22.01,43.84, Inj enoxaparin sodium,J1650,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,1.28,,,,,,,fee schedule,0.7,1.39, Inj enoxaparin sodium,J1650,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,1.39,,,,,,,fee schedule,0.7,1.39, Inj enoxaparin sodium,J1650,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.7,,,,,,,fee schedule,0.7,1.39, Inj enoxaparin sodium,J1650,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.7,,,,,,,fee schedule,0.7,1.39, Fondaparinux sodium,J1652,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,1.62,,,,,,,fee schedule,0.88,1.75, Fondaparinux sodium,J1652,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,1.75,,,,,,,fee schedule,0.88,1.75, Fondaparinux sodium,J1652,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.88,,,,,,,fee schedule,0.88,1.75, Fondaparinux sodium,J1652,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.88,,,,,,,fee schedule,0.88,1.75, Tinzaparin sodium injection,J1655,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.34,,,,,,,fee schedule,4.34,4.34, Tinzaparin sodium injection,J1655,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4.34,,,,,,,fee schedule,4.34,4.34, Tetanus immune globulin inj,J1670,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,1298.36,,,,,,,fee schedule,704,1402.23, Tetanus immune globulin inj,J1670,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,1402.23,,,,,,,fee schedule,704,1402.23, Tetanus immune globulin inj,J1670,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,704,,,,,,,fee schedule,704,1402.23, Tetanus immune globulin inj,J1670,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,704,,,,,,,fee schedule,704,1402.23, Histrelin acetate,J1675,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.18,,,,,,,fee schedule,1.18,1.18, Histrelin acetate,J1675,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.18,,,,,,,fee schedule,1.18,1.18, Hydrocortisone sodium succ i,J1720,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,47.7,,,,,,,fee schedule,25.86,51.52, Hydrocortisone sodium succ i,J1720,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,51.52,,,,,,,fee schedule,25.86,51.52, Hydrocortisone sodium succ i,J1720,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25.86,,,,,,,fee schedule,25.86,51.52, Hydrocortisone sodium succ i,J1720,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,25.86,,,,,,,fee schedule,25.86,51.52, "Makena, 10 mg",J1726,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,35.81,,,,,,,fee schedule,35.81,35.81, "Makena, 10 mg",J1726,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,35.81,,,,,,,fee schedule,35.81,35.81, Diazoxide injection,J1730,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,119.96,,,,,,,fee schedule,119.96,119.96, Diazoxide injection,J1730,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,119.96,,,,,,,fee schedule,119.96,119.96, Inj. meloxicam 1 mg,J1738,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3.03,,,,,,,fee schedule,3.03,3.03, Inj. meloxicam 1 mg,J1738,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3.03,,,,,,,fee schedule,3.03,3.03, Ibandronate sodium injection,J1740,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,69.3,,,,,,,fee schedule,37.58,74.84, Ibandronate sodium injection,J1740,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,74.84,,,,,,,fee schedule,37.58,74.84, Ibandronate sodium injection,J1740,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,37.58,,,,,,,fee schedule,37.58,74.84, Ibandronate sodium injection,J1740,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,37.58,,,,,,,fee schedule,37.58,74.84, Ibuprofen injection,J1741,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,6.84,,,,,,,fee schedule,3.71,7.39, Ibuprofen injection,J1741,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,7.39,,,,,,,fee schedule,3.71,7.39, Ibuprofen injection,J1741,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3.71,,,,,,,fee schedule,3.71,7.39, Ibuprofen injection,J1741,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3.71,,,,,,,fee schedule,3.71,7.39, Ibutilide fumarate injection,J1742,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,267.25,,,,,,,fee schedule,267.25,267.25, Ibutilide fumarate injection,J1742,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,267.25,,,,,,,fee schedule,267.25,267.25, Idursulfase injection,J1743,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,1256.76,,,,,,,fee schedule,681.44,1357.3, Idursulfase injection,J1743,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,1357.3,,,,,,,fee schedule,681.44,1357.3, Idursulfase injection,J1743,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,681.44,,,,,,,fee schedule,681.44,1357.3, Idursulfase injection,J1743,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,681.44,,,,,,,fee schedule,681.44,1357.3, Icatibant injection,J1744,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,142.02,,,,,,,fee schedule,142.02,142.02, Icatibant injection,J1744,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,142.02,,,,,,,fee schedule,142.02,142.02, Infliximab not biosimil 10mg,J1745,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,70.16,,,,,,,fee schedule,38.04,75.77, Infliximab not biosimil 10mg,J1745,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,75.77,,,,,,,fee schedule,38.04,75.77, Infliximab not biosimil 10mg,J1745,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,38.04,,,,,,,fee schedule,38.04,75.77, Infliximab not biosimil 10mg,J1745,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,38.04,,,,,,,fee schedule,38.04,75.77, "Inj., ibalizumab-uiyk, 10 mg",J1746,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,178.63,,,,,,,fee schedule,96.86,192.92, "Inj., ibalizumab-uiyk, 10 mg",J1746,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,192.92,,,,,,,fee schedule,96.86,192.92, "Inj., ibalizumab-uiyk, 10 mg",J1746,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,96.86,,,,,,,fee schedule,96.86,192.92, "Inj., ibalizumab-uiyk, 10 mg",J1746,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,96.86,,,,,,,fee schedule,96.86,192.92, "Inj, spesolimab-sbzo, 1 mg",J1747,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,147.89,,,,,,,fee schedule,80.19,159.72, "Inj, spesolimab-sbzo, 1 mg",J1747,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,159.72,,,,,,,fee schedule,80.19,159.72, "Inj, spesolimab-sbzo, 1 mg",J1747,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,80.19,,,,,,,fee schedule,80.19,159.72, "Inj, spesolimab-sbzo, 1 mg",J1747,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,80.19,,,,,,,fee schedule,80.19,159.72, "Inj, zymfentra, 10 mg",J1748,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,391.97,,,,,,,fee schedule,391.97,391.97, "Inj, zymfentra, 10 mg",J1748,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,391.97,,,,,,,fee schedule,391.97,391.97, "Inj, iloprost, 0.1 mcg",J1749,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,12.85,,,,,,,fee schedule,6.97,13.88, "Inj, iloprost, 0.1 mcg",J1749,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,13.88,,,,,,,fee schedule,6.97,13.88, "Inj, iloprost, 0.1 mcg",J1749,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.97,,,,,,,fee schedule,6.97,13.88, "Inj, iloprost, 0.1 mcg",J1749,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,6.97,,,,,,,fee schedule,6.97,13.88, Inj iron dextran,J1750,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,40.57,,,,,,,fee schedule,22,43.81, Inj iron dextran,J1750,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,43.81,,,,,,,fee schedule,22,43.81, Inj iron dextran,J1750,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22,,,,,,,fee schedule,22,43.81, Inj iron dextran,J1750,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22,,,,,,,fee schedule,22,43.81, Iron sucrose injection,J1756,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.5,,,,,,,fee schedule,0.27,0.53, Iron sucrose injection,J1756,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.53,,,,,,,fee schedule,0.27,0.53, Iron sucrose injection,J1756,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.27,,,,,,,fee schedule,0.27,0.53, Iron sucrose injection,J1756,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.27,,,,,,,fee schedule,0.27,0.53, Imuglucerase injection,J1786,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,97.4,,,,,,,fee schedule,52.81,105.19, Imuglucerase injection,J1786,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,105.19,,,,,,,fee schedule,52.81,105.19, Imuglucerase injection,J1786,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,52.81,,,,,,,fee schedule,52.81,105.19, Imuglucerase injection,J1786,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,52.81,,,,,,,fee schedule,52.81,105.19, Droperidol injection,J1790,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,12.06,,,,,,,fee schedule,6.54,13.02, Droperidol injection,J1790,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,13.02,,,,,,,fee schedule,6.54,13.02, Droperidol injection,J1790,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.54,,,,,,,fee schedule,6.54,13.02, Droperidol injection,J1790,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,6.54,,,,,,,fee schedule,6.54,13.02, Propranolol injection,J1800,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.32,,,,,,,fee schedule,12.32,12.32, Propranolol injection,J1800,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,12.32,,,,,,,fee schedule,12.32,12.32, "Inj, esmolol hcl, 10mg",J1805,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.63,,,,,,,fee schedule,0.34,0.68, "Inj, esmolol hcl, 10mg",J1805,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.68,,,,,,,fee schedule,0.34,0.68, "Inj, esmolol hcl, 10mg",J1805,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.34,,,,,,,fee schedule,0.34,0.68, "Inj, esmolol hcl, 10mg",J1805,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.34,,,,,,,fee schedule,0.34,0.68, Inj esmolol hcl wg crit care,J1806,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.95,,,,,,,fee schedule,0.51,1.02, Inj esmolol hcl wg crit care,J1806,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,1.02,,,,,,,fee schedule,0.51,1.02, Inj esmolol hcl wg crit care,J1806,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.51,,,,,,,fee schedule,0.51,1.02, Inj esmolol hcl wg crit care,J1806,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.51,,,,,,,fee schedule,0.51,1.02, "Inj, folic acid, 0.1 mg",J1808,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.14,,,,,,,fee schedule,0.07,0.15, "Inj, folic acid, 0.1 mg",J1808,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.15,,,,,,,fee schedule,0.07,0.15, "Inj, folic acid, 0.1 mg",J1808,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.07,,,,,,,fee schedule,0.07,0.15, "Inj, folic acid, 0.1 mg",J1808,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.07,,,,,,,fee schedule,0.07,0.15, Fiasp for insulin pump use,J1811,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,17.46,,,,,,,fee schedule,9.47,18.86, Fiasp for insulin pump use,J1811,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,18.86,,,,,,,fee schedule,9.47,18.86, Fiasp for insulin pump use,J1811,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.47,,,,,,,fee schedule,9.47,18.86, Fiasp for insulin pump use,J1811,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9.47,,,,,,,fee schedule,9.47,18.86, Inj. Insulin (fiasp),J1812,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2.34,,,,,,,fee schedule,2.34,2.34, Inj. Insulin (fiasp),J1812,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2.34,,,,,,,fee schedule,2.34,2.34, Lyumjev for insulin pump use,J1813,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,34.36,,,,,,,fee schedule,18.63,37.11, Lyumjev for insulin pump use,J1813,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,37.11,,,,,,,fee schedule,18.63,37.11, Lyumjev for insulin pump use,J1813,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.63,,,,,,,fee schedule,18.63,37.11, Lyumjev for insulin pump use,J1813,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,18.63,,,,,,,fee schedule,18.63,37.11, Inj. insulin (lyumjev),J1814,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2.44,,,,,,,fee schedule,2.44,2.44, Inj. insulin (lyumjev),J1814,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2.44,,,,,,,fee schedule,2.44,2.44, Insulin injection,J1815,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.68,,,,,,,fee schedule,0.68,0.68, Insulin injection,J1815,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.68,,,,,,,fee schedule,0.68,0.68, Insulin for insulin pump use,J1817,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,7.29,,,,,,,fee schedule,3.95,7.87, Insulin for insulin pump use,J1817,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,7.87,,,,,,,fee schedule,3.95,7.87, Insulin for insulin pump use,J1817,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3.95,,,,,,,fee schedule,3.95,7.87, Insulin for insulin pump use,J1817,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3.95,,,,,,,fee schedule,3.95,7.87, "Inj. inebilizumab-cdon, 1 mg",J1823,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,1112.47,,,,,,,fee schedule,603.2,1201.46, "Inj. inebilizumab-cdon, 1 mg",J1823,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,1201.46,,,,,,,fee schedule,603.2,1201.46, "Inj. inebilizumab-cdon, 1 mg",J1823,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,603.2,,,,,,,fee schedule,603.2,1201.46, "Inj. inebilizumab-cdon, 1 mg",J1823,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,603.2,,,,,,,fee schedule,603.2,1201.46, Interferon Beta-1A inj,J1826,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2687.83,,,,,,,fee schedule,2687.83,2687.83, Interferon Beta-1A inj,J1826,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2687.83,,,,,,,fee schedule,2687.83,2687.83, Interferon beta-1b / .25 MG,J1830,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,600.95,,,,,,,fee schedule,600.95,600.95, Interferon beta-1b / .25 MG,J1830,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,600.95,,,,,,,fee schedule,600.95,600.95, "Injection, isavuconazonium",J1833,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.23,,,,,,,fee schedule,1.23,1.23, "Injection, isavuconazonium",J1833,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.23,,,,,,,fee schedule,1.23,1.23, Itraconazole injection,J1835,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1109.69,,,,,,,fee schedule,1109.69,1109.69, Itraconazole injection,J1835,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1109.69,,,,,,,fee schedule,1109.69,1109.69, "Inj, metronidazole, 10 mg",J1836,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.07,,,,,,,fee schedule,0.04,0.07, "Inj, metronidazole, 10 mg",J1836,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.07,,,,,,,fee schedule,0.04,0.07, "Inj, metronidazole, 10 mg",J1836,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.04,,,,,,,fee schedule,0.04,0.07, "Inj, metronidazole, 10 mg",J1836,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.04,,,,,,,fee schedule,0.04,0.07, Ketorolac tromethamine inj,J1885,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.79,,,,,,,fee schedule,0.43,0.85, Ketorolac tromethamine inj,J1885,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.85,,,,,,,fee schedule,0.43,0.85, Ketorolac tromethamine inj,J1885,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.43,,,,,,,fee schedule,0.43,0.85, Ketorolac tromethamine inj,J1885,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.43,,,,,,,fee schedule,0.43,0.85, "Inj, labetalol hcl, 5mg",J1920,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.88,,,,,,,fee schedule,0.48,0.95, "Inj, labetalol hcl, 5mg",J1920,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.95,,,,,,,fee schedule,0.48,0.95, "Inj, labetalol hcl, 5mg",J1920,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.48,,,,,,,fee schedule,0.48,0.95, "Inj, labetalol hcl, 5mg",J1920,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.48,,,,,,,fee schedule,0.48,0.95, "Inj labetalol hcl hikma, 5mg",J1921,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,3.11,,,,,,,fee schedule,1.68,3.35, "Inj labetalol hcl hikma, 5mg",J1921,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,3.35,,,,,,,fee schedule,1.68,3.35, "Inj labetalol hcl hikma, 5mg",J1921,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.68,,,,,,,fee schedule,1.68,3.35, "Inj labetalol hcl hikma, 5mg",J1921,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.68,,,,,,,fee schedule,1.68,3.35, Lanreotide injection,J1930,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,82.49,,,,,,,fee schedule,44.73,89.08, Lanreotide injection,J1930,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,89.08,,,,,,,fee schedule,44.73,89.08, Lanreotide injection,J1930,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,44.73,,,,,,,fee schedule,44.73,89.08, Lanreotide injection,J1930,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,44.73,,,,,,,fee schedule,44.73,89.08, Laronidase injection,J1931,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,89.73,,,,,,,fee schedule,48.65,96.91, Laronidase injection,J1931,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,96.91,,,,,,,fee schedule,48.65,96.91, Laronidase injection,J1931,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,48.65,,,,,,,fee schedule,48.65,96.91, Laronidase injection,J1931,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,48.65,,,,,,,fee schedule,48.65,96.91, "Inj, lanreotide, (cipla) 1mg",J1932,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,55.01,,,,,,,fee schedule,29.83,59.41, "Inj, lanreotide, (cipla) 1mg",J1932,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,59.41,,,,,,,fee schedule,29.83,59.41, "Inj, lanreotide, (cipla) 1mg",J1932,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,29.83,,,,,,,fee schedule,29.83,59.41, "Inj, lanreotide, (cipla) 1mg",J1932,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,29.83,,,,,,,fee schedule,29.83,59.41, "Inj, furosemide, 1 mg",J1938,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.05,,,,,,,fee schedule,0.02,0.05, "Inj, furosemide, 1 mg",J1938,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.05,,,,,,,fee schedule,0.02,0.05, "Inj, furosemide, 1 mg",J1938,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.02,,,,,,,fee schedule,0.02,0.05, "Inj, furosemide, 1 mg",J1938,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.02,,,,,,,fee schedule,0.02,0.05, "Inj, bumetanide, 0.5 mg",J1939,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,1.37,,,,,,,fee schedule,0.74,1.48, "Inj, bumetanide, 0.5 mg",J1939,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,1.48,,,,,,,fee schedule,0.74,1.48, "Inj, bumetanide, 0.5 mg",J1939,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.74,,,,,,,fee schedule,0.74,1.48, "Inj, bumetanide, 0.5 mg",J1939,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.74,,,,,,,fee schedule,0.74,1.48, "Inj, furoscix, 20 mg",J1941,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,358.9,,,,,,,fee schedule,358.9,358.9, "Inj, furoscix, 20 mg",J1941,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,358.9,,,,,,,fee schedule,358.9,358.9, "Inj., aristada initio, 1 mg",J1943,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,7.34,,,,,,,fee schedule,3.98,7.92, "Inj., aristada initio, 1 mg",J1943,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,7.92,,,,,,,fee schedule,3.98,7.92, "Inj., aristada initio, 1 mg",J1943,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3.98,,,,,,,fee schedule,3.98,7.92, "Inj., aristada initio, 1 mg",J1943,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3.98,,,,,,,fee schedule,3.98,7.92, Aripirazole lauroxil 1 mg,J1944,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,7.49,,,,,,,fee schedule,4.06,8.09, Aripirazole lauroxil 1 mg,J1944,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,8.09,,,,,,,fee schedule,4.06,8.09, Aripirazole lauroxil 1 mg,J1944,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.06,,,,,,,fee schedule,4.06,8.09, Aripirazole lauroxil 1 mg,J1944,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4.06,,,,,,,fee schedule,4.06,8.09, Lepirudin,J1945,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,177.19,,,,,,,fee schedule,177.19,177.19, Lepirudin,J1945,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,177.19,,,,,,,fee schedule,177.19,177.19, Leuprolide acetate /3.75 mg,J1950,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,3908.48,,,,,,,fee schedule,2119.26,4221.15, Leuprolide acetate /3.75 mg,J1950,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,4221.15,,,,,,,fee schedule,2119.26,4221.15, Leuprolide acetate /3.75 mg,J1950,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2119.26,,,,,,,fee schedule,2119.26,4221.15, Leuprolide acetate /3.75 mg,J1950,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2119.26,,,,,,,fee schedule,2119.26,4221.15, Inj fensolvi 0.25 mg,J1951,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,315.97,,,,,,,fee schedule,171.32,341.24, Inj fensolvi 0.25 mg,J1951,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,341.24,,,,,,,fee schedule,171.32,341.24, Inj fensolvi 0.25 mg,J1951,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,171.32,,,,,,,fee schedule,171.32,341.24, Inj fensolvi 0.25 mg,J1951,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,171.32,,,,,,,fee schedule,171.32,341.24, "Leuprolide inj, camcevi, 1mg",J1952,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,115.65,,,,,,,fee schedule,62.72,124.9, "Leuprolide inj, camcevi, 1mg",J1952,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,124.9,,,,,,,fee schedule,62.72,124.9, "Leuprolide inj, camcevi, 1mg",J1952,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,62.72,,,,,,,fee schedule,62.72,124.9, "Leuprolide inj, camcevi, 1mg",J1952,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,62.72,,,,,,,fee schedule,62.72,124.9, Levetiracetam injection,J1953,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.11,,,,,,,fee schedule,0.06,0.12, Levetiracetam injection,J1953,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.12,,,,,,,fee schedule,0.06,0.12, Levetiracetam injection,J1953,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.06,,,,,,,fee schedule,0.06,0.12, Levetiracetam injection,J1953,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.06,,,,,,,fee schedule,0.06,0.12, Leuprolide depot cipla 7.5mg,J1954,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,496.67,,,,,,,fee schedule,269.3,536.4, Leuprolide depot cipla 7.5mg,J1954,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,536.4,,,,,,,fee schedule,269.3,536.4, Leuprolide depot cipla 7.5mg,J1954,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,269.3,,,,,,,fee schedule,269.3,536.4, Leuprolide depot cipla 7.5mg,J1954,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,269.3,,,,,,,fee schedule,269.3,536.4, Inj levocarnitine per 1 gm,J1955,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,54.65,,,,,,,fee schedule,29.63,59.02, Inj levocarnitine per 1 gm,J1955,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,59.02,,,,,,,fee schedule,29.63,59.02, Inj levocarnitine per 1 gm,J1955,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,29.63,,,,,,,fee schedule,29.63,59.02, Inj levocarnitine per 1 gm,J1955,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,29.63,,,,,,,fee schedule,29.63,59.02, Levofloxacin injection,J1956,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,4.41,,,,,,,fee schedule,2.39,4.76, Levofloxacin injection,J1956,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,4.76,,,,,,,fee schedule,2.39,4.76, Levofloxacin injection,J1956,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2.39,,,,,,,fee schedule,2.39,4.76, Levofloxacin injection,J1956,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2.39,,,,,,,fee schedule,2.39,4.76, Levorphanol tartrate inj,J1960,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3.55,,,,,,,fee schedule,3.55,3.55, Levorphanol tartrate inj,J1960,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3.55,,,,,,,fee schedule,3.55,3.55, "Inj, lenacapavir, 1 mg",J1961,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,49.55,,,,,,,fee schedule,26.86,53.51, "Inj, lenacapavir, 1 mg",J1961,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,53.51,,,,,,,fee schedule,26.86,53.51, "Inj, lenacapavir, 1 mg",J1961,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26.86,,,,,,,fee schedule,26.86,53.51, "Inj, lenacapavir, 1 mg",J1961,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,26.86,,,,,,,fee schedule,26.86,53.51, Hyoscyamine sulfate inj,J1980,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.05,,,,,,,fee schedule,11.05,11.05, Hyoscyamine sulfate inj,J1980,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11.05,,,,,,,fee schedule,11.05,11.05, Chlordiazepoxide injection,J1990,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24.46,,,,,,,fee schedule,24.46,24.46, Chlordiazepoxide injection,J1990,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,24.46,,,,,,,fee schedule,24.46,24.46, "Inj, lidocaine in d5w, 1 mg",J2002,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.01,,,,,,,fee schedule,0.01,0.01, "Inj, lidocaine in d5w, 1 mg",J2002,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.01,,,,,,,fee schedule,0.01,0.01, "Inj, lidocaine hcl, 1 mg",J2003,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.07,,,,,,,fee schedule,0.07,0.07, "Inj, lidocaine hcl, 1 mg",J2003,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.07,,,,,,,fee schedule,0.07,0.07, "Inj, lidocaine w epinephrine",J2004,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.05,,,,,,,fee schedule,0.05,0.05, "Inj, lidocaine w epinephrine",J2004,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.05,,,,,,,fee schedule,0.05,0.05, Lincomycin injection,J2010,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,12.62,,,,,,,fee schedule,6.84,13.63, Lincomycin injection,J2010,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,13.63,,,,,,,fee schedule,6.84,13.63, Lincomycin injection,J2010,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.84,,,,,,,fee schedule,6.84,13.63, Lincomycin injection,J2010,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,6.84,,,,,,,fee schedule,6.84,13.63, Linezolid injection,J2020,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,7.81,,,,,,,fee schedule,4.23,8.43, Linezolid injection,J2020,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,8.43,,,,,,,fee schedule,4.23,8.43, Linezolid injection,J2020,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.23,,,,,,,fee schedule,4.23,8.43, Linezolid injection,J2020,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4.23,,,,,,,fee schedule,4.23,8.43, "Inj, linezolid (hospira)",J2021,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,14.27,,,,,,,fee schedule,7.73,15.41, "Inj, linezolid (hospira)",J2021,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,15.41,,,,,,,fee schedule,7.73,15.41, "Inj, linezolid (hospira)",J2021,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.73,,,,,,,fee schedule,7.73,15.41, "Inj, linezolid (hospira)",J2021,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,7.73,,,,,,,fee schedule,7.73,15.41, Lorazepam injection,J2060,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,2.97,,,,,,,fee schedule,1.61,3.21, Lorazepam injection,J2060,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,3.21,,,,,,,fee schedule,1.61,3.21, Lorazepam injection,J2060,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.61,,,,,,,fee schedule,1.61,3.21, Lorazepam injection,J2060,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.61,,,,,,,fee schedule,1.61,3.21, Loxapine for inhalation 1 mg,J2062,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21.96,,,,,,,fee schedule,21.96,21.96, Loxapine for inhalation 1 mg,J2062,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,21.96,,,,,,,fee schedule,21.96,21.96, Mannitol injection,J2150,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,5.04,,,,,,,fee schedule,2.73,5.44, Mannitol injection,J2150,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,5.44,,,,,,,fee schedule,2.73,5.44, Mannitol injection,J2150,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2.73,,,,,,,fee schedule,2.73,5.44, Mannitol injection,J2150,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2.73,,,,,,,fee schedule,2.73,5.44, Mecasermin injection,J2170,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,538.2,,,,,,,fee schedule,538.2,538.2, Mecasermin injection,J2170,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,538.2,,,,,,,fee schedule,538.2,538.2, Meperidine hydrochl /100 MG,J2175,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,35.3,,,,,,,fee schedule,19.14,38.13, Meperidine hydrochl /100 MG,J2175,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,38.13,,,,,,,fee schedule,19.14,38.13, Meperidine hydrochl /100 MG,J2175,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.14,,,,,,,fee schedule,19.14,38.13, Meperidine hydrochl /100 MG,J2175,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19.14,,,,,,,fee schedule,19.14,38.13, Meperidine/promethazine inj,J2180,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.08,,,,,,,fee schedule,9.08,9.08, Meperidine/promethazine inj,J2180,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9.08,,,,,,,fee schedule,9.08,9.08, "Injection, mepolizumab, 1mg",J2182,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,70.49,,,,,,,fee schedule,38.22,76.13, "Injection, mepolizumab, 1mg",J2182,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,76.13,,,,,,,fee schedule,38.22,76.13, "Injection, mepolizumab, 1mg",J2182,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,38.22,,,,,,,fee schedule,38.22,76.13, "Injection, mepolizumab, 1mg",J2182,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,38.22,,,,,,,fee schedule,38.22,76.13, Inj meropenem (wg crit care),J2183,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,3.65,,,,,,,fee schedule,1.98,3.94, Inj meropenem (wg crit care),J2183,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,3.94,,,,,,,fee schedule,1.98,3.94, Inj meropenem (wg crit care),J2183,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.98,,,,,,,fee schedule,1.98,3.94, Inj meropenem (wg crit care),J2183,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.98,,,,,,,fee schedule,1.98,3.94, "Inj, meropenem (b. braun)",J2184,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,4.68,,,,,,,fee schedule,2.54,5.05, "Inj, meropenem (b. braun)",J2184,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,5.05,,,,,,,fee schedule,2.54,5.05, "Inj, meropenem (b. braun)",J2184,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2.54,,,,,,,fee schedule,2.54,5.05, "Inj, meropenem (b. braun)",J2184,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2.54,,,,,,,fee schedule,2.54,5.05, Meropenem,J2185,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.99,,,,,,,fee schedule,0.54,1.07, Meropenem,J2185,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,1.07,,,,,,,fee schedule,0.54,1.07, Meropenem,J2185,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.54,,,,,,,fee schedule,0.54,1.07, Meropenem,J2185,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.54,,,,,,,fee schedule,0.54,1.07, "Inj., meropenem, vaborbactam",J2186,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2.66,,,,,,,fee schedule,2.66,2.66, "Inj., meropenem, vaborbactam",J2186,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2.66,,,,,,,fee schedule,2.66,2.66, Methylergonovin maleate inj,J2210,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,49.64,,,,,,,fee schedule,26.91,53.61, Methylergonovin maleate inj,J2210,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,53.61,,,,,,,fee schedule,26.91,53.61, Methylergonovin maleate inj,J2210,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26.91,,,,,,,fee schedule,26.91,53.61, Methylergonovin maleate inj,J2210,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,26.91,,,,,,,fee schedule,26.91,53.61, Methylnaltrexone injection,J2212,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2.33,,,,,,,fee schedule,2.33,2.33, Methylnaltrexone injection,J2212,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2.33,,,,,,,fee schedule,2.33,2.33, "Inj, micafungin (baxter)",J2246,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,1.15,,,,,,,fee schedule,0.62,1.24, "Inj, micafungin (baxter)",J2246,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,1.24,,,,,,,fee schedule,0.62,1.24, "Inj, micafungin (baxter)",J2246,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.62,,,,,,,fee schedule,0.62,1.24, "Inj, micafungin (baxter)",J2246,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.62,,,,,,,fee schedule,0.62,1.24, "Inj, micafungin (par pharm)",J2247,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.81,,,,,,,fee schedule,0.44,0.87, "Inj, micafungin (par pharm)",J2247,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.87,,,,,,,fee schedule,0.44,0.87, "Inj, micafungin (par pharm)",J2247,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.44,,,,,,,fee schedule,0.44,0.87, "Inj, micafungin (par pharm)",J2247,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.44,,,,,,,fee schedule,0.44,0.87, Micafungin sodium injection,J2248,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.7,,,,,,,fee schedule,0.38,0.75, Micafungin sodium injection,J2248,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.75,,,,,,,fee schedule,0.38,0.75, Micafungin sodium injection,J2248,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.38,,,,,,,fee schedule,0.38,0.75, Micafungin sodium injection,J2248,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.38,,,,,,,fee schedule,0.38,0.75, "Inj, remimazolam, 1 mg",J2249,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3.07,,,,,,,fee schedule,3.07,3.07, "Inj, remimazolam, 1 mg",J2249,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3.07,,,,,,,fee schedule,3.07,3.07, Inj midazolam hydrochloride,J2250,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.36,,,,,,,fee schedule,0.2,0.39, Inj midazolam hydrochloride,J2250,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.39,,,,,,,fee schedule,0.2,0.39, Inj midazolam hydrochloride,J2250,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.2,,,,,,,fee schedule,0.2,0.39, Inj midazolam hydrochloride,J2250,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.2,,,,,,,fee schedule,0.2,0.39, Inj midazolam (wg crit care),J2251,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.38,,,,,,,fee schedule,0.21,0.41, Inj midazolam (wg crit care),J2251,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.41,,,,,,,fee schedule,0.21,0.41, Inj midazolam (wg crit care),J2251,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.21,,,,,,,fee schedule,0.21,0.41, Inj midazolam (wg crit care),J2251,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.21,,,,,,,fee schedule,0.21,0.41, Inj midazolam in 0.8% nacl,J2252,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.1,,,,,,,fee schedule,0.1,0.1, Inj midazolam in 0.8% nacl,J2252,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.1,,,,,,,fee schedule,0.1,0.1, Inj milrinone lactate / 5 mg,J2260,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,3.15,,,,,,,fee schedule,1.71,3.4, Inj milrinone lactate / 5 mg,J2260,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,3.4,,,,,,,fee schedule,1.71,3.4, Inj milrinone lactate / 5 mg,J2260,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.71,,,,,,,fee schedule,1.71,3.4, Inj milrinone lactate / 5 mg,J2260,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.71,,,,,,,fee schedule,1.71,3.4, Minocycline hydrochloride,J2265,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3.26,,,,,,,fee schedule,3.26,3.26, Minocycline hydrochloride,J2265,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3.26,,,,,,,fee schedule,3.26,3.26, "Inj, mirikizumab-mrkz, 1 mg",J2267,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,108.61,,,,,,,fee schedule,58.89,117.3, "Inj, mirikizumab-mrkz, 1 mg",J2267,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,117.3,,,,,,,fee schedule,58.89,117.3, "Inj, mirikizumab-mrkz, 1 mg",J2267,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,58.89,,,,,,,fee schedule,58.89,117.3, "Inj, mirikizumab-mrkz, 1 mg",J2267,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,58.89,,,,,,,fee schedule,58.89,117.3, Morphine sulfate injection,J2270,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,10.22,,,,,,,fee schedule,5.55,11.03, Morphine sulfate injection,J2270,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,11.03,,,,,,,fee schedule,5.55,11.03, Morphine sulfate injection,J2270,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.55,,,,,,,fee schedule,5.55,11.03, Morphine sulfate injection,J2270,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5.55,,,,,,,fee schedule,5.55,11.03, "Inj, morphine (fresenius)",J2272,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,18.29,,,,,,,fee schedule,9.92,19.76, "Inj, morphine (fresenius)",J2272,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,19.76,,,,,,,fee schedule,9.92,19.76, "Inj, morphine (fresenius)",J2272,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.92,,,,,,,fee schedule,9.92,19.76, "Inj, morphine (fresenius)",J2272,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9.92,,,,,,,fee schedule,9.92,19.76, In morphine preservativ free,J2274,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,24.28,,,,,,,fee schedule,13.16,26.22, In morphine preservativ free,J2274,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,26.22,,,,,,,fee schedule,13.16,26.22, In morphine preservativ free,J2274,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13.16,,,,,,,fee schedule,13.16,26.22, In morphine preservativ free,J2274,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13.16,,,,,,,fee schedule,13.16,26.22, "Inj, motixafortide, 0.25 mg",J2277,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,56.75,,,,,,,fee schedule,30.77,61.28, "Inj, motixafortide, 0.25 mg",J2277,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,61.28,,,,,,,fee schedule,30.77,61.28, "Inj, motixafortide, 0.25 mg",J2277,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,30.77,,,,,,,fee schedule,30.77,61.28, "Inj, motixafortide, 0.25 mg",J2277,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,30.77,,,,,,,fee schedule,30.77,61.28, Ziconotide injection,J2278,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,22.79,,,,,,,fee schedule,12.36,24.62, Ziconotide injection,J2278,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,24.62,,,,,,,fee schedule,12.36,24.62, Ziconotide injection,J2278,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.36,,,,,,,fee schedule,12.36,24.62, Ziconotide injection,J2278,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,12.36,,,,,,,fee schedule,12.36,24.62, "Inj, moxifloxacin 100 mg",J2280,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,19.6,,,,,,,fee schedule,10.63,21.17, "Inj, moxifloxacin 100 mg",J2280,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,21.17,,,,,,,fee schedule,10.63,21.17, "Inj, moxifloxacin 100 mg",J2280,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.63,,,,,,,fee schedule,10.63,21.17, "Inj, moxifloxacin 100 mg",J2280,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,10.63,,,,,,,fee schedule,10.63,21.17, Inj moxifloxacin (fres kabi),J2281,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,17.46,,,,,,,fee schedule,9.47,18.86, Inj moxifloxacin (fres kabi),J2281,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,18.86,,,,,,,fee schedule,9.47,18.86, Inj moxifloxacin (fres kabi),J2281,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.47,,,,,,,fee schedule,9.47,18.86, Inj moxifloxacin (fres kabi),J2281,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9.47,,,,,,,fee schedule,9.47,18.86, "Inj, nafcillin sodium, 20 mg",J2290,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.14,,,,,,,fee schedule,0.07,0.15, "Inj, nafcillin sodium, 20 mg",J2290,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.15,,,,,,,fee schedule,0.07,0.15, "Inj, nafcillin sodium, 20 mg",J2290,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.07,,,,,,,fee schedule,0.07,0.15, "Inj, nafcillin sodium, 20 mg",J2290,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.07,,,,,,,fee schedule,0.07,0.15, Inj nalbuphine hydrochloride,J2300,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,7.9,,,,,,,fee schedule,4.28,8.53, Inj nalbuphine hydrochloride,J2300,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,8.53,,,,,,,fee schedule,4.28,8.53, Inj nalbuphine hydrochloride,J2300,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.28,,,,,,,fee schedule,4.28,8.53, Inj nalbuphine hydrochloride,J2300,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4.28,,,,,,,fee schedule,4.28,8.53, "Inj, nitroglycerin, 5 mg",J2305,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,3.2,,,,,,,fee schedule,1.73,3.45, "Inj, nitroglycerin, 5 mg",J2305,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,3.45,,,,,,,fee schedule,1.73,3.45, "Inj, nitroglycerin, 5 mg",J2305,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.73,,,,,,,fee schedule,1.73,3.45, "Inj, nitroglycerin, 5 mg",J2305,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.73,,,,,,,fee schedule,1.73,3.45, "Inj naloxone hcl nos, 0.01mg",J2312,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.16,,,,,,,fee schedule,0.09,0.17, "Inj naloxone hcl nos, 0.01mg",J2312,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.17,,,,,,,fee schedule,0.09,0.17, "Inj naloxone hcl nos, 0.01mg",J2312,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.09,,,,,,,fee schedule,0.09,0.17, "Inj naloxone hcl nos, 0.01mg",J2312,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.09,,,,,,,fee schedule,0.09,0.17, "Inj, naloxone (zimhi) 0.01mg",J2313,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.05,,,,,,,fee schedule,0.02,0.05, "Inj, naloxone (zimhi) 0.01mg",J2313,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.05,,,,,,,fee schedule,0.02,0.05, "Inj, naloxone (zimhi) 0.01mg",J2313,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.02,,,,,,,fee schedule,0.02,0.05, "Inj, naloxone (zimhi) 0.01mg",J2313,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.02,,,,,,,fee schedule,0.02,0.05, "Naltrexone, depot form",J2315,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,9.54,,,,,,,fee schedule,5.17,10.3, "Naltrexone, depot form",J2315,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,10.3,,,,,,,fee schedule,5.17,10.3, "Naltrexone, depot form",J2315,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.17,,,,,,,fee schedule,5.17,10.3, "Naltrexone, depot form",J2315,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5.17,,,,,,,fee schedule,5.17,10.3, Nandrolone decanoate 50 MG,J2320,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.73,,,,,,,fee schedule,4.73,4.73, Nandrolone decanoate 50 MG,J2320,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4.73,,,,,,,fee schedule,4.73,4.73, Natalizumab injection,J2323,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,54.29,,,,,,,fee schedule,29.44,58.64, Natalizumab injection,J2323,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,58.64,,,,,,,fee schedule,29.44,58.64, Natalizumab injection,J2323,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,29.44,,,,,,,fee schedule,29.44,58.64, Natalizumab injection,J2323,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,29.44,,,,,,,fee schedule,29.44,58.64, Nesiritide injection,J2325,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,35.51,,,,,,,fee schedule,35.51,35.51, Nesiritide injection,J2325,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,35.51,,,,,,,fee schedule,35.51,35.51, "Inj, nusinersen, 0.1mg",J2326,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1190.63,,,,,,,fee schedule,1190.63,1190.63, "Inj, nusinersen, 0.1mg",J2326,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1190.63,,,,,,,fee schedule,1190.63,1190.63, Inj risankizumab-rzaa 1 mg,J2327,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,33.39,,,,,,,fee schedule,18.1,36.06, Inj risankizumab-rzaa 1 mg,J2327,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,36.06,,,,,,,fee schedule,18.1,36.06, Inj risankizumab-rzaa 1 mg,J2327,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.1,,,,,,,fee schedule,18.1,36.06, Inj risankizumab-rzaa 1 mg,J2327,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,18.1,,,,,,,fee schedule,18.1,36.06, "Inj ublituximab-xiiy, 1 mg",J2329,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,161.78,,,,,,,fee schedule,87.72,174.72, "Inj ublituximab-xiiy, 1 mg",J2329,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,174.72,,,,,,,fee schedule,87.72,174.72, "Inj ublituximab-xiiy, 1 mg",J2329,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,87.72,,,,,,,fee schedule,87.72,174.72, "Inj ublituximab-xiiy, 1 mg",J2329,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,87.72,,,,,,,fee schedule,87.72,174.72, "Injection, ocrelizumab, 1 mg",J2350,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,134.33,,,,,,,fee schedule,72.83,145.07, "Injection, ocrelizumab, 1 mg",J2350,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,145.07,,,,,,,fee schedule,72.83,145.07, "Injection, ocrelizumab, 1 mg",J2350,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,72.83,,,,,,,fee schedule,72.83,145.07, "Injection, ocrelizumab, 1 mg",J2350,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,72.83,,,,,,,fee schedule,72.83,145.07, Inj ocrelizumab 1mg hya-ocsq,J2351,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,106.29,,,,,,,fee schedule,57.63,114.79, Inj ocrelizumab 1mg hya-ocsq,J2351,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,114.79,,,,,,,fee schedule,57.63,114.79, Inj ocrelizumab 1mg hya-ocsq,J2351,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,57.63,,,,,,,fee schedule,57.63,114.79, Inj ocrelizumab 1mg hya-ocsq,J2351,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,57.63,,,,,,,fee schedule,57.63,114.79, "Octreotide injection, depot",J2353,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,477.45,,,,,,,fee schedule,258.88,515.65, "Octreotide injection, depot",J2353,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,515.65,,,,,,,fee schedule,258.88,515.65, "Octreotide injection, depot",J2353,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,258.88,,,,,,,fee schedule,258.88,515.65, "Octreotide injection, depot",J2353,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,258.88,,,,,,,fee schedule,258.88,515.65, "Octreotide inj, non-depot",J2354,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,1.37,,,,,,,fee schedule,0.74,1.48, "Octreotide inj, non-depot",J2354,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,1.48,,,,,,,fee schedule,0.74,1.48, "Octreotide inj, non-depot",J2354,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.74,,,,,,,fee schedule,0.74,1.48, "Octreotide inj, non-depot",J2354,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.74,,,,,,,fee schedule,0.74,1.48, Oprelvekin injection,J2355,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,292.02,,,,,,,fee schedule,292.02,292.02, Oprelvekin injection,J2355,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,292.02,,,,,,,fee schedule,292.02,292.02, "Inj tezepelumab-ekko, 1mg",J2356,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,41.18,,,,,,,fee schedule,22.33,44.47, "Inj tezepelumab-ekko, 1mg",J2356,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,44.47,,,,,,,fee schedule,22.33,44.47, "Inj tezepelumab-ekko, 1mg",J2356,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22.33,,,,,,,fee schedule,22.33,44.47, "Inj tezepelumab-ekko, 1mg",J2356,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22.33,,,,,,,fee schedule,22.33,44.47, Omalizumab injection,J2357,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,91.26,,,,,,,fee schedule,49.48,98.56, Omalizumab injection,J2357,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,98.56,,,,,,,fee schedule,49.48,98.56, Omalizumab injection,J2357,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,49.48,,,,,,,fee schedule,49.48,98.56, Omalizumab injection,J2357,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,49.48,,,,,,,fee schedule,49.48,98.56, Olanzapine long-acting inj,J2358,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,6.57,,,,,,,fee schedule,3.56,7.1, Olanzapine long-acting inj,J2358,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,7.1,,,,,,,fee schedule,3.56,7.1, Olanzapine long-acting inj,J2358,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3.56,,,,,,,fee schedule,3.56,7.1, Olanzapine long-acting inj,J2358,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3.56,,,,,,,fee schedule,3.56,7.1, "Inj. olanzapine, 0.5mg",J2359,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,2.05,,,,,,,fee schedule,1.11,2.21, "Inj. olanzapine, 0.5mg",J2359,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,2.21,,,,,,,fee schedule,1.11,2.21, "Inj. olanzapine, 0.5mg",J2359,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.11,,,,,,,fee schedule,1.11,2.21, "Inj. olanzapine, 0.5mg",J2359,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.11,,,,,,,fee schedule,1.11,2.21, Orphenadrine injection,J2360,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,21.26,,,,,,,fee schedule,11.53,22.96, Orphenadrine injection,J2360,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,22.96,,,,,,,fee schedule,11.53,22.96, Orphenadrine injection,J2360,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.53,,,,,,,fee schedule,11.53,22.96, Orphenadrine injection,J2360,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11.53,,,,,,,fee schedule,11.53,22.96, Inj phenylephrine hcl 20 mcg,J2371,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.01,,,,,,,fee schedule,0.01,0.01, Inj phenylephrine hcl 20 mcg,J2371,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.01,,,,,,,fee schedule,0.01,0.01, "Inj, biorphen, 20 micrograms",J2372,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.38,,,,,,,fee schedule,0.21,0.41, "Inj, biorphen, 20 micrograms",J2372,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.41,,,,,,,fee schedule,0.21,0.41, "Inj, biorphen, 20 micrograms",J2372,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.21,,,,,,,fee schedule,0.21,0.41, "Inj, biorphen, 20 micrograms",J2372,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.21,,,,,,,fee schedule,0.21,0.41, "Inj, immphentiv, 20 mcg",J2373,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.29,,,,,,,fee schedule,0.16,0.32, "Inj, immphentiv, 20 mcg",J2373,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.32,,,,,,,fee schedule,0.16,0.32, "Inj, immphentiv, 20 mcg",J2373,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.16,,,,,,,fee schedule,0.16,0.32, "Inj, immphentiv, 20 mcg",J2373,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.16,,,,,,,fee schedule,0.16,0.32, Chloroprocaine hcl injection,J2401,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.09,,,,,,,fee schedule,0.05,0.1, Chloroprocaine hcl injection,J2401,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.1,,,,,,,fee schedule,0.05,0.1, Chloroprocaine hcl injection,J2401,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.05,,,,,,,fee schedule,0.05,0.1, Chloroprocaine hcl injection,J2401,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.05,,,,,,,fee schedule,0.05,0.1, Chloroprocaine (clorotekal),J2402,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.45,,,,,,,fee schedule,0.45,0.45, Chloroprocaine (clorotekal),J2402,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.45,,,,,,,fee schedule,0.45,0.45, "Chloroprocaine opht gel, 1mg",J2403,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,1.35,,,,,,,fee schedule,0.73,1.46, "Chloroprocaine opht gel, 1mg",J2403,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,1.46,,,,,,,fee schedule,0.73,1.46, "Chloroprocaine opht gel, 1mg",J2403,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.73,,,,,,,fee schedule,0.73,1.46, "Chloroprocaine opht gel, 1mg",J2403,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.73,,,,,,,fee schedule,0.73,1.46, "Inj, nicardipine 0.1 mg",J2404,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.2,,,,,,,fee schedule,0.11,0.22, "Inj, nicardipine 0.1 mg",J2404,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.22,,,,,,,fee schedule,0.11,0.22, "Inj, nicardipine 0.1 mg",J2404,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.11,,,,,,,fee schedule,0.11,0.22, "Inj, nicardipine 0.1 mg",J2404,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.11,,,,,,,fee schedule,0.11,0.22, Ondansetron hcl injection,J2405,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.2,,,,,,,fee schedule,0.11,0.22, Ondansetron hcl injection,J2405,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.22,,,,,,,fee schedule,0.11,0.22, Ondansetron hcl injection,J2405,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.11,,,,,,,fee schedule,0.11,0.22, Ondansetron hcl injection,J2405,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.11,,,,,,,fee schedule,0.11,0.22, "Injection, oritavancin 10 mg",J2406,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,93.15,,,,,,,fee schedule,50.51,100.6, "Injection, oritavancin 10 mg",J2406,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,100.6,,,,,,,fee schedule,50.51,100.6, "Injection, oritavancin 10 mg",J2406,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,50.51,,,,,,,fee schedule,50.51,100.6, "Injection, oritavancin 10 mg",J2406,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,50.51,,,,,,,fee schedule,50.51,100.6, "Injection, oritavancin",J2407,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,64.17,,,,,,,fee schedule,34.79,69.3, "Injection, oritavancin",J2407,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,69.3,,,,,,,fee schedule,34.79,69.3, "Injection, oritavancin",J2407,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,34.79,,,,,,,fee schedule,34.79,69.3, "Injection, oritavancin",J2407,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,34.79,,,,,,,fee schedule,34.79,69.3, Oxymorphone hcl injection,J2410,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2.76,,,,,,,fee schedule,2.76,2.76, Oxymorphone hcl injection,J2410,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2.76,,,,,,,fee schedule,2.76,2.76, Palifermin injection,J2425,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,80.8,,,,,,,fee schedule,43.81,87.26, Palifermin injection,J2425,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,87.26,,,,,,,fee schedule,43.81,87.26, Palifermin injection,J2425,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,43.81,,,,,,,fee schedule,43.81,87.26, Palifermin injection,J2425,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,43.81,,,,,,,fee schedule,43.81,87.26, Paliperidone palmitate inj,J2426,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,33.93,,,,,,,fee schedule,18.4,36.64, Paliperidone palmitate inj,J2426,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,36.64,,,,,,,fee schedule,18.4,36.64, Paliperidone palmitate inj,J2426,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.4,,,,,,,fee schedule,18.4,36.64, Paliperidone palmitate inj,J2426,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,18.4,,,,,,,fee schedule,18.4,36.64, "Inj, invega hafyera/trinza",J2427,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,29.16,,,,,,,fee schedule,15.81,31.49, "Inj, invega hafyera/trinza",J2427,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,31.49,,,,,,,fee schedule,15.81,31.49, "Inj, invega hafyera/trinza",J2427,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.81,,,,,,,fee schedule,15.81,31.49, "Inj, invega hafyera/trinza",J2427,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,15.81,,,,,,,fee schedule,15.81,31.49, "Inj, erzofri, 1 mg",J2428,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,20.92,,,,,,,fee schedule,20.92,20.92, "Inj, erzofri, 1 mg",J2428,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,20.92,,,,,,,fee schedule,20.92,20.92, Pamidronate disodium /30 mg,J2430,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,25.11,,,,,,,fee schedule,13.62,27.12, Pamidronate disodium /30 mg,J2430,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,27.12,,,,,,,fee schedule,13.62,27.12, Pamidronate disodium /30 mg,J2430,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13.62,,,,,,,fee schedule,13.62,27.12, Pamidronate disodium /30 mg,J2430,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13.62,,,,,,,fee schedule,13.62,27.12, Papaverin hcl injection,J2440,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56.05,,,,,,,fee schedule,56.05,56.05, Papaverin hcl injection,J2440,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,56.05,,,,,,,fee schedule,56.05,56.05, "Inj, palonosetron (avyxa)",J2468,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,132.39,,,,,,,fee schedule,71.78,142.98, "Inj, palonosetron (avyxa)",J2468,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,142.98,,,,,,,fee schedule,71.78,142.98, "Inj, palonosetron (avyxa)",J2468,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,71.78,,,,,,,fee schedule,71.78,142.98, "Inj, palonosetron (avyxa)",J2468,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,71.78,,,,,,,fee schedule,71.78,142.98, Palonosetron hcl,J2469,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.99,,,,,,,fee schedule,0.55,1.07, Palonosetron hcl,J2469,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,1.07,,,,,,,fee schedule,0.55,1.07, Palonosetron hcl,J2469,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.55,,,,,,,fee schedule,0.55,1.07, Palonosetron hcl,J2469,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.55,,,,,,,fee schedule,0.55,1.07, Inj pantoprazole sodium 40mg,J2470,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.64,,,,,,,fee schedule,11.64,11.64, Inj pantoprazole sodium 40mg,J2470,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11.64,,,,,,,fee schedule,11.64,11.64, Inj pantoprazole(hikma) 40mg,J2471,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.81,,,,,,,fee schedule,6.81,6.81, Inj pantoprazole(hikma) 40mg,J2471,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,6.81,,,,,,,fee schedule,6.81,6.81, "Inj, pantoprazole sodium chl",J2472,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.69,,,,,,,fee schedule,11.69,11.69, "Inj, pantoprazole sodium chl",J2472,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11.69,,,,,,,fee schedule,11.69,11.69, Paricalcitol,J2501,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,1.51,,,,,,,fee schedule,0.82,1.63, Paricalcitol,J2501,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,1.63,,,,,,,fee schedule,0.82,1.63, Paricalcitol,J2501,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.82,,,,,,,fee schedule,0.82,1.63, Paricalcitol,J2501,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.82,,,,,,,fee schedule,0.82,1.63, "Inj, pasireotide long acting",J2502,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,1268.53,,,,,,,fee schedule,687.82,1370.01, "Inj, pasireotide long acting",J2502,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,1370.01,,,,,,,fee schedule,687.82,1370.01, "Inj, pasireotide long acting",J2502,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,687.82,,,,,,,fee schedule,687.82,1370.01, "Inj, pasireotide long acting",J2502,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,687.82,,,,,,,fee schedule,687.82,1370.01, Pegaptanib sodium injection,J2503,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1107.32,,,,,,,fee schedule,1107.32,1107.32, Pegaptanib sodium injection,J2503,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1107.32,,,,,,,fee schedule,1107.32,1107.32, "Pegademase bovine, 25 iu",J2504,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,188.64,,,,,,,fee schedule,188.64,188.64, "Pegademase bovine, 25 iu",J2504,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,188.64,,,,,,,fee schedule,188.64,188.64, Inj pegfilgrast ex bio 0.5mg,J2506,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,131.4,,,,,,,fee schedule,71.25,141.91, Inj pegfilgrast ex bio 0.5mg,J2506,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,141.91,,,,,,,fee schedule,71.25,141.91, Inj pegfilgrast ex bio 0.5mg,J2506,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,71.25,,,,,,,fee schedule,71.25,141.91, Inj pegfilgrast ex bio 0.5mg,J2506,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,71.25,,,,,,,fee schedule,71.25,141.91, Pegloticase injection,J2507,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,8187.44,,,,,,,fee schedule,4439.41,8842.43, Pegloticase injection,J2507,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,8842.43,,,,,,,fee schedule,4439.41,8842.43, Pegloticase injection,J2507,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4439.41,,,,,,,fee schedule,4439.41,8842.43, Pegloticase injection,J2507,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4439.41,,,,,,,fee schedule,4439.41,8842.43, Pegunigalsidase alfa-iwxj,J2508,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,518.13,,,,,,,fee schedule,280.94,559.58, Pegunigalsidase alfa-iwxj,J2508,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,559.58,,,,,,,fee schedule,280.94,559.58, Pegunigalsidase alfa-iwxj,J2508,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,280.94,,,,,,,fee schedule,280.94,559.58, Pegunigalsidase alfa-iwxj,J2508,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,280.94,,,,,,,fee schedule,280.94,559.58, Penicillin g procaine inj,J2510,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,57.57,,,,,,,fee schedule,57.57,57.57, Penicillin g procaine inj,J2510,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,57.57,,,,,,,fee schedule,57.57,57.57, Pentobarbital sodium inj,J2515,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,77.8,,,,,,,fee schedule,77.8,77.8, Pentobarbital sodium inj,J2515,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,77.8,,,,,,,fee schedule,77.8,77.8, Penicillin g potassium inj,J2540,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,1.98,,,,,,,fee schedule,1.07,2.14, Penicillin g potassium inj,J2540,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,2.14,,,,,,,fee schedule,1.07,2.14, Penicillin g potassium inj,J2540,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.07,,,,,,,fee schedule,1.07,2.14, Penicillin g potassium inj,J2540,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.07,,,,,,,fee schedule,1.07,2.14, Piperacillin/tazobactam,J2543,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,2.5,,,,,,,fee schedule,1.35,2.7, Piperacillin/tazobactam,J2543,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,2.7,,,,,,,fee schedule,1.35,2.7, Piperacillin/tazobactam,J2543,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.35,,,,,,,fee schedule,1.35,2.7, Piperacillin/tazobactam,J2543,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.35,,,,,,,fee schedule,1.35,2.7, Pentamidine non-comp unit,J2545,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,185.33,,,,,,,fee schedule,100.49,200.16, Pentamidine non-comp unit,J2545,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,200.16,,,,,,,fee schedule,100.49,200.16, Pentamidine non-comp unit,J2545,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,100.49,,,,,,,fee schedule,100.49,200.16, Pentamidine non-comp unit,J2545,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,100.49,,,,,,,fee schedule,100.49,200.16, "Injection, peramivir",J2547,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2.05,,,,,,,fee schedule,2.05,2.05, "Injection, peramivir",J2547,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2.05,,,,,,,fee schedule,2.05,2.05, Promethazine hcl injection,J2550,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,6.46,,,,,,,fee schedule,3.5,6.97, Promethazine hcl injection,J2550,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,6.97,,,,,,,fee schedule,3.5,6.97, Promethazine hcl injection,J2550,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3.5,,,,,,,fee schedule,3.5,6.97, Promethazine hcl injection,J2550,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3.5,,,,,,,fee schedule,3.5,6.97, Phenobarbital sodium inj,J2560,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,61.56,,,,,,,fee schedule,33.38,66.48, Phenobarbital sodium inj,J2560,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,66.48,,,,,,,fee schedule,33.38,66.48, Phenobarbital sodium inj,J2560,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,33.38,,,,,,,fee schedule,33.38,66.48, Phenobarbital sodium inj,J2560,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,33.38,,,,,,,fee schedule,33.38,66.48, "Inj, sezaby, 1 mg",J2561,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.4,,,,,,,fee schedule,1.4,1.4, "Inj, sezaby, 1 mg",J2561,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.4,,,,,,,fee schedule,1.4,1.4, Plerixafor injection,J2562,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,268.81,,,,,,,fee schedule,145.75,290.31, Plerixafor injection,J2562,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,290.31,,,,,,,fee schedule,145.75,290.31, Plerixafor injection,J2562,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,145.75,,,,,,,fee schedule,145.75,290.31, Plerixafor injection,J2562,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,145.75,,,,,,,fee schedule,145.75,290.31, Oxytocin injection,J2590,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2.45,,,,,,,fee schedule,2.45,2.45, Oxytocin injection,J2590,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2.45,,,,,,,fee schedule,2.45,2.45, Inj desmopressin acetate,J2597,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,8.75,,,,,,,fee schedule,4.75,9.45, Inj desmopressin acetate,J2597,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,9.45,,,,,,,fee schedule,4.75,9.45, Inj desmopressin acetate,J2597,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.75,,,,,,,fee schedule,4.75,9.45, Inj desmopressin acetate,J2597,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4.75,,,,,,,fee schedule,4.75,9.45, "Inj, vasopressin, 1 unit",J2598,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,2.84,,,,,,,fee schedule,1.54,3.06, "Inj, vasopressin, 1 unit",J2598,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,3.06,,,,,,,fee schedule,1.54,3.06, "Inj, vasopressin, 1 unit",J2598,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.54,,,,,,,fee schedule,1.54,3.06, "Inj, vasopressin, 1 unit",J2598,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.54,,,,,,,fee schedule,1.54,3.06, Inj vasopressin (am reg) 1 u,J2599,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,1.08,,,,,,,fee schedule,0.59,1.17, Inj vasopressin (am reg) 1 u,J2599,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,1.17,,,,,,,fee schedule,0.59,1.17, Inj vasopressin (am reg) 1 u,J2599,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.59,,,,,,,fee schedule,0.59,1.17, Inj vasopressin (am reg) 1 u,J2599,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.59,,,,,,,fee schedule,0.59,1.17, "Inj, vasopressin (baxter)",J2601,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,6.62,,,,,,,fee schedule,3.59,7.14, "Inj, vasopressin (baxter)",J2601,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,7.14,,,,,,,fee schedule,3.59,7.14, "Inj, vasopressin (baxter)",J2601,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3.59,,,,,,,fee schedule,3.59,7.14, "Inj, vasopressin (baxter)",J2601,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3.59,,,,,,,fee schedule,3.59,7.14, Inj progesterone per 50 MG,J2675,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,1.42,,,,,,,fee schedule,0.77,1.53, Inj progesterone per 50 MG,J2675,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,1.53,,,,,,,fee schedule,0.77,1.53, Inj progesterone per 50 MG,J2675,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.77,,,,,,,fee schedule,0.77,1.53, Inj progesterone per 50 MG,J2675,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.77,,,,,,,fee schedule,0.77,1.53, Inj fluphenazine hcl 1.25 mg,J2679,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,16.72,,,,,,,fee schedule,9.06,18.05, Inj fluphenazine hcl 1.25 mg,J2679,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,18.05,,,,,,,fee schedule,9.06,18.05, Inj fluphenazine hcl 1.25 mg,J2679,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.06,,,,,,,fee schedule,9.06,18.05, Inj fluphenazine hcl 1.25 mg,J2679,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9.06,,,,,,,fee schedule,9.06,18.05, Fluphenazine decanoate 25 MG,J2680,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,16.94,,,,,,,fee schedule,9.19,18.3, Fluphenazine decanoate 25 MG,J2680,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,18.3,,,,,,,fee schedule,9.19,18.3, Fluphenazine decanoate 25 MG,J2680,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.19,,,,,,,fee schedule,9.19,18.3, Fluphenazine decanoate 25 MG,J2680,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9.19,,,,,,,fee schedule,9.19,18.3, Procainamide hcl injection,J2690,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,437.22,,,,,,,fee schedule,237.07,472.2, Procainamide hcl injection,J2690,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,472.2,,,,,,,fee schedule,237.07,472.2, Procainamide hcl injection,J2690,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,237.07,,,,,,,fee schedule,237.07,472.2, Procainamide hcl injection,J2690,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,237.07,,,,,,,fee schedule,237.07,472.2, Oxacillin sodium injeciton,J2700,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,1.85,,,,,,,fee schedule,1,1.99, Oxacillin sodium injeciton,J2700,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,1.99,,,,,,,fee schedule,1,1.99, Oxacillin sodium injeciton,J2700,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1,,,,,,,fee schedule,1,1.99, Oxacillin sodium injeciton,J2700,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1,,,,,,,fee schedule,1,1.99, "Inj, propofol, 10 mg",J2704,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.2,,,,,,,fee schedule,0.11,0.22, "Inj, propofol, 10 mg",J2704,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.22,,,,,,,fee schedule,0.11,0.22, "Inj, propofol, 10 mg",J2704,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.11,,,,,,,fee schedule,0.11,0.22, "Inj, propofol, 10 mg",J2704,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.11,,,,,,,fee schedule,0.11,0.22, Neostigmine methylslfte inj,J2710,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.94,,,,,,,fee schedule,1.94,1.94, Neostigmine methylslfte inj,J2710,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.94,,,,,,,fee schedule,1.94,1.94, Inj protamine sulfate/10 MG,J2720,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,3.69,,,,,,,fee schedule,2,3.99, Inj protamine sulfate/10 MG,J2720,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,3.99,,,,,,,fee schedule,2,3.99, Inj protamine sulfate/10 MG,J2720,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2,,,,,,,fee schedule,2,3.99, Inj protamine sulfate/10 MG,J2720,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2,,,,,,,fee schedule,2,3.99, Protein C concentrate,J2724,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,3.38,,,,,,,fee schedule,3.38,18.34, Protein C concentrate,J2724,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,3.65,,,,,,,fee schedule,3.38,18.34, Protein C concentrate,J2724,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.34,,,,,,,fee schedule,3.38,18.34, Protein C concentrate,J2724,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,18.34,,,,,,,fee schedule,3.38,18.34, Pralidoxime chloride inj,J2730,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,126.93,,,,,,,fee schedule,126.93,126.93, Pralidoxime chloride inj,J2730,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,126.93,,,,,,,fee schedule,126.93,126.93, Phentolaine mesylate inj,J2760,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,982.15,,,,,,,fee schedule,532.54,1060.72, Phentolaine mesylate inj,J2760,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,1060.72,,,,,,,fee schedule,532.54,1060.72, Phentolaine mesylate inj,J2760,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,532.54,,,,,,,fee schedule,532.54,1060.72, Phentolaine mesylate inj,J2760,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,532.54,,,,,,,fee schedule,532.54,1060.72, Metoclopramide hcl injection,J2765,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,2.25,,,,,,,fee schedule,1.22,2.43, Metoclopramide hcl injection,J2765,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,2.43,,,,,,,fee schedule,1.22,2.43, Metoclopramide hcl injection,J2765,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.22,,,,,,,fee schedule,1.22,2.43, Metoclopramide hcl injection,J2765,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.22,,,,,,,fee schedule,1.22,2.43, Quinupristin/dalfopristin,J2770,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.2,,,,,,,fee schedule,5.2,5.2, Quinupristin/dalfopristin,J2770,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5.2,,,,,,,fee schedule,5.2,5.2, "Inj, faricimab-svoa, 0.1mg",J2777,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,77.58,,,,,,,fee schedule,42.07,83.79, "Inj, faricimab-svoa, 0.1mg",J2777,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,83.79,,,,,,,fee schedule,42.07,83.79, "Inj, faricimab-svoa, 0.1mg",J2777,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,42.07,,,,,,,fee schedule,42.07,83.79, "Inj, faricimab-svoa, 0.1mg",J2777,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,42.07,,,,,,,fee schedule,42.07,83.79, Ranibizumab injection,J2778,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,205,,,,,,,fee schedule,111.15,221.4, Ranibizumab injection,J2778,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,221.4,,,,,,,fee schedule,111.15,221.4, Ranibizumab injection,J2778,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,111.15,,,,,,,fee schedule,111.15,221.4, Ranibizumab injection,J2778,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,111.15,,,,,,,fee schedule,111.15,221.4, "Inj, susvimo 0.1 mg",J2779,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,176.47,,,,,,,fee schedule,95.68,190.58, "Inj, susvimo 0.1 mg",J2779,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,190.58,,,,,,,fee schedule,95.68,190.58, "Inj, susvimo 0.1 mg",J2779,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,95.68,,,,,,,fee schedule,95.68,190.58, "Inj, susvimo 0.1 mg",J2779,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,95.68,,,,,,,fee schedule,95.68,190.58, "Inj, pegcetacoplan, 1mg",J2781,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,319.3,,,,,,,fee schedule,173.13,344.84, "Inj, pegcetacoplan, 1mg",J2781,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,344.84,,,,,,,fee schedule,173.13,344.84, "Inj, pegcetacoplan, 1mg",J2781,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,173.13,,,,,,,fee schedule,173.13,344.84, "Inj, pegcetacoplan, 1mg",J2781,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,173.13,,,,,,,fee schedule,173.13,344.84, Inj avacincaptad pegol 0.1mg,J2782,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,238.28,,,,,,,fee schedule,129.2,257.34, Inj avacincaptad pegol 0.1mg,J2782,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,257.34,,,,,,,fee schedule,129.2,257.34, Inj avacincaptad pegol 0.1mg,J2782,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,129.2,,,,,,,fee schedule,129.2,257.34, Inj avacincaptad pegol 0.1mg,J2782,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,129.2,,,,,,,fee schedule,129.2,257.34, Rasburicase,J2783,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,847.08,,,,,,,fee schedule,459.31,914.85, Rasburicase,J2783,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,914.85,,,,,,,fee schedule,459.31,914.85, Rasburicase,J2783,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.31,,,,,,,fee schedule,459.31,914.85, Rasburicase,J2783,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,459.31,,,,,,,fee schedule,459.31,914.85, Regadenoson injection,J2785,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,6.5,,,,,,,fee schedule,3.53,7.02, Regadenoson injection,J2785,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,7.02,,,,,,,fee schedule,3.53,7.02, Regadenoson injection,J2785,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3.53,,,,,,,fee schedule,3.53,7.02, Regadenoson injection,J2785,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3.53,,,,,,,fee schedule,3.53,7.02, "Injection, reslizumab, 1mg",J2786,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,23.81,,,,,,,fee schedule,12.91,25.71, "Injection, reslizumab, 1mg",J2786,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,25.71,,,,,,,fee schedule,12.91,25.71, "Injection, reslizumab, 1mg",J2786,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.91,,,,,,,fee schedule,12.91,25.71, "Injection, reslizumab, 1mg",J2786,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,12.91,,,,,,,fee schedule,12.91,25.71, Riboflavin 5?phos opth<=3ml,J2787,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3337.92,,,,,,,fee schedule,3337.92,3337.92, Riboflavin 5?phos opth<=3ml,J2787,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3337.92,,,,,,,fee schedule,3337.92,3337.92, Rho d immune globulin 50 mcg,J2788,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,62.69,,,,,,,fee schedule,33.99,67.7, Rho d immune globulin 50 mcg,J2788,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,67.7,,,,,,,fee schedule,33.99,67.7, Rho d immune globulin 50 mcg,J2788,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,33.99,,,,,,,fee schedule,33.99,67.7, Rho d immune globulin 50 mcg,J2788,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,33.99,,,,,,,fee schedule,33.99,67.7, Rho d immune globulin inj,J2790,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,185.45,,,,,,,fee schedule,100.55,200.28, Rho d immune globulin inj,J2790,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,200.28,,,,,,,fee schedule,100.55,200.28, Rho d immune globulin inj,J2790,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,100.55,,,,,,,fee schedule,100.55,200.28, Rho d immune globulin inj,J2790,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,100.55,,,,,,,fee schedule,100.55,200.28, Rhophylac injection,J2791,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,11.18,,,,,,,fee schedule,6.06,12.08, Rhophylac injection,J2791,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,12.08,,,,,,,fee schedule,6.06,12.08, Rhophylac injection,J2791,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.06,,,,,,,fee schedule,6.06,12.08, Rhophylac injection,J2791,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,6.06,,,,,,,fee schedule,6.06,12.08, "Rho(D) immune globulin h, sd",J2792,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,69.23,,,,,,,fee schedule,37.54,74.77, "Rho(D) immune globulin h, sd",J2792,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,74.77,,,,,,,fee schedule,37.54,74.77, "Rho(D) immune globulin h, sd",J2792,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,37.54,,,,,,,fee schedule,37.54,74.77, "Rho(D) immune globulin h, sd",J2792,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,37.54,,,,,,,fee schedule,37.54,74.77, Rilonacept injection,J2793,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,32.94,,,,,,,fee schedule,32.94,32.94, Rilonacept injection,J2793,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,32.94,,,,,,,fee schedule,32.94,32.94, "Risperidone, long acting",J2794,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,24.62,,,,,,,fee schedule,13.35,26.58, "Risperidone, long acting",J2794,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,26.58,,,,,,,fee schedule,13.35,26.58, "Risperidone, long acting",J2794,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13.35,,,,,,,fee schedule,13.35,26.58, "Risperidone, long acting",J2794,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13.35,,,,,,,fee schedule,13.35,26.58, Ropivacaine HCl injection,J2795,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.14,,,,,,,fee schedule,0.07,0.15, Ropivacaine HCl injection,J2795,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.15,,,,,,,fee schedule,0.07,0.15, Ropivacaine HCl injection,J2795,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.07,,,,,,,fee schedule,0.07,0.15, Ropivacaine HCl injection,J2795,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.07,,,,,,,fee schedule,0.07,0.15, "Inj., perseris, 0.5 mg",J2798,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,27.32,,,,,,,fee schedule,14.81,29.5, "Inj., perseris, 0.5 mg",J2798,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,29.5,,,,,,,fee schedule,14.81,29.5, "Inj., perseris, 0.5 mg",J2798,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.81,,,,,,,fee schedule,14.81,29.5, "Inj., perseris, 0.5 mg",J2798,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,14.81,,,,,,,fee schedule,14.81,29.5, "Inj, uzedy, 1 mg",J2799,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,56.43,,,,,,,fee schedule,30.6,60.94, "Inj, uzedy, 1 mg",J2799,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,60.94,,,,,,,fee schedule,30.6,60.94, "Inj, uzedy, 1 mg",J2799,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,30.6,,,,,,,fee schedule,30.6,60.94, "Inj, uzedy, 1 mg",J2799,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,30.6,,,,,,,fee schedule,30.6,60.94, Methocarbamol injection,J2800,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,10.78,,,,,,,fee schedule,5.84,11.64, Methocarbamol injection,J2800,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,11.64,,,,,,,fee schedule,5.84,11.64, Methocarbamol injection,J2800,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.84,,,,,,,fee schedule,5.84,11.64, Methocarbamol injection,J2800,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5.84,,,,,,,fee schedule,5.84,11.64, "Inj, rykindo, 0.5 mg",J2801,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.9,,,,,,,fee schedule,15.9,15.9, "Inj, rykindo, 0.5 mg",J2801,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,15.9,,,,,,,fee schedule,15.9,15.9, "Inj, romiplostim 1 microgram",J2802,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,24.75,,,,,,,fee schedule,13.42,26.73, "Inj, romiplostim 1 microgram",J2802,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,26.73,,,,,,,fee schedule,13.42,26.73, "Inj, romiplostim 1 microgram",J2802,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13.42,,,,,,,fee schedule,13.42,26.73, "Inj, romiplostim 1 microgram",J2802,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13.42,,,,,,,fee schedule,13.42,26.73, "Inj, rifampin, 1 mg",J2804,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.36,,,,,,,fee schedule,0.2,0.39, "Inj, rifampin, 1 mg",J2804,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.39,,,,,,,fee schedule,0.2,0.39, "Inj, rifampin, 1 mg",J2804,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.2,,,,,,,fee schedule,0.2,0.39, "Inj, rifampin, 1 mg",J2804,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.2,,,,,,,fee schedule,0.2,0.39, Sincalide injection,J2805,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,305.93,,,,,,,fee schedule,165.88,330.41, Sincalide injection,J2805,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,330.41,,,,,,,fee schedule,165.88,330.41, Sincalide injection,J2805,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,165.88,,,,,,,fee schedule,165.88,330.41, Sincalide injection,J2805,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,165.88,,,,,,,fee schedule,165.88,330.41, Inj theophylline per 40 MG,J2810,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.28,,,,,,,fee schedule,1.28,1.28, Inj theophylline per 40 MG,J2810,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.28,,,,,,,fee schedule,1.28,1.28, Sargramostim injection,J2820,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,126.2,,,,,,,fee schedule,68.43,136.3, Sargramostim injection,J2820,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,136.3,,,,,,,fee schedule,68.43,136.3, Sargramostim injection,J2820,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,68.43,,,,,,,fee schedule,68.43,136.3, Sargramostim injection,J2820,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,68.43,,,,,,,fee schedule,68.43,136.3, Inj sebelipase alfa 1 mg,J2840,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,658.42,,,,,,,fee schedule,658.42,658.42, Inj sebelipase alfa 1 mg,J2840,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,658.42,,,,,,,fee schedule,658.42,658.42, Inj secretin synthetic human,J2850,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,53.42,,,,,,,fee schedule,53.42,53.42, Inj secretin synthetic human,J2850,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,53.42,,,,,,,fee schedule,53.42,53.42, "Injection, siltuximab",J2860,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,364.41,,,,,,,fee schedule,197.59,393.56, "Injection, siltuximab",J2860,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,393.56,,,,,,,fee schedule,197.59,393.56, "Injection, siltuximab",J2860,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,197.59,,,,,,,fee schedule,197.59,393.56, "Injection, siltuximab",J2860,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,197.59,,,,,,,fee schedule,197.59,393.56, Inj sulfameth/trim 5 mg/1 mg,J2865,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.11,,,,,,,fee schedule,0.06,0.12, Inj sulfameth/trim 5 mg/1 mg,J2865,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.12,,,,,,,fee schedule,0.06,0.12, Inj sulfameth/trim 5 mg/1 mg,J2865,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.06,,,,,,,fee schedule,0.06,0.12, Inj sulfameth/trim 5 mg/1 mg,J2865,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.06,,,,,,,fee schedule,0.06,0.12, Na ferric gluconate complex,J2916,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,4.91,,,,,,,fee schedule,2.66,5.3, Na ferric gluconate complex,J2916,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,5.3,,,,,,,fee schedule,2.66,5.3, Na ferric gluconate complex,J2916,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2.66,,,,,,,fee schedule,2.66,5.3, Na ferric gluconate complex,J2916,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2.66,,,,,,,fee schedule,2.66,5.3, "Inj, methylpred sod succ 5mg",J2919,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.59,,,,,,,fee schedule,0.32,0.63, "Inj, methylpred sod succ 5mg",J2919,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.63,,,,,,,fee schedule,0.32,0.63, "Inj, methylpred sod succ 5mg",J2919,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.32,,,,,,,fee schedule,0.32,0.63, "Inj, methylpred sod succ 5mg",J2919,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.32,,,,,,,fee schedule,0.32,0.63, Somatropin injection,J2941,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,59.68,,,,,,,fee schedule,59.68,59.68, Somatropin injection,J2941,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,59.68,,,,,,,fee schedule,59.68,59.68, Reteplase injection,J2993,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3543.59,,,,,,,fee schedule,3543.59,3543.59, Reteplase injection,J2993,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3543.59,,,,,,,fee schedule,3543.59,3543.59, Inj streptokinase /250000 IU,J2995,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,86.82,,,,,,,fee schedule,86.82,86.82, Inj streptokinase /250000 IU,J2995,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,86.82,,,,,,,fee schedule,86.82,86.82, Alteplase recombinant,J2997,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,211.84,,,,,,,fee schedule,114.86,228.78, Alteplase recombinant,J2997,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,228.78,,,,,,,fee schedule,114.86,228.78, Alteplase recombinant,J2997,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,114.86,,,,,,,fee schedule,114.86,228.78, Alteplase recombinant,J2997,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,114.86,,,,,,,fee schedule,114.86,228.78, Inj plasminogen tvmh 1mg,J2998,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,39.42,,,,,,,fee schedule,39.42,39.42, Inj plasminogen tvmh 1mg,J2998,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,39.42,,,,,,,fee schedule,39.42,39.42, Streptomycin injection,J3000,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,70.54,,,,,,,fee schedule,38.25,76.18, Streptomycin injection,J3000,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,76.18,,,,,,,fee schedule,38.25,76.18, Streptomycin injection,J3000,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,38.25,,,,,,,fee schedule,38.25,76.18, Streptomycin injection,J3000,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,38.25,,,,,,,fee schedule,38.25,76.18, Fentanyl citrate injeciton,J3010,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,2.16,,,,,,,fee schedule,1.17,2.33, Fentanyl citrate injeciton,J3010,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,2.33,,,,,,,fee schedule,1.17,2.33, Fentanyl citrate injeciton,J3010,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.17,,,,,,,fee schedule,1.17,2.33, Fentanyl citrate injeciton,J3010,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.17,,,,,,,fee schedule,1.17,2.33, Sumatriptan succinate / 6 MG,J3030,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,199.79,,,,,,,fee schedule,199.79,199.79, Sumatriptan succinate / 6 MG,J3030,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,199.79,,,,,,,fee schedule,199.79,199.79, "Inj., fremanezumab-vfrm 1 mg",J3031,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.94,,,,,,,fee schedule,4.94,4.94, "Inj., fremanezumab-vfrm 1 mg",J3031,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4.94,,,,,,,fee schedule,4.94,4.94, Inj. eptinezumab-jjmr 1 mg,J3032,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,44.66,,,,,,,fee schedule,24.22,48.24, Inj. eptinezumab-jjmr 1 mg,J3032,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,48.24,,,,,,,fee schedule,24.22,48.24, Inj. eptinezumab-jjmr 1 mg,J3032,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24.22,,,,,,,fee schedule,24.22,48.24, Inj. eptinezumab-jjmr 1 mg,J3032,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,24.22,,,,,,,fee schedule,24.22,48.24, Inj talquetamab-tgvs 0.25 mg,J3055,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,162.9,,,,,,,fee schedule,88.33,175.93, Inj talquetamab-tgvs 0.25 mg,J3055,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,175.93,,,,,,,fee schedule,88.33,175.93, Inj talquetamab-tgvs 0.25 mg,J3055,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,88.33,,,,,,,fee schedule,88.33,175.93, Inj talquetamab-tgvs 0.25 mg,J3055,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,88.33,,,,,,,fee schedule,88.33,175.93, "Inj, taliglucerace alfa 10 u",J3060,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,92.39,,,,,,,fee schedule,50.09,99.78, "Inj, taliglucerace alfa 10 u",J3060,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,99.78,,,,,,,fee schedule,50.09,99.78, "Inj, taliglucerace alfa 10 u",J3060,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,50.09,,,,,,,fee schedule,50.09,99.78, "Inj, taliglucerace alfa 10 u",J3060,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,50.09,,,,,,,fee schedule,50.09,99.78, Pentazocine injection,J3070,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,32.35,,,,,,,fee schedule,32.35,32.35, Pentazocine injection,J3070,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,32.35,,,,,,,fee schedule,32.35,32.35, Inj tedizolid phosphate,J3090,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,4.3,,,,,,,fee schedule,2.33,4.64, Inj tedizolid phosphate,J3090,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,4.64,,,,,,,fee schedule,2.33,4.64, Inj tedizolid phosphate,J3090,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2.33,,,,,,,fee schedule,2.33,4.64, Inj tedizolid phosphate,J3090,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2.33,,,,,,,fee schedule,2.33,4.64, Telavancin injection,J3095,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,16.81,,,,,,,fee schedule,9.11,18.15, Telavancin injection,J3095,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,18.15,,,,,,,fee schedule,9.11,18.15, Telavancin injection,J3095,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.11,,,,,,,fee schedule,9.11,18.15, Telavancin injection,J3095,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9.11,,,,,,,fee schedule,9.11,18.15, Tenecteplase injection,J3101,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,386.87,,,,,,,fee schedule,209.77,417.81, Tenecteplase injection,J3101,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,417.81,,,,,,,fee schedule,209.77,417.81, Tenecteplase injection,J3101,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,209.77,,,,,,,fee schedule,209.77,417.81, Tenecteplase injection,J3101,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,209.77,,,,,,,fee schedule,209.77,417.81, Terbutaline sulfate inj,J3105,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,6.17,,,,,,,fee schedule,3.34,6.66, Terbutaline sulfate inj,J3105,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,6.66,,,,,,,fee schedule,3.34,6.66, Terbutaline sulfate inj,J3105,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3.34,,,,,,,fee schedule,3.34,6.66, Terbutaline sulfate inj,J3105,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3.34,,,,,,,fee schedule,3.34,6.66, Teriparatide injection,J3110,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,92.51,,,,,,,fee schedule,92.51,92.51, Teriparatide injection,J3110,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,92.51,,,,,,,fee schedule,92.51,92.51, Inj. romosozumab-aqqg 1 mg,J3111,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,27,,,,,,,fee schedule,14.64,29.16, Inj. romosozumab-aqqg 1 mg,J3111,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,29.16,,,,,,,fee schedule,14.64,29.16, Inj. romosozumab-aqqg 1 mg,J3111,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.64,,,,,,,fee schedule,14.64,29.16, Inj. romosozumab-aqqg 1 mg,J3111,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,14.64,,,,,,,fee schedule,14.64,29.16, Inj testostero enanthate 1mg,J3121,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.14,,,,,,,fee schedule,0.07,0.15, Inj testostero enanthate 1mg,J3121,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.15,,,,,,,fee schedule,0.07,0.15, Inj testostero enanthate 1mg,J3121,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.07,,,,,,,fee schedule,0.07,0.15, Inj testostero enanthate 1mg,J3121,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.07,,,,,,,fee schedule,0.07,0.15, Testosterone undecanoate 1mg,J3145,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,4.48,,,,,,,fee schedule,2.43,4.84, Testosterone undecanoate 1mg,J3145,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,4.84,,,,,,,fee schedule,2.43,4.84, Testosterone undecanoate 1mg,J3145,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2.43,,,,,,,fee schedule,2.43,4.84, Testosterone undecanoate 1mg,J3145,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2.43,,,,,,,fee schedule,2.43,4.84, Chlorpromazine hcl injection,J3230,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,60.91,,,,,,,fee schedule,33.03,65.78, Chlorpromazine hcl injection,J3230,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,65.78,,,,,,,fee schedule,33.03,65.78, Chlorpromazine hcl injection,J3230,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,33.03,,,,,,,fee schedule,33.03,65.78, Chlorpromazine hcl injection,J3230,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,33.03,,,,,,,fee schedule,33.03,65.78, Thyrotropin injection,J3240,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,4754.79,,,,,,,fee schedule,2578.15,5135.17, Thyrotropin injection,J3240,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,5135.17,,,,,,,fee schedule,2578.15,5135.17, Thyrotropin injection,J3240,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2578.15,,,,,,,fee schedule,2578.15,5135.17, Thyrotropin injection,J3240,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2578.15,,,,,,,fee schedule,2578.15,5135.17, Inj. teprotumumab-trbw 10 mg,J3241,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,807.95,,,,,,,fee schedule,438.09,872.59, Inj. teprotumumab-trbw 10 mg,J3241,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,872.59,,,,,,,fee schedule,438.09,872.59, Inj. teprotumumab-trbw 10 mg,J3241,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,438.09,,,,,,,fee schedule,438.09,872.59, Inj. teprotumumab-trbw 10 mg,J3241,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,438.09,,,,,,,fee schedule,438.09,872.59, Tigecycline injection,J3243,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,1.15,,,,,,,fee schedule,0.62,1.24, Tigecycline injection,J3243,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,1.24,,,,,,,fee schedule,0.62,1.24, Tigecycline injection,J3243,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.62,,,,,,,fee schedule,0.62,1.24, Tigecycline injection,J3243,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.62,,,,,,,fee schedule,0.62,1.24, Inj. tigecycline (accord),J3244,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.12,,,,,,,fee schedule,4.12,4.12, Inj. tigecycline (accord),J3244,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4.12,,,,,,,fee schedule,4.12,4.12, "Inj., tildrakizumab, 1 mg",J3245,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,284.04,,,,,,,fee schedule,154.01,306.76, "Inj., tildrakizumab, 1 mg",J3245,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,306.76,,,,,,,fee schedule,154.01,306.76, "Inj., tildrakizumab, 1 mg",J3245,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,154.01,,,,,,,fee schedule,154.01,306.76, "Inj., tildrakizumab, 1 mg",J3245,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,154.01,,,,,,,fee schedule,154.01,306.76, Tirofiban hcl,J3246,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,7.72,,,,,,,fee schedule,4.18,8.33, Tirofiban hcl,J3246,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,8.33,,,,,,,fee schedule,4.18,8.33, Tirofiban hcl,J3246,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.18,,,,,,,fee schedule,4.18,8.33, Tirofiban hcl,J3246,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4.18,,,,,,,fee schedule,4.18,8.33, Inj secukinumab intrav 1mg,J3247,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,40.14,,,,,,,fee schedule,21.76,43.35, Inj secukinumab intrav 1mg,J3247,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,43.35,,,,,,,fee schedule,21.76,43.35, Inj secukinumab intrav 1mg,J3247,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21.76,,,,,,,fee schedule,21.76,43.35, Inj secukinumab intrav 1mg,J3247,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,21.76,,,,,,,fee schedule,21.76,43.35, Trimethobenzamide hcl inj,J3250,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,120.15,,,,,,,fee schedule,65.15,129.76, Trimethobenzamide hcl inj,J3250,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,129.76,,,,,,,fee schedule,65.15,129.76, Trimethobenzamide hcl inj,J3250,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,65.15,,,,,,,fee schedule,65.15,129.76, Trimethobenzamide hcl inj,J3250,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,65.15,,,,,,,fee schedule,65.15,129.76, Tobramycin sulfate injection,J3260,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,5.54,,,,,,,fee schedule,3,5.98, Tobramycin sulfate injection,J3260,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,5.98,,,,,,,fee schedule,3,5.98, Tobramycin sulfate injection,J3260,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3,,,,,,,fee schedule,3,5.98, Tobramycin sulfate injection,J3260,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3,,,,,,,fee schedule,3,5.98, Tocilizumab injection,J3262,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,13.03,,,,,,,fee schedule,7.06,14.07, Tocilizumab injection,J3262,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,14.07,,,,,,,fee schedule,7.06,14.07, Tocilizumab injection,J3262,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.06,,,,,,,fee schedule,7.06,14.07, Tocilizumab injection,J3262,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,7.06,,,,,,,fee schedule,7.06,14.07, "Inj, toripalimab-tpzi, 1 mg",J3263,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,88.88,,,,,,,fee schedule,48.19,95.99, "Inj, toripalimab-tpzi, 1 mg",J3263,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,95.99,,,,,,,fee schedule,48.19,95.99, "Inj, toripalimab-tpzi, 1 mg",J3263,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,48.19,,,,,,,fee schedule,48.19,95.99, "Inj, toripalimab-tpzi, 1 mg",J3263,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,48.19,,,,,,,fee schedule,48.19,95.99, Thiethylperazine maleate inj,J3280,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.53,,,,,,,fee schedule,5.53,5.53, Thiethylperazine maleate inj,J3280,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5.53,,,,,,,fee schedule,5.53,5.53, Treprostinil injection,J3285,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,124.83,,,,,,,fee schedule,67.69,134.82, Treprostinil injection,J3285,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,134.82,,,,,,,fee schedule,67.69,134.82, Treprostinil injection,J3285,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,67.69,,,,,,,fee schedule,67.69,134.82, Treprostinil injection,J3285,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,67.69,,,,,,,fee schedule,67.69,134.82, Inj xipere 1 mg,J3299,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,108,,,,,,,fee schedule,58.56,116.64, Inj xipere 1 mg,J3299,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,116.64,,,,,,,fee schedule,58.56,116.64, Inj xipere 1 mg,J3299,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,58.56,,,,,,,fee schedule,58.56,116.64, Inj xipere 1 mg,J3299,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,58.56,,,,,,,fee schedule,58.56,116.64, Triamcinolone A inj PRS-free,J3300,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,55.15,,,,,,,fee schedule,29.9,59.56, Triamcinolone A inj PRS-free,J3300,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,59.56,,,,,,,fee schedule,29.9,59.56, Triamcinolone A inj PRS-free,J3300,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,29.9,,,,,,,fee schedule,29.9,59.56, Triamcinolone A inj PRS-free,J3300,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,29.9,,,,,,,fee schedule,29.9,59.56, Triamcinolone acet inj nos,J3301,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,1.94,,,,,,,fee schedule,1.05,2.09, Triamcinolone acet inj nos,J3301,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,2.09,,,,,,,fee schedule,1.05,2.09, Triamcinolone acet inj nos,J3301,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.05,,,,,,,fee schedule,1.05,2.09, Triamcinolone acet inj nos,J3301,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.05,,,,,,,fee schedule,1.05,2.09, Triamcinolone diacetate inj,J3302,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.39,,,,,,,fee schedule,0.39,0.39, Triamcinolone diacetate inj,J3302,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.39,,,,,,,fee schedule,0.39,0.39, Triamcinolone hexacetonl inj,J3303,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.9,,,,,,,fee schedule,11.9,11.9, Triamcinolone hexacetonl inj,J3303,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11.9,,,,,,,fee schedule,11.9,11.9, Inj triamcinolone ace xr 1mg,J3304,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,40.97,,,,,,,fee schedule,22.22,44.25, Inj triamcinolone ace xr 1mg,J3304,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,44.25,,,,,,,fee schedule,22.22,44.25, Inj triamcinolone ace xr 1mg,J3304,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22.22,,,,,,,fee schedule,22.22,44.25, Inj triamcinolone ace xr 1mg,J3304,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22.22,,,,,,,fee schedule,22.22,44.25, Triptorelin pamoate,J3315,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,1106.78,,,,,,,fee schedule,600.12,1195.32, Triptorelin pamoate,J3315,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,1195.32,,,,,,,fee schedule,600.12,1195.32, Triptorelin pamoate,J3315,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,600.12,,,,,,,fee schedule,600.12,1195.32, Triptorelin pamoate,J3315,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,600.12,,,,,,,fee schedule,600.12,1195.32, "Inj., triptorelin xr 3.75 mg",J3316,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,8488.91,,,,,,,fee schedule,4602.88,9168.03, "Inj., triptorelin xr 3.75 mg",J3316,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,9168.03,,,,,,,fee schedule,4602.88,9168.03, "Inj., triptorelin xr 3.75 mg",J3316,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4602.88,,,,,,,fee schedule,4602.88,9168.03, "Inj., triptorelin xr 3.75 mg",J3316,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4602.88,,,,,,,fee schedule,4602.88,9168.03, "Urofollitropin, 75 iu",J3355,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,72.21,,,,,,,fee schedule,72.21,72.21, "Urofollitropin, 75 iu",J3355,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,72.21,,,,,,,fee schedule,72.21,72.21, "Ustekinumab sub cu inj, 1 mg",J3357,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,192.37,,,,,,,fee schedule,192.37,192.37, "Ustekinumab sub cu inj, 1 mg",J3357,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,192.37,,,,,,,fee schedule,192.37,192.37, "Ustekinumab, iv inject, 1 mg",J3358,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,29.9,,,,,,,fee schedule,16.21,32.29, "Ustekinumab, iv inject, 1 mg",J3358,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,32.29,,,,,,,fee schedule,16.21,32.29, "Ustekinumab, iv inject, 1 mg",J3358,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.21,,,,,,,fee schedule,16.21,32.29, "Ustekinumab, iv inject, 1 mg",J3358,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,16.21,,,,,,,fee schedule,16.21,32.29, Diazepam injection,J3360,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,13.88,,,,,,,fee schedule,7.53,14.99, Diazepam injection,J3360,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,14.99,,,,,,,fee schedule,7.53,14.99, Diazepam injection,J3360,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.53,,,,,,,fee schedule,7.53,14.99, Diazepam injection,J3360,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,7.53,,,,,,,fee schedule,7.53,14.99, "Inj, vancomycin hcl, 10 mg",J3373,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.07,,,,,,,fee schedule,0.04,0.07, "Inj, vancomycin hcl, 10 mg",J3373,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.07,,,,,,,fee schedule,0.04,0.07, "Inj, vancomycin hcl, 10 mg",J3373,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.04,,,,,,,fee schedule,0.04,0.07, "Inj, vancomycin hcl, 10 mg",J3373,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.04,,,,,,,fee schedule,0.04,0.07, "Inj, vancomycin (mylan) 10mg",J3374,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.27,,,,,,,fee schedule,0.15,0.29, "Inj, vancomycin (mylan) 10mg",J3374,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.29,,,,,,,fee schedule,0.15,0.29, "Inj, vancomycin (mylan) 10mg",J3374,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.15,,,,,,,fee schedule,0.15,0.29, "Inj, vancomycin (mylan) 10mg",J3374,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.15,,,,,,,fee schedule,0.15,0.29, Inj vancomycin (xellia) 10mg,J3375,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.29,,,,,,,fee schedule,0.16,0.32, Inj vancomycin (xellia) 10mg,J3375,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.32,,,,,,,fee schedule,0.16,0.32, Inj vancomycin (xellia) 10mg,J3375,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.16,,,,,,,fee schedule,0.16,0.32, Inj vancomycin (xellia) 10mg,J3375,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.16,,,,,,,fee schedule,0.16,0.32, "Injection, vedolizumab",J3380,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,49.64,,,,,,,fee schedule,26.91,53.61, "Injection, vedolizumab",J3380,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,53.61,,,,,,,fee schedule,26.91,53.61, "Injection, vedolizumab",J3380,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26.91,,,,,,,fee schedule,26.91,53.61, "Injection, vedolizumab",J3380,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,26.91,,,,,,,fee schedule,26.91,53.61, Velaglucerase alfa,J3385,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,855.41,,,,,,,fee schedule,463.82,923.84, Velaglucerase alfa,J3385,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,923.84,,,,,,,fee schedule,463.82,923.84, Velaglucerase alfa,J3385,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,463.82,,,,,,,fee schedule,463.82,923.84, Velaglucerase alfa,J3385,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,463.82,,,,,,,fee schedule,463.82,923.84, "Inj, atidarsagene autotemcel",J3391,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5340550,,,,,,,fee schedule,5340550,5340550, "Inj, atidarsagene autotemcel",J3391,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5340550,,,,,,,fee schedule,5340550,5340550, "Inj, exagamglogene autotem",J3392,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2845040,,,,,,,fee schedule,2845040,2845040, "Inj, exagamglogene autotem",J3392,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2845040,,,,,,,fee schedule,2845040,2845040, "Inj, betibeglogene autotemce",J3393,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3599837.74,,,,,,,fee schedule,3599837.74,3599837.74, "Inj, betibeglogene autotemce",J3393,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3599837.74,,,,,,,fee schedule,3599837.74,3599837.74, "Inj, lovotibeglogene autotem",J3394,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3978853.1,,,,,,,fee schedule,3978853.1,3978853.1, "Inj, lovotibeglogene autotem",J3394,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3978853.1,,,,,,,fee schedule,3978853.1,3978853.1, Verteporfin injection,J3396,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,25.99,,,,,,,fee schedule,14.09,28.07, Verteporfin injection,J3396,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,28.07,,,,,,,fee schedule,14.09,28.07, Verteporfin injection,J3396,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.09,,,,,,,fee schedule,14.09,28.07, Verteporfin injection,J3396,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,14.09,,,,,,,fee schedule,14.09,28.07, "Inj., vestronidase alfa-vjbk",J3397,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,397.62,,,,,,,fee schedule,397.62,397.62, "Inj., vestronidase alfa-vjbk",J3397,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,397.62,,,,,,,fee schedule,397.62,397.62, Inj luxturna 1 billion vec g,J3398,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3036.62,,,,,,,fee schedule,3036.62,3036.62, Inj luxturna 1 billion vec g,J3398,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3036.62,,,,,,,fee schedule,3036.62,3036.62, Inj onase abepar-xioi treat,J3399,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2260161.87,,,,,,,fee schedule,2260161.87,2260161.87, Inj onase abepar-xioi treat,J3399,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2260161.87,,,,,,,fee schedule,2260161.87,2260161.87, "Vyjuvek 5x10^9pfu/ml, 0.1 ml",J3401,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,2333.52,,,,,,,fee schedule,1265.29,2520.2, "Vyjuvek 5x10^9pfu/ml, 0.1 ml",J3401,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,2520.2,,,,,,,fee schedule,1265.29,2520.2, "Vyjuvek 5x10^9pfu/ml, 0.1 ml",J3401,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1265.29,,,,,,,fee schedule,1265.29,2520.2, "Vyjuvek 5x10^9pfu/ml, 0.1 ml",J3401,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1265.29,,,,,,,fee schedule,1265.29,2520.2, Hydroxyzine hcl injection,J3410,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,38.09,,,,,,,fee schedule,20.65,41.14, Hydroxyzine hcl injection,J3410,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,41.14,,,,,,,fee schedule,20.65,41.14, Hydroxyzine hcl injection,J3410,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,20.65,,,,,,,fee schedule,20.65,41.14, Hydroxyzine hcl injection,J3410,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,20.65,,,,,,,fee schedule,20.65,41.14, Thiamine hcl 100 mg,J3411,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,4.03,,,,,,,fee schedule,2.18,4.35, Thiamine hcl 100 mg,J3411,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,4.35,,,,,,,fee schedule,2.18,4.35, Thiamine hcl 100 mg,J3411,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2.18,,,,,,,fee schedule,2.18,4.35, Thiamine hcl 100 mg,J3411,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2.18,,,,,,,fee schedule,2.18,4.35, Pyridoxine hcl 100 mg,J3415,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,28.8,,,,,,,fee schedule,15.62,31.1, Pyridoxine hcl 100 mg,J3415,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,31.1,,,,,,,fee schedule,15.62,31.1, Pyridoxine hcl 100 mg,J3415,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.62,,,,,,,fee schedule,15.62,31.1, Pyridoxine hcl 100 mg,J3415,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,15.62,,,,,,,fee schedule,15.62,31.1, Vitamin b12 injection,J3420,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,2.14,,,,,,,fee schedule,1.16,2.31, Vitamin b12 injection,J3420,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,2.31,,,,,,,fee schedule,1.16,2.31, Vitamin b12 injection,J3420,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.16,,,,,,,fee schedule,1.16,2.31, Vitamin b12 injection,J3420,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.16,,,,,,,fee schedule,1.16,2.31, Inj hydroxocobalamin iv 25mg,J3424,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.32,,,,,,,fee schedule,6.32,6.32, Inj hydroxocobalamin iv 25mg,J3424,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,6.32,,,,,,,fee schedule,6.32,6.32, "Inj, hydroxocobalamin",J3425,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.02,,,,,,,fee schedule,0.01,0.02, "Inj, hydroxocobalamin",J3425,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.02,,,,,,,fee schedule,0.01,0.02, "Inj, hydroxocobalamin",J3425,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.01,,,,,,,fee schedule,0.01,0.02, "Inj, hydroxocobalamin",J3425,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.01,,,,,,,fee schedule,0.01,0.02, Vitamin k phytonadione inj,J3430,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,6.39,,,,,,,fee schedule,3.46,6.9, Vitamin k phytonadione inj,J3430,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,6.9,,,,,,,fee schedule,3.46,6.9, Vitamin k phytonadione inj,J3430,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3.46,,,,,,,fee schedule,3.46,6.9, Vitamin k phytonadione inj,J3430,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3.46,,,,,,,fee schedule,3.46,6.9, "Injection, voriconazole",J3465,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,1.76,,,,,,,fee schedule,0.95,1.9, "Injection, voriconazole",J3465,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,1.9,,,,,,,fee schedule,0.95,1.9, "Injection, voriconazole",J3465,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.95,,,,,,,fee schedule,0.95,1.9, "Injection, voriconazole",J3465,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.95,,,,,,,fee schedule,0.95,1.9, Hyaluronidase injection,J3470,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,70.99,,,,,,,fee schedule,38.49,76.67, Hyaluronidase injection,J3470,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,76.67,,,,,,,fee schedule,38.49,76.67, Hyaluronidase injection,J3470,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,38.49,,,,,,,fee schedule,38.49,76.67, Hyaluronidase injection,J3470,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,38.49,,,,,,,fee schedule,38.49,76.67, "Ovine, up to 999 usp units",J3471,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,1.13,,,,,,,fee schedule,0.61,1.22, "Ovine, up to 999 usp units",J3471,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,1.22,,,,,,,fee schedule,0.61,1.22, "Ovine, up to 999 usp units",J3471,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.61,,,,,,,fee schedule,0.61,1.22, "Ovine, up to 999 usp units",J3471,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.61,,,,,,,fee schedule,0.61,1.22, "Ovine, 1000 USP units",J3472,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,129.83,,,,,,,fee schedule,129.83,129.83, "Ovine, 1000 USP units",J3472,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,129.83,,,,,,,fee schedule,129.83,129.83, Hyaluronidase recombinant,J3473,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.81,,,,,,,fee schedule,0.44,0.87, Hyaluronidase recombinant,J3473,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.87,,,,,,,fee schedule,0.44,0.87, Hyaluronidase recombinant,J3473,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.44,,,,,,,fee schedule,0.44,0.87, Hyaluronidase recombinant,J3473,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.44,,,,,,,fee schedule,0.44,0.87, Inj magnesium sulfate,J3475,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,1.13,,,,,,,fee schedule,0.61,1.22, Inj magnesium sulfate,J3475,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,1.22,,,,,,,fee schedule,0.61,1.22, Inj magnesium sulfate,J3475,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.61,,,,,,,fee schedule,0.61,1.22, Inj magnesium sulfate,J3475,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.61,,,,,,,fee schedule,0.61,1.22, Inj potassium chloride,J3480,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.38,,,,,,,fee schedule,0.21,0.41, Inj potassium chloride,J3480,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.41,,,,,,,fee schedule,0.21,0.41, Inj potassium chloride,J3480,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.21,,,,,,,fee schedule,0.21,0.41, Inj potassium chloride,J3480,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.21,,,,,,,fee schedule,0.21,0.41, Zidovudine,J3485,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,3.4,,,,,,,fee schedule,1.84,3.67, Zidovudine,J3485,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,3.67,,,,,,,fee schedule,1.84,3.67, Zidovudine,J3485,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.84,,,,,,,fee schedule,1.84,3.67, Zidovudine,J3485,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.84,,,,,,,fee schedule,1.84,3.67, Ziprasidone mesylate,J3486,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,7.07,,,,,,,fee schedule,3.83,7.63, Ziprasidone mesylate,J3486,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,7.63,,,,,,,fee schedule,3.83,7.63, Ziprasidone mesylate,J3486,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3.83,,,,,,,fee schedule,3.83,7.63, Ziprasidone mesylate,J3486,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3.83,,,,,,,fee schedule,3.83,7.63, Zoledronic acid 1mg,J3489,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,11.7,,,,,,,fee schedule,6.34,12.64, Zoledronic acid 1mg,J3489,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,12.64,,,,,,,fee schedule,6.34,12.64, Zoledronic acid 1mg,J3489,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.34,,,,,,,fee schedule,6.34,12.64, Zoledronic acid 1mg,J3489,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,6.34,,,,,,,fee schedule,6.34,12.64, Edetate disodium per 150 mg,J3520,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.39,,,,,,,fee schedule,0.39,0.39, Edetate disodium per 150 mg,J3520,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.39,,,,,,,fee schedule,0.39,0.39, Normal saline solution infus,J7030,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,5.13,,,,,,,fee schedule,2.78,5.54, Normal saline solution infus,J7030,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,5.54,,,,,,,fee schedule,2.78,5.54, Normal saline solution infus,J7030,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2.78,,,,,,,fee schedule,2.78,5.54, Normal saline solution infus,J7030,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2.78,,,,,,,fee schedule,2.78,5.54, Normal saline solution infus,J7040,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,3.11,,,,,,,fee schedule,1.68,3.35, Normal saline solution infus,J7040,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,3.35,,,,,,,fee schedule,1.68,3.35, Normal saline solution infus,J7040,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.68,,,,,,,fee schedule,1.68,3.35, Normal saline solution infus,J7040,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.68,,,,,,,fee schedule,1.68,3.35, 5% dextrose/normal saline,J7042,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,3.06,,,,,,,fee schedule,1.66,3.3, 5% dextrose/normal saline,J7042,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,3.3,,,,,,,fee schedule,1.66,3.3, 5% dextrose/normal saline,J7042,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.66,,,,,,,fee schedule,1.66,3.3, 5% dextrose/normal saline,J7042,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.66,,,,,,,fee schedule,1.66,3.3, Normal saline solution infus,J7050,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,1.6,,,,,,,fee schedule,0.87,1.73, Normal saline solution infus,J7050,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,1.73,,,,,,,fee schedule,0.87,1.73, Normal saline solution infus,J7050,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.87,,,,,,,fee schedule,0.87,1.73, Normal saline solution infus,J7050,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.87,,,,,,,fee schedule,0.87,1.73, 5% dextrose/water,J7060,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,4.57,,,,,,,fee schedule,2.48,4.93, 5% dextrose/water,J7060,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,4.93,,,,,,,fee schedule,2.48,4.93, 5% dextrose/water,J7060,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2.48,,,,,,,fee schedule,2.48,4.93, 5% dextrose/water,J7060,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2.48,,,,,,,fee schedule,2.48,4.93, D5w infusion,J7070,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,6.84,,,,,,,fee schedule,3.71,7.39, D5w infusion,J7070,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,7.39,,,,,,,fee schedule,3.71,7.39, D5w infusion,J7070,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3.71,,,,,,,fee schedule,3.71,7.39, D5w infusion,J7070,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3.71,,,,,,,fee schedule,3.71,7.39, Dextran 40 infusion,J7100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,97.45,,,,,,,fee schedule,97.45,97.45, Dextran 40 infusion,J7100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,97.45,,,,,,,fee schedule,97.45,97.45, Ringers lactate infusion,J7120,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,5.54,,,,,,,fee schedule,3,5.98, Ringers lactate infusion,J7120,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,5.98,,,,,,,fee schedule,3,5.98, Ringers lactate infusion,J7120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3,,,,,,,fee schedule,3,5.98, Ringers lactate infusion,J7120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3,,,,,,,fee schedule,3,5.98, 5% dextrose in lac ringers,J7121,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.38,,,,,,,fee schedule,7.38,7.38, 5% dextrose in lac ringers,J7121,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,7.38,,,,,,,fee schedule,7.38,7.38, Hypertonic saline sol,J7131,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.12,,,,,,,fee schedule,0.12,0.12, Hypertonic saline sol,J7131,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.12,,,,,,,fee schedule,0.12,0.12, "Inj, human-lans, per i.u",J7165,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.54,,,,,,,fee schedule,1.54,1.54, "Inj, human-lans, per i.u",J7165,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.54,,,,,,,fee schedule,1.54,1.54, Prothrombin complex kcentra,J7168,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2.61,,,,,,,fee schedule,2.61,2.61, Prothrombin complex kcentra,J7168,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2.61,,,,,,,fee schedule,2.61,2.61, "Inj andexxa, 10 mg",J7169,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,160.5,,,,,,,fee schedule,160.5,160.5, "Inj andexxa, 10 mg",J7169,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,160.5,,,,,,,fee schedule,160.5,160.5, "Inj., emicizumab-kxwh 0.5 mg",J7170,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,129.22,,,,,,,fee schedule,70.06,139.55, "Inj., emicizumab-kxwh 0.5 mg",J7170,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,139.55,,,,,,,fee schedule,70.06,139.55, "Inj., emicizumab-kxwh 0.5 mg",J7170,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,70.06,,,,,,,fee schedule,70.06,139.55, "Inj., emicizumab-kxwh 0.5 mg",J7170,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,70.06,,,,,,,fee schedule,70.06,139.55, "Inj, adzynma, 10 iu",J7171,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,80.06,,,,,,,fee schedule,43.42,86.46, "Inj, adzynma, 10 iu",J7171,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,86.46,,,,,,,fee schedule,43.42,86.46, "Inj, adzynma, 10 iu",J7171,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,43.42,,,,,,,fee schedule,43.42,86.46, "Inj, adzynma, 10 iu",J7171,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,43.42,,,,,,,fee schedule,43.42,86.46, "Inj marstacim-hncq, 0.5 mg",J7172,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,114.1,,,,,,,fee schedule,61.87,123.23, "Inj marstacim-hncq, 0.5 mg",J7172,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,123.23,,,,,,,fee schedule,61.87,123.23, "Inj marstacim-hncq, 0.5 mg",J7172,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,61.87,,,,,,,fee schedule,61.87,123.23, "Inj marstacim-hncq, 0.5 mg",J7172,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,61.87,,,,,,,fee schedule,61.87,123.23, "Inj, factor x, (human), 1iu",J7175,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,22.3,,,,,,,fee schedule,12.09,24.08, "Inj, factor x, (human), 1iu",J7175,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,24.08,,,,,,,fee schedule,12.09,24.08, "Inj, factor x, (human), 1iu",J7175,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.09,,,,,,,fee schedule,12.09,24.08, "Inj, factor x, (human), 1iu",J7175,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,12.09,,,,,,,fee schedule,12.09,24.08, "Inj., fibryga, 1 mg",J7177,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,2.72,,,,,,,fee schedule,1.48,2.94, "Inj., fibryga, 1 mg",J7177,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,2.94,,,,,,,fee schedule,1.48,2.94, "Inj., fibryga, 1 mg",J7177,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.48,,,,,,,fee schedule,1.48,2.94, "Inj., fibryga, 1 mg",J7177,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.48,,,,,,,fee schedule,1.48,2.94, Human fibrinogen conc inj,J7178,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,3.42,,,,,,,fee schedule,1.85,3.69, Human fibrinogen conc inj,J7178,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,3.69,,,,,,,fee schedule,1.85,3.69, Human fibrinogen conc inj,J7178,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.85,,,,,,,fee schedule,1.85,3.69, Human fibrinogen conc inj,J7178,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.85,,,,,,,fee schedule,1.85,3.69, Vonvendi inj 1 iu vwf:rco,J7179,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,4.16,,,,,,,fee schedule,2.26,4.5, Vonvendi inj 1 iu vwf:rco,J7179,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,4.5,,,,,,,fee schedule,2.26,4.5, Vonvendi inj 1 iu vwf:rco,J7179,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2.26,,,,,,,fee schedule,2.26,4.5, Vonvendi inj 1 iu vwf:rco,J7179,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2.26,,,,,,,fee schedule,2.26,4.5, Factor XIII anti-hem factor,J7180,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,24.26,,,,,,,fee schedule,13.15,26.2, Factor XIII anti-hem factor,J7180,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,26.2,,,,,,,fee schedule,13.15,26.2, Factor XIII anti-hem factor,J7180,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13.15,,,,,,,fee schedule,13.15,26.2, Factor XIII anti-hem factor,J7180,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13.15,,,,,,,fee schedule,13.15,26.2, Factor xiii recomb a-subunit,J7181,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,41.15,,,,,,,fee schedule,22.31,44.44, Factor xiii recomb a-subunit,J7181,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,44.44,,,,,,,fee schedule,22.31,44.44, Factor xiii recomb a-subunit,J7181,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22.31,,,,,,,fee schedule,22.31,44.44, Factor xiii recomb a-subunit,J7181,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22.31,,,,,,,fee schedule,22.31,44.44, Factor viii recomb novoeight,J7182,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,3.42,,,,,,,fee schedule,1.85,3.69, Factor viii recomb novoeight,J7182,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,3.69,,,,,,,fee schedule,1.85,3.69, Factor viii recomb novoeight,J7182,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.85,,,,,,,fee schedule,1.85,3.69, Factor viii recomb novoeight,J7182,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.85,,,,,,,fee schedule,1.85,3.69, Wilate injection,J7183,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,2.86,,,,,,,fee schedule,1.55,3.09, Wilate injection,J7183,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,3.09,,,,,,,fee schedule,1.55,3.09, Wilate injection,J7183,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.55,,,,,,,fee schedule,1.55,3.09, Wilate injection,J7183,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.55,,,,,,,fee schedule,1.55,3.09, Xyntha inj,J7185,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,3.47,,,,,,,fee schedule,1.88,3.74, Xyntha inj,J7185,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,3.74,,,,,,,fee schedule,1.88,3.74, Xyntha inj,J7185,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.88,,,,,,,fee schedule,1.88,3.74, Xyntha inj,J7185,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.88,,,,,,,fee schedule,1.88,3.74, Antihemophilic viii/vwf comp,J7186,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,2.77,,,,,,,fee schedule,1.5,2.99, Antihemophilic viii/vwf comp,J7186,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,2.99,,,,,,,fee schedule,1.5,2.99, Antihemophilic viii/vwf comp,J7186,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.5,,,,,,,fee schedule,1.5,2.99, Antihemophilic viii/vwf comp,J7186,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.5,,,,,,,fee schedule,1.5,2.99, "Humate-P, inj",J7187,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,3.35,,,,,,,fee schedule,1.82,3.62, "Humate-P, inj",J7187,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,3.62,,,,,,,fee schedule,1.82,3.62, "Humate-P, inj",J7187,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.82,,,,,,,fee schedule,1.82,3.62, "Humate-P, inj",J7187,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.82,,,,,,,fee schedule,1.82,3.62, Factor viii recomb obizur,J7188,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,7.27,,,,,,,fee schedule,3.94,7.85, Factor viii recomb obizur,J7188,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,7.85,,,,,,,fee schedule,3.94,7.85, Factor viii recomb obizur,J7188,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3.94,,,,,,,fee schedule,3.94,7.85, Factor viii recomb obizur,J7188,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3.94,,,,,,,fee schedule,3.94,7.85, Factor viia,J7189,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,5.96,,,,,,,fee schedule,3.23,6.44, Factor viia,J7189,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,6.44,,,,,,,fee schedule,3.23,6.44, Factor viia,J7189,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3.23,,,,,,,fee schedule,3.23,6.44, Factor viia,J7189,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3.23,,,,,,,fee schedule,3.23,6.44, Factor viii,J7190,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,2.54,,,,,,,fee schedule,1.38,2.75, Factor viii,J7190,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,2.75,,,,,,,fee schedule,1.38,2.75, Factor viii,J7190,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.38,,,,,,,fee schedule,1.38,2.75, Factor viii,J7190,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.38,,,,,,,fee schedule,1.38,2.75, Factor viii recombinant nos,J7192,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,3.47,,,,,,,fee schedule,1.88,3.74, Factor viii recombinant nos,J7192,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,3.74,,,,,,,fee schedule,1.88,3.74, Factor viii recombinant nos,J7192,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.88,,,,,,,fee schedule,1.88,3.74, Factor viii recombinant nos,J7192,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.88,,,,,,,fee schedule,1.88,3.74, Factor ix non-recombinant,J7193,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,3.02,,,,,,,fee schedule,1.63,3.26, Factor ix non-recombinant,J7193,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,3.26,,,,,,,fee schedule,1.63,3.26, Factor ix non-recombinant,J7193,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.63,,,,,,,fee schedule,1.63,3.26, Factor ix non-recombinant,J7193,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.63,,,,,,,fee schedule,1.63,3.26, Factor ix complex,J7194,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,3.83,,,,,,,fee schedule,2.07,4.13, Factor ix complex,J7194,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,4.13,,,,,,,fee schedule,2.07,4.13, Factor ix complex,J7194,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2.07,,,,,,,fee schedule,2.07,4.13, Factor ix complex,J7194,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2.07,,,,,,,fee schedule,2.07,4.13, Factor ix recombinant nos,J7195,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,4.23,,,,,,,fee schedule,2.29,4.57, Factor ix recombinant nos,J7195,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,4.57,,,,,,,fee schedule,2.29,4.57, Factor ix recombinant nos,J7195,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2.29,,,,,,,fee schedule,2.29,4.57, Factor ix recombinant nos,J7195,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2.29,,,,,,,fee schedule,2.29,4.57, Antithrombin iii injection,J7197,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,9.2,,,,,,,fee schedule,4.99,9.94, Antithrombin iii injection,J7197,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,9.94,,,,,,,fee schedule,4.99,9.94, Antithrombin iii injection,J7197,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.99,,,,,,,fee schedule,4.99,9.94, Antithrombin iii injection,J7197,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4.99,,,,,,,fee schedule,4.99,9.94, Anti-inhibitor,J7198,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,5.51,,,,,,,fee schedule,2.99,5.95, Anti-inhibitor,J7198,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,5.95,,,,,,,fee schedule,2.99,5.95, Anti-inhibitor,J7198,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2.99,,,,,,,fee schedule,2.99,5.95, Anti-inhibitor,J7198,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2.99,,,,,,,fee schedule,2.99,5.95, Factor ix recombinan rixubis,J7200,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,3.53,,,,,,,fee schedule,1.92,3.82, Factor ix recombinan rixubis,J7200,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,3.82,,,,,,,fee schedule,1.92,3.82, Factor ix recombinan rixubis,J7200,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.92,,,,,,,fee schedule,1.92,3.82, Factor ix recombinan rixubis,J7200,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.92,,,,,,,fee schedule,1.92,3.82, Factor ix alprolix recomb,J7201,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,8.17,,,,,,,fee schedule,4.43,8.82, Factor ix alprolix recomb,J7201,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,8.82,,,,,,,fee schedule,4.43,8.82, Factor ix alprolix recomb,J7201,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.43,,,,,,,fee schedule,4.43,8.82, Factor ix alprolix recomb,J7201,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4.43,,,,,,,fee schedule,4.43,8.82, Factor ix idelvion inj,J7202,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,12.02,,,,,,,fee schedule,6.51,12.98, Factor ix idelvion inj,J7202,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,12.98,,,,,,,fee schedule,6.51,12.98, Factor ix idelvion inj,J7202,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.51,,,,,,,fee schedule,6.51,12.98, Factor ix idelvion inj,J7202,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,6.51,,,,,,,fee schedule,6.51,12.98, Factor ix recomb gly rebinyn,J7203,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,10.31,,,,,,,fee schedule,5.59,11.13, Factor ix recomb gly rebinyn,J7203,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,11.13,,,,,,,fee schedule,5.59,11.13, Factor ix recomb gly rebinyn,J7203,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.59,,,,,,,fee schedule,5.59,11.13, Factor ix recomb gly rebinyn,J7203,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5.59,,,,,,,fee schedule,5.59,11.13, Inj recombin esperoct per iu,J7204,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,5.09,,,,,,,fee schedule,2.76,5.49, Inj recombin esperoct per iu,J7204,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,5.49,,,,,,,fee schedule,2.76,5.49, Inj recombin esperoct per iu,J7204,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2.76,,,,,,,fee schedule,2.76,5.49, Inj recombin esperoct per iu,J7204,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2.76,,,,,,,fee schedule,2.76,5.49, Factor viii fc fusion recomb,J7205,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,5.45,,,,,,,fee schedule,2.95,5.88, Factor viii fc fusion recomb,J7205,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,5.88,,,,,,,fee schedule,2.95,5.88, Factor viii fc fusion recomb,J7205,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2.95,,,,,,,fee schedule,2.95,5.88, Factor viii fc fusion recomb,J7205,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2.95,,,,,,,fee schedule,2.95,5.88, Factor viii pegylated recomb,J7207,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,4.84,,,,,,,fee schedule,2.62,5.22, Factor viii pegylated recomb,J7207,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,5.22,,,,,,,fee schedule,2.62,5.22, Factor viii pegylated recomb,J7207,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2.62,,,,,,,fee schedule,2.62,5.22, Factor viii pegylated recomb,J7207,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2.62,,,,,,,fee schedule,2.62,5.22, Inj. jivi 1 iu,J7208,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,5.96,,,,,,,fee schedule,3.23,6.44, Inj. jivi 1 iu,J7208,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,6.44,,,,,,,fee schedule,3.23,6.44, Inj. jivi 1 iu,J7208,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3.23,,,,,,,fee schedule,3.23,6.44, Inj. jivi 1 iu,J7208,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3.23,,,,,,,fee schedule,3.23,6.44, Factor viii nuwiq recomb 1iu,J7209,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,2.66,,,,,,,fee schedule,1.44,2.87, Factor viii nuwiq recomb 1iu,J7209,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,2.87,,,,,,,fee schedule,1.44,2.87, Factor viii nuwiq recomb 1iu,J7209,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.44,,,,,,,fee schedule,1.44,2.87, Factor viii nuwiq recomb 1iu,J7209,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.44,,,,,,,fee schedule,1.44,2.87, "Inj, afstyla, 1 i.u.",J7210,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,3.56,,,,,,,fee schedule,1.93,3.84, "Inj, afstyla, 1 i.u.",J7210,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,3.84,,,,,,,fee schedule,1.93,3.84, "Inj, afstyla, 1 i.u.",J7210,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.93,,,,,,,fee schedule,1.93,3.84, "Inj, afstyla, 1 i.u.",J7210,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.93,,,,,,,fee schedule,1.93,3.84, "Inj, kovaltry, 1 i.u.",J7211,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,3.56,,,,,,,fee schedule,1.93,3.84, "Inj, kovaltry, 1 i.u.",J7211,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,3.84,,,,,,,fee schedule,1.93,3.84, "Inj, kovaltry, 1 i.u.",J7211,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.93,,,,,,,fee schedule,1.93,3.84, "Inj, kovaltry, 1 i.u.",J7211,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.93,,,,,,,fee schedule,1.93,3.84, Factor viia recomb sevenfact,J7212,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,5.4,,,,,,,fee schedule,2.93,5.83, Factor viia recomb sevenfact,J7212,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,5.83,,,,,,,fee schedule,2.93,5.83, Factor viia recomb sevenfact,J7212,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2.93,,,,,,,fee schedule,2.93,5.83, Factor viia recomb sevenfact,J7212,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2.93,,,,,,,fee schedule,2.93,5.83, "Inj, ixinity, 1 i.u.",J7213,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,4.3,,,,,,,fee schedule,2.33,4.64, "Inj, ixinity, 1 i.u.",J7213,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,4.64,,,,,,,fee schedule,2.33,4.64, "Inj, ixinity, 1 i.u.",J7213,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2.33,,,,,,,fee schedule,2.33,4.64, "Inj, ixinity, 1 i.u.",J7213,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2.33,,,,,,,fee schedule,2.33,4.64, Altuviiio per factor viii iu,J7214,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,10.51,,,,,,,fee schedule,5.7,11.35, Altuviiio per factor viii iu,J7214,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,11.35,,,,,,,fee schedule,5.7,11.35, Altuviiio per factor viii iu,J7214,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.7,,,,,,,fee schedule,5.7,11.35, Altuviiio per factor viii iu,J7214,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5.7,,,,,,,fee schedule,5.7,11.35, Seg acet and eth estr yearly,J7294,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3543.69,,,,,,,fee schedule,3543.69,3543.69, Seg acet and eth estr yearly,J7294,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3543.69,,,,,,,fee schedule,3543.69,3543.69, Eth estr and eton monthly,J7295,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,228.26,,,,,,,fee schedule,228.26,228.26, Eth estr and eton monthly,J7295,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,228.26,,,,,,,fee schedule,228.26,228.26, "Kyleena, 19.5 mg",J7296,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1778.22,,,,,,,fee schedule,1778.22,1778.22, "Kyleena, 19.5 mg",J7296,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1778.22,,,,,,,fee schedule,1778.22,1778.22, "Liletta, 52 mg",J7297,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1364.06,,,,,,,fee schedule,1364.06,1364.06, "Liletta, 52 mg",J7297,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1364.06,,,,,,,fee schedule,1364.06,1364.06, "Mirena, 52 mg",J7298,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1778.22,,,,,,,fee schedule,1778.22,1778.22, "Mirena, 52 mg",J7298,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1778.22,,,,,,,fee schedule,1778.22,1778.22, Intraut copper contraceptive,J7300,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1666.52,,,,,,,fee schedule,1666.52,1666.52, Intraut copper contraceptive,J7300,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1666.52,,,,,,,fee schedule,1666.52,1666.52, "Skyla, 13.5 mg",J7301,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1480.67,,,,,,,fee schedule,1480.67,1480.67, "Skyla, 13.5 mg",J7301,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1480.67,,,,,,,fee schedule,1480.67,1480.67, Levonorgestrel implant sys,J7306,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,458.56,,,,,,,fee schedule,458.56,458.56, Levonorgestrel implant sys,J7306,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,458.56,,,,,,,fee schedule,458.56,458.56, Etonogestrel implant system,J7307,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1778.22,,,,,,,fee schedule,1778.22,1778.22, Etonogestrel implant system,J7307,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1778.22,,,,,,,fee schedule,1778.22,1778.22, Aminolevulinic acid hcl top,J7308,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,886.21,,,,,,,fee schedule,480.52,957.1, Aminolevulinic acid hcl top,J7308,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,957.1,,,,,,,fee schedule,480.52,957.1, Aminolevulinic acid hcl top,J7308,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,480.52,,,,,,,fee schedule,480.52,957.1, Aminolevulinic acid hcl top,J7308,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,480.52,,,,,,,fee schedule,480.52,957.1, Ganciclovir long act implant,J7310,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5007.82,,,,,,,fee schedule,5007.82,5007.82, Ganciclovir long act implant,J7310,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5007.82,,,,,,,fee schedule,5007.82,5007.82, Fluocinolone acetonide implt,J7311,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,764.46,,,,,,,fee schedule,414.51,825.62, Fluocinolone acetonide implt,J7311,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,825.62,,,,,,,fee schedule,414.51,825.62, Fluocinolone acetonide implt,J7311,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,414.51,,,,,,,fee schedule,414.51,825.62, Fluocinolone acetonide implt,J7311,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,414.51,,,,,,,fee schedule,414.51,825.62, Dexamethasone intra implant,J7312,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,461.88,,,,,,,fee schedule,250.44,498.83, Dexamethasone intra implant,J7312,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,498.83,,,,,,,fee schedule,250.44,498.83, Dexamethasone intra implant,J7312,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,250.44,,,,,,,fee schedule,250.44,498.83, Dexamethasone intra implant,J7312,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,250.44,,,,,,,fee schedule,250.44,498.83, Fluocinol acet intravit imp,J7313,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,1120.05,,,,,,,fee schedule,607.32,1209.65, Fluocinol acet intravit imp,J7313,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,1209.65,,,,,,,fee schedule,607.32,1209.65, Fluocinol acet intravit imp,J7313,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,607.32,,,,,,,fee schedule,607.32,1209.65, Fluocinol acet intravit imp,J7313,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,607.32,,,,,,,fee schedule,607.32,1209.65, "Inj., yutiq, 0.01 mg",J7314,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,1198.31,,,,,,,fee schedule,649.75,1294.17, "Inj., yutiq, 0.01 mg",J7314,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,1294.17,,,,,,,fee schedule,649.75,1294.17, "Inj., yutiq, 0.01 mg",J7314,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,649.75,,,,,,,fee schedule,649.75,1294.17, "Inj., yutiq, 0.01 mg",J7314,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,649.75,,,,,,,fee schedule,649.75,1294.17, "Inj, durolane 1 mg",J7318,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,15.03,,,,,,,fee schedule,8.15,16.23, "Inj, durolane 1 mg",J7318,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,16.23,,,,,,,fee schedule,8.15,16.23, "Inj, durolane 1 mg",J7318,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.15,,,,,,,fee schedule,8.15,16.23, "Inj, durolane 1 mg",J7318,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,8.15,,,,,,,fee schedule,8.15,16.23, "Genvisc 850, inj, 1mg",J7320,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,13.55,,,,,,,fee schedule,7.34,14.63, "Genvisc 850, inj, 1mg",J7320,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,14.63,,,,,,,fee schedule,7.34,14.63, "Genvisc 850, inj, 1mg",J7320,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.34,,,,,,,fee schedule,7.34,14.63, "Genvisc 850, inj, 1mg",J7320,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,7.34,,,,,,,fee schedule,7.34,14.63, Hyalgan/supartz inj per dose,J7321,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,165.13,,,,,,,fee schedule,89.54,178.34, Hyalgan/supartz inj per dose,J7321,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,178.34,,,,,,,fee schedule,89.54,178.34, Hyalgan/supartz inj per dose,J7321,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,89.54,,,,,,,fee schedule,89.54,178.34, Hyalgan/supartz inj per dose,J7321,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,89.54,,,,,,,fee schedule,89.54,178.34, Hymovis injection 1 mg,J7322,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,39.24,,,,,,,fee schedule,21.28,42.38, Hymovis injection 1 mg,J7322,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,42.38,,,,,,,fee schedule,21.28,42.38, Hymovis injection 1 mg,J7322,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21.28,,,,,,,fee schedule,21.28,42.38, Hymovis injection 1 mg,J7322,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,21.28,,,,,,,fee schedule,21.28,42.38, Euflexxa inj per dose,J7323,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,257.58,,,,,,,fee schedule,139.67,278.19, Euflexxa inj per dose,J7323,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,278.19,,,,,,,fee schedule,139.67,278.19, Euflexxa inj per dose,J7323,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,139.67,,,,,,,fee schedule,139.67,278.19, Euflexxa inj per dose,J7323,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,139.67,,,,,,,fee schedule,139.67,278.19, Orthovisc inj per dose,J7324,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,219.83,,,,,,,fee schedule,119.19,237.41, Orthovisc inj per dose,J7324,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,237.41,,,,,,,fee schedule,119.19,237.41, Orthovisc inj per dose,J7324,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,119.19,,,,,,,fee schedule,119.19,237.41, Orthovisc inj per dose,J7324,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,119.19,,,,,,,fee schedule,119.19,237.41, Synvisc or Synvisc-One,J7325,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,20.45,,,,,,,fee schedule,11.09,22.09, Synvisc or Synvisc-One,J7325,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,22.09,,,,,,,fee schedule,11.09,22.09, Synvisc or Synvisc-One,J7325,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.09,,,,,,,fee schedule,11.09,22.09, Synvisc or Synvisc-One,J7325,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11.09,,,,,,,fee schedule,11.09,22.09, Gel-one,J7326,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,1179.05,,,,,,,fee schedule,639.3,1273.37, Gel-one,J7326,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,1273.37,,,,,,,fee schedule,639.3,1273.37, Gel-one,J7326,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,639.3,,,,,,,fee schedule,639.3,1273.37, Gel-one,J7326,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,639.3,,,,,,,fee schedule,639.3,1273.37, Monovisc inj per dose,J7327,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,1189.31,,,,,,,fee schedule,644.87,1284.45, Monovisc inj per dose,J7327,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,1284.45,,,,,,,fee schedule,644.87,1284.45, Monovisc inj per dose,J7327,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,644.87,,,,,,,fee schedule,644.87,1284.45, Monovisc inj per dose,J7327,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,644.87,,,,,,,fee schedule,644.87,1284.45, Gel-syn injection 0.1 mg,J7328,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,1.46,,,,,,,fee schedule,0.79,1.58, Gel-syn injection 0.1 mg,J7328,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,1.58,,,,,,,fee schedule,0.79,1.58, Gel-syn injection 0.1 mg,J7328,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.79,,,,,,,fee schedule,0.79,1.58, Gel-syn injection 0.1 mg,J7328,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.79,,,,,,,fee schedule,0.79,1.58, "Inj, trivisc 1 mg",J7329,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,12.24,,,,,,,fee schedule,6.65,13.22, "Inj, trivisc 1 mg",J7329,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,13.22,,,,,,,fee schedule,6.65,13.22, "Inj, trivisc 1 mg",J7329,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.65,,,,,,,fee schedule,6.65,13.22, "Inj, trivisc 1 mg",J7329,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,6.65,,,,,,,fee schedule,6.65,13.22, Cultured chondrocytes implnt,J7330,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,96363.41,,,,,,,fee schedule,96363.41,96363.41, Cultured chondrocytes implnt,J7330,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,96363.41,,,,,,,fee schedule,96363.41,96363.41, "Synojoynt, inj., 1 mg",J7331,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,12.62,,,,,,,fee schedule,6.84,13.63, "Synojoynt, inj., 1 mg",J7331,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,13.63,,,,,,,fee schedule,6.84,13.63, "Synojoynt, inj., 1 mg",J7331,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.84,,,,,,,fee schedule,6.84,13.63, "Synojoynt, inj., 1 mg",J7331,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,6.84,,,,,,,fee schedule,6.84,13.63, "Inj., triluron, 1 mg",J7332,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,22.86,,,,,,,fee schedule,12.4,24.69, "Inj., triluron, 1 mg",J7332,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,24.69,,,,,,,fee schedule,12.4,24.69, "Inj., triluron, 1 mg",J7332,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.4,,,,,,,fee schedule,12.4,24.69, "Inj., triluron, 1 mg",J7332,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,12.4,,,,,,,fee schedule,12.4,24.69, Capsaicin 8% patch,J7336,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,7.61,,,,,,,fee schedule,4.12,8.21, Capsaicin 8% patch,J7336,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,8.21,,,,,,,fee schedule,4.12,8.21, Capsaicin 8% patch,J7336,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.12,,,,,,,fee schedule,4.12,8.21, Capsaicin 8% patch,J7336,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4.12,,,,,,,fee schedule,4.12,8.21, Carbidopa levodopa ent 100ml,J7340,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,547.09,,,,,,,fee schedule,296.64,590.85, Carbidopa levodopa ent 100ml,J7340,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,590.85,,,,,,,fee schedule,296.64,590.85, Carbidopa levodopa ent 100ml,J7340,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,296.64,,,,,,,fee schedule,296.64,590.85, Carbidopa levodopa ent 100ml,J7340,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,296.64,,,,,,,fee schedule,296.64,590.85, Ciprofloxacin otic susp 6 mg,J7342,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,41.46,,,,,,,fee schedule,41.46,41.46, Ciprofloxacin otic susp 6 mg,J7342,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,41.46,,,,,,,fee schedule,41.46,41.46, "Aminolevulinic acid, 10% gel",J7345,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,4.07,,,,,,,fee schedule,2.21,4.4, "Aminolevulinic acid, 10% gel",J7345,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,4.4,,,,,,,fee schedule,2.21,4.4, "Aminolevulinic acid, 10% gel",J7345,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2.21,,,,,,,fee schedule,2.21,4.4, "Aminolevulinic acid, 10% gel",J7345,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2.21,,,,,,,fee schedule,2.21,4.4, Inj bimatoprost itc imp 1mcg,J7351,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,477.81,,,,,,,fee schedule,259.08,516.03, Inj bimatoprost itc imp 1mcg,J7351,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,516.03,,,,,,,fee schedule,259.08,516.03, Inj bimatoprost itc imp 1mcg,J7351,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,259.08,,,,,,,fee schedule,259.08,516.03, Inj bimatoprost itc imp 1mcg,J7351,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,259.08,,,,,,,fee schedule,259.08,516.03, "Afamelanotide implant, 1 mg",J7352,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3590.97,,,,,,,fee schedule,3590.97,3590.97, "Afamelanotide implant, 1 mg",J7352,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3590.97,,,,,,,fee schedule,3590.97,3590.97, Anacaulase-bcdb 8.8% gel 1 g,J7353,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,71.15,,,,,,,fee schedule,71.15,71.15, Anacaulase-bcdb 8.8% gel 1 g,J7353,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,71.15,,,,,,,fee schedule,71.15,71.15, "Cantharidin top, applicator",J7354,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,1506.58,,,,,,,fee schedule,816.9,1627.1, "Cantharidin top, applicator",J7354,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,1627.1,,,,,,,fee schedule,816.9,1627.1, "Cantharidin top, applicator",J7354,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,816.9,,,,,,,fee schedule,816.9,1627.1, "Cantharidin top, applicator",J7354,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,816.9,,,,,,,fee schedule,816.9,1627.1, Inj travoprost intra impl,J7355,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,439.31,,,,,,,fee schedule,238.21,474.46, Inj travoprost intra impl,J7355,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,474.46,,,,,,,fee schedule,238.21,474.46, Inj travoprost intra impl,J7355,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,238.21,,,,,,,fee schedule,238.21,474.46, Inj travoprost intra impl,J7355,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,238.21,,,,,,,fee schedule,238.21,474.46, Inj foscarb/foslevodopa 5 mg,J7356,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1,,,,,,,fee schedule,1,1, Inj foscarb/foslevodopa 5 mg,J7356,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1,,,,,,,fee schedule,1,1, Mometasone sinus sinuva,J7402,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,25.52,,,,,,,fee schedule,13.85,27.56, Mometasone sinus sinuva,J7402,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,27.56,,,,,,,fee schedule,13.85,27.56, Mometasone sinus sinuva,J7402,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13.85,,,,,,,fee schedule,13.85,27.56, Mometasone sinus sinuva,J7402,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,13.85,,,,,,,fee schedule,13.85,27.56, Azathioprine oral 50mg,J7500,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,4.82,,,,,,,fee schedule,2.61,5.2, Azathioprine oral 50mg,J7500,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,5.2,,,,,,,fee schedule,2.61,5.2, Azathioprine oral 50mg,J7500,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2.61,,,,,,,fee schedule,2.61,5.2, Azathioprine oral 50mg,J7500,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2.61,,,,,,,fee schedule,2.61,5.2, Azathioprine parenteral,J7501,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,274.46,,,,,,,fee schedule,274.46,274.46, Azathioprine parenteral,J7501,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,274.46,,,,,,,fee schedule,274.46,274.46, Cyclosporine oral 100 mg,J7502,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,4.66,,,,,,,fee schedule,2.53,5.03, Cyclosporine oral 100 mg,J7502,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,5.03,,,,,,,fee schedule,2.53,5.03, Cyclosporine oral 100 mg,J7502,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2.53,,,,,,,fee schedule,2.53,5.03, Cyclosporine oral 100 mg,J7502,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2.53,,,,,,,fee schedule,2.53,5.03, Tacrol envarsus ex rel oral,J7503,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,4.12,,,,,,,fee schedule,2.23,4.45, Tacrol envarsus ex rel oral,J7503,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,4.45,,,,,,,fee schedule,2.23,4.45, Tacrol envarsus ex rel oral,J7503,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2.23,,,,,,,fee schedule,2.23,4.45, Tacrol envarsus ex rel oral,J7503,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2.23,,,,,,,fee schedule,2.23,4.45, Lymphocyte immune globulin,J7504,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,11279.5,,,,,,,fee schedule,6115.99,12181.86, Lymphocyte immune globulin,J7504,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,12181.86,,,,,,,fee schedule,6115.99,12181.86, Lymphocyte immune globulin,J7504,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6115.99,,,,,,,fee schedule,6115.99,12181.86, Lymphocyte immune globulin,J7504,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,6115.99,,,,,,,fee schedule,6115.99,12181.86, Monoclonal antibodies,J7505,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1059.57,,,,,,,fee schedule,1059.57,1059.57, Monoclonal antibodies,J7505,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1059.57,,,,,,,fee schedule,1059.57,1059.57, Tacrolimus imme rel oral 1mg,J7507,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.34,,,,,,,fee schedule,0.18,0.36, Tacrolimus imme rel oral 1mg,J7507,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.36,,,,,,,fee schedule,0.18,0.36, Tacrolimus imme rel oral 1mg,J7507,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.18,,,,,,,fee schedule,0.18,0.36, Tacrolimus imme rel oral 1mg,J7507,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.18,,,,,,,fee schedule,0.18,0.36, Tacrol astagraf ex rel oral,J7508,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,1.33,,,,,,,fee schedule,0.72,1.43, Tacrol astagraf ex rel oral,J7508,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,1.43,,,,,,,fee schedule,0.72,1.43, Tacrol astagraf ex rel oral,J7508,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.72,,,,,,,fee schedule,0.72,1.43, Tacrol astagraf ex rel oral,J7508,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.72,,,,,,,fee schedule,0.72,1.43, Methylprednisolone oral,J7509,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.52,,,,,,,fee schedule,0.28,0.56, Methylprednisolone oral,J7509,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.56,,,,,,,fee schedule,0.28,0.56, Methylprednisolone oral,J7509,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.28,,,,,,,fee schedule,0.28,0.56, Methylprednisolone oral,J7509,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.28,,,,,,,fee schedule,0.28,0.56, Prednisolone oral per 5 mg,J7510,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.61,,,,,,,fee schedule,0.33,0.66, Prednisolone oral per 5 mg,J7510,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.66,,,,,,,fee schedule,0.33,0.66, Prednisolone oral per 5 mg,J7510,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.33,,,,,,,fee schedule,0.33,0.66, Prednisolone oral per 5 mg,J7510,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.33,,,,,,,fee schedule,0.33,0.66, Antithymocyte globuln rabbit,J7511,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,2241.88,,,,,,,fee schedule,1215.6,2421.23, Antithymocyte globuln rabbit,J7511,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,2421.23,,,,,,,fee schedule,1215.6,2421.23, Antithymocyte globuln rabbit,J7511,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1215.6,,,,,,,fee schedule,1215.6,2421.23, Antithymocyte globuln rabbit,J7511,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1215.6,,,,,,,fee schedule,1215.6,2421.23, Prednisone ir or dr oral 1mg,J7512,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.72,,,,,,,fee schedule,1.72,1.72, Prednisone ir or dr oral 1mg,J7512,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.72,,,,,,,fee schedule,1.72,1.72, "Daclizumab, parenteral",J7513,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,457.38,,,,,,,fee schedule,457.38,457.38, "Daclizumab, parenteral",J7513,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,457.38,,,,,,,fee schedule,457.38,457.38, Mycophenol (myhibbin) 100 mg,J7514,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3.2,,,,,,,fee schedule,3.2,3.2, Mycophenol (myhibbin) 100 mg,J7514,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3.2,,,,,,,fee schedule,3.2,3.2, Cyclosporine oral 25 mg,J7515,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,1.73,,,,,,,fee schedule,0.94,1.87, Cyclosporine oral 25 mg,J7515,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,1.87,,,,,,,fee schedule,0.94,1.87, Cyclosporine oral 25 mg,J7515,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.94,,,,,,,fee schedule,0.94,1.87, Cyclosporine oral 25 mg,J7515,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.94,,,,,,,fee schedule,0.94,1.87, Cyclosporin parenteral 250mg,J7516,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,163.55,,,,,,,fee schedule,88.68,176.64, Cyclosporin parenteral 250mg,J7516,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,176.64,,,,,,,fee schedule,88.68,176.64, Cyclosporin parenteral 250mg,J7516,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,88.68,,,,,,,fee schedule,88.68,176.64, Cyclosporin parenteral 250mg,J7516,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,88.68,,,,,,,fee schedule,88.68,176.64, Mycophenolate mofetil oral,J7517,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.36,,,,,,,fee schedule,0.2,0.39, Mycophenolate mofetil oral,J7517,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.39,,,,,,,fee schedule,0.2,0.39, Mycophenolate mofetil oral,J7517,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.2,,,,,,,fee schedule,0.2,0.39, Mycophenolate mofetil oral,J7517,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.2,,,,,,,fee schedule,0.2,0.39, Mycophenolic acid,J7518,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.83,,,,,,,fee schedule,0.45,0.9, Mycophenolic acid,J7518,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.9,,,,,,,fee schedule,0.45,0.9, Mycophenolic acid,J7518,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.45,,,,,,,fee schedule,0.45,0.9, Mycophenolic acid,J7518,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.45,,,,,,,fee schedule,0.45,0.9, Inj. mycophenolate mofetil,J7519,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.92,,,,,,,fee schedule,0.5,1, Inj. mycophenolate mofetil,J7519,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,1,,,,,,,fee schedule,0.5,1, Inj. mycophenolate mofetil,J7519,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.5,,,,,,,fee schedule,0.5,1, Inj. mycophenolate mofetil,J7519,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.5,,,,,,,fee schedule,0.5,1, "Sirolimus, oral",J7520,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,2.16,,,,,,,fee schedule,1.17,2.33, "Sirolimus, oral",J7520,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,2.33,,,,,,,fee schedule,1.17,2.33, "Sirolimus, oral",J7520,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.17,,,,,,,fee schedule,1.17,2.33, "Sirolimus, oral",J7520,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.17,,,,,,,fee schedule,1.17,2.33, Tacrolim granules oral susp,J7521,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,2.81,,,,,,,fee schedule,1.53,3.04, Tacrolim granules oral susp,J7521,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,3.04,,,,,,,fee schedule,1.53,3.04, Tacrolim granules oral susp,J7521,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.53,,,,,,,fee schedule,1.53,3.04, Tacrolim granules oral susp,J7521,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.53,,,,,,,fee schedule,1.53,3.04, Tacrolimus injection,J7525,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,590.02,,,,,,,fee schedule,319.92,637.22, Tacrolimus injection,J7525,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,637.22,,,,,,,fee schedule,319.92,637.22, Tacrolimus injection,J7525,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,319.92,,,,,,,fee schedule,319.92,637.22, Tacrolimus injection,J7525,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,319.92,,,,,,,fee schedule,319.92,637.22, Oral everolimus,J7527,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,4.48,,,,,,,fee schedule,2.43,4.84, Oral everolimus,J7527,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,4.84,,,,,,,fee schedule,2.43,4.84, Oral everolimus,J7527,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2.43,,,,,,,fee schedule,2.43,4.84, Oral everolimus,J7527,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2.43,,,,,,,fee schedule,2.43,4.84, Ensifentrine inh 3 mg,J7601,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,117.27,,,,,,,fee schedule,63.59,126.65, Ensifentrine inh 3 mg,J7601,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,126.65,,,,,,,fee schedule,63.59,126.65, Ensifentrine inh 3 mg,J7601,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,63.59,,,,,,,fee schedule,63.59,126.65, Ensifentrine inh 3 mg,J7601,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,63.59,,,,,,,fee schedule,63.59,126.65, Arformoterol non-comp unit,J7605,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,1.78,,,,,,,fee schedule,0.96,1.92, Arformoterol non-comp unit,J7605,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,1.92,,,,,,,fee schedule,0.96,1.92, Arformoterol non-comp unit,J7605,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.96,,,,,,,fee schedule,0.96,1.92, Arformoterol non-comp unit,J7605,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.96,,,,,,,fee schedule,0.96,1.92, "Formoterol fumarate, inh",J7606,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,4.43,,,,,,,fee schedule,2.4,4.79, "Formoterol fumarate, inh",J7606,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,4.79,,,,,,,fee schedule,2.4,4.79, "Formoterol fumarate, inh",J7606,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2.4,,,,,,,fee schedule,2.4,4.79, "Formoterol fumarate, inh",J7606,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2.4,,,,,,,fee schedule,2.4,4.79, Acetylcysteine non-comp unit,J7608,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,20,,,,,,,fee schedule,10.85,21.6, Acetylcysteine non-comp unit,J7608,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,21.6,,,,,,,fee schedule,10.85,21.6, Acetylcysteine non-comp unit,J7608,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.85,,,,,,,fee schedule,10.85,21.6, Acetylcysteine non-comp unit,J7608,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,10.85,,,,,,,fee schedule,10.85,21.6, Albuterol non-comp con,J7611,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.36,,,,,,,fee schedule,0.2,0.39, Albuterol non-comp con,J7611,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.39,,,,,,,fee schedule,0.2,0.39, Albuterol non-comp con,J7611,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.2,,,,,,,fee schedule,0.2,0.39, Albuterol non-comp con,J7611,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.2,,,,,,,fee schedule,0.2,0.39, Levalbuterol non-comp con,J7612,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.68,,,,,,,fee schedule,0.37,0.73, Levalbuterol non-comp con,J7612,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.73,,,,,,,fee schedule,0.37,0.73, Levalbuterol non-comp con,J7612,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.37,,,,,,,fee schedule,0.37,0.73, Levalbuterol non-comp con,J7612,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.37,,,,,,,fee schedule,0.37,0.73, Albuterol non-comp unit,J7613,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.18,,,,,,,fee schedule,0.1,0.19, Albuterol non-comp unit,J7613,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.19,,,,,,,fee schedule,0.1,0.19, Albuterol non-comp unit,J7613,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.1,,,,,,,fee schedule,0.1,0.19, Albuterol non-comp unit,J7613,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.1,,,,,,,fee schedule,0.1,0.19, Levalbuterol non-comp unit,J7614,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.2,,,,,,,fee schedule,0.11,0.22, Levalbuterol non-comp unit,J7614,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.22,,,,,,,fee schedule,0.11,0.22, Levalbuterol non-comp unit,J7614,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.11,,,,,,,fee schedule,0.11,0.22, Levalbuterol non-comp unit,J7614,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.11,,,,,,,fee schedule,0.11,0.22, Levalbuterol comp unit,J7615,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2.37,,,,,,,fee schedule,2.37,2.37, Levalbuterol comp unit,J7615,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2.37,,,,,,,fee schedule,2.37,2.37, Albuterol ipratrop non-comp,J7620,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.45,,,,,,,fee schedule,0.24,0.49, Albuterol ipratrop non-comp,J7620,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.49,,,,,,,fee schedule,0.24,0.49, Albuterol ipratrop non-comp,J7620,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.24,,,,,,,fee schedule,0.24,0.49, Albuterol ipratrop non-comp,J7620,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.24,,,,,,,fee schedule,0.24,0.49, Budesonide non-comp unit,J7626,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,2.88,,,,,,,fee schedule,1.56,3.11, Budesonide non-comp unit,J7626,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,3.11,,,,,,,fee schedule,1.56,3.11, Budesonide non-comp unit,J7626,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.56,,,,,,,fee schedule,1.56,3.11, Budesonide non-comp unit,J7626,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.56,,,,,,,fee schedule,1.56,3.11, Budesonide comp unit,J7627,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.53,,,,,,,fee schedule,5.53,5.53, Budesonide comp unit,J7627,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5.53,,,,,,,fee schedule,5.53,5.53, Cromolyn sodium noncomp unit,J7631,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.63,,,,,,,fee schedule,0.35,0.68, Cromolyn sodium noncomp unit,J7631,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.68,,,,,,,fee schedule,0.35,0.68, Cromolyn sodium noncomp unit,J7631,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.35,,,,,,,fee schedule,0.35,0.68, Cromolyn sodium noncomp unit,J7631,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.35,,,,,,,fee schedule,0.35,0.68, Cromolyn sodium comp unit,J7632,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.39,,,,,,,fee schedule,0.39,0.39, Cromolyn sodium comp unit,J7632,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.39,,,,,,,fee schedule,0.39,0.39, Dornase alfa non-comp unit,J7639,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,124.11,,,,,,,fee schedule,67.3,134.04, Dornase alfa non-comp unit,J7639,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,134.04,,,,,,,fee schedule,67.3,134.04, Dornase alfa non-comp unit,J7639,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,67.3,,,,,,,fee schedule,67.3,134.04, Dornase alfa non-comp unit,J7639,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,67.3,,,,,,,fee schedule,67.3,134.04, Flunisolide comp unit,J7641,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.24,,,,,,,fee schedule,12.24,12.24, Flunisolide comp unit,J7641,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,12.24,,,,,,,fee schedule,12.24,12.24, Ipratropium bromide non-comp,J7644,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.88,,,,,,,fee schedule,0.48,0.95, Ipratropium bromide non-comp,J7644,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.95,,,,,,,fee schedule,0.48,0.95, Ipratropium bromide non-comp,J7644,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.48,,,,,,,fee schedule,0.48,0.95, Ipratropium bromide non-comp,J7644,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.48,,,,,,,fee schedule,0.48,0.95, Mannitol for inhaler,J7665,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.44,,,,,,,fee schedule,1.44,1.44, Mannitol for inhaler,J7665,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.44,,,,,,,fee schedule,1.44,1.44, "Methacholine chloride, neb",J7674,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,3.89,,,,,,,fee schedule,2.11,4.2, "Methacholine chloride, neb",J7674,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,4.2,,,,,,,fee schedule,2.11,4.2, "Methacholine chloride, neb",J7674,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2.11,,,,,,,fee schedule,2.11,4.2, "Methacholine chloride, neb",J7674,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2.11,,,,,,,fee schedule,2.11,4.2, Revefenacin inh non-com 1mcg,J7677,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.43,,,,,,,fee schedule,0.23,0.46, Revefenacin inh non-com 1mcg,J7677,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.46,,,,,,,fee schedule,0.23,0.46, Revefenacin inh non-com 1mcg,J7677,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.23,,,,,,,fee schedule,0.23,0.46, Revefenacin inh non-com 1mcg,J7677,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.23,,,,,,,fee schedule,0.23,0.46, Terbutaline sulf comp con,J7680,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.4,,,,,,,fee schedule,15.4,15.4, Terbutaline sulf comp con,J7680,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,15.4,,,,,,,fee schedule,15.4,15.4, Terbutaline sulf comp unit,J7681,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.4,,,,,,,fee schedule,15.4,15.4, Terbutaline sulf comp unit,J7681,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,15.4,,,,,,,fee schedule,15.4,15.4, Tobramycin non-comp unit,J7682,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,32.54,,,,,,,fee schedule,17.64,35.14, Tobramycin non-comp unit,J7682,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,35.14,,,,,,,fee schedule,17.64,35.14, Tobramycin non-comp unit,J7682,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.64,,,,,,,fee schedule,17.64,35.14, Tobramycin non-comp unit,J7682,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,17.64,,,,,,,fee schedule,17.64,35.14, Triamcinolone comp con,J7683,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.53,,,,,,,fee schedule,5.53,5.53, Triamcinolone comp con,J7683,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5.53,,,,,,,fee schedule,5.53,5.53, Tobramycin comp unit,J7685,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,70.64,,,,,,,fee schedule,70.64,70.64, Tobramycin comp unit,J7685,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,70.64,,,,,,,fee schedule,70.64,70.64, "Treprostinil, non-comp unit",J7686,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,1800.34,,,,,,,fee schedule,976.18,1944.36, "Treprostinil, non-comp unit",J7686,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,1944.36,,,,,,,fee schedule,976.18,1944.36, "Treprostinil, non-comp unit",J7686,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,976.18,,,,,,,fee schedule,976.18,1944.36, "Treprostinil, non-comp unit",J7686,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,976.18,,,,,,,fee schedule,976.18,1944.36, Oral aprepitant,J8501,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,6.12,,,,,,,fee schedule,3.32,6.61, Oral aprepitant,J8501,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,6.61,,,,,,,fee schedule,3.32,6.61, Oral aprepitant,J8501,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3.32,,,,,,,fee schedule,3.32,6.61, Oral aprepitant,J8501,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3.32,,,,,,,fee schedule,3.32,6.61, Oral busulfan,J8510,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,102.74,,,,,,,fee schedule,102.74,102.74, Oral busulfan,J8510,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,102.74,,,,,,,fee schedule,102.74,102.74, "Cabergoline, oral 0.25mg",J8515,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22.36,,,,,,,fee schedule,22.36,22.36, "Cabergoline, oral 0.25mg",J8515,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22.36,,,,,,,fee schedule,22.36,22.36, "Capecitabine, oral, 50 mg",J8522,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.11,,,,,,,fee schedule,0.06,0.12, "Capecitabine, oral, 50 mg",J8522,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.12,,,,,,,fee schedule,0.06,0.12, "Capecitabine, oral, 50 mg",J8522,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.06,,,,,,,fee schedule,0.06,0.12, "Capecitabine, oral, 50 mg",J8522,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.06,,,,,,,fee schedule,0.06,0.12, Cyclophosphamide oral 25 MG,J8530,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,4.46,,,,,,,fee schedule,2.42,4.81, Cyclophosphamide oral 25 MG,J8530,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,4.81,,,,,,,fee schedule,2.42,4.81, Cyclophosphamide oral 25 MG,J8530,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2.42,,,,,,,fee schedule,2.42,4.81, Cyclophosphamide oral 25 MG,J8530,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2.42,,,,,,,fee schedule,2.42,4.81, Oral dexamethasone,J8540,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.05,,,,,,,fee schedule,0.02,0.05, Oral dexamethasone,J8540,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.05,,,,,,,fee schedule,0.02,0.05, Oral dexamethasone,J8540,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.02,,,,,,,fee schedule,0.02,0.05, Oral dexamethasone,J8540,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.02,,,,,,,fee schedule,0.02,0.05, "Oral, hemady, 0.25 mg",J8541,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.5,,,,,,,fee schedule,0.5,0.5, "Oral, hemady, 0.25 mg",J8541,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.5,,,,,,,fee schedule,0.5,0.5, Etoposide oral 50 mg,J8560,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,170.46,,,,,,,fee schedule,92.43,184.1, Etoposide oral 50 mg,J8560,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,184.1,,,,,,,fee schedule,92.43,184.1, Etoposide oral 50 mg,J8560,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,92.43,,,,,,,fee schedule,92.43,184.1, Etoposide oral 50 mg,J8560,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,92.43,,,,,,,fee schedule,92.43,184.1, Gefitinib oral,J8565,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,355.02,,,,,,,fee schedule,355.02,355.02, Gefitinib oral,J8565,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,355.02,,,,,,,fee schedule,355.02,355.02, Melphalan oral 2 MG,J8600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.74,,,,,,,fee schedule,15.74,15.74, Melphalan oral 2 MG,J8600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,15.74,,,,,,,fee schedule,15.74,15.74, Methotrexate oral 2.5 MG,J8610,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.45,,,,,,,fee schedule,0.24,0.49, Methotrexate oral 2.5 MG,J8610,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.49,,,,,,,fee schedule,0.24,0.49, Methotrexate oral 2.5 MG,J8610,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.24,,,,,,,fee schedule,0.24,0.49, Methotrexate oral 2.5 MG,J8610,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.24,,,,,,,fee schedule,0.24,0.49, Oral methotrexate (jylamvo),J8611,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,41.69,,,,,,,fee schedule,22.61,45.03, Oral methotrexate (jylamvo),J8611,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,45.03,,,,,,,fee schedule,22.61,45.03, Oral methotrexate (jylamvo),J8611,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22.61,,,,,,,fee schedule,22.61,45.03, Oral methotrexate (jylamvo),J8611,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22.61,,,,,,,fee schedule,22.61,45.03, Oral methotrexate (xatmep),J8612,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,50.99,,,,,,,fee schedule,27.65,55.06, Oral methotrexate (xatmep),J8612,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,55.06,,,,,,,fee schedule,27.65,55.06, Oral methotrexate (xatmep),J8612,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,27.65,,,,,,,fee schedule,27.65,55.06, Oral methotrexate (xatmep),J8612,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,27.65,,,,,,,fee schedule,27.65,55.06, Nabilone oral,J8650,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.54,,,,,,,fee schedule,18.54,18.54, Nabilone oral,J8650,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,18.54,,,,,,,fee schedule,18.54,18.54, Netupitant palonosetron oral,J8655,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,921.42,,,,,,,fee schedule,499.61,995.13, Netupitant palonosetron oral,J8655,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,995.13,,,,,,,fee schedule,499.61,995.13, Netupitant palonosetron oral,J8655,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,499.61,,,,,,,fee schedule,499.61,995.13, Netupitant palonosetron oral,J8655,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,499.61,,,,,,,fee schedule,499.61,995.13, "Rolapitant, oral, 1mg",J8670,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,3.51,,,,,,,fee schedule,1.9,3.79, "Rolapitant, oral, 1mg",J8670,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,3.79,,,,,,,fee schedule,1.9,3.79, "Rolapitant, oral, 1mg",J8670,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.9,,,,,,,fee schedule,1.9,3.79, "Rolapitant, oral, 1mg",J8670,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.9,,,,,,,fee schedule,1.9,3.79, Temozolomide,J8700,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.81,,,,,,,fee schedule,0.44,0.87, Temozolomide,J8700,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.87,,,,,,,fee schedule,0.44,0.87, Temozolomide,J8700,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.44,,,,,,,fee schedule,0.44,0.87, Temozolomide,J8700,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.44,,,,,,,fee schedule,0.44,0.87, Topotecan oral,J8705,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,281.03,,,,,,,fee schedule,152.38,303.51, Topotecan oral,J8705,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,303.51,,,,,,,fee schedule,152.38,303.51, Topotecan oral,J8705,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,152.38,,,,,,,fee schedule,152.38,303.51, Topotecan oral,J8705,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,152.38,,,,,,,fee schedule,152.38,303.51, Doxorubicin hcl injection,J9000,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,6.12,,,,,,,fee schedule,3.32,6.61, Doxorubicin hcl injection,J9000,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,6.61,,,,,,,fee schedule,3.32,6.61, Doxorubicin hcl injection,J9000,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3.32,,,,,,,fee schedule,3.32,6.61, Doxorubicin hcl injection,J9000,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3.32,,,,,,,fee schedule,3.32,6.61, Aldesleukin injection,J9015,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6467.54,,,,,,,fee schedule,6467.54,6467.54, Aldesleukin injection,J9015,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,6467.54,,,,,,,fee schedule,6467.54,6467.54, Arsenic trioxide injection,J9017,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,13.19,,,,,,,fee schedule,7.15,14.24, Arsenic trioxide injection,J9017,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,14.24,,,,,,,fee schedule,7.15,14.24, Arsenic trioxide injection,J9017,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.15,,,,,,,fee schedule,7.15,14.24, Arsenic trioxide injection,J9017,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,7.15,,,,,,,fee schedule,7.15,14.24, Erwinaze injection,J9019,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,590.11,,,,,,,fee schedule,590.11,590.11, Erwinaze injection,J9019,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,590.11,,,,,,,fee schedule,590.11,590.11, "Asparaginase, nos",J9020,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,62.35,,,,,,,fee schedule,62.35,62.35, "Asparaginase, nos",J9020,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,62.35,,,,,,,fee schedule,62.35,62.35, "Inj, aspara, rylaze, 0.1 mg",J9021,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,124.43,,,,,,,fee schedule,67.47,134.38, "Inj, aspara, rylaze, 0.1 mg",J9021,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,134.38,,,,,,,fee schedule,67.47,134.38, "Inj, aspara, rylaze, 0.1 mg",J9021,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,67.47,,,,,,,fee schedule,67.47,134.38, "Inj, aspara, rylaze, 0.1 mg",J9021,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,67.47,,,,,,,fee schedule,67.47,134.38, "Inj, atezolizumab,10 mg",J9022,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,204.8,,,,,,,fee schedule,111.04,221.18, "Inj, atezolizumab,10 mg",J9022,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,221.18,,,,,,,fee schedule,111.04,221.18, "Inj, atezolizumab,10 mg",J9022,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,111.04,,,,,,,fee schedule,111.04,221.18, "Inj, atezolizumab,10 mg",J9022,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,111.04,,,,,,,fee schedule,111.04,221.18, "Injection, avelumab, 10 mg",J9023,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,225.68,,,,,,,fee schedule,122.37,243.73, "Injection, avelumab, 10 mg",J9023,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,243.73,,,,,,,fee schedule,122.37,243.73, "Injection, avelumab, 10 mg",J9023,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,122.37,,,,,,,fee schedule,122.37,243.73, "Injection, avelumab, 10 mg",J9023,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,122.37,,,,,,,fee schedule,122.37,243.73, Inj atezolizumb 5mg hya-tqjs,J9024,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,71.19,,,,,,,fee schedule,38.6,76.89, Inj atezolizumb 5mg hya-tqjs,J9024,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,76.89,,,,,,,fee schedule,38.6,76.89, Inj atezolizumb 5mg hya-tqjs,J9024,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,38.6,,,,,,,fee schedule,38.6,76.89, Inj atezolizumb 5mg hya-tqjs,J9024,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,38.6,,,,,,,fee schedule,38.6,76.89, Azacitidine injection,J9025,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.47,,,,,,,fee schedule,0.26,0.51, Azacitidine injection,J9025,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.51,,,,,,,fee schedule,0.26,0.51, Azacitidine injection,J9025,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.26,,,,,,,fee schedule,0.26,0.51, Azacitidine injection,J9025,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.26,,,,,,,fee schedule,0.26,0.51, "Inj, tarlatamab-dlle, 1 mg",J9026,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,3526.85,,,,,,,fee schedule,1912.34,3809, "Inj, tarlatamab-dlle, 1 mg",J9026,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,3809,,,,,,,fee schedule,1912.34,3809, "Inj, tarlatamab-dlle, 1 mg",J9026,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1912.34,,,,,,,fee schedule,1912.34,3809, "Inj, tarlatamab-dlle, 1 mg",J9026,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1912.34,,,,,,,fee schedule,1912.34,3809, Clofarabine injection,J9027,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,33.12,,,,,,,fee schedule,17.96,35.77, Clofarabine injection,J9027,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,35.77,,,,,,,fee schedule,17.96,35.77, Clofarabine injection,J9027,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.96,,,,,,,fee schedule,17.96,35.77, Clofarabine injection,J9027,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,17.96,,,,,,,fee schedule,17.96,35.77, "Inj, nogapendekin pmln, 1mcg",J9028,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,211.77,,,,,,,fee schedule,114.83,228.71, "Inj, nogapendekin pmln, 1mcg",J9028,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,228.71,,,,,,,fee schedule,114.83,228.71, "Inj, nogapendekin pmln, 1mcg",J9028,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,114.83,,,,,,,fee schedule,114.83,228.71, "Inj, nogapendekin pmln, 1mcg",J9028,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,114.83,,,,,,,fee schedule,114.83,228.71, "Inj, adstiladrin, per tx dos",J9029,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,142719.86,,,,,,,fee schedule,77385.88,154137.45, "Inj, adstiladrin, per tx dos",J9029,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,154137.45,,,,,,,fee schedule,77385.88,154137.45, "Inj, adstiladrin, per tx dos",J9029,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,77385.88,,,,,,,fee schedule,77385.88,154137.45, "Inj, adstiladrin, per tx dos",J9029,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,77385.88,,,,,,,fee schedule,77385.88,154137.45, Bcg live intravesical 1mg,J9030,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,7.02,,,,,,,fee schedule,3.81,7.58, Bcg live intravesical 1mg,J9030,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,7.58,,,,,,,fee schedule,3.81,7.58, Bcg live intravesical 1mg,J9030,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3.81,,,,,,,fee schedule,3.81,7.58, Bcg live intravesical 1mg,J9030,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3.81,,,,,,,fee schedule,3.81,7.58, "Injection, belinostat, 10mg",J9032,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,117.09,,,,,,,fee schedule,63.49,126.46, "Injection, belinostat, 10mg",J9032,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,126.46,,,,,,,fee schedule,63.49,126.46, "Injection, belinostat, 10mg",J9032,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,63.49,,,,,,,fee schedule,63.49,126.46, "Injection, belinostat, 10mg",J9032,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,63.49,,,,,,,fee schedule,63.49,126.46, "Inj., treanda 1 mg",J9033,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,4.16,,,,,,,fee schedule,2.26,4.5, "Inj., treanda 1 mg",J9033,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,4.5,,,,,,,fee schedule,2.26,4.5, "Inj., treanda 1 mg",J9033,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2.26,,,,,,,fee schedule,2.26,4.5, "Inj., treanda 1 mg",J9033,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2.26,,,,,,,fee schedule,2.26,4.5, "Inj., bendeka 1 mg",J9034,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,29.52,,,,,,,fee schedule,16.01,31.88, "Inj., bendeka 1 mg",J9034,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,31.88,,,,,,,fee schedule,16.01,31.88, "Inj., bendeka 1 mg",J9034,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.01,,,,,,,fee schedule,16.01,31.88, "Inj., bendeka 1 mg",J9034,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,16.01,,,,,,,fee schedule,16.01,31.88, Bevacizumab injection,J9035,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,164.36,,,,,,,fee schedule,89.12,177.51, Bevacizumab injection,J9035,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,177.51,,,,,,,fee schedule,89.12,177.51, Bevacizumab injection,J9035,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,89.12,,,,,,,fee schedule,89.12,177.51, Bevacizumab injection,J9035,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,89.12,,,,,,,fee schedule,89.12,177.51, Inj. belrapzo/bendamustine,J9036,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,26.98,,,,,,,fee schedule,14.63,29.14, Inj. belrapzo/bendamustine,J9036,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,29.14,,,,,,,fee schedule,14.63,29.14, Inj. belrapzo/bendamustine,J9036,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.63,,,,,,,fee schedule,14.63,29.14, Inj. belrapzo/bendamustine,J9036,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,14.63,,,,,,,fee schedule,14.63,29.14, Inj axatilimab-csfr 0.1 mg,J9038,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,65.98,,,,,,,fee schedule,65.98,65.98, Inj axatilimab-csfr 0.1 mg,J9038,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,65.98,,,,,,,fee schedule,65.98,65.98, "Injection, blinatumomab",J9039,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,367.22,,,,,,,fee schedule,199.12,396.6, "Injection, blinatumomab",J9039,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,396.6,,,,,,,fee schedule,199.12,396.6, "Injection, blinatumomab",J9039,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,199.12,,,,,,,fee schedule,199.12,396.6, "Injection, blinatumomab",J9039,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,199.12,,,,,,,fee schedule,199.12,396.6, Bleomycin sulfate injection,J9040,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,47.03,,,,,,,fee schedule,25.5,50.79, Bleomycin sulfate injection,J9040,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,50.79,,,,,,,fee schedule,25.5,50.79, Bleomycin sulfate injection,J9040,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25.5,,,,,,,fee schedule,25.5,50.79, Bleomycin sulfate injection,J9040,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,25.5,,,,,,,fee schedule,25.5,50.79, Bortezomib injection,J9041,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,3.58,,,,,,,fee schedule,1.94,3.86, Bortezomib injection,J9041,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,3.86,,,,,,,fee schedule,1.94,3.86, Bortezomib injection,J9041,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.94,,,,,,,fee schedule,1.94,3.86, Bortezomib injection,J9041,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.94,,,,,,,fee schedule,1.94,3.86, Brentuximab vedotin inj,J9042,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,581.67,,,,,,,fee schedule,315.39,628.2, Brentuximab vedotin inj,J9042,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,628.2,,,,,,,fee schedule,315.39,628.2, Brentuximab vedotin inj,J9042,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,315.39,,,,,,,fee schedule,315.39,628.2, Brentuximab vedotin inj,J9042,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,315.39,,,,,,,fee schedule,315.39,628.2, Cabazitaxel injection,J9043,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,510.98,,,,,,,fee schedule,277.06,551.85, Cabazitaxel injection,J9043,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,551.85,,,,,,,fee schedule,277.06,551.85, Cabazitaxel injection,J9043,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,277.06,,,,,,,fee schedule,277.06,551.85, Cabazitaxel injection,J9043,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,277.06,,,,,,,fee schedule,277.06,551.85, Carboplatin injection,J9045,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,4.75,,,,,,,fee schedule,2.57,5.13, Carboplatin injection,J9045,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,5.13,,,,,,,fee schedule,2.57,5.13, Carboplatin injection,J9045,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2.57,,,,,,,fee schedule,2.57,5.13, Carboplatin injection,J9045,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2.57,,,,,,,fee schedule,2.57,5.13, "Inj, bortezomib, dr. reddy's",J9046,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.99,,,,,,,fee schedule,5.99,5.99, "Inj, bortezomib, dr. reddy's",J9046,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5.99,,,,,,,fee schedule,5.99,5.99, "Injection, carfilzomib, 1 mg",J9047,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,123.95,,,,,,,fee schedule,67.21,133.87, "Injection, carfilzomib, 1 mg",J9047,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,133.87,,,,,,,fee schedule,67.21,133.87, "Injection, carfilzomib, 1 mg",J9047,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,67.21,,,,,,,fee schedule,67.21,133.87, "Injection, carfilzomib, 1 mg",J9047,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,67.21,,,,,,,fee schedule,67.21,133.87, "Inj, bortezomib freseniuskab",J9048,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,20.13,,,,,,,fee schedule,20.13,20.13, "Inj, bortezomib freseniuskab",J9048,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,20.13,,,,,,,fee schedule,20.13,20.13, "Inj, bortezomib, hospira",J9049,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,3.49,,,,,,,fee schedule,1.89,3.77, "Inj, bortezomib, hospira",J9049,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,3.77,,,,,,,fee schedule,1.89,3.77, "Inj, bortezomib, hospira",J9049,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.89,,,,,,,fee schedule,1.89,3.77, "Inj, bortezomib, hospira",J9049,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.89,,,,,,,fee schedule,1.89,3.77, Carmustine injection,J9050,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,390.69,,,,,,,fee schedule,211.84,421.95, Carmustine injection,J9050,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,421.95,,,,,,,fee schedule,211.84,421.95, Carmustine injection,J9050,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,211.84,,,,,,,fee schedule,211.84,421.95, Carmustine injection,J9050,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,211.84,,,,,,,fee schedule,211.84,421.95, "Inj, carmustine (accord)",J9052,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,316.83,,,,,,,fee schedule,316.83,316.83, "Inj, carmustine (accord)",J9052,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,316.83,,,,,,,fee schedule,316.83,316.83, Inj bortezomib boruzu 0.1 mg,J9054,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31.98,,,,,,,fee schedule,31.98,31.98, Inj bortezomib boruzu 0.1 mg,J9054,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,31.98,,,,,,,fee schedule,31.98,31.98, Cetuximab injection,J9055,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,176.56,,,,,,,fee schedule,95.73,190.68, Cetuximab injection,J9055,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,190.68,,,,,,,fee schedule,95.73,190.68, Cetuximab injection,J9055,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,95.73,,,,,,,fee schedule,95.73,190.68, Cetuximab injection,J9055,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,95.73,,,,,,,fee schedule,95.73,190.68, "Inj, bendamustine, 1 mg",J9056,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,63.14,,,,,,,fee schedule,34.23,68.19, "Inj, bendamustine, 1 mg",J9056,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,68.19,,,,,,,fee schedule,34.23,68.19, "Inj, bendamustine, 1 mg",J9056,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,34.23,,,,,,,fee schedule,34.23,68.19, "Inj, bendamustine, 1 mg",J9056,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,34.23,,,,,,,fee schedule,34.23,68.19, Cisplatin 10 mg injection,J9060,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,4.39,,,,,,,fee schedule,2.38,4.74, Cisplatin 10 mg injection,J9060,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,4.74,,,,,,,fee schedule,2.38,4.74, Cisplatin 10 mg injection,J9060,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2.38,,,,,,,fee schedule,2.38,4.74, Cisplatin 10 mg injection,J9060,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2.38,,,,,,,fee schedule,2.38,4.74, "Inj, amivantamab-vmjw",J9061,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,49.97,,,,,,,fee schedule,27.1,53.97, "Inj, amivantamab-vmjw",J9061,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,53.97,,,,,,,fee schedule,27.1,53.97, "Inj, amivantamab-vmjw",J9061,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,27.1,,,,,,,fee schedule,27.1,53.97, "Inj, amivantamab-vmjw",J9061,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,27.1,,,,,,,fee schedule,27.1,53.97, "Inj, elahere, 1 mg",J9063,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,156.42,,,,,,,fee schedule,84.81,168.93, "Inj, elahere, 1 mg",J9063,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,168.93,,,,,,,fee schedule,84.81,168.93, "Inj, elahere, 1 mg",J9063,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,84.81,,,,,,,fee schedule,84.81,168.93, "Inj, elahere, 1 mg",J9063,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,84.81,,,,,,,fee schedule,84.81,168.93, Inj cladribine per 1 mg,J9065,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,21.89,,,,,,,fee schedule,11.87,23.64, Inj cladribine per 1 mg,J9065,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,23.64,,,,,,,fee schedule,11.87,23.64, Inj cladribine per 1 mg,J9065,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.87,,,,,,,fee schedule,11.87,23.64, Inj cladribine per 1 mg,J9065,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11.87,,,,,,,fee schedule,11.87,23.64, Inj cyclophosphamd auromedic,J9071,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,1.76,,,,,,,fee schedule,0.95,1.9, Inj cyclophosphamd auromedic,J9071,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,1.9,,,,,,,fee schedule,0.95,1.9, Inj cyclophosphamd auromedic,J9071,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.95,,,,,,,fee schedule,0.95,1.9, Inj cyclophosphamd auromedic,J9071,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.95,,,,,,,fee schedule,0.95,1.9, Inj cyclophos dr.reddy's 5mg,J9072,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,20.25,,,,,,,fee schedule,10.98,21.87, Inj cyclophos dr.reddy's 5mg,J9072,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,21.87,,,,,,,fee schedule,10.98,21.87, Inj cyclophos dr.reddy's 5mg,J9072,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.98,,,,,,,fee schedule,10.98,21.87, Inj cyclophos dr.reddy's 5mg,J9072,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,10.98,,,,,,,fee schedule,10.98,21.87, Inj cyclophosphamd (ingenus),J9073,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,2.61,,,,,,,fee schedule,1.42,2.82, Inj cyclophosphamd (ingenus),J9073,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,2.82,,,,,,,fee schedule,1.42,2.82, Inj cyclophosphamd (ingenus),J9073,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.42,,,,,,,fee schedule,1.42,2.82, Inj cyclophosphamd (ingenus),J9073,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.42,,,,,,,fee schedule,1.42,2.82, "Inj, cyclophosphamd, sandoz",J9074,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,9.47,,,,,,,fee schedule,5.14,10.23, "Inj, cyclophosphamd, sandoz",J9074,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,10.23,,,,,,,fee schedule,5.14,10.23, "Inj, cyclophosphamd, sandoz",J9074,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.14,,,,,,,fee schedule,5.14,10.23, "Inj, cyclophosphamd, sandoz",J9074,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5.14,,,,,,,fee schedule,5.14,10.23, "Inj, cyclophosphamide, nos",J9075,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,1.4,,,,,,,fee schedule,0.76,1.51, "Inj, cyclophosphamide, nos",J9075,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,1.51,,,,,,,fee schedule,0.76,1.51, "Inj, cyclophosphamide, nos",J9075,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.76,,,,,,,fee schedule,0.76,1.51, "Inj, cyclophosphamide, nos",J9075,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.76,,,,,,,fee schedule,0.76,1.51, "Inj, cyclophos (baxter) 5mg",J9076,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,11.32,,,,,,,fee schedule,6.14,12.22, "Inj, cyclophos (baxter) 5mg",J9076,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,12.22,,,,,,,fee schedule,6.14,12.22, "Inj, cyclophos (baxter) 5mg",J9076,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.14,,,,,,,fee schedule,6.14,12.22, "Inj, cyclophos (baxter) 5mg",J9076,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,6.14,,,,,,,fee schedule,6.14,12.22, Cytarabine liposome inj,J9098,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,498.81,,,,,,,fee schedule,498.81,498.81, Cytarabine liposome inj,J9098,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,498.81,,,,,,,fee schedule,498.81,498.81, Cytarabine hcl 100 mg inj,J9100,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,1.82,,,,,,,fee schedule,0.99,1.97, Cytarabine hcl 100 mg inj,J9100,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,1.97,,,,,,,fee schedule,0.99,1.97, Cytarabine hcl 100 mg inj,J9100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.99,,,,,,,fee schedule,0.99,1.97, Cytarabine hcl 100 mg inj,J9100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.99,,,,,,,fee schedule,0.99,1.97, Inj. calaspargase pegol-mknl,J9118,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,184.3,,,,,,,fee schedule,99.93,199.04, Inj. calaspargase pegol-mknl,J9118,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,199.04,,,,,,,fee schedule,99.93,199.04, Inj. calaspargase pegol-mknl,J9118,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,99.93,,,,,,,fee schedule,99.93,199.04, Inj. calaspargase pegol-mknl,J9118,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,99.93,,,,,,,fee schedule,99.93,199.04, "Inj., cemiplimab-rwlc, 1 mg",J9119,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,64.58,,,,,,,fee schedule,35.01,69.74, "Inj., cemiplimab-rwlc, 1 mg",J9119,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,69.74,,,,,,,fee schedule,35.01,69.74, "Inj., cemiplimab-rwlc, 1 mg",J9119,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,35.01,,,,,,,fee schedule,35.01,69.74, "Inj., cemiplimab-rwlc, 1 mg",J9119,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,35.01,,,,,,,fee schedule,35.01,69.74, Dactinomycin injection,J9120,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,681.57,,,,,,,fee schedule,369.56,736.1, Dactinomycin injection,J9120,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,736.1,,,,,,,fee schedule,369.56,736.1, Dactinomycin injection,J9120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,369.56,,,,,,,fee schedule,369.56,736.1, Dactinomycin injection,J9120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,369.56,,,,,,,fee schedule,369.56,736.1, Dacarbazine 100 mg inj,J9130,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,8.6,,,,,,,fee schedule,4.66,9.28, Dacarbazine 100 mg inj,J9130,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,9.28,,,,,,,fee schedule,4.66,9.28, Dacarbazine 100 mg inj,J9130,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.66,,,,,,,fee schedule,4.66,9.28, Dacarbazine 100 mg inj,J9130,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4.66,,,,,,,fee schedule,4.66,9.28, "Daratumumab, hyaluronidase",J9144,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,123.01,,,,,,,fee schedule,66.7,132.85, "Daratumumab, hyaluronidase",J9144,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,132.85,,,,,,,fee schedule,66.7,132.85, "Daratumumab, hyaluronidase",J9144,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,66.7,,,,,,,fee schedule,66.7,132.85, "Daratumumab, hyaluronidase",J9144,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,66.7,,,,,,,fee schedule,66.7,132.85, "Injection, daratumumab 10 mg",J9145,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,157.14,,,,,,,fee schedule,85.2,169.71, "Injection, daratumumab 10 mg",J9145,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,169.71,,,,,,,fee schedule,85.2,169.71, "Injection, daratumumab 10 mg",J9145,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,85.2,,,,,,,fee schedule,85.2,169.71, "Injection, daratumumab 10 mg",J9145,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,85.2,,,,,,,fee schedule,85.2,169.71, Daunorubicin injection,J9150,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,44.46,,,,,,,fee schedule,24.11,48.02, Daunorubicin injection,J9150,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,48.02,,,,,,,fee schedule,24.11,48.02, Daunorubicin injection,J9150,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24.11,,,,,,,fee schedule,24.11,48.02, Daunorubicin injection,J9150,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,24.11,,,,,,,fee schedule,24.11,48.02, Daunorubicin citrate inj,J9151,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,63.14,,,,,,,fee schedule,63.14,63.14, Daunorubicin citrate inj,J9151,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,63.14,,,,,,,fee schedule,63.14,63.14, "Inj daunorubicin, cytarabine",J9153,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,573.95,,,,,,,fee schedule,311.21,619.87, "Inj daunorubicin, cytarabine",J9153,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,619.87,,,,,,,fee schedule,311.21,619.87, "Inj daunorubicin, cytarabine",J9153,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,311.21,,,,,,,fee schedule,311.21,619.87, "Inj daunorubicin, cytarabine",J9153,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,311.21,,,,,,,fee schedule,311.21,619.87, Degarelix injection,J9155,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,9.81,,,,,,,fee schedule,5.32,10.59, Degarelix injection,J9155,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,10.59,,,,,,,fee schedule,5.32,10.59, Degarelix injection,J9155,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.32,,,,,,,fee schedule,5.32,10.59, Degarelix injection,J9155,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5.32,,,,,,,fee schedule,5.32,10.59, Docetaxel injection,J9171,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.86,,,,,,,fee schedule,0.46,0.92, Docetaxel injection,J9171,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.92,,,,,,,fee schedule,0.46,0.92, Docetaxel injection,J9171,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.46,,,,,,,fee schedule,0.46,0.92, Docetaxel injection,J9171,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.46,,,,,,,fee schedule,0.46,0.92, "Docetaxel (ingenus), 1 mg",J9172,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,110.43,,,,,,,fee schedule,59.88,119.26, "Docetaxel (ingenus), 1 mg",J9172,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,119.26,,,,,,,fee schedule,59.88,119.26, "Docetaxel (ingenus), 1 mg",J9172,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,59.88,,,,,,,fee schedule,59.88,119.26, "Docetaxel (ingenus), 1 mg",J9172,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,59.88,,,,,,,fee schedule,59.88,119.26, "Inj., durvalumab, 10 mg",J9173,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,191.81,,,,,,,fee schedule,104.01,207.16, "Inj., durvalumab, 10 mg",J9173,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,207.16,,,,,,,fee schedule,104.01,207.16, "Inj., durvalumab, 10 mg",J9173,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,104.01,,,,,,,fee schedule,104.01,207.16, "Inj., durvalumab, 10 mg",J9173,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,104.01,,,,,,,fee schedule,104.01,207.16, "Inj, docetaxel (beizray) 1mg",J9174,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,64.01,,,,,,,fee schedule,64.01,64.01, "Inj, docetaxel (beizray) 1mg",J9174,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,64.01,,,,,,,fee schedule,64.01,64.01, Elliotts b solution per ml,J9175,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.08,,,,,,,fee schedule,14.08,14.08, Elliotts b solution per ml,J9175,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,14.08,,,,,,,fee schedule,14.08,14.08, "Injection, elotuzumab, 1mg",J9176,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,17.73,,,,,,,fee schedule,9.61,19.15, "Injection, elotuzumab, 1mg",J9176,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,19.15,,,,,,,fee schedule,9.61,19.15, "Injection, elotuzumab, 1mg",J9176,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.61,,,,,,,fee schedule,9.61,19.15, "Injection, elotuzumab, 1mg",J9176,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9.61,,,,,,,fee schedule,9.61,19.15, Inj enfort vedo-ejfv 0.25mg,J9177,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,82.49,,,,,,,fee schedule,44.73,89.08, Inj enfort vedo-ejfv 0.25mg,J9177,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,89.08,,,,,,,fee schedule,44.73,89.08, Inj enfort vedo-ejfv 0.25mg,J9177,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,44.73,,,,,,,fee schedule,44.73,89.08, Inj enfort vedo-ejfv 0.25mg,J9177,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,44.73,,,,,,,fee schedule,44.73,89.08, "Inj, epirubicin hcl, 2 mg",J9178,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,3.58,,,,,,,fee schedule,1.94,3.86, "Inj, epirubicin hcl, 2 mg",J9178,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,3.86,,,,,,,fee schedule,1.94,3.86, "Inj, epirubicin hcl, 2 mg",J9178,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.94,,,,,,,fee schedule,1.94,3.86, "Inj, epirubicin hcl, 2 mg",J9178,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.94,,,,,,,fee schedule,1.94,3.86, Eribulin mesylate injection,J9179,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,235.31,,,,,,,fee schedule,127.59,254.13, Eribulin mesylate injection,J9179,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,254.13,,,,,,,fee schedule,127.59,254.13, Eribulin mesylate injection,J9179,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,127.59,,,,,,,fee schedule,127.59,254.13, Eribulin mesylate injection,J9179,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,127.59,,,,,,,fee schedule,127.59,254.13, Etoposide injection,J9181,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,2.93,,,,,,,fee schedule,1.59,3.16, Etoposide injection,J9181,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,3.16,,,,,,,fee schedule,1.59,3.16, Etoposide injection,J9181,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.59,,,,,,,fee schedule,1.59,3.16, Etoposide injection,J9181,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.59,,,,,,,fee schedule,1.59,3.16, Fludarabine phosphate inj,J9185,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,161.21,,,,,,,fee schedule,87.41,174.11, Fludarabine phosphate inj,J9185,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,174.11,,,,,,,fee schedule,87.41,174.11, Fludarabine phosphate inj,J9185,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,87.41,,,,,,,fee schedule,87.41,174.11, Fludarabine phosphate inj,J9185,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,87.41,,,,,,,fee schedule,87.41,174.11, Fluorouracil injection,J9190,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,3.87,,,,,,,fee schedule,2.1,4.18, Fluorouracil injection,J9190,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,4.18,,,,,,,fee schedule,2.1,4.18, Fluorouracil injection,J9190,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2.1,,,,,,,fee schedule,2.1,4.18, Fluorouracil injection,J9190,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2.1,,,,,,,fee schedule,2.1,4.18, Inj gemcitabine hcl (accord),J9196,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,11.9,,,,,,,fee schedule,6.45,12.85, Inj gemcitabine hcl (accord),J9196,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,12.85,,,,,,,fee schedule,6.45,12.85, Inj gemcitabine hcl (accord),J9196,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.45,,,,,,,fee schedule,6.45,12.85, Inj gemcitabine hcl (accord),J9196,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,6.45,,,,,,,fee schedule,6.45,12.85, Floxuridine injection,J9200,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,9282.49,,,,,,,fee schedule,5033.17,10025.09, Floxuridine injection,J9200,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,10025.09,,,,,,,fee schedule,5033.17,10025.09, Floxuridine injection,J9200,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5033.17,,,,,,,fee schedule,5033.17,10025.09, Floxuridine injection,J9200,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5033.17,,,,,,,fee schedule,5033.17,10025.09, Gemcitabine hcl injection,J9201,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,6.66,,,,,,,fee schedule,3.61,7.19, Gemcitabine hcl injection,J9201,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,7.19,,,,,,,fee schedule,3.61,7.19, Gemcitabine hcl injection,J9201,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3.61,,,,,,,fee schedule,3.61,7.19, Gemcitabine hcl injection,J9201,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3.61,,,,,,,fee schedule,3.61,7.19, Goserelin acetate implant,J9202,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,1651.84,,,,,,,fee schedule,895.66,1783.98, Goserelin acetate implant,J9202,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,1783.98,,,,,,,fee schedule,895.66,1783.98, Goserelin acetate implant,J9202,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,895.66,,,,,,,fee schedule,895.66,1783.98, Goserelin acetate implant,J9202,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,895.66,,,,,,,fee schedule,895.66,1783.98, Gemtuzumab ozogamicin 0.1 mg,J9203,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,532.4,,,,,,,fee schedule,288.68,574.99, Gemtuzumab ozogamicin 0.1 mg,J9203,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,574.99,,,,,,,fee schedule,288.68,574.99, Gemtuzumab ozogamicin 0.1 mg,J9203,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,288.68,,,,,,,fee schedule,288.68,574.99, Gemtuzumab ozogamicin 0.1 mg,J9203,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,288.68,,,,,,,fee schedule,288.68,574.99, "Inj mogamulizumab-kpkc, 1 mg",J9204,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,559.13,,,,,,,fee schedule,303.17,603.86, "Inj mogamulizumab-kpkc, 1 mg",J9204,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,603.86,,,,,,,fee schedule,303.17,603.86, "Inj mogamulizumab-kpkc, 1 mg",J9204,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,303.17,,,,,,,fee schedule,303.17,603.86, "Inj mogamulizumab-kpkc, 1 mg",J9204,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,303.17,,,,,,,fee schedule,303.17,603.86, Inj irinotecan liposome 1 mg,J9205,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,146.84,,,,,,,fee schedule,79.62,158.58, Inj irinotecan liposome 1 mg,J9205,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,158.58,,,,,,,fee schedule,79.62,158.58, Inj irinotecan liposome 1 mg,J9205,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,79.62,,,,,,,fee schedule,79.62,158.58, Inj irinotecan liposome 1 mg,J9205,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,79.62,,,,,,,fee schedule,79.62,158.58, Irinotecan injection,J9206,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,3.15,,,,,,,fee schedule,1.71,3.4, Irinotecan injection,J9206,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,3.4,,,,,,,fee schedule,1.71,3.4, Irinotecan injection,J9206,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.71,,,,,,,fee schedule,1.71,3.4, Irinotecan injection,J9206,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.71,,,,,,,fee schedule,1.71,3.4, Ixabepilone injection,J9207,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,312.01,,,,,,,fee schedule,169.18,336.97, Ixabepilone injection,J9207,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,336.97,,,,,,,fee schedule,169.18,336.97, Ixabepilone injection,J9207,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,169.18,,,,,,,fee schedule,169.18,336.97, Ixabepilone injection,J9207,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,169.18,,,,,,,fee schedule,169.18,336.97, Ifosfamide injection,J9208,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,52.88,,,,,,,fee schedule,28.67,57.11, Ifosfamide injection,J9208,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,57.11,,,,,,,fee schedule,28.67,57.11, Ifosfamide injection,J9208,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,28.67,,,,,,,fee schedule,28.67,57.11, Ifosfamide injection,J9208,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,28.67,,,,,,,fee schedule,28.67,57.11, Mesna injection,J9209,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,2.99,,,,,,,fee schedule,1.62,3.23, Mesna injection,J9209,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,3.23,,,,,,,fee schedule,1.62,3.23, Mesna injection,J9209,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.62,,,,,,,fee schedule,1.62,3.23, Mesna injection,J9209,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.62,,,,,,,fee schedule,1.62,3.23, "Inj., emapalumab-lzsg, 1 mg",J9210,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,858.69,,,,,,,fee schedule,347.29,927.39, "Inj., emapalumab-lzsg, 1 mg",J9210,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,927.39,,,,,,,fee schedule,347.29,927.39, "Inj., emapalumab-lzsg, 1 mg",J9210,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,347.29,,,,,,,fee schedule,347.29,927.39, "Inj., emapalumab-lzsg, 1 mg",J9210,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,347.29,,,,,,,fee schedule,347.29,927.39, Idarubicin hcl injection,J9211,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,83.36,,,,,,,fee schedule,45.2,90.03, Idarubicin hcl injection,J9211,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,90.03,,,,,,,fee schedule,45.2,90.03, Idarubicin hcl injection,J9211,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,45.2,,,,,,,fee schedule,45.2,90.03, Idarubicin hcl injection,J9211,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,45.2,,,,,,,fee schedule,45.2,90.03, Interferon alfacon-1 inj,J9212,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.5,,,,,,,fee schedule,7.5,7.5, Interferon alfacon-1 inj,J9212,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,7.5,,,,,,,fee schedule,7.5,7.5, Interferon alfa-2a inj,J9213,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,41.43,,,,,,,fee schedule,41.43,41.43, Interferon alfa-2a inj,J9213,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,41.43,,,,,,,fee schedule,41.43,41.43, Interferon alfa-2b inj,J9214,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.4,,,,,,,fee schedule,15.4,15.4, Interferon alfa-2b inj,J9214,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,15.4,,,,,,,fee schedule,15.4,15.4, Interferon alfa-n3 inj,J9215,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,44.09,,,,,,,fee schedule,44.09,44.09, Interferon alfa-n3 inj,J9215,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,44.09,,,,,,,fee schedule,44.09,44.09, Interferon gamma 1-b inj,J9216,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12384.93,,,,,,,fee schedule,12384.93,12384.93, Interferon gamma 1-b inj,J9216,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,12384.93,,,,,,,fee schedule,12384.93,12384.93, Leuprolide acetate suspnsion,J9217,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,349.7,,,,,,,fee schedule,189.61,377.67, Leuprolide acetate suspnsion,J9217,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,377.67,,,,,,,fee schedule,189.61,377.67, Leuprolide acetate suspnsion,J9217,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,189.61,,,,,,,fee schedule,189.61,377.67, Leuprolide acetate suspnsion,J9217,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,189.61,,,,,,,fee schedule,189.61,377.67, Leuprolide acetate injeciton,J9218,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,184.83,,,,,,,fee schedule,184.83,184.83, Leuprolide acetate injeciton,J9218,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,184.83,,,,,,,fee schedule,184.83,184.83, Indigotindisulfonate sod 1mg,J9220,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.15,,,,,,,fee schedule,12.15,12.15, Indigotindisulfonate sod 1mg,J9220,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,12.15,,,,,,,fee schedule,12.15,12.15, "Inj. lurbinectedin, 0.1 mg",J9223,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,463.77,,,,,,,fee schedule,251.48,500.87, "Inj. lurbinectedin, 0.1 mg",J9223,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,500.87,,,,,,,fee schedule,251.48,500.87, "Inj. lurbinectedin, 0.1 mg",J9223,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,251.48,,,,,,,fee schedule,251.48,500.87, "Inj. lurbinectedin, 0.1 mg",J9223,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,251.48,,,,,,,fee schedule,251.48,500.87, Vantas implant,J9225,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5564.25,,,,,,,fee schedule,5564.25,5564.25, Vantas implant,J9225,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5564.25,,,,,,,fee schedule,5564.25,5564.25, Supprelin LA implant,J9226,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,102510.88,,,,,,,fee schedule,55583.68,110711.75, Supprelin LA implant,J9226,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,110711.75,,,,,,,fee schedule,55583.68,110711.75, Supprelin LA implant,J9226,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,55583.68,,,,,,,fee schedule,55583.68,110711.75, Supprelin LA implant,J9226,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,55583.68,,,,,,,fee schedule,55583.68,110711.75, Inj. isatuximab-irfc 10 mg,J9227,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,186.44,,,,,,,fee schedule,101.09,201.35, Inj. isatuximab-irfc 10 mg,J9227,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,201.35,,,,,,,fee schedule,101.09,201.35, Inj. isatuximab-irfc 10 mg,J9227,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,101.09,,,,,,,fee schedule,101.09,201.35, Inj. isatuximab-irfc 10 mg,J9227,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,101.09,,,,,,,fee schedule,101.09,201.35, Ipilimumab injection,J9228,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,412.67,,,,,,,fee schedule,223.76,445.69, Ipilimumab injection,J9228,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,445.69,,,,,,,fee schedule,223.76,445.69, Ipilimumab injection,J9228,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,223.76,,,,,,,fee schedule,223.76,445.69, Ipilimumab injection,J9228,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,223.76,,,,,,,fee schedule,223.76,445.69, Inj inotuzumab ozogam 0.1 mg,J9229,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,6070.61,,,,,,,fee schedule,3291.62,6556.26, Inj inotuzumab ozogam 0.1 mg,J9229,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,6556.26,,,,,,,fee schedule,3291.62,6556.26, Inj inotuzumab ozogam 0.1 mg,J9229,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3291.62,,,,,,,fee schedule,3291.62,6556.26, Inj inotuzumab ozogam 0.1 mg,J9229,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3291.62,,,,,,,fee schedule,3291.62,6556.26, Mechlorethamine hcl inj,J9230,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,154.7,,,,,,,fee schedule,154.7,154.7, Mechlorethamine hcl inj,J9230,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,154.7,,,,,,,fee schedule,154.7,154.7, Inj melphalan hydrochl 50 MG,J9245,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,243.07,,,,,,,fee schedule,131.8,262.51, Inj melphalan hydrochl 50 MG,J9245,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,262.51,,,,,,,fee schedule,131.8,262.51, Inj melphalan hydrochl 50 MG,J9245,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,131.8,,,,,,,fee schedule,131.8,262.51, Inj melphalan hydrochl 50 MG,J9245,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,131.8,,,,,,,fee schedule,131.8,262.51, "Inj., evomela, 1 mg",J9246,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,39.08,,,,,,,fee schedule,21.19,42.21, "Inj., evomela, 1 mg",J9246,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,42.21,,,,,,,fee schedule,21.19,42.21, "Inj., evomela, 1 mg",J9246,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21.19,,,,,,,fee schedule,21.19,42.21, "Inj., evomela, 1 mg",J9246,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,21.19,,,,,,,fee schedule,21.19,42.21, Inj melphalan (hepzato) 1 mg,J9248,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,1772.53,,,,,,,fee schedule,961.1,1914.33, Inj melphalan (hepzato) 1 mg,J9248,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,1914.33,,,,,,,fee schedule,961.1,1914.33, Inj melphalan (hepzato) 1 mg,J9248,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,961.1,,,,,,,fee schedule,961.1,1914.33, Inj melphalan (hepzato) 1 mg,J9248,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,961.1,,,,,,,fee schedule,961.1,1914.33, "Inj, melphalan (apotex) 1 mg",J9249,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,79.03,,,,,,,fee schedule,79.03,79.03, "Inj, melphalan (apotex) 1 mg",J9249,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,79.03,,,,,,,fee schedule,79.03,79.03, Methotrexate sodium inj,J9260,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,5.09,,,,,,,fee schedule,2.76,5.49, Methotrexate sodium inj,J9260,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,5.49,,,,,,,fee schedule,2.76,5.49, Methotrexate sodium inj,J9260,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2.76,,,,,,,fee schedule,2.76,5.49, Methotrexate sodium inj,J9260,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2.76,,,,,,,fee schedule,2.76,5.49, Nelarabine injection,J9261,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,142.61,,,,,,,fee schedule,77.32,154.01, Nelarabine injection,J9261,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,154.01,,,,,,,fee schedule,77.32,154.01, Nelarabine injection,J9261,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,77.32,,,,,,,fee schedule,77.32,154.01, Nelarabine injection,J9261,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,77.32,,,,,,,fee schedule,77.32,154.01, Oxaliplatin,J9263,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.2,,,,,,,fee schedule,0.11,0.22, Oxaliplatin,J9263,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.22,,,,,,,fee schedule,0.11,0.22, Oxaliplatin,J9263,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.11,,,,,,,fee schedule,0.11,0.22, Oxaliplatin,J9263,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.11,,,,,,,fee schedule,0.11,0.22, Paclitaxel protein bound,J9264,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,27.27,,,,,,,fee schedule,14.79,29.45, Paclitaxel protein bound,J9264,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,29.45,,,,,,,fee schedule,14.79,29.45, Paclitaxel protein bound,J9264,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.79,,,,,,,fee schedule,14.79,29.45, Paclitaxel protein bound,J9264,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,14.79,,,,,,,fee schedule,14.79,29.45, Pegaspargase injection,J9266,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,63954.14,,,,,,,fee schedule,34677.35,69070.47, Pegaspargase injection,J9266,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,69070.47,,,,,,,fee schedule,34677.35,69070.47, Pegaspargase injection,J9266,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,34677.35,,,,,,,fee schedule,34677.35,69070.47, Pegaspargase injection,J9266,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,34677.35,,,,,,,fee schedule,34677.35,69070.47, Paclitaxel injection,J9267,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.25,,,,,,,fee schedule,0.13,0.27, Paclitaxel injection,J9267,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.27,,,,,,,fee schedule,0.13,0.27, Paclitaxel injection,J9267,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.13,,,,,,,fee schedule,0.13,0.27, Paclitaxel injection,J9267,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.13,,,,,,,fee schedule,0.13,0.27, Pentostatin injection,J9268,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,5723.75,,,,,,,fee schedule,3103.55,6181.65, Pentostatin injection,J9268,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,6181.65,,,,,,,fee schedule,3103.55,6181.65, Pentostatin injection,J9268,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3103.55,,,,,,,fee schedule,3103.55,6181.65, Pentostatin injection,J9268,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3103.55,,,,,,,fee schedule,3103.55,6181.65, Inj. tagraxofusp-erzs 10 mcg,J9269,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,784.4,,,,,,,fee schedule,425.32,847.15, Inj. tagraxofusp-erzs 10 mcg,J9269,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,847.15,,,,,,,fee schedule,425.32,847.15, Inj. tagraxofusp-erzs 10 mcg,J9269,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,425.32,,,,,,,fee schedule,425.32,847.15, Inj. tagraxofusp-erzs 10 mcg,J9269,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,425.32,,,,,,,fee schedule,425.32,847.15, Inj pembrolizumab,J9271,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,131.76,,,,,,,fee schedule,71.44,142.3, Inj pembrolizumab,J9271,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,142.3,,,,,,,fee schedule,71.44,142.3, Inj pembrolizumab,J9271,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,71.44,,,,,,,fee schedule,71.44,142.3, Inj pembrolizumab,J9271,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,71.44,,,,,,,fee schedule,71.44,142.3, "Inj, dostarlimab-gxly, 10 mg",J9272,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,548.6,,,,,,,fee schedule,297.46,592.48, "Inj, dostarlimab-gxly, 10 mg",J9272,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,592.48,,,,,,,fee schedule,297.46,592.48, "Inj, dostarlimab-gxly, 10 mg",J9272,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,297.46,,,,,,,fee schedule,297.46,592.48, "Inj, dostarlimab-gxly, 10 mg",J9272,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,297.46,,,,,,,fee schedule,297.46,592.48, "Inj tisotu vedotin-tftv, 1mg",J9273,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,424.46,,,,,,,fee schedule,230.15,458.42, "Inj tisotu vedotin-tftv, 1mg",J9273,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,458.42,,,,,,,fee schedule,230.15,458.42, "Inj tisotu vedotin-tftv, 1mg",J9273,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,230.15,,,,,,,fee schedule,230.15,458.42, "Inj tisotu vedotin-tftv, 1mg",J9273,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,230.15,,,,,,,fee schedule,230.15,458.42, "Inj, tebentafusp-tebn, 1 mcg",J9274,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,488.45,,,,,,,fee schedule,264.85,527.53, "Inj, tebentafusp-tebn, 1 mcg",J9274,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,527.53,,,,,,,fee schedule,264.85,527.53, "Inj, tebentafusp-tebn, 1 mcg",J9274,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,264.85,,,,,,,fee schedule,264.85,527.53, "Inj, tebentafusp-tebn, 1 mcg",J9274,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,264.85,,,,,,,fee schedule,264.85,527.53, "Inj zanidatamab-hrii, 2 mg",J9276,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,56.43,,,,,,,fee schedule,30.6,60.94, "Inj zanidatamab-hrii, 2 mg",J9276,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,60.94,,,,,,,fee schedule,30.6,60.94, "Inj zanidatamab-hrii, 2 mg",J9276,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,30.6,,,,,,,fee schedule,30.6,60.94, "Inj zanidatamab-hrii, 2 mg",J9276,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,30.6,,,,,,,fee schedule,30.6,60.94, Mitomycin injection,J9280,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,63.61,,,,,,,fee schedule,34.49,68.7, Mitomycin injection,J9280,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,68.7,,,,,,,fee schedule,34.49,68.7, Mitomycin injection,J9280,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,34.49,,,,,,,fee schedule,34.49,68.7, Mitomycin injection,J9280,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,34.49,,,,,,,fee schedule,34.49,68.7, Mitomycin instillation,J9281,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,714.2,,,,,,,fee schedule,387.25,771.33, Mitomycin instillation,J9281,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,771.33,,,,,,,fee schedule,387.25,771.33, Mitomycin instillation,J9281,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,387.25,,,,,,,fee schedule,387.25,771.33, Mitomycin instillation,J9281,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,387.25,,,,,,,fee schedule,387.25,771.33, "Inj, olaratumab, 10 mg",J9285,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,71.91,,,,,,,fee schedule,71.91,71.91, "Inj, olaratumab, 10 mg",J9285,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,71.91,,,,,,,fee schedule,71.91,71.91, "Inj glofitamab gxbm, 2.5 mg",J9286,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,6233.78,,,,,,,fee schedule,3380.1,6732.49, "Inj glofitamab gxbm, 2.5 mg",J9286,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,6732.49,,,,,,,fee schedule,3380.1,6732.49, "Inj glofitamab gxbm, 2.5 mg",J9286,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3380.1,,,,,,,fee schedule,3380.1,6732.49, "Inj glofitamab gxbm, 2.5 mg",J9286,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3380.1,,,,,,,fee schedule,3380.1,6732.49, Inj nivolumab 2 mg hyaluron,J9289,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,32.62,,,,,,,fee schedule,32.62,32.62, Inj nivolumab 2 mg hyaluron,J9289,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,32.62,,,,,,,fee schedule,32.62,32.62, "Inj, pemetrexed (avyxa) 10mg",J9292,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,187.38,,,,,,,fee schedule,101.6,202.37, "Inj, pemetrexed (avyxa) 10mg",J9292,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,202.37,,,,,,,fee schedule,101.6,202.37, "Inj, pemetrexed (avyxa) 10mg",J9292,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,101.6,,,,,,,fee schedule,101.6,202.37, "Inj, pemetrexed (avyxa) 10mg",J9292,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,101.6,,,,,,,fee schedule,101.6,202.37, Mitoxantrone hydrochl / 5 MG,J9293,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,66.6,,,,,,,fee schedule,36.11,71.93, Mitoxantrone hydrochl / 5 MG,J9293,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,71.93,,,,,,,fee schedule,36.11,71.93, Mitoxantrone hydrochl / 5 MG,J9293,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,36.11,,,,,,,fee schedule,36.11,71.93, Mitoxantrone hydrochl / 5 MG,J9293,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,36.11,,,,,,,fee schedule,36.11,71.93, "Inj pemetrexed, hospira 10mg",J9294,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,11.07,,,,,,,fee schedule,6.01,11.96, "Inj pemetrexed, hospira 10mg",J9294,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,11.96,,,,,,,fee schedule,6.01,11.96, "Inj pemetrexed, hospira 10mg",J9294,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.01,,,,,,,fee schedule,6.01,11.96, "Inj pemetrexed, hospira 10mg",J9294,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,6.01,,,,,,,fee schedule,6.01,11.96, "Injection, necitumumab, 1 mg",J9295,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,12.89,,,,,,,fee schedule,6.99,13.92, "Injection, necitumumab, 1 mg",J9295,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,13.92,,,,,,,fee schedule,6.99,13.92, "Injection, necitumumab, 1 mg",J9295,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.99,,,,,,,fee schedule,6.99,13.92, "Injection, necitumumab, 1 mg",J9295,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,6.99,,,,,,,fee schedule,6.99,13.92, Inj pemetrexed (accord) 10mg,J9296,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,21.92,,,,,,,fee schedule,11.88,23.67, Inj pemetrexed (accord) 10mg,J9296,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,23.67,,,,,,,fee schedule,11.88,23.67, Inj pemetrexed (accord) 10mg,J9296,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.88,,,,,,,fee schedule,11.88,23.67, Inj pemetrexed (accord) 10mg,J9296,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,11.88,,,,,,,fee schedule,11.88,23.67, Inj pemetrexed (sandoz) 10mg,J9297,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,2.72,,,,,,,fee schedule,1.48,2.94, Inj pemetrexed (sandoz) 10mg,J9297,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,2.94,,,,,,,fee schedule,1.48,2.94, Inj pemetrexed (sandoz) 10mg,J9297,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.48,,,,,,,fee schedule,1.48,2.94, Inj pemetrexed (sandoz) 10mg,J9297,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.48,,,,,,,fee schedule,1.48,2.94, Inj nivol relatlimab 3mg/1mg,J9298,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,444.71,,,,,,,fee schedule,241.13,480.29, Inj nivol relatlimab 3mg/1mg,J9298,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,480.29,,,,,,,fee schedule,241.13,480.29, Inj nivol relatlimab 3mg/1mg,J9298,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,241.13,,,,,,,fee schedule,241.13,480.29, Inj nivol relatlimab 3mg/1mg,J9298,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,241.13,,,,,,,fee schedule,241.13,480.29, "Injection, nivolumab",J9299,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,74.25,,,,,,,fee schedule,40.26,80.19, "Injection, nivolumab",J9299,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,80.19,,,,,,,fee schedule,40.26,80.19, "Injection, nivolumab",J9299,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,40.26,,,,,,,fee schedule,40.26,80.19, "Injection, nivolumab",J9299,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,40.26,,,,,,,fee schedule,40.26,80.19, Obinutuzumab inj,J9301,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,176.54,,,,,,,fee schedule,95.72,190.66, Obinutuzumab inj,J9301,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,190.66,,,,,,,fee schedule,95.72,190.66, Obinutuzumab inj,J9301,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,95.72,,,,,,,fee schedule,95.72,190.66, Obinutuzumab inj,J9301,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,95.72,,,,,,,fee schedule,95.72,190.66, Ofatumumab injection,J9302,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,75.92,,,,,,,fee schedule,75.92,75.92, Ofatumumab injection,J9302,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,75.92,,,,,,,fee schedule,75.92,75.92, Panitumumab injection,J9303,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,388.24,,,,,,,fee schedule,210.51,419.3, Panitumumab injection,J9303,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,419.3,,,,,,,fee schedule,210.51,419.3, Panitumumab injection,J9303,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,210.51,,,,,,,fee schedule,210.51,419.3, Panitumumab injection,J9303,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,210.51,,,,,,,fee schedule,210.51,419.3, "Inj. pemetrexed, 10 mg",J9304,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,118.67,,,,,,,fee schedule,64.34,128.16, "Inj. pemetrexed, 10 mg",J9304,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,128.16,,,,,,,fee schedule,64.34,128.16, "Inj. pemetrexed, 10 mg",J9304,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,64.34,,,,,,,fee schedule,64.34,128.16, "Inj. pemetrexed, 10 mg",J9304,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,64.34,,,,,,,fee schedule,64.34,128.16, Pemetrexed injection,J9305,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,8.39,,,,,,,fee schedule,4.55,9.06, Pemetrexed injection,J9305,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,9.06,,,,,,,fee schedule,4.55,9.06, Pemetrexed injection,J9305,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.55,,,,,,,fee schedule,4.55,9.06, Pemetrexed injection,J9305,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4.55,,,,,,,fee schedule,4.55,9.06, "Injection, pertuzumab, 1 mg",J9306,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,38,,,,,,,fee schedule,20.61,41.04, "Injection, pertuzumab, 1 mg",J9306,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,41.04,,,,,,,fee schedule,20.61,41.04, "Injection, pertuzumab, 1 mg",J9306,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,20.61,,,,,,,fee schedule,20.61,41.04, "Injection, pertuzumab, 1 mg",J9306,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,20.61,,,,,,,fee schedule,20.61,41.04, Pralatrexate injection,J9307,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,874.85,,,,,,,fee schedule,474.37,944.83, Pralatrexate injection,J9307,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,944.83,,,,,,,fee schedule,474.37,944.83, Pralatrexate injection,J9307,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,474.37,,,,,,,fee schedule,474.37,944.83, Pralatrexate injection,J9307,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,474.37,,,,,,,fee schedule,474.37,944.83, "Injection, ramucirumab",J9308,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,167.51,,,,,,,fee schedule,90.83,180.91, "Injection, ramucirumab",J9308,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,180.91,,,,,,,fee schedule,90.83,180.91, "Injection, ramucirumab",J9308,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,90.83,,,,,,,fee schedule,90.83,180.91, "Injection, ramucirumab",J9308,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,90.83,,,,,,,fee schedule,90.83,180.91, "Inj, polatuzumab vedotin 1mg",J9309,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,306.52,,,,,,,fee schedule,166.2,331.04, "Inj, polatuzumab vedotin 1mg",J9309,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,331.04,,,,,,,fee schedule,166.2,331.04, "Inj, polatuzumab vedotin 1mg",J9309,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,166.2,,,,,,,fee schedule,166.2,331.04, "Inj, polatuzumab vedotin 1mg",J9309,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,166.2,,,,,,,fee schedule,166.2,331.04, "Inj rituximab, hyaluronidase",J9311,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,83.16,,,,,,,fee schedule,45.09,89.81, "Inj rituximab, hyaluronidase",J9311,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,89.81,,,,,,,fee schedule,45.09,89.81, "Inj rituximab, hyaluronidase",J9311,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,45.09,,,,,,,fee schedule,45.09,89.81, "Inj rituximab, hyaluronidase",J9311,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,45.09,,,,,,,fee schedule,45.09,89.81, "Inj., rituximab, 10 mg",J9312,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,170.84,,,,,,,fee schedule,92.63,184.51, "Inj., rituximab, 10 mg",J9312,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,184.51,,,,,,,fee schedule,92.63,184.51, "Inj., rituximab, 10 mg",J9312,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,92.63,,,,,,,fee schedule,92.63,184.51, "Inj., rituximab, 10 mg",J9312,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,92.63,,,,,,,fee schedule,92.63,184.51, "Inj., lumoxiti, 0.01 mg",J9313,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,28.54,,,,,,,fee schedule,28.54,28.54, "Inj., lumoxiti, 0.01 mg",J9313,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,28.54,,,,,,,fee schedule,28.54,28.54, Inj pemetrexed (teva) 10mg,J9314,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,8.53,,,,,,,fee schedule,4.62,9.21, Inj pemetrexed (teva) 10mg,J9314,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,9.21,,,,,,,fee schedule,4.62,9.21, Inj pemetrexed (teva) 10mg,J9314,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.62,,,,,,,fee schedule,4.62,9.21, Inj pemetrexed (teva) 10mg,J9314,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4.62,,,,,,,fee schedule,4.62,9.21, "Pertuzu, trastuzu, 10 mg",J9316,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,142.63,,,,,,,fee schedule,77.34,154.04, "Pertuzu, trastuzu, 10 mg",J9316,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,154.04,,,,,,,fee schedule,77.34,154.04, "Pertuzu, trastuzu, 10 mg",J9316,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,77.34,,,,,,,fee schedule,77.34,154.04, "Pertuzu, trastuzu, 10 mg",J9316,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,77.34,,,,,,,fee schedule,77.34,154.04, Sacituzumab govitecan-hziy,J9317,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,81.59,,,,,,,fee schedule,44.24,88.11, Sacituzumab govitecan-hziy,J9317,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,88.11,,,,,,,fee schedule,44.24,88.11, Sacituzumab govitecan-hziy,J9317,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,44.24,,,,,,,fee schedule,44.24,88.11, Sacituzumab govitecan-hziy,J9317,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,44.24,,,,,,,fee schedule,44.24,88.11, Inj romidepsin non-lyo 0.1mg,J9318,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,64.17,,,,,,,fee schedule,34.79,69.3, Inj romidepsin non-lyo 0.1mg,J9318,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,69.3,,,,,,,fee schedule,34.79,69.3, Inj romidepsin non-lyo 0.1mg,J9318,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,34.79,,,,,,,fee schedule,34.79,69.3, Inj romidepsin non-lyo 0.1mg,J9318,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,34.79,,,,,,,fee schedule,34.79,69.3, Inj romidepsin lyophil 0.1mg,J9319,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,69.93,,,,,,,fee schedule,37.92,75.52, Inj romidepsin lyophil 0.1mg,J9319,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,75.52,,,,,,,fee schedule,37.92,75.52, Inj romidepsin lyophil 0.1mg,J9319,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,37.92,,,,,,,fee schedule,37.92,75.52, Inj romidepsin lyophil 0.1mg,J9319,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,37.92,,,,,,,fee schedule,37.92,75.52, Streptozocin injection,J9320,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,207.18,,,,,,,fee schedule,207.18,207.18, Streptozocin injection,J9320,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,207.18,,,,,,,fee schedule,207.18,207.18, Inj epcoritamab-bysp 0.16 mg,J9321,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,125.24,,,,,,,fee schedule,67.91,135.25, Inj epcoritamab-bysp 0.16 mg,J9321,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,135.25,,,,,,,fee schedule,67.91,135.25, Inj epcoritamab-bysp 0.16 mg,J9321,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,67.91,,,,,,,fee schedule,67.91,135.25, Inj epcoritamab-bysp 0.16 mg,J9321,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,67.91,,,,,,,fee schedule,67.91,135.25, Inj pemetrexed ditromethamin,J9323,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,23.27,,,,,,,fee schedule,12.61,25.13, Inj pemetrexed ditromethamin,J9323,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,25.13,,,,,,,fee schedule,12.61,25.13, Inj pemetrexed ditromethamin,J9323,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.61,,,,,,,fee schedule,12.61,25.13, Inj pemetrexed ditromethamin,J9323,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,12.61,,,,,,,fee schedule,12.61,25.13, "Inj, pemrydi rtu, 10 mg",J9324,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,180.23,,,,,,,fee schedule,97.72,194.64, "Inj, pemrydi rtu, 10 mg",J9324,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,194.64,,,,,,,fee schedule,97.72,194.64, "Inj, pemrydi rtu, 10 mg",J9324,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,97.72,,,,,,,fee schedule,97.72,194.64, "Inj, pemrydi rtu, 10 mg",J9324,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,97.72,,,,,,,fee schedule,97.72,194.64, Inj talimogene laherparepvec,J9325,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,165.49,,,,,,,fee schedule,89.73,178.73, Inj talimogene laherparepvec,J9325,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,178.73,,,,,,,fee schedule,89.73,178.73, Inj talimogene laherparepvec,J9325,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,89.73,,,,,,,fee schedule,89.73,178.73, Inj talimogene laherparepvec,J9325,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,89.73,,,,,,,fee schedule,89.73,178.73, Temozolomide injection,J9328,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,23.38,,,,,,,fee schedule,12.68,25.25, Temozolomide injection,J9328,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,25.25,,,,,,,fee schedule,12.68,25.25, Temozolomide injection,J9328,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.68,,,,,,,fee schedule,12.68,25.25, Temozolomide injection,J9328,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,12.68,,,,,,,fee schedule,12.68,25.25, "Inj, tislelizumab-jsgr",J9329,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,129.2,,,,,,,fee schedule,70.05,139.53, "Inj, tislelizumab-jsgr",J9329,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,139.53,,,,,,,fee schedule,70.05,139.53, "Inj, tislelizumab-jsgr",J9329,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,70.05,,,,,,,fee schedule,70.05,139.53, "Inj, tislelizumab-jsgr",J9329,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,70.05,,,,,,,fee schedule,70.05,139.53, Temsirolimus injection,J9330,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,72.65,,,,,,,fee schedule,39.39,78.46, Temsirolimus injection,J9330,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,78.46,,,,,,,fee schedule,39.39,78.46, Temsirolimus injection,J9330,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,39.39,,,,,,,fee schedule,39.39,78.46, Temsirolimus injection,J9330,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,39.39,,,,,,,fee schedule,39.39,78.46, Inj sirolimus prot part 1 mg,J9331,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,190.19,,,,,,,fee schedule,103.13,205.41, Inj sirolimus prot part 1 mg,J9331,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,205.41,,,,,,,fee schedule,103.13,205.41, Inj sirolimus prot part 1 mg,J9331,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,103.13,,,,,,,fee schedule,103.13,205.41, Inj sirolimus prot part 1 mg,J9331,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,103.13,,,,,,,fee schedule,103.13,205.41, Inj efgartigimod 2mg,J9332,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,72.9,,,,,,,fee schedule,39.53,78.73, Inj efgartigimod 2mg,J9332,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,78.73,,,,,,,fee schedule,39.53,78.73, Inj efgartigimod 2mg,J9332,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,39.53,,,,,,,fee schedule,39.53,78.73, Inj efgartigimod 2mg,J9332,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,39.53,,,,,,,fee schedule,39.53,78.73, Inj ronzanolixizum-noli 1 mg,J9333,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,52.11,,,,,,,fee schedule,28.26,56.28, Inj ronzanolixizum-noli 1 mg,J9333,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,56.28,,,,,,,fee schedule,28.26,56.28, Inj ronzanolixizum-noli 1 mg,J9333,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,28.26,,,,,,,fee schedule,28.26,56.28, Inj ronzanolixizum-noli 1 mg,J9333,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,28.26,,,,,,,fee schedule,28.26,56.28, Inj efgart-alfa 2mg hya-qvfc,J9334,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,75.92,,,,,,,fee schedule,41.16,81.99, Inj efgart-alfa 2mg hya-qvfc,J9334,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,81.99,,,,,,,fee schedule,41.16,81.99, Inj efgart-alfa 2mg hya-qvfc,J9334,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,41.16,,,,,,,fee schedule,41.16,81.99, Inj efgart-alfa 2mg hya-qvfc,J9334,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,41.16,,,,,,,fee schedule,41.16,81.99, Inj thiotepa (tepylute) 1 mg,J9341,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,54.38,,,,,,,fee schedule,54.38,54.38, Inj thiotepa (tepylute) 1 mg,J9341,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,54.38,,,,,,,fee schedule,54.38,54.38, Inj thiotepa nos 1 mg,J9342,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,27.54,,,,,,,fee schedule,14.93,29.74, Inj thiotepa nos 1 mg,J9342,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,29.74,,,,,,,fee schedule,14.93,29.74, Inj thiotepa nos 1 mg,J9342,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.93,,,,,,,fee schedule,14.93,29.74, Inj thiotepa nos 1 mg,J9342,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,14.93,,,,,,,fee schedule,14.93,29.74, "Inj, retifanlimab-dlwr, 1 mg",J9345,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,67.46,,,,,,,fee schedule,36.58,72.85, "Inj, retifanlimab-dlwr, 1 mg",J9345,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,72.85,,,,,,,fee schedule,36.58,72.85, "Inj, retifanlimab-dlwr, 1 mg",J9345,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,36.58,,,,,,,fee schedule,36.58,72.85, "Inj, retifanlimab-dlwr, 1 mg",J9345,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,36.58,,,,,,,fee schedule,36.58,72.85, "Inj, tremelimumab-actl, 1 mg",J9347,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,317.61,,,,,,,fee schedule,172.23,343.02, "Inj, tremelimumab-actl, 1 mg",J9347,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,343.02,,,,,,,fee schedule,172.23,343.02, "Inj, tremelimumab-actl, 1 mg",J9347,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,172.23,,,,,,,fee schedule,172.23,343.02, "Inj, tremelimumab-actl, 1 mg",J9347,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,172.23,,,,,,,fee schedule,172.23,343.02, "Inj. naxitamab-gqgk, 1 mg",J9348,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,1543.3,,,,,,,fee schedule,836.81,1666.76, "Inj. naxitamab-gqgk, 1 mg",J9348,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,1666.76,,,,,,,fee schedule,836.81,1666.76, "Inj. naxitamab-gqgk, 1 mg",J9348,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,836.81,,,,,,,fee schedule,836.81,1666.76, "Inj. naxitamab-gqgk, 1 mg",J9348,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,836.81,,,,,,,fee schedule,836.81,1666.76, "Inj., tafasitamab-cxix",J9349,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,31.68,,,,,,,fee schedule,17.18,34.21, "Inj., tafasitamab-cxix",J9349,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,34.21,,,,,,,fee schedule,17.18,34.21, "Inj., tafasitamab-cxix",J9349,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.18,,,,,,,fee schedule,17.18,34.21, "Inj., tafasitamab-cxix",J9349,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,17.18,,,,,,,fee schedule,17.18,34.21, "Inj mosunetuzumab-axgb, 1 mg",J9350,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,1468.69,,,,,,,fee schedule,796.36,1586.18, "Inj mosunetuzumab-axgb, 1 mg",J9350,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,1586.18,,,,,,,fee schedule,796.36,1586.18, "Inj mosunetuzumab-axgb, 1 mg",J9350,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,796.36,,,,,,,fee schedule,796.36,1586.18, "Inj mosunetuzumab-axgb, 1 mg",J9350,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,796.36,,,,,,,fee schedule,796.36,1586.18, Topotecan injection,J9351,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,3.02,,,,,,,fee schedule,1.63,3.26, Topotecan injection,J9351,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,3.26,,,,,,,fee schedule,1.63,3.26, Topotecan injection,J9351,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.63,,,,,,,fee schedule,1.63,3.26, Topotecan injection,J9351,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.63,,,,,,,fee schedule,1.63,3.26, Injection trabectedin 0.1mg,J9352,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,861.91,,,,,,,fee schedule,467.35,930.86, Injection trabectedin 0.1mg,J9352,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,930.86,,,,,,,fee schedule,467.35,930.86, Injection trabectedin 0.1mg,J9352,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,467.35,,,,,,,fee schedule,467.35,930.86, Injection trabectedin 0.1mg,J9352,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,467.35,,,,,,,fee schedule,467.35,930.86, "Inj. margetuximab-cmkb, 5 mg",J9353,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,113.51,,,,,,,fee schedule,61.55,122.59, "Inj. margetuximab-cmkb, 5 mg",J9353,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,122.59,,,,,,,fee schedule,61.55,122.59, "Inj. margetuximab-cmkb, 5 mg",J9353,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,61.55,,,,,,,fee schedule,61.55,122.59, "Inj. margetuximab-cmkb, 5 mg",J9353,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,61.55,,,,,,,fee schedule,61.55,122.59, "Inj, ado-trastuzumab emt 1mg",J9354,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,94.16,,,,,,,fee schedule,51.06,101.7, "Inj, ado-trastuzumab emt 1mg",J9354,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,101.7,,,,,,,fee schedule,51.06,101.7, "Inj, ado-trastuzumab emt 1mg",J9354,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,51.06,,,,,,,fee schedule,51.06,101.7, "Inj, ado-trastuzumab emt 1mg",J9354,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,51.06,,,,,,,fee schedule,51.06,101.7, Trastuzumab injection,J9355,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,171.41,,,,,,,fee schedule,92.94,185.12, Trastuzumab injection,J9355,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,185.12,,,,,,,fee schedule,92.94,185.12, Trastuzumab injection,J9355,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,92.94,,,,,,,fee schedule,92.94,185.12, Trastuzumab injection,J9355,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,92.94,,,,,,,fee schedule,92.94,185.12, "Inj. herceptin hylecta, 10mg",J9356,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,141.68,,,,,,,fee schedule,76.82,153.02, "Inj. herceptin hylecta, 10mg",J9356,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,153.02,,,,,,,fee schedule,76.82,153.02, "Inj. herceptin hylecta, 10mg",J9356,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,76.82,,,,,,,fee schedule,76.82,153.02, "Inj. herceptin hylecta, 10mg",J9356,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,76.82,,,,,,,fee schedule,76.82,153.02, Valrubicin injection,J9357,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,3097.76,,,,,,,fee schedule,1679.68,3345.58, Valrubicin injection,J9357,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,3345.58,,,,,,,fee schedule,1679.68,3345.58, Valrubicin injection,J9357,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1679.68,,,,,,,fee schedule,1679.68,3345.58, Valrubicin injection,J9357,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1679.68,,,,,,,fee schedule,1679.68,3345.58, Inj fam-trastu deru-nxki 1mg,J9358,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,67.5,,,,,,,fee schedule,36.6,72.9, Inj fam-trastu deru-nxki 1mg,J9358,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,72.9,,,,,,,fee schedule,36.6,72.9, Inj fam-trastu deru-nxki 1mg,J9358,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,36.6,,,,,,,fee schedule,36.6,72.9, Inj fam-trastu deru-nxki 1mg,J9358,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,36.6,,,,,,,fee schedule,36.6,72.9, Inj lon tesirin-lpyl 0.075mg,J9359,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,487.67,,,,,,,fee schedule,264.42,526.68, Inj lon tesirin-lpyl 0.075mg,J9359,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,526.68,,,,,,,fee schedule,264.42,526.68, Inj lon tesirin-lpyl 0.075mg,J9359,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,264.42,,,,,,,fee schedule,264.42,526.68, Inj lon tesirin-lpyl 0.075mg,J9359,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,264.42,,,,,,,fee schedule,264.42,526.68, Vinblastine sulfate inj,J9360,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,11.9,,,,,,,fee schedule,6.45,12.85, Vinblastine sulfate inj,J9360,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,12.85,,,,,,,fee schedule,6.45,12.85, Vinblastine sulfate inj,J9360,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.45,,,,,,,fee schedule,6.45,12.85, Vinblastine sulfate inj,J9360,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,6.45,,,,,,,fee schedule,6.45,12.85, Vincristine sulfate 1 MG inj,J9370,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,17.69,,,,,,,fee schedule,9.59,19.1, Vincristine sulfate 1 MG inj,J9370,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,19.1,,,,,,,fee schedule,9.59,19.1, Vincristine sulfate 1 MG inj,J9370,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.59,,,,,,,fee schedule,9.59,19.1, Vincristine sulfate 1 MG inj,J9370,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9.59,,,,,,,fee schedule,9.59,19.1, "Inj pozelimab-bbfg, 1 mg",J9376,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,126.7,,,,,,,fee schedule,126.7,126.7, "Inj pozelimab-bbfg, 1 mg",J9376,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,126.7,,,,,,,fee schedule,126.7,126.7, Inj teclistamab cqyv 0.5 mg,J9380,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,74.86,,,,,,,fee schedule,40.59,80.85, Inj teclistamab cqyv 0.5 mg,J9380,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,80.85,,,,,,,fee schedule,40.59,80.85, Inj teclistamab cqyv 0.5 mg,J9380,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,40.59,,,,,,,fee schedule,40.59,80.85, Inj teclistamab cqyv 0.5 mg,J9380,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,40.59,,,,,,,fee schedule,40.59,80.85, Inj teplizumab mzwv 5 mcg,J9381,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,84.71,,,,,,,fee schedule,45.93,91.49, Inj teplizumab mzwv 5 mcg,J9381,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,91.49,,,,,,,fee schedule,45.93,91.49, Inj teplizumab mzwv 5 mcg,J9381,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,45.93,,,,,,,fee schedule,45.93,91.49, Inj teplizumab mzwv 5 mcg,J9381,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,45.93,,,,,,,fee schedule,45.93,91.49, Inj zenocutuzumab-zbco 1 mg,J9382,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,39.8,,,,,,,fee schedule,39.8,39.8, Inj zenocutuzumab-zbco 1 mg,J9382,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,39.8,,,,,,,fee schedule,39.8,39.8, Vinorelbine tartrate inj,J9390,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,4.41,,,,,,,fee schedule,2.39,4.76, Vinorelbine tartrate inj,J9390,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,4.76,,,,,,,fee schedule,2.39,4.76, Vinorelbine tartrate inj,J9390,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2.39,,,,,,,fee schedule,2.39,4.76, Vinorelbine tartrate inj,J9390,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2.39,,,,,,,fee schedule,2.39,4.76, "Inj, fulvestrant (teva)",J9393,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56.38,,,,,,,fee schedule,56.38,56.38, "Inj, fulvestrant (teva)",J9393,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,56.38,,,,,,,fee schedule,56.38,56.38, "Inj, fulvestrant (fresenius)",J9394,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,7.47,,,,,,,fee schedule,4.05,8.07, "Inj, fulvestrant (fresenius)",J9394,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,8.07,,,,,,,fee schedule,4.05,8.07, "Inj, fulvestrant (fresenius)",J9394,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.05,,,,,,,fee schedule,4.05,8.07, "Inj, fulvestrant (fresenius)",J9394,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4.05,,,,,,,fee schedule,4.05,8.07, "Injection, Fulvestrant",J9395,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,15.71,,,,,,,fee schedule,8.52,16.96, "Injection, Fulvestrant",J9395,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,16.96,,,,,,,fee schedule,8.52,16.96, "Injection, Fulvestrant",J9395,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.52,,,,,,,fee schedule,8.52,16.96, "Injection, Fulvestrant",J9395,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,8.52,,,,,,,fee schedule,8.52,16.96, "Inj, ziv-aflibercept, 1mg",J9400,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,17.96,,,,,,,fee schedule,9.74,19.39, "Inj, ziv-aflibercept, 1mg",J9400,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,19.39,,,,,,,fee schedule,9.74,19.39, "Inj, ziv-aflibercept, 1mg",J9400,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.74,,,,,,,fee schedule,9.74,19.39, "Inj, ziv-aflibercept, 1mg",J9400,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9.74,,,,,,,fee schedule,9.74,19.39, Porfimer sodium injection,J9600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,29558.67,,,,,,,fee schedule,29558.67,29558.67, Porfimer sodium injection,J9600,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,29558.67,,,,,,,fee schedule,29558.67,29558.67, Inj bulking agent anal canal,L8605,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1256.77,,,,,,,fee schedule,1256.77,1256.77, Inj bulking agent anal canal,L8605,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1256.77,,,,,,,fee schedule,1256.77,1256.77, Inj vocal cord bulking agent,L8607,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,75.26,,,,,,,fee schedule,75.26,75.26, Inj vocal cord bulking agent,L8607,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,75.26,,,,,,,fee schedule,75.26,75.26, Cephalin floculation test,P2028,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,20.65,,,,,,,fee schedule,7.43,20.65, Cephalin floculation test,P2028,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.43,,,,,,,fee schedule,7.43,20.65, Cephalin floculation test,P2028,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,7.43,,,,,,,fee schedule,7.43,20.65, Congo red blood test,P2029,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,20.65,,,,,,,fee schedule,7.43,20.65, Congo red blood test,P2029,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.43,,,,,,,fee schedule,7.43,20.65, Congo red blood test,P2029,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,7.43,,,,,,,fee schedule,7.43,20.65, Hair analysis,P2031,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,20.65,,,,,,,fee schedule,7.43,20.65, Hair analysis,P2031,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.43,,,,,,,fee schedule,7.43,20.65, Hair analysis,P2031,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,7.43,,,,,,,fee schedule,7.43,20.65, Blood thymol turbidity,P2033,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,20.65,,,,,,,fee schedule,7.43,20.65, Blood thymol turbidity,P2033,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.43,,,,,,,fee schedule,7.43,20.65, Blood thymol turbidity,P2033,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,7.43,,,,,,,fee schedule,7.43,20.65, Blood mucoprotein,P2038,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,20.65,,,,,,,fee schedule,7.43,20.65, Blood mucoprotein,P2038,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.43,,,,,,,fee schedule,7.43,20.65, Blood mucoprotein,P2038,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,7.43,,,,,,,fee schedule,7.43,20.65, Screen pap by tech w md supv,P3000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,77.35,,,,,,,fee schedule,22.68,77.35, Screen pap by tech w md supv,P3000,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22.68,,,,,,,fee schedule,22.68,77.35, Screen pap by tech w md supv,P3000,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22.68,,,,,,,fee schedule,22.68,77.35, Screening pap smear by phys,P3001,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,127.02,,,,,,,fee schedule,39.53,127.02, Screening pap smear by phys,P3001,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,39.53,,,,,,,fee schedule,39.53,127.02, Screening pap smear by phys,P3001,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,39.53,,,,,,,fee schedule,39.53,127.02, Culture bacterial urine,P7001,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,29.24,,,,,,,fee schedule,29.24,29.24, Culture bacterial urine,P7001,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,29.24,,,,,,,fee schedule,29.24,29.24, "Albumin (human),5%, 50ml",P9041,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.96,,,,,,,fee schedule,12.96,12.96, "Albumin (human),5%, 50ml",P9041,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,12.96,,,,,,,fee schedule,12.96,12.96, "Albumin (human), 5%, 250 ml",P9045,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,64.76,,,,,,,fee schedule,64.76,64.76, "Albumin (human), 5%, 250 ml",P9045,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,64.76,,,,,,,fee schedule,64.76,64.76, "Albumin (human), 25%, 20 ml",P9046,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25.9,,,,,,,fee schedule,25.9,25.9, "Albumin (human), 25%, 20 ml",P9046,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,25.9,,,,,,,fee schedule,25.9,25.9, "Albumin (human), 25%, 50ml",P9047,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,64.76,,,,,,,fee schedule,64.76,64.76, "Albumin (human), 25%, 50ml",P9047,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,64.76,,,,,,,fee schedule,64.76,64.76, Pathogen test for platelets,P9100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,53.25,,,,,,,fee schedule,53.25,53.25, Pathogen test for platelets,P9100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,53.25,,,,,,,fee schedule,53.25,53.25, Catheterize for urine spec,P9612,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,38.97,,,,,,,fee schedule,4.5,3195, Catheterize for urine spec,P9612,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,4.5,3195, Catheterize for urine spec,P9612,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.5,,,,,,,fee schedule,4.5,3195, Catheterize for urine spec,P9612,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4.5,,,,,,,fee schedule,4.5,3195, Urine specimen collect mult,P9615,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,38.97,,,,,,,fee schedule,4.5,3195, Urine specimen collect mult,P9615,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,4.5,3195, Urine specimen collect mult,P9615,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.5,,,,,,,fee schedule,4.5,3195, Urine specimen collect mult,P9615,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4.5,,,,,,,fee schedule,4.5,3195, Cardiokymography,Q0035,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,57.85,,,,,,,fee schedule,57.85,57.85, Obtaining screen pap smear,Q0091,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,86.77,,,,,,,fee schedule,34.49,86.77, Obtaining screen pap smear,Q0091,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,34.49,,,,,,,fee schedule,34.49,86.77, Obtaining screen pap smear,Q0091,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,34.49,,,,,,,fee schedule,34.49,86.77, Set up port xray equipment,Q0092,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,133.66,,,,,,,fee schedule,133.66,133.66, Wet mounts/ w preparations,Q0111,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,77.35,,,,,,,fee schedule,22.68,77.35, Wet mounts/ w preparations,Q0111,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22.68,,,,,,,fee schedule,22.68,77.35, Wet mounts/ w preparations,Q0111,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22.68,,,,,,,fee schedule,22.68,77.35, Potassium hydroxide preps,Q0112,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,24.32,,,,,,,fee schedule,8.75,24.32, Potassium hydroxide preps,Q0112,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.75,,,,,,,fee schedule,8.75,24.32, Potassium hydroxide preps,Q0112,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,8.75,,,,,,,fee schedule,8.75,24.32, Pinworm examinations,Q0113,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,17.81,,,,,,,fee schedule,6.41,17.81, Pinworm examinations,Q0113,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.41,,,,,,,fee schedule,6.41,17.81, Pinworm examinations,Q0113,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,6.41,,,,,,,fee schedule,6.41,17.81, Fern test,Q0114,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,40.64,,,,,,,fee schedule,14.61,40.64, Fern test,Q0114,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.61,,,,,,,fee schedule,14.61,40.64, Fern test,Q0114,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,14.61,,,,,,,fee schedule,14.61,40.64, Post-coital mucous exam,Q0115,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,104.3,,,,,,,fee schedule,37.5,104.3, Post-coital mucous exam,Q0115,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,37.5,,,,,,,fee schedule,37.5,104.3, Post-coital mucous exam,Q0115,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,37.5,,,,,,,fee schedule,37.5,104.3, "Ferumoxytol, non-esrd",Q0138,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.7,,,,,,,fee schedule,0.38,0.75, "Ferumoxytol, non-esrd",Q0138,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.75,,,,,,,fee schedule,0.38,0.75, "Ferumoxytol, non-esrd",Q0138,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.38,,,,,,,fee schedule,0.38,0.75, "Ferumoxytol, non-esrd",Q0138,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.38,,,,,,,fee schedule,0.38,0.75, "Ferumoxytol, esrd use",Q0139,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.7,,,,,,,fee schedule,0.38,0.75, "Ferumoxytol, esrd use",Q0139,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.75,,,,,,,fee schedule,0.38,0.75, "Ferumoxytol, esrd use",Q0139,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.38,,,,,,,fee schedule,0.38,0.75, "Ferumoxytol, esrd use",Q0139,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.38,,,,,,,fee schedule,0.38,0.75, "Azithromycin dihydrate, oral",Q0144,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.4,,,,,,,fee schedule,15.4,15.4, "Azithromycin dihydrate, oral",Q0144,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,15.4,,,,,,,fee schedule,15.4,15.4, Dronabinol (syndros) 0.1 mg,Q0155,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.75,,,,,,,fee schedule,4.75,4.75, Dronabinol (syndros) 0.1 mg,Q0155,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4.75,,,,,,,fee schedule,4.75,4.75, Ondansetron oral,Q0162,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.02,,,,,,,fee schedule,0.01,0.02, Ondansetron oral,Q0162,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.02,,,,,,,fee schedule,0.01,0.02, Ondansetron oral,Q0162,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.01,,,,,,,fee schedule,0.01,0.02, Ondansetron oral,Q0162,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.01,,,,,,,fee schedule,0.01,0.02, Diphenhydramine HCl 50mg,Q0163,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.61,,,,,,,fee schedule,1.61,1.61, Diphenhydramine HCl 50mg,Q0163,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.61,,,,,,,fee schedule,1.61,1.61, Prochlorperazine maleate 5mg,Q0164,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.9,,,,,,,fee schedule,0.9,0.9, Prochlorperazine maleate 5mg,Q0164,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.9,,,,,,,fee schedule,0.9,0.9, Granisetron HCl 1 mg oral,Q0166,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,62.95,,,,,,,fee schedule,62.95,62.95, Granisetron HCl 1 mg oral,Q0166,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,62.95,,,,,,,fee schedule,62.95,62.95, Dronabinol 2.5mg oral,Q0167,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,3.78,,,,,,,fee schedule,2.05,4.08, Dronabinol 2.5mg oral,Q0167,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,4.08,,,,,,,fee schedule,2.05,4.08, Dronabinol 2.5mg oral,Q0167,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2.05,,,,,,,fee schedule,2.05,4.08, Dronabinol 2.5mg oral,Q0167,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2.05,,,,,,,fee schedule,2.05,4.08, Promethazine HCl 12.5mg oral,Q0169,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.34,,,,,,,fee schedule,0.34,0.34, Promethazine HCl 12.5mg oral,Q0169,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.34,,,,,,,fee schedule,0.34,0.34, Trimethobenzamide HCl 250mg,Q0173,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.79,,,,,,,fee schedule,0.79,0.79, Trimethobenzamide HCl 250mg,Q0173,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.79,,,,,,,fee schedule,0.79,0.79, Thiethylperazine maleate10mg,Q0174,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.79,,,,,,,fee schedule,0.79,0.79, Thiethylperazine maleate10mg,Q0174,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.79,,,,,,,fee schedule,0.79,0.79, Perphenazine 4mg oral,Q0175,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.79,,,,,,,fee schedule,0.79,0.79, Perphenazine 4mg oral,Q0175,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.79,,,,,,,fee schedule,0.79,0.79, Hydroxyzine pamoate 25mg,Q0177,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2.37,,,,,,,fee schedule,2.37,2.37, Hydroxyzine pamoate 25mg,Q0177,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2.37,,,,,,,fee schedule,2.37,2.37, Dolasetron mesylate oral,Q0180,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,175.4,,,,,,,fee schedule,175.4,175.4, Dolasetron mesylate oral,Q0180,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,175.4,,,,,,,fee schedule,175.4,175.4, "Inj, pemivibart, 4500 mg",Q0224,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,16287.75,,,,,,,fee schedule,8831.58,17590.77, "Inj, pemivibart, 4500 mg",Q0224,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,17590.77,,,,,,,fee schedule,8831.58,17590.77, "Inj, pemivibart, 4500 mg",Q0224,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8831.58,,,,,,,fee schedule,8831.58,17590.77, "Inj, pemivibart, 4500 mg",Q0224,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,8831.58,,,,,,,fee schedule,8831.58,17590.77, Tocilizumab for covid-19,Q0249,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,17.03,,,,,,,fee schedule,9.24,18.4, Tocilizumab for covid-19,Q0249,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,18.4,,,,,,,fee schedule,9.24,18.4, Tocilizumab for covid-19,Q0249,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.24,,,,,,,fee schedule,9.24,18.4, Tocilizumab for covid-19,Q0249,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9.24,,,,,,,fee schedule,9.24,18.4, Sermorelin acetate injection,Q0515,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.57,,,,,,,fee schedule,1.57,1.57, Sermorelin acetate injection,Q0515,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.57,,,,,,,fee schedule,1.57,1.57, Bladder calculi irrig sol,Q2004,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.97,,,,,,,fee schedule,16.97,16.97, Bladder calculi irrig sol,Q2004,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,16.97,,,,,,,fee schedule,16.97,16.97, Fosphenytoin inj pe,Q2009,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.92,,,,,,,fee schedule,8.92,8.92, Fosphenytoin inj pe,Q2009,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,8.92,,,,,,,fee schedule,8.92,8.92, "Teniposide, 50 mg",Q2017,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3654.07,,,,,,,fee schedule,3654.07,3654.07, "Teniposide, 50 mg",Q2017,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3654.07,,,,,,,fee schedule,3654.07,3654.07, Radiesse injection,Q2026,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,406.77,,,,,,,fee schedule,406.77,406.77, Radiesse injection,Q2026,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,406.77,,,,,,,fee schedule,406.77,406.77, "Inj, sculptra, 0.5mg",Q2028,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.22,,,,,,,fee schedule,1.22,1.22, "Inj, sculptra, 0.5mg",Q2028,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1.22,,,,,,,fee schedule,1.22,1.22, "Afluria vacc, 3 yrs & >, im",Q2035,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31.4,,,,,,,fee schedule,31.4,31.4, "Afluria vacc, 3 yrs & >, im",Q2035,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,31.4,,,,,,,fee schedule,31.4,31.4, "Fluvirin vacc, 3 yrs & >, im",Q2037,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.6,,,,,,,fee schedule,14.6,14.6, "Fluvirin vacc, 3 yrs & >, im",Q2037,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,14.6,,,,,,,fee schedule,14.6,14.6, "Fluzone vacc, 3 yrs & >, im",Q2038,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,58.65,,,,,,,fee schedule,58.65,58.65, "Fluzone vacc, 3 yrs & >, im",Q2038,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,58.65,,,,,,,fee schedule,58.65,58.65, Axicabtagene ciloleucel car+,Q2041,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,1199422.08,,,,,,,fee schedule,650353.31,1295375.85, Axicabtagene ciloleucel car+,Q2041,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,1295375.85,,,,,,,fee schedule,650353.31,1295375.85, Axicabtagene ciloleucel car+,Q2041,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,650353.31,,,,,,,fee schedule,650353.31,1295375.85, Axicabtagene ciloleucel car+,Q2041,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,650353.31,,,,,,,fee schedule,650353.31,1295375.85, Tisagenlecleucel car-pos t,Q2042,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,1301230.31,,,,,,,fee schedule,705555.99,1405328.73, Tisagenlecleucel car-pos t,Q2042,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,1405328.73,,,,,,,fee schedule,705555.99,1405328.73, Tisagenlecleucel car-pos t,Q2042,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,705555.99,,,,,,,fee schedule,705555.99,1405328.73, Tisagenlecleucel car-pos t,Q2042,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,705555.99,,,,,,,fee schedule,705555.99,1405328.73, Sipuleucel-t auto cd54+,Q2043,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,125878.43,,,,,,,fee schedule,68254.08,135948.71, Sipuleucel-t auto cd54+,Q2043,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,135948.71,,,,,,,fee schedule,68254.08,135948.71, Sipuleucel-t auto cd54+,Q2043,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,68254.08,,,,,,,fee schedule,68254.08,135948.71, Sipuleucel-t auto cd54+,Q2043,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,68254.08,,,,,,,fee schedule,68254.08,135948.71, Imported Lipodox inj,Q2049,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,645.21,,,,,,,fee schedule,645.21,645.21, Imported Lipodox inj,Q2049,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,645.21,,,,,,,fee schedule,645.21,645.21, Doxorubicin inj 10mg,Q2050,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,245.88,,,,,,,fee schedule,133.32,265.55, Doxorubicin inj 10mg,Q2050,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,265.55,,,,,,,fee schedule,133.32,265.55, Doxorubicin inj 10mg,Q2050,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,133.32,,,,,,,fee schedule,133.32,265.55, Doxorubicin inj 10mg,Q2050,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,133.32,,,,,,,fee schedule,133.32,265.55, Brexucabtagene car pos t,Q2053,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,1101870,,,,,,,fee schedule,597458.4,1190019.6, Brexucabtagene car pos t,Q2053,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,1190019.6,,,,,,,fee schedule,597458.4,1190019.6, Brexucabtagene car pos t,Q2053,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,597458.4,,,,,,,fee schedule,597458.4,1190019.6, Brexucabtagene car pos t,Q2053,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,597458.4,,,,,,,fee schedule,597458.4,1190019.6, Lisocabtagene mara car pos t,Q2054,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,1218680.24,,,,,,,fee schedule,660795.51,1316174.65, Lisocabtagene mara car pos t,Q2054,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,1316174.65,,,,,,,fee schedule,660795.51,1316174.65, Lisocabtagene mara car pos t,Q2054,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,660795.51,,,,,,,fee schedule,660795.51,1316174.65, Lisocabtagene mara car pos t,Q2054,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,660795.51,,,,,,,fee schedule,660795.51,1316174.65, Idecabtagene vicleucel car,Q2055,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,1217836.01,,,,,,,fee schedule,660337.75,1315262.89, Idecabtagene vicleucel car,Q2055,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,1315262.89,,,,,,,fee schedule,660337.75,1315262.89, Idecabtagene vicleucel car,Q2055,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,660337.75,,,,,,,fee schedule,660337.75,1315262.89, Idecabtagene vicleucel car,Q2055,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,660337.75,,,,,,,fee schedule,660337.75,1315262.89, Ciltacabtagene car-pos t,Q2056,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,1245102.37,,,,,,,fee schedule,675122.17,1344710.56, Ciltacabtagene car-pos t,Q2056,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,1344710.56,,,,,,,fee schedule,675122.17,1344710.56, Ciltacabtagene car-pos t,Q2056,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,675122.17,,,,,,,fee schedule,675122.17,1344710.56, Ciltacabtagene car-pos t,Q2056,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,675122.17,,,,,,,fee schedule,675122.17,1344710.56, Afamitresgene autoleucel,Q2057,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,1733895,,,,,,,fee schedule,940156.4,1872606.6, Afamitresgene autoleucel,Q2057,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,1872606.6,,,,,,,fee schedule,940156.4,1872606.6, Afamitresgene autoleucel,Q2057,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,940156.4,,,,,,,fee schedule,940156.4,1872606.6, Afamitresgene autoleucel,Q2057,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,940156.4,,,,,,,fee schedule,940156.4,1872606.6, Obecbtge autol up to 400 mil,Q2058,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,329857.5,,,,,,,fee schedule,329857.5,329857.5, Obecbtge autol up to 400 mil,Q2058,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,329857.5,,,,,,,fee schedule,329857.5,329857.5, Brachytherapy radioelements,Q3001,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,73,,,,,,,fee schedule,73,73, Brachytherapy radioelements,Q3001,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,73,,,,,,,fee schedule,73,73, Inj beta interferon im 1 mcg,Q3027,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,70.11,,,,,,,fee schedule,70.11,70.11, Inj beta interferon im 1 mcg,Q3027,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,70.11,,,,,,,fee schedule,70.11,70.11, Inj beta interferon sq 1 mcg,Q3028,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,57.17,,,,,,,fee schedule,57.17,57.17, Inj beta interferon sq 1 mcg,Q3028,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,57.17,,,,,,,fee schedule,57.17,57.17, Iloprost non-comp unit dose,Q4074,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,357.57,,,,,,,fee schedule,193.88,386.18, Iloprost non-comp unit dose,Q4074,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,386.18,,,,,,,fee schedule,193.88,386.18, Iloprost non-comp unit dose,Q4074,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,193.88,,,,,,,fee schedule,193.88,386.18, Iloprost non-comp unit dose,Q4074,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,193.88,,,,,,,fee schedule,193.88,386.18, "Epoetin alfa, 100 units ESRD",Q4081,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,1.73,,,,,,,fee schedule,0.94,1.87, "Epoetin alfa, 100 units ESRD",Q4081,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,1.87,,,,,,,fee schedule,0.94,1.87, "Epoetin alfa, 100 units ESRD",Q4081,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.94,,,,,,,fee schedule,0.94,1.87, "Epoetin alfa, 100 units ESRD",Q4081,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.94,,,,,,,fee schedule,0.94,1.87, Apligraf,Q4101,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,36.97,656.48, Apligraf,Q4101,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,36.97,,,,,,,fee schedule,36.97,656.48, Apligraf,Q4101,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,36.97,,,,,,,fee schedule,36.97,656.48, Oasis wound matrix,Q4102,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,14.27,656.48, Oasis wound matrix,Q4102,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.27,,,,,,,fee schedule,14.27,656.48, Oasis wound matrix,Q4102,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,14.27,,,,,,,fee schedule,14.27,656.48, Oasis burn matrix,Q4103,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,15.1,656.48, Oasis burn matrix,Q4103,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.1,,,,,,,fee schedule,15.1,656.48, Oasis burn matrix,Q4103,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,15.1,,,,,,,fee schedule,15.1,656.48, Integra bmwd,Q4104,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,65.59,656.48, Integra bmwd,Q4104,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,65.59,,,,,,,fee schedule,65.59,656.48, Integra bmwd,Q4104,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,65.59,,,,,,,fee schedule,65.59,656.48, Integra drt or omnigraft,Q4105,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,31.83,656.48, Integra drt or omnigraft,Q4105,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31.83,,,,,,,fee schedule,31.83,656.48, Integra drt or omnigraft,Q4105,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,31.83,,,,,,,fee schedule,31.83,656.48, Dermagraft,Q4106,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,62.15,,,,,,,fee schedule,62.15,62.15, Dermagraft,Q4106,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,62.15,,,,,,,fee schedule,62.15,62.15, Graftjacket,Q4107,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,166.49,656.48, Graftjacket,Q4107,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,166.49,,,,,,,fee schedule,166.49,656.48, Graftjacket,Q4107,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,166.49,,,,,,,fee schedule,166.49,656.48, Integra matrix,Q4108,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,59.93,656.48, Integra matrix,Q4108,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,59.93,,,,,,,fee schedule,59.93,656.48, Integra matrix,Q4108,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,59.93,,,,,,,fee schedule,59.93,656.48, Primatrix,Q4110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,79.8,656.48, Primatrix,Q4110,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,79.8,,,,,,,fee schedule,79.8,656.48, Primatrix,Q4110,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,79.8,,,,,,,fee schedule,79.8,656.48, Gammagraft,Q4111,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,8.69,656.48, Gammagraft,Q4111,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.69,,,,,,,fee schedule,8.69,656.48, Gammagraft,Q4111,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,8.69,,,,,,,fee schedule,8.69,656.48, Graftjacket xpress,Q4113,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2436.95,,,,,,,fee schedule,2436.95,2436.95, Graftjacket xpress,Q4113,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2436.95,,,,,,,fee schedule,2436.95,2436.95, Integra flowable wound matri,Q4114,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1881.53,,,,,,,fee schedule,1881.53,1881.53, Integra flowable wound matri,Q4114,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1881.53,,,,,,,fee schedule,1881.53,1881.53, Alloskin,Q4115,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,17.67,656.48, Alloskin,Q4115,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.67,,,,,,,fee schedule,17.67,656.48, Alloskin,Q4115,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,17.67,,,,,,,fee schedule,17.67,656.48, Alloderm,Q4116,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, Hyalomatrix,Q4117,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,36.51,656.48, Hyalomatrix,Q4117,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,36.51,,,,,,,fee schedule,36.51,656.48, Hyalomatrix,Q4117,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,36.51,,,,,,,fee schedule,36.51,656.48, Matristem micromatrix,Q4118,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3.12,,,,,,,fee schedule,3.12,3.12, Matristem micromatrix,Q4118,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3.12,,,,,,,fee schedule,3.12,3.12, Theraskin,Q4121,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,59.6,656.48, Theraskin,Q4121,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,59.6,,,,,,,fee schedule,59.6,656.48, Theraskin,Q4121,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,59.6,,,,,,,fee schedule,59.6,656.48, Dermacell,Q4122,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,147.66,656.48, Dermacell,Q4122,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,147.66,,,,,,,fee schedule,147.66,656.48, Dermacell,Q4122,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,147.66,,,,,,,fee schedule,147.66,656.48, Alloskin,Q4123,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,87.29,656.48, Alloskin,Q4123,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,87.29,,,,,,,fee schedule,87.29,656.48, Alloskin,Q4123,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,87.29,,,,,,,fee schedule,87.29,656.48, Oasis tri-layer wound matrix,Q4124,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,3.03,656.48, Oasis tri-layer wound matrix,Q4124,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3.03,,,,,,,fee schedule,3.03,656.48, Oasis tri-layer wound matrix,Q4124,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3.03,,,,,,,fee schedule,3.03,656.48, Arthroflex,Q4125,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, Memoderm/derma/tranz/integup,Q4126,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,72.97,656.48, Memoderm/derma/tranz/integup,Q4126,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,72.97,,,,,,,fee schedule,72.97,656.48, Memoderm/derma/tranz/integup,Q4126,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,72.97,,,,,,,fee schedule,72.97,656.48, Talymed,Q4127,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,83.56,656.48, Talymed,Q4127,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,83.56,,,,,,,fee schedule,83.56,656.48, Talymed,Q4127,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,83.56,,,,,,,fee schedule,83.56,656.48, Flexhd/allopatchhd/matrixhd,Q4128,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,37.45,656.48, Flexhd/allopatchhd/matrixhd,Q4128,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,37.45,,,,,,,fee schedule,37.45,656.48, Flexhd/allopatchhd/matrixhd,Q4128,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,37.45,,,,,,,fee schedule,37.45,656.48, Strattice TM,Q4130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, Grafix core,Q4132,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,108.8,656.48, Grafix core,Q4132,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,108.8,,,,,,,fee schedule,108.8,656.48, Grafix core,Q4132,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,108.8,,,,,,,fee schedule,108.8,656.48, Grafix prime,Q4133,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,166.14,656.48, Grafix prime,Q4133,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,166.14,,,,,,,fee schedule,166.14,656.48, Grafix prime,Q4133,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,166.14,,,,,,,fee schedule,166.14,656.48, hMatrix,Q4134,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, Mediskin,Q4135,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, EZderm,Q4136,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, "Amnioexcel or biodexcel, 1cm",Q4137,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,122.88,656.48, "Amnioexcel or biodexcel, 1cm",Q4137,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,122.88,,,,,,,fee schedule,122.88,656.48, "Amnioexcel or biodexcel, 1cm",Q4137,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,122.88,,,,,,,fee schedule,122.88,656.48, "Biodfence dryflex, 1cm",Q4138,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,122.49,656.48, "Biodfence dryflex, 1cm",Q4138,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,122.49,,,,,,,fee schedule,122.49,656.48, "Biodfence dryflex, 1cm",Q4138,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,122.49,,,,,,,fee schedule,122.49,656.48, Biodfence 1cm,Q4140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,201.1,656.48, Biodfence 1cm,Q4140,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,201.1,,,,,,,fee schedule,201.1,656.48, Biodfence 1cm,Q4140,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,201.1,,,,,,,fee schedule,201.1,656.48, "Alloskin ac, 1 cm",Q4141,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,79,656.48, "Alloskin ac, 1 cm",Q4141,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,79,,,,,,,fee schedule,79,656.48, "Alloskin ac, 1 cm",Q4141,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,79,,,,,,,fee schedule,79,656.48, Xcm biologic tiss matrix 1cm,Q4142,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, "Repriza, 1cm",Q4143,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,41.38,656.48, "Repriza, 1cm",Q4143,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,41.38,,,,,,,fee schedule,41.38,656.48, "Repriza, 1cm",Q4143,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,41.38,,,,,,,fee schedule,41.38,656.48, "Epifix, inj, 1mg",Q4145,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23.77,,,,,,,fee schedule,23.77,23.77, "Epifix, inj, 1mg",Q4145,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,23.77,,,,,,,fee schedule,23.77,23.77, "Tensix, 1cm",Q4146,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, Architect ecm px fx 1 sq cm,Q4147,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,1923.06, Architect ecm px fx 1 sq cm,Q4147,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1923.06,,,,,,,fee schedule,656.48,1923.06, Architect ecm px fx 1 sq cm,Q4147,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1923.06,,,,,,,fee schedule,656.48,1923.06, "Neox 1k, 1cm",Q4148,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,153.79,656.48, "Neox 1k, 1cm",Q4148,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,153.79,,,,,,,fee schedule,153.79,656.48, "Neox 1k, 1cm",Q4148,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,153.79,,,,,,,fee schedule,153.79,656.48, "Excellagen, 0.1 cc",Q4149,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,212.28,,,,,,,fee schedule,212.28,212.28, "Excellagen, 0.1 cc",Q4149,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,212.28,,,,,,,fee schedule,212.28,212.28, Allowrap ds or dry 1 sq cm,Q4150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,103.53,656.48, Allowrap ds or dry 1 sq cm,Q4150,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,103.53,,,,,,,fee schedule,103.53,656.48, Allowrap ds or dry 1 sq cm,Q4150,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,103.53,,,,,,,fee schedule,103.53,656.48, "Amnioband, guardian 1 sq cm",Q4151,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,167.37,656.48, "Amnioband, guardian 1 sq cm",Q4151,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,167.37,,,,,,,fee schedule,167.37,656.48, "Amnioband, guardian 1 sq cm",Q4151,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,167.37,,,,,,,fee schedule,167.37,656.48, Dermapure 1 square cm,Q4152,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,55.4,656.48, Dermapure 1 square cm,Q4152,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,55.4,,,,,,,fee schedule,55.4,656.48, Dermapure 1 square cm,Q4152,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,55.4,,,,,,,fee schedule,55.4,656.48, "Dermavest, plurivest sq cm",Q4153,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,132.49,656.48, "Dermavest, plurivest sq cm",Q4153,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,132.49,,,,,,,fee schedule,132.49,656.48, "Dermavest, plurivest sq cm",Q4153,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,132.49,,,,,,,fee schedule,132.49,656.48, Biovance 1 square cm,Q4154,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,174.29,656.48, Biovance 1 square cm,Q4154,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,174.29,,,,,,,fee schedule,174.29,656.48, Biovance 1 square cm,Q4154,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,174.29,,,,,,,fee schedule,174.29,656.48, Neoxflo or clarixflo 1 mg,Q4155,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,33.32,,,,,,,fee schedule,33.32,33.32, Neoxflo or clarixflo 1 mg,Q4155,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,33.32,,,,,,,fee schedule,33.32,33.32, Neox 100 1 square cm,Q4156,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,80.95,656.48, Neox 100 1 square cm,Q4156,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,80.95,,,,,,,fee schedule,80.95,656.48, Neox 100 1 square cm,Q4156,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,80.95,,,,,,,fee schedule,80.95,656.48, Revitalon 1 square cm,Q4157,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,247.54,656.48, Revitalon 1 square cm,Q4157,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,247.54,,,,,,,fee schedule,247.54,656.48, Revitalon 1 square cm,Q4157,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,247.54,,,,,,,fee schedule,247.54,656.48, Marigen 1 square cm,Q4158,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,80.91,656.48, Marigen 1 square cm,Q4158,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,80.91,,,,,,,fee schedule,80.91,656.48, Marigen 1 square cm,Q4158,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,80.91,,,,,,,fee schedule,80.91,656.48, Affinity1 square cm,Q4159,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,286.91,656.48, Affinity1 square cm,Q4159,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,286.91,,,,,,,fee schedule,286.91,656.48, Affinity1 square cm,Q4159,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,286.91,,,,,,,fee schedule,286.91,656.48, Nushield 1 square cm,Q4160,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,646.6,656.48, Nushield 1 square cm,Q4160,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,646.6,,,,,,,fee schedule,646.6,656.48, Nushield 1 square cm,Q4160,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,646.6,,,,,,,fee schedule,646.6,656.48, Bio-connekt per square cm,Q4161,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,2017.66, Bio-connekt per square cm,Q4161,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2017.66,,,,,,,fee schedule,656.48,2017.66, Bio-connekt per square cm,Q4161,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2017.66,,,,,,,fee schedule,656.48,2017.66, Amnio bio and woundex flow,Q4162,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3131.34,,,,,,,fee schedule,3131.34,3131.34, Amnio bio and woundex flow,Q4162,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3131.34,,,,,,,fee schedule,3131.34,3131.34, Amnio bio and woundex sq cm,Q4163,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,222.26,656.48, Amnio bio and woundex sq cm,Q4163,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,222.26,,,,,,,fee schedule,222.26,656.48, Amnio bio and woundex sq cm,Q4163,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,222.26,,,,,,,fee schedule,222.26,656.48, "Helicoll, per square cm",Q4164,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,2001.93, "Helicoll, per square cm",Q4164,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2001.93,,,,,,,fee schedule,656.48,2001.93, "Helicoll, per square cm",Q4164,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2001.93,,,,,,,fee schedule,656.48,2001.93, "Keramatrix, per square cm",Q4165,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,5124.34, "Keramatrix, per square cm",Q4165,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5124.34,,,,,,,fee schedule,656.48,5124.34, "Keramatrix, per square cm",Q4165,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5124.34,,,,,,,fee schedule,656.48,5124.34, "Cytal, per square centimeter",Q4166,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,25.44,656.48, "Cytal, per square centimeter",Q4166,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25.44,,,,,,,fee schedule,25.44,656.48, "Cytal, per square centimeter",Q4166,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,25.44,,,,,,,fee schedule,25.44,656.48, "Truskin, per sq centimeter",Q4167,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,147.64,656.48, "Truskin, per sq centimeter",Q4167,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,147.64,,,,,,,fee schedule,147.64,656.48, "Truskin, per sq centimeter",Q4167,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,147.64,,,,,,,fee schedule,147.64,656.48, "Artacent wound, per sq cm",Q4169,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,2709.1, "Artacent wound, per sq cm",Q4169,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2709.1,,,,,,,fee schedule,656.48,2709.1, "Artacent wound, per sq cm",Q4169,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2709.1,,,,,,,fee schedule,656.48,2709.1, "Cygnus, per sq cm",Q4170,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,50.69,656.48, "Cygnus, per sq cm",Q4170,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,50.69,,,,,,,fee schedule,50.69,656.48, "Cygnus, per sq cm",Q4170,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,50.69,,,,,,,fee schedule,50.69,656.48, "Interfyl, 1 mg",Q4171,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.94,,,,,,,fee schedule,12.94,12.94, "Interfyl, 1 mg",Q4171,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,12.94,,,,,,,fee schedule,12.94,12.94, Palingen or palingen xplus,Q4173,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,434.99,656.48, Palingen or palingen xplus,Q4173,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,434.99,,,,,,,fee schedule,434.99,656.48, Palingen or palingen xplus,Q4173,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,434.99,,,,,,,fee schedule,434.99,656.48, Palingen or promatrx,Q4174,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1758.63,,,,,,,fee schedule,1758.63,1758.63, Palingen or promatrx,Q4174,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1758.63,,,,,,,fee schedule,1758.63,1758.63, Miroderm,Q4175,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,82.62,656.48, Miroderm,Q4175,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,82.62,,,,,,,fee schedule,82.62,656.48, Miroderm,Q4175,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,82.62,,,,,,,fee schedule,82.62,656.48, "Neopatch, per sq centimeter",Q4176,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,216.67,656.48, "Neopatch, per sq centimeter",Q4176,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,216.67,,,,,,,fee schedule,216.67,656.48, "Neopatch, per sq centimeter",Q4176,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,216.67,,,,,,,fee schedule,216.67,656.48, "Floweramnioflo, 0.1 cc",Q4177,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,219.6,,,,,,,fee schedule,219.6,219.6, "Floweramnioflo, 0.1 cc",Q4177,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,219.6,,,,,,,fee schedule,219.6,219.6, "Floweramniopatch, per sq cm",Q4178,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,113.59,656.48, "Floweramniopatch, per sq cm",Q4178,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,113.59,,,,,,,fee schedule,113.59,656.48, "Floweramniopatch, per sq cm",Q4178,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,113.59,,,,,,,fee schedule,113.59,656.48, "Flowerderm, per sq cm",Q4179,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, "Revita, per sq cm",Q4180,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,1329.89, "Revita, per sq cm",Q4180,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1329.89,,,,,,,fee schedule,656.48,1329.89, "Revita, per sq cm",Q4180,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1329.89,,,,,,,fee schedule,656.48,1329.89, "Amnio wound, per square cm",Q4181,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,243.46,656.48, "Amnio wound, per square cm",Q4181,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,243.46,,,,,,,fee schedule,243.46,656.48, "Amnio wound, per square cm",Q4181,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,243.46,,,,,,,fee schedule,243.46,656.48, "Transcyte, per sq centimeter",Q4182,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, "Surgigraft, 1 sq cm",Q4183,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,196.32,656.48, "Surgigraft, 1 sq cm",Q4183,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,196.32,,,,,,,fee schedule,196.32,656.48, "Surgigraft, 1 sq cm",Q4183,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,196.32,,,,,,,fee schedule,196.32,656.48, "Cellesta, 1 sq cm",Q4184,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,97.65,656.48, "Cellesta, 1 sq cm",Q4184,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,97.65,,,,,,,fee schedule,97.65,656.48, "Cellesta, 1 sq cm",Q4184,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,97.65,,,,,,,fee schedule,97.65,656.48, Epifix 1 sq cm,Q4186,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,183.4,656.48, Epifix 1 sq cm,Q4186,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,183.4,,,,,,,fee schedule,183.4,656.48, Epifix 1 sq cm,Q4186,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,183.4,,,,,,,fee schedule,183.4,656.48, Epicord 1 sq cm,Q4187,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,295.08,656.48, Epicord 1 sq cm,Q4187,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,295.08,,,,,,,fee schedule,295.08,656.48, Epicord 1 sq cm,Q4187,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,295.08,,,,,,,fee schedule,295.08,656.48, Amnioarmor 1 sq cm,Q4188,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,594.86,656.48, Amnioarmor 1 sq cm,Q4188,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,594.86,,,,,,,fee schedule,594.86,656.48, Amnioarmor 1 sq cm,Q4188,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,594.86,,,,,,,fee schedule,594.86,656.48, Artacent ac 1 sq cm,Q4190,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,157.89,656.48, Artacent ac 1 sq cm,Q4190,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,157.89,,,,,,,fee schedule,157.89,656.48, Artacent ac 1 sq cm,Q4190,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,157.89,,,,,,,fee schedule,157.89,656.48, Restorigin 1 sq cm,Q4191,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,891.12, Restorigin 1 sq cm,Q4191,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,891.12,,,,,,,fee schedule,656.48,891.12, Restorigin 1 sq cm,Q4191,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,891.12,,,,,,,fee schedule,656.48,891.12, Coll-e-derm 1 sq cm,Q4193,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,2090.08, Coll-e-derm 1 sq cm,Q4193,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2090.08,,,,,,,fee schedule,656.48,2090.08, Coll-e-derm 1 sq cm,Q4193,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2090.08,,,,,,,fee schedule,656.48,2090.08, Novachor 1 sq cm,Q4194,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,875.69, Novachor 1 sq cm,Q4194,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,875.69,,,,,,,fee schedule,656.48,875.69, Novachor 1 sq cm,Q4194,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,875.69,,,,,,,fee schedule,656.48,875.69, Puraply 1 sq cm,Q4195,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,131.66,656.48, Puraply 1 sq cm,Q4195,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,131.66,,,,,,,fee schedule,131.66,656.48, Puraply 1 sq cm,Q4195,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,131.66,,,,,,,fee schedule,131.66,656.48, Puraply am 1 sq cm,Q4196,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,120.22,656.48, Puraply am 1 sq cm,Q4196,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,120.22,,,,,,,fee schedule,120.22,656.48, Puraply am 1 sq cm,Q4196,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,120.22,,,,,,,fee schedule,120.22,656.48, Puraply xt 1 sq cm,Q4197,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,86.67,656.48, Puraply xt 1 sq cm,Q4197,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,86.67,,,,,,,fee schedule,86.67,656.48, Puraply xt 1 sq cm,Q4197,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,86.67,,,,,,,fee schedule,86.67,656.48, Genesis amnio membrane 1sqcm,Q4198,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, "Cygnus matrix, per sq cm",Q4199,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,158.92,656.48, "Cygnus matrix, per sq cm",Q4199,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,158.92,,,,,,,fee schedule,158.92,656.48, "Cygnus matrix, per sq cm",Q4199,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,158.92,,,,,,,fee schedule,158.92,656.48, Skin te 1 sq cm,Q4200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, Matrion 1 sq cm,Q4201,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,96.66,656.48, Matrion 1 sq cm,Q4201,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,96.66,,,,,,,fee schedule,96.66,656.48, Matrion 1 sq cm,Q4201,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,96.66,,,,,,,fee schedule,96.66,656.48, "Derma-gide, 1 sq cm",Q4203,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,1063.07, "Derma-gide, 1 sq cm",Q4203,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1063.07,,,,,,,fee schedule,656.48,1063.07, "Derma-gide, 1 sq cm",Q4203,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1063.07,,,,,,,fee schedule,656.48,1063.07, Xwrap 1 sq cm,Q4204,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,4605.22, Xwrap 1 sq cm,Q4204,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4605.22,,,,,,,fee schedule,656.48,4605.22, Xwrap 1 sq cm,Q4204,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4605.22,,,,,,,fee schedule,656.48,4605.22, Membrane graft or wrap sq cm,Q4205,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,1452.34, Membrane graft or wrap sq cm,Q4205,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1452.34,,,,,,,fee schedule,656.48,1452.34, Membrane graft or wrap sq cm,Q4205,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1452.34,,,,,,,fee schedule,656.48,1452.34, Novafix per sq cm,Q4208,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, Surgraft per sq cm,Q4209,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, Amnion bio or axobio sq cm,Q4211,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, "Ascent, 0.5 mg",Q4213,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,84.16,,,,,,,fee schedule,84.16,84.16, "Ascent, 0.5 mg",Q4213,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,84.16,,,,,,,fee schedule,84.16,84.16, Cellesta cord per sq cm,Q4214,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, Artacent cord per sq cm,Q4216,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, Woundfix biowound plus xplus,Q4217,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,387.96,656.48, Woundfix biowound plus xplus,Q4217,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,387.96,,,,,,,fee schedule,387.96,656.48, Woundfix biowound plus xplus,Q4217,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,387.96,,,,,,,fee schedule,387.96,656.48, Surgicord per sq cm,Q4218,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, Surgigraft dual per sq cm,Q4219,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,962.57, Surgigraft dual per sq cm,Q4219,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,962.57,,,,,,,fee schedule,656.48,962.57, Surgigraft dual per sq cm,Q4219,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,962.57,,,,,,,fee schedule,656.48,962.57, "Bellacell HD, Surederm sq cm",Q4220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, Amniowrap2 per sq cm,Q4221,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,2392.42, Amniowrap2 per sq cm,Q4221,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2392.42,,,,,,,fee schedule,656.48,2392.42, Amniowrap2 per sq cm,Q4221,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2392.42,,,,,,,fee schedule,656.48,2392.42, "Progenamatrix, per sq cm",Q4222,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,155.61,656.48, "Progenamatrix, per sq cm",Q4222,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,155.61,,,,,,,fee schedule,155.61,656.48, "Progenamatrix, per sq cm",Q4222,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,155.61,,,,,,,fee schedule,155.61,656.48, Hhf10-p per sq cm,Q4224,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, "Amniobind, per sq cm",Q4225,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,1672.29, "Amniobind, per sq cm",Q4225,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1672.29,,,,,,,fee schedule,656.48,1672.29, "Amniobind, per sq cm",Q4225,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1672.29,,,,,,,fee schedule,656.48,1672.29, Amniocore per sq cm,Q4227,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,1421.78, Amniocore per sq cm,Q4227,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1421.78,,,,,,,fee schedule,656.48,1421.78, Amniocore per sq cm,Q4227,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1421.78,,,,,,,fee schedule,656.48,1421.78, Cogenex amnio memb per sq cm,Q4229,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,402.98,656.48, Cogenex amnio memb per sq cm,Q4229,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,402.98,,,,,,,fee schedule,402.98,656.48, Cogenex amnio memb per sq cm,Q4229,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,402.98,,,,,,,fee schedule,402.98,656.48, "Corplex, per sq cm",Q4232,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,158.73,656.48, "Corplex, per sq cm",Q4232,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,158.73,,,,,,,fee schedule,158.73,656.48, "Corplex, per sq cm",Q4232,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,158.73,,,,,,,fee schedule,158.73,656.48, "Xcellerate, per sq cm",Q4234,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,237.69,656.48, "Xcellerate, per sq cm",Q4234,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,237.69,,,,,,,fee schedule,237.69,656.48, "Xcellerate, per sq cm",Q4234,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,237.69,,,,,,,fee schedule,237.69,656.48, Amniorepair or altiply sq cm,Q4235,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,98.19,656.48, Amniorepair or altiply sq cm,Q4235,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,98.19,,,,,,,fee schedule,98.19,656.48, Amniorepair or altiply sq cm,Q4235,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,98.19,,,,,,,fee schedule,98.19,656.48, Carepatch per sq cm,Q4236,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,590.05,656.48, Carepatch per sq cm,Q4236,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,590.05,,,,,,,fee schedule,590.05,656.48, Carepatch per sq cm,Q4236,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,590.05,,,,,,,fee schedule,590.05,656.48, "cryo-cord, per sq cm",Q4237,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,609.29,656.48, "cryo-cord, per sq cm",Q4237,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,609.29,,,,,,,fee schedule,609.29,656.48, "cryo-cord, per sq cm",Q4237,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,609.29,,,,,,,fee schedule,609.29,656.48, "Derm-maxx, per sq cm",Q4238,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,2104.55, "Derm-maxx, per sq cm",Q4238,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2104.55,,,,,,,fee schedule,656.48,2104.55, "Derm-maxx, per sq cm",Q4238,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2104.55,,,,,,,fee schedule,656.48,2104.55, Amnio-maxx or lite per sq cm,Q4239,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,2486.97, Amnio-maxx or lite per sq cm,Q4239,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2486.97,,,,,,,fee schedule,656.48,2486.97, Amnio-maxx or lite per sq cm,Q4239,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2486.97,,,,,,,fee schedule,656.48,2486.97, "Coretext or protext, per cc",Q4246,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3928.4,,,,,,,fee schedule,3928.4,3928.4, "Coretext or protext, per cc",Q4246,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3928.4,,,,,,,fee schedule,3928.4,3928.4, "Amniotext patch, per sq cm",Q4247,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,4486.25, "Amniotext patch, per sq cm",Q4247,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4486.25,,,,,,,fee schedule,656.48,4486.25, "Amniotext patch, per sq cm",Q4247,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4486.25,,,,,,,fee schedule,656.48,4486.25, Dermacyte Amn mem allo sq cm,Q4248,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,3445.89, Dermacyte Amn mem allo sq cm,Q4248,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3445.89,,,,,,,fee schedule,656.48,3445.89, Dermacyte Amn mem allo sq cm,Q4248,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3445.89,,,,,,,fee schedule,656.48,3445.89, "Amniply, per sq cm",Q4249,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,2183.25, "Amniply, per sq cm",Q4249,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2183.25,,,,,,,fee schedule,656.48,2183.25, "Amniply, per sq cm",Q4249,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2183.25,,,,,,,fee schedule,656.48,2183.25, AmnioAMP-MP per sq cm,Q4250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,3540.03, AmnioAMP-MP per sq cm,Q4250,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3540.03,,,,,,,fee schedule,656.48,3540.03, AmnioAMP-MP per sq cm,Q4250,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3540.03,,,,,,,fee schedule,656.48,3540.03, "Vim, per square centimeter",Q4251,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,219.6,656.48, "Vim, per square centimeter",Q4251,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,219.6,,,,,,,fee schedule,219.6,656.48, "Vim, per square centimeter",Q4251,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,219.6,,,,,,,fee schedule,219.6,656.48, "Vendaje, per square centimet",Q4252,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,64.66,656.48, "Vendaje, per square centimet",Q4252,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,64.66,,,,,,,fee schedule,64.66,656.48, "Vendaje, per square centimet",Q4252,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,64.66,,,,,,,fee schedule,64.66,656.48, Zenith amniotic membrane psc,Q4253,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,101.48,656.48, Zenith amniotic membrane psc,Q4253,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,101.48,,,,,,,fee schedule,101.48,656.48, Zenith amniotic membrane psc,Q4253,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,101.48,,,,,,,fee schedule,101.48,656.48, Novafix dl per sq cm,Q4254,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, "Reguard, topical use per sq",Q4255,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, "Mlg complet, per sq cm",Q4256,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,992.12, "Mlg complet, per sq cm",Q4256,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,992.12,,,,,,,fee schedule,656.48,992.12, "Mlg complet, per sq cm",Q4256,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,992.12,,,,,,,fee schedule,656.48,992.12, "Relese, per sq cm",Q4257,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,796.25, "Relese, per sq cm",Q4257,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,796.25,,,,,,,fee schedule,656.48,796.25, "Relese, per sq cm",Q4257,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,796.25,,,,,,,fee schedule,656.48,796.25, "Enverse, per sq cm",Q4258,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,100.54,656.48, "Enverse, per sq cm",Q4258,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,100.54,,,,,,,fee schedule,100.54,656.48, "Enverse, per sq cm",Q4258,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,100.54,,,,,,,fee schedule,100.54,656.48, Celera per sq cm,Q4259,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,1148.58, Celera per sq cm,Q4259,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1148.58,,,,,,,fee schedule,656.48,1148.58, Celera per sq cm,Q4259,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1148.58,,,,,,,fee schedule,656.48,1148.58, "Signature apatch, per sq cm",Q4260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, "Tag, per square centimeter",Q4261,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,883.55, "Tag, per square centimeter",Q4261,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,883.55,,,,,,,fee schedule,656.48,883.55, "Tag, per square centimeter",Q4261,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,883.55,,,,,,,fee schedule,656.48,883.55, "Dual layer impax, per sq cm",Q4262,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,76.68,656.48, "Dual layer impax, per sq cm",Q4262,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,76.68,,,,,,,fee schedule,76.68,656.48, "Dual layer impax, per sq cm",Q4262,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,76.68,,,,,,,fee schedule,76.68,656.48, "Surgraft tl, per sq cm",Q4263,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,2089.86, "Surgraft tl, per sq cm",Q4263,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2089.86,,,,,,,fee schedule,656.48,2089.86, "Surgraft tl, per sq cm",Q4263,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2089.86,,,,,,,fee schedule,656.48,2089.86, "Cocoon membrane, per sq cm",Q4264,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,454.93,656.48, "Cocoon membrane, per sq cm",Q4264,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,454.93,,,,,,,fee schedule,454.93,656.48, "Cocoon membrane, per sq cm",Q4264,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,454.93,,,,,,,fee schedule,454.93,656.48, Neostim tl per sq cm,Q4265,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,2078.92, Neostim tl per sq cm,Q4265,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2078.92,,,,,,,fee schedule,656.48,2078.92, Neostim tl per sq cm,Q4265,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2078.92,,,,,,,fee schedule,656.48,2078.92, Neostim per sq cm,Q4266,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,683.9, Neostim per sq cm,Q4266,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,683.9,,,,,,,fee schedule,656.48,683.9, Neostim per sq cm,Q4266,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,683.9,,,,,,,fee schedule,656.48,683.9, Neostim dl per sq cm,Q4267,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,353.82,656.48, Neostim dl per sq cm,Q4267,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,353.82,,,,,,,fee schedule,353.82,656.48, Neostim dl per sq cm,Q4267,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,353.82,,,,,,,fee schedule,353.82,656.48, Surgraft ft per sq cm,Q4268,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,1458, Surgraft ft per sq cm,Q4268,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1458,,,,,,,fee schedule,656.48,1458, Surgraft ft per sq cm,Q4268,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1458,,,,,,,fee schedule,656.48,1458, Surgraft xt per sq cm,Q4269,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,2359.61, Surgraft xt per sq cm,Q4269,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2359.61,,,,,,,fee schedule,656.48,2359.61, Surgraft xt per sq cm,Q4269,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2359.61,,,,,,,fee schedule,656.48,2359.61, Complete sl per sq cm,Q4270,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,4112.38, Complete sl per sq cm,Q4270,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4112.38,,,,,,,fee schedule,656.48,4112.38, Complete sl per sq cm,Q4270,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4112.38,,,,,,,fee schedule,656.48,4112.38, Complete ft per sq cm,Q4271,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,1476.79, Complete ft per sq cm,Q4271,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1476.79,,,,,,,fee schedule,656.48,1476.79, Complete ft per sq cm,Q4271,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1476.79,,,,,,,fee schedule,656.48,1476.79, "Esano a, per sq cm",Q4272,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,427.12,656.48, "Esano a, per sq cm",Q4272,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,427.12,,,,,,,fee schedule,427.12,656.48, "Esano a, per sq cm",Q4272,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,427.12,,,,,,,fee schedule,427.12,656.48, "Esano aaa, per sq cm",Q4273,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, "Esano ac, per sq cm",Q4274,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,2235.43, "Esano ac, per sq cm",Q4274,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2235.43,,,,,,,fee schedule,656.48,2235.43, "Esano ac, per sq cm",Q4274,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2235.43,,,,,,,fee schedule,656.48,2235.43, "Esano aca, per sq cm",Q4275,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,3264.09, "Esano aca, per sq cm",Q4275,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3264.09,,,,,,,fee schedule,656.48,3264.09, "Esano aca, per sq cm",Q4275,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3264.09,,,,,,,fee schedule,656.48,3264.09, "Orion, per sq cm",Q4276,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,318.74,656.48, "Orion, per sq cm",Q4276,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,318.74,,,,,,,fee schedule,318.74,656.48, "Orion, per sq cm",Q4276,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,318.74,,,,,,,fee schedule,318.74,656.48, "Epieffect, per sq cm",Q4278,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,323.43,656.48, "Epieffect, per sq cm",Q4278,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,323.43,,,,,,,fee schedule,323.43,656.48, "Epieffect, per sq cm",Q4278,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,323.43,,,,,,,fee schedule,323.43,656.48, "Vendaje ac, per sq cm",Q4279,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,2909.7, "Vendaje ac, per sq cm",Q4279,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2909.7,,,,,,,fee schedule,656.48,2909.7, "Vendaje ac, per sq cm",Q4279,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2909.7,,,,,,,fee schedule,656.48,2909.7, Xcell amnio matrix per sq cm,Q4280,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,3529.28, Xcell amnio matrix per sq cm,Q4280,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3529.28,,,,,,,fee schedule,656.48,3529.28, Xcell amnio matrix per sq cm,Q4280,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3529.28,,,,,,,fee schedule,656.48,3529.28, Barrera slor dl per sq cm,Q4281,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,663.74, Barrera slor dl per sq cm,Q4281,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,663.74,,,,,,,fee schedule,656.48,663.74, Barrera slor dl per sq cm,Q4281,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,663.74,,,,,,,fee schedule,656.48,663.74, Cygnus dual per sq cm,Q4282,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,410.85,656.48, Cygnus dual per sq cm,Q4282,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,410.85,,,,,,,fee schedule,410.85,656.48, Cygnus dual per sq cm,Q4282,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,410.85,,,,,,,fee schedule,410.85,656.48, "Biovance tri or 3l, sq cm",Q4283,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,557.93,656.48, "Biovance tri or 3l, sq cm",Q4283,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,557.93,,,,,,,fee schedule,557.93,656.48, "Biovance tri or 3l, sq cm",Q4283,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,557.93,,,,,,,fee schedule,557.93,656.48, "Dermabind sl, per sq cm",Q4284,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, Nudyn dl or dl mesh pr sq cm,Q4285,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,234.55,656.48, Nudyn dl or dl mesh pr sq cm,Q4285,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,234.55,,,,,,,fee schedule,234.55,656.48, Nudyn dl or dl mesh pr sq cm,Q4285,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,234.55,,,,,,,fee schedule,234.55,656.48, "Nudyn sl or slw, per sq cm",Q4286,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,309.15,656.48, "Nudyn sl or slw, per sq cm",Q4286,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,309.15,,,,,,,fee schedule,309.15,656.48, "Nudyn sl or slw, per sq cm",Q4286,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,309.15,,,,,,,fee schedule,309.15,656.48, "Dermabind dl, per sq cm",Q4287,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, "Dermabind ch, per sq cm",Q4288,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, "Revoshield+ amnio, per sq cm",Q4289,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,1791.09, "Revoshield+ amnio, per sq cm",Q4289,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1791.09,,,,,,,fee schedule,656.48,1791.09, "Revoshield+ amnio, per sq cm",Q4289,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1791.09,,,,,,,fee schedule,656.48,1791.09, Membrane wrap hydr per sq cm,Q4290,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,2274.95, Membrane wrap hydr per sq cm,Q4290,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2274.95,,,,,,,fee schedule,656.48,2274.95, Membrane wrap hydr per sq cm,Q4290,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2274.95,,,,,,,fee schedule,656.48,2274.95, "Lamellas xt, per sq cm",Q4291,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,4254.09, "Lamellas xt, per sq cm",Q4291,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4254.09,,,,,,,fee schedule,656.48,4254.09, "Lamellas xt, per sq cm",Q4291,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4254.09,,,,,,,fee schedule,656.48,4254.09, "Lamellas, per sq cm",Q4292,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,1757.72, "Lamellas, per sq cm",Q4292,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1757.72,,,,,,,fee schedule,656.48,1757.72, "Lamellas, per sq cm",Q4292,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1757.72,,,,,,,fee schedule,656.48,1757.72, "Acesso dl, per sq cm",Q4293,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,1933.33, "Acesso dl, per sq cm",Q4293,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1933.33,,,,,,,fee schedule,656.48,1933.33, "Acesso dl, per sq cm",Q4293,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1933.33,,,,,,,fee schedule,656.48,1933.33, "Amnio quad-core, per sq cm",Q4294,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,3556.3, "Amnio quad-core, per sq cm",Q4294,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3556.3,,,,,,,fee schedule,656.48,3556.3, "Amnio quad-core, per sq cm",Q4294,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3556.3,,,,,,,fee schedule,656.48,3556.3, "Amnio tri-core, per sq cm",Q4295,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,3129.54, "Amnio tri-core, per sq cm",Q4295,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3129.54,,,,,,,fee schedule,656.48,3129.54, "Amnio tri-core, per sq cm",Q4295,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3129.54,,,,,,,fee schedule,656.48,3129.54, "Rebound matrix, per sq cm",Q4296,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,1775.27, "Rebound matrix, per sq cm",Q4296,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1775.27,,,,,,,fee schedule,656.48,1775.27, "Rebound matrix, per sq cm",Q4296,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1775.27,,,,,,,fee schedule,656.48,1775.27, "Emerge matrix, per sq cm",Q4297,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,2070.77, "Emerge matrix, per sq cm",Q4297,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2070.77,,,,,,,fee schedule,656.48,2070.77, "Emerge matrix, per sq cm",Q4297,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2070.77,,,,,,,fee schedule,656.48,2070.77, "Amnicore pro, per sq cm",Q4298,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,2712.27, "Amnicore pro, per sq cm",Q4298,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2712.27,,,,,,,fee schedule,656.48,2712.27, "Amnicore pro, per sq cm",Q4298,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2712.27,,,,,,,fee schedule,656.48,2712.27, "Amnicore pro+, per sq cm",Q4299,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,3485.17, "Amnicore pro+, per sq cm",Q4299,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3485.17,,,,,,,fee schedule,656.48,3485.17, "Amnicore pro+, per sq cm",Q4299,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3485.17,,,,,,,fee schedule,656.48,3485.17, "Acesso tl, per sq cm",Q4300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,2579.93, "Acesso tl, per sq cm",Q4300,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2579.93,,,,,,,fee schedule,656.48,2579.93, "Acesso tl, per sq cm",Q4300,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2579.93,,,,,,,fee schedule,656.48,2579.93, "Activate matrix, per sq cm",Q4301,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,2203.73, "Activate matrix, per sq cm",Q4301,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2203.73,,,,,,,fee schedule,656.48,2203.73, "Activate matrix, per sq cm",Q4301,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2203.73,,,,,,,fee schedule,656.48,2203.73, "Complete aca, per sq cm",Q4302,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,1551.35, "Complete aca, per sq cm",Q4302,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1551.35,,,,,,,fee schedule,656.48,1551.35, "Complete aca, per sq cm",Q4302,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1551.35,,,,,,,fee schedule,656.48,1551.35, "Complete aa, per sq cm",Q4303,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,4108.96, "Complete aa, per sq cm",Q4303,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4108.96,,,,,,,fee schedule,656.48,4108.96, "Complete aa, per sq cm",Q4303,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4108.96,,,,,,,fee schedule,656.48,4108.96, "Grafix plus, per sq cm",Q4304,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,748.69, "Grafix plus, per sq cm",Q4304,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,748.69,,,,,,,fee schedule,656.48,748.69, "Grafix plus, per sq cm",Q4304,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,748.69,,,,,,,fee schedule,656.48,748.69, Amer am ac tri-lay per sq cm,Q4305,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, Americ amnion ac per sq cm,Q4306,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, "American amnion, per sq cm",Q4307,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, "Sanopellis, per sq cm",Q4308,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, "Via matrix, per sq cm",Q4309,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,1596.43, "Via matrix, per sq cm",Q4309,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1596.43,,,,,,,fee schedule,656.48,1596.43, "Via matrix, per sq cm",Q4309,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1596.43,,,,,,,fee schedule,656.48,1596.43, "Procenta, per 100 mg",Q4310,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1607.18,,,,,,,fee schedule,1607.18,1607.18, "Procenta, per 100 mg",Q4310,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1607.18,,,,,,,fee schedule,1607.18,1607.18, "Acesso, per sq cm",Q4311,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,3047.56, "Acesso, per sq cm",Q4311,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3047.56,,,,,,,fee schedule,656.48,3047.56, "Acesso, per sq cm",Q4311,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3047.56,,,,,,,fee schedule,656.48,3047.56, "Acesso ac, per sq cm",Q4312,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,3169.46, "Acesso ac, per sq cm",Q4312,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3169.46,,,,,,,fee schedule,656.48,3169.46, "Acesso ac, per sq cm",Q4312,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3169.46,,,,,,,fee schedule,656.48,3169.46, "Dermabind fm, per sq cm",Q4313,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,4295.24, "Dermabind fm, per sq cm",Q4313,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4295.24,,,,,,,fee schedule,656.48,4295.24, "Dermabind fm, per sq cm",Q4313,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4295.24,,,,,,,fee schedule,656.48,4295.24, "Reeva, per sq cm",Q4314,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,2680.69, "Reeva, per sq cm",Q4314,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2680.69,,,,,,,fee schedule,656.48,2680.69, "Reeva, per sq cm",Q4314,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2680.69,,,,,,,fee schedule,656.48,2680.69, Regenelink amniotic mem allo,Q4315,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, "Amchoplast, per sq cm",Q4316,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,5387.48, "Amchoplast, per sq cm",Q4316,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5387.48,,,,,,,fee schedule,656.48,5387.48, "Amchoplast, per sq cm",Q4316,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5387.48,,,,,,,fee schedule,656.48,5387.48, "Vitograft, per sq cm",Q4317,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,6581.91, "Vitograft, per sq cm",Q4317,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6581.91,,,,,,,fee schedule,656.48,6581.91, "Vitograft, per sq cm",Q4317,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,6581.91,,,,,,,fee schedule,656.48,6581.91, "E-graft, per sq cm",Q4318,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,2437.97, "E-graft, per sq cm",Q4318,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2437.97,,,,,,,fee schedule,656.48,2437.97, "E-graft, per sq cm",Q4318,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2437.97,,,,,,,fee schedule,656.48,2437.97, "Sanograft, per sq cm",Q4319,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,3885.48, "Sanograft, per sq cm",Q4319,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3885.48,,,,,,,fee schedule,656.48,3885.48, "Sanograft, per sq cm",Q4319,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3885.48,,,,,,,fee schedule,656.48,3885.48, "Pellograft, per sq cm",Q4320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,401.33,656.48, "Pellograft, per sq cm",Q4320,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,401.33,,,,,,,fee schedule,401.33,656.48, "Pellograft, per sq cm",Q4320,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,401.33,,,,,,,fee schedule,401.33,656.48, "Renograft, per sq cm",Q4321,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,5272.35, "Renograft, per sq cm",Q4321,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5272.35,,,,,,,fee schedule,656.48,5272.35, "Renograft, per sq cm",Q4321,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5272.35,,,,,,,fee schedule,656.48,5272.35, "Caregraft, per sq cm",Q4322,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,2185.37, "Caregraft, per sq cm",Q4322,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2185.37,,,,,,,fee schedule,656.48,2185.37, "Caregraft, per sq cm",Q4322,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2185.37,,,,,,,fee schedule,656.48,2185.37, "Alloply, per sq cm",Q4323,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,1920.94, "Alloply, per sq cm",Q4323,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1920.94,,,,,,,fee schedule,656.48,1920.94, "Alloply, per sq cm",Q4323,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1920.94,,,,,,,fee schedule,656.48,1920.94, "Amniotx, per sq cm",Q4324,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,2366.34, "Amniotx, per sq cm",Q4324,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2366.34,,,,,,,fee schedule,656.48,2366.34, "Amniotx, per sq cm",Q4324,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2366.34,,,,,,,fee schedule,656.48,2366.34, "Acapatch, per sq cm",Q4325,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,2495.95, "Acapatch, per sq cm",Q4325,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2495.95,,,,,,,fee schedule,656.48,2495.95, "Acapatch, per sq cm",Q4325,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2495.95,,,,,,,fee schedule,656.48,2495.95, "Woundplus, per sq cm",Q4326,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,1321.2, "Woundplus, per sq cm",Q4326,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1321.2,,,,,,,fee schedule,656.48,1321.2, "Woundplus, per sq cm",Q4326,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1321.2,,,,,,,fee schedule,656.48,1321.2, "Duoamnion, per sq cm",Q4327,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, "Most, per sq cm",Q4328,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,4481.44, "Most, per sq cm",Q4328,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4481.44,,,,,,,fee schedule,656.48,4481.44, "Most, per sq cm",Q4328,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4481.44,,,,,,,fee schedule,656.48,4481.44, "Singlay, per sq cm",Q4329,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, "Total, per sq cm",Q4330,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, "Axolotl graft, per sq cm",Q4331,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,1997.81, "Axolotl graft, per sq cm",Q4331,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1997.81,,,,,,,fee schedule,656.48,1997.81, "Axolotl graft, per sq cm",Q4331,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1997.81,,,,,,,fee schedule,656.48,1997.81, "Axolotl dualgraft, per sq cm",Q4332,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,2053.83, "Axolotl dualgraft, per sq cm",Q4332,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2053.83,,,,,,,fee schedule,656.48,2053.83, "Axolotl dualgraft, per sq cm",Q4332,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2053.83,,,,,,,fee schedule,656.48,2053.83, "Ardeograft, per sq cm",Q4333,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,1044.83, "Ardeograft, per sq cm",Q4333,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1044.83,,,,,,,fee schedule,656.48,1044.83, "Ardeograft, per sq cm",Q4333,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1044.83,,,,,,,fee schedule,656.48,1044.83, "Amnioplast 1, per sq cm",Q4334,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, "Amnioplast 2, per sq cm",Q4335,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, "Artecent c, per sq cm",Q4336,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, "Artecent trident, per sq cm",Q4337,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, "Artacent velos, per sq cm",Q4338,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, "Artacent vericlen, per sq cm",Q4339,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,2507.51, "Artacent vericlen, per sq cm",Q4339,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2507.51,,,,,,,fee schedule,656.48,2507.51, "Artacent vericlen, per sq cm",Q4339,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2507.51,,,,,,,fee schedule,656.48,2507.51, "Simpligraft, per sq cm",Q4340,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,3149.49, "Simpligraft, per sq cm",Q4340,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3149.49,,,,,,,fee schedule,656.48,3149.49, "Simpligraft, per sq cm",Q4340,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3149.49,,,,,,,fee schedule,656.48,3149.49, "Simplimax, per sq cm",Q4341,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,3746.96, "Simplimax, per sq cm",Q4341,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3746.96,,,,,,,fee schedule,656.48,3746.96, "Simplimax, per sq cm",Q4341,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3746.96,,,,,,,fee schedule,656.48,3746.96, "Theramend, per sq cm",Q4342,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,2595.07, "Theramend, per sq cm",Q4342,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2595.07,,,,,,,fee schedule,656.48,2595.07, "Theramend, per sq cm",Q4342,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2595.07,,,,,,,fee schedule,656.48,2595.07, Dermacyte ac matrx per sq cm,Q4343,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,3601.56, Dermacyte ac matrx per sq cm,Q4343,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3601.56,,,,,,,fee schedule,656.48,3601.56, Dermacyte ac matrx per sq cm,Q4343,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3601.56,,,,,,,fee schedule,656.48,3601.56, "Tri membrane wrap, per sq cm",Q4344,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,3281.17, "Tri membrane wrap, per sq cm",Q4344,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3281.17,,,,,,,fee schedule,656.48,3281.17, "Tri membrane wrap, per sq cm",Q4344,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3281.17,,,,,,,fee schedule,656.48,3281.17, Matrix hd allogrft per sq cm,Q4345,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,3660.98, Matrix hd allogrft per sq cm,Q4345,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3660.98,,,,,,,fee schedule,656.48,3660.98, Matrix hd allogrft per sq cm,Q4345,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3660.98,,,,,,,fee schedule,656.48,3660.98, Shelter dm matrix per sq cm,Q4346,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,5128.4, Shelter dm matrix per sq cm,Q4346,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5128.4,,,,,,,fee schedule,656.48,5128.4, Shelter dm matrix per sq cm,Q4346,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5128.4,,,,,,,fee schedule,656.48,5128.4, Rampart dl matrix per sq cm,Q4347,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,3609.61, Rampart dl matrix per sq cm,Q4347,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3609.61,,,,,,,fee schedule,656.48,3609.61, Rampart dl matrix per sq cm,Q4347,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3609.61,,,,,,,fee schedule,656.48,3609.61, Sentry sl matrix per sq cm,Q4348,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,2857.25, Sentry sl matrix per sq cm,Q4348,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2857.25,,,,,,,fee schedule,656.48,2857.25, Sentry sl matrix per sq cm,Q4348,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2857.25,,,,,,,fee schedule,656.48,2857.25, Mantle dl matrix per sq cm,Q4349,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,5128.4, Mantle dl matrix per sq cm,Q4349,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5128.4,,,,,,,fee schedule,656.48,5128.4, Mantle dl matrix per sq cm,Q4349,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5128.4,,,,,,,fee schedule,656.48,5128.4, Palisade dm matrix per sq cm,Q4350,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,5128.4, Palisade dm matrix per sq cm,Q4350,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5128.4,,,,,,,fee schedule,656.48,5128.4, Palisade dm matrix per sq cm,Q4350,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5128.4,,,,,,,fee schedule,656.48,5128.4, "Enclose tl matrix, per sq cm",Q4351,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,5494.72, "Enclose tl matrix, per sq cm",Q4351,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5494.72,,,,,,,fee schedule,656.48,5494.72, "Enclose tl matrix, per sq cm",Q4351,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5494.72,,,,,,,fee schedule,656.48,5494.72, "Overlay sl matrix, per sq cm",Q4352,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,2857.25, "Overlay sl matrix, per sq cm",Q4352,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2857.25,,,,,,,fee schedule,656.48,2857.25, "Overlay sl matrix, per sq cm",Q4352,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2857.25,,,,,,,fee schedule,656.48,2857.25, Xceed tl matrix per sq cm,Q4353,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,5567.98, Xceed tl matrix per sq cm,Q4353,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5567.98,,,,,,,fee schedule,656.48,5567.98, Xceed tl matrix per sq cm,Q4353,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5567.98,,,,,,,fee schedule,656.48,5567.98, Palingen dual-layer sq cm,Q4354,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,1494.15, Palingen dual-layer sq cm,Q4354,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1494.15,,,,,,,fee schedule,656.48,1494.15, Palingen dual-layer sq cm,Q4354,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1494.15,,,,,,,fee schedule,656.48,1494.15, Abio xpl abio xpl hy p sq cm,Q4355,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,4397.16, Abio xpl abio xpl hy p sq cm,Q4355,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4397.16,,,,,,,fee schedule,656.48,4397.16, Abio xpl abio xpl hy p sq cm,Q4355,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4397.16,,,,,,,fee schedule,656.48,4397.16, Abio mem abio hyd per sq cm,Q4356,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,3664.31, Abio mem abio hyd per sq cm,Q4356,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3664.31,,,,,,,fee schedule,656.48,3664.31, Abio mem abio hyd per sq cm,Q4356,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3664.31,,,,,,,fee schedule,656.48,3664.31, "Xwrap plus, per sq cm",Q4357,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,5819.4, "Xwrap plus, per sq cm",Q4357,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5819.4,,,,,,,fee schedule,656.48,5819.4, "Xwrap plus, per sq cm",Q4357,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5819.4,,,,,,,fee schedule,656.48,5819.4, "Xwrap dual, per sq cm",Q4358,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,8348.8, "Xwrap dual, per sq cm",Q4358,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8348.8,,,,,,,fee schedule,656.48,8348.8, "Xwrap dual, per sq cm",Q4358,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,8348.8,,,,,,,fee schedule,656.48,8348.8, "Choriply, per sq cm",Q4359,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,3842.21, "Choriply, per sq cm",Q4359,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3842.21,,,,,,,fee schedule,656.48,3842.21, "Choriply, per sq cm",Q4359,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3842.21,,,,,,,fee schedule,656.48,3842.21, Amchoplast fd per sq cm,Q4360,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,3488, Amchoplast fd per sq cm,Q4360,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3488,,,,,,,fee schedule,656.48,3488, Amchoplast fd per sq cm,Q4360,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3488,,,,,,,fee schedule,656.48,3488, "Epixpress, per sq cm",Q4361,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,1939.8, "Epixpress, per sq cm",Q4361,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1939.8,,,,,,,fee schedule,656.48,1939.8, "Epixpress, per sq cm",Q4361,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1939.8,,,,,,,fee schedule,656.48,1939.8, "Cygnus disk, per sq cm",Q4362,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,803.63, "Cygnus disk, per sq cm",Q4362,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,803.63,,,,,,,fee schedule,656.48,803.63, "Cygnus disk, per sq cm",Q4362,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,803.63,,,,,,,fee schedule,656.48,803.63, Am bur mem hydro per sq cm,Q4363,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, Am bur xp mem xpl hy p sq cm,Q4364,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,5080.51, Am bur xp mem xpl hy p sq cm,Q4364,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5080.51,,,,,,,fee schedule,656.48,5080.51, Am bur xp mem xpl hy p sq cm,Q4364,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5080.51,,,,,,,fee schedule,656.48,5080.51, Amnio bur dl mem per sq cm,Q4365,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, Dl amnio bur x-mem per sq cm,Q4366,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, "Amniocore sl, per sq cm",Q4367,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,646.6,656.48, "Amniocore sl, per sq cm",Q4367,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,646.6,,,,,,,fee schedule,646.6,656.48, "Amniocore sl, per sq cm",Q4367,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,646.6,,,,,,,fee schedule,646.6,656.48, Amchothick per sq cm,Q4368,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,5696.29, Amchothick per sq cm,Q4368,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5696.29,,,,,,,fee schedule,656.48,5696.29, Amchothick per sq cm,Q4368,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5696.29,,,,,,,fee schedule,656.48,5696.29, Amnioplast 3 per sq cm,Q4369,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, Aeroguard per sq cm,Q4370,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, Neoguard per sq cm,Q4371,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, Amchoplast excl per sq cm,Q4372,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, Membrane wrp lt per sq cm,Q4373,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,5257.44, Membrane wrp lt per sq cm,Q4373,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5257.44,,,,,,,fee schedule,656.48,5257.44, Membrane wrp lt per sq cm,Q4373,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5257.44,,,,,,,fee schedule,656.48,5257.44, Duograft ac per sq cm,Q4375,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, Duograft aa per sq cm,Q4376,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, Trigraft ft per sq cm,Q4377,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, Renew ft matrix per sq cm,Q4378,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,5641.24, Renew ft matrix per sq cm,Q4378,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5641.24,,,,,,,fee schedule,656.48,5641.24, Renew ft matrix per sq cm,Q4378,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5641.24,,,,,,,fee schedule,656.48,5641.24, Amniodefend ft per sq cm,Q4379,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,4177.35, Amniodefend ft per sq cm,Q4379,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4177.35,,,,,,,fee schedule,656.48,4177.35, Amniodefend ft per sq cm,Q4379,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,4177.35,,,,,,,fee schedule,656.48,4177.35, Advograft one per sq cm,Q4380,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, Advograft dual per sq cm,Q4382,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, Axolotl graft ult per sq cm,Q4383,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, Axolotl dual ult per sq cm,Q4384,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, Apollo ft per sq cm,Q4385,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, Acesso trifaca per sq cm,Q4386,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, Neothelium ft per sq cm,Q4387,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, Neothelium 4l per sq cm,Q4388,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, Neothelium 4l+ per sq cm,Q4389,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, Ascendion per sq cm,Q4390,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, Amnioplast double per sq cm,Q4391,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, Grafix duo per sq cm,Q4392,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, Surgraft ac per sq cm,Q4393,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, Surgraft aca per sq cm,Q4394,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, Acelagraft per sq cm,Q4395,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, Natalin per sq cm,Q4396,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, Summit aaa per sq cm,Q4397,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, Summit ac per sq cm,Q4398,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, Summit fx per sq cm,Q4399,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, Polygon3 per sq cm,Q4400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, Absolv3 per sq cm,Q4401,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, Xwrap 2.0 per sq cm,Q4402,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, Xwrap dual plus per sq cm,Q4403,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, Xwrap hydro plus per sq cm,Q4404,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, Xwrap fenestra plus sq cm,Q4405,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, Xwrap fenestra per sq cm,Q4406,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, Xwrap tribus per sq cm,Q4407,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, Xwrap hydro per sq cm,Q4408,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, Amniomatrixf3x per sq cm,Q4409,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, Amchomatrixdl per sq cm,Q4410,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, Amniomatrixf4x per sq cm,Q4411,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, Choriofix per sq cm,Q4412,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, Cygnus solo per sq cm,Q4413,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, Simplichor per sq cm,Q4414,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, Alexiguard st-l per sq cm,Q4415,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, Alexiguard tl-t per sq cm,Q4416,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, Alexiguard dl-t per sq cm,Q4417,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, Nuform per sq cm,Q4420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,656.48,,,,,,,fee schedule,656.48,656.48, "Inj ustekinumab-srlf, 1 mg",Q5098,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,77.14,,,,,,,fee schedule,77.14,77.14, "Inj ustekinumab-srlf, 1 mg",Q5098,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,77.14,,,,,,,fee schedule,77.14,77.14, "Inj ustekinumab-stba, 1 mg",Q5099,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2.94,,,,,,,fee schedule,2.94,2.94, "Inj ustekinumab-stba, 1 mg",Q5099,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2.94,,,,,,,fee schedule,2.94,2.94, "Inj ustekinumab-kfce, 1 mg",Q5100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3.87,,,,,,,fee schedule,3.87,3.87, "Inj ustekinumab-kfce, 1 mg",Q5100,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,3.87,,,,,,,fee schedule,3.87,3.87, Inj filgrastim gcsf biosimil,Q5101,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.83,,,,,,,fee schedule,0.45,0.9, Inj filgrastim gcsf biosimil,Q5101,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.9,,,,,,,fee schedule,0.45,0.9, Inj filgrastim gcsf biosimil,Q5101,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.45,,,,,,,fee schedule,0.45,0.9, Inj filgrastim gcsf biosimil,Q5101,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.45,,,,,,,fee schedule,0.45,0.9, "Injection, inflectra",Q5103,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,44.28,,,,,,,fee schedule,24.01,47.82, "Injection, inflectra",Q5103,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,47.82,,,,,,,fee schedule,24.01,47.82, "Injection, inflectra",Q5103,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24.01,,,,,,,fee schedule,24.01,47.82, "Injection, inflectra",Q5103,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,24.01,,,,,,,fee schedule,24.01,47.82, "Injection, renflexis",Q5104,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,56.36,,,,,,,fee schedule,30.56,60.87, "Injection, renflexis",Q5104,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,60.87,,,,,,,fee schedule,30.56,60.87, "Injection, renflexis",Q5104,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,30.56,,,,,,,fee schedule,30.56,60.87, "Injection, renflexis",Q5104,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,30.56,,,,,,,fee schedule,30.56,60.87, Inj Retacrit esrd on dialysi,Q5105,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,1.71,,,,,,,fee schedule,0.93,1.85, Inj Retacrit esrd on dialysi,Q5105,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,1.85,,,,,,,fee schedule,0.93,1.85, Inj Retacrit esrd on dialysi,Q5105,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.93,,,,,,,fee schedule,0.93,1.85, Inj Retacrit esrd on dialysi,Q5105,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.93,,,,,,,fee schedule,0.93,1.85, Inj Retacrit non-esrd use,Q5106,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,17.03,,,,,,,fee schedule,9.24,18.4, Inj Retacrit non-esrd use,Q5106,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,18.4,,,,,,,fee schedule,9.24,18.4, Inj Retacrit non-esrd use,Q5106,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.24,,,,,,,fee schedule,9.24,18.4, Inj Retacrit non-esrd use,Q5106,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9.24,,,,,,,fee schedule,9.24,18.4, Inj mvasi 10 mg,Q5107,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,64.91,,,,,,,fee schedule,35.2,70.11, Inj mvasi 10 mg,Q5107,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,70.11,,,,,,,fee schedule,35.2,70.11, Inj mvasi 10 mg,Q5107,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,35.2,,,,,,,fee schedule,35.2,70.11, Inj mvasi 10 mg,Q5107,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,35.2,,,,,,,fee schedule,35.2,70.11, "Injection, fulphila",Q5108,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,233.33,,,,,,,fee schedule,126.53,251.99, "Injection, fulphila",Q5108,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,251.99,,,,,,,fee schedule,126.53,251.99, "Injection, fulphila",Q5108,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,126.53,,,,,,,fee schedule,126.53,251.99, "Injection, fulphila",Q5108,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,126.53,,,,,,,fee schedule,126.53,251.99, Nivestym,Q5110,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.65,,,,,,,fee schedule,0.35,0.7, Nivestym,Q5110,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,0.7,,,,,,,fee schedule,0.35,0.7, Nivestym,Q5110,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.35,,,,,,,fee schedule,0.35,0.7, Nivestym,Q5110,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.35,,,,,,,fee schedule,0.35,0.7, "Injection, udenyca 0.5 mg",Q5111,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,306.09,,,,,,,fee schedule,165.97,330.58, "Injection, udenyca 0.5 mg",Q5111,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,330.58,,,,,,,fee schedule,165.97,330.58, "Injection, udenyca 0.5 mg",Q5111,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,165.97,,,,,,,fee schedule,165.97,330.58, "Injection, udenyca 0.5 mg",Q5111,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,165.97,,,,,,,fee schedule,165.97,330.58, Inj ontruzant 10 mg,Q5112,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,49.46,,,,,,,fee schedule,26.83,53.41, Inj ontruzant 10 mg,Q5112,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,53.41,,,,,,,fee schedule,26.83,53.41, Inj ontruzant 10 mg,Q5112,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26.83,,,,,,,fee schedule,26.83,53.41, Inj ontruzant 10 mg,Q5112,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,26.83,,,,,,,fee schedule,26.83,53.41, Inj herzuma 10 mg,Q5113,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,174.35,,,,,,,fee schedule,94.54,188.3, Inj herzuma 10 mg,Q5113,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,188.3,,,,,,,fee schedule,94.54,188.3, Inj herzuma 10 mg,Q5113,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,94.54,,,,,,,fee schedule,94.54,188.3, Inj herzuma 10 mg,Q5113,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,94.54,,,,,,,fee schedule,94.54,188.3, Inj ogivri 10 mg,Q5114,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,100.33,,,,,,,fee schedule,54.4,108.35, Inj ogivri 10 mg,Q5114,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,108.35,,,,,,,fee schedule,54.4,108.35, Inj ogivri 10 mg,Q5114,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,54.4,,,,,,,fee schedule,54.4,108.35, Inj ogivri 10 mg,Q5114,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,54.4,,,,,,,fee schedule,54.4,108.35, Inj truxima 10 mg,Q5115,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,70.16,,,,,,,fee schedule,38.04,75.77, Inj truxima 10 mg,Q5115,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,75.77,,,,,,,fee schedule,38.04,75.77, Inj truxima 10 mg,Q5115,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,38.04,,,,,,,fee schedule,38.04,75.77, Inj truxima 10 mg,Q5115,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,38.04,,,,,,,fee schedule,38.04,75.77, "Inj., trazimera, 10 mg",Q5116,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,64.4,,,,,,,fee schedule,34.92,69.55, "Inj., trazimera, 10 mg",Q5116,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,69.55,,,,,,,fee schedule,34.92,69.55, "Inj., trazimera, 10 mg",Q5116,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,34.92,,,,,,,fee schedule,34.92,69.55, "Inj., trazimera, 10 mg",Q5116,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,34.92,,,,,,,fee schedule,34.92,69.55, "Inj., kanjinti, 10 mg",Q5117,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,97.38,,,,,,,fee schedule,52.8,105.17, "Inj., kanjinti, 10 mg",Q5117,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,105.17,,,,,,,fee schedule,52.8,105.17, "Inj., kanjinti, 10 mg",Q5117,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,52.8,,,,,,,fee schedule,52.8,105.17, "Inj., kanjinti, 10 mg",Q5117,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,52.8,,,,,,,fee schedule,52.8,105.17, "Inj., zirabev, 10 mg",Q5118,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,53.84,,,,,,,fee schedule,29.19,58.15, "Inj., zirabev, 10 mg",Q5118,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,58.15,,,,,,,fee schedule,29.19,58.15, "Inj., zirabev, 10 mg",Q5118,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,29.19,,,,,,,fee schedule,29.19,58.15, "Inj., zirabev, 10 mg",Q5118,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,29.19,,,,,,,fee schedule,29.19,58.15, "Inj ruxience, 10 mg",Q5119,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,59.63,,,,,,,fee schedule,32.33,64.4, "Inj ruxience, 10 mg",Q5119,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,64.4,,,,,,,fee schedule,32.33,64.4, "Inj ruxience, 10 mg",Q5119,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,32.33,,,,,,,fee schedule,32.33,64.4, "Inj ruxience, 10 mg",Q5119,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,32.33,,,,,,,fee schedule,32.33,64.4, Inj pegfilgrastim-bmez 0.5mg,Q5120,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,62.98,,,,,,,fee schedule,34.15,68.02, Inj pegfilgrastim-bmez 0.5mg,Q5120,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,68.02,,,,,,,fee schedule,34.15,68.02, Inj pegfilgrastim-bmez 0.5mg,Q5120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,34.15,,,,,,,fee schedule,34.15,68.02, Inj pegfilgrastim-bmez 0.5mg,Q5120,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,34.15,,,,,,,fee schedule,34.15,68.02, "Inj. avsola, 10 mg",Q5121,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,47,,,,,,,fee schedule,25.49,50.76, "Inj. avsola, 10 mg",Q5121,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,50.76,,,,,,,fee schedule,25.49,50.76, "Inj. avsola, 10 mg",Q5121,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25.49,,,,,,,fee schedule,25.49,50.76, "Inj. avsola, 10 mg",Q5121,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,25.49,,,,,,,fee schedule,25.49,50.76, "Inj, nyvepria",Q5122,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,297.09,,,,,,,fee schedule,161.09,320.86, "Inj, nyvepria",Q5122,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,320.86,,,,,,,fee schedule,161.09,320.86, "Inj, nyvepria",Q5122,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,161.09,,,,,,,fee schedule,161.09,320.86, "Inj, nyvepria",Q5122,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,161.09,,,,,,,fee schedule,161.09,320.86, "Inj. riabni, 10 mg",Q5123,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,67.32,,,,,,,fee schedule,36.5,72.71, "Inj. riabni, 10 mg",Q5123,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,72.71,,,,,,,fee schedule,36.5,72.71, "Inj. riabni, 10 mg",Q5123,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,36.5,,,,,,,fee schedule,36.5,72.71, "Inj. riabni, 10 mg",Q5123,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,36.5,,,,,,,fee schedule,36.5,72.71, "Inj. byooviz, 0.1 mg",Q5124,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,139.84,,,,,,,fee schedule,75.82,151.02, "Inj. byooviz, 0.1 mg",Q5124,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,151.02,,,,,,,fee schedule,75.82,151.02, "Inj. byooviz, 0.1 mg",Q5124,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,75.82,,,,,,,fee schedule,75.82,151.02, "Inj. byooviz, 0.1 mg",Q5124,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,75.82,,,,,,,fee schedule,75.82,151.02, "Inj, releuko 1 mcg",Q5125,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,0.92,,,,,,,fee schedule,0.5,1, "Inj, releuko 1 mcg",Q5125,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,1,,,,,,,fee schedule,0.5,1, "Inj, releuko 1 mcg",Q5125,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.5,,,,,,,fee schedule,0.5,1, "Inj, releuko 1 mcg",Q5125,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.5,,,,,,,fee schedule,0.5,1, Inj alymsys 10 mg,Q5126,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,95.85,,,,,,,fee schedule,51.97,103.52, Inj alymsys 10 mg,Q5126,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,103.52,,,,,,,fee schedule,51.97,103.52, Inj alymsys 10 mg,Q5126,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,51.97,,,,,,,fee schedule,51.97,103.52, Inj alymsys 10 mg,Q5126,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,51.97,,,,,,,fee schedule,51.97,103.52, "Inj, stimufend, 0.5 mg",Q5127,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,515.5,,,,,,,fee schedule,279.51,556.74, "Inj, stimufend, 0.5 mg",Q5127,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,556.74,,,,,,,fee schedule,279.51,556.74, "Inj, stimufend, 0.5 mg",Q5127,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,279.51,,,,,,,fee schedule,279.51,556.74, "Inj, stimufend, 0.5 mg",Q5127,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,279.51,,,,,,,fee schedule,279.51,556.74, "Inj, cimerli, 0.1 mg",Q5128,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,194.65,,,,,,,fee schedule,105.54,210.22, "Inj, cimerli, 0.1 mg",Q5128,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,210.22,,,,,,,fee schedule,105.54,210.22, "Inj, cimerli, 0.1 mg",Q5128,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,105.54,,,,,,,fee schedule,105.54,210.22, "Inj, cimerli, 0.1 mg",Q5128,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,105.54,,,,,,,fee schedule,105.54,210.22, "Inj, vegzelma, 10 mg",Q5129,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,98.15,,,,,,,fee schedule,53.22,106, "Inj, vegzelma, 10 mg",Q5129,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,106,,,,,,,fee schedule,53.22,106, "Inj, vegzelma, 10 mg",Q5129,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,53.22,,,,,,,fee schedule,53.22,106, "Inj, vegzelma, 10 mg",Q5129,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,53.22,,,,,,,fee schedule,53.22,106, "Inj, fylnetra, 0.5 mg",Q5130,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,335.72,,,,,,,fee schedule,182.04,362.58, "Inj, fylnetra, 0.5 mg",Q5130,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,362.58,,,,,,,fee schedule,182.04,362.58, "Inj, fylnetra, 0.5 mg",Q5130,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,182.04,,,,,,,fee schedule,182.04,362.58, "Inj, fylnetra, 0.5 mg",Q5130,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,182.04,,,,,,,fee schedule,182.04,362.58, "Inj, tofidence, 1 mg",Q5133,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,13.03,,,,,,,fee schedule,7.06,14.07, "Inj, tofidence, 1 mg",Q5133,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,14.07,,,,,,,fee schedule,7.06,14.07, "Inj, tofidence, 1 mg",Q5133,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.06,,,,,,,fee schedule,7.06,14.07, "Inj, tofidence, 1 mg",Q5133,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,7.06,,,,,,,fee schedule,7.06,14.07, "Inj, tyenne, 1 mg",Q5135,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,10.55,,,,,,,fee schedule,5.72,11.4, "Inj, tyenne, 1 mg",Q5135,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,11.4,,,,,,,fee schedule,5.72,11.4, "Inj, tyenne, 1 mg",Q5135,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.72,,,,,,,fee schedule,5.72,11.4, "Inj, tyenne, 1 mg",Q5135,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5.72,,,,,,,fee schedule,5.72,11.4, "Inj. denosumab-bbdz, 1 mg",Q5136,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,33.6,,,,,,,fee schedule,33.6,33.6, "Inj. denosumab-bbdz, 1 mg",Q5136,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,33.6,,,,,,,fee schedule,33.6,33.6, "Inj, wezlana, sub cu, 1 mg",Q5137,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,269.22,,,,,,,fee schedule,269.22,269.22, "Inj, wezlana, sub cu, 1 mg",Q5137,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,269.22,,,,,,,fee schedule,269.22,269.22, "Inj, wezlana, iv, 1 mg",Q5138,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.96,,,,,,,fee schedule,15.96,15.96, "Inj, wezlana, iv, 1 mg",Q5138,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,15.96,,,,,,,fee schedule,15.96,15.96, "Inj adalimumab-fkjp, 1 mg",Q5140,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,106.31,,,,,,,fee schedule,106.31,106.31, "Inj adalimumab-fkjp, 1 mg",Q5140,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,106.31,,,,,,,fee schedule,106.31,106.31, "Inj adalimumab-aaty, 1 mg",Q5141,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,53.16,,,,,,,fee schedule,53.16,53.16, "Inj adalimumab-aaty, 1 mg",Q5141,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,53.16,,,,,,,fee schedule,53.16,53.16, "Inj adalimumab-ryvk, 1 mg",Q5142,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.98,,,,,,,fee schedule,12.98,12.98, "Inj adalimumab-ryvk, 1 mg",Q5142,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,12.98,,,,,,,fee schedule,12.98,12.98, "Inj adalimumab-adbm, 1 mg",Q5143,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.72,,,,,,,fee schedule,12.72,12.72, "Inj adalimumab-adbm, 1 mg",Q5143,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,12.72,,,,,,,fee schedule,12.72,12.72, "Inj, idacio, 1 mg",Q5144,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.88,,,,,,,fee schedule,10.88,10.88, "Inj, idacio, 1 mg",Q5144,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,10.88,,,,,,,fee schedule,10.88,10.88, "Inj, abrilada, 1 mg",Q5145,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,32.49,,,,,,,fee schedule,32.49,32.49, "Inj, abrilada, 1 mg",Q5145,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,32.49,,,,,,,fee schedule,32.49,32.49, "Inj, hercessi, 10 mg",Q5146,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,171.41,,,,,,,fee schedule,92.94,185.12, "Inj, hercessi, 10 mg",Q5146,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,185.12,,,,,,,fee schedule,92.94,185.12, "Inj, hercessi, 10 mg",Q5146,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,92.94,,,,,,,fee schedule,92.94,185.12, "Inj, hercessi, 10 mg",Q5146,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,92.94,,,,,,,fee schedule,92.94,185.12, "Inj, aflibercept-ayyh, 1 mg",Q5147,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,1955.43,,,,,,,fee schedule,1060.28,2111.86, "Inj, aflibercept-ayyh, 1 mg",Q5147,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,2111.86,,,,,,,fee schedule,1060.28,2111.86, "Inj, aflibercept-ayyh, 1 mg",Q5147,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1060.28,,,,,,,fee schedule,1060.28,2111.86, "Inj, aflibercept-ayyh, 1 mg",Q5147,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1060.28,,,,,,,fee schedule,1060.28,2111.86, "Inj, nyposi 1 mcg",Q5148,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.67,,,,,,,fee schedule,0.67,0.67, "Inj, nyposi 1 mcg",Q5148,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.67,,,,,,,fee schedule,0.67,0.67, "Inj, eculizumab-aagh, 2 mg",Q5151,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,38.25,,,,,,,fee schedule,38.25,38.25, "Inj, eculizumab-aagh, 2 mg",Q5151,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,38.25,,,,,,,fee schedule,38.25,38.25, "Inj, eculizumab-aeeb, 2 mg?",Q5152,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,50.62,,,,,,,fee schedule,50.62,50.62, "Inj, eculizumab-aeeb, 2 mg?",Q5152,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,50.62,,,,,,,fee schedule,50.62,50.62, Inj sulf hexa lipid microsph,Q9950,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22.68,,,,,,,fee schedule,22.68,22.68, Inj sulf hexa lipid microsph,Q9950,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22.68,,,,,,,fee schedule,22.68,22.68, "Inj octafluoropropane mic,ml",Q9956,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,50.26,,,,,,,fee schedule,50.26,50.26, "Inj octafluoropropane mic,ml",Q9956,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,50.26,,,,,,,fee schedule,50.26,50.26, "Inj perflutren lip micros,ml",Q9957,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,50.26,,,,,,,fee schedule,50.26,50.26, "Inj perflutren lip micros,ml",Q9957,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,50.26,,,,,,,fee schedule,50.26,50.26, "HOCM <=149 mg/ml iodine, 1ml",Q9958,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.09,,,,,,,fee schedule,0.09,0.09, "HOCM <=149 mg/ml iodine, 1ml",Q9958,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.09,,,,,,,fee schedule,0.09,0.09, "HOCM 250-299mg/ml iodine,1ml",Q9961,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.35,,,,,,,fee schedule,0.35,0.35, "HOCM 250-299mg/ml iodine,1ml",Q9961,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.35,,,,,,,fee schedule,0.35,0.35, "HOCM 350-399mg/ml iodine,1ml",Q9963,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.27,,,,,,,fee schedule,0.27,0.27, "HOCM 350-399mg/ml iodine,1ml",Q9963,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.27,,,,,,,fee schedule,0.27,0.27, "LOCM 100-199mg/ml iodine,1ml",Q9965,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2.2,,,,,,,fee schedule,2.2,2.2, "LOCM 100-199mg/ml iodine,1ml",Q9965,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2.2,,,,,,,fee schedule,2.2,2.2, "LOCM 200-299mg/ml iodine,1ml",Q9966,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.55,,,,,,,fee schedule,0.55,0.55, "LOCM 200-299mg/ml iodine,1ml",Q9966,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.55,,,,,,,fee schedule,0.55,0.55, "LOCM 300-399mg/ml iodine,1ml",Q9967,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.18,,,,,,,fee schedule,0.18,0.18, "LOCM 300-399mg/ml iodine,1ml",Q9967,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,0.18,,,,,,,fee schedule,0.18,0.18, Visualization adjunct,Q9968,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.59,,,,,,,fee schedule,9.59,9.59, Visualization adjunct,Q9968,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,9.59,,,,,,,fee schedule,9.59,9.59, Non-HEU TC-99M add-on/dose,Q9969,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.2,,,,,,,fee schedule,12.2,12.2, Non-HEU TC-99M add-on/dose,Q9969,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,12.2,,,,,,,fee schedule,12.2,12.2, flutemetamol f18 diagnostic,Q9982,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2277.23,,,,,,,fee schedule,2277.23,2277.23, flutemetamol f18 diagnostic,Q9982,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2277.23,,,,,,,fee schedule,2277.23,2277.23, florbetaben f18 diagnostic,Q9983,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1553.99,,,,,,,fee schedule,1553.99,1553.99, florbetaben f18 diagnostic,Q9983,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1553.99,,,,,,,fee schedule,1553.99,1553.99, Buprenorph xr 100 mg or less,Q9991,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,4447.24,,,,,,,fee schedule,2411.39,4803.02, Buprenorph xr 100 mg or less,Q9991,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,4803.02,,,,,,,fee schedule,2411.39,4803.02, Buprenorph xr 100 mg or less,Q9991,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2411.39,,,,,,,fee schedule,2411.39,4803.02, Buprenorph xr 100 mg or less,Q9991,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2411.39,,,,,,,fee schedule,2411.39,4803.02, Buprenorphine xr over 100 mg,Q9992,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,4447.24,,,,,,,fee schedule,2411.39,4803.02, Buprenorphine xr over 100 mg,Q9992,HCPCS,,,,,facility,outpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,4803.02,,,,,,,fee schedule,2411.39,4803.02, Buprenorphine xr over 100 mg,Q9992,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2411.39,,,,,,,fee schedule,2411.39,4803.02, Buprenorphine xr over 100 mg,Q9992,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,2411.39,,,,,,,fee schedule,2411.39,4803.02, Ustekinumab-aekn inj,Q9998,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,58.32,,,,,,,fee schedule,58.32,58.32, Ustekinumab-aekn inj,Q9998,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,58.32,,,,,,,fee schedule,58.32,58.32, Inj ustekinumab-aauz 1 mg,Q9999,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,45.54,,,,,,,fee schedule,45.54,45.54, Inj ustekinumab-aauz 1 mg,Q9999,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,45.54,,,,,,,fee schedule,45.54,45.54, Screening protoscopy,S0601,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Laser in situ keratomileusis (LASIK),S0800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Photorefractive keratectomy (PRK),S0810,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Phototherapeutic keratectomy (PTK),S0812,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, "transplant sm. Intest, liver, allograft",S2053,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Transplant multivisceral organs,S2054,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, "harvesting organs, cadaver donor",S2055,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Lobar lung transplantation,S2060,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, "Donor lobectomy, live donor",S2061,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Sim Panc/renal transplant,S2065,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, "Breast reconstruct, GAP",S2066,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, "Breast reconstruct, stacked DEIP or GAP",S2067,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, "Breast reconstruct, DEIP",S2068,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Cystoerethroscopy,S2070,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Heller esophagomyotomy,S2079,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, LAUP,S2080,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, "gastric band adjustment, percutaneous",S2083,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,3195,,,,,,,fee schedule,3195,3195, "percut occlusion tumor dest, yttrium-90",S2095,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,5248, "Iselt cell transplant, allogeneic",S2102,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Adrenal tissue transplant to brain,S2103,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, "arthroscopy, harvest cartilage",S2112,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, "Osteotomy, peracteabular, with internal fixation",S2115,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, "Arthroereisis, subtalar",S2117,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Minimally invasive direct co,S2205,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Minimally invasive direct co,S2206,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Minimally invasive direct co,S2207,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Minimally invasive direct co,S2208,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Minimally invasive direct co,S2209,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, "Myringotomy, laser-assisted",S2225,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,5248,,,,,,,fee schedule,5248,5248, Implant semi-imp hear,S2230,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Implant auditory brain imp,S2235,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, "Arthroscopy, shoulder, surgi",S2300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, "Diskectomy, anterior, with d",S2350,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, "Diskectomy, anterior, with d",S2351,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Fetal surg congen hernia,S2400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Fetal surg urin trac obstr,S2401,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Fetal surg cong cyst malf,S2402,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Fetal surg pulmon sequest,S2403,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Fetal surg myelomeningo,S2404,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Fetal surg sacrococ teratoma,S2405,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Fetal surg noc,S2409,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, Robotic surgical system,S2900,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,6979,,,,,,,fee schedule,6979,6979, 2019 nCoV diagnostic P,U0001,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,149.86,,,,,,,fee schedule,53.88,149.86, 2019 nCoV diagnostic P,U0001,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,53.88,,,,,,,fee schedule,53.88,149.86, 2019 nCoV diagnostic P,U0001,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,53.88,,,,,,,fee schedule,53.88,149.86, COVID-19 lab test non-CDC,U0002,HCPCS,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,214.07,,,,,,,fee schedule,76.97,214.07, COVID-19 lab test non-CDC,U0002,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,76.97,,,,,,,fee schedule,76.97,214.07, COVID-19 lab test non-CDC,U0002,HCPCS,,,,,facility,outpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,76.97,,,,,,,fee schedule,76.97,214.07, Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,880342.79,,,,,,,fee schedule,763343.01,1145000.51, Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,763343.01,,,,,,,fee schedule,763343.01,1145000.51, Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,1145000.51,,,,,,,fee schedule,763343.01,1145000.51, Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,882136.32,,,,,,,fee schedule,763343.01,1145000.51, Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,793917.09,,,,,,,fee schedule,763343.01,1145000.51, Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],1533085.81,1533085.81,1533085.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],281047.46,281047.46,281047.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,355977.17,,,,,,,fee schedule,308666.9,462994.68, Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,308666.9,,,,,,,fee schedule,308666.9,462994.68, Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,462994.68,,,,,,,fee schedule,308666.9,462994.68, Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,356702.4,,,,,,,fee schedule,308666.9,462994.68, Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,321029.89,,,,,,,fee schedule,308666.9,462994.68, Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,666768.43,,,,,,,fee schedule,578153.22,867219.22, "Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,578153.22,,,,,,,fee schedule,578153.22,867219.22, "Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,867219.22,,,,,,,fee schedule,578153.22,867219.22, "Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,668126.85,,,,,,,fee schedule,578153.22,867219.22, "Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,601309.92,,,,,,,fee schedule,578153.22,867219.22, "Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],1187434.48,1187434.48,1187434.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],1939649.39,1930567.24,2395430.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],2838371.67,2472355.23,3241316.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],712930.53,712930.53,1087213.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],678018.26,152063.25,1322622.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],648442.94,170890.72,1880144.73,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],936365.6,936365.6,1115136.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,435127.88,,,,,,,fee schedule,377298.28,565940.5, "Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,377298.28,,,,,,,fee schedule,377298.28,565940.5, "Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,565940.5,,,,,,,fee schedule,377298.28,565940.5, "Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,436014.37,,,,,,,fee schedule,377298.28,565940.5, "Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,392410.16,,,,,,,fee schedule,377298.28,565940.5, "Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],503017.46,503017.46,503017.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],507533.84,507533.84,507533.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],155170.64,155170.64,155170.64,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],175774.41,175774.41,175774.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,323894.05,,,,,,,fee schedule,280847.71,421266.41, Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,280847.71,,,,,,,fee schedule,280847.71,421266.41, Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,421266.41,,,,,,,fee schedule,280847.71,421266.41, Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,324553.92,,,,,,,fee schedule,280847.71,421266.41, Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,292096.47,,,,,,,fee schedule,280847.71,421266.41, Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Liver Transplant Without Mcc,6,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,145666.72,,,,,,,fee schedule,126307.24,189458.55, Liver Transplant Without Mcc,6,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,126307.24,,,,,,,fee schedule,126307.24,189458.55, Liver Transplant Without Mcc,6,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,189458.55,,,,,,,fee schedule,126307.24,189458.55, Liver Transplant Without Mcc,6,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,145963.49,,,,,,,fee schedule,126307.24,189458.55, Liver Transplant Without Mcc,6,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,131366.21,,,,,,,fee schedule,126307.24,189458.55, Liver Transplant Without Mcc,6,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Liver Transplant Without Mcc,6,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Liver Transplant Without Mcc,6,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Liver Transplant Without Mcc,6,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Liver Transplant Without Mcc,6,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Liver Transplant Without Mcc,6,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Liver Transplant Without Mcc,6,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Liver Transplant Without Mcc,6,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Liver Transplant Without Mcc,6,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Liver Transplant Without Mcc,6,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Liver Transplant Without Mcc,6,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Liver Transplant Without Mcc,6,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Liver Transplant Without Mcc,6,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Liver Transplant Without Mcc,6,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Liver Transplant Without Mcc,6,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Liver Transplant Without Mcc,6,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Liver Transplant Without Mcc,6,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Liver Transplant Without Mcc,6,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Liver Transplant Without Mcc,6,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Liver Transplant Without Mcc,6,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Lung Transplant,7,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,406817.58,,,,,,,fee schedule,352750.5,529119.27, Lung Transplant,7,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,352750.5,,,,,,,fee schedule,352750.5,529119.27, Lung Transplant,7,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,529119.27,,,,,,,fee schedule,352750.5,529119.27, Lung Transplant,7,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,407646.4,,,,,,,fee schedule,352750.5,529119.27, Lung Transplant,7,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,366879.17,,,,,,,fee schedule,352750.5,529119.27, Lung Transplant,7,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Lung Transplant,7,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lung Transplant,7,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lung Transplant,7,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lung Transplant,7,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Lung Transplant,7,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lung Transplant,7,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lung Transplant,7,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lung Transplant,7,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lung Transplant,7,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lung Transplant,7,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lung Transplant,7,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lung Transplant,7,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lung Transplant,7,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lung Transplant,7,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lung Transplant,7,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Lung Transplant,7,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Lung Transplant,7,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Lung Transplant,7,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Lung Transplant,7,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,176062.9,,,,,,,fee schedule,152663.7,228992.75, Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,152663.7,,,,,,,fee schedule,152663.7,228992.75, Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,228992.75,,,,,,,fee schedule,152663.7,228992.75, Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,176421.6,,,,,,,fee schedule,152663.7,228992.75, Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,158778.32,,,,,,,fee schedule,152663.7,228992.75, Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Bone marrow transplant,9,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Bone marrow transplant,9,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bone marrow transplant,9,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bone marrow transplant,9,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bone marrow transplant,9,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Bone marrow transplant,9,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bone marrow transplant,9,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bone marrow transplant,9,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bone marrow transplant,9,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bone marrow transplant,9,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bone marrow transplant,9,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bone marrow transplant,9,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bone marrow transplant,9,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bone marrow transplant,9,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bone marrow transplant,9,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bone marrow transplant,9,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Bone marrow transplant,9,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Bone marrow transplant,9,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Bone marrow transplant,9,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Bone marrow transplant,9,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Pancreas Transplant,10,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,225417.44,,,,,,,fee schedule,195458.89,293184.75, Pancreas Transplant,10,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,195458.89,,,,,,,fee schedule,195458.89,293184.75, Pancreas Transplant,10,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,293184.75,,,,,,,fee schedule,195458.89,293184.75, Pancreas Transplant,10,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,225876.68,,,,,,,fee schedule,195458.89,293184.75, Pancreas Transplant,10,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,203287.58,,,,,,,fee schedule,195458.89,293184.75, Pancreas Transplant,10,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Pancreas Transplant,10,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pancreas Transplant,10,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pancreas Transplant,10,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pancreas Transplant,10,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Pancreas Transplant,10,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pancreas Transplant,10,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pancreas Transplant,10,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pancreas Transplant,10,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pancreas Transplant,10,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pancreas Transplant,10,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pancreas Transplant,10,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pancreas Transplant,10,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pancreas Transplant,10,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pancreas Transplant,10,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pancreas Transplant,10,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Pancreas Transplant,10,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Pancreas Transplant,10,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Pancreas Transplant,10,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Pancreas Transplant,10,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,171335.1,,,,,,,fee schedule,148564.23,222843.62, "Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,148564.23,,,,,,,fee schedule,148564.23,222843.62, "Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,222843.62,,,,,,,fee schedule,148564.23,222843.62, "Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,171684.16,,,,,,,fee schedule,148564.23,222843.62, "Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,154514.65,,,,,,,fee schedule,148564.23,222843.62, "Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],88245.56,88245.56,88245.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,132441.42,,,,,,,fee schedule,114839.62,172257.33, "Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,114839.62,,,,,,,fee schedule,114839.62,172257.33, "Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,172257.33,,,,,,,fee schedule,114839.62,172257.33, "Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,132711.25,,,,,,,fee schedule,114839.62,172257.33, "Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,119439.28,,,,,,,fee schedule,114839.62,172257.33, "Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,90528.87,,,,,,,fee schedule,78497.35,117744.58, "Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,78497.35,,,,,,,fee schedule,78497.35,117744.58, "Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,117744.58,,,,,,,fee schedule,78497.35,117744.58, "Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,90713.3,,,,,,,fee schedule,78497.35,117744.58, "Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,81641.39,,,,,,,fee schedule,78497.35,117744.58, "Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,377530.31,,,,,,,fee schedule,327355.58,491027.36, Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,327355.58,,,,,,,fee schedule,327355.58,491027.36, Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,491027.36,,,,,,,fee schedule,327355.58,491027.36, Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,378299.46,,,,,,,fee schedule,327355.58,491027.36, Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,340467.11,,,,,,,fee schedule,327355.58,491027.36, Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],558511.54,558511.54,558511.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],933524.58,933524.58,933524.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],245138.94,245138.94,245138.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],249115.05,249115.05,249115.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],185494.95,138345.9,387607.16,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,186275.6,,,,,,,fee schedule,161519.1,242275.68, Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,161519.1,,,,,,,fee schedule,161519.1,242275.68, Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,242275.68,,,,,,,fee schedule,161519.1,242275.68, Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,186655.1,,,,,,,fee schedule,161519.1,242275.68, Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,167988.4,,,,,,,fee schedule,161519.1,242275.68, Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],154295.71,154295.71,1784086.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],338311.1,338311.1,338311.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],197485.06,197485.06,197485.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,170650.27,,,,,,,fee schedule,147970.42,221952.91, Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,147970.42,,,,,,,fee schedule,147970.42,221952.91, Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,221952.91,,,,,,,fee schedule,147970.42,221952.91, Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,170997.94,,,,,,,fee schedule,147970.42,221952.91, Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,153897.06,,,,,,,fee schedule,147970.42,221952.91, Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,1356544.48,,,,,,,fee schedule,1176256.29,1764362.84, Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,1176256.29,,,,,,,fee schedule,1176256.29,1764362.84, Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,1764362.84,,,,,,,fee schedule,1176256.29,1764362.84, Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,1359308.18,,,,,,,fee schedule,1176256.29,1764362.84, Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,1223368.72,,,,,,,fee schedule,1176256.29,1764362.84, Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,224126.32,,,,,,,fee schedule,194339.37,291505.49, Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,194339.37,,,,,,,fee schedule,194339.37,291505.49, Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,291505.49,,,,,,,fee schedule,194339.37,291505.49, Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,224582.94,,,,,,,fee schedule,194339.37,291505.49, Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,202123.22,,,,,,,fee schedule,194339.37,291505.49, Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,247190.48,,,,,,,fee schedule,214338.24,321503.43, Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,214338.24,,,,,,,fee schedule,214338.24,321503.43, Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,321503.43,,,,,,,fee schedule,214338.24,321503.43, Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,247694.09,,,,,,,fee schedule,214338.24,321503.43, Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,222923.1,,,,,,,fee schedule,214338.24,321503.43, Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,166299.43,,,,,,,fee schedule,144197.82,216294.08, Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,144197.82,,,,,,,fee schedule,144197.82,216294.08, Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,216294.08,,,,,,,fee schedule,144197.82,216294.08, Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,166638.24,,,,,,,fee schedule,144197.82,216294.08, Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,149973.35,,,,,,,fee schedule,144197.82,216294.08, Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,99814.84,,,,,,,fee schedule,86549.2,129822.21, Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,86549.2,,,,,,,fee schedule,86549.2,129822.21, Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,129822.21,,,,,,,fee schedule,86549.2,129822.21, Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,100018.2,,,,,,,fee schedule,86549.2,129822.21, Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,90015.74,,,,,,,fee schedule,86549.2,129822.21, Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,180011.64,,,,,,,fee schedule,156087.64,234128.6, Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,156087.64,,,,,,,fee schedule,156087.64,234128.6, Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,234128.6,,,,,,,fee schedule,156087.64,234128.6, Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,180378.38,,,,,,,fee schedule,156087.64,234128.6, Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,162339.4,,,,,,,fee schedule,156087.64,234128.6, Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],145839.47,145839.47,145839.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],51542.63,51542.63,51542.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],291557.64,291557.64,291557.64,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],167381.93,167381.93,167381.93,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,116396.06,116396.06,116396.06,1 through 10,percent of total billed charges,,, Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,122888.43,,,,,,,fee schedule,106556.24,159832.41, Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,106556.24,,,,,,,fee schedule,106556.24,159832.41, Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,159832.41,,,,,,,fee schedule,106556.24,159832.41, Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,123138.79,,,,,,,fee schedule,106556.24,159832.41, Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,110824.13,,,,,,,fee schedule,106556.24,159832.41, Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,142830.03,,,,,,,fee schedule,123847.56,185769.07, Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,123847.56,,,,,,,fee schedule,123847.56,185769.07, Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,185769.07,,,,,,,fee schedule,123847.56,185769.07, Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,143121.02,,,,,,,fee schedule,123847.56,185769.07, Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,128808.01,,,,,,,fee schedule,123847.56,185769.07, Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],135743.25,135743.25,135743.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],57001.73,57001.73,57001.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],126175.66,126175.66,126175.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],103583.99,50675.53,171481.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],30135.11,30135.11,30135.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],31641.87,31641.87,31641.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],52251.58,43266.4,74247.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],857391.44,857391.44,857391.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],51620.32,30066.21,139338.25,17,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],218804.56,131212.81,406984.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,97672.41,,,,,,,fee schedule,84691.5,127035.69, Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,84691.5,,,,,,,fee schedule,84691.5,127035.69, Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,127035.69,,,,,,,fee schedule,84691.5,127035.69, Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,97871.4,,,,,,,fee schedule,84691.5,127035.69, Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,88083.64,,,,,,,fee schedule,84691.5,127035.69, Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],86356.51,52906.61,92834.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],27340.7,27340.7,27340.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],117275.9,117275.9,117275.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],76790.35,73230.17,78186.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],27393.44,23186.7,47580.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],33148.62,30714.9,87216.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],32111.04,32111.04,32111.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],29877.22,24378.79,48486.93,20,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],85292.12,63052.54,89736.27,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],17738.69,17738.69,17738.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,52758.25,52758.25,52758.25,1 through 10,percent of total billed charges,,, Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,79254.38,,,,,,,fee schedule,68721.27,103080.65, Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,68721.27,,,,,,,fee schedule,68721.27,103080.65, Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,103080.65,,,,,,,fee schedule,68721.27,103080.65, Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,79415.85,,,,,,,fee schedule,68721.27,103080.65, Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,71473.76,,,,,,,fee schedule,68721.27,103080.65, Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],60085.23,60085.23,60085.23,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],33507.16,33507.16,33507.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],63084.37,63084.37,63084.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],53396.36,53396.36,53396.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],23923.12,20500.57,28941.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],29877.22,24378.79,32244.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],72402.78,72402.78,72402.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,60550.25,60550.25,60550.25,1 through 10,percent of total billed charges,,, Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Spinal Procedures With Mcc,28,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,188744.74,,,,,,,fee schedule,163660.08,245487.12, Spinal Procedures With Mcc,28,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,163660.08,,,,,,,fee schedule,163660.08,245487.12, Spinal Procedures With Mcc,28,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,245487.12,,,,,,,fee schedule,163660.08,245487.12, Spinal Procedures With Mcc,28,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,189129.27,,,,,,,fee schedule,163660.08,245487.12, Spinal Procedures With Mcc,28,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,170215.14,,,,,,,fee schedule,163660.08,245487.12, Spinal Procedures With Mcc,28,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Spinal Procedures With Mcc,28,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Procedures With Mcc,28,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],117438.25,117438.25,117438.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Spinal Procedures With Mcc,28,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],56201.6,56201.6,56201.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Spinal Procedures With Mcc,28,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Spinal Procedures With Mcc,28,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Procedures With Mcc,28,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Procedures With Mcc,28,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Procedures With Mcc,28,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Procedures With Mcc,28,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],31678.36,31678.36,31678.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Spinal Procedures With Mcc,28,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Procedures With Mcc,28,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],45357.43,45357.43,72039.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Spinal Procedures With Mcc,28,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Procedures With Mcc,28,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Procedures With Mcc,28,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Procedures With Mcc,28,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,44230.1,44230.1,44230.1,1 through 10,percent of total billed charges,,, Spinal Procedures With Mcc,28,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Spinal Procedures With Mcc,28,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Spinal Procedures With Mcc,28,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Spinal Procedures With Mcc,28,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,107172,,,,,,,fee schedule,92928.57,139391.15, Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,92928.57,,,,,,,fee schedule,92928.57,139391.15, Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,139391.15,,,,,,,fee schedule,92928.57,139391.15, Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,107390.34,,,,,,,fee schedule,92928.57,139391.15, Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,96650.63,,,,,,,fee schedule,92928.57,139391.15, Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],94773.07,94773.07,94773.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],128705.95,128705.95,128705.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],85807.32,85247.32,85807.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],24747.71,24747.71,24747.71,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],26314.35,26314.35,26314.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],27510.46,27510.46,27510.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],45630.16,45630.16,45630.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],92346.01,92346.01,92346.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,56784.1,56784.1,56784.1,1 through 10,percent of total billed charges,,, Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,68960.01,,,,,,,fee schedule,59795.05,89691.48, Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,59795.05,,,,,,,fee schedule,59795.05,89691.48, Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,89691.48,,,,,,,fee schedule,59795.05,89691.48, Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,69100.51,,,,,,,fee schedule,59795.05,89691.48, Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,62190.02,,,,,,,fee schedule,59795.05,89691.48, Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],59085.56,59085.56,59085.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],56907.9,56907.9,56907.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],68018.21,68018.21,68018.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],25596.69,25596.69,25596.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],65291.01,65291.01,65291.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,140750.43,,,,,,,fee schedule,122044.34,183064.27, Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,122044.34,,,,,,,fee schedule,122044.34,183064.27, Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,183064.27,,,,,,,fee schedule,122044.34,183064.27, Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,141037.18,,,,,,,fee schedule,122044.34,183064.27, Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,126932.57,,,,,,,fee schedule,122044.34,183064.27, Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],118317.4,118317.4,118317.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],64875.04,64875.04,64875.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],18316.47,18316.47,18316.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],18665.36,18620.17,30997.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],122948.01,122948.01,122948.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,34568.4,34568.4,34568.4,1 through 10,percent of total billed charges,,, Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,66943.23,,,,,,,fee schedule,58046.31,87068.4, Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,58046.31,,,,,,,fee schedule,58046.31,87068.4, Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,87068.4,,,,,,,fee schedule,58046.31,87068.4, Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,67079.62,,,,,,,fee schedule,58046.31,87068.4, Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,60371.23,,,,,,,fee schedule,58046.31,87068.4, Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],58317.83,58317.83,58317.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],18005.19,18005.19,34574.23,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],54592.34,54028.1,54592.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],55377.1,55377.1,55377.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],11420.89,11420.89,11420.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],14884.38,14884.38,14884.38,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],18665.36,14786.32,31190.09,17,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,57474.89,57474.89,57474.89,1 through 10,percent of total billed charges,,, Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,52238.34,,,,,,,fee schedule,45295.73,67942.77, Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,45295.73,,,,,,,fee schedule,45295.73,67942.77, Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,67942.77,,,,,,,fee schedule,45295.73,67942.77, Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,52344.77,,,,,,,fee schedule,45295.73,67942.77, Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,47109.96,,,,,,,fee schedule,45295.73,67942.77, Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],40785.77,40785.77,40785.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],15576.78,15576.78,18620.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,121594.17,,,,,,,fee schedule,105434,158149.06, Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,105434,,,,,,,fee schedule,105434,158149.06, Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,158149.06,,,,,,,fee schedule,105434,158149.06, Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,121841.89,,,,,,,fee schedule,105434,158149.06, Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,109656.93,,,,,,,fee schedule,105434,158149.06, Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,75095.17,,,,,,,fee schedule,65114.83,97671.05, Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,65114.83,,,,,,,fee schedule,65114.83,97671.05, Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,97671.05,,,,,,,fee schedule,65114.83,97671.05, Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,75248.16,,,,,,,fee schedule,65114.83,97671.05, Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,67722.87,,,,,,,fee schedule,65114.83,97671.05, Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,61031.12,,,,,,,fee schedule,52919.93,79378.92, Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,52919.93,,,,,,,fee schedule,52919.93,79378.92, Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,79378.92,,,,,,,fee schedule,52919.93,79378.92, Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,61155.46,,,,,,,fee schedule,52919.93,79378.92, Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,55039.52,,,,,,,fee schedule,52919.93,79378.92, Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Extracranial Procedures With Mcc,37,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,103418.03,,,,,,,fee schedule,89673.51,134508.62, Extracranial Procedures With Mcc,37,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,89673.51,,,,,,,fee schedule,89673.51,134508.62, Extracranial Procedures With Mcc,37,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,134508.62,,,,,,,fee schedule,89673.51,134508.62, Extracranial Procedures With Mcc,37,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,103628.72,,,,,,,fee schedule,89673.51,134508.62, Extracranial Procedures With Mcc,37,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,93265.19,,,,,,,fee schedule,89673.51,134508.62, Extracranial Procedures With Mcc,37,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Extracranial Procedures With Mcc,37,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extracranial Procedures With Mcc,37,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extracranial Procedures With Mcc,37,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extracranial Procedures With Mcc,37,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Extracranial Procedures With Mcc,37,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extracranial Procedures With Mcc,37,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extracranial Procedures With Mcc,37,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extracranial Procedures With Mcc,37,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extracranial Procedures With Mcc,37,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extracranial Procedures With Mcc,37,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extracranial Procedures With Mcc,37,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extracranial Procedures With Mcc,37,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extracranial Procedures With Mcc,37,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extracranial Procedures With Mcc,37,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extracranial Procedures With Mcc,37,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Extracranial Procedures With Mcc,37,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Extracranial Procedures With Mcc,37,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Extracranial Procedures With Mcc,37,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Extracranial Procedures With Mcc,37,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Extracranial Procedures With Cc,38,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,50972.36,,,,,,,fee schedule,44198,66296.19, Extracranial Procedures With Cc,38,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,44198,,,,,,,fee schedule,44198,66296.19, Extracranial Procedures With Cc,38,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,66296.19,,,,,,,fee schedule,44198,66296.19, Extracranial Procedures With Cc,38,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,51076.2,,,,,,,fee schedule,44198,66296.19, Extracranial Procedures With Cc,38,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,45968.26,,,,,,,fee schedule,44198,66296.19, Extracranial Procedures With Cc,38,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Extracranial Procedures With Cc,38,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extracranial Procedures With Cc,38,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extracranial Procedures With Cc,38,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extracranial Procedures With Cc,38,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Extracranial Procedures With Cc,38,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extracranial Procedures With Cc,38,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extracranial Procedures With Cc,38,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extracranial Procedures With Cc,38,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extracranial Procedures With Cc,38,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extracranial Procedures With Cc,38,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extracranial Procedures With Cc,38,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extracranial Procedures With Cc,38,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extracranial Procedures With Cc,38,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extracranial Procedures With Cc,38,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extracranial Procedures With Cc,38,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Extracranial Procedures With Cc,38,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Extracranial Procedures With Cc,38,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Extracranial Procedures With Cc,38,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Extracranial Procedures With Cc,38,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,36927.16,,,,,,,fee schedule,32019.44,48028.58, Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,32019.44,,,,,,,fee schedule,32019.44,48028.58, Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,48028.58,,,,,,,fee schedule,32019.44,48028.58, Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,37002.39,,,,,,,fee schedule,32019.44,48028.58, Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,33301.92,,,,,,,fee schedule,32019.44,48028.58, Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],17591.53,17591.53,17591.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,121295.74,,,,,,,fee schedule,105175.23,157760.91, "Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,105175.23,,,,,,,fee schedule,105175.23,157760.91, "Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,157760.91,,,,,,,fee schedule,105175.23,157760.91, "Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,121542.85,,,,,,,fee schedule,105175.23,157760.91, "Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,109387.8,,,,,,,fee schedule,105175.23,157760.91, "Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],33616.26,33616.26,33616.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,69069.96,,,,,,,fee schedule,59890.39,89834.48, "Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,59890.39,,,,,,,fee schedule,59890.39,89834.48, "Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,89834.48,,,,,,,fee schedule,59890.39,89834.48, "Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,69210.68,,,,,,,fee schedule,59890.39,89834.48, "Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,62289.17,,,,,,,fee schedule,59890.39,89834.48, "Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],33616.26,33616.26,33616.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],21553.9,21553.9,21553.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,54273.97,,,,,,,fee schedule,47060.82,70590.37, "Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,47060.82,,,,,,,fee schedule,47060.82,70590.37, "Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,70590.37,,,,,,,fee schedule,47060.82,70590.37, "Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,54384.54,,,,,,,fee schedule,47060.82,70590.37, "Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,48945.74,,,,,,,fee schedule,47060.82,70590.37, "Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hyphema,43,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Hyphema,43,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hyphema,43,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hyphema,43,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hyphema,43,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Hyphema,43,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hyphema,43,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hyphema,43,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hyphema,43,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hyphema,43,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hyphema,43,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hyphema,43,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hyphema,43,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hyphema,43,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hyphema,43,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hyphema,43,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hyphema,43,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hyphema,43,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hyphema,43,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hyphema,43,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Acute Major Eye Infections,44,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Acute Major Eye Infections,44,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute Major Eye Infections,44,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute Major Eye Infections,44,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute Major Eye Infections,44,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Acute Major Eye Infections,44,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute Major Eye Infections,44,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute Major Eye Infections,44,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute Major Eye Infections,44,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute Major Eye Infections,44,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute Major Eye Infections,44,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute Major Eye Infections,44,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute Major Eye Infections,44,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute Major Eye Infections,44,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute Major Eye Infections,44,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute Major Eye Infections,44,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Acute Major Eye Infections,44,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Acute Major Eye Infections,44,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Acute Major Eye Infections,44,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Acute Major Eye Infections,44,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Neurological eye disorders,45,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Neurological eye disorders,45,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Neurological eye disorders,45,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Neurological eye disorders,45,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Neurological eye disorders,45,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Neurological eye disorders,45,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Neurological eye disorders,45,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Neurological eye disorders,45,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Neurological eye disorders,45,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Neurological eye disorders,45,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Neurological eye disorders,45,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Neurological eye disorders,45,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Neurological eye disorders,45,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Neurological eye disorders,45,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Neurological eye disorders,45,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Neurological eye disorders,45,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Neurological eye disorders,45,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Neurological eye disorders,45,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Neurological eye disorders,45,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Neurological eye disorders,45,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Disorders of the Eye Age >17 w CC,46,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders of the Eye Age >17 w CC,46,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders of the Eye Age >17 w CC,46,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders of the Eye Age >17 w CC,46,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders of the Eye Age >17 w CC,46,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders of the Eye Age >17 w CC,46,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders of the Eye Age >17 w CC,46,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders of the Eye Age >17 w CC,46,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders of the Eye Age >17 w CC,46,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders of the Eye Age >17 w CC,46,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders of the Eye Age >17 w CC,46,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders of the Eye Age >17 w CC,46,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders of the Eye Age >17 w CC,46,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders of the Eye Age >17 w CC,46,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders of the Eye Age >17 w CC,46,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders of the Eye Age >17 w CC,46,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Disorders of the Eye Age >17 w CC,46,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Disorders of the Eye Age >17 w CC,46,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Disorders of the Eye Age >17 w CC,46,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Disorders of the Eye Age >17 w CC,46,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Disorders of the Eye Age >17 w/o CC,47,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders of the Eye Age >17 w/o CC,47,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders of the Eye Age >17 w/o CC,47,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders of the Eye Age >17 w/o CC,47,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders of the Eye Age >17 w/o CC,47,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders of the Eye Age >17 w/o CC,47,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders of the Eye Age >17 w/o CC,47,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders of the Eye Age >17 w/o CC,47,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders of the Eye Age >17 w/o CC,47,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders of the Eye Age >17 w/o CC,47,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders of the Eye Age >17 w/o CC,47,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders of the Eye Age >17 w/o CC,47,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders of the Eye Age >17 w/o CC,47,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders of the Eye Age >17 w/o CC,47,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders of the Eye Age >17 w/o CC,47,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders of the Eye Age >17 w/o CC,47,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Disorders of the Eye Age >17 w/o CC,47,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Disorders of the Eye Age >17 w/o CC,47,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Disorders of the Eye Age >17 w/o CC,47,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Disorders of the Eye Age >17 w/o CC,47,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Disorders of the Eye Age 0-17,48,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders of the Eye Age 0-17,48,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders of the Eye Age 0-17,48,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders of the Eye Age 0-17,48,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders of the Eye Age 0-17,48,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders of the Eye Age 0-17,48,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders of the Eye Age 0-17,48,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders of the Eye Age 0-17,48,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders of the Eye Age 0-17,48,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders of the Eye Age 0-17,48,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders of the Eye Age 0-17,48,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders of the Eye Age 0-17,48,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders of the Eye Age 0-17,48,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders of the Eye Age 0-17,48,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders of the Eye Age 0-17,48,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders of the Eye Age 0-17,48,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Disorders of the Eye Age 0-17,48,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Disorders of the Eye Age 0-17,48,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Disorders of the Eye Age 0-17,48,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Disorders of the Eye Age 0-17,48,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Head & Neck Procedures,49,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Major Head & Neck Procedures,49,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Head & Neck Procedures,49,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Head & Neck Procedures,49,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Head & Neck Procedures,49,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Major Head & Neck Procedures,49,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Head & Neck Procedures,49,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Head & Neck Procedures,49,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Head & Neck Procedures,49,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Head & Neck Procedures,49,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Head & Neck Procedures,49,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Head & Neck Procedures,49,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Head & Neck Procedures,49,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Head & Neck Procedures,49,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Head & Neck Procedures,49,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Head & Neck Procedures,49,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Head & Neck Procedures,49,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Head & Neck Procedures,49,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Head & Neck Procedures,49,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Head & Neck Procedures,49,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Sialoadenectomy,50,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Sialoadenectomy,50,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Sialoadenectomy,50,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Sialoadenectomy,50,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Sialoadenectomy,50,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Sialoadenectomy,50,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Sialoadenectomy,50,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Sialoadenectomy,50,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Sialoadenectomy,50,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Sialoadenectomy,50,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Sialoadenectomy,50,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Sialoadenectomy,50,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Sialoadenectomy,50,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Sialoadenectomy,50,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Sialoadenectomy,50,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Sialoadenectomy,50,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Sialoadenectomy,50,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Sialoadenectomy,50,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Sialoadenectomy,50,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Sialoadenectomy,50,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Salivary Gland Procedures Except Sialoadenectomy,51,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Salivary Gland Procedures Except Sialoadenectomy,51,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Salivary Gland Procedures Except Sialoadenectomy,51,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Salivary Gland Procedures Except Sialoadenectomy,51,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Salivary Gland Procedures Except Sialoadenectomy,51,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Salivary Gland Procedures Except Sialoadenectomy,51,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Salivary Gland Procedures Except Sialoadenectomy,51,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Salivary Gland Procedures Except Sialoadenectomy,51,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Salivary Gland Procedures Except Sialoadenectomy,51,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Salivary Gland Procedures Except Sialoadenectomy,51,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Salivary Gland Procedures Except Sialoadenectomy,51,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Salivary Gland Procedures Except Sialoadenectomy,51,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Salivary Gland Procedures Except Sialoadenectomy,51,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Salivary Gland Procedures Except Sialoadenectomy,51,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Salivary Gland Procedures Except Sialoadenectomy,51,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Salivary Gland Procedures Except Sialoadenectomy,51,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Salivary Gland Procedures Except Sialoadenectomy,51,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Salivary Gland Procedures Except Sialoadenectomy,51,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Salivary Gland Procedures Except Sialoadenectomy,51,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Salivary Gland Procedures Except Sialoadenectomy,51,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,56900.18,,,,,,,fee schedule,49338,74006.1, Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,49338,,,,,,,fee schedule,49338,74006.1, Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,74006.1,,,,,,,fee schedule,49338,74006.1, Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,57016.1,,,,,,,fee schedule,49338,74006.1, Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,51314.13,,,,,,,fee schedule,49338,74006.1, Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,30760.59,,,,,,,fee schedule,26672.43,40008.15, Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,26672.43,,,,,,,fee schedule,26672.43,40008.15, Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,40008.15,,,,,,,fee schedule,26672.43,40008.15, Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,30823.26,,,,,,,fee schedule,26672.43,40008.15, Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,27740.74,,,,,,,fee schedule,26672.43,40008.15, Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,47966.04,,,,,,,fee schedule,41591.23,62386.08, Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,41591.23,,,,,,,fee schedule,41591.23,62386.08, Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,62386.08,,,,,,,fee schedule,41591.23,62386.08, Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,48063.76,,,,,,,fee schedule,41591.23,62386.08, Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,43257.08,,,,,,,fee schedule,41591.23,62386.08, Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],10526.92,10526.92,10526.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],30423.63,30423.63,30423.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,32029.71,,,,,,,fee schedule,27772.88,41658.82, Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,27772.88,,,,,,,fee schedule,27772.88,41658.82, Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,41658.82,,,,,,,fee schedule,27772.88,41658.82, Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,32094.97,,,,,,,fee schedule,27772.88,41658.82, Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,28885.27,,,,,,,fee schedule,27772.88,41658.82, Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],11578.09,11578.09,11578.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,72977.86,,,,,,,fee schedule,63278.92,94917.22, Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,63278.92,,,,,,,fee schedule,63278.92,94917.22, Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,94917.22,,,,,,,fee schedule,63278.92,94917.22, Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,73126.54,,,,,,,fee schedule,63278.92,94917.22, Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,65813.42,,,,,,,fee schedule,63278.92,94917.22, Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],86553.82,86553.82,86553.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],30468.85,30468.85,30468.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,40699.98,,,,,,,fee schedule,35290.85,52935.62, Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,35290.85,,,,,,,fee schedule,35290.85,52935.62, Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,52935.62,,,,,,,fee schedule,35290.85,52935.62, Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,40782.9,,,,,,,fee schedule,35290.85,52935.62, Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,36704.35,,,,,,,fee schedule,35290.85,52935.62, Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],39901.71,39901.71,39901.71,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],10045.21,10045.21,10045.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,13066.24,13066.24,13066.24,1 through 10,percent of total billed charges,,, Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,53702.23,,,,,,,fee schedule,46565.07,69846.75, Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,46565.07,,,,,,,fee schedule,46565.07,69846.75, Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,69846.75,,,,,,,fee schedule,46565.07,69846.75, Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,53811.64,,,,,,,fee schedule,46565.07,69846.75, Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,48430.14,,,,,,,fee schedule,46565.07,69846.75, Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],70266.58,70266.58,70266.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],23299.17,23299.17,23299.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],22663.73,22663.73,22663.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,38981.63,,,,,,,fee schedule,33800.88,50700.69, Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,33800.88,,,,,,,fee schedule,33800.88,50700.69, Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,50700.69,,,,,,,fee schedule,33800.88,50700.69, Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,39061.05,,,,,,,fee schedule,33800.88,50700.69, Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,35154.7,,,,,,,fee schedule,33800.88,50700.69, Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],23246.29,23246.29,23246.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],32816.84,32816.84,32816.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],17430.44,17430.44,17430.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,28894.6,,,,,,,fee schedule,25054.43,37581.19, Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,25054.43,,,,,,,fee schedule,25054.43,37581.19, Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,37581.19,,,,,,,fee schedule,25054.43,37581.19, Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,28953.46,,,,,,,fee schedule,25054.43,37581.19, Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,26057.93,,,,,,,fee schedule,25054.43,37581.19, Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],22812.42,22812.42,22812.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],32467.29,32467.29,32467.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],10609.89,10609.89,10609.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,86611.54,,,,,,,fee schedule,75100.65,112649.59, "Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,75100.65,,,,,,,fee schedule,75100.65,112649.59, "Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,112649.59,,,,,,,fee schedule,75100.65,112649.59, "Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,86787.99,,,,,,,fee schedule,75100.65,112649.59, "Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,78108.64,,,,,,,fee schedule,75100.65,112649.59, "Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,55200.68,,,,,,,fee schedule,47864.37,71795.68, "Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,47864.37,,,,,,,fee schedule,47864.37,71795.68, "Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,71795.68,,,,,,,fee schedule,47864.37,71795.68, "Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,55313.14,,,,,,,fee schedule,47864.37,71795.68, "Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,49781.48,,,,,,,fee schedule,47864.37,71795.68, "Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,44098.97,,,,,,,fee schedule,38238.11,57356.46, "Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,38238.11,,,,,,,fee schedule,38238.11,57356.46, "Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,57356.46,,,,,,,fee schedule,38238.11,57356.46, "Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,44188.82,,,,,,,fee schedule,38238.11,57356.46, "Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,39769.65,,,,,,,fee schedule,38238.11,57356.46, "Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,63173.55,,,,,,,fee schedule,54777.63,82165.44, Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,54777.63,,,,,,,fee schedule,54777.63,82165.44, Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,82165.44,,,,,,,fee schedule,54777.63,82165.44, Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,63302.26,,,,,,,fee schedule,54777.63,82165.44, Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,56971.63,,,,,,,fee schedule,54777.63,82165.44, Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],9190.94,9190.94,9190.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,31737.56,,,,,,,fee schedule,27519.56,41278.84, Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,27519.56,,,,,,,fee schedule,27519.56,41278.84, Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,41278.84,,,,,,,fee schedule,27519.56,41278.84, Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,31802.22,,,,,,,fee schedule,27519.56,41278.84, Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,28621.8,,,,,,,fee schedule,27519.56,41278.84, Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],29688.74,29688.74,29688.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,21499.74,,,,,,,fee schedule,18642.37,27963.22, Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,18642.37,,,,,,,fee schedule,18642.37,27963.22, Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,27963.22,,,,,,,fee schedule,18642.37,27963.22, Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,21543.54,,,,,,,fee schedule,18642.37,27963.22, Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19389.05,,,,,,,fee schedule,18642.37,27963.22, Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,46137.74,,,,,,,fee schedule,40005.92,60008.14, Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,40005.92,,,,,,,fee schedule,40005.92,60008.14, Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,60008.14,,,,,,,fee schedule,40005.92,60008.14, Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,46231.74,,,,,,,fee schedule,40005.92,60008.14, Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,41608.27,,,,,,,fee schedule,40005.92,60008.14, Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],62,62,62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,27154.26,,,,,,,fee schedule,23545.39,35317.66, Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,23545.39,,,,,,,fee schedule,23545.39,35317.66, Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,35317.66,,,,,,,fee schedule,23545.39,35317.66, Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,27209.58,,,,,,,fee schedule,23545.39,35317.66, Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,24488.45,,,,,,,fee schedule,23545.39,35317.66, Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,25093.5,,,,,,,fee schedule,21758.51,32637.37, Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,21758.51,,,,,,,fee schedule,21758.51,32637.37, Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,32637.37,,,,,,,fee schedule,21758.51,32637.37, Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,25144.63,,,,,,,fee schedule,21758.51,32637.37, Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22630,,,,,,,fee schedule,21758.51,32637.37, Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,52298.03,,,,,,,fee schedule,45347.49,68020.4, Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,45347.49,,,,,,,fee schedule,45347.49,68020.4, Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,68020.4,,,,,,,fee schedule,45347.49,68020.4, Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,52404.57,,,,,,,fee schedule,45347.49,68020.4, Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,47163.78,,,,,,,fee schedule,45347.49,68020.4, Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],31580.53,31580.53,31580.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],14427.68,14427.68,14427.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],24543.9,24543.9,24543.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,47989.51,47989.51,47989.51,1 through 10,percent of total billed charges,,, Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,32230.76,,,,,,,fee schedule,27947.21,41920.31, Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,27947.21,,,,,,,fee schedule,27947.21,41920.31, Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,41920.31,,,,,,,fee schedule,27947.21,41920.31, Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,32296.43,,,,,,,fee schedule,27947.21,41920.31, Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,29066.58,,,,,,,fee schedule,27947.21,41920.31, Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],19703.18,19703.18,19703.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],40409.69,40409.69,40409.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],4922.41,4922.41,4922.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],11622.08,11622.08,11622.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],29389.06,29389.06,29389.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,23755.27,,,,,,,fee schedule,20598.13,30896.82, Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,20598.13,,,,,,,fee schedule,20598.13,30896.82, Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,30896.82,,,,,,,fee schedule,20598.13,30896.82, Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,23803.66,,,,,,,fee schedule,20598.13,30896.82, Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,21423.15,,,,,,,fee schedule,20598.13,30896.82, Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],13069.43,13069.43,13069.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],7930.57,7930.57,7930.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,50397.48,,,,,,,fee schedule,43699.53,65548.49, Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,43699.53,,,,,,,fee schedule,43699.53,65548.49, Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,65548.49,,,,,,,fee schedule,43699.53,65548.49, Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,50500.16,,,,,,,fee schedule,43699.53,65548.49, Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,45449.82,,,,,,,fee schedule,43699.53,65548.49, Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,27866.31,27866.31,27866.31,1 through 10,percent of total billed charges,,, Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,32381.55,,,,,,,fee schedule,28077.96,42116.43, Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,28077.96,,,,,,,fee schedule,28077.96,42116.43, Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,42116.43,,,,,,,fee schedule,28077.96,42116.43, Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,32447.52,,,,,,,fee schedule,28077.96,42116.43, Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,29202.56,,,,,,,fee schedule,28077.96,42116.43, Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],43797.3,43797.3,57463.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],39968.74,39968.74,39968.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],39540.42,39540.42,39540.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],8708.47,8708.47,8708.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],8105.98,8105.98,8105.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],8874.34,8874.34,9012,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],29068.37,28858.37,29068.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,64763.73,64763.73,64763.73,1 through 10,percent of total billed charges,,, Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,60236.35,,,,,,,fee schedule,52230.78,78345.22, Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,52230.78,,,,,,,fee schedule,52230.78,78345.22, Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,78345.22,,,,,,,fee schedule,52230.78,78345.22, Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,60359.07,,,,,,,fee schedule,52230.78,78345.22, Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,54322.78,,,,,,,fee schedule,52230.78,78345.22, Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],30942.84,30942.84,30942.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],45051.45,45051.45,45051.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],25782.51,25782.51,25782.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,25922.83,,,,,,,fee schedule,22477.62,33716.02, Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,22477.62,,,,,,,fee schedule,22477.62,33716.02, Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,33716.02,,,,,,,fee schedule,22477.62,33716.02, Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,25975.65,,,,,,,fee schedule,22477.62,33716.02, Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,23377.92,,,,,,,fee schedule,22477.62,33716.02, Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],23438.71,23438.71,23438.71,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],17583.84,17583.84,17583.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],7191.38,7191.38,7191.38,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],6691.11,6691.11,6691.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],26900.93,26900.93,26900.93,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,56859.34,,,,,,,fee schedule,49302.59,73952.98, Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,49302.59,,,,,,,fee schedule,49302.59,73952.98, Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,73952.98,,,,,,,fee schedule,49302.59,73952.98, Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,56975.18,,,,,,,fee schedule,49302.59,73952.98, Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,51277.3,,,,,,,fee schedule,49302.59,73952.98, Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],26905.82,26905.82,26905.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],58320.06,58320.06,58320.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,28134.38,,,,,,,fee schedule,24395.25,36592.42, Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,24395.25,,,,,,,fee schedule,24395.25,36592.42, Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,36592.42,,,,,,,fee schedule,24395.25,36592.42, Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,28191.7,,,,,,,fee schedule,24395.25,36592.42, Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,25372.35,,,,,,,fee schedule,24395.25,36592.42, Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],12984.32,12984.32,12984.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,71799.84,,,,,,,fee schedule,62257.46,93385.04, Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,62257.46,,,,,,,fee schedule,62257.46,93385.04, Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,93385.04,,,,,,,fee schedule,62257.46,93385.04, Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,71946.12,,,,,,,fee schedule,62257.46,93385.04, Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,64751.05,,,,,,,fee schedule,62257.46,93385.04, Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],64701.1,64701.1,64701.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,43847.66,,,,,,,fee schedule,38020.2,57029.6, Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,38020.2,,,,,,,fee schedule,38020.2,57029.6, Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,57029.6,,,,,,,fee schedule,38020.2,57029.6, Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,43936.99,,,,,,,fee schedule,38020.2,57029.6, Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,39543.01,,,,,,,fee schedule,38020.2,57029.6, Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,30025.5,,,,,,,fee schedule,26035.04,39052.08, Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,26035.04,,,,,,,fee schedule,26035.04,39052.08, Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,39052.08,,,,,,,fee schedule,26035.04,39052.08, Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,30086.67,,,,,,,fee schedule,26035.04,39052.08, Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,27077.81,,,,,,,fee schedule,26035.04,39052.08, Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,71369.47,,,,,,,fee schedule,61884.28,92825.29, Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,61884.28,,,,,,,fee schedule,61884.28,92825.29, Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,92825.29,,,,,,,fee schedule,61884.28,92825.29, Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,71514.87,,,,,,,fee schedule,61884.28,92825.29, Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,64362.93,,,,,,,fee schedule,61884.28,92825.29, Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],14020.73,14020.73,14020.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],21281.5,21281.5,21281.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],19307.07,19307.07,19307.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],18976,18976,18976,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,52816.35,52816.35,52816.35,1 through 10,percent of total billed charges,,, Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,40923.02,,,,,,,fee schedule,35484.25,53225.72, Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,35484.25,,,,,,,fee schedule,35484.25,53225.72, Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,53225.72,,,,,,,fee schedule,35484.25,53225.72, Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,41006.39,,,,,,,fee schedule,35484.25,53225.72, Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,36905.49,,,,,,,fee schedule,35484.25,53225.72, Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],11494.56,11494.56,11494.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,28734.39,,,,,,,fee schedule,24915.51,37372.81, Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,24915.51,,,,,,,fee schedule,24915.51,37372.81, Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,37372.81,,,,,,,fee schedule,24915.51,37372.81, Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,28792.93,,,,,,,fee schedule,24915.51,37372.81, Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,25913.45,,,,,,,fee schedule,24915.51,37372.81, Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],19796.49,19796.49,19796.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],33895.21,33895.21,33895.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],7890.18,7890.18,7890.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],10683.39,10683.39,10683.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Concussion With Mcc,88,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,42465.45,,,,,,,fee schedule,36821.68,55231.84, Concussion With Mcc,88,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,36821.68,,,,,,,fee schedule,36821.68,55231.84, Concussion With Mcc,88,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,55231.84,,,,,,,fee schedule,36821.68,55231.84, Concussion With Mcc,88,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,42551.96,,,,,,,fee schedule,36821.68,55231.84, Concussion With Mcc,88,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,38296.49,,,,,,,fee schedule,36821.68,55231.84, Concussion With Mcc,88,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Concussion With Mcc,88,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Concussion With Mcc,88,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Concussion With Mcc,88,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Concussion With Mcc,88,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Concussion With Mcc,88,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Concussion With Mcc,88,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Concussion With Mcc,88,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Concussion With Mcc,88,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Concussion With Mcc,88,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Concussion With Mcc,88,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Concussion With Mcc,88,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Concussion With Mcc,88,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Concussion With Mcc,88,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Concussion With Mcc,88,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Concussion With Mcc,88,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Concussion With Mcc,88,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Concussion With Mcc,88,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Concussion With Mcc,88,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Concussion With Mcc,88,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Concussion With Cc,89,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,34511.42,,,,,,,fee schedule,29924.77,44886.6, Concussion With Cc,89,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,29924.77,,,,,,,fee schedule,29924.77,44886.6, Concussion With Cc,89,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,44886.6,,,,,,,fee schedule,29924.77,44886.6, Concussion With Cc,89,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,34581.73,,,,,,,fee schedule,29924.77,44886.6, Concussion With Cc,89,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,31123.34,,,,,,,fee schedule,29924.77,44886.6, Concussion With Cc,89,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Concussion With Cc,89,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Concussion With Cc,89,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Concussion With Cc,89,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Concussion With Cc,89,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Concussion With Cc,89,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Concussion With Cc,89,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Concussion With Cc,89,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Concussion With Cc,89,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Concussion With Cc,89,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Concussion With Cc,89,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Concussion With Cc,89,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],26557.89,26557.89,26557.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Concussion With Cc,89,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Concussion With Cc,89,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Concussion With Cc,89,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Concussion With Cc,89,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Concussion With Cc,89,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Concussion With Cc,89,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Concussion With Cc,89,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Concussion With Cc,89,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Concussion Without Cc/Mcc,90,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,25860,,,,,,,fee schedule,22423.14,33634.31, Concussion Without Cc/Mcc,90,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,22423.14,,,,,,,fee schedule,22423.14,33634.31, Concussion Without Cc/Mcc,90,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,33634.31,,,,,,,fee schedule,22423.14,33634.31, Concussion Without Cc/Mcc,90,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,25912.69,,,,,,,fee schedule,22423.14,33634.31, Concussion Without Cc/Mcc,90,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,23321.26,,,,,,,fee schedule,22423.14,33634.31, Concussion Without Cc/Mcc,90,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Concussion Without Cc/Mcc,90,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Concussion Without Cc/Mcc,90,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Concussion Without Cc/Mcc,90,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Concussion Without Cc/Mcc,90,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Concussion Without Cc/Mcc,90,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Concussion Without Cc/Mcc,90,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Concussion Without Cc/Mcc,90,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Concussion Without Cc/Mcc,90,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Concussion Without Cc/Mcc,90,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Concussion Without Cc/Mcc,90,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Concussion Without Cc/Mcc,90,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],7268.64,7268.64,7268.64,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Concussion Without Cc/Mcc,90,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Concussion Without Cc/Mcc,90,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Concussion Without Cc/Mcc,90,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Concussion Without Cc/Mcc,90,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Concussion Without Cc/Mcc,90,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Concussion Without Cc/Mcc,90,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Concussion Without Cc/Mcc,90,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Concussion Without Cc/Mcc,90,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,55169.27,,,,,,,fee schedule,47837.13,71754.82, Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,47837.13,,,,,,,fee schedule,47837.13,71754.82, Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,71754.82,,,,,,,fee schedule,47837.13,71754.82, Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,55281.66,,,,,,,fee schedule,47837.13,71754.82, Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,49753.15,,,,,,,fee schedule,47837.13,71754.82, Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],55328.66,55328.66,55328.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],69895.45,69895.45,69895.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],7588.71,7588.71,7588.71,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],27803.66,27803.66,27803.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,43109.88,43109.88,43109.88,1 through 10,percent of total billed charges,,, Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,32136.52,,,,,,,fee schedule,27865.5,41797.73, Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,27865.5,,,,,,,fee schedule,27865.5,41797.73, Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,41797.73,,,,,,,fee schedule,27865.5,41797.73, Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,32201.99,,,,,,,fee schedule,27865.5,41797.73, Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,28981.59,,,,,,,fee schedule,27865.5,41797.73, Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],40593.73,40593.73,40593.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],40593.73,40593.73,40593.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],32686.12,32686.12,32686.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],19921.31,19921.31,19921.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],11248.96,9941.85,13318.38,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],29522.91,29522.91,29522.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,25014.97,,,,,,,fee schedule,21690.42,32535.23, Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,21690.42,,,,,,,fee schedule,21690.42,32535.23, Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,32535.23,,,,,,,fee schedule,21690.42,32535.23, Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,25065.93,,,,,,,fee schedule,21690.42,32535.23, Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22559.18,,,,,,,fee schedule,21690.42,32535.23, Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],23956.83,23956.83,23956.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],20176.88,20176.88,20176.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],13069.43,13069.43,13069.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],11562.97,11562.97,11562.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],8397.21,7884.9,9941.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,35443.09,35443.09,35443.09,1 through 10,percent of total billed charges,,, Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,110558.43,,,,,,,fee schedule,95864.94,143795.65, Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,95864.94,,,,,,,fee schedule,95864.94,143795.65, Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,143795.65,,,,,,,fee schedule,95864.94,143795.65, Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,110783.67,,,,,,,fee schedule,95864.94,143795.65, Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,99704.6,,,,,,,fee schedule,95864.94,143795.65, Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,81022.99,,,,,,,fee schedule,70254.83,105380.95, Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,70254.83,,,,,,,fee schedule,70254.83,105380.95, Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,105380.95,,,,,,,fee schedule,70254.83,105380.95, Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,81188.06,,,,,,,fee schedule,70254.83,105380.95, Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,73068.74,,,,,,,fee schedule,70254.83,105380.95, Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],223920.05,223920.05,223920.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],22437.28,22437.28,22437.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],23505.72,23505.72,23505.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,81022.99,,,,,,,fee schedule,70254.83,105380.95, Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,70254.83,,,,,,,fee schedule,70254.83,105380.95, Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,105380.95,,,,,,,fee schedule,70254.83,105380.95, Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,81188.06,,,,,,,fee schedule,70254.83,105380.95, Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,73068.74,,,,,,,fee schedule,70254.83,105380.95, Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],22864.66,22864.66,22864.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,113461.09,,,,,,,fee schedule,98381.82,147570.92, Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,98381.82,,,,,,,fee schedule,98381.82,147570.92, Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,147570.92,,,,,,,fee schedule,98381.82,147570.92, Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,113692.24,,,,,,,fee schedule,98381.82,147570.92, Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,102322.29,,,,,,,fee schedule,98381.82,147570.92, Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],177063.28,177063.28,177063.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],15130.36,15130.36,15130.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],75220.31,75220.31,75220.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],76168.37,76168.37,76168.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,72091.99,,,,,,,fee schedule,62510.78,93765.02, Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,62510.78,,,,,,,fee schedule,62510.78,93765.02, Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,93765.02,,,,,,,fee schedule,62510.78,93765.02, Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,72238.86,,,,,,,fee schedule,62510.78,93765.02, Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,65014.52,,,,,,,fee schedule,62510.78,93765.02, Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],28476.68,28476.68,28476.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],71790.86,71790.86,71790.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],15418.56,15418.56,15418.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],60096.83,60096.83,60096.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,42798.43,,,,,,,fee schedule,37110.41,55664.94, Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,37110.41,,,,,,,fee schedule,37110.41,55664.94, Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,55664.94,,,,,,,fee schedule,37110.41,55664.94, Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,42885.63,,,,,,,fee schedule,37110.41,55664.94, Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,38596.79,,,,,,,fee schedule,37110.41,55664.94, Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],53423.3,53423.3,53423.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],15029.49,15029.49,15029.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Seizures With Mcc,100,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,60842.64,,,,,,,fee schedule,52756.5,79133.77, Seizures With Mcc,100,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,52756.5,,,,,,,fee schedule,52756.5,79133.77, Seizures With Mcc,100,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,79133.77,,,,,,,fee schedule,52756.5,79133.77, Seizures With Mcc,100,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,60966.59,,,,,,,fee schedule,52756.5,79133.77, Seizures With Mcc,100,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,54869.54,,,,,,,fee schedule,52756.5,79133.77, Seizures With Mcc,100,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],55045.62,55045.62,55045.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Seizures With Mcc,100,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],13690.14,13690.14,13690.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Seizures With Mcc,100,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],50750.22,43829.67,167695.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Seizures With Mcc,100,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],50750.22,50750.22,50750.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Seizures With Mcc,100,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Seizures With Mcc,100,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Seizures With Mcc,100,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Seizures With Mcc,100,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],7920.81,7785.15,105110.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Seizures With Mcc,100,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Seizures With Mcc,100,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],46746.68,28219.26,358359.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Seizures With Mcc,100,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],8675.17,8675.17,8675.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Seizures With Mcc,100,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],12207.04,8071.68,27449.64,43,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Seizures With Mcc,100,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],6228.86,6228.86,6228.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Seizures With Mcc,100,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],56935.22,56935.22,56935.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Seizures With Mcc,100,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Seizures With Mcc,100,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,21802.93,21498.55,49056.88,1 through 10,percent of total billed charges,,, Seizures With Mcc,100,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Seizures With Mcc,100,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Seizures With Mcc,100,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Seizures With Mcc,100,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Seizures Without Mcc,101,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,28354.28,,,,,,,fee schedule,24585.92,36878.43, Seizures Without Mcc,101,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,24585.92,,,,,,,fee schedule,24585.92,36878.43, Seizures Without Mcc,101,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,36878.43,,,,,,,fee schedule,24585.92,36878.43, Seizures Without Mcc,101,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,28412.04,,,,,,,fee schedule,24585.92,36878.43, Seizures Without Mcc,101,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,25570.66,,,,,,,fee schedule,24585.92,36878.43, Seizures Without Mcc,101,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],25901.62,13272.16,27975.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Seizures Without Mcc,101,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],7137.01,7137.01,7137.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Seizures Without Mcc,101,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],23051.23,23051.23,23051.23,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Seizures Without Mcc,101,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],23561.42,21092.4,35340.74,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Seizures Without Mcc,101,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],46644.48,46644.48,46644.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Seizures Without Mcc,101,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],5947.52,5947.52,5947.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Seizures Without Mcc,101,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],6638.62,6638.62,6638.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Seizures Without Mcc,101,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],6244.89,5808.79,7785.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Seizures Without Mcc,101,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Seizures Without Mcc,101,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],12549.3,6542.26,12549.3,17,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Seizures Without Mcc,101,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Seizures Without Mcc,101,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],8071.68,6363.84,12207.04,61,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Seizures Without Mcc,101,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],23202.43,19997.15,25702.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Seizures Without Mcc,101,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],23904.73,23904.73,23904.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Seizures Without Mcc,101,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Seizures Without Mcc,101,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,21987.4,9766.74,35563.2,1 through 10,percent of total billed charges,,, Seizures Without Mcc,101,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Seizures Without Mcc,101,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Seizures Without Mcc,101,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Seizures Without Mcc,101,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Headaches With Mcc,102,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,35211.95,,,,,,,fee schedule,30532.2,45797.73, Headaches With Mcc,102,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,30532.2,,,,,,,fee schedule,30532.2,45797.73, Headaches With Mcc,102,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,45797.73,,,,,,,fee schedule,30532.2,45797.73, Headaches With Mcc,102,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,35283.69,,,,,,,fee schedule,30532.2,45797.73, Headaches With Mcc,102,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,31755.1,,,,,,,fee schedule,30532.2,45797.73, Headaches With Mcc,102,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Headaches With Mcc,102,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Headaches With Mcc,102,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Headaches With Mcc,102,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Headaches With Mcc,102,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Headaches With Mcc,102,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Headaches With Mcc,102,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Headaches With Mcc,102,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Headaches With Mcc,102,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Headaches With Mcc,102,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],8984.45,8984.45,8984.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Headaches With Mcc,102,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],13680.11,13680.11,13680.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Headaches With Mcc,102,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Headaches With Mcc,102,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Headaches With Mcc,102,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Headaches With Mcc,102,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Headaches With Mcc,102,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Headaches With Mcc,102,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Headaches With Mcc,102,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Headaches With Mcc,102,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Headaches With Mcc,102,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Headaches Without Mcc,103,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,26271.53,,,,,,,fee schedule,22779.98,34169.55, Headaches Without Mcc,103,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,22779.98,,,,,,,fee schedule,22779.98,34169.55, Headaches Without Mcc,103,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,34169.55,,,,,,,fee schedule,22779.98,34169.55, Headaches Without Mcc,103,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,26325.05,,,,,,,fee schedule,22779.98,34169.55, Headaches Without Mcc,103,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,23692.38,,,,,,,fee schedule,22779.98,34169.55, Headaches Without Mcc,103,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],23616.06,23616.06,23616.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Headaches Without Mcc,103,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Headaches Without Mcc,103,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],21733.66,21733.66,21733.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Headaches Without Mcc,103,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],32824.35,32824.35,32824.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Headaches Without Mcc,103,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Headaches Without Mcc,103,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Headaches Without Mcc,103,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Headaches Without Mcc,103,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],18060.64,18060.64,18060.64,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Headaches Without Mcc,103,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Headaches Without Mcc,103,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],8984.45,8797.83,13691.79,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Headaches Without Mcc,103,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Headaches Without Mcc,103,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],8739.42,8557.89,19378,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Headaches Without Mcc,103,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],19360.84,19360.84,19360.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Headaches Without Mcc,103,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],22449.53,22449.53,22449.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Headaches Without Mcc,103,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],9025.04,9025.04,9025.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Headaches Without Mcc,103,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Headaches Without Mcc,103,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Headaches Without Mcc,103,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Headaches Without Mcc,103,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Headaches Without Mcc,103,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Valve & Oth Major Cardiothoracic Proc w Cardiac Cath,104,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve & Oth Major Cardiothoracic Proc w Cardiac Cath,104,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve & Oth Major Cardiothoracic Proc w Cardiac Cath,104,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve & Oth Major Cardiothoracic Proc w Cardiac Cath,104,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve & Oth Major Cardiothoracic Proc w Cardiac Cath,104,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve & Oth Major Cardiothoracic Proc w Cardiac Cath,104,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve & Oth Major Cardiothoracic Proc w Cardiac Cath,104,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve & Oth Major Cardiothoracic Proc w Cardiac Cath,104,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve & Oth Major Cardiothoracic Proc w Cardiac Cath,104,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve & Oth Major Cardiothoracic Proc w Cardiac Cath,104,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve & Oth Major Cardiothoracic Proc w Cardiac Cath,104,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve & Oth Major Cardiothoracic Proc w Cardiac Cath,104,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve & Oth Major Cardiothoracic Proc w Cardiac Cath,104,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve & Oth Major Cardiothoracic Proc w Cardiac Cath,104,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve & Oth Major Cardiothoracic Proc w Cardiac Cath,104,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve & Oth Major Cardiothoracic Proc w Cardiac Cath,104,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Valve & Oth Major Cardiothoracic Proc w Cardiac Cath,104,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Valve & Oth Major Cardiothoracic Proc w Cardiac Cath,104,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Valve & Oth Major Cardiothoracic Proc w Cardiac Cath,104,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Valve & Oth Major Cardiothoracic Proc w Cardiac Cath,104,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Valve & Oth Major Cardiothoracic Proc w/o Cardiac Cath,105,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve & Oth Major Cardiothoracic Proc w/o Cardiac Cath,105,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve & Oth Major Cardiothoracic Proc w/o Cardiac Cath,105,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve & Oth Major Cardiothoracic Proc w/o Cardiac Cath,105,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve & Oth Major Cardiothoracic Proc w/o Cardiac Cath,105,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve & Oth Major Cardiothoracic Proc w/o Cardiac Cath,105,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve & Oth Major Cardiothoracic Proc w/o Cardiac Cath,105,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve & Oth Major Cardiothoracic Proc w/o Cardiac Cath,105,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve & Oth Major Cardiothoracic Proc w/o Cardiac Cath,105,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve & Oth Major Cardiothoracic Proc w/o Cardiac Cath,105,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve & Oth Major Cardiothoracic Proc w/o Cardiac Cath,105,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve & Oth Major Cardiothoracic Proc w/o Cardiac Cath,105,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve & Oth Major Cardiothoracic Proc w/o Cardiac Cath,105,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve & Oth Major Cardiothoracic Proc w/o Cardiac Cath,105,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve & Oth Major Cardiothoracic Proc w/o Cardiac Cath,105,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve & Oth Major Cardiothoracic Proc w/o Cardiac Cath,105,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Valve & Oth Major Cardiothoracic Proc w/o Cardiac Cath,105,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Valve & Oth Major Cardiothoracic Proc w/o Cardiac Cath,105,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Valve & Oth Major Cardiothoracic Proc w/o Cardiac Cath,105,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Valve & Oth Major Cardiothoracic Proc w/o Cardiac Cath,105,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Coronary Bypass w PTCA,106,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass w PTCA,106,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass w PTCA,106,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass w PTCA,106,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass w PTCA,106,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass w PTCA,106,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass w PTCA,106,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass w PTCA,106,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass w PTCA,106,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass w PTCA,106,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass w PTCA,106,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass w PTCA,106,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass w PTCA,106,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass w PTCA,106,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass w PTCA,106,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass w PTCA,106,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Coronary Bypass w PTCA,106,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Coronary Bypass w PTCA,106,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Coronary Bypass w PTCA,106,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Coronary Bypass w PTCA,106,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. No Longer Valid,107,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,107,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,107,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,107,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,107,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,107,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,107,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,107,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,107,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,107,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,107,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,107,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,107,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,107,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,107,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,107,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. No Longer Valid,107,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. No Longer Valid,107,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. No Longer Valid,107,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. No Longer Valid,107,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Cardiothoracic Procedures,108,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Other Cardiothoracic Procedures,108,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Cardiothoracic Procedures,108,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Cardiothoracic Procedures,108,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Cardiothoracic Procedures,108,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other Cardiothoracic Procedures,108,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Cardiothoracic Procedures,108,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Cardiothoracic Procedures,108,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Cardiothoracic Procedures,108,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Cardiothoracic Procedures,108,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Cardiothoracic Procedures,108,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Cardiothoracic Procedures,108,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Cardiothoracic Procedures,108,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Cardiothoracic Procedures,108,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Cardiothoracic Procedures,108,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Cardiothoracic Procedures,108,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Cardiothoracic Procedures,108,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Cardiothoracic Procedures,108,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Cardiothoracic Procedures,108,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Cardiothoracic Procedures,108,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. No Longer Valid,109,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,109,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,109,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,109,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,109,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,109,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,109,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,109,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,109,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,109,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,109,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,109,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,109,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,109,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,109,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,109,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. No Longer Valid,109,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. No Longer Valid,109,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. No Longer Valid,109,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. No Longer Valid,109,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Cardiovascular Procedures w CC,110,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Major Cardiovascular Procedures w CC,110,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Cardiovascular Procedures w CC,110,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Cardiovascular Procedures w CC,110,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Cardiovascular Procedures w CC,110,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Major Cardiovascular Procedures w CC,110,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Cardiovascular Procedures w CC,110,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Cardiovascular Procedures w CC,110,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Cardiovascular Procedures w CC,110,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Cardiovascular Procedures w CC,110,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Cardiovascular Procedures w CC,110,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Cardiovascular Procedures w CC,110,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Cardiovascular Procedures w CC,110,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Cardiovascular Procedures w CC,110,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Cardiovascular Procedures w CC,110,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Cardiovascular Procedures w CC,110,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Cardiovascular Procedures w CC,110,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Cardiovascular Procedures w CC,110,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Cardiovascular Procedures w CC,110,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Cardiovascular Procedures w CC,110,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Cardiovascular Procedures w/o CC,111,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Major Cardiovascular Procedures w/o CC,111,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Cardiovascular Procedures w/o CC,111,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Cardiovascular Procedures w/o CC,111,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Cardiovascular Procedures w/o CC,111,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Major Cardiovascular Procedures w/o CC,111,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Cardiovascular Procedures w/o CC,111,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Cardiovascular Procedures w/o CC,111,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Cardiovascular Procedures w/o CC,111,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Cardiovascular Procedures w/o CC,111,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Cardiovascular Procedures w/o CC,111,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Cardiovascular Procedures w/o CC,111,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Cardiovascular Procedures w/o CC,111,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Cardiovascular Procedures w/o CC,111,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Cardiovascular Procedures w/o CC,111,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Cardiovascular Procedures w/o CC,111,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Cardiovascular Procedures w/o CC,111,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Cardiovascular Procedures w/o CC,111,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Cardiovascular Procedures w/o CC,111,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Cardiovascular Procedures w/o CC,111,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. No Longer Valid,112,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,112,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,112,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,112,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,112,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,112,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,112,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,112,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,112,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,112,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,112,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,112,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,112,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,112,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,112,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,112,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. No Longer Valid,112,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. No Longer Valid,112,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. No Longer Valid,112,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. No Longer Valid,112,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,73857.46,,,,,,,fee schedule,64041.61,96061.24, Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,64041.61,,,,,,,fee schedule,64041.61,96061.24, Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,96061.24,,,,,,,fee schedule,64041.61,96061.24, Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,74007.93,,,,,,,fee schedule,64041.61,96061.24, Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,66606.66,,,,,,,fee schedule,64041.61,96061.24, Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,42503.14,,,,,,,fee schedule,36854.37,55280.87, Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,36854.37,,,,,,,fee schedule,36854.37,55280.87, Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,55280.87,,,,,,,fee schedule,36854.37,55280.87, Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,42589.73,,,,,,,fee schedule,36854.37,55280.87, Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,38330.49,,,,,,,fee schedule,36854.37,55280.87, Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Extraocular Procedures Except Orbit,115,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,48217.35,,,,,,,fee schedule,41809.14,62712.94, Extraocular Procedures Except Orbit,115,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,41809.14,,,,,,,fee schedule,41809.14,62712.94, Extraocular Procedures Except Orbit,115,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,62712.94,,,,,,,fee schedule,41809.14,62712.94, Extraocular Procedures Except Orbit,115,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,48315.58,,,,,,,fee schedule,41809.14,62712.94, Extraocular Procedures Except Orbit,115,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,43483.72,,,,,,,fee schedule,41809.14,62712.94, Extraocular Procedures Except Orbit,115,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Extraocular Procedures Except Orbit,115,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extraocular Procedures Except Orbit,115,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extraocular Procedures Except Orbit,115,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extraocular Procedures Except Orbit,115,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Extraocular Procedures Except Orbit,115,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extraocular Procedures Except Orbit,115,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extraocular Procedures Except Orbit,115,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],14616.94,14616.94,14616.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Extraocular Procedures Except Orbit,115,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extraocular Procedures Except Orbit,115,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extraocular Procedures Except Orbit,115,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extraocular Procedures Except Orbit,115,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extraocular Procedures Except Orbit,115,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extraocular Procedures Except Orbit,115,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extraocular Procedures Except Orbit,115,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extraocular Procedures Except Orbit,115,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Extraocular Procedures Except Orbit,115,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Extraocular Procedures Except Orbit,115,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Extraocular Procedures Except Orbit,115,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Extraocular Procedures Except Orbit,115,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,56799.65,,,,,,,fee schedule,49250.84,73875.35, Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,49250.84,,,,,,,fee schedule,49250.84,73875.35, Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,73875.35,,,,,,,fee schedule,49250.84,73875.35, Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,56915.37,,,,,,,fee schedule,49250.84,73875.35, Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,51223.47,,,,,,,fee schedule,49250.84,73875.35, Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],190954.45,190954.45,190954.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,34081.05,,,,,,,fee schedule,29551.59,44326.84, Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,29551.59,,,,,,,fee schedule,29551.59,44326.84, Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,44326.84,,,,,,,fee schedule,29551.59,44326.84, Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,34150.48,,,,,,,fee schedule,29551.59,44326.84, Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,30735.22,,,,,,,fee schedule,29551.59,44326.84, Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Pacemaker Device Replacement,118,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Device Replacement,118,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Device Replacement,118,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Device Replacement,118,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Device Replacement,118,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Device Replacement,118,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Device Replacement,118,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Device Replacement,118,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Device Replacement,118,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Device Replacement,118,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Device Replacement,118,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Device Replacement,118,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Device Replacement,118,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Device Replacement,118,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Device Replacement,118,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Device Replacement,118,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Pacemaker Device Replacement,118,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Pacemaker Device Replacement,118,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Pacemaker Device Replacement,118,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Pacemaker Device Replacement,118,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Vein ligation & stripping,119,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Vein ligation & stripping,119,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vein ligation & stripping,119,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vein ligation & stripping,119,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vein ligation & stripping,119,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Vein ligation & stripping,119,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vein ligation & stripping,119,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vein ligation & stripping,119,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vein ligation & stripping,119,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vein ligation & stripping,119,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vein ligation & stripping,119,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vein ligation & stripping,119,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vein ligation & stripping,119,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vein ligation & stripping,119,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vein ligation & stripping,119,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vein ligation & stripping,119,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Vein ligation & stripping,119,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Vein ligation & stripping,119,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Vein ligation & stripping,119,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Vein ligation & stripping,119,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other circulatory system O.R. procedures,120,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Other circulatory system O.R. procedures,120,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other circulatory system O.R. procedures,120,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other circulatory system O.R. procedures,120,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other circulatory system O.R. procedures,120,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other circulatory system O.R. procedures,120,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other circulatory system O.R. procedures,120,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other circulatory system O.R. procedures,120,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other circulatory system O.R. procedures,120,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other circulatory system O.R. procedures,120,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other circulatory system O.R. procedures,120,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other circulatory system O.R. procedures,120,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other circulatory system O.R. procedures,120,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other circulatory system O.R. procedures,120,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other circulatory system O.R. procedures,120,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other circulatory system O.R. procedures,120,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other circulatory system O.R. procedures,120,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other circulatory system O.R. procedures,120,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other circulatory system O.R. procedures,120,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other circulatory system O.R. procedures,120,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,36543.91,,,,,,,fee schedule,31687.13,47530.11, Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,31687.13,,,,,,,fee schedule,31687.13,47530.11, Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,47530.11,,,,,,,fee schedule,31687.13,47530.11, Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,36618.36,,,,,,,fee schedule,31687.13,47530.11, Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,32956.29,,,,,,,fee schedule,31687.13,47530.11, Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],44250.58,44250.58,44250.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],6834.9,6834.9,6834.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],8795.67,8795.67,8795.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],6965.09,6965.09,6965.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],10261.19,10261.19,10261.19,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,24685.12,,,,,,,fee schedule,21404.41,32106.22, Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,21404.41,,,,,,,fee schedule,21404.41,32106.22, Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,32106.22,,,,,,,fee schedule,21404.41,32106.22, Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,24735.41,,,,,,,fee schedule,21404.41,32106.22, Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22261.71,,,,,,,fee schedule,21404.41,32106.22, Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],13018.89,13018.89,13018.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],7160.37,7160.37,7160.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Neurological Eye Disorders,123,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,25087.22,,,,,,,fee schedule,21753.07,32629.2, Neurological Eye Disorders,123,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,21753.07,,,,,,,fee schedule,21753.07,32629.2, Neurological Eye Disorders,123,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,32629.2,,,,,,,fee schedule,21753.07,32629.2, Neurological Eye Disorders,123,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,25138.33,,,,,,,fee schedule,21753.07,32629.2, Neurological Eye Disorders,123,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22624.34,,,,,,,fee schedule,21753.07,32629.2, Neurological Eye Disorders,123,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],20677.35,20677.35,20677.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Neurological Eye Disorders,123,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Neurological Eye Disorders,123,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],16579.53,16579.53,16579.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Neurological Eye Disorders,123,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Neurological Eye Disorders,123,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Neurological Eye Disorders,123,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Neurological Eye Disorders,123,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Neurological Eye Disorders,123,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Neurological Eye Disorders,123,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Neurological Eye Disorders,123,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Neurological Eye Disorders,123,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Neurological Eye Disorders,123,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],6965.09,6965.09,8357.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Neurological Eye Disorders,123,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Neurological Eye Disorders,123,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Neurological Eye Disorders,123,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Neurological Eye Disorders,123,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Neurological Eye Disorders,123,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Neurological Eye Disorders,123,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Neurological Eye Disorders,123,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Neurological Eye Disorders,123,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,41563.86,,,,,,,fee schedule,36039.92,54059.22, Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,36039.92,,,,,,,fee schedule,36039.92,54059.22, Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,54059.22,,,,,,,fee schedule,36039.92,54059.22, Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,41648.54,,,,,,,fee schedule,36039.92,54059.22, Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,37483.42,,,,,,,fee schedule,36039.92,54059.22, Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,24119.67,,,,,,,fee schedule,20914.1,31370.77, Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,20914.1,,,,,,,fee schedule,20914.1,31370.77, Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,31370.77,,,,,,,fee schedule,20914.1,31370.77, Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,24168.81,,,,,,,fee schedule,20914.1,31370.77, Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,21751.77,,,,,,,fee schedule,20914.1,31370.77, Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],17064.78,17064.78,17064.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],8795.67,8795.67,8795.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],12238.91,12238.91,12238.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],7485.84,7485.84,7485.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],23626.69,23626.69,23626.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Acute & Subacute Endocarditis,126,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Acute & Subacute Endocarditis,126,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute & Subacute Endocarditis,126,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute & Subacute Endocarditis,126,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute & Subacute Endocarditis,126,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Acute & Subacute Endocarditis,126,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute & Subacute Endocarditis,126,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute & Subacute Endocarditis,126,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute & Subacute Endocarditis,126,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute & Subacute Endocarditis,126,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute & Subacute Endocarditis,126,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute & Subacute Endocarditis,126,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute & Subacute Endocarditis,126,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute & Subacute Endocarditis,126,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute & Subacute Endocarditis,126,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute & Subacute Endocarditis,126,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Acute & Subacute Endocarditis,126,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Acute & Subacute Endocarditis,126,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Acute & Subacute Endocarditis,126,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Acute & Subacute Endocarditis,126,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Heart Failure & Shock,127,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Heart Failure & Shock,127,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Heart Failure & Shock,127,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Heart Failure & Shock,127,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Heart Failure & Shock,127,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Heart Failure & Shock,127,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Heart Failure & Shock,127,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Heart Failure & Shock,127,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Heart Failure & Shock,127,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Heart Failure & Shock,127,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Heart Failure & Shock,127,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Heart Failure & Shock,127,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Heart Failure & Shock,127,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Heart Failure & Shock,127,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Heart Failure & Shock,127,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Heart Failure & Shock,127,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Heart Failure & Shock,127,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Heart Failure & Shock,127,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Heart Failure & Shock,127,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Heart Failure & Shock,127,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Deep Vein Thrombophlebitis,128,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Deep Vein Thrombophlebitis,128,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Deep Vein Thrombophlebitis,128,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Deep Vein Thrombophlebitis,128,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Deep Vein Thrombophlebitis,128,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Deep Vein Thrombophlebitis,128,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Deep Vein Thrombophlebitis,128,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Deep Vein Thrombophlebitis,128,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Deep Vein Thrombophlebitis,128,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Deep Vein Thrombophlebitis,128,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Deep Vein Thrombophlebitis,128,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Deep Vein Thrombophlebitis,128,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Deep Vein Thrombophlebitis,128,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Deep Vein Thrombophlebitis,128,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Deep Vein Thrombophlebitis,128,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Deep Vein Thrombophlebitis,128,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Deep Vein Thrombophlebitis,128,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Deep Vein Thrombophlebitis,128,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Deep Vein Thrombophlebitis,128,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Deep Vein Thrombophlebitis,128,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Head & Neck Procedures W Cc/Mcc Or Major Device,129,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Major Head & Neck Procedures W Cc/Mcc Or Major Device,129,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Head & Neck Procedures W Cc/Mcc Or Major Device,129,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Head & Neck Procedures W Cc/Mcc Or Major Device,129,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Head & Neck Procedures W Cc/Mcc Or Major Device,129,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Major Head & Neck Procedures W Cc/Mcc Or Major Device,129,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Head & Neck Procedures W Cc/Mcc Or Major Device,129,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Head & Neck Procedures W Cc/Mcc Or Major Device,129,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Head & Neck Procedures W Cc/Mcc Or Major Device,129,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Head & Neck Procedures W Cc/Mcc Or Major Device,129,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Head & Neck Procedures W Cc/Mcc Or Major Device,129,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Head & Neck Procedures W Cc/Mcc Or Major Device,129,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Head & Neck Procedures W Cc/Mcc Or Major Device,129,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Head & Neck Procedures W Cc/Mcc Or Major Device,129,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Head & Neck Procedures W Cc/Mcc Or Major Device,129,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Head & Neck Procedures W Cc/Mcc Or Major Device,129,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Head & Neck Procedures W Cc/Mcc Or Major Device,129,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Head & Neck Procedures W Cc/Mcc Or Major Device,129,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Head & Neck Procedures W Cc/Mcc Or Major Device,129,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Head & Neck Procedures W Cc/Mcc Or Major Device,129,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Head & Neck Procedures W/O Cc/Mcc,130,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Major Head & Neck Procedures W/O Cc/Mcc,130,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Head & Neck Procedures W/O Cc/Mcc,130,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Head & Neck Procedures W/O Cc/Mcc,130,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Head & Neck Procedures W/O Cc/Mcc,130,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Major Head & Neck Procedures W/O Cc/Mcc,130,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Head & Neck Procedures W/O Cc/Mcc,130,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Head & Neck Procedures W/O Cc/Mcc,130,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Head & Neck Procedures W/O Cc/Mcc,130,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Head & Neck Procedures W/O Cc/Mcc,130,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Head & Neck Procedures W/O Cc/Mcc,130,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Head & Neck Procedures W/O Cc/Mcc,130,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Head & Neck Procedures W/O Cc/Mcc,130,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Head & Neck Procedures W/O Cc/Mcc,130,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Head & Neck Procedures W/O Cc/Mcc,130,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Head & Neck Procedures W/O Cc/Mcc,130,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Head & Neck Procedures W/O Cc/Mcc,130,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Head & Neck Procedures W/O Cc/Mcc,130,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Head & Neck Procedures W/O Cc/Mcc,130,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Head & Neck Procedures W/O Cc/Mcc,130,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cranial/Facial Procedures W Cc/Mcc,131,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Cranial/Facial Procedures W Cc/Mcc,131,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cranial/Facial Procedures W Cc/Mcc,131,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cranial/Facial Procedures W Cc/Mcc,131,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cranial/Facial Procedures W Cc/Mcc,131,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Cranial/Facial Procedures W Cc/Mcc,131,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cranial/Facial Procedures W Cc/Mcc,131,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cranial/Facial Procedures W Cc/Mcc,131,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cranial/Facial Procedures W Cc/Mcc,131,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cranial/Facial Procedures W Cc/Mcc,131,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cranial/Facial Procedures W Cc/Mcc,131,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cranial/Facial Procedures W Cc/Mcc,131,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cranial/Facial Procedures W Cc/Mcc,131,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cranial/Facial Procedures W Cc/Mcc,131,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cranial/Facial Procedures W Cc/Mcc,131,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cranial/Facial Procedures W Cc/Mcc,131,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cranial/Facial Procedures W Cc/Mcc,131,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cranial/Facial Procedures W Cc/Mcc,131,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cranial/Facial Procedures W Cc/Mcc,131,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cranial/Facial Procedures W Cc/Mcc,131,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cranial/Facial Procedures W/O Cc/Mcc,132,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Cranial/Facial Procedures W/O Cc/Mcc,132,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cranial/Facial Procedures W/O Cc/Mcc,132,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cranial/Facial Procedures W/O Cc/Mcc,132,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cranial/Facial Procedures W/O Cc/Mcc,132,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Cranial/Facial Procedures W/O Cc/Mcc,132,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cranial/Facial Procedures W/O Cc/Mcc,132,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cranial/Facial Procedures W/O Cc/Mcc,132,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cranial/Facial Procedures W/O Cc/Mcc,132,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cranial/Facial Procedures W/O Cc/Mcc,132,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cranial/Facial Procedures W/O Cc/Mcc,132,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cranial/Facial Procedures W/O Cc/Mcc,132,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cranial/Facial Procedures W/O Cc/Mcc,132,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cranial/Facial Procedures W/O Cc/Mcc,132,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cranial/Facial Procedures W/O Cc/Mcc,132,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cranial/Facial Procedures W/O Cc/Mcc,132,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cranial/Facial Procedures W/O Cc/Mcc,132,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cranial/Facial Procedures W/O Cc/Mcc,132,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cranial/Facial Procedures W/O Cc/Mcc,132,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cranial/Facial Procedures W/O Cc/Mcc,132,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth & Throat O.R. Procedures W Cc/Mcc",133,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth & Throat O.R. Procedures W Cc/Mcc",133,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth & Throat O.R. Procedures W Cc/Mcc",133,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth & Throat O.R. Procedures W Cc/Mcc",133,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth & Throat O.R. Procedures W Cc/Mcc",133,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth & Throat O.R. Procedures W Cc/Mcc",133,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth & Throat O.R. Procedures W Cc/Mcc",133,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth & Throat O.R. Procedures W Cc/Mcc",133,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth & Throat O.R. Procedures W Cc/Mcc",133,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth & Throat O.R. Procedures W Cc/Mcc",133,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth & Throat O.R. Procedures W Cc/Mcc",133,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth & Throat O.R. Procedures W Cc/Mcc",133,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth & Throat O.R. Procedures W Cc/Mcc",133,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth & Throat O.R. Procedures W Cc/Mcc",133,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth & Throat O.R. Procedures W Cc/Mcc",133,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth & Throat O.R. Procedures W Cc/Mcc",133,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth & Throat O.R. Procedures W Cc/Mcc",133,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth & Throat O.R. Procedures W Cc/Mcc",133,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth & Throat O.R. Procedures W Cc/Mcc",133,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth & Throat O.R. Procedures W Cc/Mcc",133,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth & Throat O.R. Procedures W/O Cc/Mcc",134,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth & Throat O.R. Procedures W/O Cc/Mcc",134,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth & Throat O.R. Procedures W/O Cc/Mcc",134,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth & Throat O.R. Procedures W/O Cc/Mcc",134,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth & Throat O.R. Procedures W/O Cc/Mcc",134,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth & Throat O.R. Procedures W/O Cc/Mcc",134,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth & Throat O.R. Procedures W/O Cc/Mcc",134,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth & Throat O.R. Procedures W/O Cc/Mcc",134,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth & Throat O.R. Procedures W/O Cc/Mcc",134,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth & Throat O.R. Procedures W/O Cc/Mcc",134,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth & Throat O.R. Procedures W/O Cc/Mcc",134,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth & Throat O.R. Procedures W/O Cc/Mcc",134,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth & Throat O.R. Procedures W/O Cc/Mcc",134,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth & Throat O.R. Procedures W/O Cc/Mcc",134,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth & Throat O.R. Procedures W/O Cc/Mcc",134,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth & Throat O.R. Procedures W/O Cc/Mcc",134,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth & Throat O.R. Procedures W/O Cc/Mcc",134,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth & Throat O.R. Procedures W/O Cc/Mcc",134,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth & Throat O.R. Procedures W/O Cc/Mcc",134,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth & Throat O.R. Procedures W/O Cc/Mcc",134,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,68168.38,,,,,,,fee schedule,59108.63,88661.86, Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,59108.63,,,,,,,fee schedule,59108.63,88661.86, Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,88661.86,,,,,,,fee schedule,59108.63,88661.86, Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,68307.26,,,,,,,fee schedule,59108.63,88661.86, Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,61476.1,,,,,,,fee schedule,59108.63,88661.86, Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],48225.06,48225.06,48225.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,31894.63,,,,,,,fee schedule,27655.76,41483.13, Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,27655.76,,,,,,,fee schedule,27655.76,41483.13, Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,41483.13,,,,,,,fee schedule,27655.76,41483.13, Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,31959.61,,,,,,,fee schedule,27655.76,41483.13, Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,28763.45,,,,,,,fee schedule,27655.76,41483.13, Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,46907.38,,,,,,,fee schedule,40673.27,61009.17, Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,40673.27,,,,,,,fee schedule,40673.27,61009.17, Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,61009.17,,,,,,,fee schedule,40673.27,61009.17, Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,47002.95,,,,,,,fee schedule,40673.27,61009.17, Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,42302.36,,,,,,,fee schedule,40673.27,61009.17, Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,27839.09,,,,,,,fee schedule,24139.2,36208.36, Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,24139.2,,,,,,,fee schedule,24139.2,36208.36, Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,36208.36,,,,,,,fee schedule,24139.2,36208.36, Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,27895.8,,,,,,,fee schedule,24139.2,36208.36, Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,25106.05,,,,,,,fee schedule,24139.2,36208.36, Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Salivary Gland Procedures,139,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,38818.28,,,,,,,fee schedule,33659.23,50488.23, Salivary Gland Procedures,139,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,33659.23,,,,,,,fee schedule,33659.23,50488.23, Salivary Gland Procedures,139,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,50488.23,,,,,,,fee schedule,33659.23,50488.23, Salivary Gland Procedures,139,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,38897.36,,,,,,,fee schedule,33659.23,50488.23, Salivary Gland Procedures,139,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,35007.38,,,,,,,fee schedule,33659.23,50488.23, Salivary Gland Procedures,139,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Salivary Gland Procedures,139,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Salivary Gland Procedures,139,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Salivary Gland Procedures,139,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Salivary Gland Procedures,139,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Salivary Gland Procedures,139,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Salivary Gland Procedures,139,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Salivary Gland Procedures,139,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Salivary Gland Procedures,139,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Salivary Gland Procedures,139,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Salivary Gland Procedures,139,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Salivary Gland Procedures,139,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Salivary Gland Procedures,139,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Salivary Gland Procedures,139,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Salivary Gland Procedures,139,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Salivary Gland Procedures,139,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Salivary Gland Procedures,139,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Salivary Gland Procedures,139,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Salivary Gland Procedures,139,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Salivary Gland Procedures,139,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,133990.13,,,,,,,fee schedule,116182.51,174271.63, Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,116182.51,,,,,,,fee schedule,116182.51,174271.63, Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,174271.63,,,,,,,fee schedule,116182.51,174271.63, Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,134263.11,,,,,,,fee schedule,116182.51,174271.63, Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,120835.95,,,,,,,fee schedule,116182.51,174271.63, Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,68517.08,,,,,,,fee schedule,59410.98,89115.38, Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,59410.98,,,,,,,fee schedule,59410.98,89115.38, Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,89115.38,,,,,,,fee schedule,59410.98,89115.38, Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,68656.67,,,,,,,fee schedule,59410.98,89115.38, Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,61790.56,,,,,,,fee schedule,59410.98,89115.38, Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,23342.83,23342.83,23342.83,1 through 10,percent of total billed charges,,, Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,50149.31,,,,,,,fee schedule,43484.34,65225.71, Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,43484.34,,,,,,,fee schedule,43484.34,65225.71, Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,65225.71,,,,,,,fee schedule,43484.34,65225.71, Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,50251.48,,,,,,,fee schedule,43484.34,65225.71, Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,45226.01,,,,,,,fee schedule,43484.34,65225.71, Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],35345.35,35345.35,35345.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,117695.69,,,,,,,fee schedule,102053.64,153078.58, "Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,102053.64,,,,,,,fee schedule,102053.64,153078.58, "Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,153078.58,,,,,,,fee schedule,102053.64,153078.58, "Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,117935.47,,,,,,,fee schedule,102053.64,153078.58, "Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,106141.18,,,,,,,fee schedule,102053.64,153078.58, "Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],126604.75,126604.75,126604.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],19679.76,18939.33,87284.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],28382.8,21467.16,84742.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,711511.15,711511.15,711511.15,1 through 10,percent of total billed charges,,, "Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,54437.32,,,,,,,fee schedule,47202.46,70802.83, "Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,47202.46,,,,,,,fee schedule,47202.46,70802.83, "Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,70802.83,,,,,,,fee schedule,47202.46,70802.83, "Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,54548.23,,,,,,,fee schedule,47202.46,70802.83, "Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,49093.06,,,,,,,fee schedule,47202.46,70802.83, "Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],33634.57,33634.57,49598.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],44906.52,44906.52,67357.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],67357.15,67357.15,67357.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],15940.72,15940.72,20028.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],5887.83,5887.83,19679.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],26927.89,26927.89,26927.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],13596.1,13596.1,13596.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,64667.06,64667.06,64667.06,1 through 10,percent of total billed charges,,, "Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,37769.05,,,,,,,fee schedule,32749.45,49123.57, "Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,32749.45,,,,,,,fee schedule,32749.45,49123.57, "Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,49123.57,,,,,,,fee schedule,32749.45,49123.57, "Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,37846,,,,,,,fee schedule,32749.45,49123.57, "Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,34061.16,,,,,,,fee schedule,32749.45,49123.57, "Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],34301.64,34301.64,34301.64,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],27957.04,25121.38,45428.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],10241.49,10241.49,10241.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],15057.06,15057.06,15057.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],10629.87,10629.87,10629.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],35274.28,35274.28,35274.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,66516,,,,,,,fee schedule,57675.86,86512.73, "Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,57675.86,,,,,,,fee schedule,57675.86,86512.73, "Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,86512.73,,,,,,,fee schedule,57675.86,86512.73, "Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,66651.52,,,,,,,fee schedule,57675.86,86512.73, "Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,59985.94,,,,,,,fee schedule,57675.86,86512.73, "Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,39942.9,,,,,,,fee schedule,34634.39,51950.95, "Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,34634.39,,,,,,,fee schedule,34634.39,51950.95, "Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,51950.95,,,,,,,fee schedule,34634.39,51950.95, "Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,40024.28,,,,,,,fee schedule,34634.39,51950.95, "Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,36021.6,,,,,,,fee schedule,34634.39,51950.95, "Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,25040.1,,,,,,,fee schedule,21712.21,32567.91, "Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,21712.21,,,,,,,fee schedule,21712.21,32567.91, "Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,32567.91,,,,,,,fee schedule,21712.21,32567.91, "Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,25091.11,,,,,,,fee schedule,21712.21,32567.91, "Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22581.84,,,,,,,fee schedule,21712.21,32567.91, "Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Dysequilibrium,149,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,23610.76,,,,,,,fee schedule,20472.83,30708.87, Dysequilibrium,149,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,20472.83,,,,,,,fee schedule,20472.83,30708.87, Dysequilibrium,149,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,30708.87,,,,,,,fee schedule,20472.83,30708.87, Dysequilibrium,149,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,23658.86,,,,,,,fee schedule,20472.83,30708.87, Dysequilibrium,149,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,21292.83,,,,,,,fee schedule,20472.83,30708.87, Dysequilibrium,149,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Dysequilibrium,149,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Dysequilibrium,149,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Dysequilibrium,149,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Dysequilibrium,149,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Dysequilibrium,149,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Dysequilibrium,149,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Dysequilibrium,149,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Dysequilibrium,149,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Dysequilibrium,149,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Dysequilibrium,149,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Dysequilibrium,149,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Dysequilibrium,149,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Dysequilibrium,149,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Dysequilibrium,149,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Dysequilibrium,149,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Dysequilibrium,149,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Dysequilibrium,149,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Dysequilibrium,149,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Dysequilibrium,149,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Epistaxis With Mcc,150,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,41827.74,,,,,,,fee schedule,36268.73,54402.43, Epistaxis With Mcc,150,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,36268.73,,,,,,,fee schedule,36268.73,54402.43, Epistaxis With Mcc,150,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,54402.43,,,,,,,fee schedule,36268.73,54402.43, Epistaxis With Mcc,150,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,41912.96,,,,,,,fee schedule,36268.73,54402.43, Epistaxis With Mcc,150,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,37721.4,,,,,,,fee schedule,36268.73,54402.43, Epistaxis With Mcc,150,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Epistaxis With Mcc,150,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Epistaxis With Mcc,150,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Epistaxis With Mcc,150,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Epistaxis With Mcc,150,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Epistaxis With Mcc,150,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Epistaxis With Mcc,150,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Epistaxis With Mcc,150,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Epistaxis With Mcc,150,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Epistaxis With Mcc,150,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Epistaxis With Mcc,150,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Epistaxis With Mcc,150,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Epistaxis With Mcc,150,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Epistaxis With Mcc,150,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Epistaxis With Mcc,150,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Epistaxis With Mcc,150,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Epistaxis With Mcc,150,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Epistaxis With Mcc,150,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Epistaxis With Mcc,150,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Epistaxis With Mcc,150,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Epistaxis Without Mcc,151,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,23057.88,,,,,,,fee schedule,19993.43,29989.77, Epistaxis Without Mcc,151,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,19993.43,,,,,,,fee schedule,19993.43,29989.77, Epistaxis Without Mcc,151,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,29989.77,,,,,,,fee schedule,19993.43,29989.77, Epistaxis Without Mcc,151,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,23104.85,,,,,,,fee schedule,19993.43,29989.77, Epistaxis Without Mcc,151,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,20794.22,,,,,,,fee schedule,19993.43,29989.77, Epistaxis Without Mcc,151,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Epistaxis Without Mcc,151,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Epistaxis Without Mcc,151,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Epistaxis Without Mcc,151,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Epistaxis Without Mcc,151,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Epistaxis Without Mcc,151,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Epistaxis Without Mcc,151,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Epistaxis Without Mcc,151,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Epistaxis Without Mcc,151,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Epistaxis Without Mcc,151,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Epistaxis Without Mcc,151,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Epistaxis Without Mcc,151,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Epistaxis Without Mcc,151,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Epistaxis Without Mcc,151,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Epistaxis Without Mcc,151,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Epistaxis Without Mcc,151,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Epistaxis Without Mcc,151,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Epistaxis Without Mcc,151,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Epistaxis Without Mcc,151,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Epistaxis Without Mcc,151,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Otitis Media And Uri With Mcc,152,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,37137.63,,,,,,,fee schedule,32201.95,48302.33, Otitis Media And Uri With Mcc,152,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,32201.95,,,,,,,fee schedule,32201.95,48302.33, Otitis Media And Uri With Mcc,152,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,48302.33,,,,,,,fee schedule,32201.95,48302.33, Otitis Media And Uri With Mcc,152,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,37213.29,,,,,,,fee schedule,32201.95,48302.33, Otitis Media And Uri With Mcc,152,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,33491.73,,,,,,,fee schedule,32201.95,48302.33, Otitis Media And Uri With Mcc,152,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],6588.66,6588.66,6588.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Otitis Media And Uri With Mcc,152,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Otitis Media And Uri With Mcc,152,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Otitis Media And Uri With Mcc,152,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Otitis Media And Uri With Mcc,152,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Otitis Media And Uri With Mcc,152,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Otitis Media And Uri With Mcc,152,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Otitis Media And Uri With Mcc,152,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],19145.28,19145.28,19145.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Otitis Media And Uri With Mcc,152,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Otitis Media And Uri With Mcc,152,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],9422.46,9422.46,9422.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Otitis Media And Uri With Mcc,152,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Otitis Media And Uri With Mcc,152,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],10180.75,9165.48,18728.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Otitis Media And Uri With Mcc,152,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],9664.86,9664.86,9664.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Otitis Media And Uri With Mcc,152,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Otitis Media And Uri With Mcc,152,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Otitis Media And Uri With Mcc,152,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Otitis Media And Uri With Mcc,152,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Otitis Media And Uri With Mcc,152,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Otitis Media And Uri With Mcc,152,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Otitis Media And Uri With Mcc,152,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,23189.81,,,,,,,fee schedule,20107.83,30161.38, Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,20107.83,,,,,,,fee schedule,20107.83,30161.38, Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,30161.38,,,,,,,fee schedule,20107.83,30161.38, Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,23237.06,,,,,,,fee schedule,20107.83,30161.38, Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,20913.21,,,,,,,fee schedule,20107.83,30161.38, Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],18699.95,18699.95,20094.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],6499.38,6499.38,6499.38,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],16918.19,12858.9,18193.19,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],21998.77,21998.77,21998.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],5686.96,5620.2,5686.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],5957.77,5887.83,5957.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],5795.28,4165.55,10180.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],19228.18,16979.86,19846.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,17425.91,17425.91,17425.91,1 through 10,percent of total billed charges,,, Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,49115.79,,,,,,,fee schedule,42588.18,63881.48, "Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,42588.18,,,,,,,fee schedule,42588.18,63881.48, "Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,63881.48,,,,,,,fee schedule,42588.18,63881.48, "Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,49215.85,,,,,,,fee schedule,42588.18,63881.48, "Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,44293.96,,,,,,,fee schedule,42588.18,63881.48, "Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],41573.11,41573.11,41573.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],24672.55,24672.55,24672.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,28790.93,,,,,,,fee schedule,24964.54,37446.36, "Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,24964.54,,,,,,,fee schedule,24964.54,37446.36, "Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,37446.36,,,,,,,fee schedule,24964.54,37446.36, "Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,28849.59,,,,,,,fee schedule,24964.54,37446.36, "Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,25964.45,,,,,,,fee schedule,24964.54,37446.36, "Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],42302.15,42302.15,42302.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],22175.64,22175.64,24748.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],8121.56,8121.56,8121.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],8508.3,8508.3,8508.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],8276.26,8276.26,13937.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],22534.37,22534.37,22534.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,21710.22,,,,,,,fee schedule,18824.87,28236.96, "Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,18824.87,,,,,,,fee schedule,18824.87,28236.96, "Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,28236.96,,,,,,,fee schedule,18824.87,28236.96, "Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,21754.45,,,,,,,fee schedule,18824.87,28236.96, "Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19578.86,,,,,,,fee schedule,18824.87,28236.96, "Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],14603.17,14603.17,14603.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],15202.24,15202.24,15202.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],6224.53,6224.53,6224.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],6054.77,6054.77,6054.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,53931.56,,,,,,,fee schedule,46763.92,70145.01, Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,46763.92,,,,,,,fee schedule,46763.92,70145.01, Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,70145.01,,,,,,,fee schedule,46763.92,70145.01, Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,54041.43,,,,,,,fee schedule,46763.92,70145.01, Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,48636.94,,,,,,,fee schedule,46763.92,70145.01, Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],41859.41,41859.41,41859.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],14330.06,14330.06,14330.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],45663.33,45663.33,45663.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,168253.16,168253.16,168253.16,1 through 10,percent of total billed charges,,, Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Dental And Oral Diseases With Cc,158,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,28580.46,,,,,,,fee schedule,24782.04,37172.61, Dental And Oral Diseases With Cc,158,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,24782.04,,,,,,,fee schedule,24782.04,37172.61, Dental And Oral Diseases With Cc,158,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,37172.61,,,,,,,fee schedule,24782.04,37172.61, Dental And Oral Diseases With Cc,158,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,28638.68,,,,,,,fee schedule,24782.04,37172.61, Dental And Oral Diseases With Cc,158,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,25774.63,,,,,,,fee schedule,24782.04,37172.61, Dental And Oral Diseases With Cc,158,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],18984.54,18984.54,18984.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Dental And Oral Diseases With Cc,158,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Dental And Oral Diseases With Cc,158,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Dental And Oral Diseases With Cc,158,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Dental And Oral Diseases With Cc,158,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Dental And Oral Diseases With Cc,158,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Dental And Oral Diseases With Cc,158,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Dental And Oral Diseases With Cc,158,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],8121.56,8121.56,8121.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Dental And Oral Diseases With Cc,158,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Dental And Oral Diseases With Cc,158,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],10729.18,10729.18,15779.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Dental And Oral Diseases With Cc,158,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Dental And Oral Diseases With Cc,158,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],6054.77,4880.73,13939.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Dental And Oral Diseases With Cc,158,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],24544.81,24544.81,24544.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Dental And Oral Diseases With Cc,158,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Dental And Oral Diseases With Cc,158,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Dental And Oral Diseases With Cc,158,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,106226.27,106226.27,106226.27,1 through 10,percent of total billed charges,,, Dental And Oral Diseases With Cc,158,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Dental And Oral Diseases With Cc,158,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Dental And Oral Diseases With Cc,158,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Dental And Oral Diseases With Cc,158,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,22256.82,,,,,,,fee schedule,19298.83,28947.89, Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,19298.83,,,,,,,fee schedule,19298.83,28947.89, Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,28947.89,,,,,,,fee schedule,19298.83,28947.89, Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,22302.16,,,,,,,fee schedule,19298.83,28947.89, Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,20071.81,,,,,,,fee schedule,19298.83,28947.89, Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],5473.72,5473.72,5473.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],8121.56,8121.56,8121.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],6054.77,6054.77,6054.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hernia Procedures Except Inguinal & Femoral Age >17 w/o CC,160,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Hernia Procedures Except Inguinal & Femoral Age >17 w/o CC,160,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hernia Procedures Except Inguinal & Femoral Age >17 w/o CC,160,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hernia Procedures Except Inguinal & Femoral Age >17 w/o CC,160,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hernia Procedures Except Inguinal & Femoral Age >17 w/o CC,160,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Hernia Procedures Except Inguinal & Femoral Age >17 w/o CC,160,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hernia Procedures Except Inguinal & Femoral Age >17 w/o CC,160,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hernia Procedures Except Inguinal & Femoral Age >17 w/o CC,160,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hernia Procedures Except Inguinal & Femoral Age >17 w/o CC,160,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hernia Procedures Except Inguinal & Femoral Age >17 w/o CC,160,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hernia Procedures Except Inguinal & Femoral Age >17 w/o CC,160,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hernia Procedures Except Inguinal & Femoral Age >17 w/o CC,160,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hernia Procedures Except Inguinal & Femoral Age >17 w/o CC,160,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hernia Procedures Except Inguinal & Femoral Age >17 w/o CC,160,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hernia Procedures Except Inguinal & Femoral Age >17 w/o CC,160,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hernia Procedures Except Inguinal & Femoral Age >17 w/o CC,160,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hernia Procedures Except Inguinal & Femoral Age >17 w/o CC,160,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hernia Procedures Except Inguinal & Femoral Age >17 w/o CC,160,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hernia Procedures Except Inguinal & Femoral Age >17 w/o CC,160,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hernia Procedures Except Inguinal & Femoral Age >17 w/o CC,160,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Inguinal & Femoral Hernia Procedures Age >17 w CC,161,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Inguinal & Femoral Hernia Procedures Age >17 w CC,161,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inguinal & Femoral Hernia Procedures Age >17 w CC,161,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inguinal & Femoral Hernia Procedures Age >17 w CC,161,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inguinal & Femoral Hernia Procedures Age >17 w CC,161,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Inguinal & Femoral Hernia Procedures Age >17 w CC,161,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inguinal & Femoral Hernia Procedures Age >17 w CC,161,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inguinal & Femoral Hernia Procedures Age >17 w CC,161,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inguinal & Femoral Hernia Procedures Age >17 w CC,161,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inguinal & Femoral Hernia Procedures Age >17 w CC,161,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inguinal & Femoral Hernia Procedures Age >17 w CC,161,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inguinal & Femoral Hernia Procedures Age >17 w CC,161,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inguinal & Femoral Hernia Procedures Age >17 w CC,161,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inguinal & Femoral Hernia Procedures Age >17 w CC,161,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inguinal & Femoral Hernia Procedures Age >17 w CC,161,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inguinal & Femoral Hernia Procedures Age >17 w CC,161,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Inguinal & Femoral Hernia Procedures Age >17 w CC,161,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Inguinal & Femoral Hernia Procedures Age >17 w CC,161,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Inguinal & Femoral Hernia Procedures Age >17 w CC,161,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Inguinal & Femoral Hernia Procedures Age >17 w CC,161,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Inguinal & Femoral Hernia Procedures Age >17 w/o CC,162,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Inguinal & Femoral Hernia Procedures Age >17 w/o CC,162,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inguinal & Femoral Hernia Procedures Age >17 w/o CC,162,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inguinal & Femoral Hernia Procedures Age >17 w/o CC,162,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inguinal & Femoral Hernia Procedures Age >17 w/o CC,162,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Inguinal & Femoral Hernia Procedures Age >17 w/o CC,162,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inguinal & Femoral Hernia Procedures Age >17 w/o CC,162,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inguinal & Femoral Hernia Procedures Age >17 w/o CC,162,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inguinal & Femoral Hernia Procedures Age >17 w/o CC,162,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inguinal & Femoral Hernia Procedures Age >17 w/o CC,162,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inguinal & Femoral Hernia Procedures Age >17 w/o CC,162,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inguinal & Femoral Hernia Procedures Age >17 w/o CC,162,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inguinal & Femoral Hernia Procedures Age >17 w/o CC,162,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inguinal & Femoral Hernia Procedures Age >17 w/o CC,162,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inguinal & Femoral Hernia Procedures Age >17 w/o CC,162,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inguinal & Femoral Hernia Procedures Age >17 w/o CC,162,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Inguinal & Femoral Hernia Procedures Age >17 w/o CC,162,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Inguinal & Femoral Hernia Procedures Age >17 w/o CC,162,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Inguinal & Femoral Hernia Procedures Age >17 w/o CC,162,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Inguinal & Femoral Hernia Procedures Age >17 w/o CC,162,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Chest Procedures With Mcc,163,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,140791.27,,,,,,,fee schedule,122079.75,183117.38, Major Chest Procedures With Mcc,163,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,122079.75,,,,,,,fee schedule,122079.75,183117.38, Major Chest Procedures With Mcc,163,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,183117.38,,,,,,,fee schedule,122079.75,183117.38, Major Chest Procedures With Mcc,163,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,141078.1,,,,,,,fee schedule,122079.75,183117.38, Major Chest Procedures With Mcc,163,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,126969.39,,,,,,,fee schedule,122079.75,183117.38, Major Chest Procedures With Mcc,163,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],643206.39,361392.93,2083941.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Chest Procedures With Mcc,163,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],298481.74,298481.74,298481.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Chest Procedures With Mcc,163,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],176730.56,149038.22,1228440.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Chest Procedures With Mcc,163,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],679437.55,332336.62,914077.96,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Chest Procedures With Mcc,163,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Major Chest Procedures With Mcc,163,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Chest Procedures With Mcc,163,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Chest Procedures With Mcc,163,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],961585.07,961585.07,961585.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Chest Procedures With Mcc,163,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Chest Procedures With Mcc,163,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],273608.26,262422.18,345628.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Chest Procedures With Mcc,163,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Chest Procedures With Mcc,163,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],121268.97,24574.55,347251.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Chest Procedures With Mcc,163,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],213213.15,213213.15,269667.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Chest Procedures With Mcc,163,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],6632.84,6632.84,6632.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Chest Procedures With Mcc,163,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Chest Procedures With Mcc,163,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,200449.32,200449.32,262083.62,1 through 10,percent of total billed charges,,, Major Chest Procedures With Mcc,163,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Chest Procedures With Mcc,163,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Chest Procedures With Mcc,163,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Chest Procedures With Mcc,163,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Chest Procedures With Cc,164,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,79288.94,,,,,,,fee schedule,68751.24,103125.59, Major Chest Procedures With Cc,164,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,68751.24,,,,,,,fee schedule,68751.24,103125.59, Major Chest Procedures With Cc,164,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,103125.59,,,,,,,fee schedule,68751.24,103125.59, Major Chest Procedures With Cc,164,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,79450.47,,,,,,,fee schedule,68751.24,103125.59, Major Chest Procedures With Cc,164,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,71504.92,,,,,,,fee schedule,68751.24,103125.59, Major Chest Procedures With Cc,164,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],22052.22,22052.22,22052.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Chest Procedures With Cc,164,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Major Chest Procedures With Cc,164,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],96509.33,96509.33,99372.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Chest Procedures With Cc,164,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],94658.03,63214.47,369551.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Chest Procedures With Cc,164,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Major Chest Procedures With Cc,164,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Chest Procedures With Cc,164,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Chest Procedures With Cc,164,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Chest Procedures With Cc,164,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Chest Procedures With Cc,164,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],25263.56,25263.56,25263.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Chest Procedures With Cc,164,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Chest Procedures With Cc,164,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],81213.12,81213.12,81213.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Chest Procedures With Cc,164,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],73846.26,73846.26,73846.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Chest Procedures With Cc,164,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Chest Procedures With Cc,164,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Chest Procedures With Cc,164,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Chest Procedures With Cc,164,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Chest Procedures With Cc,164,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Chest Procedures With Cc,164,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Chest Procedures With Cc,164,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,60132.68,,,,,,,fee schedule,52140.89,78210.38, Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,52140.89,,,,,,,fee schedule,52140.89,78210.38, Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,78210.38,,,,,,,fee schedule,52140.89,78210.38, Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,60255.19,,,,,,,fee schedule,52140.89,78210.38, Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,54229.29,,,,,,,fee schedule,52140.89,78210.38, Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],71213.26,71213.26,71213.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],71471.35,71471.35,71471.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],19174.67,19174.67,19174.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],15251.89,15251.89,19663.23,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],51979.5,51979.5,51979.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,51293.56,51293.56,51293.56,1 through 10,percent of total billed charges,,, Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,117416.11,,,,,,,fee schedule,101811.21,152714.95, Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,101811.21,,,,,,,fee schedule,101811.21,152714.95, Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,152714.95,,,,,,,fee schedule,101811.21,152714.95, Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,117655.32,,,,,,,fee schedule,101811.21,152714.95, Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,105889.04,,,,,,,fee schedule,101811.21,152714.95, Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],33363.51,33363.51,33363.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],350257.48,350257.48,822217.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],45290.56,45290.56,45290.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],390135.95,390135.95,390135.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,56652.01,,,,,,,fee schedule,49122.81,73683.32, Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,49122.81,,,,,,,fee schedule,49122.81,73683.32, Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,73683.32,,,,,,,fee schedule,49122.81,73683.32, Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,56767.43,,,,,,,fee schedule,49122.81,73683.32, Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,51090.32,,,,,,,fee schedule,49122.81,73683.32, Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],20087.75,20087.75,20087.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],16392.22,16392.22,16392.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],47889.48,47889.48,47889.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,42924.09,,,,,,,fee schedule,37219.37,55828.37, Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,37219.37,,,,,,,fee schedule,37219.37,55828.37, Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,55828.37,,,,,,,fee schedule,37219.37,55828.37, Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,43011.54,,,,,,,fee schedule,37219.37,55828.37, Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,38710.11,,,,,,,fee schedule,37219.37,55828.37, Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Mouth Procedures w/o CC,169,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Mouth Procedures w/o CC,169,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Mouth Procedures w/o CC,169,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Mouth Procedures w/o CC,169,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Mouth Procedures w/o CC,169,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Mouth Procedures w/o CC,169,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Mouth Procedures w/o CC,169,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Mouth Procedures w/o CC,169,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Mouth Procedures w/o CC,169,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Mouth Procedures w/o CC,169,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Mouth Procedures w/o CC,169,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Mouth Procedures w/o CC,169,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Mouth Procedures w/o CC,169,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Mouth Procedures w/o CC,169,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Mouth Procedures w/o CC,169,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Mouth Procedures w/o CC,169,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Mouth Procedures w/o CC,169,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Mouth Procedures w/o CC,169,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Mouth Procedures w/o CC,169,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Mouth Procedures w/o CC,169,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Digestive System O.R. Procedures w/o CC,171,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System O.R. Procedures w/o CC,171,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System O.R. Procedures w/o CC,171,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System O.R. Procedures w/o CC,171,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System O.R. Procedures w/o CC,171,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System O.R. Procedures w/o CC,171,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System O.R. Procedures w/o CC,171,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System O.R. Procedures w/o CC,171,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System O.R. Procedures w/o CC,171,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System O.R. Procedures w/o CC,171,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System O.R. Procedures w/o CC,171,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System O.R. Procedures w/o CC,171,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System O.R. Procedures w/o CC,171,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System O.R. Procedures w/o CC,171,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System O.R. Procedures w/o CC,171,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System O.R. Procedures w/o CC,171,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Digestive System O.R. Procedures w/o CC,171,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Digestive System O.R. Procedures w/o CC,171,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Digestive System O.R. Procedures w/o CC,171,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Digestive System O.R. Procedures w/o CC,171,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,93500.63,,,,,,,fee schedule,81074.16,121609.75, Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,81074.16,,,,,,,fee schedule,81074.16,121609.75, Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,121609.75,,,,,,,fee schedule,81074.16,121609.75, Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,93691.12,,,,,,,fee schedule,81074.16,121609.75, Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,84321.41,,,,,,,fee schedule,81074.16,121609.75, Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. G.I. hemorrhage w CC,174,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. G.I. hemorrhage w CC,174,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. G.I. hemorrhage w CC,174,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. G.I. hemorrhage w CC,174,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. G.I. hemorrhage w CC,174,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. G.I. hemorrhage w CC,174,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. G.I. hemorrhage w CC,174,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. G.I. hemorrhage w CC,174,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. G.I. hemorrhage w CC,174,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. G.I. hemorrhage w CC,174,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. G.I. hemorrhage w CC,174,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. G.I. hemorrhage w CC,174,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. G.I. hemorrhage w CC,174,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. G.I. hemorrhage w CC,174,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. G.I. hemorrhage w CC,174,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. G.I. hemorrhage w CC,174,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. G.I. hemorrhage w CC,174,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. G.I. hemorrhage w CC,174,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. G.I. hemorrhage w CC,174,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. G.I. hemorrhage w CC,174,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,43150.27,,,,,,,fee schedule,37415.49,56122.55, Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,37415.49,,,,,,,fee schedule,37415.49,56122.55, Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,56122.55,,,,,,,fee schedule,37415.49,56122.55, Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,43238.18,,,,,,,fee schedule,37415.49,56122.55, Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,38914.09,,,,,,,fee schedule,37415.49,56122.55, Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,25288.27,,,,,,,fee schedule,21927.4,32890.69, Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,21927.4,,,,,,,fee schedule,21927.4,32890.69, Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,32890.69,,,,,,,fee schedule,21927.4,32890.69, Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,25339.79,,,,,,,fee schedule,21927.4,32890.69, Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22805.65,,,,,,,fee schedule,21927.4,32890.69, Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],20813.87,20813.87,20813.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,15498.9,15498.9,15498.9,1 through 10,percent of total billed charges,,, Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,49090.66,,,,,,,fee schedule,42566.39,63848.8, Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,42566.39,,,,,,,fee schedule,42566.39,63848.8, Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,63848.8,,,,,,,fee schedule,42566.39,63848.8, Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,49190.67,,,,,,,fee schedule,42566.39,63848.8, Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,44271.29,,,,,,,fee schedule,42566.39,63848.8, Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],41288.68,41288.68,41288.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],40530.08,40530.08,40530.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],41327.16,41327.16,46133.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],11362.5,11362.5,11362.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],12037.83,12037.83,12104.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],21518.41,21518.41,92301.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],14965.11,12267.12,27756.22,21,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],27794.5,22053.01,45077.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],42683.68,42683.68,42683.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],13256.82,13256.82,13256.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,30660.06,,,,,,,fee schedule,26585.26,39877.41, Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,26585.26,,,,,,,fee schedule,26585.26,39877.41, Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,39877.41,,,,,,,fee schedule,26585.26,39877.41, Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,30722.53,,,,,,,fee schedule,26585.26,39877.41, Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,27650.08,,,,,,,fee schedule,26585.26,39877.41, Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],9583.45,9583.45,9583.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],26583.66,26583.66,26583.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],25361.05,25361.05,25361.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],12611.06,12611.06,12611.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],27556.53,12334.61,27756.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,23717.57,,,,,,,fee schedule,20565.45,30847.79, Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,20565.45,,,,,,,fee schedule,20565.45,30847.79, Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,30847.79,,,,,,,fee schedule,20565.45,30847.79, Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,23765.89,,,,,,,fee schedule,20565.45,30847.79, Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,21389.15,,,,,,,fee schedule,20565.45,30847.79, Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],12104.05,12104.05,12104.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],12611.06,12611.06,12611.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],18208.35,12334.61,18913.23,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,55477.12,,,,,,,fee schedule,48104.07,72155.23, Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,48104.07,,,,,,,fee schedule,48104.07,72155.23, Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,72155.23,,,,,,,fee schedule,48104.07,72155.23, Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,55590.15,,,,,,,fee schedule,48104.07,72155.23, Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,50030.78,,,,,,,fee schedule,48104.07,72155.23, Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],14574.08,14574.08,14574.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Respiratory Neoplasms With Cc,181,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,33644.39,,,,,,,fee schedule,29172.97,43758.92, Respiratory Neoplasms With Cc,181,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,29172.97,,,,,,,fee schedule,29172.97,43758.92, Respiratory Neoplasms With Cc,181,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,43758.92,,,,,,,fee schedule,29172.97,43758.92, Respiratory Neoplasms With Cc,181,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,33712.94,,,,,,,fee schedule,29172.97,43758.92, Respiratory Neoplasms With Cc,181,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,30341.43,,,,,,,fee schedule,29172.97,43758.92, Respiratory Neoplasms With Cc,181,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Neoplasms With Cc,181,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Neoplasms With Cc,181,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Neoplasms With Cc,181,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Neoplasms With Cc,181,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Neoplasms With Cc,181,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Neoplasms With Cc,181,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Neoplasms With Cc,181,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Neoplasms With Cc,181,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Neoplasms With Cc,181,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Neoplasms With Cc,181,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Neoplasms With Cc,181,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Neoplasms With Cc,181,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Neoplasms With Cc,181,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Neoplasms With Cc,181,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Neoplasms With Cc,181,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Respiratory Neoplasms With Cc,181,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Respiratory Neoplasms With Cc,181,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Respiratory Neoplasms With Cc,181,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Respiratory Neoplasms With Cc,181,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,23679.87,,,,,,,fee schedule,20532.76,30798.76, Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,20532.76,,,,,,,fee schedule,20532.76,30798.76, Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,30798.76,,,,,,,fee schedule,20532.76,30798.76, Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,23728.12,,,,,,,fee schedule,20532.76,30798.76, Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,21355.15,,,,,,,fee schedule,20532.76,30798.76, Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Chest Trauma With Mcc,183,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,48060.28,,,,,,,fee schedule,41672.95,62508.65, Major Chest Trauma With Mcc,183,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,41672.95,,,,,,,fee schedule,41672.95,62508.65, Major Chest Trauma With Mcc,183,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,62508.65,,,,,,,fee schedule,41672.95,62508.65, Major Chest Trauma With Mcc,183,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,48158.19,,,,,,,fee schedule,41672.95,62508.65, Major Chest Trauma With Mcc,183,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,43342.07,,,,,,,fee schedule,41672.95,62508.65, Major Chest Trauma With Mcc,183,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Major Chest Trauma With Mcc,183,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Chest Trauma With Mcc,183,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Chest Trauma With Mcc,183,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Chest Trauma With Mcc,183,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Major Chest Trauma With Mcc,183,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Chest Trauma With Mcc,183,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Chest Trauma With Mcc,183,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Chest Trauma With Mcc,183,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Chest Trauma With Mcc,183,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Chest Trauma With Mcc,183,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Chest Trauma With Mcc,183,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Chest Trauma With Mcc,183,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Chest Trauma With Mcc,183,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Chest Trauma With Mcc,183,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Chest Trauma With Mcc,183,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Chest Trauma With Mcc,183,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Chest Trauma With Mcc,183,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Chest Trauma With Mcc,183,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Chest Trauma With Mcc,183,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Chest Trauma With Cc,184,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,33427.64,,,,,,,fee schedule,28985.02,43477, Major Chest Trauma With Cc,184,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,28985.02,,,,,,,fee schedule,28985.02,43477, Major Chest Trauma With Cc,184,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,43477,,,,,,,fee schedule,28985.02,43477, Major Chest Trauma With Cc,184,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,33495.74,,,,,,,fee schedule,28985.02,43477, Major Chest Trauma With Cc,184,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,30145.95,,,,,,,fee schedule,28985.02,43477, Major Chest Trauma With Cc,184,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Major Chest Trauma With Cc,184,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Chest Trauma With Cc,184,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Chest Trauma With Cc,184,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Chest Trauma With Cc,184,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Major Chest Trauma With Cc,184,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Chest Trauma With Cc,184,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Chest Trauma With Cc,184,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Chest Trauma With Cc,184,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Chest Trauma With Cc,184,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Chest Trauma With Cc,184,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Chest Trauma With Cc,184,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Chest Trauma With Cc,184,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Chest Trauma With Cc,184,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Chest Trauma With Cc,184,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Chest Trauma With Cc,184,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Chest Trauma With Cc,184,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Chest Trauma With Cc,184,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Chest Trauma With Cc,184,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Chest Trauma With Cc,184,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,24707.11,,,,,,,fee schedule,21423.47,32134.82, Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,21423.47,,,,,,,fee schedule,21423.47,32134.82, Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,32134.82,,,,,,,fee schedule,21423.47,32134.82, Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,24757.45,,,,,,,fee schedule,21423.47,32134.82, Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22281.55,,,,,,,fee schedule,21423.47,32134.82, Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Pleural Effusion With Mcc,186,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,48958.72,,,,,,,fee schedule,42451.98,63677.19, Pleural Effusion With Mcc,186,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,42451.98,,,,,,,fee schedule,42451.98,63677.19, Pleural Effusion With Mcc,186,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,63677.19,,,,,,,fee schedule,42451.98,63677.19, Pleural Effusion With Mcc,186,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,49058.46,,,,,,,fee schedule,42451.98,63677.19, Pleural Effusion With Mcc,186,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,44152.31,,,,,,,fee schedule,42451.98,63677.19, Pleural Effusion With Mcc,186,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Pleural Effusion With Mcc,186,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pleural Effusion With Mcc,186,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],60581.94,60581.94,60581.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Pleural Effusion With Mcc,186,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pleural Effusion With Mcc,186,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Pleural Effusion With Mcc,186,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pleural Effusion With Mcc,186,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pleural Effusion With Mcc,186,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pleural Effusion With Mcc,186,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pleural Effusion With Mcc,186,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pleural Effusion With Mcc,186,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pleural Effusion With Mcc,186,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pleural Effusion With Mcc,186,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pleural Effusion With Mcc,186,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pleural Effusion With Mcc,186,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pleural Effusion With Mcc,186,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Pleural Effusion With Mcc,186,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Pleural Effusion With Mcc,186,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Pleural Effusion With Mcc,186,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Pleural Effusion With Mcc,186,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Pleural Effusion With Cc,187,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,31071.59,,,,,,,fee schedule,26942.09,40412.65, Pleural Effusion With Cc,187,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,26942.09,,,,,,,fee schedule,26942.09,40412.65, Pleural Effusion With Cc,187,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,40412.65,,,,,,,fee schedule,26942.09,40412.65, Pleural Effusion With Cc,187,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,31134.89,,,,,,,fee schedule,26942.09,40412.65, Pleural Effusion With Cc,187,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,28021.2,,,,,,,fee schedule,26942.09,40412.65, Pleural Effusion With Cc,187,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Pleural Effusion With Cc,187,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pleural Effusion With Cc,187,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],39235.62,39235.62,39235.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Pleural Effusion With Cc,187,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pleural Effusion With Cc,187,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Pleural Effusion With Cc,187,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pleural Effusion With Cc,187,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pleural Effusion With Cc,187,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pleural Effusion With Cc,187,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pleural Effusion With Cc,187,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pleural Effusion With Cc,187,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pleural Effusion With Cc,187,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pleural Effusion With Cc,187,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pleural Effusion With Cc,187,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pleural Effusion With Cc,187,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pleural Effusion With Cc,187,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Pleural Effusion With Cc,187,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Pleural Effusion With Cc,187,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Pleural Effusion With Cc,187,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Pleural Effusion With Cc,187,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,22530.12,,,,,,,fee schedule,19535.81,29303.36, Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,19535.81,,,,,,,fee schedule,19535.81,29303.36, Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,29303.36,,,,,,,fee schedule,19535.81,29303.36, Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,22576.02,,,,,,,fee schedule,19535.81,29303.36, Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,20318.28,,,,,,,fee schedule,19535.81,29303.36, Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,38808.86,,,,,,,fee schedule,33651.06,50475.97, Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,33651.06,,,,,,,fee schedule,33651.06,50475.97, Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,50475.97,,,,,,,fee schedule,33651.06,50475.97, Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,38887.92,,,,,,,fee schedule,33651.06,50475.97, Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,34998.88,,,,,,,fee schedule,33651.06,50475.97, Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],21030.42,11073.65,34936.75,23,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],9221.7,8988.4,15822.23,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],42590.81,17795.98,47445.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],24485.85,10363.02,34937.89,75,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],14891.58,14891.58,14891.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],7864.85,6056.07,14685.38,30,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],8239.36,8239.36,14503.71,69,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],14271.1,14271.1,14271.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],8222.68,8014.65,20916.47,171,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],28286.11,12259.78,34506.14,44,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],7452.87,7452.87,7452.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],8613.88,8613.88,14271.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,14601.33,3595.85,30871.39,20,percent of total billed charges,,, Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,8728.48,8728.48,8728.48,1 through 10,percent of total billed charges,,, Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,34797.29,,,,,,,fee schedule,30172.64,45258.41, Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,30172.64,,,,,,,fee schedule,30172.64,45258.41, Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,45258.41,,,,,,,fee schedule,30172.64,45258.41, Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,34868.18,,,,,,,fee schedule,30172.64,45258.41, Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,31381.14,,,,,,,fee schedule,30172.64,45258.41, Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,26482,,,,,,,fee schedule,22962.48,34443.29, Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,22962.48,,,,,,,fee schedule,22962.48,34443.29, Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,34443.29,,,,,,,fee schedule,22962.48,34443.29, Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,26535.95,,,,,,,fee schedule,22962.48,34443.29, Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,23882.19,,,,,,,fee schedule,22962.48,34443.29, Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,20167.79,,,,,,,fee schedule,17487.44,26230.84, Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,17487.44,,,,,,,fee schedule,17487.44,26230.84, Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,26230.84,,,,,,,fee schedule,17487.44,26230.84, Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,20208.88,,,,,,,fee schedule,17487.44,26230.84, Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,18187.86,,,,,,,fee schedule,17487.44,26230.84, Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,41290.56,,,,,,,fee schedule,35802.94,53703.76, Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,35802.94,,,,,,,fee schedule,35802.94,53703.76, Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,53703.76,,,,,,,fee schedule,35802.94,53703.76, Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,41374.68,,,,,,,fee schedule,35802.94,53703.76, Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,37236.95,,,,,,,fee schedule,35802.94,53703.76, Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],34455.87,19678.08,103650.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],12128.89,12128.89,12128.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],50524.57,48611.54,50524.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],33309.37,10769.4,48343.1,19,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],10612.78,9985.13,19282.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],19282.11,19282.11,19282.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],11118.15,11118.15,11118.15,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],10814.93,9165.48,19649.38,41,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],34375.07,22171.85,36745.38,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],11623.52,11623.52,11623.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,13081.23,10107.41,48875.5,1 through 10,percent of total billed charges,,, Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,25316.54,,,,,,,fee schedule,21951.91,32927.46, Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,21951.91,,,,,,,fee schedule,21951.91,32927.46, Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,32927.46,,,,,,,fee schedule,21951.91,32927.46, Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,25368.12,,,,,,,fee schedule,21951.91,32927.46, Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22831.15,,,,,,,fee schedule,21951.91,32927.46, Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],15198.86,15198.86,15198.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],20961.66,15810.12,28846.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],11118.15,6879.51,12059.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],12607.44,12607.44,12607.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],9165.48,5795.28,19649.38,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],22866.52,22866.52,22866.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,19743.7,,,,,,,fee schedule,17119.71,25679.25, Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,17119.71,,,,,,,fee schedule,17119.71,25679.25, Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,25679.25,,,,,,,fee schedule,17119.71,25679.25, Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,19783.92,,,,,,,fee schedule,17119.71,25679.25, Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,17805.41,,,,,,,fee schedule,17119.71,25679.25, Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],13778.78,13778.78,13778.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],5005.84,5005.84,5005.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],5244.22,5244.22,5244.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],5101.19,5101.19,5101.19,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],13632.21,13632.21,13632.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,59284.5,,,,,,,fee schedule,51405.44,77107.22, Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,51405.44,,,,,,,fee schedule,51405.44,77107.22, Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,77107.22,,,,,,,fee schedule,51405.44,77107.22, Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,59405.28,,,,,,,fee schedule,51405.44,77107.22, Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,53464.38,,,,,,,fee schedule,51405.44,77107.22, Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Interstitial Lung Disease With Cc,197,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,29815.03,,,,,,,fee schedule,25852.53,38778.33, Interstitial Lung Disease With Cc,197,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,25852.53,,,,,,,fee schedule,25852.53,38778.33, Interstitial Lung Disease With Cc,197,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,38778.33,,,,,,,fee schedule,25852.53,38778.33, Interstitial Lung Disease With Cc,197,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,29875.77,,,,,,,fee schedule,25852.53,38778.33, Interstitial Lung Disease With Cc,197,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,26888,,,,,,,fee schedule,25852.53,38778.33, Interstitial Lung Disease With Cc,197,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Interstitial Lung Disease With Cc,197,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Interstitial Lung Disease With Cc,197,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Interstitial Lung Disease With Cc,197,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Interstitial Lung Disease With Cc,197,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Interstitial Lung Disease With Cc,197,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Interstitial Lung Disease With Cc,197,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Interstitial Lung Disease With Cc,197,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Interstitial Lung Disease With Cc,197,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Interstitial Lung Disease With Cc,197,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],135364.55,135364.55,135364.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Interstitial Lung Disease With Cc,197,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Interstitial Lung Disease With Cc,197,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Interstitial Lung Disease With Cc,197,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Interstitial Lung Disease With Cc,197,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Interstitial Lung Disease With Cc,197,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Interstitial Lung Disease With Cc,197,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,13164.61,13164.61,13164.61,1 through 10,percent of total billed charges,,, Interstitial Lung Disease With Cc,197,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Interstitial Lung Disease With Cc,197,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Interstitial Lung Disease With Cc,197,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Interstitial Lung Disease With Cc,197,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,22498.71,,,,,,,fee schedule,19508.57,29262.5, Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,19508.57,,,,,,,fee schedule,19508.57,29262.5, Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,29262.5,,,,,,,fee schedule,19508.57,29262.5, Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,22544.54,,,,,,,fee schedule,19508.57,29262.5, Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,20289.95,,,,,,,fee schedule,19508.57,29262.5, Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Pneumothorax With Mcc,199,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,55417.44,,,,,,,fee schedule,48052.32,72077.6, Pneumothorax With Mcc,199,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,48052.32,,,,,,,fee schedule,48052.32,72077.6, Pneumothorax With Mcc,199,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,72077.6,,,,,,,fee schedule,48052.32,72077.6, Pneumothorax With Mcc,199,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,55530.34,,,,,,,fee schedule,48052.32,72077.6, Pneumothorax With Mcc,199,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,49976.95,,,,,,,fee schedule,48052.32,72077.6, Pneumothorax With Mcc,199,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Pneumothorax With Mcc,199,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pneumothorax With Mcc,199,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pneumothorax With Mcc,199,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pneumothorax With Mcc,199,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Pneumothorax With Mcc,199,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pneumothorax With Mcc,199,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pneumothorax With Mcc,199,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pneumothorax With Mcc,199,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pneumothorax With Mcc,199,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pneumothorax With Mcc,199,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pneumothorax With Mcc,199,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pneumothorax With Mcc,199,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pneumothorax With Mcc,199,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pneumothorax With Mcc,199,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pneumothorax With Mcc,199,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Pneumothorax With Mcc,199,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Pneumothorax With Mcc,199,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Pneumothorax With Mcc,199,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Pneumothorax With Mcc,199,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Pneumothorax With Cc,200,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,34533.41,,,,,,,fee schedule,29943.83,44915.2, Pneumothorax With Cc,200,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,29943.83,,,,,,,fee schedule,29943.83,44915.2, Pneumothorax With Cc,200,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,44915.2,,,,,,,fee schedule,29943.83,44915.2, Pneumothorax With Cc,200,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,34603.77,,,,,,,fee schedule,29943.83,44915.2, Pneumothorax With Cc,200,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,31143.17,,,,,,,fee schedule,29943.83,44915.2, Pneumothorax With Cc,200,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Pneumothorax With Cc,200,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pneumothorax With Cc,200,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],18003.01,18003.01,18003.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Pneumothorax With Cc,200,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pneumothorax With Cc,200,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Pneumothorax With Cc,200,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pneumothorax With Cc,200,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pneumothorax With Cc,200,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pneumothorax With Cc,200,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pneumothorax With Cc,200,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],8994.12,8994.12,8994.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Pneumothorax With Cc,200,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pneumothorax With Cc,200,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],14710,14710,14710,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Pneumothorax With Cc,200,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pneumothorax With Cc,200,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pneumothorax With Cc,200,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pneumothorax With Cc,200,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,14443.54,14443.54,14443.54,1 through 10,percent of total billed charges,,, Pneumothorax With Cc,200,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Pneumothorax With Cc,200,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Pneumothorax With Cc,200,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Pneumothorax With Cc,200,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,22464.15,,,,,,,fee schedule,19478.61,29217.56, Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,19478.61,,,,,,,fee schedule,19478.61,29217.56, Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,29217.56,,,,,,,fee schedule,19478.61,29217.56, Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,22509.92,,,,,,,fee schedule,19478.61,29217.56, Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,20258.78,,,,,,,fee schedule,19478.61,29217.56, Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],6870.84,6870.84,6870.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],6298.27,6298.27,6298.27,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,16589.91,16589.91,16589.91,1 through 10,percent of total billed charges,,, Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,30509.28,,,,,,,fee schedule,26454.52,39681.29, Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,26454.52,,,,,,,fee schedule,26454.52,39681.29, Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,39681.29,,,,,,,fee schedule,26454.52,39681.29, Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,30571.43,,,,,,,fee schedule,26454.52,39681.29, Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,27514.1,,,,,,,fee schedule,26454.52,39681.29, Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],14024.41,14024.41,14024.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],9877.29,9877.29,9877.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],10655.94,10655.94,10655.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],17938.45,13121.98,30656.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],9132.01,9132.01,9132.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],8642.63,8642.63,10218.84,22,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],9054.19,7175.56,11596.89,44,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],9465.74,9465.74,11192.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],8807.26,6641.1,10413.49,56,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],23323.77,22651.92,26957.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],8741.99,7637.76,25618.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,8075.03,8075.03,8849.59,1 through 10,percent of total billed charges,,, Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,21047.38,,,,,,,fee schedule,18250.13,27374.86, Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,18250.13,,,,,,,fee schedule,18250.13,27374.86, Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,27374.86,,,,,,,fee schedule,18250.13,27374.86, Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,21090.26,,,,,,,fee schedule,18250.13,27374.86, Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,18981.1,,,,,,,fee schedule,18250.13,27374.86, Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],8733.04,8733.04,19417.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],12101.66,7255.24,17557.19,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],3948.96,3948.96,3948.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],4866.11,4866.11,4866.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],5097.83,4765.9,5580.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],4958.8,4635.92,5428.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],10507.42,10507.42,10507.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],4016.71,4016.71,4016.71,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Respiratory Signs And Symptoms,204,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,25363.66,,,,,,,fee schedule,21992.77,32988.75, Respiratory Signs And Symptoms,204,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,21992.77,,,,,,,fee schedule,21992.77,32988.75, Respiratory Signs And Symptoms,204,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,32988.75,,,,,,,fee schedule,21992.77,32988.75, Respiratory Signs And Symptoms,204,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,25415.34,,,,,,,fee schedule,21992.77,32988.75, Respiratory Signs And Symptoms,204,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22873.64,,,,,,,fee schedule,21992.77,32988.75, Respiratory Signs And Symptoms,204,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Signs And Symptoms,204,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Signs And Symptoms,204,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Signs And Symptoms,204,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Signs And Symptoms,204,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Signs And Symptoms,204,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Signs And Symptoms,204,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Signs And Symptoms,204,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Signs And Symptoms,204,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Signs And Symptoms,204,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Signs And Symptoms,204,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Signs And Symptoms,204,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Signs And Symptoms,204,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Signs And Symptoms,204,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Signs And Symptoms,204,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory Signs And Symptoms,204,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Respiratory Signs And Symptoms,204,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Respiratory Signs And Symptoms,204,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Respiratory Signs And Symptoms,204,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Respiratory Signs And Symptoms,204,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,57519.03,,,,,,,fee schedule,49874.61,74811, Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,49874.61,,,,,,,fee schedule,49874.61,74811, Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,74811,,,,,,,fee schedule,49874.61,74811, Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,57636.22,,,,,,,fee schedule,49874.61,74811, Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,51872.23,,,,,,,fee schedule,49874.61,74811, Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],23896.56,23896.56,23896.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],14021.63,14021.63,14021.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,29563.72,,,,,,,fee schedule,25634.62,38451.46, Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,25634.62,,,,,,,fee schedule,25634.62,38451.46, Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,38451.46,,,,,,,fee schedule,25634.62,38451.46, Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,29623.95,,,,,,,fee schedule,25634.62,38451.46, Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,26661.36,,,,,,,fee schedule,25634.62,38451.46, Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],16344.76,16344.76,16344.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],26728.88,26728.88,26728.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],14301.67,14301.67,14435.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],6231.98,6231.98,6231.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,15829.46,15829.46,15829.46,1 through 10,percent of total billed charges,,, Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,202139.67,,,,,,,fee schedule,175274.79,262908.97, Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,175274.79,,,,,,,fee schedule,175274.79,262908.97, Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,262908.97,,,,,,,fee schedule,175274.79,262908.97, Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,202551.49,,,,,,,fee schedule,175274.79,262908.97, Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,182295.05,,,,,,,fee schedule,175274.79,262908.97, Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],258415.72,258415.72,258415.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],137338.29,137338.29,165321.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],62233.84,47477.18,230857.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],49792.34,49738,112416.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],48434.36,37117.63,88221.25,32,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],180344.34,180344.34,180344.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,86347.66,,,,,,,fee schedule,74871.84,112306.38, Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,74871.84,,,,,,,fee schedule,74871.84,112306.38, Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,112306.38,,,,,,,fee schedule,74871.84,112306.38, Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,86523.58,,,,,,,fee schedule,74871.84,112306.38, Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,77870.67,,,,,,,fee schedule,74871.84,112306.38, Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],75774.41,75774.41,75774.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],67259.09,50263.96,107843.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],23770,23461.16,55287.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],14271.1,14271.1,14271.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],22639.55,13805.94,23121.73,26,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],74840.45,74840.45,74840.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,56423.81,56423.81,56423.81,1 through 10,percent of total billed charges,,, Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Complex Aortic Arch Procedures,209,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,355568.78,,,,,,,fee schedule,308312.79,462463.53, Complex Aortic Arch Procedures,209,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,308312.79,,,,,,,fee schedule,308312.79,462463.53, Complex Aortic Arch Procedures,209,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,462463.53,,,,,,,fee schedule,308312.79,462463.53, Complex Aortic Arch Procedures,209,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,356293.19,,,,,,,fee schedule,308312.79,462463.53, Complex Aortic Arch Procedures,209,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,320661.6,,,,,,,fee schedule,308312.79,462463.53, Complex Aortic Arch Procedures,209,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Complex Aortic Arch Procedures,209,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complex Aortic Arch Procedures,209,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complex Aortic Arch Procedures,209,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complex Aortic Arch Procedures,209,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Complex Aortic Arch Procedures,209,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complex Aortic Arch Procedures,209,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complex Aortic Arch Procedures,209,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complex Aortic Arch Procedures,209,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complex Aortic Arch Procedures,209,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complex Aortic Arch Procedures,209,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complex Aortic Arch Procedures,209,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complex Aortic Arch Procedures,209,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complex Aortic Arch Procedures,209,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complex Aortic Arch Procedures,209,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complex Aortic Arch Procedures,209,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Complex Aortic Arch Procedures,209,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Complex Aortic Arch Procedures,209,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Complex Aortic Arch Procedures,209,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Complex Aortic Arch Procedures,209,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hip & Femur Procedures Except Major Joint Age >17 w CC,210,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Hip & Femur Procedures Except Major Joint Age >17 w CC,210,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hip & Femur Procedures Except Major Joint Age >17 w CC,210,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hip & Femur Procedures Except Major Joint Age >17 w CC,210,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hip & Femur Procedures Except Major Joint Age >17 w CC,210,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Hip & Femur Procedures Except Major Joint Age >17 w CC,210,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hip & Femur Procedures Except Major Joint Age >17 w CC,210,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hip & Femur Procedures Except Major Joint Age >17 w CC,210,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hip & Femur Procedures Except Major Joint Age >17 w CC,210,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hip & Femur Procedures Except Major Joint Age >17 w CC,210,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hip & Femur Procedures Except Major Joint Age >17 w CC,210,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hip & Femur Procedures Except Major Joint Age >17 w CC,210,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hip & Femur Procedures Except Major Joint Age >17 w CC,210,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hip & Femur Procedures Except Major Joint Age >17 w CC,210,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hip & Femur Procedures Except Major Joint Age >17 w CC,210,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hip & Femur Procedures Except Major Joint Age >17 w CC,210,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hip & Femur Procedures Except Major Joint Age >17 w CC,210,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hip & Femur Procedures Except Major Joint Age >17 w CC,210,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hip & Femur Procedures Except Major Joint Age >17 w CC,210,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hip & Femur Procedures Except Major Joint Age >17 w CC,210,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hip & Femur Procedures Except Major Joint Age >17 w/o CC,211,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Hip & Femur Procedures Except Major Joint Age >17 w/o CC,211,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hip & Femur Procedures Except Major Joint Age >17 w/o CC,211,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hip & Femur Procedures Except Major Joint Age >17 w/o CC,211,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hip & Femur Procedures Except Major Joint Age >17 w/o CC,211,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Hip & Femur Procedures Except Major Joint Age >17 w/o CC,211,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hip & Femur Procedures Except Major Joint Age >17 w/o CC,211,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hip & Femur Procedures Except Major Joint Age >17 w/o CC,211,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hip & Femur Procedures Except Major Joint Age >17 w/o CC,211,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hip & Femur Procedures Except Major Joint Age >17 w/o CC,211,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hip & Femur Procedures Except Major Joint Age >17 w/o CC,211,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hip & Femur Procedures Except Major Joint Age >17 w/o CC,211,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hip & Femur Procedures Except Major Joint Age >17 w/o CC,211,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hip & Femur Procedures Except Major Joint Age >17 w/o CC,211,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hip & Femur Procedures Except Major Joint Age >17 w/o CC,211,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hip & Femur Procedures Except Major Joint Age >17 w/o CC,211,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hip & Femur Procedures Except Major Joint Age >17 w/o CC,211,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hip & Femur Procedures Except Major Joint Age >17 w/o CC,211,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hip & Femur Procedures Except Major Joint Age >17 w/o CC,211,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hip & Femur Procedures Except Major Joint Age >17 w/o CC,211,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,341598.98,,,,,,,fee schedule,296199.61,444293.98, Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,296199.61,,,,,,,fee schedule,296199.61,444293.98, Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,444293.98,,,,,,,fee schedule,296199.61,444293.98, Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,342294.92,,,,,,,fee schedule,296199.61,444293.98, Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,308063.25,,,,,,,fee schedule,296199.61,444293.98, Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,179276.56,,,,,,,fee schedule,155450.25,233172.52, Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,155450.25,,,,,,,fee schedule,155450.25,233172.52, Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,233172.52,,,,,,,fee schedule,155450.25,233172.52, Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,179641.8,,,,,,,fee schedule,155450.25,233172.52, Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,161676.48,,,,,,,fee schedule,155450.25,233172.52, Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. No Longer Valid,214,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,214,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,214,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,214,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,214,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,214,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,214,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,214,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,214,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,214,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,214,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,214,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,214,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,214,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,214,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,214,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. No Longer Valid,214,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. No Longer Valid,214,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. No Longer Valid,214,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. No Longer Valid,214,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Heart Assist System Implant,215,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,312789.2,,,,,,,fee schedule,271218.72,406823.11, Other Heart Assist System Implant,215,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,271218.72,,,,,,,fee schedule,271218.72,406823.11, Other Heart Assist System Implant,215,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,406823.11,,,,,,,fee schedule,271218.72,406823.11, Other Heart Assist System Implant,215,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,313426.45,,,,,,,fee schedule,271218.72,406823.11, Other Heart Assist System Implant,215,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,282081.81,,,,,,,fee schedule,271218.72,406823.11, Other Heart Assist System Implant,215,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Other Heart Assist System Implant,215,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Heart Assist System Implant,215,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],332563.52,332563.52,332563.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Heart Assist System Implant,215,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Heart Assist System Implant,215,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other Heart Assist System Implant,215,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Heart Assist System Implant,215,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Heart Assist System Implant,215,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Heart Assist System Implant,215,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Heart Assist System Implant,215,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Heart Assist System Implant,215,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Heart Assist System Implant,215,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Heart Assist System Implant,215,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Heart Assist System Implant,215,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Heart Assist System Implant,215,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Heart Assist System Implant,215,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Heart Assist System Implant,215,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Heart Assist System Implant,215,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Heart Assist System Implant,215,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Heart Assist System Implant,215,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,307316.88,,,,,,,fee schedule,266473.69,399705.64, Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,266473.69,,,,,,,fee schedule,266473.69,399705.64, Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,399705.64,,,,,,,fee schedule,266473.69,399705.64, Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,307942.98,,,,,,,fee schedule,266473.69,399705.64, Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,277146.72,,,,,,,fee schedule,266473.69,399705.64, Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,206556.47,,,,,,,fee schedule,179104.6,268653.61, Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,179104.6,,,,,,,fee schedule,179104.6,268653.61, Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,268653.61,,,,,,,fee schedule,179104.6,268653.61, Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,206977.29,,,,,,,fee schedule,179104.6,268653.61, Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,186278.25,,,,,,,fee schedule,179104.6,268653.61, Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,206556.47,,,,,,,fee schedule,179104.6,268653.61, Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,179104.6,,,,,,,fee schedule,179104.6,268653.61, Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,268653.61,,,,,,,fee schedule,179104.6,268653.61, Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,206977.29,,,,,,,fee schedule,179104.6,268653.61, Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,186278.25,,,,,,,fee schedule,179104.6,268653.61, Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,241206.12,,,,,,,fee schedule,209149.21,313719.98, Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,209149.21,,,,,,,fee schedule,209149.21,313719.98, Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,313719.98,,,,,,,fee schedule,209149.21,313719.98, Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,241697.53,,,,,,,fee schedule,209149.21,313719.98, Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,217526.24,,,,,,,fee schedule,209149.21,313719.98, Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],240091.21,240091.21,833181.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],72293.83,72293.83,282503.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],49995.09,49995.09,49995.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],73670.86,70918.28,175103.23,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],227010.51,227010.51,227010.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,167524.58,,,,,,,fee schedule,145260.14,217887.54, Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,145260.14,,,,,,,fee schedule,145260.14,217887.54, Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,217887.54,,,,,,,fee schedule,145260.14,217887.54, Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,167865.88,,,,,,,fee schedule,145260.14,217887.54, Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,151078.22,,,,,,,fee schedule,145260.14,217887.54, Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],160765.44,160765.44,160765.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],38225.97,38225.97,38225.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],42433.05,42433.05,42433.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],63545.07,63545.07,63545.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,158332.84,,,,,,,fee schedule,137290.01,205932.49, Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,137290.01,,,,,,,fee schedule,137290.01,205932.49, Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,205932.49,,,,,,,fee schedule,137290.01,205932.49, Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,158655.42,,,,,,,fee schedule,137290.01,205932.49, Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,142788.87,,,,,,,fee schedule,137290.01,205932.49, Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],135399.54,135399.54,135399.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],40504.28,40504.28,40504.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],43459.82,43459.82,43459.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc",222,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc",222,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc",222,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc",222,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc",222,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc",222,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc",222,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc",222,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc",222,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc",222,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc",222,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc",222,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc",222,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc",222,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc",222,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc",222,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc",222,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc",222,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc",222,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc",222,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc",223,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc",223,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc",223,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc",223,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc",223,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc",223,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc",223,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc",223,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc",223,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc",223,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc",223,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc",223,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc",223,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc",223,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc",223,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc",223,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc",223,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc",223,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc",223,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc",223,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc",224,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc",224,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc",224,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc",224,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc",224,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc",224,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc",224,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc",224,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc",224,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc",224,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc",224,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc",224,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc",224,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc",224,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc",224,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc",224,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc",224,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc",224,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc",224,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc",224,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc",225,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc",225,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc",225,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc",225,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc",225,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc",225,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc",225,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc",225,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc",225,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc",225,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc",225,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc",225,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc",225,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc",225,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc",225,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc",225,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc",225,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc",225,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc",225,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc",225,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc,226,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc,226,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc,226,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc,226,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc,226,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc,226,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc,226,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc,226,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc,226,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc,226,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc,226,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc,226,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc,226,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc,226,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc,226,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc,226,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc,226,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc,226,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc,226,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc,226,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc,227,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc,227,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc,227,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc,227,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc,227,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc,227,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc,227,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc,227,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc,227,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc,227,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc,227,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc,227,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc,227,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc,227,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc,227,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc,227,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc,227,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc,227,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc,227,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc,227,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,155417.62,,,,,,,fee schedule,134762.23,202140.87, Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,134762.23,,,,,,,fee schedule,134762.23,202140.87, Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,202140.87,,,,,,,fee schedule,134762.23,202140.87, Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,155734.26,,,,,,,fee schedule,134762.23,202140.87, Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,140159.84,,,,,,,fee schedule,134762.23,202140.87, Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],196377.46,196377.46,196377.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],358703.88,358703.88,358703.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],56530.3,56530.3,56530.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],108172.34,59222.22,1140511.02,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],73708.27,70918.28,388396.64,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],111748.57,111748.57,111748.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,98938.39,,,,,,,fee schedule,85789.23,128682.27, Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,85789.23,,,,,,,fee schedule,85789.23,128682.27, Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,128682.27,,,,,,,fee schedule,85789.23,128682.27, Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,99139.96,,,,,,,fee schedule,85789.23,128682.27, Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,89225.34,,,,,,,fee schedule,85789.23,128682.27, Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],234980.21,234980.21,234980.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],118419.85,118419.85,119104.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],32415.06,32415.06,32415.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],33367.37,33367.37,33367.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],56129.83,56129.83,56129.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],41275.79,34205.61,80932.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],91135.74,91135.74,269317.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other cardiothoracic procedures w/o CC/MCC,230,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Other cardiothoracic procedures w/o CC/MCC,230,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other cardiothoracic procedures w/o CC/MCC,230,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other cardiothoracic procedures w/o CC/MCC,230,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other cardiothoracic procedures w/o CC/MCC,230,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other cardiothoracic procedures w/o CC/MCC,230,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other cardiothoracic procedures w/o CC/MCC,230,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other cardiothoracic procedures w/o CC/MCC,230,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other cardiothoracic procedures w/o CC/MCC,230,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other cardiothoracic procedures w/o CC/MCC,230,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other cardiothoracic procedures w/o CC/MCC,230,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other cardiothoracic procedures w/o CC/MCC,230,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other cardiothoracic procedures w/o CC/MCC,230,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other cardiothoracic procedures w/o CC/MCC,230,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other cardiothoracic procedures w/o CC/MCC,230,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other cardiothoracic procedures w/o CC/MCC,230,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other cardiothoracic procedures w/o CC/MCC,230,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other cardiothoracic procedures w/o CC/MCC,230,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other cardiothoracic procedures w/o CC/MCC,230,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other cardiothoracic procedures w/o CC/MCC,230,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,264816.88,,,,,,,fee schedule,229622.05,344428.85, Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,229622.05,,,,,,,fee schedule,229622.05,344428.85, Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,344428.85,,,,,,,fee schedule,229622.05,344428.85, Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,265356.39,,,,,,,fee schedule,229622.05,344428.85, Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,238819.07,,,,,,,fee schedule,229622.05,344428.85, Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,190450.52,,,,,,,fee schedule,165139.16,247705.71, Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,165139.16,,,,,,,fee schedule,165139.16,247705.71, Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,247705.71,,,,,,,fee schedule,165139.16,247705.71, Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,190838.52,,,,,,,fee schedule,165139.16,247705.71, Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,171753.46,,,,,,,fee schedule,165139.16,247705.71, Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,240166.31,,,,,,,fee schedule,208247.6,312367.58, Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,208247.6,,,,,,,fee schedule,208247.6,312367.58, Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,312367.58,,,,,,,fee schedule,208247.6,312367.58, Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,240655.61,,,,,,,fee schedule,208247.6,312367.58, Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,216588.52,,,,,,,fee schedule,208247.6,312367.58, Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,171605.26,,,,,,,fee schedule,148798.49,223195, Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,148798.49,,,,,,,fee schedule,148798.49,223195, Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,223195,,,,,,,fee schedule,148798.49,223195, Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,171954.87,,,,,,,fee schedule,148798.49,223195, Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,154758.29,,,,,,,fee schedule,148798.49,223195, Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,184356.2,,,,,,,fee schedule,159854.8,239779.26, Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,159854.8,,,,,,,fee schedule,159854.8,239779.26, Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,239779.26,,,,,,,fee schedule,159854.8,239779.26, Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,184731.79,,,,,,,fee schedule,159854.8,239779.26, Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,166257.44,,,,,,,fee schedule,159854.8,239779.26, Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,131586.96,,,,,,,fee schedule,114098.72,171145.99, Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,114098.72,,,,,,,fee schedule,114098.72,171145.99, Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,171145.99,,,,,,,fee schedule,114098.72,171145.99, Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,131855.05,,,,,,,fee schedule,114098.72,171145.99, Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,118668.7,,,,,,,fee schedule,114098.72,171145.99, Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major cardiovasc procedures w MCC,237,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Major cardiovasc procedures w MCC,237,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major cardiovasc procedures w MCC,237,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major cardiovasc procedures w MCC,237,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major cardiovasc procedures w MCC,237,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Major cardiovasc procedures w MCC,237,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major cardiovasc procedures w MCC,237,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major cardiovasc procedures w MCC,237,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major cardiovasc procedures w MCC,237,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major cardiovasc procedures w MCC,237,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major cardiovasc procedures w MCC,237,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major cardiovasc procedures w MCC,237,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major cardiovasc procedures w MCC,237,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major cardiovasc procedures w MCC,237,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major cardiovasc procedures w MCC,237,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major cardiovasc procedures w MCC,237,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major cardiovasc procedures w MCC,237,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major cardiovasc procedures w MCC,237,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major cardiovasc procedures w MCC,237,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major cardiovasc procedures w MCC,237,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major cardiovasc procedures w/o MCC,238,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Major cardiovasc procedures w/o MCC,238,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major cardiovasc procedures w/o MCC,238,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major cardiovasc procedures w/o MCC,238,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major cardiovasc procedures w/o MCC,238,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Major cardiovasc procedures w/o MCC,238,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major cardiovasc procedures w/o MCC,238,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major cardiovasc procedures w/o MCC,238,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major cardiovasc procedures w/o MCC,238,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major cardiovasc procedures w/o MCC,238,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major cardiovasc procedures w/o MCC,238,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major cardiovasc procedures w/o MCC,238,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major cardiovasc procedures w/o MCC,238,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major cardiovasc procedures w/o MCC,238,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major cardiovasc procedures w/o MCC,238,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major cardiovasc procedures w/o MCC,238,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major cardiovasc procedures w/o MCC,238,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major cardiovasc procedures w/o MCC,238,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major cardiovasc procedures w/o MCC,238,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major cardiovasc procedures w/o MCC,238,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,154610.28,,,,,,,fee schedule,134062.19,201090.82, Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,134062.19,,,,,,,fee schedule,134062.19,201090.82, Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,201090.82,,,,,,,fee schedule,134062.19,201090.82, Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,154925.27,,,,,,,fee schedule,134062.19,201090.82, Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,139431.76,,,,,,,fee schedule,134062.19,201090.82, Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,89545.61,,,,,,,fee schedule,77644.77,116465.73, Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,77644.77,,,,,,,fee schedule,77644.77,116465.73, Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,116465.73,,,,,,,fee schedule,77644.77,116465.73, Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,89728.04,,,,,,,fee schedule,77644.77,116465.73, Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,80754.67,,,,,,,fee schedule,77644.77,116465.73, Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,43489.54,,,,,,,fee schedule,37709.67,56563.82, Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,37709.67,,,,,,,fee schedule,37709.67,56563.82, Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,56563.82,,,,,,,fee schedule,37709.67,56563.82, Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,43578.14,,,,,,,fee schedule,37709.67,56563.82, Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,39220.05,,,,,,,fee schedule,37709.67,56563.82, Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,100298.62,,,,,,,fee schedule,86968.68,130451.42, Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,86968.68,,,,,,,fee schedule,86968.68,130451.42, Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,130451.42,,,,,,,fee schedule,86968.68,130451.42, Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,100502.96,,,,,,,fee schedule,86968.68,130451.42, Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,90452.02,,,,,,,fee schedule,86968.68,130451.42, Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],21086.89,21086.89,21086.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],94589.31,94589.31,94589.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,66940.09,,,,,,,fee schedule,58043.59,87064.31, Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,58043.59,,,,,,,fee schedule,58043.59,87064.31, Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,87064.31,,,,,,,fee schedule,58043.59,87064.31, Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,67076.47,,,,,,,fee schedule,58043.59,87064.31, Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,60368.4,,,,,,,fee schedule,58043.59,87064.31, Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],19253.25,19253.25,19253.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,125928.36,125928.36,125928.36,1 through 10,percent of total billed charges,,, Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,56780.81,,,,,,,fee schedule,49234.49,73850.84, Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,49234.49,,,,,,,fee schedule,49234.49,73850.84, Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,73850.84,,,,,,,fee schedule,49234.49,73850.84, Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,56896.49,,,,,,,fee schedule,49234.49,73850.84, Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,51206.48,,,,,,,fee schedule,49234.49,73850.84, Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Aicd Generator Procedures,245,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,143323.23,,,,,,,fee schedule,124275.21,186410.54, Aicd Generator Procedures,245,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,124275.21,,,,,,,fee schedule,124275.21,186410.54, Aicd Generator Procedures,245,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,186410.54,,,,,,,fee schedule,124275.21,186410.54, Aicd Generator Procedures,245,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,143615.23,,,,,,,fee schedule,124275.21,186410.54, Aicd Generator Procedures,245,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,129252.79,,,,,,,fee schedule,124275.21,186410.54, Aicd Generator Procedures,245,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Aicd Generator Procedures,245,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Aicd Generator Procedures,245,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Aicd Generator Procedures,245,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Aicd Generator Procedures,245,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Aicd Generator Procedures,245,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Aicd Generator Procedures,245,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Aicd Generator Procedures,245,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Aicd Generator Procedures,245,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Aicd Generator Procedures,245,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Aicd Generator Procedures,245,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Aicd Generator Procedures,245,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Aicd Generator Procedures,245,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Aicd Generator Procedures,245,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Aicd Generator Procedures,245,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Aicd Generator Procedures,245,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Aicd Generator Procedures,245,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Aicd Generator Procedures,245,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Aicd Generator Procedures,245,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Aicd Generator Procedures,245,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,246,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,246,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,246,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,246,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,246,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,246,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,246,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,246,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,246,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,246,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,246,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,246,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,246,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,246,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,246,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,246,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,246,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,246,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,246,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,246,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc,247,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc,247,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc,247,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc,247,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc,247,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc,247,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc,247,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc,247,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc,247,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc,247,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc,247,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc,247,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc,247,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc,247,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc,247,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc,247,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc,247,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc,247,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc,247,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc,247,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,248,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,248,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,248,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,248,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,248,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,248,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,248,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,248,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,248,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,248,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,248,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,248,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,248,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,248,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,248,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,248,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,248,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,248,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,248,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,248,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc,249,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc,249,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc,249,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc,249,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc,249,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc,249,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc,249,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc,249,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc,249,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc,249,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc,249,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc,249,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc,249,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc,249,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc,249,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc,249,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc,249,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc,249,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc,249,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc,249,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,68561.06,,,,,,,fee schedule,59449.12,89172.59, Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,59449.12,,,,,,,fee schedule,59449.12,89172.59, Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,89172.59,,,,,,,fee schedule,59449.12,89172.59, Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,68700.74,,,,,,,fee schedule,59449.12,89172.59, Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,61830.23,,,,,,,fee schedule,59449.12,89172.59, Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,46948.22,,,,,,,fee schedule,40708.69,61062.28, Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,40708.69,,,,,,,fee schedule,40708.69,61062.28, Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,61062.28,,,,,,,fee schedule,40708.69,61062.28, Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,47043.87,,,,,,,fee schedule,40708.69,61062.28, Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,42339.19,,,,,,,fee schedule,40708.69,61062.28, Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Vascular Procedures With Mcc,252,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,109581.46,,,,,,,fee schedule,95017.8,142524.96, Other Vascular Procedures With Mcc,252,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,95017.8,,,,,,,fee schedule,95017.8,142524.96, Other Vascular Procedures With Mcc,252,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,142524.96,,,,,,,fee schedule,95017.8,142524.96, Other Vascular Procedures With Mcc,252,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,109804.71,,,,,,,fee schedule,95017.8,142524.96, Other Vascular Procedures With Mcc,252,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,98823.54,,,,,,,fee schedule,95017.8,142524.96, Other Vascular Procedures With Mcc,252,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Other Vascular Procedures With Mcc,252,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Vascular Procedures With Mcc,252,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],131531.83,131531.83,131531.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Vascular Procedures With Mcc,252,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],129781.83,129781.83,129781.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Vascular Procedures With Mcc,252,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other Vascular Procedures With Mcc,252,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Vascular Procedures With Mcc,252,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Vascular Procedures With Mcc,252,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],105367.26,105367.26,105367.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Vascular Procedures With Mcc,252,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Vascular Procedures With Mcc,252,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Vascular Procedures With Mcc,252,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Vascular Procedures With Mcc,252,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],397208.3,397208.3,397208.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Vascular Procedures With Mcc,252,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Vascular Procedures With Mcc,252,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Vascular Procedures With Mcc,252,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Vascular Procedures With Mcc,252,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Vascular Procedures With Mcc,252,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Vascular Procedures With Mcc,252,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Vascular Procedures With Mcc,252,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Vascular Procedures With Mcc,252,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Vascular Procedures With Cc,253,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,81538.18,,,,,,,fee schedule,70701.55,106051.02, Other Vascular Procedures With Cc,253,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,70701.55,,,,,,,fee schedule,70701.55,106051.02, Other Vascular Procedures With Cc,253,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,106051.02,,,,,,,fee schedule,70701.55,106051.02, Other Vascular Procedures With Cc,253,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,81704.3,,,,,,,fee schedule,70701.55,106051.02, Other Vascular Procedures With Cc,253,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,73533.35,,,,,,,fee schedule,70701.55,106051.02, Other Vascular Procedures With Cc,253,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],58570.27,58570.27,58570.27,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Vascular Procedures With Cc,253,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],77488.66,77488.66,77488.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Vascular Procedures With Cc,253,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Vascular Procedures With Cc,253,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Vascular Procedures With Cc,253,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other Vascular Procedures With Cc,253,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Vascular Procedures With Cc,253,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Vascular Procedures With Cc,253,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Vascular Procedures With Cc,253,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Vascular Procedures With Cc,253,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Vascular Procedures With Cc,253,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Vascular Procedures With Cc,253,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Vascular Procedures With Cc,253,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],97889.68,97889.68,97889.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Vascular Procedures With Cc,253,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Vascular Procedures With Cc,253,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Vascular Procedures With Cc,253,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Vascular Procedures With Cc,253,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Vascular Procedures With Cc,253,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Vascular Procedures With Cc,253,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Vascular Procedures With Cc,253,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,55970.32,,,,,,,fee schedule,48531.73,72796.7, Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,48531.73,,,,,,,fee schedule,48531.73,72796.7, Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,72796.7,,,,,,,fee schedule,48531.73,72796.7, Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,56084.35,,,,,,,fee schedule,48531.73,72796.7, Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,50475.56,,,,,,,fee schedule,48531.73,72796.7, Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],53689.41,53689.41,53689.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],34684.1,34684.1,34684.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,84736.12,,,,,,,fee schedule,73474.48,110210.37, Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,73474.48,,,,,,,fee schedule,73474.48,110210.37, Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,110210.37,,,,,,,fee schedule,73474.48,110210.37, Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,84908.76,,,,,,,fee schedule,73474.48,110210.37, Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,76417.34,,,,,,,fee schedule,73474.48,110210.37, Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,53337.83,,,,,,,fee schedule,46249.1,69372.8, Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,46249.1,,,,,,,fee schedule,46249.1,69372.8, Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,69372.8,,,,,,,fee schedule,46249.1,69372.8, Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,53446.5,,,,,,,fee schedule,46249.1,69372.8, Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,48101.51,,,,,,,fee schedule,46249.1,69372.8, Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,34310.37,,,,,,,fee schedule,29750.44,44625.11, Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,29750.44,,,,,,,fee schedule,29750.44,44625.11, Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,44625.11,,,,,,,fee schedule,29750.44,44625.11, Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,34380.27,,,,,,,fee schedule,29750.44,44625.11, Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,30942.03,,,,,,,fee schedule,29750.44,44625.11, Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,98705.93,,,,,,,fee schedule,85587.66,128379.92, Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,85587.66,,,,,,,fee schedule,85587.66,128379.92, Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,128379.92,,,,,,,fee schedule,85587.66,128379.92, Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,98907.02,,,,,,,fee schedule,85587.66,128379.92, Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,89015.69,,,,,,,fee schedule,85587.66,128379.92, Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],71717,71717,71717,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,63522.25,,,,,,,fee schedule,55079.98,82618.96, Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,55079.98,,,,,,,fee schedule,55079.98,82618.96, Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,82618.96,,,,,,,fee schedule,55079.98,82618.96, Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,63651.66,,,,,,,fee schedule,55079.98,82618.96, Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,57286.09,,,,,,,fee schedule,55079.98,82618.96, Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,102183.46,,,,,,,fee schedule,88603.02,132902.9, Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,88603.02,,,,,,,fee schedule,88603.02,132902.9, Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,132902.9,,,,,,,fee schedule,88603.02,132902.9, Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,102391.64,,,,,,,fee schedule,88603.02,132902.9, Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,92151.82,,,,,,,fee schedule,88603.02,132902.9, Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],224086.97,224086.97,224086.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],86071.13,86071.13,86071.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,59388.17,,,,,,,fee schedule,51495.33,77242.05, Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,51495.33,,,,,,,fee schedule,51495.33,77242.05, Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,77242.05,,,,,,,fee schedule,51495.33,77242.05, Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,59509.16,,,,,,,fee schedule,51495.33,77242.05, Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,53557.87,,,,,,,fee schedule,51495.33,77242.05, Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,51201.68,,,,,,,fee schedule,44396.85,66594.45, Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,44396.85,,,,,,,fee schedule,44396.85,66594.45, Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,66594.45,,,,,,,fee schedule,44396.85,66594.45, Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,51305.99,,,,,,,fee schedule,44396.85,66594.45, Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,46175.07,,,,,,,fee schedule,44396.85,66594.45, Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Vein Ligation And Stripping,263,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,96045.16,,,,,,,fee schedule,83280.52,124919.25, Vein Ligation And Stripping,263,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,83280.52,,,,,,,fee schedule,83280.52,124919.25, Vein Ligation And Stripping,263,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,124919.25,,,,,,,fee schedule,83280.52,124919.25, Vein Ligation And Stripping,263,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,96240.84,,,,,,,fee schedule,83280.52,124919.25, Vein Ligation And Stripping,263,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,86616.14,,,,,,,fee schedule,83280.52,124919.25, Vein Ligation And Stripping,263,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Vein Ligation And Stripping,263,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vein Ligation And Stripping,263,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vein Ligation And Stripping,263,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vein Ligation And Stripping,263,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Vein Ligation And Stripping,263,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vein Ligation And Stripping,263,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vein Ligation And Stripping,263,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vein Ligation And Stripping,263,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vein Ligation And Stripping,263,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vein Ligation And Stripping,263,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vein Ligation And Stripping,263,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vein Ligation And Stripping,263,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vein Ligation And Stripping,263,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vein Ligation And Stripping,263,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vein Ligation And Stripping,263,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Vein Ligation And Stripping,263,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Vein Ligation And Stripping,263,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Vein Ligation And Stripping,263,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Vein Ligation And Stripping,263,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,104941.61,,,,,,,fee schedule,90994.6,136490.23, Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,90994.6,,,,,,,fee schedule,90994.6,136490.23, Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,136490.23,,,,,,,fee schedule,90994.6,136490.23, Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,105155.41,,,,,,,fee schedule,90994.6,136490.23, Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,94639.2,,,,,,,fee schedule,90994.6,136490.23, Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],204034.86,204034.86,204034.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],378389.28,378389.28,378389.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],96779.81,96779.81,96779.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Aicd Lead Procedures,265,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,113662.13,,,,,,,fee schedule,98556.15,147832.42, Aicd Lead Procedures,265,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,98556.15,,,,,,,fee schedule,98556.15,147832.42, Aicd Lead Procedures,265,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,147832.42,,,,,,,fee schedule,98556.15,147832.42, Aicd Lead Procedures,265,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,113893.7,,,,,,,fee schedule,98556.15,147832.42, Aicd Lead Procedures,265,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,102503.61,,,,,,,fee schedule,98556.15,147832.42, Aicd Lead Procedures,265,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Aicd Lead Procedures,265,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Aicd Lead Procedures,265,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Aicd Lead Procedures,265,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Aicd Lead Procedures,265,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Aicd Lead Procedures,265,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Aicd Lead Procedures,265,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Aicd Lead Procedures,265,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Aicd Lead Procedures,265,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Aicd Lead Procedures,265,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Aicd Lead Procedures,265,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Aicd Lead Procedures,265,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Aicd Lead Procedures,265,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Aicd Lead Procedures,265,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Aicd Lead Procedures,265,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Aicd Lead Procedures,265,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Aicd Lead Procedures,265,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Aicd Lead Procedures,265,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Aicd Lead Procedures,265,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Aicd Lead Procedures,265,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,192517.56,,,,,,,fee schedule,166931.49,250394.17, Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,166931.49,,,,,,,fee schedule,166931.49,250394.17, Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,250394.17,,,,,,,fee schedule,166931.49,250394.17, Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,192909.78,,,,,,,fee schedule,166931.49,250394.17, Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,173617.57,,,,,,,fee schedule,166931.49,250394.17, Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,149555.77,,,,,,,fee schedule,129679.43,194516.77, Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,129679.43,,,,,,,fee schedule,129679.43,194516.77, Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,194516.77,,,,,,,fee schedule,129679.43,194516.77, Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,149860.46,,,,,,,fee schedule,129679.43,194516.77, Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,134873.46,,,,,,,fee schedule,129679.43,194516.77, Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,216062.35,,,,,,,fee schedule,187347.12,281017.24, Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,187347.12,,,,,,,fee schedule,187347.12,281017.24, Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,281017.24,,,,,,,fee schedule,187347.12,281017.24, Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,216502.54,,,,,,,fee schedule,187347.12,281017.24, Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,194850.91,,,,,,,fee schedule,187347.12,281017.24, Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],435036.19,435036.19,435036.19,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],93693.79,93693.79,93693.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],288467.28,288467.28,288467.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,132667.6,,,,,,,fee schedule,115035.74,172551.51, Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,115035.74,,,,,,,fee schedule,115035.74,172551.51, Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,172551.51,,,,,,,fee schedule,115035.74,172551.51, Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,132937.89,,,,,,,fee schedule,115035.74,172551.51, Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,119643.26,,,,,,,fee schedule,115035.74,172551.51, Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],159533.72,159533.72,159533.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],34684.1,34684.1,57607.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,165749.69,,,,,,,fee schedule,143721.14,215579.07, Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,143721.14,,,,,,,fee schedule,143721.14,215579.07, Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,215579.07,,,,,,,fee schedule,143721.14,215579.07, Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,166087.37,,,,,,,fee schedule,143721.14,215579.07, Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,149477.58,,,,,,,fee schedule,143721.14,215579.07, Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],304050.76,304050.76,304050.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],100590.99,32641.54,576840.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],248134.66,35985.98,519639.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],150831.88,36461.64,251648.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],61914.14,61914.14,61914.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,111717.61,,,,,,,fee schedule,96870.06,145303.31, Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,96870.06,,,,,,,fee schedule,96870.06,145303.31, Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,145303.31,,,,,,,fee schedule,96870.06,145303.31, Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,111945.21,,,,,,,fee schedule,96870.06,145303.31, Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,100749.98,,,,,,,fee schedule,96870.06,145303.31, Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],102958.62,102958.62,102958.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],85050.57,85050.57,85050.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],59748.14,59748.14,59748.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],73670.85,73670.85,73670.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],104338.29,104338.29,104338.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,80199.94,,,,,,,fee schedule,69541.17,104310.47, Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,69541.17,,,,,,,fee schedule,69541.17,104310.47, Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,104310.47,,,,,,,fee schedule,69541.17,104310.47, Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,80363.33,,,,,,,fee schedule,69541.17,104310.47, Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,72326.49,,,,,,,fee schedule,69541.17,104310.47, Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],87249.57,87249.57,87249.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,129598.46,,,,,,,fee schedule,112374.49,168559.68, Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,112374.49,,,,,,,fee schedule,112374.49,168559.68, Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,168559.68,,,,,,,fee schedule,112374.49,168559.68, Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,129862.49,,,,,,,fee schedule,112374.49,168559.68, Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,116875.42,,,,,,,fee schedule,112374.49,168559.68, Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],123617.93,123617.93,123617.93,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],50671.02,50671.02,50671.02,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,103405.46,,,,,,,fee schedule,89662.62,134492.28, Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,89662.62,,,,,,,fee schedule,89662.62,134492.28, Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,134492.28,,,,,,,fee schedule,89662.62,134492.28, Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,103616.13,,,,,,,fee schedule,89662.62,134492.28, Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,93253.86,,,,,,,fee schedule,89662.62,134492.28, Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],11120.44,11120.44,11120.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],30349.41,30349.41,30349.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],11625.91,11625.91,11625.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,60200.62,60200.62,60200.62,1 through 10,percent of total billed charges,,, Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,223994.39,,,,,,,fee schedule,194224.97,291333.88, Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,194224.97,,,,,,,fee schedule,194224.97,291333.88, Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,291333.88,,,,,,,fee schedule,194224.97,291333.88, Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,224450.73,,,,,,,fee schedule,194224.97,291333.88, Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,202004.23,,,,,,,fee schedule,194224.97,291333.88, Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,188691.33,,,,,,,fee schedule,163613.78,245417.66, Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,163613.78,,,,,,,fee schedule,163613.78,245417.66, Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,245417.66,,,,,,,fee schedule,163613.78,245417.66, Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,189075.75,,,,,,,fee schedule,163613.78,245417.66, Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,170166.98,,,,,,,fee schedule,163613.78,245417.66, Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,145085.56,,,,,,,fee schedule,125803.32,188702.67, Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,125803.32,,,,,,,fee schedule,125803.32,188702.67, Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,188702.67,,,,,,,fee schedule,125803.32,188702.67, Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,145381.14,,,,,,,fee schedule,125803.32,188702.67, Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,130842.11,,,,,,,fee schedule,125803.32,188702.67, Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,174856.61,,,,,,,fee schedule,151617.72,227423.8, Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,151617.72,,,,,,,fee schedule,151617.72,227423.8, Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,227423.8,,,,,,,fee schedule,151617.72,227423.8, Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,175212.84,,,,,,,fee schedule,151617.72,227423.8, Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,157690.45,,,,,,,fee schedule,151617.72,227423.8, Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,113291.45,,,,,,,fee schedule,98234.73,147350.29, Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,98234.73,,,,,,,fee schedule,98234.73,147350.29, Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,147350.29,,,,,,,fee schedule,98234.73,147350.29, Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,113522.26,,,,,,,fee schedule,98234.73,147350.29, Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,102169.31,,,,,,,fee schedule,98234.73,147350.29, Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,50391.2,,,,,,,fee schedule,43694.08,65540.32, "Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,43694.08,,,,,,,fee schedule,43694.08,65540.32, "Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,65540.32,,,,,,,fee schedule,43694.08,65540.32, "Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,50493.86,,,,,,,fee schedule,43694.08,65540.32, "Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,45444.15,,,,,,,fee schedule,43694.08,65540.32, "Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,28872.61,,,,,,,fee schedule,25035.36,37552.59, "Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,25035.36,,,,,,,fee schedule,25035.36,37552.59, "Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,37552.59,,,,,,,fee schedule,25035.36,37552.59, "Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,28931.43,,,,,,,fee schedule,25035.36,37552.59, "Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,26038.1,,,,,,,fee schedule,25035.36,37552.59, "Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,22715.46,,,,,,,fee schedule,19696.52,29544.42, "Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,19696.52,,,,,,,fee schedule,19696.52,29544.42, "Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,29544.42,,,,,,,fee schedule,19696.52,29544.42, "Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,22761.74,,,,,,,fee schedule,19696.52,29544.42, "Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,20485.42,,,,,,,fee schedule,19696.52,29544.42, "Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,62224.85,,,,,,,fee schedule,53955.01,80931.53, "Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,53955.01,,,,,,,fee schedule,53955.01,80931.53, "Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,80931.53,,,,,,,fee schedule,53955.01,80931.53, "Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,62351.62,,,,,,,fee schedule,53955.01,80931.53, "Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,56116.06,,,,,,,fee schedule,53955.01,80931.53, "Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,21744.77,,,,,,,fee schedule,18854.84,28281.91, "Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,18854.84,,,,,,,fee schedule,18854.84,28281.91, "Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,28281.91,,,,,,,fee schedule,18854.84,28281.91, "Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,21789.07,,,,,,,fee schedule,18854.84,28281.91, "Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19610.03,,,,,,,fee schedule,18854.84,28281.91, "Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,18813.84,,,,,,,fee schedule,16313.44,24469.86, "Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,16313.44,,,,,,,fee schedule,16313.44,24469.86, "Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,24469.86,,,,,,,fee schedule,16313.44,24469.86, "Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,18852.17,,,,,,,fee schedule,16313.44,24469.86, "Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,16966.84,,,,,,,fee schedule,16313.44,24469.86, "Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,69512.9,,,,,,,fee schedule,60274.46,90410.58, "Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,60274.46,,,,,,,fee schedule,60274.46,90410.58, "Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,90410.58,,,,,,,fee schedule,60274.46,90410.58, "Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,69654.52,,,,,,,fee schedule,60274.46,90410.58, "Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,62688.62,,,,,,,fee schedule,60274.46,90410.58, "Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],388271.65,388271.65,388271.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],122601.42,37724.38,233618.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],80538.08,80538.08,80538.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,64983.53,64983.53,64983.53,1 through 10,percent of total billed charges,,, "Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,33616.12,,,,,,,fee schedule,29148.45,43722.15, "Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,29148.45,,,,,,,fee schedule,29148.45,43722.15, "Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,43722.15,,,,,,,fee schedule,29148.45,43722.15, "Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,33684.61,,,,,,,fee schedule,29148.45,43722.15, "Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,30315.93,,,,,,,fee schedule,29148.45,43722.15, "Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],21733.02,21733.02,21733.02,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,85012.57,,,,,,,fee schedule,73714.18,110569.92, Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,73714.18,,,,,,,fee schedule,73714.18,110569.92, Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,110569.92,,,,,,,fee schedule,73714.18,110569.92, Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,85185.76,,,,,,,fee schedule,73714.18,110569.92, Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,76666.65,,,,,,,fee schedule,73714.18,110569.92, Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,53620.56,,,,,,,fee schedule,46494.25,69740.52, Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,46494.25,,,,,,,fee schedule,46494.25,69740.52, Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,69740.52,,,,,,,fee schedule,46494.25,69740.52, Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,53729.8,,,,,,,fee schedule,46494.25,69740.52, Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,48356.48,,,,,,,fee schedule,46494.25,69740.52, Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,29205.6,,,,,,,fee schedule,25324.1,37985.68, Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,25324.1,,,,,,,fee schedule,25324.1,37985.68, Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,37985.68,,,,,,,fee schedule,25324.1,37985.68, Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,29265.1,,,,,,,fee schedule,25324.1,37985.68, Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,26338.4,,,,,,,fee schedule,25324.1,37985.68, Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Heart Failure And Shock With Mcc,291,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,40329.29,,,,,,,fee schedule,34969.43,52453.5, Heart Failure And Shock With Mcc,291,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,34969.43,,,,,,,fee schedule,34969.43,52453.5, Heart Failure And Shock With Mcc,291,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,52453.5,,,,,,,fee schedule,34969.43,52453.5, Heart Failure And Shock With Mcc,291,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,40411.46,,,,,,,fee schedule,34969.43,52453.5, Heart Failure And Shock With Mcc,291,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,36370.05,,,,,,,fee schedule,34969.43,52453.5, Heart Failure And Shock With Mcc,291,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Heart Failure And Shock With Mcc,291,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Heart Failure And Shock With Mcc,291,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Heart Failure And Shock With Mcc,291,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Heart Failure And Shock With Mcc,291,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Heart Failure And Shock With Mcc,291,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Heart Failure And Shock With Mcc,291,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Heart Failure And Shock With Mcc,291,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],73358.88,73358.88,73358.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Heart Failure And Shock With Mcc,291,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Heart Failure And Shock With Mcc,291,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],12373.32,12373.32,12373.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Heart Failure And Shock With Mcc,291,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Heart Failure And Shock With Mcc,291,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],12035.86,12035.86,12035.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Heart Failure And Shock With Mcc,291,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Heart Failure And Shock With Mcc,291,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Heart Failure And Shock With Mcc,291,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Heart Failure And Shock With Mcc,291,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Heart Failure And Shock With Mcc,291,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Heart Failure And Shock With Mcc,291,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Heart Failure And Shock With Mcc,291,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Heart Failure And Shock With Mcc,291,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Heart Failure And Shock With Cc,292,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,26670.49,,,,,,,fee schedule,23125.91,34688.44, Heart Failure And Shock With Cc,292,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,23125.91,,,,,,,fee schedule,23125.91,34688.44, Heart Failure And Shock With Cc,292,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,34688.44,,,,,,,fee schedule,23125.91,34688.44, Heart Failure And Shock With Cc,292,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,26724.82,,,,,,,fee schedule,23125.91,34688.44, Heart Failure And Shock With Cc,292,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,24052.17,,,,,,,fee schedule,23125.91,34688.44, Heart Failure And Shock With Cc,292,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Heart Failure And Shock With Cc,292,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Heart Failure And Shock With Cc,292,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],32423.64,32423.64,32423.64,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Heart Failure And Shock With Cc,292,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Heart Failure And Shock With Cc,292,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Heart Failure And Shock With Cc,292,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Heart Failure And Shock With Cc,292,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Heart Failure And Shock With Cc,292,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],26783.66,26783.66,26783.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Heart Failure And Shock With Cc,292,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Heart Failure And Shock With Cc,292,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Heart Failure And Shock With Cc,292,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Heart Failure And Shock With Cc,292,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Heart Failure And Shock With Cc,292,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Heart Failure And Shock With Cc,292,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Heart Failure And Shock With Cc,292,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Heart Failure And Shock With Cc,292,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,32284.99,32284.99,32284.99,1 through 10,percent of total billed charges,,, Heart Failure And Shock With Cc,292,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Heart Failure And Shock With Cc,292,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Heart Failure And Shock With Cc,292,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Heart Failure And Shock With Cc,292,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,17780.32,,,,,,,fee schedule,15417.27,23125.63, Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,15417.27,,,,,,,fee schedule,15417.27,23125.63, Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,23125.63,,,,,,,fee schedule,15417.27,23125.63, Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,17816.55,,,,,,,fee schedule,15417.27,23125.63, Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,16034.78,,,,,,,fee schedule,15417.27,23125.63, Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,49065.53,,,,,,,fee schedule,42544.59,63816.11, "Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,42544.59,,,,,,,fee schedule,42544.59,63816.11, "Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,63816.11,,,,,,,fee schedule,42544.59,63816.11, "Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,49165.49,,,,,,,fee schedule,42544.59,63816.11, "Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,44248.63,,,,,,,fee schedule,42544.59,63816.11, "Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,19916.48,,,,,,,fee schedule,17269.53,25903.97, "Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,17269.53,,,,,,,fee schedule,17269.53,25903.97, "Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,25903.97,,,,,,,fee schedule,17269.53,25903.97, "Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,19957.05,,,,,,,fee schedule,17269.53,25903.97, "Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,17961.22,,,,,,,fee schedule,17269.53,25903.97, "Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,14296.51,,,,,,,fee schedule,12396.47,18594.48, "Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,12396.47,,,,,,,fee schedule,12396.47,18594.48, "Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,18594.48,,,,,,,fee schedule,12396.47,18594.48, "Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,14325.64,,,,,,,fee schedule,12396.47,18594.48, "Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,12892.98,,,,,,,fee schedule,12396.47,18594.48, "Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,51289.64,,,,,,,fee schedule,44473.12,66708.86, Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,44473.12,,,,,,,fee schedule,44473.12,66708.86, Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,66708.86,,,,,,,fee schedule,44473.12,66708.86, Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,51394.13,,,,,,,fee schedule,44473.12,66708.86, Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,46254.39,,,,,,,fee schedule,44473.12,66708.86, Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],25714.26,25714.26,25714.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,33534.45,,,,,,,fee schedule,29077.63,43615.92, Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,29077.63,,,,,,,fee schedule,29077.63,43615.92, Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,43615.92,,,,,,,fee schedule,29077.63,43615.92, Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,33602.77,,,,,,,fee schedule,29077.63,43615.92, Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,30242.28,,,,,,,fee schedule,29077.63,43615.92, Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],39392.76,39392.76,39392.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],23608.06,23608.06,23608.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,22608.66,,,,,,,fee schedule,19603.91,29405.5, Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,19603.91,,,,,,,fee schedule,19603.91,29405.5, Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,29405.5,,,,,,,fee schedule,19603.91,29405.5, Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,22654.72,,,,,,,fee schedule,19603.91,29405.5, Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,20389.1,,,,,,,fee schedule,19603.91,29405.5, Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Atherosclerosis With Mcc,302,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,37589.99,,,,,,,fee schedule,32594.19,48890.68, Atherosclerosis With Mcc,302,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,32594.19,,,,,,,fee schedule,32594.19,48890.68, Atherosclerosis With Mcc,302,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,48890.68,,,,,,,fee schedule,32594.19,48890.68, Atherosclerosis With Mcc,302,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,37666.57,,,,,,,fee schedule,32594.19,48890.68, Atherosclerosis With Mcc,302,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,33899.68,,,,,,,fee schedule,32594.19,48890.68, Atherosclerosis With Mcc,302,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Atherosclerosis With Mcc,302,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Atherosclerosis With Mcc,302,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Atherosclerosis With Mcc,302,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Atherosclerosis With Mcc,302,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Atherosclerosis With Mcc,302,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Atherosclerosis With Mcc,302,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Atherosclerosis With Mcc,302,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Atherosclerosis With Mcc,302,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Atherosclerosis With Mcc,302,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Atherosclerosis With Mcc,302,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Atherosclerosis With Mcc,302,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Atherosclerosis With Mcc,302,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Atherosclerosis With Mcc,302,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Atherosclerosis With Mcc,302,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Atherosclerosis With Mcc,302,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Atherosclerosis With Mcc,302,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Atherosclerosis With Mcc,302,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Atherosclerosis With Mcc,302,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Atherosclerosis With Mcc,302,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Atherosclerosis Without Mcc,303,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,21147.9,,,,,,,fee schedule,18337.29,27505.61, Atherosclerosis Without Mcc,303,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,18337.29,,,,,,,fee schedule,18337.29,27505.61, Atherosclerosis Without Mcc,303,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,27505.61,,,,,,,fee schedule,18337.29,27505.61, Atherosclerosis Without Mcc,303,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,21190.99,,,,,,,fee schedule,18337.29,27505.61, Atherosclerosis Without Mcc,303,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19071.76,,,,,,,fee schedule,18337.29,27505.61, Atherosclerosis Without Mcc,303,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Atherosclerosis Without Mcc,303,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Atherosclerosis Without Mcc,303,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Atherosclerosis Without Mcc,303,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Atherosclerosis Without Mcc,303,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Atherosclerosis Without Mcc,303,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Atherosclerosis Without Mcc,303,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Atherosclerosis Without Mcc,303,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Atherosclerosis Without Mcc,303,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Atherosclerosis Without Mcc,303,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Atherosclerosis Without Mcc,303,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Atherosclerosis Without Mcc,303,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Atherosclerosis Without Mcc,303,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Atherosclerosis Without Mcc,303,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Atherosclerosis Without Mcc,303,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Atherosclerosis Without Mcc,303,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Atherosclerosis Without Mcc,303,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Atherosclerosis Without Mcc,303,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Atherosclerosis Without Mcc,303,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Atherosclerosis Without Mcc,303,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hypertension With Mcc,304,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,37382.66,,,,,,,fee schedule,32414.41,48621.02, Hypertension With Mcc,304,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,32414.41,,,,,,,fee schedule,32414.41,48621.02, Hypertension With Mcc,304,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,48621.02,,,,,,,fee schedule,32414.41,48621.02, Hypertension With Mcc,304,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,37458.82,,,,,,,fee schedule,32414.41,48621.02, Hypertension With Mcc,304,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,33712.7,,,,,,,fee schedule,32414.41,48621.02, Hypertension With Mcc,304,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],33169.3,33169.3,33169.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Hypertension With Mcc,304,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hypertension With Mcc,304,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],28485.86,28485.86,28485.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Hypertension With Mcc,304,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],44695.36,44695.36,44695.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Hypertension With Mcc,304,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Hypertension With Mcc,304,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hypertension With Mcc,304,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hypertension With Mcc,304,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hypertension With Mcc,304,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hypertension With Mcc,304,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],23146.72,23146.72,23146.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Hypertension With Mcc,304,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hypertension With Mcc,304,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],20107.38,20107.38,20107.38,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Hypertension With Mcc,304,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],30035.76,30035.76,30035.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Hypertension With Mcc,304,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hypertension With Mcc,304,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hypertension With Mcc,304,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hypertension With Mcc,304,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hypertension With Mcc,304,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hypertension With Mcc,304,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hypertension With Mcc,304,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hypertension Without Mcc,305,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,23720.71,,,,,,,fee schedule,20568.17,30851.88, Hypertension Without Mcc,305,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,20568.17,,,,,,,fee schedule,20568.17,30851.88, Hypertension Without Mcc,305,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,30851.88,,,,,,,fee schedule,20568.17,30851.88, Hypertension Without Mcc,305,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,23769.04,,,,,,,fee schedule,20568.17,30851.88, Hypertension Without Mcc,305,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,21391.98,,,,,,,fee schedule,20568.17,30851.88, Hypertension Without Mcc,305,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Hypertension Without Mcc,305,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hypertension Without Mcc,305,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],27264.7,27264.7,27264.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Hypertension Without Mcc,305,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hypertension Without Mcc,305,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Hypertension Without Mcc,305,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hypertension Without Mcc,305,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hypertension Without Mcc,305,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hypertension Without Mcc,305,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hypertension Without Mcc,305,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],7462.93,7462.93,11348.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Hypertension Without Mcc,305,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hypertension Without Mcc,305,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],11039.39,11039.39,11039.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Hypertension Without Mcc,305,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],22024.79,22024.79,22024.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Hypertension Without Mcc,305,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hypertension Without Mcc,305,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hypertension Without Mcc,305,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hypertension Without Mcc,305,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hypertension Without Mcc,305,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hypertension Without Mcc,305,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hypertension Without Mcc,305,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,49502.18,,,,,,,fee schedule,42923.22,64384.04, Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,42923.22,,,,,,,fee schedule,42923.22,64384.04, Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,64384.04,,,,,,,fee schedule,42923.22,64384.04, Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,49603.03,,,,,,,fee schedule,42923.22,64384.04, Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,44642.41,,,,,,,fee schedule,42923.22,64384.04, Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],35981.27,35981.27,38278.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],27681.17,27681.17,27681.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],32641.54,32641.54,32641.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],115563.45,115563.45,115563.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],33321.93,33321.93,33321.93,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],115.41,115.41,115.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],43932.22,43932.22,43932.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,124613.95,124613.95,124613.95,1 through 10,percent of total billed charges,,, Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,28687.26,,,,,,,fee schedule,24874.65,37311.53, Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,24874.65,,,,,,,fee schedule,24874.65,37311.53, Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,37311.53,,,,,,,fee schedule,24874.65,37311.53, Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,28745.71,,,,,,,fee schedule,24874.65,37311.53, Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,25870.96,,,,,,,fee schedule,24874.65,37311.53, Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],26155.98,26155.98,26155.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],9369.05,9369.05,9369.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],7702.48,7702.48,7702.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],9189.31,9189.31,9189.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],66379.18,66379.18,66379.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,37822.46,,,,,,,fee schedule,32795.76,49193.03, Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,32795.76,,,,,,,fee schedule,32795.76,49193.03, Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,49193.03,,,,,,,fee schedule,32795.76,49193.03, Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,37899.51,,,,,,,fee schedule,32795.76,49193.03, Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,34109.32,,,,,,,fee schedule,32795.76,49193.03, Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],15257.35,15257.35,15257.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],30826.42,30826.42,30826.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],11610.12,11610.12,11610.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],6503.06,6503.06,6503.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,23111.28,,,,,,,fee schedule,20039.73,30059.23, Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,20039.73,,,,,,,fee schedule,20039.73,30059.23, Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,30059.23,,,,,,,fee schedule,20039.73,30059.23, Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,23158.36,,,,,,,fee schedule,20039.73,30059.23, Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,20842.38,,,,,,,fee schedule,20039.73,30059.23, Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],18888.73,18888.73,18888.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],6381.51,6381.51,6381.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],11105.34,11105.34,11105.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],6570.5,6570.5,11198.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,17783.47,,,,,,,fee schedule,15420,23129.71, Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,15420,,,,,,,fee schedule,15420,23129.71, Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,23129.71,,,,,,,fee schedule,15420,23129.71, Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,17819.7,,,,,,,fee schedule,15420,23129.71, Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,16037.61,,,,,,,fee schedule,15420,23129.71, Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],13102.5,13102.5,13102.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],4959.27,4959.27,4959.27,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],5020.93,5020.93,5020.93,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],5249.15,5249.15,5249.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],6989.27,6989.27,6989.27,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Angina Pectoris,311,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,22049.49,,,,,,,fee schedule,19119.05,28678.23, Angina Pectoris,311,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,19119.05,,,,,,,fee schedule,19119.05,28678.23, Angina Pectoris,311,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,28678.23,,,,,,,fee schedule,19119.05,28678.23, Angina Pectoris,311,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,22094.41,,,,,,,fee schedule,19119.05,28678.23, Angina Pectoris,311,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19884.83,,,,,,,fee schedule,19119.05,28678.23, Angina Pectoris,311,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Angina Pectoris,311,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Angina Pectoris,311,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Angina Pectoris,311,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Angina Pectoris,311,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Angina Pectoris,311,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Angina Pectoris,311,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Angina Pectoris,311,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Angina Pectoris,311,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Angina Pectoris,311,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],6312.47,6312.47,6312.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Angina Pectoris,311,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Angina Pectoris,311,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Angina Pectoris,311,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Angina Pectoris,311,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Angina Pectoris,311,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Angina Pectoris,311,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Angina Pectoris,311,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Angina Pectoris,311,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Angina Pectoris,311,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Angina Pectoris,311,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Syncope And Collapse,312,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,27380.44,,,,,,,fee schedule,23741.51,35611.83, Syncope And Collapse,312,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,23741.51,,,,,,,fee schedule,23741.51,35611.83, Syncope And Collapse,312,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,35611.83,,,,,,,fee schedule,23741.51,35611.83, Syncope And Collapse,312,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,27436.22,,,,,,,fee schedule,23741.51,35611.83, Syncope And Collapse,312,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,24692.43,,,,,,,fee schedule,23741.51,35611.83, Syncope And Collapse,312,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Syncope And Collapse,312,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Syncope And Collapse,312,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],33408.26,33408.26,33408.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Syncope And Collapse,312,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],22273.04,22273.04,22273.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Syncope And Collapse,312,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Syncope And Collapse,312,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Syncope And Collapse,312,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Syncope And Collapse,312,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Syncope And Collapse,312,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Syncope And Collapse,312,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Syncope And Collapse,312,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Syncope And Collapse,312,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],7764.78,7764.78,7764.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Syncope And Collapse,312,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Syncope And Collapse,312,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Syncope And Collapse,312,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Syncope And Collapse,312,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Syncope And Collapse,312,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Syncope And Collapse,312,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Syncope And Collapse,312,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Syncope And Collapse,312,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Chest Pain,313,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,22618.08,,,,,,,fee schedule,19612.08,29417.76, Chest Pain,313,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,19612.08,,,,,,,fee schedule,19612.08,29417.76, Chest Pain,313,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,29417.76,,,,,,,fee schedule,19612.08,29417.76, Chest Pain,313,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,22664.16,,,,,,,fee schedule,19612.08,29417.76, Chest Pain,313,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,20397.6,,,,,,,fee schedule,19612.08,29417.76, Chest Pain,313,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Chest Pain,313,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chest Pain,313,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chest Pain,313,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chest Pain,313,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Chest Pain,313,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chest Pain,313,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chest Pain,313,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chest Pain,313,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chest Pain,313,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chest Pain,313,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chest Pain,313,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chest Pain,313,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chest Pain,313,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chest Pain,313,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chest Pain,313,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Chest Pain,313,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Chest Pain,313,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Chest Pain,313,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Chest Pain,313,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,65504.47,,,,,,,fee schedule,56798.76,85197.1, Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,56798.76,,,,,,,fee schedule,56798.76,85197.1, Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,85197.1,,,,,,,fee schedule,56798.76,85197.1, Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,65637.93,,,,,,,fee schedule,56798.76,85197.1, Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,59073.72,,,,,,,fee schedule,56798.76,85197.1, Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],55049.92,55049.92,82571.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],481330.51,481330.51,481330.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],31082.14,18072.85,330390.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],18894.34,18894.34,18894.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],23461.82,15627.23,69123.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],52442.34,52442.34,52442.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,156674.16,156674.16,156674.16,1 through 10,percent of total billed charges,,, Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,30261.11,,,,,,,fee schedule,26239.33,39358.51, Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,26239.33,,,,,,,fee schedule,26239.33,39358.51, Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,39358.51,,,,,,,fee schedule,26239.33,39358.51, Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,30322.76,,,,,,,fee schedule,26239.33,39358.51, Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,27290.29,,,,,,,fee schedule,26239.33,39358.51, Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],8679.57,8679.57,8679.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],24599.27,24199.27,25475.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],16101.86,16101.86,48331.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],50535.1,50535.1,50535.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],8649.02,8649.02,8649.02,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,28148.21,28148.21,28148.21,1 through 10,percent of total billed charges,,, Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,21427.49,,,,,,,fee schedule,18579.72,27869.24, Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,18579.72,,,,,,,fee schedule,18579.72,27869.24, Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,27869.24,,,,,,,fee schedule,18579.72,27869.24, Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,21471.14,,,,,,,fee schedule,18579.72,27869.24, Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19323.89,,,,,,,fee schedule,18579.72,27869.24, Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],8047.35,8047.35,23084.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,210049.71,,,,,,,fee schedule,182133.57,273197.02, Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,182133.57,,,,,,,fee schedule,182133.57,273197.02, Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,273197.02,,,,,,,fee schedule,182133.57,273197.02, Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,210477.65,,,,,,,fee schedule,182133.57,273197.02, Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,189428.55,,,,,,,fee schedule,182133.57,273197.02, Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,76090.99,,,,,,,fee schedule,65978.31,98966.25, Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,65978.31,,,,,,,fee schedule,65978.31,98966.25, Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,98966.25,,,,,,,fee schedule,65978.31,98966.25, Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,76246.01,,,,,,,fee schedule,65978.31,98966.25, Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,68620.93,,,,,,,fee schedule,65978.31,98966.25, Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,140197.54,,,,,,,fee schedule,121564.93,182345.17, Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,121564.93,,,,,,,fee schedule,121564.93,182345.17, Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,182345.17,,,,,,,fee schedule,121564.93,182345.17, Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,140483.17,,,,,,,fee schedule,121564.93,182345.17, Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,126433.96,,,,,,,fee schedule,121564.93,182345.17, Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],242175.1,242175.1,242175.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],36226.68,36226.68,36226.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,75560.09,,,,,,,fee schedule,65517.97,98275.75, Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,65517.97,,,,,,,fee schedule,65517.97,98275.75, Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,98275.75,,,,,,,fee schedule,65517.97,98275.75, Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,75714.03,,,,,,,fee schedule,65517.97,98275.75, Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,68142.15,,,,,,,fee schedule,65517.97,98275.75, Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],25952.17,25952.17,25952.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,85471.21,,,,,,,fee schedule,74111.87,111166.45, Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,74111.87,,,,,,,fee schedule,74111.87,111166.45, Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,111166.45,,,,,,,fee schedule,74111.87,111166.45, Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,85645.34,,,,,,,fee schedule,74111.87,111166.45, Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,77080.26,,,,,,,fee schedule,74111.87,111166.45, Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,55382.88,,,,,,,fee schedule,48022.36,72032.65, Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,48022.36,,,,,,,fee schedule,48022.36,72032.65, Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,72032.65,,,,,,,fee schedule,48022.36,72032.65, Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,55495.71,,,,,,,fee schedule,48022.36,72032.65, Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,49945.79,,,,,,,fee schedule,48022.36,72032.65, Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,135940.94,,,,,,,fee schedule,117874.05,176808.91, Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,117874.05,,,,,,,fee schedule,117874.05,176808.91, Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,176808.91,,,,,,,fee schedule,117874.05,176808.91, Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,136217.9,,,,,,,fee schedule,117874.05,176808.91, Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,122595.24,,,,,,,fee schedule,117874.05,176808.91, Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,98985.51,,,,,,,fee schedule,85830.09,128743.56, Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,85830.09,,,,,,,fee schedule,85830.09,128743.56, Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,128743.56,,,,,,,fee schedule,85830.09,128743.56, Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,99187.18,,,,,,,fee schedule,85830.09,128743.56, Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,89267.83,,,,,,,fee schedule,85830.09,128743.56, Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,100851.51,,,,,,,fee schedule,87448.09,131170.52, Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,87448.09,,,,,,,fee schedule,87448.09,131170.52, Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,131170.52,,,,,,,fee schedule,87448.09,131170.52, Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,101056.97,,,,,,,fee schedule,87448.09,131170.52, Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,90950.63,,,,,,,fee schedule,87448.09,131170.52, Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,156674.18,,,,,,,fee schedule,135851.79,203775.19, "Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,135851.79,,,,,,,fee schedule,135851.79,203775.19, "Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,203775.19,,,,,,,fee schedule,135851.79,203775.19, "Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,156993.38,,,,,,,fee schedule,135851.79,203775.19, "Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,141293.04,,,,,,,fee schedule,135851.79,203775.19, "Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],448911.44,85839.55,767852,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],73107.21,73107.21,73107.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],25130.26,25130.26,25130.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],50535.14,50535.14,50535.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],63990.25,25962.76,345051.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],329812.99,329812.99,329812.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],17048.96,17048.96,17048.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,235350.63,235350.63,235350.63,1 through 10,percent of total billed charges,,, "Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,76782.1,,,,,,,fee schedule,66577.56,99865.12, "Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,66577.56,,,,,,,fee schedule,66577.56,99865.12, "Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,99865.12,,,,,,,fee schedule,66577.56,99865.12, "Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,76938.53,,,,,,,fee schedule,66577.56,99865.12, "Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,69244.19,,,,,,,fee schedule,66577.56,99865.12, "Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],93100.64,93100.64,93100.64,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],93100.64,93100.64,93100.64,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],15485.47,15485.47,75261.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],23763.82,23763.82,23763.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],17708.46,17708.46,17708.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],29214.31,17010.15,49599.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,108217.99,108217.99,108217.99,1 through 10,percent of total billed charges,,, "Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,50334.65,,,,,,,fee schedule,43645.05,65466.77, "Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,43645.05,,,,,,,fee schedule,43645.05,65466.77, "Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,65466.77,,,,,,,fee schedule,43645.05,65466.77, "Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,50437.2,,,,,,,fee schedule,43645.05,65466.77, "Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,45393.16,,,,,,,fee schedule,43645.05,65466.77, "Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],24554.94,24554.94,24554.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],9224.01,9224.01,9224.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],17708.46,17708.46,17708.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],15862.94,15862.94,15862.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],9643.28,9643.28,9643.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,144394.45,,,,,,,fee schedule,125204.06,187803.8, Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,125204.06,,,,,,,fee schedule,125204.06,187803.8, Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,187803.8,,,,,,,fee schedule,125204.06,187803.8, Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,144688.63,,,,,,,fee schedule,125204.06,187803.8, Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,130218.85,,,,,,,fee schedule,125204.06,187803.8, Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],302748,302748,302748,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],154013.85,154013.85,154013.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],117382.74,117382.74,117382.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],546558.45,546558.45,546558.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],69564.13,69564.13,69564.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],34745.08,34745.08,34745.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],34104.78,20367.86,54128.38,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,36905.31,36905.31,36905.31,1 through 10,percent of total billed charges,,, Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,75305.64,,,,,,,fee schedule,65297.33,97944.8, Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,65297.33,,,,,,,fee schedule,65297.33,97944.8, Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,97944.8,,,,,,,fee schedule,65297.33,97944.8, Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,75459.06,,,,,,,fee schedule,65297.33,97944.8, Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,67912.68,,,,,,,fee schedule,65297.33,97944.8, Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],38248.36,38248.36,38248.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],53518.82,53518.82,61971.93,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],65280.06,65280.06,65280.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],19693.17,19693.17,31723.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],12890.52,12890.52,12890.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],34104.78,34104.78,34104.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],21890.69,21890.69,21890.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,23998.96,23998.96,23998.96,1 through 10,percent of total billed charges,,, Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,52866.62,,,,,,,fee schedule,45840.51,68759.93, Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,45840.51,,,,,,,fee schedule,45840.51,68759.93, Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,68759.93,,,,,,,fee schedule,45840.51,68759.93, Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,52974.33,,,,,,,fee schedule,45840.51,68759.93, Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,47676.56,,,,,,,fee schedule,45840.51,68759.93, Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],26695.73,26695.73,26695.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],40891.51,40891.51,40891.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],62904.29,62904.29,62904.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],19242.99,19242.99,19242.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],20938.92,20938.92,20938.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],12581.05,12581.05,20367.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],13476.45,13476.45,13476.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Rectal Resection With Mcc,332,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,113740.67,,,,,,,fee schedule,98624.25,147934.56, Rectal Resection With Mcc,332,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,98624.25,,,,,,,fee schedule,98624.25,147934.56, Rectal Resection With Mcc,332,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,147934.56,,,,,,,fee schedule,98624.25,147934.56, Rectal Resection With Mcc,332,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,113972.39,,,,,,,fee schedule,98624.25,147934.56, Rectal Resection With Mcc,332,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,102574.43,,,,,,,fee schedule,98624.25,147934.56, Rectal Resection With Mcc,332,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Rectal Resection With Mcc,332,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Rectal Resection With Mcc,332,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Rectal Resection With Mcc,332,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Rectal Resection With Mcc,332,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Rectal Resection With Mcc,332,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Rectal Resection With Mcc,332,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Rectal Resection With Mcc,332,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Rectal Resection With Mcc,332,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Rectal Resection With Mcc,332,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Rectal Resection With Mcc,332,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Rectal Resection With Mcc,332,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Rectal Resection With Mcc,332,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Rectal Resection With Mcc,332,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Rectal Resection With Mcc,332,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Rectal Resection With Mcc,332,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Rectal Resection With Mcc,332,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Rectal Resection With Mcc,332,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Rectal Resection With Mcc,332,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Rectal Resection With Mcc,332,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Rectal Resection With Cc,333,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,73577.87,,,,,,,fee schedule,63799.19,95697.61, Rectal Resection With Cc,333,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,63799.19,,,,,,,fee schedule,63799.19,95697.61, Rectal Resection With Cc,333,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,95697.61,,,,,,,fee schedule,63799.19,95697.61, Rectal Resection With Cc,333,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,73727.77,,,,,,,fee schedule,63799.19,95697.61, Rectal Resection With Cc,333,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,66354.53,,,,,,,fee schedule,63799.19,95697.61, Rectal Resection With Cc,333,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Rectal Resection With Cc,333,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Rectal Resection With Cc,333,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Rectal Resection With Cc,333,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Rectal Resection With Cc,333,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Rectal Resection With Cc,333,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Rectal Resection With Cc,333,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Rectal Resection With Cc,333,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Rectal Resection With Cc,333,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Rectal Resection With Cc,333,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Rectal Resection With Cc,333,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Rectal Resection With Cc,333,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Rectal Resection With Cc,333,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Rectal Resection With Cc,333,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Rectal Resection With Cc,333,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Rectal Resection With Cc,333,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Rectal Resection With Cc,333,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Rectal Resection With Cc,333,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Rectal Resection With Cc,333,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Rectal Resection With Cc,333,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,51452.99,,,,,,,fee schedule,44614.76,66921.32, Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,44614.76,,,,,,,fee schedule,44614.76,66921.32, Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,66921.32,,,,,,,fee schedule,44614.76,66921.32, Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,51557.82,,,,,,,fee schedule,44614.76,66921.32, Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,46401.71,,,,,,,fee schedule,44614.76,66921.32, Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,112176.25,,,,,,,fee schedule,97267.75,145899.83, Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,97267.75,,,,,,,fee schedule,97267.75,145899.83, Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,145899.83,,,,,,,fee schedule,97267.75,145899.83, Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,112404.79,,,,,,,fee schedule,97267.75,145899.83, Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,101163.6,,,,,,,fee schedule,97267.75,145899.83, Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],64236.64,64236.64,64236.64,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],32647.29,32647.29,47549.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],119860.13,119860.13,119860.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,66242.7,,,,,,,fee schedule,57438.88,86157.26, Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,57438.88,,,,,,,fee schedule,57438.88,86157.26, Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,86157.26,,,,,,,fee schedule,57438.88,86157.26, Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,66377.66,,,,,,,fee schedule,57438.88,86157.26, Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,59739.47,,,,,,,fee schedule,57438.88,86157.26, Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],32590.35,32590.35,32590.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],53746.72,53746.72,53746.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,48220.49,,,,,,,fee schedule,41811.87,62717.03, Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,41811.87,,,,,,,fee schedule,41811.87,62717.03, Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,62717.03,,,,,,,fee schedule,41811.87,62717.03, Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,48318.73,,,,,,,fee schedule,41811.87,62717.03, Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,43486.55,,,,,,,fee schedule,41811.87,62717.03, Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],35037.86,35037.86,35037.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],36652.59,36652.59,36652.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],14670.77,14670.77,14670.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Appendectomy With Complicated Principal Diagnosis With Mcc,338,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy With Complicated Principal Diagnosis With Mcc,338,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy With Complicated Principal Diagnosis With Mcc,338,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy With Complicated Principal Diagnosis With Mcc,338,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy With Complicated Principal Diagnosis With Mcc,338,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy With Complicated Principal Diagnosis With Mcc,338,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy With Complicated Principal Diagnosis With Mcc,338,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy With Complicated Principal Diagnosis With Mcc,338,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy With Complicated Principal Diagnosis With Mcc,338,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy With Complicated Principal Diagnosis With Mcc,338,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy With Complicated Principal Diagnosis With Mcc,338,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy With Complicated Principal Diagnosis With Mcc,338,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy With Complicated Principal Diagnosis With Mcc,338,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy With Complicated Principal Diagnosis With Mcc,338,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy With Complicated Principal Diagnosis With Mcc,338,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy With Complicated Principal Diagnosis With Mcc,338,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Appendectomy With Complicated Principal Diagnosis With Mcc,338,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Appendectomy With Complicated Principal Diagnosis With Mcc,338,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Appendectomy With Complicated Principal Diagnosis With Mcc,338,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Appendectomy With Complicated Principal Diagnosis With Mcc,338,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Appendectomy With Complicated Principal Diagnosis With Cc,339,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy With Complicated Principal Diagnosis With Cc,339,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy With Complicated Principal Diagnosis With Cc,339,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy With Complicated Principal Diagnosis With Cc,339,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy With Complicated Principal Diagnosis With Cc,339,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy With Complicated Principal Diagnosis With Cc,339,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy With Complicated Principal Diagnosis With Cc,339,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy With Complicated Principal Diagnosis With Cc,339,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy With Complicated Principal Diagnosis With Cc,339,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy With Complicated Principal Diagnosis With Cc,339,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy With Complicated Principal Diagnosis With Cc,339,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy With Complicated Principal Diagnosis With Cc,339,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy With Complicated Principal Diagnosis With Cc,339,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy With Complicated Principal Diagnosis With Cc,339,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy With Complicated Principal Diagnosis With Cc,339,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy With Complicated Principal Diagnosis With Cc,339,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Appendectomy With Complicated Principal Diagnosis With Cc,339,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Appendectomy With Complicated Principal Diagnosis With Cc,339,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Appendectomy With Complicated Principal Diagnosis With Cc,339,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Appendectomy With Complicated Principal Diagnosis With Cc,339,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc,340,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc,340,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc,340,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc,340,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc,340,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc,340,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc,340,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc,340,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc,340,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc,340,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc,340,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc,340,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc,340,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc,340,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc,340,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc,340,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc,340,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc,340,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc,340,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc,340,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Appendectomy Without Complicated Principal Diagnosis With Mcc,341,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy Without Complicated Principal Diagnosis With Mcc,341,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy Without Complicated Principal Diagnosis With Mcc,341,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy Without Complicated Principal Diagnosis With Mcc,341,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy Without Complicated Principal Diagnosis With Mcc,341,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy Without Complicated Principal Diagnosis With Mcc,341,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy Without Complicated Principal Diagnosis With Mcc,341,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy Without Complicated Principal Diagnosis With Mcc,341,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy Without Complicated Principal Diagnosis With Mcc,341,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy Without Complicated Principal Diagnosis With Mcc,341,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy Without Complicated Principal Diagnosis With Mcc,341,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy Without Complicated Principal Diagnosis With Mcc,341,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy Without Complicated Principal Diagnosis With Mcc,341,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy Without Complicated Principal Diagnosis With Mcc,341,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy Without Complicated Principal Diagnosis With Mcc,341,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy Without Complicated Principal Diagnosis With Mcc,341,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Appendectomy Without Complicated Principal Diagnosis With Mcc,341,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Appendectomy Without Complicated Principal Diagnosis With Mcc,341,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Appendectomy Without Complicated Principal Diagnosis With Mcc,341,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Appendectomy Without Complicated Principal Diagnosis With Mcc,341,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Appendectomy Without Complicated Principal Diagnosis With Cc,342,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy Without Complicated Principal Diagnosis With Cc,342,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy Without Complicated Principal Diagnosis With Cc,342,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy Without Complicated Principal Diagnosis With Cc,342,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy Without Complicated Principal Diagnosis With Cc,342,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy Without Complicated Principal Diagnosis With Cc,342,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy Without Complicated Principal Diagnosis With Cc,342,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy Without Complicated Principal Diagnosis With Cc,342,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy Without Complicated Principal Diagnosis With Cc,342,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy Without Complicated Principal Diagnosis With Cc,342,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy Without Complicated Principal Diagnosis With Cc,342,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy Without Complicated Principal Diagnosis With Cc,342,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy Without Complicated Principal Diagnosis With Cc,342,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy Without Complicated Principal Diagnosis With Cc,342,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy Without Complicated Principal Diagnosis With Cc,342,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy Without Complicated Principal Diagnosis With Cc,342,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Appendectomy Without Complicated Principal Diagnosis With Cc,342,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Appendectomy Without Complicated Principal Diagnosis With Cc,342,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Appendectomy Without Complicated Principal Diagnosis With Cc,342,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Appendectomy Without Complicated Principal Diagnosis With Cc,342,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc,343,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc,343,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc,343,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc,343,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc,343,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc,343,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc,343,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc,343,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc,343,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc,343,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc,343,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc,343,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc,343,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc,343,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc,343,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc,343,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc,343,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc,343,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc,343,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc,343,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,81136.08,,,,,,,fee schedule,70352.89,105528.04, Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,70352.89,,,,,,,fee schedule,70352.89,105528.04, Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,105528.04,,,,,,,fee schedule,70352.89,105528.04, Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,81301.38,,,,,,,fee schedule,70352.89,105528.04, Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,73170.72,,,,,,,fee schedule,70352.89,105528.04, Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],12581.05,12581.05,12581.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],55315.46,55315.46,55315.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,47268.65,,,,,,,fee schedule,40986.52,61479.03, Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,40986.52,,,,,,,fee schedule,40986.52,61479.03, Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,61479.03,,,,,,,fee schedule,40986.52,61479.03, Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,47364.95,,,,,,,fee schedule,40986.52,61479.03, Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,42628.15,,,,,,,fee schedule,40986.52,61479.03, Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],44585.02,44585.02,44585.02,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],38055.64,38055.64,38055.64,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],23948.85,23948.85,23948.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],16051.46,16051.46,16051.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,37263.29,,,,,,,fee schedule,32310.9,48465.76, Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,32310.9,,,,,,,fee schedule,32310.9,48465.76, Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,48465.76,,,,,,,fee schedule,32310.9,48465.76, Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,37339.2,,,,,,,fee schedule,32310.9,48465.76, Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,33605.05,,,,,,,fee schedule,32310.9,48465.76, Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,72113.98,,,,,,,fee schedule,62529.85,93793.62, Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,62529.85,,,,,,,fee schedule,62529.85,93793.62, Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,93793.62,,,,,,,fee schedule,62529.85,93793.62, Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,72260.9,,,,,,,fee schedule,62529.85,93793.62, Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,65034.35,,,,,,,fee schedule,62529.85,93793.62, Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,41114.64,,,,,,,fee schedule,35650.4,53474.95, Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,35650.4,,,,,,,fee schedule,35650.4,53474.95, Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,53474.95,,,,,,,fee schedule,35650.4,53474.95, Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,41198.41,,,,,,,fee schedule,35650.4,53474.95, Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,37078.3,,,,,,,fee schedule,35650.4,53474.95, Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],11584.23,11584.23,11584.23,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,27349.03,,,,,,,fee schedule,23714.27,35570.97, Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,23714.27,,,,,,,fee schedule,23714.27,35570.97, Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,35570.97,,,,,,,fee schedule,23714.27,35570.97, Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,27404.75,,,,,,,fee schedule,23714.27,35570.97, Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,24664.1,,,,,,,fee schedule,23714.27,35570.97, Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],29463.73,29463.73,29463.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,78280.55,,,,,,,fee schedule,67876.86,101814.05, Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,67876.86,,,,,,,fee schedule,67876.86,101814.05, Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,101814.05,,,,,,,fee schedule,67876.86,101814.05, Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,78440.03,,,,,,,fee schedule,67876.86,101814.05, Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,70595.53,,,,,,,fee schedule,67876.86,101814.05, Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],92740.21,92740.21,92740.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],21089.89,21089.89,21089.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,47890.64,,,,,,,fee schedule,41525.86,62288.02, Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,41525.86,,,,,,,fee schedule,41525.86,62288.02, Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,62288.02,,,,,,,fee schedule,41525.86,62288.02, Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,47988.21,,,,,,,fee schedule,41525.86,62288.02, Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,43189.09,,,,,,,fee schedule,41525.86,62288.02, Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,36685.27,,,,,,,fee schedule,31809.7,47713.97, Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,31809.7,,,,,,,fee schedule,31809.7,47713.97, Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,47713.97,,,,,,,fee schedule,31809.7,47713.97, Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,36760.01,,,,,,,fee schedule,31809.7,47713.97, Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,33083.77,,,,,,,fee schedule,31809.7,47713.97, Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,91163.43,,,,,,,fee schedule,79047.58,118569.92, Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,79047.58,,,,,,,fee schedule,79047.58,118569.92, Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,118569.92,,,,,,,fee schedule,79047.58,118569.92, Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,91349.16,,,,,,,fee schedule,79047.58,118569.92, Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,82213.66,,,,,,,fee schedule,79047.58,118569.92, Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],848912.59,848912.59,848912.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],52469.41,52469.41,52469.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],44712.77,44712.77,44712.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],354690.53,354690.53,354690.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],34240.48,34240.48,34240.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,52850.91,,,,,,,fee schedule,45826.89,68739.5, Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,45826.89,,,,,,,fee schedule,45826.89,68739.5, Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,68739.5,,,,,,,fee schedule,45826.89,68739.5, Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,52958.59,,,,,,,fee schedule,45826.89,68739.5, Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,47662.39,,,,,,,fee schedule,45826.89,68739.5, Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,42251.83,,,,,,,fee schedule,36636.46,54954.01, Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,36636.46,,,,,,,fee schedule,36636.46,54954.01, Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,54954.01,,,,,,,fee schedule,36636.46,54954.01, Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,42337.91,,,,,,,fee schedule,36636.46,54954.01, Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,38103.85,,,,,,,fee schedule,36636.46,54954.01, Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,137995.42,,,,,,,fee schedule,119655.48,179481.02, Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,119655.48,,,,,,,fee schedule,119655.48,179481.02, Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,179481.02,,,,,,,fee schedule,119655.48,179481.02, Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,138276.56,,,,,,,fee schedule,119655.48,179481.02, Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,124448.02,,,,,,,fee schedule,119655.48,179481.02, Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],96589.06,96589.06,96589.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,73053.26,,,,,,,fee schedule,63344.29,95015.28, Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,63344.29,,,,,,,fee schedule,63344.29,95015.28, Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,95015.28,,,,,,,fee schedule,63344.29,95015.28, Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,73202.09,,,,,,,fee schedule,63344.29,95015.28, Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,65881.42,,,,,,,fee schedule,63344.29,95015.28, Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],118829.55,118829.55,118829.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],125877.61,125877.61,125877.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,43913.63,,,,,,,fee schedule,38077.4,57115.4, Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,38077.4,,,,,,,fee schedule,38077.4,57115.4, Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,57115.4,,,,,,,fee schedule,38077.4,57115.4, Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,44003.1,,,,,,,fee schedule,38077.4,57115.4, Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,39602.51,,,,,,,fee schedule,38077.4,57115.4, Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,108020.18,,,,,,,fee schedule,93664.03,140494.32, Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,93664.03,,,,,,,fee schedule,93664.03,140494.32, Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,140494.32,,,,,,,fee schedule,93664.03,140494.32, Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,108240.25,,,,,,,fee schedule,93664.03,140494.32, Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,97415.54,,,,,,,fee schedule,93664.03,140494.32, Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,75842.82,,,,,,,fee schedule,65763.12,98643.47, Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,65763.12,,,,,,,fee schedule,65763.12,98643.47, Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,98643.47,,,,,,,fee schedule,65763.12,98643.47, Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,75997.34,,,,,,,fee schedule,65763.12,98643.47, Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,68397.12,,,,,,,fee schedule,65763.12,98643.47, Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Laparoscopy & Incisional Tubal Interruption,361,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Laparoscopy & Incisional Tubal Interruption,361,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Laparoscopy & Incisional Tubal Interruption,361,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Laparoscopy & Incisional Tubal Interruption,361,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Laparoscopy & Incisional Tubal Interruption,361,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Laparoscopy & Incisional Tubal Interruption,361,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Laparoscopy & Incisional Tubal Interruption,361,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Laparoscopy & Incisional Tubal Interruption,361,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Laparoscopy & Incisional Tubal Interruption,361,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Laparoscopy & Incisional Tubal Interruption,361,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Laparoscopy & Incisional Tubal Interruption,361,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Laparoscopy & Incisional Tubal Interruption,361,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Laparoscopy & Incisional Tubal Interruption,361,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Laparoscopy & Incisional Tubal Interruption,361,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Laparoscopy & Incisional Tubal Interruption,361,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Laparoscopy & Incisional Tubal Interruption,361,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Laparoscopy & Incisional Tubal Interruption,361,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Laparoscopy & Incisional Tubal Interruption,361,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Laparoscopy & Incisional Tubal Interruption,361,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Laparoscopy & Incisional Tubal Interruption,361,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Endoscopic Tubal Interruption,362,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Endoscopic Tubal Interruption,362,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endoscopic Tubal Interruption,362,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endoscopic Tubal Interruption,362,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endoscopic Tubal Interruption,362,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Endoscopic Tubal Interruption,362,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endoscopic Tubal Interruption,362,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endoscopic Tubal Interruption,362,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endoscopic Tubal Interruption,362,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endoscopic Tubal Interruption,362,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endoscopic Tubal Interruption,362,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endoscopic Tubal Interruption,362,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endoscopic Tubal Interruption,362,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endoscopic Tubal Interruption,362,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endoscopic Tubal Interruption,362,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endoscopic Tubal Interruption,362,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Endoscopic Tubal Interruption,362,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Endoscopic Tubal Interruption,362,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Endoscopic Tubal Interruption,362,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Endoscopic Tubal Interruption,362,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "D&C, Conization & Radio-Implant, for Malignancy",363,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "D&C, Conization & Radio-Implant, for Malignancy",363,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "D&C, Conization & Radio-Implant, for Malignancy",363,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "D&C, Conization & Radio-Implant, for Malignancy",363,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "D&C, Conization & Radio-Implant, for Malignancy",363,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "D&C, Conization & Radio-Implant, for Malignancy",363,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "D&C, Conization & Radio-Implant, for Malignancy",363,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "D&C, Conization & Radio-Implant, for Malignancy",363,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "D&C, Conization & Radio-Implant, for Malignancy",363,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "D&C, Conization & Radio-Implant, for Malignancy",363,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "D&C, Conization & Radio-Implant, for Malignancy",363,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "D&C, Conization & Radio-Implant, for Malignancy",363,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "D&C, Conization & Radio-Implant, for Malignancy",363,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "D&C, Conization & Radio-Implant, for Malignancy",363,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "D&C, Conization & Radio-Implant, for Malignancy",363,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "D&C, Conization & Radio-Implant, for Malignancy",363,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "D&C, Conization & Radio-Implant, for Malignancy",363,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "D&C, Conization & Radio-Implant, for Malignancy",363,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "D&C, Conization & Radio-Implant, for Malignancy",363,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "D&C, Conization & Radio-Implant, for Malignancy",363,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "D&C, Conization Except for Malignancy",364,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "D&C, Conization Except for Malignancy",364,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "D&C, Conization Except for Malignancy",364,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "D&C, Conization Except for Malignancy",364,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "D&C, Conization Except for Malignancy",364,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "D&C, Conization Except for Malignancy",364,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "D&C, Conization Except for Malignancy",364,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "D&C, Conization Except for Malignancy",364,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "D&C, Conization Except for Malignancy",364,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "D&C, Conization Except for Malignancy",364,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "D&C, Conization Except for Malignancy",364,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "D&C, Conization Except for Malignancy",364,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "D&C, Conization Except for Malignancy",364,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "D&C, Conization Except for Malignancy",364,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "D&C, Conization Except for Malignancy",364,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "D&C, Conization Except for Malignancy",364,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "D&C, Conization Except for Malignancy",364,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "D&C, Conization Except for Malignancy",364,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "D&C, Conization Except for Malignancy",364,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "D&C, Conization Except for Malignancy",364,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Female Reproductive System O.R. Procedures,365,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Other Female Reproductive System O.R. Procedures,365,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Female Reproductive System O.R. Procedures,365,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Female Reproductive System O.R. Procedures,365,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Female Reproductive System O.R. Procedures,365,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other Female Reproductive System O.R. Procedures,365,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Female Reproductive System O.R. Procedures,365,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Female Reproductive System O.R. Procedures,365,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Female Reproductive System O.R. Procedures,365,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Female Reproductive System O.R. Procedures,365,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Female Reproductive System O.R. Procedures,365,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Female Reproductive System O.R. Procedures,365,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Female Reproductive System O.R. Procedures,365,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Female Reproductive System O.R. Procedures,365,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Female Reproductive System O.R. Procedures,365,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Female Reproductive System O.R. Procedures,365,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Female Reproductive System O.R. Procedures,365,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Female Reproductive System O.R. Procedures,365,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Female Reproductive System O.R. Procedures,365,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Female Reproductive System O.R. Procedures,365,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Malignancy, female reproductive system w CC",366,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, female reproductive system w CC",366,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, female reproductive system w CC",366,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, female reproductive system w CC",366,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, female reproductive system w CC",366,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, female reproductive system w CC",366,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, female reproductive system w CC",366,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, female reproductive system w CC",366,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, female reproductive system w CC",366,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, female reproductive system w CC",366,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, female reproductive system w CC",366,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, female reproductive system w CC",366,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, female reproductive system w CC",366,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, female reproductive system w CC",366,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, female reproductive system w CC",366,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, female reproductive system w CC",366,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Malignancy, female reproductive system w CC",366,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Malignancy, female reproductive system w CC",366,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Malignancy, female reproductive system w CC",366,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Malignancy, female reproductive system w CC",366,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Malignancy, Female Reproductive System w/o CC",367,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Female Reproductive System w/o CC",367,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Female Reproductive System w/o CC",367,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Female Reproductive System w/o CC",367,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Female Reproductive System w/o CC",367,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Female Reproductive System w/o CC",367,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Female Reproductive System w/o CC",367,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Female Reproductive System w/o CC",367,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Female Reproductive System w/o CC",367,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Female Reproductive System w/o CC",367,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Female Reproductive System w/o CC",367,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Female Reproductive System w/o CC",367,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Female Reproductive System w/o CC",367,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Female Reproductive System w/o CC",367,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Female Reproductive System w/o CC",367,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Female Reproductive System w/o CC",367,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Malignancy, Female Reproductive System w/o CC",367,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Malignancy, Female Reproductive System w/o CC",367,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Malignancy, Female Reproductive System w/o CC",367,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Malignancy, Female Reproductive System w/o CC",367,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,50007.95,,,,,,,fee schedule,43361.76,65041.85, Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,43361.76,,,,,,,fee schedule,43361.76,65041.85, Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,65041.85,,,,,,,fee schedule,43361.76,65041.85, Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,50109.83,,,,,,,fee schedule,43361.76,65041.85, Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,45098.53,,,,,,,fee schedule,43361.76,65041.85, Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],24483.23,24483.23,24483.23,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Esophageal Disorders With Cc,369,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,31420.28,,,,,,,fee schedule,27244.45,40866.17, Major Esophageal Disorders With Cc,369,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,27244.45,,,,,,,fee schedule,27244.45,40866.17, Major Esophageal Disorders With Cc,369,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,40866.17,,,,,,,fee schedule,27244.45,40866.17, Major Esophageal Disorders With Cc,369,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,31484.3,,,,,,,fee schedule,27244.45,40866.17, Major Esophageal Disorders With Cc,369,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,28335.67,,,,,,,fee schedule,27244.45,40866.17, Major Esophageal Disorders With Cc,369,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Major Esophageal Disorders With Cc,369,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Esophageal Disorders With Cc,369,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Esophageal Disorders With Cc,369,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Esophageal Disorders With Cc,369,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Major Esophageal Disorders With Cc,369,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Esophageal Disorders With Cc,369,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Esophageal Disorders With Cc,369,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Esophageal Disorders With Cc,369,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Esophageal Disorders With Cc,369,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Esophageal Disorders With Cc,369,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Esophageal Disorders With Cc,369,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],8486.45,8486.45,8486.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Esophageal Disorders With Cc,369,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Esophageal Disorders With Cc,369,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Esophageal Disorders With Cc,369,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Esophageal Disorders With Cc,369,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Esophageal Disorders With Cc,369,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Esophageal Disorders With Cc,369,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Esophageal Disorders With Cc,369,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Esophageal Disorders With Cc,369,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,22014.93,,,,,,,fee schedule,19089.09,28633.29, Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,19089.09,,,,,,,fee schedule,19089.09,28633.29, Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,28633.29,,,,,,,fee schedule,19089.09,28633.29, Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,22059.78,,,,,,,fee schedule,19089.09,28633.29, Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19853.66,,,,,,,fee schedule,19089.09,28633.29, Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,55700.16,,,,,,,fee schedule,48297.47,72445.32, Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,48297.47,,,,,,,fee schedule,48297.47,72445.32, Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,72445.32,,,,,,,fee schedule,48297.47,72445.32, Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,55813.64,,,,,,,fee schedule,48297.47,72445.32, Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,50231.92,,,,,,,fee schedule,48297.47,72445.32, Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],24730.9,24730.9,24730.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],13649.29,13649.29,25201.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],8491.44,8491.44,8491.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],47627.14,47627.14,47627.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,32073.69,,,,,,,fee schedule,27811.02,41716.02, Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,27811.02,,,,,,,fee schedule,27811.02,41716.02, Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,41716.02,,,,,,,fee schedule,27811.02,41716.02, Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,32139.04,,,,,,,fee schedule,27811.02,41716.02, Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,28924.93,,,,,,,fee schedule,27811.02,41716.02, Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],27261.26,27261.26,27261.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],37716.45,37716.45,37716.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],26312,26312,26312,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],12794.29,12794.29,12794.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],8122.25,5951.33,13403.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],7893.23,5789.02,13649.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],28703.06,28434.05,28703.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,22850.54,,,,,,,fee schedule,19813.65,29720.11, Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,19813.65,,,,,,,fee schedule,19813.65,29720.11, Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,29720.11,,,,,,,fee schedule,19813.65,29720.11, Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,22897.1,,,,,,,fee schedule,19813.65,29720.11, Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,20607.24,,,,,,,fee schedule,19813.65,29720.11, Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],18124.42,18124.42,18124.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],8852.22,8852.22,8860.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],18486.82,18486.82,18486.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],6034.75,6034.75,6034.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],8491.44,8491.44,8491.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],5789.02,5789.02,5789.02,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],6309.06,6309.06,6309.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],17382.32,17382.32,17382.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Digestive Malignancy With Mcc,374,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,67185.12,,,,,,,fee schedule,58256.05,87383, Digestive Malignancy With Mcc,374,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,58256.05,,,,,,,fee schedule,58256.05,87383, Digestive Malignancy With Mcc,374,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,87383,,,,,,,fee schedule,58256.05,87383, Digestive Malignancy With Mcc,374,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,67322,,,,,,,fee schedule,58256.05,87383, Digestive Malignancy With Mcc,374,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,60589.37,,,,,,,fee schedule,58256.05,87383, Digestive Malignancy With Mcc,374,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Digestive Malignancy With Mcc,374,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Digestive Malignancy With Mcc,374,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Digestive Malignancy With Mcc,374,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Digestive Malignancy With Mcc,374,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Digestive Malignancy With Mcc,374,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Digestive Malignancy With Mcc,374,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Digestive Malignancy With Mcc,374,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Digestive Malignancy With Mcc,374,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Digestive Malignancy With Mcc,374,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Digestive Malignancy With Mcc,374,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Digestive Malignancy With Mcc,374,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Digestive Malignancy With Mcc,374,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Digestive Malignancy With Mcc,374,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Digestive Malignancy With Mcc,374,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Digestive Malignancy With Mcc,374,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Digestive Malignancy With Mcc,374,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Digestive Malignancy With Mcc,374,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Digestive Malignancy With Mcc,374,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Digestive Malignancy With Mcc,374,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Digestive Malignancy With Cc,375,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,37998.37,,,,,,,fee schedule,32948.29,49421.84, Digestive Malignancy With Cc,375,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,32948.29,,,,,,,fee schedule,32948.29,49421.84, Digestive Malignancy With Cc,375,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,49421.84,,,,,,,fee schedule,32948.29,49421.84, Digestive Malignancy With Cc,375,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,38075.79,,,,,,,fee schedule,32948.29,49421.84, Digestive Malignancy With Cc,375,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,34267.97,,,,,,,fee schedule,32948.29,49421.84, Digestive Malignancy With Cc,375,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Digestive Malignancy With Cc,375,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Digestive Malignancy With Cc,375,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Digestive Malignancy With Cc,375,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Digestive Malignancy With Cc,375,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Digestive Malignancy With Cc,375,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Digestive Malignancy With Cc,375,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Digestive Malignancy With Cc,375,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Digestive Malignancy With Cc,375,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Digestive Malignancy With Cc,375,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Digestive Malignancy With Cc,375,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Digestive Malignancy With Cc,375,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Digestive Malignancy With Cc,375,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Digestive Malignancy With Cc,375,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Digestive Malignancy With Cc,375,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Digestive Malignancy With Cc,375,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Digestive Malignancy With Cc,375,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Digestive Malignancy With Cc,375,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Digestive Malignancy With Cc,375,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Digestive Malignancy With Cc,375,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,29035.96,,,,,,,fee schedule,25177.01,37765.05, Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,25177.01,,,,,,,fee schedule,25177.01,37765.05, Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,37765.05,,,,,,,fee schedule,25177.01,37765.05, Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,29095.12,,,,,,,fee schedule,25177.01,37765.05, Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,26185.42,,,,,,,fee schedule,25177.01,37765.05, Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,57424.79,,,,,,,fee schedule,49792.89,74688.42, Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,49792.89,,,,,,,fee schedule,49792.89,74688.42, Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,74688.42,,,,,,,fee schedule,49792.89,74688.42, Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,57541.78,,,,,,,fee schedule,49792.89,74688.42, Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,51787.24,,,,,,,fee schedule,49792.89,74688.42, Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],28739.38,28739.38,28739.38,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],69715.24,69715.24,69715.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],13762.39,13762.39,13960.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,30807.71,,,,,,,fee schedule,26713.29,40069.44, Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,26713.29,,,,,,,fee schedule,26713.29,40069.44, Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,40069.44,,,,,,,fee schedule,26713.29,40069.44, Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,30870.47,,,,,,,fee schedule,26713.29,40069.44, Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,27783.23,,,,,,,fee schedule,26713.29,40069.44, Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],17488.09,17488.09,17488.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],13505.15,13505.15,13505.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,19803.39,,,,,,,fee schedule,17171.47,25756.88, Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,17171.47,,,,,,,fee schedule,17171.47,25756.88, Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,25756.88,,,,,,,fee schedule,17171.47,25756.88, Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,19843.73,,,,,,,fee schedule,17171.47,25756.88, Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,17859.23,,,,,,,fee schedule,17171.47,25756.88, Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],20006.49,20006.49,20006.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],8354.45,8354.45,8354.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],6230.26,6230.26,6230.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,61640.55,,,,,,,fee schedule,53448.37,80171.57, Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,53448.37,,,,,,,fee schedule,53448.37,80171.57, Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,80171.57,,,,,,,fee schedule,53448.37,80171.57, Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,61766.13,,,,,,,fee schedule,53448.37,80171.57, Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,55589.13,,,,,,,fee schedule,53448.37,80171.57, Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,34037.07,,,,,,,fee schedule,29513.46,44269.64, Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,29513.46,,,,,,,fee schedule,29513.46,44269.64, Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,44269.64,,,,,,,fee schedule,29513.46,44269.64, Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,34106.41,,,,,,,fee schedule,29513.46,44269.64, Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,30695.56,,,,,,,fee schedule,29513.46,44269.64, Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,25150.05,,,,,,,fee schedule,21807.54,32710.91, Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,21807.54,,,,,,,fee schedule,21807.54,32710.91, Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,32710.91,,,,,,,fee schedule,21807.54,32710.91, Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,25201.29,,,,,,,fee schedule,21807.54,32710.91, Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22681,,,,,,,fee schedule,21807.54,32710.91, Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,43373.31,,,,,,,fee schedule,37608.89,56412.64, Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,37608.89,,,,,,,fee schedule,37608.89,56412.64, Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,56412.64,,,,,,,fee schedule,37608.89,56412.64, Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,43461.67,,,,,,,fee schedule,37608.89,56412.64, Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,39115.23,,,,,,,fee schedule,37608.89,56412.64, Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,26852.69,,,,,,,fee schedule,23283.9,34925.42, Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,23283.9,,,,,,,fee schedule,23283.9,34925.42, Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,34925.42,,,,,,,fee schedule,23283.9,34925.42, Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,26907.39,,,,,,,fee schedule,23283.9,34925.42, Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,24216.48,,,,,,,fee schedule,23283.9,34925.42, Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],7312.2,7312.2,7312.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,49706.37,,,,,,,fee schedule,43100.27,64649.61, Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,43100.27,,,,,,,fee schedule,43100.27,64649.61, Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,64649.61,,,,,,,fee schedule,43100.27,64649.61, Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,49807.64,,,,,,,fee schedule,43100.27,64649.61, Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,44826.56,,,,,,,fee schedule,43100.27,64649.61, Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],45874.6,45874.6,45874.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],16418.15,16418.15,16418.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],41534.76,41534.76,41534.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],15049.96,15049.96,15049.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],14639.5,14639.5,14639.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],15734.05,15734.05,15734.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,30669.49,,,,,,,fee schedule,26593.44,39889.67, Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,26593.44,,,,,,,fee schedule,26593.44,39889.67, Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,39889.67,,,,,,,fee schedule,26593.44,39889.67, Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,30731.97,,,,,,,fee schedule,26593.44,39889.67, Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,27658.58,,,,,,,fee schedule,26593.44,39889.67, Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],16418.15,16418.15,16418.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],28070.61,28070.61,29227.38,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],25272.78,25272.78,25371.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],16570.22,16570.22,16570.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],13955.11,13955.11,14639.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],18691.99,18160.07,25487.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],9074.17,9074.17,9074.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,21402.36,,,,,,,fee schedule,18557.93,27836.56, Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,18557.93,,,,,,,fee schedule,18557.93,27836.56, Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,27836.56,,,,,,,fee schedule,18557.93,27836.56, Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,21445.96,,,,,,,fee schedule,18557.93,27836.56, Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19301.23,,,,,,,fee schedule,18557.93,27836.56, Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],9468.69,9468.69,9468.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],18544.95,18544.95,18544.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],17134.88,17134.88,17134.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],15049.96,15049.96,15049.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],18691.99,18691.99,18691.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,34137.96,34137.96,34137.96,1 through 10,percent of total billed charges,,, Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,46392.2,,,,,,,fee schedule,40226.56,60339.09, Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,40226.56,,,,,,,fee schedule,40226.56,60339.09, Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,60339.09,,,,,,,fee schedule,40226.56,60339.09, Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,46486.71,,,,,,,fee schedule,40226.56,60339.09, Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,41837.74,,,,,,,fee schedule,40226.56,60339.09, Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],16608.61,16608.61,16608.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],29120.4,29120.4,29120.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],13134.16,13134.16,13134.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],11780.8,6841.68,12220.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,24810.78,,,,,,,fee schedule,21513.36,32269.65, Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,21513.36,,,,,,,fee schedule,21513.36,32269.65, Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,32269.65,,,,,,,fee schedule,21513.36,32269.65, Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,24861.32,,,,,,,fee schedule,21513.36,32269.65, Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22375.03,,,,,,,fee schedule,21513.36,32269.65, Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],18678.24,15910.65,29335.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],15037.78,15037.78,22154.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],6554.49,6554.49,11560.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],7033.5,6866.61,7033.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],6841.68,6679.34,11780.8,25,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],22285.71,10960.93,23518.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,4450.45,4450.45,4450.45,1 through 10,percent of total billed charges,,, Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,17089.22,,,,,,,fee schedule,14818.02,22226.75, Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,14818.02,,,,,,,fee schedule,14818.02,22226.75, Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,22226.75,,,,,,,fee schedule,14818.02,22226.75, Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,17124.03,,,,,,,fee schedule,14818.02,22226.75, Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,15411.52,,,,,,,fee schedule,14818.02,22226.75, Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],12011.95,12011.95,12011.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],5836.9,5836.9,5836.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],10928.2,10928.2,18580.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],5107.28,5107.28,6554.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],5350.49,5135.85,7033.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],7353.2,7353.2,7353.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],5204.57,4995.78,6679.34,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],8706.44,8706.44,14984.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,10612.75,10612.75,10612.75,1 through 10,percent of total billed charges,,, Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,39842.38,,,,,,,fee schedule,34547.22,51820.2, "Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,34547.22,,,,,,,fee schedule,34547.22,51820.2, "Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,51820.2,,,,,,,fee schedule,34547.22,51820.2, "Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,39923.55,,,,,,,fee schedule,34547.22,51820.2, "Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,35930.94,,,,,,,fee schedule,34547.22,51820.2, "Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],36266.57,36266.57,36266.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],32885.08,32885.08,32885.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],12732,12732,12732,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],11005.1,11005.1,21363.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],13762.39,11291.81,28018.05,18,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],35069.57,35069.57,35069.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,24490.35,,,,,,,fee schedule,21235.52,31852.9, "Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,21235.52,,,,,,,fee schedule,21235.52,31852.9, "Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,31852.9,,,,,,,fee schedule,21235.52,31852.9, "Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,24540.25,,,,,,,fee schedule,21235.52,31852.9, "Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22086.07,,,,,,,fee schedule,21235.52,31852.9, "Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],21442.01,19160.6,22030.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],9127.13,9127.13,9517.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],18414.85,16071.35,19946.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],29919.04,29919.04,29919.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],12125.71,12125.71,12125.71,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],6520.81,6487.13,6549.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],6861.07,5673.64,11005.1,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],6673.95,6145.49,13727.63,45,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],21759.45,19274.33,21759.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],20603.82,20603.82,20603.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],11505.34,8746.83,13944.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,18393.99,16641.48,28630.47,1 through 10,percent of total billed charges,,, "Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,50240.41,,,,,,,fee schedule,43563.33,65344.2, Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,43563.33,,,,,,,fee schedule,43563.33,65344.2, Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,65344.2,,,,,,,fee schedule,43563.33,65344.2, Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,50342.77,,,,,,,fee schedule,43563.33,65344.2, Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,45308.17,,,,,,,fee schedule,43563.33,65344.2, Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],15904.87,15904.87,15904.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],309444.96,309444.96,309444.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],42332.33,42332.33,42332.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],29299.94,14579.47,45491.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],9332.65,9332.65,9332.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],15078.11,10704.96,28500.85,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],355454.38,355454.38,355454.38,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,52233.71,52233.71,52233.71,1 through 10,percent of total billed charges,,, Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,29394.08,,,,,,,fee schedule,25487.53,38230.83, Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,25487.53,,,,,,,fee schedule,25487.53,38230.83, Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,38230.83,,,,,,,fee schedule,25487.53,38230.83, Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,29453.96,,,,,,,fee schedule,25487.53,38230.83, Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,26508.38,,,,,,,fee schedule,25487.53,38230.83, Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],26076.66,26076.66,26076.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],33597.03,33597.03,33597.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],14579.47,14579.47,14579.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],8670.56,8670.56,8670.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],8138.36,8067.39,32936.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],24487.25,24487.25,24487.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,28672.25,28672.25,28672.25,1 through 10,percent of total billed charges,,, Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,20387.69,,,,,,,fee schedule,17678.11,26516.84, Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,17678.11,,,,,,,fee schedule,17678.11,26516.84, Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,26516.84,,,,,,,fee schedule,17678.11,26516.84, Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,20429.22,,,,,,,fee schedule,17678.11,26516.84, Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,18386.17,,,,,,,fee schedule,17678.11,26516.84, Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],6861.07,6861.07,6861.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,24113.83,24113.83,24113.83,1 through 10,percent of total billed charges,,, Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Red Blood Cell Disorders Age 0-17,396,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Red Blood Cell Disorders Age 0-17,396,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Red Blood Cell Disorders Age 0-17,396,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Red Blood Cell Disorders Age 0-17,396,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Red Blood Cell Disorders Age 0-17,396,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Red Blood Cell Disorders Age 0-17,396,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Red Blood Cell Disorders Age 0-17,396,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Red Blood Cell Disorders Age 0-17,396,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Red Blood Cell Disorders Age 0-17,396,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Red Blood Cell Disorders Age 0-17,396,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Red Blood Cell Disorders Age 0-17,396,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Red Blood Cell Disorders Age 0-17,396,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Red Blood Cell Disorders Age 0-17,396,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Red Blood Cell Disorders Age 0-17,396,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Red Blood Cell Disorders Age 0-17,396,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Red Blood Cell Disorders Age 0-17,396,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Red Blood Cell Disorders Age 0-17,396,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Red Blood Cell Disorders Age 0-17,396,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Red Blood Cell Disorders Age 0-17,396,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Red Blood Cell Disorders Age 0-17,396,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Appendix Procedures With Mcc,397,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,75233.39,,,,,,,fee schedule,65234.68,97850.82, Appendix Procedures With Mcc,397,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,65234.68,,,,,,,fee schedule,65234.68,97850.82, Appendix Procedures With Mcc,397,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,97850.82,,,,,,,fee schedule,65234.68,97850.82, Appendix Procedures With Mcc,397,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,75386.66,,,,,,,fee schedule,65234.68,97850.82, Appendix Procedures With Mcc,397,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,67847.52,,,,,,,fee schedule,65234.68,97850.82, Appendix Procedures With Mcc,397,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Appendix Procedures With Mcc,397,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendix Procedures With Mcc,397,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendix Procedures With Mcc,397,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendix Procedures With Mcc,397,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Appendix Procedures With Mcc,397,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendix Procedures With Mcc,397,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendix Procedures With Mcc,397,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendix Procedures With Mcc,397,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendix Procedures With Mcc,397,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendix Procedures With Mcc,397,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendix Procedures With Mcc,397,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],52425,52425,52425,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Appendix Procedures With Mcc,397,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendix Procedures With Mcc,397,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendix Procedures With Mcc,397,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendix Procedures With Mcc,397,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Appendix Procedures With Mcc,397,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Appendix Procedures With Mcc,397,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Appendix Procedures With Mcc,397,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Appendix Procedures With Mcc,397,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Appendix Procedures With Cc,398,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,47548.23,,,,,,,fee schedule,41228.95,61842.67, Appendix Procedures With Cc,398,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,41228.95,,,,,,,fee schedule,41228.95,61842.67, Appendix Procedures With Cc,398,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,61842.67,,,,,,,fee schedule,41228.95,61842.67, Appendix Procedures With Cc,398,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,47645.1,,,,,,,fee schedule,41228.95,61842.67, Appendix Procedures With Cc,398,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,42880.29,,,,,,,fee schedule,41228.95,61842.67, Appendix Procedures With Cc,398,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],37143.71,37143.71,40830.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Appendix Procedures With Cc,398,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendix Procedures With Cc,398,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],52027.53,52027.53,52027.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Appendix Procedures With Cc,398,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendix Procedures With Cc,398,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Appendix Procedures With Cc,398,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendix Procedures With Cc,398,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendix Procedures With Cc,398,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],14346.77,14346.77,14346.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Appendix Procedures With Cc,398,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendix Procedures With Cc,398,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],15029.95,15029.95,15029.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Appendix Procedures With Cc,398,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendix Procedures With Cc,398,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],14620.04,14141.13,14620.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Appendix Procedures With Cc,398,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],40220.32,40220.32,40220.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Appendix Procedures With Cc,398,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendix Procedures With Cc,398,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendix Procedures With Cc,398,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Appendix Procedures With Cc,398,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Appendix Procedures With Cc,398,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Appendix Procedures With Cc,398,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Appendix Procedures With Cc,398,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,35959.61,,,,,,,fee schedule,31180.48,46770.15, Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,31180.48,,,,,,,fee schedule,31180.48,46770.15, Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,46770.15,,,,,,,fee schedule,31180.48,46770.15, Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,36032.87,,,,,,,fee schedule,31180.48,46770.15, Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,32429.35,,,,,,,fee schedule,31180.48,46770.15, Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],33809.58,33809.58,33809.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],12865.07,12865.07,12865.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],26392.7,26175.95,28727.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],10321.19,7753.05,11256.93,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],11792.98,11792.98,14537.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],11775.55,11775.55,11775.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],11471.35,11471.35,14620.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],30577.17,30577.17,30577.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. No Longer Valid,400,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,400,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,400,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,400,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,400,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,400,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,400,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,400,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,400,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,400,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,400,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,400,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,400,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,400,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,400,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,400,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. No Longer Valid,400,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. No Longer Valid,400,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. No Longer Valid,400,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. No Longer Valid,400,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Lymphoma & non-acute leukemia w other O.R. proc w CC,401,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma & non-acute leukemia w other O.R. proc w CC,401,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma & non-acute leukemia w other O.R. proc w CC,401,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma & non-acute leukemia w other O.R. proc w CC,401,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma & non-acute leukemia w other O.R. proc w CC,401,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma & non-acute leukemia w other O.R. proc w CC,401,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma & non-acute leukemia w other O.R. proc w CC,401,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma & non-acute leukemia w other O.R. proc w CC,401,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma & non-acute leukemia w other O.R. proc w CC,401,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma & non-acute leukemia w other O.R. proc w CC,401,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma & non-acute leukemia w other O.R. proc w CC,401,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma & non-acute leukemia w other O.R. proc w CC,401,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma & non-acute leukemia w other O.R. proc w CC,401,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma & non-acute leukemia w other O.R. proc w CC,401,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma & non-acute leukemia w other O.R. proc w CC,401,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma & non-acute leukemia w other O.R. proc w CC,401,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Lymphoma & non-acute leukemia w other O.R. proc w CC,401,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Lymphoma & non-acute leukemia w other O.R. proc w CC,401,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Lymphoma & non-acute leukemia w other O.R. proc w CC,401,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Lymphoma & non-acute leukemia w other O.R. proc w CC,401,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,126299.99,,,,,,,fee schedule,109514.4,164269.59, Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,109514.4,,,,,,,fee schedule,109514.4,164269.59, Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,164269.59,,,,,,,fee schedule,109514.4,164269.59, Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,126557.3,,,,,,,fee schedule,109514.4,164269.59, Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,113900.77,,,,,,,fee schedule,109514.4,164269.59, Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Lymphoma & non-acute leukemia w CC,403,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma & non-acute leukemia w CC,403,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma & non-acute leukemia w CC,403,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma & non-acute leukemia w CC,403,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma & non-acute leukemia w CC,403,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma & non-acute leukemia w CC,403,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma & non-acute leukemia w CC,403,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma & non-acute leukemia w CC,403,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma & non-acute leukemia w CC,403,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma & non-acute leukemia w CC,403,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma & non-acute leukemia w CC,403,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma & non-acute leukemia w CC,403,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma & non-acute leukemia w CC,403,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma & non-acute leukemia w CC,403,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma & non-acute leukemia w CC,403,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma & non-acute leukemia w CC,403,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Lymphoma & non-acute leukemia w CC,403,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Lymphoma & non-acute leukemia w CC,403,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Lymphoma & non-acute leukemia w CC,403,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Lymphoma & non-acute leukemia w CC,403,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Lymphoma & Non-Acute Leukemia w/o CC,404,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma & Non-Acute Leukemia w/o CC,404,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma & Non-Acute Leukemia w/o CC,404,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma & Non-Acute Leukemia w/o CC,404,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma & Non-Acute Leukemia w/o CC,404,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma & Non-Acute Leukemia w/o CC,404,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma & Non-Acute Leukemia w/o CC,404,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma & Non-Acute Leukemia w/o CC,404,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma & Non-Acute Leukemia w/o CC,404,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma & Non-Acute Leukemia w/o CC,404,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma & Non-Acute Leukemia w/o CC,404,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma & Non-Acute Leukemia w/o CC,404,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma & Non-Acute Leukemia w/o CC,404,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma & Non-Acute Leukemia w/o CC,404,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma & Non-Acute Leukemia w/o CC,404,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma & Non-Acute Leukemia w/o CC,404,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Lymphoma & Non-Acute Leukemia w/o CC,404,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Lymphoma & Non-Acute Leukemia w/o CC,404,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Lymphoma & Non-Acute Leukemia w/o CC,404,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Lymphoma & Non-Acute Leukemia w/o CC,404,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,171850.29,,,,,,,fee schedule,149010.95,223513.69, "Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,149010.95,,,,,,,fee schedule,149010.95,223513.69, "Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,223513.69,,,,,,,fee schedule,149010.95,223513.69, "Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,172200.4,,,,,,,fee schedule,149010.95,223513.69, "Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,154979.27,,,,,,,fee schedule,149010.95,223513.69, "Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,91106.88,,,,,,,fee schedule,78998.55,118496.37, "Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,78998.55,,,,,,,fee schedule,78998.55,118496.37, "Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,118496.37,,,,,,,fee schedule,78998.55,118496.37, "Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,91292.5,,,,,,,fee schedule,78998.55,118496.37, "Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,82162.67,,,,,,,fee schedule,78998.55,118496.37, "Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],71791.13,71791.13,71791.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],26357.49,26357.49,26357.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,69726.51,,,,,,,fee schedule,60459.68,90688.42, "Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,60459.68,,,,,,,fee schedule,60459.68,90688.42, "Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,90688.42,,,,,,,fee schedule,60459.68,90688.42, "Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,69868.57,,,,,,,fee schedule,60459.68,90688.42, "Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,62881.27,,,,,,,fee schedule,60459.68,90688.42, "Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,112009.76,,,,,,,fee schedule,97123.38,145683.28, Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,97123.38,,,,,,,fee schedule,97123.38,145683.28, Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,145683.28,,,,,,,fee schedule,97123.38,145683.28, Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,112237.96,,,,,,,fee schedule,97123.38,145683.28, Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,101013.45,,,,,,,fee schedule,97123.38,145683.28, Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,68397.7,,,,,,,fee schedule,59307.47,88960.12, Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,59307.47,,,,,,,fee schedule,59307.47,88960.12, Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,88960.12,,,,,,,fee schedule,59307.47,88960.12, Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,68537.05,,,,,,,fee schedule,59307.47,88960.12, Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,61682.91,,,,,,,fee schedule,59307.47,88960.12, Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],63632.97,63632.97,63632.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,49876.01,,,,,,,fee schedule,43247.36,64870.25, Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,43247.36,,,,,,,fee schedule,43247.36,64870.25, Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,64870.25,,,,,,,fee schedule,43247.36,64870.25, Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,49977.62,,,,,,,fee schedule,43247.36,64870.25, Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,44979.54,,,,,,,fee schedule,43247.36,64870.25, Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,103769.87,,,,,,,fee schedule,89978.59,134966.23, Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,89978.59,,,,,,,fee schedule,89978.59,134966.23, Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,134966.23,,,,,,,fee schedule,89978.59,134966.23, Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,103981.28,,,,,,,fee schedule,89978.59,134966.23, Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,93582.49,,,,,,,fee schedule,89978.59,134966.23, Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,66047.94,,,,,,,fee schedule,57270,85903.95, Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,57270,,,,,,,fee schedule,57270,85903.95, Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,85903.95,,,,,,,fee schedule,57270,85903.95, Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,66182.5,,,,,,,fee schedule,57270,85903.95, Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,59563.83,,,,,,,fee schedule,57270,85903.95, Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,52162.95,,,,,,,fee schedule,45230.36,67844.71, Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,45230.36,,,,,,,fee schedule,45230.36,67844.71, Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,67844.71,,,,,,,fee schedule,45230.36,67844.71, Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,52269.22,,,,,,,fee schedule,45230.36,67844.71, Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,47041.97,,,,,,,fee schedule,45230.36,67844.71, Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,111915.52,,,,,,,fee schedule,97041.66,145560.71, Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,97041.66,,,,,,,fee schedule,97041.66,145560.71, Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,145560.71,,,,,,,fee schedule,97041.66,145560.71, Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,112143.52,,,,,,,fee schedule,97041.66,145560.71, Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,100928.46,,,,,,,fee schedule,97041.66,145560.71, Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,64923.31,,,,,,,fee schedule,56294.84,84441.23, Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,56294.84,,,,,,,fee schedule,56294.84,84441.23, Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,84441.23,,,,,,,fee schedule,56294.84,84441.23, Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,65055.58,,,,,,,fee schedule,56294.84,84441.23, Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,58549.61,,,,,,,fee schedule,56294.84,84441.23, Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,42826.71,,,,,,,fee schedule,37134.93,55701.71, Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,37134.93,,,,,,,fee schedule,37134.93,55701.71, Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,55701.71,,,,,,,fee schedule,37134.93,55701.71, Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,42913.96,,,,,,,fee schedule,37134.93,55701.71, Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,38622.29,,,,,,,fee schedule,37134.93,55701.71, Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,74966.37,,,,,,,fee schedule,65003.15,97503.53, Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,65003.15,,,,,,,fee schedule,65003.15,97503.53, Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,97503.53,,,,,,,fee schedule,65003.15,97503.53, Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,75119.1,,,,,,,fee schedule,65003.15,97503.53, Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,67606.71,,,,,,,fee schedule,65003.15,97503.53, Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],15370.04,15370.04,15370.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,53139.92,,,,,,,fee schedule,46077.49,69115.39, Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,46077.49,,,,,,,fee schedule,46077.49,69115.39, Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,69115.39,,,,,,,fee schedule,46077.49,69115.39, Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,53248.18,,,,,,,fee schedule,46077.49,69115.39, Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,47923.03,,,,,,,fee schedule,46077.49,69115.39, Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],15800.97,15800.97,15800.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,42905.24,,,,,,,fee schedule,37203.03,55803.86, Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,37203.03,,,,,,,fee schedule,37203.03,55803.86, Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,55803.86,,,,,,,fee schedule,37203.03,55803.86, Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,42992.65,,,,,,,fee schedule,37203.03,55803.86, Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,38693.11,,,,,,,fee schedule,37203.03,55803.86, Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],39897.93,39897.93,39897.93,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],33681.81,33681.81,33681.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],12641.17,12641.17,12641.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],36742.59,36742.59,36742.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,107030.64,,,,,,,fee schedule,92806,139207.29, Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,92806,,,,,,,fee schedule,92806,139207.29, Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,139207.29,,,,,,,fee schedule,92806,139207.29, Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,107248.69,,,,,,,fee schedule,92806,139207.29, Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,96523.14,,,,,,,fee schedule,92806,139207.29, Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,54581.83,,,,,,,fee schedule,47327.76,70990.78, Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,47327.76,,,,,,,fee schedule,47327.76,70990.78, Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,70990.78,,,,,,,fee schedule,47327.76,70990.78, Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,54693.03,,,,,,,fee schedule,47327.76,70990.78, Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,49223.38,,,,,,,fee schedule,47327.76,70990.78, Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],28235.58,28235.58,28235.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,43963.89,,,,,,,fee schedule,38120.98,57180.77, Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,38120.98,,,,,,,fee schedule,38120.98,57180.77, Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,57180.77,,,,,,,fee schedule,38120.98,57180.77, Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,44053.46,,,,,,,fee schedule,38120.98,57180.77, Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,39647.84,,,,,,,fee schedule,38120.98,57180.77, Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,130462.34,,,,,,,fee schedule,113123.57,169683.27, Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,113123.57,,,,,,,fee schedule,113123.57,169683.27, Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,169683.27,,,,,,,fee schedule,113123.57,169683.27, Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,130728.13,,,,,,,fee schedule,113123.57,169683.27, Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,117654.49,,,,,,,fee schedule,113123.57,169683.27, Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,68730.69,,,,,,,fee schedule,59596.21,89393.22, Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,59596.21,,,,,,,fee schedule,59596.21,89393.22, Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,89393.22,,,,,,,fee schedule,59596.21,89393.22, Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,68870.72,,,,,,,fee schedule,59596.21,89393.22, Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,61983.21,,,,,,,fee schedule,59596.21,89393.22, Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,63082.08,63082.08,63082.08,1 through 10,percent of total billed charges,,, Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,47130.42,,,,,,,fee schedule,40866.67,61299.26, Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,40866.67,,,,,,,fee schedule,40866.67,61299.26, Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,61299.26,,,,,,,fee schedule,40866.67,61299.26, Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,47226.44,,,,,,,fee schedule,40866.67,61299.26, Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,42503.5,,,,,,,fee schedule,40866.67,61299.26, Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,346219.98,,,,,,,fee schedule,300206.47,450304.19, Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,300206.47,,,,,,,fee schedule,300206.47,450304.19, Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,450304.19,,,,,,,fee schedule,300206.47,450304.19, Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,346925.33,,,,,,,fee schedule,300206.47,450304.19, Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,312230.6,,,,,,,fee schedule,300206.47,450304.19, Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,226765.1,,,,,,,fee schedule,196627.45,294937.56, Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,196627.45,,,,,,,fee schedule,196627.45,294937.56, Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,294937.56,,,,,,,fee schedule,196627.45,294937.56, Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,227227.09,,,,,,,fee schedule,196627.45,294937.56, Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,204502.94,,,,,,,fee schedule,196627.45,294937.56, Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,176609.51,,,,,,,fee schedule,153137.66,229703.68, Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,153137.66,,,,,,,fee schedule,153137.66,229703.68, Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,229703.68,,,,,,,fee schedule,153137.66,229703.68, Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,176969.32,,,,,,,fee schedule,153137.66,229703.68, Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,159271.26,,,,,,,fee schedule,153137.66,229703.68, Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,283027.57,,,,,,,fee schedule,245412.49,368114.24, Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,245412.49,,,,,,,fee schedule,245412.49,368114.24, Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,368114.24,,,,,,,fee schedule,245412.49,368114.24, Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,283604.19,,,,,,,fee schedule,245412.49,368114.24, Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,255241.97,,,,,,,fee schedule,245412.49,368114.24, Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,181167.68,,,,,,,fee schedule,157090.04,235632.17, Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,157090.04,,,,,,,fee schedule,157090.04,235632.17, Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,235632.17,,,,,,,fee schedule,157090.04,235632.17, Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,181536.77,,,,,,,fee schedule,157090.04,235632.17, Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,163381.94,,,,,,,fee schedule,157090.04,235632.17, Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Childhood Mental Disorders,431,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Childhood Mental Disorders,431,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Childhood Mental Disorders,431,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Childhood Mental Disorders,431,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Childhood Mental Disorders,431,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Childhood Mental Disorders,431,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Childhood Mental Disorders,431,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Childhood Mental Disorders,431,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Childhood Mental Disorders,431,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Childhood Mental Disorders,431,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Childhood Mental Disorders,431,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Childhood Mental Disorders,431,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Childhood Mental Disorders,431,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Childhood Mental Disorders,431,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Childhood Mental Disorders,431,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Childhood Mental Disorders,431,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Childhood Mental Disorders,431,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Childhood Mental Disorders,431,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Childhood Mental Disorders,431,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Childhood Mental Disorders,431,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,61829.03,,,,,,,fee schedule,53611.8,80416.72, Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,53611.8,,,,,,,fee schedule,53611.8,80416.72, Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,80416.72,,,,,,,fee schedule,53611.8,80416.72, Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,61955,,,,,,,fee schedule,53611.8,80416.72, Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,55759.11,,,,,,,fee schedule,53611.8,80416.72, Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],59738.81,59738.81,59738.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,33179.47,,,,,,,fee schedule,28769.83,43154.22, Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,28769.83,,,,,,,fee schedule,28769.83,43154.22, Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,43154.22,,,,,,,fee schedule,28769.83,43154.22, Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,33247.06,,,,,,,fee schedule,28769.83,43154.22, Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,29922.15,,,,,,,fee schedule,28769.83,43154.22, Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,22382.48,,,,,,,fee schedule,19407.79,29111.33, Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,19407.79,,,,,,,fee schedule,19407.79,29111.33, Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,29111.33,,,,,,,fee schedule,19407.79,29111.33, Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,22428.08,,,,,,,fee schedule,19407.79,29111.33, Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,20185.13,,,,,,,fee schedule,19407.79,29111.33, Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,57698.09,,,,,,,fee schedule,50029.87,75043.89, Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,50029.87,,,,,,,fee schedule,50029.87,75043.89, Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,75043.89,,,,,,,fee schedule,50029.87,75043.89, Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,57815.64,,,,,,,fee schedule,50029.87,75043.89, Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,52033.71,,,,,,,fee schedule,50029.87,75043.89, Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,35532.38,,,,,,,fee schedule,30810.03,46214.48, Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,30810.03,,,,,,,fee schedule,30810.03,46214.48, Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,46214.48,,,,,,,fee schedule,30810.03,46214.48, Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,35604.77,,,,,,,fee schedule,30810.03,46214.48, Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,32044.06,,,,,,,fee schedule,30810.03,46214.48, Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,26805.57,,,,,,,fee schedule,23243.04,34864.13, Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,23243.04,,,,,,,fee schedule,23243.04,34864.13, Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,34864.13,,,,,,,fee schedule,23243.04,34864.13, Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,26860.18,,,,,,,fee schedule,23243.04,34864.13, Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,24173.99,,,,,,,fee schedule,23243.04,34864.13, Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,51211.1,,,,,,,fee schedule,44405.02,66606.71, Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,44405.02,,,,,,,fee schedule,44405.02,66606.71, Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,66606.71,,,,,,,fee schedule,44405.02,66606.71, Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,51315.44,,,,,,,fee schedule,44405.02,66606.71, Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,46183.57,,,,,,,fee schedule,44405.02,66606.71, Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],32156.4,32156.4,32156.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,26425.46,,,,,,,fee schedule,22913.45,34369.75, Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,22913.45,,,,,,,fee schedule,22913.45,34369.75, Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,34369.75,,,,,,,fee schedule,22913.45,34369.75, Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,26479.29,,,,,,,fee schedule,22913.45,34369.75, Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,23831.2,,,,,,,fee schedule,22913.45,34369.75, Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],17366.73,17366.73,17366.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],21989.29,21989.29,22246.38,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],7719.3,7719.3,7719.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,19520.66,,,,,,,fee schedule,16926.31,25389.16, Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,16926.31,,,,,,,fee schedule,16926.31,25389.16, Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,25389.16,,,,,,,fee schedule,16926.31,25389.16, Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,19560.43,,,,,,,fee schedule,16926.31,25389.16, Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,17604.26,,,,,,,fee schedule,16926.31,25389.16, Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],6551.43,6551.43,6551.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],6005.48,6005.48,6005.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],7719.3,7719.3,7719.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,56378.71,,,,,,,fee schedule,48885.83,73327.85, "Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,48885.83,,,,,,,fee schedule,48885.83,73327.85, "Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,73327.85,,,,,,,fee schedule,48885.83,73327.85, "Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,56493.57,,,,,,,fee schedule,48885.83,73327.85, "Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,50843.85,,,,,,,fee schedule,48885.83,73327.85, "Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],53372.06,53372.06,53372.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],12526.73,12526.73,12526.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,30323.93,,,,,,,fee schedule,26293.81,39440.23, "Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,26293.81,,,,,,,fee schedule,26293.81,39440.23, "Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,39440.23,,,,,,,fee schedule,26293.81,39440.23, "Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,30385.71,,,,,,,fee schedule,26293.81,39440.23, "Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,27346.95,,,,,,,fee schedule,26293.81,39440.23, "Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],12292.58,12292.58,12292.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],8643.75,8643.75,8643.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],26943.45,26943.45,26943.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,21980.38,,,,,,,fee schedule,19059.13,28588.34, "Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,19059.13,,,,,,,fee schedule,19059.13,28588.34, "Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,28588.34,,,,,,,fee schedule,19059.13,28588.34, "Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,22025.16,,,,,,,fee schedule,19059.13,28588.34, "Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19822.5,,,,,,,fee schedule,19059.13,28588.34, "Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,52489.65,,,,,,,fee schedule,45513.65,68269.63, Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,45513.65,,,,,,,fee schedule,45513.65,68269.63, Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,68269.63,,,,,,,fee schedule,45513.65,68269.63, Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,52596.59,,,,,,,fee schedule,45513.65,68269.63, Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,47336.6,,,,,,,fee schedule,45513.65,68269.63, Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],51124.91,51124.91,51124.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],43058.32,43058.32,43058.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],15446.28,15446.28,15446.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],15740.49,15740.49,15740.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,34379.48,,,,,,,fee schedule,29810.36,44715, Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,29810.36,,,,,,,fee schedule,29810.36,44715, Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,44715,,,,,,,fee schedule,29810.36,44715, Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,34449.52,,,,,,,fee schedule,29810.36,44715, Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,31004.35,,,,,,,fee schedule,29810.36,44715, Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],9976.65,9976.65,9976.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,25988.8,,,,,,,fee schedule,22534.82,33801.82, Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,22534.82,,,,,,,fee schedule,22534.82,33801.82, Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,33801.82,,,,,,,fee schedule,22534.82,33801.82, Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,26041.75,,,,,,,fee schedule,22534.82,33801.82, Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,23437.41,,,,,,,fee schedule,22534.82,33801.82, Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],9738.4,9738.4,9738.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,209895.78,,,,,,,fee schedule,182000.1,272996.81, Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,182000.1,,,,,,,fee schedule,182000.1,272996.81, Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,272996.81,,,,,,,fee schedule,182000.1,272996.81, Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,210323.4,,,,,,,fee schedule,182000.1,272996.81, Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,189289.73,,,,,,,fee schedule,182000.1,272996.81, Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,133220.49,,,,,,,fee schedule,115515.15,173270.61, Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,115515.15,,,,,,,fee schedule,115515.15,173270.61, Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,173270.61,,,,,,,fee schedule,115515.15,173270.61, Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,133491.9,,,,,,,fee schedule,115515.15,173270.61, Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,120141.86,,,,,,,fee schedule,115515.15,173270.61, Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],39996.62,39996.62,39996.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],26253.78,26253.78,26253.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,97538.84,97538.84,97538.84,1 through 10,percent of total billed charges,,, Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Poisoning & toxic Effects of Drugs Age >17 w CC,449,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Poisoning & toxic Effects of Drugs Age >17 w CC,449,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Poisoning & toxic Effects of Drugs Age >17 w CC,449,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Poisoning & toxic Effects of Drugs Age >17 w CC,449,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Poisoning & toxic Effects of Drugs Age >17 w CC,449,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Poisoning & toxic Effects of Drugs Age >17 w CC,449,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Poisoning & toxic Effects of Drugs Age >17 w CC,449,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Poisoning & toxic Effects of Drugs Age >17 w CC,449,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Poisoning & toxic Effects of Drugs Age >17 w CC,449,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Poisoning & toxic Effects of Drugs Age >17 w CC,449,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Poisoning & toxic Effects of Drugs Age >17 w CC,449,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Poisoning & toxic Effects of Drugs Age >17 w CC,449,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Poisoning & toxic Effects of Drugs Age >17 w CC,449,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Poisoning & toxic Effects of Drugs Age >17 w CC,449,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Poisoning & toxic Effects of Drugs Age >17 w CC,449,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Poisoning & toxic Effects of Drugs Age >17 w CC,449,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Poisoning & toxic Effects of Drugs Age >17 w CC,449,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Poisoning & toxic Effects of Drugs Age >17 w CC,449,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Poisoning & toxic Effects of Drugs Age >17 w CC,449,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Poisoning & toxic Effects of Drugs Age >17 w CC,449,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,167424.05,,,,,,,fee schedule,145172.97,217756.8, Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,145172.97,,,,,,,fee schedule,145172.97,217756.8, Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,217756.8,,,,,,,fee schedule,145172.97,217756.8, Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,167765.15,,,,,,,fee schedule,145172.97,217756.8, Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,150987.57,,,,,,,fee schedule,145172.97,217756.8, Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,101479.79,,,,,,,fee schedule,87992.87,131987.68, Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,87992.87,,,,,,,fee schedule,87992.87,131987.68, Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,131987.68,,,,,,,fee schedule,87992.87,131987.68, Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,101686.53,,,,,,,fee schedule,87992.87,131987.68, Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,91517.23,,,,,,,fee schedule,87992.87,131987.68, Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Complications of treatment w CC,452,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Complications of treatment w CC,452,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complications of treatment w CC,452,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complications of treatment w CC,452,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complications of treatment w CC,452,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Complications of treatment w CC,452,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complications of treatment w CC,452,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complications of treatment w CC,452,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complications of treatment w CC,452,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complications of treatment w CC,452,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complications of treatment w CC,452,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complications of treatment w CC,452,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complications of treatment w CC,452,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complications of treatment w CC,452,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complications of treatment w CC,452,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complications of treatment w CC,452,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Complications of treatment w CC,452,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Complications of treatment w CC,452,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Complications of treatment w CC,452,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Complications of treatment w CC,452,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,263984.41,,,,,,,fee schedule,228900.21,343346.12, "Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,228900.21,,,,,,,fee schedule,228900.21,343346.12, "Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,343346.12,,,,,,,fee schedule,228900.21,343346.12, "Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,264522.23,,,,,,,fee schedule,228900.21,343346.12, "Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,238068.32,,,,,,,fee schedule,228900.21,343346.12, "Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],216298.16,216298.16,216298.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],75841.07,75841.07,75841.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],91819.15,91819.15,91819.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,187324.82,,,,,,,fee schedule,162428.88,243640.34, "Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,162428.88,,,,,,,fee schedule,162428.88,243640.34, "Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,243640.34,,,,,,,fee schedule,162428.88,243640.34, "Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,187706.46,,,,,,,fee schedule,162428.88,243640.34, "Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,168934.62,,,,,,,fee schedule,162428.88,243640.34, "Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],244626.74,244626.74,244626.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],186402.6,186402.6,186402.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],145816.28,142668.28,157556.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],46140.26,46140.26,46140.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],51347,51347,51347,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],60141.85,60141.85,60141.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],55958.07,47019.12,73772.68,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],168388.26,168388.26,168388.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,124022.32,124022.32,124022.32,1 through 10,percent of total billed charges,,, "Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,131078.06,,,,,,,fee schedule,113657.45,170484.09, "Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,113657.45,,,,,,,fee schedule,113657.45,170484.09, "Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,170484.09,,,,,,,fee schedule,113657.45,170484.09, "Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,131345.1,,,,,,,fee schedule,113657.45,170484.09, "Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,118209.76,,,,,,,fee schedule,113657.45,170484.09, "Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],173182.71,129577.72,186312.2,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],49962.62,49962.62,49962.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],165565.07,161540.06,165565.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],110381.03,108586.03,165565.07,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],43717.3,43717.3,43717.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],45799.07,41901.22,45799.07,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],47880.85,43805.82,47880.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],44550.01,40758.46,55958.07,17,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],120411.75,120411.75,126949.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],102671.39,102671.39,102671.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,126194.32,126194.32,126194.32,1 through 10,percent of total billed charges,,, "Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,173499.52,,,,,,,fee schedule,150441,225658.73, Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,150441,,,,,,,fee schedule,150441,225658.73, Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,225658.73,,,,,,,fee schedule,150441,225658.73, Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,173852.99,,,,,,,fee schedule,150441,225658.73, Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,156466.59,,,,,,,fee schedule,150441,225658.73, Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,83561.24,,,,,,,fee schedule,72455.74,108682.28, Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,72455.74,,,,,,,fee schedule,72455.74,108682.28, Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,108682.28,,,,,,,fee schedule,72455.74,108682.28, Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,83731.48,,,,,,,fee schedule,72455.74,108682.28, Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,75357.8,,,,,,,fee schedule,72455.74,108682.28, Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,179044.09,,,,,,,fee schedule,155248.68,232870.17, Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,155248.68,,,,,,,fee schedule,155248.68,232870.17, Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,232870.17,,,,,,,fee schedule,155248.68,232870.17, Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,179408.86,,,,,,,fee schedule,155248.68,232870.17, Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,161466.84,,,,,,,fee schedule,155248.68,232870.17, Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,97845.19,,,,,,,fee schedule,84841.31,127260.41, Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,84841.31,,,,,,,fee schedule,84841.31,127260.41, Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,127260.41,,,,,,,fee schedule,84841.31,127260.41, Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,98044.53,,,,,,,fee schedule,84841.31,127260.41, Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,88239.45,,,,,,,fee schedule,84841.31,127260.41, Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,57289.71,,,,,,,fee schedule,49675.76,74512.73, Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,49675.76,,,,,,,fee schedule,49675.76,74512.73, Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,74512.73,,,,,,,fee schedule,49675.76,74512.73, Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,57406.43,,,,,,,fee schedule,49675.76,74512.73, Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,51665.42,,,,,,,fee schedule,49675.76,74512.73, Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,163522.44,,,,,,,fee schedule,141789.89,212682.23, Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,141789.89,,,,,,,fee schedule,141789.89,212682.23, Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,212682.23,,,,,,,fee schedule,141789.89,212682.23, Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,163855.58,,,,,,,fee schedule,141789.89,212682.23, Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,147468.98,,,,,,,fee schedule,141789.89,212682.23, Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,110784.61,,,,,,,fee schedule,96061.06,144089.82, Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,96061.06,,,,,,,fee schedule,96061.06,144089.82, Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,144089.82,,,,,,,fee schedule,96061.06,144089.82, Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,111010.31,,,,,,,fee schedule,96061.06,144089.82, Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,99908.58,,,,,,,fee schedule,96061.06,144089.82, Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],254188.98,254188.98,254188.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,86325.67,,,,,,,fee schedule,74852.77,112277.78, Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,74852.77,,,,,,,fee schedule,74852.77,112277.78, Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,112277.78,,,,,,,fee schedule,74852.77,112277.78, Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,86501.54,,,,,,,fee schedule,74852.77,112277.78, Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,77850.84,,,,,,,fee schedule,74852.77,112277.78, Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,95284.94,,,,,,,fee schedule,82621.33,123930.49, Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,82621.33,,,,,,,fee schedule,82621.33,123930.49, Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,123930.49,,,,,,,fee schedule,82621.33,123930.49, Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,95479.07,,,,,,,fee schedule,82621.33,123930.49, Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,85930.56,,,,,,,fee schedule,82621.33,123930.49, Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,60594.46,,,,,,,fee schedule,52541.31,78811, Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,52541.31,,,,,,,fee schedule,52541.31,78811, Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,78811,,,,,,,fee schedule,52541.31,78811, Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,60717.91,,,,,,,fee schedule,52541.31,78811, Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,54645.74,,,,,,,fee schedule,52541.31,78811, Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],111447.26,111447.26,111447.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,151688.78,,,,,,,fee schedule,131528.96,197291.02, Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,131528.96,,,,,,,fee schedule,131528.96,197291.02, Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,197291.02,,,,,,,fee schedule,131528.96,197291.02, Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,151997.82,,,,,,,fee schedule,131528.96,197291.02, Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,136797.07,,,,,,,fee schedule,131528.96,197291.02, Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],36930.6,36930.6,36930.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,92548.79,,,,,,,fee schedule,80248.82,120371.75, Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,80248.82,,,,,,,fee schedule,80248.82,120371.75, Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,120371.75,,,,,,,fee schedule,80248.82,120371.75, Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,92737.34,,,,,,,fee schedule,80248.82,120371.75, Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,83463.01,,,,,,,fee schedule,80248.82,120371.75, Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],76201.23,76201.23,76201.23,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],42317.42,42317.42,42317.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,76691,,,,,,,fee schedule,66498.57,99746.64, Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,66498.57,,,,,,,fee schedule,66498.57,99746.64, Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,99746.64,,,,,,,fee schedule,66498.57,99746.64, Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,76847.24,,,,,,,fee schedule,66498.57,99746.64, Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,69162.03,,,,,,,fee schedule,66498.57,99746.64, Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],19790.86,19790.86,19790.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,134857.16,,,,,,,fee schedule,116934.3,175399.31, Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,116934.3,,,,,,,fee schedule,116934.3,175399.31, Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,175399.31,,,,,,,fee schedule,116934.3,175399.31, Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,135131.91,,,,,,,fee schedule,116934.3,175399.31, Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,121617.86,,,,,,,fee schedule,116934.3,175399.31, Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,71488.84,,,,,,,fee schedule,61987.79,92980.55, Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,61987.79,,,,,,,fee schedule,61987.79,92980.55, Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,92980.55,,,,,,,fee schedule,61987.79,92980.55, Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,71634.48,,,,,,,fee schedule,61987.79,92980.55, Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,64470.58,,,,,,,fee schedule,61987.79,92980.55, Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,37074.8,,,,,,,fee schedule,32147.47,48220.61, Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,32147.47,,,,,,,fee schedule,32147.47,48220.61, Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,48220.61,,,,,,,fee schedule,32147.47,48220.61, Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,37150.34,,,,,,,fee schedule,32147.47,48220.61, Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,33435.07,,,,,,,fee schedule,32147.47,48220.61, Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,108522.8,,,,,,,fee schedule,94099.85,141148.05, Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,94099.85,,,,,,,fee schedule,94099.85,141148.05, Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,141148.05,,,,,,,fee schedule,94099.85,141148.05, Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,108743.9,,,,,,,fee schedule,94099.85,141148.05, Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,97868.82,,,,,,,fee schedule,94099.85,141148.05, Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],24261.94,24261.94,24261.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,97852.07,97852.07,97852.07,1 through 10,percent of total billed charges,,, Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,77253.31,,,,,,,fee schedule,66986.15,100477.99, Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,66986.15,,,,,,,fee schedule,66986.15,100477.99, Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,100477.99,,,,,,,fee schedule,66986.15,100477.99, Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,77410.7,,,,,,,fee schedule,66986.15,100477.99, Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,69669.14,,,,,,,fee schedule,66986.15,100477.99, Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],65214.2,65214.2,65214.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,95600.59,95600.59,95600.59,1 through 10,percent of total billed charges,,, Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,58395.48,,,,,,,fee schedule,50634.58,75950.94, Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,50634.58,,,,,,,fee schedule,50634.58,75950.94, Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,75950.94,,,,,,,fee schedule,50634.58,75950.94, Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,58514.45,,,,,,,fee schedule,50634.58,75950.94, Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,52662.64,,,,,,,fee schedule,50634.58,75950.94, Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],68089.5,68089.5,68089.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],7778.86,7778.86,7778.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,91486.99,,,,,,,fee schedule,79328.14,118990.75, Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,79328.14,,,,,,,fee schedule,79328.14,118990.75, Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,118990.75,,,,,,,fee schedule,79328.14,118990.75, Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,91673.38,,,,,,,fee schedule,79328.14,118990.75, Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,82505.46,,,,,,,fee schedule,79328.14,118990.75, Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],75180.78,75180.78,75180.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],31680.91,31680.91,31680.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],21061.94,20743.99,32876.71,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,65796.62,,,,,,,fee schedule,57052.09,85577.08, Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,57052.09,,,,,,,fee schedule,57052.09,85577.08, Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,85577.08,,,,,,,fee schedule,57052.09,85577.08, Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,65930.67,,,,,,,fee schedule,57052.09,85577.08, Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,59337.19,,,,,,,fee schedule,57052.09,85577.08, Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],58582.73,58582.73,58582.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],79307.89,79307.89,79307.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],20668.26,20668.26,20668.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],32284.36,20743.99,32876.71,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],56318.94,56318.94,56318.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],22294.95,22294.95,22294.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,51236.23,,,,,,,fee schedule,44426.81,66639.4, Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,44426.81,,,,,,,fee schedule,44426.81,66639.4, Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,66639.4,,,,,,,fee schedule,44426.81,66639.4, Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,51340.62,,,,,,,fee schedule,44426.81,66639.4, Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,46206.23,,,,,,,fee schedule,44426.81,66639.4, Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],23620.87,23620.87,23620.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],47112.78,47112.78,47112.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],40553.14,40553.14,64698.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],60801.57,60801.57,60801.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],79048.76,79048.76,79048.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],16734.65,16734.65,16734.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],15834.5,15834.5,15834.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],41263.06,41263.06,44238.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,87076.47,,,,,,,fee schedule,75503.78,113254.29, Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,75503.78,,,,,,,fee schedule,75503.78,113254.29, Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,113254.29,,,,,,,fee schedule,75503.78,113254.29, Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,87253.87,,,,,,,fee schedule,75503.78,113254.29, Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,78527.93,,,,,,,fee schedule,75503.78,113254.29, Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,93748.58,93748.58,93748.58,1 through 10,percent of total billed charges,,, Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major joint & limb reattachment proc of upper extremity w/o CC/MCC,484,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Major joint & limb reattachment proc of upper extremity w/o CC/MCC,484,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major joint & limb reattachment proc of upper extremity w/o CC/MCC,484,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major joint & limb reattachment proc of upper extremity w/o CC/MCC,484,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major joint & limb reattachment proc of upper extremity w/o CC/MCC,484,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Major joint & limb reattachment proc of upper extremity w/o CC/MCC,484,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major joint & limb reattachment proc of upper extremity w/o CC/MCC,484,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major joint & limb reattachment proc of upper extremity w/o CC/MCC,484,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major joint & limb reattachment proc of upper extremity w/o CC/MCC,484,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major joint & limb reattachment proc of upper extremity w/o CC/MCC,484,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major joint & limb reattachment proc of upper extremity w/o CC/MCC,484,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major joint & limb reattachment proc of upper extremity w/o CC/MCC,484,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major joint & limb reattachment proc of upper extremity w/o CC/MCC,484,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major joint & limb reattachment proc of upper extremity w/o CC/MCC,484,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major joint & limb reattachment proc of upper extremity w/o CC/MCC,484,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major joint & limb reattachment proc of upper extremity w/o CC/MCC,484,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major joint & limb reattachment proc of upper extremity w/o CC/MCC,484,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major joint & limb reattachment proc of upper extremity w/o CC/MCC,484,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major joint & limb reattachment proc of upper extremity w/o CC/MCC,484,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major joint & limb reattachment proc of upper extremity w/o CC/MCC,484,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,101376.12,,,,,,,fee schedule,87902.98,131852.85, Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,87902.98,,,,,,,fee schedule,87902.98,131852.85, Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,131852.85,,,,,,,fee schedule,87902.98,131852.85, Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,101582.65,,,,,,,fee schedule,87902.98,131852.85, Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,91423.74,,,,,,,fee schedule,87902.98,131852.85, Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],86739.87,86739.87,86739.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,65689.82,,,,,,,fee schedule,56959.47,85438.16, Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,56959.47,,,,,,,fee schedule,56959.47,85438.16, Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,85438.16,,,,,,,fee schedule,56959.47,85438.16, Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,65823.65,,,,,,,fee schedule,56959.47,85438.16, Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,59240.86,,,,,,,fee schedule,56959.47,85438.16, Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],14565.7,14565.7,14565.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],56248.85,56248.85,56248.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,49200.61,,,,,,,fee schedule,42661.72,63991.8, Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,42661.72,,,,,,,fee schedule,42661.72,63991.8, Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,63991.8,,,,,,,fee schedule,42661.72,63991.8, Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,49300.84,,,,,,,fee schedule,42661.72,63991.8, Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,44370.45,,,,,,,fee schedule,42661.72,63991.8, Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],40198.69,40198.69,40198.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,55568.22,,,,,,,fee schedule,48183.07,72273.72, Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,48183.07,,,,,,,fee schedule,48183.07,72273.72, Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,72273.72,,,,,,,fee schedule,48183.07,72273.72, Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,55681.43,,,,,,,fee schedule,48183.07,72273.72, Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,50112.94,,,,,,,fee schedule,48183.07,72273.72, Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],31197.79,31197.79,31197.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,35083.16,,,,,,,fee schedule,30420.52,45630.21, Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,30420.52,,,,,,,fee schedule,30420.52,45630.21, Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,45630.21,,,,,,,fee schedule,30420.52,45630.21, Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,35154.63,,,,,,,fee schedule,30420.52,45630.21, Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,31638.94,,,,,,,fee schedule,30420.52,45630.21, Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Back & neck proc exc spinal fusion w CC/MCC or disc device/neurostim,490,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Back & neck proc exc spinal fusion w CC/MCC or disc device/neurostim,490,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Back & neck proc exc spinal fusion w CC/MCC or disc device/neurostim,490,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Back & neck proc exc spinal fusion w CC/MCC or disc device/neurostim,490,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Back & neck proc exc spinal fusion w CC/MCC or disc device/neurostim,490,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Back & neck proc exc spinal fusion w CC/MCC or disc device/neurostim,490,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Back & neck proc exc spinal fusion w CC/MCC or disc device/neurostim,490,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Back & neck proc exc spinal fusion w CC/MCC or disc device/neurostim,490,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Back & neck proc exc spinal fusion w CC/MCC or disc device/neurostim,490,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Back & neck proc exc spinal fusion w CC/MCC or disc device/neurostim,490,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Back & neck proc exc spinal fusion w CC/MCC or disc device/neurostim,490,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Back & neck proc exc spinal fusion w CC/MCC or disc device/neurostim,490,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Back & neck proc exc spinal fusion w CC/MCC or disc device/neurostim,490,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Back & neck proc exc spinal fusion w CC/MCC or disc device/neurostim,490,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Back & neck proc exc spinal fusion w CC/MCC or disc device/neurostim,490,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Back & neck proc exc spinal fusion w CC/MCC or disc device/neurostim,490,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Back & neck proc exc spinal fusion w CC/MCC or disc device/neurostim,490,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Back & neck proc exc spinal fusion w CC/MCC or disc device/neurostim,490,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Back & neck proc exc spinal fusion w CC/MCC or disc device/neurostim,490,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Back & neck proc exc spinal fusion w CC/MCC or disc device/neurostim,490,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Back & neck proc exc spinal fusion w/o CC/MCC,491,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Back & neck proc exc spinal fusion w/o CC/MCC,491,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Back & neck proc exc spinal fusion w/o CC/MCC,491,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Back & neck proc exc spinal fusion w/o CC/MCC,491,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Back & neck proc exc spinal fusion w/o CC/MCC,491,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Back & neck proc exc spinal fusion w/o CC/MCC,491,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Back & neck proc exc spinal fusion w/o CC/MCC,491,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Back & neck proc exc spinal fusion w/o CC/MCC,491,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Back & neck proc exc spinal fusion w/o CC/MCC,491,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Back & neck proc exc spinal fusion w/o CC/MCC,491,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Back & neck proc exc spinal fusion w/o CC/MCC,491,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Back & neck proc exc spinal fusion w/o CC/MCC,491,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Back & neck proc exc spinal fusion w/o CC/MCC,491,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Back & neck proc exc spinal fusion w/o CC/MCC,491,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Back & neck proc exc spinal fusion w/o CC/MCC,491,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Back & neck proc exc spinal fusion w/o CC/MCC,491,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Back & neck proc exc spinal fusion w/o CC/MCC,491,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Back & neck proc exc spinal fusion w/o CC/MCC,491,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Back & neck proc exc spinal fusion w/o CC/MCC,491,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Back & neck proc exc spinal fusion w/o CC/MCC,491,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,115339.64,,,,,,,fee schedule,100010.71,150014.23, "Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,100010.71,,,,,,,fee schedule,100010.71,150014.23, "Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,150014.23,,,,,,,fee schedule,100010.71,150014.23, "Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,115574.62,,,,,,,fee schedule,100010.71,150014.23, "Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,104016.43,,,,,,,fee schedule,100010.71,150014.23, "Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,79669.05,,,,,,,fee schedule,69080.83,103619.97, "Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,69080.83,,,,,,,fee schedule,69080.83,103619.97, "Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,103619.97,,,,,,,fee schedule,69080.83,103619.97, "Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,79831.36,,,,,,,fee schedule,69080.83,103619.97, "Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,71847.71,,,,,,,fee schedule,69080.83,103619.97, "Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],15654.57,15654.57,15654.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],31451.9,31451.9,31451.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],63398.41,63398.41,63398.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,63032.19,,,,,,,fee schedule,54655.05,81981.58, "Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,54655.05,,,,,,,fee schedule,54655.05,81981.58, "Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,81981.58,,,,,,,fee schedule,54655.05,81981.58, "Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,63160.61,,,,,,,fee schedule,54655.05,81981.58, "Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,56844.15,,,,,,,fee schedule,54655.05,81981.58, "Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],15654.57,15654.57,15654.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,113897.74,,,,,,,fee schedule,98760.44,148138.85, Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,98760.44,,,,,,,fee schedule,98760.44,148138.85, Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,148138.85,,,,,,,fee schedule,98760.44,148138.85, Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,114129.78,,,,,,,fee schedule,98760.44,148138.85, Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,102716.08,,,,,,,fee schedule,98760.44,148138.85, Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,56667.71,,,,,,,fee schedule,49136.43,73703.75, Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,49136.43,,,,,,,fee schedule,49136.43,73703.75, Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,73703.75,,,,,,,fee schedule,49136.43,73703.75, Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,56783.16,,,,,,,fee schedule,49136.43,73703.75, Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,51104.49,,,,,,,fee schedule,49136.43,73703.75, Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],18007.14,18007.14,28353.71,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,37957.54,,,,,,,fee schedule,32912.88,49368.72, Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,32912.88,,,,,,,fee schedule,32912.88,49368.72, Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,49368.72,,,,,,,fee schedule,32912.88,49368.72, Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,38034.87,,,,,,,fee schedule,32912.88,49368.72, Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,34231.14,,,,,,,fee schedule,32912.88,49368.72, Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],33000.1,33000.1,33000.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,94769.76,,,,,,,fee schedule,82174.62,123260.41, Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,82174.62,,,,,,,fee schedule,82174.62,123260.41, Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,123260.41,,,,,,,fee schedule,82174.62,123260.41, Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,94962.83,,,,,,,fee schedule,82174.62,123260.41, Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,85465.94,,,,,,,fee schedule,82174.62,123260.41, Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,63292.93,,,,,,,fee schedule,54881.14,82320.7, Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,54881.14,,,,,,,fee schedule,54881.14,82320.7, Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,82320.7,,,,,,,fee schedule,54881.14,82320.7, Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,63421.87,,,,,,,fee schedule,54881.14,82320.7, Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,57079.28,,,,,,,fee schedule,54881.14,82320.7, Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],16278.46,16278.46,16278.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,99419.03,,,,,,,fee schedule,86205.99,129307.4, Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,86205.99,,,,,,,fee schedule,86205.99,129307.4, Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,129307.4,,,,,,,fee schedule,86205.99,129307.4, Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,99621.57,,,,,,,fee schedule,86205.99,129307.4, Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,89658.78,,,,,,,fee schedule,86205.99,129307.4, Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],120330.33,120330.33,120330.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Soft Tissue Procedures With Cc,501,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,54914.81,,,,,,,fee schedule,47616.5,71423.87, Soft Tissue Procedures With Cc,501,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,47616.5,,,,,,,fee schedule,47616.5,71423.87, Soft Tissue Procedures With Cc,501,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,71423.87,,,,,,,fee schedule,47616.5,71423.87, Soft Tissue Procedures With Cc,501,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,55026.69,,,,,,,fee schedule,47616.5,71423.87, Soft Tissue Procedures With Cc,501,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,49523.67,,,,,,,fee schedule,47616.5,71423.87, Soft Tissue Procedures With Cc,501,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Soft Tissue Procedures With Cc,501,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Soft Tissue Procedures With Cc,501,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Soft Tissue Procedures With Cc,501,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Soft Tissue Procedures With Cc,501,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Soft Tissue Procedures With Cc,501,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Soft Tissue Procedures With Cc,501,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Soft Tissue Procedures With Cc,501,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Soft Tissue Procedures With Cc,501,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Soft Tissue Procedures With Cc,501,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Soft Tissue Procedures With Cc,501,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Soft Tissue Procedures With Cc,501,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],14862.66,14862.66,14862.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Soft Tissue Procedures With Cc,501,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Soft Tissue Procedures With Cc,501,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Soft Tissue Procedures With Cc,501,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Soft Tissue Procedures With Cc,501,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Soft Tissue Procedures With Cc,501,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Soft Tissue Procedures With Cc,501,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Soft Tissue Procedures With Cc,501,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Soft Tissue Procedures With Cc,501,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,42280.1,,,,,,,fee schedule,36660.97,54990.78, Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,36660.97,,,,,,,fee schedule,36660.97,54990.78, Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,54990.78,,,,,,,fee schedule,36660.97,54990.78, Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,42366.24,,,,,,,fee schedule,36660.97,54990.78, Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,38129.35,,,,,,,fee schedule,36660.97,54990.78, Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],34648.32,34648.32,34648.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,48196.94,48196.94,48196.94,1 through 10,percent of total billed charges,,, Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Foot Procedures With Mcc,503,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,87679.62,,,,,,,fee schedule,76026.77,114038.76, Foot Procedures With Mcc,503,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,76026.77,,,,,,,fee schedule,76026.77,114038.76, Foot Procedures With Mcc,503,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,114038.76,,,,,,,fee schedule,76026.77,114038.76, Foot Procedures With Mcc,503,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,87858.25,,,,,,,fee schedule,76026.77,114038.76, Foot Procedures With Mcc,503,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,79071.86,,,,,,,fee schedule,76026.77,114038.76, Foot Procedures With Mcc,503,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Foot Procedures With Mcc,503,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Foot Procedures With Mcc,503,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Foot Procedures With Mcc,503,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Foot Procedures With Mcc,503,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Foot Procedures With Mcc,503,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Foot Procedures With Mcc,503,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Foot Procedures With Mcc,503,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Foot Procedures With Mcc,503,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Foot Procedures With Mcc,503,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Foot Procedures With Mcc,503,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Foot Procedures With Mcc,503,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Foot Procedures With Mcc,503,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Foot Procedures With Mcc,503,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Foot Procedures With Mcc,503,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Foot Procedures With Mcc,503,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Foot Procedures With Mcc,503,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Foot Procedures With Mcc,503,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Foot Procedures With Mcc,503,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Foot Procedures With Mcc,503,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Foot Procedures With Cc,504,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,58719.05,,,,,,,fee schedule,50915.14,76371.77, Foot Procedures With Cc,504,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,50915.14,,,,,,,fee schedule,50915.14,76371.77, Foot Procedures With Cc,504,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,76371.77,,,,,,,fee schedule,50915.14,76371.77, Foot Procedures With Cc,504,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,58838.68,,,,,,,fee schedule,50915.14,76371.77, Foot Procedures With Cc,504,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,52954.44,,,,,,,fee schedule,50915.14,76371.77, Foot Procedures With Cc,504,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Foot Procedures With Cc,504,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Foot Procedures With Cc,504,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Foot Procedures With Cc,504,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Foot Procedures With Cc,504,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Foot Procedures With Cc,504,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Foot Procedures With Cc,504,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Foot Procedures With Cc,504,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Foot Procedures With Cc,504,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Foot Procedures With Cc,504,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Foot Procedures With Cc,504,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Foot Procedures With Cc,504,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],13344.94,13344.94,13344.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Foot Procedures With Cc,504,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Foot Procedures With Cc,504,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Foot Procedures With Cc,504,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Foot Procedures With Cc,504,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Foot Procedures With Cc,504,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Foot Procedures With Cc,504,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Foot Procedures With Cc,504,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Foot Procedures With Cc,504,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,56319.02,,,,,,,fee schedule,48834.08,73250.22, Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,48834.08,,,,,,,fee schedule,48834.08,73250.22, Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,73250.22,,,,,,,fee schedule,48834.08,73250.22, Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,56433.76,,,,,,,fee schedule,48834.08,73250.22, Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,50790.02,,,,,,,fee schedule,48834.08,73250.22, Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Thumb Or Joint Procedures,506,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,42383.77,,,,,,,fee schedule,36750.86,55125.61, Major Thumb Or Joint Procedures,506,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,36750.86,,,,,,,fee schedule,36750.86,55125.61, Major Thumb Or Joint Procedures,506,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,55125.61,,,,,,,fee schedule,36750.86,55125.61, Major Thumb Or Joint Procedures,506,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,42470.12,,,,,,,fee schedule,36750.86,55125.61, Major Thumb Or Joint Procedures,506,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,38222.84,,,,,,,fee schedule,36750.86,55125.61, Major Thumb Or Joint Procedures,506,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Major Thumb Or Joint Procedures,506,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Thumb Or Joint Procedures,506,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Thumb Or Joint Procedures,506,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Thumb Or Joint Procedures,506,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Major Thumb Or Joint Procedures,506,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Thumb Or Joint Procedures,506,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Thumb Or Joint Procedures,506,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Thumb Or Joint Procedures,506,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Thumb Or Joint Procedures,506,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Thumb Or Joint Procedures,506,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Thumb Or Joint Procedures,506,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Thumb Or Joint Procedures,506,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Thumb Or Joint Procedures,506,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Thumb Or Joint Procedures,506,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Thumb Or Joint Procedures,506,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Thumb Or Joint Procedures,506,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Thumb Or Joint Procedures,506,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Thumb Or Joint Procedures,506,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Thumb Or Joint Procedures,506,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,56746.25,,,,,,,fee schedule,49204.53,73805.89, Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,49204.53,,,,,,,fee schedule,49204.53,73805.89, Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,73805.89,,,,,,,fee schedule,49204.53,73805.89, Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,56861.86,,,,,,,fee schedule,49204.53,73805.89, Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,51175.31,,,,,,,fee schedule,49204.53,73805.89, Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,47573.36,,,,,,,fee schedule,41250.74,61875.36, Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,41250.74,,,,,,,fee schedule,41250.74,61875.36, Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,61875.36,,,,,,,fee schedule,41250.74,61875.36, Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,47670.28,,,,,,,fee schedule,41250.74,61875.36, Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,42902.95,,,,,,,fee schedule,41250.74,61875.36, Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Arthroscopy,509,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Arthroscopy,509,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Arthroscopy,509,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Arthroscopy,509,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Arthroscopy,509,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Arthroscopy,509,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Arthroscopy,509,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Arthroscopy,509,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Arthroscopy,509,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Arthroscopy,509,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Arthroscopy,509,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Arthroscopy,509,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Arthroscopy,509,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Arthroscopy,509,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Arthroscopy,509,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Arthroscopy,509,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Arthroscopy,509,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Arthroscopy,509,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Arthroscopy,509,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Arthroscopy,509,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,94885.99,,,,,,,fee schedule,82275.4,123411.59, "Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,82275.4,,,,,,,fee schedule,82275.4,123411.59, "Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,123411.59,,,,,,,fee schedule,82275.4,123411.59, "Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,95079.3,,,,,,,fee schedule,82275.4,123411.59, "Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,85570.77,,,,,,,fee schedule,82275.4,123411.59, "Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,65322.27,,,,,,,fee schedule,56640.78,84960.13, "Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,56640.78,,,,,,,fee schedule,56640.78,84960.13, "Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,84960.13,,,,,,,fee schedule,56640.78,84960.13, "Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,65455.35,,,,,,,fee schedule,56640.78,84960.13, "Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,58909.4,,,,,,,fee schedule,56640.78,84960.13, "Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,52002.74,,,,,,,fee schedule,45091.44,67636.33, "Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,45091.44,,,,,,,fee schedule,45091.44,67636.33, "Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,67636.33,,,,,,,fee schedule,45091.44,67636.33, "Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,52108.68,,,,,,,fee schedule,45091.44,67636.33, "Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,46897.48,,,,,,,fee schedule,45091.44,67636.33, "Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,49455.06,,,,,,,fee schedule,42882.36,64322.75, "Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,42882.36,,,,,,,fee schedule,42882.36,64322.75, "Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,64322.75,,,,,,,fee schedule,42882.36,64322.75, "Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,49555.82,,,,,,,fee schedule,42882.36,64322.75, "Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,44599.92,,,,,,,fee schedule,42882.36,64322.75, "Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,32114.53,,,,,,,fee schedule,27846.43,41769.13, "Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,27846.43,,,,,,,fee schedule,27846.43,41769.13, "Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,41769.13,,,,,,,fee schedule,27846.43,41769.13, "Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,32179.96,,,,,,,fee schedule,27846.43,41769.13, "Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,28961.76,,,,,,,fee schedule,27846.43,41769.13, "Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,100113.28,,,,,,,fee schedule,86807.97,130210.36, Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,86807.97,,,,,,,fee schedule,86807.97,130210.36, Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,130210.36,,,,,,,fee schedule,86807.97,130210.36, Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,100317.24,,,,,,,fee schedule,86807.97,130210.36, Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,90284.88,,,,,,,fee schedule,86807.97,130210.36, Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],110423.57,110423.57,110423.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],567262.51,567262.51,567262.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,65281.43,,,,,,,fee schedule,56605.37,84907.01, Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,56605.37,,,,,,,fee schedule,56605.37,84907.01, Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,84907.01,,,,,,,fee schedule,56605.37,84907.01, Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,65414.43,,,,,,,fee schedule,56605.37,84907.01, Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,58872.57,,,,,,,fee schedule,56605.37,84907.01, Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],55935.88,55935.88,55935.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],31798.55,31798.55,31798.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],54957.43,54957.43,54957.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],24840.83,24840.83,24840.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],24686.32,24686.32,24686.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],49129.7,49129.7,49129.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],56098.27,56098.27,56098.27,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,56236.51,56236.51,56236.51,1 through 10,percent of total billed charges,,, Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,48273.89,,,,,,,fee schedule,41858.17,62786.49, Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,41858.17,,,,,,,fee schedule,41858.17,62786.49, Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,62786.49,,,,,,,fee schedule,41858.17,62786.49, Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,48372.24,,,,,,,fee schedule,41858.17,62786.49, Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,43534.71,,,,,,,fee schedule,41858.17,62786.49, Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],41798.83,41798.83,41798.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],17104.93,17104.93,17104.93,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],56640.83,56640.83,56640.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],38157.89,38157.89,57234.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],19528.59,19528.59,19528.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],20981.86,20981.86,20981.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],19760.27,19760.27,19760.27,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],21237.67,21237.67,21237.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,45253.28,45253.28,45253.28,1 through 10,percent of total billed charges,,, Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,117403.54,,,,,,,fee schedule,101800.31,152698.6, Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,101800.31,,,,,,,fee schedule,101800.31,152698.6, Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,152698.6,,,,,,,fee schedule,101800.31,152698.6, Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,117642.73,,,,,,,fee schedule,101800.31,152698.6, Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,105877.71,,,,,,,fee schedule,101800.31,152698.6, Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],824797.22,824797.22,824797.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,62834.28,,,,,,,fee schedule,54483.45,81724.17, Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,54483.45,,,,,,,fee schedule,54483.45,81724.17, Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,81724.17,,,,,,,fee schedule,54483.45,81724.17, Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,62962.3,,,,,,,fee schedule,54483.45,81724.17, Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,56665.67,,,,,,,fee schedule,54483.45,81724.17, Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],17670.55,17670.55,17670.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],18056.37,18056.37,18056.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,46929.37,,,,,,,fee schedule,40692.34,61037.77, Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,40692.34,,,,,,,fee schedule,40692.34,61037.77, Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,61037.77,,,,,,,fee schedule,40692.34,61037.77, Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,47024.98,,,,,,,fee schedule,40692.34,61037.77, Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,42322.19,,,,,,,fee schedule,40692.34,61037.77, Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],38363.92,38363.92,38363.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],56566.49,56566.49,56566.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],31116.76,31116.76,31116.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,90164.46,,,,,,,fee schedule,78181.38,117270.63, Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,78181.38,,,,,,,fee schedule,78181.38,117270.63, Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,117270.63,,,,,,,fee schedule,78181.38,117270.63, Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,90348.16,,,,,,,fee schedule,78181.38,117270.63, Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,81312.77,,,,,,,fee schedule,78181.38,117270.63, Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,66525.43,,,,,,,fee schedule,57684.03,86524.99, Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,57684.03,,,,,,,fee schedule,57684.03,86524.99, Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,86524.99,,,,,,,fee schedule,57684.03,86524.99, Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,66660.96,,,,,,,fee schedule,57684.03,86524.99, Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,59994.44,,,,,,,fee schedule,57684.03,86524.99, Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Alc/Drug Abuse or Depend w/o Rehabilitation therapy w/o CC,523,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Alc/Drug Abuse or Depend w/o Rehabilitation therapy w/o CC,523,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Alc/Drug Abuse or Depend w/o Rehabilitation therapy w/o CC,523,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Alc/Drug Abuse or Depend w/o Rehabilitation therapy w/o CC,523,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Alc/Drug Abuse or Depend w/o Rehabilitation therapy w/o CC,523,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Alc/Drug Abuse or Depend w/o Rehabilitation therapy w/o CC,523,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Alc/Drug Abuse or Depend w/o Rehabilitation therapy w/o CC,523,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Alc/Drug Abuse or Depend w/o Rehabilitation therapy w/o CC,523,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Alc/Drug Abuse or Depend w/o Rehabilitation therapy w/o CC,523,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Alc/Drug Abuse or Depend w/o Rehabilitation therapy w/o CC,523,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Alc/Drug Abuse or Depend w/o Rehabilitation therapy w/o CC,523,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Alc/Drug Abuse or Depend w/o Rehabilitation therapy w/o CC,523,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Alc/Drug Abuse or Depend w/o Rehabilitation therapy w/o CC,523,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Alc/Drug Abuse or Depend w/o Rehabilitation therapy w/o CC,523,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Alc/Drug Abuse or Depend w/o Rehabilitation therapy w/o CC,523,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Alc/Drug Abuse or Depend w/o Rehabilitation therapy w/o CC,523,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Alc/Drug Abuse or Depend w/o Rehabilitation therapy w/o CC,523,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Alc/Drug Abuse or Depend w/o Rehabilitation therapy w/o CC,523,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Alc/Drug Abuse or Depend w/o Rehabilitation therapy w/o CC,523,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Alc/Drug Abuse or Depend w/o Rehabilitation therapy w/o CC,523,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Transient ischemia,524,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Transient ischemia,524,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transient ischemia,524,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transient ischemia,524,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transient ischemia,524,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Transient ischemia,524,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transient ischemia,524,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transient ischemia,524,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transient ischemia,524,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transient ischemia,524,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transient ischemia,524,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transient ischemia,524,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transient ischemia,524,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transient ischemia,524,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transient ischemia,524,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transient ischemia,524,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Transient ischemia,524,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Transient ischemia,524,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Transient ischemia,524,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Transient ischemia,524,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other heart assist system implant,525,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Other heart assist system implant,525,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other heart assist system implant,525,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other heart assist system implant,525,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other heart assist system implant,525,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other heart assist system implant,525,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other heart assist system implant,525,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other heart assist system implant,525,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other heart assist system implant,525,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other heart assist system implant,525,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other heart assist system implant,525,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other heart assist system implant,525,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other heart assist system implant,525,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other heart assist system implant,525,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other heart assist system implant,525,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other heart assist system implant,525,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other heart assist system implant,525,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other heart assist system implant,525,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other heart assist system implant,525,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other heart assist system implant,525,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. No Longer Valid,526,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,526,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,526,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,526,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,526,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,526,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,526,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,526,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,526,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,526,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,526,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,526,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,526,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,526,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,526,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,526,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. No Longer Valid,526,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. No Longer Valid,526,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. No Longer Valid,526,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. No Longer Valid,526,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. No Longer Valid,527,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,527,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,527,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,527,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,527,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,527,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,527,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,527,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,527,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,527,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,527,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,527,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,527,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,527,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,527,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. No Longer Valid,527,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. No Longer Valid,527,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. No Longer Valid,527,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. No Longer Valid,527,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. No Longer Valid,527,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Intracranial Vascular Proc w Pdx Hemorrhage,528,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Vascular Proc w Pdx Hemorrhage,528,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Vascular Proc w Pdx Hemorrhage,528,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Vascular Proc w Pdx Hemorrhage,528,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Vascular Proc w Pdx Hemorrhage,528,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Vascular Proc w Pdx Hemorrhage,528,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Vascular Proc w Pdx Hemorrhage,528,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Vascular Proc w Pdx Hemorrhage,528,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Vascular Proc w Pdx Hemorrhage,528,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Vascular Proc w Pdx Hemorrhage,528,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Vascular Proc w Pdx Hemorrhage,528,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Vascular Proc w Pdx Hemorrhage,528,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Vascular Proc w Pdx Hemorrhage,528,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Vascular Proc w Pdx Hemorrhage,528,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Vascular Proc w Pdx Hemorrhage,528,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Intracranial Vascular Proc w Pdx Hemorrhage,528,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Intracranial Vascular Proc w Pdx Hemorrhage,528,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Intracranial Vascular Proc w Pdx Hemorrhage,528,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Intracranial Vascular Proc w Pdx Hemorrhage,528,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Intracranial Vascular Proc w Pdx Hemorrhage,528,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Ventricular shunt procedures w CC,529,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Ventricular shunt procedures w CC,529,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ventricular shunt procedures w CC,529,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ventricular shunt procedures w CC,529,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ventricular shunt procedures w CC,529,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Ventricular shunt procedures w CC,529,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ventricular shunt procedures w CC,529,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ventricular shunt procedures w CC,529,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ventricular shunt procedures w CC,529,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ventricular shunt procedures w CC,529,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ventricular shunt procedures w CC,529,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ventricular shunt procedures w CC,529,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ventricular shunt procedures w CC,529,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ventricular shunt procedures w CC,529,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ventricular shunt procedures w CC,529,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ventricular shunt procedures w CC,529,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Ventricular shunt procedures w CC,529,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Ventricular shunt procedures w CC,529,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Ventricular shunt procedures w CC,529,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Ventricular shunt procedures w CC,529,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Ventricular Shunt Procedures w/o CC,530,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Ventricular Shunt Procedures w/o CC,530,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ventricular Shunt Procedures w/o CC,530,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ventricular Shunt Procedures w/o CC,530,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ventricular Shunt Procedures w/o CC,530,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Ventricular Shunt Procedures w/o CC,530,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ventricular Shunt Procedures w/o CC,530,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ventricular Shunt Procedures w/o CC,530,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ventricular Shunt Procedures w/o CC,530,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ventricular Shunt Procedures w/o CC,530,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ventricular Shunt Procedures w/o CC,530,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ventricular Shunt Procedures w/o CC,530,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ventricular Shunt Procedures w/o CC,530,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ventricular Shunt Procedures w/o CC,530,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ventricular Shunt Procedures w/o CC,530,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ventricular Shunt Procedures w/o CC,530,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Ventricular Shunt Procedures w/o CC,530,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Ventricular Shunt Procedures w/o CC,530,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Ventricular Shunt Procedures w/o CC,530,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Ventricular Shunt Procedures w/o CC,530,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Spinal Procedures w CC,531,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Spinal Procedures w CC,531,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Procedures w CC,531,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Procedures w CC,531,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Procedures w CC,531,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Spinal Procedures w CC,531,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Procedures w CC,531,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Procedures w CC,531,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Procedures w CC,531,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Procedures w CC,531,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Procedures w CC,531,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Procedures w CC,531,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Procedures w CC,531,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Procedures w CC,531,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Procedures w CC,531,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Procedures w CC,531,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Spinal Procedures w CC,531,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Spinal Procedures w CC,531,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Spinal Procedures w CC,531,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Spinal Procedures w CC,531,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Spinal Procedures w/o CC,532,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Spinal Procedures w/o CC,532,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Procedures w/o CC,532,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Procedures w/o CC,532,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Procedures w/o CC,532,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Spinal Procedures w/o CC,532,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Procedures w/o CC,532,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Procedures w/o CC,532,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Procedures w/o CC,532,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Procedures w/o CC,532,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Procedures w/o CC,532,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Procedures w/o CC,532,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Procedures w/o CC,532,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Procedures w/o CC,532,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Procedures w/o CC,532,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Spinal Procedures w/o CC,532,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Spinal Procedures w/o CC,532,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Spinal Procedures w/o CC,532,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Spinal Procedures w/o CC,532,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Spinal Procedures w/o CC,532,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Fractures Of Femur With Mcc,533,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,49247.73,,,,,,,fee schedule,42702.58,64053.09, Fractures Of Femur With Mcc,533,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,42702.58,,,,,,,fee schedule,42702.58,64053.09, Fractures Of Femur With Mcc,533,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,64053.09,,,,,,,fee schedule,42702.58,64053.09, Fractures Of Femur With Mcc,533,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,49348.06,,,,,,,fee schedule,42702.58,64053.09, Fractures Of Femur With Mcc,533,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,44412.94,,,,,,,fee schedule,42702.58,64053.09, Fractures Of Femur With Mcc,533,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Fractures Of Femur With Mcc,533,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Fractures Of Femur With Mcc,533,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Fractures Of Femur With Mcc,533,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Fractures Of Femur With Mcc,533,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Fractures Of Femur With Mcc,533,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Fractures Of Femur With Mcc,533,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Fractures Of Femur With Mcc,533,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Fractures Of Femur With Mcc,533,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Fractures Of Femur With Mcc,533,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Fractures Of Femur With Mcc,533,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Fractures Of Femur With Mcc,533,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Fractures Of Femur With Mcc,533,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Fractures Of Femur With Mcc,533,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Fractures Of Femur With Mcc,533,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Fractures Of Femur With Mcc,533,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Fractures Of Femur With Mcc,533,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Fractures Of Femur With Mcc,533,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Fractures Of Femur With Mcc,533,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Fractures Of Femur With Mcc,533,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Fractures Of Femur Without Mcc,534,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,25322.83,,,,,,,fee schedule,21957.36,32935.63, Fractures Of Femur Without Mcc,534,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,21957.36,,,,,,,fee schedule,21957.36,32935.63, Fractures Of Femur Without Mcc,534,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,32935.63,,,,,,,fee schedule,21957.36,32935.63, Fractures Of Femur Without Mcc,534,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,25374.42,,,,,,,fee schedule,21957.36,32935.63, Fractures Of Femur Without Mcc,534,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22836.81,,,,,,,fee schedule,21957.36,32935.63, Fractures Of Femur Without Mcc,534,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Fractures Of Femur Without Mcc,534,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Fractures Of Femur Without Mcc,534,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Fractures Of Femur Without Mcc,534,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Fractures Of Femur Without Mcc,534,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Fractures Of Femur Without Mcc,534,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Fractures Of Femur Without Mcc,534,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Fractures Of Femur Without Mcc,534,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Fractures Of Femur Without Mcc,534,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Fractures Of Femur Without Mcc,534,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Fractures Of Femur Without Mcc,534,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Fractures Of Femur Without Mcc,534,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Fractures Of Femur Without Mcc,534,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Fractures Of Femur Without Mcc,534,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Fractures Of Femur Without Mcc,534,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Fractures Of Femur Without Mcc,534,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,6343.62,6343.62,6343.62,1 through 10,percent of total billed charges,,, Fractures Of Femur Without Mcc,534,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Fractures Of Femur Without Mcc,534,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Fractures Of Femur Without Mcc,534,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Fractures Of Femur Without Mcc,534,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,40272.75,,,,,,,fee schedule,34920.4,52379.96, Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,34920.4,,,,,,,fee schedule,34920.4,52379.96, Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,52379.96,,,,,,,fee schedule,34920.4,52379.96, Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,40354.8,,,,,,,fee schedule,34920.4,52379.96, Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,36319.06,,,,,,,fee schedule,34920.4,52379.96, Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,25369.95,,,,,,,fee schedule,21998.22,32996.92, Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,21998.22,,,,,,,fee schedule,21998.22,32996.92, Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,32996.92,,,,,,,fee schedule,21998.22,32996.92, Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,25421.63,,,,,,,fee schedule,21998.22,32996.92, Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22879.31,,,,,,,fee schedule,21998.22,32996.92, Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,29978.38,,,,,,,fee schedule,25994.18,38990.79, "Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,25994.18,,,,,,,fee schedule,25994.18,38990.79, "Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,38990.79,,,,,,,fee schedule,25994.18,38990.79, "Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,30039.46,,,,,,,fee schedule,25994.18,38990.79, "Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,27035.32,,,,,,,fee schedule,25994.18,38990.79, "Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,22627.5,,,,,,,fee schedule,19620.25,29430.02, "Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,19620.25,,,,,,,fee schedule,19620.25,29430.02, "Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,29430.02,,,,,,,fee schedule,19620.25,29430.02, "Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,22673.6,,,,,,,fee schedule,19620.25,29430.02, "Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,20406.1,,,,,,,fee schedule,19620.25,29430.02, "Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Osteomyelitis With Mcc,539,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,61876.16,,,,,,,fee schedule,53652.66,80478, Osteomyelitis With Mcc,539,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,53652.66,,,,,,,fee schedule,53652.66,80478, Osteomyelitis With Mcc,539,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,80478,,,,,,,fee schedule,53652.66,80478, Osteomyelitis With Mcc,539,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,62002.22,,,,,,,fee schedule,53652.66,80478, Osteomyelitis With Mcc,539,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,55801.6,,,,,,,fee schedule,53652.66,80478, Osteomyelitis With Mcc,539,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Osteomyelitis With Mcc,539,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Osteomyelitis With Mcc,539,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Osteomyelitis With Mcc,539,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Osteomyelitis With Mcc,539,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Osteomyelitis With Mcc,539,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Osteomyelitis With Mcc,539,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Osteomyelitis With Mcc,539,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Osteomyelitis With Mcc,539,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Osteomyelitis With Mcc,539,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Osteomyelitis With Mcc,539,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Osteomyelitis With Mcc,539,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Osteomyelitis With Mcc,539,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Osteomyelitis With Mcc,539,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Osteomyelitis With Mcc,539,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Osteomyelitis With Mcc,539,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Osteomyelitis With Mcc,539,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Osteomyelitis With Mcc,539,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Osteomyelitis With Mcc,539,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Osteomyelitis With Mcc,539,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Osteomyelitis With Cc,540,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,40721.97,,,,,,,fee schedule,35309.92,52964.23, Osteomyelitis With Cc,540,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,35309.92,,,,,,,fee schedule,35309.92,52964.23, Osteomyelitis With Cc,540,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,52964.23,,,,,,,fee schedule,35309.92,52964.23, Osteomyelitis With Cc,540,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,40804.93,,,,,,,fee schedule,35309.92,52964.23, Osteomyelitis With Cc,540,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,36724.18,,,,,,,fee schedule,35309.92,52964.23, Osteomyelitis With Cc,540,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Osteomyelitis With Cc,540,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Osteomyelitis With Cc,540,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],33081.08,33081.08,33081.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Osteomyelitis With Cc,540,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Osteomyelitis With Cc,540,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Osteomyelitis With Cc,540,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Osteomyelitis With Cc,540,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Osteomyelitis With Cc,540,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Osteomyelitis With Cc,540,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Osteomyelitis With Cc,540,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Osteomyelitis With Cc,540,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Osteomyelitis With Cc,540,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],10214.13,10214.13,10214.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Osteomyelitis With Cc,540,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],35509.46,35509.46,35509.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Osteomyelitis With Cc,540,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Osteomyelitis With Cc,540,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Osteomyelitis With Cc,540,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Osteomyelitis With Cc,540,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Osteomyelitis With Cc,540,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Osteomyelitis With Cc,540,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Osteomyelitis With Cc,540,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,24735.38,,,,,,,fee schedule,21447.99,32171.59, Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,21447.99,,,,,,,fee schedule,21447.99,32171.59, Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,32171.59,,,,,,,fee schedule,21447.99,32171.59, Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,24785.78,,,,,,,fee schedule,21447.99,32171.59, Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22307.04,,,,,,,fee schedule,21447.99,32171.59, Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,55492.83,,,,,,,fee schedule,48117.69,72175.66, Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,48117.69,,,,,,,fee schedule,48117.69,72175.66, Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,72175.66,,,,,,,fee schedule,48117.69,72175.66, Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,55605.89,,,,,,,fee schedule,48117.69,72175.66, Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,50044.95,,,,,,,fee schedule,48117.69,72175.66, Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],71513.53,71513.53,71513.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,32293.59,,,,,,,fee schedule,28001.69,42002.02, Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,28001.69,,,,,,,fee schedule,28001.69,42002.02, Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,42002.02,,,,,,,fee schedule,28001.69,42002.02, Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,32359.38,,,,,,,fee schedule,28001.69,42002.02, Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,29123.24,,,,,,,fee schedule,28001.69,42002.02, Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],12061.48,12061.48,12061.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],25567,25567,25567,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,23705,,,,,,,fee schedule,20554.55,30831.45, Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,20554.55,,,,,,,fee schedule,20554.55,30831.45, Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,30831.45,,,,,,,fee schedule,20554.55,30831.45, Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,23753.3,,,,,,,fee schedule,20554.55,30831.45, Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,21377.82,,,,,,,fee schedule,20554.55,30831.45, Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,77960.12,,,,,,,fee schedule,67599.03,101397.3, Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,67599.03,,,,,,,fee schedule,67599.03,101397.3, Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,101397.3,,,,,,,fee schedule,67599.03,101397.3, Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,78118.95,,,,,,,fee schedule,67599.03,101397.3, Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,70306.56,,,,,,,fee schedule,67599.03,101397.3, Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],18479.83,18479.83,18479.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],96888.93,96888.93,96888.93,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],11102.21,11102.21,11102.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],18038.49,18038.49,18038.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],41016.18,41016.18,41016.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],70465.13,70465.13,70465.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Connective Tissue Disorders With Cc,546,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,36232.91,,,,,,,fee schedule,31417.46,47125.62, Connective Tissue Disorders With Cc,546,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,31417.46,,,,,,,fee schedule,31417.46,47125.62, Connective Tissue Disorders With Cc,546,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,47125.62,,,,,,,fee schedule,31417.46,47125.62, Connective Tissue Disorders With Cc,546,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,36306.73,,,,,,,fee schedule,31417.46,47125.62, Connective Tissue Disorders With Cc,546,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,32675.82,,,,,,,fee schedule,31417.46,47125.62, Connective Tissue Disorders With Cc,546,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],12816.47,12816.47,12816.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Connective Tissue Disorders With Cc,546,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Connective Tissue Disorders With Cc,546,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],28323.63,28323.63,28594.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Connective Tissue Disorders With Cc,546,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],14633.81,14633.81,14633.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Connective Tissue Disorders With Cc,546,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Connective Tissue Disorders With Cc,546,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Connective Tissue Disorders With Cc,546,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Connective Tissue Disorders With Cc,546,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Connective Tissue Disorders With Cc,546,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Connective Tissue Disorders With Cc,546,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],18544.24,11102.21,18544.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Connective Tissue Disorders With Cc,546,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Connective Tissue Disorders With Cc,546,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],11428.02,11428.02,19455.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Connective Tissue Disorders With Cc,546,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],33965.76,33965.76,33965.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Connective Tissue Disorders With Cc,546,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Connective Tissue Disorders With Cc,546,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Connective Tissue Disorders With Cc,546,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,54275.12,54275.12,54275.12,1 through 10,percent of total billed charges,,, Connective Tissue Disorders With Cc,546,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Connective Tissue Disorders With Cc,546,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Connective Tissue Disorders With Cc,546,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Connective Tissue Disorders With Cc,546,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,26268.39,,,,,,,fee schedule,22777.25,34165.46, Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,22777.25,,,,,,,fee schedule,22777.25,34165.46, Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,34165.46,,,,,,,fee schedule,22777.25,34165.46, Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,26321.9,,,,,,,fee schedule,22777.25,34165.46, Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,23689.55,,,,,,,fee schedule,22777.25,34165.46, Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],22409.91,22409.91,22409.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],17575.11,17575.11,17575.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],8112.76,8112.76,8112.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Septic Arthritis With Mcc,548,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,60657.29,,,,,,,fee schedule,52595.79,78892.71, Septic Arthritis With Mcc,548,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,52595.79,,,,,,,fee schedule,52595.79,78892.71, Septic Arthritis With Mcc,548,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,78892.71,,,,,,,fee schedule,52595.79,78892.71, Septic Arthritis With Mcc,548,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,60780.87,,,,,,,fee schedule,52595.79,78892.71, Septic Arthritis With Mcc,548,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,54702.4,,,,,,,fee schedule,52595.79,78892.71, Septic Arthritis With Mcc,548,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Septic Arthritis With Mcc,548,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Septic Arthritis With Mcc,548,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Septic Arthritis With Mcc,548,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Septic Arthritis With Mcc,548,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Septic Arthritis With Mcc,548,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Septic Arthritis With Mcc,548,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Septic Arthritis With Mcc,548,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Septic Arthritis With Mcc,548,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Septic Arthritis With Mcc,548,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Septic Arthritis With Mcc,548,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Septic Arthritis With Mcc,548,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Septic Arthritis With Mcc,548,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Septic Arthritis With Mcc,548,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Septic Arthritis With Mcc,548,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Septic Arthritis With Mcc,548,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Septic Arthritis With Mcc,548,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Septic Arthritis With Mcc,548,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Septic Arthritis With Mcc,548,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Septic Arthritis With Mcc,548,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Septic Arthritis With Cc,549,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,37922.98,,,,,,,fee schedule,32882.92,49323.78, Septic Arthritis With Cc,549,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,32882.92,,,,,,,fee schedule,32882.92,49323.78, Septic Arthritis With Cc,549,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,49323.78,,,,,,,fee schedule,32882.92,49323.78, Septic Arthritis With Cc,549,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,38000.24,,,,,,,fee schedule,32882.92,49323.78, Septic Arthritis With Cc,549,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,34199.98,,,,,,,fee schedule,32882.92,49323.78, Septic Arthritis With Cc,549,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Septic Arthritis With Cc,549,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Septic Arthritis With Cc,549,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Septic Arthritis With Cc,549,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Septic Arthritis With Cc,549,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Septic Arthritis With Cc,549,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Septic Arthritis With Cc,549,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Septic Arthritis With Cc,549,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Septic Arthritis With Cc,549,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Septic Arthritis With Cc,549,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Septic Arthritis With Cc,549,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Septic Arthritis With Cc,549,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Septic Arthritis With Cc,549,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Septic Arthritis With Cc,549,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Septic Arthritis With Cc,549,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Septic Arthritis With Cc,549,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Septic Arthritis With Cc,549,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Septic Arthritis With Cc,549,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Septic Arthritis With Cc,549,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Septic Arthritis With Cc,549,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,27458.98,,,,,,,fee schedule,23809.61,35713.98, Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,23809.61,,,,,,,fee schedule,23809.61,35713.98, Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,35713.98,,,,,,,fee schedule,23809.61,35713.98, Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,27514.92,,,,,,,fee schedule,23809.61,35713.98, Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,24763.25,,,,,,,fee schedule,23809.61,35713.98, Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],8108.53,8108.53,8108.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Medical Back Problems With Mcc,551,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,52653.01,,,,,,,fee schedule,45655.29,68482.09, Medical Back Problems With Mcc,551,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,45655.29,,,,,,,fee schedule,45655.29,68482.09, Medical Back Problems With Mcc,551,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,68482.09,,,,,,,fee schedule,45655.29,68482.09, Medical Back Problems With Mcc,551,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,52760.28,,,,,,,fee schedule,45655.29,68482.09, Medical Back Problems With Mcc,551,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,47483.91,,,,,,,fee schedule,45655.29,68482.09, Medical Back Problems With Mcc,551,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Medical Back Problems With Mcc,551,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Medical Back Problems With Mcc,551,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Medical Back Problems With Mcc,551,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Medical Back Problems With Mcc,551,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Medical Back Problems With Mcc,551,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Medical Back Problems With Mcc,551,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Medical Back Problems With Mcc,551,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Medical Back Problems With Mcc,551,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Medical Back Problems With Mcc,551,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Medical Back Problems With Mcc,551,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Medical Back Problems With Mcc,551,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Medical Back Problems With Mcc,551,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Medical Back Problems With Mcc,551,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Medical Back Problems With Mcc,551,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Medical Back Problems With Mcc,551,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Medical Back Problems With Mcc,551,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Medical Back Problems With Mcc,551,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Medical Back Problems With Mcc,551,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Medical Back Problems With Mcc,551,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Medical Back Problems Without Mcc,552,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,30198.28,,,,,,,fee schedule,26184.85,39276.8, Medical Back Problems Without Mcc,552,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,26184.85,,,,,,,fee schedule,26184.85,39276.8, Medical Back Problems Without Mcc,552,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,39276.8,,,,,,,fee schedule,26184.85,39276.8, Medical Back Problems Without Mcc,552,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,30259.8,,,,,,,fee schedule,26184.85,39276.8, Medical Back Problems Without Mcc,552,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,27233.63,,,,,,,fee schedule,26184.85,39276.8, Medical Back Problems Without Mcc,552,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Medical Back Problems Without Mcc,552,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Medical Back Problems Without Mcc,552,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],35100.27,35100.27,35100.27,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Medical Back Problems Without Mcc,552,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Medical Back Problems Without Mcc,552,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Medical Back Problems Without Mcc,552,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Medical Back Problems Without Mcc,552,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Medical Back Problems Without Mcc,552,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Medical Back Problems Without Mcc,552,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Medical Back Problems Without Mcc,552,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],9705.18,9705.18,9705.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Medical Back Problems Without Mcc,552,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Medical Back Problems Without Mcc,552,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],13908.64,13908.64,13908.64,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Medical Back Problems Without Mcc,552,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],26876.53,26876.53,26876.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Medical Back Problems Without Mcc,552,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Medical Back Problems Without Mcc,552,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Medical Back Problems Without Mcc,552,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Medical Back Problems Without Mcc,552,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Medical Back Problems Without Mcc,552,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Medical Back Problems Without Mcc,552,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Medical Back Problems Without Mcc,552,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,40721.97,,,,,,,fee schedule,35309.92,52964.23, Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,35309.92,,,,,,,fee schedule,35309.92,52964.23, Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,52964.23,,,,,,,fee schedule,35309.92,52964.23, Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,40804.93,,,,,,,fee schedule,35309.92,52964.23, Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,36724.18,,,,,,,fee schedule,35309.92,52964.23, Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,26076.76,,,,,,,fee schedule,22611.09,33916.23, Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,22611.09,,,,,,,fee schedule,22611.09,33916.23, Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,33916.23,,,,,,,fee schedule,22611.09,33916.23, Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,26129.89,,,,,,,fee schedule,22611.09,33916.23, Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,23516.73,,,,,,,fee schedule,22611.09,33916.23, Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],12738.53,12738.53,12738.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,41523.03,,,,,,,fee schedule,36004.51,54006.1, Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,36004.51,,,,,,,fee schedule,36004.51,54006.1, Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,54006.1,,,,,,,fee schedule,36004.51,54006.1, Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,41607.62,,,,,,,fee schedule,36004.51,54006.1, Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,37446.59,,,,,,,fee schedule,36004.51,54006.1, Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],24480.63,24480.63,24480.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],12280.72,12280.72,12280.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,26092.47,,,,,,,fee schedule,22624.71,33936.65, Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,22624.71,,,,,,,fee schedule,22624.71,33936.65, Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,33936.65,,,,,,,fee schedule,22624.71,33936.65, Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,26145.63,,,,,,,fee schedule,22624.71,33936.65, Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,23530.9,,,,,,,fee schedule,22624.71,33936.65, Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],13277.74,13277.74,13277.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],31307.06,31307.06,31307.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],27374.62,27374.62,27374.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],12738.53,12738.53,12738.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],21559.76,21559.76,21559.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,46709.48,,,,,,,fee schedule,40501.67,60751.76, "Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,40501.67,,,,,,,fee schedule,40501.67,60751.76, "Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,60751.76,,,,,,,fee schedule,40501.67,60751.76, "Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,46804.64,,,,,,,fee schedule,40501.67,60751.76, "Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,42123.88,,,,,,,fee schedule,40501.67,60751.76, "Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],25040.53,25040.53,25040.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],26145.15,26145.15,26145.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,28058.98,,,,,,,fee schedule,24329.87,36494.37, "Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,24329.87,,,,,,,fee schedule,24329.87,36494.37, "Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,36494.37,,,,,,,fee schedule,24329.87,36494.37, "Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,28116.15,,,,,,,fee schedule,24329.87,36494.37, "Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,25304.36,,,,,,,fee schedule,24329.87,36494.37, "Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],19308.18,19308.18,19308.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],19737.53,19737.53,19737.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],20146.07,20146.07,22081.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],16902.2,16902.2,16902.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],7521.49,7521.49,7521.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],7316.36,7316.36,8108.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],7863.38,7863.38,7863.38,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,11120.9,11120.9,11120.9,1 through 10,percent of total billed charges,,, "Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,10640.34,10640.34,10640.34,1 through 10,percent of total billed charges,,, "Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,58583.97,,,,,,,fee schedule,50798.01,76196.08, "Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,50798.01,,,,,,,fee schedule,50798.01,76196.08, "Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,76196.08,,,,,,,fee schedule,50798.01,76196.08, "Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,58703.32,,,,,,,fee schedule,50798.01,76196.08, "Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,52832.62,,,,,,,fee schedule,50798.01,76196.08, "Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,35375.31,,,,,,,fee schedule,30673.84,46010.19, "Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,30673.84,,,,,,,fee schedule,30673.84,46010.19, "Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,46010.19,,,,,,,fee schedule,30673.84,46010.19, "Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,35447.38,,,,,,,fee schedule,30673.84,46010.19, "Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,31902.41,,,,,,,fee schedule,30673.84,46010.19, "Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,25253.71,,,,,,,fee schedule,21897.43,32845.75, "Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,21897.43,,,,,,,fee schedule,21897.43,32845.75, "Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,32845.75,,,,,,,fee schedule,21897.43,32845.75, "Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,25305.16,,,,,,,fee schedule,21897.43,32845.75, "Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22774.49,,,,,,,fee schedule,21897.43,32845.75, "Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],20500.04,20500.04,20500.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,44758.67,,,,,,,fee schedule,38810.13,58214.48, "Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,38810.13,,,,,,,fee schedule,38810.13,58214.48, "Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,58214.48,,,,,,,fee schedule,38810.13,58214.48, "Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,44849.85,,,,,,,fee schedule,38810.13,58214.48, "Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,40364.58,,,,,,,fee schedule,38810.13,58214.48, "Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,28131.24,,,,,,,fee schedule,24392.52,36588.34, "Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,24392.52,,,,,,,fee schedule,24392.52,36588.34, "Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,36588.34,,,,,,,fee schedule,24392.52,36588.34, "Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,28188.55,,,,,,,fee schedule,24392.52,36588.34, "Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,25369.52,,,,,,,fee schedule,24392.52,36588.34, "Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],8149.67,8149.67,8149.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,48490.65,,,,,,,fee schedule,42046.12,63068.41, Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,42046.12,,,,,,,fee schedule,42046.12,63068.41, Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,63068.41,,,,,,,fee schedule,42046.12,63068.41, Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,48589.44,,,,,,,fee schedule,42046.12,63068.41, Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,43730.19,,,,,,,fee schedule,42046.12,63068.41, Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],42791.91,42791.91,42791.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,30609.8,,,,,,,fee schedule,26541.68,39812.04, Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,26541.68,,,,,,,fee schedule,26541.68,39812.04, Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,39812.04,,,,,,,fee schedule,26541.68,39812.04, Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,30672.16,,,,,,,fee schedule,26541.68,39812.04, Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,27604.75,,,,,,,fee schedule,26541.68,39812.04, Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],25694.08,25694.08,25694.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],10975.76,10975.76,10975.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,23538.51,,,,,,,fee schedule,20410.18,30614.9, Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,20410.18,,,,,,,fee schedule,20410.18,30614.9, Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,30614.9,,,,,,,fee schedule,20410.18,30614.9, Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,23586.47,,,,,,,fee schedule,20410.18,30614.9, Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,21227.67,,,,,,,fee schedule,20410.18,30614.9, Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],21506.33,21506.33,21506.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],7587.31,7587.31,7587.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],20861.52,20861.52,20861.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Stomach, Esophageal & Duodenal Proc Age > 17 w CC w Major Gi Dx",567,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Stomach, Esophageal & Duodenal Proc Age > 17 w CC w Major Gi Dx",567,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Stomach, Esophageal & Duodenal Proc Age > 17 w CC w Major Gi Dx",567,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Stomach, Esophageal & Duodenal Proc Age > 17 w CC w Major Gi Dx",567,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Stomach, Esophageal & Duodenal Proc Age > 17 w CC w Major Gi Dx",567,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Stomach, Esophageal & Duodenal Proc Age > 17 w CC w Major Gi Dx",567,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Stomach, Esophageal & Duodenal Proc Age > 17 w CC w Major Gi Dx",567,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Stomach, Esophageal & Duodenal Proc Age > 17 w CC w Major Gi Dx",567,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Stomach, Esophageal & Duodenal Proc Age > 17 w CC w Major Gi Dx",567,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Stomach, Esophageal & Duodenal Proc Age > 17 w CC w Major Gi Dx",567,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Stomach, Esophageal & Duodenal Proc Age > 17 w CC w Major Gi Dx",567,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Stomach, Esophageal & Duodenal Proc Age > 17 w CC w Major Gi Dx",567,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Stomach, Esophageal & Duodenal Proc Age > 17 w CC w Major Gi Dx",567,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Stomach, Esophageal & Duodenal Proc Age > 17 w CC w Major Gi Dx",567,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Stomach, Esophageal & Duodenal Proc Age > 17 w CC w Major Gi Dx",567,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Stomach, Esophageal & Duodenal Proc Age > 17 w CC w Major Gi Dx",567,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Stomach, Esophageal & Duodenal Proc Age > 17 w CC w Major Gi Dx",567,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Stomach, Esophageal & Duodenal Proc Age > 17 w CC w Major Gi Dx",567,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Stomach, Esophageal & Duodenal Proc Age > 17 w CC w Major Gi Dx",567,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Stomach, Esophageal & Duodenal Proc Age > 17 w CC w Major Gi Dx",567,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Stomach, Esophageal & Duodenal Procedures Proc Age > 17 w CC w/o Major Gi Dx",568,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Stomach, Esophageal & Duodenal Procedures Proc Age > 17 w CC w/o Major Gi Dx",568,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Stomach, Esophageal & Duodenal Procedures Proc Age > 17 w CC w/o Major Gi Dx",568,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Stomach, Esophageal & Duodenal Procedures Proc Age > 17 w CC w/o Major Gi Dx",568,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Stomach, Esophageal & Duodenal Procedures Proc Age > 17 w CC w/o Major Gi Dx",568,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Stomach, Esophageal & Duodenal Procedures Proc Age > 17 w CC w/o Major Gi Dx",568,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Stomach, Esophageal & Duodenal Procedures Proc Age > 17 w CC w/o Major Gi Dx",568,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Stomach, Esophageal & Duodenal Procedures Proc Age > 17 w CC w/o Major Gi Dx",568,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Stomach, Esophageal & Duodenal Procedures Proc Age > 17 w CC w/o Major Gi Dx",568,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Stomach, Esophageal & Duodenal Procedures Proc Age > 17 w CC w/o Major Gi Dx",568,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Stomach, Esophageal & Duodenal Procedures Proc Age > 17 w CC w/o Major Gi Dx",568,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Stomach, Esophageal & Duodenal Procedures Proc Age > 17 w CC w/o Major Gi Dx",568,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Stomach, Esophageal & Duodenal Procedures Proc Age > 17 w CC w/o Major Gi Dx",568,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Stomach, Esophageal & Duodenal Procedures Proc Age > 17 w CC w/o Major Gi Dx",568,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Stomach, Esophageal & Duodenal Procedures Proc Age > 17 w CC w/o Major Gi Dx",568,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Stomach, Esophageal & Duodenal Procedures Proc Age > 17 w CC w/o Major Gi Dx",568,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Stomach, Esophageal & Duodenal Procedures Proc Age > 17 w CC w/o Major Gi Dx",568,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Stomach, Esophageal & Duodenal Procedures Proc Age > 17 w CC w/o Major Gi Dx",568,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Stomach, Esophageal & Duodenal Procedures Proc Age > 17 w CC w/o Major Gi Dx",568,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Stomach, Esophageal & Duodenal Procedures Proc Age > 17 w CC w/o Major Gi Dx",568,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Small & Large Bowel Procedures w CC w Major Gi Dx,569,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Major Small & Large Bowel Procedures w CC w Major Gi Dx,569,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Small & Large Bowel Procedures w CC w Major Gi Dx,569,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Small & Large Bowel Procedures w CC w Major Gi Dx,569,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Small & Large Bowel Procedures w CC w Major Gi Dx,569,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Major Small & Large Bowel Procedures w CC w Major Gi Dx,569,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Small & Large Bowel Procedures w CC w Major Gi Dx,569,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Small & Large Bowel Procedures w CC w Major Gi Dx,569,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Small & Large Bowel Procedures w CC w Major Gi Dx,569,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Small & Large Bowel Procedures w CC w Major Gi Dx,569,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Small & Large Bowel Procedures w CC w Major Gi Dx,569,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Small & Large Bowel Procedures w CC w Major Gi Dx,569,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Small & Large Bowel Procedures w CC w Major Gi Dx,569,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Small & Large Bowel Procedures w CC w Major Gi Dx,569,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Small & Large Bowel Procedures w CC w Major Gi Dx,569,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Small & Large Bowel Procedures w CC w Major Gi Dx,569,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Small & Large Bowel Procedures w CC w Major Gi Dx,569,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Small & Large Bowel Procedures w CC w Major Gi Dx,569,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Small & Large Bowel Procedures w CC w Major Gi Dx,569,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Small & Large Bowel Procedures w CC w Major Gi Dx,569,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Skin Debridement With Mcc,570,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,92391.72,,,,,,,fee schedule,80112.62,120167.46, Skin Debridement With Mcc,570,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,80112.62,,,,,,,fee schedule,80112.62,120167.46, Skin Debridement With Mcc,570,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,120167.46,,,,,,,fee schedule,80112.62,120167.46, Skin Debridement With Mcc,570,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,92579.95,,,,,,,fee schedule,80112.62,120167.46, Skin Debridement With Mcc,570,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,83321.36,,,,,,,fee schedule,80112.62,120167.46, Skin Debridement With Mcc,570,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Skin Debridement With Mcc,570,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Debridement With Mcc,570,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Debridement With Mcc,570,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Debridement With Mcc,570,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Skin Debridement With Mcc,570,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Debridement With Mcc,570,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Debridement With Mcc,570,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Debridement With Mcc,570,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Debridement With Mcc,570,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Debridement With Mcc,570,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Debridement With Mcc,570,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Debridement With Mcc,570,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Debridement With Mcc,570,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Debridement With Mcc,570,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Debridement With Mcc,570,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,30610.97,30610.97,30610.97,1 through 10,percent of total billed charges,,, Skin Debridement With Mcc,570,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Skin Debridement With Mcc,570,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Skin Debridement With Mcc,570,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Skin Debridement With Mcc,570,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Skin Debridement With Cc,571,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,53073.95,,,,,,,fee schedule,46020.29,69029.59, Skin Debridement With Cc,571,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,46020.29,,,,,,,fee schedule,46020.29,69029.59, Skin Debridement With Cc,571,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,69029.59,,,,,,,fee schedule,46020.29,69029.59, Skin Debridement With Cc,571,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,53182.08,,,,,,,fee schedule,46020.29,69029.59, Skin Debridement With Cc,571,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,47863.54,,,,,,,fee schedule,46020.29,69029.59, Skin Debridement With Cc,571,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Skin Debridement With Cc,571,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Debridement With Cc,571,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],41323.93,41323.93,41323.93,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Skin Debridement With Cc,571,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Debridement With Cc,571,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Skin Debridement With Cc,571,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Debridement With Cc,571,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Debridement With Cc,571,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Debridement With Cc,571,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Debridement With Cc,571,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Debridement With Cc,571,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Debridement With Cc,571,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],22557.95,22557.95,22557.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Skin Debridement With Cc,571,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Debridement With Cc,571,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Debridement With Cc,571,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Debridement With Cc,571,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Skin Debridement With Cc,571,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Skin Debridement With Cc,571,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Skin Debridement With Cc,571,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Skin Debridement With Cc,571,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,36009.87,,,,,,,fee schedule,31224.07,46835.53, Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,31224.07,,,,,,,fee schedule,31224.07,46835.53, Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,46835.53,,,,,,,fee schedule,31224.07,46835.53, Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,36083.23,,,,,,,fee schedule,31224.07,46835.53, Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,32474.68,,,,,,,fee schedule,31224.07,46835.53, Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,205805.68,,,,,,,fee schedule,178453.58,267677.1, Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,178453.58,,,,,,,fee schedule,178453.58,267677.1, Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,267677.1,,,,,,,fee schedule,178453.58,267677.1, Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,206224.97,,,,,,,fee schedule,178453.58,267677.1, Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,185601.16,,,,,,,fee schedule,178453.58,267677.1, Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],277696.51,277696.51,277696.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,109050.56,,,,,,,fee schedule,94557.46,141834.46, Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,94557.46,,,,,,,fee schedule,94557.46,141834.46, Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,141834.46,,,,,,,fee schedule,94557.46,141834.46, Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,109272.73,,,,,,,fee schedule,94557.46,141834.46, Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,98344.76,,,,,,,fee schedule,94557.46,141834.46, Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,56450.96,,,,,,,fee schedule,48948.48,73421.83, Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,48948.48,,,,,,,fee schedule,48948.48,73421.83, Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,73421.83,,,,,,,fee schedule,48948.48,73421.83, Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,56565.97,,,,,,,fee schedule,48948.48,73421.83, Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,50909.01,,,,,,,fee schedule,48948.48,73421.83, Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,153966.3,,,,,,,fee schedule,133503.79,200253.23, Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,133503.79,,,,,,,fee schedule,133503.79,200253.23, Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,200253.23,,,,,,,fee schedule,133503.79,200253.23, Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,154279.97,,,,,,,fee schedule,133503.79,200253.23, Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,138851,,,,,,,fee schedule,133503.79,200253.23, Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,83269.09,,,,,,,fee schedule,72202.42,108302.3, Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,72202.42,,,,,,,fee schedule,72202.42,108302.3, Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,108302.3,,,,,,,fee schedule,72202.42,108302.3, Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,83438.73,,,,,,,fee schedule,72202.42,108302.3, Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,75094.33,,,,,,,fee schedule,72202.42,108302.3, Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,50463.45,,,,,,,fee schedule,43756.73,65634.29, Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,43756.73,,,,,,,fee schedule,43756.73,65634.29, Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,65634.29,,,,,,,fee schedule,43756.73,65634.29, Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,50566.26,,,,,,,fee schedule,43756.73,65634.29, Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,45509.31,,,,,,,fee schedule,43756.73,65634.29, Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,101734.24,,,,,,,fee schedule,88213.5,132318.63, "Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,88213.5,,,,,,,fee schedule,88213.5,132318.63, "Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,132318.63,,,,,,,fee schedule,88213.5,132318.63, "Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,101941.5,,,,,,,fee schedule,88213.5,132318.63, "Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,91746.71,,,,,,,fee schedule,88213.5,132318.63, "Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],36649.46,36649.46,36649.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,54283.39,,,,,,,fee schedule,47068.99,70602.62, "Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,47068.99,,,,,,,fee schedule,47068.99,70602.62, "Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,70602.62,,,,,,,fee schedule,47068.99,70602.62, "Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,54393.98,,,,,,,fee schedule,47068.99,70602.62, "Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,48954.24,,,,,,,fee schedule,47068.99,70602.62, "Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],11213.44,11213.44,11213.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,45333.54,,,,,,,fee schedule,39308.6,58962.18, "Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,39308.6,,,,,,,fee schedule,39308.6,58962.18, "Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,58962.18,,,,,,,fee schedule,39308.6,58962.18, "Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,45425.9,,,,,,,fee schedule,39308.6,58962.18, "Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,40883.02,,,,,,,fee schedule,39308.6,58962.18, "Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],9120.13,8658.03,9120.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,60522.21,,,,,,,fee schedule,52478.66,78717.02, Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,52478.66,,,,,,,fee schedule,52478.66,78717.02, Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,78717.02,,,,,,,fee schedule,52478.66,78717.02, Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,60645.51,,,,,,,fee schedule,52478.66,78717.02, Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,54580.58,,,,,,,fee schedule,52478.66,78717.02, Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,54170.3,,,,,,,fee schedule,46970.93,70455.54, Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,46970.93,,,,,,,fee schedule,46970.93,70455.54, Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,70455.54,,,,,,,fee schedule,46970.93,70455.54, Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,54280.66,,,,,,,fee schedule,46970.93,70455.54, Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,48852.25,,,,,,,fee schedule,46970.93,70455.54, Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,67247.95,,,,,,,fee schedule,58310.53,87464.72, "Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,58310.53,,,,,,,fee schedule,58310.53,87464.72, "Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,87464.72,,,,,,,fee schedule,58310.53,87464.72, "Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,67384.95,,,,,,,fee schedule,58310.53,87464.72, "Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,60646.03,,,,,,,fee schedule,58310.53,87464.72, "Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,60600.75,,,,,,,fee schedule,52546.75,78819.17, "Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,52546.75,,,,,,,fee schedule,52546.75,78819.17, "Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,78819.17,,,,,,,fee schedule,52546.75,78819.17, "Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,60724.21,,,,,,,fee schedule,52546.75,78819.17, "Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,54651.4,,,,,,,fee schedule,52546.75,78819.17, "Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],60251.76,60251.76,60251.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Skin Ulcers With Mcc,592,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,60795.51,,,,,,,fee schedule,52715.64,79072.49, Skin Ulcers With Mcc,592,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,52715.64,,,,,,,fee schedule,52715.64,79072.49, Skin Ulcers With Mcc,592,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,79072.49,,,,,,,fee schedule,52715.64,79072.49, Skin Ulcers With Mcc,592,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,60919.37,,,,,,,fee schedule,52715.64,79072.49, Skin Ulcers With Mcc,592,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,54827.05,,,,,,,fee schedule,52715.64,79072.49, Skin Ulcers With Mcc,592,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Skin Ulcers With Mcc,592,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Ulcers With Mcc,592,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Ulcers With Mcc,592,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Ulcers With Mcc,592,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Skin Ulcers With Mcc,592,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Ulcers With Mcc,592,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Ulcers With Mcc,592,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Ulcers With Mcc,592,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Ulcers With Mcc,592,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Ulcers With Mcc,592,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Ulcers With Mcc,592,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Ulcers With Mcc,592,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Ulcers With Mcc,592,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Ulcers With Mcc,592,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Ulcers With Mcc,592,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Skin Ulcers With Mcc,592,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Skin Ulcers With Mcc,592,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Skin Ulcers With Mcc,592,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Skin Ulcers With Mcc,592,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Skin Ulcers With Cc,593,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,37266.43,,,,,,,fee schedule,32313.63,48469.85, Skin Ulcers With Cc,593,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,32313.63,,,,,,,fee schedule,32313.63,48469.85, Skin Ulcers With Cc,593,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,48469.85,,,,,,,fee schedule,32313.63,48469.85, Skin Ulcers With Cc,593,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,37342.35,,,,,,,fee schedule,32313.63,48469.85, Skin Ulcers With Cc,593,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,33607.88,,,,,,,fee schedule,32313.63,48469.85, Skin Ulcers With Cc,593,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Skin Ulcers With Cc,593,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Ulcers With Cc,593,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Ulcers With Cc,593,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Ulcers With Cc,593,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Skin Ulcers With Cc,593,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Ulcers With Cc,593,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Ulcers With Cc,593,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Ulcers With Cc,593,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Ulcers With Cc,593,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Ulcers With Cc,593,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Ulcers With Cc,593,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],7891.24,7891.24,7891.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Skin Ulcers With Cc,593,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Ulcers With Cc,593,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Ulcers With Cc,593,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Ulcers With Cc,593,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Skin Ulcers With Cc,593,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Skin Ulcers With Cc,593,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Skin Ulcers With Cc,593,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Skin Ulcers With Cc,593,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,27229.66,,,,,,,fee schedule,23610.77,35415.71, Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,23610.77,,,,,,,fee schedule,23610.77,35415.71, Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,35415.71,,,,,,,fee schedule,23610.77,35415.71, Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,27285.13,,,,,,,fee schedule,23610.77,35415.71, Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,24556.44,,,,,,,fee schedule,23610.77,35415.71, Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Skin Disorders With Mcc,595,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,66619.67,,,,,,,fee schedule,57765.75,86647.56, Major Skin Disorders With Mcc,595,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,57765.75,,,,,,,fee schedule,57765.75,86647.56, Major Skin Disorders With Mcc,595,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,86647.56,,,,,,,fee schedule,57765.75,86647.56, Major Skin Disorders With Mcc,595,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,66755.39,,,,,,,fee schedule,57765.75,86647.56, Major Skin Disorders With Mcc,595,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,60079.43,,,,,,,fee schedule,57765.75,86647.56, Major Skin Disorders With Mcc,595,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Major Skin Disorders With Mcc,595,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Skin Disorders With Mcc,595,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Skin Disorders With Mcc,595,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Skin Disorders With Mcc,595,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Major Skin Disorders With Mcc,595,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Skin Disorders With Mcc,595,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Skin Disorders With Mcc,595,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Skin Disorders With Mcc,595,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Skin Disorders With Mcc,595,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Skin Disorders With Mcc,595,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Skin Disorders With Mcc,595,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Skin Disorders With Mcc,595,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Skin Disorders With Mcc,595,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Skin Disorders With Mcc,595,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Skin Disorders With Mcc,595,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Skin Disorders With Mcc,595,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Skin Disorders With Mcc,595,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Skin Disorders With Mcc,595,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Skin Disorders With Mcc,595,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Skin Disorders Without Mcc,596,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,34005.66,,,,,,,fee schedule,29486.22,44228.79, Major Skin Disorders Without Mcc,596,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,29486.22,,,,,,,fee schedule,29486.22,44228.79, Major Skin Disorders Without Mcc,596,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,44228.79,,,,,,,fee schedule,29486.22,44228.79, Major Skin Disorders Without Mcc,596,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,34074.94,,,,,,,fee schedule,29486.22,44228.79, Major Skin Disorders Without Mcc,596,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,30667.23,,,,,,,fee schedule,29486.22,44228.79, Major Skin Disorders Without Mcc,596,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],15457.19,15457.19,30386.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Skin Disorders Without Mcc,596,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Skin Disorders Without Mcc,596,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],9922.73,7240,23175.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Skin Disorders Without Mcc,596,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Skin Disorders Without Mcc,596,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Major Skin Disorders Without Mcc,596,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Skin Disorders Without Mcc,596,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Skin Disorders Without Mcc,596,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],4800.41,4800.41,4800.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Skin Disorders Without Mcc,596,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Skin Disorders Without Mcc,596,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],8550.59,8550.59,8550.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Skin Disorders Without Mcc,596,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Skin Disorders Without Mcc,596,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],4891.85,4891.85,8317.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Skin Disorders Without Mcc,596,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],7852.36,7852.36,7852.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Skin Disorders Without Mcc,596,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],5190.1,5190.1,5190.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Skin Disorders Without Mcc,596,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],14668.36,14668.36,25880.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Skin Disorders Without Mcc,596,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,5344.28,4825.3,9530.49,1 through 10,percent of total billed charges,,, Major Skin Disorders Without Mcc,596,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Skin Disorders Without Mcc,596,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Skin Disorders Without Mcc,596,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Skin Disorders Without Mcc,596,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,52370.28,,,,,,,fee schedule,45410.14,68114.37, Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,45410.14,,,,,,,fee schedule,45410.14,68114.37, Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,68114.37,,,,,,,fee schedule,45410.14,68114.37, Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,52476.97,,,,,,,fee schedule,45410.14,68114.37, Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,47228.94,,,,,,,fee schedule,45410.14,68114.37, Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Malignant Breast Disorders With Cc,598,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,35538.66,,,,,,,fee schedule,30815.48,46222.66, Malignant Breast Disorders With Cc,598,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,30815.48,,,,,,,fee schedule,30815.48,46222.66, Malignant Breast Disorders With Cc,598,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,46222.66,,,,,,,fee schedule,30815.48,46222.66, Malignant Breast Disorders With Cc,598,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,35611.06,,,,,,,fee schedule,30815.48,46222.66, Malignant Breast Disorders With Cc,598,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,32049.73,,,,,,,fee schedule,30815.48,46222.66, Malignant Breast Disorders With Cc,598,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Malignant Breast Disorders With Cc,598,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Malignant Breast Disorders With Cc,598,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Malignant Breast Disorders With Cc,598,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Malignant Breast Disorders With Cc,598,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Malignant Breast Disorders With Cc,598,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Malignant Breast Disorders With Cc,598,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Malignant Breast Disorders With Cc,598,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Malignant Breast Disorders With Cc,598,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Malignant Breast Disorders With Cc,598,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Malignant Breast Disorders With Cc,598,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Malignant Breast Disorders With Cc,598,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Malignant Breast Disorders With Cc,598,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Malignant Breast Disorders With Cc,598,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Malignant Breast Disorders With Cc,598,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Malignant Breast Disorders With Cc,598,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Malignant Breast Disorders With Cc,598,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Malignant Breast Disorders With Cc,598,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Malignant Breast Disorders With Cc,598,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Malignant Breast Disorders With Cc,598,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,24169.93,,,,,,,fee schedule,20957.69,31436.15, Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,20957.69,,,,,,,fee schedule,20957.69,31436.15, Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,31436.15,,,,,,,fee schedule,20957.69,31436.15, Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,24219.17,,,,,,,fee schedule,20957.69,31436.15, Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,21797.1,,,,,,,fee schedule,20957.69,31436.15, Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,32720.82,,,,,,,fee schedule,28372.14,42557.69, Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,28372.14,,,,,,,fee schedule,28372.14,42557.69, Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,42557.69,,,,,,,fee schedule,28372.14,42557.69, Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,32787.48,,,,,,,fee schedule,28372.14,42557.69, Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,29508.53,,,,,,,fee schedule,28372.14,42557.69, Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,19005.47,,,,,,,fee schedule,16479.6,24719.09, Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,16479.6,,,,,,,fee schedule,16479.6,24719.09, Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,24719.09,,,,,,,fee schedule,16479.6,24719.09, Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,19044.19,,,,,,,fee schedule,16479.6,24719.09, Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,17139.65,,,,,,,fee schedule,16479.6,24719.09, Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cellulitis With Mcc,602,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,44648.72,,,,,,,fee schedule,38714.79,58071.48, Cellulitis With Mcc,602,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,38714.79,,,,,,,fee schedule,38714.79,58071.48, Cellulitis With Mcc,602,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,58071.48,,,,,,,fee schedule,38714.79,58071.48, Cellulitis With Mcc,602,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,44739.68,,,,,,,fee schedule,38714.79,58071.48, Cellulitis With Mcc,602,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,40265.43,,,,,,,fee schedule,38714.79,58071.48, Cellulitis With Mcc,602,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Cellulitis With Mcc,602,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cellulitis With Mcc,602,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cellulitis With Mcc,602,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cellulitis With Mcc,602,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Cellulitis With Mcc,602,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cellulitis With Mcc,602,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cellulitis With Mcc,602,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cellulitis With Mcc,602,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cellulitis With Mcc,602,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cellulitis With Mcc,602,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cellulitis With Mcc,602,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],11712.51,11712.51,11712.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Cellulitis With Mcc,602,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cellulitis With Mcc,602,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cellulitis With Mcc,602,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cellulitis With Mcc,602,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cellulitis With Mcc,602,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cellulitis With Mcc,602,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cellulitis With Mcc,602,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cellulitis With Mcc,602,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cellulitis Without Mcc,603,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,27358.45,,,,,,,fee schedule,23722.45,35583.23, Cellulitis Without Mcc,603,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,23722.45,,,,,,,fee schedule,23722.45,35583.23, Cellulitis Without Mcc,603,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,35583.23,,,,,,,fee schedule,23722.45,35583.23, Cellulitis Without Mcc,603,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,27414.19,,,,,,,fee schedule,23722.45,35583.23, Cellulitis Without Mcc,603,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,24672.6,,,,,,,fee schedule,23722.45,35583.23, Cellulitis Without Mcc,603,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],23326.69,23326.69,23326.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Cellulitis Without Mcc,603,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],5518.06,5518.06,5518.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Cellulitis Without Mcc,603,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],32603.88,32603.88,32603.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Cellulitis Without Mcc,603,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],22515.89,22515.89,22515.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Cellulitis Without Mcc,603,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Cellulitis Without Mcc,603,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cellulitis Without Mcc,603,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cellulitis Without Mcc,603,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],11213.44,11213.44,11213.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Cellulitis Without Mcc,603,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cellulitis Without Mcc,603,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],5302.78,5302.78,8900.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Cellulitis Without Mcc,603,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],7113.38,7113.38,7113.38,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Cellulitis Without Mcc,603,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],5158.16,5158.16,6757.29,17,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Cellulitis Without Mcc,603,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],17329.22,14756.95,20166.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Cellulitis Without Mcc,603,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cellulitis Without Mcc,603,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cellulitis Without Mcc,603,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,29502.11,29502.11,29502.11,1 through 10,percent of total billed charges,,, Cellulitis Without Mcc,603,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cellulitis Without Mcc,603,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cellulitis Without Mcc,603,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cellulitis Without Mcc,603,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,46244.55,,,,,,,fee schedule,40098.53,60147.06, "Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,40098.53,,,,,,,fee schedule,40098.53,60147.06, "Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,60147.06,,,,,,,fee schedule,40098.53,60147.06, "Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,46338.76,,,,,,,fee schedule,40098.53,60147.06, "Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,41704.59,,,,,,,fee schedule,40098.53,60147.06, "Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,28775.22,,,,,,,fee schedule,24950.92,37425.93, "Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,24950.92,,,,,,,fee schedule,24950.92,37425.93, "Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,37425.93,,,,,,,fee schedule,24950.92,37425.93, "Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,28833.85,,,,,,,fee schedule,24950.92,37425.93, "Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,25950.28,,,,,,,fee schedule,24950.92,37425.93, "Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],1141.09,1141.09,1141.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,16852.02,16852.02,16852.02,1 through 10,percent of total billed charges,,, "Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Minor Skin Disorders With Mcc,606,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,47535.66,,,,,,,fee schedule,41218.05,61826.33, Minor Skin Disorders With Mcc,606,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,41218.05,,,,,,,fee schedule,41218.05,61826.33, Minor Skin Disorders With Mcc,606,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,61826.33,,,,,,,fee schedule,41218.05,61826.33, Minor Skin Disorders With Mcc,606,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,47632.51,,,,,,,fee schedule,41218.05,61826.33, Minor Skin Disorders With Mcc,606,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,42868.96,,,,,,,fee schedule,41218.05,61826.33, Minor Skin Disorders With Mcc,606,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Minor Skin Disorders With Mcc,606,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Skin Disorders With Mcc,606,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Skin Disorders With Mcc,606,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Skin Disorders With Mcc,606,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Minor Skin Disorders With Mcc,606,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Skin Disorders With Mcc,606,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Skin Disorders With Mcc,606,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Skin Disorders With Mcc,606,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Skin Disorders With Mcc,606,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Skin Disorders With Mcc,606,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Skin Disorders With Mcc,606,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],31582.88,31582.88,105634.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Minor Skin Disorders With Mcc,606,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],33957.32,33957.32,33957.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Minor Skin Disorders With Mcc,606,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Skin Disorders With Mcc,606,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Skin Disorders With Mcc,606,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Minor Skin Disorders With Mcc,606,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Minor Skin Disorders With Mcc,606,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Minor Skin Disorders With Mcc,606,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Minor Skin Disorders With Mcc,606,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,28473.65,,,,,,,fee schedule,24689.43,37033.69, Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,24689.43,,,,,,,fee schedule,24689.43,37033.69, Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,37033.69,,,,,,,fee schedule,24689.43,37033.69, Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,28531.66,,,,,,,fee schedule,24689.43,37033.69, Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,25678.31,,,,,,,fee schedule,24689.43,37033.69, Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],24399.82,24399.82,24399.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],33136.02,33136.02,33136.02,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],7424.97,7424.97,7424.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],5746.76,5746.76,7222.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],6176.42,6176.42,6176.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,8744.46,8744.46,8744.46,1 through 10,percent of total billed charges,,, Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,68853.21,,,,,,,fee schedule,59702.44,89552.56, Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,59702.44,,,,,,,fee schedule,59702.44,89552.56, Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,89552.56,,,,,,,fee schedule,59702.44,89552.56, Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,68993.48,,,,,,,fee schedule,59702.44,89552.56, Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,62093.69,,,,,,,fee schedule,59702.44,89552.56, Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],86944.32,86944.32,86944.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,86702.75,86702.75,86702.75,1 through 10,percent of total billed charges,,, Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,43957.61,,,,,,,fee schedule,38115.53,57172.6, Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,38115.53,,,,,,,fee schedule,38115.53,57172.6, Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,57172.6,,,,,,,fee schedule,38115.53,57172.6, Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,44047.17,,,,,,,fee schedule,38115.53,57172.6, Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,39642.17,,,,,,,fee schedule,38115.53,57172.6, Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,109553.18,,,,,,,fee schedule,94993.29,142488.19, "Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,94993.29,,,,,,,fee schedule,94993.29,142488.19, "Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,142488.19,,,,,,,fee schedule,94993.29,142488.19, "Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,109776.38,,,,,,,fee schedule,94993.29,142488.19, "Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,98798.04,,,,,,,fee schedule,94993.29,142488.19, "Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,58753.6,,,,,,,fee schedule,50945.1,76416.72, "Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,50945.1,,,,,,,fee schedule,50945.1,76416.72, "Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,76416.72,,,,,,,fee schedule,50945.1,76416.72, "Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,58873.3,,,,,,,fee schedule,50945.1,76416.72, "Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,52985.6,,,,,,,fee schedule,50945.1,76416.72, "Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,44554.48,,,,,,,fee schedule,38633.07,57948.9, "Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,38633.07,,,,,,,fee schedule,38633.07,57948.9, "Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,57948.9,,,,,,,fee schedule,38633.07,57948.9, "Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,44645.25,,,,,,,fee schedule,38633.07,57948.9, "Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,40180.44,,,,,,,fee schedule,38633.07,57948.9, "Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,90704.78,,,,,,,fee schedule,78649.89,117973.39, O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,78649.89,,,,,,,fee schedule,78649.89,117973.39, O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,117973.39,,,,,,,fee schedule,78649.89,117973.39, O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,90889.58,,,,,,,fee schedule,78649.89,117973.39, O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,81800.04,,,,,,,fee schedule,78649.89,117973.39, O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,50271.82,,,,,,,fee schedule,43590.57,65385.06, O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,43590.57,,,,,,,fee schedule,43590.57,65385.06, O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,65385.06,,,,,,,fee schedule,43590.57,65385.06, O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,50374.24,,,,,,,fee schedule,43590.57,65385.06, O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,45336.5,,,,,,,fee schedule,43590.57,65385.06, O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,47384.88,,,,,,,fee schedule,41087.31,61630.21, O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,41087.31,,,,,,,fee schedule,41087.31,61630.21, O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,61630.21,,,,,,,fee schedule,41087.31,61630.21, O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,47481.42,,,,,,,fee schedule,41087.31,61630.21, O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,42732.97,,,,,,,fee schedule,41087.31,61630.21, O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,111808.71,,,,,,,fee schedule,96949.05,145421.79, "Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,96949.05,,,,,,,fee schedule,96949.05,145421.79, "Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,145421.79,,,,,,,fee schedule,96949.05,145421.79, "Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,112036.5,,,,,,,fee schedule,96949.05,145421.79, "Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,100832.14,,,,,,,fee schedule,96949.05,145421.79, "Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,56353.57,,,,,,,fee schedule,48864.04,73295.17, "Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,48864.04,,,,,,,fee schedule,48864.04,73295.17, "Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,73295.17,,,,,,,fee schedule,48864.04,73295.17, "Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,56468.38,,,,,,,fee schedule,48864.04,73295.17, "Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,50821.19,,,,,,,fee schedule,48864.04,73295.17, "Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,39327.19,,,,,,,fee schedule,34100.5,51150.13, "Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,34100.5,,,,,,,fee schedule,34100.5,51150.13, "Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,51150.13,,,,,,,fee schedule,34100.5,51150.13, "Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,39407.31,,,,,,,fee schedule,34100.5,51150.13, "Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,35466.33,,,,,,,fee schedule,34100.5,51150.13, "Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,94873.42,,,,,,,fee schedule,82264.5,123395.25, "Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,82264.5,,,,,,,fee schedule,82264.5,123395.25, "Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,123395.25,,,,,,,fee schedule,82264.5,123395.25, "Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,95066.71,,,,,,,fee schedule,82264.5,123395.25, "Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,85559.43,,,,,,,fee schedule,82264.5,123395.25, "Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,47102.15,,,,,,,fee schedule,40842.16,61262.49, "Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,40842.16,,,,,,,fee schedule,40842.16,61262.49, "Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,61262.49,,,,,,,fee schedule,40842.16,61262.49, "Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,47198.11,,,,,,,fee schedule,40842.16,61262.49, "Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,42478,,,,,,,fee schedule,40842.16,61262.49, "Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,41727.22,,,,,,,fee schedule,36181.56,54271.68, "Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,36181.56,,,,,,,fee schedule,36181.56,54271.68, "Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,54271.68,,,,,,,fee schedule,36181.56,54271.68, "Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,41812.23,,,,,,,fee schedule,36181.56,54271.68, "Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,37630.74,,,,,,,fee schedule,36181.56,54271.68, "Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],32385.76,32385.76,32385.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],12217,12217,12217,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,117073.7,,,,,,,fee schedule,101514.31,152269.59, "Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,101514.31,,,,,,,fee schedule,101514.31,152269.59, "Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,152269.59,,,,,,,fee schedule,101514.31,152269.59, "Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,117312.21,,,,,,,fee schedule,101514.31,152269.59, "Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,105580.24,,,,,,,fee schedule,101514.31,152269.59, "Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,68444.82,,,,,,,fee schedule,59348.33,89021.41, "Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,59348.33,,,,,,,fee schedule,59348.33,89021.41, "Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,89021.41,,,,,,,fee schedule,59348.33,89021.41, "Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,68584.27,,,,,,,fee schedule,59348.33,89021.41, "Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,61725.4,,,,,,,fee schedule,59348.33,89021.41, "Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],76762.77,76762.77,76762.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,45848.73,,,,,,,fee schedule,39755.32,59632.25, "Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,39755.32,,,,,,,fee schedule,39755.32,59632.25, "Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,59632.25,,,,,,,fee schedule,39755.32,59632.25, "Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,45942.14,,,,,,,fee schedule,39755.32,59632.25, "Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,41347.64,,,,,,,fee schedule,39755.32,59632.25, "Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Diabetes With Mcc,637,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,45132.49,,,,,,,fee schedule,39134.27,58700.69, Diabetes With Mcc,637,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,39134.27,,,,,,,fee schedule,39134.27,58700.69, Diabetes With Mcc,637,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,58700.69,,,,,,,fee schedule,39134.27,58700.69, Diabetes With Mcc,637,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,45224.44,,,,,,,fee schedule,39134.27,58700.69, Diabetes With Mcc,637,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,40701.71,,,,,,,fee schedule,39134.27,58700.69, Diabetes With Mcc,637,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Diabetes With Mcc,637,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Diabetes With Mcc,637,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],40417.74,40417.74,40417.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Diabetes With Mcc,637,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],55838.91,55838.91,55838.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Diabetes With Mcc,637,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Diabetes With Mcc,637,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Diabetes With Mcc,637,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Diabetes With Mcc,637,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],6185.89,6185.89,6185.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Diabetes With Mcc,637,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],6185.89,6185.89,6185.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Diabetes With Mcc,637,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Diabetes With Mcc,637,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Diabetes With Mcc,637,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],10567.8,6906.82,10567.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Diabetes With Mcc,637,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],6247.4,6247.4,6247.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Diabetes With Mcc,637,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Diabetes With Mcc,637,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Diabetes With Mcc,637,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,14730.63,14730.63,14730.63,1 through 10,percent of total billed charges,,, Diabetes With Mcc,637,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Diabetes With Mcc,637,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Diabetes With Mcc,637,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Diabetes With Mcc,637,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Diabetes With Cc,638,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,28153.23,,,,,,,fee schedule,24411.59,36616.94, Diabetes With Cc,638,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,24411.59,,,,,,,fee schedule,24411.59,36616.94, Diabetes With Cc,638,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,36616.94,,,,,,,fee schedule,24411.59,36616.94, Diabetes With Cc,638,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,28210.58,,,,,,,fee schedule,24411.59,36616.94, Diabetes With Cc,638,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,25389.35,,,,,,,fee schedule,24411.59,36616.94, Diabetes With Cc,638,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],7069.58,7069.58,7069.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Diabetes With Cc,638,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Diabetes With Cc,638,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],20030.33,17446.38,33172.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Diabetes With Cc,638,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Diabetes With Cc,638,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Diabetes With Cc,638,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Diabetes With Cc,638,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Diabetes With Cc,638,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],10370.27,6360.11,11705.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Diabetes With Cc,638,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Diabetes With Cc,638,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],6480.45,6480.45,7100.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Diabetes With Cc,638,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],6775.02,6775.02,6775.02,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Diabetes With Cc,638,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],6303.71,6303.71,10567.8,23,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Diabetes With Cc,638,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],25577.04,25577.04,25577.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Diabetes With Cc,638,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Diabetes With Cc,638,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Diabetes With Cc,638,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,26085.81,26085.81,26085.81,1 through 10,percent of total billed charges,,, Diabetes With Cc,638,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Diabetes With Cc,638,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Diabetes With Cc,638,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Diabetes With Cc,638,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Diabetes Without Cc/Mcc,639,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,19514.38,,,,,,,fee schedule,16920.87,25380.99, Diabetes Without Cc/Mcc,639,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,16920.87,,,,,,,fee schedule,16920.87,25380.99, Diabetes Without Cc/Mcc,639,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,25380.99,,,,,,,fee schedule,16920.87,25380.99, Diabetes Without Cc/Mcc,639,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,19554.13,,,,,,,fee schedule,16920.87,25380.99, Diabetes Without Cc/Mcc,639,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,17598.6,,,,,,,fee schedule,16920.87,25380.99, Diabetes Without Cc/Mcc,639,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Diabetes Without Cc/Mcc,639,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Diabetes Without Cc/Mcc,639,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],22522.21,22522.21,22522.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Diabetes Without Cc/Mcc,639,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],18478.81,15610.78,23320.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Diabetes Without Cc/Mcc,639,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],16280.18,16280.18,16280.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Diabetes Without Cc/Mcc,639,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Diabetes Without Cc/Mcc,639,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Diabetes Without Cc/Mcc,639,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],6185.89,6185.89,6777.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Diabetes Without Cc/Mcc,639,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Diabetes Without Cc/Mcc,639,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],6480.45,6480.45,6480.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Diabetes Without Cc/Mcc,639,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],6775.02,6775.02,6775.02,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Diabetes Without Cc/Mcc,639,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],6303.71,6303.71,6303.71,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Diabetes Without Cc/Mcc,639,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],15021.38,13575.75,17473.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Diabetes Without Cc/Mcc,639,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],6775.02,6775.02,6775.02,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Diabetes Without Cc/Mcc,639,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Diabetes Without Cc/Mcc,639,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,12231.44,12231.44,12231.44,1 through 10,percent of total billed charges,,, Diabetes Without Cc/Mcc,639,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Diabetes Without Cc/Mcc,639,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Diabetes Without Cc/Mcc,639,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Diabetes Without Cc/Mcc,639,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,41956.54,,,,,,,fee schedule,36380.41,54569.94, "Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,36380.41,,,,,,,fee schedule,36380.41,54569.94, "Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,54569.94,,,,,,,fee schedule,36380.41,54569.94, "Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,42042.02,,,,,,,fee schedule,36380.41,54569.94, "Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,37837.55,,,,,,,fee schedule,36380.41,54569.94, "Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],22062.05,22062.05,37494.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],10642.66,10642.66,10642.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],27547.33,13820.09,337751.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],10504.87,10400.52,20978.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],9755.77,9755.77,11608.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],11291.81,7803.69,23837.88,32,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],37032.61,37032.61,37620.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,203393.42,203393.42,203393.42,1 through 10,percent of total billed charges,,, "Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,24446.37,,,,,,,fee schedule,21197.39,31795.7, "Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,21197.39,,,,,,,fee schedule,21197.39,31795.7, "Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,31795.7,,,,,,,fee schedule,21197.39,31795.7, "Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,24496.18,,,,,,,fee schedule,21197.39,31795.7, "Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22046.41,,,,,,,fee schedule,21197.39,31795.7, "Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],20804.17,15843.16,23717.05,22,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],12005.57,12005.57,13577.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],27134.23,9746.99,30869.64,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],19974.93,15985.21,25576.58,22,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],14868.7,14868.7,14868.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],9312.32,5857.75,13010.11,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],6861.07,4604.62,13629.64,36,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],7172.94,7172.94,7172.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],6673.95,5518.9,13257.92,92,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],21015.95,15191.64,22265.23,19,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],14249.17,14249.17,14249.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,33747.71,16596.35,38783.11,12,percent of total billed charges,,, "Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,7683.12,7683.12,7683.12,1 through 10,percent of total billed charges,,, "Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,44673.85,,,,,,,fee schedule,38736.58,58104.16, Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,38736.58,,,,,,,fee schedule,38736.58,58104.16, Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,58104.16,,,,,,,fee schedule,38736.58,58104.16, Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,44764.86,,,,,,,fee schedule,38736.58,58104.16, Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,40288.09,,,,,,,fee schedule,38736.58,58104.16, Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],47472.4,47472.4,47472.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],31326.24,31326.24,31326.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],8740.86,8740.86,8740.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],16724.6,16724.6,17365.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],137784.95,137784.95,137784.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],34359.31,34359.31,34359.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Endocrine Disorders With Mcc,643,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,51710.59,,,,,,,fee schedule,44838.12,67256.35, Endocrine Disorders With Mcc,643,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,44838.12,,,,,,,fee schedule,44838.12,67256.35, Endocrine Disorders With Mcc,643,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,67256.35,,,,,,,fee schedule,44838.12,67256.35, Endocrine Disorders With Mcc,643,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,51815.94,,,,,,,fee schedule,44838.12,67256.35, Endocrine Disorders With Mcc,643,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,46634.01,,,,,,,fee schedule,44838.12,67256.35, Endocrine Disorders With Mcc,643,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Endocrine Disorders With Mcc,643,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endocrine Disorders With Mcc,643,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],42365.56,42365.56,42365.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Endocrine Disorders With Mcc,643,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],32982.39,32982.39,32982.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Endocrine Disorders With Mcc,643,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Endocrine Disorders With Mcc,643,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endocrine Disorders With Mcc,643,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endocrine Disorders With Mcc,643,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endocrine Disorders With Mcc,643,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endocrine Disorders With Mcc,643,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endocrine Disorders With Mcc,643,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endocrine Disorders With Mcc,643,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],12106.35,12106.35,21805.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Endocrine Disorders With Mcc,643,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endocrine Disorders With Mcc,643,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endocrine Disorders With Mcc,643,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endocrine Disorders With Mcc,643,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Endocrine Disorders With Mcc,643,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Endocrine Disorders With Mcc,643,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Endocrine Disorders With Mcc,643,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Endocrine Disorders With Mcc,643,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Endocrine Disorders With Cc,644,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,32199.35,,,,,,,fee schedule,27919.98,41879.45, Endocrine Disorders With Cc,644,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,27919.98,,,,,,,fee schedule,27919.98,41879.45, Endocrine Disorders With Cc,644,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,41879.45,,,,,,,fee schedule,27919.98,41879.45, Endocrine Disorders With Cc,644,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,32264.95,,,,,,,fee schedule,27919.98,41879.45, Endocrine Disorders With Cc,644,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,29038.25,,,,,,,fee schedule,27919.98,41879.45, Endocrine Disorders With Cc,644,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Endocrine Disorders With Cc,644,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endocrine Disorders With Cc,644,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],24162.23,24162.23,24162.23,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Endocrine Disorders With Cc,644,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endocrine Disorders With Cc,644,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Endocrine Disorders With Cc,644,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endocrine Disorders With Cc,644,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endocrine Disorders With Cc,644,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endocrine Disorders With Cc,644,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endocrine Disorders With Cc,644,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],9230.42,9230.42,10505.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Endocrine Disorders With Cc,644,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endocrine Disorders With Cc,644,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],8943.97,8943.97,15322.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Endocrine Disorders With Cc,644,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endocrine Disorders With Cc,644,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endocrine Disorders With Cc,644,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endocrine Disorders With Cc,644,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Endocrine Disorders With Cc,644,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Endocrine Disorders With Cc,644,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Endocrine Disorders With Cc,644,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Endocrine Disorders With Cc,644,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,24135.38,,,,,,,fee schedule,20927.72,31391.2, Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,20927.72,,,,,,,fee schedule,20927.72,31391.2, Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,31391.2,,,,,,,fee schedule,20927.72,31391.2, Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,24184.55,,,,,,,fee schedule,20927.72,31391.2, Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,21765.94,,,,,,,fee schedule,20927.72,31391.2, Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,147689.78,,,,,,,fee schedule,128061.43,192089.8, Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,128061.43,,,,,,,fee schedule,128061.43,192089.8, Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,192089.8,,,,,,,fee schedule,128061.43,192089.8, Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,147990.67,,,,,,,fee schedule,128061.43,192089.8, Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,133190.66,,,,,,,fee schedule,128061.43,192089.8, Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,116414,,,,,,,fee schedule,100942.29,151411.58, Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,100942.29,,,,,,,fee schedule,100942.29,151411.58, Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,151411.58,,,,,,,fee schedule,100942.29,151411.58, Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,116651.17,,,,,,,fee schedule,100942.29,151411.58, Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,104985.31,,,,,,,fee schedule,100942.29,151411.58, Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Kidney Transplant,652,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,101451.51,,,,,,,fee schedule,87968.35,131950.91, Kidney Transplant,652,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,87968.35,,,,,,,fee schedule,87968.35,131950.91, Kidney Transplant,652,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,131950.91,,,,,,,fee schedule,87968.35,131950.91, Kidney Transplant,652,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,101658.2,,,,,,,fee schedule,87968.35,131950.91, Kidney Transplant,652,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,91491.74,,,,,,,fee schedule,87968.35,131950.91, Kidney Transplant,652,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Kidney Transplant,652,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney Transplant,652,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney Transplant,652,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney Transplant,652,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Kidney Transplant,652,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney Transplant,652,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney Transplant,652,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney Transplant,652,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney Transplant,652,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney Transplant,652,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney Transplant,652,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney Transplant,652,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney Transplant,652,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney Transplant,652,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney Transplant,652,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Kidney Transplant,652,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Kidney Transplant,652,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Kidney Transplant,652,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Kidney Transplant,652,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Bladder Procedures With Mcc,653,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,163239.71,,,,,,,fee schedule,141544.74,212314.51, Major Bladder Procedures With Mcc,653,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,141544.74,,,,,,,fee schedule,141544.74,212314.51, Major Bladder Procedures With Mcc,653,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,212314.51,,,,,,,fee schedule,141544.74,212314.51, Major Bladder Procedures With Mcc,653,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,163572.28,,,,,,,fee schedule,141544.74,212314.51, Major Bladder Procedures With Mcc,653,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,147214.01,,,,,,,fee schedule,141544.74,212314.51, Major Bladder Procedures With Mcc,653,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Major Bladder Procedures With Mcc,653,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Bladder Procedures With Mcc,653,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Bladder Procedures With Mcc,653,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Bladder Procedures With Mcc,653,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Major Bladder Procedures With Mcc,653,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Bladder Procedures With Mcc,653,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Bladder Procedures With Mcc,653,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Bladder Procedures With Mcc,653,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Bladder Procedures With Mcc,653,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Bladder Procedures With Mcc,653,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Bladder Procedures With Mcc,653,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Bladder Procedures With Mcc,653,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Bladder Procedures With Mcc,653,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Bladder Procedures With Mcc,653,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Bladder Procedures With Mcc,653,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Bladder Procedures With Mcc,653,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Bladder Procedures With Mcc,653,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Bladder Procedures With Mcc,653,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Bladder Procedures With Mcc,653,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Bladder Procedures With Cc,654,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,87937.21,,,,,,,fee schedule,76250.13,114373.8, Major Bladder Procedures With Cc,654,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,76250.13,,,,,,,fee schedule,76250.13,114373.8, Major Bladder Procedures With Cc,654,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,114373.8,,,,,,,fee schedule,76250.13,114373.8, Major Bladder Procedures With Cc,654,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,88116.37,,,,,,,fee schedule,76250.13,114373.8, Major Bladder Procedures With Cc,654,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,79304.17,,,,,,,fee schedule,76250.13,114373.8, Major Bladder Procedures With Cc,654,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Major Bladder Procedures With Cc,654,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Bladder Procedures With Cc,654,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Bladder Procedures With Cc,654,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Bladder Procedures With Cc,654,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Major Bladder Procedures With Cc,654,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Bladder Procedures With Cc,654,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Bladder Procedures With Cc,654,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],13590.11,13590.11,13590.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Bladder Procedures With Cc,654,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Bladder Procedures With Cc,654,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Bladder Procedures With Cc,654,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Bladder Procedures With Cc,654,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],14175.96,14175.96,14175.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Bladder Procedures With Cc,654,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Bladder Procedures With Cc,654,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Bladder Procedures With Cc,654,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Bladder Procedures With Cc,654,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Bladder Procedures With Cc,654,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Bladder Procedures With Cc,654,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Bladder Procedures With Cc,654,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Bladder Procedures With Cc,654,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,66490.87,,,,,,,fee schedule,57654.07,86480.04, Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,57654.07,,,,,,,fee schedule,57654.07,86480.04, Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,86480.04,,,,,,,fee schedule,57654.07,86480.04, Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,66626.33,,,,,,,fee schedule,57654.07,86480.04, Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,59963.28,,,,,,,fee schedule,57654.07,86480.04, Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,100015.89,,,,,,,fee schedule,86723.53,130083.7, Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,86723.53,,,,,,,fee schedule,86723.53,130083.7, Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,130083.7,,,,,,,fee schedule,86723.53,130083.7, Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,100219.66,,,,,,,fee schedule,86723.53,130083.7, Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,90197.05,,,,,,,fee schedule,86723.53,130083.7, Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,57487.62,,,,,,,fee schedule,49847.37,74770.14, Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,49847.37,,,,,,,fee schedule,49847.37,74770.14, Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,74770.14,,,,,,,fee schedule,49847.37,74770.14, Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,57604.74,,,,,,,fee schedule,49847.37,74770.14, Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,51843.9,,,,,,,fee schedule,49847.37,74770.14, Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,48748.25,,,,,,,fee schedule,42269.48,63403.44, Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,42269.48,,,,,,,fee schedule,42269.48,63403.44, Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,63403.44,,,,,,,fee schedule,42269.48,63403.44, Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,48847.56,,,,,,,fee schedule,42269.48,63403.44, Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,43962.49,,,,,,,fee schedule,42269.48,63403.44, Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,79819.83,,,,,,,fee schedule,69211.58,103816.09, Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,69211.58,,,,,,,fee schedule,69211.58,103816.09, Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,103816.09,,,,,,,fee schedule,69211.58,103816.09, Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,79982.45,,,,,,,fee schedule,69211.58,103816.09, Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,71983.7,,,,,,,fee schedule,69211.58,103816.09, Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],14146.08,14146.08,14146.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,41519.88,,,,,,,fee schedule,36001.79,54002.02, Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,36001.79,,,,,,,fee schedule,36001.79,54002.02, Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,54002.02,,,,,,,fee schedule,36001.79,54002.02, Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,41604.47,,,,,,,fee schedule,36001.79,54002.02, Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,37443.76,,,,,,,fee schedule,36001.79,54002.02, Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],15531.55,15531.55,15531.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],51379.62,51379.62,51379.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],15755.58,15755.58,15755.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],6835.25,6835.25,27025.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],32935.26,32935.26,32935.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,32526.06,,,,,,,fee schedule,28203.26,42304.37, Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,28203.26,,,,,,,fee schedule,28203.26,42304.37, Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,42304.37,,,,,,,fee schedule,28203.26,42304.37, Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,32592.32,,,,,,,fee schedule,28203.26,42304.37, Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,29332.88,,,,,,,fee schedule,28203.26,42304.37, Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],28895.02,28895.02,28895.02,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],26242.98,26242.98,36181.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],39362.92,39362.92,39362.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],16349.66,16349.66,16349.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],16505.84,16505.84,16505.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],13868.55,13848.97,13868.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],30288.01,30288.01,30288.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,96173.96,,,,,,,fee schedule,83392.2,125086.77, Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,83392.2,,,,,,,fee schedule,83392.2,125086.77, Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,125086.77,,,,,,,fee schedule,83392.2,125086.77, Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,96369.9,,,,,,,fee schedule,83392.2,125086.77, Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,86732.3,,,,,,,fee schedule,83392.2,125086.77, Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Minor Bladder Procedures With Cc,663,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,47755.56,,,,,,,fee schedule,41408.73,62112.33, Minor Bladder Procedures With Cc,663,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,41408.73,,,,,,,fee schedule,41408.73,62112.33, Minor Bladder Procedures With Cc,663,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,62112.33,,,,,,,fee schedule,41408.73,62112.33, Minor Bladder Procedures With Cc,663,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,47852.86,,,,,,,fee schedule,41408.73,62112.33, Minor Bladder Procedures With Cc,663,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,43067.27,,,,,,,fee schedule,41408.73,62112.33, Minor Bladder Procedures With Cc,663,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Minor Bladder Procedures With Cc,663,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Bladder Procedures With Cc,663,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Bladder Procedures With Cc,663,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Bladder Procedures With Cc,663,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Minor Bladder Procedures With Cc,663,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Bladder Procedures With Cc,663,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Bladder Procedures With Cc,663,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Bladder Procedures With Cc,663,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Bladder Procedures With Cc,663,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Bladder Procedures With Cc,663,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Bladder Procedures With Cc,663,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],15652.12,15652.12,15652.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Minor Bladder Procedures With Cc,663,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Bladder Procedures With Cc,663,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Bladder Procedures With Cc,663,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Bladder Procedures With Cc,663,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Minor Bladder Procedures With Cc,663,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Minor Bladder Procedures With Cc,663,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Minor Bladder Procedures With Cc,663,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Minor Bladder Procedures With Cc,663,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,32887.32,,,,,,,fee schedule,28516.51,42774.24, Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,28516.51,,,,,,,fee schedule,28516.51,42774.24, Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,42774.24,,,,,,,fee schedule,28516.51,42774.24, Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,32954.32,,,,,,,fee schedule,28516.51,42774.24, Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,29658.68,,,,,,,fee schedule,28516.51,42774.24, Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],41962.58,41962.58,41962.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Prostatectomy With Mcc,665,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,98049.38,,,,,,,fee schedule,85018.37,127525.99, Prostatectomy With Mcc,665,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,85018.37,,,,,,,fee schedule,85018.37,127525.99, Prostatectomy With Mcc,665,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,127525.99,,,,,,,fee schedule,85018.37,127525.99, Prostatectomy With Mcc,665,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,98249.13,,,,,,,fee schedule,85018.37,127525.99, Prostatectomy With Mcc,665,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,88423.6,,,,,,,fee schedule,85018.37,127525.99, Prostatectomy With Mcc,665,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Prostatectomy With Mcc,665,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prostatectomy With Mcc,665,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prostatectomy With Mcc,665,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prostatectomy With Mcc,665,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Prostatectomy With Mcc,665,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prostatectomy With Mcc,665,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prostatectomy With Mcc,665,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prostatectomy With Mcc,665,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prostatectomy With Mcc,665,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prostatectomy With Mcc,665,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prostatectomy With Mcc,665,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prostatectomy With Mcc,665,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prostatectomy With Mcc,665,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prostatectomy With Mcc,665,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prostatectomy With Mcc,665,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Prostatectomy With Mcc,665,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Prostatectomy With Mcc,665,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Prostatectomy With Mcc,665,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Prostatectomy With Mcc,665,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Prostatectomy With Cc,666,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,54952.51,,,,,,,fee schedule,47649.18,71472.9, Prostatectomy With Cc,666,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,47649.18,,,,,,,fee schedule,47649.18,71472.9, Prostatectomy With Cc,666,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,71472.9,,,,,,,fee schedule,47649.18,71472.9, Prostatectomy With Cc,666,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,55064.47,,,,,,,fee schedule,47649.18,71472.9, Prostatectomy With Cc,666,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,49557.67,,,,,,,fee schedule,47649.18,71472.9, Prostatectomy With Cc,666,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Prostatectomy With Cc,666,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prostatectomy With Cc,666,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prostatectomy With Cc,666,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prostatectomy With Cc,666,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Prostatectomy With Cc,666,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prostatectomy With Cc,666,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prostatectomy With Cc,666,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prostatectomy With Cc,666,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prostatectomy With Cc,666,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prostatectomy With Cc,666,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prostatectomy With Cc,666,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prostatectomy With Cc,666,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prostatectomy With Cc,666,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prostatectomy With Cc,666,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prostatectomy With Cc,666,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Prostatectomy With Cc,666,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Prostatectomy With Cc,666,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Prostatectomy With Cc,666,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Prostatectomy With Cc,666,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,34750.17,,,,,,,fee schedule,30131.78,45197.12, Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,30131.78,,,,,,,fee schedule,30131.78,45197.12, Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,45197.12,,,,,,,fee schedule,30131.78,45197.12, Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,34820.96,,,,,,,fee schedule,30131.78,45197.12, Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,31338.65,,,,,,,fee schedule,30131.78,45197.12, Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Transurethral Procedures With Mcc,668,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,91728.88,,,,,,,fee schedule,79537.88,119305.36, Transurethral Procedures With Mcc,668,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,79537.88,,,,,,,fee schedule,79537.88,119305.36, Transurethral Procedures With Mcc,668,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,119305.36,,,,,,,fee schedule,79537.88,119305.36, Transurethral Procedures With Mcc,668,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,91915.76,,,,,,,fee schedule,79537.88,119305.36, Transurethral Procedures With Mcc,668,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,82723.6,,,,,,,fee schedule,79537.88,119305.36, Transurethral Procedures With Mcc,668,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Transurethral Procedures With Mcc,668,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transurethral Procedures With Mcc,668,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transurethral Procedures With Mcc,668,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transurethral Procedures With Mcc,668,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Transurethral Procedures With Mcc,668,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transurethral Procedures With Mcc,668,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transurethral Procedures With Mcc,668,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transurethral Procedures With Mcc,668,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transurethral Procedures With Mcc,668,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transurethral Procedures With Mcc,668,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transurethral Procedures With Mcc,668,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transurethral Procedures With Mcc,668,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transurethral Procedures With Mcc,668,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transurethral Procedures With Mcc,668,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transurethral Procedures With Mcc,668,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Transurethral Procedures With Mcc,668,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Transurethral Procedures With Mcc,668,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Transurethral Procedures With Mcc,668,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Transurethral Procedures With Mcc,668,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Transurethral Procedures With Cc,669,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,48754.53,,,,,,,fee schedule,42274.93,63411.62, Transurethral Procedures With Cc,669,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,42274.93,,,,,,,fee schedule,42274.93,63411.62, Transurethral Procedures With Cc,669,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,63411.62,,,,,,,fee schedule,42274.93,63411.62, Transurethral Procedures With Cc,669,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,48853.86,,,,,,,fee schedule,42274.93,63411.62, Transurethral Procedures With Cc,669,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,43968.16,,,,,,,fee schedule,42274.93,63411.62, Transurethral Procedures With Cc,669,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Transurethral Procedures With Cc,669,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transurethral Procedures With Cc,669,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transurethral Procedures With Cc,669,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transurethral Procedures With Cc,669,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Transurethral Procedures With Cc,669,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transurethral Procedures With Cc,669,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transurethral Procedures With Cc,669,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transurethral Procedures With Cc,669,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transurethral Procedures With Cc,669,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transurethral Procedures With Cc,669,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transurethral Procedures With Cc,669,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transurethral Procedures With Cc,669,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transurethral Procedures With Cc,669,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transurethral Procedures With Cc,669,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transurethral Procedures With Cc,669,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Transurethral Procedures With Cc,669,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Transurethral Procedures With Cc,669,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Transurethral Procedures With Cc,669,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Transurethral Procedures With Cc,669,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,30700.9,,,,,,,fee schedule,26620.67,39930.52, Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,26620.67,,,,,,,fee schedule,26620.67,39930.52, Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,39930.52,,,,,,,fee schedule,26620.67,39930.52, Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,30763.45,,,,,,,fee schedule,26620.67,39930.52, Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,27686.91,,,,,,,fee schedule,26620.67,39930.52, Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,56388.13,,,,,,,fee schedule,48894.01,73340.11, Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,48894.01,,,,,,,fee schedule,48894.01,73340.11, Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,73340.11,,,,,,,fee schedule,48894.01,73340.11, Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,56503.01,,,,,,,fee schedule,48894.01,73340.11, Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,50852.35,,,,,,,fee schedule,48894.01,73340.11, Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],44062.94,44062.94,44062.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],64623.6,64623.6,64623.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],12764.48,12764.48,12764.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,33911.41,,,,,,,fee schedule,29404.5,44106.21, Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,29404.5,,,,,,,fee schedule,29404.5,44106.21, Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,44106.21,,,,,,,fee schedule,29404.5,44106.21, Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,33980.5,,,,,,,fee schedule,29404.5,44106.21, Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,30582.24,,,,,,,fee schedule,29404.5,44106.21, Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],13218.79,13218.79,13218.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,131989.06,,,,,,,fee schedule,114447.38,171668.97, Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,114447.38,,,,,,,fee schedule,114447.38,171668.97, Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,171668.97,,,,,,,fee schedule,114447.38,171668.97, Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,132257.96,,,,,,,fee schedule,114447.38,171668.97, Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,119031.33,,,,,,,fee schedule,114447.38,171668.97, Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],376581.17,376581.17,376581.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,73464.78,,,,,,,fee schedule,63701.13,95550.52, Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,63701.13,,,,,,,fee schedule,63701.13,95550.52, Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,95550.52,,,,,,,fee schedule,63701.13,95550.52, Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,73614.45,,,,,,,fee schedule,63701.13,95550.52, Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,66252.54,,,,,,,fee schedule,63701.13,95550.52, Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],13027.12,13027.12,13027.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],27025.99,27025.99,27025.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,51562.94,,,,,,,fee schedule,44710.09,67064.32, Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,44710.09,,,,,,,fee schedule,44710.09,67064.32, Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,67064.32,,,,,,,fee schedule,44710.09,67064.32, Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,51667.99,,,,,,,fee schedule,44710.09,67064.32, Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,46500.86,,,,,,,fee schedule,44710.09,67064.32, Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Renal Failure With Mcc,682,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,46524.13,,,,,,,fee schedule,40340.96,60510.7, Renal Failure With Mcc,682,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,40340.96,,,,,,,fee schedule,40340.96,60510.7, Renal Failure With Mcc,682,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,60510.7,,,,,,,fee schedule,40340.96,60510.7, Renal Failure With Mcc,682,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,46618.92,,,,,,,fee schedule,40340.96,60510.7, Renal Failure With Mcc,682,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,41956.73,,,,,,,fee schedule,40340.96,60510.7, Renal Failure With Mcc,682,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Renal Failure With Mcc,682,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Renal Failure With Mcc,682,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],58748.31,58748.31,58748.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Renal Failure With Mcc,682,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Renal Failure With Mcc,682,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Renal Failure With Mcc,682,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Renal Failure With Mcc,682,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Renal Failure With Mcc,682,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Renal Failure With Mcc,682,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Renal Failure With Mcc,682,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],13619.27,13619.27,13619.27,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Renal Failure With Mcc,682,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Renal Failure With Mcc,682,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],26142.88,16442.04,26142.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Renal Failure With Mcc,682,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Renal Failure With Mcc,682,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Renal Failure With Mcc,682,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Renal Failure With Mcc,682,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Renal Failure With Mcc,682,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Renal Failure With Mcc,682,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Renal Failure With Mcc,682,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Renal Failure With Mcc,682,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Renal Failure With Cc,683,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,27512.38,,,,,,,fee schedule,23855.92,35783.44, Renal Failure With Cc,683,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,23855.92,,,,,,,fee schedule,23855.92,35783.44, Renal Failure With Cc,683,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,35783.44,,,,,,,fee schedule,23855.92,35783.44, Renal Failure With Cc,683,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,27568.43,,,,,,,fee schedule,23855.92,35783.44, Renal Failure With Cc,683,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,24811.41,,,,,,,fee schedule,23855.92,35783.44, Renal Failure With Cc,683,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],25097.2,25097.2,25097.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Renal Failure With Cc,683,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Renal Failure With Cc,683,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],34083.09,34083.09,34083.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Renal Failure With Cc,683,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],21472.95,21472.95,21472.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Renal Failure With Cc,683,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Renal Failure With Cc,683,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Renal Failure With Cc,683,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Renal Failure With Cc,683,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],25654.23,25654.23,25654.23,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Renal Failure With Cc,683,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Renal Failure With Cc,683,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Renal Failure With Cc,683,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Renal Failure With Cc,683,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],7022.05,7022.05,12671.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Renal Failure With Cc,683,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Renal Failure With Cc,683,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Renal Failure With Cc,683,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Renal Failure With Cc,683,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Renal Failure With Cc,683,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Renal Failure With Cc,683,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Renal Failure With Cc,683,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Renal Failure With Cc,683,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,18857.82,,,,,,,fee schedule,16351.57,24527.06, Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,16351.57,,,,,,,fee schedule,16351.57,24527.06, Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,24527.06,,,,,,,fee schedule,16351.57,24527.06, Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,18896.24,,,,,,,fee schedule,16351.57,24527.06, Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,17006.5,,,,,,,fee schedule,16351.57,24527.06, Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],7875.2,7875.2,7875.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],6041.99,6041.99,6041.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Admit For Renal Dialysis,685,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Admit For Renal Dialysis,685,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Admit For Renal Dialysis,685,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Admit For Renal Dialysis,685,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Admit For Renal Dialysis,685,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Admit For Renal Dialysis,685,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Admit For Renal Dialysis,685,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Admit For Renal Dialysis,685,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Admit For Renal Dialysis,685,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Admit For Renal Dialysis,685,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Admit For Renal Dialysis,685,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Admit For Renal Dialysis,685,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Admit For Renal Dialysis,685,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Admit For Renal Dialysis,685,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Admit For Renal Dialysis,685,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Admit For Renal Dialysis,685,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Admit For Renal Dialysis,685,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Admit For Renal Dialysis,685,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Admit For Renal Dialysis,685,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Admit For Renal Dialysis,685,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,56661.43,,,,,,,fee schedule,49130.98,73695.57, Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,49130.98,,,,,,,fee schedule,49130.98,73695.57, Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,73695.57,,,,,,,fee schedule,49130.98,73695.57, Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,56776.87,,,,,,,fee schedule,49130.98,73695.57, Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,51098.82,,,,,,,fee schedule,49130.98,73695.57, Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,32915.59,,,,,,,fee schedule,28541.02,42811.01, Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,28541.02,,,,,,,fee schedule,28541.02,42811.01, Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,42811.01,,,,,,,fee schedule,28541.02,42811.01, Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,32982.65,,,,,,,fee schedule,28541.02,42811.01, Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,29684.17,,,,,,,fee schedule,28541.02,42811.01, Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,24826.48,,,,,,,fee schedule,21526.98,32290.08, Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,21526.98,,,,,,,fee schedule,21526.98,32290.08, Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,32290.08,,,,,,,fee schedule,21526.98,32290.08, Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,24877.06,,,,,,,fee schedule,21526.98,32290.08, Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22389.2,,,,,,,fee schedule,21526.98,32290.08, Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,36449.66,,,,,,,fee schedule,31605.41,47407.54, Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,31605.41,,,,,,,fee schedule,31605.41,47407.54, Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,47407.54,,,,,,,fee schedule,31605.41,47407.54, Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,36523.92,,,,,,,fee schedule,31605.41,47407.54, Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,32871.3,,,,,,,fee schedule,31605.41,47407.54, Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],29916.38,29916.38,29916.38,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],10948.15,10948.15,10948.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],6835.25,6835.25,6835.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,10806.88,10806.88,10806.88,1 through 10,percent of total billed charges,,, Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,25429.63,,,,,,,fee schedule,22049.97,33074.55, Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,22049.97,,,,,,,fee schedule,22049.97,33074.55, Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,33074.55,,,,,,,fee schedule,22049.97,33074.55, Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,25481.44,,,,,,,fee schedule,22049.97,33074.55, Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22933.14,,,,,,,fee schedule,22049.97,33074.55, Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],19448.06,19448.06,24368.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],6370.43,6370.43,6370.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],19916.86,13297.01,30774.09,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],30774.09,30774.09,30774.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],5574.12,5574.12,6707.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],10948.15,7026.89,10948.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],7346.29,7346.29,7346.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],6711.93,5324.25,10021.38,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],17110.07,17110.07,20530.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,72346.77,72346.77,72346.77,1 through 10,percent of total billed charges,,, Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Urinary Stones W Esw Lithotripsy W Cc/Mcc,691,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Urinary Stones W Esw Lithotripsy W Cc/Mcc,691,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Urinary Stones W Esw Lithotripsy W Cc/Mcc,691,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Urinary Stones W Esw Lithotripsy W Cc/Mcc,691,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Urinary Stones W Esw Lithotripsy W Cc/Mcc,691,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Urinary Stones W Esw Lithotripsy W Cc/Mcc,691,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Urinary Stones W Esw Lithotripsy W Cc/Mcc,691,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Urinary Stones W Esw Lithotripsy W Cc/Mcc,691,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Urinary Stones W Esw Lithotripsy W Cc/Mcc,691,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Urinary Stones W Esw Lithotripsy W Cc/Mcc,691,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Urinary Stones W Esw Lithotripsy W Cc/Mcc,691,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Urinary Stones W Esw Lithotripsy W Cc/Mcc,691,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Urinary Stones W Esw Lithotripsy W Cc/Mcc,691,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Urinary Stones W Esw Lithotripsy W Cc/Mcc,691,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Urinary Stones W Esw Lithotripsy W Cc/Mcc,691,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Urinary Stones W Esw Lithotripsy W Cc/Mcc,691,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Urinary Stones W Esw Lithotripsy W Cc/Mcc,691,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Urinary Stones W Esw Lithotripsy W Cc/Mcc,691,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Urinary Stones W Esw Lithotripsy W Cc/Mcc,691,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Urinary Stones W Esw Lithotripsy W Cc/Mcc,691,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Urinary Stones W Esw Lithotripsy W/O Cc/Mcc,692,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Urinary Stones W Esw Lithotripsy W/O Cc/Mcc,692,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Urinary Stones W Esw Lithotripsy W/O Cc/Mcc,692,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Urinary Stones W Esw Lithotripsy W/O Cc/Mcc,692,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Urinary Stones W Esw Lithotripsy W/O Cc/Mcc,692,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Urinary Stones W Esw Lithotripsy W/O Cc/Mcc,692,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Urinary Stones W Esw Lithotripsy W/O Cc/Mcc,692,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Urinary Stones W Esw Lithotripsy W/O Cc/Mcc,692,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Urinary Stones W Esw Lithotripsy W/O Cc/Mcc,692,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Urinary Stones W Esw Lithotripsy W/O Cc/Mcc,692,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Urinary Stones W Esw Lithotripsy W/O Cc/Mcc,692,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Urinary Stones W Esw Lithotripsy W/O Cc/Mcc,692,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Urinary Stones W Esw Lithotripsy W/O Cc/Mcc,692,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Urinary Stones W Esw Lithotripsy W/O Cc/Mcc,692,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Urinary Stones W Esw Lithotripsy W/O Cc/Mcc,692,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Urinary Stones W Esw Lithotripsy W/O Cc/Mcc,692,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Urinary Stones W Esw Lithotripsy W/O Cc/Mcc,692,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Urinary Stones W Esw Lithotripsy W/O Cc/Mcc,692,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Urinary Stones W Esw Lithotripsy W/O Cc/Mcc,692,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Urinary Stones W Esw Lithotripsy W/O Cc/Mcc,692,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Urinary Stones With Mcc,693,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,42236.12,,,,,,,fee schedule,36622.84,54933.58, Urinary Stones With Mcc,693,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,36622.84,,,,,,,fee schedule,36622.84,54933.58, Urinary Stones With Mcc,693,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,54933.58,,,,,,,fee schedule,36622.84,54933.58, Urinary Stones With Mcc,693,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,42322.17,,,,,,,fee schedule,36622.84,54933.58, Urinary Stones With Mcc,693,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,38089.69,,,,,,,fee schedule,36622.84,54933.58, Urinary Stones With Mcc,693,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Urinary Stones With Mcc,693,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Urinary Stones With Mcc,693,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Urinary Stones With Mcc,693,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Urinary Stones With Mcc,693,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Urinary Stones With Mcc,693,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Urinary Stones With Mcc,693,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Urinary Stones With Mcc,693,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Urinary Stones With Mcc,693,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Urinary Stones With Mcc,693,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Urinary Stones With Mcc,693,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Urinary Stones With Mcc,693,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Urinary Stones With Mcc,693,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Urinary Stones With Mcc,693,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Urinary Stones With Mcc,693,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Urinary Stones With Mcc,693,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Urinary Stones With Mcc,693,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Urinary Stones With Mcc,693,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Urinary Stones With Mcc,693,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Urinary Stones With Mcc,693,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Urinary Stones Without Mcc,694,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,24556.32,,,,,,,fee schedule,21292.73,31938.7, Urinary Stones Without Mcc,694,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,21292.73,,,,,,,fee schedule,21292.73,31938.7, Urinary Stones Without Mcc,694,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,31938.7,,,,,,,fee schedule,21292.73,31938.7, Urinary Stones Without Mcc,694,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,24606.35,,,,,,,fee schedule,21292.73,31938.7, Urinary Stones Without Mcc,694,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22145.56,,,,,,,fee schedule,21292.73,31938.7, Urinary Stones Without Mcc,694,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Urinary Stones Without Mcc,694,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Urinary Stones Without Mcc,694,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],19974.93,19974.93,19974.93,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Urinary Stones Without Mcc,694,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],28768.87,28768.87,28768.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Urinary Stones Without Mcc,694,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Urinary Stones Without Mcc,694,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Urinary Stones Without Mcc,694,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Urinary Stones Without Mcc,694,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],9635.45,9635.45,9635.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Urinary Stones Without Mcc,694,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Urinary Stones Without Mcc,694,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Urinary Stones Without Mcc,694,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Urinary Stones Without Mcc,694,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],11786.75,11786.75,11786.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Urinary Stones Without Mcc,694,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Urinary Stones Without Mcc,694,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Urinary Stones Without Mcc,694,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Urinary Stones Without Mcc,694,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,56787.3,56787.3,56787.3,1 through 10,percent of total billed charges,,, Urinary Stones Without Mcc,694,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Urinary Stones Without Mcc,694,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Urinary Stones Without Mcc,694,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Urinary Stones Without Mcc,694,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,35931.33,,,,,,,fee schedule,31155.97,46733.38, Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,31155.97,,,,,,,fee schedule,31155.97,46733.38, Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,46733.38,,,,,,,fee schedule,31155.97,46733.38, Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,36004.54,,,,,,,fee schedule,31155.97,46733.38, Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,32403.85,,,,,,,fee schedule,31155.97,46733.38, Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,21644.25,,,,,,,fee schedule,18767.67,28151.16, Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,18767.67,,,,,,,fee schedule,18767.67,28151.16, Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,28151.16,,,,,,,fee schedule,18767.67,28151.16, Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,21688.34,,,,,,,fee schedule,18767.67,28151.16, Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19519.37,,,,,,,fee schedule,18767.67,28151.16, Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Urethral Stricture,697,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,33858.01,,,,,,,fee schedule,29358.19,44036.75, Urethral Stricture,697,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,29358.19,,,,,,,fee schedule,29358.19,44036.75, Urethral Stricture,697,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,44036.75,,,,,,,fee schedule,29358.19,44036.75, Urethral Stricture,697,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,33926.99,,,,,,,fee schedule,29358.19,44036.75, Urethral Stricture,697,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,30534.07,,,,,,,fee schedule,29358.19,44036.75, Urethral Stricture,697,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Urethral Stricture,697,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Urethral Stricture,697,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Urethral Stricture,697,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Urethral Stricture,697,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Urethral Stricture,697,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Urethral Stricture,697,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Urethral Stricture,697,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Urethral Stricture,697,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Urethral Stricture,697,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Urethral Stricture,697,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Urethral Stricture,697,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Urethral Stricture,697,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Urethral Stricture,697,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Urethral Stricture,697,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Urethral Stricture,697,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Urethral Stricture,697,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Urethral Stricture,697,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Urethral Stricture,697,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Urethral Stricture,697,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,51971.32,,,,,,,fee schedule,45064.2,67595.48, Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,45064.2,,,,,,,fee schedule,45064.2,67595.48, Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,67595.48,,,,,,,fee schedule,45064.2,67595.48, Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,52077.2,,,,,,,fee schedule,45064.2,67595.48, Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,46869.15,,,,,,,fee schedule,45064.2,67595.48, Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],87642.08,87642.08,87642.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],23108.13,11657.22,46664.02,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,31885.21,,,,,,,fee schedule,27647.59,41470.87, Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,27647.59,,,,,,,fee schedule,27647.59,41470.87, Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,41470.87,,,,,,,fee schedule,27647.59,41470.87, Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,31950.17,,,,,,,fee schedule,27647.59,41470.87, Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,28754.95,,,,,,,fee schedule,27647.59,41470.87, Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],28795.86,28795.86,28795.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],39106.03,26071.7,39106.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],8521.32,8521.32,8521.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],8472.71,8472.71,11657.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],27363.13,27363.13,27363.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,36140.67,36140.67,36140.67,1 through 10,percent of total billed charges,,, Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,21672.52,,,,,,,fee schedule,18792.19,28187.93, Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,18792.19,,,,,,,fee schedule,18792.19,28187.93, Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,28187.93,,,,,,,fee schedule,18792.19,28187.93, Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,21716.67,,,,,,,fee schedule,18792.19,28187.93, Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19544.87,,,,,,,fee schedule,18792.19,28187.93, Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],10025.22,10025.22,10025.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],8521.32,8521.32,8521.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],6455.32,6455.32,6455.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,62837.42,,,,,,,fee schedule,54486.17,81728.26, Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,54486.17,,,,,,,fee schedule,54486.17,81728.26, Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,81728.26,,,,,,,fee schedule,54486.17,81728.26, Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,62965.44,,,,,,,fee schedule,54486.17,81728.26, Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,56668.5,,,,,,,fee schedule,54486.17,81728.26, Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,48195.36,,,,,,,fee schedule,41790.07,62684.34, Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,41790.07,,,,,,,fee schedule,41790.07,62684.34, Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,62684.34,,,,,,,fee schedule,41790.07,62684.34, Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,48293.55,,,,,,,fee schedule,41790.07,62684.34, Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,43463.89,,,,,,,fee schedule,41790.07,62684.34, Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,73103.52,,,,,,,fee schedule,63387.88,95080.65, Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,63387.88,,,,,,,fee schedule,63387.88,95080.65, Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,95080.65,,,,,,,fee schedule,63387.88,95080.65, Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,73252.45,,,,,,,fee schedule,63387.88,95080.65, Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,65926.74,,,,,,,fee schedule,63387.88,95080.65, Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,44017.3,,,,,,,fee schedule,38167.29,57250.23, Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,38167.29,,,,,,,fee schedule,38167.29,57250.23, Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,57250.23,,,,,,,fee schedule,38167.29,57250.23, Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,44106.97,,,,,,,fee schedule,38167.29,57250.23, Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,39696,,,,,,,fee schedule,38167.29,57250.23, Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,65460.49,,,,,,,fee schedule,56760.63,85139.9, Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,56760.63,,,,,,,fee schedule,56760.63,85139.9, Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,85139.9,,,,,,,fee schedule,56760.63,85139.9, Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,65593.86,,,,,,,fee schedule,56760.63,85139.9, Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,59034.05,,,,,,,fee schedule,56760.63,85139.9, Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],15558.98,15558.98,15558.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,34545.98,,,,,,,fee schedule,29954.73,44931.54, Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,29954.73,,,,,,,fee schedule,29954.73,44931.54, Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,44931.54,,,,,,,fee schedule,29954.73,44931.54, Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,34616.36,,,,,,,fee schedule,29954.73,44931.54, Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,31154.5,,,,,,,fee schedule,29954.73,44931.54, Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,47227.81,,,,,,,fee schedule,40951.11,61425.92, Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,40951.11,,,,,,,fee schedule,40951.11,61425.92, Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,61425.92,,,,,,,fee schedule,40951.11,61425.92, Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,47324.03,,,,,,,fee schedule,40951.11,61425.92, Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,42591.32,,,,,,,fee schedule,40951.11,61425.92, Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,33217.16,,,,,,,fee schedule,28802.52,43203.25, Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,28802.52,,,,,,,fee schedule,28802.52,43203.25, Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,43203.25,,,,,,,fee schedule,28802.52,43203.25, Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,33284.84,,,,,,,fee schedule,28802.52,43203.25, Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,29956.14,,,,,,,fee schedule,28802.52,43203.25, Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,70282.54,,,,,,,fee schedule,60941.81,91411.6, Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,60941.81,,,,,,,fee schedule,60941.81,91411.6, Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,91411.6,,,,,,,fee schedule,60941.81,91411.6, Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,70425.73,,,,,,,fee schedule,60941.81,91411.6, Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,63382.71,,,,,,,fee schedule,60941.81,91411.6, Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,46209.99,,,,,,,fee schedule,40068.57,60102.12, Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,40068.57,,,,,,,fee schedule,40068.57,60102.12, Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,60102.12,,,,,,,fee schedule,40068.57,60102.12, Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,46304.14,,,,,,,fee schedule,40068.57,60102.12, Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,41673.43,,,,,,,fee schedule,40068.57,60102.12, Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,59388.17,,,,,,,fee schedule,51495.33,77242.05, Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,51495.33,,,,,,,fee schedule,51495.33,77242.05, Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,77242.05,,,,,,,fee schedule,51495.33,77242.05, Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,59509.16,,,,,,,fee schedule,51495.33,77242.05, Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,53557.87,,,,,,,fee schedule,51495.33,77242.05, Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,42192.14,,,,,,,fee schedule,36584.7,54876.38, Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,36584.7,,,,,,,fee schedule,36584.7,54876.38, Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,54876.38,,,,,,,fee schedule,36584.7,54876.38, Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,42278.1,,,,,,,fee schedule,36584.7,54876.38, Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,38050.02,,,,,,,fee schedule,36584.7,54876.38, Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,19864.53,19864.53,19864.53,1 through 10,percent of total billed charges,,, Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,56849.92,,,,,,,fee schedule,49294.42,73940.72, "Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,49294.42,,,,,,,fee schedule,49294.42,73940.72, "Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,73940.72,,,,,,,fee schedule,49294.42,73940.72, "Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,56965.74,,,,,,,fee schedule,49294.42,73940.72, "Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,51268.8,,,,,,,fee schedule,49294.42,73940.72, "Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,35896.78,,,,,,,fee schedule,31126.01,46688.44, "Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,31126.01,,,,,,,fee schedule,31126.01,46688.44, "Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,46688.44,,,,,,,fee schedule,31126.01,46688.44, "Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,35969.91,,,,,,,fee schedule,31126.01,46688.44, "Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,32372.69,,,,,,,fee schedule,31126.01,46688.44, "Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,20598.16,,,,,,,fee schedule,17860.61,26790.59, "Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,17860.61,,,,,,,fee schedule,17860.61,26790.59, "Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,26790.59,,,,,,,fee schedule,17860.61,26790.59, "Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,20640.12,,,,,,,fee schedule,17860.61,26790.59, "Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,18575.98,,,,,,,fee schedule,17860.61,26790.59, "Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,36760.66,,,,,,,fee schedule,31875.08,47812.03, Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,31875.08,,,,,,,fee schedule,31875.08,47812.03, Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,47812.03,,,,,,,fee schedule,31875.08,47812.03, Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,36835.56,,,,,,,fee schedule,31875.08,47812.03, Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,33151.77,,,,,,,fee schedule,31875.08,47812.03, Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,22680.91,,,,,,,fee schedule,19666.56,29499.48, Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,19666.56,,,,,,,fee schedule,19666.56,29499.48, Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,29499.48,,,,,,,fee schedule,19666.56,29499.48, Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,22727.12,,,,,,,fee schedule,19666.56,29499.48, Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,20454.26,,,,,,,fee schedule,19666.56,29499.48, Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,46583.82,,,,,,,fee schedule,40392.71,60588.33, Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,40392.71,,,,,,,fee schedule,40392.71,60588.33, Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,60588.33,,,,,,,fee schedule,40392.71,60588.33, Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,46678.73,,,,,,,fee schedule,40392.71,60588.33, Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,42010.56,,,,,,,fee schedule,40392.71,60588.33, Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,25483.04,,,,,,,fee schedule,22096.28,33144.01, Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,22096.28,,,,,,,fee schedule,22096.28,33144.01, Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,33144.01,,,,,,,fee schedule,22096.28,33144.01, Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,25534.95,,,,,,,fee schedule,22096.28,33144.01, Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22981.3,,,,,,,fee schedule,22096.28,33144.01, Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],7322.45,7322.45,7322.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],12046.06,12046.06,12046.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,33258,,,,,,,fee schedule,28837.93,43256.36, Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,28837.93,,,,,,,fee schedule,28837.93,43256.36, Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,43256.36,,,,,,,fee schedule,28837.93,43256.36, Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,33325.76,,,,,,,fee schedule,28837.93,43256.36, Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,29992.97,,,,,,,fee schedule,28837.93,43256.36, Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],25336.5,25336.5,25336.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,21110.21,,,,,,,fee schedule,18304.61,27456.58, Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,18304.61,,,,,,,fee schedule,18304.61,27456.58, Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,27456.58,,,,,,,fee schedule,18304.61,27456.58, Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,21153.22,,,,,,,fee schedule,18304.61,27456.58, Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19037.76,,,,,,,fee schedule,18304.61,27456.58, Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,48386.75,48386.75,48386.75,1 through 10,percent of total billed charges,,, Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,66911.82,,,,,,,fee schedule,58019.07,87027.54, "Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,58019.07,,,,,,,fee schedule,58019.07,87027.54, "Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,87027.54,,,,,,,fee schedule,58019.07,87027.54, "Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,67048.14,,,,,,,fee schedule,58019.07,87027.54, "Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,60342.9,,,,,,,fee schedule,58019.07,87027.54, "Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,42267.54,,,,,,,fee schedule,36650.07,54974.44, "Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,36650.07,,,,,,,fee schedule,36650.07,54974.44, "Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,54974.44,,,,,,,fee schedule,36650.07,54974.44, "Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,42353.65,,,,,,,fee schedule,36650.07,54974.44, "Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,38118.02,,,,,,,fee schedule,36650.07,54974.44, "Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,112289.34,,,,,,,fee schedule,97365.81,146046.92, Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,97365.81,,,,,,,fee schedule,97365.81,146046.92, Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,146046.92,,,,,,,fee schedule,97365.81,146046.92, Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,112518.11,,,,,,,fee schedule,97365.81,146046.92, Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,101265.59,,,,,,,fee schedule,97365.81,146046.92, Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,64731.69,,,,,,,fee schedule,56128.68,84191.99, Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,56128.68,,,,,,,fee schedule,56128.68,84191.99, Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,84191.99,,,,,,,fee schedule,56128.68,84191.99, Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,64863.57,,,,,,,fee schedule,56128.68,84191.99, Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,58376.8,,,,,,,fee schedule,56128.68,84191.99, Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,46131.46,,,,,,,fee schedule,40000.47,59999.97, Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,40000.47,,,,,,,fee schedule,40000.47,59999.97, Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,59999.97,,,,,,,fee schedule,40000.47,59999.97, Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,46225.44,,,,,,,fee schedule,40000.47,59999.97, Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,41602.61,,,,,,,fee schedule,40000.47,59999.97, Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,112550.08,,,,,,,fee schedule,97591.89,146386.04, Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,97591.89,,,,,,,fee schedule,97591.89,146386.04, Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,146386.04,,,,,,,fee schedule,97591.89,146386.04, Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,112779.38,,,,,,,fee schedule,97591.89,146386.04, Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,101500.72,,,,,,,fee schedule,97591.89,146386.04, Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,56846.77,,,,,,,fee schedule,49291.69,73936.64, Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,49291.69,,,,,,,fee schedule,49291.69,73936.64, Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,73936.64,,,,,,,fee schedule,49291.69,73936.64, Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,56962.59,,,,,,,fee schedule,49291.69,73936.64, Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,51265.97,,,,,,,fee schedule,49291.69,73936.64, Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,44799.51,,,,,,,fee schedule,38845.54,58267.59, Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,38845.54,,,,,,,fee schedule,38845.54,58267.59, Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,58267.59,,,,,,,fee schedule,38845.54,58267.59, Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,44890.78,,,,,,,fee schedule,38845.54,58267.59, Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,40401.41,,,,,,,fee schedule,38845.54,58267.59, Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,57638.41,,,,,,,fee schedule,49978.12,74966.26, Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,49978.12,,,,,,,fee schedule,49978.12,74966.26, Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,74966.26,,,,,,,fee schedule,49978.12,74966.26, Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,57755.83,,,,,,,fee schedule,49978.12,74966.26, Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,51979.88,,,,,,,fee schedule,49978.12,74966.26, Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],46695.93,46695.93,46695.93,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],23165.94,23165.94,23165.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,38975.35,,,,,,,fee schedule,33795.43,50692.52, Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,33795.43,,,,,,,fee schedule,33795.43,50692.52, Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,50692.52,,,,,,,fee schedule,33795.43,50692.52, Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,39054.75,,,,,,,fee schedule,33795.43,50692.52, Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,35149.03,,,,,,,fee schedule,33795.43,50692.52, Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],10893.61,10893.61,10893.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],14180.37,14180.37,14180.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,64370.43,,,,,,,fee schedule,55815.43,83722.13, "D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,55815.43,,,,,,,fee schedule,55815.43,83722.13, "D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,83722.13,,,,,,,fee schedule,55815.43,83722.13, "D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,64501.57,,,,,,,fee schedule,55815.43,83722.13, "D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,58051,,,,,,,fee schedule,55815.43,83722.13, "D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,35733.43,,,,,,,fee schedule,30984.36,46475.98, "D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,30984.36,,,,,,,fee schedule,30984.36,46475.98, "D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,46475.98,,,,,,,fee schedule,30984.36,46475.98, "D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,35806.23,,,,,,,fee schedule,30984.36,46475.98, "D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,32225.38,,,,,,,fee schedule,30984.36,46475.98, "D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,54569.26,,,,,,,fee schedule,47316.87,70974.43, "Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,47316.87,,,,,,,fee schedule,47316.87,70974.43, "Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,70974.43,,,,,,,fee schedule,47316.87,70974.43, "Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,54680.43,,,,,,,fee schedule,47316.87,70974.43, "Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,49212.04,,,,,,,fee schedule,47316.87,70974.43, "Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,42424.94,42424.94,42424.94,1 through 10,percent of total billed charges,,, "Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,27006.62,,,,,,,fee schedule,23417.37,35125.62, "Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,23417.37,,,,,,,fee schedule,23417.37,35125.62, "Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,35125.62,,,,,,,fee schedule,23417.37,35125.62, "Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,27061.64,,,,,,,fee schedule,23417.37,35125.62, "Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,24355.3,,,,,,,fee schedule,23417.37,35125.62, "Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,43580.64,,,,,,,fee schedule,37788.66,56682.3, Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,37788.66,,,,,,,fee schedule,37788.66,56682.3, Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,56682.3,,,,,,,fee schedule,37788.66,56682.3, Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,43669.43,,,,,,,fee schedule,37788.66,56682.3, Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,39302.21,,,,,,,fee schedule,37788.66,56682.3, Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,80658.59,,,,,,,fee schedule,69938.86,104907, Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,69938.86,,,,,,,fee schedule,69938.86,104907, Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,104907,,,,,,,fee schedule,69938.86,104907, Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,80822.91,,,,,,,fee schedule,69938.86,104907, Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,72740.11,,,,,,,fee schedule,69938.86,104907, Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,46360.78,,,,,,,fee schedule,40199.32,60298.24, Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,40199.32,,,,,,,fee schedule,40199.32,60298.24, Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,60298.24,,,,,,,fee schedule,40199.32,60298.24, Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,46455.23,,,,,,,fee schedule,40199.32,60298.24, Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,41809.41,,,,,,,fee schedule,40199.32,60298.24, Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,57855.16,,,,,,,fee schedule,50166.07,75248.18, "Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,50166.07,,,,,,,fee schedule,50166.07,75248.18, "Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,75248.18,,,,,,,fee schedule,50166.07,75248.18, "Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,57973.03,,,,,,,fee schedule,50166.07,75248.18, "Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,52175.36,,,,,,,fee schedule,50166.07,75248.18, "Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,34172.15,,,,,,,fee schedule,29630.58,44445.33, "Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,29630.58,,,,,,,fee schedule,29630.58,44445.33, "Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,44445.33,,,,,,,fee schedule,29630.58,44445.33, "Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,34241.77,,,,,,,fee schedule,29630.58,44445.33, "Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,30817.37,,,,,,,fee schedule,29630.58,44445.33, "Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,30173.15,,,,,,,fee schedule,26163.06,39244.11, "Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,26163.06,,,,,,,fee schedule,26163.06,39244.11, "Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,39244.11,,,,,,,fee schedule,26163.06,39244.11, "Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,30234.62,,,,,,,fee schedule,26163.06,39244.11, "Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,27210.97,,,,,,,fee schedule,26163.06,39244.11, "Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,44981.71,,,,,,,fee schedule,39003.52,58504.57, "Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,39003.52,,,,,,,fee schedule,39003.52,58504.57, "Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,58504.57,,,,,,,fee schedule,39003.52,58504.57, "Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,45073.35,,,,,,,fee schedule,39003.52,58504.57, "Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,40565.73,,,,,,,fee schedule,39003.52,58504.57, "Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],39213.94,39213.94,39213.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,30754.31,,,,,,,fee schedule,26666.98,39999.98, "Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,26666.98,,,,,,,fee schedule,26666.98,39999.98, "Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,39999.98,,,,,,,fee schedule,26666.98,39999.98, "Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,30816.96,,,,,,,fee schedule,26666.98,39999.98, "Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,27735.07,,,,,,,fee schedule,26666.98,39999.98, "Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],22961.94,22961.94,22961.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],10021.38,10021.38,10021.38,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,20846.33,,,,,,,fee schedule,18075.8,27113.37, "Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,18075.8,,,,,,,fee schedule,18075.8,27113.37, "Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,27113.37,,,,,,,fee schedule,18075.8,27113.37, "Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,20888.8,,,,,,,fee schedule,18075.8,27113.37, "Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,18799.79,,,,,,,fee schedule,18075.8,27113.37, "Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],7436.13,7436.13,7436.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,31649.61,,,,,,,fee schedule,27443.29,41164.44, Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,27443.29,,,,,,,fee schedule,27443.29,41164.44, Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,41164.44,,,,,,,fee schedule,27443.29,41164.44, Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,31714.09,,,,,,,fee schedule,27443.29,41164.44, Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,28542.48,,,,,,,fee schedule,27443.29,41164.44, Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,17921.69,,,,,,,fee schedule,15539.85,23309.49, Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,15539.85,,,,,,,fee schedule,15539.85,23309.49, Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,23309.49,,,,,,,fee schedule,15539.85,23309.49, Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,17958.2,,,,,,,fee schedule,15539.85,23309.49, Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,16162.27,,,,,,,fee schedule,15539.85,23309.49, Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cesarean Section W Cc/Mcc,765,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section W Cc/Mcc,765,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section W Cc/Mcc,765,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section W Cc/Mcc,765,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section W Cc/Mcc,765,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section W Cc/Mcc,765,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section W Cc/Mcc,765,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section W Cc/Mcc,765,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section W Cc/Mcc,765,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section W Cc/Mcc,765,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section W Cc/Mcc,765,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section W Cc/Mcc,765,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section W Cc/Mcc,765,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section W Cc/Mcc,765,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section W Cc/Mcc,765,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section W Cc/Mcc,765,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cesarean Section W Cc/Mcc,765,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cesarean Section W Cc/Mcc,765,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cesarean Section W Cc/Mcc,765,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cesarean Section W Cc/Mcc,765,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cesarean Section W/O Cc/Mcc,766,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section W/O Cc/Mcc,766,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section W/O Cc/Mcc,766,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section W/O Cc/Mcc,766,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section W/O Cc/Mcc,766,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section W/O Cc/Mcc,766,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section W/O Cc/Mcc,766,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section W/O Cc/Mcc,766,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section W/O Cc/Mcc,766,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section W/O Cc/Mcc,766,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section W/O Cc/Mcc,766,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section W/O Cc/Mcc,766,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section W/O Cc/Mcc,766,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section W/O Cc/Mcc,766,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section W/O Cc/Mcc,766,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section W/O Cc/Mcc,766,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cesarean Section W/O Cc/Mcc,766,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cesarean Section W/O Cc/Mcc,766,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cesarean Section W/O Cc/Mcc,766,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cesarean Section W/O Cc/Mcc,766,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Vaginal Delivery W Sterilization &/Or D&C,767,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery W Sterilization &/Or D&C,767,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery W Sterilization &/Or D&C,767,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery W Sterilization &/Or D&C,767,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery W Sterilization &/Or D&C,767,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery W Sterilization &/Or D&C,767,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery W Sterilization &/Or D&C,767,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery W Sterilization &/Or D&C,767,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery W Sterilization &/Or D&C,767,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery W Sterilization &/Or D&C,767,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery W Sterilization &/Or D&C,767,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery W Sterilization &/Or D&C,767,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery W Sterilization &/Or D&C,767,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery W Sterilization &/Or D&C,767,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery W Sterilization &/Or D&C,767,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery W Sterilization &/Or D&C,767,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Vaginal Delivery W Sterilization &/Or D&C,767,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Vaginal Delivery W Sterilization &/Or D&C,767,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Vaginal Delivery W Sterilization &/Or D&C,767,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Vaginal Delivery W Sterilization &/Or D&C,767,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,33663.24,,,,,,,fee schedule,29189.31,43783.43, Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,29189.31,,,,,,,fee schedule,29189.31,43783.43, Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,43783.43,,,,,,,fee schedule,29189.31,43783.43, Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,33731.82,,,,,,,fee schedule,29189.31,43783.43, Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,30358.43,,,,,,,fee schedule,29189.31,43783.43, Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,53083.38,,,,,,,fee schedule,46028.46,69041.85, Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,46028.46,,,,,,,fee schedule,46028.46,69041.85, Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,69041.85,,,,,,,fee schedule,46028.46,69041.85, Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,53191.52,,,,,,,fee schedule,46028.46,69041.85, Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,47872.03,,,,,,,fee schedule,46028.46,69041.85, Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,31498.82,,,,,,,fee schedule,27312.55,40968.32, "Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,27312.55,,,,,,,fee schedule,27312.55,40968.32, "Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,40968.32,,,,,,,fee schedule,27312.55,40968.32, "Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,31562.99,,,,,,,fee schedule,27312.55,40968.32, "Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,28406.49,,,,,,,fee schedule,27312.55,40968.32, "Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Vaginal Delivery W Complicating Diagnoses,774,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery W Complicating Diagnoses,774,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery W Complicating Diagnoses,774,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery W Complicating Diagnoses,774,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery W Complicating Diagnoses,774,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery W Complicating Diagnoses,774,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery W Complicating Diagnoses,774,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery W Complicating Diagnoses,774,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery W Complicating Diagnoses,774,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery W Complicating Diagnoses,774,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery W Complicating Diagnoses,774,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery W Complicating Diagnoses,774,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery W Complicating Diagnoses,774,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery W Complicating Diagnoses,774,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery W Complicating Diagnoses,774,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery W Complicating Diagnoses,774,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Vaginal Delivery W Complicating Diagnoses,774,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Vaginal Delivery W Complicating Diagnoses,774,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Vaginal Delivery W Complicating Diagnoses,774,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Vaginal Delivery W Complicating Diagnoses,774,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Vaginal Delivery W/O Complicating Diagnoses,775,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery W/O Complicating Diagnoses,775,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery W/O Complicating Diagnoses,775,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery W/O Complicating Diagnoses,775,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery W/O Complicating Diagnoses,775,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery W/O Complicating Diagnoses,775,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery W/O Complicating Diagnoses,775,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery W/O Complicating Diagnoses,775,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery W/O Complicating Diagnoses,775,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery W/O Complicating Diagnoses,775,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery W/O Complicating Diagnoses,775,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery W/O Complicating Diagnoses,775,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery W/O Complicating Diagnoses,775,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery W/O Complicating Diagnoses,775,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery W/O Complicating Diagnoses,775,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery W/O Complicating Diagnoses,775,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Vaginal Delivery W/O Complicating Diagnoses,775,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Vaginal Delivery W/O Complicating Diagnoses,775,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Vaginal Delivery W/O Complicating Diagnoses,775,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Vaginal Delivery W/O Complicating Diagnoses,775,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,20566.75,,,,,,,fee schedule,17833.37,26749.73, Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,17833.37,,,,,,,fee schedule,17833.37,26749.73, Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,26749.73,,,,,,,fee schedule,17833.37,26749.73, Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,20608.65,,,,,,,fee schedule,17833.37,26749.73, Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,18547.65,,,,,,,fee schedule,17833.37,26749.73, Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Ectopic Pregnancy,777,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Ectopic Pregnancy,777,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ectopic Pregnancy,777,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ectopic Pregnancy,777,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ectopic Pregnancy,777,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Ectopic Pregnancy,777,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ectopic Pregnancy,777,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ectopic Pregnancy,777,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ectopic Pregnancy,777,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ectopic Pregnancy,777,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ectopic Pregnancy,777,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ectopic Pregnancy,777,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ectopic Pregnancy,777,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ectopic Pregnancy,777,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ectopic Pregnancy,777,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ectopic Pregnancy,777,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Ectopic Pregnancy,777,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Ectopic Pregnancy,777,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Ectopic Pregnancy,777,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Ectopic Pregnancy,777,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Threatened Abortion,778,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Threatened Abortion,778,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Threatened Abortion,778,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Threatened Abortion,778,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Threatened Abortion,778,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Threatened Abortion,778,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Threatened Abortion,778,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Threatened Abortion,778,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Threatened Abortion,778,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Threatened Abortion,778,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Threatened Abortion,778,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Threatened Abortion,778,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Threatened Abortion,778,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Threatened Abortion,778,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Threatened Abortion,778,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Threatened Abortion,778,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Threatened Abortion,778,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Threatened Abortion,778,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Threatened Abortion,778,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Threatened Abortion,778,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Abortion Without D&C,779,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,26428.6,,,,,,,fee schedule,22916.17,34373.84, Abortion Without D&C,779,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,22916.17,,,,,,,fee schedule,22916.17,34373.84, Abortion Without D&C,779,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,34373.84,,,,,,,fee schedule,22916.17,34373.84, Abortion Without D&C,779,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,26482.44,,,,,,,fee schedule,22916.17,34373.84, Abortion Without D&C,779,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,23834.03,,,,,,,fee schedule,22916.17,34373.84, Abortion Without D&C,779,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Abortion Without D&C,779,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Abortion Without D&C,779,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Abortion Without D&C,779,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Abortion Without D&C,779,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Abortion Without D&C,779,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Abortion Without D&C,779,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Abortion Without D&C,779,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Abortion Without D&C,779,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Abortion Without D&C,779,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Abortion Without D&C,779,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Abortion Without D&C,779,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Abortion Without D&C,779,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Abortion Without D&C,779,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Abortion Without D&C,779,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Abortion Without D&C,779,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Abortion Without D&C,779,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Abortion Without D&C,779,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Abortion Without D&C,779,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Abortion Without D&C,779,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. False Labor,780,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. False Labor,780,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. False Labor,780,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. False Labor,780,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. False Labor,780,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. False Labor,780,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. False Labor,780,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. False Labor,780,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. False Labor,780,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. False Labor,780,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. False Labor,780,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. False Labor,780,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. False Labor,780,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. False Labor,780,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. False Labor,780,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. False Labor,780,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. False Labor,780,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. False Labor,780,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. False Labor,780,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. False Labor,780,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses W Medical Complications,781,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses W Medical Complications,781,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses W Medical Complications,781,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses W Medical Complications,781,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses W Medical Complications,781,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses W Medical Complications,781,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses W Medical Complications,781,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses W Medical Complications,781,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses W Medical Complications,781,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses W Medical Complications,781,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses W Medical Complications,781,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses W Medical Complications,781,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses W Medical Complications,781,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses W Medical Complications,781,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses W Medical Complications,781,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses W Medical Complications,781,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses W Medical Complications,781,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses W Medical Complications,781,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses W Medical Complications,781,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses W Medical Complications,781,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses W/O Medical Complications,782,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses W/O Medical Complications,782,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses W/O Medical Complications,782,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses W/O Medical Complications,782,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses W/O Medical Complications,782,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses W/O Medical Complications,782,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses W/O Medical Complications,782,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses W/O Medical Complications,782,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses W/O Medical Complications,782,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses W/O Medical Complications,782,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses W/O Medical Complications,782,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses W/O Medical Complications,782,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses W/O Medical Complications,782,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses W/O Medical Complications,782,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses W/O Medical Complications,782,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses W/O Medical Complications,782,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses W/O Medical Complications,782,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses W/O Medical Complications,782,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses W/O Medical Complications,782,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses W/O Medical Complications,782,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,77124.51,,,,,,,fee schedule,66874.47,100310.48, Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,66874.47,,,,,,,fee schedule,66874.47,100310.48, Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,100310.48,,,,,,,fee schedule,66874.47,100310.48, Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,77281.64,,,,,,,fee schedule,66874.47,100310.48, Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,69552.98,,,,,,,fee schedule,66874.47,100310.48, Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,33301.98,,,,,,,fee schedule,28876.06,43313.57, Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,28876.06,,,,,,,fee schedule,28876.06,43313.57, Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,43313.57,,,,,,,fee schedule,28876.06,43313.57, Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,33369.83,,,,,,,fee schedule,28876.06,43313.57, Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,30032.63,,,,,,,fee schedule,28876.06,43313.57, Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,30088.33,,,,,,,fee schedule,26089.51,39133.79, Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,26089.51,,,,,,,fee schedule,26089.51,39133.79, Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,39133.79,,,,,,,fee schedule,26089.51,39133.79, Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,30149.63,,,,,,,fee schedule,26089.51,39133.79, Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,27134.47,,,,,,,fee schedule,26089.51,39133.79, Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,51817.39,,,,,,,fee schedule,44930.73,67395.27, Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,44930.73,,,,,,,fee schedule,44930.73,67395.27, Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,67395.27,,,,,,,fee schedule,44930.73,67395.27, Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,51922.96,,,,,,,fee schedule,44930.73,67395.27, Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,46730.34,,,,,,,fee schedule,44930.73,67395.27, Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,35083.16,,,,,,,fee schedule,30420.52,45630.21, Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,30420.52,,,,,,,fee schedule,30420.52,45630.21, Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,45630.21,,,,,,,fee schedule,30420.52,45630.21, Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,35154.63,,,,,,,fee schedule,30420.52,45630.21, Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,31638.94,,,,,,,fee schedule,30420.52,45630.21, Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,30119.74,,,,,,,fee schedule,26116.75,39174.65, Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,26116.75,,,,,,,fee schedule,26116.75,39174.65, Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,39174.65,,,,,,,fee schedule,26116.75,39174.65, Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,30181.11,,,,,,,fee schedule,26116.75,39174.65, Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,27162.8,,,,,,,fee schedule,26116.75,39174.65, Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,56614.31,,,,,,,fee schedule,49090.13,73634.29, "Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,49090.13,,,,,,,fee schedule,49090.13,73634.29, "Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,73634.29,,,,,,,fee schedule,49090.13,73634.29, "Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,56729.65,,,,,,,fee schedule,49090.13,73634.29, "Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,51056.33,,,,,,,fee schedule,49090.13,73634.29, "Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,186709.11,,,,,,,fee schedule,161895,242839.52, "Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,161895,,,,,,,fee schedule,161895,242839.52, "Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,242839.52,,,,,,,fee schedule,161895,242839.52, "Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,187089.49,,,,,,,fee schedule,161895,242839.52, "Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,168379.36,,,,,,,fee schedule,161895,242839.52, "Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],140471.59,113805.97,866897.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],201593.5,201593.5,201593.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],449720.26,449720.26,449720.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],151966.92,139237.12,1251338.43,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],235945.61,235945.61,235945.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],356465.52,356465.52,356465.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],233350.93,26555.06,567280.33,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],7609.24,7609.24,7609.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],129637.43,16817.68,612794.26,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],114149.54,38043.45,360629.28,44,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],174414.49,125838.44,1074186.27,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],631231.69,240917.11,992835.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,238054.48,97914.24,1511294.81,1 through 10,percent of total billed charges,,, "Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Prematurity With Major Problems,791,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,127509.43,,,,,,,fee schedule,110563.1,165842.62, Prematurity With Major Problems,791,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,110563.1,,,,,,,fee schedule,110563.1,165842.62, Prematurity With Major Problems,791,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,165842.62,,,,,,,fee schedule,110563.1,165842.62, Prematurity With Major Problems,791,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,127769.2,,,,,,,fee schedule,110563.1,165842.62, Prematurity With Major Problems,791,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,114991.47,,,,,,,fee schedule,110563.1,165842.62, Prematurity With Major Problems,791,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],34767.94,34767.94,34767.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Prematurity With Major Problems,791,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Prematurity With Major Problems,791,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],103101.4,94707.36,285255.75,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Prematurity With Major Problems,791,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],155668.75,155668.75,155668.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Prematurity With Major Problems,791,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Prematurity With Major Problems,791,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prematurity With Major Problems,791,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prematurity With Major Problems,791,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],24645.1,17891.1,113119.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Prematurity With Major Problems,791,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prematurity With Major Problems,791,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],37279.98,25259.6,423029.21,17,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Prematurity With Major Problems,791,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prematurity With Major Problems,791,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],24572.04,8359.43,91469.16,30,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Prematurity With Major Problems,791,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],113214.37,110764.46,160259.37,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Prematurity With Major Problems,791,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],100187.75,100187.75,100187.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Prematurity With Major Problems,791,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],17575.04,17575.04,17575.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Prematurity With Major Problems,791,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,195400.94,71905.25,367286.62,1 through 10,percent of total billed charges,,, Prematurity With Major Problems,791,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,32320.26,32320.26,32320.26,1 through 10,percent of total billed charges,,, Prematurity With Major Problems,791,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Prematurity With Major Problems,791,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Prematurity With Major Problems,791,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Prematurity Without Major Problems,792,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,76939.17,,,,,,,fee schedule,66713.76,100069.41, Prematurity Without Major Problems,792,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,66713.76,,,,,,,fee schedule,66713.76,100069.41, Prematurity Without Major Problems,792,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,100069.41,,,,,,,fee schedule,66713.76,100069.41, Prematurity Without Major Problems,792,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,77095.92,,,,,,,fee schedule,66713.76,100069.41, Prematurity Without Major Problems,792,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,69385.84,,,,,,,fee schedule,66713.76,100069.41, Prematurity Without Major Problems,792,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],69164.83,69164.83,69164.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Prematurity Without Major Problems,792,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prematurity Without Major Problems,792,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],54458.87,54458.87,54458.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Prematurity Without Major Problems,792,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prematurity Without Major Problems,792,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Prematurity Without Major Problems,792,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prematurity Without Major Problems,792,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],4413.77,4413.77,4413.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Prematurity Without Major Problems,792,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],7461.91,5167.05,39152.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Prematurity Without Major Problems,792,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prematurity Without Major Problems,792,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],18930.56,12498.42,25259.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Prematurity Without Major Problems,792,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prematurity Without Major Problems,792,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],16360.36,3985.01,26204.64,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Prematurity Without Major Problems,792,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],67022.5,67022.5,67022.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Prematurity Without Major Problems,792,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prematurity Without Major Problems,792,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prematurity Without Major Problems,792,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Prematurity Without Major Problems,792,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Prematurity Without Major Problems,792,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Prematurity Without Major Problems,792,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Prematurity Without Major Problems,792,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Full Term Neonate With Major Problems,793,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,130983.81,,,,,,,fee schedule,113575.73,170361.52, Full Term Neonate With Major Problems,793,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,113575.73,,,,,,,fee schedule,113575.73,170361.52, Full Term Neonate With Major Problems,793,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,170361.52,,,,,,,fee schedule,113575.73,170361.52, Full Term Neonate With Major Problems,793,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,131250.67,,,,,,,fee schedule,113575.73,170361.52, Full Term Neonate With Major Problems,793,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,118124.77,,,,,,,fee schedule,113575.73,170361.52, Full Term Neonate With Major Problems,793,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],59870.05,24101.23,126583.02,17,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Full Term Neonate With Major Problems,793,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],1903.5,49.41,110379.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Full Term Neonate With Major Problems,793,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],159909.48,68662.59,388258.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Full Term Neonate With Major Problems,793,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],100943.64,50482.18,159909.48,46,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Full Term Neonate With Major Problems,793,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Full Term Neonate With Major Problems,793,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Full Term Neonate With Major Problems,793,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],30957.82,30957.82,30957.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Full Term Neonate With Major Problems,793,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],10600.27,5663.14,52586.75,33,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Full Term Neonate With Major Problems,793,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],32686.12,32686.12,32686.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Full Term Neonate With Major Problems,793,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],12320.41,5361.33,63422.35,38,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Full Term Neonate With Major Problems,793,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Full Term Neonate With Major Problems,793,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],16360.36,5158.16,70851.47,52,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Full Term Neonate With Major Problems,793,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],70520.45,18635,276251.56,20,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Full Term Neonate With Major Problems,793,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],8786.57,8786.57,13463.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Full Term Neonate With Major Problems,793,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Full Term Neonate With Major Problems,793,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,50674.62,27259.92,182328.2,17,percent of total billed charges,,, Full Term Neonate With Major Problems,793,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Full Term Neonate With Major Problems,793,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Full Term Neonate With Major Problems,793,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Full Term Neonate With Major Problems,793,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Neonate With Other Significant Problems,794,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,46363.92,,,,,,,fee schedule,40202.04,60302.32, Neonate With Other Significant Problems,794,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,40202.04,,,,,,,fee schedule,40202.04,60302.32, Neonate With Other Significant Problems,794,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,60302.32,,,,,,,fee schedule,40202.04,60302.32, Neonate With Other Significant Problems,794,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,46458.38,,,,,,,fee schedule,40202.04,60302.32, Neonate With Other Significant Problems,794,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,41812.25,,,,,,,fee schedule,40202.04,60302.32, Neonate With Other Significant Problems,794,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],40002.17,25580.39,44805.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Neonate With Other Significant Problems,794,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],49.41,49.41,49.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Neonate With Other Significant Problems,794,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],37687.14,35435.51,37736.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Neonate With Other Significant Problems,794,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],30669.13,23180,56601.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Neonate With Other Significant Problems,794,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Neonate With Other Significant Problems,794,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Neonate With Other Significant Problems,794,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Neonate With Other Significant Problems,794,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],3940.04,1665.56,7243.77,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Neonate With Other Significant Problems,794,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Neonate With Other Significant Problems,794,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],4095.35,1794.29,16661.51,26,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Neonate With Other Significant Problems,794,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Neonate With Other Significant Problems,794,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],3980.18,1765.02,8354.6,25,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Neonate With Other Significant Problems,794,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],36698.87,35752.08,41165.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Neonate With Other Significant Problems,794,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],38979.06,38979.06,38979.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Neonate With Other Significant Problems,794,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],6745.48,6745.48,6745.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Neonate With Other Significant Problems,794,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,27399.25,20114.09,79572.02,1 through 10,percent of total billed charges,,, Neonate With Other Significant Problems,794,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Neonate With Other Significant Problems,794,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Neonate With Other Significant Problems,794,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Neonate With Other Significant Problems,794,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Normal Newborn,795,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,6276.52,,,,,,,fee schedule,5442.35,8163.43, Normal Newborn,795,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,5442.35,,,,,,,fee schedule,5442.35,8163.43, Normal Newborn,795,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,8163.43,,,,,,,fee schedule,5442.35,8163.43, Normal Newborn,795,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,6289.3,,,,,,,fee schedule,5442.35,8163.43, Normal Newborn,795,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,5660.33,,,,,,,fee schedule,5442.35,8163.43, Normal Newborn,795,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],6064.33,6064.33,6064.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Normal Newborn,795,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Normal Newborn,795,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Normal Newborn,795,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Normal Newborn,795,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Normal Newborn,795,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Normal Newborn,795,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Normal Newborn,795,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Normal Newborn,795,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Normal Newborn,795,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],1173.34,1173.34,1173.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Normal Newborn,795,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Normal Newborn,795,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],5548.8,5548.8,5548.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Normal Newborn,795,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],1290.16,1290.16,1290.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Normal Newborn,795,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],5304.16,5304.16,5304.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Normal Newborn,795,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Normal Newborn,795,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,12971.99,12971.99,12971.99,1 through 10,percent of total billed charges,,, Normal Newborn,795,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Normal Newborn,795,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Normal Newborn,795,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Normal Newborn,795,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,36660.14,,,,,,,fee schedule,31787.91,47681.29, Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,31787.91,,,,,,,fee schedule,31787.91,47681.29, Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,47681.29,,,,,,,fee schedule,31787.91,47681.29, Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,36734.83,,,,,,,fee schedule,31787.91,47681.29, Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,33061.11,,,,,,,fee schedule,31787.91,47681.29, Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,31426.57,,,,,,,fee schedule,27249.9,40874.34, Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,27249.9,,,,,,,fee schedule,27249.9,40874.34, Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,40874.34,,,,,,,fee schedule,27249.9,40874.34, Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,31490.59,,,,,,,fee schedule,27249.9,40874.34, Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,28341.33,,,,,,,fee schedule,27249.9,40874.34, Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,30066.34,,,,,,,fee schedule,26070.45,39105.19, Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,26070.45,,,,,,,fee schedule,26070.45,39105.19, Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,39105.19,,,,,,,fee schedule,26070.45,39105.19, Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,30127.59,,,,,,,fee schedule,26070.45,39105.19, Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,27114.64,,,,,,,fee schedule,26070.45,39105.19, Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Splenic Procedures With Mcc,799,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,142270.86,,,,,,,fee schedule,123362.71,185041.8, Splenic Procedures With Mcc,799,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,123362.71,,,,,,,fee schedule,123362.71,185041.8, Splenic Procedures With Mcc,799,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,185041.8,,,,,,,fee schedule,123362.71,185041.8, Splenic Procedures With Mcc,799,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,142560.71,,,,,,,fee schedule,123362.71,185041.8, Splenic Procedures With Mcc,799,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,128303.74,,,,,,,fee schedule,123362.71,185041.8, Splenic Procedures With Mcc,799,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Splenic Procedures With Mcc,799,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Splenic Procedures With Mcc,799,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Splenic Procedures With Mcc,799,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Splenic Procedures With Mcc,799,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Splenic Procedures With Mcc,799,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Splenic Procedures With Mcc,799,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Splenic Procedures With Mcc,799,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Splenic Procedures With Mcc,799,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Splenic Procedures With Mcc,799,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Splenic Procedures With Mcc,799,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Splenic Procedures With Mcc,799,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Splenic Procedures With Mcc,799,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Splenic Procedures With Mcc,799,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Splenic Procedures With Mcc,799,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Splenic Procedures With Mcc,799,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Splenic Procedures With Mcc,799,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Splenic Procedures With Mcc,799,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Splenic Procedures With Mcc,799,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Splenic Procedures With Mcc,799,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Splenic Procedures With Cc,800,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,88254.49,,,,,,,fee schedule,76525.25,114786.47, Splenic Procedures With Cc,800,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,76525.25,,,,,,,fee schedule,76525.25,114786.47, Splenic Procedures With Cc,800,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,114786.47,,,,,,,fee schedule,76525.25,114786.47, Splenic Procedures With Cc,800,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,88434.29,,,,,,,fee schedule,76525.25,114786.47, Splenic Procedures With Cc,800,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,79590.3,,,,,,,fee schedule,76525.25,114786.47, Splenic Procedures With Cc,800,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Splenic Procedures With Cc,800,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Splenic Procedures With Cc,800,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Splenic Procedures With Cc,800,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Splenic Procedures With Cc,800,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Splenic Procedures With Cc,800,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Splenic Procedures With Cc,800,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Splenic Procedures With Cc,800,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Splenic Procedures With Cc,800,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Splenic Procedures With Cc,800,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],21180.74,21180.74,21180.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Splenic Procedures With Cc,800,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Splenic Procedures With Cc,800,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],20603.09,20603.09,20603.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Splenic Procedures With Cc,800,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],48840.77,48840.77,48840.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Splenic Procedures With Cc,800,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Splenic Procedures With Cc,800,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Splenic Procedures With Cc,800,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Splenic Procedures With Cc,800,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Splenic Procedures With Cc,800,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Splenic Procedures With Cc,800,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Splenic Procedures With Cc,800,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,59966.18,,,,,,,fee schedule,51996.53,77993.84, Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,51996.53,,,,,,,fee schedule,51996.53,77993.84, Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,77993.84,,,,,,,fee schedule,51996.53,77993.84, Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,60088.35,,,,,,,fee schedule,51996.53,77993.84, Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,54079.14,,,,,,,fee schedule,51996.53,77993.84, Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],41966.78,41966.78,41966.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],14855.37,14855.37,14855.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,125156.52,,,,,,,fee schedule,108522.9,162782.36, Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,108522.9,,,,,,,fee schedule,108522.9,162782.36, Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,162782.36,,,,,,,fee schedule,108522.9,162782.36, Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,125411.5,,,,,,,fee schedule,108522.9,162782.36, Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,112869.55,,,,,,,fee schedule,108522.9,162782.36, Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],56596.74,56596.74,56596.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,569947.69,569947.69,569947.69,1 through 10,percent of total billed charges,,, Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,58395.48,,,,,,,fee schedule,50634.58,75950.94, Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,50634.58,,,,,,,fee schedule,50634.58,75950.94, Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,75950.94,,,,,,,fee schedule,50634.58,75950.94, Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,58514.45,,,,,,,fee schedule,50634.58,75950.94, Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,52662.64,,,,,,,fee schedule,50634.58,75950.94, Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],48924.05,48924.05,48924.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],16673.78,16673.78,16673.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,42597.38,,,,,,,fee schedule,36936.08,55403.45, Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,36936.08,,,,,,,fee schedule,36936.08,55403.45, Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,55403.45,,,,,,,fee schedule,36936.08,55403.45, Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,42684.17,,,,,,,fee schedule,36936.08,55403.45, Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,38415.48,,,,,,,fee schedule,36936.08,55403.45, Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],5908.14,5908.14,5908.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,33901.99,,,,,,,fee schedule,29396.33,44093.95, Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,29396.33,,,,,,,fee schedule,29396.33,44093.95, Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,44093.95,,,,,,,fee schedule,29396.33,44093.95, Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,33971.06,,,,,,,fee schedule,29396.33,44093.95, Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,30573.74,,,,,,,fee schedule,29396.33,44093.95, Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,23686.16,,,,,,,fee schedule,20538.21,30806.93, Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,20538.21,,,,,,,fee schedule,20538.21,30806.93, Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,30806.93,,,,,,,fee schedule,20538.21,30806.93, Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,23734.41,,,,,,,fee schedule,20538.21,30806.93, Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,21360.82,,,,,,,fee schedule,20538.21,30806.93, Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,21179.32,,,,,,,fee schedule,18364.53,27546.46, Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,18364.53,,,,,,,fee schedule,18364.53,27546.46, Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,27546.46,,,,,,,fee schedule,18364.53,27546.46, Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,21222.47,,,,,,,fee schedule,18364.53,27546.46, Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19100.09,,,,,,,fee schedule,18364.53,27546.46, Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,69358.97,,,,,,,fee schedule,60140.99,90210.38, Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,60140.99,,,,,,,fee schedule,60140.99,90210.38, Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,90210.38,,,,,,,fee schedule,60140.99,90210.38, Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,69500.28,,,,,,,fee schedule,60140.99,90210.38, Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,62549.81,,,,,,,fee schedule,60140.99,90210.38, Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],382161.86,382161.86,382161.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],58546.94,58546.94,58546.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],15223.89,15223.89,15223.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],16939.85,16939.85,16939.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],68870.03,16477.85,236036.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,39766.98,,,,,,,fee schedule,34481.85,51722.14, Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,34481.85,,,,,,,fee schedule,34481.85,51722.14, Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,51722.14,,,,,,,fee schedule,34481.85,51722.14, Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,39848,,,,,,,fee schedule,34481.85,51722.14, Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,35862.95,,,,,,,fee schedule,34481.85,51722.14, Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],32256.13,32256.13,365128.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],31659.78,19906.35,31659.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],47487.81,47487.81,47487.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],15223.89,15223.89,15223.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],9407.28,9407.28,15948.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],15513.87,9128.68,37963.34,17,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],34536.81,22616.2,36336.35,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,132142.94,38103.53,370305,1 through 10,percent of total billed charges,,, Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,32877.89,,,,,,,fee schedule,28508.34,42761.98, Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,28508.34,,,,,,,fee schedule,28508.34,42761.98, Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,42761.98,,,,,,,fee schedule,28508.34,42761.98, Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,32944.87,,,,,,,fee schedule,28508.34,42761.98, Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,29650.18,,,,,,,fee schedule,28508.34,42761.98, Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],23980.86,23980.86,23980.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],8418.29,8418.29,8418.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],9150.71,9150.71,9150.71,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,44114.68,,,,,,,fee schedule,38251.73,57376.89, Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,38251.73,,,,,,,fee schedule,38251.73,57376.89, Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,57376.89,,,,,,,fee schedule,38251.73,57376.89, Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,44204.56,,,,,,,fee schedule,38251.73,57376.89, Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,39783.82,,,,,,,fee schedule,38251.73,57376.89, Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],39722.41,39722.41,39722.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],17649.13,17649.13,17649.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],34097.33,34097.33,35964.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],15442.98,15442.98,28606.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],13771.03,13771.03,13771.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],14426.8,14426.8,17408.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],8740.86,8740.86,8740.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],14033.34,12555.07,28526.02,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],33542.65,33232.81,35522.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],15082.56,15082.56,15082.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,28844.33,,,,,,,fee schedule,25010.85,37515.82, Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,25010.85,,,,,,,fee schedule,25010.85,37515.82, Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,37515.82,,,,,,,fee schedule,25010.85,37515.82, Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,28903.1,,,,,,,fee schedule,25010.85,37515.82, Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,26012.61,,,,,,,fee schedule,25010.85,37515.82, Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],23861.49,17948.07,28011.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],7006.88,7006.88,9566.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],35386.75,35386.75,35386.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],23592.09,20354.69,36423.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],8371.02,6168.66,13771.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],8371.02,8371.02,8371.02,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],8769.64,6422.98,8863.49,21,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],6349.87,6349.87,6349.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],8530.47,6247.8,12555.07,55,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],24523.96,24523.96,27076.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],8740.86,8740.86,8740.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,33448.26,33448.26,34784.32,1 through 10,percent of total billed charges,,, Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Coagulation Disorders,813,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,47915.77,,,,,,,fee schedule,41547.65,62320.71, Coagulation Disorders,813,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,41547.65,,,,,,,fee schedule,41547.65,62320.71, Coagulation Disorders,813,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,62320.71,,,,,,,fee schedule,41547.65,62320.71, Coagulation Disorders,813,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,48013.39,,,,,,,fee schedule,41547.65,62320.71, Coagulation Disorders,813,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,43211.75,,,,,,,fee schedule,41547.65,62320.71, Coagulation Disorders,813,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],31204.14,31204.14,31204.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Coagulation Disorders,813,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coagulation Disorders,813,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],33185.48,33185.48,33185.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Coagulation Disorders,813,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coagulation Disorders,813,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Coagulation Disorders,813,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coagulation Disorders,813,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coagulation Disorders,813,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],7982.38,7982.38,7982.38,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Coagulation Disorders,813,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coagulation Disorders,813,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coagulation Disorders,813,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coagulation Disorders,813,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],12489.28,12489.28,35920.64,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Coagulation Disorders,813,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],38325.53,38325.53,38325.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Coagulation Disorders,813,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coagulation Disorders,813,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Coagulation Disorders,813,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Coagulation Disorders,813,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Coagulation Disorders,813,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Coagulation Disorders,813,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Coagulation Disorders,813,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,66808.15,,,,,,,fee schedule,57929.18,86892.71, Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,57929.18,,,,,,,fee schedule,57929.18,86892.71, Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,86892.71,,,,,,,fee schedule,57929.18,86892.71, Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,66944.26,,,,,,,fee schedule,57929.18,86892.71, Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,60249.41,,,,,,,fee schedule,57929.18,86892.71, Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],8740.86,8740.86,8740.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],3212245.49,3212245.49,3212245.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,31853.8,,,,,,,fee schedule,27620.35,41430.01, Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,27620.35,,,,,,,fee schedule,27620.35,41430.01, Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,41430.01,,,,,,,fee schedule,27620.35,41430.01, Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,31918.69,,,,,,,fee schedule,27620.35,41430.01, Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,28726.62,,,,,,,fee schedule,27620.35,41430.01, Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],12582.68,12582.68,12582.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],25974.56,25974.56,25974.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],7884.24,7884.24,7884.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],8132.8,8132.8,12555.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],8635.12,8635.12,8635.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,29185.19,29185.19,29185.19,1 through 10,percent of total billed charges,,, Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,41987.56,41987.56,41987.56,1 through 10,percent of total billed charges,,, Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,19853.65,,,,,,,fee schedule,17215.05,25822.26, Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,17215.05,,,,,,,fee schedule,17215.05,25822.26, Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,25822.26,,,,,,,fee schedule,17215.05,25822.26, Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,19894.1,,,,,,,fee schedule,17215.05,25822.26, Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,17904.56,,,,,,,fee schedule,17215.05,25822.26, Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],9766.34,9766.34,9766.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],8132.8,8132.8,8132.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,71674.18,,,,,,,fee schedule,62148.5,93221.61, Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,62148.5,,,,,,,fee schedule,62148.5,93221.61, Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,93221.61,,,,,,,fee schedule,62148.5,93221.61, Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,71820.2,,,,,,,fee schedule,62148.5,93221.61, Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,64637.73,,,,,,,fee schedule,62148.5,93221.61, Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,36415.11,,,,,,,fee schedule,31575.45,47362.59, Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,31575.45,,,,,,,fee schedule,31575.45,47362.59, Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,47362.59,,,,,,,fee schedule,31575.45,47362.59, Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,36489.3,,,,,,,fee schedule,31575.45,47362.59, Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,32840.14,,,,,,,fee schedule,31575.45,47362.59, Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,27012.9,,,,,,,fee schedule,23422.82,35133.79, Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,23422.82,,,,,,,fee schedule,23422.82,35133.79, Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,35133.79,,,,,,,fee schedule,23422.82,35133.79, Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,27067.93,,,,,,,fee schedule,23422.82,35133.79, Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,24360.97,,,,,,,fee schedule,23422.82,35133.79, Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,184236.83,,,,,,,fee schedule,159751.29,239624, Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,159751.29,,,,,,,fee schedule,159751.29,239624, Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,239624,,,,,,,fee schedule,159751.29,239624, Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,184612.17,,,,,,,fee schedule,159751.29,239624, Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,166149.78,,,,,,,fee schedule,159751.29,239624, Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],162360.66,162360.66,162360.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,125796.91,125796.91,125796.91,1 through 10,percent of total billed charges,,, Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,70323.38,,,,,,,fee schedule,60977.23,91464.72, Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,60977.23,,,,,,,fee schedule,60977.23,91464.72, Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,91464.72,,,,,,,fee schedule,60977.23,91464.72, Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,70466.65,,,,,,,fee schedule,60977.23,91464.72, Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,63419.54,,,,,,,fee schedule,60977.23,91464.72, Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],95,95,95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,37822.46,,,,,,,fee schedule,32795.76,49193.03, Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,32795.76,,,,,,,fee schedule,32795.76,49193.03, Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,49193.03,,,,,,,fee schedule,32795.76,49193.03, Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,37899.51,,,,,,,fee schedule,32795.76,49193.03, Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,34109.32,,,,,,,fee schedule,32795.76,49193.03, Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,144026.91,,,,,,,fee schedule,124885.37,187325.76, Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,124885.37,,,,,,,fee schedule,124885.37,187325.76, Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,187325.76,,,,,,,fee schedule,124885.37,187325.76, Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,144320.33,,,,,,,fee schedule,124885.37,187325.76, Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,129887.38,,,,,,,fee schedule,124885.37,187325.76, Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],18132.85,18132.85,18132.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,71171.56,,,,,,,fee schedule,61712.68,92567.88, Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,61712.68,,,,,,,fee schedule,61712.68,92567.88, Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,92567.88,,,,,,,fee schedule,61712.68,92567.88, Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,71316.56,,,,,,,fee schedule,61712.68,92567.88, Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,64184.45,,,,,,,fee schedule,61712.68,92567.88, Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],84031.59,84031.59,84031.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,42390.05,,,,,,,fee schedule,36756.31,55133.79, Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,36756.31,,,,,,,fee schedule,36756.31,55133.79, Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,55133.79,,,,,,,fee schedule,36756.31,55133.79, Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,42476.41,,,,,,,fee schedule,36756.31,55133.79, Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,38228.5,,,,,,,fee schedule,36756.31,55133.79, Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,146948.41,,,,,,,fee schedule,127418.59,191125.55, Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,127418.59,,,,,,,fee schedule,127418.59,191125.55, Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,191125.55,,,,,,,fee schedule,127418.59,191125.55, Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,147247.79,,,,,,,fee schedule,127418.59,191125.55, Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,132522.07,,,,,,,fee schedule,127418.59,191125.55, Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,72604.04,,,,,,,fee schedule,62954.78,94431.01, Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,62954.78,,,,,,,fee schedule,62954.78,94431.01, Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,94431.01,,,,,,,fee schedule,62954.78,94431.01, Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,72751.95,,,,,,,fee schedule,62954.78,94431.01, Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,65476.3,,,,,,,fee schedule,62954.78,94431.01, Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],18035.61,18035.61,18035.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,53523.17,,,,,,,fee schedule,46409.81,69613.86, Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,46409.81,,,,,,,fee schedule,46409.81,69613.86, Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,69613.86,,,,,,,fee schedule,46409.81,69613.86, Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,53632.22,,,,,,,fee schedule,46409.81,69613.86, Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,48268.65,,,,,,,fee schedule,46409.81,69613.86, Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,99268.24,,,,,,,fee schedule,86075.24,129111.28, Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,86075.24,,,,,,,fee schedule,86075.24,129111.28, Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,129111.28,,,,,,,fee schedule,86075.24,129111.28, Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,99470.48,,,,,,,fee schedule,86075.24,129111.28, Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,89522.8,,,,,,,fee schedule,86075.24,129111.28, Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],93782.6,93782.6,93782.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],17995,17995,17995,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],10343.26,10343.26,10343.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],109425.9,109425.9,109425.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],85794.48,85794.48,85794.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,47278.07,,,,,,,fee schedule,40994.7,61491.29, Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,40994.7,,,,,,,fee schedule,40994.7,61491.29, Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,61491.29,,,,,,,fee schedule,40994.7,61491.29, Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,47374.39,,,,,,,fee schedule,40994.7,61491.29, Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,42636.65,,,,,,,fee schedule,40994.7,61491.29, Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,37775.34,,,,,,,fee schedule,32754.9,49131.75, Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,32754.9,,,,,,,fee schedule,32754.9,49131.75, Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,49131.75,,,,,,,fee schedule,32754.9,49131.75, Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,37852.3,,,,,,,fee schedule,32754.9,49131.75, Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,34066.83,,,,,,,fee schedule,32754.9,49131.75, Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,22668.34,,,,,,,fee schedule,19655.66,29483.13, Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,19655.66,,,,,,,fee schedule,19655.66,29483.13, Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,29483.13,,,,,,,fee schedule,19655.66,29483.13, Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,22714.52,,,,,,,fee schedule,19655.66,29483.13, Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,20442.93,,,,,,,fee schedule,19655.66,29483.13, Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,16426.38,,,,,,,fee schedule,14243.27,21364.65, Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,14243.27,,,,,,,fee schedule,14243.27,21364.65, Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,21364.65,,,,,,,fee schedule,14243.27,21364.65, Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,16459.85,,,,,,,fee schedule,14243.27,21364.65, Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,14813.76,,,,,,,fee schedule,14243.27,21364.65, Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Acute Leukemia With Mcc,834,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,172459.72,,,,,,,fee schedule,149539.39,224306.33, Acute Leukemia With Mcc,834,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,149539.39,,,,,,,fee schedule,149539.39,224306.33, Acute Leukemia With Mcc,834,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,224306.33,,,,,,,fee schedule,149539.39,224306.33, Acute Leukemia With Mcc,834,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,172811.07,,,,,,,fee schedule,149539.39,224306.33, Acute Leukemia With Mcc,834,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,155528.87,,,,,,,fee schedule,149539.39,224306.33, Acute Leukemia With Mcc,834,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Acute Leukemia With Mcc,834,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute Leukemia With Mcc,834,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],488830.49,488830.49,488830.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Acute Leukemia With Mcc,834,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute Leukemia With Mcc,834,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Acute Leukemia With Mcc,834,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute Leukemia With Mcc,834,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute Leukemia With Mcc,834,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute Leukemia With Mcc,834,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute Leukemia With Mcc,834,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],183148.96,183148.96,183148.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Acute Leukemia With Mcc,834,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute Leukemia With Mcc,834,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],66927.72,47502.94,143926.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Acute Leukemia With Mcc,834,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute Leukemia With Mcc,834,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute Leukemia With Mcc,834,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute Leukemia With Mcc,834,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,205623.08,205623.08,205623.08,1 through 10,percent of total billed charges,,, Acute Leukemia With Mcc,834,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Acute Leukemia With Mcc,834,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Acute Leukemia With Mcc,834,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Acute Leukemia With Mcc,834,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Acute Leukemia With Cc,835,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,65523.32,,,,,,,fee schedule,56815.11,85221.62, Acute Leukemia With Cc,835,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,56815.11,,,,,,,fee schedule,56815.11,85221.62, Acute Leukemia With Cc,835,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,85221.62,,,,,,,fee schedule,56815.11,85221.62, Acute Leukemia With Cc,835,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,65656.81,,,,,,,fee schedule,56815.11,85221.62, Acute Leukemia With Cc,835,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,59090.71,,,,,,,fee schedule,56815.11,85221.62, Acute Leukemia With Cc,835,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Acute Leukemia With Cc,835,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute Leukemia With Cc,835,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],54600.01,54600.01,251008.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Acute Leukemia With Cc,835,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute Leukemia With Cc,835,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Acute Leukemia With Cc,835,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute Leukemia With Cc,835,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute Leukemia With Cc,835,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute Leukemia With Cc,835,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute Leukemia With Cc,835,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],25407.29,25407.29,25407.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Acute Leukemia With Cc,835,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute Leukemia With Cc,835,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],47502.94,47502.94,47502.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Acute Leukemia With Cc,835,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],87788.71,87788.71,87788.71,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Acute Leukemia With Cc,835,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute Leukemia With Cc,835,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute Leukemia With Cc,835,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Acute Leukemia With Cc,835,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Acute Leukemia With Cc,835,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Acute Leukemia With Cc,835,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Acute Leukemia With Cc,835,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,38309.37,,,,,,,fee schedule,33217.96,49826.33, Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,33217.96,,,,,,,fee schedule,33217.96,49826.33, Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,49826.33,,,,,,,fee schedule,33217.96,49826.33, Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,38387.42,,,,,,,fee schedule,33217.96,49826.33, Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,34548.44,,,,,,,fee schedule,33217.96,49826.33, Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,150922.28,,,,,,,fee schedule,130864.33,196294.09, Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,130864.33,,,,,,,fee schedule,130864.33,196294.09, Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,196294.09,,,,,,,fee schedule,130864.33,196294.09, Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,151229.76,,,,,,,fee schedule,130864.33,196294.09, Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,136105.82,,,,,,,fee schedule,130864.33,196294.09, Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],511388.81,511388.81,511388.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],376121.63,281126.41,748717.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],68006.63,68006.63,68006.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],26572.53,26572.53,111643.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],52882.54,52882.54,52882.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,151726.91,151726.91,151726.91,1 through 10,percent of total billed charges,,, Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,65573.58,,,,,,,fee schedule,56858.69,85286.99, Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,56858.69,,,,,,,fee schedule,56858.69,85286.99, Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,85286.99,,,,,,,fee schedule,56858.69,85286.99, Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,65707.18,,,,,,,fee schedule,56858.69,85286.99, Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,59136.04,,,,,,,fee schedule,56858.69,85286.99, Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],39912.57,39366.51,54852.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],193684.27,193684.27,193684.27,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],13902.8,13902.8,13902.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],14564.84,10682.55,27317.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],26572.53,10391.21,26572.53,22,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],56558.39,33304.77,59505.23,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,38448.81,29405.12,198304.3,1 through 10,percent of total billed charges,,, Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,45358.67,,,,,,,fee schedule,39330.39,58994.87, Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,39330.39,,,,,,,fee schedule,39330.39,58994.87, Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,58994.87,,,,,,,fee schedule,39330.39,58994.87, Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,45451.08,,,,,,,fee schedule,39330.39,58994.87, Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,40905.69,,,,,,,fee schedule,39330.39,58994.87, Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,101621.15,,,,,,,fee schedule,88115.44,132171.54, Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,88115.44,,,,,,,fee schedule,88115.44,132171.54, Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,132171.54,,,,,,,fee schedule,88115.44,132171.54, Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,101828.18,,,,,,,fee schedule,88115.44,132171.54, Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,91644.72,,,,,,,fee schedule,88115.44,132171.54, Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],136088.21,136088.21,136088.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,51248.8,,,,,,,fee schedule,44437.7,66655.74, Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,44437.7,,,,,,,fee schedule,44437.7,66655.74, Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,66655.74,,,,,,,fee schedule,44437.7,66655.74, Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,51353.21,,,,,,,fee schedule,44437.7,66655.74, Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,46217.56,,,,,,,fee schedule,44437.7,66655.74, Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,31740.71,,,,,,,fee schedule,27522.29,41282.92, Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,27522.29,,,,,,,fee schedule,27522.29,41282.92, Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,41282.92,,,,,,,fee schedule,27522.29,41282.92, Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,31805.37,,,,,,,fee schedule,27522.29,41282.92, Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,28624.63,,,,,,,fee schedule,27522.29,41282.92, Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],17186.56,17186.56,17186.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,62664.65,,,,,,,fee schedule,54336.36,81503.54, Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,54336.36,,,,,,,fee schedule,54336.36,81503.54, Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,81503.54,,,,,,,fee schedule,54336.36,81503.54, Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,62792.31,,,,,,,fee schedule,54336.36,81503.54, Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,56512.68,,,,,,,fee schedule,54336.36,81503.54, Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,38243.4,,,,,,,fee schedule,33160.76,49740.53, Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,33160.76,,,,,,,fee schedule,33160.76,49740.53, Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,49740.53,,,,,,,fee schedule,33160.76,49740.53, Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,38321.32,,,,,,,fee schedule,33160.76,49740.53, Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,34488.94,,,,,,,fee schedule,33160.76,49740.53, Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,26752.16,,,,,,,fee schedule,23196.73,34794.67, Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,23196.73,,,,,,,fee schedule,23196.73,34794.67, Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,34794.67,,,,,,,fee schedule,23196.73,34794.67, Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,26806.66,,,,,,,fee schedule,23196.73,34794.67, Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,24125.83,,,,,,,fee schedule,23196.73,34794.67, Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,81440.8,,,,,,,fee schedule,70617.11,105924.37, Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,70617.11,,,,,,,fee schedule,70617.11,105924.37, Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,105924.37,,,,,,,fee schedule,70617.11,105924.37, Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,81606.72,,,,,,,fee schedule,70617.11,105924.37, Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,73445.53,,,,,,,fee schedule,70617.11,105924.37, Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],78687.56,78687.56,78687.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],61975.55,52699.74,76766.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],46626,20275.43,389941.29,29,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],17995,17995,17995,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],18337.77,18337.77,18609.32,23,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],20424.39,19399.71,24471.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,43435.59,43435.59,43435.59,1 through 10,percent of total billed charges,,, Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,41095.79,,,,,,,fee schedule,35634.06,53450.44, Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,35634.06,,,,,,,fee schedule,35634.06,53450.44, Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,53450.44,,,,,,,fee schedule,35634.06,53450.44, Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,41179.52,,,,,,,fee schedule,35634.06,53450.44, Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,37061.31,,,,,,,fee schedule,35634.06,53450.44, Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],38542.7,38542.7,39556.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],48722.45,48722.45,48722.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],32482.9,29748.59,48722.45,17,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],9873.11,9873.11,9873.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],8281.86,8281.86,19131.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],18337.77,10061.17,18609.32,23,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],21730.86,19562.26,35434.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],33552.83,33552.83,33552.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,14742.82,9701.76,21789,18,percent of total billed charges,,, Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,16024,16024,16024,1 through 10,percent of total billed charges,,, Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,26683.05,,,,,,,fee schedule,23136.81,34704.79, Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,23136.81,,,,,,,fee schedule,23136.81,34704.79, Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,34704.79,,,,,,,fee schedule,23136.81,34704.79, Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,26737.41,,,,,,,fee schedule,23136.81,34704.79, Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,24063.5,,,,,,,fee schedule,23136.81,34704.79, Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Radiotherapy,849,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,85116.23,,,,,,,fee schedule,73804.07,110704.75, Radiotherapy,849,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,73804.07,,,,,,,fee schedule,73804.07,110704.75, Radiotherapy,849,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,110704.75,,,,,,,fee schedule,73804.07,110704.75, Radiotherapy,849,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,85289.64,,,,,,,fee schedule,73804.07,110704.75, Radiotherapy,849,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,76760.14,,,,,,,fee schedule,73804.07,110704.75, Radiotherapy,849,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Radiotherapy,849,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Radiotherapy,849,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Radiotherapy,849,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Radiotherapy,849,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Radiotherapy,849,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Radiotherapy,849,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Radiotherapy,849,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Radiotherapy,849,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Radiotherapy,849,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Radiotherapy,849,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Radiotherapy,849,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Radiotherapy,849,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Radiotherapy,849,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Radiotherapy,849,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Radiotherapy,849,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Radiotherapy,849,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Radiotherapy,849,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Radiotherapy,849,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Radiotherapy,849,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Acute Leukemia With Other Procedures,850,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,272029.53,,,,,,,fee schedule,235876.12,353809.85, Acute Leukemia With Other Procedures,850,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,235876.12,,,,,,,fee schedule,235876.12,353809.85, Acute Leukemia With Other Procedures,850,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,353809.85,,,,,,,fee schedule,235876.12,353809.85, Acute Leukemia With Other Procedures,850,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,272583.74,,,,,,,fee schedule,235876.12,353809.85, Acute Leukemia With Other Procedures,850,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,245323.64,,,,,,,fee schedule,235876.12,353809.85, Acute Leukemia With Other Procedures,850,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Acute Leukemia With Other Procedures,850,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute Leukemia With Other Procedures,850,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute Leukemia With Other Procedures,850,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute Leukemia With Other Procedures,850,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Acute Leukemia With Other Procedures,850,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute Leukemia With Other Procedures,850,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute Leukemia With Other Procedures,850,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],99058.07,99058.07,99058.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Acute Leukemia With Other Procedures,850,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute Leukemia With Other Procedures,850,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],143143.99,143143.99,143143.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Acute Leukemia With Other Procedures,850,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute Leukemia With Other Procedures,850,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],90359.67,90359.67,90359.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Acute Leukemia With Other Procedures,850,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute Leukemia With Other Procedures,850,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute Leukemia With Other Procedures,850,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute Leukemia With Other Procedures,850,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,329294,329294,329294,1 through 10,percent of total billed charges,,, Acute Leukemia With Other Procedures,850,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Acute Leukemia With Other Procedures,850,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Acute Leukemia With Other Procedures,850,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Acute Leukemia With Other Procedures,850,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,155141.18,,,,,,,fee schedule,134522.53,201781.32, Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,134522.53,,,,,,,fee schedule,134522.53,201781.32, Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,201781.32,,,,,,,fee schedule,134522.53,201781.32, Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,155457.25,,,,,,,fee schedule,134522.53,201781.32, Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,139910.54,,,,,,,fee schedule,134522.53,201781.32, Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],547183.94,547183.94,547183.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],816859.29,816859.29,816859.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],13615.1,13615.1,13615.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],28714.9,28714.9,28714.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],234422.18,234422.18,422957.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],146733.14,146733.14,146733.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,62768.31,,,,,,,fee schedule,54426.25,81638.37, Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,54426.25,,,,,,,fee schedule,54426.25,81638.37, Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,81638.37,,,,,,,fee schedule,54426.25,81638.37, Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,62896.19,,,,,,,fee schedule,54426.25,81638.37, Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,56606.17,,,,,,,fee schedule,54426.25,81638.37, Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],20463.56,20463.56,20463.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,47033.04,,,,,,,fee schedule,40782.23,61172.6, Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,40782.23,,,,,,,fee schedule,40782.23,61172.6, Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,61172.6,,,,,,,fee schedule,40782.23,61172.6, Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,47128.86,,,,,,,fee schedule,40782.23,61172.6, Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,42415.68,,,,,,,fee schedule,40782.23,61172.6, Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,142892.86,,,,,,,fee schedule,123902.04,185850.78, Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,123902.04,,,,,,,fee schedule,123902.04,185850.78, Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,185850.78,,,,,,,fee schedule,123902.04,185850.78, Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,143183.98,,,,,,,fee schedule,123902.04,185850.78, Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,128864.67,,,,,,,fee schedule,123902.04,185850.78, Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,67273.08,,,,,,,fee schedule,58332.32,87497.41, Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,58332.32,,,,,,,fee schedule,58332.32,87497.41, Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,87497.41,,,,,,,fee schedule,58332.32,87497.41, Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,67410.14,,,,,,,fee schedule,58332.32,87497.41, Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,60668.7,,,,,,,fee schedule,58332.32,87497.41, Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],16120.98,16120.98,16120.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],43196.12,43196.12,43196.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,43756.56,,,,,,,fee schedule,37941.2,56911.11, Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,37941.2,,,,,,,fee schedule,37941.2,56911.11, Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,56911.11,,,,,,,fee schedule,37941.2,56911.11, Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,43845.71,,,,,,,fee schedule,37941.2,56911.11, Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,39460.86,,,,,,,fee schedule,37941.2,56911.11, Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],30900.57,30900.57,30900.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],32935.37,32935.37,32935.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],12263.55,12263.55,12263.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,57289.71,,,,,,,fee schedule,49675.76,74512.73, Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,49675.76,,,,,,,fee schedule,49675.76,74512.73, Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,74512.73,,,,,,,fee schedule,49675.76,74512.73, Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,57406.43,,,,,,,fee schedule,49675.76,74512.73, Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,51665.42,,,,,,,fee schedule,49675.76,74512.73, Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],48229.57,48229.57,48229.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],28315.4,28315.4,28315.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],9092.7,9092.7,9092.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,31348.03,,,,,,,fee schedule,27181.8,40772.2, Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,27181.8,,,,,,,fee schedule,27181.8,40772.2, Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,40772.2,,,,,,,fee schedule,27181.8,40772.2, Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,31411.9,,,,,,,fee schedule,27181.8,40772.2, Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,28270.51,,,,,,,fee schedule,27181.8,40772.2, Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],26390.46,26390.46,26390.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],6700.33,6700.33,6700.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Fever And Inflammatory Conditions,864,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,27886.21,,,,,,,fee schedule,24180.06,36269.65, Fever And Inflammatory Conditions,864,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,24180.06,,,,,,,fee schedule,24180.06,36269.65, Fever And Inflammatory Conditions,864,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,36269.65,,,,,,,fee schedule,24180.06,36269.65, Fever And Inflammatory Conditions,864,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,27943.02,,,,,,,fee schedule,24180.06,36269.65, Fever And Inflammatory Conditions,864,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,25148.54,,,,,,,fee schedule,24180.06,36269.65, Fever And Inflammatory Conditions,864,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],27256.1,27256.1,27256.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Fever And Inflammatory Conditions,864,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Fever And Inflammatory Conditions,864,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],22955.57,22955.57,22955.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Fever And Inflammatory Conditions,864,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],34432.01,34432.01,34432.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Fever And Inflammatory Conditions,864,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Fever And Inflammatory Conditions,864,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Fever And Inflammatory Conditions,864,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Fever And Inflammatory Conditions,864,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],10183.37,10183.37,10183.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Fever And Inflammatory Conditions,864,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Fever And Inflammatory Conditions,864,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],10668.3,10668.3,10668.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Fever And Inflammatory Conditions,864,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Fever And Inflammatory Conditions,864,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],6746.74,4851.2,12867.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Fever And Inflammatory Conditions,864,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],24833.31,24833.31,24833.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Fever And Inflammatory Conditions,864,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Fever And Inflammatory Conditions,864,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Fever And Inflammatory Conditions,864,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Fever And Inflammatory Conditions,864,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Fever And Inflammatory Conditions,864,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Fever And Inflammatory Conditions,864,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Fever And Inflammatory Conditions,864,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Viral Illness With Mcc,865,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,47067.6,,,,,,,fee schedule,40812.19,61217.54, Viral Illness With Mcc,865,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,40812.19,,,,,,,fee schedule,40812.19,61217.54, Viral Illness With Mcc,865,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,61217.54,,,,,,,fee schedule,40812.19,61217.54, Viral Illness With Mcc,865,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,47163.49,,,,,,,fee schedule,40812.19,61217.54, Viral Illness With Mcc,865,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,42446.84,,,,,,,fee schedule,40812.19,61217.54, Viral Illness With Mcc,865,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Viral Illness With Mcc,865,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Viral Illness With Mcc,865,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Viral Illness With Mcc,865,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Viral Illness With Mcc,865,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Viral Illness With Mcc,865,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Viral Illness With Mcc,865,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Viral Illness With Mcc,865,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Viral Illness With Mcc,865,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Viral Illness With Mcc,865,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],24163.46,24163.46,24163.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Viral Illness With Mcc,865,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Viral Illness With Mcc,865,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],10888.62,10888.62,10888.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Viral Illness With Mcc,865,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Viral Illness With Mcc,865,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Viral Illness With Mcc,865,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Viral Illness With Mcc,865,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Viral Illness With Mcc,865,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Viral Illness With Mcc,865,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Viral Illness With Mcc,865,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Viral Illness With Mcc,865,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Viral Illness Without Mcc,866,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,27317.61,,,,,,,fee schedule,23687.03,35530.12, Viral Illness Without Mcc,866,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,23687.03,,,,,,,fee schedule,23687.03,35530.12, Viral Illness Without Mcc,866,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,35530.12,,,,,,,fee schedule,23687.03,35530.12, Viral Illness Without Mcc,866,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,27373.27,,,,,,,fee schedule,23687.03,35530.12, Viral Illness Without Mcc,866,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,24635.77,,,,,,,fee schedule,23687.03,35530.12, Viral Illness Without Mcc,866,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],24458.54,24458.54,24458.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Viral Illness Without Mcc,866,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Viral Illness Without Mcc,866,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],18357.96,18048.63,22618.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Viral Illness Without Mcc,866,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Viral Illness Without Mcc,866,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Viral Illness Without Mcc,866,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Viral Illness Without Mcc,866,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Viral Illness Without Mcc,866,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],4626.98,4626.98,4626.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Viral Illness Without Mcc,866,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Viral Illness Without Mcc,866,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],4847.32,4847.32,6646.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Viral Illness Without Mcc,866,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],5067.65,5067.65,5067.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Viral Illness Without Mcc,866,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],6348.01,4715.12,10888.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Viral Illness Without Mcc,866,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],5067.65,5067.65,5067.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Viral Illness Without Mcc,866,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],23392.3,23392.3,23392.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Viral Illness Without Mcc,866,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Viral Illness Without Mcc,866,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,15376.88,15376.88,15376.88,1 through 10,percent of total billed charges,,, Viral Illness Without Mcc,866,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Viral Illness Without Mcc,866,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Viral Illness Without Mcc,866,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Viral Illness Without Mcc,866,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,65755.78,,,,,,,fee schedule,57016.67,85523.97, Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,57016.67,,,,,,,fee schedule,57016.67,85523.97, Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,85523.97,,,,,,,fee schedule,57016.67,85523.97, Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,65889.75,,,,,,,fee schedule,57016.67,85523.97, Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,59300.36,,,,,,,fee schedule,57016.67,85523.97, Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],13034.12,13034.12,13034.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,32390.98,,,,,,,fee schedule,28086.13,42128.68, Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,28086.13,,,,,,,fee schedule,28086.13,42128.68, Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,42128.68,,,,,,,fee schedule,28086.13,42128.68, Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,32456.97,,,,,,,fee schedule,28086.13,42128.68, Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,29211.06,,,,,,,fee schedule,28086.13,42128.68, Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],40263.98,40263.98,40263.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,22922.8,,,,,,,fee schedule,19876.3,29814.08, Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,19876.3,,,,,,,fee schedule,19876.3,29814.08, Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,29814.08,,,,,,,fee schedule,19876.3,29814.08, Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,22969.5,,,,,,,fee schedule,19876.3,29814.08, Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,20672.4,,,,,,,fee schedule,19876.3,29814.08, Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],6892.52,6892.52,6892.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],10215.33,10215.33,10215.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,217127.29,,,,,,,fee schedule,188270.52,282402.32, Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,188270.52,,,,,,,fee schedule,188270.52,282402.32, Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,282402.32,,,,,,,fee schedule,188270.52,282402.32, Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,217569.64,,,,,,,fee schedule,188270.52,282402.32, Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,195811.29,,,,,,,fee schedule,188270.52,282402.32, Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],177829.01,177829.01,177829.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],436859.92,436859.92,436859.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],174475.01,174475.01,174475.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],75593.87,28714.9,295005.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],31687.99,27931.76,154384.19,18,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],193988.96,193988.96,193988.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],34057.18,34057.18,34057.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,782277,782277,782277,1 through 10,percent of total billed charges,,, Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,61021.7,,,,,,,fee schedule,52911.76,79366.67, Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,52911.76,,,,,,,fee schedule,52911.76,79366.67, Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,79366.67,,,,,,,fee schedule,52911.76,79366.67, Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,61146.02,,,,,,,fee schedule,52911.76,79366.67, Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,55031.03,,,,,,,fee schedule,52911.76,79366.67, Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],56071.66,56071.66,73244.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],50157.16,48698.22,227004.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],13985.73,13985.73,31095.69,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],17665.66,14651.71,32576.43,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],17183.87,14252.12,38532.43,30,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],54715.12,54715.12,56991.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,66752.7,66752.7,66752.7,1 through 10,percent of total billed charges,,, Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,32145.95,,,,,,,fee schedule,27873.67,41809.99, Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,27873.67,,,,,,,fee schedule,27873.67,41809.99, Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,41809.99,,,,,,,fee schedule,27873.67,41809.99, Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,32211.44,,,,,,,fee schedule,27873.67,41809.99, Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,28990.09,,,,,,,fee schedule,27873.67,41809.99, Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],28859.25,28859.25,30006.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],24419.57,15737.94,25605.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],8338.93,6619.91,12074.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],9737.44,6935.15,17665.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],9471.88,6746.01,14652.3,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],21913.18,21913.18,21913.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],7213.75,7213.75,7213.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,14497,14497,16130.91,1 through 10,percent of total billed charges,,, Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,121411.97,,,,,,,fee schedule,105276.01,157912.08, O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,105276.01,,,,,,,fee schedule,105276.01,157912.08, O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,157912.08,,,,,,,fee schedule,105276.01,157912.08, O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,121659.32,,,,,,,fee schedule,105276.01,157912.08, O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,109492.62,,,,,,,fee schedule,105276.01,157912.08, O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,30163.72,,,,,,,fee schedule,26154.89,39231.85, Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,26154.89,,,,,,,fee schedule,26154.89,39231.85, Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,39231.85,,,,,,,fee schedule,26154.89,39231.85, Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,30225.18,,,,,,,fee schedule,26154.89,39231.85, Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,27202.47,,,,,,,fee schedule,26154.89,39231.85, Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],24504.69,24504.69,24504.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],7404.89,7404.89,7404.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],7172.89,7172.89,7172.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Depressive Neuroses,881,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,29557.43,,,,,,,fee schedule,25629.18,38443.29, Depressive Neuroses,881,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,25629.18,,,,,,,fee schedule,25629.18,38443.29, Depressive Neuroses,881,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,38443.29,,,,,,,fee schedule,25629.18,38443.29, Depressive Neuroses,881,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,29617.65,,,,,,,fee schedule,25629.18,38443.29, Depressive Neuroses,881,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,26655.7,,,,,,,fee schedule,25629.18,38443.29, Depressive Neuroses,881,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Depressive Neuroses,881,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Depressive Neuroses,881,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Depressive Neuroses,881,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Depressive Neuroses,881,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Depressive Neuroses,881,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Depressive Neuroses,881,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Depressive Neuroses,881,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Depressive Neuroses,881,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Depressive Neuroses,881,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Depressive Neuroses,881,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Depressive Neuroses,881,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Depressive Neuroses,881,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Depressive Neuroses,881,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Depressive Neuroses,881,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Depressive Neuroses,881,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Depressive Neuroses,881,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Depressive Neuroses,881,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Depressive Neuroses,881,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Depressive Neuroses,881,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Neuroses Except Depressive,882,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,33732.35,,,,,,,fee schedule,29249.24,43873.32, Neuroses Except Depressive,882,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,29249.24,,,,,,,fee schedule,29249.24,43873.32, Neuroses Except Depressive,882,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,43873.32,,,,,,,fee schedule,29249.24,43873.32, Neuroses Except Depressive,882,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,33801.08,,,,,,,fee schedule,29249.24,43873.32, Neuroses Except Depressive,882,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,30420.75,,,,,,,fee schedule,29249.24,43873.32, Neuroses Except Depressive,882,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Neuroses Except Depressive,882,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Neuroses Except Depressive,882,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Neuroses Except Depressive,882,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Neuroses Except Depressive,882,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Neuroses Except Depressive,882,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Neuroses Except Depressive,882,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Neuroses Except Depressive,882,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Neuroses Except Depressive,882,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Neuroses Except Depressive,882,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Neuroses Except Depressive,882,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Neuroses Except Depressive,882,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Neuroses Except Depressive,882,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Neuroses Except Depressive,882,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Neuroses Except Depressive,882,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Neuroses Except Depressive,882,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Neuroses Except Depressive,882,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Neuroses Except Depressive,882,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Neuroses Except Depressive,882,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Neuroses Except Depressive,882,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,61769.35,,,,,,,fee schedule,53560.05,80339.09, Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,53560.05,,,,,,,fee schedule,53560.05,80339.09, Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,80339.09,,,,,,,fee schedule,53560.05,80339.09, Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,61895.19,,,,,,,fee schedule,53560.05,80339.09, Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,55705.28,,,,,,,fee schedule,53560.05,80339.09, Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],48182.95,48182.95,51114.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],71084.09,71084.09,71084.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],13041.48,13041.48,13041.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],24368.2,24368.2,24368.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],23703.61,23703.61,23703.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],24687.99,24687.99,48058.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,50541.98,,,,,,,fee schedule,43824.83,65736.44, Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,43824.83,,,,,,,fee schedule,43824.83,65736.44, Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,65736.44,,,,,,,fee schedule,43824.83,65736.44, Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,50644.95,,,,,,,fee schedule,43824.83,65736.44, Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,45580.14,,,,,,,fee schedule,43824.83,65736.44, Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],10980.59,10980.59,10980.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Psychoses,885,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,43879.08,,,,,,,fee schedule,38047.44,57070.45, Psychoses,885,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,38047.44,,,,,,,fee schedule,38047.44,57070.45, Psychoses,885,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,57070.45,,,,,,,fee schedule,38047.44,57070.45, Psychoses,885,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,43968.47,,,,,,,fee schedule,38047.44,57070.45, Psychoses,885,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,39571.34,,,,,,,fee schedule,38047.44,57070.45, Psychoses,885,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Psychoses,885,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Psychoses,885,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],28070.87,28070.87,28070.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Psychoses,885,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Psychoses,885,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Psychoses,885,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Psychoses,885,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Psychoses,885,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Psychoses,885,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Psychoses,885,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Psychoses,885,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Psychoses,885,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],6411.3,6411.3,6411.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Psychoses,885,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Psychoses,885,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Psychoses,885,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Psychoses,885,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Psychoses,885,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Psychoses,885,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Psychoses,885,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Psychoses,885,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Behavioral And Developmental Disorders,886,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,65193.47,,,,,,,fee schedule,56529.1,84792.61, Behavioral And Developmental Disorders,886,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,56529.1,,,,,,,fee schedule,56529.1,84792.61, Behavioral And Developmental Disorders,886,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,84792.61,,,,,,,fee schedule,56529.1,84792.61, Behavioral And Developmental Disorders,886,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,65326.29,,,,,,,fee schedule,56529.1,84792.61, Behavioral And Developmental Disorders,886,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,58793.25,,,,,,,fee schedule,56529.1,84792.61, Behavioral And Developmental Disorders,886,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Behavioral And Developmental Disorders,886,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Behavioral And Developmental Disorders,886,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Behavioral And Developmental Disorders,886,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Behavioral And Developmental Disorders,886,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Behavioral And Developmental Disorders,886,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Behavioral And Developmental Disorders,886,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Behavioral And Developmental Disorders,886,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Behavioral And Developmental Disorders,886,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Behavioral And Developmental Disorders,886,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Behavioral And Developmental Disorders,886,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Behavioral And Developmental Disorders,886,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Behavioral And Developmental Disorders,886,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Behavioral And Developmental Disorders,886,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Behavioral And Developmental Disorders,886,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Behavioral And Developmental Disorders,886,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Behavioral And Developmental Disorders,886,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Behavioral And Developmental Disorders,886,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Behavioral And Developmental Disorders,886,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Behavioral And Developmental Disorders,886,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Mental Disorder Diagnoses,887,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,33641.25,,,,,,,fee schedule,29170.25,43754.83, Other Mental Disorder Diagnoses,887,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,29170.25,,,,,,,fee schedule,29170.25,43754.83, Other Mental Disorder Diagnoses,887,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,43754.83,,,,,,,fee schedule,29170.25,43754.83, Other Mental Disorder Diagnoses,887,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,33709.79,,,,,,,fee schedule,29170.25,43754.83, Other Mental Disorder Diagnoses,887,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,30338.6,,,,,,,fee schedule,29170.25,43754.83, Other Mental Disorder Diagnoses,887,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],36100.67,36100.67,36100.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Mental Disorder Diagnoses,887,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Mental Disorder Diagnoses,887,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],43855.16,43855.16,43855.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Mental Disorder Diagnoses,887,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],30154.63,30154.63,30154.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Mental Disorder Diagnoses,887,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other Mental Disorder Diagnoses,887,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Mental Disorder Diagnoses,887,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Mental Disorder Diagnoses,887,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],14414.68,14414.68,14414.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Mental Disorder Diagnoses,887,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Mental Disorder Diagnoses,887,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],24368.2,24368.2,24368.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Mental Disorder Diagnoses,887,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Mental Disorder Diagnoses,887,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],13952.85,13952.85,14689.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Mental Disorder Diagnoses,887,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],279768.2,279768.2,279768.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Mental Disorder Diagnoses,887,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Mental Disorder Diagnoses,887,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Mental Disorder Diagnoses,887,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,27007.07,27007.07,27007.07,1 through 10,percent of total billed charges,,, Other Mental Disorder Diagnoses,887,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Mental Disorder Diagnoses,887,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Mental Disorder Diagnoses,887,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Mental Disorder Diagnoses,887,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,19379.3,,,,,,,fee schedule,16803.74,25205.3, "Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,16803.74,,,,,,,fee schedule,16803.74,25205.3, "Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,25205.3,,,,,,,fee schedule,16803.74,25205.3, "Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,19418.78,,,,,,,fee schedule,16803.74,25205.3, "Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,17476.78,,,,,,,fee schedule,16803.74,25205.3, "Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,44469.66,,,,,,,fee schedule,38559.53,57838.58, "Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,38559.53,,,,,,,fee schedule,38559.53,57838.58, "Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,57838.58,,,,,,,fee schedule,38559.53,57838.58, "Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,44560.26,,,,,,,fee schedule,38559.53,57838.58, "Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,40103.95,,,,,,,fee schedule,38559.53,57838.58, "Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,54820.57,,,,,,,fee schedule,47534.78,71301.3, "Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,47534.78,,,,,,,fee schedule,47534.78,71301.3, "Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,71301.3,,,,,,,fee schedule,47534.78,71301.3, "Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,54932.26,,,,,,,fee schedule,47534.78,71301.3, "Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,49438.68,,,,,,,fee schedule,47534.78,71301.3, "Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],25684.41,25684.41,25684.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],22811.87,22811.87,22811.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,27732.28,,,,,,,fee schedule,24046.59,36069.44, "Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,24046.59,,,,,,,fee schedule,24046.59,36069.44, "Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,36069.44,,,,,,,fee schedule,24046.59,36069.44, "Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,27788.78,,,,,,,fee schedule,24046.59,36069.44, "Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,25009.72,,,,,,,fee schedule,24046.59,36069.44, "Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],4595.75,4595.75,4595.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,131831.99,,,,,,,fee schedule,114311.19,171464.68, Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,114311.19,,,,,,,fee schedule,114311.19,171464.68, Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,171464.68,,,,,,,fee schedule,114311.19,171464.68, Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,132100.57,,,,,,,fee schedule,114311.19,171464.68, Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,118889.68,,,,,,,fee schedule,114311.19,171464.68, Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,60142.1,,,,,,,fee schedule,52149.07,78222.64, Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,52149.07,,,,,,,fee schedule,52149.07,78222.64, Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,78222.64,,,,,,,fee schedule,52149.07,78222.64, Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,60264.63,,,,,,,fee schedule,52149.07,78222.64, Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,54237.79,,,,,,,fee schedule,52149.07,78222.64, Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,36741.81,,,,,,,fee schedule,31858.73,47787.52, Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,31858.73,,,,,,,fee schedule,31858.73,47787.52, Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,47787.52,,,,,,,fee schedule,31858.73,47787.52, Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,36816.67,,,,,,,fee schedule,31858.73,47787.52, Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,33134.77,,,,,,,fee schedule,31858.73,47787.52, Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,115386.76,,,,,,,fee schedule,100051.57,150075.52, Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,100051.57,,,,,,,fee schedule,100051.57,150075.52, Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,150075.52,,,,,,,fee schedule,100051.57,150075.52, Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,115621.84,,,,,,,fee schedule,100051.57,150075.52, Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,104058.92,,,,,,,fee schedule,100051.57,150075.52, Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,46599.53,,,,,,,fee schedule,40406.33,60608.76, Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,40406.33,,,,,,,fee schedule,40406.33,60608.76, Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,60608.76,,,,,,,fee schedule,40406.33,60608.76, Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,46694.47,,,,,,,fee schedule,40406.33,60608.76, Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,42024.72,,,,,,,fee schedule,40406.33,60608.76, Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hand Procedures For Injuries,906,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,61706.52,,,,,,,fee schedule,53505.57,80257.37, Hand Procedures For Injuries,906,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,53505.57,,,,,,,fee schedule,53505.57,80257.37, Hand Procedures For Injuries,906,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,80257.37,,,,,,,fee schedule,53505.57,80257.37, Hand Procedures For Injuries,906,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,61832.24,,,,,,,fee schedule,53505.57,80257.37, Hand Procedures For Injuries,906,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,55648.62,,,,,,,fee schedule,53505.57,80257.37, Hand Procedures For Injuries,906,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Hand Procedures For Injuries,906,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hand Procedures For Injuries,906,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hand Procedures For Injuries,906,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hand Procedures For Injuries,906,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Hand Procedures For Injuries,906,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hand Procedures For Injuries,906,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hand Procedures For Injuries,906,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hand Procedures For Injuries,906,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hand Procedures For Injuries,906,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hand Procedures For Injuries,906,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hand Procedures For Injuries,906,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hand Procedures For Injuries,906,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hand Procedures For Injuries,906,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hand Procedures For Injuries,906,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hand Procedures For Injuries,906,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hand Procedures For Injuries,906,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hand Procedures For Injuries,906,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hand Procedures For Injuries,906,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hand Procedures For Injuries,906,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,120607.77,,,,,,,fee schedule,104578.69,156866.12, Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,104578.69,,,,,,,fee schedule,104578.69,156866.12, Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,156866.12,,,,,,,fee schedule,104578.69,156866.12, Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,120853.49,,,,,,,fee schedule,104578.69,156866.12, Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,108767.37,,,,,,,fee schedule,104578.69,156866.12, Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],170024.7,170024.7,170024.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,62677.21,,,,,,,fee schedule,54347.25,81519.88, Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,54347.25,,,,,,,fee schedule,54347.25,81519.88, Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,81519.88,,,,,,,fee schedule,54347.25,81519.88, Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,62804.91,,,,,,,fee schedule,54347.25,81519.88, Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,56524.02,,,,,,,fee schedule,54347.25,81519.88, Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],19848.87,19848.87,55423.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,41237.16,,,,,,,fee schedule,35756.64,53634.3, Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,35756.64,,,,,,,fee schedule,35756.64,53634.3, Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,53634.3,,,,,,,fee schedule,35756.64,53634.3, Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,41321.17,,,,,,,fee schedule,35756.64,53634.3, Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,37188.79,,,,,,,fee schedule,35756.64,53634.3, Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],31029.96,31029.96,31029.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,13699.19,13699.19,13699.19,1 through 10,percent of total billed charges,,, Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Traumatic Injury With Mcc,913,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,51349.32,,,,,,,fee schedule,44524.87,66786.49, Traumatic Injury With Mcc,913,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,44524.87,,,,,,,fee schedule,44524.87,66786.49, Traumatic Injury With Mcc,913,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,66786.49,,,,,,,fee schedule,44524.87,66786.49, Traumatic Injury With Mcc,913,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,51453.94,,,,,,,fee schedule,44524.87,66786.49, Traumatic Injury With Mcc,913,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,46308.22,,,,,,,fee schedule,44524.87,66786.49, Traumatic Injury With Mcc,913,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Injury With Mcc,913,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Injury With Mcc,913,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Injury With Mcc,913,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Injury With Mcc,913,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Injury With Mcc,913,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Injury With Mcc,913,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Injury With Mcc,913,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Injury With Mcc,913,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Injury With Mcc,913,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Injury With Mcc,913,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Injury With Mcc,913,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],12997.19,12997.19,12997.19,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Traumatic Injury With Mcc,913,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Injury With Mcc,913,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Injury With Mcc,913,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Injury With Mcc,913,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Traumatic Injury With Mcc,913,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Traumatic Injury With Mcc,913,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Traumatic Injury With Mcc,913,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Traumatic Injury With Mcc,913,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Traumatic Injury Without Mcc,914,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,27817.1,,,,,,,fee schedule,24120.13,36179.76, Traumatic Injury Without Mcc,914,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,24120.13,,,,,,,fee schedule,24120.13,36179.76, Traumatic Injury Without Mcc,914,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,36179.76,,,,,,,fee schedule,24120.13,36179.76, Traumatic Injury Without Mcc,914,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,27873.77,,,,,,,fee schedule,24120.13,36179.76, Traumatic Injury Without Mcc,914,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,25086.22,,,,,,,fee schedule,24120.13,36179.76, Traumatic Injury Without Mcc,914,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Injury Without Mcc,914,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Injury Without Mcc,914,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],23417.93,23417.93,23417.93,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Traumatic Injury Without Mcc,914,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Injury Without Mcc,914,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Injury Without Mcc,914,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Injury Without Mcc,914,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Injury Without Mcc,914,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Injury Without Mcc,914,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Injury Without Mcc,914,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Injury Without Mcc,914,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Injury Without Mcc,914,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Injury Without Mcc,914,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Injury Without Mcc,914,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Injury Without Mcc,914,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Traumatic Injury Without Mcc,914,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Traumatic Injury Without Mcc,914,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Traumatic Injury Without Mcc,914,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Traumatic Injury Without Mcc,914,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Traumatic Injury Without Mcc,914,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Allergic Reactions With Mcc,915,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,52825.78,,,,,,,fee schedule,45805.1,68706.81, Allergic Reactions With Mcc,915,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,45805.1,,,,,,,fee schedule,45805.1,68706.81, Allergic Reactions With Mcc,915,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,68706.81,,,,,,,fee schedule,45805.1,68706.81, Allergic Reactions With Mcc,915,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,52933.4,,,,,,,fee schedule,45805.1,68706.81, Allergic Reactions With Mcc,915,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,47639.73,,,,,,,fee schedule,45805.1,68706.81, Allergic Reactions With Mcc,915,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Allergic Reactions With Mcc,915,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Allergic Reactions With Mcc,915,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Allergic Reactions With Mcc,915,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Allergic Reactions With Mcc,915,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Allergic Reactions With Mcc,915,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Allergic Reactions With Mcc,915,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Allergic Reactions With Mcc,915,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Allergic Reactions With Mcc,915,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Allergic Reactions With Mcc,915,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],13156.64,13156.64,13156.64,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Allergic Reactions With Mcc,915,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Allergic Reactions With Mcc,915,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Allergic Reactions With Mcc,915,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Allergic Reactions With Mcc,915,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Allergic Reactions With Mcc,915,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Allergic Reactions With Mcc,915,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Allergic Reactions With Mcc,915,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Allergic Reactions With Mcc,915,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Allergic Reactions With Mcc,915,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Allergic Reactions With Mcc,915,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Allergic Reactions Without Mcc,916,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,20931.15,,,,,,,fee schedule,18149.35,27223.69, Allergic Reactions Without Mcc,916,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,18149.35,,,,,,,fee schedule,18149.35,27223.69, Allergic Reactions Without Mcc,916,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,27223.69,,,,,,,fee schedule,18149.35,27223.69, Allergic Reactions Without Mcc,916,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,20973.79,,,,,,,fee schedule,18149.35,27223.69, Allergic Reactions Without Mcc,916,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,18876.28,,,,,,,fee schedule,18149.35,27223.69, Allergic Reactions Without Mcc,916,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],16132.02,16132.02,16132.02,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Allergic Reactions Without Mcc,916,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Allergic Reactions Without Mcc,916,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Allergic Reactions Without Mcc,916,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Allergic Reactions Without Mcc,916,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Allergic Reactions Without Mcc,916,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Allergic Reactions Without Mcc,916,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Allergic Reactions Without Mcc,916,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Allergic Reactions Without Mcc,916,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Allergic Reactions Without Mcc,916,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],5971.49,5971.49,5971.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Allergic Reactions Without Mcc,916,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Allergic Reactions Without Mcc,916,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Allergic Reactions Without Mcc,916,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Allergic Reactions Without Mcc,916,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Allergic Reactions Without Mcc,916,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Allergic Reactions Without Mcc,916,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,6895.15,6895.15,6895.15,1 through 10,percent of total billed charges,,, Allergic Reactions Without Mcc,916,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Allergic Reactions Without Mcc,916,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Allergic Reactions Without Mcc,916,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Allergic Reactions Without Mcc,916,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,49269.72,,,,,,,fee schedule,42721.65,64081.69, Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,42721.65,,,,,,,fee schedule,42721.65,64081.69, Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,64081.69,,,,,,,fee schedule,42721.65,64081.69, Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,49370.1,,,,,,,fee schedule,42721.65,64081.69, Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,44432.77,,,,,,,fee schedule,42721.65,64081.69, Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],21299.83,21299.83,21299.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],17758.79,13586.4,20922.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],10317.51,6385.78,11927.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],6384.2,5839.06,10545.12,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,26924.94,,,,,,,fee schedule,23346.55,35019.39, Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,23346.55,,,,,,,fee schedule,23346.55,35019.39, Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,35019.39,,,,,,,fee schedule,23346.55,35019.39, Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,26979.79,,,,,,,fee schedule,23346.55,35019.39, Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,24281.64,,,,,,,fee schedule,23346.55,35019.39, Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],6966.31,6966.31,6966.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],20879.5,20879.5,26849.38,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],22416.87,15506.8,28205.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],12836,12836,12836,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],8187.64,8187.64,9848.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],5521.49,4417.9,6253.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],4346.99,3835.3,6384.2,25,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],24667.96,24513.09,24667.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,19896.99,19896.99,19896.99,1 through 10,percent of total billed charges,,, Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Complications Of Treatment With Mcc,919,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,57512.75,,,,,,,fee schedule,49869.16,74802.83, Complications Of Treatment With Mcc,919,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,49869.16,,,,,,,fee schedule,49869.16,74802.83, Complications Of Treatment With Mcc,919,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,74802.83,,,,,,,fee schedule,49869.16,74802.83, Complications Of Treatment With Mcc,919,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,57629.92,,,,,,,fee schedule,49869.16,74802.83, Complications Of Treatment With Mcc,919,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,51866.56,,,,,,,fee schedule,49869.16,74802.83, Complications Of Treatment With Mcc,919,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Complications Of Treatment With Mcc,919,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complications Of Treatment With Mcc,919,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],19007.01,19007.01,19007.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Complications Of Treatment With Mcc,919,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],48326.34,48326.34,48326.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Complications Of Treatment With Mcc,919,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Complications Of Treatment With Mcc,919,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complications Of Treatment With Mcc,919,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complications Of Treatment With Mcc,919,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],8398.97,8398.97,8398.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Complications Of Treatment With Mcc,919,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complications Of Treatment With Mcc,919,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],13992.09,13992.09,13992.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Complications Of Treatment With Mcc,919,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],9198.87,9198.87,9198.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Complications Of Treatment With Mcc,919,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],10629.59,8558.95,25784.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Complications Of Treatment With Mcc,919,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],16957.81,16957.81,16957.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Complications Of Treatment With Mcc,919,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complications Of Treatment With Mcc,919,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complications Of Treatment With Mcc,919,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Complications Of Treatment With Mcc,919,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Complications Of Treatment With Mcc,919,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Complications Of Treatment With Mcc,919,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Complications Of Treatment With Mcc,919,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Complications Of Treatment With Cc,920,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,31486.25,,,,,,,fee schedule,27301.65,40951.97, Complications Of Treatment With Cc,920,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,27301.65,,,,,,,fee schedule,27301.65,40951.97, Complications Of Treatment With Cc,920,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,40951.97,,,,,,,fee schedule,27301.65,40951.97, Complications Of Treatment With Cc,920,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,31550.4,,,,,,,fee schedule,27301.65,40951.97, Complications Of Treatment With Cc,920,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,28395.16,,,,,,,fee schedule,27301.65,40951.97, Complications Of Treatment With Cc,920,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Complications Of Treatment With Cc,920,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complications Of Treatment With Cc,920,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],38952.65,38952.65,38952.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Complications Of Treatment With Cc,920,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complications Of Treatment With Cc,920,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Complications Of Treatment With Cc,920,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complications Of Treatment With Cc,920,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complications Of Treatment With Cc,920,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],13964.01,13964.01,13964.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Complications Of Treatment With Cc,920,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complications Of Treatment With Cc,920,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complications Of Treatment With Cc,920,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complications Of Treatment With Cc,920,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],8509.98,8509.98,8509.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Complications Of Treatment With Cc,920,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complications Of Treatment With Cc,920,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complications Of Treatment With Cc,920,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complications Of Treatment With Cc,920,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Complications Of Treatment With Cc,920,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Complications Of Treatment With Cc,920,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Complications Of Treatment With Cc,920,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Complications Of Treatment With Cc,920,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,21625.4,,,,,,,fee schedule,18751.33,28126.65, Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,18751.33,,,,,,,fee schedule,18751.33,28126.65, Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,28126.65,,,,,,,fee schedule,18751.33,28126.65, Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,21669.46,,,,,,,fee schedule,18751.33,28126.65, Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,19502.37,,,,,,,fee schedule,18751.33,28126.65, Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],18416.52,18416.52,18416.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],7152.78,7152.78,7152.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],5553.7,5553.7,5553.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,54955.65,,,,,,,fee schedule,47651.91,71476.99, "Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,47651.91,,,,,,,fee schedule,47651.91,71476.99, "Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,71476.99,,,,,,,fee schedule,47651.91,71476.99, "Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,55067.61,,,,,,,fee schedule,47651.91,71476.99, "Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,49560.5,,,,,,,fee schedule,47651.91,71476.99, "Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],38637.69,38637.69,38637.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],21149.73,21149.73,21149.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],13478.14,7009.65,29965.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],15067.46,13257.92,29148.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,95132.7,95132.7,95132.7,1 through 10,percent of total billed charges,,, "Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,31970.03,,,,,,,fee schedule,27721.13,41581.19, "Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,27721.13,,,,,,,fee schedule,27721.13,41581.19, "Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,41581.19,,,,,,,fee schedule,27721.13,41581.19, "Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,32035.16,,,,,,,fee schedule,27721.13,41581.19, "Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,28831.44,,,,,,,fee schedule,27721.13,41581.19, "Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],23285.48,23285.48,23285.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],23559.04,23559.04,23559.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],404439.28,404439.28,404439.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],13708.6,13708.6,13708.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,670704.61,,,,,,,fee schedule,581566.27,872338.73, Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,581566.27,,,,,,,fee schedule,581566.27,872338.73, Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,872338.73,,,,,,,fee schedule,581566.27,872338.73, Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,672071.04,,,,,,,fee schedule,581566.27,872338.73, Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,604859.67,,,,,,,fee schedule,581566.27,872338.73, Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,225323.2,,,,,,,fee schedule,195377.18,293062.18, Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,195377.18,,,,,,,fee schedule,195377.18,293062.18, Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,293062.18,,,,,,,fee schedule,195377.18,293062.18, Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,225782.25,,,,,,,fee schedule,195377.18,293062.18, Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,203202.59,,,,,,,fee schedule,195377.18,293062.18, Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,101178.21,,,,,,,fee schedule,87731.37,131595.45, Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,87731.37,,,,,,,fee schedule,87731.37,131595.45, Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,131595.45,,,,,,,fee schedule,87731.37,131595.45, Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,101384.34,,,,,,,fee schedule,87731.37,131595.45, Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,91245.26,,,,,,,fee schedule,87731.37,131595.45, Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,122332.4,,,,,,,fee schedule,106074.11,159109.22, Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,106074.11,,,,,,,fee schedule,106074.11,159109.22, Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,159109.22,,,,,,,fee schedule,106074.11,159109.22, Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,122581.63,,,,,,,fee schedule,106074.11,159109.22, Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,110322.69,,,,,,,fee schedule,106074.11,159109.22, Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,69443.79,,,,,,,fee schedule,60214.53,90320.69, Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,60214.53,,,,,,,fee schedule,60214.53,90320.69, Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,90320.69,,,,,,,fee schedule,60214.53,90320.69, Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,69585.27,,,,,,,fee schedule,60214.53,90320.69, Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,62626.3,,,,,,,fee schedule,60214.53,90320.69, Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Non-Extensive Burns,935,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,64712.84,,,,,,,fee schedule,56112.34,84167.48, Non-Extensive Burns,935,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,56112.34,,,,,,,fee schedule,56112.34,84167.48, Non-Extensive Burns,935,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,84167.48,,,,,,,fee schedule,56112.34,84167.48, Non-Extensive Burns,935,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,64844.68,,,,,,,fee schedule,56112.34,84167.48, Non-Extensive Burns,935,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,58359.8,,,,,,,fee schedule,56112.34,84167.48, Non-Extensive Burns,935,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Non-Extensive Burns,935,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Extensive Burns,935,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Extensive Burns,935,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Extensive Burns,935,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Non-Extensive Burns,935,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Extensive Burns,935,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Extensive Burns,935,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Extensive Burns,935,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Extensive Burns,935,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Extensive Burns,935,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Extensive Burns,935,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Extensive Burns,935,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Extensive Burns,935,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Extensive Burns,935,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Extensive Burns,935,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Non-Extensive Burns,935,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Non-Extensive Burns,935,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Non-Extensive Burns,935,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Non-Extensive Burns,935,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,113985.7,,,,,,,fee schedule,98836.71,148253.25, O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,98836.71,,,,,,,fee schedule,98836.71,148253.25, O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,148253.25,,,,,,,fee schedule,98836.71,148253.25, O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,114217.92,,,,,,,fee schedule,98836.71,148253.25, O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,102795.41,,,,,,,fee schedule,98836.71,148253.25, O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,73411.38,,,,,,,fee schedule,63654.82,95481.06, O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,63654.82,,,,,,,fee schedule,63654.82,95481.06, O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,95481.06,,,,,,,fee schedule,63654.82,95481.06, O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,73560.94,,,,,,,fee schedule,63654.82,95481.06, O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,66204.38,,,,,,,fee schedule,63654.82,95481.06, O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,63698.17,,,,,,,fee schedule,55232.52,82847.77, O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,55232.52,,,,,,,fee schedule,55232.52,82847.77, O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,82847.77,,,,,,,fee schedule,55232.52,82847.77, O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,63827.94,,,,,,,fee schedule,55232.52,82847.77, O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,57444.74,,,,,,,fee schedule,55232.52,82847.77, O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,48647.72,,,,,,,fee schedule,42182.32,63272.7, Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,42182.32,,,,,,,fee schedule,42182.32,63272.7, Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,63272.7,,,,,,,fee schedule,42182.32,63272.7, Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,48746.83,,,,,,,fee schedule,42182.32,63272.7, Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,43871.84,,,,,,,fee schedule,42182.32,63272.7, Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,36025.58,,,,,,,fee schedule,31237.69,46855.95, Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,31237.69,,,,,,,fee schedule,31237.69,46855.95, Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,46855.95,,,,,,,fee schedule,31237.69,46855.95, Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,36098.97,,,,,,,fee schedule,31237.69,46855.95, Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,32488.84,,,,,,,fee schedule,31237.69,46855.95, Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Signs And Symptoms With Mcc,947,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,39876.93,,,,,,,fee schedule,34577.19,51865.15, Signs And Symptoms With Mcc,947,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,34577.19,,,,,,,fee schedule,34577.19,51865.15, Signs And Symptoms With Mcc,947,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,51865.15,,,,,,,fee schedule,34577.19,51865.15, Signs And Symptoms With Mcc,947,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,39958.17,,,,,,,fee schedule,34577.19,51865.15, Signs And Symptoms With Mcc,947,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,35962.1,,,,,,,fee schedule,34577.19,51865.15, Signs And Symptoms With Mcc,947,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Signs And Symptoms With Mcc,947,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Signs And Symptoms With Mcc,947,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Signs And Symptoms With Mcc,947,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Signs And Symptoms With Mcc,947,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Signs And Symptoms With Mcc,947,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Signs And Symptoms With Mcc,947,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Signs And Symptoms With Mcc,947,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Signs And Symptoms With Mcc,947,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Signs And Symptoms With Mcc,947,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Signs And Symptoms With Mcc,947,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Signs And Symptoms With Mcc,947,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],11936.1,11936.1,11936.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Signs And Symptoms With Mcc,947,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Signs And Symptoms With Mcc,947,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Signs And Symptoms With Mcc,947,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Signs And Symptoms With Mcc,947,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Signs And Symptoms With Mcc,947,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Signs And Symptoms With Mcc,947,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Signs And Symptoms With Mcc,947,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Signs And Symptoms With Mcc,947,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Signs And Symptoms Without Mcc,948,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,25146.91,,,,,,,fee schedule,21804.82,32706.83, Signs And Symptoms Without Mcc,948,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,21804.82,,,,,,,fee schedule,21804.82,32706.83, Signs And Symptoms Without Mcc,948,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,32706.83,,,,,,,fee schedule,21804.82,32706.83, Signs And Symptoms Without Mcc,948,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,25198.14,,,,,,,fee schedule,21804.82,32706.83, Signs And Symptoms Without Mcc,948,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,22678.17,,,,,,,fee schedule,21804.82,32706.83, Signs And Symptoms Without Mcc,948,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],6292.35,6292.35,6292.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Signs And Symptoms Without Mcc,948,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Signs And Symptoms Without Mcc,948,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],17465.63,17465.63,17465.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Signs And Symptoms Without Mcc,948,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Signs And Symptoms Without Mcc,948,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Signs And Symptoms Without Mcc,948,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Signs And Symptoms Without Mcc,948,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Signs And Symptoms Without Mcc,948,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],5376.76,5376.76,5376.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Signs And Symptoms Without Mcc,948,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Signs And Symptoms Without Mcc,948,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],5632.79,5632.79,5632.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Signs And Symptoms Without Mcc,948,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Signs And Symptoms Without Mcc,948,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],7381.75,7327.85,7381.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Signs And Symptoms Without Mcc,948,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Signs And Symptoms Without Mcc,948,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Signs And Symptoms Without Mcc,948,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Signs And Symptoms Without Mcc,948,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,8493.94,8493.94,8493.94,1 through 10,percent of total billed charges,,, Signs And Symptoms Without Mcc,948,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Signs And Symptoms Without Mcc,948,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Signs And Symptoms Without Mcc,948,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Signs And Symptoms Without Mcc,948,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Aftercare With Cc/Mcc,949,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,37373.24,,,,,,,fee schedule,32406.24,48608.76, Aftercare With Cc/Mcc,949,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,32406.24,,,,,,,fee schedule,32406.24,48608.76, Aftercare With Cc/Mcc,949,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,48608.76,,,,,,,fee schedule,32406.24,48608.76, Aftercare With Cc/Mcc,949,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,37449.38,,,,,,,fee schedule,32406.24,48608.76, Aftercare With Cc/Mcc,949,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,33704.2,,,,,,,fee schedule,32406.24,48608.76, Aftercare With Cc/Mcc,949,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Aftercare With Cc/Mcc,949,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Aftercare With Cc/Mcc,949,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Aftercare With Cc/Mcc,949,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Aftercare With Cc/Mcc,949,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Aftercare With Cc/Mcc,949,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Aftercare With Cc/Mcc,949,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Aftercare With Cc/Mcc,949,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Aftercare With Cc/Mcc,949,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Aftercare With Cc/Mcc,949,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Aftercare With Cc/Mcc,949,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Aftercare With Cc/Mcc,949,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Aftercare With Cc/Mcc,949,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Aftercare With Cc/Mcc,949,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Aftercare With Cc/Mcc,949,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Aftercare With Cc/Mcc,949,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Aftercare With Cc/Mcc,949,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Aftercare With Cc/Mcc,949,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Aftercare With Cc/Mcc,949,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Aftercare With Cc/Mcc,949,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Aftercare Without Cc/Mcc,950,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,19718.57,,,,,,,fee schedule,17097.92,25646.57, Aftercare Without Cc/Mcc,950,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,17097.92,,,,,,,fee schedule,17097.92,25646.57, Aftercare Without Cc/Mcc,950,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,25646.57,,,,,,,fee schedule,17097.92,25646.57, Aftercare Without Cc/Mcc,950,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,19758.74,,,,,,,fee schedule,17097.92,25646.57, Aftercare Without Cc/Mcc,950,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,17782.74,,,,,,,fee schedule,17097.92,25646.57, Aftercare Without Cc/Mcc,950,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Aftercare Without Cc/Mcc,950,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Aftercare Without Cc/Mcc,950,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Aftercare Without Cc/Mcc,950,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Aftercare Without Cc/Mcc,950,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Aftercare Without Cc/Mcc,950,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Aftercare Without Cc/Mcc,950,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Aftercare Without Cc/Mcc,950,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Aftercare Without Cc/Mcc,950,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Aftercare Without Cc/Mcc,950,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Aftercare Without Cc/Mcc,950,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Aftercare Without Cc/Mcc,950,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Aftercare Without Cc/Mcc,950,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Aftercare Without Cc/Mcc,950,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Aftercare Without Cc/Mcc,950,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Aftercare Without Cc/Mcc,950,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Aftercare Without Cc/Mcc,950,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Aftercare Without Cc/Mcc,950,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Aftercare Without Cc/Mcc,950,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Aftercare Without Cc/Mcc,950,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Factors Influencing Health Status,951,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,17466.18,,,,,,,fee schedule,15144.88,22717.05, Other Factors Influencing Health Status,951,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,15144.88,,,,,,,fee schedule,15144.88,22717.05, Other Factors Influencing Health Status,951,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,22717.05,,,,,,,fee schedule,15144.88,22717.05, Other Factors Influencing Health Status,951,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,17501.77,,,,,,,fee schedule,15144.88,22717.05, Other Factors Influencing Health Status,951,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,15751.48,,,,,,,fee schedule,15144.88,22717.05, Other Factors Influencing Health Status,951,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Other Factors Influencing Health Status,951,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Factors Influencing Health Status,951,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Factors Influencing Health Status,951,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Factors Influencing Health Status,951,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other Factors Influencing Health Status,951,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Factors Influencing Health Status,951,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Factors Influencing Health Status,951,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Factors Influencing Health Status,951,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Factors Influencing Health Status,951,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],216656.17,216656.17,216656.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Factors Influencing Health Status,951,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Factors Influencing Health Status,951,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],1190.75,1190.75,11936.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Factors Influencing Health Status,951,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],69374.49,69374.49,69374.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Factors Influencing Health Status,951,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Factors Influencing Health Status,951,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Factors Influencing Health Status,951,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Factors Influencing Health Status,951,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Factors Influencing Health Status,951,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Factors Influencing Health Status,951,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Factors Influencing Health Status,951,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,211450.78,,,,,,,fee schedule,183348.43,275019.28, Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,183348.43,,,,,,,fee schedule,183348.43,275019.28, Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,275019.28,,,,,,,fee schedule,183348.43,275019.28, Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,211881.57,,,,,,,fee schedule,183348.43,275019.28, Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,190692.06,,,,,,,fee schedule,183348.43,275019.28, Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,118210.88,,,,,,,fee schedule,102500.36,153748.65, "Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,102500.36,,,,,,,fee schedule,102500.36,153748.65, "Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,153748.65,,,,,,,fee schedule,102500.36,153748.65, "Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,118451.71,,,,,,,fee schedule,102500.36,153748.65, "Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,106605.79,,,,,,,fee schedule,102500.36,153748.65, "Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. "Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. "Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],73827.21,73827.21,73827.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." "Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. "Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. "Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,239371.54,,,,,,,fee schedule,207558.46,311333.87, Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,207558.46,,,,,,,fee schedule,207558.46,311333.87, Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,311333.87,,,,,,,fee schedule,207558.46,311333.87, Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,239859.21,,,,,,,fee schedule,207558.46,311333.87, Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,215871.77,,,,,,,fee schedule,207558.46,311333.87, Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],98098.94,98098.94,98098.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],208146.68,208146.68,208146.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,132375.45,,,,,,,fee schedule,114782.42,172171.53, Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,114782.42,,,,,,,fee schedule,114782.42,172171.53, Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,172171.53,,,,,,,fee schedule,114782.42,172171.53, Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,132645.14,,,,,,,fee schedule,114782.42,172171.53, Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,119379.79,,,,,,,fee schedule,114782.42,172171.53, Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,92485.96,,,,,,,fee schedule,80194.34,120290.04, Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,80194.34,,,,,,,fee schedule,80194.34,120290.04, Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,120290.04,,,,,,,fee schedule,80194.34,120290.04, Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,92674.38,,,,,,,fee schedule,80194.34,120290.04, Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,83406.35,,,,,,,fee schedule,80194.34,120290.04, Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,85879.59,,,,,,,fee schedule,74465.98,111697.6, Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,74465.98,,,,,,,fee schedule,74465.98,111697.6, Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,111697.6,,,,,,,fee schedule,74465.98,111697.6, Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,86054.56,,,,,,,fee schedule,74465.98,111697.6, Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,77448.55,,,,,,,fee schedule,74465.98,111697.6, Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],18269.63,18269.63,18269.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],39083.39,39083.39,39083.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],74844.36,74844.36,74844.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,48145.1,,,,,,,fee schedule,41746.49,62618.97, Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,41746.49,,,,,,,fee schedule,41746.49,62618.97, Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,62618.97,,,,,,,fee schedule,41746.49,62618.97, Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,48243.18,,,,,,,fee schedule,41746.49,62618.97, Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,43418.56,,,,,,,fee schedule,41746.49,62618.97, Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],10917.42,10917.42,10917.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],11437.29,11437.29,11437.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],39060.72,39060.72,39060.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,29544.87,,,,,,,fee schedule,25618.28,38426.95, Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,25618.28,,,,,,,fee schedule,25618.28,38426.95, Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,38426.95,,,,,,,fee schedule,25618.28,38426.95, Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,29605.06,,,,,,,fee schedule,25618.28,38426.95, Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,26644.37,,,,,,,fee schedule,25618.28,38426.95, Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],27468.62,27468.62,27468.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,192294.52,,,,,,,fee schedule,166738.09,250104.08, Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,166738.09,,,,,,,fee schedule,166738.09,250104.08, Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,250104.08,,,,,,,fee schedule,166738.09,250104.08, Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,192686.28,,,,,,,fee schedule,166738.09,250104.08, Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,173416.43,,,,,,,fee schedule,166738.09,250104.08, Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,82851.28,,,,,,,fee schedule,71840.14,107758.89, Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,71840.14,,,,,,,fee schedule,71840.14,107758.89, Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,107758.89,,,,,,,fee schedule,71840.14,107758.89, Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,83020.08,,,,,,,fee schedule,71840.14,107758.89, Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,74717.54,,,,,,,fee schedule,71840.14,107758.89, Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,90660.8,,,,,,,fee schedule,78611.75,117916.19, Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,78611.75,,,,,,,fee schedule,78611.75,117916.19, Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,117916.19,,,,,,,fee schedule,78611.75,117916.19, Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,90845.51,,,,,,,fee schedule,78611.75,117916.19, Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,81760.38,,,,,,,fee schedule,78611.75,117916.19, Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,40681.13,,,,,,,fee schedule,35274.51,52911.11, Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,35274.51,,,,,,,fee schedule,35274.51,52911.11, Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,52911.11,,,,,,,fee schedule,35274.51,52911.11, Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,40764.01,,,,,,,fee schedule,35274.51,52911.11, Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,36687.35,,,,,,,fee schedule,35274.51,52911.11, Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,28357.42,,,,,,,fee schedule,24588.65,36882.52, Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,24588.65,,,,,,,fee schedule,24588.65,36882.52, Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,36882.52,,,,,,,fee schedule,24588.65,36882.52, Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,28415.19,,,,,,,fee schedule,24588.65,36882.52, Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,25573.49,,,,,,,fee schedule,24588.65,36882.52, Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,40765.95,,,,,,,fee schedule,35348.05,53021.43, Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,35348.05,,,,,,,fee schedule,35348.05,53021.43, Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,53021.43,,,,,,,fee schedule,35348.05,53021.43, Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,40849,,,,,,,fee schedule,35348.05,53021.43, Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,36763.84,,,,,,,fee schedule,35348.05,53021.43, Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,147388.21,,,,,,,fee schedule,127799.94,191697.56, Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,127799.94,,,,,,,fee schedule,127799.94,191697.56, Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,191697.56,,,,,,,fee schedule,127799.94,191697.56, Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,147688.48,,,,,,,fee schedule,127799.94,191697.56, Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,132918.69,,,,,,,fee schedule,127799.94,191697.56, Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],21358.57,21358.57,21358.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],142678.06,142678.06,142678.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],254688.96,254688.96,254688.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],15050.56,15050.56,15050.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],52076.04,23725.76,73063.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],132567.26,132567.26,396019.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,77231.32,,,,,,,fee schedule,66967.08,100449.39, Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,66967.08,,,,,,,fee schedule,66967.08,100449.39, Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,100449.39,,,,,,,fee schedule,66967.08,100449.39, Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,77388.66,,,,,,,fee schedule,66967.08,100449.39, Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,69649.31,,,,,,,fee schedule,66967.08,100449.39, Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],25534.95,25534.95,25534.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],37407.86,16055.68,70102.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,53843.6,,,,,,,fee schedule,46687.65,70030.61, Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,46687.65,,,,,,,fee schedule,46687.65,70030.61, Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,70030.61,,,,,,,fee schedule,46687.65,70030.61, Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,53953.29,,,,,,,fee schedule,46687.65,70030.61, Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,48557.62,,,,,,,fee schedule,46687.65,70030.61, Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],16055.69,16055.69,16055.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Mcc,984,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Mcc,984,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Mcc,984,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Mcc,984,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Mcc,984,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Mcc,984,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Mcc,984,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Mcc,984,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Mcc,984,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Mcc,984,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Mcc,984,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Mcc,984,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Mcc,984,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Mcc,984,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Mcc,984,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Mcc,984,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Mcc,984,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Mcc,984,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Mcc,984,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Mcc,984,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Cc,985,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Cc,985,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Cc,985,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Cc,985,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Cc,985,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Cc,985,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Cc,985,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Cc,985,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Cc,985,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Cc,985,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Cc,985,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Cc,985,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Cc,985,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Cc,985,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Cc,985,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Cc,985,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Cc,985,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Cc,985,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Cc,985,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Cc,985,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Prostatic O.R. Procedure Unrelated To Principal Diagnosis W/O Cc/Mcc,986,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Prostatic O.R. Procedure Unrelated To Principal Diagnosis W/O Cc/Mcc,986,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prostatic O.R. Procedure Unrelated To Principal Diagnosis W/O Cc/Mcc,986,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prostatic O.R. Procedure Unrelated To Principal Diagnosis W/O Cc/Mcc,986,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prostatic O.R. Procedure Unrelated To Principal Diagnosis W/O Cc/Mcc,986,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Prostatic O.R. Procedure Unrelated To Principal Diagnosis W/O Cc/Mcc,986,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prostatic O.R. Procedure Unrelated To Principal Diagnosis W/O Cc/Mcc,986,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prostatic O.R. Procedure Unrelated To Principal Diagnosis W/O Cc/Mcc,986,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prostatic O.R. Procedure Unrelated To Principal Diagnosis W/O Cc/Mcc,986,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prostatic O.R. Procedure Unrelated To Principal Diagnosis W/O Cc/Mcc,986,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prostatic O.R. Procedure Unrelated To Principal Diagnosis W/O Cc/Mcc,986,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prostatic O.R. Procedure Unrelated To Principal Diagnosis W/O Cc/Mcc,986,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prostatic O.R. Procedure Unrelated To Principal Diagnosis W/O Cc/Mcc,986,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prostatic O.R. Procedure Unrelated To Principal Diagnosis W/O Cc/Mcc,986,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prostatic O.R. Procedure Unrelated To Principal Diagnosis W/O Cc/Mcc,986,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Prostatic O.R. Procedure Unrelated To Principal Diagnosis W/O Cc/Mcc,986,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Prostatic O.R. Procedure Unrelated To Principal Diagnosis W/O Cc/Mcc,986,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Prostatic O.R. Procedure Unrelated To Principal Diagnosis W/O Cc/Mcc,986,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Prostatic O.R. Procedure Unrelated To Principal Diagnosis W/O Cc/Mcc,986,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Prostatic O.R. Procedure Unrelated To Principal Diagnosis W/O Cc/Mcc,986,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,107699.76,,,,,,,fee schedule,93386.19,140077.57, Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,93386.19,,,,,,,fee schedule,93386.19,140077.57, Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,140077.57,,,,,,,fee schedule,93386.19,140077.57, Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,107919.18,,,,,,,fee schedule,93386.19,140077.57, Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,97126.57,,,,,,,fee schedule,93386.19,140077.57, Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],134304.03,134304.03,134304.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],43905.74,43905.74,43905.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],97676.29,97676.29,97676.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,51632.05,,,,,,,fee schedule,44770.02,67154.21, Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,44770.02,,,,,,,fee schedule,44770.02,67154.21, Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,67154.21,,,,,,,fee schedule,44770.02,67154.21, Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,51737.24,,,,,,,fee schedule,44770.02,67154.21, Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,46563.19,,,,,,,fee schedule,44770.02,67154.21, Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],5908.14,5908.14,5908.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm." Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,37671.67,,,,,,,fee schedule,32665.01,48996.91, Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,32665.01,,,,,,,fee schedule,32665.01,48996.91, Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,48996.91,,,,,,,fee schedule,32665.01,48996.91, Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,37748.42,,,,,,,fee schedule,32665.01,48996.91, Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,33973.34,,,,,,,fee schedule,32665.01,48996.91, Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Principal Diagnosis Invalid As Discharge Diagnosis,998,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Principal Diagnosis Invalid As Discharge Diagnosis,998,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Principal Diagnosis Invalid As Discharge Diagnosis,998,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Principal Diagnosis Invalid As Discharge Diagnosis,998,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Principal Diagnosis Invalid As Discharge Diagnosis,998,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Principal Diagnosis Invalid As Discharge Diagnosis,998,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Principal Diagnosis Invalid As Discharge Diagnosis,998,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Principal Diagnosis Invalid As Discharge Diagnosis,998,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Principal Diagnosis Invalid As Discharge Diagnosis,998,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Principal Diagnosis Invalid As Discharge Diagnosis,998,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Principal Diagnosis Invalid As Discharge Diagnosis,998,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Principal Diagnosis Invalid As Discharge Diagnosis,998,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Principal Diagnosis Invalid As Discharge Diagnosis,998,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Principal Diagnosis Invalid As Discharge Diagnosis,998,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Principal Diagnosis Invalid As Discharge Diagnosis,998,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Principal Diagnosis Invalid As Discharge Diagnosis,998,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Principal Diagnosis Invalid As Discharge Diagnosis,998,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Principal Diagnosis Invalid As Discharge Diagnosis,998,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Principal Diagnosis Invalid As Discharge Diagnosis,998,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Principal Diagnosis Invalid As Discharge Diagnosis,998,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Ungroupable,999,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > 1096901 | Total % of Charge: 59.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP Prosthetics/Implants/Devices ($): 0 Charge Threshold 30000 (%BC): 54.1],,,,0,other,,,No services performed during 15-month lookback period. Ungroupable,999,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Better Health Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ungroupable,999,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 2 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ungroupable,999,MS-DRG,,,,,facility,inpatient,,,,,,Bcbs,Tier 1 All Commercial Plans,,,[Stop Loss: Total Charges > 404043 | Excess % of Charge: 62.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [IP High Cost Drugs ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ungroupable,999,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Baycare Other Commercial Plan,,,[Nursery Level 3 (%BC): 70] [Nursery Level 4-NICU (%BC): 70] [IP High Cost Drugs (%BC): 70] [IP Prosthetics/Implants/Devices (%BC): 70] [All Other IP (%BC): 80],,,,0,other,,,No services performed during 15-month lookback period. Ungroupable,999,MS-DRG,,,,,facility,inpatient,,,,,,Community Care Plan,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ungroupable,999,MS-DRG,,,,,facility,inpatient,,,,,,Florida Community Care,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ungroupable,999,MS-DRG,,,,,facility,inpatient,,,,,,Humana,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ungroupable,999,MS-DRG,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ungroupable,999,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ungroupable,999,MS-DRG,,,,,facility,inpatient,,,,,,Simply Health,Healthy Kids Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ungroupable,999,MS-DRG,,,,,facility,inpatient,,,,,,Sunshine Health,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ungroupable,999,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 10621] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ungroupable,999,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Neighborhood Health Partnership Other Commercial Plan,,,[Stop Loss: Length of Stay > 18 days | Excess % of Charge: 9558] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ungroupable,999,MS-DRG,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 14.3244] [Lesser Than Charges paid at %: 100] [APR DRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period. Ungroupable,999,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Hmo,,52,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Ungroupable,999,MS-DRG,,,,,facility,inpatient,,,,,,Cigna,Ppo,,60,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Ungroupable,999,MS-DRG,,,,,facility,inpatient,,,,,,Evolutions Healthcare,Select Ppo,,90,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Ungroupable,999,MS-DRG,,,,,facility,inpatient,,,,,,Multiplan,All Commercial Plans,,78,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Ungroupable,999,MS-DRG,,,,,facility,inpatient,,,,,,Phcs,All Commercial Plans,,68,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period. Hyoscyamine Sulfate Sl: 100 Tablet In 1 Bottle (42192-339-01),250,RC,42192-339-01,NDC,,,facility,both,1,EA,,7.04,7.04,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,42023-216-01,NDC,,,facility,both,1,EA,,35.56,35.56,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Ethacrynate Sodium: 1 Vial In 1 Carton (42023-157-01) / 50 Ml In 1 Vial,250,RC,42023-157-01,NDC,,,facility,both,1,EA,,2920.07,2920.07,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Ketalar: 10 Vial In 1 Carton (42023-113-10) / 20 Ml In 1 Vial,250,RC,42023-113-10,NDC,,,facility,both,1,EA,,64.49,64.49,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Aplisol: 1 Vial In 1 Carton (42023-104-01) / 1 Ml In 1 Vial,250,RC,42023-104-01,NDC,,,facility,both,1,EA,,95.28,95.28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,42023-103-01,NDC,,,facility,both,1,EA,,1576.74,1576.74,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,39822-4200-5,NDC,,,facility,both,1,EA,,48.02,48.02,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Gabapentin: 470 Ml In 1 Bottle (42192-608-16),250,RC,42192-608-16,NDC,,,facility,both,1,EA,,4.78,4.78,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Benzonatate: 100 Capsule In 1 Bottle (42806-714-01),250,RC,42806-714-01,NDC,,,facility,both,1,EA,,12.83,12.83,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,42806-266-98,NDC,,,facility,both,1,EA,,17.46,17.46,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Cholestyramine: 9 G In 1 Pouch (42806-265-98),250,RC,42806-265-98,NDC,,,facility,both,1,EA,,12.82,12.82,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,42457-420-01,NDC,,,facility,both,1,EA,,171.29,171.29,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,42292-038-01,NDC,,,facility,both,1,EA,,13.38,13.38,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Azelastine Hydrochloride: 1 Bottle, Spray In 1 Carton (42291-094-30) / 30 Ml In 1 Bottle, Spray",250,RC,42291-094-30,NDC,,,facility,both,1,EA,,77.02,77.02,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Clobetasol Propionate: 1 Tube In 1 Carton (42291-076-15) / 15 G In 1 Tube,250,RC,42291-076-15,NDC,,,facility,both,1,EA,,19.27,19.27,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Atomoxetine: 30 Capsule In 1 Bottle (42291-066-30),250,RC,42291-066-30,NDC,,,facility,both,1,EA,,12.42,12.42,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Atomoxetine: 30 Capsule In 1 Bottle (42291-065-30),250,RC,42291-065-30,NDC,,,facility,both,1,EA,,20.27,20.27,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Atomoxetine: 30 Capsule In 1 Bottle (42291-064-30),250,RC,42291-064-30,NDC,,,facility,both,1,EA,,16.17,16.17,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Amoxicillin And Clavulanate Potassium: 20 Tablet, Film Coated In 1 Bottle (42571-161-42)",250,RC,42571-161-42,NDC,,,facility,both,1,EA,,14.97,14.97,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Rufinamide: 120 Tablet, Film Coated In 1 Bottle (31722-598-12)",250,RC,31722-598-12,NDC,,,facility,both,1,EA,,13.14,13.14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Levetiracetam: 473 Ml In 1 Bottle (31722-574-47),250,RC,31722-574-47,NDC,,,facility,both,1,EA,,12.55,12.55,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Indomethacin: 12 Bottle In 1 Case (31722-542-01) / 100 Capsule In 1 Bottle,250,RC,31722-542-01,NDC,,,facility,both,1,EA,,10.64,10.64,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Sildenafil: 1 Bottle, Glass In 1 Carton (31722-136-31) / 112 Ml In 1 Bottle, Glass",250,RC,31722-136-31,NDC,,,facility,both,1,EA,,15.92,15.92,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Famotidine: 50 Ml In 1 Bottle (31722-063-31),250,RC,31722-063-31,NDC,,,facility,both,1,EA,,10.1,10.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ivabradine: 60 Tablet, Film Coated In 1 Bottle (31722-053-60)",250,RC,31722-053-60,NDC,,,facility,both,1,EA,,24.04,24.04,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Amitriptyline Hydrochloride: 100 Tablet, Film Coated In 1 Bottle (29300-419-01)",250,RC,29300-419-01,NDC,,,facility,both,1,EA,,11.12,11.12,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Cyclobenzaprine Hydrochloride: 100 Tablet, Film Coated In 1 Bottle (29300-413-01)",250,RC,29300-413-01,NDC,,,facility,both,1,EA,,10.69,10.69,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Tramadol Hydrochloride: 100 Tablet, Film Coated In 1 Bottle, Plastic (29300-355-01)",250,RC,29300-355-01,NDC,,,facility,both,1,EA,,12.29,12.29,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Divalproex Sodium: 100 Tablet, Delayed Release In 1 Bottle, Plastic (29300-140-01)",250,RC,29300-140-01,NDC,,,facility,both,1,EA,,11.65,11.65,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Xopenex Hfa: 1 Inhaler In 1 Carton (27437-056-01) / 200 Aerosol, Metered In 1 Inhaler",250,RC,27437-056-01,NDC,,,facility,both,1,EA,,160.88,160.88,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Oseltamivir Phosphate: 10 Capsule In 1 Carton (31722-630-31),250,RC,31722-630-31,NDC,,,facility,both,1,EA,,26.4,26.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Oseltamivir Phosphate: 10 Capsule In 1 Carton (31722-632-31),250,RC,31722-632-31,NDC,,,facility,both,1,EA,,27.76,27.76,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Amantadine Hydrochloride: 473 Ml In 1 Bottle, Plastic (39328-530-16)",250,RC,39328-530-16,NDC,,,facility,both,1,EA,,2.35,2.35,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,39328-063-25,NDC,,,facility,both,1,EA,,96.24,96.24,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Senna: 237 Ml In 1 Bottle, Plastic (39328-020-08)",250,RC,39328-020-08,NDC,,,facility,both,1,EA,,12.79,12.79,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,38779-1938-5,NDC,,,facility,both,1,EA,,10.97,10.97,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Metamucil Therapy For Regularity: 12 G In 1 Packet (37000-023-10),250,RC,37000-023-10,NDC,,,facility,both,1,EA,,14.8,14.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Tranexamic Acid: 10 Vial In 1 Carton (39822-1000-1) / 10 Ml In 1 Vial,250,RC,39822-1000-1,NDC,,,facility,both,1,EA,,41.9,41.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Albendazole 200 Mg: 2 Tablet, Film Coated In 1 Bottle (31722-935-02)",250,RC,31722-935-02,NDC,,,facility,both,1,EA,,194.94,194.94,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Eltrombopag: 30 Tablet, Film Coated In 1 Bottle (31722-843-30)",250,RC,31722-843-30,NDC,,,facility,both,1,EA,,2418.76,2418.76,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Montelukast Sodium: 90 Tablet, Chewable In 1 Bottle (31722-728-90)",250,RC,31722-728-90,NDC,,,facility,both,1,EA,,13.24,13.24,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Montelukast Sodium: 90 Tablet, Chewable In 1 Bottle (31722-727-90)",250,RC,31722-727-90,NDC,,,facility,both,1,EA,,10.53,10.53,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Atomoxetine: 30 Capsule In 1 Bottle (31722-717-30),250,RC,31722-717-30,NDC,,,facility,both,1,EA,,23.09,23.09,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Naproxen: 500 Ml In 1 Bottle (31722-682-05),250,RC,31722-682-05,NDC,,,facility,both,1,EA,,48.92,48.92,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Oxycodone Hydrochloride: 10 Blister Pack In 1 Carton (42858-001-10) / 10 Tablet In 1 Blister Pack,250,RC,42858-001-10,NDC,,,facility,both,1,EA,,13.25,13.25,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Hydromorphone Hydrochloride: 100 Tablet In 1 Bottle, Plastic (42858-301-01)",250,RC,42858-301-01,NDC,,,facility,both,1,EA,,8.08,8.08,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Hydromorphone Hydrochloride: 4 Blister Pack In 1 Carton (42858-301-25) / 25 Tablet In 1 Blister Pack,250,RC,42858-301-25,NDC,,,facility,both,1,EA,,8.92,8.92,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,44206-451-90,NDC,,,facility,both,1,EA,,866.02,866.02,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,44206-452-91,NDC,,,facility,both,1,EA,,1736.74,1736.74,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,44206-454-92,NDC,,,facility,both,1,EA,,3463.95,3463.95,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,44206-455-93,NDC,,,facility,both,1,EA,,7144.67,7144.67,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Triamcinolone Acetonide: 1 Tube In 1 Carton (45802-054-35) / 15 G In 1 Tube,250,RC,45802-054-35,NDC,,,facility,both,1,EA,,29.35,29.35,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Nystatin: 1 Tube In 1 Carton (45802-048-35) / 15 G In 1 Tube,250,RC,45802-048-35,NDC,,,facility,both,1,EA,,51.45,51.45,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Nystatin: 1 Tube In 1 Carton (45802-048-11) / 30 G In 1 Tube,250,RC,45802-048-11,NDC,,,facility,both,1,EA,,142.56,142.56,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ephedrine Sulfate: 25 Vial, Single-Dose In 1 Carton (43598-725-25) / 1 Ml In 1 Vial, Single-Dose (43598-725-11)",250,RC,43598-725-25,NDC,,,facility,both,1,EA,,33.38,33.38,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,44567-451-01,NDC,,,facility,both,1,EA,,440.38,440.38,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,44206-458-96,NDC,,,facility,both,1,EA,,3634.26,3634.26,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,44206-455-97,NDC,,,facility,both,1,EA,,7510.07,7510.07,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,43598-725-11,NDC,,,facility,both,1,EA,,34.13,34.13,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,43598-697-11,NDC,,,facility,both,1,EA,,460.05,460.05,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA SENSI CARE PROTECTIVE BARRIER: 113 g in 1 TUBE (43553-3256-4) ,250,RC,43553-3256-4,NDC,,,facility,both,1,EA,,6.27,6.27,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Ciprofloxacin: 100 Tablet In 1 Bottle (43547-688-10),250,RC,43547-688-10,NDC,,,facility,both,1,EA,,9.89,9.89,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Hydrochlorothiazide: 100 Tablet In 1 Bottle, Plastic (43547-397-10)",250,RC,43547-397-10,NDC,,,facility,both,1,EA,,12.51,12.51,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Fintepla: 1 Bottle, Plastic In 1 Carton (43376-322-30) / 30 Ml In 1 Bottle, Plastic",250,RC,43376-322-30,NDC,,,facility,both,1,EA,,1116.91,1116.91,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,43066-997-01,NDC,,,facility,both,1,EA,,24.86,24.86,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Cardene Iv: 10 Bag In 1 Carton (43066-016-10) / 200 Ml In 1 Bag,250,RC,43066-016-10,NDC,,,facility,both,1,EA,,419.06,419.06,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Valganciclovir Hydrochloride: 1 Pouch In 1 Carton (27241-159-19) / 1 Bottle In 1 Pouch / 100 Ml In 1 Bottle,250,RC,27241-159-19,NDC,,,facility,both,1,EA,,177.29,177.29,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Sodium Nitroprusside: 1 Vial, Single-Dose In 1 Carton (43598-587-23) / 2 Ml In 1 Vial, Single-Dose",250,RC,43598-587-23,NDC,,,facility,both,1,EA,,63.49,63.49,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Nicotine Transdermal System Step 1: 14 Patch In 1 Carton (43598-448-74) / 24 H In 1 Patch,250,RC,43598-448-74,NDC,,,facility,both,1,EA,,20.51,20.51,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,43598-448-71,NDC,,,facility,both,1,EA,,19.41,19.41,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Nicotine Transdermal System Step 2: 14 Patch In 1 Carton (43598-447-74) / 24 H In 1 Patch,250,RC,43598-447-74,NDC,,,facility,both,1,EA,,20.71,20.71,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,43598-447-71,NDC,,,facility,both,1,EA,,21.61,21.61,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,43598-446-71,NDC,,,facility,both,1,EA,,21.64,21.64,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Nicotine Transdermal System Step 3: 7 Patch In 1 Carton (43598-446-70) / 24 H In 1 Patch,250,RC,43598-446-70,NDC,,,facility,both,1,EA,,22.5,22.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,43598-436-35,NDC,,,facility,both,1,EA,,139.71,139.71,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Tetrabenazine: 112 Tablet In 1 Bottle (43598-394-67),250,RC,43598-394-67,NDC,,,facility,both,1,EA,,20.81,20.81,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ciprofloxacin And Dexamethasone: 1 Bottle, Dropper In 1 Carton (43598-326-75) / 7.5 Ml In 1 Bottle, Dropper",250,RC,43598-326-75,NDC,,,facility,both,1,EA,,283.78,283.78,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Olanzapine: 30 Tablet, Film Coated In 1 Bottle (43598-164-30)",250,RC,43598-164-30,NDC,,,facility,both,1,EA,,9.99,9.99,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Oseltamivir Phosphate: 1 Pouch In 1 Carton (27241-139-09) / 1 Bottle In 1 Pouch / 60 Ml In 1 Bottle,250,RC,27241-139-09,NDC,,,facility,both,1,EA,,28.14,28.14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Clonidine Hydrochloride: 60 Tablet, Extended Release In 1 Bottle (27241-108-06)",250,RC,27241-108-06,NDC,,,facility,both,1,EA,,19.87,19.87,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,17856-0049-01,NDC,,,facility,both,1,EA,,17.2,17.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ofloxacin: 1 BOTTLE, DROPPER in 1 CARTON (17478-713-10) / 5 mL in 1 BOTTLE, DROPPER",250,RC,17478-713-10,NDC,,,facility,both,1,EA,,66.63,66.63,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA FUL-GLO: 300 APPLICATOR in 1 CARTON (17478-403-03) / 1 STRIP in 1 APPLICATOR,250,RC,17478-403-03,NDC,,,facility,both,1,EA,,12.64,12.64,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Phenylephrine Hydrochloride: 1 Bottle, Dropper In 1 Carton (17478-201-02) / 2 Ml In 1 Bottle, Dropper",250,RC,17478-201-02,NDC,,,facility,both,1,EA,,206.9,206.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Cyclopentolate Hydrochloride: 1 BOTTLE, DROPPER in 1 CARTON (17478-100-02) / 2 mL in 1 BOTTLE, DROPPER",250,RC,17478-100-02,NDC,,,facility,both,1,EA,,37.82,37.82,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Artificial Tears: 1 TUBE in 1 CARTON (17478-062-35) / 3.5 g in 1 TUBE,250,RC,17478-062-35,NDC,,,facility,both,1,EA,,49.31,49.31,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sodium Chloride: 250 Ml In 1 Bag (17271-701-05),250,RC,17271-701-05,NDC,,,facility,both,1,EA,,29.46,29.46,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,17238-900-99,NDC,,,facility,both,1,EA,,12.93,12.93,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Bioglo: 100 Packet In 1 Box (17238-900-11) / 1 Mg In 1 Packet (17238-900-99),250,RC,17238-900-11,NDC,,,facility,both,1,EA,,13.11,13.11,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Domeboro: 12 Powder, For Solution In 1 Box (16864-240-01)",250,RC,16864-240-01,NDC,,,facility,both,1,EA,,16.32,16.32,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Bupropion Hydrochloride: 30 Tablet, Extended Release In 1 Bottle (16729-443-10)",250,RC,16729-443-10,NDC,,,facility,both,1,EA,,9.51,9.51,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dexmedetomidine: 25 Vial In 1 Carton (16729-239-93) / 2 Ml In 1 Vial (16729-239-30),250,RC,16729-239-93,NDC,,,facility,both,1,EA,,29.02,29.02,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,17856-0049-05,NDC,,,facility,both,1,EA,,23.13,23.13,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Ethosuximide: 100 Capsule In 1 Bottle (23155-532-01),250,RC,23155-532-01,NDC,,,facility,both,1,EA,,19.38,19.38,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Desmopressin Acetate: 100 Tablet In 1 Bottle (23155-489-01),250,RC,23155-489-01,NDC,,,facility,both,1,EA,,14.58,14.58,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,23155-166-31,NDC,,,facility,both,1,EA,,28.33,28.33,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Mupirocin: 1 Tube In 1 Carton (21922-029-04) / 15 G In 1 Tube,250,RC,21922-029-04,NDC,,,facility,both,1,EA,,163.93,163.93,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,16729-239-30,NDC,,,facility,both,1,EA,,30.78,30.78,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Tacrolimus: 1 Tube In 1 Carton (21922-011-05) / 30 G In 1 Tube,250,RC,21922-011-05,NDC,,,facility,both,1,EA,,311.67,311.67,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Infants: 120 Syringe In 1 Box, Unit-Dose (17856-1303-1) / .3 Ml In 1 Syringe",250,RC,17856-1303-1,NDC,,,facility,both,1,EA,,10.31,10.31,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Teeny Tummy Gas Relief Drops: 120 Syringe In 1 Box, Unit-Dose (17856-1141-1) / .3 Ml In 1 Syringe (17856-1141-6)",250,RC,17856-1141-1,NDC,,,facility,both,1,EA,,19.54,19.54,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Mylicon: 120 Syringe In 1 Box, Unit-Dose (17856-0799-1) / .3 Ml In 1 Syringe",250,RC,17856-0799-1,NDC,,,facility,both,1,EA,,17.54,17.54,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Clonazepam: 100 Tablet In 1 Bottle, Plastic (16729-136-00)",250,RC,16729-136-00,NDC,,,facility,both,1,EA,,10.88,10.88,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Quetiapine Fumarate: 60 Tablet, Extended Release In 1 Bottle (16729-132-12)",250,RC,16729-132-12,NDC,,,facility,both,1,EA,,7,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Fluoxetine: 100 Capsule In 1 Bottle (16714-720-02),250,RC,16714-720-02,NDC,,,facility,both,1,EA,,11.78,11.78,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Gabapentin: 100 Capsule In 1 Bottle (16714-663-01),250,RC,16714-663-01,NDC,,,facility,both,1,EA,,6.22,6.22,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Sertraline Hydrochloride: 1 Bottle, Plastic In 1 Carton (16714-601-02) / 60 Ml In 1 Bottle, Plastic",250,RC,16714-601-02,NDC,,,facility,both,1,EA,,26.5,26.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Lacosamide: 60 Tablet In 1 Bottle (16714-548-01),250,RC,16714-548-01,NDC,,,facility,both,1,EA,,7.11,7.11,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Clindamycin Palmitate Hydrochloride (Pediatric): 1 Bottle, Plastic In 1 Carton (16714-483-02) / 100 Ml In 1 Bottle, Plastic",250,RC,16714-483-02,NDC,,,facility,both,1,EA,,2.19,2.19,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Atomoxetine: 30 Capsule In 1 Bottle (16714-758-01),250,RC,16714-758-01,NDC,,,facility,both,1,EA,,21.89,21.89,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Levetiracetam: 473 Ml In 1 Bottle, Plastic (16714-358-01)",250,RC,16714-358-01,NDC,,,facility,both,1,EA,,12.15,12.15,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Levetiracetam: 500 Tablet, Film Coated In 1 Bottle (16714-355-02)",250,RC,16714-355-02,NDC,,,facility,both,1,EA,,0.69,0.69,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Amoxicillin: 100 Capsule In 1 Bottle (16714-299-03),250,RC,16714-299-03,NDC,,,facility,both,1,EA,,8.33,8.33,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Amoxicillin: 100 Capsule In 1 Bottle (16714-298-01),250,RC,16714-298-01,NDC,,,facility,both,1,EA,,7.82,7.82,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Amoxicillin And Clavulanate Potassium: 125 Ml In 1 Bottle (16714-294-02),250,RC,16714-294-02,NDC,,,facility,both,1,EA,,13.19,13.19,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Amoxicillin And Clavulanate Potassium: 75 Ml In 1 Bottle (16714-294-01),250,RC,16714-294-01,NDC,,,facility,both,1,EA,,14.24,14.24,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Valganciclovir: 60 TABLET, FILM COATED in 1 BOTTLE (16714-765-01) ",250,RC,16714-765-01,NDC,,,facility,both,1,EA,,35.05,35.05,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Naltrexone Hydrochloride: 30 Tablet, Film Coated In 1 Bottle (16729-081-10)",250,RC,16729-081-10,NDC,,,facility,both,1,EA,,18.63,18.63,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Rosuvastatin Calcium: 90 Tablet, Film Coated In 1 Bottle (16714-988-01)",250,RC,16714-988-01,NDC,,,facility,both,1,EA,,12.57,12.57,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Triamcinolone Acetonide: 1 Tube In 1 Carton (16714-987-01) / 15 G In 1 Tube,250,RC,16714-987-01,NDC,,,facility,both,1,EA,,39.54,39.54,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Triamcinolone Acetonide: 1 Tube In 1 Carton (16714-986-03) / 80 G In 1 Tube,250,RC,16714-986-03,NDC,,,facility,both,1,EA,,38.9,38.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Triamcinolone Acetonide: 1 Tube In 1 Carton (16714-986-01) / 15 G In 1 Tube,250,RC,16714-986-01,NDC,,,facility,both,1,EA,,13.43,13.43,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Nystatin: 15 G In 1 Bottle, Plastic (16714-769-01)",250,RC,16714-769-01,NDC,,,facility,both,1,EA,,113.25,113.25,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Triamcinolone Acetonide: 1 Tube In 1 Carton (16714-985-01) / 15 G In 1 Tube,250,RC,16714-985-01,NDC,,,facility,both,1,EA,,17.93,17.93,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Budesonide: 100 Capsule, Coated Pellets In 1 Bottle (16714-829-01)",250,RC,16714-829-01,NDC,,,facility,both,1,EA,,22.99,22.99,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Oseltamivir Phosphate: 10 CAPSULE in 1 CARTON (16714-819-01) ,250,RC,16714-819-01,NDC,,,facility,both,1,EA,,74.07,74.07,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Oseltamivir Phosphate: 10 CAPSULE in 1 CARTON (16714-817-01) ,250,RC,16714-817-01,NDC,,,facility,both,1,EA,,70.37,70.37,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sumatriptan: 1 Blister Pack In 1 Carton (16714-796-01) / 9 Tablet In 1 Blister Pack,250,RC,16714-796-01,NDC,,,facility,both,1,EA,,14.45,14.45,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Dextroamphetamine Saccharate, Amphetamine Aspartate, Dextroamphetamine Sulfate And Amphetamine Sulfate: 100 Tablet In 1 Bottle (16714-950-01)",250,RC,16714-950-01,NDC,,,facility,both,1,EA,,14.14,14.14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Triamcinolone Acetonide: 1 Tube In 1 Carton (45802-055-36) / 80 G In 1 Tube,250,RC,45802-055-36,NDC,,,facility,both,1,EA,,33.55,33.55,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Duloxetine: 60 Capsule, Delayed Release In 1 Bottle (27241-097-06)",250,RC,27241-097-06,NDC,,,facility,both,1,EA,,8.2,8.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Ketamine Hydrochloride: 10 Vial In 1 Carton (25021-682-20) / 20 Ml In 1 Vial,250,RC,25021-682-20,NDC,,,facility,both,1,EA,,59.5,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Dexamethasone Sodium Phosphate: 1 Bottle, Dropper In 1 Carton (24208-720-02) / 5 Ml In 1 Bottle, Dropper",250,RC,24208-720-02,NDC,,,facility,both,1,EA,,278.13,278.13,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Sulfacetamide Sodium: 1 Bottle, Dropper In 1 Carton (24208-670-04) / 15 Ml In 1 Bottle, Dropper",250,RC,24208-670-04,NDC,,,facility,both,1,EA,,259.83,259.83,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Bacitracin Zinc And Polymyxin B Sulfate: 1 Tube In 1 Carton (24208-555-55) / 3.5 G In 1 Tube,250,RC,24208-555-55,NDC,,,facility,both,1,EA,,43.07,43.07,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Miochol E: 1 Kit In 1 Blister Pack (24208-539-20) * 2 Ml In 1 Vial * 2 Ml In 1 Ampule,250,RC,24208-539-20,NDC,,,facility,both,1,EA,,505,505,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Zirgan: 1 Tube, With Applicator In 1 Carton (24208-535-35) / 5 G In 1 Tube, With Applicator",250,RC,24208-535-35,NDC,,,facility,both,1,EA,,2868.64,2868.64,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Dorzolamide Hcl: 1 Bottle, Dropper In 1 Carton (24208-485-10) / 10 Ml In 1 Bottle, Dropper",250,RC,24208-485-10,NDC,,,facility,both,1,EA,,81.02,81.02,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Tobramycin And Dexamethasone: 1 Bottle, Dropper In 1 Carton (24208-295-05) / 5 Ml In 1 Bottle, Dropper",250,RC,24208-295-05,NDC,,,facility,both,1,EA,,454.54,454.54,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Sodium Tetradecyl Sulfate: 5 Vial, Glass In 1 Carton (24201-201-05) / 2 Ml In 1 Vial, Glass (24201-201-01)",250,RC,24201-201-05,NDC,,,facility,both,1,EA,,389.29,389.29,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Proparacaine Hydrochloride: 1 Bottle, Dropper In 1 Carton (24208-730-06) / 15 Ml In 1 Bottle, Dropper",250,RC,24208-730-06,NDC,,,facility,both,1,EA,,210.8,210.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Vancomycin Hydrochloride: 2 Blister Pack In 1 Carton (23155-858-78) / 10 Capsule In 1 Blister Pack,250,RC,23155-858-78,NDC,,,facility,both,1,EA,,23.78,23.78,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Hydralazine Hydrochloride: 100 Tablet In 1 Bottle (23155-833-01),250,RC,23155-833-01,NDC,,,facility,both,1,EA,,8.06,8.06,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Pentamidine Isethionate: 10 Vial, Single-Dose In 1 Carton (23155-748-41) / 300 Mg In 1 Vial, Single-Dose (23155-748-31)",250,RC,23155-748-41,NDC,,,facility,both,1,EA,,124.89,124.89,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,23155-748-31,NDC,,,facility,both,1,EA,,132.3,132.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,23155-661-31,NDC,,,facility,both,1,EA,,506.15,506.15,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Glycopyrrolate: 100 Tablet In 1 Bottle (23155-606-01),250,RC,23155-606-01,NDC,,,facility,both,1,EA,,9.02,9.02,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Cyclopentolate Hydrochloride: 1 Bottle, Dropper In 1 Carton (24208-735-01) / 2 Ml In 1 Bottle, Dropper",250,RC,24208-735-01,NDC,,,facility,both,1,EA,,67.41,67.41,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Neomycin And Polymyxin B Sulfates And Gramicidin: 1 Bottle, Dropper In 1 Carton (24208-790-62) / 10 Ml In 1 Bottle, Dropper",250,RC,24208-790-62,NDC,,,facility,both,1,EA,,241.33,241.33,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Neomycin And Polymyxin B Sulfates And Bacitracin Zinc: 1 Tube In 1 Carton (24208-780-55) / 3.5 G In 1 Tube,250,RC,24208-780-55,NDC,,,facility,both,1,EA,,288.39,288.39,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Prismasol Bk0/0/1.2: 2 Bag In 1 Case (24571-113-06) / 5 L In 1 Bag,250,RC,24571-113-06,NDC,,,facility,both,1,EA,,279.64,279.64,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Prismasol B22Gk4/0: 2 Bag In 1 Case (24571-111-06) / 5 L In 1 Bag,250,RC,24571-111-06,NDC,,,facility,both,1,EA,,308.63,308.63,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Prismasol Bgk4/2.5: 2 Bag In 1 Case (24571-105-06) / 5 L In 1 Bag,250,RC,24571-105-06,NDC,,,facility,both,1,EA,,273.28,273.28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Prismasol Bgk2/3.5: 2 Bag In 1 Case (24571-103-06) / 5 L In 1 Bag,250,RC,24571-103-06,NDC,,,facility,both,1,EA,,275.28,275.28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Quillivant Xr: 1 Bottle In 1 Carton (24478-321-02) / 60 Ml In 1 Bottle,250,RC,24478-321-02,NDC,,,facility,both,1,EA,,195.18,195.18,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,24357-701-05,NDC,,,facility,both,1,EA,,24.16,24.16,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sotylize: 250 Ml In 1 Bottle (24338-530-25),250,RC,24338-530-25,NDC,,,facility,both,1,EA,,55.59,55.59,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA E.E.S: 100 Ml In 1 Bottle (24338-134-02),250,RC,24338-134-02,NDC,,,facility,both,1,EA,,33.62,33.62,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Ery-Ped: 100 Ml In 1 Bottle (24338-130-13),250,RC,24338-130-13,NDC,,,facility,both,1,EA,,32.54,32.54,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Erythromycin: 50 Tube In 1 Box (24208-910-19) / 1 G In 1 Tube,250,RC,24208-910-19,NDC,,,facility,both,1,EA,,51.91,51.91,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Neomycin And Polymyxin B Sulfates And Dexamethasone: 1 Tube In 1 Carton (24208-795-35) / 3.5 G In 1 Tube,250,RC,24208-795-35,NDC,,,facility,both,1,EA,,88.19,88.19,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Mexiletine Hydrochloride: 100 Capsule In 1 Bottle (50742-239-01),250,RC,50742-239-01,NDC,,,facility,both,1,EA,,13.91,13.91,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Tylenol For Children Plus Adults: 1 Bottle In 1 Carton (50580-177-08) / 240 Ml In 1 Bottle,250,RC,50580-177-08,NDC,,,facility,both,1,EA,,11.24,11.24,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Collagenase Santyl: 1 Tube In 1 Carton (50484-010-30) / 30 G In 1 Tube,250,RC,50484-010-30,NDC,,,facility,both,1,EA,,1850.21,1850.21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Briviact: 1 Bottle In 1 Carton (50474-870-15) / 300 Ml In 1 Bottle,250,RC,50474-870-15,NDC,,,facility,both,1,EA,,70.79,70.79,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Briviact: 100 Blister Pack In 1 Carton (50474-770-09) / 1 Tablet, Film Coated In 1 Blister Pack",250,RC,50474-770-09,NDC,,,facility,both,1,EA,,167.1,167.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Briviact: 1 Bottle In 1 Carton (50474-370-66) / 60 Tablet, Film Coated In 1 Bottle",250,RC,50474-370-66,NDC,,,facility,both,1,EA,,161.13,161.13,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Risperidone: 30 Ml In 1 Bottle (50458-596-01),250,RC,50458-596-01,NDC,,,facility,both,1,EA,,23.77,23.77,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Mexiletine Hydrochloride: 100 Capsule In 1 Bottle (50742-240-01),250,RC,50742-240-01,NDC,,,facility,both,1,EA,,15.28,15.28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Clonidine: 60 Tablet, Extended Release In 1 Bottle (50742-247-60)",250,RC,50742-247-60,NDC,,,facility,both,1,EA,,13.02,13.02,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,51079-255-01,NDC,,,facility,both,1,EA,,6.08,6.08,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,51079-206-01,NDC,,,facility,both,1,EA,,11.78,11.78,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Allopurinol: 100 Blister Pack In 1 Carton (51079-205-20) / 1 Tablet In 1 Blister Pack (51079-205-01),250,RC,51079-205-20,NDC,,,facility,both,1,EA,,13.19,13.19,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,51079-205-01,NDC,,,facility,both,1,EA,,6.85,6.85,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,51079-165-01,NDC,,,facility,both,1,EA,,95.08,95.08,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Voriconazole: 30 Blister Pack In 1 Carton (51079-164-03) / 1 Tablet, Film Coated In 1 Blister Pack (51079-164-01)",250,RC,51079-164-03,NDC,,,facility,both,1,EA,,48.93,48.93,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,51079-164-01,NDC,,,facility,both,1,EA,,39.22,39.22,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,51079-103-01,NDC,,,facility,both,1,EA,,9.43,9.43,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Xarelto: 30 Tablet, Film Coated In 1 Bottle (50458-580-30)",250,RC,50458-580-30,NDC,,,facility,both,1,EA,,11.42,11.42,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,51079-074-01,NDC,,,facility,both,1,EA,,7.99,7.99,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Metolazone: 100 Blister Pack In 1 Carton (51079-024-20) / 1 Tablet In 1 Blister Pack (51079-024-01),250,RC,51079-024-20,NDC,,,facility,both,1,EA,,12.37,12.37,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,51079-024-01,NDC,,,facility,both,1,EA,,21.32,21.32,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Jakafi: 60 Tablet In 1 Bottle, Plastic (50881-005-60)",250,RC,50881-005-60,NDC,,,facility,both,1,EA,,1320.69,1320.69,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Scopolamine: 24 Pouch In 1 Carton (50742-505-24) / 1 Patch, Extended Release In 1 Pouch",250,RC,50742-505-24,NDC,,,facility,both,1,EA,,44.12,44.12,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,50742-505-01,NDC,,,facility,both,1,EA,,70.16,70.16,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,51079-284-01,NDC,,,facility,both,1,EA,,10.31,10.31,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,50458-578-01,NDC,,,facility,both,1,EA,,11.85,11.85,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,50268-772-11,NDC,,,facility,both,1,EA,,25.21,25.21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,50268-759-11,NDC,,,facility,both,1,EA,,11.59,11.59,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,50268-730-11,NDC,,,facility,both,1,EA,,7.18,7.18,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,50268-728-11,NDC,,,facility,both,1,EA,,8.2,8.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Sevelamer Carbonate: 50 Blister Pack In 1 Box (50268-720-15) / 1 Tablet, Film Coated In 1 Blister Pack (50268-720-11)",250,RC,50268-720-15,NDC,,,facility,both,1,EA,,17.37,17.37,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,50268-720-11,NDC,,,facility,both,1,EA,,12.86,12.86,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,50268-717-11,NDC,,,facility,both,1,EA,,15.07,15.07,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Polyvinyl Alcohol: 15 Ml In 1 Bottle (50268-678-15),250,RC,50268-678-15,NDC,,,facility,both,1,EA,,59.33,59.33,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,50268-652-11,NDC,,,facility,both,1,EA,,17.13,17.13,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,50268-635-11,NDC,,,facility,both,1,EA,,9.82,9.82,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,50268-630-11,NDC,,,facility,both,1,EA,,9.05,9.05,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Nifedipine Er: 50 Blister Pack In 1 Box, Unit-Dose (50268-597-15) / 1 Tablet, Film Coated, Extended Release In 1 Blister Pack (50268-597-11)",250,RC,50268-597-15,NDC,,,facility,both,1,EA,,16.75,16.75,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,50268-787-11,NDC,,,facility,both,1,EA,,92.64,92.64,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Valganciclovir: 20 Blister Pack In 1 Box, Unit-Dose (50268-787-12) / 1 Tablet, Film Coated In 1 Blister Pack (50268-787-11)",250,RC,50268-787-12,NDC,,,facility,both,1,EA,,94.67,94.67,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,50268-788-11,NDC,,,facility,both,1,EA,,20.27,20.27,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Xarelto: 1 Bottle In 1 Carton (50458-575-01) / 1 Granule, For Suspension In 1 Bottle",250,RC,50458-575-01,NDC,,,facility,both,1,EA,,156.61,156.61,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,50419-775-01,NDC,,,facility,both,1,EA,,12.55,12.55,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Cipro: 1 Kit In 1 Kit (50419-773-01) * 100 Ml In 1 Bottle, Glass * 100 Ml In 1 Bottle, Glass",250,RC,50419-773-01,NDC,,,facility,both,1,EA,,12.74,12.74,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,50458-580-01,NDC,,,facility,both,1,EA,,9.15,9.15,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Levofloxacin: 1 BOTTLE in 1 CARTON (50383-286-16) / 480 mL in 1 BOTTLE,250,RC,50383-286-16,NDC,,,facility,both,1,EA,,51.55,51.55,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Levocarnitine: 9 BLISTER PACK in 1 CARTON (50383-172-90) / 10 TABLET in 1 BLISTER PACK,250,RC,50383-172-90,NDC,,,facility,both,1,EA,,11.09,11.09,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Levocarnitine: 118 mL in 1 BOTTLE (50383-171-04) ,250,RC,50383-171-04,NDC,,,facility,both,1,EA,,19.42,19.42,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,50268-816-11,NDC,,,facility,both,1,EA,,7.5,7.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,50268-812-11,NDC,,,facility,both,1,EA,,20.99,20.99,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Diazepam: 100 Blister Pack In 1 Carton (51079-284-20) / 1 Tablet In 1 Blister Pack (51079-284-01),250,RC,51079-284-20,NDC,,,facility,both,1,EA,,11.03,11.03,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,51079-285-01,NDC,,,facility,both,1,EA,,5.26,5.26,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Lidocaine and Prilocaine: 5 TUBE in 1 CARTON (52565-007-07) / 5 g in 1 TUBE,250,RC,52565-007-07,NDC,,,facility,both,1,EA,,36.3,36.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Baclofen: 1 Bottle In 1 Carton (52536-600-11) / 120 Ml In 1 Bottle,250,RC,52536-600-11,NDC,,,facility,both,1,EA,,56.91,56.91,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Aplicare Povidone-Iodine: 1 G In 1 Packet (52380-0126-2),250,RC,52380-0126-2,NDC,,,facility,both,1,EA,,5.71,5.71,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Nulytely: 4 L In 1 Package (52268-302-01),250,RC,52268-302-01,NDC,,,facility,both,1,EA,,130.89,130.89,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Dificid: 1 Bottle In 1 Carton (52015-080-01) / 20 Tablet, Film Coated In 1 Bottle",250,RC,52015-080-01,NDC,,,facility,both,1,EA,,799.28,799.28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Clonidine: 4 Pouch In 1 Carton (51862-453-04) / 1 Patch In 1 Pouch (51862-453-01) / 24 H In 1 Patch,250,RC,51862-453-04,NDC,,,facility,both,1,EA,,98,98,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,51754-5001-1,NDC,,,facility,both,1,EA,,39.75,39.75,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Verapamil Hydrochloride: 5 Vial In 1 Carton (51754-0203-2) / 2 Ml In 1 Vial,250,RC,51754-0203-2,NDC,,,facility,both,1,EA,,43.57,43.57,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Phenytoin: 237 Ml In 1 Bottle (51672-4069-1),250,RC,51672-4069-1,NDC,,,facility,both,1,EA,,13.86,13.86,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Enalapril Maleate: 100 Tablet In 1 Bottle (51672-4038-1),250,RC,51672-4038-1,NDC,,,facility,both,1,EA,,10.73,10.73,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Enalapril Maleate: 100 Tablet In 1 Bottle (51672-4037-1),250,RC,51672-4037-1,NDC,,,facility,both,1,EA,,12.09,12.09,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Nortriptyline Hydrochloride: 100 Capsule In 1 Bottle (51672-4001-1),250,RC,51672-4001-1,NDC,,,facility,both,1,EA,,12.13,12.13,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Ibuprofen: 1 Bottle In 1 Carton (51672-2130-8) / 120 Ml In 1 Bottle,250,RC,51672-2130-8,NDC,,,facility,both,1,EA,,3.02,3.02,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Qbrelis: 150 Ml In 1 Bottle (52652-3001-1),250,RC,52652-3001-1,NDC,,,facility,both,1,EA,,145.65,145.65,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Epaned: 150 Ml In 1 Bottle (52652-4001-1),250,RC,52652-4001-1,NDC,,,facility,both,1,EA,,28.72,28.72,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Zonisade: 1 Bottle In 1 Carton (52652-8001-1) / 150 Ml In 1 Bottle,250,RC,52652-8001-1,NDC,,,facility,both,1,EA,,83.89,83.89,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,54288-105-02,NDC,,,facility,both,1,EA,,4167.75,4167.75,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,54162-600-02,NDC,,,facility,both,1,EA,,24.77,24.77,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Adderall Xr: 100 Capsule, Extended Release In 1 Bottle (54092-383-01)",250,RC,54092-383-01,NDC,,,facility,both,1,EA,,54.17,54.17,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Adderall Xr: 100 Capsule, Extended Release In 1 Bottle (54092-381-01)",250,RC,54092-381-01,NDC,,,facility,both,1,EA,,51.68,51.68,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sensi-Care: 113 G In 1 Tube (53329-771-44),250,RC,53329-771-44,NDC,,,facility,both,1,EA,,51.4,51.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Aminocaproic Acid: 236.5 Ml In 1 Bottle, Plastic (52817-815-08)",250,RC,52817-815-08,NDC,,,facility,both,1,EA,,183.31,183.31,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Triple Antibiotic: 1 Tube In 1 Carton (51672-2120-2) / 28.4 G In 1 Tube,250,RC,51672-2120-2,NDC,,,facility,both,1,EA,,15.38,15.38,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Clonidine Transdermal System Usp, 0.3 Mg/Day: 4 Pouch In 1 Carton (52817-612-04) / 1 Patch In 1 Pouch / 1 D In 1 Patch",250,RC,52817-612-04,NDC,,,facility,both,1,EA,,109.49,109.49,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Clonidine Transdermal System Usp, 0.2 Mg/Day: 4 Pouch In 1 Carton (52817-611-04) / 1 Patch In 1 Pouch / 1 D In 1 Patch",250,RC,52817-611-04,NDC,,,facility,both,1,EA,,103.47,103.47,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Clonidine Transdermal System Usp, 0.1 Mg/Day: 4 Pouch In 1 Carton (52817-610-04) / 1 Patch In 1 Pouch / 1 D In 1 Patch",250,RC,52817-610-04,NDC,,,facility,both,1,EA,,57.84,57.84,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Metoprolol Tartrate: 100 Tablet, Film Coated In 1 Bottle (52817-362-10)",250,RC,52817-362-10,NDC,,,facility,both,1,EA,,11.75,11.75,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Cyproheptadine Hydrochloride: 100 Tablet In 1 Bottle, Plastic (52817-210-10)",250,RC,52817-210-10,NDC,,,facility,both,1,EA,,11.94,11.94,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Eprontia: 473 Ml In 1 Bottle (52652-9001-1),250,RC,52652-9001-1,NDC,,,facility,both,1,EA,,29.59,29.59,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Feverall Jr. Strength: 6 Blister Pack In 1 Carton (51672-2116-2) / 1 Suppository In 1 Blister Pack (51672-2116-0),250,RC,51672-2116-2,NDC,,,facility,both,1,EA,,18.52,18.52,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,51079-821-01,NDC,,,facility,both,1,EA,,8.04,8.04,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Atenolol: 100 Blister Pack In 1 Carton (51079-759-20) / 1 Tablet In 1 Blister Pack (51079-759-01),250,RC,51079-759-20,NDC,,,facility,both,1,EA,,6.91,6.91,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,51079-759-01,NDC,,,facility,both,1,EA,,11.27,11.27,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sucralfate: 100 Blister Pack In 1 Carton (51079-753-20) / 1 Tablet In 1 Blister Pack (51079-753-01),250,RC,51079-753-20,NDC,,,facility,both,1,EA,,14.03,14.03,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,51079-753-01,NDC,,,facility,both,1,EA,,13.73,13.73,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,51079-733-01,NDC,,,facility,both,1,EA,,5.2,5.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,51079-882-01,NDC,,,facility,both,1,EA,,5.21,5.21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,51079-630-01,NDC,,,facility,both,1,EA,,14.48,14.48,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,51079-597-01,NDC,,,facility,both,1,EA,,12.59,12.59,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,51079-453-01,NDC,,,facility,both,1,EA,,12.66,12.66,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Levothyroxine Sodium: 100 Blister Pack In 1 Carton (51079-442-20) / 1 Tablet In 1 Blister Pack (51079-442-01),250,RC,51079-442-20,NDC,,,facility,both,1,EA,,13.57,13.57,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,51079-442-01,NDC,,,facility,both,1,EA,,12.66,12.66,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Levothyroxine Sodium: 100 Blister Pack In 1 Carton (51079-440-20) / 1 Tablet In 1 Blister Pack (51079-440-01),250,RC,51079-440-20,NDC,,,facility,both,1,EA,,14.14,14.14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Diazepam: 100 Blister Pack In 1 Carton (51079-285-20) / 1 Tablet In 1 Blister Pack (51079-285-01),250,RC,51079-285-20,NDC,,,facility,both,1,EA,,3.18,3.18,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,51079-632-01,NDC,,,facility,both,1,EA,,28.04,28.04,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,50268-597-11,NDC,,,facility,both,1,EA,,11.35,11.35,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,51079-985-01,NDC,,,facility,both,1,EA,,3.89,3.89,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,51672-2116-0,NDC,,,facility,both,1,EA,,17.71,17.71,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,51672-2115-0,NDC,,,facility,both,1,EA,,1.78,1.78,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Feverall Infants: 6 Blister Pack In 1 Carton (51672-2114-2) / 1 Suppository In 1 Blister Pack (51672-2114-0),250,RC,51672-2114-2,NDC,,,facility,both,1,EA,,1.59,1.59,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,51672-2114-0,NDC,,,facility,both,1,EA,,1.61,1.61,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Miconazole Nitrate: 1 Tube In 1 Carton (51672-2001-1) / 15 G In 1 Tube,250,RC,51672-2001-1,NDC,,,facility,both,1,EA,,20.38,20.38,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Betamethasone Dipropionate: 1 Tube In 1 Carton (51672-1310-1) / 15 G In 1 Tube,250,RC,51672-1310-1,NDC,,,facility,both,1,EA,,137.38,137.38,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Clotrimazole: 1 Bottle, Plastic In 1 Carton (51672-1260-3) / 30 Ml In 1 Bottle, Plastic",250,RC,51672-1260-3,NDC,,,facility,both,1,EA,,297.58,297.58,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Plus Pharma: 150 TABLET, CHEWABLE in 1 BOTTLE, PLASTIC (51645-735-15) ",250,RC,51645-735-15,NDC,,,facility,both,1,EA,,11.68,11.68,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,51224-162-12,NDC,,,facility,both,1,EA,,16.47,16.47,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Trikafta: 4 Package In 1 Carton (51167-445-01) / 1 Kit In 1 Package * 1 Granule In 1 Packet (51167-545-07) * 1 Granule In 1 Packet (51167-645-07),250,RC,51167-445-01,NDC,,,facility,both,1,EA,,3154.27,3154.27,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Trikafta: 4 Blister Pack In 1 Carton (51167-331-01) / 1 Kit In 1 Blister Pack * 14 Tablet, Film Coated In 1 Blister Pack (51167-431-14) * 7 Tablet, Film Coated In 1 Blister Pack (51167-531-07)",250,RC,51167-331-01,NDC,,,facility,both,1,EA,,2064.84,2064.84,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Trikafta: 4 Blister Pack In 1 Carton (51167-106-02) / 1 Kit In 1 Blister Pack * 14 Tablet, Film Coated In 1 Blister Pack (51167-206-14) * 7 Tablet, Film Coated In 1 Blister Pack (51167-306-07)",250,RC,51167-106-02,NDC,,,facility,both,1,EA,,2107.05,2107.05,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Phenazopyridine Hydrochloride: 100 TABLET in 1 BOTTLE (51293-811-01) ,250,RC,51293-811-01,NDC,,,facility,both,1,EA,,15.45,15.45,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Naproxen: 50 Blister Pack In 1 Box, Unit-Dose (50268-594-15) / 1 Tablet In 1 Blister Pack (50268-594-11)",250,RC,50268-594-15,NDC,,,facility,both,1,EA,,6.67,6.67,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,50268-594-11,NDC,,,facility,both,1,EA,,8.18,8.18,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,49502-102-01,NDC,,,facility,both,1,EA,,866.94,866.94,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Epinephrine: 2 Container In 1 Carton (49502-101-02) / 1 Syringe, Glass In 1 Container (49502-101-01) / .3 Ml In 1 Syringe, Glass",250,RC,49502-101-02,NDC,,,facility,both,1,EA,,885.83,885.83,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,49502-101-01,NDC,,,facility,both,1,EA,,885.88,885.88,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sunmark Mineral Oil Laxative: 1 Bottle In 1 Carton (49348-185-20) / 133 Ml In 1 Bottle,250,RC,49348-185-20,NDC,,,facility,both,1,EA,,17.67,17.67,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Antibiotic Bacitracin Zinc: 1 Tube In 1 Carton (49348-154-72) / 28.4 G In 1 Tube,250,RC,49348-154-72,NDC,,,facility,both,1,EA,,20.8,20.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Epivir: 240 Ml In 1 Bottle (49702-205-48),250,RC,49702-205-48,NDC,,,facility,both,1,EA,,13.53,13.53,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Trazodone Hydrochloride: 100 Tablet In 1 Bottle (50111-560-01),250,RC,50111-560-01,NDC,,,facility,both,1,EA,,5.13,5.13,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,50102-240-21,NDC,,,facility,both,1,EA,,1.64,1.64,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,50102-240-01,NDC,,,facility,both,1,EA,,1.66,1.66,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,49884-948-52,NDC,,,facility,both,1,EA,,142.83,142.83,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Cholestyramine: 60 Packet In 1 Carton (49884-465-65) / 9 G In 1 Packet (49884-465-64),250,RC,49884-465-65,NDC,,,facility,both,1,EA,,52.75,52.75,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,49884-465-64,NDC,,,facility,both,1,EA,,24.92,24.92,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ursodiol: 100 Tablet, Film Coated In 1 Bottle (49884-412-01)",250,RC,49884-412-01,NDC,,,facility,both,1,EA,,21.19,21.19,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,49884-311-52,NDC,,,facility,both,1,EA,,12.47,12.47,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,49884-308-52,NDC,,,facility,both,1,EA,,11.08,11.08,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Clonazepam: 60 Tablet, Orally Disintegrating In 1 Blister Pack (49884-308-02)",250,RC,49884-308-02,NDC,,,facility,both,1,EA,,10.64,10.64,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,49884-306-52,NDC,,,facility,both,1,EA,,12.96,12.96,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Clonazepam: 60 Tablet, Orally Disintegrating In 1 Blister Pack (49884-306-02)",250,RC,49884-306-02,NDC,,,facility,both,1,EA,,14.01,14.01,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Minoxidil: 100 Tablet In 1 Bottle (49884-256-01),250,RC,49884-256-01,NDC,,,facility,both,1,EA,,8.63,8.63,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Glycopyrrolate: 16 Ml In 1 Bottle (49884-042-33),250,RC,49884-042-33,NDC,,,facility,both,1,EA,,18.1,18.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sodium Phenylbutyrate: 1 Bottle In 1 Carton (49884-006-04) / 250 G In 1 Bottle,250,RC,49884-006-04,NDC,,,facility,both,1,EA,,38.9,38.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Mineral Oil: 30 Ml In 1 Cup, Unit-Dose (48433-202-30)",250,RC,48433-202-30,NDC,,,facility,both,1,EA,,17.91,17.91,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Acetaminophen For Children: 12 Blister Pack In 1 Carton (45802-732-30) / 1 Suppository In 1 Blister Pack,250,RC,45802-732-30,NDC,,,facility,both,1,EA,,1.11,1.11,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,45802-732-00,NDC,,,facility,both,1,EA,,1.1,1.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Acetaminophen Pain Reliever Fever Reducer: 50 Blister Pack In 1 Carton (45802-730-32) / 1 Suppository In 1 Blister Pack,250,RC,45802-730-32,NDC,,,facility,both,1,EA,,1.11,1.11,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Acetaminophen Pain Reliever Fever Reducer: 1 Suppository In 1 Blister Pack (45802-730-00),250,RC,45802-730-00,NDC,,,facility,both,1,EA,,1.22,1.22,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Ketoconazole: 120 Ml In 1 Bottle (45802-465-64),250,RC,45802-465-64,NDC,,,facility,both,1,EA,,123.77,123.77,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Hydrocortisone: 1 Tube In 1 Carton (45802-438-03) / 28 G In 1 Tube,250,RC,45802-438-03,NDC,,,facility,both,1,EA,,16.26,16.26,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dextromethorphan Polistirex Extended Release: 1 Bottle In 1 Carton (45802-433-21) / 89 Ml In 1 Bottle,250,RC,45802-433-21,NDC,,,facility,both,1,EA,,14.01,14.01,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA vitamin a and d: 1 TUBE in 1 CARTON (45802-395-04) / 113 g in 1 TUBE,250,RC,45802-395-04,NDC,,,facility,both,1,EA,,24.56,24.56,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Betamethasone Dipropionate: 1 Tube In 1 Carton (45802-376-35) / 15 G In 1 Tube,250,RC,45802-376-35,NDC,,,facility,both,1,EA,,24.82,24.82,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,45802-357-58,NDC,,,facility,both,1,EA,,10.65,10.65,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,45802-344-03,NDC,,,facility,both,1,EA,,13.89,13.89,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Triple Antibiotic: 1 Tube In 1 Carton (45802-143-01) / 14 G In 1 Tube,250,RC,45802-143-01,NDC,,,facility,both,1,EA,,14.93,14.93,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Mupirocin: 1 Tube In 1 Carton (45802-112-22) / 22 G In 1 Tube,250,RC,45802-112-22,NDC,,,facility,both,1,EA,,46.81,46.81,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Triamcinolone Acetonide: 1 Tube In 1 Carton (45802-064-36) / 80 G In 1 Tube,250,RC,45802-064-36,NDC,,,facility,both,1,EA,,44.82,44.82,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Nystatin: 1 Tube In 1 Carton (45802-059-35) / 15 G In 1 Tube,250,RC,45802-059-35,NDC,,,facility,both,1,EA,,89.85,89.85,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Oxymetazoline Hcl: 1 Bottle, Spray In 1 Carton (45802-410-59) / 30 Ml In 1 Bottle, Spray",250,RC,45802-410-59,NDC,,,facility,both,1,EA,,19.64,19.64,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Fluoxetine: 100 Capsule In 1 Bottle (50228-113-01),250,RC,50228-113-01,NDC,,,facility,both,1,EA,,11.48,11.48,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Acetaminophen For Children: 100 Blister Pack In 1 Carton (45802-732-33) / 1 Suppository In 1 Blister Pack,250,RC,45802-732-33,NDC,,,facility,both,1,EA,,1.06,1.06,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Lisdexamfetamine Dimesylate: 100 Capsule In 1 Bottle (47781-562-01),250,RC,47781-562-01,NDC,,,facility,both,1,EA,,58.57,58.57,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,47781-423-11,NDC,,,facility,both,1,EA,,48.45,48.45,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ambrisentan: 30 Tablet, Film Coated In 1 Bottle (47335-236-83)",250,RC,47335-236-83,NDC,,,facility,both,1,EA,,57.03,57.03,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Carospir: 473 Ml In 1 Bottle (46287-020-01),250,RC,46287-020-01,NDC,,,facility,both,1,EA,,41.71,41.71,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Isoniazid: 473 Ml In 1 Bottle (46287-009-01),250,RC,46287-009-01,NDC,,,facility,both,1,EA,,4.89,4.89,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Sodium Polystyrene Sulfonate: 10 Bottle, Unit-Dose In 1 Carton (46287-006-60) / 60 Ml In 1 Bottle, Unit-Dose",250,RC,46287-006-60,NDC,,,facility,both,1,EA,,74.44,74.44,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Ibuprofen: 1 Bottle In 1 Carton (45802-952-26) / 120 Ml In 1 Bottle,250,RC,45802-952-26,NDC,,,facility,both,1,EA,,3.42,3.42,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Polyethylene Glycol 3350: 510 G In 1 Bottle (45802-868-03),250,RC,45802-868-03,NDC,,,facility,both,1,EA,,31.42,31.42,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Polyethylene Glycol 3350: 238 G In 1 Bottle (45802-868-02),250,RC,45802-868-02,NDC,,,facility,both,1,EA,,7.75,7.75,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Tadliq: 150 Ml In 1 Bottle (46287-045-15),250,RC,46287-045-15,NDC,,,facility,both,1,EA,,374.02,374.02,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Gentamicin Sulfate: 1 Tube In 1 Carton (45802-056-35) / 15 G In 1 Tube,250,RC,45802-056-35,NDC,,,facility,both,1,EA,,210.69,210.69,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Enalapril Maleate: 100 Tablet In 1 Bottle (50228-228-01),250,RC,50228-228-01,NDC,,,facility,both,1,EA,,13.09,13.09,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,50268-330-11,NDC,,,facility,both,1,EA,,13.14,13.14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Famotidine: 50 Blister Pack In 1 Box, Unit-Dose (50268-304-15) / 1 Tablet In 1 Blister Pack (50268-304-11)",250,RC,50268-304-15,NDC,,,facility,both,1,EA,,13.63,13.63,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,50268-304-11,NDC,,,facility,both,1,EA,,13.19,13.19,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,50268-297-11,NDC,,,facility,both,1,EA,,19.32,19.32,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,50268-277-11,NDC,,,facility,both,1,EA,,14.22,14.22,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Duloxetine: 50 Blister Pack In 1 Box (50268-269-15) / 1 Capsule, Delayed Release In 1 Blister Pack (50268-269-11)",250,RC,50268-269-15,NDC,,,facility,both,1,EA,,12.65,12.65,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,50268-260-11,NDC,,,facility,both,1,EA,,18.29,18.29,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,50268-259-11,NDC,,,facility,both,1,EA,,5.69,5.69,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Capsaicin External Analgesic: 1 Tube In 1 Carton (50268-195-60) / 60 G In 1 Tube,250,RC,50268-195-60,NDC,,,facility,both,1,EA,,26.91,26.91,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Cyproheptadine Hydrochloride: 50 Blister Pack In 1 Box (50268-189-15) / 1 Tablet In 1 Blister Pack (50268-189-11),250,RC,50268-189-15,NDC,,,facility,both,1,EA,,14.22,14.22,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,50268-189-11,NDC,,,facility,both,1,EA,,13.3,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,50268-172-11,NDC,,,facility,both,1,EA,,19.68,19.68,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,50268-171-11,NDC,,,facility,both,1,EA,,22.15,22.15,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,50268-152-11,NDC,,,facility,both,1,EA,,12.08,12.08,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,50268-337-11,NDC,,,facility,both,1,EA,,12.64,12.64,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Fluconazole: 50 Blister Pack In 1 Box (50268-337-15) / 1 Tablet In 1 Blister Pack (50268-337-11),250,RC,50268-337-15,NDC,,,facility,both,1,EA,,19.1,19.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,50268-585-11,NDC,,,facility,both,1,EA,,8.99,8.99,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Montelukast Sodium: 50 Blister Pack In 1 Box (50268-574-15) / 1 Tablet, Chewable In 1 Blister Pack (50268-574-11)",250,RC,50268-574-15,NDC,,,facility,both,1,EA,,16.09,16.09,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,50268-574-11,NDC,,,facility,both,1,EA,,16.11,16.11,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,50268-550-11,NDC,,,facility,both,1,EA,,14.64,14.64,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,50268-534-11,NDC,,,facility,both,1,EA,,7.85,7.85,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Methocarbamol: 50 Blister Pack In 1 Box (50268-521-15) / 1 Tablet In 1 Blister Pack (50268-521-11),250,RC,50268-521-15,NDC,,,facility,both,1,EA,,13.7,13.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,50268-521-11,NDC,,,facility,both,1,EA,,13.32,13.32,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,50268-151-11,NDC,,,facility,both,1,EA,,7.79,7.79,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Methocarbamol: 50 Blister Pack In 1 Box (50268-520-15) / 1 Tablet In 1 Blister Pack (50268-520-11),250,RC,50268-520-15,NDC,,,facility,both,1,EA,,12.67,12.67,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,50268-520-11,NDC,,,facility,both,1,EA,,11.75,11.75,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,50268-504-11,NDC,,,facility,both,1,EA,,8.73,8.73,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,50268-447-11,NDC,,,facility,both,1,EA,,6.73,6.73,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Hydrocortisone: 50 Blister Pack In 1 Box (50268-405-15) / 1 Tablet In 1 Blister Pack (50268-405-11),250,RC,50268-405-15,NDC,,,facility,both,1,EA,,18.29,18.29,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,50268-405-11,NDC,,,facility,both,1,EA,,16.76,16.76,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,50268-350-11,NDC,,,facility,both,1,EA,,13.01,13.01,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,50268-339-11,NDC,,,facility,both,1,EA,,15.36,15.36,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,50268-142-11,NDC,,,facility,both,1,EA,,16.4,16.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Bumetanide: 50 Blister Pack In 1 Box (50268-131-15) / 1 Tablet In 1 Blister Pack (50268-131-11),250,RC,50268-131-15,NDC,,,facility,both,1,EA,,12.75,12.75,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,50268-131-11,NDC,,,facility,both,1,EA,,12.49,12.49,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Diltiazem Hydrochloride: 100 Tablet In 1 Bottle (50228-482-01),250,RC,50228-482-01,NDC,,,facility,both,1,EA,,12.28,12.28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Enalapril Maleate: 100 Tablet In 1 Bottle (50228-229-01),250,RC,50228-229-01,NDC,,,facility,both,1,EA,,12.24,12.24,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Bupropion Hydrochloride Sr: 60 Tablet, Film Coated, Extended Release In 1 Bottle, Plastic (50228-174-60)",250,RC,50228-174-60,NDC,,,facility,both,1,EA,,13.1,13.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,50268-130-11,NDC,,,facility,both,1,EA,,13.24,13.24,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Aripiprazole: 50 Blister Pack In 1 Box, Unit-Dose (50268-089-15) / 1 Tablet In 1 Blister Pack (50268-089-11)",250,RC,50268-089-15,NDC,,,facility,both,1,EA,,7.37,7.37,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,50268-089-11,NDC,,,facility,both,1,EA,,11.2,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Aripiprazole: 50 Blister Pack In 1 Box, Unit-Dose (50268-088-15) / 1 Tablet In 1 Blister Pack (50268-088-11)",250,RC,50268-088-15,NDC,,,facility,both,1,EA,,14.42,14.42,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,50268-088-11,NDC,,,facility,both,1,EA,,13.27,13.27,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Azithromycin Dihydrate: 50 Blister Pack In 1 Box (50268-074-15) / 1 Tablet, Film Coated In 1 Blister Pack (50268-074-11)",250,RC,50268-074-15,NDC,,,facility,both,1,EA,,11.75,11.75,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,50268-074-11,NDC,,,facility,both,1,EA,,11.71,11.71,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Acyclovir: 50 Blister Pack In 1 Bottle, Unit-Dose (50268-062-15) / 1 Tablet In 1 Blister Pack (50268-062-11)",250,RC,50268-062-15,NDC,,,facility,both,1,EA,,14.58,14.58,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,50268-062-11,NDC,,,facility,both,1,EA,,14.28,14.28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,50268-057-11,NDC,,,facility,both,1,EA,,24.44,24.44,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Acetazolamide: 50 Blister Pack In 1 Box (50268-054-15) / 1 Tablet In 1 Blister Pack (50268-054-11),250,RC,50268-054-15,NDC,,,facility,both,1,EA,,26.76,26.76,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,50268-054-11,NDC,,,facility,both,1,EA,,17.18,17.18,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,50268-069-11,NDC,,,facility,both,1,EA,,20.17,20.17,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Amoxicillin And Clavulanate Potassium: 50 Ml In 1 Bottle (16714-293-01),250,RC,16714-293-01,NDC,,,facility,both,1,EA,,14.59,14.59,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Phenobarbital Sodium: 25 Vial In 1 Carton (0641-0476-25) / 1 Ml In 1 Vial (0641-0476-21),250,RC,0641-0476-25,NDC,,,facility,both,1,EA,,39.23,39.23,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Lisinopril: 100 TABLET in 1 BOTTLE (0603-4209-21) ,250,RC,0603-4209-21,NDC,,,facility,both,1,EA,,11.84,11.84,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Hydrocortisone: 100 TABLET in 1 BOTTLE, PLASTIC (0603-3901-21) ",250,RC,0603-3901-21,NDC,,,facility,both,1,EA,,12.07,12.07,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Dicyclomine Hydrochloride: 473 Ml In 1 Bottle, Plastic (0603-1161-58)",250,RC,0603-1161-58,NDC,,,facility,both,1,EA,,4.06,4.06,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0641-6147-01,NDC,,,facility,both,1,EA,,30.91,30.91,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0597-0450-26,NDC,,,facility,both,1,EA,,551.56,551.56,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0641-6127-01,NDC,,,facility,both,1,EA,,38.7,38.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Pradaxa: 1 Bag In 1 Carton (0597-0450-16) / 60 Pellet In 1 Bag,250,RC,0597-0450-16,NDC,,,facility,both,1,EA,,577.06,577.06,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Pradaxa: 1 Bag In 1 Carton (0597-0425-78) / 60 Pellet In 1 Bag,250,RC,0597-0425-78,NDC,,,facility,both,1,EA,,568.45,568.45,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Nystop: 15 G In 1 Bottle, Plastic (0574-2008-15)",250,RC,0574-2008-15,NDC,,,facility,both,1,EA,,40.28,40.28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Spironolactone: 473 Ml In 1 Bottle (0574-1133-16),250,RC,0574-1133-16,NDC,,,facility,both,1,EA,,34.32,34.32,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Actidose: 120 Ml In 1 Tube (0574-0520-74),250,RC,0574-0520-74,NDC,,,facility,both,1,EA,,91.41,91.41,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Amiloride Hydrochloride: 100 Tablet In 1 Bottle (0574-0292-01),250,RC,0574-0292-01,NDC,,,facility,both,1,EA,,5.22,5.22,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Bromocriptine Mesylate: 30 Tablet In 1 Bottle, Plastic (0574-0106-03)",250,RC,0574-0106-03,NDC,,,facility,both,1,EA,,28.05,28.05,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Preparation H: 1 Tube In 1 Carton (0573-2871-93) / 28 G In 1 Tube,250,RC,0573-2871-93,NDC,,,facility,both,1,EA,,54.6,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Junior Strength Advil: 1 Bottle In 1 Carton (0573-0179-20) / 24 Tablet, Chewable In 1 Bottle",250,RC,0573-0179-20,NDC,,,facility,both,1,EA,,0.5,0.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0555-9010-79,NDC,,,facility,both,1,EA,,3.25,3.25,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Medroxyprogesterone Acetate: 100 Tablet In 1 Bottle (0555-0779-02),250,RC,0555-0779-02,NDC,,,facility,both,1,EA,,12.42,12.42,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Megestrol Acetate: 100 Tablet In 1 Bottle (0555-0607-02),250,RC,0555-0607-02,NDC,,,facility,both,1,EA,,11.84,11.84,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Leucovorin Calcium: 100 Tablet In 1 Bottle (0555-0484-02),250,RC,0555-0484-02,NDC,,,facility,both,1,EA,,6.82,6.82,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Isoproterenol Hydrochloride: 10 Vial In 1 Carton (0548-9502-00) / 5 Ml In 1 Vial,250,RC,0548-9502-00,NDC,,,facility,both,1,EA,,1205.34,1205.34,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Aspirin: 12 Packet In 1 Carton (0574-7034-12) / 1 Suppository In 1 Packet,250,RC,0574-7034-12,NDC,,,facility,both,1,EA,,1.48,1.48,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Bisacodyl: 12 Blister Pack In 1 Carton (0574-7050-12) / 1 Suppository In 1 Blister Pack,250,RC,0574-7050-12,NDC,,,facility,both,1,EA,,1.24,1.24,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Bisacodyl: 50 Blister Pack In 1 Carton (0574-7050-50) / 1 Suppository In 1 Blister Pack,250,RC,0574-7050-50,NDC,,,facility,both,1,EA,,1.15,1.15,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Jardiance: 30 Blister Pack In 1 Carton (0597-0152-37) / 1 Tablet, Film Coated In 1 Blister Pack",250,RC,0597-0152-37,NDC,,,facility,both,1,EA,,83.06,83.06,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Jardiance: 30 Tablet, Film Coated In 1 Bottle (0597-0152-30)",250,RC,0597-0152-30,NDC,,,facility,both,1,EA,,83.77,83.77,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Spiriva Respimat: 1 Cartridge In 1 Carton (0597-0100-51) / 10 Spray, Metered In 1 Cartridge",250,RC,0597-0100-51,NDC,,,facility,both,1,EA,,244.26,244.26,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Atrovent Hfa: 1 Canister In 1 Carton (0597-0087-17) / 200 Aerosol, Metered In 1 Canister",250,RC,0597-0087-17,NDC,,,facility,both,1,EA,,2174.25,2174.25,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Probenecid: 100 Tablet, Film Coated In 1 Bottle, Plastic (0591-5347-01)",250,RC,0591-5347-01,NDC,,,facility,both,1,EA,,15.09,15.09,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Trihexyphenidyl Hydrochloride: 100 Tablet In 1 Bottle, Plastic (0591-5335-01)",250,RC,0591-5335-01,NDC,,,facility,both,1,EA,,12.26,12.26,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0597-0425-84,NDC,,,facility,both,1,EA,,566.14,566.14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Valproic: 100 Capsule, Liquid Filled In 1 Bottle (0591-4012-01)",250,RC,0591-4012-01,NDC,,,facility,both,1,EA,,8,8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0591-3525-11,NDC,,,facility,both,1,EA,,21.67,21.67,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Ursodiol: 100 Tablet In 1 Bottle (0591-2998-01),250,RC,0591-2998-01,NDC,,,facility,both,1,EA,,15.56,15.56,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Desmopressin Acetate: 100 TABLET in 1 BOTTLE, PLASTIC (0591-2464-01) ",250,RC,0591-2464-01,NDC,,,facility,both,1,EA,,36.43,36.43,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ambrisentan: 30 Tablet, Film Coated In 1 Bottle (0591-2405-30)",250,RC,0591-2405-30,NDC,,,facility,both,1,EA,,212.33,212.33,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Verapamil Hydrochloride: 100 Tablet, Film Coated In 1 Bottle, Plastic (0591-0343-01)",250,RC,0591-0343-01,NDC,,,facility,both,1,EA,,11.68,11.68,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Proglycem: 1 Bottle, Dropper In 1 Box (0575-6200-30) / 30 Ml In 1 Bottle, Dropper",250,RC,0575-6200-30,NDC,,,facility,both,1,EA,,25.52,25.52,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Lidocaine: 30 Pouch In 1 Carton (0591-3525-30) / 1 G In 1 Pouch (0591-3525-11),250,RC,0591-3525-30,NDC,,,facility,both,1,EA,,20.96,20.96,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Metronidazole: 100 BLISTER PACK in 1 CARTON (0904-1453-61) / 1 TABLET in 1 BLISTER PACK,250,RC,0904-1453-61,NDC,,,facility,both,1,EA,,7.37,7.37,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Bismatrol: 5 BLISTER PACK in 1 CARTON (0904-1315-46) / 6 TABLET, CHEWABLE in 1 BLISTER PACK",250,RC,0904-1315-46,NDC,,,facility,both,1,EA,,6.46,6.46,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Triple Antibiotic: 1 Tube In 1 Carton (0904-0734-31) / 28 G In 1 Tube,250,RC,0904-0734-31,NDC,,,facility,both,1,EA,,19.64,19.64,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Doxycycline Hyclate: 50 Blister Pack In 1 Carton (0904-0430-06) / 1 Tablet, Coated In 1 Blister Pack",250,RC,0904-0430-06,NDC,,,facility,both,1,EA,,20.36,20.36,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Oil: 473 Ml In 1 Bottle, Plastic (0869-0831-43)",250,RC,0869-0831-43,NDC,,,facility,both,1,EA,,13.14,13.14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Moxifloxacin Hydrochloride: 1 Bottle, Plastic In 1 Carton (0832-1410-03) / 3 Ml In 1 Bottle, Plastic",250,RC,0832-1410-03,NDC,,,facility,both,1,EA,,165.21,165.21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0832-0512-89,NDC,,,facility,both,1,EA,,12.25,12.25,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Bethanechol Chloride: 100 Blister Pack In 1 Carton (0832-0512-01) / 1 Tablet In 1 Blister Pack (0832-0512-89),250,RC,0832-0512-01,NDC,,,facility,both,1,EA,,12.38,12.38,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0832-0038-89,NDC,,,facility,both,1,EA,,12.43,12.43,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Clarithromycin: 50 Ml In 1 Bottle (0781-6023-52),250,RC,0781-6023-52,NDC,,,facility,both,1,EA,,56.48,56.48,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Hydroxychloroquine Sulfate: 100 TABLET, FILM COATED in 1 BOTTLE (0781-5994-01) ",250,RC,0781-5994-01,NDC,,,facility,both,1,EA,,14.33,14.33,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sulfamethoxazole And Trimethoprim: 100 Blister Pack In 1 Carton (0904-2725-61) / 1 Tablet In 1 Blister Pack,250,RC,0904-2725-61,NDC,,,facility,both,1,EA,,9.67,9.67,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0904-3865-75,NDC,,,facility,both,1,EA,,10.2,10.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Captopril: 100 BLISTER PACK in 1 CARTON (0904-5045-61) / 1 TABLET in 1 BLISTER PACK,250,RC,0904-5045-61,NDC,,,facility,both,1,EA,,13.07,13.07,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Citalopram: 100 Blister Pack In 1 Carton (0904-6084-61) / 1 Tablet, Film Coated In 1 Blister Pack",250,RC,0904-6084-61,NDC,,,facility,both,1,EA,,11.84,11.84,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Lorazepam: 100 Blister Pack In 1 Carton (0904-6008-61) / 1 Tablet In 1 Blister Pack,250,RC,0904-6008-61,NDC,,,facility,both,1,EA,,9.66,9.66,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Lorazepam: 100 Blister Pack In 1 Carton (0904-6007-61) / 1 Tablet In 1 Blister Pack,250,RC,0904-6007-61,NDC,,,facility,both,1,EA,,10.99,10.99,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Clindamycin Hydrochloride: 100 Blister Pack In 1 Carton (0904-5959-61) / 1 Capsule In 1 Blister Pack,250,RC,0904-5959-61,NDC,,,facility,both,1,EA,,5.24,5.24,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Labetalol hydrochloride: 100 BLISTER PACK in 1 CARTON (0904-5929-61) / 1 TABLET, FILM COATED in 1 BLISTER PACK",250,RC,0904-5929-61,NDC,,,facility,both,1,EA,,12.17,12.17,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Digoxin: 100 Blister Pack In 1 Carton (0904-5922-61) / 1 Tablet In 1 Blister Pack,250,RC,0904-5922-61,NDC,,,facility,both,1,EA,,17.85,17.85,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Digoxin: 100 Blister Pack In 1 Carton (0904-5921-61) / 1 Tablet In 1 Blister Pack,250,RC,0904-5921-61,NDC,,,facility,both,1,EA,,15.27,15.27,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Pravastatin Sodium: 100 Blister Pack In 1 Box, Unit-Dose (0904-5891-61) / 1 Tablet In 1 Blister Pack",250,RC,0904-5891-61,NDC,,,facility,both,1,EA,,10.99,10.99,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Ibuprofen: 100 Blister Pack In 1 Carton (0904-5854-61) / 1 Tablet In 1 Blister Pack,250,RC,0904-5854-61,NDC,,,facility,both,1,EA,,11.97,11.97,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Childrens Mapap: 1 Bottle, Plastic In 1 Carton (0904-5791-46) / 30 Tablet, Chewable In 1 Bottle, Plastic",250,RC,0904-5791-46,NDC,,,facility,both,1,EA,,3.63,3.63,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Acyclovir: 100 Blister Pack In 1 Carton (0904-5789-61) / 1 Capsule In 1 Blister Pack,250,RC,0904-5789-61,NDC,,,facility,both,1,EA,,8.4,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Fluoxetine: 100 Blister Pack In 1 Carton (0904-5785-61) / 1 Capsule In 1 Blister Pack,250,RC,0904-5785-61,NDC,,,facility,both,1,EA,,9.74,9.74,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Fluoxetine: 100 Blister Pack In 1 Carton (0904-5784-61) / 1 Capsule In 1 Blister Pack,250,RC,0904-5784-61,NDC,,,facility,both,1,EA,,12.12,12.12,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Heartburn Relief Original Strength: 1 Bottle In 1 Carton (0904-5529-52) / 60 Tablet, Film Coated In 1 Bottle",250,RC,0904-5529-52,NDC,,,facility,both,1,EA,,8.88,8.88,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Doxazosin: 100 Blister Pack In 1 Carton (0904-5522-61) / 1 Tablet In 1 Blister Pack,250,RC,0904-5522-61,NDC,,,facility,both,1,EA,,7.58,7.58,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Triple Antibiotic: 1 Tube In 1 Carton (0713-0268-31) / 28.4 G In 1 Tube,250,RC,0713-0268-31,NDC,,,facility,both,1,EA,,23.58,23.58,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0781-3269-71,NDC,,,facility,both,1,EA,,33.58,33.58,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Bacitracin: 28.4 G In 1 Tube (0713-0280-31),250,RC,0713-0280-31,NDC,,,facility,both,1,EA,,16.4,16.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0781-3152-70,NDC,,,facility,both,1,EA,,47.82,47.82,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Amoxicillin And Clavulanate Potassium: 28 Tablet, Multilayer, Extended Release In 1 Bottle (0781-1943-82)",250,RC,0781-1943-82,NDC,,,facility,both,1,EA,,39.3,39.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Griseofulvin: 118 Ml In 1 Bottle, Plastic (0713-0850-04)",250,RC,0713-0850-04,NDC,,,facility,both,1,EA,,5.21,5.21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Mometasone Furoate: 1 Tube In 1 Carton (0713-0634-15) / 15 G In 1 Tube,250,RC,0713-0634-15,NDC,,,facility,both,1,EA,,82.02,82.02,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Ready-To-Use: 1 Bottle In 1 Carton (0536-7415-51) / 133 Ml In 1 Bottle,250,RC,0536-7415-51,NDC,,,facility,both,1,EA,,16.22,16.22,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Capsaicin: 1 Tube In 1 Carton (0536-2525-25) / 60 G In 1 Tube,250,RC,0536-2525-25,NDC,,,facility,both,1,EA,,41.43,41.43,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sodium Bicarbonate: 10 Carton In 1 Package (0409-5534-14) / 1 Syringe In 1 Carton / 10 Ml In 1 Syringe (0409-5534-24),250,RC,0409-5534-14,NDC,,,facility,both,1,EA,,122.14,122.14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0409-4888-03,NDC,,,facility,both,1,EA,,29.89,29.89,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0409-4888-02,NDC,,,facility,both,1,EA,,19.44,19.44,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0409-4887-25,NDC,,,facility,both,1,EA,,43.51,43.51,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0409-4887-24,NDC,,,facility,both,1,EA,,33.19,33.19,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0409-4887-23,NDC,,,facility,both,1,EA,,29.06,29.06,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Sterile Water: 25 Vial, Plastic In 1 Tray (0409-4887-10) / 10 Ml In 1 Vial, Plastic (0409-4887-17)",250,RC,0409-4887-10,NDC,,,facility,both,1,EA,,28.72,28.72,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0409-4713-75,NDC,,,facility,both,1,EA,,42.46,42.46,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0409-4279-16,NDC,,,facility,both,1,EA,,11.74,11.74,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sodium Bicarbonate: 25 VIAL in 1 TRAY (0409-6625-02) / 50 mL in 1 VIAL,250,RC,0409-6625-02,NDC,,,facility,both,1,EA,,49.51,49.51,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Sodium Bicarbonate: 25 Vial, Single-Dose In 1 Tray (0409-6625-14) / 50 Ml In 1 Vial, Single-Dose (0409-6625-22)",250,RC,0409-6625-14,NDC,,,facility,both,1,EA,,48.7,48.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Heparin Sodium: 24 Pouch In 1 Case (0409-7650-62) / 1 Bag In 1 Pouch / 250 Ml In 1 Bag (0409-7650-52),250,RC,0409-7650-62,NDC,,,facility,both,1,EA,,48.8,48.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Sodium Phosphates: 25 Vial, Single-Dose In 1 Tray (0409-7391-72) / 15 Ml In 1 Vial, Single-Dose (0409-7391-82)",250,RC,0409-7391-72,NDC,,,facility,both,1,EA,,70.75,70.75,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0409-7295-11,NDC,,,facility,both,1,EA,,51.13,51.13,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Potassium Phosphates: 25 Vial, Single-Dose In 1 Tray (0409-7295-01) / 15 Ml In 1 Vial, Single-Dose (0409-7295-11)",250,RC,0409-7295-01,NDC,,,facility,both,1,EA,,58.36,58.36,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0409-7037-01,NDC,,,facility,both,1,EA,,29.14,29.14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sodium Bicarbonate: 10 CARTON in 1 PACKAGE (0409-6637-34) / 1 SYRINGE in 1 CARTON / 50 mL in 1 SYRINGE,250,RC,0409-6637-34,NDC,,,facility,both,1,EA,,59.59,59.59,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sodium Bicarbonate: 10 Carton In 1 Package (0409-6637-14) / 1 Syringe In 1 Carton / 50 Ml In 1 Syringe (0409-6637-24),250,RC,0409-6637-14,NDC,,,facility,both,1,EA,,88.08,88.08,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0409-2051-15,NDC,,,facility,both,1,EA,,49.65,49.65,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0409-1749-70,NDC,,,facility,both,1,EA,,43.66,43.66,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0409-2308-21,NDC,,,facility,both,1,EA,,28.08,28.08,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Marcaine With Epinephrine: 10 Vial, Single-Dose In 1 Carton (0409-1746-10) / 10 Ml In 1 Vial, Single-Dose (0409-1746-70)",250,RC,0409-1746-10,NDC,,,facility,both,1,EA,,38.25,38.25,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Precedex: 10 Bottle In 1 Tray (0409-1660-10) / 100 Ml In 1 Bottle (0409-1660-35),250,RC,0409-1660-10,NDC,,,facility,both,1,EA,,34.6,34.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0409-1638-32,NDC,,,facility,both,1,EA,,43.42,43.42,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Calcium Chloride: 10 Carton In 1 Container (0409-1631-10) / 1 Syringe, Plastic In 1 Carton (0409-1631-40) / 10 Ml In 1 Syringe, Plastic",250,RC,0409-1631-10,NDC,,,facility,both,1,EA,,34.88,34.88,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Marcaine With Epinephrine: 10 Vial, Single-Dose In 1 Carton (0409-1749-10) / 10 Ml In 1 Vial, Single-Dose (0409-1749-70)",250,RC,0409-1749-10,NDC,,,facility,both,1,EA,,40.39,40.39,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Sufentanil Citrate: 10 Vial, Single-Dose In 1 Carton (0409-3382-21) / 1 Ml In 1 Vial, Single-Dose (0409-3382-11)",250,RC,0409-3382-21,NDC,,,facility,both,1,EA,,74.37,74.37,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0409-3382-11,NDC,,,facility,both,1,EA,,78.1,78.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0409-3308-11,NDC,,,facility,both,1,EA,,21.74,21.74,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Acetylcysteine: 3 Vial In 1 Carton (0409-3308-03) / 30 Ml In 1 Vial (0409-3308-11),250,RC,0409-3308-03,NDC,,,facility,both,1,EA,,21.95,21.95,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0409-2308-22,NDC,,,facility,both,1,EA,,32.05,32.05,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0409-3294-61,NDC,,,facility,both,1,EA,,38.95,38.95,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Lidocaine Hydrochloride And Epinephrine: 25 Vial, Multi-Dose In 1 Tray (0409-3178-01) / 20 Ml In 1 Vial, Multi-Dose (0409-3178-16)",250,RC,0409-3178-01,NDC,,,facility,both,1,EA,,31.23,31.23,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0409-3177-16,NDC,,,facility,both,1,EA,,29.51,29.51,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Lidocaine Hydrochloride And Epinephrine: 25 Vial, Multi-Dose In 1 Tray (0409-3177-01) / 50 Ml In 1 Vial, Multi-Dose (0409-3177-16)",250,RC,0409-3177-01,NDC,,,facility,both,1,EA,,29.52,29.52,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0409-3178-17,NDC,,,facility,both,1,EA,,33.25,33.25,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Aminocaproic Acid: 25 Vial, Multi-Dose In 1 Tray (0517-9120-25) / 20 Ml In 1 Vial, Multi-Dose",250,RC,0517-9120-25,NDC,,,facility,both,1,EA,,27.64,27.64,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Caffeine And Sodium Benzoate: 10 Vial, Single-Dose In 1 Box (0517-2502-10) / 2 Ml In 1 Vial, Single-Dose (0517-2502-01)",250,RC,0517-2502-10,NDC,,,facility,both,1,EA,,194.43,194.43,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0517-2502-01,NDC,,,facility,both,1,EA,,152.51,152.51,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dicyclomine Hydrochloride: 100 Capsule In 1 Bottle (0527-0586-01),250,RC,0527-0586-01,NDC,,,facility,both,1,EA,,8.29,8.29,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Levofloxacin: 1 Bottle, Plastic In 1 Carton (0527-1948-68) / 200 Ml In 1 Bottle, Plastic",250,RC,0527-1948-68,NDC,,,facility,both,1,EA,,141.76,141.76,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Rugby Anti-Dandruff: 207 Ml In 1 Bottle, Plastic (0536-1995-53)",250,RC,0536-1995-53,NDC,,,facility,both,1,EA,,19.93,19.93,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Rugby Polyvinyl Alcohol 1.4% Lubricating Eye Drops: 1 Bottle, Dropper In 1 Box (0536-1408-94) / 15 Ml In 1 Bottle, Dropper",250,RC,0536-1408-94,NDC,,,facility,both,1,EA,,40.59,40.59,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Rugby Muscle Rub Cream: 1 Tube In 1 Carton (0536-1349-57) / 85 G In 1 Tube,250,RC,0536-1349-57,NDC,,,facility,both,1,EA,,21.59,21.59,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Rugby Lubricating Drops: 15 Ml In 1 Bottle (0536-1325-94),250,RC,0536-1325-94,NDC,,,facility,both,1,EA,,40.75,40.75,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Infants: 1 Bottle, Dropper In 1 Carton (0536-1303-75) / 30 Ml In 1 Bottle, Dropper",250,RC,0536-1303-75,NDC,,,facility,both,1,EA,,12.96,12.96,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Bacitracin Zinc: 1 Tube In 1 Box (0536-1263-28) / 28 G In 1 Tube,250,RC,0536-1263-28,NDC,,,facility,both,1,EA,,17.89,17.89,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Rugby Cherry Flavor: 177 Ml In 1 Bottle, Spray (0536-1228-58)",250,RC,0536-1228-58,NDC,,,facility,both,1,EA,,21,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Rugby Petrolatum Hydrating Skin Protectant: 100 G In 1 Jar (0536-1143-97),250,RC,0536-1143-97,NDC,,,facility,both,1,EA,,36.14,36.14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Rugby Benzoyl Peroxide Acne Medication: 1 Tube In 1 Carton (0536-1055-56) / 42.5 Ml In 1 Tube,250,RC,0536-1055-56,NDC,,,facility,both,1,EA,,20.55,20.55,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Aspirin: 1 Bottle, Plastic In 1 Carton (0536-1054-29) / 100 Tablet, Film Coated In 1 Bottle, Plastic",250,RC,0536-1054-29,NDC,,,facility,both,1,EA,,0.62,0.62,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sodium Bicarbonate Antacid: 1000 Tablet In 1 Bottle (0536-1046-10),250,RC,0536-1046-10,NDC,,,facility,both,1,EA,,5.71,5.71,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Oseltamivir Phosphate: 1 Bottle, Plastic In 1 Carton (0527-5137-62) / 60 Ml In 1 Bottle, Plastic",250,RC,0527-5137-62,NDC,,,facility,both,1,EA,,18.05,18.05,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Oseltamivir Phosphate: 1 Blister Pack In 1 Carton (0527-4591-13) / 10 Capsule In 1 Blister Pack,250,RC,0527-4591-13,NDC,,,facility,both,1,EA,,12.94,12.94,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Posaconazole: 60 Tablet, Delayed Release In 1 Bottle (0527-2133-35)",250,RC,0527-2133-35,NDC,,,facility,both,1,EA,,35.86,35.86,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Rugby Petrolatum Hydrating Skin Protectant: 454 G In 1 Jar (0536-1143-98),250,RC,0536-1143-98,NDC,,,facility,both,1,EA,,74.29,74.29,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Lmx4: 5 Tube In 1 Carton (0496-0882-06) / 5 G In 1 Tube (0496-0882-05),250,RC,0496-0882-06,NDC,,,facility,both,1,EA,,26.81,26.81,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Lmx4: 5 G In 1 Tube (0496-0882-05),250,RC,0496-0882-05,NDC,,,facility,both,1,EA,,24.15,24.15,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Linzess: 1 Bottle In 1 Carton (0456-1203-30) / 30 Capsule, Gelatin Coated In 1 Bottle",250,RC,0456-1203-30,NDC,,,facility,both,1,EA,,135.05,135.05,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Linzess: 1 Bottle In 1 Carton (0456-1201-30) / 30 Capsule, Gelatin Coated In 1 Bottle",250,RC,0456-1201-30,NDC,,,facility,both,1,EA,,133.58,133.58,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Lo Loestrin Fe: 5 Blister Pack In 1 Carton (0430-0420-14) / 1 Kit In 1 Blister Pack,250,RC,0430-0420-14,NDC,,,facility,both,1,EA,,47.31,47.31,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0409-8183-11,NDC,,,facility,both,1,EA,,35.9,35.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Potassium Acetate: 25 Vial, Single-Dose In 1 Tray (0409-8183-01) / 20 Ml In 1 Vial, Single-Dose (0409-8183-11)",250,RC,0409-8183-01,NDC,,,facility,both,1,EA,,36.78,36.78,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sterile Water: 12 POUCH in 1 CASE (0409-7990-09) / 1 BAG in 1 POUCH / 1000 mL in 1 BAG,250,RC,0409-7990-09,NDC,,,facility,both,1,EA,,66.35,66.35,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Budesonide: 6 Pouch In 1 Carton (0487-9701-01) / 5 Ampule In 1 Pouch / 2 Ml In 1 Ampule,250,RC,0487-9701-01,NDC,,,facility,both,1,EA,,62.09,62.09,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0487-9301-33,NDC,,,facility,both,1,EA,,13.95,13.95,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0487-9301-03,NDC,,,facility,both,1,EA,,13.85,13.85,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "S2: 30 Pouch In 1 Carton (0487-5901-99) / 1 Vial, Single-Use In 1 Pouch / .5 Ml In 1 Vial, Single-Use",250,RC,0487-5901-99,NDC,,,facility,both,1,EA,,23.93,23.93,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Asthmanefrin: 30 Pouch In 1 Carton (0487-2784-01) / 1 Vial, Single-Use In 1 Pouch / .5 Ml In 1 Vial, Single-Use",250,RC,0487-2784-01,NDC,,,facility,both,1,EA,,24.35,24.35,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "K-Phos No. 2: 100 Tablet, Coated In 1 Bottle (0486-1134-01)",250,RC,0486-1134-01,NDC,,,facility,both,1,EA,,17.24,17.24,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Antifungal: 1 TUBE in 1 CARTON (0472-0735-14) / 14 g in 1 TUBE,250,RC,0472-0735-14,NDC,,,facility,both,1,EA,,16.11,16.11,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Permethrin: 1 Tube In 1 Carton (0472-0242-60) / 60 G In 1 Tube,250,RC,0472-0242-60,NDC,,,facility,both,1,EA,,137.18,137.18,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Griseofulvin: 120 Ml In 1 Bottle (0472-0013-04),250,RC,0472-0013-04,NDC,,,facility,both,1,EA,,3.52,3.52,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Myrbetriq: 1 Bottle In 1 Carton (0469-5020-99) / 100 Ml In 1 Bottle,250,RC,0469-5020-99,NDC,,,facility,both,1,EA,,105.07,105.07,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Xospata: 1 Bottle In 1 Carton (0469-1425-90) / 90 Tablet In 1 Bottle,250,RC,0469-1425-90,NDC,,,facility,both,1,EA,,2098.04,2098.04,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Cresemba: 2 Blister Pack In 1 Carton (0469-0520-02) / 7 Capsule In 1 Blister Pack,250,RC,0469-0520-02,NDC,,,facility,both,1,EA,,570.57,570.57,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Citalopram: 100 Blister Pack In 1 Carton (0904-6085-61) / 1 Tablet, Film Coated In 1 Blister Pack",250,RC,0904-6085-61,NDC,,,facility,both,1,EA,,10.6,10.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Ursodiol: 100 Blister Pack In 1 Carton (0904-6221-61) / 1 Capsule In 1 Blister Pack,250,RC,0904-6221-61,NDC,,,facility,both,1,EA,,21.39,21.39,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Alcaine: 1 Bottle In 1 Carton (0998-0016-15) / 15 Ml In 1 Bottle,250,RC,0998-0016-15,NDC,,,facility,both,1,EA,,197.06,197.06,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Potassium Chloride In Dextrose And Sodium Chloride: 12 Pouch In 1 Case (0990-7904-09) / 1 Bag In 1 Pouch / 1000 Ml In 1 Bag,250,RC,0990-7904-09,NDC,,,facility,both,1,EA,,105.14,105.14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sodium Chloride: 20 Pouch In 1 Case (0990-7730-37) / 4 Bag In 1 Pouch / 100 Ml In 1 Bag,250,RC,0990-7730-37,NDC,,,facility,both,1,EA,,87.94,87.94,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Mannitol: 24 Pouch In 1 Case (0990-7715-02) / 1 Bag In 1 Pouch / 250 Ml In 1 Bag (0990-7715-12),250,RC,0990-7715-02,NDC,,,facility,both,1,EA,,138.82,138.82,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Physiosol: 12 Bottle, Plastic In 1 Case (0990-6141-09) / 1000 Ml In 1 Bottle, Plastic",250,RC,0990-6141-09,NDC,,,facility,both,1,EA,,1.38,1.38,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Brevibloc: 10 Bag In 1 Carton (10019-075-87) / 100 Ml In 1 Bag,250,RC,10019-075-87,NDC,,,facility,both,1,EA,,856.64,856.64,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Transderm Scop: 10 Pouch In 1 Box (10019-553-03) / 1 Patch In 1 Pouch / 3 D In 1 Patch,250,RC,10019-553-03,NDC,,,facility,both,1,EA,,94.53,94.53,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Critic-Aid Clear: 71 G In 1 Tube (11701-083-33),250,RC,11701-083-33,NDC,,,facility,both,1,EA,,42.39,42.39,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Critic Aid Clear Af: 57 G In 1 Tube (11701-067-23),250,RC,11701-067-23,NDC,,,facility,both,1,EA,,48.9,48.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Polyethylene Glycol 3350 Nf: 238 G In 1 Bottle (11534-180-28),250,RC,11534-180-28,NDC,,,facility,both,1,EA,,7.68,7.68,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Afrin Original: 1 Bottle, Spray In 1 Carton (11523-1167-6) / 15 Ml In 1 Bottle, Spray",250,RC,11523-1167-6,NDC,,,facility,both,1,EA,,46.6,46.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dexmethylphenidate Hydrochloride: 100 Tablet In 1 Bottle (10702-107-01),250,RC,10702-107-01,NDC,,,facility,both,1,EA,,10.36,10.36,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Peg-3350, Sodium Chloride, Sodium Bicarbonate And Potassium Chloride: 4 L In 1 Bottle (10572-302-01)",250,RC,10572-302-01,NDC,,,facility,both,1,EA,,182.81,182.81,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Rifabutin: 100 Capsule In 1 Bottle (10135-738-01),250,RC,10135-738-01,NDC,,,facility,both,1,EA,,36.27,36.27,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Pyrazinamide: 100 Tablet In 1 Bottle (10135-735-01),250,RC,10135-735-01,NDC,,,facility,both,1,EA,,27.41,27.41,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Menthol And Zinc Oxide: 113 G In 1 Tube (10135-701-04),250,RC,10135-701-04,NDC,,,facility,both,1,EA,,22.29,22.29,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Curosurf: 1.5 Ml In 1 Vial, Glass (10122-510-01)",250,RC,10122-510-01,NDC,,,facility,both,1,EA,,2857.83,2857.83,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Cardene IV: 10 CARTON in 1 BOX (10122-325-10) / 1 BAG in 1 CARTON (10122-325-01) / 200 mL in 1 BAG,250,RC,10122-325-10,NDC,,,facility,both,1,EA,,494.51,494.51,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Curosurf: 3 Ml In 1 Vial, Glass (10122-510-03)",250,RC,10122-510-03,NDC,,,facility,both,1,EA,,5958.14,5958.14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Acd-A: 1000 Ml In 1 Bag (0942-0641-04),250,RC,0942-0641-04,NDC,,,facility,both,1,EA,,75.98,75.98,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0941-0696-01,NDC,,,facility,both,1,EA,,127.39,127.39,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dianeal Low Calcium With Dextrose: 6000 Ml In 1 Bag (0941-0459-01),250,RC,0941-0459-01,NDC,,,facility,both,1,EA,,130.94,130.94,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dianeal Low Calcium With Dextrose: 2000 Ml In 1 Bag (0941-0457-08),250,RC,0941-0457-08,NDC,,,facility,both,1,EA,,118.99,118.99,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dianeal Low Calcium With Dextrose: 3000 Ml In 1 Bag (0941-0457-02),250,RC,0941-0457-02,NDC,,,facility,both,1,EA,,152.11,152.11,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dianeal Low Calcium With Dextrose: 6000 Ml In 1 Bag (0941-0457-01),250,RC,0941-0457-01,NDC,,,facility,both,1,EA,,147.27,147.27,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dianeal Pd-2 With Dextrose: 2000 Ml In 1 Bag (0941-0415-06),250,RC,0941-0415-06,NDC,,,facility,both,1,EA,,122.11,122.11,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dianeal Pd-2 With Dextrose: 2000 Ml In 1 Bag (0941-0413-06),250,RC,0941-0413-06,NDC,,,facility,both,1,EA,,137.72,137.72,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dianeal Pd-2 With Dextrose: 2000 Ml In 1 Bag (0941-0411-06),250,RC,0941-0411-06,NDC,,,facility,both,1,EA,,68.29,68.29,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dianeal Low Calcium With Dextrose: 2000 Ml In 1 Bag (0941-0409-06),250,RC,0941-0409-06,NDC,,,facility,both,1,EA,,106.48,106.48,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dianeal Low Calcium With Dextrose: 3000 Ml In 1 Bag (0941-0409-05),250,RC,0941-0409-05,NDC,,,facility,both,1,EA,,153.35,153.35,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dianeal Low Calcium With Dextrose: 6000 Ml In 1 Bag (0941-0409-01),250,RC,0941-0409-01,NDC,,,facility,both,1,EA,,139.71,139.71,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ibuprofen: 10 Blister Pack In 1 Carton (0904-7914-61) / 10 Tablet, Film Coated In 1 Blister Pack",250,RC,0904-7914-61,NDC,,,facility,both,1,EA,,0.49,0.49,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dianeal Low Calcium With Dextrose: 2000 Ml In 1 Bag (0941-0459-08),250,RC,0941-0459-08,NDC,,,facility,both,1,EA,,105.3,105.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Diazoxide: 1 Bottle, Dropper In 1 Carton (13517-100-30) / 30 Ml In 1 Bottle, Dropper",250,RC,13517-100-30,NDC,,,facility,both,1,EA,,17.47,17.47,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Isoproterenol Hydrochloride: 10 Vial, Single-Dose In 1 Carton (14789-015-05) / 5 Ml In 1 Vial, Single-Dose",250,RC,14789-015-05,NDC,,,facility,both,1,EA,,1466.89,1466.89,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Pentamidine Isethionate: 10 Vial In 1 Tray (13925-515-10) / 300 Mg In 1 Vial,250,RC,13925-515-10,NDC,,,facility,both,1,EA,,355.26,355.26,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,13925-515-01,NDC,,,facility,both,1,EA,,404.61,404.61,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Methylphenidate Hydrochloride: 100 Tablet, Extended Release In 1 Bottle (13811-706-10)",250,RC,13811-706-10,NDC,,,facility,both,1,EA,,9.56,9.56,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Erythromycin: 30 Tablet, Coated In 1 Bottle (13668-606-30)",250,RC,13668-606-30,NDC,,,facility,both,1,EA,,35.91,35.91,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Tadalafil: 30 Tablet In 1 Bottle (13668-581-30),250,RC,13668-581-30,NDC,,,facility,both,1,EA,,14.4,14.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,14789-015-07,NDC,,,facility,both,1,EA,,1146.11,1146.11,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Liothyronine Sodium: 100 Tablet In 1 Bottle (16714-166-01),250,RC,16714-166-01,NDC,,,facility,both,1,EA,,14.36,14.36,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Clobazam: 1 Bottle, Glass In 1 Carton (16714-087-01) / 120 Ml In 1 Bottle, Glass",250,RC,16714-087-01,NDC,,,facility,both,1,EA,,25.08,25.08,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Hydroxyzine Hydrochloride: 100 Tablet In 1 Bottle (16714-082-10),250,RC,16714-082-10,NDC,,,facility,both,1,EA,,12.55,12.55,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Clopidogrel: 10 Tablet In 1 Blister Pack (16714-052-10),250,RC,16714-052-10,NDC,,,facility,both,1,EA,,12.05,12.05,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sulfamylon: 453.6 G In 1 Jar (16571-723-48),250,RC,16571-723-48,NDC,,,facility,both,1,EA,,2949.21,2949.21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Lansoprazole: 90 Capsule, Delayed Release In 1 Bottle (16571-698-09)",250,RC,16571-698-09,NDC,,,facility,both,1,EA,,12.08,12.08,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Phenobarbital: 100 Tablet In 1 Bottle (16571-671-01),250,RC,16571-671-01,NDC,,,facility,both,1,EA,,5.02,5.02,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Phenobarbital: 100 Tablet In 1 Bottle (16571-669-01),250,RC,16571-669-01,NDC,,,facility,both,1,EA,,5.61,5.61,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Cetirizine Hydrochloride: 100 Tablet In 1 Bottle (16571-401-10),250,RC,16571-401-10,NDC,,,facility,both,1,EA,,6.7,6.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Isradipine: 100 Capsule In 1 Bottle (16252-540-01),250,RC,16252-540-01,NDC,,,facility,both,1,EA,,16.2,16.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Isradipine: 100 Capsule In 1 Bottle (16252-539-01),250,RC,16252-539-01,NDC,,,facility,both,1,EA,,21.31,21.31,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,14789-134-07,NDC,,,facility,both,1,EA,,72.95,72.95,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Phenobarbital: 100 Tablet In 1 Bottle (13517-758-01),250,RC,13517-758-01,NDC,,,facility,both,1,EA,,14.59,14.59,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Silver Nitrate Applicators: 100 Applicator In 1 Vial (12870-0001-2) / 100 Mg In 1 Applicator,250,RC,12870-0001-2,NDC,,,facility,both,1,EA,,14.72,14.72,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Clonazepam: 100 Blister Pack In 1 Carton (0904-7728-61) / 1 Tablet In 1 Blister Pack,250,RC,0904-7728-61,NDC,,,facility,both,1,EA,,13.02,13.02,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Lisinopril: 100 Blister Pack In 1 Carton (0904-6797-61) / 1 Tablet In 1 Blister Pack,250,RC,0904-6797-61,NDC,,,facility,both,1,EA,,11.14,11.14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Aspirin Low Dose Chewable Orange: 300 Blister Pack In 1 Carton (0904-6794-30) / 1 Tablet, Chewable In 1 Blister Pack",250,RC,0904-6794-30,NDC,,,facility,both,1,EA,,0.93,0.93,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Haloperidol: 100 Blister Pack In 1 Carton (0904-6782-61) / 1 Tablet In 1 Blister Pack,250,RC,0904-6782-61,NDC,,,facility,both,1,EA,,15.49,15.49,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Rosuvastatin Calcium: 100 Blister Pack In 1 Carton (0904-6778-61) / 1 Tablet, Coated In 1 Blister Pack",250,RC,0904-6778-61,NDC,,,facility,both,1,EA,,16.75,16.75,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Acetaminophen: 10 Blister Pack In 1 Box, Unit-Dose (0904-6773-61) / 10 Tablet In 1 Blister Pack",250,RC,0904-6773-61,NDC,,,facility,both,1,EA,,0.58,0.58,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Childrens Loratadine Oral: 1 Bottle In 1 Carton (0904-6767-20) / 120 Ml In 1 Bottle,250,RC,0904-6767-20,NDC,,,facility,both,1,EA,,13.07,13.07,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Acetaminophen: 10 Blister Pack In 1 Box, Unit-Dose (0904-6730-61) / 10 Tablet In 1 Blister Pack",250,RC,0904-6730-61,NDC,,,facility,both,1,EA,,9.35,9.35,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Pseudoephedrine Hydrochloride: 30 Tablet In 1 Bottle (0904-6728-46),250,RC,0904-6728-46,NDC,,,facility,both,1,EA,,11.92,11.92,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Cetirizine: 100 Blister Pack In 1 Carton (0904-6717-61) / 1 Tablet, Film Coated In 1 Blister Pack",250,RC,0904-6717-61,NDC,,,facility,both,1,EA,,11.59,11.59,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Gabapentin: 100 Blister Pack In 1 Carton (0904-6667-61) / 1 Capsule In 1 Blister Pack,250,RC,0904-6667-61,NDC,,,facility,both,1,EA,,7.87,7.87,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Gabapentin: 100 Blister Pack In 1 Carton (0904-6665-61) / 1 Capsule In 1 Blister Pack,250,RC,0904-6665-61,NDC,,,facility,both,1,EA,,8.62,8.62,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Acetazolamide: 100 Blister Pack In 1 Carton (0904-6663-61) / 1 Tablet In 1 Blister Pack,250,RC,0904-6663-61,NDC,,,facility,both,1,EA,,15.14,15.14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Quetiapine: 100 Blister Pack In 1 Carton (0904-6640-61) / 1 Tablet, Film Coated In 1 Blister Pack",250,RC,0904-6640-61,NDC,,,facility,both,1,EA,,10.55,10.55,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Quetiapine: 100 Blister Pack In 1 Carton (0904-6638-61) / 1 Tablet, Film Coated In 1 Blister Pack",250,RC,0904-6638-61,NDC,,,facility,both,1,EA,,7.93,7.93,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Lisinopril: 100 Blister Pack In 1 Carton (0904-6798-61) / 1 Tablet In 1 Blister Pack,250,RC,0904-6798-61,NDC,,,facility,both,1,EA,,9.62,9.62,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Montelukast Sodium: 100 Blister Pack In 1 Carton (0904-6808-61) / 1 Tablet, Film Coated In 1 Blister Pack",250,RC,0904-6808-61,NDC,,,facility,both,1,EA,,13.13,13.13,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Levothyroxine Sodium: 100 Blister Pack In 1 Carton (0904-6954-61) / 1 Tablet In 1 Blister Pack,250,RC,0904-6954-61,NDC,,,facility,both,1,EA,,14.26,14.26,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Levothyroxine Sodium: 100 Blister Pack In 1 Carton (0904-6953-61) / 1 Tablet In 1 Blister Pack,250,RC,0904-6953-61,NDC,,,facility,both,1,EA,,12.33,12.33,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Levothyroxine Sodium: 100 Blister Pack In 1 Carton (0904-6952-61) / 1 Tablet In 1 Blister Pack,250,RC,0904-6952-61,NDC,,,facility,both,1,EA,,13.85,13.85,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Levothyroxine Sodium: 100 Blister Pack In 1 Carton (0904-6951-61) / 1 Tablet In 1 Blister Pack,250,RC,0904-6951-61,NDC,,,facility,both,1,EA,,10.88,10.88,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Levothyroxine Sodium: 100 Blister Pack In 1 Carton (0904-6950-61) / 1 Tablet In 1 Blister Pack,250,RC,0904-6950-61,NDC,,,facility,both,1,EA,,13.75,13.75,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Hydroxyurea: 100 Blister Pack In 1 Carton (0904-6939-61) / 1 Capsule In 1 Blister Pack,250,RC,0904-6939-61,NDC,,,facility,both,1,EA,,9.22,9.22,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Polyethylene Glycol 3350: 17 G In 1 Packet (0904-6931-86),250,RC,0904-6931-86,NDC,,,facility,both,1,EA,,17.86,17.86,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Spironolactone: 100 Blister Pack In 1 Carton (0904-6927-61) / 1 Tablet, Film Coated In 1 Blister Pack",250,RC,0904-6927-61,NDC,,,facility,both,1,EA,,8.03,8.03,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Pseudoephedrine Hydrochloride: 5 Blister Pack In 1 Box (0904-6907-06) / 10 Tablet In 1 Blister Pack,250,RC,0904-6907-06,NDC,,,facility,both,1,EA,,11.71,11.71,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Minocycline Hydrochloride: 50 Blister Pack In 1 Carton (0904-6888-06) / 1 Capsule In 1 Blister Pack,250,RC,0904-6888-06,NDC,,,facility,both,1,EA,,13.26,13.26,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Trazodone Hydrochloride: 100 Blister Pack In 1 Carton (0904-6868-61) / 1 Tablet In 1 Blister Pack,250,RC,0904-6868-61,NDC,,,facility,both,1,EA,,7.95,7.95,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Divalproex Sodium: 100 Blister Pack In 1 Carton (0904-6860-61) / 1 Tablet, Delayed Release In 1 Blister Pack",250,RC,0904-6860-61,NDC,,,facility,both,1,EA,,11.91,11.91,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Loratadine: 100 Blister Pack In 1 Carton (0904-6852-61) / 1 Tablet In 1 Blister Pack,250,RC,0904-6852-61,NDC,,,facility,both,1,EA,,12.57,12.57,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Oxycodone Hydrochloride: 4 Tray In 1 Carton (0904-6828-94) / 10 Cup, Unit-Dose In 1 Tray / 5 Ml In 1 Cup, Unit-Dose (0904-6828-05)",250,RC,0904-6828-94,NDC,,,facility,both,1,EA,,19.96,19.96,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0904-6828-05,NDC,,,facility,both,1,EA,,20.21,20.21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Ear Drops Major: 1 Bottle In 1 Carton (0904-6627-35) / 15 Ml In 1 Bottle,250,RC,0904-6627-35,NDC,,,facility,both,1,EA,,14.9,14.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Bisacodyl: 10 Blister Pack In 1 Box (0904-6407-61) / 10 Tablet, Delayed Release In 1 Blister Pack",250,RC,0904-6407-61,NDC,,,facility,both,1,EA,,0.53,0.53,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Amlodipine Besylate: 100 Blister Pack In 1 Carton (0904-6371-61) / 1 Tablet In 1 Blister Pack,250,RC,0904-6371-61,NDC,,,facility,both,1,EA,,11.92,11.92,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Amlodipine Besylate: 100 Blister Pack In 1 Carton (0904-6370-61) / 1 Tablet In 1 Blister Pack,250,RC,0904-6370-61,NDC,,,facility,both,1,EA,,9.91,9.91,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Amlodipine Besylate: 100 Blister Pack In 1 Carton (0904-6369-61) / 1 Tablet In 1 Blister Pack,250,RC,0904-6369-61,NDC,,,facility,both,1,EA,,11.14,11.14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Risperidone: 100 Tablet In 1 Box, Unit-Dose (0904-6359-61)",250,RC,0904-6359-61,NDC,,,facility,both,1,EA,,4.32,4.32,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Levofloxacin: 100 Blister Pack In 1 Carton (0904-6351-61) / 1 Tablet, Film Coated In 1 Blister Pack",250,RC,0904-6351-61,NDC,,,facility,both,1,EA,,6.5,6.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Metoprolol Succinate: 100 Blister Pack In 1 Carton (0904-6322-61) / 1 Tablet, Film Coated, Extended Release In 1 Blister Pack",250,RC,0904-6322-61,NDC,,,facility,both,1,EA,,12.38,12.38,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Sore Throat Cherry: 177 Ml In 1 Bottle, Spray (0904-6305-21)",250,RC,0904-6305-21,NDC,,,facility,both,1,EA,,18.79,18.79,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Carvedilol: 100 Tablet, Film Coated In 1 Box, Unit-Dose (0904-6303-61)",250,RC,0904-6303-61,NDC,,,facility,both,1,EA,,11.96,11.96,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Carvedilol: 100 Tablet, Film Coated In 1 Box, Unit-Dose (0904-6300-61)",250,RC,0904-6300-61,NDC,,,facility,both,1,EA,,5.26,5.26,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Clopidogrel: 100 Blister Pack In 1 Carton (0904-6294-61) / 1 Tablet, Film Coated In 1 Blister Pack",250,RC,0904-6294-61,NDC,,,facility,both,1,EA,,11.57,11.57,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Atorvastatin Calcium: 100 Blister Pack In 1 Carton (0904-6290-61) / 1 Tablet, Film Coated In 1 Blister Pack",250,RC,0904-6290-61,NDC,,,facility,both,1,EA,,9.38,9.38,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Ziprasidone: 80 Blister Pack In 1 Carton (0904-6270-45) / 1 Capsule In 1 Blister Pack,250,RC,0904-6270-45,NDC,,,facility,both,1,EA,,24.03,24.03,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Ziprasidone: 40 Blister Pack In 1 Carton (0904-6269-08) / 1 Capsule In 1 Blister Pack,250,RC,0904-6269-08,NDC,,,facility,both,1,EA,,32.78,32.78,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Oxycodone Hydrochloride: 100 Blister Pack In 1 Carton (0904-6966-61) / 1 Tablet In 1 Blister Pack,250,RC,0904-6966-61,NDC,,,facility,both,1,EA,,11.9,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Major Regular Strength Assorted Flavors: 150 Tablet, Chewable In 1 Bottle, Plastic (0904-6412-92)",250,RC,0904-6412-92,NDC,,,facility,both,1,EA,,9.83,9.83,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Hydroxyzine Hydrochloride: 100 Blister Pack In 1 Carton (0904-6617-61) / 1 Tablet, Film Coated In 1 Blister Pack",250,RC,0904-6617-61,NDC,,,facility,both,1,EA,,12.89,12.89,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Tolterodine Tartrate: 30 Blister Pack In 1 Carton (0904-6592-04) / 1 Capsule, Extended Release In 1 Blister Pack",250,RC,0904-6592-04,NDC,,,facility,both,1,EA,,43.39,43.39,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Allopurinol: 100 Blister Pack In 1 Carton (0904-6572-61) / 1 Tablet In 1 Blister Pack,250,RC,0904-6572-61,NDC,,,facility,both,1,EA,,11.22,11.22,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Oxybutynin Chloride: 100 Blister Pack In 1 Carton (0904-6570-61) / 1 Tablet, Extended Release In 1 Blister Pack",250,RC,0904-6570-61,NDC,,,facility,both,1,EA,,14.52,14.52,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Oxybutynin Chloride: 50 Blister Pack In 1 Carton (0904-6570-06) / 1 Tablet, Extended Release In 1 Blister Pack",250,RC,0904-6570-06,NDC,,,facility,both,1,EA,,18.2,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Valacyclovir Hydrochloride: 100 Blister Pack In 1 Carton (0904-6565-61) / 1 Tablet, Film Coated In 1 Blister Pack",250,RC,0904-6565-61,NDC,,,facility,both,1,EA,,18.44,18.44,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Propranolol Hydrochloride: 100 Blister Pack In 1 Carton (0904-6550-61) / 1 Tablet In 1 Blister Pack,250,RC,0904-6550-61,NDC,,,facility,both,1,EA,,9.34,9.34,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Escitalopram: 100 Blister Pack In 1 Carton (0904-6426-61) / 1 Tablet, Film Coated In 1 Blister Pack",250,RC,0904-6426-61,NDC,,,facility,both,1,EA,,9.01,9.01,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Mirtazapine: 100 Blister Pack In 1 Carton (0904-6519-61) / 1 Tablet, Film Coated In 1 Blister Pack",250,RC,0904-6519-61,NDC,,,facility,both,1,EA,,12.67,12.67,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Memantine Hydrochloride: 50 Blister Pack In 1 Carton (0904-6505-06) / 1 Tablet, Film Coated In 1 Blister Pack",250,RC,0904-6505-06,NDC,,,facility,both,1,EA,,7.94,7.94,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Celecoxib: 100 Blister Pack In 1 Carton (0904-6502-61) / 1 Capsule In 1 Blister Pack,250,RC,0904-6502-61,NDC,,,facility,both,1,EA,,14.77,14.77,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Major Lubrifresh Pm: 1 Tube In 1 Carton (0904-6488-38) / 3.5 G In 1 Tube,250,RC,0904-6488-38,NDC,,,facility,both,1,EA,,33.78,33.78,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Baclofen: 100 Blister Pack In 1 Carton (0904-6476-61) / 1 Tablet In 1 Blister Pack,250,RC,0904-6476-61,NDC,,,facility,both,1,EA,,10.14,10.14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Pantoprazole Sodium: 100 Blister Pack In 1 Carton (0904-6474-61) / 1 Tablet, Delayed Release In 1 Blister Pack",250,RC,0904-6474-61,NDC,,,facility,both,1,EA,,13,13,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Hydralazine Hydrochloride: 100 Blister Pack In 1 Carton (0904-6441-61) / 1 Tablet, Film Coated In 1 Blister Pack",250,RC,0904-6441-61,NDC,,,facility,both,1,EA,,12.55,12.55,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Hydralazine Hydrochloride: 100 BLISTER PACK in 1 CARTON (0904-6440-61) / 1 TABLET, FILM COATED in 1 BLISTER PACK",250,RC,0904-6440-61,NDC,,,facility,both,1,EA,,12.24,12.24,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Aripiprazole: 30 Blister Pack In 1 Carton (0904-6509-04) / 1 Tablet In 1 Blister Pack,250,RC,0904-6509-04,NDC,,,facility,both,1,EA,,150.05,150.05,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Anti Diarrheal: 24 Blister Pack In 1 Carton (0904-7725-24) / 1 Tablet, Film Coated In 1 Blister Pack",250,RC,0904-7725-24,NDC,,,facility,both,1,EA,,11.38,11.38,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Cephalexin: 50 Blister Pack In 1 Carton (0904-7337-06) / 1 Capsule In 1 Blister Pack,250,RC,0904-7337-06,NDC,,,facility,both,1,EA,,13.01,13.01,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Rifampin: 100 Blister Pack In 1 Carton (0904-7315-61) / 1 Capsule In 1 Blister Pack,250,RC,0904-7315-61,NDC,,,facility,both,1,EA,,13.55,13.55,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Carvedilol: 100 Blister Pack In 1 Carton (0904-7308-61) / 1 Tablet, Film Coated In 1 Blister Pack",250,RC,0904-7308-61,NDC,,,facility,both,1,EA,,11.1,11.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Carvedilol: 100 Blister Pack In 1 Carton (0904-7305-61) / 1 Tablet, Film Coated In 1 Blister Pack",250,RC,0904-7305-61,NDC,,,facility,both,1,EA,,8.09,8.09,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Potassium Chloride: 100 Blister Pack In 1 Carton (0904-7293-61) / 1 Tablet, Extended Release In 1 Blister Pack",250,RC,0904-7293-61,NDC,,,facility,both,1,EA,,10.36,10.36,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Benztropine Mesylate: 100 Blister Pack In 1 Carton (0904-7289-61) / 1 Tablet In 1 Blister Pack,250,RC,0904-7289-61,NDC,,,facility,both,1,EA,,12.12,12.12,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Docusate Sodium: 10 Tray In 1 Case (0904-7279-72) / 10 Cup, Unit-Dose In 1 Tray / 10 Ml In 1 Cup, Unit-Dose (0904-7279-66)",250,RC,0904-7279-72,NDC,,,facility,both,1,EA,,1.43,1.43,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0904-7279-66,NDC,,,facility,both,1,EA,,1.51,1.51,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0904-7276-41,NDC,,,facility,both,1,EA,,14.57,14.57,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0904-7265-41,NDC,,,facility,both,1,EA,,24.11,24.11,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Oxcarbazepine: 100 Blister Pack In 1 Carton (0904-7263-61) / 1 Tablet, Film Coated In 1 Blister Pack",250,RC,0904-7263-61,NDC,,,facility,both,1,EA,,11.02,11.02,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0904-7337-35,NDC,,,facility,both,1,EA,,12.7,12.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Fluoxetine: 100 Blister Pack In 1 Carton (0904-7346-61) / 1 Capsule In 1 Blister Pack,250,RC,0904-7346-61,NDC,,,facility,both,1,EA,,6.37,6.37,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Sucralfate: 10 Ml In 1 Cup, Unit-Dose (0904-7470-66)",250,RC,0904-7470-66,NDC,,,facility,both,1,EA,,20.65,20.65,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Sucralfate: 20 Cup, Unit-Dose In 1 Case (0904-7470-56) / 10 Ml In 1 Cup, Unit-Dose (0904-7470-66)",250,RC,0904-7470-56,NDC,,,facility,both,1,EA,,42.73,42.73,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Labetalol Hydrochloride: 100 Blister Pack In 1 Carton (0904-7452-61) / 1 Tablet, Film Coated In 1 Blister Pack",250,RC,0904-7452-61,NDC,,,facility,both,1,EA,,12.08,12.08,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Clonidine Hydrochloride: 100 Blister Pack In 1 Carton (0904-7442-61) / 1 Tablet In 1 Blister Pack,250,RC,0904-7442-61,NDC,,,facility,both,1,EA,,11.21,11.21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Major Nasal Decongestant: 1 Bottle, Spray In 1 Carton (0904-7435-35) / 15 Ml In 1 Bottle, Spray",250,RC,0904-7435-35,NDC,,,facility,both,1,EA,,14.35,14.35,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Major Nasal Decongestant: 1 Bottle, Pump In 1 Carton (0904-7427-30) / 30 Ml In 1 Bottle, Pump",250,RC,0904-7427-30,NDC,,,facility,both,1,EA,,18.23,18.23,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Tamsulosin Hydrochloride: 100 Blister Pack In 1 Carton (0904-7383-61) / 1 Capsule In 1 Blister Pack,250,RC,0904-7383-61,NDC,,,facility,both,1,EA,,12.49,12.49,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Aripiprazole: 30 Blister Pack In 1 Carton (0904-7366-04) / 1 Tablet In 1 Blister Pack,250,RC,0904-7366-04,NDC,,,facility,both,1,EA,,18.22,18.22,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Risperidone: 100 Blister Pack In 1 Carton (0904-7361-61) / 1 Tablet, Film Coated In 1 Blister Pack",250,RC,0904-7361-61,NDC,,,facility,both,1,EA,,8.86,8.86,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Risperidone: 100 Blister Pack In 1 Carton (0904-7360-61) / 1 Tablet, Film Coated In 1 Blister Pack",250,RC,0904-7360-61,NDC,,,facility,both,1,EA,,12.6,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Lurasidone Hydrochloride: 30 Blister Pack In 1 Carton (0904-7355-04) / 1 Tablet, Film Coated In 1 Blister Pack",250,RC,0904-7355-04,NDC,,,facility,both,1,EA,,16.08,16.08,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Azithromycin: 100 Blister Pack In 1 Carton (0904-7350-61) / 1 Tablet, Film Coated In 1 Blister Pack",250,RC,0904-7350-61,NDC,,,facility,both,1,EA,,16.13,16.13,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Azithromycin: 50 Blister Pack In 1 Carton (0904-7350-06) / 1 Tablet, Film Coated In 1 Blister Pack",250,RC,0904-7350-06,NDC,,,facility,both,1,EA,,12.62,12.62,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Meclizine Hydrochloride: 100 Blister Pack In 1 Carton (0904-7376-61) / 1 Tablet In 1 Blister Pack,250,RC,0904-7376-61,NDC,,,facility,both,1,EA,,13.6,13.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Oxcarbazepine: 100 Blister Pack In 1 Carton (0904-7262-61) / 1 Tablet, Film Coated In 1 Blister Pack",250,RC,0904-7262-61,NDC,,,facility,both,1,EA,,12.58,12.58,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Sennosides: 10 Blister Pack In 1 Box, Unit-Dose (0904-7252-61) / 10 Tablet, Film Coated In 1 Blister Pack",250,RC,0904-7252-61,NDC,,,facility,both,1,EA,,8.94,8.94,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Buspirone Hydrochloride: 100 Blister Pack In 1 Carton (0904-7122-61) / 1 Tablet In 1 Blister Pack,250,RC,0904-7122-61,NDC,,,facility,both,1,EA,,4.58,4.58,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Colchicine: 30 Blister Pack In 1 Carton (0904-7120-04) / 1 Tablet, Film Coated In 1 Blister Pack",250,RC,0904-7120-04,NDC,,,facility,both,1,EA,,39.36,39.36,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Labetalol Hydrochloride: 100 Blister Pack In 1 Carton (0904-7111-61) / 1 Tablet, Film Coated In 1 Blister Pack",250,RC,0904-7111-61,NDC,,,facility,both,1,EA,,12.97,12.97,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Captopril: 100 Blister Pack In 1 Carton (0904-7106-61) / 1 Tablet In 1 Blister Pack,250,RC,0904-7106-61,NDC,,,facility,both,1,EA,,12.53,12.53,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Bupropion Hydrochloride Xl: 30 Blister Pack In 1 Carton (0904-7084-04) / 1 Tablet, Extended Release In 1 Blister Pack",250,RC,0904-7084-04,NDC,,,facility,both,1,EA,,13.68,13.68,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Doxepin Hydrochloride: 100 Blister Pack In 1 Carton (0904-7052-61) / 1 Capsule In 1 Blister Pack,250,RC,0904-7052-61,NDC,,,facility,both,1,EA,,15.19,15.19,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Hydroxychloroquine Sulfate: 100 Blister Pack In 1 Carton (0904-7046-61) / 1 Tablet, Film Coated In 1 Blister Pack",250,RC,0904-7046-61,NDC,,,facility,both,1,EA,,17.65,17.65,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Hydroxychloroquine Sulfate: 50 Blister Pack In 1 Carton (0904-7046-06) / 1 Tablet, Film Coated In 1 Blister Pack",250,RC,0904-7046-06,NDC,,,facility,both,1,EA,,16.66,16.66,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Duloxetine: 100 Blister Pack In 1 Carton (0904-7044-61) / 1 Capsule, Delayed Release In 1 Blister Pack",250,RC,0904-7044-61,NDC,,,facility,both,1,EA,,14.77,14.77,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Duloxetine: 30 Blister Pack In 1 Carton (0904-7043-04) / 1 Capsule, Delayed Release In 1 Blister Pack",250,RC,0904-7043-04,NDC,,,facility,both,1,EA,,17.15,17.15,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Allopurinol: 100 Blister Pack In 1 Carton (0904-7041-61) / 1 Tablet In 1 Blister Pack,250,RC,0904-7041-61,NDC,,,facility,both,1,EA,,6.4,6.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Oxybutynin Chloride: 100 Blister Pack In 1 Carton (0904-7027-61) / 1 Tablet In 1 Blister Pack,250,RC,0904-7027-61,NDC,,,facility,both,1,EA,,14.95,14.95,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Lamotrigine: 100 Blister Pack In 1 Carton (0904-7007-61) / 1 Tablet In 1 Blister Pack,250,RC,0904-7007-61,NDC,,,facility,both,1,EA,,5.96,5.96,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Pregabalin: 100 Blister Pack In 1 Carton (0904-7000-61) / 1 Capsule In 1 Blister Pack,250,RC,0904-7000-61,NDC,,,facility,both,1,EA,,12.02,12.02,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Pregabalin: 100 Blister Pack In 1 Carton (0904-6992-61) / 1 Capsule In 1 Blister Pack,250,RC,0904-6992-61,NDC,,,facility,both,1,EA,,13.88,13.88,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Pseudoephedrine Hcl: 10 Blister Pack In 1 Carton (0904-6990-61) / 10 Tablet, Film Coated In 1 Blister Pack",250,RC,0904-6990-61,NDC,,,facility,both,1,EA,,12.41,12.41,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Lacosamide: 60 Blister Pack In 1 Carton (0904-7245-68) / 1 Tablet, Film Coated In 1 Blister Pack",250,RC,0904-7245-68,NDC,,,facility,both,1,EA,,15.67,15.67,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Lacosamide: 60 Blister Pack In 1 Carton (0904-7244-68) / 1 Tablet, Film Coated In 1 Blister Pack",250,RC,0904-7244-68,NDC,,,facility,both,1,EA,,12.43,12.43,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ciprofloxacin: 100 Blister Pack In 1 Carton (0904-7243-61) / 1 Tablet, Film Coated In 1 Blister Pack",250,RC,0904-7243-61,NDC,,,facility,both,1,EA,,8.4,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Folic Acid: 100 Blister Pack In 1 Carton (0904-7224-61) / 1 Tablet In 1 Blister Pack,250,RC,0904-7224-61,NDC,,,facility,both,1,EA,,11.58,11.58,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Famotidine: 100 Blister Pack In 1 Carton (0904-7193-61) / 1 Tablet, Film Coated In 1 Blister Pack",250,RC,0904-7193-61,NDC,,,facility,both,1,EA,,11.72,11.72,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Atenolol: 100 Blister Pack In 1 Carton (0904-7187-61) / 1 Tablet In 1 Blister Pack,250,RC,0904-7187-61,NDC,,,facility,both,1,EA,,12.18,12.18,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Levetiracetam: 100 Blister Pack In 1 Carton (0904-7124-61) / 1 Tablet, Film Coated In 1 Blister Pack",250,RC,0904-7124-61,NDC,,,facility,both,1,EA,,6.98,6.98,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Ursodiol: 100 Blister Pack In 1 Carton (0904-7168-61) / 1 Capsule In 1 Blister Pack,250,RC,0904-7168-61,NDC,,,facility,both,1,EA,,18.93,18.93,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Metformin Hydrochloride: 100 Blister Pack In 1 Carton (0904-7162-61) / 1 Tablet In 1 Blister Pack,250,RC,0904-7162-61,NDC,,,facility,both,1,EA,,11.89,11.89,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Metronidazole: 100 Blister Pack In 1 Carton (0904-7156-61) / 1 Tablet In 1 Blister Pack,250,RC,0904-7156-61,NDC,,,facility,both,1,EA,,9.94,9.94,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Benzonatate: 100 Blister Pack In 1 Carton (0904-7153-61) / 1 Capsule In 1 Blister Pack,250,RC,0904-7153-61,NDC,,,facility,both,1,EA,,13.67,13.67,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sotalol Hydrochloride: 100 Blister Pack In 1 Carton (0904-7143-61) / 1 Tablet In 1 Blister Pack,250,RC,0904-7143-61,NDC,,,facility,both,1,EA,,10.12,10.12,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Guanfacine: 30 Blister Pack In 1 Carton (0904-7140-04) / 1 Tablet In 1 Blister Pack,250,RC,0904-7140-04,NDC,,,facility,both,1,EA,,17.03,17.03,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Docusate Sodium - Stool Softener Laxative: 10 Blister Pack In 1 Carton (0904-7183-61) / 10 Capsule, Liquid Filled In 1 Blister Pack",250,RC,0904-7183-61,NDC,,,facility,both,1,EA,,11.98,11.98,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Epinephrine Chloride Solution: 10 Ml In 1 Box (54288-123-01),250,RC,54288-123-01,NDC,,,facility,both,1,EA,,405.51,405.51,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Tacrolimus: 1 Tube In 1 Carton (68462-881-35) / 30 G In 1 Tube,250,RC,68462-881-35,NDC,,,facility,both,1,EA,,238.28,238.28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Defitelio: 25 Ml In 1 Carton (68727-800-02),250,RC,68727-800-02,NDC,,,facility,both,1,EA,,4079.54,4079.54,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Defitelio: 2.5 Ml In 1 Vial (68727-800-01),250,RC,68727-800-01,NDC,,,facility,both,1,EA,,5628.8,5628.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Fluorescein Sodium And Benoxinate Hydrochloride: 1 Bottle, Glass In 1 Carton (68682-732-05) / 5 Ml In 1 Bottle, Glass",250,RC,68682-732-05,NDC,,,facility,both,1,EA,,204.17,204.17,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Diazepam: 2 Syringe, Plastic In 1 Package (68682-655-20) / 4 Ml In 1 Syringe, Plastic",250,RC,68682-655-20,NDC,,,facility,both,1,EA,,597.19,597.19,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Diazepam: 2 Syringe, Plastic In 1 Package (68682-652-20) / 2 Ml In 1 Syringe, Plastic",250,RC,68682-652-20,NDC,,,facility,both,1,EA,,548.64,548.64,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Diazepam: 2 Syringe, Plastic In 1 Package (68682-650-20) / .5 Ml In 1 Syringe, Plastic",250,RC,68682-650-20,NDC,,,facility,both,1,EA,,962.35,962.35,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Budesonide: 30 Tablet, Extended Release In 1 Bottle (68682-309-30)",250,RC,68682-309-30,NDC,,,facility,both,1,EA,,240.77,240.77,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Pyridostigmine Bromide: 100 Tablet In 1 Bottle (68682-302-10),250,RC,68682-302-10,NDC,,,facility,both,1,EA,,16.92,16.92,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Topiramate: 60 Capsule, Coated Pellets In 1 Bottle (68382-004-14)",250,RC,68382-004-14,NDC,,,facility,both,1,EA,,14.11,14.11,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Nystatin: 15 G In 1 Bottle, Plastic (68308-152-15)",250,RC,68308-152-15,NDC,,,facility,both,1,EA,,47.3,47.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Albuterol Sulfate: 1 Canister In 1 Carton (68180-963-01) / 200 Aerosol, Metered In 1 Canister",250,RC,68180-963-01,NDC,,,facility,both,1,EA,,165.61,165.61,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA My Way: 1 Blister Pack In 1 Carton (68180-852-11) / 1 Tablet In 1 Blister Pack,250,RC,68180-852-11,NDC,,,facility,both,1,EA,,81.96,81.96,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Cefdinir: 100 Ml In 1 Bottle (68180-723-05),250,RC,68180-723-05,NDC,,,facility,both,1,EA,,15.41,15.41,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Doxycycline: 60 Ml In 1 Bottle (68180-657-01),250,RC,68180-657-01,NDC,,,facility,both,1,EA,,30.58,30.58,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Duloxetine: 90 Capsule, Delayed Release In 1 Bottle (68180-295-09)",250,RC,68180-295-09,NDC,,,facility,both,1,EA,,13.76,13.76,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Ethambutol Hydrochloride: 100 Tablet In 1 Bottle (68180-280-01),250,RC,68180-280-01,NDC,,,facility,both,1,EA,,7.39,7.39,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Famotidine: 50 Ml In 1 Bottle (68180-150-01),250,RC,68180-150-01,NDC,,,facility,both,1,EA,,10.09,10.09,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,68094-764-59,NDC,,,facility,both,1,EA,,27.65,27.65,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,68094-762-59,NDC,,,facility,both,1,EA,,32.62,32.62,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Furosemide: 3 Tray In 1 Case (68094-756-62) / 10 Cup, Unit-Dose In 1 Tray / 4 Ml In 1 Cup, Unit-Dose (68094-756-59)",250,RC,68094-756-62,NDC,,,facility,both,1,EA,,14.89,14.89,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,68094-756-59,NDC,,,facility,both,1,EA,,14.42,14.42,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,68094-750-59,NDC,,,facility,both,1,EA,,17.5,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,68094-600-59,NDC,,,facility,both,1,EA,,10.08,10.08,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Topiramate: 60 Capsule, Coated Pellets In 1 Bottle (68382-005-14)",250,RC,68382-005-14,NDC,,,facility,both,1,EA,,14.71,14.71,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Carvedilol: 100 Tablet, Film Coated In 1 Bottle (68382-095-01)",250,RC,68382-095-01,NDC,,,facility,both,1,EA,,11.58,11.58,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Mupirocin: 15 G In 1 Tube (68462-564-17),250,RC,68462-564-17,NDC,,,facility,both,1,EA,,888.01,888.01,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Tacrolimus: 1 Tube In 1 Carton (68462-534-35) / 30 G In 1 Tube,250,RC,68462-534-35,NDC,,,facility,both,1,EA,,513.44,513.44,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Norethindrone Acetate: 50 Tablet In 1 Bottle (68462-304-50),250,RC,68462-304-50,NDC,,,facility,both,1,EA,,8.73,8.73,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Lamotrigine: 100 Tablet, Chewable In 1 Bottle (68462-229-01)",250,RC,68462-229-01,NDC,,,facility,both,1,EA,,3.95,3.95,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Mupirocin: 22 G In 1 Tube (68462-180-22),250,RC,68462-180-22,NDC,,,facility,both,1,EA,,43.93,43.93,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Zonisamide: 100 Capsule In 1 Bottle (68462-128-01),250,RC,68462-128-01,NDC,,,facility,both,1,EA,,6.47,6.47,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Lansoprazole: 10 Blister Pack In 1 Carton (68382-772-77) / 10 Tablet, Orally Disintegrating In 1 Blister Pack (68382-772-30)",250,RC,68382-772-77,NDC,,,facility,both,1,EA,,42.94,42.94,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,68382-772-30,NDC,,,facility,both,1,EA,,43.11,43.11,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Lansoprazole: 10 Blister Pack In 1 Carton (68382-771-77) / 10 Tablet, Orally Disintegrating In 1 Blister Pack (68382-771-30)",250,RC,68382-771-77,NDC,,,facility,both,1,EA,,33.09,33.09,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,68382-771-30,NDC,,,facility,both,1,EA,,33.74,33.74,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Mesalamine: 120 Capsule, Extended Release In 1 Bottle (68382-452-19)",250,RC,68382-452-19,NDC,,,facility,both,1,EA,,11.04,11.04,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Bosentan: 60 Tablet, Coated In 1 Bottle (68382-446-14)",250,RC,68382-446-14,NDC,,,facility,both,1,EA,,47.73,47.73,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Fycompa: 30 Tablet In 1 Bottle (69616-272-30),250,RC,69616-272-30,NDC,,,facility,both,1,EA,,137.04,137.04,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Atovaquone: 1 Bottle In 1 Carton (69452-252-87) / 210 Ml In 1 Bottle,250,RC,69452-252-87,NDC,,,facility,both,1,EA,,11.09,11.09,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Rufinamide: 1 Bottle In 1 Carton (69452-223-84) / 460 Ml In 1 Bottle,250,RC,69452-223-84,NDC,,,facility,both,1,EA,,45.38,45.38,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Calcitriol: 100 Capsule, Liquid Filled In 1 Bottle, Plastic (69452-208-20)",250,RC,69452-208-20,NDC,,,facility,both,1,EA,,8.54,8.54,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,69452-156-74,NDC,,,facility,both,1,EA,,16.55,16.55,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ethosuximide: 100 Capsule, Liquid Filled In 1 Bottle, Plastic (69452-152-20)",250,RC,69452-152-20,NDC,,,facility,both,1,EA,,7.44,7.44,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Oxcarbazepine: 1 Bottle, Glass In 1 Carton (69452-125-50) / 250 Ml In 1 Bottle, Glass",250,RC,69452-125-50,NDC,,,facility,both,1,EA,,20.25,20.25,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,69374-914-50,NDC,,,facility,both,1,EA,,53.54,53.54,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,69374-544-10,NDC,,,facility,both,1,EA,,30.68,30.68,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Phenazopyridine Hydrochloride: 100 Tablet In 1 Bottle (69367-192-01),250,RC,69367-192-01,NDC,,,facility,both,1,EA,,15.6,15.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Indocin: 1 Bottle, Glass In 1 Carton (69344-101-01) / 237 Ml In 1 Bottle, Glass",250,RC,69344-101-01,NDC,,,facility,both,1,EA,,65.44,65.44,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,69339-157-05,NDC,,,facility,both,1,EA,,20.95,20.95,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Dash Chlorhexidine Gluconate 0.12% Oral Rinse: 15 Ml In 1 Cup, Unit-Dose (69339-138-15)",250,RC,69339-138-15,NDC,,,facility,both,1,EA,,17.31,17.31,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Fycompa: 340 Ml In 1 Bottle (69616-290-38),250,RC,69616-290-38,NDC,,,facility,both,1,EA,,32.32,32.32,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Senna: 100 Tablet In 1 Bottle (69618-064-01),250,RC,69618-064-01,NDC,,,facility,both,1,EA,,7.88,7.88,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,69918-735-01,NDC,,,facility,both,1,EA,,361.98,361.98,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Tranexamic Acid: 30 Tablet In 1 Bottle (69918-301-30),250,RC,69918-301-30,NDC,,,facility,both,1,EA,,18.45,18.45,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Dojolvi: 1 Bottle, Glass In 1 Carton (69794-050-50) / 500 Ml In 1 Bottle, Glass",250,RC,69794-050-50,NDC,,,facility,both,1,EA,,735.2,735.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Polyethylene Glycol 3350 Nf: 100 Pouch In 1 Carton (69784-180-10) / 17 G In 1 Pouch (69784-180-01),250,RC,69784-180-10,NDC,,,facility,both,1,EA,,19.87,19.87,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Lorazepam: 100 Tablet In 1 Bottle (69315-905-01),250,RC,69315-905-01,NDC,,,facility,both,1,EA,,8.4,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Visionblue: 10 Pouch In 1 Carton (68803-612-10) / 1 Syringe, Glass In 1 Pouch / .5 Ml In 1 Syringe, Glass",250,RC,68803-612-10,NDC,,,facility,both,1,EA,,548.14,548.14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,68094-503-59,NDC,,,facility,both,1,EA,,62.8,62.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Acyclovir: 100 Capsule In 1 Bottle (69076-146-01),250,RC,69076-146-01,NDC,,,facility,both,1,EA,,7.97,7.97,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Lorazepam: 100 Tablet In 1 Bottle (69315-904-01),250,RC,69315-904-01,NDC,,,facility,both,1,EA,,9.73,9.73,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ciprofloxacin: 1 Bottle, Plastic In 1 Carton (69315-308-02) / 2.5 Ml In 1 Bottle, Plastic",250,RC,69315-308-02,NDC,,,facility,both,1,EA,,71.4,71.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Digoxin: 1 Bottle In 1 Carton (69292-605-60) / 60 Ml In 1 Bottle,250,RC,69292-605-60,NDC,,,facility,both,1,EA,,15.91,15.91,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Mupirocin: 1 Tube In 1 Carton (69238-2029-5) / 15 G In 1 Tube,250,RC,69238-2029-5,NDC,,,facility,both,1,EA,,191.71,191.71,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Pilocarpine Hydrochloride: 1 Bottle In 1 Carton (69238-1746-8) / 15 Ml In 1 Bottle,250,RC,69238-1746-8,NDC,,,facility,both,1,EA,,405.89,405.89,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Enalapril Maleate: 1 Bottle In 1 Carton (69238-1729-7) / 150 Ml In 1 Bottle,250,RC,69238-1729-7,NDC,,,facility,both,1,EA,,12.63,12.63,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Sildenafil: 1 Bottle, Glass In 1 Carton (69238-1574-1) / 112 Ml In 1 Bottle, Glass",250,RC,69238-1574-1,NDC,,,facility,both,1,EA,,16.4,16.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Bumetanide: 100 Tablet In 1 Bottle (69238-1489-1),250,RC,69238-1489-1,NDC,,,facility,both,1,EA,,10.39,10.39,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Clobazam: 100 Tablet In 1 Bottle (69238-1305-1),250,RC,69238-1305-1,NDC,,,facility,both,1,EA,,9.98,9.98,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Topiramate: 60 Tablet In 1 Bottle (69097-123-03),250,RC,69097-123-03,NDC,,,facility,both,1,EA,,8.09,8.09,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Nadolol: 90 Tablet In 1 Bottle (69238-1124-9),250,RC,69238-1124-9,NDC,,,facility,both,1,EA,,12.93,12.93,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Vigabatrin: 50 Packet In 1 Carton (69097-964-53) / 10 Ml In 1 Packet,250,RC,69097-964-53,NDC,,,facility,both,1,EA,,47.48,47.48,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Calcium Acetate: 200 Capsule In 1 Bottle (69097-862-83),250,RC,69097-862-83,NDC,,,facility,both,1,EA,,13.19,13.19,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ambrisentan: 30 Tablet, Film Coated In 1 Bottle, Plastic (69097-386-02)",250,RC,69097-386-02,NDC,,,facility,both,1,EA,,67.28,67.28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,69097-319-32,NDC,,,facility,both,1,EA,,33.18,33.18,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Ethacrynic Acid: 100 Tablet In 1 Bottle (69238-1126-1),250,RC,69238-1126-1,NDC,,,facility,both,1,EA,,19.14,19.14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,68094-494-59,NDC,,,facility,both,1,EA,,9.61,9.61,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Acetaminophen: 10 Tray In 1 Case (68094-231-61) / 10 Cup, Unit-Dose In 1 Tray / 5 Ml In 1 Cup, Unit-Dose (68094-231-59)",250,RC,68094-231-61,NDC,,,facility,both,1,EA,,1.17,1.17,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ethacrynic Sodium: 1 Vial, Single-Dose In 1 Carton (67457-297-50) / 50 Ml In 1 Vial, Single-Dose",250,RC,67457-297-50,NDC,,,facility,both,1,EA,,805.65,805.65,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Rocuronium Bromide: 10 Vial, Multi-Dose In 1 Carton (67457-228-10) / 10 Ml In 1 Vial, Multi-Dose (67457-228-99)",250,RC,67457-228-10,NDC,,,facility,both,1,EA,,59.06,59.06,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Onfi: 1 Bottle In 1 Carton (67386-313-21) / 120 Ml In 1 Bottle,250,RC,67386-313-21,NDC,,,facility,both,1,EA,,422.97,422.97,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ascor: 1 Vial, Glass In 1 Carton (67157-101-50) / 50 Ml In 1 Vial, Glass",250,RC,67157-101-50,NDC,,,facility,both,1,EA,,129.38,129.38,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Fluticasone Propionate Hfa: 1 Inhaler In 1 Carton (66993-079-96) / 120 Aerosol, Metered In 1 Inhaler",250,RC,66993-079-96,NDC,,,facility,both,1,EA,,1197.01,1197.01,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Fluticasone Propionate Hfa: 1 Inhaler In 1 Carton (66993-078-96) / 120 Aerosol, Metered In 1 Inhaler",250,RC,66993-078-96,NDC,,,facility,both,1,EA,,849.75,849.75,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,66993-023-35,NDC,,,facility,both,1,EA,,30.54,30.54,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,66993-022-35,NDC,,,facility,both,1,EA,,29.79,29.79,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Albuterol Sulfate Hfa: 1 Inhaler In 1 Carton (66993-019-68) / 200 Aerosol, Metered In 1 Inhaler",250,RC,66993-019-68,NDC,,,facility,both,1,EA,,184.12,184.12,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Famotidine: 25 Vial In 1 Carton (67457-433-22) / 2 Ml In 1 Vial (67457-433-00),250,RC,67457-433-22,NDC,,,facility,both,1,EA,,31.25,31.25,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Doxycycline: 10 Vial In 1 Carton (67457-437-10) / 10 Ml In 1 Vial (67457-437-00),250,RC,67457-437-10,NDC,,,facility,both,1,EA,,646.4,646.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA PETROLATUM: 144 PACKET in 1 BOX (67777-211-01) / 5 g in 1 PACKET,250,RC,67777-211-01,NDC,,,facility,both,1,EA,,5.84,5.84,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Senokot: 1 Bottle, Plastic In 1 Carton (67618-300-50) / 50 Tablet In 1 Bottle, Plastic",250,RC,67618-300-50,NDC,,,facility,both,1,EA,,8.75,8.75,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Betadine Solution: 118 Ml In 1 Bottle (67618-150-04),250,RC,67618-150-04,NDC,,,facility,both,1,EA,,18.3,18.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Resinol: 50 G In 1 Tube (67492-105-15),250,RC,67492-105-15,NDC,,,facility,both,1,EA,,54.79,54.79,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,66794-230-02,NDC,,,facility,both,1,EA,,23.41,23.41,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,67457-852-00,NDC,,,facility,both,1,EA,,39.6,39.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Phenytoin: 237 Ml In 1 Bottle (66689-775-08),250,RC,66689-775-08,NDC,,,facility,both,1,EA,,15.65,15.65,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,65862-898-28,NDC,,,facility,both,1,EA,,1.37,1.37,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Valganciclovir Hydrochloride: 60 Tablet In 1 Bottle (65862-753-60),250,RC,65862-753-60,NDC,,,facility,both,1,EA,,28.75,28.75,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Amoxicillin And Clavulanate Potassium: 20 Tablet, Film Coated In 1 Bottle (65862-503-20)",250,RC,65862-503-20,NDC,,,facility,both,1,EA,,14.1,14.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sulfamethoxazole And Trimethoprim: 473 Ml In 1 Bottle (65862-496-47),250,RC,65862-496-47,NDC,,,facility,both,1,EA,,15.09,15.09,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sulfamethoxazole And Trimethoprim: 100 Tablet In 1 Bottle (65862-419-01),250,RC,65862-419-01,NDC,,,facility,both,1,EA,,8.42,8.42,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Lamotrigine: 100 Tablet, Chewable In 1 Bottle (65862-362-01)",250,RC,65862-362-01,NDC,,,facility,both,1,EA,,6.7,6.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Celecoxib: 60 Capsule In 1 Bottle (65862-907-60),250,RC,65862-907-60,NDC,,,facility,both,1,EA,,12.34,12.34,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Lamotrigine: 100 Tablet, Chewable In 1 Bottle (65862-361-01)",250,RC,65862-361-01,NDC,,,facility,both,1,EA,,6.54,6.54,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Cefdinir: 1 Bottle In 1 Carton (65862-219-60) / 60 Ml In 1 Bottle,250,RC,65862-219-60,NDC,,,facility,both,1,EA,,16.66,16.66,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sumatriptan: 1 Blister Pack In 1 Carton (65862-146-36) / 9 Tablet In 1 Blister Pack,250,RC,65862-146-36,NDC,,,facility,both,1,EA,,9.4,9.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Terbinafine: 30 Tablet In 1 Bottle (65862-079-30),250,RC,65862-079-30,NDC,,,facility,both,1,EA,,13.19,13.19,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ciprofloxacin: 50 Tablet, Film Coated In 1 Bottle (65862-078-50)",250,RC,65862-078-50,NDC,,,facility,both,1,EA,,13.31,13.31,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Amoxicillin: 100 Ml In 1 Bottle (65862-071-01),250,RC,65862-071-01,NDC,,,facility,both,1,EA,,12.86,12.86,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Nevirapine: 240 Ml In 1 Bottle (65862-057-24),250,RC,65862-057-24,NDC,,,facility,both,1,EA,,15.7,15.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Zidovudine: 240 Ml In 1 Bottle (65862-048-24),250,RC,65862-048-24,NDC,,,facility,both,1,EA,,12.68,12.68,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Clarithromycin: 60 Tablet, Film Coated In 1 Bottle (65862-225-60)",250,RC,65862-225-60,NDC,,,facility,both,1,EA,,10.74,10.74,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Silver Sulfadiazine: 20 G In 1 Tube (67877-124-20),250,RC,67877-124-20,NDC,,,facility,both,1,EA,,39.75,39.75,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,65862-930-08,NDC,,,facility,both,1,EA,,19.54,19.54,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,65862-931-08,NDC,,,facility,both,1,EA,,12.61,12.61,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,66689-401-01,NDC,,,facility,both,1,EA,,46.89,46.89,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Cyproheptadine Hydrochloride: 473 mL in 1 BOTTLE (66689-333-16) ,250,RC,66689-333-16,NDC,,,facility,both,1,EA,,15.8,15.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Digoxin: 1 Bottle, Glass In 1 Carton (66689-327-02) / 60 Ml In 1 Bottle, Glass",250,RC,66689-327-02,NDC,,,facility,both,1,EA,,18.07,18.07,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Insta-Char Sorbitol: 120 Ml In 1 Bottle, Plastic (66689-203-04)",250,RC,66689-203-04,NDC,,,facility,both,1,EA,,137.88,137.88,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Nystatin: 10 Tray In 1 Case (66689-037-99) / 10 Cup, Unit-Dose In 1 Tray / 5 Ml In 1 Cup, Unit-Dose (66689-037-01)",250,RC,66689-037-99,NDC,,,facility,both,1,EA,,12.65,12.65,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Sevelamer Carbonate: 90 Pouch In 1 Carton (65862-930-90) / 1 Powder, For Suspension In 1 Pouch (65862-930-08)",250,RC,65862-930-90,NDC,,,facility,both,1,EA,,20.84,20.84,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,66658-234-01,NDC,,,facility,both,1,EA,,1357.43,1357.43,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,66553-008-01,NDC,,,facility,both,1,EA,,11.89,11.89,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,66553-001-01,NDC,,,facility,both,1,EA,,1.08,1.08,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Unituxin: 1 Vial, Single-Dose In 1 Box (66302-014-01) / 5 Ml In 1 Vial, Single-Dose",250,RC,66302-014-01,NDC,,,facility,both,1,EA,,82777.25,82777.25,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,66259-146-01,NDC,,,facility,both,1,EA,,278.84,278.84,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sancuso: 168 H In 1 Pouch (66220-637-31),250,RC,66220-637-31,NDC,,,facility,both,1,EA,,4417.79,4417.79,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Uptravi: 1 Bottle In 1 Carton (66215-602-06) / 60 Tablet, Coated In 1 Bottle",250,RC,66215-602-06,NDC,,,facility,both,1,EA,,1756.01,1756.01,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Opsumit: 1 Blister Pack In 1 Carton (66215-501-15) / 15 Tablet, Film Coated In 1 Blister Pack",250,RC,66215-501-15,NDC,,,facility,both,1,EA,,1603.28,1603.28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Sevelamer Carbonate: 90 Pouch In 1 Carton (65862-931-90) / 1 Powder, For Suspension In 1 Pouch (65862-931-08)",250,RC,65862-931-90,NDC,,,facility,both,1,EA,,0.14,0.14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Kineret: 7 Syringe, Glass In 1 Carton (66658-234-07) / .67 Ml In 1 Syringe, Glass",250,RC,66658-234-07,NDC,,,facility,both,1,EA,,1350.79,1350.79,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,68084-808-11,NDC,,,facility,both,1,EA,,11.57,11.57,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,68084-805-11,NDC,,,facility,both,1,EA,,19.24,19.24,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Gabapentin: 100 BLISTER PACK in 1 BOX, UNIT-DOSE (68084-762-01) / 1 CAPSULE in 1 BLISTER PACK (68084-762-11) ",250,RC,68084-762-01,NDC,,,facility,both,1,EA,,6.7,6.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,68084-728-11,NDC,,,facility,both,1,EA,,10.52,10.52,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,68084-709-11,NDC,,,facility,both,1,EA,,10.69,10.69,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,68084-708-95,NDC,,,facility,both,1,EA,,14.81,14.81,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,68084-698-11,NDC,,,facility,both,1,EA,,10.45,10.45,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Venlafaxine Hydrochloride: 100 Blister Pack In 1 Box, Unit-Dose (68084-698-01) / 1 Capsule, Extended Release In 1 Blister Pack (68084-698-11)",250,RC,68084-698-01,NDC,,,facility,both,1,EA,,14.12,14.12,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,68084-655-11,NDC,,,facility,both,1,EA,,14.44,14.44,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,68084-654-11,NDC,,,facility,both,1,EA,,14.44,14.44,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Nifedipine: 100 Blister Pack In 1 Box, Unit-Dose (68084-597-01) / 1 Tablet, Film Coated, Extended Release In 1 Blister Pack (68084-597-11)",250,RC,68084-597-01,NDC,,,facility,both,1,EA,,13.16,13.16,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,68084-494-11,NDC,,,facility,both,1,EA,,15.1,15.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,68084-444-11,NDC,,,facility,both,1,EA,,13.49,13.49,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,68084-388-11,NDC,,,facility,both,1,EA,,13.6,13.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Rifampin: 100 BLISTER PACK in 1 BOX, UNIT-DOSE (68084-358-01) / 1 CAPSULE in 1 BLISTER PACK (68084-358-11) ",250,RC,68084-358-01,NDC,,,facility,both,1,EA,,13.55,13.55,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,68084-354-11,NDC,,,facility,both,1,EA,,13.45,13.45,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,68084-823-11,NDC,,,facility,both,1,EA,,21.21,21.21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Venlafaxine: 100 Blister Pack In 1 Box, Unit-Dose (68084-844-01) / 1 Tablet In 1 Blister Pack (68084-844-11)",250,RC,68084-844-01,NDC,,,facility,both,1,EA,,9.49,9.49,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,68094-231-59,NDC,,,facility,both,1,EA,,1.12,1.12,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,68094-074-01,NDC,,,facility,both,1,EA,,34.36,34.36,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,68094-034-59,NDC,,,facility,both,1,EA,,20.86,20.86,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,68094-031-59,NDC,,,facility,both,1,EA,,15.58,15.58,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,68084-344-11,NDC,,,facility,both,1,EA,,10.35,10.35,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,68094-004-59,NDC,,,facility,both,1,EA,,23.09,23.09,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,68094-001-59,NDC,,,facility,both,1,EA,,12.75,12.75,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,68084-996-11,NDC,,,facility,both,1,EA,,15.64,15.64,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Prazosin Hydrochloride: 100 Blister Pack In 1 Box, Unit-Dose (68084-996-01) / 1 Capsule In 1 Blister Pack (68084-996-11)",250,RC,68084-996-01,NDC,,,facility,both,1,EA,,19.31,19.31,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,68084-859-11,NDC,,,facility,both,1,EA,,7,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,68084-844-11,NDC,,,facility,both,1,EA,,12.65,12.65,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,68084-342-11,NDC,,,facility,both,1,EA,,10.46,10.46,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,68084-215-11,NDC,,,facility,both,1,EA,,28.51,28.51,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,68084-205-11,NDC,,,facility,both,1,EA,,14.46,14.46,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,68084-204-11,NDC,,,facility,both,1,EA,,13.23,13.23,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,68084-027-11,NDC,,,facility,both,1,EA,,9.83,9.83,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Oscimin: 100 Tablet, Orally Disintegrating In 1 Bottle (68047-253-01)",250,RC,68047-253-01,NDC,,,facility,both,1,EA,,9.16,9.16,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Rivaroxaban: 1 Bottle In 1 Carton (67877-882-71) / 1 Granule, For Suspension In 1 Bottle",250,RC,67877-882-71,NDC,,,facility,both,1,EA,,38.77,38.77,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Lacosamide Oral Solution: 200 Ml In 1 Bottle (67877-732-95),250,RC,67877-732-95,NDC,,,facility,both,1,EA,,17.48,17.48,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Clobazam: 1 Bottle In 1 Carton (67877-658-61) / 120 Ml In 1 Bottle,250,RC,67877-658-61,NDC,,,facility,both,1,EA,,18.81,18.81,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Cefdinir: 60 Ml In 1 Bottle (67877-548-98),250,RC,67877-548-98,NDC,,,facility,both,1,EA,,16.07,16.07,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Pregabalin: 473 Ml In 1 Bottle (67877-457-47),250,RC,67877-457-47,NDC,,,facility,both,1,EA,,16.94,16.94,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Linezolid: 1 Blister Pack In 1 Carton (67877-419-33) / 10 Tablet, Film Coated In 1 Blister Pack",250,RC,67877-419-33,NDC,,,facility,both,1,EA,,30.37,30.37,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Cephalexin: 100 Capsule In 1 Bottle (67877-220-01),250,RC,67877-220-01,NDC,,,facility,both,1,EA,,9.12,9.12,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Hydroxyzine Hydrochloride: 100 BLISTER PACK in 1 BOX, UNIT-DOSE (68084-253-01) / 1 TABLET, FILM COATED in 1 BLISTER PACK (68084-253-11) ",250,RC,68084-253-01,NDC,,,facility,both,1,EA,,3.89,3.89,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Topiramate: 100 Blister Pack In 1 Box, Unit-Dose (68084-342-01) / 1 Tablet, Film Coated In 1 Blister Pack (68084-342-11)",250,RC,68084-342-01,NDC,,,facility,both,1,EA,,12.96,12.96,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,68084-319-11,NDC,,,facility,both,1,EA,,5.46,5.46,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,68084-318-11,NDC,,,facility,both,1,EA,,12.06,12.06,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Lamotrigine: 100 Blister Pack In 1 Box, Unit-Dose (68084-318-01) / 1 Tablet In 1 Blister Pack (68084-318-11)",250,RC,68084-318-01,NDC,,,facility,both,1,EA,,6.74,6.74,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,68084-313-11,NDC,,,facility,both,1,EA,,9.16,9.16,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Divalproex Sodium: 100 Blister Pack In 1 Box, Unit-Dose (68084-313-01) / 1 Capsule, Coated Pellets In 1 Blister Pack (68084-313-11)",250,RC,68084-313-01,NDC,,,facility,both,1,EA,,10.71,10.71,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Valacyclovir Hydrochloride: 30 Blister Pack In 1 Box, Unit-Dose (68084-309-21) / 1 Tablet, Film Coated In 1 Blister Pack (68084-309-11)",250,RC,68084-309-21,NDC,,,facility,both,1,EA,,19.71,19.71,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,68084-248-11,NDC,,,facility,both,1,EA,,14.02,14.02,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,68084-309-11,NDC,,,facility,both,1,EA,,18.36,18.36,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,68084-288-11,NDC,,,facility,both,1,EA,,13.74,13.74,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Fludrocortisone Acetate: 100 Blister Pack In 1 Box, Unit-Dose (68084-288-01) / 1 Tablet In 1 Blister Pack (68084-288-11)",250,RC,68084-288-01,NDC,,,facility,both,1,EA,,14.83,14.83,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,68084-284-11,NDC,,,facility,both,1,EA,,9.39,9.39,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Hydroxyurea: 100 Blister Pack In 1 Box, Unit-Dose (68084-284-01) / 1 Capsule In 1 Blister Pack (68084-284-11)",250,RC,68084-284-01,NDC,,,facility,both,1,EA,,13.99,13.99,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,68084-280-11,NDC,,,facility,both,1,EA,,7.16,7.16,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,68084-272-11,NDC,,,facility,both,1,EA,,8.45,8.45,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,68084-270-11,NDC,,,facility,both,1,EA,,12.72,12.72,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,68084-269-11,NDC,,,facility,both,1,EA,,15.19,15.19,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,68084-291-11,NDC,,,facility,both,1,EA,,30.22,30.22,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Cephalexin: 100 Capsule In 1 Bottle (65862-019-01),250,RC,65862-019-01,NDC,,,facility,both,1,EA,,10.03,10.03,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Tobramycin: 1 Bottle In 1 Carton (70069-131-01) / 5 Ml In 1 Bottle,250,RC,70069-131-01,NDC,,,facility,both,1,EA,,30.83,30.83,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,72603-387-01,NDC,,,facility,both,1,EA,,25.24,25.24,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Lacosamide: 200 Ml In 1 Bottle, Plastic (72603-305-01)",250,RC,72603-305-01,NDC,,,facility,both,1,EA,,16.89,16.89,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ofloxacin: 5 Ml In 1 Bottle, Dropper (72603-192-01)",250,RC,72603-192-01,NDC,,,facility,both,1,EA,,81.19,81.19,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Norepinephrine Bitartrate: 10 Vial, Single-Dose In 1 Carton (72603-180-10) / 4 Ml In 1 Vial, Single-Dose (72603-180-01)",250,RC,72603-180-10,NDC,,,facility,both,1,EA,,36.21,36.21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,72603-180-01,NDC,,,facility,both,1,EA,,33.53,33.53,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Famotidine: 50 Ml In 1 Bottle (72603-171-01),250,RC,72603-171-01,NDC,,,facility,both,1,EA,,16.76,16.76,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Tizanidine: 150 Tablet In 1 Bottle, Plastic (72789-326-77)",250,RC,72789-326-77,NDC,,,facility,both,1,EA,,7.63,7.63,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,73177-123-02,NDC,,,facility,both,1,EA,,68.62,68.62,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,73177-118-03,NDC,,,facility,both,1,EA,,44.51,44.51,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,73177-110-12,NDC,,,facility,both,1,EA,,44.94,44.94,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,73177-105-30,NDC,,,facility,both,1,EA,,116.86,116.86,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,73177-104-05,NDC,,,facility,both,1,EA,,122.85,122.85,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,73177-102-01,NDC,,,facility,both,1,EA,,53.15,53.15,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,73177-101-02,NDC,,,facility,both,1,EA,,53.25,53.25,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Lidocaine Hydrochloride: 100 Ml In 1 Bottle (72888-125-26),250,RC,72888-125-26,NDC,,,facility,both,1,EA,,12.89,12.89,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Lamotrigine: 100 Tablet In 1 Bottle (72888-026-01),250,RC,72888-026-01,NDC,,,facility,both,1,EA,,2.07,2.07,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Insulin Aspart: 1 Vial, Glass In 1 Carton (73070-100-11) / 10 Ml In 1 Vial, Glass",250,RC,73070-100-11,NDC,,,facility,both,1,EA,,1.23,1.23,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Posaconazole: 60 Tablet, Coated In 1 Bottle (72205-168-60)",250,RC,72205-168-60,NDC,,,facility,both,1,EA,,12.9,12.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Albendazole: 2 Tablet In 1 Bottle (72205-051-08),250,RC,72205-051-08,NDC,,,facility,both,1,EA,,158.2,158.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Oseltamivir Phosphate: 1 Blister Pack In 1 Carton (72205-044-11) / 10 Capsule In 1 Blister Pack,250,RC,72205-044-11,NDC,,,facility,both,1,EA,,24.35,24.35,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Oseltamivir Phosphate: 1 Blister Pack In 1 Carton (72205-043-11) / 10 Capsule In 1 Blister Pack,250,RC,72205-043-11,NDC,,,facility,both,1,EA,,22.31,22.31,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,72196-0422-1,NDC,,,facility,both,1,EA,,374.63,374.63,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,72196-0419-1,NDC,,,facility,both,1,EA,,383.72,383.72,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ultiva: 10 Vial, Glass In 1 Carton (72078-035-02) / 5 Ml In 1 Vial, Glass (72078-035-00)",250,RC,72078-035-02,NDC,,,facility,both,1,EA,,266.61,266.61,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Nystatin: 30 G In 1 Tube (72578-089-04),250,RC,72578-089-04,NDC,,,facility,both,1,EA,,86.38,86.38,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Felbamate: 90 Tablet In 1 Bottle (72578-056-16),250,RC,72578-056-16,NDC,,,facility,both,1,EA,,13.24,13.24,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Erythromycin: 50 Tube In 1 Carton (72485-670-31) / 1 G In 1 Tube,250,RC,72485-670-31,NDC,,,facility,both,1,EA,,40.89,40.89,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,72485-510-01,NDC,,,facility,both,1,EA,,29.17,29.17,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,72485-116-01,NDC,,,facility,both,1,EA,,74.83,74.83,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Tranexamic Acid: 1 Vial, Glass In 1 Carton (72485-107-01) / 10 Ml In 1 Vial, Glass",250,RC,72485-107-01,NDC,,,facility,both,1,EA,,39.48,39.48,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Sodium Nitroprusside: 1 Vial, Single-Dose In 1 Carton (72485-105-01) / 2 Ml In 1 Vial, Single-Dose",250,RC,72485-105-01,NDC,,,facility,both,1,EA,,69.26,69.26,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Posaconazole: 60 Tablet, Delayed Release In 1 Bottle (72319-023-02)",250,RC,72319-023-02,NDC,,,facility,both,1,EA,,43,43,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Tranexamic Acid: 10 Vial, Glass In 1 Carton (72485-107-10) / 10 Ml In 1 Vial, Glass",250,RC,72485-107-10,NDC,,,facility,both,1,EA,,33.18,33.18,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,73177-149-43,NDC,,,facility,both,1,EA,,130.75,130.75,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Lidocaine 5%: 30 Pouch In 1 Package (82347-0505-5) / 14 G In 1 Pouch (82347-0505-4),250,RC,82347-0505-5,NDC,,,facility,both,1,EA,,23.1,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Fluorescein Sodium And Benoxinate Hydrochloride: 1 Bottle, Glass In 1 Carton (82260-734-05) / 5 Ml In 1 Bottle, Glass",250,RC,82260-734-05,NDC,,,facility,both,1,EA,,151.59,151.59,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Amoxicillin And Clavulanate Potassium: 20 Tablet, Coated In 1 Bottle (81964-221-14)",250,RC,81964-221-14,NDC,,,facility,both,1,EA,,14.62,14.62,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Tranexamic Acid: 10 Vial, Single-Dose In 1 Carton (81284-611-10) / 10 Ml In 1 Vial, Single-Dose (81284-611-00)",250,RC,81284-611-10,NDC,,,facility,both,1,EA,,28.58,28.58,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,81284-611-00,NDC,,,facility,both,1,EA,,24.27,24.27,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Potassium Chloride: 5 Tray In 1 Case (81033-220-52) / 10 Cup, Unit-Dose In 1 Tray / 15 Ml In 1 Cup, Unit-Dose (81033-220-15)",250,RC,81033-220-52,NDC,,,facility,both,1,EA,,28.9,28.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Metolazone: 100 Tablet In 1 Bottle (81005-125-01),250,RC,81005-125-01,NDC,,,facility,both,1,EA,,12.3,12.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,80830-1691-1,NDC,,,facility,both,1,EA,,44.07,44.07,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Tabloid: 1 Bottle In 1 Carton (80725-630-25) / 25 Tablet In 1 Bottle,250,RC,80725-630-25,NDC,,,facility,both,1,EA,,2941.61,2941.61,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,80196-291-14,NDC,,,facility,both,1,EA,,11.62,11.62,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Rezurock: 1 Bottle In 1 Carton (79802-200-30) / 30 Tablet In 1 Bottle,250,RC,79802-200-30,NDC,,,facility,both,1,EA,,3981.03,3981.03,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,9999-6183-34,NDC,,,facility,both,1,EA,,0.5,0.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,9999-6173-73,NDC,,,facility,both,1,EA,,1,1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,9999-6170-52,NDC,,,facility,both,1,EA,,0.17,0.17,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,9999-6169-68,NDC,,,facility,both,1,EA,,0.11,0.11,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,9999-6165-15,NDC,,,facility,both,1,EA,,1,1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,9999-2006-52,NDC,,,facility,both,1,EA,,1,1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,9999-2004-67,NDC,,,facility,both,1,EA,,1,1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,9999-2004-66,NDC,,,facility,both,1,EA,,0.5,0.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,9999-2004-43,NDC,,,facility,both,1,EA,,1,1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,9999-2004-42,NDC,,,facility,both,1,EA,,1,1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,9999-2003-98,NDC,,,facility,both,1,EA,,1,1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,9999-2003-68,NDC,,,facility,both,1,EA,,1,1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,9999-2003-67,NDC,,,facility,both,1,EA,,0.07,0.07,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,9999-1999-22,NDC,,,facility,both,1,EA,,17.53,17.53,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA C20H10Na2O5 Fluorescein Sodium Ophthalmic Strips: 300 Packet In 1 Box (83851-100-30) / 1 Mg In 1 Packet,250,RC,83851-100-30,NDC,,,facility,both,1,EA,,14.58,14.58,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Nortriptyline Hydrochloride: 100 Capsule In 1 Bottle, Plastic (75907-069-01)",250,RC,75907-069-01,NDC,,,facility,both,1,EA,,11.51,11.51,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Erythromycin Ethylsuccinate: 100 Ml In 1 Bottle (75834-295-01),250,RC,75834-295-01,NDC,,,facility,both,1,EA,,22.86,22.86,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Verapamil Hydrochloride: 100 Tablet In 1 Bottle (75834-158-01),250,RC,75834-158-01,NDC,,,facility,both,1,EA,,12.52,12.52,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Zenpep: 100 Capsule, Delayed Release In 1 Bottle (73562-116-01)",250,RC,73562-116-01,NDC,,,facility,both,1,EA,,77.93,77.93,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Zenpep: 100 Capsule, Delayed Release In 1 Bottle (73562-114-01)",250,RC,73562-114-01,NDC,,,facility,both,1,EA,,117.5,117.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Zenpep: 100 Capsule, Delayed Release In 1 Bottle (73562-112-01)",250,RC,73562-112-01,NDC,,,facility,both,1,EA,,60.02,60.02,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Zenpep: 100 Capsule, Delayed Release In 1 Bottle (73562-110-01)",250,RC,73562-110-01,NDC,,,facility,both,1,EA,,32.7,32.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Viokace: 1 Bottle In 1 Carton (73562-104-10) / 100 Tablet In 1 Bottle,250,RC,73562-104-10,NDC,,,facility,both,1,EA,,42.18,42.18,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,73177-156-02,NDC,,,facility,both,1,EA,,49.27,49.27,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Phenazopyridine Hydrochloride: 100 Tablet In 1 Bottle, Plastic (75826-114-10)",250,RC,75826-114-10,NDC,,,facility,both,1,EA,,12.96,12.96,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,72078-035-00,NDC,,,facility,both,1,EA,,315.34,315.34,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Levalbuterol: 30 Pouch In 1 Carton (76204-800-01) / 1 Ampule In 1 Pouch (76204-800-11) / 3 Ml In 1 Ampule,250,RC,76204-800-01,NDC,,,facility,both,1,EA,,17.37,17.37,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,76204-900-11,NDC,,,facility,both,1,EA,,20.01,20.01,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,77333-812-25,NDC,,,facility,both,1,EA,,11.16,11.16,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Simethicone 80Mg: 100 Blister Pack In 1 Box (77333-812-10) / 1 Tablet, Chewable In 1 Blister Pack (77333-812-25)",250,RC,77333-812-10,NDC,,,facility,both,1,EA,,12.53,12.53,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,77333-049-25,NDC,,,facility,both,1,EA,,0.99,0.99,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Aspirin 81Mg: 150 Blister Pack In 1 Carton (77333-049-20) / 1 Tablet, Chewable In 1 Blister Pack (77333-049-25)",250,RC,77333-049-20,NDC,,,facility,both,1,EA,,1.06,1.06,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,76204-800-11,NDC,,,facility,both,1,EA,,17.26,17.26,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sodium Bicarbonate: 1 Syringe In 1 Carton (76329-3352-1) / 50 Ml In 1 Syringe,250,RC,76329-3352-1,NDC,,,facility,both,1,EA,,52.13,52.13,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Lidocaine Hydrochloride: 25 Vial, Single-Use In 1 Box (76329-3012-5) / 5 Ml In 1 Vial, Single-Use",250,RC,76329-3012-5,NDC,,,facility,both,1,EA,,40.88,40.88,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Lidocaine Hydrochloride: 25 Vial, Single-Use In 1 Box (76329-3011-5) / 5 Ml In 1 Vial, Single-Use",250,RC,76329-3011-5,NDC,,,facility,both,1,EA,,43.31,43.31,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Oseltamivir Phosphate: 10 Capsule In 1 Blister Pack (76282-704-45),250,RC,76282-704-45,NDC,,,facility,both,1,EA,,22.76,22.76,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Lidocaine Hydrochloride: 25 Vial In 1 Carton (76329-6300-5) / 4 Ml In 1 Vial,250,RC,76329-6300-5,NDC,,,facility,both,1,EA,,157.78,157.78,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ultiva: 10 Vial, Glass In 1 Carton (72078-034-01) / 3 Ml In 1 Vial, Glass (72078-034-00)",250,RC,72078-034-01,NDC,,,facility,both,1,EA,,149.97,149.97,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,72078-034-00,NDC,,,facility,both,1,EA,,162.06,162.06,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Foster And Thrive Nasal: 1 Bottle, Spray In 1 Carton (70677-1037-1) / 30 Ml In 1 Bottle, Spray",250,RC,70677-1037-1,NDC,,,facility,both,1,EA,,17.02,17.02,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Sunmark Childrens Ibuprofen Ib: 1 Bottle In 1 Carton (70677-0072-1) / 24 Tablet, Chewable In 1 Bottle",250,RC,70677-0072-1,NDC,,,facility,both,1,EA,,0.57,0.57,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sunmark Anti Diarrheal: 120 Ml In 1 Bottle (70677-0054-1),250,RC,70677-0054-1,NDC,,,facility,both,1,EA,,1.04,1.04,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Voriconazole: 1 Bottle In 1 Carton (70436-230-39) / 75 Ml In 1 Bottle,250,RC,70436-230-39,NDC,,,facility,both,1,EA,,42.28,42.28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Tetrabenazine: 112 Tablet In 1 Bottle (70436-101-09),250,RC,70436-101-09,NDC,,,facility,both,1,EA,,18.8,18.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Nitrofurantoin: 240 Ml In 1 Bottle, Plastic (70408-239-32)",250,RC,70408-239-32,NDC,,,facility,both,1,EA,,504.42,504.42,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Nitrofurantoin: 1 Bottle, Glass In 1 Carton (70377-118-31) / 230 Ml In 1 Bottle, Glass",250,RC,70377-118-31,NDC,,,facility,both,1,EA,,177.45,177.45,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Epidiolex: 1 Bottle, Glass In 1 Carton (70127-100-10) / 100 Ml In 1 Bottle, Glass (70127-100-01)",250,RC,70127-100-10,NDC,,,facility,both,1,EA,,269.23,269.23,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,70127-100-01,NDC,,,facility,both,1,EA,,292.2,292.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Foster And Thrive Anti-Diarrheal: 120 Ml In 1 Bottle (70677-1107-1),250,RC,70677-1107-1,NDC,,,facility,both,1,EA,,1.34,1.34,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Magnesium Citrate: 296 Ml In 1 Bottle, Plastic (70677-1111-1)",250,RC,70677-1111-1,NDC,,,facility,both,1,EA,,17.65,17.65,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Stay Awake: 2 Blister Pack In 1 Carton (70677-1126-1) / 8 Tablet In 1 Blister Pack,250,RC,70677-1126-1,NDC,,,facility,both,1,EA,,11.13,11.13,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sodium Phenylacetate And Sodium Benzoate: 1 Vial In 1 Carton (70710-1926-1) / 20 Ml In 1 Vial,250,RC,70710-1926-1,NDC,,,facility,both,1,EA,,4670.97,4670.97,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Verapamil Hydrochloride: 25 Carton In 1 Carton (70710-1643-7) / 5 Vial In 1 Carton (70710-1643-5) / 2 Ml In 1 Vial,250,RC,70710-1643-7,NDC,,,facility,both,1,EA,,39.46,39.46,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ambrisentan: 30 Tablet, Film Coated In 1 Bottle (70710-1179-3)",250,RC,70710-1179-3,NDC,,,facility,both,1,EA,,38.99,38.99,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,70700-317-84,NDC,,,facility,both,1,EA,,6.48,6.48,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Deferasirox: 30 Tablet In 1 Bottle, Plastic (70700-271-30)",250,RC,70700-271-30,NDC,,,facility,both,1,EA,,17.82,17.82,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Deferasirox: 30 Tablet In 1 Bottle, Plastic (70700-269-30)",250,RC,70700-269-30,NDC,,,facility,both,1,EA,,11.67,11.67,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Lansoprazole: 30 Capsule, Delayed Release In 1 Bottle (70700-263-30)",250,RC,70700-263-30,NDC,,,facility,both,1,EA,,11.8,11.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Foster And Thrive Earwax Removal Drops: 1 Bottle In 1 Box (70677-1154-1) / 15 Ml In 1 Bottle,250,RC,70677-1154-1,NDC,,,facility,both,1,EA,,19.7,19.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Foster And Thrive Childrens Ibuprofen Ib: 1 Bottle In 1 Carton (70677-1145-1) / 24 Tablet, Chewable In 1 Bottle",250,RC,70677-1145-1,NDC,,,facility,both,1,EA,,0.46,0.46,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Cyproheptadine Hydrochloride: 100 Tablet In 1 Bottle (70710-1110-1),250,RC,70710-1110-1,NDC,,,facility,both,1,EA,,12.21,12.21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,70092-1486-46,NDC,,,facility,both,1,EA,,33.3,33.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,70092-1443-43,NDC,,,facility,both,1,EA,,40.77,40.77,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,70092-1400-43,NDC,,,facility,both,1,EA,,48.06,48.06,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,70092-1175-46,NDC,,,facility,both,1,EA,,58.43,58.43,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,70092-1125-48,NDC,,,facility,both,1,EA,,84.55,84.55,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,70092-1114-50,NDC,,,facility,both,1,EA,,117.27,117.27,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Valganciclovir Hydrochloride: 100 Ml In 1 Bottle (70069-810-01),250,RC,70069-810-01,NDC,,,facility,both,1,EA,,51.57,51.57,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Potassium Phosphate: 25 Bottle In 1 Carton (70069-746-25) / 5 Ml In 1 Bottle,250,RC,70069-746-25,NDC,,,facility,both,1,EA,,78.63,78.63,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Proparacaine Hydrochloride: 1 Bottle In 1 Carton (70069-601-01) / 15 Ml In 1 Bottle,250,RC,70069-601-01,NDC,,,facility,both,1,EA,,187.6,187.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dorzolamide Hydrochloride: 1 Bottle In 1 Carton (70069-501-01) / 10 Ml In 1 Bottle,250,RC,70069-501-01,NDC,,,facility,both,1,EA,,60.23,60.23,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Latanoprost: 1 Bottle In 1 Carton (70069-421-01) / 2.5 Ml In 1 Bottle,250,RC,70069-421-01,NDC,,,facility,both,1,EA,,34.88,34.88,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Brimonidine Tartrate: 1 Bottle In 1 Carton (70069-231-01) / 5 Ml In 1 Bottle,250,RC,70069-231-01,NDC,,,facility,both,1,EA,,34.55,34.55,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Cisatracurium Besylate: 1 Vial In 1 Carton (70069-161-01) / 10 Ml In 1 Vial,250,RC,70069-161-01,NDC,,,facility,both,1,EA,,60.68,60.68,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Leflunomide: 30 Tablet, Film Coated In 1 Bottle (70748-129-06)",250,RC,70748-129-06,NDC,,,facility,both,1,EA,,7.74,7.74,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,70092-1573-43,NDC,,,facility,both,1,EA,,55.89,55.89,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,70092-1688-46,NDC,,,facility,both,1,EA,,41.07,41.07,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dexmedetomidine Hydrochloride: 12 Pouch In 1 Carton (70121-1712-3) / 1 Bag In 1 Pouch / 100 Ml In 1 Bag,250,RC,70121-1712-3,NDC,,,facility,both,1,EA,,102.3,102.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,70121-1712-1,NDC,,,facility,both,1,EA,,103.16,103.16,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,70092-1617-46,NDC,,,facility,both,1,EA,,40.3,40.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,70100-424-01,NDC,,,facility,both,1,EA,,43.54,43.54,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Leflunomide: 30 Tablet, Film Coated In 1 Bottle (70748-130-06)",250,RC,70748-130-06,NDC,,,facility,both,1,EA,,13.03,13.03,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,71288-505-02,NDC,,,facility,both,1,EA,,42.63,42.63,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Sski: 1 Bottle, With Applicator In 1 Carton (71740-112-30) / 30 Ml In 1 Bottle, With Applicator",250,RC,71740-112-30,NDC,,,facility,both,1,EA,,17.72,17.72,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Xcopri: 30 Tablet, Film Coated In 1 Bottle (71699-050-30)",250,RC,71699-050-30,NDC,,,facility,both,1,EA,,249.8,249.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Glycopyrrolate: 1 Bottle In 1 Bottle (71656-061-16) / 473 Ml In 1 Bottle,250,RC,71656-061-16,NDC,,,facility,both,1,EA,,17.17,17.17,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Hydrophor: 100 G In 1 Jar (71399-5101-2),250,RC,71399-5101-2,NDC,,,facility,both,1,EA,,32.98,32.98,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Low Dose Aspirin: 120 Tablet, Coated In 1 Bottle (71399-1014-2)",250,RC,71399-1014-2,NDC,,,facility,both,1,EA,,1.02,1.02,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Medpura Vitamin A And D Vitamin A And D: 113 G In 1 Tube (71399-0122-4),250,RC,71399-0122-4,NDC,,,facility,both,1,EA,,23.59,23.59,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Medpura Vitamin A And D Vitamin A And D: 1 Tube In 1 Carton (71399-0122-2) / 56 G In 1 Tube,250,RC,71399-0122-2,NDC,,,facility,both,1,EA,,20.83,20.83,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Rocuronium Bromide: 10 Vial, Multi-Dose In 1 Carton (71288-718-11) / 10 Ml In 1 Vial, Multi-Dose (71288-718-10)",250,RC,71288-718-11,NDC,,,facility,both,1,EA,,36.3,36.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,71288-718-10,NDC,,,facility,both,1,EA,,30.39,30.39,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,71288-712-05,NDC,,,facility,both,1,EA,,28,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,71288-700-05,NDC,,,facility,both,1,EA,,32.03,32.03,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Paroxetine: 250 Ml In 1 Bottle (70954-319-10),250,RC,70954-319-10,NDC,,,facility,both,1,EA,,112.63,112.63,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Naproxen Oral Suspension: 500 Ml In 1 Bottle (70954-151-10),250,RC,70954-151-10,NDC,,,facility,both,1,EA,,35.3,35.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Pyridostigmine: 473 Ml In 1 Bottle (70954-148-10),250,RC,70954-148-10,NDC,,,facility,both,1,EA,,30.17,30.17,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Levocarnitine: 118 Ml In 1 Bottle (70954-140-10),250,RC,70954-140-10,NDC,,,facility,both,1,EA,,15.57,15.57,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Felbamate: 237 Ml In 1 Bottle (70954-051-10),250,RC,70954-051-10,NDC,,,facility,both,1,EA,,11.83,11.83,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Levocarnitine: 90 Blister Pack In 1 Carton (70954-492-10) / 10 Tablet In 1 Blister Pack,250,RC,70954-492-10,NDC,,,facility,both,1,EA,,9.72,9.72,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dexmedetomidine: 25 VIAL in 1 CARTON (70860-605-03) / 2 mL in 1 VIAL (70860-605-41) ,250,RC,70860-605-03,NDC,,,facility,both,1,EA,,42.26,42.26,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Lansoprazole: 90 Capsule, Delayed Release In 1 Bottle (70756-807-90)",250,RC,70756-807-90,NDC,,,facility,both,1,EA,,11.69,11.69,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Lidocaine Hydrochloride: 1 Vial In 1 Carton (70756-640-82) / 2 Ml In 1 Vial,250,RC,70756-640-82,NDC,,,facility,both,1,EA,,25.44,25.44,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Phenylephrine Hydrochloride: 1 Bottle, Dropper In 1 Carton (70756-629-25) / 2 Ml In 1 Bottle, Dropper",250,RC,70756-629-25,NDC,,,facility,both,1,EA,,165.28,165.28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Phenylephrine Hydrochloride: 1 Bottle, Dropper In 1 Carton (70756-614-30) / 5 Ml In 1 Bottle, Dropper",250,RC,70756-614-30,NDC,,,facility,both,1,EA,,191.76,191.76,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Nitrofurantoin (Monohydrate/Macrocrystals): 100 Capsule In 1 Bottle (70756-404-11),250,RC,70756-404-11,NDC,,,facility,both,1,EA,,14.58,14.58,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Amitriptyline Hydrochloride: 100 Tablet, Film Coated In 1 Bottle (70756-201-11)",250,RC,70756-201-11,NDC,,,facility,both,1,EA,,11.68,11.68,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Cyproheptadine Hydrochloride: 473 Ml In 1 Bottle, Glass (70752-101-12)",250,RC,70752-101-12,NDC,,,facility,both,1,EA,,14.54,14.54,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Posaconazole: 60 Tablet, Delayed Release In 1 Bottle (70748-258-07)",250,RC,70748-258-07,NDC,,,facility,both,1,EA,,42.2,42.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Nitrofurantoin: 230 Ml In 1 Bottle (70954-496-10),250,RC,70954-496-10,NDC,,,facility,both,1,EA,,285.53,285.53,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,71286-3022-1,NDC,,,facility,both,1,EA,,48.86,48.86,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,71286-2010-2,NDC,,,facility,both,1,EA,,105.35,105.35,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,71285-0422-1,NDC,,,facility,both,1,EA,,321.45,321.45,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,71285-0419-1,NDC,,,facility,both,1,EA,,383.72,383.72,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,71266-6290-1,NDC,,,facility,both,1,EA,,62.11,62.11,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,71266-6290-1,NDC,,,facility,both,1,EA,,60.98,60.98,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Nitazoxanide: 6 Tablet In 1 Bottle (70954-934-10),250,RC,70954-934-10,NDC,,,facility,both,1,EA,,686.96,686.96,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Levofloxacin: 200 Ml In 1 Bottle (70954-852-20),250,RC,70954-852-20,NDC,,,facility,both,1,EA,,85.38,85.38,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Fluoxetine Hydrochloride: 120 Ml In 1 Bottle, Plastic (70954-600-10)",250,RC,70954-600-10,NDC,,,facility,both,1,EA,,18.35,18.35,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,71285-0202-1,NDC,,,facility,both,1,EA,,197.22,197.22,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Amoxicillin: 100 Capsule In 1 Bottle (65862-016-01),250,RC,65862-016-01,NDC,,,facility,both,1,EA,,4.18,4.18,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Relistor: 7 Blister Pack In 1 Carton (65649-552-04) / 1 Syringe In 1 Blister Pack / .4 Ml In 1 Syringe,250,RC,65649-552-04,NDC,,,facility,both,1,EA,,917.1,917.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Relistor: 1 Blister Pack In 1 Carton (65649-551-07) / 1 Syringe In 1 Blister Pack / .6 Ml In 1 Syringe,250,RC,65649-551-07,NDC,,,facility,both,1,EA,,177.35,177.35,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Sertraline Hydrochloride: 100 Blister Pack In 1 Box, Unit-Dose (60687-242-01) / 1 Tablet In 1 Blister Pack (60687-242-11)",250,RC,60687-242-01,NDC,,,facility,both,1,EA,,9.68,9.68,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,60687-231-11,NDC,,,facility,both,1,EA,,8.97,8.97,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Sertraline Hydrochloride: 100 Blister Pack In 1 Box, Unit-Dose (60687-231-01) / 1 Tablet In 1 Blister Pack (60687-231-11)",250,RC,60687-231-01,NDC,,,facility,both,1,EA,,8.93,8.93,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,60687-224-11,NDC,,,facility,both,1,EA,,13.07,13.07,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,60687-211-11,NDC,,,facility,both,1,EA,,15.44,15.44,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,60687-163-11,NDC,,,facility,both,1,EA,,9.01,9.01,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,60687-156-95,NDC,,,facility,both,1,EA,,11.13,11.13,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Phenytoin: 30 Blister Pack In 1 Box, Unit-Dose (60687-156-25) / 1 Tablet, Chewable In 1 Blister Pack (60687-156-95)",250,RC,60687-156-25,NDC,,,facility,both,1,EA,,10.85,10.85,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Metformin Hydrochloride: 100 Blister Pack In 1 Box, Unit-Dose (60687-155-01) / 1 Tablet, Film Coated In 1 Blister Pack (60687-155-11)",250,RC,60687-155-01,NDC,,,facility,both,1,EA,,12.85,12.85,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,60687-152-11,NDC,,,facility,both,1,EA,,7.18,7.18,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,60687-124-11,NDC,,,facility,both,1,EA,,12.07,12.07,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Clonidine Hydrochloride: 100 Blister Pack In 1 Box, Unit-Dose (60687-124-01) / 1 Tablet In 1 Blister Pack (60687-124-11)",250,RC,60687-124-01,NDC,,,facility,both,1,EA,,12.48,12.48,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,60687-242-11,NDC,,,facility,both,1,EA,,9.28,9.28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,60687-312-11,NDC,,,facility,both,1,EA,,21.7,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,60687-313-95,NDC,,,facility,both,1,EA,,19.98,19.98,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,60687-433-11,NDC,,,facility,both,1,EA,,7.72,7.72,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Clobazam: 30 Blister Pack In 1 Box, Unit-Dose (60687-423-21) / 1 Tablet In 1 Blister Pack (60687-423-11)",250,RC,60687-423-21,NDC,,,facility,both,1,EA,,19.11,19.11,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,60687-423-11,NDC,,,facility,both,1,EA,,19.8,19.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,60687-381-11,NDC,,,facility,both,1,EA,,341.42,341.42,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Dicyclomine Hydrochloride: 100 Blister Pack In 1 Box, Unit-Dose (60687-369-01) / 1 Capsule In 1 Blister Pack (60687-369-11)",250,RC,60687-369-01,NDC,,,facility,both,1,EA,,10.57,10.57,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Benztropine Mesylate: 100 BLISTER PACK in 1 BOX, UNIT-DOSE (60687-368-01) / 1 TABLET in 1 BLISTER PACK (60687-368-11) ",250,RC,60687-368-01,NDC,,,facility,both,1,EA,,13.01,13.01,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,60687-345-11,NDC,,,facility,both,1,EA,,16.57,16.57,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,60687-326-95,NDC,,,facility,both,1,EA,,43.36,43.36,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,60687-319-11,NDC,,,facility,both,1,EA,,40.48,40.48,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,60687-315-11,NDC,,,facility,both,1,EA,,13.54,13.54,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,60687-369-11,NDC,,,facility,both,1,EA,,10.57,10.57,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,60687-436-11,NDC,,,facility,both,1,EA,,18.29,18.29,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,60687-113-11,NDC,,,facility,both,1,EA,,10.05,10.05,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA OXYBUTYNIN CHLORIDE: 473 mL in 1 BOTTLE (60432-092-16) ,250,RC,60432-092-16,NDC,,,facility,both,1,EA,,12.43,12.43,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Sodium Thiosulfate: 50 Ml In 1 Vial, Single-Dose (60267-705-50)",250,RC,60267-705-50,NDC,,,facility,both,1,EA,,557.51,557.51,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Atropine: 1 Bottle, Dropper In 1 Carton (60219-1749-3) / 5 Ml In 1 Bottle, Dropper",250,RC,60219-1749-3,NDC,,,facility,both,1,EA,,221.38,221.38,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sulfasalazine: 1 Bottle In 1 Carton (59762-5000-5) / 100 Tablet In 1 Bottle,250,RC,59762-5000-5,NDC,,,facility,both,1,EA,,10.77,10.77,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Alprazolam: 100 Tablet In 1 Bottle (59762-3720-1),250,RC,59762-3720-1,NDC,,,facility,both,1,EA,,2.84,2.84,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ethosuximide: 1 Bottle, Plastic In 1 Carton (59762-2350-7) / 474 Ml In 1 Bottle, Plastic",250,RC,59762-2350-7,NDC,,,facility,both,1,EA,,2.28,2.28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Rifabutin: 100 Capsule In 1 Bottle (59762-1350-1),250,RC,59762-1350-1,NDC,,,facility,both,1,EA,,97.11,97.11,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Linezolid: 150 Ml In 1 Bottle (59762-1308-4),250,RC,59762-1308-4,NDC,,,facility,both,1,EA,,113.32,113.32,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Voriconazole: 1 Bottle In 1 Carton (59762-0935-3) / 75 Ml In 1 Bottle,250,RC,59762-0935-3,NDC,,,facility,both,1,EA,,374.44,374.44,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Latanoprost: 1 Bottle, Dropper In 1 Carton (59762-0333-2) / 2.5 Ml In 1 Bottle, Dropper",250,RC,59762-0333-2,NDC,,,facility,both,1,EA,,17.89,17.89,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,59762-0118-1,NDC,,,facility,both,1,EA,,49.1,49.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Mesalamine: 180 Capsule, Delayed Release In 1 Bottle (59762-0117-1)",250,RC,59762-0117-1,NDC,,,facility,both,1,EA,,15.4,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Hydrocortisone: 100 Tablet In 1 Bottle (59762-0075-1),250,RC,59762-0075-1,NDC,,,facility,both,1,EA,,11.81,11.81,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Medroxyprogesterone Acetate: 100 Tablet In 1 Bottle (59762-0056-1),250,RC,59762-0056-1,NDC,,,facility,both,1,EA,,13.28,13.28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "DOXEPIN HYDROCHLORIDE: 118 mL in 1 BOTTLE, PLASTIC (60432-651-04) ",250,RC,60432-651-04,NDC,,,facility,both,1,EA,,12.67,12.67,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Fluvoxamine Maleate: 100 Tablet In 1 Bottle (60505-0165-1),250,RC,60505-0165-1,NDC,,,facility,both,1,EA,,8.06,8.06,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Mirtazapine: 30 Tablet, Film Coated In 1 Bottle (60505-0247-1)",250,RC,60505-0247-1,NDC,,,facility,both,1,EA,,13.21,13.21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,60687-100-11,NDC,,,facility,both,1,EA,,25.75,25.75,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Atropine: 1 Bottle, Dropper In 1 Carton (60505-6226-1) / 5 Ml In 1 Bottle, Dropper",250,RC,60505-6226-1,NDC,,,facility,both,1,EA,,233.03,233.03,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Guanfacine Extended-Release: 100 Tablet, Extended Release In 1 Bottle (60505-3927-1)",250,RC,60505-3927-1,NDC,,,facility,both,1,EA,,7.63,7.63,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Clonidine Hydrochloride: 100 Blister Pack In 1 Box, Unit-Dose (60687-113-01) / 1 Tablet In 1 Blister Pack (60687-113-11)",250,RC,60687-113-01,NDC,,,facility,both,1,EA,,11.24,11.24,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Celecoxib: 60 Capsule In 1 Bottle (60505-3847-6),250,RC,60505-3847-6,NDC,,,facility,both,1,EA,,13.29,13.29,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Olanzapine: 10 Blister Pack In 1 Carton (60505-3275-0) / 10 Tablet, Orally Disintegrating In 1 Blister Pack",250,RC,60505-3275-0,NDC,,,facility,both,1,EA,,17.73,17.73,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Olanzapine: 10 Blister Pack In 1 Carton (60505-3110-0) / 10 Tablet, Film Coated In 1 Blister Pack",250,RC,60505-3110-0,NDC,,,facility,both,1,EA,,11.26,11.26,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Desmopressin Acetate: 1 Bottle, Spray In 1 Carton (60505-0815-0) / 50 Spray In 1 Bottle, Spray",250,RC,60505-0815-0,NDC,,,facility,both,1,EA,,553.23,553.23,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ofloxacin: 1 Bottle, Dropper In 1 Carton (60505-0560-1) / 10 Ml In 1 Bottle, Dropper",250,RC,60505-0560-1,NDC,,,facility,both,1,EA,,205.98,205.98,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Aripiprazole: 1 Bottle In 1 Carton (60505-0404-5) / 150 Ml In 1 Bottle,250,RC,60505-0404-5,NDC,,,facility,both,1,EA,,59.14,59.14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Desmopressin Acetate: 100 Tablet In 1 Bottle (60505-0257-1),250,RC,60505-0257-1,NDC,,,facility,both,1,EA,,16.34,16.34,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Dasatinib: 60 Tablet, Film Coated In 1 Bottle (60505-3629-6)",250,RC,60505-3629-6,NDC,,,facility,both,1,EA,,483.07,483.07,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Labetalol Hydrochloride: 100 Blister Pack In 1 Box, Unit-Dose (60687-439-01) / 1 Tablet, Film Coated In 1 Blister Pack (60687-439-11)",250,RC,60687-439-01,NDC,,,facility,both,1,EA,,13.59,13.59,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,60687-657-11,NDC,,,facility,both,1,EA,,8.4,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,60687-650-33,NDC,,,facility,both,1,EA,,29.65,29.65,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,60687-640-11,NDC,,,facility,both,1,EA,,13.27,13.27,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Nitrofurantoin (Monohydrate/Macrocrystals): 50 Blister Pack In 1 Carton (60687-633-65) / 1 Capsule In 1 Blister Pack (60687-633-11),250,RC,60687-633-65,NDC,,,facility,both,1,EA,,27.69,27.69,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,60687-633-11,NDC,,,facility,both,1,EA,,30.73,30.73,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,60687-620-11,NDC,,,facility,both,1,EA,,14.81,14.81,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Metoclopramide: 100 Blister Pack In 1 Box, Unit-Dose (60687-620-01) / 1 Tablet In 1 Blister Pack (60687-620-11)",250,RC,60687-620-01,NDC,,,facility,both,1,EA,,15.7,15.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,60687-612-11,NDC,,,facility,both,1,EA,,16.33,16.33,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,60687-609-11,NDC,,,facility,both,1,EA,,11.74,11.74,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Propranolol Hydrochloride: 100 Blister Pack In 1 Box, Unit-Dose (60687-609-01) / 1 Tablet In 1 Blister Pack (60687-609-11)",250,RC,60687-609-01,NDC,,,facility,both,1,EA,,11.95,11.95,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,60687-598-11,NDC,,,facility,both,1,EA,,11.87,11.87,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Propranolol Hydrochloride: 100 Blister Pack In 1 Box, Unit-Dose (60687-598-01) / 1 Tablet In 1 Blister Pack (60687-598-11)",250,RC,60687-598-01,NDC,,,facility,both,1,EA,,13.59,13.59,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,60687-596-33,NDC,,,facility,both,1,EA,,81.95,81.95,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,60687-593-11,NDC,,,facility,both,1,EA,,11.2,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Hydrochlorothiazide: 100 Blister Pack In 1 Box, Unit-Dose (60687-593-01) / 1 Tablet In 1 Blister Pack (60687-593-11)",250,RC,60687-593-01,NDC,,,facility,both,1,EA,,12.41,12.41,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,60687-661-11,NDC,,,facility,both,1,EA,,7.51,7.51,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Pantoprazole Sodium: 50 Blister Pack In 1 Carton (60687-736-65) / 1 Tablet, Delayed Release In 1 Blister Pack (60687-736-11)",250,RC,60687-736-65,NDC,,,facility,both,1,EA,,12.95,12.95,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,60687-736-11,NDC,,,facility,both,1,EA,,12.65,12.65,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,60687-734-11,NDC,,,facility,both,1,EA,,15.8,15.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,60687-732-11,NDC,,,facility,both,1,EA,,28.72,28.72,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,60687-725-11,NDC,,,facility,both,1,EA,,8.03,8.03,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,60687-722-11,NDC,,,facility,both,1,EA,,13.51,13.51,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Desmopressin Acetate: 30 Blister Pack In 1 Carton (60687-721-21) / 1 Tablet In 1 Blister Pack (60687-721-11),250,RC,60687-721-21,NDC,,,facility,both,1,EA,,22.71,22.71,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,60687-721-11,NDC,,,facility,both,1,EA,,22.34,22.34,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,60687-699-11,NDC,,,facility,both,1,EA,,27.19,27.19,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,60687-681-11,NDC,,,facility,both,1,EA,,11.84,11.84,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Folic Acid: 100 Blister Pack In 1 Carton (60687-681-01) / 1 Tablet In 1 Blister Pack (60687-681-11),250,RC,60687-681-01,NDC,,,facility,both,1,EA,,12.65,12.65,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,60687-671-40,NDC,,,facility,both,1,EA,,20.05,20.05,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,60687-669-11,NDC,,,facility,both,1,EA,,11.22,11.22,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Methimazole: 100 Blister Pack In 1 Carton (60687-669-01) / 1 Tablet In 1 Blister Pack (60687-669-11),250,RC,60687-669-01,NDC,,,facility,both,1,EA,,14.95,14.95,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,60687-664-11,NDC,,,facility,both,1,EA,,7.69,7.69,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,60687-591-11,NDC,,,facility,both,1,EA,,8.7,8.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Gabapentin: 100 Blister Pack In 1 Box, Unit-Dose (60687-591-01) / 1 Capsule In 1 Blister Pack (60687-591-11)",250,RC,60687-591-01,NDC,,,facility,both,1,EA,,8.34,8.34,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Levothyroxine Sodium: 100 Blister Pack In 1 Box, Unit-Dose (60687-508-01) / 1 Tablet In 1 Blister Pack (60687-508-11)",250,RC,60687-508-01,NDC,,,facility,both,1,EA,,13.11,13.11,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,60687-497-11,NDC,,,facility,both,1,EA,,12.43,12.43,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,60687-495-11,NDC,,,facility,both,1,EA,,13.49,13.49,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Pregabalin: 100 Blister Pack In 1 Box, Unit-Dose (60687-495-01) / 1 Capsule In 1 Blister Pack (60687-495-11)",250,RC,60687-495-01,NDC,,,facility,both,1,EA,,14.27,14.27,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,60687-484-11,NDC,,,facility,both,1,EA,,8.36,8.36,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,60687-479-11,NDC,,,facility,both,1,EA,,9.65,9.65,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,60687-473-11,NDC,,,facility,both,1,EA,,14.83,14.83,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,60687-461-11,NDC,,,facility,both,1,EA,,12.55,12.55,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,60687-457-11,NDC,,,facility,both,1,EA,,13.03,13.03,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,60687-453-11,NDC,,,facility,both,1,EA,,8.67,8.67,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Levothyroxine Sodium: 100 Blister Pack In 1 Box, Unit-Dose (60687-453-01) / 1 Tablet In 1 Blister Pack (60687-453-11)",250,RC,60687-453-01,NDC,,,facility,both,1,EA,,6.32,6.32,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,60687-451-11,NDC,,,facility,both,1,EA,,27.79,27.79,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,60687-450-11,NDC,,,facility,both,1,EA,,12.26,12.26,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,60687-443-11,NDC,,,facility,both,1,EA,,6.86,6.86,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,60687-439-11,NDC,,,facility,both,1,EA,,7.26,7.26,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ibuprofen: 100 Blister Pack In 1 Box, Unit-Dose (60687-457-01) / 1 Tablet In 1 Blister Pack (60687-457-11)",250,RC,60687-457-01,NDC,,,facility,both,1,EA,,12.64,12.64,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ciprofloxacin: 50 Tablet, Film Coated In 1 Bottle (59651-873-50)",250,RC,59651-873-50,NDC,,,facility,both,1,EA,,13.08,13.08,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,60687-508-11,NDC,,,facility,both,1,EA,,13.64,13.64,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,60687-524-79,NDC,,,facility,both,1,EA,,59.38,59.38,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,60687-587-11,NDC,,,facility,both,1,EA,,12.4,12.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Propranolol Hydrochloride: 100 Blister Pack In 1 Box, Unit-Dose (60687-587-01) / 1 Tablet In 1 Blister Pack (60687-587-11)",250,RC,60687-587-01,NDC,,,facility,both,1,EA,,9.06,9.06,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,60687-586-11,NDC,,,facility,both,1,EA,,21.72,21.72,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Pantoprazole Sodium: 100 Blister Pack In 1 Box, Unit-Dose (60687-585-01) / 1 Tablet, Delayed Release In 1 Blister Pack (60687-585-11)",250,RC,60687-585-01,NDC,,,facility,both,1,EA,,13.5,13.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,60687-580-11,NDC,,,facility,both,1,EA,,9.01,9.01,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Midazolam Hydrochloride: 3 Tray In 1 Case (60687-576-86) / 10 Cup, Unit-Dose In 1 Tray (60687-576-46) / 5 Ml In 1 Cup, Unit-Dose (60687-576-40)",250,RC,60687-576-86,NDC,,,facility,both,1,EA,,36.02,36.02,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,60687-576-40,NDC,,,facility,both,1,EA,,25.04,25.04,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Methocarbamol: 100 Blister Pack In 1 Box, Unit-Dose (60687-559-01) / 1 Tablet In 1 Blister Pack (60687-559-11)",250,RC,60687-559-01,NDC,,,facility,both,1,EA,,8.79,8.79,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,60687-555-11,NDC,,,facility,both,1,EA,,11.94,11.94,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Clonazepam: 100 Blister Pack In 1 Box, Unit-Dose (60687-555-01) / 1 Tablet In 1 Blister Pack (60687-555-11)",250,RC,60687-555-01,NDC,,,facility,both,1,EA,,12.52,12.52,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,60687-550-11,NDC,,,facility,both,1,EA,,13.63,13.63,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Metronidazole: 100 Blister Pack In 1 Box, Unit-Dose (60687-550-01) / 1 Tablet In 1 Blister Pack (60687-550-11)",250,RC,60687-550-01,NDC,,,facility,both,1,EA,,21.95,21.95,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Metronidazole: 100 Blister Pack In 1 Box, Unit-Dose (60687-550-01) / 1 Tablet In 1 Blister Pack (60687-550-11)",250,RC,60687-550-01,NDC,,,facility,both,1,EA,,13.72,13.72,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Clonazepam: 100 Blister Pack In 1 Box, Unit-Dose (60687-544-01) / 1 Tablet In 1 Blister Pack (60687-544-11)",250,RC,60687-544-01,NDC,,,facility,both,1,EA,,13.41,13.41,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,60687-530-11,NDC,,,facility,both,1,EA,,14.99,14.99,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,60687-576-03,NDC,,,facility,both,1,EA,,29.82,29.82,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,55150-438-01,NDC,,,facility,both,1,EA,,73.78,73.78,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,55150-297-01,NDC,,,facility,both,1,EA,,72.32,72.32,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Sensipar: 30 Tablet, Coated In 1 Bottle, Plastic (55513-073-30)",250,RC,55513-073-30,NDC,,,facility,both,1,EA,,12.14,12.14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,55111-789-48,NDC,,,facility,both,1,EA,,43.82,43.82,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ethambutol Hydrochloride: 12 Carton In 1 Box (54879-001-01) / 12 Bottle In 1 Carton / 100 Tablet, Film Coated In 1 Bottle",250,RC,54879-001-01,NDC,,,facility,both,1,EA,,8.67,8.67,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Doxepin Hydrochloride: 120 Ml In 1 Bottle, Plastic (54838-512-40)",250,RC,54838-512-40,NDC,,,facility,both,1,EA,,12.47,12.47,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Oxybutynin Chloride: 473 Ml In 1 Bottle, Plastic (54838-510-80)",250,RC,54838-510-80,NDC,,,facility,both,1,EA,,12.58,12.58,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Hyosyne: 15 Ml In 1 Bottle, Plastic (54838-506-15)",250,RC,54838-506-15,NDC,,,facility,both,1,EA,,19.08,19.08,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Hydroxyzine Hydrochloride: 473 Ml In 1 Bottle, Plastic (54838-502-80)",250,RC,54838-502-80,NDC,,,facility,both,1,EA,,3.21,3.21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Haloperidol: 120 Ml In 1 Bottle, Dropper (54838-501-40)",250,RC,54838-501-40,NDC,,,facility,both,1,EA,,12.71,12.71,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,54629-0772-41,NDC,,,facility,both,1,EA,,13.02,13.02,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Carnitor Sf: 24 Bottle, Plastic In 1 Case (54482-148-01) / 118 Ml In 1 Bottle, Plastic",250,RC,54482-148-01,NDC,,,facility,both,1,EA,,19.73,19.73,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Rocuronium Bromide: 10 Vial, Multi-Dose In 1 Carton (55150-226-10) / 10 Ml In 1 Vial, Multi-Dose",250,RC,55150-226-10,NDC,,,facility,both,1,EA,,33.53,33.53,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dexmedetomidine: 25 Vial In 1 Carton (55150-209-02) / 2 Ml In 1 Vial,250,RC,55150-209-02,NDC,,,facility,both,1,EA,,22.04,22.04,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Tranexamic Acid: 10 Vial, Single-Dose In 1 Carton (55150-188-10) / 10 Ml In 1 Vial, Single-Dose",250,RC,55150-188-10,NDC,,,facility,both,1,EA,,23.84,23.84,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,55150-183-01,NDC,,,facility,both,1,EA,,80.61,80.61,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Sildenafil: 1 Vial, Single-Dose In 1 Carton (55150-166-13) / 12.5 Ml In 1 Vial, Single-Dose",250,RC,55150-166-13,NDC,,,facility,both,1,EA,,654.54,654.54,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Lidocaine Hydrochloride: 10 Vial, Single-Dose In 1 Carton (55150-165-05) / 5 Ml In 1 Vial, Single-Dose",250,RC,55150-165-05,NDC,,,facility,both,1,EA,,30.45,30.45,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Lidocaine Hydrochloride: 1 Vial, Single-Dose In 1 Carton (55150-163-30) / 30 Ml In 1 Vial, Single-Dose",250,RC,55150-163-30,NDC,,,facility,both,1,EA,,29.6,29.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Lidocaine Hydrochloride: 10 Vial, Single-Dose In 1 Carton (55150-162-05) / 5 Ml In 1 Vial, Single-Dose",250,RC,55150-162-05,NDC,,,facility,both,1,EA,,28.49,28.49,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Lidocaine Hydrochloride: 10 Vial, Single-Dose In 1 Carton (55150-161-02) / 2 Ml In 1 Vial, Single-Dose",250,RC,55150-161-02,NDC,,,facility,both,1,EA,,26.09,26.09,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,60687-743-40,NDC,,,facility,both,1,EA,,9.54,9.54,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Amjevita: 2 Syringe In 1 Carton (55513-481-02) / .8 Ml In 1 Syringe,250,RC,55513-481-02,NDC,,,facility,both,1,EA,,8248.59,8248.59,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Diclofenac Sodium: 1 Tube In 1 Carton (58602-604-07) / 100 G In 1 Tube,250,RC,58602-604-07,NDC,,,facility,both,1,EA,,55.47,55.47,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Olopatadine Hydrochloride: 1 Bottle, Plastic In 1 Carton (58602-006-40) / 5 Ml In 1 Bottle, Plastic",250,RC,58602-006-40,NDC,,,facility,both,1,EA,,53.83,53.83,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Gleostine: 1 Bottle In 1 Carton (58181-3041-5) / 5 Capsule, Gelatin Coated In 1 Bottle",250,RC,58181-3041-5,NDC,,,facility,both,1,EA,,2919.54,2919.54,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Loperamide Hydrochloride: 4 Blister Pack In 1 Carton (58602-701-76) / 6 Tablet In 1 Blister Pack,250,RC,58602-701-76,NDC,,,facility,both,1,EA,,10.19,10.19,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Loratadine: 10 Blister Pack In 1 Carton (58602-702-04) / 10 Tablet In 1 Blister Pack,250,RC,58602-702-04,NDC,,,facility,both,1,EA,,13,13,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Valganciclovir: 1 Bottle, Glass In 1 Carton (59651-444-01) / 100 Ml In 1 Bottle, Glass",250,RC,59651-444-01,NDC,,,facility,both,1,EA,,120.31,120.31,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sildenafil Citrate: 1 Bottle In 1 Carton (59651-420-11) / 112 Ml In 1 Bottle,250,RC,59651-420-11,NDC,,,facility,both,1,EA,,13.2,13.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Hydrocortisone: 100 Tablet In 1 Bottle (59651-414-01),250,RC,59651-414-01,NDC,,,facility,both,1,EA,,7.36,7.36,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Clobazam: 1 Bottle In 1 Carton (59651-401-12) / 120 Ml In 1 Bottle,250,RC,59651-401-12,NDC,,,facility,both,1,EA,,4.67,4.67,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Mesalamine: 120 Capsule, Extended Release In 1 Bottle (59651-397-08)",250,RC,59651-397-08,NDC,,,facility,both,1,EA,,10.04,10.04,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Baclofen: 100 Tablet In 1 Bottle (59651-394-01),250,RC,59651-394-01,NDC,,,facility,both,1,EA,,7.54,7.54,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Azelastine Hydrochloride: 1 Bottle, Spray In 1 Carton (59651-214-30) / 200 Spray, Metered In 1 Bottle, Spray",250,RC,59651-214-30,NDC,,,facility,both,1,EA,,15.09,15.09,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Vyvanse: 100 Capsule In 1 Bottle (59417-102-10),250,RC,59417-102-10,NDC,,,facility,both,1,EA,,88.14,88.14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Qvar Redihaler: 1 Inhaler In 1 Carton (59310-304-80) / 1 Canister In 1 Inhaler / 120 Aerosol, Metered In 1 Canister",250,RC,59310-304-80,NDC,,,facility,both,1,EA,,1766.39,1766.39,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Stratuscare Glycerin Laxative Pediatric: 25 Suppository In 1 Jar (58980-409-25),250,RC,58980-409-25,NDC,,,facility,both,1,EA,,13.69,13.69,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Bacitracin Zinc: 1 Tube In 1 Box (58980-011-10) / 28.35 G In 1 Tube,250,RC,58980-011-10,NDC,,,facility,both,1,EA,,25.64,25.64,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Bacitracin Zinc: 1 Tube In 1 Box (58980-011-10) / 28.35 G In 1 Tube,250,RC,58980-011-10,NDC,,,facility,both,1,EA,,25.16,25.16,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Theratears: 6 Pouch In 1 Carton (58790-003-30) / 5 Vial In 1 Pouch / .6 Ml In 1 Vial,250,RC,58790-003-30,NDC,,,facility,both,1,EA,,12.17,12.17,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Theratears: 7 Pouch In 1 Carton (58790-002-28) / .6 Ml In 1 Pouch,250,RC,58790-002-28,NDC,,,facility,both,1,EA,,11.8,11.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ciprofloxacin: 100 Tablet, Coated In 1 Bottle (58657-675-01)",250,RC,58657-675-01,NDC,,,facility,both,1,EA,,6.74,6.74,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Loratadine: 1 Blister Pack In 1 Carton (58602-702-83) / 10 Tablet In 1 Blister Pack,250,RC,58602-702-83,NDC,,,facility,both,1,EA,,12.86,12.86,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Tramadol Hydrochloride: 100 Tablet In 1 Bottle (57664-377-08),250,RC,57664-377-08,NDC,,,facility,both,1,EA,,11.8,11.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sulfamethoxazole And Trimethoprim: 100 Tablet In 1 Bottle (57237-233-01),250,RC,57237-233-01,NDC,,,facility,both,1,EA,,10.51,10.51,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sulfamethoxazole And Trimethoprim: 100 Tablet In 1 Bottle (57237-232-01),250,RC,57237-232-01,NDC,,,facility,both,1,EA,,7.53,7.53,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Rizatriptan Benzoate: 3 Blister Pack In 1 Carton (57237-086-63) / 6 Tablet, Orally Disintegrating In 1 Blister Pack",250,RC,57237-086-63,NDC,,,facility,both,1,EA,,16.81,16.81,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Rizatriptan Benzoate: 3 Blister Pack In 1 Carton (57237-085-63) / 6 Tablet, Orally Disintegrating In 1 Blister Pack",250,RC,57237-085-63,NDC,,,facility,both,1,EA,,21.89,21.89,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Penicillin V Potassium: 100 Tablet, Film Coated In 1 Bottle (57237-040-01)",250,RC,57237-040-01,NDC,,,facility,both,1,EA,,11.82,11.82,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Fluconazole: 12 Blister Pack In 1 Carton (57237-005-11) / 1 Tablet In 1 Blister Pack,250,RC,57237-005-11,NDC,,,facility,both,1,EA,,13.2,13.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Corlanor: 28 Ampule In 1 Carton (55513-813-28) / 5 Ml In 1 Ampule (55513-813-01),250,RC,55513-813-28,NDC,,,facility,both,1,EA,,19.36,19.36,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,55513-813-01,NDC,,,facility,both,1,EA,,23.87,23.87,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Amjevita: 2 Syringe In 1 Carton (55513-482-02) / .4 Ml In 1 Syringe,250,RC,55513-482-02,NDC,,,facility,both,1,EA,,4145.76,4145.76,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Amjevita: 1 Syringe In 1 Carton (55513-482-01) / .4 Ml In 1 Syringe,250,RC,55513-482-01,NDC,,,facility,both,1,EA,,4145.76,4145.76,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Fluconazole: 30 Tablet In 1 Bottle (57237-003-30),250,RC,57237-003-30,NDC,,,facility,both,1,EA,,13.73,13.73,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Amjevita: 1 Syringe In 1 Carton (55513-481-01) / .8 Ml In 1 Syringe,250,RC,55513-481-01,NDC,,,facility,both,1,EA,,8255.12,8255.12,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,58151-237-32,NDC,,,facility,both,1,EA,,78.83,78.83,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,58151-110-32,NDC,,,facility,both,1,EA,,17.13,17.13,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Geri-Lanta Antacid Antigas: 355 Ml In 1 Bottle (57896-629-12),250,RC,57896-629-12,NDC,,,facility,both,1,EA,,1.03,1.03,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Polyethylene Glycol 3350: 30 Packet In 1 Carton (57896-490-03) / 17 G In 1 Packet (57896-490-01),250,RC,57896-490-03,NDC,,,facility,both,1,EA,,15.06,15.06,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,57896-490-01,NDC,,,facility,both,1,EA,,15.22,15.22,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Extra Strength Acetaminophen: 100 Tablet In 1 Bottle (57896-204-01),250,RC,57896-204-01,NDC,,,facility,both,1,EA,,9.27,9.27,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA 100 TABLET in 1 BOTTLE (57896-201-01) ,250,RC,57896-201-01,NDC,,,facility,both,1,EA,,9.37,9.37,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Analgesic Balm: 1 Tube In 1 Box (57896-116-03) / 85 G In 1 Tube,250,RC,57896-116-03,NDC,,,facility,both,1,EA,,26.05,26.05,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Regular Strength Pain Relief: 100 TABLET in 1 BOTTLE (57896-101-01) ,250,RC,57896-101-01,NDC,,,facility,both,1,EA,,0.51,0.51,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Linezolid: 1 Bottle, Glass In 1 Carton (60687-754-05) / 150 Ml In 1 Bottle, Glass",250,RC,60687-754-05,NDC,,,facility,both,1,EA,,100.73,100.73,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,63739-354-10,NDC,,,facility,both,1,EA,,11.85,11.85,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,63739-354-01,NDC,,,facility,both,1,EA,,8.1,8.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,63739-225-10,NDC,,,facility,both,1,EA,,12.21,12.21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Low Dose Aspirin: 30 Blister Pack In 1 Box (63739-212-02) / 10 Tablet, Coated In 1 Blister Pack",250,RC,63739-212-02,NDC,,,facility,both,1,EA,,1.04,1.04,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,63739-198-62,NDC,,,facility,both,1,EA,,15.91,15.91,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,63739-193-72,NDC,,,facility,both,1,EA,,28.16,28.16,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Sucralfate: 2 Tray In 1 Case (63739-193-51) / 10 Cup, Unit-Dose In 1 Tray / 10 Ml In 1 Cup, Unit-Dose (63739-193-72)",250,RC,63739-193-51,NDC,,,facility,both,1,EA,,16.37,16.37,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Lidocaine Hydrochloride: 10 Vial In 1 Box (63739-170-24) / 5 Ml In 1 Vial (63739-170-13),250,RC,63739-170-24,NDC,,,facility,both,1,EA,,32.12,32.12,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,63739-170-13,NDC,,,facility,both,1,EA,,29.14,29.14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Nystatin: 5 Ml In 1 Cup, Unit-Dose (63739-160-70)",250,RC,63739-160-70,NDC,,,facility,both,1,EA,,14.24,14.24,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,63739-159-77,NDC,,,facility,both,1,EA,,2.27,2.27,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,63739-158-70,NDC,,,facility,both,1,EA,,19.7,19.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Midodrine Hydrochloride: 10 Blister Pack In 1 Box, Unit-Dose (63739-145-10) / 10 Tablet In 1 Blister Pack",250,RC,63739-145-10,NDC,,,facility,both,1,EA,,10.56,10.56,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Hydrochlorothiazide: 10 BLISTER PACK in 1 BOX, UNIT-DOSE (63739-128-10) / 10 TABLET in 1 BLISTER PACK",250,RC,63739-128-10,NDC,,,facility,both,1,EA,,11.61,11.61,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Valproic Acid: 10 Blister Pack In 1 Box, Unit-Dose (63739-086-10) / 10 Capsule In 1 Blister Pack",250,RC,63739-086-10,NDC,,,facility,both,1,EA,,14.35,14.35,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Valacyclovir: 10 Blister Pack In 1 Box, Unit-Dose (63739-077-10) / 10 Tablet, Film Coated In 1 Blister Pack",250,RC,63739-077-10,NDC,,,facility,both,1,EA,,16.97,16.97,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Levetiracetam: 10 Blister Pack In 1 Box, Unit-Dose (63739-411-10) / 10 Tablet, Film Coated In 1 Blister Pack",250,RC,63739-411-10,NDC,,,facility,both,1,EA,,10.73,10.73,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Aspirin Chewable: 30 Blister Pack In 1 Box (63739-434-02) / 10 Tablet In 1 Blister Pack,250,RC,63739-434-02,NDC,,,facility,both,1,EA,,0.97,0.97,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,63739-976-01,NDC,,,facility,both,1,EA,,1.76,1.76,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Gabapentin: 10 Blister Pack In 1 Carton (63739-904-10) / 10 Capsule In 1 Blister Pack,250,RC,63739-904-10,NDC,,,facility,both,1,EA,,10.93,10.93,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Gabapentin: 10 Blister Pack In 1 Carton (63739-902-10) / 10 Capsule In 1 Blister Pack,250,RC,63739-902-10,NDC,,,facility,both,1,EA,,7.79,7.79,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Paroxetine: 10 Blister Pack In 1 Box, Unit-Dose (63739-888-10) / 10 Tablet, Film Coated In 1 Blister Pack",250,RC,63739-888-10,NDC,,,facility,both,1,EA,,15.51,15.51,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Childrens Ibuprofen Oral Suspension: 100 Cup, Unit-Dose In 1 Case (63739-798-10) / 5 Ml In 1 Cup, Unit-Dose (63739-798-01)",250,RC,63739-798-10,NDC,,,facility,both,1,EA,,10.31,10.31,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Childrens Ibuprofen Oral Suspension: 5 Ml In 1 Cup, Unit-Dose (63739-798-01)",250,RC,63739-798-01,NDC,,,facility,both,1,EA,,10.59,10.59,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Allopurinol: 10 BLISTER PACK in 1 BOX, UNIT-DOSE (63739-796-10) / 10 TABLET in 1 BLISTER PACK",250,RC,63739-796-10,NDC,,,facility,both,1,EA,,12.01,12.01,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Levetiracetam: 10 Blister Pack In 1 Box, Unit-Dose (63739-795-10) / 10 Tablet, Film Coated In 1 Blister Pack",250,RC,63739-795-10,NDC,,,facility,both,1,EA,,7.08,7.08,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Sky Oral Rinse: 15 Ml In 1 Cup, Unit-Dose (63739-052-74)",250,RC,63739-052-74,NDC,,,facility,both,1,EA,,16.36,16.36,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Losortan Potassium: 10 Blister Pack In 1 Box, Unit-Dose (63739-673-10) / 10 Tablet, Film Coated In 1 Blister Pack",250,RC,63739-673-10,NDC,,,facility,both,1,EA,,13.8,13.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Famotidine: 10 Blister Pack In 1 Box, Unit-Dose (63739-645-10) / 10 Tablet In 1 Blister Pack",250,RC,63739-645-10,NDC,,,facility,both,1,EA,,7.49,7.49,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Amlodipine Besylate: 10 BLISTER PACK in 1 BOX, UNIT-DOSE (63739-631-10) / 10 TABLET in 1 BLISTER PACK",250,RC,63739-631-10,NDC,,,facility,both,1,EA,,12.84,12.84,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Tamsulosin Hydrochloride: 10 Blister Pack In 1 Box, Unit-Dose (63739-567-10) / 10 Capsule In 1 Blister Pack",250,RC,63739-567-10,NDC,,,facility,both,1,EA,,13.65,13.65,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Spironolactone: 10 Blister Pack In 1 Box, Unit-Dose (63739-544-10) / 10 Tablet In 1 Blister Pack",250,RC,63739-544-10,NDC,,,facility,both,1,EA,,11.61,11.61,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Hydroxyzine Hydrochloride: 10 Blister Pack In 1 Box, Unit-Dose (63739-486-10) / 10 Tablet In 1 Blister Pack",250,RC,63739-486-10,NDC,,,facility,both,1,EA,,12.33,12.33,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Hydroxyzine Hydrochloride: 10 Blister Pack In 1 Box, Unit-Dose (63739-483-10) / 10 Tablet In 1 Blister Pack",250,RC,63739-483-10,NDC,,,facility,both,1,EA,,6.85,6.85,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Baclofen: 10 Blister Pack In 1 Box, Unit-Dose (63739-480-10) / 10 Tablet In 1 Blister Pack",250,RC,63739-480-10,NDC,,,facility,both,1,EA,,12.28,12.28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,63739-019-70,NDC,,,facility,both,1,EA,,20.59,20.59,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Voriconazole: 3 Blister Pack In 1 Box, Unit-Dose (63739-008-33) / 10 Tablet In 1 Blister Pack",250,RC,63739-008-33,NDC,,,facility,both,1,EA,,117.11,117.11,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Nix: 1 BOTTLE in 1 CARTON (63736-024-03) / 59 mL in 1 BOTTLE,250,RC,63736-024-03,NDC,,,facility,both,1,EA,,68.76,68.76,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Smoflipid: 10 Bag In 1 Case (63323-820-74) / 250 Ml In 1 Bag (63323-820-04),250,RC,63323-820-74,NDC,,,facility,both,1,EA,,229.1,229.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,63323-820-05,NDC,,,facility,both,1,EA,,421.72,421.72,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,63323-884-01,NDC,,,facility,both,1,EA,,52.43,52.43,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,63323-820-04,NDC,,,facility,both,1,EA,,236.49,236.49,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,63323-820-01,NDC,,,facility,both,1,EA,,206.74,206.74,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,63323-724-01,NDC,,,facility,both,1,EA,,763.41,763.41,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,63323-723-01,NDC,,,facility,both,1,EA,,453.08,453.08,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Acetylcysteine: 3 Vial In 1 Carton (63323-692-10) / 10 Ml In 1 Vial (63323-692-22),250,RC,63323-692-10,NDC,,,facility,both,1,EA,,50.66,50.66,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,63323-820-03,NDC,,,facility,both,1,EA,,273.87,273.87,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Levothyroxine Sodium: 1 Vial, Single-Dose In 1 Carton (63323-885-10) / 5 Ml In 1 Vial, Single-Dose",250,RC,63323-885-10,NDC,,,facility,both,1,EA,,101.45,101.45,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Lidoderm: 30 Pouch In 1 Carton (63481-687-06) / 1 G In 1 Pouch (63481-687-01),250,RC,63481-687-06,NDC,,,facility,both,1,EA,,176.24,176.24,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Aptiom: 60 Tablet In 1 Bottle (63402-206-60),250,RC,63402-206-60,NDC,,,facility,both,1,EA,,267.7,267.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Aptiom: 30 Tablet In 1 Bottle (63402-202-30),250,RC,63402-202-30,NDC,,,facility,both,1,EA,,279.22,279.22,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ziprasidone Hydrochloride: 4 Blister Pack In 1 Box, Unit-Dose (63739-988-32) / 10 Capsule In 1 Blister Pack",250,RC,63739-988-32,NDC,,,facility,both,1,EA,,29.69,29.69,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,65219-188-01,NDC,,,facility,both,1,EA,,55.05,55.05,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Ketamine Hydrochloride: 10 Vial In 1 Tray (65219-184-20) / 20 Ml In 1 Vial (65219-184-01),250,RC,65219-184-20,NDC,,,facility,both,1,EA,,78.28,78.28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,65219-184-01,NDC,,,facility,both,1,EA,,55.8,55.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,65219-054-09,NDC,,,facility,both,1,EA,,96.17,96.17,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,65219-052-09,NDC,,,facility,both,1,EA,,74.23,74.23,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Aripiprazole: 1 Bottle In 1 Carton (65162-893-74) / 150 Ml In 1 Bottle,250,RC,65162-893-74,NDC,,,facility,both,1,EA,,32.03,32.03,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Escitalopram Oxalate: 240 Ml In 1 Bottle (65162-705-88),250,RC,65162-705-88,NDC,,,facility,both,1,EA,,30.21,30.21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Gabapentin: 473 Ml In 1 Bottle (65162-698-90),250,RC,65162-698-90,NDC,,,facility,both,1,EA,,4.69,4.69,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Felbamate: 237 Ml In 1 Bottle (65162-686-88),250,RC,65162-686-88,NDC,,,facility,both,1,EA,,8.87,8.87,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Phenazopyridine Hydrochloride: 100 Tablet In 1 Bottle (65162-682-10),250,RC,65162-682-10,NDC,,,facility,both,1,EA,,13.46,13.46,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Phenazopyridine Hydrochloride: 100 Tablet In 1 Bottle (65162-681-10),250,RC,65162-681-10,NDC,,,facility,both,1,EA,,12.42,12.42,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Oxcarbazepine: 1 Bottle In 1 Carton (65162-649-78) / 250 Ml In 1 Bottle,250,RC,65162-649-78,NDC,,,facility,both,1,EA,,34.22,34.22,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Ketamine Hydrochloride: 10 Vial In 1 Tray (65219-188-10) / 10 Ml In 1 Vial (65219-188-01),250,RC,65219-188-10,NDC,,,facility,both,1,EA,,47.35,47.35,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Diuril: 1 Bottle In 1 Carton (65649-311-12) / 237 Ml In 1 Bottle,250,RC,65649-311-12,NDC,,,facility,both,1,EA,,14.3,14.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Xifaxan: 6 Blister Pack In 1 Carton (65649-303-03) / 10 Tablet In 1 Blister Pack,250,RC,65649-303-03,NDC,,,facility,both,1,EA,,251.95,251.95,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Xifaxan: 30 Tablet In 1 Bottle (65649-301-03),250,RC,65649-301-03,NDC,,,facility,both,1,EA,,85.94,85.94,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Lansoprazole: 1 Kit In 1 Container (65628-080-10) * 300 Ml In 1 Bottle, Plastic * .9 G In 1 Bottle, Plastic",250,RC,65628-080-10,NDC,,,facility,both,1,EA,,23.65,23.65,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Diphenhydramine Hydrochloride And Lidocaine Hydrochloride And Aluminum Hydroxide And Magnesium Hydro: 1 Kit In 1 Container (65628-050-01) * 236 Ml In 1 Bottle, Plastic * .2 G In 1 Bottle, Glass * 1.6 G In 1 Bottle, Glass",250,RC,65628-050-01,NDC,,,facility,both,1,EA,,29.9,29.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Ibuprofen: 100 Tablet In 1 Bottle (65162-465-10),250,RC,65162-465-10,NDC,,,facility,both,1,EA,,12.42,12.42,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,65219-535-01,NDC,,,facility,both,1,EA,,199.32,199.32,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,65219-533-01,NDC,,,facility,both,1,EA,,173.11,173.11,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,65219-531-01,NDC,,,facility,both,1,EA,,149.27,149.27,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sodium Bicarbonate: 1000 Tablet In 1 Bottle (64980-528-10),250,RC,64980-528-10,NDC,,,facility,both,1,EA,,11.96,11.96,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Nitazoxanide: 6 Tablet, Film Coated In 1 Bottle (64980-526-60)",250,RC,64980-526-60,NDC,,,facility,both,1,EA,,661.87,661.87,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Cyproheptadine Hydrochloride: 473 Ml In 1 Bottle (64980-504-48),250,RC,64980-504-48,NDC,,,facility,both,1,EA,,13.8,13.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Calcitriol: 100 Capsule In 1 Container (64380-724-06),250,RC,64380-724-06,NDC,,,facility,both,1,EA,,8.7,8.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Megestrol Acetate: 240 Ml In 1 Bottle, Plastic (64380-160-01)",250,RC,64380-160-01,NDC,,,facility,both,1,EA,,15.12,15.12,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Provocholine Inhalation Solution: 6 Package In 1 Package (64281-110-06) / 6 Carton In 1 Package (64281-110-05) / 1 Kit In 1 Carton * 1 Vial, Plastic In 1 Kit / 3 Ml In 1 Vial, Plastic (64281-113-00) * 1 Vial, Plastic In 1 Kit / 3 Ml In 1 Vial, Plastic (64281-115-00) * 1 Vial, Plastic In 1 Kit / 3 Ml In 1 Vial, Plastic (64281-114-00) * 1 Vial, Plastic In 1 Kit / 3 Ml In 1 Vial, Plastic (64281-116-00) * 1 Vial, Plastic In 1 Kit / 3 Ml In 1 Vial, Plastic (64281-112-00) * 1 Vial, Plastic In 1 Kit / 3 Ml In 1 Vial, Plastic (64281-111-00)",250,RC,64281-110-06,NDC,,,facility,both,1,EA,,913.8,913.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Oseltamivir Phosphate: 10 Capsule In 1 Blister Pack (64380-799-01),250,RC,64380-799-01,NDC,,,facility,both,1,EA,,24.44,24.44,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Methocarbamol: 10 Blister Pack In 1 Box, Unit-Dose (63739-991-10) / 10 Tablet, Coated In 1 Blister Pack",250,RC,63739-991-10,NDC,,,facility,both,1,EA,,11.7,11.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Ethosuximide: 100 Capsule In 1 Bottle (64380-878-06),250,RC,64380-878-06,NDC,,,facility,both,1,EA,,10.58,10.58,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Cinacalcet: 30 Tablet, Film Coated In 1 Bottle (64380-883-04)",250,RC,64380-883-04,NDC,,,facility,both,1,EA,,13.3,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Calcitriol: 1 Bottle, Glass In 1 Carton (64980-447-15) / 15 Ml In 1 Bottle, Glass",250,RC,64980-447-15,NDC,,,facility,both,1,EA,,102.72,102.72,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Lithium Carbonate: 100 Tablet, Extended Release In 1 Bottle (64980-205-01)",250,RC,64980-205-01,NDC,,,facility,both,1,EA,,12.8,12.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Isoniazid: 100 Tablet In 1 Bottle (64950-216-10),250,RC,64950-216-10,NDC,,,facility,both,1,EA,,17.17,17.17,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Isradipine: 100 Capsule In 1 Bottle (64850-911-01),250,RC,64850-911-01,NDC,,,facility,both,1,EA,,20.49,20.49,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Dextroamphetamine Saccharate, Amphetamine Aspartate, Dextroamphetamine Sulfate And Amphetamine Sulfate: 100 Tablet In 1 Bottle (64850-500-01)",250,RC,64850-500-01,NDC,,,facility,both,1,EA,,9.26,9.26,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,64764-543-30,NDC,,,facility,both,1,EA,,99.17,99.17,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Hydrocortisone: 100 Tablet In 1 Bottle, Plastic (64380-971-06)",250,RC,64380-971-06,NDC,,,facility,both,1,EA,,11.58,11.58,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Prevacid Solutab: 10 Blister Pack In 1 Carton (64764-543-11) / 10 Tablet, Orally Disintegrating, Delayed Release In 1 Blister Pack (64764-543-30)",250,RC,64764-543-11,NDC,,,facility,both,1,EA,,101.74,101.74,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Acetylcysteine: 3 Vial In 1 Carton (63323-690-30) / 30 Ml In 1 Vial (63323-690-22),250,RC,63323-690-30,NDC,,,facility,both,1,EA,,38.66,38.66,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,62584-267-11,NDC,,,facility,both,1,EA,,11.86,11.86,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Flecainide Acetate: 100 Tablet In 1 Bottle (62559-381-01),250,RC,62559-381-01,NDC,,,facility,both,1,EA,,12.38,12.38,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,62559-356-60,NDC,,,facility,both,1,EA,,27.36,27.36,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Valproic Acid: 473 Ml In 1 Bottle (62559-266-16),250,RC,62559-266-16,NDC,,,facility,both,1,EA,,13.23,13.23,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Baclofen: 1 Bottle In 1 Carton (62559-204-12) / 120 Ml In 1 Bottle,250,RC,62559-204-12,NDC,,,facility,both,1,EA,,63.78,63.78,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Metoclopramide: 473 Ml In 1 Bottle, Plastic (62559-190-16)",250,RC,62559-190-16,NDC,,,facility,both,1,EA,,13.12,13.12,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,62559-157-17,NDC,,,facility,both,1,EA,,17.17,17.17,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Pancreaze: 1 Bottle, Glass In 1 Carton (62541-403-10) / 100 Capsule, Delayed Release In 1 Bottle, Glass",250,RC,62541-403-10,NDC,,,facility,both,1,EA,,34.26,34.26,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Purixan: 1 Bottle In 1 Carton (62484-0020-2) / 100 Ml In 1 Bottle (62484-0020-1),250,RC,62484-0020-2,NDC,,,facility,both,1,EA,,78.7,78.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,62484-0020-1,NDC,,,facility,both,1,EA,,132.39,132.39,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Fluphenazine Hydrochloride: 100 Tablet, Film Coated In 1 Bottle (62332-791-31)",250,RC,62332-791-31,NDC,,,facility,both,1,EA,,14.87,14.87,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Guanfacine: 100 Tablet, Extended Release In 1 Bottle (62332-745-31)",250,RC,62332-745-31,NDC,,,facility,both,1,EA,,6.49,6.49,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Lidocaine And Prilocaine: 1 Tube In 1 Carton (62332-582-04) / 5 G In 1 Tube,250,RC,62332-582-04,NDC,,,facility,both,1,EA,,58,58,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Clonazepam: 60 Blister Pack In 1 Carton (62332-367-06) / 6 Tablet, Orally Disintegrating In 1 Blister Pack",250,RC,62332-367-06,NDC,,,facility,both,1,EA,,14.1,14.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Clonazepam: 60 Blister Pack In 1 Carton (62332-366-06) / 6 Tablet, Orally Disintegrating In 1 Blister Pack",250,RC,62332-366-06,NDC,,,facility,both,1,EA,,15.4,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Clonazepam: 60 Blister Pack In 1 Carton (62332-365-06) / 6 Tablet, Orally Disintegrating In 1 Blister Pack",250,RC,62332-365-06,NDC,,,facility,both,1,EA,,13.57,13.57,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Clonazepam: 60 Blister Pack In 1 Carton (62332-364-06) / 6 Tablet, Orally Disintegrating In 1 Blister Pack",250,RC,62332-364-06,NDC,,,facility,both,1,EA,,17.07,17.07,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Folic Acid: 100 BLISTER PACK in 1 BOX, UNIT-DOSE (62584-897-01) / 1 TABLET in 1 BLISTER PACK (62584-897-11) ",250,RC,62584-897-01,NDC,,,facility,both,1,EA,,12.05,12.05,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Divalproex Sodium: 100 Tablet, Delayed Release In 1 Bottle (62756-796-88)",250,RC,62756-796-88,NDC,,,facility,both,1,EA,,6.33,6.33,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Pentam 300: 10 Vial In 1 Tray (63323-113-10) / 3 Ml In 1 Vial (63323-113-01),250,RC,63323-113-10,NDC,,,facility,both,1,EA,,155.75,155.75,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,63323-113-01,NDC,,,facility,both,1,EA,,174.45,174.45,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Leflunomide: 30 Tablet In 1 Bottle (62332-062-30),250,RC,62332-062-30,NDC,,,facility,both,1,EA,,14.41,14.41,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA BROMOCRIPTINE MESYLATE: 30 TABLET in 1 BOTTLE (63304-962-30) ,250,RC,63304-962-30,NDC,,,facility,both,1,EA,,18.82,18.82,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Valacyclovir: 30 Tablet, Film Coated In 1 Bottle (63304-905-30)",250,RC,63304-905-30,NDC,,,facility,both,1,EA,,22.06,22.06,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,63323-093-01,NDC,,,facility,both,1,EA,,38.88,38.88,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Clonidine Hydrochloride: 100 Tablet In 1 Bottle (62332-054-31),250,RC,62332-054-31,NDC,,,facility,both,1,EA,,12.35,12.35,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Methylphenidate Hydrochloride: 100 Tablet, Extended Release In 1 Bottle (62175-310-37)",250,RC,62175-310-37,NDC,,,facility,both,1,EA,,28.63,28.63,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Tropicamide: 1 Bottle, Plastic In 1 Carton (61314-355-01) / 3 Ml In 1 Bottle, Plastic",250,RC,61314-355-01,NDC,,,facility,both,1,EA,,57.47,57.47,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Timolol Maleate: 5 Ml In 1 Bottle, Plastic (61314-227-05)",250,RC,61314-227-05,NDC,,,facility,both,1,EA,,36.2,36.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Droxia: 60 Capsule In 1 Bottle (61269-402-60),250,RC,61269-402-60,NDC,,,facility,both,1,EA,,7.33,7.33,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Neomycin And Polymyxin B Sulfates And Dexamethasone: 5 Ml In 1 Bottle, Plastic (61314-630-06)",250,RC,61314-630-06,NDC,,,facility,both,1,EA,,78.82,78.82,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Prednisolone Acetate: 1 Bottle, Dropper In 1 Carton (60758-119-05) / 5 Ml In 1 Bottle, Dropper",250,RC,60758-119-05,NDC,,,facility,both,1,EA,,257.38,257.38,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,60687-847-40,NDC,,,facility,both,1,EA,,143.69,143.69,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,60687-822-11,NDC,,,facility,both,1,EA,,3.55,3.55,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,60687-818-40,NDC,,,facility,both,1,EA,,16.89,16.89,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,60687-760-40,NDC,,,facility,both,1,EA,,13.37,13.37,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,60687-758-11,NDC,,,facility,both,1,EA,,34.48,34.48,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Diazepam: 3 Tray In 1 Case (60687-755-86) / 10 Cup, Unit-Dose In 1 Tray (60687-755-46) / 5 Ml In 1 Cup, Unit-Dose (60687-755-40)",250,RC,60687-755-86,NDC,,,facility,both,1,EA,,17.2,17.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,60687-755-40,NDC,,,facility,both,1,EA,,16.68,16.68,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Neomycin And Polymyxin B Sulfates And Dexamethasone: 3.5 G In 1 Tube (61314-631-36),250,RC,61314-631-36,NDC,,,facility,both,1,EA,,104.43,104.43,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Neomycin And Polymyxin B Sulfates And Hydrocortisone: 10 Ml In 1 Bottle, Plastic (61314-645-11)",250,RC,61314-645-11,NDC,,,facility,both,1,EA,,425.86,425.86,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ciprofloxacin: 100 Tablet, Film Coated In 1 Bottle, Plastic (62135-308-01)",250,RC,62135-308-01,NDC,,,facility,both,1,EA,,27.42,27.42,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Cetirizine Hydrochloride Oral Solution: 120 Ml In 1 Bottle (62135-057-41),250,RC,62135-057-41,NDC,,,facility,both,1,EA,,7.36,7.36,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Gentamicin Sulfate: 1 Bottle, Dropper In 1 Carton (61314-633-05) / 5 Ml In 1 Bottle, Dropper",250,RC,61314-633-05,NDC,,,facility,both,1,EA,,37.64,37.64,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Silvadene: 1 Tube In 1 Carton (61570-131-20) / 20 G In 1 Tube,250,RC,61570-131-20,NDC,,,facility,both,1,EA,,57.15,57.15,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ciprofloxacin Hydrochloride: 1 Bottle, Plastic In 1 Carton (61314-656-25) / 2.5 Ml In 1 Bottle, Plastic",250,RC,61314-656-25,NDC,,,facility,both,1,EA,,35.3,35.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Tobramycin And Dexamethasone: 1 Bottle In 1 Carton (61314-647-05) / 5 Ml In 1 Bottle,250,RC,61314-647-05,NDC,,,facility,both,1,EA,,146.93,146.93,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,63323-492-04,NDC,,,facility,both,1,EA,,29.69,29.69,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,63323-488-07,NDC,,,facility,both,1,EA,,40.86,40.86,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Xylocaine: 25 Vial, Multi-Dose In 1 Tray (63323-483-27) / 20 Ml In 1 Vial, Multi-Dose (63323-483-03)",250,RC,63323-483-27,NDC,,,facility,both,1,EA,,33.19,33.19,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,63323-483-03,NDC,,,facility,both,1,EA,,34.57,34.57,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,63323-482-03,NDC,,,facility,both,1,EA,,40.61,40.61,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,63323-481-01,NDC,,,facility,both,1,EA,,30.84,30.84,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,63323-417-01,NDC,,,facility,both,1,EA,,37.4,37.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,63323-492-07,NDC,,,facility,both,1,EA,,42.5,42.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Xylocaine Mpf: 25 Vial, Single-Dose In 1 Carton (63323-492-27) / 2 Ml In 1 Vial, Single-Dose (63323-492-04)",250,RC,63323-492-27,NDC,,,facility,both,1,EA,,30.12,30.12,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,63323-494-01,NDC,,,facility,both,1,EA,,45.53,45.53,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Indomethacin: 1 Vial In 1 Carton (63323-659-03) / 1 Ml In 1 Vial,250,RC,63323-659-03,NDC,,,facility,both,1,EA,,152.81,152.81,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,63323-626-02,NDC,,,facility,both,1,EA,,74.14,74.14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Xylocaine Mpf: 25 Vial, Single-Dose In 1 Carton (63323-495-07) / 5 Ml In 1 Vial, Single-Dose (63323-495-04)",250,RC,63323-495-07,NDC,,,facility,both,1,EA,,30.99,30.99,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Omegaven: 10 Vial, Single-Dose In 1 Carton (63323-205-50) / 50 Ml In 1 Vial, Single-Dose (63323-205-21)",250,RC,63323-205-50,NDC,,,facility,both,1,EA,,450.75,450.75,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,63323-205-31,NDC,,,facility,both,1,EA,,611.85,611.85,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,63323-205-21,NDC,,,facility,both,1,EA,,456.65,456.65,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Lidocaine: 25 Vial In 1 Tray (63323-201-10) / 10 Ml In 1 Vial (63323-201-03),250,RC,63323-201-10,NDC,,,facility,both,1,EA,,34.07,34.07,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Sodium Chloride: 25 Vial, Single-Dose In 1 Tray (63323-186-20) / 20 Ml In 1 Vial, Single-Dose (63323-186-03)",250,RC,63323-186-20,NDC,,,facility,both,1,EA,,9.44,9.44,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Sodium Chloride: 25 Vial, Single-Dose In 1 Tray (63323-186-10) / 10 Ml In 1 Vial, Single-Dose (63323-186-01)",250,RC,63323-186-10,NDC,,,facility,both,1,EA,,31.4,31.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,63323-186-03,NDC,,,facility,both,1,EA,,29.55,29.55,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,63323-186-01,NDC,,,facility,both,1,EA,,28.69,28.69,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sterile Water: 25 Vial In 1 Tray (63323-185-10) / 10 Ml In 1 Vial (63323-185-07),250,RC,63323-185-10,NDC,,,facility,both,1,EA,,40.89,40.89,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,63323-185-07,NDC,,,facility,both,1,EA,,31.64,31.64,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Sterile Water: 25 Vial, Single-Dose In 1 Tray (63323-185-05) / 5 Ml In 1 Vial, Single-Dose (63323-185-04)",250,RC,63323-185-05,NDC,,,facility,both,1,EA,,40.02,40.02,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Pyridoxine Hydrochloride: 25 Vial In 1 Tray (63323-180-01) / 1 Ml In 1 Vial (63323-180-00),250,RC,63323-180-01,NDC,,,facility,both,1,EA,,29.9,29.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,63323-185-09,NDC,,,facility,both,1,EA,,36.54,36.54,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Vancomycin Hydrochloride: 1 Bottle In 1 Carton (63323-314-61) / 100 Ml In 1 Bottle,250,RC,63323-314-61,NDC,,,facility,both,1,EA,,17.1,17.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Naropin: 25 Vial, Single-Dose In 1 Carton (63323-288-11) / 10 Ml In 1 Vial, Single-Dose (63323-288-03)",250,RC,63323-288-11,NDC,,,facility,both,1,EA,,4.85,4.85,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,9999-6183-45,NDC,,,facility,both,1,EA,,1,1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Creon: 100 Capsule, Delayed Release Pellets In 1 Bottle (0032-2636-01)",250,RC,0032-2636-01,NDC,,,facility,both,1,EA,,62.48,62.48,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Creon: 100 Capsule, Delayed Release Pellets In 1 Bottle (0032-1224-01)",250,RC,0032-1224-01,NDC,,,facility,both,1,EA,,60.45,60.45,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Creon: 100 Capsule, Delayed Release Pellets In 1 Bottle (0032-1212-01)",250,RC,0032-1212-01,NDC,,,facility,both,1,EA,,31.95,31.95,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Creon: 1 Bottle In 1 Carton (0032-1206-01) / 100 Capsule, Delayed Release Pellets In 1 Bottle",250,RC,0032-1206-01,NDC,,,facility,both,1,EA,,21.71,21.71,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Creon: 1 Bottle In 1 Carton (0032-1203-70) / 70 Capsule, Delayed Release In 1 Bottle",250,RC,0032-1203-70,NDC,,,facility,both,1,EA,,17.85,17.85,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Creon: 100 Capsule, Delayed Release Pellets In 1 Bottle (0032-0047-70)",250,RC,0032-0047-70,NDC,,,facility,both,1,EA,,32.45,32.45,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Creon: 100 Capsule, Delayed Release Pellets In 1 Bottle (0032-0046-70)",250,RC,0032-0046-70,NDC,,,facility,both,1,EA,,20.48,20.48,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Creon: 70 Capsule, Delayed Release In 1 Bottle (0032-0045-70)",250,RC,0032-0045-70,NDC,,,facility,both,1,EA,,22.54,22.54,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0023-9637-01,NDC,,,facility,both,1,EA,,30.39,30.39,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Creon: 100 Capsule, Delayed Release Pellets In 1 Bottle (0032-3016-13)",250,RC,0032-3016-13,NDC,,,facility,both,1,EA,,94.43,94.43,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Fluticasone Propionate: 1 Bottle, Glass In 1 Carton (0054-3270-99) / 120 Spray, Metered In 1 Bottle, Glass",250,RC,0054-3270-99,NDC,,,facility,both,1,EA,,59.41,59.41,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Diazepam: 500 Ml In 1 Bottle, Plastic (0054-3188-63)",250,RC,0054-3188-63,NDC,,,facility,both,1,EA,,12.68,12.68,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Calcitriol: 1 Bottle, Glass In 1 Carton (0054-3120-41) / 15 Ml In 1 Bottle, Glass",250,RC,0054-3120-41,NDC,,,facility,both,1,EA,,38.36,38.36,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Methadone Hydrochloride: 100 Tablet In 1 Bottle, Plastic (0054-0709-25)",250,RC,0054-0709-25,NDC,,,facility,both,1,EA,,12.49,12.49,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Methadone Hydrochloride: 1 Blister Pack In 1 Carton (0054-0709-20) / 100 Tablet In 1 Blister Pack,250,RC,0054-0709-20,NDC,,,facility,both,1,EA,,11.38,11.38,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dicyclomine Hydrochloride: 473 Ml In 1 Bottle (0054-0622-63),250,RC,0054-0622-63,NDC,,,facility,both,1,EA,,3.31,3.31,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Posaconazole: 1 Bottle, Glass In 1 Carton (0054-0449-49) / 105 Ml In 1 Bottle, Glass",250,RC,0054-0449-49,NDC,,,facility,both,1,EA,,169.65,169.65,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Linezolid: 150 Ml In 1 Bottle (0054-0319-50),250,RC,0054-0319-50,NDC,,,facility,both,1,EA,,81.08,81.08,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Morphine Sulfate: 500 Ml In 1 Bottle (0054-0237-63),250,RC,0054-0237-63,NDC,,,facility,both,1,EA,,12.07,12.07,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Morphine Sulfate: 100 Blister Pack In 1 Carton (0054-0235-24) / 1 Tablet In 1 Blister Pack,250,RC,0054-0235-24,NDC,,,facility,both,1,EA,,14.12,14.12,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Nexplanon: 1 BLISTER PACK in 1 CARTON (0052-4330-01) / 1 IMPLANT in 1 BLISTER PACK,250,RC,0052-4330-01,NDC,,,facility,both,1,EA,,6203.36,6203.36,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Diflucan: 1 Bottle In 1 Carton (0049-3450-19) / 35 Ml In 1 Bottle,250,RC,0049-3450-19,NDC,,,facility,both,1,EA,,17.02,17.02,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Vfend: 1 Bottle In 1 Carton (0049-3160-44) / 75 Ml In 1 Bottle,250,RC,0049-3160-44,NDC,,,facility,both,1,EA,,277.57,277.57,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Hydromorphone Hydrochloride: 473 Ml In 1 Bottle (0054-0386-63),250,RC,0054-0386-63,NDC,,,facility,both,1,EA,,14.22,14.22,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Refresh Classic: 30 Vial, Single-Use In 1 Carton (0023-0506-01) / .4 Ml In 1 Vial, Single-Use",250,RC,0023-0506-01,NDC,,,facility,both,1,EA,,14.27,14.27,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Refresh Lacri-Lube: 1 Tube In 1 Carton (0023-0312-04) / 3.5 G In 1 Tube,250,RC,0023-0312-04,NDC,,,facility,both,1,EA,,72.91,72.91,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0006-5423-02,NDC,,,facility,both,1,EA,,465.06,465.06,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0006-5085-99,NDC,,,facility,both,1,EA,,488.98,488.98,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Isentress: 60 Packet In 1 Carton (0006-3603-61) / 1 Granule, For Suspension In 1 Packet (0006-3603-01)",250,RC,0006-3603-61,NDC,,,facility,both,1,EA,,15.1,15.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0006-3603-01,NDC,,,facility,both,1,EA,,13.91,13.91,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0006-3076-03,NDC,,,facility,both,1,EA,,1762.14,1762.14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Prevymis: 30 Packet In 1 Carton (0006-5085-01) / 48 Pellet In 1 Packet,250,RC,0006-5085-01,NDC,,,facility,both,1,EA,,488.24,488.24,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA 1 TUBE in 1 CARTON (0023-0240-04) / 3.5 g in 1 TUBE,250,RC,0023-0240-04,NDC,,,facility,both,1,EA,,63.26,63.26,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Cyklokapron: 10 Vial In 1 Box (0013-1114-21) / 10 Ml In 1 Vial (0013-1114-20),250,RC,0013-1114-21,NDC,,,facility,both,1,EA,,55.94,55.94,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0013-1114-20,NDC,,,facility,both,1,EA,,58.54,58.54,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0013-1114-01,NDC,,,facility,both,1,EA,,61.23,61.23,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Azulfidine: 1 Bottle In 1 Carton (0013-0101-10) / 100 Tablet In 1 Bottle,250,RC,0013-0101-10,NDC,,,facility,both,1,EA,,17.91,17.91,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Zyvox: 150 Ml In 1 Bottle (0009-5136-04),250,RC,0009-5136-04,NDC,,,facility,both,1,EA,,161.16,161.16,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Prostin Vr Pediatric: 5 Ampule In 1 Package (0009-3169-06) / 1 Ml In 1 Ampule (0009-3169-01),250,RC,0009-3169-06,NDC,,,facility,both,1,EA,,790.91,790.91,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0009-3169-01,NDC,,,facility,both,1,EA,,574.15,574.15,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0009-3169-01,NDC,,,facility,both,1,EA,,400.94,400.94,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA R-Gene: 1 Container In 1 Carton (0009-0436-01) / 300 Ml In 1 Container,250,RC,0009-0436-01,NDC,,,facility,both,1,EA,,70.56,70.56,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Furosemide: 60 Ml In 1 Bottle (0054-3294-46),250,RC,0054-3294-46,NDC,,,facility,both,1,EA,,12.55,12.55,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Furosemide: 120 Ml In 1 Bottle (0054-3294-50),250,RC,0054-3294-50,NDC,,,facility,both,1,EA,,9.65,9.65,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Venclexta: 1 Blister Pack In 1 Carton (0074-0576-11) / 1 Tablet, Film Coated In 1 Blister Pack",250,RC,0074-0576-11,NDC,,,facility,both,1,EA,,871.32,871.32,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Nitrostat: 4 Bottle In 1 Carton (0071-0418-13) / 25 Tablet In 1 Bottle,250,RC,0071-0418-13,NDC,,,facility,both,1,EA,,259.65,259.65,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Dilantin Infatabs: 100 Blister Pack In 1 Box, Unit-Dose (0071-0007-40) / 1 Tablet, Chewable In 1 Blister Pack",250,RC,0071-0007-40,NDC,,,facility,both,1,EA,,17.18,17.18,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Rinvoq: 28 Tablet, Extended Release In 1 Bottle (0074-1043-28)",250,RC,0074-1043-28,NDC,,,facility,both,1,EA,,2855.75,2855.75,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Rinvoq: 30 Tablet, Extended Release In 1 Bottle (0074-2306-30)",250,RC,0074-2306-30,NDC,,,facility,both,1,EA,,1413.03,1413.03,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Buspirone Hydrochloride: 100 Tablet In 1 Bottle (0093-0053-01),250,RC,0093-0053-01,NDC,,,facility,both,1,EA,,7.58,7.58,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Lantus: 1 Vial, Glass In 1 Carton (0088-2220-33) / 10 Ml In 1 Vial, Glass",250,RC,0088-2220-33,NDC,,,facility,both,1,EA,,17.18,17.18,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Arava: 1 Bottle In 1 Carton (0088-2160-30) / 30 Tablet, Film Coated In 1 Bottle",250,RC,0088-2160-30,NDC,,,facility,both,1,EA,,241.34,241.34,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Noxafil: 8 Packet In 1 Carton (0085-2224-02) / 1 Powder, For Suspension In 1 Packet (0085-2224-01)",250,RC,0085-2224-02,NDC,,,facility,both,1,EA,,696.18,696.18,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0085-2224-01,NDC,,,facility,both,1,EA,,670.38,670.38,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Mekinist: 30 Tablet, Film Coated In 1 Bottle (0078-1105-15)",250,RC,0078-1105-15,NDC,,,facility,both,1,EA,,1132.24,1132.24,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0078-0972-19,NDC,,,facility,both,1,EA,,1705.88,1705.88,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Tobradex: 3.5 G In 1 Tube (0078-0876-01),250,RC,0078-0876-01,NDC,,,facility,both,1,EA,,1754.1,1754.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Entresto: 60 Tablet, Film Coated In 1 Bottle (0078-0777-20)",250,RC,0078-0777-20,NDC,,,facility,both,1,EA,,66.21,66.21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Promacta: 14 Tablet, Film Coated In 1 Bottle (0078-0686-55)",250,RC,0078-0686-55,NDC,,,facility,both,1,EA,,3140.54,3140.54,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Promacta: 30 Tablet, Film Coated In 1 Bottle (0078-0686-15)",250,RC,0078-0686-15,NDC,,,facility,both,1,EA,,3133.79,3133.79,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Mekinist: 30 TABLET, FILM COATED in 1 BOTTLE (0078-0666-15) ",250,RC,0078-0666-15,NDC,,,facility,both,1,EA,,678.78,678.78,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Entresto: 60 Tablet, Film Coated In 1 Bottle (0078-0659-20)",250,RC,0078-0659-20,NDC,,,facility,both,1,EA,,78.07,78.07,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Coartem: 24 Tablet In 1 Bottle (0078-0568-45),250,RC,0078-0568-45,NDC,,,facility,both,1,EA,,50.56,50.56,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Nimbex: 5 mL in 1 VIAL, SINGLE-DOSE (0074-4378-05) ",250,RC,0074-4378-05,NDC,,,facility,both,1,EA,,90.2,90.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Diovan: 30 Tablet In 1 Bottle (0078-0423-15),250,RC,0078-0423-15,NDC,,,facility,both,1,EA,,63.22,63.22,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Focalin Xr: 100 Capsule, Extended Release In 1 Bottle (0078-0430-05)",250,RC,0078-0430-05,NDC,,,facility,both,1,EA,,37.84,37.84,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Prevymis: 14 Blister Pack In 1 Carton (0006-3075-04) / 1 Tablet, Film Coated In 1 Blister Pack (0006-3075-03)",250,RC,0006-3075-04,NDC,,,facility,both,1,EA,,1767.57,1767.57,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Systane: 1 Tube In 1 Carton (0065-0474-01) / 10 G In 1 Tube,250,RC,0065-0474-01,NDC,,,facility,both,1,EA,,6.16,6.16,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Cyclogyl: 1 Bottle, Plastic In 1 Carton (0065-0397-02) / 2 Ml In 1 Bottle, Plastic",250,RC,0065-0397-02,NDC,,,facility,both,1,EA,,245.6,245.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Cyclogyl: 1 Bottle, Plastic In 1 Carton (0065-0396-02) / 2 Ml In 1 Bottle, Plastic",250,RC,0065-0396-02,NDC,,,facility,both,1,EA,,195.01,195.01,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Cyclomydril: 2 Ml In 1 Bottle, Plastic (0065-0359-02)",250,RC,0065-0359-02,NDC,,,facility,both,1,EA,,216.24,216.24,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "1 BOTTLE, DROPPER in 1 CARTON (0065-0303-55) / 5 mL in 1 BOTTLE, DROPPER",250,RC,0065-0303-55,NDC,,,facility,both,1,EA,,322.38,322.38,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Lithium Carbonate: 10 Capsule, Gelatin Coated In 1 Blister Pack (0054-8527-25)",250,RC,0054-8527-25,NDC,,,facility,both,1,EA,,11.63,11.63,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Lithium Carbonate: 10 Capsule, Gelatin Coated In 1 Blister Pack (0054-8526-25)",250,RC,0054-8526-25,NDC,,,facility,both,1,EA,,12.34,12.34,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Leucovorin Calcium: 5 Blister Pack In 1 Carton (0054-8496-19) / 10 Tablet In 1 Blister Pack,250,RC,0054-8496-19,NDC,,,facility,both,1,EA,,12.37,12.37,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Furosemide: 10 Blister Pack In 1 Carton (0054-8297-25) / 10 Tablet In 1 Blister Pack,250,RC,0054-8297-25,NDC,,,facility,both,1,EA,,10.44,10.44,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Genteal Tears Night-Time: 1 Tube In 1 Carton (0065-0518-01) / 3.5 G In 1 Tube,250,RC,0065-0518-01,NDC,,,facility,both,1,EA,,55,55,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Mercaptopurine: 25 Tablet In 1 Bottle, Plastic (0054-4581-11)",250,RC,0054-4581-11,NDC,,,facility,both,1,EA,,22.58,22.58,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Propranolol Hydrochloride: 500 Ml In 1 Bottle, Plastic (0054-3727-63)",250,RC,0054-3727-63,NDC,,,facility,both,1,EA,,12.52,12.52,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Methadone Hydrochloride: 500 Ml In 1 Bottle (0054-3556-63),250,RC,0054-3556-63,NDC,,,facility,both,1,EA,,11.99,11.99,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Methadone Hydrochloride: 500 Ml In 1 Bottle (0054-3555-63),250,RC,0054-3555-63,NDC,,,facility,both,1,EA,,12.27,12.27,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Lorazepam: 1 Bottle In 1 Carton (0054-3532-44) / 30 Ml In 1 Bottle,250,RC,0054-3532-44,NDC,,,facility,both,1,EA,,13.27,13.27,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Lidocaine Viscous: 1 Bottle In 1 Carton (0054-3500-49) / 100 Ml In 1 Bottle,250,RC,0054-3500-49,NDC,,,facility,both,1,EA,,12.27,12.27,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA TobraDex: 1 TUBE in 1 CARTON (0065-0648-35) / 3.5 g in 1 TUBE,250,RC,0065-0648-35,NDC,,,facility,both,1,EA,,1372.71,1372.71,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Tetracaine Hydrochloride: 12 Blister Pack In 1 Carton (0065-0741-14) / 1 Bottle, Dropper In 1 Blister Pack / 4 Ml In 1 Bottle, Dropper",250,RC,0065-0741-14,NDC,,,facility,both,1,EA,,86.46,86.46,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Bss: 15 Ml In 1 Bottle (0065-0795-15),250,RC,0065-0795-15,NDC,,,facility,both,1,EA,,49.66,49.66,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Xeljanz: 60 Tablet, Film Coated In 1 Bottle (0069-1002-01)",250,RC,0069-1002-01,NDC,,,facility,both,1,EA,,636.62,636.62,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Xeljanz: 60 Tablet, Film Coated In 1 Bottle (0069-1001-01)",250,RC,0069-1001-01,NDC,,,facility,both,1,EA,,668.65,668.65,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Bss Plus: 1 Kit In 1 Package (0065-0800-50) * 480 Ml In 1 Bottle, Glass * 20 Ml In 1 Vial, Single-Dose",250,RC,0065-0800-50,NDC,,,facility,both,1,EA,,397.43,397.43,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Genteal Tears Severe: 1 Tube In 1 Carton (0065-8064-01) / 10 G In 1 Tube,250,RC,0065-8064-01,NDC,,,facility,both,1,EA,,5.99,5.99,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0006-3075-03,NDC,,,facility,both,1,EA,,1758.17,1758.17,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0006-3075-01,NDC,,,facility,both,1,EA,,1627.05,1627.05,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,4056511182,NDC,,,facility,both,1,EA,,158.42,158.42,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,4009311213,NDC,,,facility,both,1,EA,,12.1,12.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,3932855750,NDC,,,facility,both,1,EA,,13.18,13.18,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,3932806412,NDC,,,facility,both,1,EA,,92.84,92.84,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,3877917791,NDC,,,facility,both,1,EA,,5.88,5.88,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,3877915564,NDC,,,facility,both,1,EA,,18.84,18.84,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,3877905108,NDC,,,facility,both,1,EA,,5.82,5.82,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,3877905025,NDC,,,facility,both,1,EA,,6.47,6.47,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,3660207917,NDC,,,facility,both,1,EA,,1.04,1.04,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,4110081123,NDC,,,facility,both,1,EA,,35.64,35.64,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,3172293847,NDC,,,facility,both,1,EA,,5.9,5.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,3172213747,NDC,,,facility,both,1,EA,,8.45,8.45,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,3010304000,NDC,,,facility,both,1,EA,,19.27,19.27,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,2055503901,NDC,,,facility,both,1,EA,,9.39,9.39,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,1878777232,NDC,,,facility,both,1,EA,,12.59,12.59,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,1785600102,NDC,,,facility,both,1,EA,,19.55,19.55,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,1513702127,NDC,,,facility,both,1,EA,,51.59,51.59,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,1093995732,NDC,,,facility,both,1,EA,,11.03,11.03,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,1093988744,NDC,,,facility,both,1,EA,,12.39,12.39,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,4110081124,NDC,,,facility,both,1,EA,,17.77,17.77,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,4329255538,NDC,,,facility,both,1,EA,,7.08,7.08,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,6248400202,NDC,,,facility,both,1,EA,,70.35,70.35,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,6025816001,NDC,,,facility,both,1,EA,,11.94,11.94,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,6025800615,NDC,,,facility,both,1,EA,,12.43,12.43,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,6025800601,NDC,,,facility,both,1,EA,,13.86,13.86,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,5789687503,NDC,,,facility,both,1,EA,,8.78,8.78,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,5789684401,NDC,,,facility,both,1,EA,,12.86,12.86,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,5789675101,NDC,,,facility,both,1,EA,,5.99,5.99,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,5789660501,NDC,,,facility,both,1,EA,,12.39,12.39,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,5777100702,NDC,,,facility,both,1,EA,,21.57,21.57,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,4746907402,NDC,,,facility,both,1,EA,,15.41,15.41,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,4858200155,NDC,,,facility,both,1,EA,,37.74,37.74,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,4945215801,NDC,,,facility,both,1,EA,,6.06,6.06,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,5019014263,NDC,,,facility,both,1,EA,,15.68,15.68,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,5026885111,NDC,,,facility,both,1,EA,,7.81,7.81,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,1093976744,NDC,,,facility,both,1,EA,,16.17,16.17,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,5026885115,NDC,,,facility,both,1,EA,,12.68,12.68,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,5164590901,NDC,,,facility,both,1,EA,,9.73,9.73,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,5192726100,NDC,,,facility,both,1,EA,,6.6,6.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,5483801150,NDC,,,facility,both,1,EA,,11.88,11.88,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,5485951608,NDC,,,facility,both,1,EA,,12.51,12.51,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,5155205946,NDC,,,facility,both,1,EA,,5.76,5.76,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,6332325410,NDC,,,facility,both,1,EA,,156.64,156.64,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,1093941433,NDC,,,facility,both,1,EA,,16.61,16.61,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,1093920444,NDC,,,facility,both,1,EA,,49.33,49.33,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,574030216,NDC,,,facility,both,1,EA,,6.11,6.11,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,574007030,NDC,,,facility,both,1,EA,,26.46,26.46,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,574007015,NDC,,,facility,both,1,EA,,27.48,27.48,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,574006915,NDC,,,facility,both,1,EA,,28.05,28.05,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,536344308,NDC,,,facility,both,1,EA,,11.99,11.99,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,536135807,NDC,,,facility,both,1,EA,,3.19,3.19,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,487900760,NDC,,,facility,both,1,EA,,13.73,13.73,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,487900330,NDC,,,facility,both,1,EA,,16.27,16.27,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,395268594,NDC,,,facility,both,1,EA,,5.82,5.82,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,395266216,NDC,,,facility,both,1,EA,,5.58,5.58,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,574030316,NDC,,,facility,both,1,EA,,11.95,11.95,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,395266116,NDC,,,facility,both,1,EA,,5.81,5.81,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,225052848,NDC,,,facility,both,1,EA,,37.46,37.46,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,132030140,NDC,,,facility,both,1,EA,,17.85,17.85,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,121067616,NDC,,,facility,both,1,EA,,14.57,14.57,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,121059516,NDC,,,facility,both,1,EA,,13.25,13.25,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,87086644,NDC,,,facility,both,1,EA,,23.69,23.69,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,87040501,NDC,,,facility,both,1,EA,,12.13,12.13,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,87040203,NDC,,,facility,both,1,EA,,12.89,12.89,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,574030416,NDC,,,facility,both,1,EA,,11.99,11.99,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,1043202931,NDC,,,facility,both,1,EA,,6.81,6.81,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,1013578801,NDC,,,facility,both,1,EA,,10.87,10.87,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,1013574901,NDC,,,facility,both,1,EA,,6.44,6.44,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,1000673051,NDC,,,facility,both,1,EA,,5.88,5.88,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,1000673019,NDC,,,facility,both,1,EA,,11.64,11.64,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,1000670038,NDC,,,facility,both,1,EA,,8.5,8.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,1000670028,NDC,,,facility,both,1,EA,,6.88,6.88,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,904759161,NDC,,,facility,both,1,EA,,10.2,10.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,904723961,NDC,,,facility,both,1,EA,,10.04,10.04,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,904598463,NDC,,,facility,both,1,EA,,35.13,35.13,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,904582360,NDC,,,facility,both,1,EA,,8.79,8.79,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,574031116,NDC,,,facility,both,1,EA,,12.26,12.26,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,574031216,NDC,,,facility,both,1,EA,,11.81,11.81,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,592800308,NDC,,,facility,both,1,EA,,10.98,10.98,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,904052361,NDC,,,facility,both,1,EA,,10.87,10.87,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,1093941233,NDC,,,facility,both,1,EA,,17.99,17.99,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,904053061,NDC,,,facility,both,1,EA,,12.09,12.09,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,904188361,NDC,,,facility,both,1,EA,,12.11,12.11,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,904208560,NDC,,,facility,both,1,EA,,5.37,5.37,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,904506260,NDC,,,facility,both,1,EA,,5.95,5.95,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,904522452,NDC,,,facility,both,1,EA,,6.51,6.51,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Diltiazem Hydrochloride: 100 Tablet, Film Coated In 1 Bottle (0093-0319-01)",250,RC,0093-0319-01,NDC,,,facility,both,1,EA,,12.09,12.09,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,6373612002,NDC,,,facility,both,1,EA,,54.36,54.36,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0002-4453-01,NDC,,,facility,both,1,EA,,117.04,117.04,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Trulicity: 4 Syringe In 1 Carton (0002-1434-80) / .5 Ml In 1 Syringe (0002-1434-01),250,RC,0002-1434-80,NDC,,,facility,both,1,EA,,1678.59,1678.59,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,97344038787,NDC,,,facility,both,1,EA,,12.24,12.24,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,8770142917,NDC,,,facility,both,1,EA,,12.75,12.75,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,8770140073,NDC,,,facility,both,1,EA,,23.21,23.21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,8770140072,NDC,,,facility,both,1,EA,,5.57,5.57,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,8770140065,NDC,,,facility,both,1,EA,,6.95,6.95,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,8349030760,NDC,,,facility,both,1,EA,,17.36,17.36,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,8290306553,NDC,,,facility,both,1,EA,,46.75,46.75,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,8290306546,NDC,,,facility,both,1,EA,,29.1,29.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,8137003640,NDC,,,facility,both,1,EA,,16.19,16.19,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,8137003601,NDC,,,facility,both,1,EA,,45.69,45.69,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,8068117400,NDC,,,facility,both,1,EA,,4.54,4.54,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,8068116900,NDC,,,facility,both,1,EA,,5.62,5.62,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,8068115500,NDC,,,facility,both,1,EA,,19.36,19.36,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,8068114000,NDC,,,facility,both,1,EA,,5.35,5.35,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,8068113100,NDC,,,facility,both,1,EA,,6.92,6.92,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,8290306499,NDC,,,facility,both,1,EA,,65.73,65.73,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sprycel: 1 Bottle In 1 Carton (0003-0527-11) / 60 Tablet In 1 Bottle,250,RC,0003-0527-11,NDC,,,facility,both,1,EA,,1047.3,1047.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sprycel: 1 Bottle In 1 Carton (0003-0528-11) / 60 Tablet In 1 Bottle,250,RC,0003-0528-11,NDC,,,facility,both,1,EA,,2102.84,2102.84,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Eliquis: 10 Blister Pack In 1 Carton (0003-0893-31) / 10 Tablet, Film Coated In 1 Blister Pack",250,RC,0003-0893-31,NDC,,,facility,both,1,EA,,15.28,15.28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Tamiflu: 1 Blister Pack In 1 Carton (0004-0800-85) / 10 Capsule In 1 Blister Pack,250,RC,0004-0800-85,NDC,,,facility,both,1,EA,,112.47,112.47,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Valcyte: 1 Bottle, Glass In 1 Carton (0004-0039-09) / 100 Ml In 1 Bottle, Glass",250,RC,0004-0039-09,NDC,,,facility,both,1,EA,,61.44,61.44,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,8068111600,NDC,,,facility,both,1,EA,,11.73,11.73,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,7214045231,NDC,,,facility,both,1,EA,,36.84,36.84,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,7214011047,NDC,,,facility,both,1,EA,,12.02,12.02,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,7214003147,NDC,,,facility,both,1,EA,,100.86,100.86,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,7139974805,NDC,,,facility,both,1,EA,,12.22,12.22,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,7139974015,NDC,,,facility,both,1,EA,,14.13,14.13,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,7132180230,NDC,,,facility,both,1,EA,,49.73,49.73,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,6961801854,NDC,,,facility,both,1,EA,,12.47,12.47,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,7214063386,NDC,,,facility,both,1,EA,,108.24,108.24,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,6936722001,NDC,,,facility,both,1,EA,,11.55,11.55,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,6817600015,NDC,,,facility,both,1,EA,,15.44,15.44,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,6817600011,NDC,,,facility,both,1,EA,,15.76,15.76,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,6817600010,NDC,,,facility,both,1,EA,,13.62,13.62,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,6809422401,NDC,,,facility,both,1,EA,,14.5,14.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,6498010401,NDC,,,facility,both,1,EA,,8.79,8.79,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,6936725001,NDC,,,facility,both,1,EA,,7.8,7.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,7430000070,NDC,,,facility,both,1,EA,,27.11,27.11,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,8068104900,NDC,,,facility,both,1,EA,,12.25,12.25,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,8068104100,NDC,,,facility,both,1,EA,,5.32,5.32,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,8068101000,NDC,,,facility,both,1,EA,,13.91,13.91,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,8065183085,NDC,,,facility,both,1,EA,,1516.03,1516.03,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,7985401163,NDC,,,facility,both,1,EA,,12.32,12.32,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,7811273623,NDC,,,facility,both,1,EA,,32.52,32.52,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,7733398325,NDC,,,facility,both,1,EA,,12.18,12.18,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,7733398310,NDC,,,facility,both,1,EA,,12.57,12.57,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,7733394025,NDC,,,facility,both,1,EA,,8.74,8.74,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,7733393725,NDC,,,facility,both,1,EA,,5.45,5.45,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,7733393710,NDC,,,facility,both,1,EA,,4.88,4.88,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,7431200640,NDC,,,facility,both,1,EA,,12.8,12.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,7431202832,NDC,,,facility,both,1,EA,,5.56,5.56,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,7431207961,NDC,,,facility,both,1,EA,,2.08,2.08,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,8068109700,NDC,,,facility,both,1,EA,,3.85,3.85,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,7583401060,NDC,,,facility,both,1,EA,,13.73,13.73,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,7620402260,NDC,,,facility,both,1,EA,,14.58,14.58,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,7733352025,NDC,,,facility,both,1,EA,,11.4,11.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,7733386125,NDC,,,facility,both,1,EA,,12.9,12.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,7733393425,NDC,,,facility,both,1,EA,,13.01,13.01,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,7583402001,NDC,,,facility,both,1,EA,,5.61,5.61,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Nortriptyline Hydrochloride: 100 Capsule In 1 Bottle (0093-0811-01),250,RC,0093-0811-01,NDC,,,facility,both,1,EA,,12.77,12.77,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Mupirocin: 1 Tube In 1 Carton (0093-1010-42) / 22 G In 1 Tube,250,RC,0093-1010-42,NDC,,,facility,both,1,EA,,43.3,43.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Warfarin Sodium: 100 Tablet In 1 Bottle (0093-1712-01),250,RC,0093-1712-01,NDC,,,facility,both,1,EA,,5.83,5.83,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sterile Water: 2000 Ml In 1 Bag (0338-0013-06),250,RC,0338-0013-06,NDC,,,facility,both,1,EA,,65.27,65.27,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sterile Water: 1000 Ml In 1 Bag (0338-0013-04),250,RC,0338-0013-04,NDC,,,facility,both,1,EA,,64.81,64.81,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Sterile Water: 12 Bottle, Plastic In 1 Carton (0338-0004-04) / 1000 Ml In 1 Bottle, Plastic",250,RC,0338-0004-04,NDC,,,facility,both,1,EA,,62.17,62.17,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Sterile Water: 18 Bottle, Plastic In 1 Carton (0338-0004-03) / 500 Ml In 1 Bottle, Plastic",250,RC,0338-0004-03,NDC,,,facility,both,1,EA,,61.25,61.25,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Sterile Water: 24 Bottle, Plastic In 1 Carton (0338-0004-02) / 250 Ml In 1 Bottle, Plastic",250,RC,0338-0004-02,NDC,,,facility,both,1,EA,,62.42,62.42,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sterile Water: 4 Bag In 1 Carton (0338-0003-47) / 3000 Ml In 1 Bag,250,RC,0338-0003-47,NDC,,,facility,both,1,EA,,167.25,167.25,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Seroquel Xr: 60 Tablet, Extended Release In 1 Bottle (0310-0280-60)",250,RC,0310-0280-60,NDC,,,facility,both,1,EA,,62.27,62.27,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Hurricaine Topical Anesthetic: 59.7 G In 1 Can (0283-0679-02),250,RC,0283-0679-02,NDC,,,facility,both,1,EA,,209.86,209.86,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Nitro-Bid: 30 G In 1 Tube (0281-0326-30),250,RC,0281-0326-30,NDC,,,facility,both,1,EA,,216.96,216.96,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sodium Chloride: 500 Ml In 1 Bag (0338-0043-03),250,RC,0338-0043-03,NDC,,,facility,both,1,EA,,73.16,73.16,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Lactated Ringers: 12 Bottle, Plastic In 1 Carton (0338-0114-04) / 1000 Ml In 1 Bottle, Plastic",250,RC,0338-0114-04,NDC,,,facility,both,1,EA,,17.04,17.04,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sodium Chloride: 1 Bag In 1 Package (0338-0049-48) / 100 Ml In 1 Bag,250,RC,0338-0049-48,NDC,,,facility,both,1,EA,,30.01,30.01,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sodium Chloride: 1 Bag In 1 Package (0338-0049-41) / 50 Ml In 1 Bag,250,RC,0338-0049-41,NDC,,,facility,both,1,EA,,19.45,19.45,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sodium Chloride: 1000 Ml In 1 Bag (0338-0043-04),250,RC,0338-0043-04,NDC,,,facility,both,1,EA,,81.9,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sodium Chloride: 14 Bag In 1 Carton (0338-0047-44) / 1000 Ml In 1 Bag,250,RC,0338-0047-44,NDC,,,facility,both,1,EA,,93.97,93.97,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sodium Chloride: 6 Bag In 1 Carton (0338-0047-46) / 2000 Ml In 1 Bag,250,RC,0338-0047-46,NDC,,,facility,both,1,EA,,197.88,197.88,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sterile Water: 12 Container In 1 Case (0264-7850-00) / 1000 Ml In 1 Container,250,RC,0264-7850-00,NDC,,,facility,both,1,EA,,66,66,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sodium Chloride: 4 Bag In 1 Carton (0338-0047-47) / 3000 Ml In 1 Bag,250,RC,0338-0047-47,NDC,,,facility,both,1,EA,,108.82,108.82,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sodium Chloride: 1000 Ml In 1 Bag (0338-0049-04),250,RC,0338-0049-04,NDC,,,facility,both,1,EA,,1,1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sodium Chloride: 4 Bag In 1 Package (0338-0049-10) / 25 Ml In 1 Bag,250,RC,0338-0049-10,NDC,,,facility,both,1,EA,,1,1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sodium Chloride: 24 Container In 1 Case (0264-7802-10) / 500 Ml In 1 Container,250,RC,0264-7802-10,NDC,,,facility,both,1,EA,,81.79,81.79,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sodium Chloride: 16 Container In 1 Case (0264-2201-00) / 1000 Ml In 1 Container,250,RC,0264-2201-00,NDC,,,facility,both,1,EA,,13.52,13.52,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sterile Water: 16 Container In 1 Case (0264-2101-10) / 500 Ml In 1 Container,250,RC,0264-2101-10,NDC,,,facility,both,1,EA,,62.86,62.86,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sterile Water: 16 Container In 1 Case (0264-2101-00) / 1000 Ml In 1 Container,250,RC,0264-2101-00,NDC,,,facility,both,1,EA,,63.9,63.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Trophamine: 12 Container In 1 Case (0264-1933-10) / 500 Ml In 1 Container,250,RC,0264-1933-10,NDC,,,facility,both,1,EA,,1320.29,1320.29,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sodium Chloride: 64 Container In 1 Case (0264-1800-32) / 100 Ml In 1 Container,250,RC,0264-1800-32,NDC,,,facility,both,1,EA,,27.01,27.01,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sodium Chloride: 84 Container In 1 Case (0264-1800-31) / 50 Ml In 1 Container,250,RC,0264-1800-31,NDC,,,facility,both,1,EA,,3.15,3.15,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dextrose: 84 Container In 1 Case (0264-1510-31) / 50 Ml In 1 Container,250,RC,0264-1510-31,NDC,,,facility,both,1,EA,,1,1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sodium Chloride: 16 Container In 1 Case (0264-2201-10) / 500 Ml In 1 Container,250,RC,0264-2201-10,NDC,,,facility,both,1,EA,,50.22,50.22,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Lubiprostone: 60 Capsule, Gelatin Coated In 1 Bottle (0254-3029-02)",250,RC,0254-3029-02,NDC,,,facility,both,1,EA,,16.47,16.47,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0245-5319-89,NDC,,,facility,both,1,EA,,10.36,10.36,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0245-5317-89,NDC,,,facility,both,1,EA,,11.31,11.31,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0245-0212-89,NDC,,,facility,both,1,EA,,8.45,8.45,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Midodrine Hydrochloride: 100 Blister Pack In 1 Carton (0245-0212-01) / 1 Tablet In 1 Blister Pack (0245-0212-89),250,RC,0245-0212-01,NDC,,,facility,both,1,EA,,17.2,17.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Clonidine Hydrochloride: 100 Tablet In 1 Bottle (0228-2127-10),250,RC,0228-2127-10,NDC,,,facility,both,1,EA,,9.62,9.62,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0223-1760-01,NDC,,,facility,both,1,EA,,12.01,12.01,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Cuvposa: 1 Bottle In 1 Carton (0259-0501-16) / 473 Ml In 1 Bottle,250,RC,0259-0501-16,NDC,,,facility,both,1,EA,,21.93,21.93,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Nutrilipid I.V. Fat Emulsion: 8 Carton In 1 Case (0264-4460-00) / 1 Container In 1 Carton / 1000 Ml In 1 Container,250,RC,0264-4460-00,NDC,,,facility,both,1,EA,,315.69,315.69,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sodium Chloride: 12 Container In 1 Case (0264-5802-00) / 1000 Ml In 1 Container,250,RC,0264-5802-00,NDC,,,facility,both,1,EA,,1,1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Isolyte S Ph 7.4: 24 Container In 1 Case (0264-7707-10) / 500 Ml In 1 Container,250,RC,0264-7707-10,NDC,,,facility,both,1,EA,,78,78,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Isolyte S Ph 7.4: 12 Container In 1 Case (0264-7707-00) / 1000 Ml In 1 Container,250,RC,0264-7707-00,NDC,,,facility,both,1,EA,,83.86,83.86,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Potassium Chloride In Dextrose And Sodium Chloride: 12 Container In 1 Case (0264-7652-00) / 1000 Ml In 1 Container,250,RC,0264-7652-00,NDC,,,facility,both,1,EA,,92.29,92.29,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Potassium Chloride In Dextrose And Sodium Chloride: 12 Container In 1 Case (0264-7638-00) / 1000 Ml In 1 Container,250,RC,0264-7638-00,NDC,,,facility,both,1,EA,,108.82,108.82,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Potassium Chloride In Dextrose And Sodium Chloride: 12 Container In 1 Case (0264-7635-00) / 1000 Ml In 1 Container,250,RC,0264-7635-00,NDC,,,facility,both,1,EA,,86.48,86.48,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Potassium Chloride In Dextrose And Sodium Chloride: 12 Container In 1 Case (0264-7634-00) / 1000 Ml In 1 Container,250,RC,0264-7634-00,NDC,,,facility,both,1,EA,,116.24,116.24,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dextrose And Sodium Chloride: 24 Container In 1 Case (0264-7623-20) / 250 Ml In 1 Container,250,RC,0264-7623-20,NDC,,,facility,both,1,EA,,99.73,99.73,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dextrose And Sodium Chloride: 12 Container In 1 Case (0264-7622-00) / 1000 Ml In 1 Container,250,RC,0264-7622-00,NDC,,,facility,both,1,EA,,110.99,110.99,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sodium Chloride: 24 Container In 1 Case (0264-5802-10) / 500 Ml In 1 Container,250,RC,0264-5802-10,NDC,,,facility,both,1,EA,,28.44,28.44,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sodium Chloride: 12 Container In 1 Case (0264-5804-00) / 1000 Ml In 1 Container,250,RC,0264-5804-00,NDC,,,facility,both,1,EA,,85.64,85.64,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sterile Water: 4 Container In 1 Case (0264-7385-50) / 2000 Ml In 1 Container,250,RC,0264-7385-50,NDC,,,facility,both,1,EA,,65.77,65.77,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sodium Chloride: 12 Container In 1 Case (0264-7802-00) / 1000 Ml In 1 Container,250,RC,0264-7802-00,NDC,,,facility,both,1,EA,,84.54,84.54,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Nexium: 30 Granule, Delayed Release In 1 Carton (0186-4010-01)",250,RC,0186-4010-01,NDC,,,facility,both,1,EA,,28.5,28.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Plasma-Lyte A: 500 Ml In 1 Bag (0338-0221-03),250,RC,0338-0221-03,NDC,,,facility,both,1,EA,,62.44,62.44,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Methadone Hydrochloride: 500 Ml In 1 Bottle (0406-6225-05),250,RC,0406-6225-05,NDC,,,facility,both,1,EA,,12.9,12.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Methadone Hydrochloride: 1 Tablet In 1 Blister Pack (0406-5771-23),250,RC,0406-5771-23,NDC,,,facility,both,1,EA,,8.65,8.65,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Methadone Hydrochloride: 1 Tablet In 1 Blister Pack (0406-5755-23),250,RC,0406-5755-23,NDC,,,facility,both,1,EA,,12.41,12.41,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Hydromorphone Hydrochloride: 100 Tablet In 1 Bottle (0406-3243-01),250,RC,0406-3243-01,NDC,,,facility,both,1,EA,,8.47,8.47,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Diphenoxylate Hydrochloride And Atropine Sulfate: 100 Tablet In 1 Bottle (0406-1236-01),250,RC,0406-1236-01,NDC,,,facility,both,1,EA,,10.1,10.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Oxycodone Hydrochloride: 1 Tablet In 1 Blister Pack (0406-0552-23),250,RC,0406-0552-23,NDC,,,facility,both,1,EA,,12.85,12.85,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Oxycodone Hydrochloride: 100 Tablet In 1 Bottle (0406-0552-01),250,RC,0406-0552-01,NDC,,,facility,both,1,EA,,9.41,9.41,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Methylphenidate Hydrochloride Extended-Release: 100 Tablet, Extended Release In 1 Bottle (0406-0127-01)",250,RC,0406-0127-01,NDC,,,facility,both,1,EA,,27.84,27.84,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Oxycodone Hydrochloride: 1 Tablet In 1 Blister Pack (0406-8510-23),250,RC,0406-8510-23,NDC,,,facility,both,1,EA,,14.3,14.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0409-0007-01,NDC,,,facility,both,1,EA,,31.46,31.46,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0409-1209-10,NDC,,,facility,both,1,EA,,38.07,38.07,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Lidocaine Hydrochloride And Epinephrine: 10 Ampule In 1 Tray (0409-1209-01) / 5 Ml In 1 Ampule (0409-1209-10),250,RC,0409-1209-01,NDC,,,facility,both,1,EA,,38.58,38.58,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0409-1141-12,NDC,,,facility,both,1,EA,,50.56,50.56,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Sodium Chloride: 25 Vial, Pharmacy Bulk Package In 1 Case (0409-1141-02) / 100 Ml In 1 Vial, Pharmacy Bulk Package (0409-1141-12)",250,RC,0409-1141-02,NDC,,,facility,both,1,EA,,13.09,13.09,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0409-0007-01,NDC,,,facility,both,1,EA,,32.64,32.64,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Lidocaine Hydrochloride And Epinephrine: 10 Vial, Multi-Dose In 1 Carton (0409-0007-10) / 20 Ml In 1 Vial, Multi-Dose (0409-0007-01)",250,RC,0409-0007-10,NDC,,,facility,both,1,EA,,30.41,30.41,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0395-1031-96,NDC,,,facility,both,1,EA,,5.67,5.67,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Lactated Ringers: 3000 Ml In 1 Bag (0338-0137-27),250,RC,0338-0137-27,NDC,,,facility,both,1,EA,,124.84,124.84,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0395-1031-16,NDC,,,facility,both,1,EA,,6.97,6.97,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Potassium Chloride In Dextrose And Sodium Chloride: 1000 Ml In 1 Bag (0338-0807-04),250,RC,0338-0807-04,NDC,,,facility,both,1,EA,,91.45,91.45,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Potassium Chloride In Dextrose And Sodium Chloride: 1000 Ml In 1 Bag (0338-0803-04),250,RC,0338-0803-04,NDC,,,facility,both,1,EA,,96.08,96.08,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Potassium Chloride In Dextrose And Sodium Chloride: 1000 Ml In 1 Bag (0338-0675-04),250,RC,0338-0675-04,NDC,,,facility,both,1,EA,,113.48,113.48,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Potassium Chloride In Dextrose And Sodium Chloride: 1000 Ml In 1 Bag (0338-0671-04),250,RC,0338-0671-04,NDC,,,facility,both,1,EA,,88.65,88.65,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Potassium Chloride In Dextrose And Sodium Chloride: 1000 Ml In 1 Bag (0338-0669-04),250,RC,0338-0669-04,NDC,,,facility,both,1,EA,,107.9,107.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Potassium Chloride In Dextrose And Sodium Chloride: 1000 Ml In 1 Bag (0338-0663-04),250,RC,0338-0663-04,NDC,,,facility,both,1,EA,,99.84,99.84,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Intralipid: 100 Ml In 1 Bag (0338-0519-58),250,RC,0338-0519-58,NDC,,,facility,both,1,EA,,135.22,135.22,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Intralipid: 250 Ml In 1 Bag (0338-0519-09),250,RC,0338-0519-09,NDC,,,facility,both,1,EA,,150.16,150.16,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Osmitrol: 250 Ml In 1 Bag (0338-0357-02),250,RC,0338-0357-02,NDC,,,facility,both,1,EA,,293.36,293.36,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Recothrom: 1 Kit In 1 Kit (0338-0330-01) * 20 Ml In 1 Vial (0338-0328-01) * 20 Ml In 1 Vial,250,RC,0338-0330-01,NDC,,,facility,both,1,EA,,1681.41,1681.41,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0338-0328-01,NDC,,,facility,both,1,EA,,1546.74,1546.74,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0338-0324-01,NDC,,,facility,both,1,EA,,413.48,413.48,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Recothrom: 1 Kit In 1 Kit (0338-0322-01) * 5 Ml In 1 Vial (0338-0324-01) * 5 Ml In 1 Syringe,250,RC,0338-0322-01,NDC,,,facility,both,1,EA,,426.27,426.27,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Plasma-Lyte A: 1000 Ml In 1 Bag (0338-0221-04),250,RC,0338-0221-04,NDC,,,facility,both,1,EA,,68.08,68.08,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Potassium Chloride In Dextrose And Sodium Chloride: 1000 Ml In 1 Bag (0338-0673-04),250,RC,0338-0673-04,NDC,,,facility,both,1,EA,,82.43,82.43,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Humco Gentian Violet 1%: 59 Ml In 1 Bottle, Plastic (0395-1003-92)",250,RC,0395-1003-92,NDC,,,facility,both,1,EA,,48.5,48.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Humco Calamine: 177 Ml In 1 Bottle, Plastic (0395-0413-96)",250,RC,0395-0413-96,NDC,,,facility,both,1,EA,,34.83,34.83,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Levalbuterol: 1 Pouch In 1 Carton (0378-9691-52) / 25 Ampule In 1 Pouch (0378-9691-62) / 3 Ml In 1 Ampule,250,RC,0378-9691-52,NDC,,,facility,both,1,EA,,13.6,13.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0378-7272-85,NDC,,,facility,both,1,EA,,1.2,1.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Norethindrone: 3 Pouch In 1 Carton (0378-7272-53) / 1 Blister Pack In 1 Pouch (0378-7272-85) / 28 Tablet In 1 Blister Pack,250,RC,0378-7272-53,NDC,,,facility,both,1,EA,,0.82,0.82,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0378-6985-01,NDC,,,facility,both,1,EA,,14.43,14.43,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Mercaptopurine: 25 Tablet In 1 Bottle, Plastic (0378-3547-52)",250,RC,0378-3547-52,NDC,,,facility,both,1,EA,,21.57,21.57,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0378-0873-16,NDC,,,facility,both,1,EA,,180.57,180.57,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Clonidine: 4 Pouch In 1 Carton (0378-0872-99) / 1 Patch In 1 Pouch (0378-0872-16) / 7 D In 1 Patch,250,RC,0378-0872-99,NDC,,,facility,both,1,EA,,144.46,144.46,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sodium Chloride: 250 Ml In 1 Bag (0338-9543-02),250,RC,0338-9543-02,NDC,,,facility,both,1,EA,,30.14,30.14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sodium Chloride: 500 Ml In 1 Bag (0338-9543-04),250,RC,0338-9543-04,NDC,,,facility,both,1,EA,,26.27,26.27,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dexmedetomidine Hydrochloride: 12 Bag In 1 Carton (0338-9557-12) / 100 Ml In 1 Bag,250,RC,0338-9557-12,NDC,,,facility,both,1,EA,,81.81,81.81,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Diltiazem Hydrochloride: 100 TABLET, FILM COATED in 1 BOTTLE, PLASTIC (0378-0045-01) ",250,RC,0378-0045-01,NDC,,,facility,both,1,EA,,11.94,11.94,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0378-0871-16,NDC,,,facility,both,1,EA,,88.42,88.42,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,45016604,NDC,,,facility,both,1,EA,,2.84,2.84,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Symbicort: 1 Pouch In 1 Carton (0186-0372-28) / 1 Canister In 1 Pouch / 60 Aerosol In 1 Canister,250,RC,0186-0372-28,NDC,,,facility,both,1,EA,,393.6,393.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Arnuity Ellipta: 1 Inhaler In 1 Carton (0173-0874-14) / 14 Powder In 1 Inhaler,250,RC,0173-0874-14,NDC,,,facility,both,1,EA,,447.61,447.61,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Dye Free Childrens Ibuprofen: 10 Cup, Unit-Dose In 1 Case (0121-1022-00) / 5 Ml In 1 Cup, Unit-Dose",250,RC,0121-1022-00,NDC,,,facility,both,1,EA,,10.76,10.76,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0121-1012-05,NDC,,,facility,both,1,EA,,114.89,114.89,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Lacosamide: 1 Tray In 1 Case (0121-0992-95) / 10 Cup, Unit-Dose In 1 Tray / 5 Ml In 1 Cup, Unit-Dose (0121-0992-05)",250,RC,0121-0992-95,NDC,,,facility,both,1,EA,,100.62,100.62,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0121-0974-10,NDC,,,facility,both,1,EA,,22.15,22.15,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Lidocaine Hydrochloride: 1 Bottle, Glass In 1 Carton (0121-0972-51) / 50 Ml In 1 Bottle, Glass",250,RC,0121-0972-51,NDC,,,facility,both,1,EA,,103.3,103.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Potassium Chloride: 473 Ml In 1 Bottle (0121-0948-16),250,RC,0121-0948-16,NDC,,,facility,both,1,EA,,13.54,13.54,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Phenobarbital Oral Solution: 5 Tray In 1 Case (0121-0942-50) / 10 Cup, Unit-Dose In 1 Tray / 5 Ml In 1 Cup, Unit-Dose (0121-0942-05)",250,RC,0121-0942-50,NDC,,,facility,both,1,EA,,16.59,16.59,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0121-0942-05,NDC,,,facility,both,1,EA,,16.77,16.77,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0121-0914-05,NDC,,,facility,both,1,EA,,11.01,11.01,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Diazepam: 3 Tray In 1 Case (0121-0905-94) / 10 Cup, Unit-Dose In 1 Tray / 5 Ml In 1 Cup, Unit-Dose (0121-0905-05)",250,RC,0121-0905-94,NDC,,,facility,both,1,EA,,15.13,15.13,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0121-0905-05,NDC,,,facility,both,1,EA,,16.84,16.84,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0121-0904-05,NDC,,,facility,both,1,EA,,11.74,11.74,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Lidocaine Viscous: 4 Tray In 1 Case (0121-0903-40) / 10 Cup, Unit-Dose In 1 Tray / 15 Ml In 1 Cup, Unit-Dose (0121-0903-15)",250,RC,0121-0903-40,NDC,,,facility,both,1,EA,,17.14,17.14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Chlorhexidine Gluconate: 4 Tray In 1 Case (0121-0893-40) / 10 Cup, Unit-Dose In 1 Tray / 15 Ml In 1 Cup, Unit-Dose (0121-0893-15)",250,RC,0121-0893-40,NDC,,,facility,both,1,EA,,18.87,18.87,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0121-0893-15,NDC,,,facility,both,1,EA,,19.08,19.08,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Nystatin: 5 Tray In 1 Case (0121-0868-50) / 10 Cup, Unit-Dose In 1 Tray / 5 Ml In 1 Cup, Unit-Dose (0121-0868-05)",250,RC,0121-0868-50,NDC,,,facility,both,1,EA,,17.51,17.51,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0121-0868-05,NDC,,,facility,both,1,EA,,15.9,15.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Dye Free Childrens Ibuprofen: 10 Cup, Unit-Dose In 1 Tray (0121-1022-05) / 5 Ml In 1 Cup, Unit-Dose",250,RC,0121-1022-05,NDC,,,facility,both,1,EA,,9.98,9.98,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Nystatin: 473 Ml In 1 Bottle (0121-1045-16),250,RC,0121-1045-16,NDC,,,facility,both,1,EA,,14.48,14.48,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Vimpat: 6 Blister Pack In 1 Carton (0131-2478-60) / 10 Tablet, Film Coated In 1 Blister Pack",250,RC,0131-2478-60,NDC,,,facility,both,1,EA,,127.72,127.72,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Vimpat: 6 Blister Pack In 1 Carton (0131-2477-60) / 10 Tablet, Film Coated In 1 Blister Pack",250,RC,0131-2477-60,NDC,,,facility,both,1,EA,,87.48,87.48,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0121-4950-15,NDC,,,facility,both,1,EA,,19.14,19.14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0121-4827-05,NDC,,,facility,both,1,EA,,22.83,22.83,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0121-4799-05,NDC,,,facility,both,1,EA,,22.64,22.64,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Calcium Carbonate: 4 Tray In 1 Case (0121-4766-05) / 10 Cup, Unit-Dose In 1 Tray / 5 Ml In 1 Cup, Unit-Dose",250,RC,0121-4766-05,NDC,,,facility,both,1,EA,,17.28,17.28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Lactulose: 4 Tray In 1 Case (0121-4577-40) / 10 Cup, Unit-Dose In 1 Tray / 15 Ml In 1 Cup, Unit-Dose (0121-4577-15)",250,RC,0121-4577-40,NDC,,,facility,both,1,EA,,16.95,16.95,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0121-4577-15,NDC,,,facility,both,1,EA,,14.83,14.83,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0121-2024-10,NDC,,,facility,both,1,EA,,154.58,154.58,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0121-1884-07,NDC,,,facility,both,1,EA,,27.58,27.58,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0121-1154-30,NDC,,,facility,both,1,EA,,16.86,16.86,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Lactulose: 4 Tray In 1 Case (0121-1154-40) / 10 Cup, Unit-Dose In 1 Tray / 30 Ml In 1 Cup, Unit-Dose (0121-1154-30)",250,RC,0121-1154-40,NDC,,,facility,both,1,EA,,16.98,16.98,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Metoclopramide: 10 Tray In 1 Case (0121-1576-10) / 10 Cup, Unit-Dose In 1 Tray / 10 Ml In 1 Cup, Unit-Dose",250,RC,0121-1576-10,NDC,,,facility,both,1,EA,,14,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA 473 mL in 1 BOTTLE (0121-1680-16) ,250,RC,0121-1680-16,NDC,,,facility,both,1,EA,,15.38,15.38,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Mag-Al Plus: 10 Tray In 1 Case (0121-1761-30) / 10 Cup, Unit-Dose In 1 Tray / 30 Ml In 1 Cup, Unit-Dose",250,RC,0121-1761-30,NDC,,,facility,both,1,EA,,2.9,2.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0121-1828-10,NDC,,,facility,both,1,EA,,13.98,13.98,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0121-1870-10,NDC,,,facility,both,1,EA,,1.65,1.65,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Clonazepam: 60 Blister Pack In 1 Carton (0093-9291-67) / 1 Tablet, Orally Disintegrating In 1 Blister Pack",250,RC,0093-9291-67,NDC,,,facility,both,1,EA,,12.52,12.52,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0093-9291-19,NDC,,,facility,both,1,EA,,11.01,11.01,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0093-9290-19,NDC,,,facility,both,1,EA,,18.25,18.25,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Granisetron Hydrochloride: 20 BLISTER PACK in 1 BOX (0093-7485-20) / 1 TABLET, FILM COATED in 1 BLISTER PACK (0093-7485-19) ",250,RC,0093-7485-20,NDC,,,facility,both,1,EA,,56.31,56.31,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0093-5985-19,NDC,,,facility,both,1,EA,,932.36,932.36,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Olanzapine: 30 Blister Pack In 1 Carton (0093-5245-65) / 1 Tablet, Orally Disintegrating In 1 Blister Pack (0093-5245-19)",250,RC,0093-5245-65,NDC,,,facility,both,1,EA,,16.82,16.82,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0093-5245-19,NDC,,,facility,both,1,EA,,18.89,18.89,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Cephalexin: 200 Ml In 1 Bottle (0093-4177-74),250,RC,0093-4177-74,NDC,,,facility,both,1,EA,,15.84,15.84,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Penicillin V Potassium: 100 Ml In 1 Bottle (0093-4127-73),250,RC,0093-4127-73,NDC,,,facility,both,1,EA,,12.92,12.92,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Prazosin Hydrochloride: 100 Capsule In 1 Bottle (0093-4067-01),250,RC,0093-4067-01,NDC,,,facility,both,1,EA,,7.63,7.63,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Lorazepam: 100 Tablet In 1 Bottle, Plastic (0093-3426-01)",250,RC,0093-3426-01,NDC,,,facility,both,1,EA,,8.5,8.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Cyclobenzaprine Hydrochloride: 100 Tablet, Film Coated In 1 Bottle (0093-3422-01)",250,RC,0093-3422-01,NDC,,,facility,both,1,EA,,11.86,11.86,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Disopyramide Phosphate: 100 Capsule In 1 Bottle (0093-3127-01),250,RC,0093-3127-01,NDC,,,facility,both,1,EA,,14.02,14.02,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Amoxicillin And Clavulanate Potassium: 20 Tablet, Chewable In 1 Bottle (0093-2272-34)",250,RC,0093-2272-34,NDC,,,facility,both,1,EA,,40.28,40.28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Amoxicillin: 100 Tablet, Chewable In 1 Bottle (0093-2268-01)",250,RC,0093-2268-01,NDC,,,facility,both,1,EA,,5.98,5.98,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Warfarin Sodium: 100 Tablet In 1 Bottle (0093-1716-01),250,RC,0093-1716-01,NDC,,,facility,both,1,EA,,12.67,12.67,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Penicillin V Potassium: 200 Ml In 1 Bottle (0093-4127-74),250,RC,0093-4127-74,NDC,,,facility,both,1,EA,,13.02,13.02,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0093-9292-19,NDC,,,facility,both,1,EA,,17.64,17.64,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0093-9293-19,NDC,,,facility,both,1,EA,,13.76,13.76,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Levetiracetam: 473 Ml In 1 Bottle (0121-0799-16),250,RC,0121-0799-16,NDC,,,facility,both,1,EA,,12.63,12.63,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Lorazepam: 1 Bottle, Dropper In 1 Carton (0121-0770-01) / 30 Ml In 1 Bottle, Dropper",250,RC,0121-0770-01,NDC,,,facility,both,1,EA,,5.97,5.97,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Calcium Carbonate: 12 Bottle In 1 Case (0121-0766-16) / 473 Ml In 1 Bottle,250,RC,0121-0766-16,NDC,,,facility,both,1,EA,,5.11,5.11,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Valproic Acid: 473 Ml In 1 Bottle (0121-0675-85),250,RC,0121-0675-85,NDC,,,facility,both,1,EA,,13.48,13.48,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Ethosuximide: 473 Ml In 1 Bottle (0121-0670-16),250,RC,0121-0670-16,NDC,,,facility,both,1,EA,,2.82,2.82,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Trihexyphenidyl Hydrochloride: 473 Ml In 1 Bottle (0121-0658-16),250,RC,0121-0658-16,NDC,,,facility,both,1,EA,,12.04,12.04,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Amantadine Hydrochloride: 473 Ml In 1 Bottle (0121-0646-16),250,RC,0121-0646-16,NDC,,,facility,both,1,EA,,1.24,1.24,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Haloperidol: 120 Ml In 1 Bottle (0121-0581-04),250,RC,0121-0581-04,NDC,,,facility,both,1,EA,,5.18,5.18,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Metoclopramide: 473 Ml In 1 Bottle (0121-0576-16),250,RC,0121-0576-16,NDC,,,facility,both,1,EA,,12.53,12.53,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dipyridamole: 100 Tablet In 1 Bottle (0115-1070-01),250,RC,0115-1070-01,NDC,,,facility,both,1,EA,,14.87,14.87,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dipyridamole: 100 Tablet In 1 Bottle (0115-1071-01),250,RC,0115-1071-01,NDC,,,facility,both,1,EA,,8.73,8.73,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Epinephrine: 1 Case In 1 Carton (0115-1694-30) / 1 Syringe, Glass In 1 Case / .3 Ml In 1 Syringe, Glass",250,RC,0115-1694-30,NDC,,,facility,both,1,EA,,910.9,910.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0121-0865-05,NDC,,,facility,both,1,EA,,12.5,12.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Epinephrine: 2 Case In 1 Carton (0115-1694-49) / 1 Syringe, Glass In 1 Case / .3 Ml In 1 Syringe, Glass",250,RC,0115-1694-49,NDC,,,facility,both,1,EA,,910.98,910.98,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Dexmethylphenidate Hydrochloride: 100 Capsule, Extended Release In 1 Bottle, Plastic (0115-9918-01)",250,RC,0115-9918-01,NDC,,,facility,both,1,EA,,20.02,20.02,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Lactulose: 15 Ml In 1 Cup, Unit-Dose (0116-4005-15)",250,RC,0116-4005-15,NDC,,,facility,both,1,EA,,15.43,15.43,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0116-4005-40,NDC,,,facility,both,1,EA,,16.09,16.09,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Milk Of Magnesia: 10 Tray In 1 Case (0121-0431-30) / 10 Cup, Unit-Dose In 1 Tray / 30 Ml In 1 Cup, Unit-Dose",250,RC,0121-0431-30,NDC,,,facility,both,1,EA,,13.12,13.12,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Pyridostigmine Bromide: 100 Tablet In 1 Bottle (0115-3511-01),250,RC,0115-3511-01,NDC,,,facility,both,1,EA,,14.41,14.41,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Symbicort: 1 Pouch In 1 Carton (0186-0370-28) / 1 Canister In 1 Pouch / 60 Aerosol In 1 Canister,250,RC,0186-0370-28,NDC,,,facility,both,1,EA,,392.08,392.08,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Fleet: 12 SUPPOSITORY in 1 JAR (0132-0079-12) ,250,RC,0132-0079-12,NDC,,,facility,both,1,EA,,12.58,12.58,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Nystatin: 15 g in 1 TUBE (0168-0007-15) ,250,RC,0168-0007-15,NDC,,,facility,both,1,EA,,92.65,92.65,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Triamcinolone Acetonide: 1 Tube In 1 Carton (0168-0003-15) / 15 G In 1 Tube,250,RC,0168-0003-15,NDC,,,facility,both,1,EA,,19.44,19.44,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Triamcinolone Acetonide: 1 Tube In 1 Carton (0168-0002-15) / 15 G In 1 Tube,250,RC,0168-0002-15,NDC,,,facility,both,1,EA,,40.13,40.13,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Amoxicillin And Clavulanate Potassium: 200 Ml In 1 Bottle (0143-9853-24),250,RC,0143-9853-24,NDC,,,facility,both,1,EA,,18.59,18.59,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0143-9785-01,NDC,,,facility,both,1,EA,,31.6,31.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0143-9689-01,NDC,,,facility,both,1,EA,,85.51,85.51,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Valproate Sodium: 10 Vial, Single-Dose In 1 Carton (0143-9785-10) / 5 Ml In 1 Vial, Single-Dose (0143-9785-01)",250,RC,0143-9785-10,NDC,,,facility,both,1,EA,,89.46,89.46,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Hydrocortisone: 1 Tube In 1 Carton (0168-0020-31) / 28.35 G In 1 Tube,250,RC,0168-0020-31,NDC,,,facility,both,1,EA,,30.35,30.35,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Betamethasone Valerate: 15 G In 1 Tube (0168-0033-15),250,RC,0168-0033-15,NDC,,,facility,both,1,EA,,57.57,57.57,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Breo Ellipta: 1 Tray In 1 Carton (0173-0859-14) / 1 Inhaler In 1 Tray / 14 Powder In 1 Inhaler,250,RC,0173-0859-14,NDC,,,facility,both,1,EA,,406.32,406.32,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Flovent Hfa: 1 Inhaler In 1 Carton (0173-0720-20) / 120 Aerosol, Metered In 1 Inhaler",250,RC,0173-0720-20,NDC,,,facility,both,1,EA,,2560.03,2560.03,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Flovent Hfa: 1 Inhaler In 1 Carton (0173-0719-20) / 120 Aerosol, Metered In 1 Inhaler",250,RC,0173-0719-20,NDC,,,facility,both,1,EA,,1738.4,1738.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Flovent Hfa: 1 Inhaler In 1 Carton (0173-0718-20) / 120 Aerosol, Metered In 1 Inhaler",250,RC,0173-0718-20,NDC,,,facility,both,1,EA,,1233.98,1233.98,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ventolin Hfa: 1 Inhaler In 1 Carton (0173-0682-24) / 60 Aerosol, Metered In 1 Inhaler",250,RC,0173-0682-24,NDC,,,facility,both,1,EA,,147.74,147.74,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Famotidine: 100 Tablet, Film Coated In 1 Bottle (0172-5728-60)",250,RC,0172-5728-60,NDC,,,facility,both,1,EA,,11.59,11.59,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Baclofen: 100 Tablet In 1 Bottle (0172-4096-60),250,RC,0172-4096-60,NDC,,,facility,both,1,EA,,8,8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Diazepam: 100 Tablet In 1 Bottle (0172-3925-60),250,RC,0172-3925-60,NDC,,,facility,both,1,EA,,9.47,9.47,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Norditropin: 1 Syringe, Plastic In 1 Carton (0169-7704-21) / 1.5 Ml In 1 Syringe, Plastic",250,RC,0169-7704-21,NDC,,,facility,both,1,EA,,2721.98,2721.98,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Novolog: 1 Vial, Glass In 1 Carton (0169-7501-11) / 10 Ml In 1 Vial, Glass",250,RC,0169-7501-11,NDC,,,facility,both,1,EA,,1.16,1.16,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Pedia-Lax: 12 Suppository In 1 Jar (0132-0081-12),250,RC,0132-0081-12,NDC,,,facility,both,1,EA,,12.27,12.27,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0143-9251-01,NDC,,,facility,both,1,EA,,31.11,31.11,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Pedia-Lax: 66 Ml In 1 Bottle, With Applicator (0132-0202-20)",250,RC,0132-0202-20,NDC,,,facility,both,1,EA,,20.68,20.68,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Fleet: 133 Ml In 1 Bottle, With Applicator (0132-0201-40)",250,RC,0132-0201-40,NDC,,,facility,both,1,EA,,19,19,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Pedia-Lax: 6 Applicator In 1 Carton (0132-0190-12) / 4 Ml In 1 Applicator,250,RC,0132-0190-12,NDC,,,facility,both,1,EA,,17.22,17.22,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Nicardipine Hydrochloride: 10 Bag In 1 Carton (0143-9633-10) / 200 Ml In 1 Bag (0143-9633-01),250,RC,0143-9633-10,NDC,,,facility,both,1,EA,,338.28,338.28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0143-9633-01,NDC,,,facility,both,1,EA,,228.36,228.36,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0143-9595-01,NDC,,,facility,both,1,EA,,27.91,27.91,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0143-9525-01,NDC,,,facility,both,1,EA,,66.18,66.18,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0143-9391-01,NDC,,,facility,both,1,EA,,391.89,391.89,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0143-9392-01,NDC,,,facility,both,1,EA,,508.22,508.22,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Remifentanil Hydrochloride: 10 Vial In 1 Carton (0143-9392-10) / 5 Ml In 1 Vial (0143-9392-01),250,RC,0143-9392-10,NDC,,,facility,both,1,EA,,637.14,637.14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0143-9393-01,NDC,,,facility,both,1,EA,,1508.25,1508.25,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Remifentanil Hydrochloride: 10 Vial In 1 Carton (0143-9393-10) / 10 Ml In 1 Vial (0143-9393-01),250,RC,0143-9393-10,NDC,,,facility,both,1,EA,,1528.45,1528.45,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0143-9397-01,NDC,,,facility,both,1,EA,,38.31,38.31,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0143-9508-01,NDC,,,facility,both,1,EA,,64.35,64.35,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,250,RC,0143-9509-01,NDC,,,facility,both,1,EA,,40.59,40.59,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Gadavist: 15 Carton In 1 Box (50419-325-37) / 3 Vial, Single-Dose In 1 Carton / 2 Ml In 1 Vial, Single-Dose",255,RC,50419-325-37,NDC,,,facility,both,1,EA,,18.02,18.02,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Gadavist: 2 Carton In 1 Box (50419-325-11) / 10 Vial, Single-Dose In 1 Carton / 7.5 Ml In 1 Vial, Single-Dose",255,RC,50419-325-11,NDC,,,facility,both,1,EA,,1.95,1.95,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Gadavist: 2 Carton In 1 Box (50419-325-11) / 10 Vial, Single-Dose In 1 Carton / 7.5 Ml In 1 Vial, Single-Dose",255,RC,50419-325-11,NDC,,,facility,both,1,EA,,1.5,1.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Eovist: 5 Vial, Single-Dose In 1 Box (50419-320-05) / 10 Ml In 1 Vial, Single-Dose",255,RC,50419-320-05,NDC,,,facility,both,1,EA,,95.46,95.46,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Eovist: 5 Vial, Single-Dose In 1 Box (50419-320-05) / 10 Ml In 1 Vial, Single-Dose",255,RC,50419-320-05,NDC,,,facility,both,1,EA,,90.8,90.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,255,RC,50419-325-01,NDC,,,facility,both,1,EA,,1.87,1.87,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Lipiodol: 1 Vial In 1 Carton (67684-1901-2) / 10 Ml In 1 Vial,255,RC,67684-1901-2,NDC,,,facility,both,1,EA,,2247.8,2247.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Iodixanol: 10 Bottle, Plastic In 1 Box (65219-383-05) / 50 Ml In 1 Bottle, Plastic (65219-383-02)",255,RC,65219-383-05,NDC,,,facility,both,1,EA,,2.43,2.43,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Gadobutrol: 2 Carton In 1 Box (65219-281-07) / 10 Vial, Single-Dose In 1 Carton / 7.5 Ml In 1 Vial, Single-Dose (65219-281-03)",255,RC,65219-281-07,NDC,,,facility,both,1,EA,,1.62,1.62,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Gadobutrol: 2 Carton In 1 Box (65219-281-07) / 10 Vial, Single-Dose In 1 Carton / 7.5 Ml In 1 Vial, Single-Dose (65219-281-03)",255,RC,65219-281-07,NDC,,,facility,both,1,EA,,1.28,1.28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,255,RC,65219-281-03,NDC,,,facility,both,1,EA,,1.57,1.57,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Cysto-Conray Ii: 12 Bottle, Glass In 1 Box (0019-0862-50) / 250 Ml In 1 Bottle, Glass",255,RC,0019-0862-50,NDC,,,facility,both,1,EA,,0.72,0.72,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,255,RC,1513702127,NDC,,,facility,both,1,EA,,51.57,51.57,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Gastrografin: 12 Bottle In 1 Box (0270-0445-40) / 120 Ml In 1 Bottle,255,RC,0270-0445-40,NDC,,,facility,both,1,EA,,1.19,1.19,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Gastrografin: 12 Bottle In 1 Box (0270-0445-40) / 120 Ml In 1 Bottle,255,RC,0270-0445-40,NDC,,,facility,both,1,EA,,1.16,1.16,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Gastrografin: 12 Bottle In 1 Box (0270-0445-40) / 120 Ml In 1 Bottle,255,RC,0270-0445-40,NDC,,,facility,both,1,EA,,1.15,1.15,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Gastrografin: 24 Bottle In 1 Box (0270-0445-35) / 30 Ml In 1 Bottle,255,RC,0270-0445-35,NDC,,,facility,both,1,EA,,2.88,2.88,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Gastrografin: 24 Bottle In 1 Box (0270-0445-35) / 30 Ml In 1 Bottle,255,RC,0270-0445-35,NDC,,,facility,both,1,EA,,2.85,2.85,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Omnipaque: 10 Bottle, Plastic In 1 Box (0407-1414-91) / 100 Ml In 1 Bottle, Plastic",255,RC,0407-1414-91,NDC,,,facility,both,1,EA,,1.5,1.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Omnipaque: 10 Bottle, Plastic In 1 Box (0407-1414-91) / 100 Ml In 1 Bottle, Plastic",255,RC,0407-1414-91,NDC,,,facility,both,1,EA,,1.04,1.04,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Omnipaque: 10 Bottle, Plastic In 1 Box (0407-1413-63) / 100 Ml In 1 Bottle, Plastic",255,RC,0407-1413-63,NDC,,,facility,both,1,EA,,1.4,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Omnipaque: 10 Bottle, Plastic In 1 Box (0407-1413-61) / 50 Ml In 1 Bottle, Plastic",255,RC,0407-1413-61,NDC,,,facility,both,1,EA,,1.47,1.47,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Omnipaque: 10 Bottle, Plastic In 1 Box (0407-1413-61) / 50 Ml In 1 Bottle, Plastic",255,RC,0407-1413-61,NDC,,,facility,both,1,EA,,1.45,1.45,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Omnipaque: 10 Bottle, Plastic In 1 Box (0407-1413-61) / 50 Ml In 1 Bottle, Plastic",255,RC,0407-1413-61,NDC,,,facility,both,1,EA,,0.98,0.98,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Omnipaque: 10 Vial, Glass In 1 Box (0407-1413-10) / 10 Ml In 1 Vial, Glass",255,RC,0407-1413-10,NDC,,,facility,both,1,EA,,19.41,19.41,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Omnipaque: 10 Vial, Glass In 1 Box (0407-1413-10) / 10 Ml In 1 Vial, Glass",255,RC,0407-1413-10,NDC,,,facility,both,1,EA,,16.3,16.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Omnipaque: 10 Bottle, Plastic In 1 Box (0407-1412-30) / 50 Ml In 1 Bottle, Plastic",255,RC,0407-1412-30,NDC,,,facility,both,1,EA,,1.54,1.54,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Omnipaque: 10 Vial, Glass In 1 Box (0407-1412-20) / 20 Ml In 1 Vial, Glass",255,RC,0407-1412-20,NDC,,,facility,both,1,EA,,11.56,11.56,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Omnipaque: 10 Vial, Glass In 1 Box (0407-1412-10) / 10 Ml In 1 Vial, Glass",255,RC,0407-1412-10,NDC,,,facility,both,1,EA,,22.09,22.09,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Omnipaque: 10 Vial, Glass In 1 Box (0407-1412-10) / 10 Ml In 1 Vial, Glass",255,RC,0407-1412-10,NDC,,,facility,both,1,EA,,21.61,21.61,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Omnipaque: 10 Vial, Glass In 1 Box (0407-1411-10) / 10 Ml In 1 Vial, Glass",255,RC,0407-1411-10,NDC,,,facility,both,1,EA,,21.47,21.47,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Omnipaque: 10 Vial, Glass In 1 Box (0407-1411-10) / 10 Ml In 1 Vial, Glass",255,RC,0407-1411-10,NDC,,,facility,both,1,EA,,16.17,16.17,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Visipaque: 10 Bottle, Plastic In 1 Box (0407-2223-16) / 50 Ml In 1 Bottle, Plastic",255,RC,0407-2223-16,NDC,,,facility,both,1,EA,,2.6,2.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Visipaque: 10 Bottle, Plastic In 1 Box (0407-2223-17) / 100 Ml In 1 Bottle, Plastic",255,RC,0407-2223-17,NDC,,,facility,both,1,EA,,2.17,2.17,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Visipaque: 10 Bottle, Plastic In 1 Box (0407-2223-17) / 100 Ml In 1 Bottle, Plastic",255,RC,0407-2223-17,NDC,,,facility,both,1,EA,,2.37,2.37,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Copper: 25 Vial, Single-Dose In 1 Tray (0409-4092-01) / 10 Ml In 1 Vial, Single-Dose (0409-4092-11)",258,RC,0409-4092-01,NDC,,,facility,both,1,EA,,1040,1040,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Famotidine: 10 Vial In 1 Carton (67457-457-20) / 20 Ml In 1 Vial (67457-457-00),258,RC,67457-457-20,NDC,,,facility,both,1,EA,,1040,1040,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Carnitor: 5 Vial In 1 Carton (54482-147-01) / 5 Ml In 1 Vial,258,RC,54482-147-01,NDC,,,facility,both,1,EA,,1040,1040,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Infuvite Adult: 1 Kit In 1 Carton (54643-5649-1) * 5 Ml In 1 Vial (54643-5657-1) * 5 Ml In 1 Vial (54643-5659-1),258,RC,54643-5649-1,NDC,,,facility,both,1,EA,,1040,1040,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "M.V.I. Pediatric: 10 VIAL, SINGLE-DOSE in 1 BOX (61703-421-53) / 5 mL in 1 VIAL, SINGLE-DOSE (61703-421-63) ",258,RC,61703-421-53,NDC,,,facility,both,1,EA,,1040,1040,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,258,RC,63323-360-05,NDC,,,facility,both,1,EA,,1040,1040,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sterile Water: 2000 Ml In 1 Bag (0338-0013-06),258,RC,0338-0013-06,NDC,,,facility,both,1,EA,,1040,1040,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Rabavert: 1 Kit In 1 Carton (50632-010-01) * 1 Ml In 1 Syringe (50632-011-01) * 1 Ml In 1 Vial, Glass (50632-013-01)",260,RC,96372,HCPCS,50632-010-01,NDC,facility,both,1,EA,,294,294,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Kit For The Preparation Of Technetium Tc 99M Medronate: 5 Vial, Multi-Dose In 1 Kit (45567-0040-1) / 10 Ml In 1 Vial, Multi-Dose",343,RC,45567-0040-1,NDC,,,facility,both,1,EA,,308.62,308.62,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Kit For The Prepartion Of Technetium Tc99M Sulfur Colloid: 1 Kit In 1 Package (45567-0030-1) * 3 Ml In 1 Vial * 3 Ml In 1 Vial * 10 Ml In 1 Vial,343,RC,45567-0030-1,NDC,,,facility,both,1,EA,,475.2,475.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Adreview: 1 Vial, Glass In 1 Container (17156-235-01) / 5 Ml In 1 Vial, Glass",343,RC,17156-235-01,NDC,,,facility,both,1,EA,,21121.44,21121.44,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Adreview: 1 Vial, Glass In 1 Container (17156-235-01) / 5 Ml In 1 Vial, Glass",343,RC,17156-235-01,NDC,,,facility,both,1,EA,,17829.6,17829.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sodium Iodide: 1 CAPSULE in 1 BOX (17156-201-05) ,343,RC,17156-201-05,NDC,,,facility,both,1,EA,,399.87,399.87,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Fludeoxyglucose F 18: 30 Ml In 1 Vial, Multi-Dose (49609-101-01)",343,RC,49609-101-01,NDC,,,facility,both,1,EA,,450,450,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Fludeoxyglucose F 18: 30 Ml In 1 Vial, Multi-Dose (49609-101-01)",343,RC,49609-101-01,NDC,,,facility,both,1,EA,,613.36,613.36,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Technelite: 1 Vial In 1 Carton (11994-090-01) / 12 Ml In 1 Vial,343,RC,11994-090-01,NDC,,,facility,both,1,EA,,141.18,141.18,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Technescan Mag3: 5 Vial In 1 Cello Pack (69945-096-20) / 1 Injection, Powder, Lyophilized, For Solution In 1 Vial",343,RC,69945-096-20,NDC,,,facility,both,1,EA,,1872.7,1872.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ultratag Rbc: 5 Cello Pack In 1 Box (69945-068-20) / 1 Kit In 1 Cello Pack (69945-068-10) * .6 Ml In 1 Syringe, Glass * 1 Ml In 1 Syringe, Glass * 9.5 Mg In 1 Vial, Glass",343,RC,69945-068-20,NDC,,,facility,both,1,EA,,228,228,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Nephroscan: 5 Vial, Single-Dose In 1 Carton (71083-0020-5) / 1 Injection, Powder, Lyophilized, For Solution In 1 Vial, Single-Dose (71083-0020-1)",343,RC,71083-0020-5,NDC,,,facility,both,1,EA,,3534.18,3534.18,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,343,RC,65174-288-05,NDC,,,facility,both,1,EA,,1325.55,1325.55,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Draximage Maa: 30 Injection, Powder, For Solution In 1 Kit (65174-270-30)",343,RC,65174-270-30,NDC,,,facility,both,1,EA,,1057.53,1057.53,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Drax Exametazime: 5 Vial In 1 Carton (65174-200-05) / 1 Injection, Powder, Lyophilized, For Solution In 1 Vial (65174-200-01)",343,RC,65174-200-05,NDC,,,facility,both,1,EA,,20102.96,20102.96,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Drax Exametazime: 5 Vial In 1 Carton (65174-200-05) / 1 Injection, Powder, Lyophilized, For Solution In 1 Vial (65174-200-01)",343,RC,65174-200-05,NDC,,,facility,both,1,EA,,19053.37,19053.37,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Choletec: 10 Vial In 1 Carton (0270-0083-20) / 1 Injection, Powder, Lyophilized, For Solution In 1 Vial",343,RC,0270-0083-20,NDC,,,facility,both,1,EA,,200.01,200.01,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,634,RC,55513-144-01,NDC,,,facility,both,1,EA,,10.16,10.16,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,634,RC,0069-1311-01,NDC,,,facility,both,1,EA,,9.62,9.62,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,634,RC,0069-1311-01,NDC,,,facility,both,1,EA,,7.35,7.35,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,634,RC,0069-1308-01,NDC,,,facility,both,1,EA,,7.02,7.02,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,634,RC,0069-1308-01,NDC,,,facility,both,1,EA,,6.94,6.94,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,634,RC,0069-1308-01,NDC,,,facility,both,1,EA,,6.63,6.63,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,634,RC,0069-1308-01,NDC,,,facility,both,1,EA,,6.59,6.59,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,634,RC,0069-1308-01,NDC,,,facility,both,1,EA,,6.55,6.55,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,634,RC,0069-1308-01,NDC,,,facility,both,1,EA,,6.28,6.28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,634,RC,0069-1308-01,NDC,,,facility,both,1,EA,,6.2,6.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,634,RC,0069-1308-01,NDC,,,facility,both,1,EA,,5.95,5.95,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,634,RC,0069-1307-01,NDC,,,facility,both,1,EA,,9.39,9.39,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,634,RC,0069-1307-01,NDC,,,facility,both,1,EA,,7.87,7.87,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,634,RC,0069-1307-01,NDC,,,facility,both,1,EA,,7.05,7.05,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,634,RC,0069-1307-01,NDC,,,facility,both,1,EA,,6.7,6.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,634,RC,0069-1307-01,NDC,,,facility,both,1,EA,,6.62,6.62,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,634,RC,0069-1307-01,NDC,,,facility,both,1,EA,,6.62,6.62,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,634,RC,0069-1307-01,NDC,,,facility,both,1,EA,,6.48,6.48,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,634,RC,0069-1307-01,NDC,,,facility,both,1,EA,,6.44,6.44,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,634,RC,0069-1308-01,NDC,,,facility,both,1,EA,,6.24,6.24,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,634,RC,0069-1307-01,NDC,,,facility,both,1,EA,,6.33,6.33,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,634,RC,0069-1306-01,NDC,,,facility,both,1,EA,,6.8,6.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,634,RC,0069-1306-01,NDC,,,facility,both,1,EA,,6.48,6.48,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,634,RC,0069-1306-01,NDC,,,facility,both,1,EA,,6.46,6.46,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,634,RC,0069-1306-01,NDC,,,facility,both,1,EA,,6.4,6.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,634,RC,0069-1305-01,NDC,,,facility,both,1,EA,,15.51,15.51,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,634,RC,0069-1305-01,NDC,,,facility,both,1,EA,,12.43,12.43,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,634,RC,0069-1305-01,NDC,,,facility,both,1,EA,,8.56,8.56,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,634,RC,0069-1305-01,NDC,,,facility,both,1,EA,,8.29,8.29,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,634,RC,0069-1305-01,NDC,,,facility,both,1,EA,,7.34,7.34,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,634,RC,0069-1305-01,NDC,,,facility,both,1,EA,,5.95,5.95,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,634,RC,0069-1305-01,NDC,,,facility,both,1,EA,,5.91,5.91,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,634,RC,0069-1306-01,NDC,,,facility,both,1,EA,,9.31,9.31,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,635,RC,0069-1311-01,NDC,,,facility,both,1,EA,,6.42,6.42,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,635,RC,0069-1308-01,NDC,,,facility,both,1,EA,,6.07,6.07,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,635,RC,0069-1308-01,NDC,,,facility,both,1,EA,,5.95,5.95,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,635,RC,0069-1308-01,NDC,,,facility,both,1,EA,,5.88,5.88,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,635,RC,0069-1307-01,NDC,,,facility,both,1,EA,,6.44,6.44,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,635,RC,0069-1307-01,NDC,,,facility,both,1,EA,,6.38,6.38,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0409-1273-03,NDC,,,facility,both,1,EA,,45.49,45.49,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Bivalirudin: 10 Vial, Single-Dose In 1 Carton (42023-622-10) / 1 Injection, Solution In 1 Vial, Single-Dose",636,RC,42023-622-10,NDC,,,facility,both,1,EA,,1.23,1.23,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Bivalirudin: 1 Vial, Single-Dose In 1 Carton (42023-622-01) / 1 Injection, Solution In 1 Vial, Single-Dose",636,RC,42023-622-01,NDC,,,facility,both,1,EA,,1.23,1.23,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,42023-229-01,NDC,,,facility,both,1,EA,,2.06,2.06,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Posaconazole: 1 Vial, Glass In 1 Carton (42023-195-01) / 16.7 Ml In 1 Vial, Glass",636,RC,42023-195-01,NDC,,,facility,both,1,EA,,1009.36,1009.36,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ganciclovir: 25 Vial, Single-Dose In 1 Carton (42023-173-25) / 10 Ml In 1 Vial, Single-Dose (42023-173-01)",636,RC,42023-173-25,NDC,,,facility,both,1,EA,,70.72,70.72,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Mycophenolate Mofetil: 4 Vial In 1 Carton (42023-172-04) / 20 Ml In 1 Vial,636,RC,42023-172-04,NDC,,,facility,both,1,EA,,5.04,5.04,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Adrenalin: 1 Vial In 1 Carton (42023-168-01) / 30 Ml In 1 Vial,636,RC,42023-168-01,NDC,,,facility,both,1,EA,,3.96,3.96,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Vasostrict: 25 Vial In 1 Carton (42023-164-25) / 1 Ml In 1 Vial (42023-164-01),636,RC,42023-164-25,NDC,,,facility,both,1,EA,,7.32,7.32,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Adrenalin: 25 Vial In 1 Carton (42023-159-25) / 1 Ml In 1 Vial (42023-159-01),636,RC,42023-159-25,NDC,,,facility,both,1,EA,,10.44,10.44,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,42023-159-01,NDC,,,facility,both,1,EA,,12.65,12.65,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Pentamidine Isethionate: 1 Vial, Single-Dose In 1 Carton (39822-3030-2) / 6 Ml In 1 Vial, Single-Dose (39822-3030-1)",636,RC,39822-3030-2,NDC,,,facility,both,1,EA,,487,487,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Pentamidine Isethionate: 1 Vial, Single-Dose In 1 Carton (39822-3030-2) / 6 Ml In 1 Vial, Single-Dose (39822-3030-1)",636,RC,39822-3030-2,NDC,,,facility,both,1,EA,,485.72,485.72,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,39822-3030-1,NDC,,,facility,both,1,EA,,481.02,481.02,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Dactinomycin: 1 Vial, Single-Dose In 1 Carton (39822-2100-2) / 1 Ml In 1 Vial, Single-Dose (39822-2100-1)",636,RC,39822-2100-2,NDC,,,facility,both,1,EA,,2029.21,2029.21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Dactinomycin: 1 Vial, Single-Dose In 1 Carton (39822-2100-2) / 1 Ml In 1 Vial, Single-Dose (39822-2100-1)",636,RC,39822-2100-2,NDC,,,facility,both,1,EA,,2029.04,2029.04,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,39822-2100-1,NDC,,,facility,both,1,EA,,2141.59,2141.59,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Folic Acid: 1 Vial, Multi-Dose In 1 Carton (39822-1100-1) / 10 Ml In 1 Vial, Multi-Dose",636,RC,39822-1100-1,NDC,,,facility,both,1,EA,,5.68,5.68,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Prednisolone Sodium Phosphate: 237 Ml In 1 Bottle, Plastic (42799-815-01)",636,RC,42799-815-01,NDC,,,facility,both,1,EA,,4.96,4.96,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Daunorubicin Hydrochloride: 10 Vial In 1 Carton (42658-021-02) / 4 Ml In 1 Vial,636,RC,42658-021-02,NDC,,,facility,both,1,EA,,172.24,172.24,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Daunorubicin Hydrochloride: 10 Vial In 1 Carton (42658-021-02) / 4 Ml In 1 Vial,636,RC,42658-021-02,NDC,,,facility,both,1,EA,,146.93,146.93,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Daunorubicin Hydrochloride: 10 Vial In 1 Carton (42658-021-02) / 4 Ml In 1 Vial,636,RC,42658-021-02,NDC,,,facility,both,1,EA,,136.22,136.22,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Daunorubicin Hydrochloride: 1 Vial In 1 Box (42658-021-01) / 4 Ml In 1 Vial,636,RC,42658-021-01,NDC,,,facility,both,1,EA,,249.43,249.43,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Daunorubicin Hydrochloride: 1 Vial In 1 Box (42658-021-01) / 4 Ml In 1 Vial,636,RC,42658-021-01,NDC,,,facility,both,1,EA,,207.2,207.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Daunorubicin Hydrochloride: 1 Vial In 1 Box (42658-021-01) / 4 Ml In 1 Vial,636,RC,42658-021-01,NDC,,,facility,both,1,EA,,192.33,192.33,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Dactinomycin: 1 Vial In 1 Carton (42658-008-01) / 1 Injection, Powder, Lyophilized, For Solution In 1 Vial",636,RC,42658-008-01,NDC,,,facility,both,1,EA,,1660.73,1660.73,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Dactinomycin: 1 Vial In 1 Carton (42658-008-01) / 1 Injection, Powder, Lyophilized, For Solution In 1 Vial",636,RC,42658-008-01,NDC,,,facility,both,1,EA,,1621.69,1621.69,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Amphotericin B: 10 Ml In 1 Vial (39822-1055-5),636,RC,39822-1055-5,NDC,,,facility,both,1,EA,,68.02,68.02,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,42494-415-01,NDC,,,facility,both,1,EA,,51.46,51.46,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,39822-1030-1,NDC,,,facility,both,1,EA,,817.55,817.55,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Acetazolamide: 1 Vial, Glass In 1 Carton (39822-0190-1) / 5 Ml In 1 Vial, Glass",636,RC,39822-0190-1,NDC,,,facility,both,1,EA,,36.68,36.68,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Olanzapine: 1 Vial In 1 Carton (31722-308-01) / 2 Ml In 1 Vial,636,RC,31722-308-01,NDC,,,facility,both,1,EA,,6.41,6.41,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Olanzapine: 1 Vial In 1 Carton (31722-308-01) / 2 Ml In 1 Vial,636,RC,31722-308-01,NDC,,,facility,both,1,EA,,4.04,4.04,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,31722-205-31,NDC,,,facility,both,1,EA,,1.51,1.51,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Acetaminophen: 24 Vial, Single-Dose In 1 Carton (31722-205-24) / 100 Ml In 1 Vial, Single-Dose (31722-205-31)",636,RC,31722-205-24,NDC,,,facility,both,1,EA,,1.24,1.24,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Promethazine Hydrochloride: 473 Ml In 1 Bottle (27808-051-02),636,RC,27808-051-02,NDC,,,facility,both,1,EA,,12.8,12.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Labetalol Hydrochloride: 10 Vial In 1 Carton (36000-320-10) / 4 Ml In 1 Vial (36000-320-01),636,RC,36000-320-10,NDC,,,facility,both,1,EA,,13.58,13.58,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,36000-320-01,NDC,,,facility,both,1,EA,,18.22,18.22,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,36000-308-01,NDC,,,facility,both,1,EA,,3.56,3.56,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Furosemide: 25 Vial, Single-Dose In 1 Box (36000-284-25) / 10 Ml In 1 Vial, Single-Dose",636,RC,36000-284-25,NDC,,,facility,both,1,EA,,1.04,1.04,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Furosemide: 25 Vial, Single-Dose In 1 Box (36000-282-25) / 2 Ml In 1 Vial, Single-Dose",636,RC,36000-282-25,NDC,,,facility,both,1,EA,,17.06,17.06,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Furosemide: 25 Vial, Single-Dose In 1 Box (36000-282-25) / 2 Ml In 1 Vial, Single-Dose",636,RC,36000-282-25,NDC,,,facility,both,1,EA,,0.17,0.17,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Tobramycin: 1 Vial, Multi-Dose In 1 Carton (36000-242-01) / 30 Ml In 1 Vial, Multi-Dose",636,RC,36000-242-01,NDC,,,facility,both,1,EA,,21.18,21.18,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Ciprofloxacin: 200 Ml In 1 Bag (36000-009-24),636,RC,36000-009-24,NDC,,,facility,both,1,EA,,29.9,29.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Acyclovir: 473 Ml In 1 Bottle (31722-681-47),636,RC,31722-681-47,NDC,,,facility,both,1,EA,,10.09,10.09,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,36000-063-01,NDC,,,facility,both,1,EA,,22.94,22.94,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,44206-452-91,NDC,,,facility,both,1,EA,,86.24,86.24,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Privigen: 1 Vial, Glass In 1 Carton (44206-436-05) / 50 Ml In 1 Vial, Glass (44206-436-90)",636,RC,44206-436-05,NDC,,,facility,both,1,EA,,319.18,319.18,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,44206-310-91,NDC,,,facility,both,1,EA,,229.64,229.64,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,44206-310-91,NDC,,,facility,both,1,EA,,221.65,221.65,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Alburx: 1 Vial, Glass In 1 Carton (44206-310-50) / 500 Ml In 1 Vial, Glass (44206-310-91)",636,RC,44206-310-50,NDC,,,facility,both,1,EA,,227.02,227.02,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Alburx: 1 Vial, Glass In 1 Carton (44206-310-50) / 500 Ml In 1 Vial, Glass (44206-310-91)",636,RC,44206-310-50,NDC,,,facility,both,1,EA,,125.23,125.23,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Alburx: 1 Vial, Glass In 1 Carton (44206-310-50) / 500 Ml In 1 Vial, Glass (44206-310-91)",636,RC,44206-310-50,NDC,,,facility,both,1,EA,,122.02,122.02,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Alburx: 1 Vial, Glass In 1 Carton (44206-310-25) / 250 Ml In 1 Vial, Glass (44206-310-90)",636,RC,44206-310-25,NDC,,,facility,both,1,EA,,157.54,157.54,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Alburx: 1 Vial, Glass In 1 Carton (44206-310-25) / 250 Ml In 1 Vial, Glass (44206-310-90)",636,RC,44206-310-25,NDC,,,facility,both,1,EA,,131.68,131.68,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Alburx: 1 Vial, Glass In 1 Carton (44206-310-25) / 250 Ml In 1 Vial, Glass (44206-310-90)",636,RC,44206-310-25,NDC,,,facility,both,1,EA,,49.25,49.25,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Alburx: 1 Vial, Glass In 1 Carton (44206-310-25) / 250 Ml In 1 Vial, Glass (44206-310-90)",636,RC,44206-310-25,NDC,,,facility,both,1,EA,,46.26,46.26,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Alburx: 1 Vial, Glass In 1 Carton (44206-251-10) / 100 Ml In 1 Vial, Glass (44206-251-91)",636,RC,44206-251-10,NDC,,,facility,both,1,EA,,237.81,237.81,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Alburx: 1 Vial, Glass In 1 Carton (44206-251-10) / 100 Ml In 1 Vial, Glass (44206-251-91)",636,RC,44206-251-10,NDC,,,facility,both,1,EA,,223.51,223.51,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Alburx: 1 Vial, Glass In 1 Carton (44206-251-05) / 50 Ml In 1 Vial, Glass (44206-251-90)",636,RC,44206-251-05,NDC,,,facility,both,1,EA,,252.11,252.11,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Alburx: 1 Vial, Glass In 1 Carton (44206-251-05) / 50 Ml In 1 Vial, Glass (44206-251-90)",636,RC,44206-251-05,NDC,,,facility,both,1,EA,,252.11,252.11,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ofirmev: 24 VIAL, GLASS in 1 CARTON (43825-102-01) / 100 mL in 1 VIAL, GLASS",636,RC,43825-102-01,NDC,,,facility,both,1,EA,,1.1,1.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,43598-931-11,NDC,,,facility,both,1,EA,,46.49,46.49,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,43598-931-11,NDC,,,facility,both,1,EA,,32.48,32.48,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,43598-914-11,NDC,,,facility,both,1,EA,,4.82,4.82,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,43598-901-11,NDC,,,facility,both,1,EA,,45.91,45.91,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,43598-848-11,NDC,,,facility,both,1,EA,,143.61,143.61,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Methocarbamol: 10 Vial In 1 Carton (43598-839-36) / 10 Ml In 1 Vial (43598-839-11),636,RC,43598-839-36,NDC,,,facility,both,1,EA,,39.81,39.81,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,43598-839-11,NDC,,,facility,both,1,EA,,68.45,68.45,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Naloxone Hydrochloride: 1 Syringe In 1 Box (43598-750-11) / 2 Ml In 1 Syringe,636,RC,43598-750-11,NDC,,,facility,both,1,EA,,0.37,0.37,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,44206-454-92,NDC,,,facility,both,1,EA,,86.6,86.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Piperacillin And Tazobactam: 10 Vial In 1 Box (44567-802-10) / 1 Injection, Powder, For Solution In 1 Vial",636,RC,44567-802-10,NDC,,,facility,both,1,EA,,25.87,25.87,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Cefazolin: 25 Vial In 1 Carton (44567-707-25) / 1 Injection, Powder, For Solution In 1 Vial",636,RC,44567-707-25,NDC,,,facility,both,1,EA,,19.63,19.63,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Calcium Gluconate In Sodium Chloride: 24 Pouch In 1 Carton (44567-620-24) / 1 Bag In 1 Pouch (44567-620-01) / 50 Ml In 1 Bag,636,RC,44567-620-24,NDC,,,facility,both,1,EA,,0.67,0.67,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,44567-620-01,NDC,,,facility,both,1,EA,,0.69,0.69,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,44567-451-01,NDC,,,facility,both,1,EA,,2.79,2.79,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,44567-450-01,NDC,,,facility,both,1,EA,,1.92,1.92,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Levofloxacin: 24 Pouch In 1 Carton (44567-435-24) / 1 Bag In 1 Pouch / 50 Ml In 1 Bag,636,RC,44567-435-24,NDC,,,facility,both,1,EA,,46.01,46.01,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Magnesium Sulfate In Water: 24 Pouch In 1 Carton (44567-420-24) / 1 Bag In 1 Pouch / 50 Ml In 1 Bag,636,RC,44567-420-24,NDC,,,facility,both,1,EA,,21.1,21.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Ceftazidime: 6 Vial In 1 Carton (44567-237-06) / 100 Ml In 1 Vial,636,RC,44567-237-06,NDC,,,facility,both,1,EA,,14.06,14.06,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ceftazidime: 10 Vial In 1 Carton (44567-236-10) / 1 Injection, Powder, For Solution In 1 Vial",636,RC,44567-236-10,NDC,,,facility,both,1,EA,,18.95,18.95,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Ampicillin: 1 Vial In 1 Carton (44567-104-01) / 100 Ml In 1 Vial,636,RC,44567-104-01,NDC,,,facility,both,1,EA,,13.82,13.82,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ampicillin: 10 Vial In 1 Tray (44567-101-10) / 1 Injection, Powder, For Solution In 1 Vial",636,RC,44567-101-10,NDC,,,facility,both,1,EA,,31.76,31.76,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,44206-458-96,NDC,,,facility,both,1,EA,,91.49,91.49,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,44567-620-01,NDC,,,facility,both,1,EA,,0.68,0.68,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Lacosamide: 10 Vial, Single-Dose In 1 Carton (43598-087-58) / 20 Ml In 1 Vial, Single-Dose (43598-087-11)",636,RC,43598-087-58,NDC,,,facility,both,1,EA,,3.18,3.18,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,43598-087-11,NDC,,,facility,both,1,EA,,0.88,0.88,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Desmopressin Acetate: 1 Vial In 1 Carton (43598-053-11) / 10 Ml In 1 Vial,636,RC,43598-053-11,NDC,,,facility,both,1,EA,,21.74,21.74,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Desmopressin Acetate: 1 Vial In 1 Carton (43598-053-11) / 10 Ml In 1 Vial,636,RC,43598-053-11,NDC,,,facility,both,1,EA,,21.35,21.35,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Calcitonin Salmon: 1 Vial, Multi-Dose In 1 Carton (43598-051-11) / 2 Ml In 1 Vial, Multi-Dose",636,RC,43598-051-11,NDC,,,facility,both,1,EA,,1013.85,1013.85,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Glycopyrrolate: 25 Vial, Single-Dose In 1 Carton (43547-544-25) / 2 Ml In 1 Vial, Single-Dose (43547-544-01)",636,RC,43547-544-25,NDC,,,facility,both,1,EA,,19.63,19.63,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Glycopyrrolate: 25 Vial, Single-Dose In 1 Carton (43547-544-25) / 2 Ml In 1 Vial, Single-Dose (43547-544-01)",636,RC,43547-544-25,NDC,,,facility,both,1,EA,,18.5,18.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Glycopyrrolate: 25 Vial, Single-Dose In 1 Carton (43547-544-25) / 2 Ml In 1 Vial, Single-Dose (43547-544-01)",636,RC,43547-544-25,NDC,,,facility,both,1,EA,,12.25,12.25,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Glycopyrrolate: 25 Vial, Single-Dose In 1 Carton (43547-544-25) / 2 Ml In 1 Vial, Single-Dose (43547-544-01)",636,RC,43547-544-25,NDC,,,facility,both,1,EA,,3.07,3.07,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Diazepam: 10 Syringe, Glass In 1 Carton (43598-106-10) / 2 Ml In 1 Syringe, Glass (43598-106-11)",636,RC,43598-106-10,NDC,,,facility,both,1,EA,,41.51,41.51,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Glycopyrrolate: 25 Vial, Single-Dose In 1 Carton (43547-544-25) / 2 Ml In 1 Vial, Single-Dose (43547-544-01)",636,RC,43547-544-25,NDC,,,facility,both,1,EA,,2.91,2.91,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,43547-544-01,NDC,,,facility,both,1,EA,,21.4,21.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,43547-544-01,NDC,,,facility,both,1,EA,,3.14,3.14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,43547-544-01,NDC,,,facility,both,1,EA,,2.95,2.95,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Nexterone: 100 Ml In 1 Bag (43066-150-10),636,RC,43066-150-10,NDC,,,facility,both,1,EA,,35.28,35.28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,43066-090-01,NDC,,,facility,both,1,EA,,40.28,40.28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,43066-015-01,NDC,,,facility,both,1,EA,,1.88,1.88,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,43547-544-01,NDC,,,facility,both,1,EA,,24.27,24.27,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,43598-106-11,NDC,,,facility,both,1,EA,,39.66,39.66,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Nelarabine: 1 Vial, Single-Dose In 1 Carton (43598-142-11) / 50 Ml In 1 Vial, Single-Dose",636,RC,43598-142-11,NDC,,,facility,both,1,EA,,291.17,291.17,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Thiotepa: 1 Vial In 1 Carton (43598-650-11) / 1 Injection, Powder, Lyophilized, For Solution In 1 Vial",636,RC,43598-650-11,NDC,,,facility,both,1,EA,,751.94,751.94,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,43598-637-52,NDC,,,facility,both,1,EA,,1.16,1.16,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Levetiracetam: 10 Bag In 1 Carton (43598-637-10) / 100 Ml In 1 Bag (43598-637-52),636,RC,43598-637-10,NDC,,,facility,both,1,EA,,0.83,0.83,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Nelarabine: 1 Vial, Single-Dose In 1 Carton (43598-142-11) / 50 Ml In 1 Vial, Single-Dose",636,RC,43598-142-11,NDC,,,facility,both,1,EA,,283.57,283.57,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Bortezomib: 1 Vial, Single-Dose In 1 Carton (43598-426-60) / 1 Injection, Powder, Lyophilized, For Solution In 1 Vial, Single-Dose",636,RC,43598-426-60,NDC,,,facility,both,1,EA,,16.74,16.74,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Bortezomib: 1 Vial, Single-Dose In 1 Carton (43598-426-60) / 1 Injection, Powder, Lyophilized, For Solution In 1 Vial, Single-Dose",636,RC,43598-426-60,NDC,,,facility,both,1,EA,,3.01,3.01,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Daptomycin: 1 Vial, Single-Dose In 1 Carton (43598-413-11) / 10 Ml In 1 Vial, Single-Dose",636,RC,43598-413-11,NDC,,,facility,both,1,EA,,1.06,1.06,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Daptomycin: 1 Vial, Single-Dose In 1 Carton (43598-413-11) / 10 Ml In 1 Vial, Single-Dose",636,RC,43598-413-11,NDC,,,facility,both,1,EA,,0.38,0.38,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,43598-405-11,NDC,,,facility,both,1,EA,,17.31,17.31,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Azacitidine: 1 Injection, Powder, Lyophilized, For Solution In 1 Carton (43598-305-62)",636,RC,43598-305-62,NDC,,,facility,both,1,EA,,15.39,15.39,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Nelarabine: 1 Vial, Single-Dose In 1 Carton (43598-142-11) / 50 Ml In 1 Vial, Single-Dose",636,RC,43598-142-11,NDC,,,facility,both,1,EA,,323.01,323.01,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Nelarabine: 1 Vial, Single-Dose In 1 Carton (43598-142-11) / 50 Ml In 1 Vial, Single-Dose",636,RC,43598-142-11,NDC,,,facility,both,1,EA,,316.87,316.87,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Bortezomib: 1 Vial, Single-Dose In 1 Carton (43598-426-60) / 1 Injection, Powder, Lyophilized, For Solution In 1 Vial, Single-Dose",636,RC,43598-426-60,NDC,,,facility,both,1,EA,,11.69,11.69,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Labetalol Hydrochloride: 1 VIAL, MULTI-DOSE in 1 BOX (17478-420-20) / 20 mL in 1 VIAL, MULTI-DOSE",636,RC,17478-420-20,NDC,,,facility,both,1,EA,,35.66,35.66,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Methadone Hydrochloride: 20 mL in 1 VIAL, MULTI-DOSE (17478-380-20) ",636,RC,17478-380-20,NDC,,,facility,both,1,EA,,58.39,58.39,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sodium Chloride: 250 Ml In 1 Bag (17271-701-05),636,RC,17271-701-05,NDC,,,facility,both,1,EA,,64.98,64.98,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Atropine Sulfate: 25 Vial, Single-Dose In 1 Carton (16729-526-08) / 1 Ml In 1 Vial, Single-Dose",636,RC,16729-526-08,NDC,,,facility,both,1,EA,,1.34,1.34,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Busulfan: 8 Vial, Single-Dose In 1 Carton (16729-351-92) / 10 Ml In 1 Vial, Single-Dose (16729-351-03)",636,RC,16729-351-92,NDC,,,facility,both,1,EA,,4.6,4.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,16729-351-03,NDC,,,facility,both,1,EA,,6.89,6.89,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Cisplatin: 50 Ml In 1 Vial (16729-288-11),636,RC,16729-288-11,NDC,,,facility,both,1,EA,,43.02,43.02,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Methotrexate: 1 Vial In 1 Carton (16729-277-30) / 2 Ml In 1 Vial,636,RC,16729-277-30,NDC,,,facility,both,1,EA,,172.94,172.94,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ondansetron: 2.5 Ml In 1 Syringe, Plastic (17856-0691-4)",636,RC,17856-0691-4,NDC,,,facility,both,1,EA,,13.41,13.41,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ondansetron: 60 Syringe In 1 Box, Unit-Dose (17856-0691-8) / 2.5 Ml In 1 Syringe",636,RC,17856-0691-8,NDC,,,facility,both,1,EA,,15.69,15.69,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,17856-0759-2,NDC,,,facility,both,1,EA,,2.72,2.72,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Acetazolamide: 5 Ml In 1 Vial, Glass (23155-313-31)",636,RC,23155-313-31,NDC,,,facility,both,1,EA,,35.73,35.73,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,23155-294-31,NDC,,,facility,both,1,EA,,38.92,38.92,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,23155-290-31,NDC,,,facility,both,1,EA,,8.67,8.67,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,23155-240-31,NDC,,,facility,both,1,EA,,31.55,31.55,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Cidofovir Dihydrate: 5 Ml In 1 Vial, Glass (23155-216-31)",636,RC,23155-216-31,NDC,,,facility,both,1,EA,,439.79,439.79,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Cidofovir Dihydrate: 5 Ml In 1 Vial, Glass (23155-216-31)",636,RC,23155-216-31,NDC,,,facility,both,1,EA,,367.82,367.82,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Flulaval 2025/2026: 10 Syringe In 1 Carton (19515-904-52) / .5 Ml In 1 Syringe (19515-904-41),636,RC,19515-904-52,NDC,,,facility,both,1,EA,,116.52,116.52,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,19515-904-41,NDC,,,facility,both,1,EA,,116.52,116.52,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,19515-810-41,NDC,,,facility,both,1,EA,,123.35,123.35,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,18657-117-01,NDC,,,facility,both,1,EA,,1.92,1.92,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Etoposide: 1 Vial, Multi-Dose In 1 Box (16729-114-11) / 50 Ml In 1 Vial, Multi-Dose",636,RC,16729-114-11,NDC,,,facility,both,1,EA,,16.46,16.46,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,16714-690-01,NDC,,,facility,both,1,EA,,0.78,0.78,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ondansetron: 1 Bottle, Plastic In 1 Carton (16714-671-02) / 50 Ml In 1 Bottle, Plastic",636,RC,16714-671-02,NDC,,,facility,both,1,EA,,6.06,6.06,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,16714-309-01,NDC,,,facility,both,1,EA,,8.15,8.15,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,23155-547-31,NDC,,,facility,both,1,EA,,6.01,6.01,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Etoposide: 1 Vial, Multi-Dose In 1 Box (16729-114-08) / 25 Ml In 1 Vial, Multi-Dose",636,RC,16729-114-08,NDC,,,facility,both,1,EA,,19.82,19.82,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Tacrolimus: 100 Capsule In 1 Bottle (16729-043-01),636,RC,16729-043-01,NDC,,,facility,both,1,EA,,8.65,8.65,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Bleomycin: 1 Vial, Single-Dose In 1 Carton (16714-908-01) / 30 Powder, For Solution In 1 Vial, Single-Dose",636,RC,16714-908-01,NDC,,,facility,both,1,EA,,199.31,199.31,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Bleomycin: 1 Vial, Single-Dose In 1 Carton (16714-886-01) / 15 Powder, For Solution In 1 Vial, Single-Dose",636,RC,16714-886-01,NDC,,,facility,both,1,EA,,284.62,284.62,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Cyclophosphamide: 1 Vial, Single-Dose In 1 Carton (16714-859-01) / 25 Ml In 1 Vial, Single-Dose",636,RC,16714-859-01,NDC,,,facility,both,1,EA,,7.26,7.26,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Cyclophosphamide: 1 Vial, Single-Dose In 1 Carton (16714-859-01) / 25 Ml In 1 Vial, Single-Dose",636,RC,16714-859-01,NDC,,,facility,both,1,EA,,5.38,5.38,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Cyclophosphamide: 1 Vial, Single-Dose In 1 Carton (16714-857-01) / 50 Ml In 1 Vial, Single-Dose",636,RC,16714-857-01,NDC,,,facility,both,1,EA,,7.48,7.48,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Cyclophosphamide: 1 Vial, Single-Dose In 1 Carton (16714-857-01) / 50 Ml In 1 Vial, Single-Dose",636,RC,16714-857-01,NDC,,,facility,both,1,EA,,4.83,4.83,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Cyclophosphamide: 1 Vial, Single-Dose In 1 Carton (16714-857-01) / 50 Ml In 1 Vial, Single-Dose",636,RC,16714-857-01,NDC,,,facility,both,1,EA,,3.36,3.36,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Palonosetron: 1 Vial, Single-Use In 1 Carton (16714-834-01) / 5 Ml In 1 Vial, Single-Use",636,RC,16714-834-01,NDC,,,facility,both,1,EA,,7.18,7.18,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,23155-600-31,NDC,,,facility,both,1,EA,,23.5,23.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,23155-601-32,NDC,,,facility,both,1,EA,,0.9,0.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Bumetanide: 10 Vial In 1 Carton (25021-321-10) / 10 Ml In 1 Vial,636,RC,25021-321-10,NDC,,,facility,both,1,EA,,7.47,7.47,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Bumetanide: 10 Vial In 1 Carton (25021-321-10) / 10 Ml In 1 Vial,636,RC,25021-321-10,NDC,,,facility,both,1,EA,,2.37,2.37,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Bumetanide: 10 Vial In 1 Carton (25021-321-04) / 4 Ml In 1 Vial,636,RC,25021-321-04,NDC,,,facility,both,1,EA,,29.57,29.57,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Bumetanide: 10 Vial In 1 Carton (25021-321-04) / 4 Ml In 1 Vial,636,RC,25021-321-04,NDC,,,facility,both,1,EA,,10.16,10.16,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Milrinone Lactate In Dextrose: 10 Bag In 1 Carton (25021-313-82) / 100 Ml In 1 Bag,636,RC,25021-313-82,NDC,,,facility,both,1,EA,,23.77,23.77,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Esmolol Hydrochloride: 10 Bag In 1 Carton (25021-308-84) / 250 Ml In 1 Bag,636,RC,25021-308-84,NDC,,,facility,both,1,EA,,1.78,1.78,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Chlorothiazide Sodium: 1 Vial In 1 Carton (25021-305-20) / 18 Ml In 1 Vial,636,RC,25021-305-20,NDC,,,facility,both,1,EA,,43.79,43.79,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Nelarabine: 1 Vial In 1 Carton (25021-259-50) / 50 Ml In 1 Vial,636,RC,25021-259-50,NDC,,,facility,both,1,EA,,315.82,315.82,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Cisplatin: 1 Vial In 1 Carton (25021-253-50) / 50 Ml In 1 Vial,636,RC,25021-253-50,NDC,,,facility,both,1,EA,,49.04,49.04,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Cyclophosphamide: 1 Vial In 1 Carton (25021-249-51) / 100 Ml In 1 Vial,636,RC,25021-249-51,NDC,,,facility,both,1,EA,,2.99,2.99,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Cyclophosphamide: 1 Vial In 1 Carton (25021-249-51) / 100 Ml In 1 Vial,636,RC,25021-249-51,NDC,,,facility,both,1,EA,,2.91,2.91,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Cyclophosphamide: 1 Vial In 1 Carton (25021-249-51) / 100 Ml In 1 Vial,636,RC,25021-249-51,NDC,,,facility,both,1,EA,,2.87,2.87,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Cyclophosphamide: 1 Vial In 1 Carton (25021-249-51) / 100 Ml In 1 Vial,636,RC,25021-249-51,NDC,,,facility,both,1,EA,,2.54,2.54,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Cyclophosphamide: 1 Vial In 1 Carton (25021-249-51) / 100 Ml In 1 Vial,636,RC,25021-249-51,NDC,,,facility,both,1,EA,,2.21,2.21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Cyclophosphamide: 1 Vial In 1 Carton (25021-249-51) / 100 Ml In 1 Vial,636,RC,25021-249-51,NDC,,,facility,both,1,EA,,1.85,1.85,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Cyclophosphamide: 1 Vial In 1 Carton (25021-248-51) / 50 Ml In 1 Vial,636,RC,25021-248-51,NDC,,,facility,both,1,EA,,3.78,3.78,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Cyclophosphamide: 1 Vial In 1 Carton (25021-248-51) / 50 Ml In 1 Vial,636,RC,25021-248-51,NDC,,,facility,both,1,EA,,3.66,3.66,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Cyclophosphamide: 1 Vial In 1 Carton (25021-248-51) / 50 Ml In 1 Vial,636,RC,25021-248-51,NDC,,,facility,both,1,EA,,2.94,2.94,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Cyclophosphamide: 1 Vial In 1 Carton (25021-248-51) / 50 Ml In 1 Vial,636,RC,25021-248-51,NDC,,,facility,both,1,EA,,2.83,2.83,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Cyclophosphamide: 1 Vial In 1 Carton (25021-247-50) / 25 Ml In 1 Vial,636,RC,25021-247-50,NDC,,,facility,both,1,EA,,4.12,4.12,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Cyclophosphamide: 1 Vial In 1 Carton (25021-247-50) / 25 Ml In 1 Vial,636,RC,25021-247-50,NDC,,,facility,both,1,EA,,3.55,3.55,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Cyclophosphamide: 1 Vial In 1 Carton (25021-247-50) / 25 Ml In 1 Vial,636,RC,25021-247-50,NDC,,,facility,both,1,EA,,3,3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Cyclophosphamide: 1 Vial In 1 Carton (25021-247-50) / 25 Ml In 1 Vial,636,RC,25021-247-50,NDC,,,facility,both,1,EA,,3,3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Cyclophosphamide: 1 Vial In 1 Carton (25021-247-50) / 25 Ml In 1 Vial,636,RC,25021-247-50,NDC,,,facility,both,1,EA,,3,3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Thiotepa: 1 Vial In 1 Carton (25021-246-02) / 1.5 Ml In 1 Vial,636,RC,25021-246-02,NDC,,,facility,both,1,EA,,78.42,78.42,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Heparin Sodium: 25 Vial In 1 Carton (25021-401-02) / 2 Ml In 1 Vial,636,RC,25021-401-02,NDC,,,facility,both,1,EA,,26.28,26.28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Heparin Sodium: 25 Vial In 1 Carton (25021-402-01) / 1 Ml In 1 Vial,636,RC,25021-402-01,NDC,,,facility,both,1,EA,,6.62,6.62,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Enoxaparin Sodium: 10 Syringe In 1 Carton (25021-410-70) / .3 Ml In 1 Syringe,636,RC,25021-410-70,NDC,,,facility,both,1,EA,,14.11,14.11,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Enoxaparin Sodium: 10 Syringe In 1 Carton (25021-410-78) / .8 Ml In 1 Syringe,636,RC,25021-410-78,NDC,,,facility,both,1,EA,,8.11,8.11,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ultomiris: 1 Vial, Glass In 1 Carton (25682-025-01) / 3 Ml In 1 Vial, Glass",636,RC,25682-025-01,NDC,,,facility,both,1,EA,,1341.59,1341.59,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ultomiris: 1 Vial, Glass In 1 Carton (25682-025-01) / 3 Ml In 1 Vial, Glass",636,RC,25682-025-01,NDC,,,facility,both,1,EA,,1324.2,1324.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Kanuma: 1 Vial, Glass In 1 Carton (25682-007-01) / 10 Ml In 1 Vial, Glass",636,RC,25682-007-01,NDC,,,facility,both,1,EA,,3588.18,3588.18,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Kanuma: 1 Vial, Glass In 1 Carton (25682-007-01) / 10 Ml In 1 Vial, Glass",636,RC,25682-007-01,NDC,,,facility,both,1,EA,,3148.98,3148.98,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Kanuma: 1 Vial, Glass In 1 Carton (25682-007-01) / 10 Ml In 1 Vial, Glass",636,RC,25682-007-01,NDC,,,facility,both,1,EA,,3106.86,3106.86,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Kanuma: 1 Vial, Glass In 1 Carton (25682-007-01) / 10 Ml In 1 Vial, Glass",636,RC,25682-007-01,NDC,,,facility,both,1,EA,,3100.34,3100.34,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Soliris: 1 Vial In 1 Carton (25682-001-01) / 30 Ml In 1 Vial,636,RC,25682-001-01,NDC,,,facility,both,1,EA,,1387.59,1387.59,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Soliris: 1 Vial In 1 Carton (25682-001-01) / 30 Ml In 1 Vial,636,RC,25682-001-01,NDC,,,facility,both,1,EA,,447.55,447.55,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Soliris: 1 Vial In 1 Carton (25682-001-01) / 30 Ml In 1 Vial,636,RC,25682-001-01,NDC,,,facility,both,1,EA,,307.75,307.75,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Thiotepa: 1 Vial In 1 Carton (25021-246-02) / 1.5 Ml In 1 Vial,636,RC,25021-246-02,NDC,,,facility,both,1,EA,,78.42,78.42,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Fomepizole: 1 Vial In 1 Carton (25021-829-02) / 1.5 Ml In 1 Vial,636,RC,25021-829-02,NDC,,,facility,both,1,EA,,44.44,44.44,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Acetylcysteine: 4 Vial In 1 Carton (25021-812-30) / 30 Ml In 1 Vial,636,RC,25021-812-30,NDC,,,facility,both,1,EA,,2.58,2.58,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Acetylcysteine: 4 Vial In 1 Carton (25021-812-30) / 30 Ml In 1 Vial,636,RC,25021-812-30,NDC,,,facility,both,1,EA,,2.15,2.15,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Lacosamide: 10 Vial, Glass In 1 Carton (25021-791-20) / 20 Ml In 1 Vial, Glass",636,RC,25021-791-20,NDC,,,facility,both,1,EA,,0.74,0.74,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Prochlorperazine Edisylate: 10 Vial In 1 Carton (25021-790-02) / 2 Ml In 1 Vial,636,RC,25021-790-02,NDC,,,facility,both,1,EA,,36.3,36.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Ketorolac Tromethamine: 25 Vial In 1 Carton (25021-700-01) / 1 Ml In 1 Vial,636,RC,25021-700-01,NDC,,,facility,both,1,EA,,27.73,27.73,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Ketorolac Tromethamine: 25 Vial In 1 Carton (25021-700-01) / 1 Ml In 1 Vial,636,RC,25021-700-01,NDC,,,facility,both,1,EA,,25.71,25.71,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Vecuronium Bromide: 10 Vial In 1 Carton (25021-686-20) / 20 Ml In 1 Vial,636,RC,25021-686-20,NDC,,,facility,both,1,EA,,113.91,113.91,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Pentobarbital Sodium: 1 Vial In 1 Carton (25021-676-50) / 50 Ml In 1 Vial,636,RC,25021-676-50,NDC,,,facility,both,1,EA,,126.05,126.05,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Magnesium Sulfate: 10 Bag In 1 Carton (25021-612-81) / 50 Ml In 1 Bag,636,RC,25021-612-81,NDC,,,facility,both,1,EA,,11.76,11.76,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Caffeine Citrate: 10 Vial In 1 Carton (25021-602-03) / 3 Ml In 1 Vial,636,RC,25021-602-03,NDC,,,facility,both,1,EA,,7.26,7.26,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Caffeine Citrate: 1 Vial In 1 Carton (25021-601-03) / 3 Ml In 1 Vial,636,RC,25021-601-03,NDC,,,facility,both,1,EA,,12.27,12.27,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Leucovorin Calcium: 1 Vial In 1 Carton (25021-816-30) / 17.5 Ml In 1 Vial,636,RC,25021-816-30,NDC,,,facility,both,1,EA,,19.71,19.71,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Docetaxel: 1 Vial In 1 Carton (25021-245-04) / 4 Ml In 1 Vial,636,RC,25021-245-04,NDC,,,facility,both,1,EA,,3.96,3.96,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Docetaxel: 1 Vial In 1 Carton (25021-245-04) / 4 Ml In 1 Vial,636,RC,25021-245-04,NDC,,,facility,both,1,EA,,2.86,2.86,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Busulfan: 8 Vial In 1 Carton (25021-241-10) / 10 Ml In 1 Vial,636,RC,25021-241-10,NDC,,,facility,both,1,EA,,51.64,51.64,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Miochol E: 1 Kit In 1 Blister Pack (24208-539-20) * 2 Ml In 1 Vial * 2 Ml In 1 Ampule,636,RC,24208-539-20,NDC,,,facility,both,1,EA,,512.52,512.52,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Calcitonin Salmon: 1 Vial, Multi-Dose In 1 Carton (24201-400-02) / 2 Ml In 1 Vial, Multi-Dose",636,RC,24201-400-02,NDC,,,facility,both,1,EA,,109.05,109.05,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Acetaminophen: 24 Vial, Glass In 1 Carton (24201-100-24) / 100 Ml In 1 Vial, Glass",636,RC,24201-100-24,NDC,,,facility,both,1,EA,,0.64,0.64,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,24201-100-01,NDC,,,facility,both,1,EA,,1.22,1.22,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Pentobarbital Sodium: 1 Vial In 1 Carton (24201-010-20) / 20 Ml In 1 Vial,636,RC,24201-010-20,NDC,,,facility,both,1,EA,,196.67,196.67,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Mycophenolate Mofetil: 1 Bottle, Plastic In 1 Carton (23155-848-51) / 225 Ml In 1 Bottle, Plastic",636,RC,23155-848-51,NDC,,,facility,both,1,EA,,16.28,16.28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Foscarnet Sodium: 1 Bottle, Glass In 1 Carton (23155-771-31) / 250 Ml In 1 Bottle, Glass",636,RC,23155-771-31,NDC,,,facility,both,1,EA,,155.66,155.66,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Carmustine: 1 Kit In 1 Carton (23155-649-41) * 3 Ml In 1 Vial (23155-648-31) * 30 Ml In 1 Vial, Single-Dose (23155-647-31)",636,RC,23155-649-41,NDC,,,facility,both,1,EA,,1062.05,1062.05,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Pentobarbital Sodium: 1 Vial In 1 Carton (24201-010-50) / 50 Ml In 1 Vial,636,RC,24201-010-50,NDC,,,facility,both,1,EA,,121.23,121.23,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Midazolam Hydrochloride: 25 Vial, Single-Dose In 1 Carton (23155-600-41) / 2 Ml In 1 Vial, Single-Dose (23155-600-31)",636,RC,23155-600-41,NDC,,,facility,both,1,EA,,20.05,20.05,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Cytarabine: 5 Vial In 1 Carton (25021-229-05) / 5 Ml In 1 Vial,636,RC,25021-229-05,NDC,,,facility,both,1,EA,,135.11,135.11,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Doxorubicin Hydrochloride: 1 Vial In 1 Carton (25021-207-25) / 25 Ml In 1 Vial,636,RC,25021-207-25,NDC,,,facility,both,1,EA,,43.7,43.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Doxorubicin Hydrochloride: 1 Vial In 1 Carton (25021-207-25) / 25 Ml In 1 Vial,636,RC,25021-207-25,NDC,,,facility,both,1,EA,,13.36,13.36,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Vinorelbine: 1 Vial In 1 Carton (25021-204-05) / 5 Ml In 1 Vial,636,RC,25021-204-05,NDC,,,facility,both,1,EA,,85,85,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Vinorelbine: 1 Vial In 1 Carton (25021-204-05) / 5 Ml In 1 Vial,636,RC,25021-204-05,NDC,,,facility,both,1,EA,,61.21,61.21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Ciprofloxacin: 24 Pouch In 1 Carton (25021-192-82) / 1 Bag In 1 Pouch / 100 Ml In 1 Bag,636,RC,25021-192-82,NDC,,,facility,both,1,EA,,29.72,29.72,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Micafungin: 1 Vial In 1 Carton (25021-190-10) / 5 Ml In 1 Vial,636,RC,25021-190-10,NDC,,,facility,both,1,EA,,1.87,1.87,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Fluconazole: 10 Pouch In 1 Carton (25021-184-87) / 1 Bag In 1 Pouch / 200 Ml In 1 Bag,636,RC,25021-184-87,NDC,,,facility,both,1,EA,,27.95,27.95,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Fluconazole: 10 Pouch In 1 Carton (25021-184-82) / 1 Bag In 1 Pouch / 100 Ml In 1 Bag,636,RC,25021-184-82,NDC,,,facility,both,1,EA,,32.57,32.57,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Oxacillin: 10 Vial In 1 Carton (25021-162-24) / 1 Injection, Powder, For Solution In 1 Vial",636,RC,25021-162-24,NDC,,,facility,both,1,EA,,13.26,13.26,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Levofloxacin: 24 Pouch In 1 Carton (25021-132-81) / 1 Bag In 1 Pouch / 50 Ml In 1 Bag,636,RC,25021-132-81,NDC,,,facility,both,1,EA,,38.12,38.12,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Clindamycin: 25 Vial In 1 Carton (25021-115-04) / 4 Ml In 1 Vial,636,RC,25021-115-04,NDC,,,facility,both,1,EA,,24.85,24.85,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Clindamycin: 25 Vial In 1 Carton (25021-115-04) / 4 Ml In 1 Vial,636,RC,25021-115-04,NDC,,,facility,both,1,EA,,24.82,24.82,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ceftriaxone: 25 Vial In 1 Carton (25021-107-20) / 1 Injection, Powder, For Solution In 1 Vial",636,RC,25021-107-20,NDC,,,facility,both,1,EA,,11.88,11.88,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Ciprofloxacin: 24 Pouch In 1 Carton (25021-114-87) / 1 Bag In 1 Pouch / 200 Ml In 1 Bag,636,RC,25021-114-87,NDC,,,facility,both,1,EA,,23.2,23.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,50633-110-11,NDC,,,facility,both,1,EA,,21294.13,21294.13,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,50632-013-01,NDC,,,facility,both,1,EA,,1980.77,1980.77,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,50632-013-01,NDC,,,facility,both,1,EA,,1781.45,1781.45,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Rabavert: 1 Kit In 1 Carton (50632-010-01) * 1 Ml In 1 Syringe (50632-011-01) * 1 Ml In 1 Vial, Glass (50632-013-01)",636,RC,50632-010-01,NDC,,,facility,both,1,EA,,2064.48,2064.48,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Rabavert: 1 Kit In 1 Carton (50632-010-01) * 1 Ml In 1 Syringe (50632-011-01) * 1 Ml In 1 Vial, Glass (50632-013-01)",636,RC,50632-010-01,NDC,,,facility,both,1,EA,,1781.45,1781.45,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Childrens Benadryl Allergy: 1 Bottle In 1 Carton (50580-534-08) / 236 Ml In 1 Bottle,636,RC,50580-534-08,NDC,,,facility,both,1,EA,,12.33,12.33,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,50474-970-63,NDC,,,facility,both,1,EA,,35.64,35.64,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,50474-970-63,NDC,,,facility,both,1,EA,,24.72,24.72,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,51079-028-01,NDC,,,facility,both,1,EA,,14.85,14.85,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Niktimvo: 1 Vial, Single-Use In 1 Carton (50881-034-12) / .18 Ml In 1 Vial, Single-Use",636,RC,50881-034-12,NDC,,,facility,both,1,EA,,317.38,317.38,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Niktimvo: 1 Vial, Single-Use In 1 Carton (50881-034-12) / .18 Ml In 1 Vial, Single-Use",636,RC,50881-034-12,NDC,,,facility,both,1,EA,,311.77,311.77,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Carboplatin: 1 Vial, Multi-Dose In 1 Carton (50742-447-45) / 45 Ml In 1 Vial, Multi-Dose",636,RC,50742-447-45,NDC,,,facility,both,1,EA,,64.01,64.01,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sirolimus: 30 Blister Pack In 1 Box (50268-718-13) / 1 Tablet In 1 Blister Pack (50268-718-11),636,RC,50268-718-13,NDC,,,facility,both,1,EA,,60.63,60.63,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,50268-718-11,NDC,,,facility,both,1,EA,,57.26,57.26,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,50268-684-11,NDC,,,facility,both,1,EA,,13.63,13.63,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Mirena: 1 Intrauterine Device In 1 Carton (50419-423-01),636,RC,50419-423-01,NDC,,,facility,both,1,EA,,7643.55,7643.55,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Mirena: 1 Intrauterine Device In 1 Carton (50419-423-01),636,RC,50419-423-01,NDC,,,facility,both,1,EA,,7493.67,7493.67,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Acyclovir: 473 mL in 1 BOTTLE (50383-810-16) ,636,RC,50383-810-16,NDC,,,facility,both,1,EA,,9.73,9.73,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Xatmep: 120 Ml In 1 Bottle (52652-2001-1),636,RC,52652-2001-1,NDC,,,facility,both,1,EA,,123.57,123.57,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,51991-735-99,NDC,,,facility,both,1,EA,,25.69,25.69,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,51991-381-99,NDC,,,facility,both,1,EA,,13.12,13.12,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,51862-458-01,NDC,,,facility,both,1,EA,,7.87,7.87,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Caffeine Citrate: 10 Vial In 1 Carton (51754-0501-3) / 3 Ml In 1 Vial,636,RC,51754-0501-3,NDC,,,facility,both,1,EA,,6.9,6.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Caffeine Citrate: 1 Vial In 1 Carton (51754-0500-1) / 3 Ml In 1 Vial,636,RC,51754-0500-1,NDC,,,facility,both,1,EA,,7.04,7.04,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Vpriv: 1 Vial, Glass In 1 Box (54092-701-04) / 4 Ml In 1 Vial, Glass",636,RC,54092-701-04,NDC,,,facility,both,1,EA,,3244.81,3244.81,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Vpriv: 1 Vial, Glass In 1 Box (54092-701-04) / 4 Ml In 1 Vial, Glass",636,RC,54092-701-04,NDC,,,facility,both,1,EA,,2282.9,2282.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,51079-721-01,NDC,,,facility,both,1,EA,,8.15,8.15,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,51079-670-01,NDC,,,facility,both,1,EA,,15.44,15.44,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Mycophenolic Acid: 100 BLISTER PACK in 1 CARTON (51079-508-20) / 1 TABLET, DELAYED RELEASE in 1 BLISTER PACK (51079-508-01) ",636,RC,51079-508-20,NDC,,,facility,both,1,EA,,38.69,38.69,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Mycophenolate Mofetil: 100 Blister Pack In 1 Carton (51079-379-20) / 1 Tablet, Film Coated In 1 Blister Pack (51079-379-01)",636,RC,51079-379-20,NDC,,,facility,both,1,EA,,9.02,9.02,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Padcev Ejfv: 1 Vial, Single-Dose In 1 Box (51144-030-01) / 3 Ml In 1 Vial, Single-Dose",636,RC,51144-030-01,NDC,,,facility,both,1,EA,,212.56,212.56,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Adcetris: 1 Vial, Single-Dose In 1 Box (51144-050-01) / 10.5 Ml In 1 Vial, Single-Dose",636,RC,51144-050-01,NDC,,,facility,both,1,EA,,1175.46,1175.46,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Adcetris: 1 Vial, Single-Dose In 1 Box (51144-050-01) / 10.5 Ml In 1 Vial, Single-Dose",636,RC,51144-050-01,NDC,,,facility,both,1,EA,,1174.93,1174.93,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Adcetris: 1 Vial, Single-Dose In 1 Box (51144-050-01) / 10.5 Ml In 1 Vial, Single-Dose",636,RC,51144-050-01,NDC,,,facility,both,1,EA,,1173.7,1173.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Adcetris: 1 Vial, Single-Dose In 1 Box (51144-050-01) / 10.5 Ml In 1 Vial, Single-Dose",636,RC,51144-050-01,NDC,,,facility,both,1,EA,,1173.7,1173.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,49502-102-01,NDC,,,facility,both,1,EA,,288.98,288.98,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Epinephrine: 2 Container In 1 Carton (49502-101-02) / 1 Syringe, Glass In 1 Container (49502-101-01) / .3 Ml In 1 Syringe, Glass",636,RC,49502-101-02,NDC,,,facility,both,1,EA,,421.92,421.92,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,49502-101-01,NDC,,,facility,both,1,EA,,421.92,421.92,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Benlysta: 1 Vial In 1 Carton (49401-102-01) / 5 Ml In 1 Vial,636,RC,49401-102-01,NDC,,,facility,both,1,EA,,331.14,331.14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Benlysta: 1 Vial In 1 Carton (49401-102-01) / 5 Ml In 1 Vial,636,RC,49401-102-01,NDC,,,facility,both,1,EA,,328.52,328.52,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Benlysta: 1 Vial In 1 Carton (49401-102-01) / 5 Ml In 1 Vial,636,RC,49401-102-01,NDC,,,facility,both,1,EA,,328.52,328.52,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Benlysta: 1 Vial In 1 Carton (49401-102-01) / 5 Ml In 1 Vial,636,RC,49401-102-01,NDC,,,facility,both,1,EA,,321.27,321.27,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Benlysta: 1 Vial In 1 Carton (49401-102-01) / 5 Ml In 1 Vial,636,RC,49401-102-01,NDC,,,facility,both,1,EA,,320.66,320.66,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Benlysta: 1 Vial In 1 Carton (49401-101-01) / 1.5 Ml In 1 Vial,636,RC,49401-101-01,NDC,,,facility,both,1,EA,,340.67,340.67,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Benlysta: 1 Vial In 1 Carton (49401-101-01) / 1.5 Ml In 1 Vial,636,RC,49401-101-01,NDC,,,facility,both,1,EA,,338.72,338.72,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Benlysta: 1 Vial In 1 Carton (49401-101-01) / 1.5 Ml In 1 Vial,636,RC,49401-101-01,NDC,,,facility,both,1,EA,,338.34,338.34,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Benlysta: 1 Vial In 1 Carton (49401-101-01) / 1.5 Ml In 1 Vial,636,RC,49401-101-01,NDC,,,facility,both,1,EA,,336.73,336.73,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Benlysta: 1 Vial In 1 Carton (49401-101-01) / 1.5 Ml In 1 Vial,636,RC,49401-101-01,NDC,,,facility,both,1,EA,,328.37,328.37,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Benlysta: 1 Vial In 1 Carton (49401-101-01) / 1.5 Ml In 1 Vial,636,RC,49401-101-01,NDC,,,facility,both,1,EA,,327.43,327.43,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,49281-860-78,NDC,,,facility,both,1,EA,,291.82,291.82,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ipol: 1 Vial, Multi-Dose In 1 Package (49281-860-10) / 5 Ml In 1 Vial, Multi-Dose (49281-860-78)",636,RC,49281-860-10,NDC,,,facility,both,1,EA,,291.62,291.62,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Beyfortus: 1 Syringe In 1 Carton (49281-575-00) / .5 Ml In 1 Syringe,636,RC,49281-575-00,NDC,,,facility,both,1,EA,,3189.35,3189.35,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Beyfortus: 1 Syringe In 1 Carton (49281-574-88) / 1 Ml In 1 Syringe,636,RC,49281-574-88,NDC,,,facility,both,1,EA,,3269.82,3269.82,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,49281-286-58,NDC,,,facility,both,1,EA,,213.17,213.17,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Daptacel: 10 Vial In 1 Package (49281-286-10) / .5 Ml In 1 Vial (49281-286-58),636,RC,49281-286-10,NDC,,,facility,both,1,EA,,213.8,213.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,49702-213-01,NDC,,,facility,both,1,EA,,32.57,32.57,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,49281-215-88,NDC,,,facility,both,1,EA,,275.14,275.14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Promethazine Hydrochloride: 12 Blister Pack In 1 Carton (45802-758-30) / 1 Suppository In 1 Blister Pack (45802-758-00),636,RC,45802-758-30,NDC,,,facility,both,1,EA,,4.23,4.23,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Metronidazole: 1 Bag In 1 Pouch (47335-993-01) / 100 Ml In 1 Bag,636,RC,47335-993-01,NDC,,,facility,both,1,EA,,0.95,0.95,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Metronidazole: 1 Bag In 1 Pouch (47335-993-01) / 100 Ml In 1 Bag,636,RC,47335-993-01,NDC,,,facility,both,1,EA,,0.91,0.91,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Metronidazole: 1 Bag In 1 Pouch (47335-993-01) / 100 Ml In 1 Bag,636,RC,47335-993-01,NDC,,,facility,both,1,EA,,0.61,0.61,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Metronidazole: 1 Bag In 1 Pouch (47335-993-01) / 100 Ml In 1 Bag,636,RC,47335-993-01,NDC,,,facility,both,1,EA,,0.34,0.34,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,47335-932-40,NDC,,,facility,both,1,EA,,206.52,206.52,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,47335-931-40,NDC,,,facility,both,1,EA,,54.26,54.26,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,47335-892-60,NDC,,,facility,both,1,EA,,5.93,5.93,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,47335-891-60,NDC,,,facility,both,1,EA,,8.19,8.19,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,47335-890-60,NDC,,,facility,both,1,EA,,17.17,17.17,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Chlorothiazide Sodium: 1 Vial, Single-Dose In 1 Carton (47335-330-40) / 18 Ml In 1 Vial, Single-Dose",636,RC,47335-330-40,NDC,,,facility,both,1,EA,,46.88,46.88,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,45802-758-00,NDC,,,facility,both,1,EA,,3.89,3.89,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Topotecan Hydrochloride: 1 Vial In 1 Carton (45963-615-56) / 4 Ml In 1 Vial,636,RC,45963-615-56,NDC,,,facility,both,1,EA,,23.72,23.72,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Fludarabine Phosphate: 1 Vial, Glass In 1 Carton (45963-609-55) / 2 Ml In 1 Vial, Glass",636,RC,45963-609-55,NDC,,,facility,both,1,EA,,474.29,474.29,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,50268-163-11,NDC,,,facility,both,1,EA,,3.19,3.19,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,50268-557-11,NDC,,,facility,both,1,EA,,7.81,7.81,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Actemra: 1 Vial, Single-Use In 1 Box (50242-136-01) / 10 Ml In 1 Vial, Single-Use",636,RC,50242-136-01,NDC,,,facility,both,1,EA,,41.09,41.09,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Actemra: 1 Vial, Single-Use In 1 Box (50242-136-01) / 10 Ml In 1 Vial, Single-Use",636,RC,50242-136-01,NDC,,,facility,both,1,EA,,41.09,41.09,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Pulmozyme: 5 Pouch In 1 Carton (50242-100-40) / 6 Ampule In 1 Pouch (50242-100-39) / 2.5 Ml In 1 Ampule,636,RC,50242-100-40,NDC,,,facility,both,1,EA,,307.32,307.32,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,50242-100-39,NDC,,,facility,both,1,EA,,304.54,304.54,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Nutropin Aq Nuspin 10: 1 Cartridge In 1 Carton (50242-074-01) / 2 Ml In 1 Cartridge,636,RC,50242-074-01,NDC,,,facility,both,1,EA,,749.83,749.83,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Nutropin Aq Nuspin 10: 1 Cartridge In 1 Carton (50242-074-01) / 2 Ml In 1 Cartridge,636,RC,50242-074-01,NDC,,,facility,both,1,EA,,749.83,749.83,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Avastin: 1 Vial, Single-Use In 1 Carton (50242-060-01) / 4 Ml In 1 Vial, Single-Use",636,RC,50242-060-01,NDC,,,facility,both,1,EA,,190,190,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Rituxan: 1 Vial, Single-Use In 1 Carton (50242-053-06) / 50 Ml In 1 Vial, Single-Use",636,RC,50242-053-06,NDC,,,facility,both,1,EA,,520.14,520.14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Rituxan: 1 Vial, Single-Use In 1 Carton (50242-053-06) / 50 Ml In 1 Vial, Single-Use",636,RC,50242-053-06,NDC,,,facility,both,1,EA,,513.63,513.63,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Rituxan: 1 Vial, Single-Use In 1 Carton (50242-053-06) / 50 Ml In 1 Vial, Single-Use",636,RC,50242-053-06,NDC,,,facility,both,1,EA,,509.5,509.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Rituxan: 1 Vial, Single-Use In 1 Carton (50242-051-21) / 10 Ml In 1 Vial, Single-Use",636,RC,50242-051-21,NDC,,,facility,both,1,EA,,513.63,513.63,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,50242-044-06,NDC,,,facility,both,1,EA,,546.9,546.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Actemra: 1 Vial, Single-Use In 1 Box (50242-136-01) / 10 Ml In 1 Vial, Single-Use",636,RC,50242-136-01,NDC,,,facility,both,1,EA,,41.12,41.12,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Cathflo Activase: 1 Vial In 1 Carton (50242-041-64) / 2 Ml In 1 Vial,636,RC,50242-041-64,NDC,,,facility,both,1,EA,,731,731,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Cathflo Activase: 1 Vial In 1 Carton (50242-041-64) / 2 Ml In 1 Vial,636,RC,50242-041-64,NDC,,,facility,both,1,EA,,559.99,559.99,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Cathflo Activase: 1 Vial In 1 Carton (50242-041-64) / 2 Ml In 1 Vial,636,RC,50242-041-64,NDC,,,facility,both,1,EA,,533.11,533.11,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Cathflo Activase: 1 Vial In 1 Carton (50242-041-64) / 2 Ml In 1 Vial,636,RC,50242-041-64,NDC,,,facility,both,1,EA,,515.31,515.31,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Cathflo Activase: 1 Vial In 1 Carton (50242-041-64) / 2 Ml In 1 Vial,636,RC,50242-041-64,NDC,,,facility,both,1,EA,,473.57,473.57,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Cathflo Activase: 10 Vial In 1 Carton (50242-041-10) / 2 Ml In 1 Vial,636,RC,50242-041-10,NDC,,,facility,both,1,EA,,706.63,706.63,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Cathflo Activase: 10 Vial In 1 Carton (50242-041-10) / 2 Ml In 1 Vial,636,RC,50242-041-10,NDC,,,facility,both,1,EA,,573.82,573.82,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Cathflo Activase: 10 Vial In 1 Carton (50242-041-10) / 2 Ml In 1 Vial,636,RC,50242-041-10,NDC,,,facility,both,1,EA,,572.94,572.94,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Cathflo Activase: 10 Vial In 1 Carton (50242-041-10) / 2 Ml In 1 Vial,636,RC,50242-041-10,NDC,,,facility,both,1,EA,,546.41,546.41,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Cathflo Activase: 1 Vial In 1 Carton (50242-041-64) / 2 Ml In 1 Vial,636,RC,50242-041-64,NDC,,,facility,both,1,EA,,578.16,578.16,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Actemra: 1 Vial, Single-Use In 1 Box (50242-136-01) / 10 Ml In 1 Vial, Single-Use",636,RC,50242-136-01,NDC,,,facility,both,1,EA,,41.15,41.15,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Actemra: 1 Vial, Single-Use In 1 Box (50242-136-01) / 10 Ml In 1 Vial, Single-Use",636,RC,50242-136-01,NDC,,,facility,both,1,EA,,41.17,41.17,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Actemra: 1 Vial, Single-Use In 1 Box (50242-136-01) / 10 Ml In 1 Vial, Single-Use",636,RC,50242-136-01,NDC,,,facility,both,1,EA,,41.16,41.16,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Actemra: 1 Vial, Single-Use In 1 Box (50242-136-01) / 10 Ml In 1 Vial, Single-Use",636,RC,50242-136-01,NDC,,,facility,both,1,EA,,42.26,42.26,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Actemra: 1 Vial, Single-Use In 1 Box (50242-136-01) / 10 Ml In 1 Vial, Single-Use",636,RC,50242-136-01,NDC,,,facility,both,1,EA,,41.43,41.43,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Actemra: 1 Vial, Single-Use In 1 Box (50242-136-01) / 10 Ml In 1 Vial, Single-Use",636,RC,50242-136-01,NDC,,,facility,both,1,EA,,41.2,41.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Actemra: 1 Vial, Single-Use In 1 Box (50242-136-01) / 10 Ml In 1 Vial, Single-Use",636,RC,50242-136-01,NDC,,,facility,both,1,EA,,41.17,41.17,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Fosaprepitant: 1 Vial, Single-Dose In 1 Carton (16714-248-01) / 5 Ml In 1 Vial, Single-Dose",636,RC,16714-248-01,NDC,,,facility,both,1,EA,,1.13,1.13,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Fosaprepitant: 1 Vial, Single-Dose In 1 Carton (16714-248-01) / 5 Ml In 1 Vial, Single-Dose",636,RC,16714-248-01,NDC,,,facility,both,1,EA,,1.08,1.08,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0641-6052-01,NDC,,,facility,both,1,EA,,38.64,38.64,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Lorazepam: 25 Vial In 1 Carton (0641-6044-25) / 1 Ml In 1 Vial (0641-6044-01),636,RC,0641-6044-25,NDC,,,facility,both,1,EA,,29.19,29.19,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0641-6044-01,NDC,,,facility,both,1,EA,,29.91,29.91,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Infumorph 500: 20 Ml In 1 Ampule (0641-6040-01),636,RC,0641-6040-01,NDC,,,facility,both,1,EA,,43.26,43.26,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Fentanyl Citrate: 20 Ml In 1 Vial (0641-6029-01),636,RC,0641-6029-01,NDC,,,facility,both,1,EA,,9.98,9.98,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Fentanyl Citrate: 25 Vial In 1 Carton (0641-6027-25) / 2 Ml In 1 Vial (0641-6027-01),636,RC,0641-6027-25,NDC,,,facility,both,1,EA,,33.78,33.78,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0641-6027-01,NDC,,,facility,both,1,EA,,26.31,26.31,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0641-6022-01,NDC,,,facility,both,1,EA,,0.77,0.77,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0641-6022-01,NDC,,,facility,both,1,EA,,0.52,0.52,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Bumetanide: 10 Vial In 1 Carton (0641-6008-10) / 4 Ml In 1 Vial (0641-6008-01),636,RC,0641-6008-10,NDC,,,facility,both,1,EA,,17.74,17.74,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Bumetanide: 10 Vial In 1 Carton (0641-6008-10) / 4 Ml In 1 Vial (0641-6008-01),636,RC,0641-6008-10,NDC,,,facility,both,1,EA,,6.46,6.46,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0641-6008-01,NDC,,,facility,both,1,EA,,19.69,19.69,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0641-6008-01,NDC,,,facility,both,1,EA,,6.81,6.81,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0641-6007-01,NDC,,,facility,both,1,EA,,6.48,6.48,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0641-6001-01,NDC,,,facility,both,1,EA,,32.71,32.71,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0641-1495-31,NDC,,,facility,both,1,EA,,32.49,32.49,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Digoxin: 25 Ampule In 1 Carton (0641-1410-35) / 2 Ml In 1 Ampule (0641-1410-31),636,RC,0641-1410-35,NDC,,,facility,both,1,EA,,29.56,29.56,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Promethazine Hydrochloride: 25 Vial, Single-Dose In 1 Package (0641-0928-25) / 1 Ml In 1 Vial, Single-Dose (0641-0928-21)",636,RC,0641-0928-25,NDC,,,facility,both,1,EA,,30.24,30.24,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0641-0928-21,NDC,,,facility,both,1,EA,,32.38,32.38,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Diphenhydramine Hydrochloride: 25 Vial In 1 Package (0641-0376-25) / 1 Ml In 1 Vial (0641-0376-21),636,RC,0641-0376-25,NDC,,,facility,both,1,EA,,30.45,30.45,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0641-0376-21,NDC,,,facility,both,1,EA,,30.21,30.21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0641-6057-01,NDC,,,facility,both,1,EA,,22.88,22.88,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Midazolam: 25 Vial In 1 Carton (0641-6057-25) / 2 Ml In 1 Vial (0641-6057-01),636,RC,0641-6057-25,NDC,,,facility,both,1,EA,,15.16,15.16,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0641-6059-01,NDC,,,facility,both,1,EA,,11.04,11.04,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0641-6060-01,NDC,,,facility,both,1,EA,,0.62,0.62,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0641-6151-01,NDC,,,facility,both,1,EA,,5.25,5.25,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0641-6151-01,NDC,,,facility,both,1,EA,,4.62,4.62,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0641-6151-01,NDC,,,facility,both,1,EA,,0.21,0.21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0641-6151-01,NDC,,,facility,both,1,EA,,0.21,0.21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Neostigmine Methylsulfate: 10 Vial, Multi-Dose In 1 Carton (0641-6149-10) / 10 Ml In 1 Vial, Multi-Dose (0641-6149-01)",636,RC,0641-6149-10,NDC,,,facility,both,1,EA,,5.37,5.37,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0641-6149-01,NDC,,,facility,both,1,EA,,6.98,6.98,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0641-6145-01,NDC,,,facility,both,1,EA,,7.74,7.74,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Phenylephrine Hydrochloride: 25 Vial In 1 Carton (0641-6142-25) / 1 Ml In 1 Vial (0641-6142-01),636,RC,0641-6142-25,NDC,,,facility,both,1,EA,,4.6,4.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Phenylephrine Hydrochloride: 25 Vial In 1 Carton (0641-6142-25) / 1 Ml In 1 Vial (0641-6142-01),636,RC,0641-6142-25,NDC,,,facility,both,1,EA,,0.17,0.17,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0641-6142-01,NDC,,,facility,both,1,EA,,0.05,0.05,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Prochlorperazine Edisylate: 25 Vial In 1 Carton (0641-6135-25) / 2 Ml In 1 Vial (0641-6135-01),636,RC,0641-6135-25,NDC,,,facility,both,1,EA,,46.3,46.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0641-6135-01,NDC,,,facility,both,1,EA,,45.36,45.36,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Morphine Sulfate: 25 Vial, Single-Dose In 1 Package (0641-6127-25) / 1 Ml In 1 Vial, Single-Dose (0641-6127-01)",636,RC,0641-6127-25,NDC,,,facility,both,1,EA,,16.9,16.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0641-6127-01,NDC,,,facility,both,1,EA,,24.3,24.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Morphine Sulfate: 25 Vial, Single-Dose In 1 Package (0641-6125-25) / 1 Ml In 1 Vial, Single-Dose (0641-6125-01)",636,RC,0641-6125-25,NDC,,,facility,both,1,EA,,42.79,42.79,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0641-6125-01,NDC,,,facility,both,1,EA,,47.5,47.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0641-6117-01,NDC,,,facility,both,1,EA,,25.97,25.97,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0641-6082-01,NDC,,,facility,both,1,EA,,38.97,38.97,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Ondansetron: 25 Vial In 1 Carton (0641-6078-25) / 2 Ml In 1 Vial (0641-6078-01),636,RC,0641-6078-25,NDC,,,facility,both,1,EA,,8.56,8.56,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Ondansetron: 25 Vial In 1 Carton (0641-6078-25) / 2 Ml In 1 Vial (0641-6078-01),636,RC,0641-6078-25,NDC,,,facility,both,1,EA,,7.28,7.28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0641-6078-01,NDC,,,facility,both,1,EA,,7.75,7.75,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0641-6078-01,NDC,,,facility,both,1,EA,,6.94,6.94,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0641-6061-01,NDC,,,facility,both,1,EA,,12.93,12.93,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0641-6132-01,NDC,,,facility,both,1,EA,,31.91,31.91,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0641-6151-01,NDC,,,facility,both,1,EA,,10.03,10.03,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Cortrosyn: 10 Vial In 1 Carton (0548-5900-00) / 1 Ml In 1 Vial,636,RC,0548-5900-00,NDC,,,facility,both,1,EA,,48.08,48.08,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Glucagon: 1 Kit In 1 Kit (0548-5850-00) * 1 Ml In 1 Vial (0548-5905-00) * 1 Ml In 1 Syringe (0548-5831-00),636,RC,0548-5850-00,NDC,,,facility,both,1,EA,,1612.14,1612.14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Medroxyprogesterone Acetate: 1 Syringe In 1 Carton (0548-5701-00) / 1 Ml In 1 Syringe,636,RC,0548-5701-00,NDC,,,facility,both,1,EA,,1.19,1.19,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Enoxaparin Sodium: 1 Vial In 1 Carton (0548-5608-00) / 3 Ml In 1 Vial,636,RC,0548-5608-00,NDC,,,facility,both,1,EA,,29.47,29.47,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Enoxaparin Sodium: 10 Syringe In 1 Carton (0548-5602-00) / .4 Ml In 1 Syringe,636,RC,0548-5602-00,NDC,,,facility,both,1,EA,,16.46,16.46,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "GlucaGen: 1 KIT in 1 KIT (0597-0260-10) * 1 mL in 1 VIAL, GLASS (0597-0053-01) * 1 mL in 1 VIAL, GLASS (0597-0265-94) ",636,RC,0597-0260-10,NDC,,,facility,both,1,EA,,840.12,840.12,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "GlucaGen: 1 KIT in 1 KIT (0597-0260-10) * 1 mL in 1 VIAL, GLASS (0597-0053-01) * 1 mL in 1 VIAL, GLASS (0597-0265-94) ",636,RC,0597-0260-10,NDC,,,facility,both,1,EA,,423.38,423.38,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Prednisone: 100 Tablet In 1 Bottle (0591-5443-01),636,RC,0591-5443-01,NDC,,,facility,both,1,EA,,0.36,0.36,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Hydroxocobalamin: 1 Vial, Multi-Dose In 1 Carton (0591-2888-30) / 30 Ml In 1 Vial, Multi-Dose",636,RC,0591-2888-30,NDC,,,facility,both,1,EA,,0.33,0.33,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Hydromorphone Hydrochloride: 25 Vial, Single-Dose In 1 Carton (0641-6151-25) / 1 Ml In 1 Vial, Single-Dose (0641-6151-01)",636,RC,0641-6151-25,NDC,,,facility,both,1,EA,,0.21,0.21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Hydromorphone Hydrochloride: 25 Vial, Single-Dose In 1 Carton (0641-6151-25) / 1 Ml In 1 Vial, Single-Dose (0641-6151-01)",636,RC,0641-6151-25,NDC,,,facility,both,1,EA,,0.21,0.21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Hydromorphone Hydrochloride: 25 Vial, Single-Dose In 1 Carton (0641-6151-25) / 1 Ml In 1 Vial, Single-Dose (0641-6151-01)",636,RC,0641-6151-25,NDC,,,facility,both,1,EA,,1.64,1.64,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Diphenhydramine Hydrochloride: 10 Blister Pack In 1 Box (0904-2056-61) / 10 Capsule In 1 Blister Pack,636,RC,0904-2056-61,NDC,,,facility,both,1,EA,,1.04,1.04,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Leuprolide Acetate: 1 Kit In 1 Carton (0781-4003-32) * 1 Vial, Multi-Dose In 1 Carton (0781-3006-42) / 2.8 Ml In 1 Vial, Multi-Dose * 1 Ml In 1 Packet",636,RC,0781-4003-32,NDC,,,facility,both,1,EA,,139.61,139.61,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Heparin Sodium: 25 Vial, Single-Dose In 1 Carton (0781-3555-25) / 2 Ml In 1 Vial, Single-Dose (0781-3555-10)",636,RC,0781-3555-25,NDC,,,facility,both,1,EA,,18.52,18.52,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0781-3545-10,NDC,,,facility,both,1,EA,,7.29,7.29,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0781-3540-10,NDC,,,facility,both,1,EA,,27.47,27.47,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Azacitidine: 1 Injection, Powder, Lyophilized, For Solution In 1 Carton (0781-3491-94)",636,RC,0781-3491-94,NDC,,,facility,both,1,EA,,4.46,4.46,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Azacitidine: 1 Injection, Powder, Lyophilized, For Solution In 1 Carton (0781-3491-94)",636,RC,0781-3491-94,NDC,,,facility,both,1,EA,,2.77,2.77,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Azacitidine: 1 Injection, Powder, Lyophilized, For Solution In 1 Carton (0781-3491-94)",636,RC,0781-3491-94,NDC,,,facility,both,1,EA,,0.95,0.95,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Fondaparinux Sodium: 10 Syringe In 1 Carton (0781-3465-95) / .6 Ml In 1 Syringe (0781-3465-94),636,RC,0781-3465-95,NDC,,,facility,both,1,EA,,8.85,8.85,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0781-3465-94,NDC,,,facility,both,1,EA,,9.03,9.03,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Banophen: 1 Bottle, Plastic In 1 Carton (0904-5551-59) / 100 Tablet, Film Coated In 1 Bottle, Plastic",636,RC,0904-5551-59,NDC,,,facility,both,1,EA,,12.31,12.31,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0781-3451-70,NDC,,,facility,both,1,EA,,16.67,16.67,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Cosyntropin: 10 Vial In 1 Carton (0781-3440-95) / 1 Ml In 1 Vial (0781-3440-71),636,RC,0781-3440-95,NDC,,,facility,both,1,EA,,124.62,124.62,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0781-3440-71,NDC,,,facility,both,1,EA,,66.47,66.47,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0703-9514-01,NDC,,,facility,both,1,EA,,1.3,1.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Amikacin Sulfate: 10 VIAL, SINGLE-DOSE in 1 CARTON (0703-9032-03) / 2 mL in 1 VIAL, SINGLE-DOSE (0703-9032-01) ",636,RC,0703-9032-03,NDC,,,facility,both,1,EA,,20.98,20.98,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Cisplatin: 1 Vial, Multi-Dose In 1 Carton (0703-5747-11) / 50 Ml In 1 Vial, Multi-Dose",636,RC,0703-5747-11,NDC,,,facility,both,1,EA,,64.28,64.28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Leucovorin Calcium: 1 VIAL, SINGLE-USE in 1 CARTON (0703-5140-01) / 10 mL in 1 VIAL, SINGLE-USE",636,RC,0703-5140-01,NDC,,,facility,both,1,EA,,33.44,33.44,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0703-4502-01,NDC,,,facility,both,1,EA,,29.83,29.83,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Vincasar PFS: 1 VIAL, SINGLE-DOSE in 1 CARTON (0703-4412-11) / 2 mL in 1 VIAL, SINGLE-DOSE",636,RC,0703-4412-11,NDC,,,facility,both,1,EA,,133.9,133.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Methotrexate: 1 Vial, Single-Dose In 1 Carton (0703-3675-01) / 10 Ml In 1 Vial, Single-Dose",636,RC,0703-3675-01,NDC,,,facility,both,1,EA,,127.53,127.53,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Methotrexate: 1 Vial, Single-Dose In 1 Carton (0703-3675-01) / 10 Ml In 1 Vial, Single-Dose",636,RC,0703-3675-01,NDC,,,facility,both,1,EA,,6.67,6.67,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Treprostinil: 1 Vial, Multi-Dose In 1 Carton (0703-0686-01) / 20 Ml In 1 Vial, Multi-Dose",636,RC,0703-0686-01,NDC,,,facility,both,1,EA,,136.27,136.27,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Treprostinil: 1 Vial, Multi-Dose In 1 Carton (0703-0686-01) / 20 Ml In 1 Vial, Multi-Dose",636,RC,0703-0686-01,NDC,,,facility,both,1,EA,,132.83,132.83,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0703-0113-01,NDC,,,facility,both,1,EA,,0.17,0.17,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Hydromorphone Hydrochloride: 10 Vial In 1 Carton (0703-0110-03) / 1 Ml In 1 Vial (0703-0110-01),636,RC,0703-0110-03,NDC,,,facility,both,1,EA,,0.49,0.49,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Sulfamethoxazole And Trimethoprim: 10 Vial, Multi-Dose In 1 Carton (0703-9514-03) / 10 Ml In 1 Vial, Multi-Dose (0703-9514-01)",636,RC,0703-9514-03,NDC,,,facility,both,1,EA,,57.79,57.79,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0703-0110-01,NDC,,,facility,both,1,EA,,0.42,0.42,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Hydromorphone Hydrochloride: 1 Vial In 1 Carton (0703-0018-01) / 50 Ml In 1 Vial,636,RC,0703-0018-01,NDC,,,facility,both,1,EA,,0.13,0.13,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0641-6267-01,NDC,,,facility,both,1,EA,,11.99,11.99,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0641-6246-01,NDC,,,facility,both,1,EA,,4.19,4.19,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0641-6246-01,NDC,,,facility,both,1,EA,,2.61,2.61,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0641-6246-01,NDC,,,facility,both,1,EA,,0.71,0.71,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0641-6244-01,NDC,,,facility,both,1,EA,,43.74,43.74,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Hydralazine Hydrochloride: 25 Vial, Single-Dose In 1 Carton (0641-6231-25) / 20 Ml In 1 Vial, Single-Dose (0641-6231-01)",636,RC,0641-6231-25,NDC,,,facility,both,1,EA,,34.3,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0641-6231-01,NDC,,,facility,both,1,EA,,34.28,34.28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0641-6228-01,NDC,,,facility,both,1,EA,,19.51,19.51,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0641-6174-01,NDC,,,facility,both,1,EA,,36.03,36.03,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Hydromorphone Hydrochloride: 25 Vial, Single-Dose In 1 Carton (0641-6151-25) / 1 Ml In 1 Vial, Single-Dose (0641-6151-01)",636,RC,0641-6151-25,NDC,,,facility,both,1,EA,,3.83,3.83,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Hydromorphone Hydrochloride: 25 Vial, Single-Dose In 1 Carton (0641-6151-25) / 1 Ml In 1 Vial, Single-Dose (0641-6151-01)",636,RC,0641-6151-25,NDC,,,facility,both,1,EA,,3.57,3.57,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Hydromorphone Hydrochloride: 1 Vial In 1 Carton (0703-0018-01) / 50 Ml In 1 Vial,636,RC,0703-0018-01,NDC,,,facility,both,1,EA,,0.23,0.23,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Medroxyprogesterone Acetate: 1 Vial, Single-Dose In 1 Carton (0548-5400-00) / 1 Ml In 1 Vial, Single-Dose",636,RC,0548-5400-00,NDC,,,facility,both,1,EA,,1.19,1.19,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0713-0351-02,NDC,,,facility,both,1,EA,,44.93,44.93,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0781-3433-46,NDC,,,facility,both,1,EA,,27.84,27.84,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ampicillin: 10 Vial, Glass In 1 Package (0781-3407-95) / 1 Injection, Powder, For Solution In 1 Vial, Glass (0781-3407-78)",636,RC,0781-3407-95,NDC,,,facility,both,1,EA,,30.74,30.74,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0781-3407-78,NDC,,,facility,both,1,EA,,30.12,30.12,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0781-3404-85,NDC,,,facility,both,1,EA,,13.85,13.85,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Palonosetron Hydrochloride: 1 Vial, Single-Dose In 1 Carton (0781-3312-75) / 5 Ml In 1 Vial, Single-Dose",636,RC,0781-3312-75,NDC,,,facility,both,1,EA,,18.9,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Cyclophosphamide: 1 Vial, Single-Dose In 1 Carton (0781-3255-94) / 100 Ml In 1 Vial, Single-Dose",636,RC,0781-3255-94,NDC,,,facility,both,1,EA,,3.24,3.24,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Cyclophosphamide: 1 Vial, Single-Dose In 1 Carton (0781-3255-94) / 100 Ml In 1 Vial, Single-Dose",636,RC,0781-3255-94,NDC,,,facility,both,1,EA,,2.67,2.67,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Cyclophosphamide: 1 Vial, Single-Dose In 1 Carton (0781-3255-94) / 100 Ml In 1 Vial, Single-Dose",636,RC,0781-3255-94,NDC,,,facility,both,1,EA,,2.55,2.55,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Cyclophosphamide: 1 Vial, Single-Dose In 1 Carton (0781-3255-94) / 100 Ml In 1 Vial, Single-Dose",636,RC,0781-3255-94,NDC,,,facility,both,1,EA,,1.66,1.66,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0781-3156-06,NDC,,,facility,both,1,EA,,1.62,1.62,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ferumoxytol: 1 Vial, Single-Dose In 1 Carton (0781-3154-01) / 17 Ml In 1 Vial, Single-Dose",636,RC,0781-3154-01,NDC,,,facility,both,1,EA,,3.56,3.56,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ferumoxytol: 1 Vial, Single-Dose In 1 Carton (0781-3154-01) / 17 Ml In 1 Vial, Single-Dose",636,RC,0781-3154-01,NDC,,,facility,both,1,EA,,3.19,3.19,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ferumoxytol: 1 Vial, Single-Dose In 1 Carton (0781-3154-01) / 17 Ml In 1 Vial, Single-Dose",636,RC,0781-3154-01,NDC,,,facility,both,1,EA,,2.39,2.39,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0781-3113-90,NDC,,,facility,both,1,EA,,29.04,29.04,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Aprepitant: 1 Blister Pack In 1 Carton (0781-2323-68) / 6 Capsule In 1 Blister Pack (0781-2323-06),636,RC,0781-2323-68,NDC,,,facility,both,1,EA,,53.58,53.58,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Aprepitant: 1 Blister Pack In 1 Carton (0781-2321-06) / 1 Capsule In 1 Blister Pack,636,RC,0781-2321-06,NDC,,,facility,both,1,EA,,58.75,58.75,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ferumoxytol: 1 Vial, Single-Dose In 1 Carton (0781-3154-01) / 17 Ml In 1 Vial, Single-Dose",636,RC,0781-3154-01,NDC,,,facility,both,1,EA,,2.89,2.89,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Vancomycin Hydrochloride: 1 Vial, Pharmacy Bulk Package In 1 Carton (0409-6509-01) / 100 Ml In 1 Vial, Pharmacy Bulk Package",636,RC,0409-6509-01,NDC,,,facility,both,1,EA,,1.28,1.28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0409-6482-11,NDC,,,facility,both,1,EA,,153.4,153.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Erythrocin Lactobionate: 10 Vial In 1 Tray (0409-6482-01) / 10 Ml In 1 Vial (0409-6482-11),636,RC,0409-6482-01,NDC,,,facility,both,1,EA,,517.52,517.52,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0409-6102-19,NDC,,,facility,both,1,EA,,9.27,9.27,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0409-6102-19,NDC,,,facility,both,1,EA,,2.16,2.16,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0409-6102-19,NDC,,,facility,both,1,EA,,1.17,1.17,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0409-5921-16,NDC,,,facility,both,1,EA,,72.19,72.19,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Dopamine Hydrochloride: 25 Vial, Single-Dose In 1 Tray (0409-5820-01) / 5 Ml In 1 Vial, Single-Dose (0409-5820-11)",636,RC,0409-5820-01,NDC,,,facility,both,1,EA,,21.73,21.73,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0409-5084-13,NDC,,,facility,both,1,EA,,16.08,16.08,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Epinephrine: 10 Carton In 1 Package (0409-4933-01) / 1 Syringe, Glass In 1 Carton / 10 Ml In 1 Syringe, Glass (0409-4933-11)",636,RC,0409-4933-01,NDC,,,facility,both,1,EA,,9.68,9.68,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0409-4888-03,NDC,,,facility,both,1,EA,,67.2,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0409-4755-18,NDC,,,facility,both,1,EA,,6.31,6.31,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0409-4520-02,NDC,,,facility,both,1,EA,,10.22,10.22,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0409-4346-16,NDC,,,facility,both,1,EA,,56.72,56.72,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Lidocaine Hydrochloride: 25 Vial, Multi-Dose In 1 Tray (0409-4277-01) / 20 Ml In 1 Vial, Multi-Dose (0409-4277-16)",636,RC,0409-4277-01,NDC,,,facility,both,1,EA,,0.54,0.54,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0409-6533-11,NDC,,,facility,both,1,EA,,24.01,24.01,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Testosterone Cypionate: 1 Vial In 1 Carton (0409-6562-01) / 1 Ml In 1 Vial,636,RC,0409-6562-01,NDC,,,facility,both,1,EA,,0.94,0.94,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0409-7809-11,NDC,,,facility,both,1,EA,,15.22,15.22,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0409-7650-52,NDC,,,facility,both,1,EA,,4.53,4.53,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0409-7650-05,NDC,,,facility,both,1,EA,,4.43,4.43,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0409-7620-13,NDC,,,facility,both,1,EA,,52.17,52.17,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Heparin Sodium: 18 Pouch In 1 Case (0409-7620-03) / 1 Bag In 1 Pouch / 500 Ml In 1 Bag (0409-7620-13),636,RC,0409-7620-03,NDC,,,facility,both,1,EA,,50.12,50.12,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0409-7517-66,NDC,,,facility,both,1,EA,,66.02,66.02,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0409-7335-13,NDC,,,facility,both,1,EA,,11.35,11.35,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ceftriaxone Sodium: 10 Vial, Single-Use In 1 Carton (0409-7335-03) / 1 Injection, Powder, For Solution In 1 Vial, Single-Use (0409-7335-13)",636,RC,0409-7335-03,NDC,,,facility,both,1,EA,,5.25,5.25,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ceftriaxone Sodium: 1 Vial, Pharmacy Bulk Package In 1 Carton (0409-7334-10) / 100 Ml In 1 Vial, Pharmacy Bulk Package",636,RC,0409-7334-10,NDC,,,facility,both,1,EA,,10.19,10.19,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0409-7332-11,NDC,,,facility,both,1,EA,,7.51,7.51,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Mannitol: 25 Vial, Single-Dose In 1 Tray (0409-4031-01) / 50 Ml In 1 Vial, Single-Dose (0409-4031-16)",636,RC,0409-4031-01,NDC,,,facility,both,1,EA,,6.46,6.46,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ceftriaxone Sodium: 10 Vial, Single-Use In 1 Carton (0409-7332-01) / 1 Injection, Powder, For Solution In 1 Vial, Single-Use (0409-7332-11)",636,RC,0409-7332-01,NDC,,,facility,both,1,EA,,6.65,6.65,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Potassium Chloride: 24 POUCH in 1 CASE (0409-7075-26) / 1 BAG in 1 POUCH / 100 mL in 1 BAG,636,RC,0409-7075-26,NDC,,,facility,both,1,EA,,21.95,21.95,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Magnesium Sulfate In Water: 24 Pouch In 1 Case (0409-6729-24) / 1 Bag In 1 Pouch / 50 Ml In 1 Bag (0409-6729-11),636,RC,0409-6729-24,NDC,,,facility,both,1,EA,,21.94,21.94,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0409-6729-11,NDC,,,facility,both,1,EA,,13.9,13.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0409-6653-18,NDC,,,facility,both,1,EA,,4.2,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0409-6651-19,NDC,,,facility,both,1,EA,,7.32,7.32,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Dextrose: 25 Vial, Single-Dose In 1 Tray (0409-6648-02) / 50 Ml In 1 Vial, Single-Dose (0409-6648-16)",636,RC,0409-6648-02,NDC,,,facility,both,1,EA,,67.18,67.18,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0409-6635-18,NDC,,,facility,both,1,EA,,11.87,11.87,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0409-7299-83,NDC,,,facility,both,1,EA,,38.69,38.69,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Morphine Sulfate: 5 Vial, Glass In 1 Carton (0409-3815-12) / 10 Ml In 1 Vial, Glass (0409-3815-11)",636,RC,0409-3815-12,NDC,,,facility,both,1,EA,,40.06,40.06,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0409-3815-11,NDC,,,facility,both,1,EA,,103.65,103.65,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0409-3414-21,NDC,,,facility,both,1,EA,,31.59,31.59,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0409-2308-21,NDC,,,facility,both,1,EA,,4.06,4.06,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Midazolam: 10 Vial, Single-Dose In 1 Carton (0409-2308-01) / 1 Ml In 1 Vial, Single-Dose (0409-2308-21)",636,RC,0409-2308-01,NDC,,,facility,both,1,EA,,9.97,9.97,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Midazolam: 25 Vial, Single-Dose In 1 Tray (0409-2305-17) / 2 Ml In 1 Vial, Single-Dose (0409-2305-16)",636,RC,0409-2305-17,NDC,,,facility,both,1,EA,,16.89,16.89,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0409-2305-16,NDC,,,facility,both,1,EA,,16.43,16.43,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0409-2300-01,NDC,,,facility,both,1,EA,,34.11,34.11,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0409-2045-01,NDC,,,facility,both,1,EA,,35.97,35.97,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0409-1890-13,NDC,,,facility,both,1,EA,,35.29,35.29,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0409-1890-03,NDC,,,facility,both,1,EA,,32.89,32.89,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Morphine Sulfate: 10 Cartridge In 1 Carton (0409-1890-01) / 1 Ml In 1 Cartridge (0409-1890-03),636,RC,0409-1890-01,NDC,,,facility,both,1,EA,,29.57,29.57,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0409-1749-70,NDC,,,facility,both,1,EA,,48.67,48.67,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Marcaine With Epinephrine: 10 Vial, Single-Dose In 1 Carton (0409-1749-10) / 10 Ml In 1 Vial, Single-Dose (0409-1749-70)",636,RC,0409-1749-10,NDC,,,facility,both,1,EA,,45.39,45.39,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Marcaine With Epinephrine: 10 Vial, Single-Dose In 1 Carton (0409-1746-10) / 10 Ml In 1 Vial, Single-Dose (0409-1746-70)",636,RC,0409-1746-10,NDC,,,facility,both,1,EA,,46.16,46.16,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Vecuronium Bromide: 10 Vial In 1 Carton (0409-1632-01) / 10 Ml In 1 Vial (0409-1632-21),636,RC,0409-1632-01,NDC,,,facility,both,1,EA,,232.02,232.02,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0409-1631-40,NDC,,,facility,both,1,EA,,55.19,55.19,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Calcium Chloride: 10 Carton In 1 Container (0409-1631-10) / 1 Syringe, Plastic In 1 Carton (0409-1631-40) / 10 Ml In 1 Syringe, Plastic",636,RC,0409-1631-10,NDC,,,facility,both,1,EA,,65.48,65.48,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0409-1623-21,NDC,,,facility,both,1,EA,,54.52,54.52,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Butorphanol Tartrate: 10 Vial, Single-Dose In 1 Carton (0409-1623-01) / 1 Ml In 1 Vial, Single-Dose (0409-1623-21)",636,RC,0409-1623-01,NDC,,,facility,both,1,EA,,46.14,46.14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0409-1559-19,NDC,,,facility,both,1,EA,,0.39,0.39,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0409-1323-15,NDC,,,facility,both,1,EA,,1.12,1.12,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dopamine Hydrochloride In Dextrose: 12 Bag In 1 Carton (0409-7809-22) / 250 Ml In 1 Bag (0409-7809-11),636,RC,0409-7809-22,NDC,,,facility,both,1,EA,,10.98,10.98,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0409-2308-22,NDC,,,facility,both,1,EA,,5.32,5.32,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0409-2634-10,NDC,,,facility,both,1,EA,,0.14,0.14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0409-3414-18,NDC,,,facility,both,1,EA,,29.59,29.59,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Metoclopramide: 25 Vial, Single-Dose In 1 Tray (0409-3414-01) / 2 Ml In 1 Vial, Single-Dose (0409-3414-18)",636,RC,0409-3414-01,NDC,,,facility,both,1,EA,,31.77,31.77,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "25 VIAL, SINGLE-DOSE in 1 TRAY (0409-3365-01) / 1 mL in 1 VIAL, SINGLE-DOSE (0409-3365-11) ",636,RC,0409-3365-01,NDC,,,facility,both,1,EA,,4.6,4.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "25 VIAL, SINGLE-DOSE in 1 TRAY (0409-3365-01) / 1 mL in 1 VIAL, SINGLE-DOSE (0409-3365-11) ",636,RC,0409-3365-01,NDC,,,facility,both,1,EA,,3.63,3.63,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "25 VIAL, SINGLE-DOSE in 1 TRAY (0409-3365-01) / 1 mL in 1 VIAL, SINGLE-DOSE (0409-3365-11) ",636,RC,0409-3365-01,NDC,,,facility,both,1,EA,,0.48,0.48,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "25 VIAL, SINGLE-DOSE in 1 TRAY (0409-3365-01) / 1 mL in 1 VIAL, SINGLE-DOSE (0409-3365-11) ",636,RC,0409-3365-01,NDC,,,facility,both,1,EA,,0.48,0.48,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0409-3300-01,NDC,,,facility,both,1,EA,,30.89,30.89,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0409-3299-15,NDC,,,facility,both,1,EA,,44.73,44.73,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0409-2723-30,NDC,,,facility,both,1,EA,,6.5,6.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Heparin Sodium: 25 Vial, Single-Dose In 1 Tray (0409-2723-01) / 1 Ml In 1 Vial, Single-Dose (0409-2723-30)",636,RC,0409-2723-01,NDC,,,facility,both,1,EA,,6.63,6.63,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0409-2720-31,NDC,,,facility,both,1,EA,,28.51,28.51,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0409-2720-30,NDC,,,facility,both,1,EA,,13.08,13.08,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Heparin Sodium: 25 Vial, Single-Dose In 1 Tray (0409-2720-01) / 1 Ml In 1 Vial, Single-Dose (0409-2720-30)",636,RC,0409-2720-01,NDC,,,facility,both,1,EA,,36.84,36.84,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Hydromorphone Hydrochloride: 1 Vial, Single-Dose In 1 Box (0409-2634-50) / 50 Ml In 1 Vial, Single-Dose",636,RC,0409-2634-50,NDC,,,facility,both,1,EA,,0.21,0.21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0409-2634-25,NDC,,,facility,both,1,EA,,0.18,0.18,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0409-2634-25,NDC,,,facility,both,1,EA,,0.13,0.13,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0409-2634-10,NDC,,,facility,both,1,EA,,0.59,0.59,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0409-7810-11,NDC,,,facility,both,1,EA,,8.62,8.62,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Metronidazole: 24 POUCH in 1 CASE (0409-7811-24) / 1 BAG in 1 POUCH / 100 mL in 1 BAG (0409-7811-31) ,636,RC,0409-7811-24,NDC,,,facility,both,1,EA,,0.57,0.57,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0517-9702-01,NDC,,,facility,both,1,EA,,50.75,50.75,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0517-9120-01,NDC,,,facility,both,1,EA,,30.35,30.35,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Acetylcysteine: 25 Vial, Glass In 1 Tray (0517-7504-25) / 4 Ml In 1 Vial, Glass",636,RC,0517-7504-25,NDC,,,facility,both,1,EA,,49.78,49.78,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Calcium Chloride: 10 Vial, Glass In 1 Box (0517-6710-10) / 10 Ml In 1 Vial, Glass",636,RC,0517-6710-10,NDC,,,facility,both,1,EA,,58.19,58.19,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0517-6710-01,NDC,,,facility,both,1,EA,,171.83,171.83,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Hydroxyzine Hydrochloride: 25 Vial, Single-Dose In 1 Tray (0517-5601-25) / 1 Ml In 1 Vial, Single-Dose (0517-5601-01)",636,RC,0517-5601-25,NDC,,,facility,both,1,EA,,92.89,92.89,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0517-5601-01,NDC,,,facility,both,1,EA,,85.94,85.94,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Nitroglycerin: 25 Vial, Single-Dose In 1 Tray (0517-4810-25) / 10 Ml In 1 Vial, Single-Dose (0517-4810-01)",636,RC,0517-4810-25,NDC,,,facility,both,1,EA,,36.91,36.91,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Papaverine Hydrochloride: 25 Vial In 1 Carton (0517-4002-25) / 2 Ml In 1 Vial (0517-4002-01),636,RC,0517-4002-25,NDC,,,facility,both,1,EA,,108.92,108.92,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0517-4002-01,NDC,,,facility,both,1,EA,,90.4,90.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Venofer: 25 Vial, Single-Dose In 1 Tray (0517-2340-25) / 5 Ml In 1 Vial, Single-Dose",636,RC,0517-2340-25,NDC,,,facility,both,1,EA,,2.37,2.37,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Venofer: 10 Vial, Single-Dose In 1 Box (0517-2340-10) / 5 Ml In 1 Vial, Single-Dose",636,RC,0517-2340-10,NDC,,,facility,both,1,EA,,2.48,2.48,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Venofer: 1 Vial, Single-Dose In 1 Box (0517-2340-01) / 5 Ml In 1 Vial, Single-Dose",636,RC,0517-2340-01,NDC,,,facility,both,1,EA,,3.14,3.14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Venofer: 5 Vial, Single-Dose In 1 Box (0517-2310-05) / 10 Ml In 1 Vial, Single-Dose (0517-2310-01)",636,RC,0517-2310-05,NDC,,,facility,both,1,EA,,2.27,2.27,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0517-2310-01,NDC,,,facility,both,1,EA,,2.29,2.29,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Chlorothiazide Sodium: 1 Vial In 1 Carton (0517-1820-01) / 18 Ml In 1 Vial,636,RC,0517-1820-01,NDC,,,facility,both,1,EA,,58.68,58.68,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Atropine Sulfate: 25 Vial, Glass In 1 Tray (0517-1001-25) / 1 Ml In 1 Vial, Glass (0517-1001-01)",636,RC,0517-1001-25,NDC,,,facility,both,1,EA,,2.05,2.05,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0517-0901-01,NDC,,,facility,both,1,EA,,42.34,42.34,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Provayblue: 5 Ampule In 1 Carton (0517-0374-05) / 10 Ml In 1 Ampule (0517-0374-01),636,RC,0517-0374-05,NDC,,,facility,both,1,EA,,12.99,12.99,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Provayblue: 5 Ampule In 1 Carton (0517-0374-05) / 10 Ml In 1 Ampule (0517-0374-01),636,RC,0517-0374-05,NDC,,,facility,both,1,EA,,12.73,12.73,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Provayblue: 5 Ampule In 1 Carton (0517-0374-05) / 10 Ml In 1 Ampule (0517-0374-01),636,RC,0517-0374-05,NDC,,,facility,both,1,EA,,12.61,12.61,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Provayblue: 5 Ampule In 1 Carton (0517-0374-05) / 10 Ml In 1 Ampule (0517-0374-01),636,RC,0517-0374-05,NDC,,,facility,both,1,EA,,11.5,11.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0517-0374-01,NDC,,,facility,both,1,EA,,11.56,11.56,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Diphenhydramine Hcl: 100 Tablet, Film Coated In 1 Bottle, Plastic (0536-1214-29)",636,RC,0536-1214-29,NDC,,,facility,both,1,EA,,11.75,11.75,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0517-0374-01,NDC,,,facility,both,1,EA,,10.92,10.92,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Avycaz: 10 Vial, Single-Dose In 1 Carton (0456-2700-10) / 1 Powder, For Solution In 1 Vial, Single-Dose (0456-2700-01)",636,RC,0456-2700-10,NDC,,,facility,both,1,EA,,252.57,252.57,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0456-2700-01,NDC,,,facility,both,1,EA,,559.87,559.87,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0456-2700-01,NDC,,,facility,both,1,EA,,481.1,481.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0456-0600-01,NDC,,,facility,both,1,EA,,20.73,20.73,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0409-9158-50,NDC,,,facility,both,1,EA,,22.35,22.35,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0409-9158-31,NDC,,,facility,both,1,EA,,22.64,22.64,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0409-9104-21,NDC,,,facility,both,1,EA,,19.06,19.06,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Fentanyl Citrate: 25 Carton In 1 Tray (0409-9094-61) / 1 Vial, Single-Dose In 1 Carton / 50 Ml In 1 Vial, Single-Dose (0409-9094-41)",636,RC,0409-9094-61,NDC,,,facility,both,1,EA,,4.43,4.43,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Cresemba: 1 Vial, Single-Dose In 1 Carton (0469-0420-01) / 5 Ml In 1 Vial, Single-Dose",636,RC,0469-0420-01,NDC,,,facility,both,1,EA,,5.04,5.04,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0409-9094-41,NDC,,,facility,both,1,EA,,5.06,5.06,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Fentanyl Citrate: 25 Vial, Single-Dose In 1 Tray (0409-9094-25) / 5 Ml In 1 Vial, Single-Dose (0409-9094-18)",636,RC,0409-9094-25,NDC,,,facility,both,1,EA,,10.7,10.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Fentanyl Citrate: 25 Vial, Single-Dose In 1 Tray (0409-9094-22) / 2 Ml In 1 Vial, Single-Dose (0409-9094-12)",636,RC,0409-9094-22,NDC,,,facility,both,1,EA,,32.55,32.55,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0409-9094-18,NDC,,,facility,both,1,EA,,8.34,8.34,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0409-9094-17,NDC,,,facility,both,1,EA,,10.03,10.03,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0409-9094-16,NDC,,,facility,both,1,EA,,13.42,13.42,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0409-9094-12,NDC,,,facility,both,1,EA,,28.86,28.86,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Bupivacaine Hydrochloride And Epinephrine: 10 Vial, Single-Dose In 1 Carton (0409-9042-01) / 10 Ml In 1 Vial, Single-Dose (0409-9042-11)",636,RC,0409-9042-01,NDC,,,facility,both,1,EA,,39.44,39.44,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Metronidazole: 24 POUCH in 1 CASE (0409-7811-24) / 1 BAG in 1 POUCH / 100 mL in 1 BAG (0409-7811-31) ,636,RC,0409-7811-24,NDC,,,facility,both,1,EA,,0.91,0.91,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Metronidazole: 24 POUCH in 1 CASE (0409-7811-24) / 1 BAG in 1 POUCH / 100 mL in 1 BAG (0409-7811-31) ,636,RC,0409-7811-24,NDC,,,facility,both,1,EA,,0.83,0.83,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Fentanyl Citrate: 25 Vial, Single-Dose In 1 Tray (0409-9094-31) / 20 Ml In 1 Vial, Single-Dose (0409-9094-16)",636,RC,0409-9094-31,NDC,,,facility,both,1,EA,,11.15,11.15,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Metronidazole: 24 POUCH in 1 CASE (0409-7811-24) / 1 BAG in 1 POUCH / 100 mL in 1 BAG (0409-7811-31) ,636,RC,0409-7811-24,NDC,,,facility,both,1,EA,,0.26,0.26,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Cresemba: 1 Vial, Single-Dose In 1 Carton (0469-0420-01) / 5 Ml In 1 Vial, Single-Dose",636,RC,0469-0420-01,NDC,,,facility,both,1,EA,,5.09,5.09,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Cresemba: 10 Carton In 1 Carton (0469-0420-99) / 1 Vial, Single-Dose In 1 Carton (0469-0420-01) / 5 Ml In 1 Vial, Single-Dose",636,RC,0469-0420-99,NDC,,,facility,both,1,EA,,0.68,0.68,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Albuterol Sulfate: 30 Pouch In 1 Carton (0487-9904-01) / 1 Vial, Single-Dose In 1 Pouch / 3 Ml In 1 Vial, Single-Dose",636,RC,0487-9904-01,NDC,,,facility,both,1,EA,,10.3,10.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Albuterol Sulfate: 30 Pouch In 1 Carton (0487-9901-30) / 1 Vial, Single-Dose In 1 Pouch / .5 Ml In 1 Vial, Single-Dose",636,RC,0487-9901-30,NDC,,,facility,both,1,EA,,4.09,4.09,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ipratropium Bromide: 30 Pouch In 1 Carton (0487-9801-01) / 1 Vial, Single-Dose In 1 Pouch / 2.5 Ml In 1 Vial, Single-Dose",636,RC,0487-9801-01,NDC,,,facility,both,1,EA,,12.47,12.47,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Budesonide: 30 Pouch In 1 Carton (0487-9701-30) / 1 Ampule In 1 Pouch / 2 Ml In 1 Ampule,636,RC,0487-9701-30,NDC,,,facility,both,1,EA,,29.31,29.31,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Budesonide: 6 Pouch In 1 Carton (0487-9701-01) / 5 Ampule In 1 Pouch / 2 Ml In 1 Ampule,636,RC,0487-9701-01,NDC,,,facility,both,1,EA,,62.85,62.85,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Budesonide: 6 Pouch In 1 Carton (0487-9601-01) / 5 Ampule In 1 Pouch / 2 Ml In 1 Ampule,636,RC,0487-9601-01,NDC,,,facility,both,1,EA,,40.98,40.98,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Albuterol Sulfate: 30 Pouch In 1 Carton (0487-9501-01) / 1 Vial, Single-Dose In 1 Pouch / 3 Ml In 1 Vial, Single-Dose",636,RC,0487-9501-01,NDC,,,facility,both,1,EA,,4.57,4.57,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Cresemba: 1 Vial, Single-Dose In 1 Carton (0469-0420-01) / 5 Ml In 1 Vial, Single-Dose",636,RC,0469-0420-01,NDC,,,facility,both,1,EA,,5.17,5.17,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Albuterol Sulfate: 30 Pouch In 1 Carton (0487-0301-01) / 1 Vial, Single-Dose In 1 Pouch / 3 Ml In 1 Vial, Single-Dose",636,RC,0487-0301-01,NDC,,,facility,both,1,EA,,21.11,21.11,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ambisome: 12.5 Ml In 1 Vial, Single-Dose (0469-3051-30)",636,RC,0469-3051-30,NDC,,,facility,both,1,EA,,163.45,163.45,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Prograf: 10 Ampule In 1 Box (0469-3016-01) / 1 Ml In 1 Ampule,636,RC,0469-3016-01,NDC,,,facility,both,1,EA,,796.15,796.15,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ipratropium Bromide And Albuterol Sulfate: 30 Pouch In 1 Carton (0487-0201-01) / 1 Vial, Single-Use In 1 Pouch / 3 Ml In 1 Vial, Single-Use",636,RC,0487-0201-01,NDC,,,facility,both,1,EA,,14.46,14.46,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Potassium Chloride In Sodium Chloride: 12 Pouch In 1 Case (0990-9257-39) / 1 Bag In 1 Pouch / 1000 Ml In 1 Bag,636,RC,0990-9257-39,NDC,,,facility,both,1,EA,,11.07,11.07,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dextrose And Sodium Chloride: 12 Pouch In 1 Case (0990-7941-09) / 1 Bag In 1 Pouch / 1000 Ml In 1 Bag,636,RC,0990-7941-09,NDC,,,facility,both,1,EA,,54.41,54.41,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dextrose: 12 Pouch In 1 Case (0990-7935-19) / 1 Bag In 1 Pouch / 500 Ml In 1 Bag,636,RC,0990-7935-19,NDC,,,facility,both,1,EA,,147.11,147.11,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dextrose: 12 Pouch In 1 Case (0990-7918-19) / 1 Bag In 1 Pouch / 500 Ml In 1 Bag,636,RC,0990-7918-19,NDC,,,facility,both,1,EA,,70.28,70.28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sodium Chloride: 20 Pouch In 1 Case (0990-7730-37) / 4 Bag In 1 Pouch / 100 Ml In 1 Bag,636,RC,0990-7730-37,NDC,,,facility,both,1,EA,,78.46,78.46,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0990-7715-12,NDC,,,facility,both,1,EA,,48.33,48.33,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Mannitol: 24 Pouch In 1 Case (0990-7715-02) / 1 Bag In 1 Pouch / 250 Ml In 1 Bag (0990-7715-12),636,RC,0990-7715-02,NDC,,,facility,both,1,EA,,45.03,45.03,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dextrose: 6 Pouch In 1 Case (0990-7120-07) / 1 Bag In 1 Pouch / 2000 Ml In 1 Bag,636,RC,0990-7120-07,NDC,,,facility,both,1,EA,,68.08,68.08,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Potassium Chloride In Sodium Chloride: 12 Pouch In 1 Case (0990-7115-09) / 1 Bag In 1 Pouch / 1000 Ml In 1 Bag,636,RC,0990-7115-09,NDC,,,facility,both,1,EA,,11.15,11.15,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Potassium Chloride: 24 Pouch In 1 Case (0990-7075-26) / 1 Bag In 1 Pouch / 100 Ml In 1 Bag,636,RC,0990-7075-26,NDC,,,facility,both,1,EA,,8.52,8.52,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Sodium Chloride: 24 Bottle, Plastic In 1 Case (0990-6138-22) / 250 Ml In 1 Bottle, Plastic",636,RC,0990-6138-22,NDC,,,facility,both,1,EA,,92.89,92.89,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Vonvendi: 1 Kit In 1 Carton (0944-7553-02) * 10 Ml In 1 Vial, Single-Dose (0944-7552-01) * 10 Ml In 1 Vial, Glass (64764-516-10)",636,RC,0944-7553-02,NDC,,,facility,both,1,EA,,13.02,13.02,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0944-7552-01,NDC,,,facility,both,1,EA,,13.02,13.02,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Advate: 1 Blister Pack In 1 Carton (0944-3053-02) / 1 Container In 1 Blister Pack (0944-3053-04) / 1 Kit In 1 Container (0944-3053-03) * 5 Ml In 1 Vial, Glass (0944-2943-02) * 2 Ml In 1 Vial, Glass (64764-514-02)",636,RC,0944-3053-02,NDC,,,facility,both,1,EA,,9.04,9.04,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Advate: 1 Blister Pack In 1 Carton (0944-3053-02) / 1 Container In 1 Blister Pack (0944-3053-04) / 1 Kit In 1 Container (0944-3053-03) * 5 Ml In 1 Vial, Glass (0944-2943-02) * 2 Ml In 1 Vial, Glass (64764-514-02)",636,RC,0944-3053-02,NDC,,,facility,both,1,EA,,9.04,9.04,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Advate: 1 Blister Pack In 1 Carton (0944-3053-02) / 1 Container In 1 Blister Pack (0944-3053-04) / 1 Kit In 1 Container (0944-3053-03) * 5 Ml In 1 Vial, Glass (0944-2943-02) * 2 Ml In 1 Vial, Glass (64764-514-02)",636,RC,0944-3053-02,NDC,,,facility,both,1,EA,,9.03,9.03,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Advate: 1 Blister Pack In 1 Carton (0944-3052-02) / 1 Container In 1 Blister Pack (0944-3052-03) / 1 Kit In 1 Container (0944-3052-04) * 5 Ml In 1 Vial, Glass (0944-2942-02) * 2 Ml In 1 Vial, Glass (64764-514-02)",636,RC,0944-3052-02,NDC,,,facility,both,1,EA,,9.08,9.08,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Advate: 1 Blister Pack In 1 Carton (0944-3052-02) / 1 Container In 1 Blister Pack (0944-3052-03) / 1 Kit In 1 Container (0944-3052-04) * 5 Ml In 1 Vial, Glass (0944-2942-02) * 2 Ml In 1 Vial, Glass (64764-514-02)",636,RC,0944-3052-02,NDC,,,facility,both,1,EA,,9.08,9.08,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Advate: 1 Blister Pack In 1 Carton (0944-3052-02) / 1 Container In 1 Blister Pack (0944-3052-03) / 1 Kit In 1 Container (0944-3052-04) * 5 Ml In 1 Vial, Glass (0944-2942-02) * 2 Ml In 1 Vial, Glass (64764-514-02)",636,RC,0944-3052-02,NDC,,,facility,both,1,EA,,9.06,9.06,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Advate: 1 Blister Pack In 1 Carton (0944-3051-02) / 1 Container In 1 Blister Pack (0944-3051-03) / 1 Kit In 1 Container (0944-3051-04) * 5 Ml In 1 Vial, Glass (0944-2941-01) * 2 Ml In 1 Vial, Glass (64764-514-02)",636,RC,0944-3051-02,NDC,,,facility,both,1,EA,,9.13,9.13,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Brevibloc: 10 Bag In 1 Carton (10019-055-61) / 250 Ml In 1 Bag,636,RC,10019-055-61,NDC,,,facility,both,1,EA,,2.31,2.31,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Brevibloc: 10 Bag In 1 Carton (10019-075-87) / 100 Ml In 1 Bag,636,RC,10019-075-87,NDC,,,facility,both,1,EA,,4.86,4.86,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Advate: 1 Blister Pack In 1 Carton (0944-3051-02) / 1 Container In 1 Blister Pack (0944-3051-03) / 1 Kit In 1 Container (0944-3051-04) * 5 Ml In 1 Vial, Glass (0944-2941-01) * 2 Ml In 1 Vial, Glass (64764-514-02)",636,RC,0944-3051-02,NDC,,,facility,both,1,EA,,9.09,9.09,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,10122-160-01,NDC,,,facility,both,1,EA,,1371.34,1371.34,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,10122-160-01,NDC,,,facility,both,1,EA,,1370.73,1370.73,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Cyclophosphamide: 1 Vial, Single-Dose In 1 Carton (10019-957-01) / 100 Ml In 1 Vial, Single-Dose (10019-957-11)",636,RC,10019-957-01,NDC,,,facility,both,1,EA,,5.3,5.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Cyclophosphamide: 1 Vial, Single-Dose In 1 Carton (10019-957-01) / 100 Ml In 1 Vial, Single-Dose (10019-957-11)",636,RC,10019-957-01,NDC,,,facility,both,1,EA,,4.46,4.46,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,10019-953-62,NDC,,,facility,both,1,EA,,14.3,14.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Mesna: 1 Vial, Multi-Dose In 1 Box (10019-953-01) / 10 Ml In 1 Vial, Multi-Dose (10019-953-62)",636,RC,10019-953-01,NDC,,,facility,both,1,EA,,16.71,16.71,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,10019-926-16,NDC,,,facility,both,1,EA,,206.91,206.91,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,10019-926-16,NDC,,,facility,both,1,EA,,191.35,191.35,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ifosfamide: 1 Vial, Single-Dose In 1 Carton (10019-926-02) / 60 Ml In 1 Vial, Single-Dose (10019-926-16)",636,RC,10019-926-02,NDC,,,facility,both,1,EA,,244.03,244.03,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ifosfamide: 1 Vial, Single-Dose In 1 Carton (10019-926-02) / 60 Ml In 1 Vial, Single-Dose (10019-926-16)",636,RC,10019-926-02,NDC,,,facility,both,1,EA,,201.49,201.49,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Advate: 1 Blister Pack In 1 Carton (0944-3051-02) / 1 Container In 1 Blister Pack (0944-3051-03) / 1 Kit In 1 Container (0944-3051-04) * 5 Ml In 1 Vial, Glass (0944-2941-01) * 2 Ml In 1 Vial, Glass (64764-514-02)",636,RC,0944-3051-02,NDC,,,facility,both,1,EA,,9.06,9.06,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0944-2700-12,NDC,,,facility,both,1,EA,,369.97,369.97,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0944-2700-12,NDC,,,facility,both,1,EA,,369.73,369.73,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0944-0493-04,NDC,,,facility,both,1,EA,,327.74,327.74,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0944-0493-04,NDC,,,facility,both,1,EA,,309.93,309.93,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0944-0493-04,NDC,,,facility,both,1,EA,,220.89,220.89,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0944-0493-04,NDC,,,facility,both,1,EA,,218.62,218.62,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0944-0493-04,NDC,,,facility,both,1,EA,,204.61,204.61,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0944-0493-03,NDC,,,facility,both,1,EA,,219.46,219.46,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0944-0493-03,NDC,,,facility,both,1,EA,,211.27,211.27,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Flexbumin: 6 Bag In 1 Carton (0944-0493-02) / 100 Ml In 1 Bag (0944-0493-04),636,RC,0944-0493-02,NDC,,,facility,both,1,EA,,228.05,228.05,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Flexbumin: 12 Bag In 1 Carton (0944-0493-01) / 50 Ml In 1 Bag (0944-0493-03),636,RC,0944-0493-01,NDC,,,facility,both,1,EA,,235.34,235.34,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Flexbumin: 12 Bag In 1 Carton (0944-0493-01) / 50 Ml In 1 Bag (0944-0493-03),636,RC,0944-0493-01,NDC,,,facility,both,1,EA,,211.69,211.69,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Flexbumin: 12 Bag In 1 Carton (0944-0493-01) / 50 Ml In 1 Bag (0944-0493-03),636,RC,0944-0493-01,NDC,,,facility,both,1,EA,,205.71,205.71,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Flexbumin: 2 Bag In 1 Carton (0944-0495-05) / 250 Ml In 1 Bag (0944-0495-06),636,RC,0944-0495-05,NDC,,,facility,both,1,EA,,48.47,48.47,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Flexbumin: 2 Bag In 1 Carton (0944-0495-05) / 250 Ml In 1 Bag (0944-0495-06),636,RC,0944-0495-05,NDC,,,facility,both,1,EA,,242.35,242.35,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0944-0495-06,NDC,,,facility,both,1,EA,,48.47,48.47,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0944-2700-12,NDC,,,facility,both,1,EA,,369.25,369.25,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0944-2700-12,NDC,,,facility,both,1,EA,,263.51,263.51,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0944-2700-11,NDC,,,facility,both,1,EA,,371.12,371.12,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0944-2700-11,NDC,,,facility,both,1,EA,,370.68,370.68,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0944-2700-11,NDC,,,facility,both,1,EA,,370.68,370.68,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0944-2700-11,NDC,,,facility,both,1,EA,,264.17,264.17,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0944-2700-10,NDC,,,facility,both,1,EA,,372.43,372.43,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0944-2700-10,NDC,,,facility,both,1,EA,,372.11,372.11,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0944-2700-10,NDC,,,facility,both,1,EA,,372.11,372.11,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0944-2700-10,NDC,,,facility,both,1,EA,,298.32,298.32,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0944-2700-10,NDC,,,facility,both,1,EA,,263.22,263.22,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0944-2700-10,NDC,,,facility,both,1,EA,,217.73,217.73,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0944-0495-06,NDC,,,facility,both,1,EA,,45.61,45.61,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0944-2700-10,NDC,,,facility,both,1,EA,,217.73,217.73,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Gammagard Liquid: 1 Bottle, Glass In 1 Carton (0944-2700-06) / 200 Ml In 1 Bottle, Glass (0944-2700-12)",636,RC,0944-2700-06,NDC,,,facility,both,1,EA,,369.97,369.97,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Gammagard Liquid: 1 Bottle, Glass In 1 Carton (0944-2700-06) / 200 Ml In 1 Bottle, Glass (0944-2700-12)",636,RC,0944-2700-06,NDC,,,facility,both,1,EA,,369.68,369.68,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Gammagard Liquid: 1 Bottle, Glass In 1 Carton (0944-2700-06) / 200 Ml In 1 Bottle, Glass (0944-2700-12)",636,RC,0944-2700-06,NDC,,,facility,both,1,EA,,369.55,369.55,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Gammagard Liquid: 1 Bottle, Glass In 1 Carton (0944-2700-06) / 200 Ml In 1 Bottle, Glass (0944-2700-12)",636,RC,0944-2700-06,NDC,,,facility,both,1,EA,,263.94,263.94,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Gammagard Liquid: 1 Bottle, Glass In 1 Carton (0944-2700-06) / 200 Ml In 1 Bottle, Glass (0944-2700-12)",636,RC,0944-2700-06,NDC,,,facility,both,1,EA,,263.22,263.22,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Gammagard Liquid: 1 Bottle, Glass In 1 Carton (0944-2700-05) / 100 Ml In 1 Bottle, Glass (0944-2700-11)",636,RC,0944-2700-05,NDC,,,facility,both,1,EA,,370.68,370.68,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Gammagard Liquid: 1 Bottle, Glass In 1 Carton (0944-2700-05) / 100 Ml In 1 Bottle, Glass (0944-2700-11)",636,RC,0944-2700-05,NDC,,,facility,both,1,EA,,263.46,263.46,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Gammagard Liquid: 1 Bottle, Glass In 1 Carton (0944-2700-05) / 100 Ml In 1 Bottle, Glass (0944-2700-11)",636,RC,0944-2700-05,NDC,,,facility,both,1,EA,,263.22,263.22,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Gammagard Liquid: 1 Bottle, Glass In 1 Carton (0944-2700-04) / 50 Ml In 1 Bottle, Glass (0944-2700-10)",636,RC,0944-2700-04,NDC,,,facility,both,1,EA,,372.83,372.83,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Gammagard Liquid: 1 Bottle, Glass In 1 Carton (0944-2700-04) / 50 Ml In 1 Bottle, Glass (0944-2700-10)",636,RC,0944-2700-04,NDC,,,facility,both,1,EA,,372.11,372.11,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Gammagard Liquid: 1 Bottle, Glass In 1 Carton (0944-2700-04) / 50 Ml In 1 Bottle, Glass (0944-2700-10)",636,RC,0944-2700-04,NDC,,,facility,both,1,EA,,372.11,372.11,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Gammagard Liquid: 1 Bottle, Glass In 1 Carton (0944-2700-04) / 50 Ml In 1 Bottle, Glass (0944-2700-10)",636,RC,0944-2700-04,NDC,,,facility,both,1,EA,,265.37,265.37,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0944-2700-08,NDC,,,facility,both,1,EA,,372.83,372.83,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Aprepitant: 6 Blister Pack In 1 Carton (13668-593-86) / 1 Capsule In 1 Blister Pack (13668-593-80),636,RC,13668-593-86,NDC,,,facility,both,1,EA,,46.26,46.26,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,13668-593-80,NDC,,,facility,both,1,EA,,46.56,46.56,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,13533-800-72,NDC,,,facility,both,1,EA,,234.83,234.83,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,13533-800-72,NDC,,,facility,both,1,EA,,234.06,234.06,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,13533-800-72,NDC,,,facility,both,1,EA,,233.5,233.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Gamunex-C: 1 Vial, Glass In 1 Carton (13533-800-71) / 100 Ml In 1 Vial, Glass (13533-800-72)",636,RC,13533-800-71,NDC,,,facility,both,1,EA,,238.29,238.29,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Gamunex-C: 1 Vial, Glass In 1 Carton (13533-800-71) / 100 Ml In 1 Vial, Glass (13533-800-72)",636,RC,13533-800-71,NDC,,,facility,both,1,EA,,237.88,237.88,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Gamunex-C: 1 Vial, Glass In 1 Carton (13533-800-71) / 100 Ml In 1 Vial, Glass (13533-800-72)",636,RC,13533-800-71,NDC,,,facility,both,1,EA,,237.8,237.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Gamunex-C: 1 Vial, Glass In 1 Carton (13533-800-71) / 100 Ml In 1 Vial, Glass (13533-800-72)",636,RC,13533-800-71,NDC,,,facility,both,1,EA,,237.59,237.59,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Gamunex-C: 1 Vial, Glass In 1 Carton (13533-800-71) / 100 Ml In 1 Vial, Glass (13533-800-72)",636,RC,13533-800-71,NDC,,,facility,both,1,EA,,237,237,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Gamunex-C: 1 Vial, Glass In 1 Carton (13533-800-71) / 100 Ml In 1 Vial, Glass (13533-800-72)",636,RC,13533-800-71,NDC,,,facility,both,1,EA,,237,237,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Gamunex-C: 1 Vial, Glass In 1 Carton (13533-800-71) / 100 Ml In 1 Vial, Glass (13533-800-72)",636,RC,13533-800-71,NDC,,,facility,both,1,EA,,237,237,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Gamunex-C: 1 Vial, Glass In 1 Carton (13533-800-71) / 100 Ml In 1 Vial, Glass (13533-800-72)",636,RC,13533-800-71,NDC,,,facility,both,1,EA,,235.72,235.72,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Gamunex-C: 1 Vial, Glass In 1 Carton (13533-800-71) / 100 Ml In 1 Vial, Glass (13533-800-72)",636,RC,13533-800-71,NDC,,,facility,both,1,EA,,235.07,235.07,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Gamunex-C: 1 Vial, Glass In 1 Carton (13533-800-71) / 100 Ml In 1 Vial, Glass (13533-800-72)",636,RC,13533-800-71,NDC,,,facility,both,1,EA,,234.9,234.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,13533-800-25,NDC,,,facility,both,1,EA,,233.79,233.79,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Papaverine Hydrochloride: 10 Vial, Single-Use In 1 Carton (14789-121-05) / 2 Ml In 1 Vial, Single-Use (14789-121-07)",636,RC,14789-121-05,NDC,,,facility,both,1,EA,,108.65,108.65,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,14789-121-07,NDC,,,facility,both,1,EA,,77.61,77.61,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Phenobarbital Sodium: 10 Vial, Glass In 1 Carton (14789-127-05) / 1 Ml In 1 Vial, Glass (14789-127-07)",636,RC,14789-127-05,NDC,,,facility,both,1,EA,,78.93,78.93,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Fosaprepitant: 1 Vial, Single-Dose In 1 Carton (16714-248-01) / 5 Ml In 1 Vial, Single-Dose",636,RC,16714-248-01,NDC,,,facility,both,1,EA,,0.89,0.89,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,16714-200-10,NDC,,,facility,both,1,EA,,3.48,3.48,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Triamcinolone Acetonide: 1 Vial In 1 Carton (16714-140-01) / 5 Ml In 1 Vial,636,RC,16714-140-01,NDC,,,facility,both,1,EA,,15.37,15.37,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,16714-016-01,NDC,,,facility,both,1,EA,,10.55,10.55,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,13533-800-25,NDC,,,facility,both,1,EA,,233.5,233.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Levetiracetam In Sodium Chloride: 10 Bag In 1 Carton (14789-330-15) / 100 Ml In 1 Bag (14789-330-08),636,RC,14789-330-15,NDC,,,facility,both,1,EA,,0.57,0.57,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,14789-330-08,NDC,,,facility,both,1,EA,,0.93,0.93,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,14789-127-07,NDC,,,facility,both,1,EA,,62.29,62.29,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Gamunex-C: 1 Vial, Glass In 1 Carton (13533-800-24) / 200 Ml In 1 Vial, Glass (13533-800-25)",636,RC,13533-800-24,NDC,,,facility,both,1,EA,,237.49,237.49,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Gamunex-C: 1 Vial, Glass In 1 Carton (13533-800-24) / 200 Ml In 1 Vial, Glass (13533-800-25)",636,RC,13533-800-24,NDC,,,facility,both,1,EA,,237.43,237.43,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Gamunex-C: 1 Vial, Glass In 1 Carton (13533-800-24) / 200 Ml In 1 Vial, Glass (13533-800-25)",636,RC,13533-800-24,NDC,,,facility,both,1,EA,,237.3,237.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,13533-800-13,NDC,,,facility,both,1,EA,,237.81,237.81,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Gamunex-C: 1 Vial, Glass In 1 Carton (13533-800-12) / 10 Ml In 1 Vial, Glass (13533-800-13)",636,RC,13533-800-12,NDC,,,facility,both,1,EA,,364.99,364.99,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Gamunex-C: 1 Vial, Glass In 1 Carton (13533-800-12) / 10 Ml In 1 Vial, Glass (13533-800-13)",636,RC,13533-800-12,NDC,,,facility,both,1,EA,,264.63,264.63,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Gamunex-C: 1 Vial, Glass In 1 Carton (13533-800-12) / 10 Ml In 1 Vial, Glass (13533-800-13)",636,RC,13533-800-12,NDC,,,facility,both,1,EA,,262.1,262.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Gamunex-C: 1 Vial, Glass In 1 Carton (13533-800-12) / 10 Ml In 1 Vial, Glass (13533-800-13)",636,RC,13533-800-12,NDC,,,facility,both,1,EA,,244.15,244.15,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Gamunex-C: 1 Vial, Glass In 1 Carton (13533-800-12) / 10 Ml In 1 Vial, Glass (13533-800-13)",636,RC,13533-800-12,NDC,,,facility,both,1,EA,,243.65,243.65,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Gamunex-C: 1 Vial, Glass In 1 Carton (13533-800-12) / 10 Ml In 1 Vial, Glass (13533-800-13)",636,RC,13533-800-12,NDC,,,facility,both,1,EA,,236.9,236.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Gamunex-C: 1 Vial, Glass In 1 Carton (13533-800-12) / 10 Ml In 1 Vial, Glass (13533-800-13)",636,RC,13533-800-12,NDC,,,facility,both,1,EA,,229.57,229.57,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,13533-636-50,NDC,,,facility,both,1,EA,,997.59,997.59,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,13533-636-50,NDC,,,facility,both,1,EA,,194.87,194.87,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,13533-636-30,NDC,,,facility,both,1,EA,,509.85,509.85,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Hyperhep B: 1 Syringe, Glass In 1 Carton (13533-636-03) / .5 Ml In 1 Syringe, Glass (13533-636-30)",636,RC,13533-636-03,NDC,,,facility,both,1,EA,,509.85,509.85,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,13533-800-13,NDC,,,facility,both,1,EA,,256.85,256.85,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,13533-634-20,NDC,,,facility,both,1,EA,,3346.61,3346.61,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Thrombate Iii: 1 Kit In 1 Carton (13533-606-12) * 10 Ml In 1 Vial, Glass (13533-605-21) * 10 Ml In 1 Vial, Glass (76297-002-12)",636,RC,13533-606-12,NDC,,,facility,both,1,EA,,24.14,24.14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,13533-605-21,NDC,,,facility,both,1,EA,,24.13,24.13,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Gamastan: 1 Vial In 1 Carton (13533-335-04) / 2 Ml In 1 Vial (13533-335-40),636,RC,13533-335-04,NDC,,,facility,both,1,EA,,362.71,362.71,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Gamastan: 1 Vial In 1 Carton (13533-335-04) / 2 Ml In 1 Vial (13533-335-40),636,RC,13533-335-04,NDC,,,facility,both,1,EA,,270.41,270.41,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,13533-318-10,NDC,,,facility,both,1,EA,,1988.13,1988.13,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,13533-318-10,NDC,,,facility,both,1,EA,,1303.66,1303.66,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,13533-318-10,NDC,,,facility,both,1,EA,,1144.22,1144.22,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Hyperrab: 1 Vial In 1 Carton (13533-318-05) / 5 Ml In 1 Vial (13533-318-50),636,RC,13533-318-05,NDC,,,facility,both,1,EA,,1362.26,1362.26,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Hyperrab: 1 Vial In 1 Carton (13533-318-01) / 1 Ml In 1 Vial (13533-318-10),636,RC,13533-318-01,NDC,,,facility,both,1,EA,,2180.71,2180.71,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Hyperrab: 1 Vial In 1 Carton (13533-318-01) / 1 Ml In 1 Vial (13533-318-10),636,RC,13533-318-01,NDC,,,facility,both,1,EA,,1253.89,1253.89,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Hyperrab: 1 Vial In 1 Carton (13533-318-01) / 1 Ml In 1 Vial (13533-318-10),636,RC,13533-318-01,NDC,,,facility,both,1,EA,,1229.97,1229.97,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Hypertet: 1 Syringe, Glass In 1 Box (13533-634-02) / 1 Ml In 1 Syringe, Glass (13533-634-20)",636,RC,13533-634-02,NDC,,,facility,both,1,EA,,3346.61,3346.61,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Gamunex-C: 1 Vial, Glass In 1 Carton (13533-800-15) / 25 Ml In 1 Vial, Glass (13533-800-16)",636,RC,13533-800-15,NDC,,,facility,both,1,EA,,233.5,233.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Gamunex-C: 1 Vial, Glass In 1 Carton (13533-800-15) / 25 Ml In 1 Vial, Glass (13533-800-16)",636,RC,13533-800-15,NDC,,,facility,both,1,EA,,235.13,235.13,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Gamunex-C: 1 Vial, Glass In 1 Carton (13533-800-24) / 200 Ml In 1 Vial, Glass (13533-800-25)",636,RC,13533-800-24,NDC,,,facility,both,1,EA,,237.17,237.17,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Gamunex-C: 1 Vial, Glass In 1 Carton (13533-800-24) / 200 Ml In 1 Vial, Glass (13533-800-25)",636,RC,13533-800-24,NDC,,,facility,both,1,EA,,237.15,237.15,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Gamunex-C: 1 Vial, Glass In 1 Carton (13533-800-24) / 200 Ml In 1 Vial, Glass (13533-800-25)",636,RC,13533-800-24,NDC,,,facility,both,1,EA,,237.01,237.01,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Gamunex-C: 1 Vial, Glass In 1 Carton (13533-800-24) / 200 Ml In 1 Vial, Glass (13533-800-25)",636,RC,13533-800-24,NDC,,,facility,both,1,EA,,237,237,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Gamunex-C: 1 Vial, Glass In 1 Carton (13533-800-24) / 200 Ml In 1 Vial, Glass (13533-800-25)",636,RC,13533-800-24,NDC,,,facility,both,1,EA,,237,237,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Gamunex-C: 1 Vial, Glass In 1 Carton (13533-800-24) / 200 Ml In 1 Vial, Glass (13533-800-25)",636,RC,13533-800-24,NDC,,,facility,both,1,EA,,234.7,234.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Gamunex-C: 1 Vial, Glass In 1 Carton (13533-800-24) / 200 Ml In 1 Vial, Glass (13533-800-25)",636,RC,13533-800-24,NDC,,,facility,both,1,EA,,234.68,234.68,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Gamunex-C: 1 Vial, Glass In 1 Carton (13533-800-24) / 200 Ml In 1 Vial, Glass (13533-800-25)",636,RC,13533-800-24,NDC,,,facility,both,1,EA,,233.5,233.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,13533-800-21,NDC,,,facility,both,1,EA,,282.54,282.54,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,13533-800-21,NDC,,,facility,both,1,EA,,237.08,237.08,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,13533-800-21,NDC,,,facility,both,1,EA,,235.58,235.58,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,13533-800-21,NDC,,,facility,both,1,EA,,233.5,233.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Gamunex-C: 1 Vial, Glass In 1 Carton (13533-800-15) / 25 Ml In 1 Vial, Glass (13533-800-16)",636,RC,13533-800-15,NDC,,,facility,both,1,EA,,234.82,234.82,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,13533-800-21,NDC,,,facility,both,1,EA,,231.12,231.12,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Gamunex-C: 1 Vial, Glass In 1 Carton (13533-800-20) / 50 Ml In 1 Vial, Glass (13533-800-21)",636,RC,13533-800-20,NDC,,,facility,both,1,EA,,240.86,240.86,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Gamunex-C: 1 Vial, Glass In 1 Carton (13533-800-20) / 50 Ml In 1 Vial, Glass (13533-800-21)",636,RC,13533-800-20,NDC,,,facility,both,1,EA,,239.86,239.86,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Gamunex-C: 1 Vial, Glass In 1 Carton (13533-800-20) / 50 Ml In 1 Vial, Glass (13533-800-21)",636,RC,13533-800-20,NDC,,,facility,both,1,EA,,239.85,239.85,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Gamunex-C: 1 Vial, Glass In 1 Carton (13533-800-20) / 50 Ml In 1 Vial, Glass (13533-800-21)",636,RC,13533-800-20,NDC,,,facility,both,1,EA,,238.86,238.86,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Gamunex-C: 1 Vial, Glass In 1 Carton (13533-800-20) / 50 Ml In 1 Vial, Glass (13533-800-21)",636,RC,13533-800-20,NDC,,,facility,both,1,EA,,237.82,237.82,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Gamunex-C: 1 Vial, Glass In 1 Carton (13533-800-20) / 50 Ml In 1 Vial, Glass (13533-800-21)",636,RC,13533-800-20,NDC,,,facility,both,1,EA,,237.32,237.32,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Gamunex-C: 1 Vial, Glass In 1 Carton (13533-800-20) / 50 Ml In 1 Vial, Glass (13533-800-21)",636,RC,13533-800-20,NDC,,,facility,both,1,EA,,237.01,237.01,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Gamunex-C: 1 Vial, Glass In 1 Carton (13533-800-20) / 50 Ml In 1 Vial, Glass (13533-800-21)",636,RC,13533-800-20,NDC,,,facility,both,1,EA,,234.87,234.87,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Gamunex-C: 1 Vial, Glass In 1 Carton (13533-800-20) / 50 Ml In 1 Vial, Glass (13533-800-21)",636,RC,13533-800-20,NDC,,,facility,both,1,EA,,233.19,233.19,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,13533-800-16,NDC,,,facility,both,1,EA,,233.5,233.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Gamunex-C: 1 Vial, Glass In 1 Carton (13533-800-15) / 25 Ml In 1 Vial, Glass (13533-800-16)",636,RC,13533-800-15,NDC,,,facility,both,1,EA,,280.49,280.49,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Gamunex-C: 1 Vial, Glass In 1 Carton (13533-800-15) / 25 Ml In 1 Vial, Glass (13533-800-16)",636,RC,13533-800-15,NDC,,,facility,both,1,EA,,239.02,239.02,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Gamunex-C: 1 Vial, Glass In 1 Carton (13533-800-20) / 50 Ml In 1 Vial, Glass (13533-800-21)",636,RC,13533-800-20,NDC,,,facility,both,1,EA,,249.55,249.55,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,54288-119-01,NDC,,,facility,both,1,EA,,12.03,12.03,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Prednisone: 100 Blister Pack In 1 Carton (0904-6923-61) / 1 Tablet In 1 Blister Pack,636,RC,0904-6923-61,NDC,,,facility,both,1,EA,,0.64,0.64,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Tacrolimus: 100 Blister Pack In 1 Carton (0904-6624-61) / 1 Capsule In 1 Blister Pack,636,RC,0904-6624-61,NDC,,,facility,both,1,EA,,13.22,13.22,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Tacrolimus: 100 Blister Pack In 1 Carton (0904-6623-61) / 1 Capsule In 1 Blister Pack,636,RC,0904-6623-61,NDC,,,facility,both,1,EA,,16.85,16.85,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Diphenhydramine Hcl Oral Solution: 100 Cup, Unit-Dose In 1 Box, Unit-Dose (0904-7323-70) / 5 Ml In 1 Cup, Unit-Dose (0904-7323-41)",636,RC,0904-7323-70,NDC,,,facility,both,1,EA,,19.83,19.83,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0904-7323-41,NDC,,,facility,both,1,EA,,23.54,23.54,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Promethazine Hydrochloride: 100 Blister Pack In 1 Carton (0904-7304-61) / 1 Tablet In 1 Blister Pack,636,RC,0904-7304-61,NDC,,,facility,both,1,EA,,7.78,7.78,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dexamethasone: 100 Blister Pack In 1 Carton (0904-7266-61) / 1 Tablet In 1 Blister Pack,636,RC,0904-7266-61,NDC,,,facility,both,1,EA,,0.53,0.53,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Tacrolimus: 100 Blister Pack In 1 Carton (0904-7097-61) / 1 Capsule In 1 Blister Pack,636,RC,0904-7097-61,NDC,,,facility,both,1,EA,,11,11,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Prednisone: 100 Blister Pack In 1 Carton (0904-7127-61) / 1 Tablet In 1 Blister Pack,636,RC,0904-7127-61,NDC,,,facility,both,1,EA,,0.2,0.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Diphenhydramine Hydrochloride: 10 Blister Pack In 1 Box, Unit-Dose (0904-7237-61) / 10 Capsule In 1 Blister Pack",636,RC,0904-7237-61,NDC,,,facility,both,1,EA,,1.03,1.03,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Lidocaine Hydrochloride: 10 Carton In 1 Container (0409-1323-05) / 1 Syringe, Plastic In 1 Carton / 5 Ml In 1 Syringe, Plastic (0409-1323-15)",636,RC,0409-1323-05,NDC,,,facility,both,1,EA,,0.97,0.97,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Epinephrine: 1 Vial In 1 Carton (54288-120-01) / 10 Ml In 1 Vial,636,RC,54288-120-01,NDC,,,facility,both,1,EA,,3.37,3.37,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Alphanate: 1 Kit In 1 Carton (68516-4617-1) * 5 Ml In 1 Vial (68516-4606-1) * 5 Ml In 1 Vial, Glass (76297-002-02)",636,RC,68516-4617-1,NDC,,,facility,both,1,EA,,6.26,6.26,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Alphanate: 1 Kit In 1 Carton (68516-4617-1) * 5 Ml In 1 Vial (68516-4606-1) * 5 Ml In 1 Vial, Glass (76297-002-02)",636,RC,68516-4617-1,NDC,,,facility,both,1,EA,,6.13,6.13,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Alphanate: 1 Kit In 1 Carton (68516-4613-2) * 10 Ml In 1 Vial (68516-4607-2) * 10 Ml In 1 Vial, Single-Dose (68516-1002-2)",636,RC,68516-4613-2,NDC,,,facility,both,1,EA,,6.15,6.15,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Alphanate: 1 Kit In 1 Carton (68516-4612-1) * 5 Ml In 1 Vial (68516-4606-1) * 5 Ml In 1 Vial, Single-Dose (68516-1001-1)",636,RC,68516-4612-1,NDC,,,facility,both,1,EA,,6.19,6.19,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,68516-4606-1,NDC,,,facility,both,1,EA,,6.21,6.21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,68516-4606-1,NDC,,,facility,both,1,EA,,6.13,6.13,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Octreotide Acetate: 10 Vial In 1 Carton (68462-897-10) / 1 Ml In 1 Vial (68462-897-01),636,RC,68462-897-10,NDC,,,facility,both,1,EA,,3.85,3.85,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,68462-897-01,NDC,,,facility,both,1,EA,,2.98,2.98,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Epinephrine: 1 Vial, Multi-Dose In 1 Carton (68462-760-10) / 10 Ml In 1 Vial, Multi-Dose",636,RC,68462-760-10,NDC,,,facility,both,1,EA,,3.35,3.35,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ketorolac Tromethamine: 25 Vial, Single-Dose In 1 Carton (68462-756-25) / 1 Ml In 1 Vial, Single-Dose (68462-756-01)",636,RC,68462-756-25,NDC,,,facility,both,1,EA,,24.05,24.05,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ketorolac Tromethamine: 25 Vial, Single-Dose In 1 Carton (68462-756-25) / 1 Ml In 1 Vial, Single-Dose (68462-756-01)",636,RC,68462-756-25,NDC,,,facility,both,1,EA,,22.45,22.45,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ketorolac Tromethamine: 25 Vial, Single-Dose In 1 Carton (68462-756-25) / 1 Ml In 1 Vial, Single-Dose (68462-756-01)",636,RC,68462-756-25,NDC,,,facility,both,1,EA,,16.92,16.92,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ketorolac Tromethamine: 25 Vial, Single-Dose In 1 Carton (68462-756-25) / 1 Ml In 1 Vial, Single-Dose (68462-756-01)",636,RC,68462-756-25,NDC,,,facility,both,1,EA,,3.29,3.29,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ketorolac Tromethamine: 25 Vial, Single-Dose In 1 Carton (68462-756-25) / 1 Ml In 1 Vial, Single-Dose (68462-756-01)",636,RC,68462-756-25,NDC,,,facility,both,1,EA,,3.23,3.23,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,68462-756-01,NDC,,,facility,both,1,EA,,17.64,17.64,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,68462-756-01,NDC,,,facility,both,1,EA,,16.86,16.86,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,68462-756-01,NDC,,,facility,both,1,EA,,3.51,3.51,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,68462-755-01,NDC,,,facility,both,1,EA,,23.91,23.91,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Fosphenytoin Sodium: 10 Vial, Single-Dose In 1 Carton (68462-622-10) / 10 Ml In 1 Vial, Single-Dose (68462-622-64)",636,RC,68462-622-10,NDC,,,facility,both,1,EA,,14.67,14.67,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Fosphenytoin Sodium: 10 Vial, Single-Dose In 1 Carton (68462-622-10) / 10 Ml In 1 Vial, Single-Dose (68462-622-64)",636,RC,68462-622-10,NDC,,,facility,both,1,EA,,13.71,13.71,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Fosphenytoin Sodium: 10 Vial, Single-Dose In 1 Carton (68462-622-10) / 10 Ml In 1 Vial, Single-Dose (68462-622-64)",636,RC,68462-622-10,NDC,,,facility,both,1,EA,,8.01,8.01,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Aprepitant: 1 Blister Pack In 1 Carton (68462-585-76) / 6 Capsule In 1 Blister Pack (68462-585-40),636,RC,68462-585-76,NDC,,,facility,both,1,EA,,42.19,42.19,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Alphanate: 1 Kit In 1 Carton (68516-4620-2) * 10 Ml In 1 Vial (68516-4610-2) * 10 Ml In 1 Vial, Glass (76297-002-12)",636,RC,68516-4620-2,NDC,,,facility,both,1,EA,,6.13,6.13,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Alphanate: 1 Kit In 1 Carton (68516-4620-2) * 10 Ml In 1 Vial (68516-4610-2) * 10 Ml In 1 Vial, Glass (76297-002-12)",636,RC,68516-4620-2,NDC,,,facility,both,1,EA,,6.14,6.14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Albutein: 1 Vial In 1 Carton (68516-5214-1) / 250 Ml In 1 Vial (68516-5214-3),636,RC,68516-5214-1,NDC,,,facility,both,1,EA,,143.47,143.47,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Albutein: 1 Vial In 1 Carton (68516-5214-2) / 500 Ml In 1 Vial (68516-5214-4),636,RC,68516-5214-2,NDC,,,facility,both,1,EA,,54.57,54.57,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,68516-5218-0,NDC,,,facility,both,1,EA,,59.58,59.58,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,68516-5216-6,NDC,,,facility,both,1,EA,,101.09,101.09,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,68462-585-40,NDC,,,facility,both,1,EA,,41.16,41.16,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,68516-5216-6,NDC,,,facility,both,1,EA,,47.47,47.47,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Albutein: 1 Vial In 1 Carton (68516-5216-5) / 20 Ml In 1 Vial (68516-5216-6),636,RC,68516-5216-5,NDC,,,facility,both,1,EA,,71.82,71.82,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,68516-5216-4,NDC,,,facility,both,1,EA,,277.56,277.56,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Albutein: 1 Vial In 1 Carton (68516-5216-2) / 100 Ml In 1 Vial (68516-5216-4),636,RC,68516-5216-2,NDC,,,facility,both,1,EA,,269.62,269.62,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,68516-5214-6,NDC,,,facility,both,1,EA,,226.01,226.01,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,68516-5214-6,NDC,,,facility,both,1,EA,,225.2,225.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Albutein: 1 Vial In 1 Carton (68516-5214-5) / 50 Ml In 1 Vial (68516-5214-6),636,RC,68516-5214-5,NDC,,,facility,both,1,EA,,1050.19,1050.19,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Albutein: 1 Vial In 1 Carton (68516-5214-5) / 50 Ml In 1 Vial (68516-5214-6),636,RC,68516-5214-5,NDC,,,facility,both,1,EA,,464.19,464.19,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Albutein: 1 Vial In 1 Carton (68516-5214-5) / 50 Ml In 1 Vial (68516-5214-6),636,RC,68516-5214-5,NDC,,,facility,both,1,EA,,328.94,328.94,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Albutein: 1 Vial In 1 Carton (68516-5214-5) / 50 Ml In 1 Vial (68516-5214-6),636,RC,68516-5214-5,NDC,,,facility,both,1,EA,,207.18,207.18,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,68516-5214-4,NDC,,,facility,both,1,EA,,215.43,215.43,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,68516-5214-3,NDC,,,facility,both,1,EA,,297.88,297.88,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Albutein: 1 Vial In 1 Carton (68516-5214-2) / 500 Ml In 1 Vial (68516-5214-4),636,RC,68516-5214-2,NDC,,,facility,both,1,EA,,56.72,56.72,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Albutein: 1 Vial In 1 Carton (68516-5216-5) / 20 Ml In 1 Vial (68516-5216-6),636,RC,68516-5216-5,NDC,,,facility,both,1,EA,,199.83,199.83,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,68727-900-01,NDC,,,facility,both,1,EA,,316.62,316.62,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Aprepitant: 2 Capsule In 1 Dose Pack (68462-584-58),636,RC,68462-584-58,NDC,,,facility,both,1,EA,,29.26,29.26,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Aprepitant: 1 Blister Pack In 1 Carton (68462-583-40) / 1 Capsule In 1 Blister Pack,636,RC,68462-583-40,NDC,,,facility,both,1,EA,,51.22,51.22,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,68462-469-40,NDC,,,facility,both,1,EA,,20.79,20.79,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,68462-469-40,NDC,,,facility,both,1,EA,,7.59,7.59,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,68462-584-40,NDC,,,facility,both,1,EA,,39.94,39.94,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,68403-1100-6,NDC,,,facility,both,1,EA,,69300,69300,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Doxycycline: 10 Vial In 1 Carton (68382-910-10) / 10 Ml In 1 Vial,636,RC,68382-910-10,NDC,,,facility,both,1,EA,,2.67,2.67,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,68382-910-01,NDC,,,facility,both,1,EA,,1.45,1.45,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,68382-860-02,NDC,,,facility,both,1,EA,,87.97,87.97,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Sirolimus: 100 Tablet, Film Coated In 1 Bottle (68382-520-01)",636,RC,68382-520-01,NDC,,,facility,both,1,EA,,35.25,35.25,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Methylprednisolone: 50 Tablet In 1 Bottle (68382-918-18),636,RC,68382-918-18,NDC,,,facility,both,1,EA,,3.18,3.18,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,68727-900-01,NDC,,,facility,both,1,EA,,316.93,316.93,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,68727-900-01,NDC,,,facility,both,1,EA,,317.03,317.03,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Rylaze: 3 Vial, Single-Dose In 1 Carton (68727-900-03) / .5 Ml In 1 Vial, Single-Dose (68727-900-01)",636,RC,68727-900-03,NDC,,,facility,both,1,EA,,310.37,310.37,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Granisetron Hydrochloride: 2 Blister Pack In 1 Carton (69452-350-92) / 10 Tablet, Film Coated In 1 Blister Pack",636,RC,69452-350-92,NDC,,,facility,both,1,EA,,17.02,17.02,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,69452-350-60,NDC,,,facility,both,1,EA,,25.98,25.98,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Diphenhydramine Hcl Oral Solution: 10 Tray In 1 Case (69339-151-19) / 10 Cup, Unit-Dose In 1 Tray / 5 Ml In 1 Cup, Unit-Dose (69339-151-05)",636,RC,69339-151-19,NDC,,,facility,both,1,EA,,29.6,29.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,69339-151-05,NDC,,,facility,both,1,EA,,28.78,28.78,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Ropivacaine Hydrochloride: 10 Vial In 1 Carton (70069-061-10) / 10 Ml In 1 Vial (70069-061-01),636,RC,70069-061-10,NDC,,,facility,both,1,EA,,1.97,1.97,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,70069-061-01,NDC,,,facility,both,1,EA,,2.32,2.32,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dexamethasone Sodium Phosphate: 25 Vial In 1 Carton (70069-021-25) / 1 Ml In 1 Vial (70069-021-01),636,RC,70069-021-25,NDC,,,facility,both,1,EA,,3.93,3.93,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,70069-021-01,NDC,,,facility,both,1,EA,,4.05,4.05,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,70069-012-01,NDC,,,facility,both,1,EA,,19.44,19.44,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,70069-012-01,NDC,,,facility,both,1,EA,,16.8,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,70069-012-01,NDC,,,facility,both,1,EA,,2.53,2.53,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Desmopressin Acetate: 1 Vial, Multi-Dose In 1 Carton (69918-901-10) / 10 Ml In 1 Vial, Multi-Dose",636,RC,69918-901-10,NDC,,,facility,both,1,EA,,28.16,28.16,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Desmopressin Acetate: 1 Vial, Multi-Dose In 1 Carton (69918-901-10) / 10 Ml In 1 Vial, Multi-Dose",636,RC,69918-901-10,NDC,,,facility,both,1,EA,,26.68,26.68,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,69339-136-03,NDC,,,facility,both,1,EA,,35.38,35.38,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,69800-0250-2,NDC,,,facility,both,1,EA,,2957.71,2957.71,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,69800-0250-2,NDC,,,facility,both,1,EA,,2951.06,2951.06,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Asceniv: 1 Vial, Single-Use In 1 Carton (69800-0250-1) / 50 Ml In 1 Vial, Single-Use (69800-0250-2)",636,RC,69800-0250-1,NDC,,,facility,both,1,EA,,2900.53,2900.53,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Asceniv: 1 Vial, Single-Use In 1 Carton (69800-0250-1) / 50 Ml In 1 Vial, Single-Use (69800-0250-2)",636,RC,69800-0250-1,NDC,,,facility,both,1,EA,,2899.71,2899.71,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Sodium Acetate: 100 Ml In 1 Vial, Pharmacy Bulk Package (69784-231-10)",636,RC,69784-231-10,NDC,,,facility,both,1,EA,,81.24,81.24,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Sodium Acetate: 50 Ml In 1 Vial, Pharmacy Bulk Package (69784-230-10)",636,RC,69784-230-10,NDC,,,facility,both,1,EA,,88.92,88.92,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sotalol Hydrochloride: 1 Vial In 1 Carton (69724-112-10) / 10 Ml In 1 Vial,636,RC,69724-112-10,NDC,,,facility,both,1,EA,,151.9,151.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Envarsus Xr: 1 Pouch In 1 Carton (68992-3010-3) / 1 Bottle, Plastic In 1 Pouch / 30 Tablet, Extended Release In 1 Bottle, Plastic",636,RC,68992-3010-3,NDC,,,facility,both,1,EA,,2.32,2.32,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Albumin (Human): 250 Ml In 1 Bottle, Glass (68982-623-02)",636,RC,68982-623-02,NDC,,,facility,both,1,EA,,119.8,119.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Albumin (Human): 250 Ml In 1 Bottle, Glass (68982-623-02)",636,RC,68982-623-02,NDC,,,facility,both,1,EA,,102.96,102.96,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Albumin (Human): 250 Ml In 1 Bottle, Glass (68982-623-02)",636,RC,68982-623-02,NDC,,,facility,both,1,EA,,58.33,58.33,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,68982-349-81,NDC,,,facility,both,1,EA,,6.02,6.02,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,68982-349-81,NDC,,,facility,both,1,EA,,5.92,5.92,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Fibryga: 1 Bottle, Glass In 1 Carton (68982-349-01) / 50 Ml In 1 Bottle, Glass (68982-349-81)",636,RC,68982-349-01,NDC,,,facility,both,1,EA,,5.7,5.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Fibryga: 1 Bottle, Glass In 1 Carton (68982-349-01) / 50 Ml In 1 Bottle, Glass (68982-349-81)",636,RC,68982-349-01,NDC,,,facility,both,1,EA,,5.51,5.51,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Fibryga: 1 Bottle, Glass In 1 Carton (68982-349-01) / 50 Ml In 1 Bottle, Glass (68982-349-81)",636,RC,68982-349-01,NDC,,,facility,both,1,EA,,5.5,5.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Fibryga: 1 Bottle, Glass In 1 Carton (68982-349-01) / 50 Ml In 1 Bottle, Glass (68982-349-81)",636,RC,68982-349-01,NDC,,,facility,both,1,EA,,5.45,5.45,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Fibryga: 1 Bottle, Glass In 1 Carton (68982-349-01) / 50 Ml In 1 Bottle, Glass (68982-349-81)",636,RC,68982-349-01,NDC,,,facility,both,1,EA,,5.45,5.45,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Fibryga: 1 Kit In 1 Carton (68982-347-01) * 50 Ml In 1 Bottle, Glass (68982-348-01)",636,RC,68982-347-01,NDC,,,facility,both,1,EA,,5.51,5.51,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Envarsus Xr: 1 Pouch In 1 Carton (68992-3040-3) / 1 Bottle, Plastic In 1 Pouch / 30 Tablet, Extended Release In 1 Bottle, Plastic",636,RC,68992-3040-3,NDC,,,facility,both,1,EA,,1.5,1.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Fibryga: 1 Kit In 1 Carton (68982-347-01) * 50 Ml In 1 Bottle, Glass (68982-348-01)",636,RC,68982-347-01,NDC,,,facility,both,1,EA,,5.49,5.49,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Fibryga: 1 Kit In 1 Carton (68982-347-01) * 50 Ml In 1 Bottle, Glass (68982-348-01)",636,RC,68982-347-01,NDC,,,facility,both,1,EA,,5.45,5.45,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Wilate - Von Willebrand Factor/Coagulation Factor Viii Complex (Human): 10 Ml In 1 Vial (68982-182-02),636,RC,68982-182-02,NDC,,,facility,both,1,EA,,7.15,7.15,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Wilate - Von Willebrand Factor/Coagulation Factor Viii Complex (Human): 5 Ml In 1 Vial (68982-182-01),636,RC,68982-182-01,NDC,,,facility,both,1,EA,,7.14,7.14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Rylaze: 3 Vial, Single-Dose In 1 Carton (68727-900-03) / .5 Ml In 1 Vial, Single-Dose (68727-900-01)",636,RC,68727-900-03,NDC,,,facility,both,1,EA,,321.81,321.81,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Rylaze: 3 Vial, Single-Dose In 1 Carton (68727-900-03) / .5 Ml In 1 Vial, Single-Dose (68727-900-01)",636,RC,68727-900-03,NDC,,,facility,both,1,EA,,319.45,319.45,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Rylaze: 3 Vial, Single-Dose In 1 Carton (68727-900-03) / .5 Ml In 1 Vial, Single-Dose (68727-900-01)",636,RC,68727-900-03,NDC,,,facility,both,1,EA,,318.91,318.91,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Rylaze: 3 Vial, Single-Dose In 1 Carton (68727-900-03) / .5 Ml In 1 Vial, Single-Dose (68727-900-01)",636,RC,68727-900-03,NDC,,,facility,both,1,EA,,317.46,317.46,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Rylaze: 3 Vial, Single-Dose In 1 Carton (68727-900-03) / .5 Ml In 1 Vial, Single-Dose (68727-900-01)",636,RC,68727-900-03,NDC,,,facility,both,1,EA,,316.75,316.75,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Rylaze: 3 Vial, Single-Dose In 1 Carton (68727-900-03) / .5 Ml In 1 Vial, Single-Dose (68727-900-01)",636,RC,68727-900-03,NDC,,,facility,both,1,EA,,311.28,311.28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Rylaze: 3 Vial, Single-Dose In 1 Carton (68727-900-03) / .5 Ml In 1 Vial, Single-Dose (68727-900-01)",636,RC,68727-900-03,NDC,,,facility,both,1,EA,,311.09,311.09,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Rylaze: 3 Vial, Single-Dose In 1 Carton (68727-900-03) / .5 Ml In 1 Vial, Single-Dose (68727-900-01)",636,RC,68727-900-03,NDC,,,facility,both,1,EA,,310.68,310.68,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Fibryga: 1 Kit In 1 Carton (68982-347-01) * 50 Ml In 1 Bottle, Glass (68982-348-01)",636,RC,68982-347-01,NDC,,,facility,both,1,EA,,5.45,5.45,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Sirolimus: 1 Carton In 1 Kit (69238-1594-3) / 1 Bottle, Glass In 1 Carton (69238-1594-6) / 60 Ml In 1 Bottle, Glass",636,RC,69238-1594-3,NDC,,,facility,both,1,EA,,50.28,50.28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Phytonadione: 10 Vial In 1 Carton (69097-709-96) / .5 Ml In 1 Vial,636,RC,69097-709-96,NDC,,,facility,both,1,EA,,51.54,51.54,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,69097-708-31,NDC,,,facility,both,1,EA,,15.74,15.74,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Cyclophosphamide: 100 Capsule In 1 Bottle (69097-516-07),636,RC,69097-516-07,NDC,,,facility,both,1,EA,,17.97,17.97,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Budesonide Inhalation Suspension: 30 Pouch In 1 Carton (69097-319-53) / 1 Ampule In 1 Pouch (69097-319-32) / 2 Ml In 1 Ampule,636,RC,69097-319-53,NDC,,,facility,both,1,EA,,28.13,28.13,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,69097-319-32,NDC,,,facility,both,1,EA,,23.54,23.54,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Pamidronate Disodium: 1 Vial In 1 Carton (67457-430-10) / 10 Ml In 1 Vial,636,RC,67457-430-10,NDC,,,facility,both,1,EA,,62.93,62.93,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,67457-428-00,NDC,,,facility,both,1,EA,,21.28,21.28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,67457-426-00,NDC,,,facility,both,1,EA,,31.13,31.13,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dexamethasone Sodium Phosphate: 25 Vial In 1 Carton (67457-423-12) / 1 Ml In 1 Vial (67457-423-00),636,RC,67457-423-12,NDC,,,facility,both,1,EA,,5.78,5.78,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,67457-423-00,NDC,,,facility,both,1,EA,,6.8,6.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Heparin Sodium: 25 Vial, Multi-Dose In 1 Carton (67457-384-99) / 30 Ml In 1 Vial, Multi-Dose (67457-384-31)",636,RC,67457-384-99,NDC,,,facility,both,1,EA,,1.5,1.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,67457-384-31,NDC,,,facility,both,1,EA,,2.21,2.21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,67457-340-00,NDC,,,facility,both,1,EA,,29.09,29.09,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,67457-299-00,NDC,,,facility,both,1,EA,,0.96,0.96,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Naloxone Hydrochloride: 10 Vial, Single-Dose In 1 Carton (67457-292-02) / 1 Ml In 1 Vial, Single-Dose (67457-292-00)",636,RC,67457-292-02,NDC,,,facility,both,1,EA,,51.19,51.19,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Cosyntropin: 10 VIAL in 1 CARTON (67457-227-02) / 1 mL in 1 VIAL (67457-227-00) ,636,RC,67457-227-02,NDC,,,facility,both,1,EA,,120.52,120.52,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Duraclon: 1 Vial In 1 Carton (67457-218-10) / 10 Ml In 1 Vial,636,RC,67457-218-10,NDC,,,facility,both,1,EA,,32.5,32.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Methadone Hydrochloride: 1 Vial, Multi-Dose In 1 Carton (67457-217-20) / 20 Ml In 1 Vial, Multi-Dose",636,RC,67457-217-20,NDC,,,facility,both,1,EA,,92.4,92.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Amiodarone Hydrochloride: 1 Vial, Glass In 1 Carton (67457-153-18) / 18 Ml In 1 Vial, Glass",636,RC,67457-153-18,NDC,,,facility,both,1,EA,,16.05,16.05,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,67457-153-00,NDC,,,facility,both,1,EA,,18.27,18.27,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Chirhostim: 8 Ml In 1 Vial, Single-Use (67066-005-01)",636,RC,67066-005-01,NDC,,,facility,both,1,EA,,226.66,226.66,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,67457-433-00,NDC,,,facility,both,1,EA,,1.06,1.06,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,67457-438-00,NDC,,,facility,both,1,EA,,37.68,37.68,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,67871-4790-6,NDC,,,facility,both,1,EA,,2978.11,2978.11,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,67871-4790-6,NDC,,,facility,both,1,EA,,2281.78,2281.78,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Acetaminophen: 24 Bag In 1 Carton (67457-940-10) / 100 Ml In 1 Bag,636,RC,67457-940-10,NDC,,,facility,both,1,EA,,1.21,1.21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,67457-887-00,NDC,,,facility,both,1,EA,,0.55,0.55,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Granisetron Hydrochloride: 1 Vial In 1 Carton (67457-863-01) / 1 Ml In 1 Vial,636,RC,67457-863-01,NDC,,,facility,both,1,EA,,4.19,4.19,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Adenosine: 10 Vial, Single-Dose In 1 Carton (67457-855-02) / 2 Ml In 1 Vial, Single-Dose (67457-855-00)",636,RC,67457-855-02,NDC,,,facility,both,1,EA,,6.09,6.09,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Acetazolamide: 1 Vial In 1 Carton (67457-853-50) / 5 Ml In 1 Vial,636,RC,67457-853-50,NDC,,,facility,both,1,EA,,42.38,42.38,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Clindamycin: 25 VIAL, SINGLE-DOSE in 1 CARTON (67457-815-04) / 4 mL in 1 VIAL, SINGLE-DOSE (67457-815-00) ",636,RC,67457-815-04,NDC,,,facility,both,1,EA,,23.75,23.75,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Miacalcin: 1 Vial, Multi-Dose In 1 Carton (67457-675-02) / 2 Ml In 1 Vial, Multi-Dose",636,RC,67457-675-02,NDC,,,facility,both,1,EA,,2512.2,2512.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Esmolol Hydrochloride In Sodium Chloride: 1 Bag In 1 Pouch (67457-657-25) / 250 Ml In 1 Bag,636,RC,67457-657-25,NDC,,,facility,both,1,EA,,7.45,7.45,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,67457-638-00,NDC,,,facility,both,1,EA,,2.06,2.06,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Triamcinolone Acetonide: 1 Vial, Multi-Dose In 1 Carton (67457-622-05) / 5 Ml In 1 Vial, Multi-Dose",636,RC,67457-622-05,NDC,,,facility,both,1,EA,,18.7,18.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,67457-584-00,NDC,,,facility,both,1,EA,,28.95,28.95,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,67457-582-00,NDC,,,facility,both,1,EA,,35.95,35.95,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,67457-473-00,NDC,,,facility,both,1,EA,,24.8,24.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,67457-457-00,NDC,,,facility,both,1,EA,,0.43,0.43,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,67457-855-00,NDC,,,facility,both,1,EA,,17.07,17.07,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,66794-219-63,NDC,,,facility,both,1,EA,,29.6,29.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ondansetron: 3 Blister Pack In 1 Carton (65862-390-10) / 10 Tablet, Orally Disintegrating In 1 Blister Pack",636,RC,65862-390-10,NDC,,,facility,both,1,EA,,3.72,3.72,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Mycophenolate Mofetil: 1 Bottle, Plastic In 1 Carton (66689-307-08) / 250 Ml In 1 Bottle, Plastic",636,RC,66689-307-08,NDC,,,facility,both,1,EA,,17.2,17.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Gamifant: 1 Vial, Single-Use In 1 Carton (66658-505-01) / 10 Ml In 1 Vial, Single-Use",636,RC,66658-505-01,NDC,,,facility,both,1,EA,,2237.38,2237.38,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Gamifant: 1 Vial, Single-Use In 1 Carton (66658-505-01) / 10 Ml In 1 Vial, Single-Use",636,RC,66658-505-01,NDC,,,facility,both,1,EA,,2158.5,2158.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Gamifant: 1 Vial, Single-Use In 1 Carton (66658-501-01) / 2 Ml In 1 Vial, Single-Use",636,RC,66658-501-01,NDC,,,facility,both,1,EA,,3783.53,3783.53,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,70069-067-01,NDC,,,facility,both,1,EA,,0.19,0.19,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Tacrolimus: 100 Blister Pack In 1 Box, Unit-Dose (68084-450-01) / 1 Capsule In 1 Blister Pack (68084-450-11)",636,RC,68084-450-01,NDC,,,facility,both,1,EA,,18.74,18.74,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Phentolamine Mesylate: 1 Vial In 1 Carton (68094-101-20) / 1 Injection In 1 Vial,636,RC,68094-101-20,NDC,,,facility,both,1,EA,,257.56,257.56,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,68094-022-59,NDC,,,facility,both,1,EA,,32.41,32.41,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Diphenhydramine Hydrochloride: 10 Blister Pack In 1 Carton (68094-018-61) / 10 Tablet In 1 Blister Pack (68094-018-59),636,RC,68094-018-61,NDC,,,facility,both,1,EA,,13.25,13.25,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,68094-018-59,NDC,,,facility,both,1,EA,,13.91,13.91,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,68084-918-95,NDC,,,facility,both,1,EA,,21.83,21.83,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Mycophenolic Acid: 30 Blister Pack In 1 Box, Unit-Dose (68084-918-25) / 1 Tablet, Delayed Release In 1 Blister Pack (68084-918-95)",636,RC,68084-918-25,NDC,,,facility,both,1,EA,,20.96,20.96,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,68084-907-11,NDC,,,facility,both,1,EA,,30.9,30.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ondansetron Hydrochloride: 100 Blister Pack In 1 Box, Unit-Dose (68084-220-01) / 1 Tablet, Film Coated In 1 Blister Pack (68084-220-11)",636,RC,68084-220-01,NDC,,,facility,both,1,EA,,2.62,2.62,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,68084-149-11,NDC,,,facility,both,1,EA,,14.2,14.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Zerbaxa: 10 Vial, Single-Dose In 1 Carton (67919-030-01) / 10 Ml In 1 Vial, Single-Dose",636,RC,67919-030-01,NDC,,,facility,both,1,EA,,52.03,52.03,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,68084-220-11,NDC,,,facility,both,1,EA,,2.55,2.55,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dronabinol: 60 Capsule In 1 Bottle (67877-753-60),636,RC,67877-753-60,NDC,,,facility,both,1,EA,,18.31,18.31,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,67877-718-33,NDC,,,facility,both,1,EA,,30.03,30.03,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Everolimus: 6 Blister Pack In 1 Carton (67877-718-31) / 10 Tablet In 1 Blister Pack (67877-718-33),636,RC,67877-718-31,NDC,,,facility,both,1,EA,,31.52,31.52,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Mycophenolate Mofetil: 1 Bottle, Plastic In 1 Carton (67877-230-22) / 225 Ml In 1 Bottle, Plastic",636,RC,67877-230-22,NDC,,,facility,both,1,EA,,26.42,26.42,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dronabinol: 60 Capsule In 1 Bottle (67877-754-60),636,RC,67877-754-60,NDC,,,facility,both,1,EA,,15.74,15.74,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,68084-229-11,NDC,,,facility,both,1,EA,,15.86,15.86,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,70069-101-01,NDC,,,facility,both,1,EA,,48.63,48.63,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Asparlas: 1 Vial, Single-Use In 1 Carton (72694-515-01) / 5 Ml In 1 Vial, Single-Use",636,RC,72694-515-01,NDC,,,facility,both,1,EA,,416.35,416.35,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Asparlas: 1 Vial, Single-Use In 1 Carton (72694-515-01) / 5 Ml In 1 Vial, Single-Use",636,RC,72694-515-01,NDC,,,facility,both,1,EA,,416.2,416.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Asparlas: 1 Vial, Single-Use In 1 Carton (72694-515-01) / 5 Ml In 1 Vial, Single-Use",636,RC,72694-515-01,NDC,,,facility,both,1,EA,,415.98,415.98,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Dexrazoxane: 1 Vial, Single-Dose In 1 Carton (72611-716-01) / 50 Ml In 1 Vial, Single-Dose",636,RC,72611-716-01,NDC,,,facility,both,1,EA,,465.86,465.86,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Dexrazoxane: 1 Vial, Single-Dose In 1 Carton (72611-716-01) / 50 Ml In 1 Vial, Single-Dose",636,RC,72611-716-01,NDC,,,facility,both,1,EA,,299.34,299.34,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ampicillin: 10 Vial, Pharmacy Bulk Package In 1 Box (72603-578-01) / 100 Ml In 1 Vial, Pharmacy Bulk Package",636,RC,72603-578-01,NDC,,,facility,both,1,EA,,15.04,15.04,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,72603-474-01,NDC,,,facility,both,1,EA,,2.49,2.49,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ampicillin: 10 Vial In 1 Carton (72603-363-10) / 1 Injection, Powder, For Solution In 1 Vial (72603-363-01)",636,RC,72603-363-10,NDC,,,facility,both,1,EA,,16.34,16.34,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,72603-363-01,NDC,,,facility,both,1,EA,,15.37,15.37,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ampicillin And Sulbactam: 1 Injection, Powder, For Solution In 1 Vial, Single-Dose (72603-335-01)",636,RC,72603-335-01,NDC,,,facility,both,1,EA,,26.42,26.42,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,72603-251-01,NDC,,,facility,both,1,EA,,0.36,0.36,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,72603-221-01,NDC,,,facility,both,1,EA,,31.84,31.84,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,72603-219-01,NDC,,,facility,both,1,EA,,0.24,0.24,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dexamethasone: 100 Mg In 1 Bottle (72603-212-01),636,RC,72603-212-01,NDC,,,facility,both,1,EA,,3.07,3.07,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Daptomycin: 1 Vial, Single-Dose In 1 Carton (72603-152-01) / 10 Ml In 1 Vial, Single-Dose",636,RC,72603-152-01,NDC,,,facility,both,1,EA,,0.65,0.65,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Daptomycin: 1 Vial, Single-Dose In 1 Carton (72603-152-01) / 10 Ml In 1 Vial, Single-Dose",636,RC,72603-152-01,NDC,,,facility,both,1,EA,,0.31,0.31,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Daptomycin: 1 Vial, Single-Dose In 1 Carton (72603-152-01) / 10 Ml In 1 Vial, Single-Dose",636,RC,72603-152-01,NDC,,,facility,both,1,EA,,0.27,0.27,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Asparlas: 1 Vial, Single-Use In 1 Carton (72694-515-01) / 5 Ml In 1 Vial, Single-Use",636,RC,72694-515-01,NDC,,,facility,both,1,EA,,416.41,416.41,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Asparlas: 1 Vial, Single-Use In 1 Carton (72694-515-01) / 5 Ml In 1 Vial, Single-Use",636,RC,72694-515-01,NDC,,,facility,both,1,EA,,416.41,416.41,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Asparlas: 1 Vial, Single-Use In 1 Carton (72694-515-01) / 5 Ml In 1 Vial, Single-Use",636,RC,72694-515-01,NDC,,,facility,both,1,EA,,416.53,416.53,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,73177-116-02,NDC,,,facility,both,1,EA,,27.51,27.51,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,73177-108-03,NDC,,,facility,both,1,EA,,9.12,9.12,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,73177-108-03,NDC,,,facility,both,1,EA,,4.25,4.25,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,73177-105-01,NDC,,,facility,both,1,EA,,46.48,46.48,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Insulin Aspart: 1 Vial, Glass In 1 Carton (73070-100-11) / 10 Ml In 1 Vial, Glass",636,RC,73070-100-11,NDC,,,facility,both,1,EA,,25.09,25.09,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,72603-133-01,NDC,,,facility,both,1,EA,,8.68,8.68,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,72990-103-03,NDC,,,facility,both,1,EA,,53.7,53.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,72990-103-03,NDC,,,facility,both,1,EA,,53.33,53.33,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,72990-103-03,NDC,,,facility,both,1,EA,,52.1,52.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,72990-103-03,NDC,,,facility,both,1,EA,,52.1,52.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Evomela: 1 Vial In 1 Carton (72893-001-01) / 20 Ml In 1 Vial,636,RC,72893-001-01,NDC,,,facility,both,1,EA,,132.6,132.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Evomela: 1 Vial In 1 Carton (72893-001-01) / 20 Ml In 1 Vial,636,RC,72893-001-01,NDC,,,facility,both,1,EA,,132.16,132.16,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Evomela: 1 Vial In 1 Carton (72893-001-01) / 20 Ml In 1 Vial,636,RC,72893-001-01,NDC,,,facility,both,1,EA,,131.38,131.38,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,73177-146-33,NDC,,,facility,both,1,EA,,3.7,3.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,72603-133-01,NDC,,,facility,both,1,EA,,0.22,0.22,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,72266-118-01,NDC,,,facility,both,1,EA,,22.63,22.63,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,72266-118-01,NDC,,,facility,both,1,EA,,20.65,20.65,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,72266-118-01,NDC,,,facility,both,1,EA,,2,2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,72266-118-01,NDC,,,facility,both,1,EA,,1.81,1.81,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dexrazoxane: 1 Vial In 1 Carton (72266-101-01) / 50 Ml In 1 Vial,636,RC,72266-101-01,NDC,,,facility,both,1,EA,,750.55,750.55,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dexrazoxane: 1 Vial In 1 Carton (72266-101-01) / 50 Ml In 1 Vial,636,RC,72266-101-01,NDC,,,facility,both,1,EA,,606.83,606.83,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dexrazoxane: 1 Vial In 1 Carton (72266-101-01) / 50 Ml In 1 Vial,636,RC,72266-101-01,NDC,,,facility,both,1,EA,,408.86,408.86,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dexrazoxane: 1 Vial In 1 Carton (72266-101-01) / 50 Ml In 1 Vial,636,RC,72266-101-01,NDC,,,facility,both,1,EA,,404.09,404.09,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dexrazoxane: 1 Vial In 1 Carton (72266-101-01) / 50 Ml In 1 Vial,636,RC,72266-101-01,NDC,,,facility,both,1,EA,,395.13,395.13,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dexrazoxane: 1 Vial In 1 Carton (72266-101-01) / 50 Ml In 1 Vial,636,RC,72266-101-01,NDC,,,facility,both,1,EA,,374.7,374.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Sirolimus: 1 Bottle, Glass In 1 Carton (72205-099-78) / 60 Ml In 1 Bottle, Glass",636,RC,72205-099-78,NDC,,,facility,both,1,EA,,45.32,45.32,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Thiotepa: 1 Vial, Glass In 1 Box (72205-046-01) / 1 Injection, Powder, Lyophilized, For Solution In 1 Vial, Glass",636,RC,72205-046-01,NDC,,,facility,both,1,EA,,204.59,204.59,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Thiotepa: 1 Vial, Glass In 1 Box (72205-045-01) / 1 Injection, Powder, Lyophilized, For Solution In 1 Vial, Glass",636,RC,72205-045-01,NDC,,,facility,both,1,EA,,74.67,74.67,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Thiotepa: 1 Vial, Glass In 1 Box (72205-045-01) / 1 Injection, Powder, Lyophilized, For Solution In 1 Vial, Glass",636,RC,72205-045-01,NDC,,,facility,both,1,EA,,33.17,33.17,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,72196-6011-1,NDC,,,facility,both,1,EA,,31.09,31.09,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Voriconazole: 1 Vial, Single-Dose In 1 Carton (72266-131-01) / 20 Ml In 1 Vial, Single-Dose",636,RC,72266-131-01,NDC,,,facility,both,1,EA,,6.98,6.98,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,72266-159-01,NDC,,,facility,both,1,EA,,76.88,76.88,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,72266-234-01,NDC,,,facility,both,1,EA,,23.46,23.46,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,72266-234-01,NDC,,,facility,both,1,EA,,24.82,24.82,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Thiamine: 25 Vial, Multi-Dose In 1 Carton (72485-507-25) / 2 Ml In 1 Vial, Multi-Dose (72485-507-01)",636,RC,72485-507-25,NDC,,,facility,both,1,EA,,37.11,37.11,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,72485-507-01,NDC,,,facility,both,1,EA,,19.63,19.63,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Milrinone Lactate: 10 Vial In 1 Carton (72485-501-10) / 10 Ml In 1 Vial (72485-501-01),636,RC,72485-501-10,NDC,,,facility,both,1,EA,,19.89,19.89,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,72485-501-01,NDC,,,facility,both,1,EA,,19.5,19.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,72485-423-01,NDC,,,facility,both,1,EA,,11.58,11.58,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Mycophenolate Mofetil: 4 Vial In 1 Carton (72485-415-04) / 20 Ml In 1 Vial,636,RC,72485-415-04,NDC,,,facility,both,1,EA,,2.82,2.82,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,72485-415-01,NDC,,,facility,both,1,EA,,2.89,2.89,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dexamethasone: 100 Tablet In 1 Bottle (72578-170-01),636,RC,72578-170-01,NDC,,,facility,both,1,EA,,1.19,1.19,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,72485-101-01,NDC,,,facility,both,1,EA,,34.81,34.81,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Cisplatin: 1 Vial In 1 Carton (72266-253-01) / 100 Ml In 1 Vial,636,RC,72266-253-01,NDC,,,facility,both,1,EA,,26.34,26.34,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Doxycycline: 5 Vial In 1 Carton (72266-237-05) / 10 Ml In 1 Vial (72266-237-01),636,RC,72266-237-05,NDC,,,facility,both,1,EA,,0.59,0.59,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,72266-237-01,NDC,,,facility,both,1,EA,,0.92,0.92,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dexrazoxane: 1 Vial In 1 Carton (72266-235-01) / 25 Ml In 1 Vial,636,RC,72266-235-01,NDC,,,facility,both,1,EA,,353.67,353.67,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dexrazoxane: 1 Vial In 1 Carton (72266-235-01) / 25 Ml In 1 Vial,636,RC,72266-235-01,NDC,,,facility,both,1,EA,,342.87,342.87,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Ketorolac Tromethamine: 25 Vial In 1 Carton (72266-234-25) / 1 Ml In 1 Vial (72266-234-01),636,RC,72266-234-25,NDC,,,facility,both,1,EA,,26.47,26.47,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Ketorolac Tromethamine: 25 Vial In 1 Carton (72266-234-25) / 1 Ml In 1 Vial (72266-234-01),636,RC,72266-234-25,NDC,,,facility,both,1,EA,,23.52,23.52,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,72266-234-01,NDC,,,facility,both,1,EA,,31.83,31.83,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,73177-149-02,NDC,,,facility,both,1,EA,,185.3,185.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,73177-149-43,NDC,,,facility,both,1,EA,,435.6,435.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Methadone Hydrochloride: 1 Vial, Glass In 1 Carton (81298-7500-1) / 20 Ml In 1 Vial, Glass",636,RC,81298-7500-1,NDC,,,facility,both,1,EA,,60.99,60.99,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,81284-411-00,NDC,,,facility,both,1,EA,,224.53,224.53,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,81284-152-00,NDC,,,facility,both,1,EA,,27.77,27.77,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,80830-2365-1,NDC,,,facility,both,1,EA,,0.8,0.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Calcium Gluconate: 24 Pouch In 1 Carton (80830-2362-9) / 1 Bag In 1 Pouch / 50 Ml In 1 Bag,636,RC,80830-2362-9,NDC,,,facility,both,1,EA,,0.59,0.59,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,80830-2362-1,NDC,,,facility,both,1,EA,,0.61,0.61,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,80830-2362-1,NDC,,,facility,both,1,EA,,0.57,0.57,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,80830-1188-1,NDC,,,facility,both,1,EA,,2.29,2.29,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Daptomycin: 1 Vial, Single-Dose In 1 Carton (83090-011-01) / 10 Ml In 1 Vial, Single-Dose",636,RC,83090-011-01,NDC,,,facility,both,1,EA,,0.2,0.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Daptomycin: 1 Vial, Single-Dose In 1 Carton (83090-011-01) / 10 Ml In 1 Vial, Single-Dose",636,RC,83090-011-01,NDC,,,facility,both,1,EA,,0.27,0.27,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Fulphila: 1 Syringe In 1 Carton (83257-005-41) / .6 Ml In 1 Syringe,636,RC,83257-005-41,NDC,,,facility,both,1,EA,,766.84,766.84,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,78206-162-99,NDC,,,facility,both,1,EA,,254.76,254.76,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,9999-1019-54,NDC,,,facility,both,1,EA,,16.19,16.19,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Palonosetron Hydrochloride: 1 Vial, Single-Dose In 1 Carton (83634-777-05) / 5 Ml In 1 Vial, Single-Dose",636,RC,83634-777-05,NDC,,,facility,both,1,EA,,8.63,8.63,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Magnesium Sulfate In Water: 24 Pouch In 1 Carton (83634-500-81) / 1 Bag In 1 Pouch (83634-500-41) / 50 Ml In 1 Bag,636,RC,83634-500-81,NDC,,,facility,both,1,EA,,11.61,11.61,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,83634-500-41,NDC,,,facility,both,1,EA,,14.31,14.31,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,83634-400-41,NDC,,,facility,both,1,EA,,1.03,1.03,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Bivalirudin: 10 Vial, Single-Dose In 1 Carton (83634-400-10) / 1 Injection, Powder, Lyophilized, For Solution In 1 Vial, Single-Dose (83634-400-41)",636,RC,83634-400-10,NDC,,,facility,both,1,EA,,1.03,1.03,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Ampicillin: 1 Bottle In 1 Carton (83634-100-99) / 100 Ml In 1 Bottle,636,RC,83634-100-99,NDC,,,facility,both,1,EA,,17.93,17.93,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Fulphila: 1 Syringe In 1 Carton (83257-005-41) / .6 Ml In 1 Syringe,636,RC,83257-005-41,NDC,,,facility,both,1,EA,,815.49,815.49,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Fulphila: 1 Syringe In 1 Carton (83257-005-41) / .6 Ml In 1 Syringe,636,RC,83257-005-41,NDC,,,facility,both,1,EA,,804.27,804.27,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Fulphila: 1 Syringe In 1 Carton (83257-005-41) / .6 Ml In 1 Syringe,636,RC,83257-005-41,NDC,,,facility,both,1,EA,,795.22,795.22,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,78206-162-99,NDC,,,facility,both,1,EA,,246,246,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,78206-162-99,NDC,,,facility,both,1,EA,,240.83,240.83,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,78206-162-99,NDC,,,facility,both,1,EA,,239.69,239.69,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Albuterol Sulfate: 30 Pouch In 1 Carton (76204-200-01) / 1 Ampule In 1 Pouch / 3 Ml In 1 Ampule,636,RC,76204-200-01,NDC,,,facility,both,1,EA,,4.45,4.45,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Ipratropium Bromide: 30 Pouch In 1 Carton (76204-100-01) / 1 Ampule In 1 Pouch / 2.5 Ml In 1 Ampule,636,RC,76204-100-01,NDC,,,facility,both,1,EA,,12.96,12.96,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,76204-011-05,NDC,,,facility,both,1,EA,,7.33,7.33,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Albuked: 1 Vial In 1 Carton (76125-792-25) / 50 Ml In 1 Vial (76125-792-26),636,RC,76125-792-25,NDC,,,facility,both,1,EA,,221.08,221.08,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,76045-204-00,NDC,,,facility,both,1,EA,,38.16,38.16,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,76045-004-01,NDC,,,facility,both,1,EA,,39.31,39.31,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Bloxiverz: 10 CARTON in 1 PACKAGE (76014-003-10) / 1 VIAL, MULTI-DOSE in 1 CARTON (76014-003-33) / 10 mL in 1 VIAL, MULTI-DOSE",636,RC,76014-003-10,NDC,,,facility,both,1,EA,,6.2,6.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Ipratropium Bromide And Albuterol Sulfate: 30 Pouch In 1 Carton (76204-600-01) / 1 Ampule In 1 Pouch / 3 Ml In 1 Ampule,636,RC,76204-600-01,NDC,,,facility,both,1,EA,,14.54,14.54,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,73177-163-33,NDC,,,facility,both,1,EA,,3.84,3.84,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,78206-162-99,NDC,,,facility,both,1,EA,,234.41,234.41,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,78206-162-99,NDC,,,facility,both,1,EA,,234.32,234.32,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Renflexis: 1 Vial In 1 Carton (78206-162-01) / 1 Injection, Powder, Lyophilized, For Solution In 1 Vial (78206-162-99)",636,RC,78206-162-01,NDC,,,facility,both,1,EA,,234.57,234.57,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Renflexis: 1 Vial In 1 Carton (78206-162-01) / 1 Injection, Powder, Lyophilized, For Solution In 1 Vial (78206-162-99)",636,RC,78206-162-01,NDC,,,facility,both,1,EA,,234.36,234.36,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Epinephrine: 1 Vial In 1 Carton (76329-9060-0) / 30 Ml In 1 Vial,636,RC,76329-9060-0,NDC,,,facility,both,1,EA,,5.7,5.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Epinephrine: 10 Carton In 1 Package (76329-3318-1) / 1 Syringe In 1 Carton / 10 Ml In 1 Syringe,636,RC,76329-3318-1,NDC,,,facility,both,1,EA,,13.84,13.84,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Epinephrine: 10 VIAL in 1 PACKAGE (76329-3316-1) / 10 mL in 1 VIAL,636,RC,76329-3316-1,NDC,,,facility,both,1,EA,,13.74,13.74,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Calcium Chloride: 10 Syringe In 1 Package (76329-3304-1) / 10 Ml In 1 Syringe,636,RC,76329-3304-1,NDC,,,facility,both,1,EA,,137.06,137.06,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dextrose Monohydrate: 1 Syringe In 1 Carton (76329-3302-1) / 50 Ml In 1 Syringe,636,RC,76329-3302-1,NDC,,,facility,both,1,EA,,59.12,59.12,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Phytonadione: 1 Syringe In 1 Carton (76329-1240-1) / .5 Ml In 1 Syringe,636,RC,76329-1240-1,NDC,,,facility,both,1,EA,,160.68,160.68,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,76310-024-15,NDC,,,facility,both,1,EA,,211.85,211.85,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,76297-001-42,NDC,,,facility,both,1,EA,,48.29,48.29,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,71837-5843-1,NDC,,,facility,both,1,EA,,673.47,673.47,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Vancomycin Hydrochloride: 1 Vial, Glass In 1 Carton (70594-047-01) / 1 Injection, Powder, Lyophilized, For Solution In 1 Vial, Glass",636,RC,70594-047-01,NDC,,,facility,both,1,EA,,24.65,24.65,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Colistimethate: 1 Vial, Glass In 1 Vial (70594-023-01) / 1 Injection, Powder, For Solution In 1 Vial, Glass",636,RC,70594-023-01,NDC,,,facility,both,1,EA,,92.22,92.22,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Lanoxin: 10 Vial In 1 Box (70515-263-10) / 1 Ml In 1 Vial,636,RC,70515-263-10,NDC,,,facility,both,1,EA,,167.97,167.97,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Lanoxin: 10 Ampule In 1 Box (70515-262-10) / 1 Ml In 1 Ampule,636,RC,70515-262-10,NDC,,,facility,both,1,EA,,118.87,118.87,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Dobutamine: 1 Vial, Single-Dose In 1 Carton (70436-203-80) / 20 Ml In 1 Vial, Single-Dose",636,RC,70436-203-80,NDC,,,facility,both,1,EA,,38.49,38.49,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Ganciclovir: 25 Vial In 1 Carton (70436-089-55) / 10 Ml In 1 Vial,636,RC,70436-089-55,NDC,,,facility,both,1,EA,,52.65,52.65,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Voriconazole: 1 Injection, Powder, Lyophilized, For Solution In 1 Box (70436-029-80)",636,RC,70436-029-80,NDC,,,facility,both,1,EA,,5.65,5.65,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Vancomycin Hydrochloride: 10 Vial In 1 Carton (70436-021-82) / 1 Injection, Powder, Lyophilized, For Solution In 1 Vial",636,RC,70436-021-82,NDC,,,facility,both,1,EA,,34.59,34.59,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Leuprolide Acetate: 1 Kit In 1 Carton (70121-2537-6) * 1 Vial, Multi-Dose In 1 Carton (70121-1695-2) / 2.8 Ml In 1 Vial, Multi-Dose * 1 Ml In 1 Packet (70121-2538-9)",636,RC,70121-2537-6,NDC,,,facility,both,1,EA,,131.4,131.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Lioresal (Baclofen): 1 Ampule In 1 Box (70121-2503-1) / 1 Kit In 1 Ampule,636,RC,70121-2503-1,NDC,,,facility,both,1,EA,,818.5,818.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,70710-1838-1,NDC,,,facility,both,1,EA,,10.55,10.55,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Nelarabine: 6 Vial, Single-Dose In 1 Carton (70710-1726-8) / 50 Ml In 1 Vial, Single-Dose",636,RC,70710-1726-8,NDC,,,facility,both,1,EA,,253.24,253.24,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Nelarabine: 6 Vial, Single-Dose In 1 Carton (70710-1726-8) / 50 Ml In 1 Vial, Single-Dose",636,RC,70710-1726-8,NDC,,,facility,both,1,EA,,221.77,221.77,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Nelarabine: 6 Vial, Single-Dose In 1 Carton (70710-1726-8) / 50 Ml In 1 Vial, Single-Dose",636,RC,70710-1726-8,NDC,,,facility,both,1,EA,,215.82,215.82,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Nelarabine: 1 Vial, Single-Dose In 1 Carton (70710-1726-1) / 50 Ml In 1 Vial, Single-Dose",636,RC,70710-1726-1,NDC,,,facility,both,1,EA,,231.64,231.64,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Micafungin: 10 Vial In 1 Carton (70710-1724-6) / 5 Ml In 1 Vial,636,RC,70710-1724-6,NDC,,,facility,both,1,EA,,3.35,3.35,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Micafungin: 1 Vial In 1 Carton (70710-1724-1) / 5 Ml In 1 Vial,636,RC,70710-1724-1,NDC,,,facility,both,1,EA,,2.28,2.28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Azithromycin: 1 Bottle In 1 Carton (70710-1460-2) / 30 Ml In 1 Bottle,636,RC,70710-1460-2,NDC,,,facility,both,1,EA,,21.5,21.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,70710-1359-1,NDC,,,facility,both,1,EA,,1.07,1.07,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Lioresal (Baclofen): 1 Ampule In 1 Box (70121-2503-1) / 1 Kit In 1 Ampule,636,RC,70121-2503-1,NDC,,,facility,both,1,EA,,818.5,818.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Fluorouracil: 10 Vial In 1 Carton (70700-186-23) / 10 Ml In 1 Vial (70700-186-22),636,RC,70700-186-23,NDC,,,facility,both,1,EA,,183.55,183.55,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Lioresal (Baclofen): 5 Ampule In 1 Box (70121-2496-5) / 1 Ml In 1 Ampule,636,RC,70121-2496-5,NDC,,,facility,both,1,EA,,223.96,223.96,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,70121-2495-1,NDC,,,facility,both,1,EA,,818.5,818.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,70121-1719-1,NDC,,,facility,both,1,EA,,13.83,13.83,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,70092-1475-50,NDC,,,facility,both,1,EA,,50.01,50.01,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,70092-1125-48,NDC,,,facility,both,1,EA,,28.18,28.18,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,70092-1046-46,NDC,,,facility,both,1,EA,,29.21,29.21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,70092-1046-46,NDC,,,facility,both,1,EA,,0.7,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,70092-1009-44,NDC,,,facility,both,1,EA,,23.06,23.06,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,70092-1486-46,NDC,,,facility,both,1,EA,,38.31,38.31,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Milrinone Lactate: 10 Vial In 1 Carton (70069-807-10) / 10 Ml In 1 Vial (70069-807-01),636,RC,70069-807-10,NDC,,,facility,both,1,EA,,24.4,24.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,70069-788-01,NDC,,,facility,both,1,EA,,2.61,2.61,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,70069-788-01,NDC,,,facility,both,1,EA,,2.23,2.23,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,70069-727-01,NDC,,,facility,both,1,EA,,0.25,0.25,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,70069-727-01,NDC,,,facility,both,1,EA,,0.22,0.22,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sulfamethoxazole And Trimethoprim: 10 Vial In 1 Carton (70069-362-10) / 10 Ml In 1 Vial (70069-362-01),636,RC,70069-362-10,NDC,,,facility,both,1,EA,,0.56,0.56,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,70069-807-01,NDC,,,facility,both,1,EA,,17.2,17.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,70121-1716-1,NDC,,,facility,both,1,EA,,2.25,2.25,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Plerixafor: 1 Vial, Single-Dose In 1 Carton (70121-1694-2) / 1.2 Ml In 1 Vial, Single-Dose",636,RC,70121-1694-2,NDC,,,facility,both,1,EA,,49.97,49.97,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Plerixafor: 1 Vial, Single-Dose In 1 Carton (70121-1694-2) / 1.2 Ml In 1 Vial, Single-Dose",636,RC,70121-1694-2,NDC,,,facility,both,1,EA,,49.65,49.65,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Plerixafor: 1 Vial, Single-Dose In 1 Carton (70121-1694-2) / 1.2 Ml In 1 Vial, Single-Dose",636,RC,70121-1694-2,NDC,,,facility,both,1,EA,,49.5,49.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Plerixafor: 1 Vial, Single-Dose In 1 Carton (70121-1694-2) / 1.2 Ml In 1 Vial, Single-Dose",636,RC,70121-1694-2,NDC,,,facility,both,1,EA,,48.07,48.07,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Tepadina: 1 Vial, Glass In 1 Box (70121-1631-1) / 1 Injection, Powder, For Solution In 1 Vial, Glass",636,RC,70121-1631-1,NDC,,,facility,both,1,EA,,1451.36,1451.36,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Releuko: 1 Syringe In 1 Box (70121-1570-1) / .8 Ml In 1 Syringe,636,RC,70121-1570-1,NDC,,,facility,both,1,EA,,1.37,1.37,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Releuko: 1 Syringe In 1 Box (70121-1570-1) / .8 Ml In 1 Syringe,636,RC,70121-1570-1,NDC,,,facility,both,1,EA,,1.36,1.36,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Releuko: 1 Syringe In 1 Box (70121-1568-1) / .5 Ml In 1 Syringe,636,RC,70121-1568-1,NDC,,,facility,both,1,EA,,1.74,1.74,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Releuko: 1 Syringe In 1 Box (70121-1568-1) / .5 Ml In 1 Syringe,636,RC,70121-1568-1,NDC,,,facility,both,1,EA,,1.51,1.51,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Releuko: 1 Syringe In 1 Box (70121-1568-1) / .5 Ml In 1 Syringe,636,RC,70121-1568-1,NDC,,,facility,both,1,EA,,1.48,1.48,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Releuko: 1 Syringe In 1 Box (70121-1568-1) / .5 Ml In 1 Syringe,636,RC,70121-1568-1,NDC,,,facility,both,1,EA,,1.37,1.37,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Cyclophosphamide: 1 Vial, Single-Dose In 1 Carton (70121-1239-1) / 50 Ml In 1 Vial, Single-Dose",636,RC,70121-1239-1,NDC,,,facility,both,1,EA,,3.14,3.14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Cyclophosphamide: 1 Vial, Single-Dose In 1 Carton (70121-1239-1) / 50 Ml In 1 Vial, Single-Dose",636,RC,70121-1239-1,NDC,,,facility,both,1,EA,,3,3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Cyclophosphamide: 1 Vial, Single-Dose In 1 Carton (70121-1239-1) / 50 Ml In 1 Vial, Single-Dose",636,RC,70121-1239-1,NDC,,,facility,both,1,EA,,2.02,2.02,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Cyclophosphamide: 1 Vial, Single-Dose In 1 Carton (70121-1238-1) / 25 Ml In 1 Vial, Single-Dose",636,RC,70121-1238-1,NDC,,,facility,both,1,EA,,4.44,4.44,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Cyclophosphamide: 1 Vial, Single-Dose In 1 Carton (70121-1238-1) / 25 Ml In 1 Vial, Single-Dose",636,RC,70121-1238-1,NDC,,,facility,both,1,EA,,3.23,3.23,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Cyclophosphamide: 1 Vial, Single-Dose In 1 Carton (70121-1238-1) / 25 Ml In 1 Vial, Single-Dose",636,RC,70121-1238-1,NDC,,,facility,both,1,EA,,1.96,1.96,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Cyclophosphamide: 1 Vial, Single-Dose In 1 Carton (70121-1238-1) / 25 Ml In 1 Vial, Single-Dose",636,RC,70121-1238-1,NDC,,,facility,both,1,EA,,1.96,1.96,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Cyclophosphamide: 1 Vial, Single-Dose In 1 Carton (70121-1238-1) / 25 Ml In 1 Vial, Single-Dose",636,RC,70121-1238-1,NDC,,,facility,both,1,EA,,1.96,1.96,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Triamcinolone Acetonide: 1 Vial, Multi-Dose In 1 Carton (70121-1168-1) / 5 Ml In 1 Vial, Multi-Dose",636,RC,70121-1168-1,NDC,,,facility,both,1,EA,,9.93,9.93,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Triamcinolone Acetonide: 1 Vial In 1 Carton (70121-1049-2) / 1 Ml In 1 Vial (70121-1049-1),636,RC,70121-1049-2,NDC,,,facility,both,1,EA,,8.65,8.65,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Releuko: 1 Syringe In 1 Box (70121-1568-1) / .5 Ml In 1 Syringe,636,RC,70121-1568-1,NDC,,,facility,both,1,EA,,1.43,1.43,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Methocarbamol: 25 Vial In 1 Carton (70069-101-25) / 10 Ml In 1 Vial,636,RC,70069-101-25,NDC,,,facility,both,1,EA,,46.33,46.33,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,71288-434-84,NDC,,,facility,both,1,EA,,8.21,8.21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Enoxaparin Sodium: 10 Syringe In 1 Carton (71288-433-83) / .4 Ml In 1 Syringe (71288-433-82),636,RC,71288-433-83,NDC,,,facility,both,1,EA,,10.74,10.74,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,71288-433-82,NDC,,,facility,both,1,EA,,10.61,10.61,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,71288-432-80,NDC,,,facility,both,1,EA,,13.39,13.39,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,71288-427-10,NDC,,,facility,both,1,EA,,1.08,1.08,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Enoxaparin Sodium: 1 Vial, Multi-Dose In 1 Carton (71288-426-03) / 3 Ml In 1 Vial, Multi-Dose",636,RC,71288-426-03,NDC,,,facility,both,1,EA,,23.82,23.82,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Palonosetron Hydrochloride: 1 Vial, Single-Dose In 1 Carton (71288-409-05) / 5 Ml In 1 Vial, Single-Dose",636,RC,71288-409-05,NDC,,,facility,both,1,EA,,4.02,4.02,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Palonosetron Hydrochloride: 1 Vial, Single-Dose In 1 Carton (71288-409-05) / 5 Ml In 1 Vial, Single-Dose",636,RC,71288-409-05,NDC,,,facility,both,1,EA,,1.15,1.15,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,71288-403-01,NDC,,,facility,both,1,EA,,6.85,6.85,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,71288-402-30,NDC,,,facility,both,1,EA,,5,5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Heparin Sodium: 25 Vial, Multi-Dose In 1 Carton (71288-402-11) / 10 Ml In 1 Vial, Multi-Dose (71288-402-10)",636,RC,71288-402-11,NDC,,,facility,both,1,EA,,4.19,4.19,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Heparin Sodium: 25 Vial, Single-Dose In 1 Carton (71288-402-02) / 1 Ml In 1 Vial, Single-Dose (71288-402-01)",636,RC,71288-402-02,NDC,,,facility,both,1,EA,,17.04,17.04,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,71288-402-01,NDC,,,facility,both,1,EA,,23.38,23.38,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,71288-400-02,NDC,,,facility,both,1,EA,,16.19,16.19,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,71288-303-01,NDC,,,facility,both,1,EA,,33.19,33.19,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,71288-203-10,NDC,,,facility,both,1,EA,,1.37,1.37,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,71288-203-02,NDC,,,facility,both,1,EA,,3.93,3.93,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,71288-203-02,NDC,,,facility,both,1,EA,,1.33,1.33,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,71288-203-02,NDC,,,facility,both,1,EA,,0.11,0.11,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Nelarabine: 1 Vial, Single-Dose In 1 Carton (71288-165-54) / 50 Ml In 1 Vial, Single-Dose (71288-165-52)",636,RC,71288-165-54,NDC,,,facility,both,1,EA,,214.14,214.14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Nelarabine: 1 Vial, Single-Dose In 1 Carton (71288-165-54) / 50 Ml In 1 Vial, Single-Dose (71288-165-52)",636,RC,71288-165-54,NDC,,,facility,both,1,EA,,193.98,193.98,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Nelarabine: 1 Vial, Single-Dose In 1 Carton (71288-165-54) / 50 Ml In 1 Vial, Single-Dose (71288-165-52)",636,RC,71288-165-54,NDC,,,facility,both,1,EA,,188.74,188.74,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Thiotepa: 1 Vial, Single-Dose In 1 Carton (71288-157-10) / 1 Injection, Powder, For Solution In 1 Vial, Single-Dose",636,RC,71288-157-10,NDC,,,facility,both,1,EA,,159.82,159.82,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Thiotepa: 1 Vial, Single-Dose In 1 Carton (71288-157-10) / 1 Injection, Powder, For Solution In 1 Vial, Single-Dose",636,RC,71288-157-10,NDC,,,facility,both,1,EA,,32.83,32.83,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Thiotepa: 1 Vial, Single-Dose In 1 Carton (71288-157-10) / 1 Injection, Powder, For Solution In 1 Vial, Single-Dose",636,RC,71288-157-10,NDC,,,facility,both,1,EA,,32.02,32.02,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,71288-435-86,NDC,,,facility,both,1,EA,,7.14,7.14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Enoxaparin Sodium: 10 Syringe In 1 Carton (71288-435-87) / .8 Ml In 1 Syringe (71288-435-86),636,RC,71288-435-87,NDC,,,facility,both,1,EA,,7.14,7.14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,71288-600-10,NDC,,,facility,both,1,EA,,30.41,30.41,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,71837-5843-1,NDC,,,facility,both,1,EA,,379.72,379.72,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,71837-5843-1,NDC,,,facility,both,1,EA,,360.06,360.06,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,71837-5843-1,NDC,,,facility,both,1,EA,,307.67,307.67,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Dactinomycin: 1 Vial, Single-Dose In 1 Carton (71288-129-02) / 1 Ml In 1 Vial, Single-Dose",636,RC,71288-129-02,NDC,,,facility,both,1,EA,,3076.07,3076.07,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,71390-011-00,NDC,,,facility,both,1,EA,,14.77,14.77,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Mycophenolate Mofetil: 4 Vial, Single-Dose In 1 Carton (71288-803-21) / 20 Ml In 1 Vial, Single-Dose (71288-803-20)",636,RC,71288-803-21,NDC,,,facility,both,1,EA,,2.75,2.75,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,71288-803-20,NDC,,,facility,both,1,EA,,3.48,3.48,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,71288-737-10,NDC,,,facility,both,1,EA,,0.8,0.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Bupivacaine Hydrochloride: 1 Vial, Single-Dose In 1 Carton (71288-721-11) / 10 Ml In 1 Vial, Single-Dose",636,RC,71288-721-11,NDC,,,facility,both,1,EA,,0.83,0.83,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Bupivacaine Hydrochloride: 1 Vial, Single-Dose In 1 Carton (71288-721-11) / 10 Ml In 1 Vial, Single-Dose",636,RC,71288-721-11,NDC,,,facility,both,1,EA,,0.76,0.76,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Diphenhydramine Hcl: 236 Ml In 1 Bottle, Plastic (71399-0125-8)",636,RC,71399-0125-8,NDC,,,facility,both,1,EA,,11.84,11.84,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Busulfan: 8 Vial, Single-Dose In 1 Carton (71288-116-11) / 10 Ml In 1 Vial, Single-Dose (71288-116-10)",636,RC,71288-116-11,NDC,,,facility,both,1,EA,,5.45,5.45,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Busulfan: 8 Vial, Single-Dose In 1 Carton (71288-116-11) / 10 Ml In 1 Vial, Single-Dose (71288-116-10)",636,RC,71288-116-11,NDC,,,facility,both,1,EA,,3.39,3.39,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,71288-116-10,NDC,,,facility,both,1,EA,,5.62,5.62,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Acyclovir: 473 Ml In 1 Bottle (70954-188-10),636,RC,70954-188-10,NDC,,,facility,both,1,EA,,10.38,10.38,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Prednisone: 100 Tablet In 1 Bottle (70954-059-10),636,RC,70954-059-10,NDC,,,facility,both,1,EA,,0.7,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,70860-776-41,NDC,,,facility,both,1,EA,,5.48,5.48,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,70842-160-01,NDC,,,facility,both,1,EA,,15.49,15.49,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,70756-604-44,NDC,,,facility,both,1,EA,,43.19,43.19,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,70860-100-41,NDC,,,facility,both,1,EA,,32.88,32.88,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,71288-116-10,NDC,,,facility,both,1,EA,,3.37,3.37,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Azacitidine: 1 Vial, Single-Dose In 1 Carton (71288-115-30) / 1 Injection, Powder, Lyophilized, For Solution In 1 Vial, Single-Dose",636,RC,71288-115-30,NDC,,,facility,both,1,EA,,4.77,4.77,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Azacitidine: 1 Vial, Single-Dose In 1 Carton (71288-115-30) / 1 Injection, Powder, Lyophilized, For Solution In 1 Vial, Single-Dose",636,RC,71288-115-30,NDC,,,facility,both,1,EA,,1.64,1.64,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Gemcitabine: 1 Vial, Single-Dose In 1 Carton (71288-113-10) / 1 Injection, Powder, Lyophilized, For Solution In 1 Vial, Single-Dose",636,RC,71288-113-10,NDC,,,facility,both,1,EA,,43.7,43.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ampicillin And Sulbactam: 1 Bottle In 1 Carton (71288-033-75) / 1 Injection, Powder, For Solution In 1 Bottle",636,RC,71288-033-75,NDC,,,facility,both,1,EA,,28.07,28.07,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,71288-028-10,NDC,,,facility,both,1,EA,,2.08,2.08,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Daptomycin: 1 Vial, Single-Dose In 1 Carton (71288-016-15) / 10 Ml In 1 Vial, Single-Dose",636,RC,71288-016-15,NDC,,,facility,both,1,EA,,0.51,0.51,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Daptomycin: 1 Vial, Single-Dose In 1 Carton (71288-016-15) / 10 Ml In 1 Vial, Single-Dose",636,RC,71288-016-15,NDC,,,facility,both,1,EA,,0.36,0.36,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,71286-6011-1,NDC,,,facility,both,1,EA,,30.17,30.17,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Sevenfact: 1 Kit In 1 Package (71127-5000-1) * 5 Ml In 1 Vial, Single-Dose (71127-5100-1) * 5.2 Ml In 1 Syringe (71127-5200-1)",636,RC,71127-5000-1,NDC,,,facility,both,1,EA,,12.81,12.81,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Sevenfact: 1 Kit In 1 Package (71127-1000-1) * 1 Ml In 1 Vial, Single-Dose (71127-1100-1) * 1.1 Ml In 1 Syringe (71127-1200-1)",636,RC,71127-1000-1,NDC,,,facility,both,1,EA,,12.81,12.81,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,60687-145-11,NDC,,,facility,both,1,EA,,0.14,0.14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Prednisone: 100 Blister Pack In 1 Box, Unit-Dose (60687-145-01) / 1 Tablet In 1 Blister Pack (60687-145-11)",636,RC,60687-145-01,NDC,,,facility,both,1,EA,,0.63,0.63,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,60687-134-11,NDC,,,facility,both,1,EA,,0.69,0.69,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,60687-122-11,NDC,,,facility,both,1,EA,,1.64,1.64,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,60687-394-79,NDC,,,facility,both,1,EA,,12.79,12.79,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dronabinol: 20 Blister Pack In 1 Carton (60687-386-94) / 1 Capsule In 1 Blister Pack (60687-386-11),636,RC,60687-386-94,NDC,,,facility,both,1,EA,,52.44,52.44,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,60687-386-11,NDC,,,facility,both,1,EA,,52.44,52.44,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dronabinol: 30 Blister Pack In 1 Carton (60687-375-21) / 1 Capsule In 1 Blister Pack (60687-375-11),636,RC,60687-375-21,NDC,,,facility,both,1,EA,,57.67,57.67,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,60687-375-11,NDC,,,facility,both,1,EA,,55.22,55.22,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,59923-615-01,NDC,,,facility,both,1,EA,,120.71,120.71,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Azithromycin: 1 Bottle In 1 Carton (59762-3140-1) / 30 Ml In 1 Bottle,636,RC,59762-3140-1,NDC,,,facility,both,1,EA,,18.4,18.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Azithromycin: 1 Bottle In 1 Carton (59762-3120-1) / 15 Ml In 1 Bottle,636,RC,59762-3120-1,NDC,,,facility,both,1,EA,,25.78,25.78,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Sirolimus: 100 Tablet, Sugar Coated In 1 Bottle (59762-1001-1)",636,RC,59762-1001-1,NDC,,,facility,both,1,EA,,34.27,34.27,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Prochlorperazine Maleate: 100 Tablet In 1 Bottle (59746-113-06),636,RC,59746-113-06,NDC,,,facility,both,1,EA,,11.5,11.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Yondelis: 20 Ml In 1 Vial, Single-Use (59676-610-01)",636,RC,59676-610-01,NDC,,,facility,both,1,EA,,2242.36,2242.36,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Yondelis: 20 Ml In 1 Vial, Single-Use (59676-610-01)",636,RC,59676-610-01,NDC,,,facility,both,1,EA,,2232.05,2232.05,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Sirolimus: 1 Bottle, Glass In 1 Carton (60505-6197-2) / 60 Ml In 1 Bottle, Glass",636,RC,60505-6197-2,NDC,,,facility,both,1,EA,,104.42,104.42,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Cefepime: 10 Vial, Single-Dose In 1 Carton (60505-6147-4) / 1 Injection, Powder, For Solution In 1 Vial, Single-Dose",636,RC,60505-6147-4,NDC,,,facility,both,1,EA,,30.04,30.04,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Cefepime: 1 Vial, Single-Dose In 1 Carton (60505-6147-0) / 1 Injection, Powder, For Solution In 1 Vial, Single-Dose",636,RC,60505-6147-0,NDC,,,facility,both,1,EA,,25.42,25.42,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Cefepime: 1 Vial, Single-Dose In 1 Carton (60505-6146-0) / 1 Injection, Powder, For Solution In 1 Vial, Single-Dose",636,RC,60505-6146-0,NDC,,,facility,both,1,EA,,26.11,26.11,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,60505-6130-0,NDC,,,facility,both,1,EA,,5.91,5.91,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Irinotecan Hydrochloride: 1 Vial, Single-Use In 1 Carton (60505-6128-1) / 5 Ml In 1 Vial, Single-Use",636,RC,60505-6128-1,NDC,,,facility,both,1,EA,,47.98,47.98,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Irinotecan Hydrochloride: 1 Vial, Single-Use In 1 Carton (60505-6128-1) / 5 Ml In 1 Vial, Single-Use",636,RC,60505-6128-1,NDC,,,facility,both,1,EA,,7.89,7.89,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ceftriaxone: 10 VIAL in 1 CARTON (60505-0753-4) / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL",636,RC,60505-0753-4,NDC,,,facility,both,1,EA,,9.48,9.48,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,60687-438-11,NDC,,,facility,both,1,EA,,6.91,6.91,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Promethazine Hydrochloride: 100 Blister Pack In 1 Carton (60687-660-01) / 1 Tablet In 1 Blister Pack (60687-660-11),636,RC,60687-660-01,NDC,,,facility,both,1,EA,,13.31,13.31,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,60687-660-11,NDC,,,facility,both,1,EA,,13.24,13.24,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Tobramycin: 30 Pouch In 1 Carton (60687-731-83) / 1 Ampule In 1 Pouch (60687-731-79) / 5 Ml In 1 Ampule,636,RC,60687-731-83,NDC,,,facility,both,1,EA,,124.1,124.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,60687-731-79,NDC,,,facility,both,1,EA,,123.88,123.88,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,60687-524-79,NDC,,,facility,both,1,EA,,47.4,47.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Prednisone: 100 Tablet In 1 Bottle (59651-489-01),636,RC,59651-489-01,NDC,,,facility,both,1,EA,,0.08,0.08,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Prednisone: 100 Tablet In 1 Bottle (59651-488-01),636,RC,59651-488-01,NDC,,,facility,both,1,EA,,0.35,0.35,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,55513-003-01,NDC,,,facility,both,1,EA,,41.08,41.08,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,55513-003-01,NDC,,,facility,both,1,EA,,25.87,25.87,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,55292-702-54,NDC,,,facility,both,1,EA,,193.55,193.55,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Leuprolide Acetate: 1 Kit In 1 Carton (55150-478-01) * 1 Vial, Multi-Dose In 1 Carton (55150-338-01) / 2.8 Ml In 1 Vial, Multi-Dose * 1 Ml In 1 Packet (60913-006-01)",636,RC,55150-478-01,NDC,,,facility,both,1,EA,,141.01,141.01,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Dactinomycin: 1 Vial, Single-Dose In 1 Carton (55150-431-01) / 1 Ml In 1 Vial, Single-Dose",636,RC,55150-431-01,NDC,,,facility,both,1,EA,,2223.75,2223.75,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,55150-420-01,NDC,,,facility,both,1,EA,,2.62,2.62,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Gentamicin: 25 Vial, Multi-Dose In 1 Carton (55150-402-25) / 2 Ml In 1 Vial, Multi-Dose (55150-402-01)",636,RC,55150-402-25,NDC,,,facility,both,1,EA,,38.01,38.01,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,55150-400-01,NDC,,,facility,both,1,EA,,33.96,33.96,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Vasopressin: 1 Vial, Multi-Dose In 1 Carton (55150-370-01) / 1 Ml In 1 Vial, Multi-Dose",636,RC,55150-370-01,NDC,,,facility,both,1,EA,,31.01,31.01,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Amphotericin B: 1 Vial, Single-Dose In 1 Carton (55150-365-01) / 12.5 Ml In 1 Vial, Single-Dose",636,RC,55150-365-01,NDC,,,facility,both,1,EA,,108.48,108.48,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Amphotericin B: 1 Vial, Single-Dose In 1 Carton (55150-365-01) / 12.5 Ml In 1 Vial, Single-Dose",636,RC,55150-365-01,NDC,,,facility,both,1,EA,,107.63,107.63,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Bortezomib: 1 Vial, Single-Dose In 1 Carton (55150-337-01) / 1 Injection, Powder, Lyophilized, For Solution In 1 Vial, Single-Dose",636,RC,55150-337-01,NDC,,,facility,both,1,EA,,26.91,26.91,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Bortezomib: 1 Vial, Single-Dose In 1 Carton (55150-337-01) / 1 Injection, Powder, Lyophilized, For Solution In 1 Vial, Single-Dose",636,RC,55150-337-01,NDC,,,facility,both,1,EA,,10.35,10.35,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Bortezomib: 1 Vial, Single-Dose In 1 Carton (55150-337-01) / 1 Injection, Powder, Lyophilized, For Solution In 1 Vial, Single-Dose",636,RC,55150-337-01,NDC,,,facility,both,1,EA,,6.54,6.54,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Carboplatin: 1 Vial, Multi-Dose In 1 Carton (55150-335-01) / 45 Ml In 1 Vial, Multi-Dose",636,RC,55150-335-01,NDC,,,facility,both,1,EA,,31.21,31.21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,55150-328-01,NDC,,,facility,both,1,EA,,0.8,0.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,55150-322-01,NDC,,,facility,both,1,EA,,9.7,9.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,55150-322-01,NDC,,,facility,both,1,EA,,0.17,0.17,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,55150-307-01,NDC,,,facility,both,1,EA,,1.33,1.33,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,55150-287-01,NDC,,,facility,both,1,EA,,19.42,19.42,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ertapenem: 10 Vial, Single-Dose In 1 Carton (55150-282-20) / 1 Injection In 1 Vial, Single-Dose",636,RC,55150-282-20,NDC,,,facility,both,1,EA,,78.82,78.82,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Acetylcysteine: 4 Vial, Single-Dose In 1 Carton (55150-259-30) / 30 Ml In 1 Vial, Single-Dose",636,RC,55150-259-30,NDC,,,facility,both,1,EA,,4.39,4.39,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Acetylcysteine: 4 Vial, Single-Dose In 1 Carton (55150-259-30) / 30 Ml In 1 Vial, Single-Dose",636,RC,55150-259-30,NDC,,,facility,both,1,EA,,3.27,3.27,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,55513-003-01,NDC,,,facility,both,1,EA,,48.54,48.54,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,55513-003-01,NDC,,,facility,both,1,EA,,49.28,49.28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,55513-003-01,NDC,,,facility,both,1,EA,,49.64,49.64,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,55513-005-01,NDC,,,facility,both,1,EA,,46.5,46.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Riabni: 1 Vial, Single-Dose In 1 Carton (55513-224-01) / 10 Ml In 1 Vial, Single-Dose",636,RC,55513-224-01,NDC,,,facility,both,1,EA,,303.45,303.45,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Nplate: 1 Vial, Single-Dose In 1 Carton (55513-223-01) / .25 Ml In 1 Vial, Single-Dose",636,RC,55513-223-01,NDC,,,facility,both,1,EA,,68.26,68.26,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Nplate: 1 Vial, Single-Dose In 1 Carton (55513-223-01) / .25 Ml In 1 Vial, Single-Dose",636,RC,55513-223-01,NDC,,,facility,both,1,EA,,68.05,68.05,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Nplate: 1 Vial, Single-Dose In 1 Carton (55513-223-01) / .25 Ml In 1 Vial, Single-Dose",636,RC,55513-223-01,NDC,,,facility,both,1,EA,,67.83,67.83,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Nplate: 1 Vial, Single-Dose In 1 Carton (55513-223-01) / .25 Ml In 1 Vial, Single-Dose",636,RC,55513-223-01,NDC,,,facility,both,1,EA,,67.83,67.83,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Nplate: 1 Vial In 1 Carton (55513-221-01) / .5 Ml In 1 Vial,636,RC,55513-221-01,NDC,,,facility,both,1,EA,,67.92,67.92,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Mvasi: 1 Vial In 1 Carton (55513-207-01) / 16 Ml In 1 Vial,636,RC,55513-207-01,NDC,,,facility,both,1,EA,,425.1,425.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Mvasi: 1 Vial In 1 Carton (55513-207-01) / 16 Ml In 1 Vial,636,RC,55513-207-01,NDC,,,facility,both,1,EA,,332.39,332.39,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Mvasi: 1 Vial In 1 Carton (55513-207-01) / 16 Ml In 1 Vial,636,RC,55513-207-01,NDC,,,facility,both,1,EA,,315.97,315.97,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Mvasi: 1 Vial In 1 Carton (55513-207-01) / 16 Ml In 1 Vial,636,RC,55513-207-01,NDC,,,facility,both,1,EA,,309.03,309.03,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Mvasi: 1 Vial In 1 Carton (55513-207-01) / 16 Ml In 1 Vial,636,RC,55513-207-01,NDC,,,facility,both,1,EA,,300.01,300.01,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Mvasi: 1 Vial In 1 Carton (55513-207-01) / 16 Ml In 1 Vial,636,RC,55513-207-01,NDC,,,facility,both,1,EA,,295.94,295.94,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Levetiracetam: 10 Pouch In 1 Carton (55150-248-47) / 1 Bag In 1 Pouch / 100 Ml In 1 Bag,636,RC,55150-248-47,NDC,,,facility,both,1,EA,,1.17,1.17,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Mvasi: 1 Vial In 1 Carton (55513-206-01) / 4 Ml In 1 Vial,636,RC,55513-206-01,NDC,,,facility,both,1,EA,,324.21,324.21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Mvasi: 1 Vial In 1 Carton (55513-206-01) / 4 Ml In 1 Vial,636,RC,55513-206-01,NDC,,,facility,both,1,EA,,317.84,317.84,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Blincyto: 1 Kit In 1 Package (55513-160-01) * 3.088 Ml In 1 Vial (55513-150-01) * 10.6 Ml In 1 Vial (55513-155-01),636,RC,55513-160-01,NDC,,,facility,both,1,EA,,969.86,969.86,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Blincyto: 1 Kit In 1 Package (55513-160-01) * 3.088 Ml In 1 Vial (55513-150-01) * 10.6 Ml In 1 Vial (55513-155-01),636,RC,55513-160-01,NDC,,,facility,both,1,EA,,952.08,952.08,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Blincyto: 1 Kit In 1 Package (55513-160-01) * 3.088 Ml In 1 Vial (55513-150-01) * 10.6 Ml In 1 Vial (55513-155-01),636,RC,55513-160-01,NDC,,,facility,both,1,EA,,934.22,934.22,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Aranesp: 4 Vial, Single-Dose In 1 Package (55513-005-04) / 1 Ml In 1 Vial, Single-Dose (55513-005-01)",636,RC,55513-005-04,NDC,,,facility,both,1,EA,,37.4,37.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,55513-005-01,NDC,,,facility,both,1,EA,,46.87,46.87,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,55513-005-01,NDC,,,facility,both,1,EA,,46.65,46.65,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,55513-005-01,NDC,,,facility,both,1,EA,,46.65,46.65,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,55513-005-01,NDC,,,facility,both,1,EA,,46.5,46.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Mvasi: 1 Vial In 1 Carton (55513-206-01) / 4 Ml In 1 Vial,636,RC,55513-206-01,NDC,,,facility,both,1,EA,,321.2,321.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,55150-236-01,NDC,,,facility,both,1,EA,,79.78,79.78,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Vecuronium Bromide: 10 Vial In 1 Carton (55150-235-10) / 1 Injection, Powder, Lyophilized, For Solution In 1 Vial (55150-235-01)",636,RC,55150-235-10,NDC,,,facility,both,1,EA,,31.28,31.28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,55150-235-01,NDC,,,facility,both,1,EA,,22.5,22.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ampicillin: 10 Vial In 1 Box (55150-113-10) / 1 Injection, Powder, For Solution In 1 Vial",636,RC,55150-113-10,NDC,,,facility,both,1,EA,,14.85,14.85,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Zoledronic Acid: 1 Vial, Glass In 1 Carton (55111-685-07) / 5 Ml In 1 Vial, Glass",636,RC,55111-685-07,NDC,,,facility,both,1,EA,,20.76,20.76,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Zoledronic Acid: 1 Vial, Glass In 1 Carton (55111-685-07) / 5 Ml In 1 Vial, Glass",636,RC,55111-685-07,NDC,,,facility,both,1,EA,,11.08,11.08,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,55111-652-07,NDC,,,facility,both,1,EA,,1.31,1.31,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ampicillin: 10 Vial, Pharmacy Bulk Package In 1 Box (55150-115-99) / 100 Ml In 1 Vial, Pharmacy Bulk Package",636,RC,55150-115-99,NDC,,,facility,both,1,EA,,19.04,19.04,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Carnitor: 5 Vial In 1 Carton (54482-147-01) / 5 Ml In 1 Vial,636,RC,54482-147-01,NDC,,,facility,both,1,EA,,211.97,211.97,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Carboplatin: 1 Vial, Multi-Dose In 1 Carton (54288-166-01) / 45 Ml In 1 Vial, Multi-Dose",636,RC,54288-166-01,NDC,,,facility,both,1,EA,,74.43,74.43,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Carboplatin: 1 Vial, Multi-Dose In 1 Carton (54288-165-01) / 15 Ml In 1 Vial, Multi-Dose",636,RC,54288-165-01,NDC,,,facility,both,1,EA,,94.35,94.35,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,54288-142-01,NDC,,,facility,both,1,EA,,79.32,79.32,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Mycophenolate Mofetil: 4 Vial In 1 Carton (54288-141-04) / 20 Ml In 1 Vial,636,RC,54288-141-04,NDC,,,facility,both,1,EA,,3.33,3.33,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,54288-141-01,NDC,,,facility,both,1,EA,,4.55,4.55,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,54288-136-01,NDC,,,facility,both,1,EA,,111.87,111.87,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Riabni: 1 Vial, Single-Dose In 1 Carton (55513-224-01) / 10 Ml In 1 Vial, Single-Dose",636,RC,55513-224-01,NDC,,,facility,both,1,EA,,303.45,303.45,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ampicillin And Sulbactam: 10 Vial In 1 Carton (55150-117-20) / 1 Injection, Powder, For Solution In 1 Vial",636,RC,55150-117-20,NDC,,,facility,both,1,EA,,27.53,27.53,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Piperacillin And Tazobactam: 10 Vial In 1 Box (55150-120-30) / 1 Injection, Powder, Lyophilized, For Solution In 1 Vial",636,RC,55150-120-30,NDC,,,facility,both,1,EA,,24.52,24.52,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Methocarbamol: 25 Vial, Single-Dose In 1 Carton (55150-223-10) / 10 Ml In 1 Vial, Single-Dose",636,RC,55150-223-10,NDC,,,facility,both,1,EA,,41.9,41.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Meropenem: 10 Vial In 1 Carton (55150-208-30) / 1 Injection, Powder, For Solution In 1 Vial",636,RC,55150-208-30,NDC,,,facility,both,1,EA,,6.37,6.37,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Pantoprazole Sodium: 10 Vial, Single-Dose In 1 Carton (55150-202-10) / 1 Injection, Powder, For Solution In 1 Vial, Single-Dose (55150-202-00)",636,RC,55150-202-10,NDC,,,facility,both,1,EA,,36.01,36.01,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,55150-202-00,NDC,,,facility,both,1,EA,,30.47,30.47,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ropivacaine Hydrochloride: 25 Vial, Single-Dose In 1 Carton (55150-197-20) / 20 Ml In 1 Vial, Single-Dose",636,RC,55150-197-20,NDC,,,facility,both,1,EA,,0.44,0.44,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Esmolol Hydrochloride: 25 Vial, Single-Dose In 1 Carton (55150-194-10) / 10 Ml In 1 Vial, Single-Dose",636,RC,55150-194-10,NDC,,,facility,both,1,EA,,10.39,10.39,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Adenosine: 1 Vial, Single-Dose In 1 Carton (55150-192-01) / 20 Ml In 1 Vial, Single-Dose",636,RC,55150-192-01,NDC,,,facility,both,1,EA,,4.24,4.24,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Adenosine: 1 Vial, Single-Dose In 1 Carton (55150-192-01) / 20 Ml In 1 Vial, Single-Dose",636,RC,55150-192-01,NDC,,,facility,both,1,EA,,1.94,1.94,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ampicillin And Sulbactam: 1 Vial, Pharmacy Bulk Package In 1 Carton (55150-118-99) / 100 Ml In 1 Vial, Pharmacy Bulk Package",636,RC,55150-118-99,NDC,,,facility,both,1,EA,,28.87,28.87,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Azithromycin: 10 Vial, Single-Dose In 1 Carton (55150-174-10) / 1 Injection, Powder, Lyophilized, For Solution In 1 Vial, Single-Dose",636,RC,55150-174-10,NDC,,,facility,both,1,EA,,31.28,31.28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Bupivacaine Hydrochloride: 25 Vial, Single-Dose In 1 Carton (55150-167-10) / 10 Ml In 1 Vial, Single-Dose",636,RC,55150-167-10,NDC,,,facility,both,1,EA,,0.73,0.73,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Bupivacaine Hydrochloride: 25 Vial, Single-Dose In 1 Carton (55150-167-10) / 10 Ml In 1 Vial, Single-Dose",636,RC,55150-167-10,NDC,,,facility,both,1,EA,,0.17,0.17,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Bupivacaine Hydrochloride: 25 Vial, Single-Dose In 1 Carton (55150-167-10) / 10 Ml In 1 Vial, Single-Dose",636,RC,55150-167-10,NDC,,,facility,both,1,EA,,0.17,0.17,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Lidocaine Hydrochloride: 10 Vial, Single-Dose In 1 Carton (55150-165-05) / 5 Ml In 1 Vial, Single-Dose",636,RC,55150-165-05,NDC,,,facility,both,1,EA,,0.32,0.32,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Acyclovir Sodium: 10 Vial, Single-Dose In 1 Carton (55150-155-20) / 20 Ml In 1 Vial, Single-Dose",636,RC,55150-155-20,NDC,,,facility,both,1,EA,,0.91,0.91,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Oxacillin: 1 Vial, Pharmacy Bulk Package In 1 Box (55150-129-99) / 100 Ml In 1 Vial, Pharmacy Bulk Package",636,RC,55150-129-99,NDC,,,facility,both,1,EA,,30.41,30.41,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Oxacillin: 10 Vial In 1 Box (55150-128-24) / 1 Injection, Powder, For Solution In 1 Vial",636,RC,55150-128-24,NDC,,,facility,both,1,EA,,24.57,24.57,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Bupivacaine Hydrochloride: 25 Vial, Single-Dose In 1 Carton (55150-167-10) / 10 Ml In 1 Vial, Single-Dose",636,RC,55150-167-10,NDC,,,facility,both,1,EA,,0.83,0.83,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Riabni: 1 Vial, Single-Dose In 1 Carton (55513-224-01) / 10 Ml In 1 Vial, Single-Dose",636,RC,55513-224-01,NDC,,,facility,both,1,EA,,305.1,305.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Cerezyme: 1 Vial, Glass In 1 Carton (58468-4663-1) / 10 Ml In 1 Vial, Glass",636,RC,58468-4663-1,NDC,,,facility,both,1,EA,,264.48,264.48,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Cerezyme: 1 Vial, Glass In 1 Carton (58468-4663-1) / 10 Ml In 1 Vial, Glass",636,RC,58468-4663-1,NDC,,,facility,both,1,EA,,264.48,264.48,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Nexviazyme: 1 Vial, Single-Dose In 1 Carton (58468-0426-1) / 10 Ml In 1 Vial, Single-Dose",636,RC,58468-0426-1,NDC,,,facility,both,1,EA,,479.94,479.94,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Nexviazyme: 1 Vial, Single-Dose In 1 Carton (58468-0426-1) / 10 Ml In 1 Vial, Single-Dose",636,RC,58468-0426-1,NDC,,,facility,both,1,EA,,460.9,460.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Thymoglobulin: 1 Vial, Glass In 1 Carton (58468-0080-1) / 5 Ml In 1 Vial, Glass",636,RC,58468-0080-1,NDC,,,facility,both,1,EA,,5331.93,5331.93,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Aldurazyme: 5 Ml In 1 Vial, Glass (58468-0070-1)",636,RC,58468-0070-1,NDC,,,facility,both,1,EA,,241.23,241.23,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,58406-055-01,NDC,,,facility,both,1,EA,,6107.22,6107.22,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Benefix: 1 Kit In 1 Carton (58394-636-03) * 5 Ml In 1 Syringe (58394-041-11) * 1 Ml In 1 Packet (0069-1111-01) * 5 Ml In 1 Vial, Single-Use (58394-136-03)",636,RC,58394-636-03,NDC,,,facility,both,1,EA,,6.85,6.85,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Benefix: 1 Kit In 1 Carton (58394-636-03) * 5 Ml In 1 Syringe (58394-041-11) * 1 Ml In 1 Packet (0069-1111-01) * 5 Ml In 1 Vial, Single-Use (58394-136-03)",636,RC,58394-636-03,NDC,,,facility,both,1,EA,,6.83,6.83,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Benefix: 1 Kit In 1 Carton (58394-634-03) * 5 Ml In 1 Syringe (58394-041-11) * 1 Ml In 1 Packet (0069-1111-01) * 5 Ml In 1 Vial, Single-Use (58394-134-03)",636,RC,58394-634-03,NDC,,,facility,both,1,EA,,6.89,6.89,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,58394-136-03,NDC,,,facility,both,1,EA,,6.85,6.85,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,58394-134-03,NDC,,,facility,both,1,EA,,6.9,6.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,58394-134-03,NDC,,,facility,both,1,EA,,6.85,6.85,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,58160-976-02,NDC,,,facility,both,1,EA,,546.47,546.47,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,58160-958-01,NDC,,,facility,both,1,EA,,741.23,741.23,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Menveo: 1 Kit In 1 Carton (58160-955-09) * .5 Ml In 1 Vial, Single-Dose (58160-958-01) * .5 Ml In 1 Vial, Single-Dose (58160-959-01)",636,RC,58160-955-09,NDC,,,facility,both,1,EA,,745.87,745.87,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Boostrix: 10 Syringe In 1 Carton (58160-842-52) / .5 Ml In 1 Syringe (58160-842-43),636,RC,58160-842-52,NDC,,,facility,both,1,EA,,265.73,265.73,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,58160-842-43,NDC,,,facility,both,1,EA,,268.01,268.01,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,58160-825-43,NDC,,,facility,both,1,EA,,220.72,220.72,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,58160-821-01,NDC,,,facility,both,1,EA,,332.75,332.75,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Azithromycin: 1 Bottle In 1 Carton (59651-008-30) / 30 Ml In 1 Bottle,636,RC,59651-008-30,NDC,,,facility,both,1,EA,,21.76,21.76,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Engerix-B: 10 Syringe In 1 Carton (58160-820-52) / .5 Ml In 1 Syringe (58160-820-43),636,RC,58160-820-52,NDC,,,facility,both,1,EA,,159.13,159.13,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Remicade: 1 Vial, Single-Use In 1 Box (57894-030-01) / 10 Ml In 1 Vial, Single-Use",636,RC,57894-030-01,NDC,,,facility,both,1,EA,,697.45,697.45,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Xgeva: 1 Vial, Single-Use In 1 Carton (55513-730-01) / 1.7 Ml In 1 Vial, Single-Use",636,RC,55513-730-01,NDC,,,facility,both,1,EA,,172,172,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Xgeva: 1 Vial, Single-Use In 1 Carton (55513-730-01) / 1.7 Ml In 1 Vial, Single-Use",636,RC,55513-730-01,NDC,,,facility,both,1,EA,,172,172,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Xgeva: 1 Vial, Single-Use In 1 Carton (55513-730-01) / 1.7 Ml In 1 Vial, Single-Use",636,RC,55513-730-01,NDC,,,facility,both,1,EA,,166.54,166.54,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Avsola: 1 Vial, Single-Dose In 1 Carton (55513-670-01) / 10 Ml In 1 Vial, Single-Dose",636,RC,55513-670-01,NDC,,,facility,both,1,EA,,297.08,297.08,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Avsola: 1 Vial, Single-Dose In 1 Carton (55513-670-01) / 10 Ml In 1 Vial, Single-Dose",636,RC,55513-670-01,NDC,,,facility,both,1,EA,,295.71,295.71,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Avsola: 1 Vial, Single-Dose In 1 Carton (55513-670-01) / 10 Ml In 1 Vial, Single-Dose",636,RC,55513-670-01,NDC,,,facility,both,1,EA,,274.9,274.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Avsola: 1 Vial, Single-Dose In 1 Carton (55513-670-01) / 10 Ml In 1 Vial, Single-Dose",636,RC,55513-670-01,NDC,,,facility,both,1,EA,,274.73,274.73,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Avsola: 1 Vial, Single-Dose In 1 Carton (55513-670-01) / 10 Ml In 1 Vial, Single-Dose",636,RC,55513-670-01,NDC,,,facility,both,1,EA,,274.19,274.19,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Remicade: 1 Vial, Single-Use In 1 Box (57894-030-01) / 10 Ml In 1 Vial, Single-Use",636,RC,57894-030-01,NDC,,,facility,both,1,EA,,697.94,697.94,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Remicade: 1 Vial, Single-Use In 1 Box (57894-030-01) / 10 Ml In 1 Vial, Single-Use",636,RC,57894-030-01,NDC,,,facility,both,1,EA,,698.08,698.08,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,58160-820-43,NDC,,,facility,both,1,EA,,158.12,158.12,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Remicade: 1 Vial, Single-Use In 1 Box (57894-030-01) / 10 Ml In 1 Vial, Single-Use",636,RC,57894-030-01,NDC,,,facility,both,1,EA,,698.02,698.02,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Darzalex Iv: 1 Vial, Single-Dose In 1 Box (57894-505-05) / 5 Ml In 1 Vial, Single-Dose",636,RC,57894-505-05,NDC,,,facility,both,1,EA,,500.56,500.56,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Darzalex Iv: 1 Vial, Single-Dose In 1 Box (57894-505-05) / 5 Ml In 1 Vial, Single-Dose",636,RC,57894-505-05,NDC,,,facility,both,1,EA,,492.38,492.38,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Simponi Aria: 1 Vial, Single-Dose In 1 Carton (57894-350-01) / 4 Ml In 1 Vial, Single-Dose",636,RC,57894-350-01,NDC,,,facility,both,1,EA,,244.91,244.91,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Simponi Aria: 1 Vial, Single-Dose In 1 Carton (57894-350-01) / 4 Ml In 1 Vial, Single-Dose",636,RC,57894-350-01,NDC,,,facility,both,1,EA,,244.77,244.77,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Stelara: 1 Syringe In 1 Carton (57894-061-03) / 1 Ml In 1 Syringe,636,RC,57894-061-03,NDC,,,facility,both,1,EA,,1815.83,1815.83,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Stelara: 1 Vial, Single-Use In 1 Box (57894-054-27) / 26 Ml In 1 Vial, Single-Use",636,RC,57894-054-27,NDC,,,facility,both,1,EA,,101.96,101.96,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Stelara: 1 Vial, Single-Use In 1 Box (57894-054-27) / 26 Ml In 1 Vial, Single-Use",636,RC,57894-054-27,NDC,,,facility,both,1,EA,,99.31,99.31,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Remicade: 1 Vial, Single-Use In 1 Box (57894-030-01) / 10 Ml In 1 Vial, Single-Use",636,RC,57894-030-01,NDC,,,facility,both,1,EA,,703.91,703.91,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Doxorubicin Hydrochloride: 1 Vial, Single-Dose In 1 Carton (63323-883-30) / 25 Ml In 1 Vial, Single-Dose",636,RC,63323-883-30,NDC,,,facility,both,1,EA,,40.05,40.05,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Nebupent: 1 Vial, Single-Dose In 1 Carton (63323-877-15) / 6 Ml In 1 Vial, Single-Dose",636,RC,63323-877-15,NDC,,,facility,both,1,EA,,583.16,583.16,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Foscarnet: 1 Bottle In 1 Carton (63323-875-50) / 250 Ml In 1 Bottle,636,RC,63323-875-50,NDC,,,facility,both,1,EA,,252.53,252.53,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,63323-853-03,NDC,,,facility,both,1,EA,,6.48,6.48,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,63323-853-03,NDC,,,facility,both,1,EA,,6.17,6.17,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,63323-853-03,NDC,,,facility,both,1,EA,,5.04,5.04,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,63323-853-03,NDC,,,facility,both,1,EA,,0.55,0.55,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,63323-853-03,NDC,,,facility,both,1,EA,,0.55,0.55,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,63323-851-07,NDC,,,facility,both,1,EA,,0.49,0.49,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,63323-851-03,NDC,,,facility,both,1,EA,,0.48,0.48,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,63323-812-01,NDC,,,facility,both,1,EA,,18.25,18.25,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Oxacillin: 1 Vial, Pharmacy Bulk Package In 1 Carton (63323-811-00) / 100 Ml In 1 Vial, Pharmacy Bulk Package",636,RC,63323-811-00,NDC,,,facility,both,1,EA,,10.46,10.46,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Topotecan Hydrochloride: 1 Vial In 1 Box (63323-762-10) / 4 Ml In 1 Vial,636,RC,63323-762-10,NDC,,,facility,both,1,EA,,24.65,24.65,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Phenylephrine Hydrochloride: 25 Vial, Single-Dose In 1 Carton (63323-751-01) / 1 Ml In 1 Vial, Single-Dose (63323-751-00)",636,RC,63323-751-01,NDC,,,facility,both,1,EA,,0.28,0.28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,63323-751-00,NDC,,,facility,both,1,EA,,0.04,0.04,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,63323-739-11,NDC,,,facility,both,1,EA,,1.31,1.31,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Micafungin: 10 Carton In 1 Carton (63323-728-10) / 1 Vial, Single-Dose In 1 Carton (63323-728-01) / 1 Injection, Powder, Lyophilized, For Solution In 1 Vial, Single-Dose",636,RC,63323-728-10,NDC,,,facility,both,1,EA,,3.45,3.45,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ampicillin: 10 VIAL, GLASS in 1 PACKAGE (63323-704-08) / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL, GLASS",636,RC,63323-704-08,NDC,,,facility,both,1,EA,,23.56,23.56,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,63323-965-01,NDC,,,facility,both,1,EA,,9.32,9.32,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Truxima: 1 Vial, Single-Use In 1 Carton (63459-104-50) / 50 Ml In 1 Vial, Single-Use",636,RC,63459-104-50,NDC,,,facility,both,1,EA,,323.21,323.21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Truxima: 1 Vial, Single-Use In 1 Carton (63459-104-50) / 50 Ml In 1 Vial, Single-Use",636,RC,63459-104-50,NDC,,,facility,both,1,EA,,322.46,322.46,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Truxima: 1 Vial, Single-Use In 1 Carton (63459-104-50) / 50 Ml In 1 Vial, Single-Use",636,RC,63459-104-50,NDC,,,facility,both,1,EA,,321.23,321.23,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Truxima: 1 Vial, Single-Use In 1 Carton (63459-104-50) / 50 Ml In 1 Vial, Single-Use",636,RC,63459-104-50,NDC,,,facility,both,1,EA,,321.06,321.06,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Truxima: 1 Vial, Single-Use In 1 Carton (63459-104-50) / 50 Ml In 1 Vial, Single-Use",636,RC,63459-104-50,NDC,,,facility,both,1,EA,,321.01,321.01,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Truxima: 1 Vial, Single-Use In 1 Carton (63459-104-50) / 50 Ml In 1 Vial, Single-Use",636,RC,63459-104-50,NDC,,,facility,both,1,EA,,320.6,320.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Truxima: 1 Vial, Single-Use In 1 Carton (63459-104-50) / 50 Ml In 1 Vial, Single-Use",636,RC,63459-104-50,NDC,,,facility,both,1,EA,,318.81,318.81,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Truxima: 1 Vial, Single-Use In 1 Carton (63459-104-50) / 50 Ml In 1 Vial, Single-Use",636,RC,63459-104-50,NDC,,,facility,both,1,EA,,318.81,318.81,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Truxima: 1 Vial, Single-Use In 1 Carton (63459-103-10) / 10 Ml In 1 Vial, Single-Use",636,RC,63459-103-10,NDC,,,facility,both,1,EA,,478.22,478.22,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Truxima: 1 Vial, Single-Use In 1 Carton (63459-103-10) / 10 Ml In 1 Vial, Single-Use",636,RC,63459-103-10,NDC,,,facility,both,1,EA,,343.76,343.76,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Truxima: 1 Vial, Single-Use In 1 Carton (63459-103-10) / 10 Ml In 1 Vial, Single-Use",636,RC,63459-103-10,NDC,,,facility,both,1,EA,,323.7,323.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,63323-930-00,NDC,,,facility,both,1,EA,,4.13,4.13,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Truxima: 1 Vial, Single-Use In 1 Carton (63459-103-10) / 10 Ml In 1 Vial, Single-Use",636,RC,63459-103-10,NDC,,,facility,both,1,EA,,322.88,322.88,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Truxima: 1 Vial, Single-Use In 1 Carton (63459-103-10) / 10 Ml In 1 Vial, Single-Use",636,RC,63459-103-10,NDC,,,facility,both,1,EA,,322.18,322.18,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Truxima: 1 Vial, Single-Use In 1 Carton (63459-103-10) / 10 Ml In 1 Vial, Single-Use",636,RC,63459-103-10,NDC,,,facility,both,1,EA,,320.84,320.84,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Truxima: 1 Vial, Single-Use In 1 Carton (63459-103-10) / 10 Ml In 1 Vial, Single-Use",636,RC,63459-103-10,NDC,,,facility,both,1,EA,,318.81,318.81,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Truxima: 1 Vial, Single-Use In 1 Carton (63459-103-10) / 10 Ml In 1 Vial, Single-Use",636,RC,63459-103-10,NDC,,,facility,both,1,EA,,318.81,318.81,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,63361-243-88,NDC,,,facility,both,1,EA,,935.85,935.85,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Potassium Chloride: 25 Vial, Single-Dose In 1 Tray (63323-965-20) / 20 Ml In 1 Vial, Single-Dose (63323-965-02)",636,RC,63323-965-20,NDC,,,facility,both,1,EA,,6.63,6.63,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,63323-965-03,NDC,,,facility,both,1,EA,,6.04,6.04,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,63323-965-02,NDC,,,facility,both,1,EA,,2.83,2.83,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Truxima: 1 Vial, Single-Use In 1 Carton (63459-103-10) / 10 Ml In 1 Vial, Single-Use",636,RC,63459-103-10,NDC,,,facility,both,1,EA,,322.35,322.35,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Acetylcysteine: 3 Vial In 1 Carton (63323-691-30) / 30 Ml In 1 Vial (63323-691-22),636,RC,63323-691-30,NDC,,,facility,both,1,EA,,30.35,30.35,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Cyclophosphamide: 1 Vial, Single-Dose In 1 Carton (65219-131-20) / 50 Ml In 1 Vial, Single-Dose",636,RC,65219-131-20,NDC,,,facility,both,1,EA,,11.41,11.41,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,65219-016-01,NDC,,,facility,both,1,EA,,36.87,36.87,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Temsirolimus: 1 Kit In 1 Kit (65219-200-05) * 1 Ml In 1 Vial, Single-Dose (65219-205-05) * 1.8 Ml In 1 Vial, Single-Dose (65219-202-05)",636,RC,65219-200-05,NDC,,,facility,both,1,EA,,176.97,176.97,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Temsirolimus: 1 Kit In 1 Kit (65219-200-05) * 1 Ml In 1 Vial, Single-Dose (65219-205-05) * 1.8 Ml In 1 Vial, Single-Dose (65219-202-05)",636,RC,65219-200-05,NDC,,,facility,both,1,EA,,176.97,176.97,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Temsirolimus: 1 Kit In 1 Kit (65219-200-05) * 1 Ml In 1 Vial, Single-Dose (65219-205-05) * 1.8 Ml In 1 Vial, Single-Dose (65219-202-05)",636,RC,65219-200-05,NDC,,,facility,both,1,EA,,190.72,190.72,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Tyenne: 1 Vial, Single-Dose In 1 Carton (65219-594-20) / 20 Ml In 1 Vial, Single-Dose",636,RC,65219-594-20,NDC,,,facility,both,1,EA,,29.61,29.61,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Tyenne: 1 Vial, Single-Dose In 1 Carton (65219-592-10) / 10 Ml In 1 Vial, Single-Dose",636,RC,65219-592-10,NDC,,,facility,both,1,EA,,29.62,29.62,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Tyenne: 1 Vial, Single-Dose In 1 Carton (65219-592-10) / 10 Ml In 1 Vial, Single-Dose",636,RC,65219-592-10,NDC,,,facility,both,1,EA,,29.54,29.54,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,65219-572-01,NDC,,,facility,both,1,EA,,11.18,11.18,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,65219-474-05,NDC,,,facility,both,1,EA,,57.63,57.63,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,65219-468-05,NDC,,,facility,both,1,EA,,66.89,66.89,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Desmopressin Acetate: 1 Vial, Multi-Dose In 1 Carton (65219-295-10) / 10 Ml In 1 Vial, Multi-Dose",636,RC,65219-295-10,NDC,,,facility,both,1,EA,,24.5,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Desmopressin Acetate: 1 Vial, Multi-Dose In 1 Carton (65219-295-10) / 10 Ml In 1 Vial, Multi-Dose",636,RC,65219-295-10,NDC,,,facility,both,1,EA,,24.37,24.37,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Temsirolimus: 1 Kit In 1 Kit (65219-200-05) * 1 Ml In 1 Vial, Single-Dose (65219-205-05) * 1.8 Ml In 1 Vial, Single-Dose (65219-202-05)",636,RC,65219-200-05,NDC,,,facility,both,1,EA,,190.72,190.72,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,65219-570-01,NDC,,,facility,both,1,EA,,36.12,36.12,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Prednisone: 100 Tablet In 1 Bottle, Plastic (64380-782-06)",636,RC,64380-782-06,NDC,,,facility,both,1,EA,,6.42,6.42,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,64253-900-30,NDC,,,facility,both,1,EA,,46.06,46.06,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Atropine Sulfate: 10 Syringe, Plastic In 1 Box (64253-400-91) / 10 Ml In 1 Syringe, Plastic (64253-400-30)",636,RC,64253-400-91,NDC,,,facility,both,1,EA,,1.49,1.49,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Atropine Sulfate: 10 Syringe, Plastic In 1 Box (64253-400-91) / 10 Ml In 1 Syringe, Plastic (64253-400-30)",636,RC,64253-400-91,NDC,,,facility,both,1,EA,,0.55,0.55,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,64253-400-30,NDC,,,facility,both,1,EA,,2.61,2.61,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,64253-400-30,NDC,,,facility,both,1,EA,,0.54,0.54,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Berinert: 1 Kit In 1 Carton (63833-825-02) * 10 Ml In 1 Vial (63833-835-01) * 10 Ml In 1 Vial (63833-765-15),636,RC,63833-825-02,NDC,,,facility,both,1,EA,,436.2,436.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Berinert: 1 Kit In 1 Carton (63833-825-02) * 10 Ml In 1 Vial (63833-835-01) * 10 Ml In 1 Vial (63833-765-15),636,RC,63833-825-02,NDC,,,facility,both,1,EA,,413.99,413.99,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,63833-625-01,NDC,,,facility,both,1,EA,,7.39,7.39,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Humate-P: 1 Kit In 1 Carton (63833-617-02) * 15 Ml In 1 Vial (63833-627-01) * 15 Ml In 1 Vial, Single-Dose (63833-765-55)",636,RC,63833-617-02,NDC,,,facility,both,1,EA,,7.36,7.36,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Humate-P: 1 Kit In 1 Carton (63833-617-02) * 15 Ml In 1 Vial (63833-627-01) * 15 Ml In 1 Vial, Single-Dose (63833-765-55)",636,RC,63833-617-02,NDC,,,facility,both,1,EA,,7.35,7.35,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Humate-P: 1 Kit In 1 Carton (63833-616-02) * 10 Ml In 1 Vial (63833-626-01) * 10 Ml In 1 Vial, Single-Dose (63833-765-54)",636,RC,63833-616-02,NDC,,,facility,both,1,EA,,7.37,7.37,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Humate-P: 1 Kit In 1 Carton (63833-616-02) * 10 Ml In 1 Vial (63833-626-01) * 10 Ml In 1 Vial, Single-Dose (63833-765-54)",636,RC,63833-616-02,NDC,,,facility,both,1,EA,,7.36,7.36,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Humate-P: 1 Kit In 1 Carton (63833-615-02) * 5 Ml In 1 Vial (63833-625-01) * 5 Ml In 1 Vial, Single-Dose (63833-765-53)",636,RC,63833-615-02,NDC,,,facility,both,1,EA,,7.39,7.39,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,63833-396-01,NDC,,,facility,both,1,EA,,14.89,14.89,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,63833-396-01,NDC,,,facility,both,1,EA,,14.68,14.68,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Kcentra: 1 Kit In 1 Carton (63833-386-02) * 20 Ml In 1 Vial, Single-Use (63833-396-01) * 20 Ml In 1 Vial, Single-Use (63833-761-20)",636,RC,63833-386-02,NDC,,,facility,both,1,EA,,14.78,14.78,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Kcentra: 1 Kit In 1 Carton (63833-386-02) * 20 Ml In 1 Vial, Single-Use (63833-396-01) * 20 Ml In 1 Vial, Single-Use (63833-761-20)",636,RC,63833-386-02,NDC,,,facility,both,1,EA,,14.75,14.75,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Kcentra: 1 Kit In 1 Carton (63833-386-02) * 20 Ml In 1 Vial, Single-Use (63833-396-01) * 20 Ml In 1 Vial, Single-Use (63833-761-20)",636,RC,63833-386-02,NDC,,,facility,both,1,EA,,14.68,14.68,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Kcentra: 1 Kit In 1 Carton (63833-386-02) * 20 Ml In 1 Vial, Single-Use (63833-396-01) * 20 Ml In 1 Vial, Single-Use (63833-761-20)",636,RC,63833-386-02,NDC,,,facility,both,1,EA,,14.68,14.68,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,63833-626-01,NDC,,,facility,both,1,EA,,7.37,7.37,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Entyvio: 1 Vial, Single-Dose In 1 Carton (64764-300-20) / 5 Ml In 1 Vial, Single-Dose",636,RC,64764-300-20,NDC,,,facility,both,1,EA,,189.33,189.33,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Entyvio: 1 Vial, Single-Dose In 1 Carton (64764-300-20) / 5 Ml In 1 Vial, Single-Dose",636,RC,64764-300-20,NDC,,,facility,both,1,EA,,189.21,189.21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Entyvio: 1 Vial, Single-Dose In 1 Carton (64764-300-20) / 5 Ml In 1 Vial, Single-Dose",636,RC,64764-300-20,NDC,,,facility,both,1,EA,,189.17,189.17,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Entyvio: 1 Vial, Single-Dose In 1 Carton (64764-300-20) / 5 Ml In 1 Vial, Single-Dose",636,RC,64764-300-20,NDC,,,facility,both,1,EA,,188.76,188.76,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Entyvio: 1 Vial, Single-Dose In 1 Carton (64764-300-20) / 5 Ml In 1 Vial, Single-Dose",636,RC,64764-300-20,NDC,,,facility,both,1,EA,,188.71,188.71,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Entyvio: 1 Vial, Single-Dose In 1 Carton (64764-300-20) / 5 Ml In 1 Vial, Single-Dose",636,RC,64764-300-20,NDC,,,facility,both,1,EA,,179.2,179.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Entyvio: 1 Vial, Single-Dose In 1 Carton (64764-300-20) / 5 Ml In 1 Vial, Single-Dose",636,RC,64764-300-20,NDC,,,facility,both,1,EA,,175.64,175.64,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Spinraza: 1 Vial, Single-Use In 1 Box (64406-058-01) / 5 Ml In 1 Vial, Single-Use",636,RC,64406-058-01,NDC,,,facility,both,1,EA,,7161.31,7161.31,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Spinraza: 1 Vial, Single-Use In 1 Box (64406-058-01) / 5 Ml In 1 Vial, Single-Use",636,RC,64406-058-01,NDC,,,facility,both,1,EA,,7161.31,7161.31,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Spinraza: 1 Vial, Single-Use In 1 Box (64406-058-01) / 5 Ml In 1 Vial, Single-Use",636,RC,64406-058-01,NDC,,,facility,both,1,EA,,7161.31,7161.31,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,63323-665-00,NDC,,,facility,both,1,EA,,11,11,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Cyclophosphamide: 100 Capsule In 1 Bottle (62332-618-31),636,RC,62332-618-31,NDC,,,facility,both,1,EA,,17.31,17.31,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Desmopressin Acetate: 1 Vial In 1 Carton (62756-529-40) / 10 Ml In 1 Vial,636,RC,62756-529-40,NDC,,,facility,both,1,EA,,62.69,62.69,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Dacarbazine: 10 Vial, Single-Dose In 1 Tray (63323-128-20) / 20 Ml In 1 Vial, Single-Dose (63323-128-00)",636,RC,63323-128-20,NDC,,,facility,both,1,EA,,60.47,60.47,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Dacarbazine: 10 Vial, Single-Dose In 1 Tray (63323-128-20) / 20 Ml In 1 Vial, Single-Dose (63323-128-00)",636,RC,63323-128-20,NDC,,,facility,both,1,EA,,50.6,50.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,63323-128-00,NDC,,,facility,both,1,EA,,62.21,62.21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,63323-128-00,NDC,,,facility,both,1,EA,,58.46,58.46,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Cytarabine: 1 Vial, Single-Dose In 1 Carton (63323-120-20) / 20 Ml In 1 Vial, Single-Dose",636,RC,63323-120-20,NDC,,,facility,both,1,EA,,21.25,21.25,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Cytarabine: 1 Vial, Single-Dose In 1 Carton (63323-120-20) / 20 Ml In 1 Vial, Single-Dose",636,RC,63323-120-20,NDC,,,facility,both,1,EA,,3.93,3.93,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Fluorouracil: 10 Vial, Single-Dose In 1 Tray (63323-117-10) / 10 Ml In 1 Vial, Single-Dose (63323-117-00)",636,RC,63323-117-10,NDC,,,facility,both,1,EA,,170.25,170.25,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,63323-106-02,NDC,,,facility,both,1,EA,,15.29,15.29,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Etoposide: 1 Vial, Multi-Dose In 1 Carton (63323-104-25) / 25 Ml In 1 Vial, Multi-Dose",636,RC,63323-104-25,NDC,,,facility,both,1,EA,,12.73,12.73,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Cisplatin: 1 Vial In 1 Carton (63323-103-51) / 50 Ml In 1 Vial,636,RC,63323-103-51,NDC,,,facility,both,1,EA,,37.11,37.11,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Gemcitabine: 1 Vial, Single-Dose In 1 Box (63323-102-13) / 5 Ml In 1 Vial, Single-Dose",636,RC,63323-102-13,NDC,,,facility,both,1,EA,,92.19,92.19,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,63323-093-01,NDC,,,facility,both,1,EA,,2.1,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,63323-064-04,NDC,,,facility,both,1,EA,,19.15,19.15,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,63323-064-01,NDC,,,facility,both,1,EA,,24.22,24.22,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Heparin Sodium: 25 Vial In 1 Tray (63323-047-10) / 10 Ml In 1 Vial (63323-047-01),636,RC,63323-047-10,NDC,,,facility,both,1,EA,,6.56,6.56,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,63323-010-03,NDC,,,facility,both,1,EA,,30.29,30.29,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Gentamicin: 25 Vial In 1 Tray (63323-010-02) / 2 Ml In 1 Vial (63323-010-01),636,RC,63323-010-02,NDC,,,facility,both,1,EA,,29.81,29.81,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,63323-010-01,NDC,,,facility,both,1,EA,,21.51,21.51,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Iclusig: 30 Tablet, Film Coated In 1 Bottle (63020-535-30)",636,RC,63020-535-30,NDC,,,facility,both,1,EA,,4069.41,4069.41,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Velcade: 1 Vial In 1 Carton (63020-049-01) / 1 Injection, Powder, Lyophilized, For Solution In 1 Vial",636,RC,63020-049-01,NDC,,,facility,both,1,EA,,289.63,289.63,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Velcade: 1 Vial In 1 Carton (63020-049-01) / 1 Injection, Powder, Lyophilized, For Solution In 1 Vial",636,RC,63020-049-01,NDC,,,facility,both,1,EA,,282.13,282.13,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Zarxio: 2 Blister Pack In 1 Carton (61314-318-10) / 5 Syringe In 1 Blister Pack (61314-318-05) / .5 Ml In 1 Syringe,636,RC,61314-318-10,NDC,,,facility,both,1,EA,,4.32,4.32,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Zarxio: 1 Blister Pack In 1 Carton (61314-318-01) / 1 Syringe In 1 Blister Pack / .5 Ml In 1 Syringe,636,RC,61314-318-01,NDC,,,facility,both,1,EA,,4.59,4.59,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Zarxio: 1 Blister Pack In 1 Carton (61314-318-01) / 1 Syringe In 1 Blister Pack / .5 Ml In 1 Syringe,636,RC,61314-318-01,NDC,,,facility,both,1,EA,,4.24,4.24,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Zarxio: 1 Blister Pack In 1 Carton (61314-318-01) / 1 Syringe In 1 Blister Pack / .5 Ml In 1 Syringe,636,RC,61314-318-01,NDC,,,facility,both,1,EA,,4.19,4.19,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Zarxio: 1 Blister Pack In 1 Carton (61314-318-01) / 1 Syringe In 1 Blister Pack / .5 Ml In 1 Syringe,636,RC,61314-318-01,NDC,,,facility,both,1,EA,,4.16,4.16,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Zarxio: 1 Blister Pack In 1 Carton (61314-318-01) / 1 Syringe In 1 Blister Pack / .5 Ml In 1 Syringe,636,RC,61314-318-01,NDC,,,facility,both,1,EA,,3.75,3.75,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Zarxio: 1 Blister Pack In 1 Carton (61314-318-01) / 1 Syringe In 1 Blister Pack / .5 Ml In 1 Syringe,636,RC,61314-318-01,NDC,,,facility,both,1,EA,,3.06,3.06,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,60793-701-02,NDC,,,facility,both,1,EA,,163.57,163.57,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,60793-701-02,NDC,,,facility,both,1,EA,,143.57,143.57,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,60793-700-01,NDC,,,facility,both,1,EA,,199.4,199.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,60793-700-01,NDC,,,facility,both,1,EA,,162.17,162.17,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,60793-700-01,NDC,,,facility,both,1,EA,,195.53,195.53,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Doxy 100: 10 Vial In 1 Tray (63323-130-11) / 10 Ml In 1 Vial (63323-130-02),636,RC,63323-130-11,NDC,,,facility,both,1,EA,,127.62,127.62,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Veklury: 1 Vial, Single-Dose In 1 Carton (61958-2901-2) / 1 Injection, Powder, Lyophilized, For Solution In 1 Vial, Single-Dose",636,RC,61958-2901-2,NDC,,,facility,both,1,EA,,3918.12,3918.12,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Veklury: 1 Vial, Single-Dose In 1 Carton (61958-2901-2) / 1 Injection, Powder, Lyophilized, For Solution In 1 Vial, Single-Dose",636,RC,61958-2901-2,NDC,,,facility,both,1,EA,,43.35,43.35,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Veklury: 1 Vial, Single-Dose In 1 Carton (61958-2901-2) / 1 Injection, Powder, Lyophilized, For Solution In 1 Vial, Single-Dose",636,RC,61958-2901-2,NDC,,,facility,both,1,EA,,42.68,42.68,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Veklury: 1 Vial, Single-Dose In 1 Carton (61958-2901-2) / 1 Injection, Powder, Lyophilized, For Solution In 1 Vial, Single-Dose",636,RC,61958-2901-2,NDC,,,facility,both,1,EA,,42.06,42.06,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Veklury: 1 Vial, Single-Dose In 1 Carton (61958-2901-2) / 1 Injection, Powder, Lyophilized, For Solution In 1 Vial, Single-Dose",636,RC,61958-2901-2,NDC,,,facility,both,1,EA,,39.3,39.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Veklury: 1 Vial, Single-Dose In 1 Carton (61958-2901-2) / 1 Injection, Powder, Lyophilized, For Solution In 1 Vial, Single-Dose",636,RC,61958-2901-2,NDC,,,facility,both,1,EA,,39.2,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Methotrexate: 1 Vial, Single-Dose In 1 Carton (61703-408-41) / 40 Ml In 1 Vial, Single-Dose",636,RC,61703-408-41,NDC,,,facility,both,1,EA,,3.78,3.78,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Carboplatin: 1 Vial, Multi-Dose In 1 Carton (61703-339-50) / 45 Ml In 1 Vial, Multi-Dose",636,RC,61703-339-50,NDC,,,facility,both,1,EA,,29.3,29.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Carboplatin: 1 Vial, Multi-Dose In 1 Carton (61703-339-22) / 15 Ml In 1 Vial, Multi-Dose",636,RC,61703-339-22,NDC,,,facility,both,1,EA,,59.43,59.43,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Bleomycin: 1 Vial, Single-Dose In 1 Carton (61703-332-18) / 1 Injection, Powder, Lyophilized, For Solution In 1 Vial, Single-Dose",636,RC,61703-332-18,NDC,,,facility,both,1,EA,,240.11,240.11,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Pamidronate Disodium: 1 Vial, Single-Dose In 1 Carton (61703-324-18) / 10 Ml In 1 Vial, Single-Dose",636,RC,61703-324-18,NDC,,,facility,both,1,EA,,80.89,80.89,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Vincristine Sulfate: 1 Vial, Single-Dose In 1 Carton (61703-309-16) / 2 Ml In 1 Vial, Single-Dose",636,RC,61703-309-16,NDC,,,facility,both,1,EA,,111.1,111.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Vincristine Sulfate: 1 Vial, Single-Dose In 1 Carton (61703-309-06) / 1 Ml In 1 Vial, Single-Dose",636,RC,61703-309-06,NDC,,,facility,both,1,EA,,177.77,177.77,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Cytarabine: 5 Vial, Single-Dose In 1 Carton (61703-305-38) / 5 Ml In 1 Vial, Single-Dose (61703-305-58)",636,RC,61703-305-38,NDC,,,facility,both,1,EA,,118.62,118.62,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Methotrexate: 1 Vial, Single-Dose In 1 Carton (61703-408-41) / 40 Ml In 1 Vial, Single-Dose",636,RC,61703-408-41,NDC,,,facility,both,1,EA,,5.68,5.68,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,63323-686-01,NDC,,,facility,both,1,EA,,8.45,8.45,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Mitoxantrone: 1 Vial, Multi-Dose In 1 Box (63323-132-10) / 10 Ml In 1 Vial, Multi-Dose",636,RC,63323-132-10,NDC,,,facility,both,1,EA,,165.81,165.81,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,63323-161-00,NDC,,,facility,both,1,EA,,27.4,27.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Xylocaine: 25 Vial, Multi-Dose In 1 Tray (63323-486-27) / 20 Ml In 1 Vial, Multi-Dose (63323-486-02)",636,RC,63323-486-27,NDC,,,facility,both,1,EA,,0.46,0.46,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Xylocaine: 25 Vial, Multi-Dose In 1 Tray (63323-484-57) / 50 Ml In 1 Vial, Multi-Dose",636,RC,63323-484-57,NDC,,,facility,both,1,EA,,4.71,4.71,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Haloperidol: 25 Vial In 1 Tray (63323-474-01) / 1 Ml In 1 Vial (63323-474-00),636,RC,63323-474-01,NDC,,,facility,both,1,EA,,31.51,31.51,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,63323-474-00,NDC,,,facility,both,1,EA,,30.72,30.72,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Sensorcaine Mpf: 25 Vial, Single-Dose In 1 Tray (63323-466-17) / 10 Ml In 1 Vial, Single-Dose (63323-466-03)",636,RC,63323-466-17,NDC,,,facility,both,1,EA,,0.47,0.47,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,63323-452-00,NDC,,,facility,both,1,EA,,33.6,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,63323-434-41,NDC,,,facility,both,1,EA,,1.25,1.25,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Flumazenil: 10 Vial, Multi-Dose In 1 Tray (63323-424-05) / 5 Ml In 1 Vial, Multi-Dose (63323-424-01)",636,RC,63323-424-05,NDC,,,facility,both,1,EA,,30.9,30.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Midazolam: 25 Vial In 1 Tray (63323-411-25) / 5 Ml In 1 Vial (63323-411-18),636,RC,63323-411-25,NDC,,,facility,both,1,EA,,15.13,15.13,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,63323-411-18,NDC,,,facility,both,1,EA,,18.67,18.67,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Calcium Gluconate: 25 Vial, Plastic In 1 Tray (63323-360-19) / 10 Ml In 1 Vial, Plastic (63323-360-01)",636,RC,63323-360-19,NDC,,,facility,both,1,EA,,1.02,1.02,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Calcium Gluconate: 25 Vial, Plastic In 1 Tray (63323-360-19) / 10 Ml In 1 Vial, Plastic (63323-360-01)",636,RC,63323-360-19,NDC,,,facility,both,1,EA,,0.68,0.68,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,63323-360-03,NDC,,,facility,both,1,EA,,0.37,0.37,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,63323-360-01,NDC,,,facility,both,1,EA,,0.8,0.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,63323-360-01,NDC,,,facility,both,1,EA,,0.78,0.78,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,63323-360-01,NDC,,,facility,both,1,EA,,0.76,0.76,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,63323-360-01,NDC,,,facility,both,1,EA,,0.5,0.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Xylocaine Mpf: 25 Vial, Single-Dose In 1 Carton (63323-495-07) / 5 Ml In 1 Vial, Single-Dose (63323-495-04)",636,RC,63323-495-07,NDC,,,facility,both,1,EA,,0.89,0.89,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Chlorothiazide: 1 Vial In 1 Box (63323-658-20) / 18 Ml In 1 Vial,636,RC,63323-658-20,NDC,,,facility,both,1,EA,,46.09,46.09,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,63323-655-21,NDC,,,facility,both,1,EA,,7.06,7.06,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,63323-626-02,NDC,,,facility,both,1,EA,,67.23,67.23,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Amiodarone Hydrochloride: 25 Vial, Single-Dose In 1 Tray (63323-616-03) / 3 Ml In 1 Vial, Single-Dose (63323-616-01)",636,RC,63323-616-03,NDC,,,facility,both,1,EA,,9.9,9.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,63323-614-00,NDC,,,facility,both,1,EA,,33.6,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,63323-604-00,NDC,,,facility,both,1,EA,,22.16,22.16,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Deferoxamine: 1 Vial In 1 Box (63323-599-30) / 21.1 Ml In 1 Vial,636,RC,63323-599-30,NDC,,,facility,both,1,EA,,37.81,37.81,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,63323-596-03,NDC,,,facility,both,1,EA,,754.2,754.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,63323-596-03,NDC,,,facility,both,1,EA,,690.34,690.34,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,63323-596-03,NDC,,,facility,both,1,EA,,234.22,234.22,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,63323-360-01,NDC,,,facility,both,1,EA,,0.5,0.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Glucagon: 1 Kit In 1 Carton (63323-593-03) * 1 Ml In 1 Vial, Single-Dose (63323-596-03) * 1 Ml In 1 Vial, Single-Dose (63323-185-03)",636,RC,63323-593-03,NDC,,,facility,both,1,EA,,464.04,464.04,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,63323-545-05,NDC,,,facility,both,1,EA,,0.78,0.78,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,63323-540-33,NDC,,,facility,both,1,EA,,2.29,2.29,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Heparin Sodium: 25 Vial In 1 Tray (63323-540-13) / 1 Ml In 1 Vial (63323-540-03),636,RC,63323-540-13,NDC,,,facility,both,1,EA,,10.78,10.78,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,63323-540-05,NDC,,,facility,both,1,EA,,29.1,29.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,63323-540-03,NDC,,,facility,both,1,EA,,22.14,22.14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Heparin Sodium: 25 Vial In 1 Tray (63323-540-01) / 1 Ml In 1 Vial,636,RC,63323-540-01,NDC,,,facility,both,1,EA,,29.45,29.45,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sodium Chloride: 20 Bag In 1 Case (63323-530-75) / 500 Ml In 1 Bag (63323-530-21),636,RC,63323-530-75,NDC,,,facility,both,1,EA,,74.18,74.18,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,63323-530-21,NDC,,,facility,both,1,EA,,71.81,71.81,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,63323-517-01,NDC,,,facility,both,1,EA,,4.18,4.18,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Meropenem: 10 Vial In 1 Carton (63323-508-30) / 20 Ml In 1 Vial (63323-508-01),636,RC,63323-508-30,NDC,,,facility,both,1,EA,,9.68,9.68,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dexamethasone Sodium Phosphate: 25 Vial In 1 Tray (63323-506-01) / 1 Ml In 1 Vial (63323-506-00),636,RC,63323-506-01,NDC,,,facility,both,1,EA,,3.88,3.88,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Enoxaparin sodium: 10 SYRINGE in 1 CARTON (63323-568-83) / .3 mL in 1 SYRINGE,636,RC,63323-568-83,NDC,,,facility,both,1,EA,,21.52,21.52,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,63323-356-01,NDC,,,facility,both,1,EA,,41.03,41.03,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Acyclovir: 10 Vial, Single-Dose In 1 Tray (63323-325-10) / 10 Ml In 1 Vial, Single-Dose (63323-325-03)",636,RC,63323-325-10,NDC,,,facility,both,1,EA,,1.84,1.84,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,63323-325-09,NDC,,,facility,both,1,EA,,0.86,0.86,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,63323-229-01,NDC,,,facility,both,1,EA,,25.15,25.15,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Fludarabine: 1 Vial In 1 Box (63323-192-02) / 2 Ml In 1 Vial,636,RC,63323-192-02,NDC,,,facility,both,1,EA,,343.53,343.53,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,63323-186-03,NDC,,,facility,both,1,EA,,67.69,67.69,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,63323-186-01,NDC,,,facility,both,1,EA,,61.1,61.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Protamine Sulfate: 25 Vial, Single-Dose In 1 Tray (63323-229-05) / 5 Ml In 1 Vial, Single-Dose (63323-229-01)",636,RC,63323-229-05,NDC,,,facility,both,1,EA,,18.06,18.06,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Pyridoxine Hydrochloride: 25 Vial In 1 Tray (63323-180-01) / 1 Ml In 1 Vial (63323-180-00),636,RC,63323-180-01,NDC,,,facility,both,1,EA,,69.88,69.88,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,63323-180-00,NDC,,,facility,both,1,EA,,69.42,69.42,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,63323-165-02,NDC,,,facility,both,1,EA,,13.22,13.22,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dexamethasone Sodium Phosphate: 25 Vial In 1 Tray (63323-165-01) / 1 Ml In 1 Vial (63323-165-02),636,RC,63323-165-01,NDC,,,facility,both,1,EA,,29.15,29.15,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,63323-162-00,NDC,,,facility,both,1,EA,,19.02,19.02,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,63323-162-00,NDC,,,facility,both,1,EA,,16.42,16.42,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,63323-162-00,NDC,,,facility,both,1,EA,,3.38,3.38,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ketorolac Tromethamine: 25 Vial, Single-Use In 1 Tray (63323-161-01) / 1 Ml In 1 Vial, Single-Use (63323-161-00)",636,RC,63323-161-01,NDC,,,facility,both,1,EA,,23.89,23.89,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ketorolac Tromethamine: 25 Vial, Single-Use In 1 Tray (63323-161-01) / 1 Ml In 1 Vial, Single-Use (63323-161-00)",636,RC,63323-161-01,NDC,,,facility,both,1,EA,,19.37,19.37,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,63323-161-00,NDC,,,facility,both,1,EA,,23.01,23.01,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Protamine Sulfate: 1 Vial, Single-Dose In 1 Box (63323-229-30) / 25 Ml In 1 Vial, Single-Dose",636,RC,63323-229-30,NDC,,,facility,both,1,EA,,9.59,9.59,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,63323-262-03,NDC,,,facility,both,1,EA,,6.88,6.88,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Imipenem And Cilastatin: 25 Vial, Single-Dose In 1 Carton (63323-322-25) / 20 Ml In 1 Vial, Single-Dose (63323-322-01)",636,RC,63323-322-25,NDC,,,facility,both,1,EA,,40.88,40.88,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,63323-322-01,NDC,,,facility,both,1,EA,,42.23,42.23,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Vancomycin Hydrochloride: 1 Bottle In 1 Carton (63323-314-61) / 100 Ml In 1 Bottle,636,RC,63323-314-61,NDC,,,facility,both,1,EA,,2.48,2.48,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,63323-306-05,NDC,,,facility,both,1,EA,,19.48,19.48,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Tobramycin: 25 Vial, Multi-Dose In 1 Tray (63323-306-02) / 2 Ml In 1 Vial, Multi-Dose (63323-306-01)",636,RC,63323-306-02,NDC,,,facility,both,1,EA,,22.79,22.79,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,63323-306-01,NDC,,,facility,both,1,EA,,24.8,24.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,63323-288-07,NDC,,,facility,both,1,EA,,0.28,0.28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,63323-288-03,NDC,,,facility,both,1,EA,,0.34,0.34,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,63323-286-05,NDC,,,facility,both,1,EA,,0.51,0.51,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Naropin: 25 Vial, Single-Dose In 1 Carton (63323-285-13) / 10 Ml In 1 Vial, Single-Dose (63323-285-03)",636,RC,63323-285-13,NDC,,,facility,both,1,EA,,2.58,2.58,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,63323-237-01,NDC,,,facility,both,1,EA,,21.47,21.47,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Naropin: 5 Ampule In 1 Box (63323-285-10) / 10 Ml In 1 Ampule (63323-285-01),636,RC,63323-285-10,NDC,,,facility,both,1,EA,,2.93,2.93,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Vancomycin Hydrochloride: 10 Vial In 1 Tray (63323-284-20) / 20 Ml In 1 Vial (63323-284-01),636,RC,63323-284-20,NDC,,,facility,both,1,EA,,21.06,21.06,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Furosemide: 25 Vial In 1 Tray (63323-280-02) / 2 Ml In 1 Vial (63323-280-01),636,RC,63323-280-02,NDC,,,facility,both,1,EA,,4.44,4.44,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Furosemide: 25 Vial In 1 Tray (63323-280-02) / 2 Ml In 1 Vial (63323-280-01),636,RC,63323-280-02,NDC,,,facility,both,1,EA,,0.65,0.65,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Vinblastine Sulfate: 1 Vial, Multi-Dose In 1 Box (63323-278-10) / 10 Ml In 1 Vial, Multi-Dose",636,RC,63323-278-10,NDC,,,facility,both,1,EA,,54.02,54.02,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,63323-276-01,NDC,,,facility,both,1,EA,,23.71,23.71,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Diprivan: 10 Vial In 1 Box (63323-269-65) / 100 Ml In 1 Vial (63323-269-35),636,RC,63323-269-65,NDC,,,facility,both,1,EA,,1.2,1.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Diprivan: 20 Vial In 1 Box (63323-269-50) / 50 Ml In 1 Vial (63323-269-30),636,RC,63323-269-50,NDC,,,facility,both,1,EA,,1.02,1.02,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,63323-269-35,NDC,,,facility,both,1,EA,,0.89,0.89,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,63323-269-30,NDC,,,facility,both,1,EA,,1.2,1.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Diprivan: 10 Vial In 1 Box (63323-269-29) / 20 Ml In 1 Vial (63323-269-22),636,RC,63323-269-29,NDC,,,facility,both,1,EA,,1.62,1.62,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,63323-269-22,NDC,,,facility,both,1,EA,,3.04,3.04,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Diprivan: 10 Vial In 1 Box (63323-269-10) / 10 Ml In 1 Vial (63323-269-01),636,RC,63323-269-10,NDC,,,facility,both,1,EA,,2.75,2.75,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,63323-285-07,NDC,,,facility,both,1,EA,,1.87,1.87,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,99999-1010-35,NDC,,,facility,both,1,EA,,36.38,36.38,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Naloxone Hydrochloride: 25 Carton In 1 Case (0409-1219-01) / 1 Vial, Multi-Dose In 1 Carton / 10 Ml In 1 Vial, Multi-Dose (0409-1219-41)",636,RC,0409-1219-01,NDC,,,facility,both,1,EA,,0.34,0.34,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0024-5154-11,NDC,,,facility,both,1,EA,,2249.56,2249.56,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0024-5154-11,NDC,,,facility,both,1,EA,,2215.88,2215.88,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Infed: 10 Vial, Single-Dose In 1 Carton (0023-6082-10) / 2 Ml In 1 Vial, Single-Dose (0023-6082-01)",636,RC,0023-6082-10,NDC,,,facility,both,1,EA,,84.55,84.55,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0023-6082-01,NDC,,,facility,both,1,EA,,109.43,109.43,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0023-6082-01,NDC,,,facility,both,1,EA,,101.49,101.49,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Botox: 1 Vial In 1 Carton (0023-1145-01) / 1 Injection, Powder, Lyophilized, For Solution In 1 Vial",636,RC,0023-1145-01,NDC,,,facility,both,1,EA,,45.19,45.19,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Botox: 1 Vial In 1 Carton (0023-1145-01) / 1 Injection, Powder, Lyophilized, For Solution In 1 Vial",636,RC,0023-1145-01,NDC,,,facility,both,1,EA,,41.61,41.61,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Botox: 1 Vial In 1 Carton (0023-1145-01) / 1 Injection, Powder, Lyophilized, For Solution In 1 Vial",636,RC,0023-1145-01,NDC,,,facility,both,1,EA,,41.2,41.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Botox: 1 Vial In 1 Carton (0023-1145-01) / 1 Injection, Powder, Lyophilized, For Solution In 1 Vial",636,RC,0023-1145-01,NDC,,,facility,both,1,EA,,40.93,40.93,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Botox: 1 Vial In 1 Carton (0023-1145-01) / 1 Injection, Powder, Lyophilized, For Solution In 1 Vial",636,RC,0023-1145-01,NDC,,,facility,both,1,EA,,40.79,40.79,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Botox: 1 Vial In 1 Carton (0023-1145-01) / 1 Injection, Powder, Lyophilized, For Solution In 1 Vial",636,RC,0023-1145-01,NDC,,,facility,both,1,EA,,39.73,39.73,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Botox: 1 Vial In 1 Carton (0023-1145-01) / 1 Injection, Powder, Lyophilized, For Solution In 1 Vial",636,RC,0023-1145-01,NDC,,,facility,both,1,EA,,39.68,39.68,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Botox: 1 Vial In 1 Carton (0023-1145-01) / 1 Injection, Powder, Lyophilized, For Solution In 1 Vial",636,RC,0023-1145-01,NDC,,,facility,both,1,EA,,38.54,38.54,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Botox: 1 Vial In 1 Carton (0023-1145-01) / 1 Injection, Powder, Lyophilized, For Solution In 1 Vial",636,RC,0023-1145-01,NDC,,,facility,both,1,EA,,37.84,37.84,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Botox: 1 Vial In 1 Carton (0023-1145-01) / 1 Injection, Powder, Lyophilized, For Solution In 1 Vial",636,RC,0023-1145-01,NDC,,,facility,both,1,EA,,37.51,37.51,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Botox: 1 Vial In 1 Carton (0023-1145-01) / 1 Injection, Powder, Lyophilized, For Solution In 1 Vial",636,RC,0023-1145-01,NDC,,,facility,both,1,EA,,36.96,36.96,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Botox: 1 Vial In 1 Carton (0023-1145-01) / 1 Injection, Powder, Lyophilized, For Solution In 1 Vial",636,RC,0023-1145-01,NDC,,,facility,both,1,EA,,35.03,35.03,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0023-6082-01,NDC,,,facility,both,1,EA,,167.43,167.43,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Botox: 1 Vial In 1 Carton (0023-1145-01) / 1 Injection, Powder, Lyophilized, For Solution In 1 Vial",636,RC,0023-1145-01,NDC,,,facility,both,1,EA,,35.01,35.01,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Dexamethasone: 500 Ml In 1 Bottle, Plastic (0054-3177-63)",636,RC,0054-3177-63,NDC,,,facility,both,1,EA,,6.91,6.91,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Dexamethasone: 240 Ml In 1 Bottle, Plastic (0054-3177-57)",636,RC,0054-3177-57,NDC,,,facility,both,1,EA,,7.87,7.87,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Everolimus: 60 Tablet In 1 Bottle (0054-0472-21),636,RC,0054-0472-21,NDC,,,facility,both,1,EA,,34.3,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Prednisone: 10 Blister Pack In 1 Carton (0054-0018-20) / 10 Tablet In 1 Blister Pack,636,RC,0054-0018-20,NDC,,,facility,both,1,EA,,0.24,0.24,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Vfend: 1 Vial, Single-Dose In 1 Carton (0049-3190-28) / 20 Ml In 1 Vial, Single-Dose",636,RC,0049-3190-28,NDC,,,facility,both,1,EA,,16.31,16.31,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0049-0520-84,NDC,,,facility,both,1,EA,,17.12,17.12,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Pfizerpen: 10 Vial In 1 Carton (0049-0520-83) / 1 Powder, For Solution In 1 Vial (0049-0520-84)",636,RC,0049-0520-83,NDC,,,facility,both,1,EA,,28.62,28.62,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Unasyn: 1 Vial, Pharmacy Bulk Package In 1 Carton (0049-0024-28) / 100 Ml In 1 Vial, Pharmacy Bulk Package",636,RC,0049-0024-28,NDC,,,facility,both,1,EA,,47.96,47.96,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0009-0011-03,NDC,,,facility,both,1,EA,,135.86,135.86,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0009-0011-03,NDC,,,facility,both,1,EA,,45.84,45.84,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Solu-Medrol: 1 Vial In 1 Carton (0009-0003-02) / 4 Ml In 1 Vial,636,RC,0009-0003-02,NDC,,,facility,both,1,EA,,3.11,3.11,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Solu-Medrol: 1 Vial In 1 Carton (0009-0003-02) / 4 Ml In 1 Vial,636,RC,0009-0003-02,NDC,,,facility,both,1,EA,,3.08,3.08,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Solu-Medrol: 1 Vial In 1 Carton (0009-0003-02) / 4 Ml In 1 Vial,636,RC,0009-0003-02,NDC,,,facility,both,1,EA,,3.07,3.07,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Solu-Medrol: 1 Vial In 1 Carton (0009-0003-02) / 4 Ml In 1 Vial,636,RC,0009-0003-02,NDC,,,facility,both,1,EA,,2.78,2.78,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Solu-Medrol: 1 Vial In 1 Carton (0009-0003-02) / 4 Ml In 1 Vial,636,RC,0009-0003-02,NDC,,,facility,both,1,EA,,2.78,2.78,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Mylotarg: 1 Vial, Single-Dose In 1 Carton (0008-4510-01) / 5 Ml In 1 Vial, Single-Dose",636,RC,0008-4510-01,NDC,,,facility,both,1,EA,,1501.54,1501.54,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Mylotarg: 1 Vial, Single-Dose In 1 Carton (0008-4510-01) / 5 Ml In 1 Vial, Single-Dose",636,RC,0008-4510-01,NDC,,,facility,both,1,EA,,1341.12,1341.12,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Rapamune: 100 Blister Pack In 1 Carton (0008-1040-10) / 1 Tablet, Sugar Coated In 1 Blister Pack",636,RC,0008-1040-10,NDC,,,facility,both,1,EA,,119.94,119.94,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Protonix I.V.: 1 Vial In 1 Carton (0008-0923-51) / 10 Ml In 1 Vial,636,RC,0008-0923-51,NDC,,,facility,both,1,EA,,28.45,28.45,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Besponsa: 1 Vial, Single-Dose In 1 Carton (0008-0100-01) / 4 Ml In 1 Vial, Single-Dose",636,RC,0008-0100-01,NDC,,,facility,both,1,EA,,16297.56,16297.56,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Besponsa: 1 Vial, Single-Dose In 1 Carton (0008-0100-01) / 4 Ml In 1 Vial, Single-Dose",636,RC,0008-0100-01,NDC,,,facility,both,1,EA,,15166.18,15166.18,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Solu-Cortef: 25 Vial, Single-Dose In 1 Carton (0009-0011-04) / 2 Ml In 1 Vial, Single-Dose (0009-0011-03)",636,RC,0009-0011-04,NDC,,,facility,both,1,EA,,55.54,55.54,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0006-5003-02,NDC,,,facility,both,1,EA,,1984.64,1984.64,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Prevymis: 1 Vial, Single-Dose In 1 Carton (0006-5003-01) / 12 Ml In 1 Vial, Single-Dose (0006-5003-02)",636,RC,0006-5003-01,NDC,,,facility,both,1,EA,,1872.25,1872.25,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0006-4897-01,NDC,,,facility,both,1,EA,,212.48,212.48,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0006-4837-01,NDC,,,facility,both,1,EA,,753.23,753.23,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Varivax: 10 Vial, Single-Dose In 1 Carton (0006-4827-00) / .5 Ml In 1 Vial, Single-Dose (0006-4827-01)",636,RC,0006-4827-00,NDC,,,facility,both,1,EA,,1138.02,1138.02,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0006-4681-01,NDC,,,facility,both,1,EA,,589.43,589.43,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0006-4171-01,NDC,,,facility,both,1,EA,,1680.39,1680.39,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0006-4095-01,NDC,,,facility,both,1,EA,,211.83,211.83,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Primaxin Iv: 25 Vial, Single-Dose In 1 Tray (0006-3516-59) / 100 Ml In 1 Vial, Single-Dose",636,RC,0006-3516-59,NDC,,,facility,both,1,EA,,126.64,126.64,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Solu-Medrol: 1 Vial In 1 Carton (0009-0018-20) / 8 Ml In 1 Vial,636,RC,0009-0018-20,NDC,,,facility,both,1,EA,,1.81,1.81,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Solu-Medrol: 1 Vial In 1 Carton (0009-0018-20) / 8 Ml In 1 Vial,636,RC,0009-0018-20,NDC,,,facility,both,1,EA,,1.93,1.93,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Solu-Medrol: 1 Vial In 1 Carton (0009-0018-20) / 8 Ml In 1 Vial,636,RC,0009-0018-20,NDC,,,facility,both,1,EA,,2,2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0009-7224-01,NDC,,,facility,both,1,EA,,24812.77,24812.77,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0009-5140-01,NDC,,,facility,both,1,EA,,58.51,58.51,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0009-0047-25,NDC,,,facility,both,1,EA,,9.8,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0009-0047-25,NDC,,,facility,both,1,EA,,8.81,8.81,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0009-0047-25,NDC,,,facility,both,1,EA,,4.54,4.54,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Solu-Medrol: 1 Vial In 1 Carton (0009-0018-20) / 8 Ml In 1 Vial,636,RC,0009-0018-20,NDC,,,facility,both,1,EA,,2.07,2.07,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Solu-Medrol: 1 Vial In 1 Carton (0009-0018-20) / 8 Ml In 1 Vial,636,RC,0009-0018-20,NDC,,,facility,both,1,EA,,2.17,2.17,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Solu-Medrol: 25 Vial In 1 Carton (0009-0039-28) / 1 Ml In 1 Vial (0009-0039-30),636,RC,0009-0039-28,NDC,,,facility,both,1,EA,,6.13,6.13,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Solu-Medrol: 25 Vial In 1 Carton (0009-0039-28) / 1 Ml In 1 Vial (0009-0039-30),636,RC,0009-0039-28,NDC,,,facility,both,1,EA,,9.47,9.47,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0009-0039-30,NDC,,,facility,both,1,EA,,4.24,4.24,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0009-0039-30,NDC,,,facility,both,1,EA,,4.3,4.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0009-0039-30,NDC,,,facility,both,1,EA,,6.85,6.85,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Solu-Medrol: 25 Vial In 1 Carton (0009-0047-22) / 2 Ml In 1 Vial (0009-0047-25),636,RC,0009-0047-22,NDC,,,facility,both,1,EA,,2.02,2.02,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Solu-Medrol: 25 Vial In 1 Carton (0009-0047-22) / 2 Ml In 1 Vial (0009-0047-25),636,RC,0009-0047-22,NDC,,,facility,both,1,EA,,2.04,2.04,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Solu-Medrol: 25 Vial In 1 Carton (0009-0047-22) / 2 Ml In 1 Vial (0009-0047-25),636,RC,0009-0047-22,NDC,,,facility,both,1,EA,,3.43,3.43,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Solu-Medrol: 25 Vial In 1 Carton (0009-0047-22) / 2 Ml In 1 Vial (0009-0047-25),636,RC,0009-0047-22,NDC,,,facility,both,1,EA,,6.23,6.23,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0009-0047-25,NDC,,,facility,both,1,EA,,2.05,2.05,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0009-0047-25,NDC,,,facility,both,1,EA,,2.07,2.07,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0009-0039-30,NDC,,,facility,both,1,EA,,8.93,8.93,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0069-6001-10,NDC,,,facility,both,1,EA,,88.55,88.55,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Zemplar: 25 Vial, Single-Dose In 1 Tray (0074-1658-01) / 1 Ml In 1 Vial, Single-Dose",636,RC,0074-1658-01,NDC,,,facility,both,1,EA,,15.05,15.05,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Lupron Depot: 1 Kit In 1 Carton (0074-3663-03) * 1.5 Ml In 1 Syringe * 1 Ml In 1 Packet,636,RC,0074-3663-03,NDC,,,facility,both,1,EA,,9863.71,9863.71,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Lupron Depot: 1 Kit In 1 Carton (0074-3663-03) * 1.5 Ml In 1 Syringe * 1 Ml In 1 Packet,636,RC,0074-3663-03,NDC,,,facility,both,1,EA,,10101.85,10101.85,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Lupron Depot: 1 Kit In 1 Carton (0074-3663-03) * 1.5 Ml In 1 Syringe * 1 Ml In 1 Packet,636,RC,0074-3663-03,NDC,,,facility,both,1,EA,,10102.94,10102.94,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Skyrizi: 1 Vial, Single-Dose In 1 Carton (0074-5015-01) / 10 Ml In 1 Vial, Single-Dose",636,RC,0074-5015-01,NDC,,,facility,both,1,EA,,103.35,103.35,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Skyrizi: 1 Vial, Single-Dose In 1 Carton (0074-5015-01) / 10 Ml In 1 Vial, Single-Dose",636,RC,0074-5015-01,NDC,,,facility,both,1,EA,,105.26,105.26,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0078-0248-61,NDC,,,facility,both,1,EA,,81.37,81.37,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Simulect: 1 Vial, Single-Use In 1 Carton (0078-0331-84) / 5 Ml In 1 Vial, Single-Use",636,RC,0078-0331-84,NDC,,,facility,both,1,EA,,13673.9,13673.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Zortress: 60 Blister Pack In 1 Box (0078-0415-20) / 1 Tablet In 1 Blister Pack (0078-0415-61),636,RC,0078-0415-20,NDC,,,facility,both,1,EA,,67.78,67.78,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Zortress: 60 Blister Pack In 1 Box (0078-0417-20) / 1 Tablet In 1 Blister Pack (0078-0417-61),636,RC,0078-0417-20,NDC,,,facility,both,1,EA,,81.63,81.63,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Neoral: 1 Bottle In 1 Carton (0078-0274-22) / 50 Ml In 1 Bottle,636,RC,0078-0274-22,NDC,,,facility,both,1,EA,,44.64,44.64,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Prednisone: 10 Blister Pack In 1 Carton (0054-8724-25) / 10 Tablet In 1 Blister Pack,636,RC,0054-8724-25,NDC,,,facility,both,1,EA,,1.48,1.48,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dexamethasone: 100 Blister Pack In 1 Carton (0054-8181-25) / 1 Tablet In 1 Blister Pack,636,RC,0054-8181-25,NDC,,,facility,both,1,EA,,1.14,1.14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dexamethasone: 100 Blister Pack In 1 Carton (0054-8176-25) / 1 Tablet In 1 Blister Pack,636,RC,0054-8176-25,NDC,,,facility,both,1,EA,,1.57,1.57,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dexamethasone: 100 Blister Pack In 1 Carton (0054-8175-25) / 1 Tablet In 1 Blister Pack,636,RC,0054-8175-25,NDC,,,facility,both,1,EA,,0.54,0.54,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Dexamethasone: 100 Tablet In 1 Bottle, Plastic (0054-4182-25)",636,RC,0054-4182-25,NDC,,,facility,both,1,EA,,1.06,1.06,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dexamethasone: 100 Blister Pack In 1 Carton (0054-8179-25) / 1 Tablet In 1 Blister Pack,636,RC,0054-8179-25,NDC,,,facility,both,1,EA,,4.04,4.04,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Inflectra: 1 Vial, Single-Use In 1 Carton (0069-0809-01) / 10 Ml In 1 Vial, Single-Use",636,RC,0069-0809-01,NDC,,,facility,both,1,EA,,319.93,319.93,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Inflectra: 1 Vial, Single-Use In 1 Carton (0069-0809-01) / 10 Ml In 1 Vial, Single-Use",636,RC,0069-0809-01,NDC,,,facility,both,1,EA,,315.61,315.61,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Inflectra: 1 Vial, Single-Use In 1 Carton (0069-0809-01) / 10 Ml In 1 Vial, Single-Use",636,RC,0069-0809-01,NDC,,,facility,both,1,EA,,275.14,275.14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Inflectra: 1 Vial, Single-Use In 1 Carton (0069-0809-01) / 10 Ml In 1 Vial, Single-Use",636,RC,0069-0809-01,NDC,,,facility,both,1,EA,,274.91,274.91,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Inflectra: 1 Vial, Single-Use In 1 Carton (0069-0809-01) / 10 Ml In 1 Vial, Single-Use",636,RC,0069-0809-01,NDC,,,facility,both,1,EA,,274.66,274.66,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Rifadin Iv: 1 Vial, Glass In 1 Carton (0068-0597-01) / 10 Ml In 1 Vial, Glass",636,RC,0068-0597-01,NDC,,,facility,both,1,EA,,1.13,1.13,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Elelyso: 1 Vial, Glass In 1 Carton (0069-0106-01) / 5 Ml In 1 Vial, Glass",636,RC,0069-0106-01,NDC,,,facility,both,1,EA,,281.36,281.36,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA 1 VIAL in 1 CARTON (0069-0234-01) / 50 mL in 1 VIAL,636,RC,0069-0234-01,NDC,,,facility,both,1,EA,,1.03,1.03,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ruxience: 1 Vial, Single-Use In 1 Carton (0069-0238-01) / 10 Ml In 1 Vial, Single-Use",636,RC,0069-0238-01,NDC,,,facility,both,1,EA,,343.71,343.71,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ruxience: 1 Vial, Single-Use In 1 Carton (0069-0238-01) / 10 Ml In 1 Vial, Single-Use",636,RC,0069-0238-01,NDC,,,facility,both,1,EA,,374.09,374.09,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Propofol: 10 Vial In 1 Carton (0069-0248-10) / 100 Ml In 1 Vial,636,RC,0069-0248-10,NDC,,,facility,both,1,EA,,0.88,0.88,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ruxience: 1 Vial, Single-Use In 1 Carton (0069-0249-01) / 50 Ml In 1 Vial, Single-Use",636,RC,0069-0249-01,NDC,,,facility,both,1,EA,,270.37,270.37,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ruxience: 1 Vial, Single-Use In 1 Carton (0069-0249-01) / 50 Ml In 1 Vial, Single-Use",636,RC,0069-0249-01,NDC,,,facility,both,1,EA,,270.37,270.37,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ruxience: 1 Vial, Single-Use In 1 Carton (0069-0249-01) / 50 Ml In 1 Vial, Single-Use",636,RC,0069-0249-01,NDC,,,facility,both,1,EA,,345.09,345.09,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Doxorubicin Hydrochloride: 1 Vial, Single-Dose In 1 Carton (0069-0343-02) / 25 Ml In 1 Vial, Single-Dose",636,RC,0069-0343-02,NDC,,,facility,both,1,EA,,65.23,65.23,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Inflectra: 1 Vial, Single-Use In 1 Carton (0069-0809-01) / 10 Ml In 1 Vial, Single-Use",636,RC,0069-0809-01,NDC,,,facility,both,1,EA,,274.19,274.19,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA 1 VIAL in 1 CARTON (0069-0248-01) / 100 mL in 1 VIAL,636,RC,0069-0248-01,NDC,,,facility,both,1,EA,,0.88,0.88,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,6380760051,NDC,,,facility,both,1,EA,,3.47,3.47,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Humulin R: 1 Vial, Multi-Dose In 1 Carton (0002-8215-01) / 10 Ml In 1 Vial, Multi-Dose",636,RC,0002-8215-01,NDC,,,facility,both,1,EA,,10.51,10.51,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,8290306553,NDC,,,facility,both,1,EA,,68.32,68.32,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Kenalog-10: 1 Vial, Multi-Dose In 1 Carton (0003-0494-20) / 5 Ml In 1 Vial, Multi-Dose",636,RC,0003-0494-20,NDC,,,facility,both,1,EA,,27.08,27.08,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,8290306545,NDC,,,facility,both,1,EA,,84.21,84.21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,8290306424,NDC,,,facility,both,1,EA,,0.98,0.98,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Keytruda: 1 Vial In 1 Carton (0006-3026-02) / 4 Ml In 1 Vial (0006-3026-01),636,RC,0006-3026-02,NDC,,,facility,both,1,EA,,364.12,364.12,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Prevnar 20: 1 Syringe In 1 Carton (0005-2000-02) / .5 Ml In 1 Syringe (0005-2000-01),636,RC,0005-2000-02,NDC,,,facility,both,1,EA,,1490.41,1490.41,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0005-2000-01,NDC,,,facility,both,1,EA,,1483.22,1483.22,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Cellcept: 4 Vial In 1 Carton (0004-0298-09) / 20 Ml In 1 Vial,636,RC,0004-0298-09,NDC,,,facility,both,1,EA,,8.95,8.95,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Opdivo: 1 Vial, Single-Dose In 1 Carton (0003-3774-12) / 10 Ml In 1 Vial, Single-Dose",636,RC,0003-3774-12,NDC,,,facility,both,1,EA,,211.84,211.84,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Opdivo: 1 Vial, Single-Dose In 1 Carton (0003-3774-12) / 10 Ml In 1 Vial, Single-Dose",636,RC,0003-3774-12,NDC,,,facility,both,1,EA,,211.15,211.15,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Opdivo: 1 Vial, Single-Dose In 1 Carton (0003-3774-12) / 10 Ml In 1 Vial, Single-Dose",636,RC,0003-3774-12,NDC,,,facility,both,1,EA,,210.37,210.37,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Opdivo: 1 Vial, Single-Dose In 1 Carton (0003-3774-12) / 10 Ml In 1 Vial, Single-Dose",636,RC,0003-3774-12,NDC,,,facility,both,1,EA,,209.31,209.31,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Opdivo: 1 Vial, Single-Dose In 1 Carton (0003-3774-12) / 10 Ml In 1 Vial, Single-Dose",636,RC,0003-3774-12,NDC,,,facility,both,1,EA,,208.19,208.19,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Opdivo: 1 Vial, Single-Dose In 1 Carton (0003-3774-12) / 10 Ml In 1 Vial, Single-Dose",636,RC,0003-3774-12,NDC,,,facility,both,1,EA,,207.01,207.01,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Opdivo: 1 Vial, Single-Dose In 1 Carton (0003-3774-12) / 10 Ml In 1 Vial, Single-Dose",636,RC,0003-3774-12,NDC,,,facility,both,1,EA,,204.72,204.72,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Opdivo: 1 Vial, Single-Dose In 1 Carton (0003-3774-12) / 10 Ml In 1 Vial, Single-Dose",636,RC,0003-3774-12,NDC,,,facility,both,1,EA,,203.59,203.59,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Yervoy: 1 Vial, Single-Use In 1 Carton (0003-2327-11) / 10 Ml In 1 Vial, Single-Use",636,RC,0003-2327-11,NDC,,,facility,both,1,EA,,1137.82,1137.82,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Orencia: 1 Vial, Single-Use In 1 Carton (0003-2187-13) / 15 Ml In 1 Vial, Single-Use",636,RC,0003-2187-13,NDC,,,facility,both,1,EA,,346.16,346.16,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Orencia: 1 Vial, Single-Use In 1 Carton (0003-2187-13) / 15 Ml In 1 Vial, Single-Use",636,RC,0003-2187-13,NDC,,,facility,both,1,EA,,349.93,349.93,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Orencia: 1 Vial, Single-Use In 1 Carton (0003-2187-13) / 15 Ml In 1 Vial, Single-Use",636,RC,0003-2187-13,NDC,,,facility,both,1,EA,,350.65,350.65,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Orencia: 1 Vial, Single-Use In 1 Carton (0003-2187-13) / 15 Ml In 1 Vial, Single-Use",636,RC,0003-2187-13,NDC,,,facility,both,1,EA,,356.04,356.04,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Orencia: 1 Vial, Single-Use In 1 Carton (0003-2187-13) / 15 Ml In 1 Vial, Single-Use",636,RC,0003-2187-13,NDC,,,facility,both,1,EA,,364.74,364.74,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Orencia: 1 Vial, Single-Use In 1 Carton (0003-2187-13) / 15 Ml In 1 Vial, Single-Use",636,RC,0003-2187-13,NDC,,,facility,both,1,EA,,364.88,364.88,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Orencia: 1 Vial, Single-Use In 1 Carton (0003-2187-13) / 15 Ml In 1 Vial, Single-Use",636,RC,0003-2187-13,NDC,,,facility,both,1,EA,,375.92,375.92,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Orencia: 1 Vial, Single-Use In 1 Carton (0003-2187-13) / 15 Ml In 1 Vial, Single-Use",636,RC,0003-2187-13,NDC,,,facility,both,1,EA,,383.69,383.69,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Orencia: 4 Syringe, Glass In 1 Carton (0003-2188-11) / 1 Ml In 1 Syringe, Glass",636,RC,0003-2188-11,NDC,,,facility,both,1,EA,,704.75,704.75,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Yervoy: 1 Vial, Single-Use In 1 Carton (0003-2327-11) / 10 Ml In 1 Vial, Single-Use",636,RC,0003-2327-11,NDC,,,facility,both,1,EA,,1106.06,1106.06,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Yervoy: 1 Vial, Single-Use In 1 Carton (0003-2327-11) / 10 Ml In 1 Vial, Single-Use",636,RC,0003-2327-11,NDC,,,facility,both,1,EA,,1121.01,1121.01,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Yervoy: 1 Vial, Single-Use In 1 Carton (0003-2327-11) / 10 Ml In 1 Vial, Single-Use",636,RC,0003-2327-11,NDC,,,facility,both,1,EA,,1124.68,1124.68,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Orencia: 1 Vial, Single-Use In 1 Carton (0003-2187-13) / 15 Ml In 1 Vial, Single-Use",636,RC,0003-2187-13,NDC,,,facility,both,1,EA,,366.35,366.35,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,6425333333,NDC,,,facility,both,1,EA,,2.6,2.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,6425333323,NDC,,,facility,both,1,EA,,1.71,1.71,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dextrose: 250 Ml In 1 Bag (0338-0023-02),636,RC,0338-0023-02,NDC,,,facility,both,1,EA,,71.14,71.14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dextrose: 1 Bag In 1 Package (0338-0017-48) / 100 Ml In 1 Bag,636,RC,0338-0017-48,NDC,,,facility,both,1,EA,,68.7,68.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dextrose: 1 Bag In 1 Package (0338-0017-41) / 50 Ml In 1 Bag,636,RC,0338-0017-41,NDC,,,facility,both,1,EA,,72.7,72.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dextrose: 4 Bag In 1 Pouch (0338-0017-11) / 50 Ml In 1 Bag,636,RC,0338-0017-11,NDC,,,facility,both,1,EA,,66.36,66.36,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dextrose: 4 Bag In 1 Pouch (0338-0017-10) / 25 Ml In 1 Bag,636,RC,0338-0017-10,NDC,,,facility,both,1,EA,,73.71,73.71,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dextrose: 1000 Ml In 1 Bag (0338-0017-04),636,RC,0338-0017-04,NDC,,,facility,both,1,EA,,67.82,67.82,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dextrose: 500 Ml In 1 Bag (0338-0017-03),636,RC,0338-0017-03,NDC,,,facility,both,1,EA,,62.15,62.15,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dextrose: 250 Ml In 1 Bag (0338-0017-02),636,RC,0338-0017-02,NDC,,,facility,both,1,EA,,62.44,62.44,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dextrose: 500 Ml In 1 Bag (0338-0023-03),636,RC,0338-0023-03,NDC,,,facility,both,1,EA,,84.09,84.09,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Kinevac: 10 Vial In 1 Package (0270-0556-15) / 5 Ml In 1 Vial,636,RC,0270-0556-15,NDC,,,facility,both,1,EA,,206.69,206.69,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Heparin Sodium In Sodium Chloride: 24 Container In 1 Case (0264-9872-10) / 500 Ml In 1 Container,636,RC,0264-9872-10,NDC,,,facility,both,1,EA,,52.23,52.23,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Heparin Sodium In Sodium Chloride: 12 Container In 1 Case (0264-9872-00) / 1000 Ml In 1 Container,636,RC,0264-9872-00,NDC,,,facility,both,1,EA,,23.73,23.73,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Potassium Chloride In Sodium Chloride: 12 Container In 1 Case (0264-7865-00) / 1000 Ml In 1 Container,636,RC,0264-7865-00,NDC,,,facility,both,1,EA,,19.41,19.41,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Saphnelo: 1 Vial, Glass In 1 Carton (0310-3040-00) / 2 Ml In 1 Vial, Glass",636,RC,0310-3040-00,NDC,,,facility,both,1,EA,,110.62,110.62,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dextrose: 1000 Ml In 1 Bag (0338-0023-04),636,RC,0338-0023-04,NDC,,,facility,both,1,EA,,53.33,53.33,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sodium Chloride: 500 Ml In 1 Bag (0338-0043-03),636,RC,0338-0043-03,NDC,,,facility,both,1,EA,,69.89,69.89,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Lactated Ringers And Dextrose: 500 Ml In 1 Bag (0338-0125-03),636,RC,0338-0125-03,NDC,,,facility,both,1,EA,,69.9,69.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Lactated Ringers: 1000 Ml In 1 Bag (0338-0117-04),636,RC,0338-0117-04,NDC,,,facility,both,1,EA,,62.6,62.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dextrose And Sodium Chloride: 14 Bag In 1 Carton (0338-0089-04) / 1000 Ml In 1 Bag,636,RC,0338-0089-04,NDC,,,facility,both,1,EA,,37.76,37.76,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dextrose And Sodium Chloride: 24 Bag In 1 Carton (0338-0089-03) / 500 Ml In 1 Bag,636,RC,0338-0089-03,NDC,,,facility,both,1,EA,,70.86,70.86,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dextrose And Sodium Chloride: 14 Bag In 1 Carton (0338-0085-04) / 1000 Ml In 1 Bag,636,RC,0338-0085-04,NDC,,,facility,both,1,EA,,75.63,75.63,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dextrose And Sodium Chloride: 24 Bag In 1 Carton (0338-0085-03) / 500 Ml In 1 Bag,636,RC,0338-0085-03,NDC,,,facility,both,1,EA,,71.91,71.91,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dextrose And Sodium Chloride: 14 Bag In 1 Carton (0338-0077-04) / 1000 Ml In 1 Bag,636,RC,0338-0077-04,NDC,,,facility,both,1,EA,,75.39,75.39,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dextrose: 20 Bag In 1 Carton (0338-0066-20) / 500 Ml In 1 Bag,636,RC,0338-0066-20,NDC,,,facility,both,1,EA,,64.75,64.75,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dextrose: 30 Bag In 1 Carton (0338-0062-30) / 250 Ml In 1 Bag,636,RC,0338-0062-30,NDC,,,facility,both,1,EA,,73.17,73.17,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sodium Chloride: 24 Bag In 1 Carton (0338-0054-03) / 500 Ml In 1 Bag,636,RC,0338-0054-03,NDC,,,facility,both,1,EA,,73.37,73.37,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sodium Chloride: 1 Bag In 1 Package (0338-0049-48) / 100 Ml In 1 Bag,636,RC,0338-0049-48,NDC,,,facility,both,1,EA,,68.3,68.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sodium Chloride: 1 Bag In 1 Package (0338-0049-41) / 50 Ml In 1 Bag,636,RC,0338-0049-41,NDC,,,facility,both,1,EA,,63.44,63.44,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sodium Chloride: 16 Bag In 1 Package (0338-0049-31) / 50 Ml In 1 Bag,636,RC,0338-0049-31,NDC,,,facility,both,1,EA,,64.74,64.74,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sodium Chloride: 4 Bag In 1 Package (0338-0049-18) / 100 Ml In 1 Bag,636,RC,0338-0049-18,NDC,,,facility,both,1,EA,,69.14,69.14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sodium Chloride: 14 Bag In 1 Carton (0338-0047-44) / 1000 Ml In 1 Bag,636,RC,0338-0047-44,NDC,,,facility,both,1,EA,,45.81,45.81,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sodium Chloride: 6 Bag In 1 Carton (0338-0047-46) / 2000 Ml In 1 Bag,636,RC,0338-0047-46,NDC,,,facility,both,1,EA,,48.29,48.29,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sodium Chloride: 4 Bag In 1 Carton (0338-0047-47) / 3000 Ml In 1 Bag,636,RC,0338-0047-47,NDC,,,facility,both,1,EA,,16.43,16.43,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Sodium Chloride: 18 Bottle, Plastic In 1 Carton (0338-0048-03) / 500 Ml In 1 Bottle, Plastic",636,RC,0338-0048-03,NDC,,,facility,both,1,EA,,61.42,61.42,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sodium Chloride: 250 Ml In 1 Bag (0338-0049-02),636,RC,0338-0049-02,NDC,,,facility,both,1,EA,,83.24,83.24,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sodium Chloride: 1000 Ml In 1 Bag (0338-0049-04),636,RC,0338-0049-04,NDC,,,facility,both,1,EA,,69.74,69.74,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sodium Chloride: 4 Bag In 1 Package (0338-0049-10) / 25 Ml In 1 Bag,636,RC,0338-0049-10,NDC,,,facility,both,1,EA,,72.84,72.84,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Sodium Chloride: 24 Bottle, Plastic In 1 Carton (0338-0048-02) / 250 Ml In 1 Bottle, Plastic",636,RC,0338-0048-02,NDC,,,facility,both,1,EA,,70.66,70.66,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Lactated Ringers And Dextrose: 1000 Ml In 1 Bag (0338-0125-04),636,RC,0338-0125-04,NDC,,,facility,both,1,EA,,75.62,75.62,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sodium Chloride: 24 Container In 1 Case (0264-7800-20) / 250 Ml In 1 Container,636,RC,0264-7800-20,NDC,,,facility,both,1,EA,,64.71,64.71,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sodium Chloride: 16 Container In 1 Case (0264-2201-10) / 500 Ml In 1 Container,636,RC,0264-2201-10,NDC,,,facility,both,1,EA,,19.28,19.28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sodium Chloride: 16 Container In 1 Case (0264-2201-00) / 1000 Ml In 1 Container,636,RC,0264-2201-00,NDC,,,facility,both,1,EA,,5.36,5.36,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sodium Chloride: 116 Container In 1 Case (0264-1800-36) / 25 Ml In 1 Container,636,RC,0264-1800-36,NDC,,,facility,both,1,EA,,101.55,101.55,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sodium Chloride: 64 Container In 1 Case (0264-1800-32) / 100 Ml In 1 Container,636,RC,0264-1800-32,NDC,,,facility,both,1,EA,,66.7,66.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sodium Chloride: 84 Container In 1 Case (0264-1800-31) / 50 Ml In 1 Container,636,RC,0264-1800-31,NDC,,,facility,both,1,EA,,65.29,65.29,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dextrose: 64 Container In 1 Case (0264-1510-32) / 100 Ml In 1 Container,636,RC,0264-1510-32,NDC,,,facility,both,1,EA,,75.29,75.29,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dextrose: 84 Container In 1 Case (0264-1510-31) / 50 Ml In 1 Container,636,RC,0264-1510-31,NDC,,,facility,both,1,EA,,70.29,70.29,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0206-8862-01,NDC,,,facility,both,1,EA,,28,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0206-8861-01,NDC,,,facility,both,1,EA,,31.54,31.54,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Acetaminophen: 24 Container In 1 Case (0264-4100-90) / 100 Ml In 1 Container,636,RC,0264-4100-90,NDC,,,facility,both,1,EA,,1.41,1.41,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sodium Chloride: 12 Container In 1 Case (0264-7800-09) / 1000 Ml In 1 Container,636,RC,0264-7800-09,NDC,,,facility,both,1,EA,,71.26,71.26,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sodium Chloride: 12 Container In 1 Case (0264-7800-00) / 1000 Ml In 1 Container,636,RC,0264-7800-00,NDC,,,facility,both,1,EA,,75.36,75.36,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dextrose In Lactated Ringers: 24 Container In 1 Case (0264-7751-10) / 500 Ml In 1 Container,636,RC,0264-7751-10,NDC,,,facility,both,1,EA,,86.03,86.03,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dextrose In Lactated Ringers: 12 Container In 1 Case (0264-7751-00) / 1000 Ml In 1 Container,636,RC,0264-7751-00,NDC,,,facility,both,1,EA,,86.17,86.17,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Lactated Ringers: 12 Container In 1 Case (0264-7750-07) / 1000 Ml In 1 Container,636,RC,0264-7750-07,NDC,,,facility,both,1,EA,,69.85,69.85,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Lactated Ringers: 12 Container In 1 Case (0264-7750-00) / 1000 Ml In 1 Container,636,RC,0264-7750-00,NDC,,,facility,both,1,EA,,86.55,86.55,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dextrose And Sodium Chloride: 12 Container In 1 Case (0264-7616-00) / 1000 Ml In 1 Container,636,RC,0264-7616-00,NDC,,,facility,both,1,EA,,92.97,92.97,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dextrose And Sodium Chloride: 24 Container In 1 Case (0264-7612-10) / 500 Ml In 1 Container,636,RC,0264-7612-10,NDC,,,facility,both,1,EA,,82.37,82.37,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dextrose And Sodium Chloride: 12 Container In 1 Case (0264-7612-00) / 1000 Ml In 1 Container,636,RC,0264-7612-00,NDC,,,facility,both,1,EA,,85.92,85.92,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sodium Chloride: 12 Container In 1 Case (0264-5802-00) / 1000 Ml In 1 Container,636,RC,0264-5802-00,NDC,,,facility,both,1,EA,,56.65,56.65,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sodium Chloride: 24 Container In 1 Case (0264-5802-10) / 500 Ml In 1 Container,636,RC,0264-5802-10,NDC,,,facility,both,1,EA,,65.84,65.84,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sodium Chloride For Irrigation: 4 Container In 1 Case (0264-7388-60) / 3000 Ml In 1 Container,636,RC,0264-7388-60,NDC,,,facility,both,1,EA,,2.94,2.94,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dextrose: 12 Container In 1 Case (0264-7510-00) / 1000 Ml In 1 Container,636,RC,0264-7510-00,NDC,,,facility,both,1,EA,,77.36,77.36,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dextrose: 24 Container In 1 Case (0264-7510-20) / 250 Ml In 1 Container,636,RC,0264-7510-20,NDC,,,facility,both,1,EA,,65.23,65.23,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dextrose: 12 Container In 1 Case (0264-7520-00) / 1000 Ml In 1 Container,636,RC,0264-7520-00,NDC,,,facility,both,1,EA,,48.36,48.36,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dextrose: 24 Container In 1 Case (0264-7520-10) / 500 Ml In 1 Container,636,RC,0264-7520-10,NDC,,,facility,both,1,EA,,82.13,82.13,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dextrose: 24 Container In 1 Case (0264-7520-20) / 250 Ml In 1 Container,636,RC,0264-7520-20,NDC,,,facility,both,1,EA,,83.03,83.03,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dextrose And Sodium Chloride: 12 Container In 1 Case (0264-7610-00) / 1000 Ml In 1 Container,636,RC,0264-7610-00,NDC,,,facility,both,1,EA,,42.79,42.79,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dextrose And Sodium Chloride: 24 Container In 1 Case (0264-7610-10) / 500 Ml In 1 Container,636,RC,0264-7610-10,NDC,,,facility,both,1,EA,,81.24,81.24,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dextrose: 24 Container In 1 Case (0264-7510-10) / 500 Ml In 1 Container,636,RC,0264-7510-10,NDC,,,facility,both,1,EA,,64.53,64.53,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Myxredlin: 12 Container In 1 Carton (0338-0126-12) / 100 Ml In 1 Container,636,RC,0338-0126-12,NDC,,,facility,both,1,EA,,8.05,8.05,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Naloxone Hydrochloride: 10 Vial, Single-Dose In 1 Carton (0409-1215-01) / 1 Ml In 1 Vial, Single-Dose (0409-1215-21)",636,RC,0409-1215-01,NDC,,,facility,both,1,EA,,3.66,3.66,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0409-1207-13,NDC,,,facility,both,1,EA,,23.19,23.19,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0409-1162-18,NDC,,,facility,both,1,EA,,2.19,2.19,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Bupivacaine Hydrochloride: 25 Vial, Single-Dose In 1 Tray (0409-1162-02) / 30 Ml In 1 Vial, Single-Dose (0409-1162-19)",636,RC,0409-1162-02,NDC,,,facility,both,1,EA,,0.14,0.14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Bupivacaine Hydrochloride: 25 Vial, Single-Dose In 1 Tray (0409-1162-02) / 30 Ml In 1 Vial, Single-Dose (0409-1162-19)",636,RC,0409-1162-02,NDC,,,facility,both,1,EA,,0.14,0.14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Bupivacaine Hydrochloride: 25 Vial, Single-Dose In 1 Tray (0409-1162-01) / 10 Ml In 1 Vial, Single-Dose (0409-1162-18)",636,RC,0409-1162-01,NDC,,,facility,both,1,EA,,0.37,0.37,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Bupivacaine Hydrochloride: 25 Vial, Single-Dose In 1 Tray (0409-1162-01) / 10 Ml In 1 Vial, Single-Dose (0409-1162-18)",636,RC,0409-1162-01,NDC,,,facility,both,1,EA,,0.36,0.36,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Bupivacaine Hydrochloride: 25 Vial, Single-Dose In 1 Tray (0409-1162-01) / 10 Ml In 1 Vial, Single-Dose (0409-1162-18)",636,RC,0409-1162-01,NDC,,,facility,both,1,EA,,0.27,0.27,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Bupivacaine Hydrochloride: 25 Vial, Single-Dose In 1 Tray (0409-1162-01) / 10 Ml In 1 Vial, Single-Dose (0409-1162-18)",636,RC,0409-1162-01,NDC,,,facility,both,1,EA,,0.22,0.22,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Bupivacaine Hydrochloride: 25 Vial, Single-Dose In 1 Tray (0409-1162-01) / 10 Ml In 1 Vial, Single-Dose (0409-1162-18)",636,RC,0409-1162-01,NDC,,,facility,both,1,EA,,0.13,0.13,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0409-1159-18,NDC,,,facility,both,1,EA,,1.7,1.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Bupivacaine Hydrochloride: 25 Vial, Single-Dose In 1 Tray (0409-1159-01) / 10 Ml In 1 Vial, Single-Dose (0409-1159-18)",636,RC,0409-1159-01,NDC,,,facility,both,1,EA,,0.84,0.84,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Heparin Sodium: 20 Pouch In 1 Case (0409-1005-20) / 1 Bag In 1 Pouch / 500 Ml In 1 Bag (0409-1005-01),636,RC,0409-1005-20,NDC,,,facility,both,1,EA,,51.33,51.33,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0409-0125-01,NDC,,,facility,both,1,EA,,12.09,12.09,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0409-0152-01,NDC,,,facility,both,1,EA,,0.49,0.49,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0409-0152-01,NDC,,,facility,both,1,EA,,0.84,0.84,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Metronidazole: 24 Pouch In 1 Carton (0409-0152-24) / 1 Bag In 1 Pouch (0409-0152-01) / 100 Ml In 1 Bag,636,RC,0409-0152-24,NDC,,,facility,both,1,EA,,0.2,0.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Metronidazole: 24 Pouch In 1 Carton (0409-0152-24) / 1 Bag In 1 Pouch (0409-0152-01) / 100 Ml In 1 Bag,636,RC,0409-0152-24,NDC,,,facility,both,1,EA,,0.56,0.56,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Milrinone Lactate: 1 Vial, Single-Dose In 1 Carton (0409-0212-03) / 50 Ml In 1 Vial, Single-Dose",636,RC,0409-0212-03,NDC,,,facility,both,1,EA,,10.49,10.49,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0409-0212-10,NDC,,,facility,both,1,EA,,20.67,20.67,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Topotecan: 1 Vial, Single-Dose In 1 Carton (0409-0302-01) / 4 Ml In 1 Vial, Single-Dose",636,RC,0409-0302-01,NDC,,,facility,both,1,EA,,15.93,15.93,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Topotecan: 1 Vial, Single-Dose In 1 Carton (0409-0302-01) / 4 Ml In 1 Vial, Single-Dose",636,RC,0409-0302-01,NDC,,,facility,both,1,EA,,29.68,29.68,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Docetaxel: 1 Vial, Multi-Dose In 1 Carton (0409-0367-01) / 4 Ml In 1 Vial, Multi-Dose",636,RC,0409-0367-01,NDC,,,facility,both,1,EA,,13.29,13.29,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0409-1005-01,NDC,,,facility,both,1,EA,,61.42,61.42,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Metronidazole: 24 Pouch In 1 Carton (0409-0152-24) / 1 Bag In 1 Pouch (0409-0152-01) / 100 Ml In 1 Bag,636,RC,0409-0152-24,NDC,,,facility,both,1,EA,,0.58,0.58,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Mesnex: 1 Vial, Multi-Dose In 1 Box (0338-1305-01) / 10 Ml In 1 Vial, Multi-Dose",636,RC,0338-1305-01,NDC,,,facility,both,1,EA,,16.18,16.18,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Cefepime: 12 Bag In 1 Box (0338-1301-48) / 100 Ml In 1 Bag,636,RC,0338-1301-48,NDC,,,facility,both,1,EA,,18.81,18.81,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dobutamine Hydrochloride In Dextrose: 18 Bag In 1 Carton (0338-1077-02) / 250 Ml In 1 Bag,636,RC,0338-1077-02,NDC,,,facility,both,1,EA,,49.89,49.89,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Metronidazole: 24 Bag In 1 Carton (0338-1055-48) / 100 Ml In 1 Bag,636,RC,0338-1055-48,NDC,,,facility,both,1,EA,,0.8,0.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Metronidazole: 24 Bag In 1 Carton (0338-1055-48) / 100 Ml In 1 Bag,636,RC,0338-1055-48,NDC,,,facility,both,1,EA,,0.5,0.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Metronidazole: 24 Bag In 1 Carton (0338-1055-48) / 100 Ml In 1 Bag,636,RC,0338-1055-48,NDC,,,facility,both,1,EA,,0.22,0.22,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dopamine Hydrochloride And Dextrose: 18 Bag In 1 Carton (0338-1009-02) / 250 Ml In 1 Bag,636,RC,0338-1009-02,NDC,,,facility,both,1,EA,,9.51,9.51,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dopamine Hydrochloride And Dextrose: 18 Bag In 1 Carton (0338-1007-02) / 250 Ml In 1 Bag,636,RC,0338-1007-02,NDC,,,facility,both,1,EA,,23.96,23.96,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dopamine Hydrochloride And Dextrose: 18 Bag In 1 Carton (0338-1005-02) / 250 Ml In 1 Bag,636,RC,0338-1005-02,NDC,,,facility,both,1,EA,,34.22,34.22,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Potassium Chloride: 24 Bag In 1 Carton (0338-0705-48) / 100 Ml In 1 Bag,636,RC,0338-0705-48,NDC,,,facility,both,1,EA,,8.79,8.79,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Potassium Chloride In Sodium Chloride: 14 Bag In 1 Carton (0338-0704-34) / 1000 Ml In 1 Bag,636,RC,0338-0704-34,NDC,,,facility,both,1,EA,,10.71,10.71,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Potassium Chloride In Sodium Chloride: 14 Bag In 1 Carton (0338-0691-04) / 1000 Ml In 1 Bag,636,RC,0338-0691-04,NDC,,,facility,both,1,EA,,8.91,8.91,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Cefazolin: 24 Bag In 1 Carton (0338-3503-41) / 50 Ml In 1 Bag,636,RC,0338-3503-41,NDC,,,facility,both,1,EA,,37.02,37.02,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Heparin Sodium In Sodium Chloride: 1 Bag In 1 Carton (0338-0424-18) / 500 Ml In 1 Bag,636,RC,0338-0424-18,NDC,,,facility,both,1,EA,,52.68,52.68,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Lidocaine Hydrochloride And Dextrose: 24 Bag In 1 Carton (0338-0411-02) / 250 Ml In 1 Bag,636,RC,0338-0411-02,NDC,,,facility,both,1,EA,,0.04,0.04,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Osmitrol: 250 Ml In 1 Bag (0338-0357-02),636,RC,0338-0357-02,NDC,,,facility,both,1,EA,,47.55,47.55,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Vancomycin Hydrochloride: 200 Ml In 1 Bag (0338-3552-48),636,RC,0338-3552-48,NDC,,,facility,both,1,EA,,1.66,1.66,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Ceftriaxone: 24 Bag In 1 Case (0338-5003-41) / 50 Ml In 1 Bag,636,RC,0338-5003-41,NDC,,,facility,both,1,EA,,31.85,31.85,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Metronidazole: 24 Bag In 1 Carton (0338-9541-24) / 100 Ml In 1 Bag,636,RC,0338-9541-24,NDC,,,facility,both,1,EA,,0.14,0.14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Albuterol Sulfate: 2 Pouch In 1 Carton (0378-8270-91) / 30 Ampule In 1 Pouch (0378-8270-64) / 3 Ml In 1 Ampule,636,RC,0378-8270-91,NDC,,,facility,both,1,EA,,4.2,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0378-8270-64,NDC,,,facility,both,1,EA,,4.11,4.11,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0378-8270-31,NDC,,,facility,both,1,EA,,4.41,4.41,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0378-7970-31,NDC,,,facility,both,1,EA,,12.61,12.61,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ondansetron: 30 TABLET, ORALLY DISINTEGRATING in 1 BOTTLE, PLASTIC (0378-7732-93) ",636,RC,0378-7732-93,NDC,,,facility,both,1,EA,,7.12,7.12,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0378-3266-32,NDC,,,facility,both,1,EA,,476.87,476.87,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Metronidazole: 24 Bag In 1 Carton (0338-9541-24) / 100 Ml In 1 Bag,636,RC,0338-9541-24,NDC,,,facility,both,1,EA,,0.41,0.41,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Metronidazole: 24 Bag In 1 Carton (0338-9541-24) / 100 Ml In 1 Bag,636,RC,0338-9541-24,NDC,,,facility,both,1,EA,,0.42,0.42,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sodium Chloride: 250 Ml In 1 Bag (0338-9543-02),636,RC,0338-9543-02,NDC,,,facility,both,1,EA,,67.09,67.09,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sodium Chloride: 500 Ml In 1 Bag (0338-9543-04),636,RC,0338-9543-04,NDC,,,facility,both,1,EA,,68.89,68.89,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0338-9553-50,NDC,,,facility,both,1,EA,,28.7,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0338-9632-01,NDC,,,facility,both,1,EA,,14.81,14.81,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0338-9636-01,NDC,,,facility,both,1,EA,,31.55,31.55,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0338-9638-01,NDC,,,facility,both,1,EA,,27.85,27.85,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0338-9553-50,NDC,,,facility,both,1,EA,,29.45,29.45,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0121-0865-05,NDC,,,facility,both,1,EA,,24.56,24.56,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Diphenhydramine Hcl: 10 Tray In 1 Case (0121-0865-00) / 10 Cup, Unit-Dose In 1 Tray / 5 Ml In 1 Cup, Unit-Dose (0121-0865-05)",636,RC,0121-0865-00,NDC,,,facility,both,1,EA,,22.45,22.45,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Mycophenolate Mofetil: 100 Capsule In 1 Bottle (0093-7334-01),636,RC,0093-7334-01,NDC,,,facility,both,1,EA,,9.23,9.23,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0093-5985-19,NDC,,,facility,both,1,EA,,443.98,443.98,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0121-0489-05,NDC,,,facility,both,1,EA,,33.14,33.14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Epinephrine: 1 Case In 1 Carton (0115-1694-30) / 1 Syringe, Glass In 1 Case / .3 Ml In 1 Syringe, Glass",636,RC,0115-1694-30,NDC,,,facility,both,1,EA,,264.59,264.59,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Epinephrine: 2 Case In 1 Carton (0115-1694-49) / 1 Syringe, Glass In 1 Case / .3 Ml In 1 Syringe, Glass",636,RC,0115-1694-49,NDC,,,facility,both,1,EA,,255.8,255.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0143-9983-91,NDC,,,facility,both,1,EA,,19.39,19.39,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Cefazolin: 3 Ml In 1 Vial (0143-9924-90),636,RC,0143-9924-90,NDC,,,facility,both,1,EA,,14.31,14.31,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0143-9875-01,NDC,,,facility,both,1,EA,,11.52,11.52,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ceftriaxone: 25 Vial In 1 Box (0143-9857-25) / 1 Injection, Powder, For Solution In 1 Vial (0143-9857-01)",636,RC,0143-9857-25,NDC,,,facility,both,1,EA,,7.98,7.98,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0143-9857-01,NDC,,,facility,both,1,EA,,7.8,7.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0143-9856-01,NDC,,,facility,both,1,EA,,10.88,10.88,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Levocarnitine: 10 Vial, Single-Use In 1 Carton (0143-9852-10) / 5 Ml In 1 Vial, Single-Use (0143-9852-01)",636,RC,0143-9852-10,NDC,,,facility,both,1,EA,,41.82,41.82,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0143-9852-01,NDC,,,facility,both,1,EA,,84.42,84.42,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0143-9786-01,NDC,,,facility,both,1,EA,,28.97,28.97,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0143-9784-01,NDC,,,facility,both,1,EA,,32.05,32.05,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Testosterone Enanthate: 5 Ml In 1 Vial, Multi-Dose (0143-9750-01)",636,RC,0143-9750-01,NDC,,,facility,both,1,EA,,70.76,70.76,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0143-9746-01,NDC,,,facility,both,1,EA,,8.66,8.66,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Granisetron Hydrochloride: 10 Vial, Single-Use In 1 Package (0143-9744-10) / 1 Ml In 1 Vial, Single-Use (0143-9744-01)",636,RC,0143-9744-10,NDC,,,facility,both,1,EA,,4.66,4.66,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0143-9744-01,NDC,,,facility,both,1,EA,,4.94,4.94,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0143-9722-01,NDC,,,facility,both,1,EA,,43.87,43.87,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0143-9719-01,NDC,,,facility,both,1,EA,,18.31,18.31,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0143-9710-01,NDC,,,facility,both,1,EA,,21.52,21.52,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Milrinone Lactate: 50 Ml In 1 Box (0143-9708-01),636,RC,0143-9708-01,NDC,,,facility,both,1,EA,,11.57,11.57,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Glycopyrrolate: 25 Vial In 1 Carton (0143-9681-25) / 2 Ml In 1 Vial (0143-9681-01),636,RC,0143-9681-25,NDC,,,facility,both,1,EA,,20.79,20.79,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Glycopyrrolate: 25 Vial In 1 Carton (0143-9681-25) / 2 Ml In 1 Vial (0143-9681-01),636,RC,0143-9681-25,NDC,,,facility,both,1,EA,,19.03,19.03,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Glycopyrrolate: 25 Vial In 1 Carton (0143-9681-25) / 2 Ml In 1 Vial (0143-9681-01),636,RC,0143-9681-25,NDC,,,facility,both,1,EA,,7.05,7.05,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Cyclosporine: 1 Bottle In 1 Package (0172-7313-20) / 50 Ml In 1 Bottle,636,RC,0172-7313-20,NDC,,,facility,both,1,EA,,15.35,15.35,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0169-7211-11,NDC,,,facility,both,1,EA,,14.78,14.78,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0169-7211-11,NDC,,,facility,both,1,EA,,14.74,14.74,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Novolin R: 1 Vial In 1 Carton (0169-1833-11) / 10 Ml In 1 Vial,636,RC,0169-1833-11,NDC,,,facility,both,1,EA,,14.18,14.18,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Novoseven Rt: 1 Kit In 1 Kit (0169-7201-01) * 1 Ml In 1 Vial, Glass (0169-7211-11) * 1 Ml In 1 Syringe, Glass (0169-7011-98)",636,RC,0169-7201-01,NDC,,,facility,both,1,EA,,14.74,14.74,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Novoseven Rt: 1 Kit In 1 Kit (0169-7201-01) * 1 Ml In 1 Vial, Glass (0169-7211-11) * 1 Ml In 1 Syringe, Glass (0169-7011-98)",636,RC,0169-7201-01,NDC,,,facility,both,1,EA,,14.74,14.74,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Novoseven Rt: 1 Kit In 1 Kit (0169-7201-01) * 1 Ml In 1 Vial, Glass (0169-7211-11) * 1 Ml In 1 Syringe, Glass (0169-7011-98)",636,RC,0169-7201-01,NDC,,,facility,both,1,EA,,14.76,14.76,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Novoseven Rt: 1 Kit In 1 Kit (0169-7201-01) * 1 Ml In 1 Vial, Glass (0169-7211-11) * 1 Ml In 1 Syringe, Glass (0169-7011-98)",636,RC,0169-7201-01,NDC,,,facility,both,1,EA,,14.77,14.77,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Glycopyrrolate: 25 Vial In 1 Carton (0143-9681-25) / 2 Ml In 1 Vial (0143-9681-01),636,RC,0143-9681-25,NDC,,,facility,both,1,EA,,3.61,3.61,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Novoseven Rt: 1 Kit In 1 Kit (0169-7201-01) * 1 Ml In 1 Vial, Glass (0169-7211-11) * 1 Ml In 1 Syringe, Glass (0169-7011-98)",636,RC,0169-7201-01,NDC,,,facility,both,1,EA,,14.84,14.84,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Novoseven Rt: 1 Kit In 1 Kit (0169-7202-01) * 2 Ml In 1 Vial, Glass (0169-7212-11) * 2 Ml In 1 Syringe, Glass (0169-7012-98)",636,RC,0169-7202-01,NDC,,,facility,both,1,EA,,14.75,14.75,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Novoseven Rt: 1 Kit In 1 Kit (0169-7202-01) * 2 Ml In 1 Vial, Glass (0169-7212-11) * 2 Ml In 1 Syringe, Glass (0169-7012-98)",636,RC,0169-7202-01,NDC,,,facility,both,1,EA,,14.75,14.75,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Novoseven Rt: 1 Kit In 1 Kit (0169-7202-01) * 2 Ml In 1 Vial, Glass (0169-7212-11) * 2 Ml In 1 Syringe, Glass (0169-7012-98)",636,RC,0169-7202-01,NDC,,,facility,both,1,EA,,14.76,14.76,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Novoseven Rt: 1 Kit In 1 Kit (0169-7205-01) * 5 Ml In 1 Vial, Glass (0169-7215-11) * 5 Ml In 1 Syringe, Glass (0169-7015-98)",636,RC,0169-7205-01,NDC,,,facility,both,1,EA,,14.75,14.75,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Novoseven Rt: 1 Kit In 1 Kit (0169-7205-01) * 5 Ml In 1 Vial, Glass (0169-7215-11) * 5 Ml In 1 Syringe, Glass (0169-7015-98)",636,RC,0169-7205-01,NDC,,,facility,both,1,EA,,14.75,14.75,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Novoseven Rt: 1 Kit In 1 Kit (0169-7205-01) * 5 Ml In 1 Vial, Glass (0169-7215-11) * 5 Ml In 1 Syringe, Glass (0169-7015-98)",636,RC,0169-7205-01,NDC,,,facility,both,1,EA,,14.75,14.75,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Novoseven Rt: 1 Kit In 1 Kit (0169-7202-01) * 2 Ml In 1 Vial, Glass (0169-7212-11) * 2 Ml In 1 Syringe, Glass (0169-7012-98)",636,RC,0169-7202-01,NDC,,,facility,both,1,EA,,14.75,14.75,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Glycopyrrolate: 25 Vial In 1 Carton (0143-9681-25) / 2 Ml In 1 Vial (0143-9681-01),636,RC,0143-9681-25,NDC,,,facility,both,1,EA,,3.54,3.54,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0143-9681-01,NDC,,,facility,both,1,EA,,14.2,14.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Bupivacaine Hydrochloride: 10 Vial, Single-Dose In 1 Carton (0143-9333-10) / 30 Ml In 1 Vial, Single-Dose (0143-9333-01)",636,RC,0143-9333-10,NDC,,,facility,both,1,EA,,0.25,0.25,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Thiotepa: 1 Vial In 1 Box, Unit-Dose (0143-9292-01) / 1 Injection, Powder, Lyophilized, For Solution In 1 Vial",636,RC,0143-9292-01,NDC,,,facility,both,1,EA,,962.91,962.91,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dihydroergotamine Mesylate: 10 Ampule In 1 Carton (0143-9273-10) / 1 Ml In 1 Ampule (0143-9273-01),636,RC,0143-9273-10,NDC,,,facility,both,1,EA,,212.62,212.62,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0143-9273-01,NDC,,,facility,both,1,EA,,217.03,217.03,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0143-9254-01,NDC,,,facility,both,1,EA,,27.2,27.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Dexrazoxane: 1 Vial In 1 Box (0143-9247-01) / 1 Injection, Powder, Lyophilized, For Solution In 1 Vial",636,RC,0143-9247-01,NDC,,,facility,both,1,EA,,660.56,660.56,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Dexrazoxane: 1 Vial In 1 Box (0143-9247-01) / 1 Injection, Powder, Lyophilized, For Solution In 1 Vial",636,RC,0143-9247-01,NDC,,,facility,both,1,EA,,578.98,578.98,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Dacarbazine: 10 Vial In 1 Carton (0143-9245-10) / 1 Injection, Powder, Lyophilized, For Solution In 1 Vial (0143-9245-01)",636,RC,0143-9245-10,NDC,,,facility,both,1,EA,,49.39,49.39,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Dacarbazine: 10 Vial In 1 Carton (0143-9245-10) / 1 Injection, Powder, Lyophilized, For Solution In 1 Vial (0143-9245-01)",636,RC,0143-9245-10,NDC,,,facility,both,1,EA,,35.42,35.42,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Bleomycin: 1 Vial In 1 Box, Unit-Dose (0143-9241-01) / 1 Injection, Powder, Lyophilized, For Solution In 1 Vial",636,RC,0143-9241-01,NDC,,,facility,both,1,EA,,160.1,160.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Bleomycin: 1 Vial In 1 Box, Unit-Dose (0143-9241-01) / 1 Injection, Powder, Lyophilized, For Solution In 1 Vial",636,RC,0143-9241-01,NDC,,,facility,both,1,EA,,109.94,109.94,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Bleomycin: 1 Vial In 1 Box, Unit-Dose (0143-9240-01) / 1 Injection, Powder, Lyophilized, For Solution In 1 Vial",636,RC,0143-9240-01,NDC,,,facility,both,1,EA,,264.24,264.24,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Idarubicin Hydrochloride: 1 Vial, Glass In 1 Box (0143-9218-01) / 10 Ml In 1 Vial, Glass",636,RC,0143-9218-01,NDC,,,facility,both,1,EA,,220.11,220.11,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Micafungin: 1 Vial In 1 Carton (0143-9361-01) / 5 Injection, Powder, Lyophilized, For Solution In 1 Vial",636,RC,0143-9361-01,NDC,,,facility,both,1,EA,,1.75,1.75,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Foscarnet Sodium: 10 Carton In 1 Case (0143-9192-01) / 1 Bottle In 1 Carton / 250 Ml In 1 Bottle,636,RC,0143-9192-01,NDC,,,facility,both,1,EA,,195.69,195.69,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0143-9184-01,NDC,,,facility,both,1,EA,,0.29,0.29,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0143-9184-01,NDC,,,facility,both,1,EA,,0.23,0.23,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Calcium Gluconate: 25 Vial In 1 Carton (0143-9180-25) / 10 Ml In 1 Vial (0143-9180-01),636,RC,0143-9180-25,NDC,,,facility,both,1,EA,,0.53,0.53,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0143-9180-01,NDC,,,facility,both,1,EA,,0.8,0.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0143-9180-01,NDC,,,facility,both,1,EA,,0.52,0.52,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Vancomycin Hydrochloride: 1 Vial, Pharmacy Bulk Package In 1 Carton (0143-9163-01) / 5.13 G In 1 Vial, Pharmacy Bulk Package",636,RC,0143-9163-01,NDC,,,facility,both,1,EA,,2.26,2.26,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Vancomycin Hydrochloride: 10 Vial In 1 Package (0143-9162-10) / 1025 Mg In 1 Vial (0143-9162-01),636,RC,0143-9162-10,NDC,,,facility,both,1,EA,,0.61,0.61,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0143-9162-01,NDC,,,facility,both,1,EA,,13.96,13.96,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Doxorubicin Hydrochloride: 1 Vial In 1 Box (0143-9086-01) / 25 Ml In 1 Vial,636,RC,0143-9086-01,NDC,,,facility,both,1,EA,,76.26,76.26,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Foscarnet Sodium: 10 Carton In 1 Case (0143-9192-01) / 1 Bottle In 1 Carton / 250 Ml In 1 Bottle,636,RC,0143-9192-01,NDC,,,facility,both,1,EA,,163.28,163.28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0143-9383-01,NDC,,,facility,both,1,EA,,22.42,22.42,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Fosaprepitant Dimeglumine: 1 Vial, Single-Dose In 1 Carton (0143-9384-01) / 5 Ml In 1 Vial, Single-Dose",636,RC,0143-9384-01,NDC,,,facility,both,1,EA,,0.92,0.92,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Fosaprepitant Dimeglumine: 1 Vial, Single-Dose In 1 Carton (0143-9384-01) / 5 Ml In 1 Vial, Single-Dose",636,RC,0143-9384-01,NDC,,,facility,both,1,EA,,1.12,1.12,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0143-9681-01,NDC,,,facility,both,1,EA,,2.72,2.72,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0143-9681-01,NDC,,,facility,both,1,EA,,2.67,2.67,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Azacitidine: 1 Vial In 1 Carton (0143-9606-01) / 1 Injection, Powder, Lyophilized, For Solution In 1 Vial",636,RC,0143-9606-01,NDC,,,facility,both,1,EA,,4.76,4.76,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Azacitidine: 1 Vial In 1 Carton (0143-9606-01) / 1 Injection, Powder, Lyophilized, For Solution In 1 Vial",636,RC,0143-9606-01,NDC,,,facility,both,1,EA,,3.15,3.15,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Azacitidine: 1 Vial In 1 Carton (0143-9606-01) / 1 Injection, Powder, Lyophilized, For Solution In 1 Vial",636,RC,0143-9606-01,NDC,,,facility,both,1,EA,,1.5,1.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0143-9594-01,NDC,,,facility,both,1,EA,,1.49,1.49,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sodium Ferric Gluconate Complex In Sucrose: 10 Vial In 1 Carton (0143-9570-10) / 5 Ml In 1 Vial (0143-9570-01),636,RC,0143-9570-10,NDC,,,facility,both,1,EA,,14.84,14.84,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0143-9570-01,NDC,,,facility,both,1,EA,,16.47,16.47,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0143-9570-01,NDC,,,facility,both,1,EA,,14.47,14.47,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Thiotepa: 1 Vial In 1 Box, Unit-Dose (0143-9565-01) / 1.5 Ml In 1 Vial",636,RC,0143-9565-01,NDC,,,facility,both,1,EA,,970.72,970.72,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Phentolamine Mesylate: 1 Vial In 1 Box (0143-9564-01) / 1 Ml In 1 Vial,636,RC,0143-9564-01,NDC,,,facility,both,1,EA,,265.73,265.73,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Leucovorin Calcium: 1 Vial In 1 Box (0143-9554-01) / 10 Ml In 1 Vial,636,RC,0143-9554-01,NDC,,,facility,both,1,EA,,36.6,36.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0143-9519-01,NDC,,,facility,both,1,EA,,170,170,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Fosaprepitant Dimeglumine: 1 Vial, Single-Dose In 1 Carton (0143-9384-01) / 5 Ml In 1 Vial, Single-Dose",636,RC,0143-9384-01,NDC,,,facility,both,1,EA,,1.18,1.18,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0143-9681-01,NDC,,,facility,both,1,EA,,29.59,29.59,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Acetazolamide: 1 Vial In 1 Box, Unit-Dose (0143-9503-01) / 1 Injection, Powder, Lyophilized, For Solution In 1 Vial",636,RC,0143-9503-01,NDC,,,facility,both,1,EA,,39.46,39.46,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0143-9506-01,NDC,,,facility,both,1,EA,,31.56,31.56,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Etomidate: 10 Vial, Single-Dose In 1 Carton (0143-9506-10) / 10 Ml In 1 Vial, Single-Dose (0143-9506-01)",636,RC,0143-9506-10,NDC,,,facility,both,1,EA,,35.8,35.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Etoposide: 1 Vial In 1 Box, Unit-Dose (0143-9512-01) / 50 Ml In 1 Vial",636,RC,0143-9512-01,NDC,,,facility,both,1,EA,,14.45,14.45,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0143-9431-01,NDC,,,facility,both,1,EA,,6.89,6.89,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,636,RC,0409-1219-41,NDC,,,facility,both,1,EA,,1.64,1.64,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,42023-103-01,NDC,,,facility,both,1,EA,,1582,1582,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Hyoscyamine Sulfate Sl: 100 Tablet In 1 Bottle (42192-339-01),637,RC,42192-339-01,NDC,,,facility,both,1,EA,,12.81,12.81,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Gabapentin: 470 Ml In 1 Bottle (42192-608-16),637,RC,42192-608-16,NDC,,,facility,both,1,EA,,3.81,3.81,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Atomoxetine: 30 Capsule In 1 Bottle (42291-064-30),637,RC,42291-064-30,NDC,,,facility,both,1,EA,,15.37,15.37,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Amoxicillin And Clavulanate Potassium: 20 Tablet, Film Coated In 1 Bottle (42571-161-42)",637,RC,42571-161-42,NDC,,,facility,both,1,EA,,15.56,15.56,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,42292-038-01,NDC,,,facility,both,1,EA,,14.03,14.03,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Azelastine Hydrochloride: 1 Bottle, Spray In 1 Carton (42291-094-30) / 30 Ml In 1 Bottle, Spray",637,RC,42291-094-30,NDC,,,facility,both,1,EA,,76.25,76.25,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Clobetasol Propionate: 1 Tube In 1 Carton (42291-076-15) / 15 G In 1 Tube,637,RC,42291-076-15,NDC,,,facility,both,1,EA,,19.2,19.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Atomoxetine: 30 Capsule In 1 Bottle (42291-066-30),637,RC,42291-066-30,NDC,,,facility,both,1,EA,,20.5,20.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Oxycodone Hydrochloride: 10 Blister Pack In 1 Carton (42858-001-10) / 10 Tablet In 1 Blister Pack,637,RC,42858-001-10,NDC,,,facility,both,1,EA,,13.02,13.02,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Levetiracetam: 473 Ml In 1 Bottle (31722-574-47),637,RC,31722-574-47,NDC,,,facility,both,1,EA,,12.97,12.97,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Indomethacin: 12 Bottle In 1 Case (31722-542-01) / 100 Capsule In 1 Bottle,637,RC,31722-542-01,NDC,,,facility,both,1,EA,,6.63,6.63,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Famotidine: 50 Ml In 1 Bottle (31722-063-31),637,RC,31722-063-31,NDC,,,facility,both,1,EA,,8.13,8.13,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Rocaltrol: 100 Capsule, Gelatin Coated In 1 Bottle (30698-144-01)",637,RC,30698-144-01,NDC,,,facility,both,1,EA,,29.81,29.81,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Amitriptyline Hydrochloride: 100 Tablet, Film Coated In 1 Bottle (29300-419-01)",637,RC,29300-419-01,NDC,,,facility,both,1,EA,,10.49,10.49,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Cyclobenzaprine Hydrochloride: 100 Tablet, Film Coated In 1 Bottle (29300-413-01)",637,RC,29300-413-01,NDC,,,facility,both,1,EA,,10.72,10.72,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Tramadol Hydrochloride: 100 Tablet, Film Coated In 1 Bottle, Plastic (29300-355-01)",637,RC,29300-355-01,NDC,,,facility,both,1,EA,,12.29,12.29,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Divalproex Sodium: 100 Tablet, Delayed Release In 1 Bottle, Plastic (29300-140-01)",637,RC,29300-140-01,NDC,,,facility,both,1,EA,,8.53,8.53,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Valganciclovir Hydrochloride: 1 Pouch In 1 Carton (27241-159-19) / 1 Bottle In 1 Pouch / 100 Ml In 1 Bottle,637,RC,27241-159-19,NDC,,,facility,both,1,EA,,460.22,460.22,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Rufinamide: 120 Tablet, Film Coated In 1 Bottle (31722-598-12)",637,RC,31722-598-12,NDC,,,facility,both,1,EA,,13.48,13.48,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Oseltamivir Phosphate: 10 Capsule In 1 Carton (31722-632-31),637,RC,31722-632-31,NDC,,,facility,both,1,EA,,28.5,28.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Senna: 237 Ml In 1 Bottle, Plastic (39328-020-08)",637,RC,39328-020-08,NDC,,,facility,both,1,EA,,12.89,12.89,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Albendazole 200 Mg: 2 Tablet, Film Coated In 1 Bottle (31722-935-02)",637,RC,31722-935-02,NDC,,,facility,both,1,EA,,200.21,200.21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Montelukast Sodium: 90 Tablet, Chewable In 1 Bottle (31722-728-90)",637,RC,31722-728-90,NDC,,,facility,both,1,EA,,13.33,13.33,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Montelukast Sodium: 90 Tablet, Chewable In 1 Bottle (31722-727-90)",637,RC,31722-727-90,NDC,,,facility,both,1,EA,,11.99,11.99,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Atomoxetine: 30 Capsule In 1 Bottle (31722-717-30),637,RC,31722-717-30,NDC,,,facility,both,1,EA,,15.39,15.39,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Triamcinolone Acetonide: 1 Tube In 1 Carton (45802-055-35) / 15 G In 1 Tube,637,RC,45802-055-35,NDC,,,facility,both,1,EA,,20.75,20.75,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Triamcinolone Acetonide: 1 Tube In 1 Carton (45802-054-35) / 15 G In 1 Tube,637,RC,45802-054-35,NDC,,,facility,both,1,EA,,29.11,29.11,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Nystatin: 1 Tube In 1 Carton (45802-048-35) / 15 G In 1 Tube,637,RC,45802-048-35,NDC,,,facility,both,1,EA,,51.45,51.45,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Nystatin: 1 Tube In 1 Carton (45802-048-11) / 30 G In 1 Tube,637,RC,45802-048-11,NDC,,,facility,both,1,EA,,142.56,142.56,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,43598-697-11,NDC,,,facility,both,1,EA,,456.66,456.66,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Ciprofloxacin: 100 Tablet In 1 Bottle (43547-688-10),637,RC,43547-688-10,NDC,,,facility,both,1,EA,,9.66,9.66,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Hydrochlorothiazide: 100 Tablet In 1 Bottle, Plastic (43547-397-10)",637,RC,43547-397-10,NDC,,,facility,both,1,EA,,12.87,12.87,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Fintepla: 1 Bottle, Plastic In 1 Carton (43376-322-30) / 30 Ml In 1 Bottle, Plastic",637,RC,43376-322-30,NDC,,,facility,both,1,EA,,1030.84,1030.84,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,43598-436-35,NDC,,,facility,both,1,EA,,138.49,138.49,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ciprofloxacin And Dexamethasone: 1 Bottle, Dropper In 1 Carton (43598-326-75) / 7.5 Ml In 1 Bottle, Dropper",637,RC,43598-326-75,NDC,,,facility,both,1,EA,,601.56,601.56,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Olanzapine: 30 Tablet, Film Coated In 1 Bottle (43598-164-30)",637,RC,43598-164-30,NDC,,,facility,both,1,EA,,8.49,8.49,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Oseltamivir Phosphate: 1 Pouch In 1 Carton (27241-139-09) / 1 Bottle In 1 Pouch / 60 Ml In 1 Bottle,637,RC,27241-139-09,NDC,,,facility,both,1,EA,,29.04,29.04,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,17856-0049-01,NDC,,,facility,both,1,EA,,18.04,18.04,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Domeboro: 12 Powder, For Solution In 1 Box (16864-240-01)",637,RC,16864-240-01,NDC,,,facility,both,1,EA,,16.03,16.03,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Desmopressin Acetate: 100 Tablet In 1 Bottle (23155-489-01),637,RC,23155-489-01,NDC,,,facility,both,1,EA,,13.36,13.36,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Mupirocin: 1 Tube In 1 Carton (21922-029-04) / 15 G In 1 Tube,637,RC,21922-029-04,NDC,,,facility,both,1,EA,,160.71,160.71,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Infants: 120 Syringe In 1 Box, Unit-Dose (17856-1303-1) / .3 Ml In 1 Syringe",637,RC,17856-1303-1,NDC,,,facility,both,1,EA,,14.92,14.92,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Teeny Tummy Gas Relief Drops: 120 Syringe In 1 Box, Unit-Dose (17856-1141-1) / .3 Ml In 1 Syringe (17856-1141-6)",637,RC,17856-1141-1,NDC,,,facility,both,1,EA,,18.24,18.24,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Mylicon: 120 Syringe In 1 Box, Unit-Dose (17856-0799-1) / .3 Ml In 1 Syringe",637,RC,17856-0799-1,NDC,,,facility,both,1,EA,,15.87,15.87,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Atomoxetine: 30 Capsule In 1 Bottle (16714-758-01),637,RC,16714-758-01,NDC,,,facility,both,1,EA,,21.18,21.18,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Atomoxetine: 30 Capsule In 1 Bottle (16714-757-01),637,RC,16714-757-01,NDC,,,facility,both,1,EA,,24.42,24.42,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Fluoxetine: 100 Capsule In 1 Bottle (16714-720-02),637,RC,16714-720-02,NDC,,,facility,both,1,EA,,11.78,11.78,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Sertraline Hydrochloride: 1 Bottle, Plastic In 1 Carton (16714-601-02) / 60 Ml In 1 Bottle, Plastic",637,RC,16714-601-02,NDC,,,facility,both,1,EA,,28.27,28.27,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Lacosamide: 60 Tablet In 1 Bottle (16714-548-01),637,RC,16714-548-01,NDC,,,facility,both,1,EA,,12.61,12.61,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Clindamycin Palmitate Hydrochloride (Pediatric): 1 Bottle, Plastic In 1 Carton (16714-483-02) / 100 Ml In 1 Bottle, Plastic",637,RC,16714-483-02,NDC,,,facility,both,1,EA,,2.08,2.08,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Levetiracetam: 473 Ml In 1 Bottle, Plastic (16714-358-01)",637,RC,16714-358-01,NDC,,,facility,both,1,EA,,12.23,12.23,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Amoxicillin: 100 Capsule In 1 Bottle (16714-299-03),637,RC,16714-299-03,NDC,,,facility,both,1,EA,,6.34,6.34,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Amoxicillin: 100 Capsule In 1 Bottle (16714-298-01),637,RC,16714-298-01,NDC,,,facility,both,1,EA,,3.97,3.97,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Amoxicillin And Clavulanate Potassium: 125 Ml In 1 Bottle (16714-294-02),637,RC,16714-294-02,NDC,,,facility,both,1,EA,,13.84,13.84,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Amoxicillin And Clavulanate Potassium: 75 Ml In 1 Bottle (16714-294-01),637,RC,16714-294-01,NDC,,,facility,both,1,EA,,16.12,16.12,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Enalapril Maleate: 100 Tablet In 1 Bottle (16714-442-01),637,RC,16714-442-01,NDC,,,facility,both,1,EA,,12.92,12.92,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Nystatin: 15 G In 1 Bottle, Plastic (16714-769-01)",637,RC,16714-769-01,NDC,,,facility,both,1,EA,,113.25,113.25,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Rosuvastatin Calcium: 90 Tablet, Film Coated In 1 Bottle (16714-988-01)",637,RC,16714-988-01,NDC,,,facility,both,1,EA,,12.57,12.57,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Triamcinolone Acetonide: 1 Tube In 1 Carton (16714-987-01) / 15 G In 1 Tube,637,RC,16714-987-01,NDC,,,facility,both,1,EA,,39.54,39.54,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Triamcinolone Acetonide: 1 Tube In 1 Carton (16714-986-03) / 80 G In 1 Tube,637,RC,16714-986-03,NDC,,,facility,both,1,EA,,38.9,38.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Triamcinolone Acetonide: 1 Tube In 1 Carton (16714-986-01) / 15 G In 1 Tube,637,RC,16714-986-01,NDC,,,facility,both,1,EA,,13.51,13.51,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Triamcinolone Acetonide: 1 Tube In 1 Carton (16714-985-01) / 15 G In 1 Tube,637,RC,16714-985-01,NDC,,,facility,both,1,EA,,18.47,18.47,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Clonidine Hydrochloride: 60 Tablet, Extended Release In 1 Bottle (27241-108-06)",637,RC,27241-108-06,NDC,,,facility,both,1,EA,,13.8,13.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Duloxetine: 60 Capsule, Delayed Release In 1 Bottle (27241-097-06)",637,RC,27241-097-06,NDC,,,facility,both,1,EA,,13.78,13.78,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Dexamethasone Sodium Phosphate: 1 Bottle, Dropper In 1 Carton (24208-720-02) / 5 Ml In 1 Bottle, Dropper",637,RC,24208-720-02,NDC,,,facility,both,1,EA,,279.9,279.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Vancomycin Hydrochloride: 2 Blister Pack In 1 Carton (23155-858-78) / 10 Capsule In 1 Blister Pack,637,RC,23155-858-78,NDC,,,facility,both,1,EA,,25.15,25.15,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Glycopyrrolate: 100 Tablet In 1 Bottle (23155-606-01),637,RC,23155-606-01,NDC,,,facility,both,1,EA,,9.79,9.79,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Amoxicillin And Clavulanate Potassium: 50 Ml In 1 Bottle (16714-293-01),637,RC,16714-293-01,NDC,,,facility,both,1,EA,,15.33,15.33,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Triamcinolone Acetonide: 1 Tube In 1 Carton (45802-055-36) / 80 G In 1 Tube,637,RC,45802-055-36,NDC,,,facility,both,1,EA,,33.91,33.91,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Nystatin: 1 Tube In 1 Carton (45802-059-35) / 15 G In 1 Tube,637,RC,45802-059-35,NDC,,,facility,both,1,EA,,85.92,85.92,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Mexiletine Hydrochloride: 100 Capsule In 1 Bottle (50742-239-01),637,RC,50742-239-01,NDC,,,facility,both,1,EA,,13.38,13.38,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Tylenol For Children Plus Adults: 1 Bottle In 1 Carton (50580-177-08) / 240 Ml In 1 Bottle,637,RC,50580-177-08,NDC,,,facility,both,1,EA,,1.37,1.37,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Briviact: 1 Bottle In 1 Carton (50474-870-15) / 300 Ml In 1 Bottle,637,RC,50474-870-15,NDC,,,facility,both,1,EA,,49.09,49.09,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Briviact: 100 Blister Pack In 1 Carton (50474-770-09) / 1 Tablet, Film Coated In 1 Blister Pack",637,RC,50474-770-09,NDC,,,facility,both,1,EA,,171.62,171.62,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Briviact: 1 Bottle In 1 Carton (50474-470-66) / 60 Tablet, Film Coated In 1 Bottle",637,RC,50474-470-66,NDC,,,facility,both,1,EA,,165.52,165.52,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Briviact: 1 Bottle In 1 Carton (50474-370-66) / 60 Tablet, Film Coated In 1 Bottle",637,RC,50474-370-66,NDC,,,facility,both,1,EA,,163.52,163.52,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Risperidone: 30 Ml In 1 Bottle (50458-596-01),637,RC,50458-596-01,NDC,,,facility,both,1,EA,,26.98,26.98,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Mexiletine Hydrochloride: 100 Capsule In 1 Bottle (50742-240-01),637,RC,50742-240-01,NDC,,,facility,both,1,EA,,15.56,15.56,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Clonidine: 60 Tablet, Extended Release In 1 Bottle (50742-247-60)",637,RC,50742-247-60,NDC,,,facility,both,1,EA,,14.41,14.41,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,51079-284-01,NDC,,,facility,both,1,EA,,8.58,8.58,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,51079-255-01,NDC,,,facility,both,1,EA,,7.23,7.23,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,51079-206-01,NDC,,,facility,both,1,EA,,12.5,12.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,51079-205-01,NDC,,,facility,both,1,EA,,13.19,13.19,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,51079-103-01,NDC,,,facility,both,1,EA,,5.69,5.69,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Scopolamine: 24 Pouch In 1 Carton (50742-505-24) / 1 Patch, Extended Release In 1 Pouch",637,RC,50742-505-24,NDC,,,facility,both,1,EA,,43.91,43.91,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,50742-505-01,NDC,,,facility,both,1,EA,,61.1,61.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,51079-074-01,NDC,,,facility,both,1,EA,,8.03,8.03,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,50458-580-01,NDC,,,facility,both,1,EA,,9.42,9.42,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,50268-772-11,NDC,,,facility,both,1,EA,,20.43,20.43,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,50268-759-11,NDC,,,facility,both,1,EA,,15.18,15.18,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,50268-728-11,NDC,,,facility,both,1,EA,,7.71,7.71,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,50268-720-11,NDC,,,facility,both,1,EA,,10.97,10.97,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,50268-717-11,NDC,,,facility,both,1,EA,,16.19,16.19,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Polyvinyl Alcohol: 15 Ml In 1 Bottle (50268-678-15),637,RC,50268-678-15,NDC,,,facility,both,1,EA,,59.33,59.33,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,50268-635-11,NDC,,,facility,both,1,EA,,12.62,12.62,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Quetiapine Fumarate: 50 Blister Pack In 1 Box (50268-630-15) / 1 Tablet In 1 Blister Pack (50268-630-11),637,RC,50268-630-15,NDC,,,facility,both,1,EA,,13.02,13.02,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,50268-630-11,NDC,,,facility,both,1,EA,,5.84,5.84,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,50268-597-11,NDC,,,facility,both,1,EA,,13.47,13.47,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,50268-787-11,NDC,,,facility,both,1,EA,,96.4,96.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,50458-578-01,NDC,,,facility,both,1,EA,,11.59,11.59,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,50458-577-01,NDC,,,facility,both,1,EA,,11.62,11.62,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Xarelto: 1 Bottle In 1 Carton (50458-575-01) / 1 Granule, For Suspension In 1 Bottle",637,RC,50458-575-01,NDC,,,facility,both,1,EA,,64.25,64.25,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,50419-775-01,NDC,,,facility,both,1,EA,,11.88,11.88,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Cipro: 1 Kit In 1 Kit (50419-773-01) * 100 Ml In 1 Bottle, Glass * 100 Ml In 1 Bottle, Glass",637,RC,50419-773-01,NDC,,,facility,both,1,EA,,12.55,12.55,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Lactulose: 10 TRAY in 1 CASE (50383-779-33) / 10 CUP in 1 TRAY / 30 mL in 1 CUP,637,RC,50383-779-33,NDC,,,facility,both,1,EA,,3.82,3.82,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Levocarnitine: 118 mL in 1 BOTTLE (50383-171-04) ,637,RC,50383-171-04,NDC,,,facility,both,1,EA,,19.42,19.42,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,50268-816-11,NDC,,,facility,both,1,EA,,8.16,8.16,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,50268-788-11,NDC,,,facility,both,1,EA,,20.68,20.68,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,51079-285-01,NDC,,,facility,both,1,EA,,9.52,9.52,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Baclofen: 1 Bottle In 1 Carton (52536-600-11) / 120 Ml In 1 Bottle,637,RC,52536-600-11,NDC,,,facility,both,1,EA,,47.89,47.89,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Aplicare Povidone-Iodine: 1 G In 1 Packet (52380-0126-2),637,RC,52380-0126-2,NDC,,,facility,both,1,EA,,5.68,5.68,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Cystadane: 180 G In 1 Bottle (52276-400-01),637,RC,52276-400-01,NDC,,,facility,both,1,EA,,63.13,63.13,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Nulytely: 4 L In 1 Package (52268-302-01),637,RC,52268-302-01,NDC,,,facility,both,1,EA,,130.89,130.89,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Phenytoin: 237 Ml In 1 Bottle (51672-4069-1),637,RC,51672-4069-1,NDC,,,facility,both,1,EA,,13.25,13.25,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Ibuprofen: 1 Bottle In 1 Carton (51672-2130-8) / 120 Ml In 1 Bottle,637,RC,51672-2130-8,NDC,,,facility,both,1,EA,,1.75,1.75,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Epaned: 150 Ml In 1 Bottle (52652-4001-1),637,RC,52652-4001-1,NDC,,,facility,both,1,EA,,28.03,28.03,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,54162-600-02,NDC,,,facility,both,1,EA,,24.77,24.77,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Adderall Xr: 100 Capsule, Extended Release In 1 Bottle (54092-383-01)",637,RC,54092-383-01,NDC,,,facility,both,1,EA,,51.06,51.06,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Adderall Xr: 100 Capsule, Extended Release In 1 Bottle (54092-381-01)",637,RC,54092-381-01,NDC,,,facility,both,1,EA,,52,52,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Doxycycline Hyclate: 50 Capsule In 1 Bottle, Plastic (53489-118-02)",637,RC,53489-118-02,NDC,,,facility,both,1,EA,,6.59,6.59,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Aminocaproic Acid: 236.5 Ml In 1 Bottle, Plastic (52817-815-08)",637,RC,52817-815-08,NDC,,,facility,both,1,EA,,108.49,108.49,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Clonidine Transdermal System Usp, 0.2 Mg/Day: 4 Pouch In 1 Carton (52817-611-04) / 1 Patch In 1 Pouch / 1 D In 1 Patch",637,RC,52817-611-04,NDC,,,facility,both,1,EA,,101.81,101.81,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Clonidine Transdermal System Usp, 0.1 Mg/Day: 4 Pouch In 1 Carton (52817-610-04) / 1 Patch In 1 Pouch / 1 D In 1 Patch",637,RC,52817-610-04,NDC,,,facility,both,1,EA,,66.6,66.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Metoprolol Tartrate: 100 Tablet, Film Coated In 1 Bottle (52817-362-10)",637,RC,52817-362-10,NDC,,,facility,both,1,EA,,11.79,11.79,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Cyproheptadine Hydrochloride: 100 Tablet In 1 Bottle, Plastic (52817-210-10)",637,RC,52817-210-10,NDC,,,facility,both,1,EA,,11.67,11.67,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Eprontia: 473 Ml In 1 Bottle (52652-9001-1),637,RC,52652-9001-1,NDC,,,facility,both,1,EA,,32.38,32.38,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Zonisade: 1 Bottle In 1 Carton (52652-8001-1) / 150 Ml In 1 Bottle,637,RC,52652-8001-1,NDC,,,facility,both,1,EA,,214.46,214.46,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Clonidine Transdermal System Usp, 0.3 Mg/Day: 4 Pouch In 1 Carton (52817-612-04) / 1 Patch In 1 Pouch / 1 D In 1 Patch",637,RC,52817-612-04,NDC,,,facility,both,1,EA,,132.65,132.65,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Feverall Jr. Strength: 6 Blister Pack In 1 Carton (51672-2116-2) / 1 Suppository In 1 Blister Pack (51672-2116-0),637,RC,51672-2116-2,NDC,,,facility,both,1,EA,,19,19,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,51672-2116-0,NDC,,,facility,both,1,EA,,17.75,17.75,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,51079-882-01,NDC,,,facility,both,1,EA,,1.74,1.74,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,51079-821-01,NDC,,,facility,both,1,EA,,15.35,15.35,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,51079-759-01,NDC,,,facility,both,1,EA,,10,10,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sucralfate: 100 Blister Pack In 1 Carton (51079-753-20) / 1 Tablet In 1 Blister Pack (51079-753-01),637,RC,51079-753-20,NDC,,,facility,both,1,EA,,14.26,14.26,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,51079-753-01,NDC,,,facility,both,1,EA,,14.26,14.26,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,51079-632-01,NDC,,,facility,both,1,EA,,19.66,19.66,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,51079-597-01,NDC,,,facility,both,1,EA,,12.59,12.59,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,51079-453-01,NDC,,,facility,both,1,EA,,15.53,15.53,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,51672-2115-0,NDC,,,facility,both,1,EA,,1.7,1.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Feverall Infants: 6 Blister Pack In 1 Carton (51672-2114-2) / 1 Suppository In 1 Blister Pack (51672-2114-0),637,RC,51672-2114-2,NDC,,,facility,both,1,EA,,1.47,1.47,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,51672-2114-0,NDC,,,facility,both,1,EA,,1.48,1.48,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Miconazole Nitrate: 1 Tube In 1 Carton (51672-2001-1) / 15 G In 1 Tube,637,RC,51672-2001-1,NDC,,,facility,both,1,EA,,20.72,20.72,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,51079-985-01,NDC,,,facility,both,1,EA,,12.21,12.21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Phenazopyridine Hydrochloride: 100 TABLET in 1 BOTTLE (51293-811-01) ,637,RC,51293-811-01,NDC,,,facility,both,1,EA,,16.55,16.55,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,51224-162-12,NDC,,,facility,both,1,EA,,16.47,16.47,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Trikafta: 4 Package In 1 Carton (51167-446-01) / 1 Kit In 1 Package * 1 Granule In 1 Packet (51167-746-07) * 1 Granule In 1 Packet (51167-846-07),637,RC,51167-446-01,NDC,,,facility,both,1,EA,,3206.84,3206.84,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Trikafta: 4 Blister Pack In 1 Carton (51167-331-01) / 1 Kit In 1 Blister Pack * 14 Tablet, Film Coated In 1 Blister Pack (51167-431-14) * 7 Tablet, Film Coated In 1 Blister Pack (51167-531-07)",637,RC,51167-331-01,NDC,,,facility,both,1,EA,,2055.05,2055.05,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Trikafta: 4 Blister Pack In 1 Carton (51167-106-02) / 1 Kit In 1 Blister Pack * 14 Tablet, Film Coated In 1 Blister Pack (51167-206-14) * 7 Tablet, Film Coated In 1 Blister Pack (51167-306-07)",637,RC,51167-106-02,NDC,,,facility,both,1,EA,,2006.8,2006.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,50268-594-11,NDC,,,facility,both,1,EA,,7.98,7.98,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Trazodone Hydrochloride: 100 TABLET in 1 BOTTLE (50111-433-01) ,637,RC,50111-433-01,NDC,,,facility,both,1,EA,,6.05,6.05,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Jasmiel: 3 Pouch In 1 Carton (50102-240-23) / 1 Blister Pack In 1 Pouch (50102-240-21) / 1 Kit In 1 Blister Pack,637,RC,50102-240-23,NDC,,,facility,both,1,EA,,6.95,6.95,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,50102-240-21,NDC,,,facility,both,1,EA,,1.73,1.73,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,50102-240-01,NDC,,,facility,both,1,EA,,1.68,1.68,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Cholestyramine: 60 Packet In 1 Carton (49884-465-65) / 9 G In 1 Packet (49884-465-64),637,RC,49884-465-65,NDC,,,facility,both,1,EA,,53.85,53.85,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ursodiol: 100 Tablet, Film Coated In 1 Bottle (49884-412-01)",637,RC,49884-412-01,NDC,,,facility,both,1,EA,,21.84,21.84,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,49884-308-52,NDC,,,facility,both,1,EA,,13.28,13.28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,49884-306-52,NDC,,,facility,both,1,EA,,13.39,13.39,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Clonazepam: 60 Tablet, Orally Disintegrating In 1 Blister Pack (49884-306-02)",637,RC,49884-306-02,NDC,,,facility,both,1,EA,,13.29,13.29,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Glycopyrrolate: 16 Ml In 1 Bottle (49884-042-33),637,RC,49884-042-33,NDC,,,facility,both,1,EA,,34.66,34.66,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,49884-311-52,NDC,,,facility,both,1,EA,,12.7,12.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Mineral Oil: 30 Ml In 1 Cup, Unit-Dose (48433-202-30)",637,RC,48433-202-30,NDC,,,facility,both,1,EA,,18.28,18.28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Lisdexamfetamine Dimesylate: 100 Capsule In 1 Bottle (47781-562-01),637,RC,47781-562-01,NDC,,,facility,both,1,EA,,59.15,59.15,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Acetaminophen For Children: 12 Blister Pack In 1 Carton (45802-732-30) / 1 Suppository In 1 Blister Pack,637,RC,45802-732-30,NDC,,,facility,both,1,EA,,1.15,1.15,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,45802-732-00,NDC,,,facility,both,1,EA,,1,1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Acetaminophen Pain Reliever Fever Reducer: 50 Blister Pack In 1 Carton (45802-730-32) / 1 Suppository In 1 Blister Pack,637,RC,45802-730-32,NDC,,,facility,both,1,EA,,1.14,1.14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Acetaminophen Pain Reliever Fever Reducer: 1 Suppository In 1 Blister Pack (45802-730-00),637,RC,45802-730-00,NDC,,,facility,both,1,EA,,1.23,1.23,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Hydrocortisone: 1 Tube In 1 Carton (45802-438-03) / 28 G In 1 Tube,637,RC,45802-438-03,NDC,,,facility,both,1,EA,,16.1,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Acetaminophen For Children: 100 Blister Pack In 1 Carton (45802-732-33) / 1 Suppository In 1 Blister Pack,637,RC,45802-732-33,NDC,,,facility,both,1,EA,,1.03,1.03,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dextromethorphan Polistirex Extended Release: 1 Bottle In 1 Carton (45802-433-21) / 89 Ml In 1 Bottle,637,RC,45802-433-21,NDC,,,facility,both,1,EA,,13.15,13.15,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA vitamin a and d: 1 TUBE in 1 CARTON (45802-395-04) / 113 g in 1 TUBE,637,RC,45802-395-04,NDC,,,facility,both,1,EA,,24.96,24.96,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Betamethasone Dipropionate: 1 Tube In 1 Carton (45802-376-35) / 15 G In 1 Tube,637,RC,45802-376-35,NDC,,,facility,both,1,EA,,24.59,24.59,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,45802-357-58,NDC,,,facility,both,1,EA,,10.65,10.65,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Triamcinolone Acetonide: 1 Tube In 1 Carton (45802-064-36) / 80 G In 1 Tube,637,RC,45802-064-36,NDC,,,facility,both,1,EA,,44.82,44.82,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Tadliq: 150 Ml In 1 Bottle (46287-045-15),637,RC,46287-045-15,NDC,,,facility,both,1,EA,,234.44,234.44,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Carospir: 473 Ml In 1 Bottle (46287-020-01),637,RC,46287-020-01,NDC,,,facility,both,1,EA,,41.53,41.53,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Sodium Polystyrene Sulfonate: 10 Bottle, Unit-Dose In 1 Carton (46287-006-60) / 60 Ml In 1 Bottle, Unit-Dose",637,RC,46287-006-60,NDC,,,facility,both,1,EA,,174.89,174.89,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Polyethylene Glycol 3350: 238 G In 1 Bottle (45802-868-02),637,RC,45802-868-02,NDC,,,facility,both,1,EA,,7.51,7.51,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Fluoxetine: 100 Capsule In 1 Bottle (50228-113-01),637,RC,50228-113-01,NDC,,,facility,both,1,EA,,12.31,12.31,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,50268-304-11,NDC,,,facility,both,1,EA,,13.31,13.31,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,50268-297-11,NDC,,,facility,both,1,EA,,19.32,19.32,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,50268-277-11,NDC,,,facility,both,1,EA,,14.06,14.06,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,50268-260-11,NDC,,,facility,both,1,EA,,13,13,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,50268-259-11,NDC,,,facility,both,1,EA,,12.35,12.35,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Capsaicin External Analgesic: 1 Tube In 1 Carton (50268-195-60) / 60 G In 1 Tube,637,RC,50268-195-60,NDC,,,facility,both,1,EA,,27.25,27.25,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Cyproheptadine Hydrochloride: 50 Blister Pack In 1 Box (50268-189-15) / 1 Tablet In 1 Blister Pack (50268-189-11),637,RC,50268-189-15,NDC,,,facility,both,1,EA,,15.25,15.25,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,50268-189-11,NDC,,,facility,both,1,EA,,11.75,11.75,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,50268-172-11,NDC,,,facility,both,1,EA,,19.68,19.68,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,50268-152-11,NDC,,,facility,both,1,EA,,13.17,13.17,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,50268-330-11,NDC,,,facility,both,1,EA,,13.8,13.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,50268-337-11,NDC,,,facility,both,1,EA,,19.1,19.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,50268-585-11,NDC,,,facility,both,1,EA,,10.14,10.14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,50268-574-11,NDC,,,facility,both,1,EA,,16.17,16.17,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,50268-534-11,NDC,,,facility,both,1,EA,,7.53,7.53,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,50268-521-11,NDC,,,facility,both,1,EA,,13.12,13.12,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,50268-504-11,NDC,,,facility,both,1,EA,,8.72,8.72,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Hydrocortisone: 50 Blister Pack In 1 Box (50268-405-15) / 1 Tablet In 1 Blister Pack (50268-405-11),637,RC,50268-405-15,NDC,,,facility,both,1,EA,,16.27,16.27,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,50268-405-11,NDC,,,facility,both,1,EA,,16.55,16.55,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,50268-350-11,NDC,,,facility,both,1,EA,,12.43,12.43,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,50268-339-11,NDC,,,facility,both,1,EA,,12.67,12.67,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,50268-520-11,NDC,,,facility,both,1,EA,,13.47,13.47,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Enalapril Maleate: 100 Tablet In 1 Bottle (50228-229-01),637,RC,50228-229-01,NDC,,,facility,both,1,EA,,13.09,13.09,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Enalapril Maleate: 100 Tablet In 1 Bottle (50228-228-01),637,RC,50228-228-01,NDC,,,facility,both,1,EA,,13.09,13.09,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,50268-130-11,NDC,,,facility,both,1,EA,,10.5,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Aripiprazole: 50 Blister Pack In 1 Box, Unit-Dose (50268-089-15) / 1 Tablet In 1 Blister Pack (50268-089-11)",637,RC,50268-089-15,NDC,,,facility,both,1,EA,,15.5,15.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,50268-089-11,NDC,,,facility,both,1,EA,,12.1,12.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,50268-088-11,NDC,,,facility,both,1,EA,,10.51,10.51,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Azithromycin Dihydrate: 50 Blister Pack In 1 Box (50268-074-15) / 1 Tablet, Film Coated In 1 Blister Pack (50268-074-11)",637,RC,50268-074-15,NDC,,,facility,both,1,EA,,9.12,9.12,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,50268-074-11,NDC,,,facility,both,1,EA,,8.46,8.46,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,50268-069-11,NDC,,,facility,both,1,EA,,20.09,20.09,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,50268-062-11,NDC,,,facility,both,1,EA,,15.03,15.03,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,50268-054-11,NDC,,,facility,both,1,EA,,21.08,21.08,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Nystop: 15 G In 1 Bottle, Plastic (0574-2008-15)",637,RC,0574-2008-15,NDC,,,facility,both,1,EA,,40.81,40.81,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Spironolactone: 473 Ml In 1 Bottle (0574-1133-16),637,RC,0574-1133-16,NDC,,,facility,both,1,EA,,42.49,42.49,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Actidose: 120 Ml In 1 Tube (0574-0520-74),637,RC,0574-0520-74,NDC,,,facility,both,1,EA,,85.89,85.89,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Junior Strength Advil: 1 Bottle In 1 Carton (0573-0179-20) / 24 Tablet, Chewable In 1 Bottle",637,RC,0573-0179-20,NDC,,,facility,both,1,EA,,0.47,0.47,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,0555-9010-79,NDC,,,facility,both,1,EA,,3.19,3.19,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Medroxyprogesterone Acetate: 100 Tablet In 1 Bottle (0555-0779-02),637,RC,0555-0779-02,NDC,,,facility,both,1,EA,,12.42,12.42,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Leucovorin Calcium: 100 Tablet In 1 Bottle (0555-0484-02),637,RC,0555-0484-02,NDC,,,facility,both,1,EA,,8.83,8.83,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Clonazepam: 10 BLISTER PACK in 1 CARTON (0555-0097-96) / 6 TABLET, ORALLY DISINTEGRATING in 1 BLISTER PACK",637,RC,0555-0097-96,NDC,,,facility,both,1,EA,,12.76,12.76,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Bisacodyl: 12 Blister Pack In 1 Carton (0574-7050-12) / 1 Suppository In 1 Blister Pack,637,RC,0574-7050-12,NDC,,,facility,both,1,EA,,1.33,1.33,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Propranolol Hydrochloride: 100 Tablet In 1 Bottle, Plastic (0591-5555-01)",637,RC,0591-5555-01,NDC,,,facility,both,1,EA,,13.8,13.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Probenecid: 100 Tablet, Film Coated In 1 Bottle, Plastic (0591-5347-01)",637,RC,0591-5347-01,NDC,,,facility,both,1,EA,,13.88,13.88,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Trihexyphenidyl Hydrochloride: 100 Tablet In 1 Bottle, Plastic (0591-5335-01)",637,RC,0591-5335-01,NDC,,,facility,both,1,EA,,12.54,12.54,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,0591-3525-11,NDC,,,facility,both,1,EA,,22.43,22.43,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Desmopressin Acetate: 100 TABLET in 1 BOTTLE, PLASTIC (0591-2464-01) ",637,RC,0591-2464-01,NDC,,,facility,both,1,EA,,23.99,23.99,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ambrisentan: 30 Tablet, Film Coated In 1 Bottle (0591-2405-30)",637,RC,0591-2405-30,NDC,,,facility,both,1,EA,,660.86,660.86,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Verapamil Hydrochloride: 100 Tablet, Film Coated In 1 Bottle, Plastic (0591-0343-01)",637,RC,0591-0343-01,NDC,,,facility,both,1,EA,,11.65,11.65,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Proglycem: 1 Bottle, Dropper In 1 Box (0575-6200-30) / 30 Ml In 1 Bottle, Dropper",637,RC,0575-6200-30,NDC,,,facility,both,1,EA,,79.23,79.23,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sulfamethoxazole And Trimethoprim: 100 Blister Pack In 1 Carton (0904-2725-61) / 1 Tablet In 1 Blister Pack,637,RC,0904-2725-61,NDC,,,facility,both,1,EA,,9.02,9.02,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Metronidazole: 100 BLISTER PACK in 1 CARTON (0904-1453-61) / 1 TABLET in 1 BLISTER PACK,637,RC,0904-1453-61,NDC,,,facility,both,1,EA,,7.9,7.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Oil: 473 Ml In 1 Bottle, Plastic (0869-0831-43)",637,RC,0869-0831-43,NDC,,,facility,both,1,EA,,13.19,13.19,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,0832-0512-89,NDC,,,facility,both,1,EA,,13.25,13.25,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,0832-0038-89,NDC,,,facility,both,1,EA,,11.86,11.86,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,0904-3865-75,NDC,,,facility,both,1,EA,,10.22,10.22,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Lorazepam: 100 Blister Pack In 1 Carton (0904-6008-61) / 1 Tablet In 1 Blister Pack,637,RC,0904-6008-61,NDC,,,facility,both,1,EA,,12.16,12.16,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Clindamycin Hydrochloride: 100 Blister Pack In 1 Carton (0904-5959-61) / 1 Capsule In 1 Blister Pack,637,RC,0904-5959-61,NDC,,,facility,both,1,EA,,5.68,5.68,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Digoxin: 100 Blister Pack In 1 Carton (0904-5921-61) / 1 Tablet In 1 Blister Pack,637,RC,0904-5921-61,NDC,,,facility,both,1,EA,,10.8,10.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Pravastatin Sodium: 100 Blister Pack In 1 Box, Unit-Dose (0904-5891-61) / 1 Tablet In 1 Blister Pack",637,RC,0904-5891-61,NDC,,,facility,both,1,EA,,7.65,7.65,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Childrens Mapap: 1 Bottle, Plastic In 1 Carton (0904-5791-46) / 30 Tablet, Chewable In 1 Bottle, Plastic",637,RC,0904-5791-46,NDC,,,facility,both,1,EA,,2.64,2.64,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Acyclovir: 100 Blister Pack In 1 Carton (0904-5789-61) / 1 Capsule In 1 Blister Pack,637,RC,0904-5789-61,NDC,,,facility,both,1,EA,,6.48,6.48,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Fluoxetine: 100 Blister Pack In 1 Carton (0904-5785-61) / 1 Capsule In 1 Blister Pack,637,RC,0904-5785-61,NDC,,,facility,both,1,EA,,8.2,8.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Fluoxetine: 100 Blister Pack In 1 Carton (0904-5784-61) / 1 Capsule In 1 Blister Pack,637,RC,0904-5784-61,NDC,,,facility,both,1,EA,,12.12,12.12,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Heartburn Relief Original Strength: 1 Bottle In 1 Carton (0904-5529-52) / 60 Tablet, Film Coated In 1 Bottle",637,RC,0904-5529-52,NDC,,,facility,both,1,EA,,8.89,8.89,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Ibuprofen: 100 Blister Pack In 1 Carton (0904-5854-61) / 1 Tablet In 1 Blister Pack,637,RC,0904-5854-61,NDC,,,facility,both,1,EA,,11.96,11.96,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Amoxicillin And Clavulanate Potassium: 28 Tablet, Multilayer, Extended Release In 1 Bottle (0781-1943-82)",637,RC,0781-1943-82,NDC,,,facility,both,1,EA,,40.93,40.93,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Griseofulvin: 118 Ml In 1 Bottle, Plastic (0713-0850-04)",637,RC,0713-0850-04,NDC,,,facility,both,1,EA,,5.68,5.68,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Mometasone Furoate: 1 Tube In 1 Carton (0713-0635-15) / 15 G In 1 Tube,637,RC,0713-0635-15,NDC,,,facility,both,1,EA,,35.79,35.79,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Mometasone Furoate: 1 Tube In 1 Carton (0713-0634-15) / 15 G In 1 Tube,637,RC,0713-0634-15,NDC,,,facility,both,1,EA,,78.11,78.11,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Capsaicin: 1 Tube In 1 Carton (0536-2525-25) / 60 G In 1 Tube,637,RC,0536-2525-25,NDC,,,facility,both,1,EA,,40.91,40.91,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Citalopram: 100 Blister Pack In 1 Carton (0904-6084-61) / 1 Tablet, Film Coated In 1 Blister Pack",637,RC,0904-6084-61,NDC,,,facility,both,1,EA,,12.44,12.44,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dicyclomine Hydrochloride: 100 Capsule In 1 Bottle (0527-0586-01),637,RC,0527-0586-01,NDC,,,facility,both,1,EA,,10.29,10.29,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Levofloxacin: 1 Bottle, Plastic In 1 Carton (0527-1948-68) / 200 Ml In 1 Bottle, Plastic",637,RC,0527-1948-68,NDC,,,facility,both,1,EA,,150.9,150.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Rugby Anti-Dandruff: 207 Ml In 1 Bottle, Plastic (0536-1995-53)",637,RC,0536-1995-53,NDC,,,facility,both,1,EA,,19.44,19.44,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Rugby Polyvinyl Alcohol 1.4% Lubricating Eye Drops: 1 Bottle, Dropper In 1 Box (0536-1408-94) / 15 Ml In 1 Bottle, Dropper",637,RC,0536-1408-94,NDC,,,facility,both,1,EA,,40.67,40.67,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Rugby Muscle Rub Cream: 1 Tube In 1 Carton (0536-1349-57) / 85 G In 1 Tube,637,RC,0536-1349-57,NDC,,,facility,both,1,EA,,21.3,21.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Infants: 1 Bottle, Dropper In 1 Carton (0536-1303-75) / 30 Ml In 1 Bottle, Dropper",637,RC,0536-1303-75,NDC,,,facility,both,1,EA,,12.37,12.37,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Rugby Cherry Flavor: 177 Ml In 1 Bottle, Spray (0536-1228-58)",637,RC,0536-1228-58,NDC,,,facility,both,1,EA,,21,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Rugby Petrolatum Hydrating Skin Protectant: 100 G In 1 Jar (0536-1143-97),637,RC,0536-1143-97,NDC,,,facility,both,1,EA,,41.18,41.18,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Rugby Benzoyl Peroxide Acne Medication: 1 Tube In 1 Carton (0536-1055-56) / 42.5 Ml In 1 Tube,637,RC,0536-1055-56,NDC,,,facility,both,1,EA,,17.2,17.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Aspirin: 1 Bottle, Plastic In 1 Carton (0536-1054-29) / 100 Tablet, Film Coated In 1 Bottle, Plastic",637,RC,0536-1054-29,NDC,,,facility,both,1,EA,,1.02,1.02,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Oseltamivir Phosphate: 1 Bottle, Plastic In 1 Carton (0527-5137-62) / 60 Ml In 1 Bottle, Plastic",637,RC,0527-5137-62,NDC,,,facility,both,1,EA,,17.65,17.65,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Oseltamivir Phosphate: 1 Blister Pack In 1 Carton (0527-4591-13) / 10 Capsule In 1 Blister Pack,637,RC,0527-4591-13,NDC,,,facility,both,1,EA,,11.26,11.26,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Linzess: 1 Bottle In 1 Carton (0456-1203-30) / 30 Capsule, Gelatin Coated In 1 Bottle",637,RC,0456-1203-30,NDC,,,facility,both,1,EA,,130.86,130.86,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "K-Phos No. 2: 100 Tablet, Coated In 1 Bottle (0486-1134-01)",637,RC,0486-1134-01,NDC,,,facility,both,1,EA,,18.63,18.63,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Permethrin: 1 Tube In 1 Carton (0472-0242-60) / 60 G In 1 Tube,637,RC,0472-0242-60,NDC,,,facility,both,1,EA,,137.18,137.18,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Myrbetriq: 1 Bottle In 1 Carton (0469-5020-99) / 100 Ml In 1 Bottle,637,RC,0469-5020-99,NDC,,,facility,both,1,EA,,132,132,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Citalopram: 100 Blister Pack In 1 Carton (0904-6085-61) / 1 Tablet, Film Coated In 1 Blister Pack",637,RC,0904-6085-61,NDC,,,facility,both,1,EA,,11.87,11.87,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Critic Aid Clear Af: 57 G In 1 Tube (11701-067-23),637,RC,11701-067-23,NDC,,,facility,both,1,EA,,49.71,49.71,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dexmethylphenidate Hydrochloride: 100 Tablet In 1 Bottle (10702-107-01),637,RC,10702-107-01,NDC,,,facility,both,1,EA,,7.74,7.74,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Peg-3350, Sodium Chloride, Sodium Bicarbonate And Potassium Chloride: 4 L In 1 Bottle (10572-302-01)",637,RC,10572-302-01,NDC,,,facility,both,1,EA,,172.48,172.48,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Rifabutin: 100 Capsule In 1 Bottle (10135-738-01),637,RC,10135-738-01,NDC,,,facility,both,1,EA,,37.84,37.84,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ibuprofen: 10 Blister Pack In 1 Carton (0904-7914-61) / 10 Tablet, Film Coated In 1 Blister Pack",637,RC,0904-7914-61,NDC,,,facility,both,1,EA,,0.52,0.52,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Clonazepam: 100 Blister Pack In 1 Carton (0904-7728-61) / 1 Tablet In 1 Blister Pack,637,RC,0904-7728-61,NDC,,,facility,both,1,EA,,13.37,13.37,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Silver Nitrate Applicators: 100 Applicator In 1 Vial (12870-0001-2) / 100 Mg In 1 Applicator,637,RC,12870-0001-2,NDC,,,facility,both,1,EA,,12.46,12.46,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Methylphenidate Hydrochloride: 100 Tablet, Extended Release In 1 Bottle (13811-706-10)",637,RC,13811-706-10,NDC,,,facility,both,1,EA,,8.72,8.72,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Erythromycin: 30 Tablet, Coated In 1 Bottle (13668-606-30)",637,RC,13668-606-30,NDC,,,facility,both,1,EA,,37.19,37.19,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Tadalafil: 30 Tablet In 1 Bottle (13668-581-30),637,RC,13668-581-30,NDC,,,facility,both,1,EA,,14.67,14.67,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Clobazam: 1 Bottle, Glass In 1 Carton (16714-087-01) / 120 Ml In 1 Bottle, Glass",637,RC,16714-087-01,NDC,,,facility,both,1,EA,,25.8,25.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Hydroxyzine Hydrochloride: 100 Tablet In 1 Bottle (16714-082-10),637,RC,16714-082-10,NDC,,,facility,both,1,EA,,12.55,12.55,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Clopidogrel: 10 Tablet In 1 Blister Pack (16714-052-10),637,RC,16714-052-10,NDC,,,facility,both,1,EA,,12.27,12.27,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Phenobarbital: 100 Tablet In 1 Bottle (16571-671-01),637,RC,16571-671-01,NDC,,,facility,both,1,EA,,4.25,4.25,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Cetirizine Hydrochloride: 100 Tablet In 1 Bottle (16571-401-10),637,RC,16571-401-10,NDC,,,facility,both,1,EA,,7.37,7.37,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Isradipine: 100 Capsule In 1 Bottle (16252-540-01),637,RC,16252-540-01,NDC,,,facility,both,1,EA,,16.51,16.51,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Lansoprazole: 90 Capsule, Delayed Release In 1 Bottle (16571-698-09)",637,RC,16571-698-09,NDC,,,facility,both,1,EA,,12.06,12.06,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Anti Diarrheal: 24 Blister Pack In 1 Carton (0904-7725-24) / 1 Tablet, Film Coated In 1 Blister Pack",637,RC,0904-7725-24,NDC,,,facility,both,1,EA,,8.71,8.71,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Lisinopril: 100 Blister Pack In 1 Carton (0904-6798-61) / 1 Tablet In 1 Blister Pack,637,RC,0904-6798-61,NDC,,,facility,both,1,EA,,4.49,4.49,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Lisinopril: 100 Blister Pack In 1 Carton (0904-6797-61) / 1 Tablet In 1 Blister Pack,637,RC,0904-6797-61,NDC,,,facility,both,1,EA,,12.24,12.24,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Aspirin Low Dose Chewable Orange: 300 Blister Pack In 1 Carton (0904-6794-30) / 1 Tablet, Chewable In 1 Blister Pack",637,RC,0904-6794-30,NDC,,,facility,both,1,EA,,0.83,0.83,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Haloperidol: 100 Blister Pack In 1 Carton (0904-6782-61) / 1 Tablet In 1 Blister Pack,637,RC,0904-6782-61,NDC,,,facility,both,1,EA,,15.49,15.49,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Acetaminophen: 10 Blister Pack In 1 Box, Unit-Dose (0904-6773-61) / 10 Tablet In 1 Blister Pack",637,RC,0904-6773-61,NDC,,,facility,both,1,EA,,0.55,0.55,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Childrens Loratadine Oral: 1 Bottle In 1 Carton (0904-6767-20) / 120 Ml In 1 Bottle,637,RC,0904-6767-20,NDC,,,facility,both,1,EA,,12.9,12.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Acetaminophen: 10 Blister Pack In 1 Box, Unit-Dose (0904-6730-61) / 10 Tablet In 1 Blister Pack",637,RC,0904-6730-61,NDC,,,facility,both,1,EA,,8.73,8.73,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Pseudoephedrine Hydrochloride: 30 Tablet In 1 Bottle (0904-6728-46),637,RC,0904-6728-46,NDC,,,facility,both,1,EA,,12.37,12.37,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Cetirizine: 100 Blister Pack In 1 Carton (0904-6717-61) / 1 Tablet, Film Coated In 1 Blister Pack",637,RC,0904-6717-61,NDC,,,facility,both,1,EA,,12.31,12.31,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Gabapentin: 100 Blister Pack In 1 Carton (0904-6665-61) / 1 Capsule In 1 Blister Pack,637,RC,0904-6665-61,NDC,,,facility,both,1,EA,,7.7,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Quetiapine: 100 Blister Pack In 1 Carton (0904-6640-61) / 1 Tablet, Film Coated In 1 Blister Pack",637,RC,0904-6640-61,NDC,,,facility,both,1,EA,,7.52,7.52,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Montelukast Sodium: 100 Blister Pack In 1 Carton (0904-6808-61) / 1 Tablet, Film Coated In 1 Blister Pack",637,RC,0904-6808-61,NDC,,,facility,both,1,EA,,13.29,13.29,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,0904-6828-05,NDC,,,facility,both,1,EA,,19.2,19.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Levothyroxine Sodium: 100 Blister Pack In 1 Carton (0904-6954-61) / 1 Tablet In 1 Blister Pack,637,RC,0904-6954-61,NDC,,,facility,both,1,EA,,15.12,15.12,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Levothyroxine Sodium: 100 Blister Pack In 1 Carton (0904-6953-61) / 1 Tablet In 1 Blister Pack,637,RC,0904-6953-61,NDC,,,facility,both,1,EA,,13.9,13.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Levothyroxine Sodium: 100 Blister Pack In 1 Carton (0904-6951-61) / 1 Tablet In 1 Blister Pack,637,RC,0904-6951-61,NDC,,,facility,both,1,EA,,14.32,14.32,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Levothyroxine Sodium: 100 Blister Pack In 1 Carton (0904-6950-61) / 1 Tablet In 1 Blister Pack,637,RC,0904-6950-61,NDC,,,facility,both,1,EA,,8.38,8.38,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Polyethylene Glycol 3350: 17 G In 1 Packet (0904-6931-86),637,RC,0904-6931-86,NDC,,,facility,both,1,EA,,17.91,17.91,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Quetiapine: 100 Blister Pack In 1 Carton (0904-6638-61) / 1 Tablet, Film Coated In 1 Blister Pack",637,RC,0904-6638-61,NDC,,,facility,both,1,EA,,5.49,5.49,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Pseudoephedrine Hydrochloride: 5 Blister Pack In 1 Box (0904-6907-06) / 10 Tablet In 1 Blister Pack,637,RC,0904-6907-06,NDC,,,facility,both,1,EA,,11.39,11.39,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Trazodone Hydrochloride: 100 Blister Pack In 1 Carton (0904-6868-61) / 1 Tablet In 1 Blister Pack,637,RC,0904-6868-61,NDC,,,facility,both,1,EA,,8.1,8.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Divalproex Sodium: 100 Blister Pack In 1 Carton (0904-6860-61) / 1 Tablet, Delayed Release In 1 Blister Pack",637,RC,0904-6860-61,NDC,,,facility,both,1,EA,,12.78,12.78,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Loratadine: 100 Blister Pack In 1 Carton (0904-6852-61) / 1 Tablet In 1 Blister Pack,637,RC,0904-6852-61,NDC,,,facility,both,1,EA,,12.63,12.63,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Oxycodone Hydrochloride: 4 Tray In 1 Carton (0904-6828-94) / 10 Cup, Unit-Dose In 1 Tray / 5 Ml In 1 Cup, Unit-Dose (0904-6828-05)",637,RC,0904-6828-94,NDC,,,facility,both,1,EA,,21.33,21.33,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Bisacodyl: 10 Blister Pack In 1 Box (0904-6407-61) / 10 Tablet, Delayed Release In 1 Blister Pack",637,RC,0904-6407-61,NDC,,,facility,both,1,EA,,0.61,0.61,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Amlodipine Besylate: 100 Blister Pack In 1 Carton (0904-6371-61) / 1 Tablet In 1 Blister Pack,637,RC,0904-6371-61,NDC,,,facility,both,1,EA,,12.05,12.05,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Amlodipine Besylate: 100 Blister Pack In 1 Carton (0904-6370-61) / 1 Tablet In 1 Blister Pack,637,RC,0904-6370-61,NDC,,,facility,both,1,EA,,8.95,8.95,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Amlodipine Besylate: 100 Blister Pack In 1 Carton (0904-6369-61) / 1 Tablet In 1 Blister Pack,637,RC,0904-6369-61,NDC,,,facility,both,1,EA,,12.36,12.36,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Risperidone: 100 Tablet In 1 Box, Unit-Dose (0904-6359-61)",637,RC,0904-6359-61,NDC,,,facility,both,1,EA,,4.32,4.32,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Levofloxacin: 100 Blister Pack In 1 Carton (0904-6351-61) / 1 Tablet, Film Coated In 1 Blister Pack",637,RC,0904-6351-61,NDC,,,facility,both,1,EA,,6.12,6.12,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Major Regular Strength Assorted Flavors: 150 Tablet, Chewable In 1 Bottle, Plastic (0904-6412-92)",637,RC,0904-6412-92,NDC,,,facility,both,1,EA,,4.62,4.62,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Sore Throat Cherry: 177 Ml In 1 Bottle, Spray (0904-6305-21)",637,RC,0904-6305-21,NDC,,,facility,both,1,EA,,18.69,18.69,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Clopidogrel: 100 Blister Pack In 1 Carton (0904-6294-61) / 1 Tablet, Film Coated In 1 Blister Pack",637,RC,0904-6294-61,NDC,,,facility,both,1,EA,,11.57,11.57,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Atorvastatin Calcium: 100 Blister Pack In 1 Carton (0904-6290-61) / 1 Tablet, Film Coated In 1 Blister Pack",637,RC,0904-6290-61,NDC,,,facility,both,1,EA,,10.35,10.35,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Ziprasidone: 40 Blister Pack In 1 Carton (0904-6269-08) / 1 Capsule In 1 Blister Pack,637,RC,0904-6269-08,NDC,,,facility,both,1,EA,,36.92,36.92,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Ursodiol: 100 Blister Pack In 1 Carton (0904-6221-61) / 1 Capsule In 1 Blister Pack,637,RC,0904-6221-61,NDC,,,facility,both,1,EA,,28.6,28.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Metoprolol Succinate: 100 Blister Pack In 1 Carton (0904-6322-61) / 1 Tablet, Film Coated, Extended Release In 1 Blister Pack",637,RC,0904-6322-61,NDC,,,facility,both,1,EA,,8.82,8.82,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Escitalopram: 100 Blister Pack In 1 Carton (0904-6426-61) / 1 Tablet, Film Coated In 1 Blister Pack",637,RC,0904-6426-61,NDC,,,facility,both,1,EA,,9.92,9.92,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Hydroxyzine Hydrochloride: 100 Blister Pack In 1 Carton (0904-6617-61) / 1 Tablet, Film Coated In 1 Blister Pack",637,RC,0904-6617-61,NDC,,,facility,both,1,EA,,11.27,11.27,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Oxybutynin Chloride: 50 Blister Pack In 1 Carton (0904-6570-06) / 1 Tablet, Extended Release In 1 Blister Pack",637,RC,0904-6570-06,NDC,,,facility,both,1,EA,,20.61,20.61,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Valacyclovir Hydrochloride: 100 Blister Pack In 1 Carton (0904-6565-61) / 1 Tablet, Film Coated In 1 Blister Pack",637,RC,0904-6565-61,NDC,,,facility,both,1,EA,,19.04,19.04,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Propranolol Hydrochloride: 100 Blister Pack In 1 Carton (0904-6550-61) / 1 Tablet In 1 Blister Pack,637,RC,0904-6550-61,NDC,,,facility,both,1,EA,,6.85,6.85,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Mirtazapine: 100 Blister Pack In 1 Carton (0904-6519-61) / 1 Tablet, Film Coated In 1 Blister Pack",637,RC,0904-6519-61,NDC,,,facility,both,1,EA,,12.82,12.82,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Memantine Hydrochloride: 100 Blister Pack In 1 Carton (0904-6505-61) / 1 Tablet, Film Coated In 1 Blister Pack",637,RC,0904-6505-61,NDC,,,facility,both,1,EA,,13.65,13.65,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Memantine Hydrochloride: 50 Blister Pack In 1 Carton (0904-6505-06) / 1 Tablet, Film Coated In 1 Blister Pack",637,RC,0904-6505-06,NDC,,,facility,both,1,EA,,7.95,7.95,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Celecoxib: 100 Blister Pack In 1 Carton (0904-6502-61) / 1 Capsule In 1 Blister Pack,637,RC,0904-6502-61,NDC,,,facility,both,1,EA,,17.54,17.54,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Baclofen: 100 Blister Pack In 1 Carton (0904-6476-61) / 1 Tablet In 1 Blister Pack,637,RC,0904-6476-61,NDC,,,facility,both,1,EA,,15.11,15.11,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Pantoprazole Sodium: 100 Blister Pack In 1 Carton (0904-6474-61) / 1 Tablet, Delayed Release In 1 Blister Pack",637,RC,0904-6474-61,NDC,,,facility,both,1,EA,,13.18,13.18,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Oxycodone Hydrochloride: 100 Blister Pack In 1 Carton (0904-6966-61) / 1 Tablet In 1 Blister Pack,637,RC,0904-6966-61,NDC,,,facility,both,1,EA,,12.05,12.05,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Pseudoephedrine Hcl: 10 Blister Pack In 1 Carton (0904-6990-61) / 10 Tablet, Film Coated In 1 Blister Pack",637,RC,0904-6990-61,NDC,,,facility,both,1,EA,,12.41,12.41,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Rifampin: 100 Blister Pack In 1 Carton (0904-7315-61) / 1 Capsule In 1 Blister Pack,637,RC,0904-7315-61,NDC,,,facility,both,1,EA,,10.78,10.78,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Carvedilol: 100 Blister Pack In 1 Carton (0904-7308-61) / 1 Tablet, Film Coated In 1 Blister Pack",637,RC,0904-7308-61,NDC,,,facility,both,1,EA,,11.84,11.84,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Carvedilol: 100 Blister Pack In 1 Carton (0904-7305-61) / 1 Tablet, Film Coated In 1 Blister Pack",637,RC,0904-7305-61,NDC,,,facility,both,1,EA,,6.69,6.69,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Potassium Chloride: 100 Blister Pack In 1 Carton (0904-7293-61) / 1 Tablet, Extended Release In 1 Blister Pack",637,RC,0904-7293-61,NDC,,,facility,both,1,EA,,13.67,13.67,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Benztropine Mesylate: 100 Blister Pack In 1 Carton (0904-7289-61) / 1 Tablet In 1 Blister Pack,637,RC,0904-7289-61,NDC,,,facility,both,1,EA,,13.85,13.85,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Docusate Sodium: 10 Tray In 1 Case (0904-7279-72) / 10 Cup, Unit-Dose In 1 Tray / 10 Ml In 1 Cup, Unit-Dose (0904-7279-66)",637,RC,0904-7279-72,NDC,,,facility,both,1,EA,,1.14,1.14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,0904-7279-66,NDC,,,facility,both,1,EA,,9.28,9.28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,0904-7276-41,NDC,,,facility,both,1,EA,,14.7,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,0904-7265-41,NDC,,,facility,both,1,EA,,21.67,21.67,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Oxcarbazepine: 100 Blister Pack In 1 Carton (0904-7263-61) / 1 Tablet, Film Coated In 1 Blister Pack",637,RC,0904-7263-61,NDC,,,facility,both,1,EA,,10.08,10.08,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Cephalexin: 50 Blister Pack In 1 Carton (0904-7337-06) / 1 Capsule In 1 Blister Pack,637,RC,0904-7337-06,NDC,,,facility,both,1,EA,,13.01,13.01,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,0904-7337-35,NDC,,,facility,both,1,EA,,13.18,13.18,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Sucralfate: 10 Ml In 1 Cup, Unit-Dose (0904-7470-66)",637,RC,0904-7470-66,NDC,,,facility,both,1,EA,,34.56,34.56,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Sucralfate: 20 Cup, Unit-Dose In 1 Case (0904-7470-56) / 10 Ml In 1 Cup, Unit-Dose (0904-7470-66)",637,RC,0904-7470-56,NDC,,,facility,both,1,EA,,38.64,38.64,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Labetalol Hydrochloride: 100 Blister Pack In 1 Carton (0904-7452-61) / 1 Tablet, Film Coated In 1 Blister Pack",637,RC,0904-7452-61,NDC,,,facility,both,1,EA,,13.83,13.83,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Clonidine Hydrochloride: 100 Blister Pack In 1 Carton (0904-7442-61) / 1 Tablet In 1 Blister Pack,637,RC,0904-7442-61,NDC,,,facility,both,1,EA,,10.57,10.57,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Tamsulosin Hydrochloride: 100 Blister Pack In 1 Carton (0904-7383-61) / 1 Capsule In 1 Blister Pack,637,RC,0904-7383-61,NDC,,,facility,both,1,EA,,13.37,13.37,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Oxcarbazepine: 100 Blister Pack In 1 Carton (0904-7262-61) / 1 Tablet, Film Coated In 1 Blister Pack",637,RC,0904-7262-61,NDC,,,facility,both,1,EA,,14.56,14.56,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Meclizine Hydrochloride: 100 Blister Pack In 1 Carton (0904-7376-61) / 1 Tablet In 1 Blister Pack,637,RC,0904-7376-61,NDC,,,facility,both,1,EA,,13.7,13.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Risperidone: 100 Blister Pack In 1 Carton (0904-7361-61) / 1 Tablet, Film Coated In 1 Blister Pack",637,RC,0904-7361-61,NDC,,,facility,both,1,EA,,6.71,6.71,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Risperidone: 100 Blister Pack In 1 Carton (0904-7360-61) / 1 Tablet, Film Coated In 1 Blister Pack",637,RC,0904-7360-61,NDC,,,facility,both,1,EA,,12.6,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Lurasidone Hydrochloride: 30 Blister Pack In 1 Carton (0904-7355-04) / 1 Tablet, Film Coated In 1 Blister Pack",637,RC,0904-7355-04,NDC,,,facility,both,1,EA,,16.89,16.89,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Azithromycin: 100 Blister Pack In 1 Carton (0904-7350-61) / 1 Tablet, Film Coated In 1 Blister Pack",637,RC,0904-7350-61,NDC,,,facility,both,1,EA,,15.18,15.18,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Azithromycin: 50 Blister Pack In 1 Carton (0904-7350-06) / 1 Tablet, Film Coated In 1 Blister Pack",637,RC,0904-7350-06,NDC,,,facility,both,1,EA,,9.53,9.53,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Fluoxetine: 100 Blister Pack In 1 Carton (0904-7346-61) / 1 Capsule In 1 Blister Pack,637,RC,0904-7346-61,NDC,,,facility,both,1,EA,,7.92,7.92,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Sennosides: 10 Blister Pack In 1 Box, Unit-Dose (0904-7252-61) / 10 Tablet, Film Coated In 1 Blister Pack",637,RC,0904-7252-61,NDC,,,facility,both,1,EA,,9.41,9.41,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Colchicine: 30 Blister Pack In 1 Carton (0904-7120-04) / 1 Tablet, Film Coated In 1 Blister Pack",637,RC,0904-7120-04,NDC,,,facility,both,1,EA,,27.19,27.19,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Captopril: 100 Blister Pack In 1 Carton (0904-7106-61) / 1 Tablet In 1 Blister Pack,637,RC,0904-7106-61,NDC,,,facility,both,1,EA,,14.48,14.48,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ciprofloxacin: 100 Blister Pack In 1 Carton (0904-7083-61) / 1 Tablet, Film Coated In 1 Blister Pack",637,RC,0904-7083-61,NDC,,,facility,both,1,EA,,9.28,9.28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Hydroxychloroquine Sulfate: 100 Blister Pack In 1 Carton (0904-7046-61) / 1 Tablet, Film Coated In 1 Blister Pack",637,RC,0904-7046-61,NDC,,,facility,both,1,EA,,17.99,17.99,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Buspirone Hydrochloride: 100 Blister Pack In 1 Carton (0904-7122-61) / 1 Tablet In 1 Blister Pack,637,RC,0904-7122-61,NDC,,,facility,both,1,EA,,5.62,5.62,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Duloxetine: 100 Blister Pack In 1 Carton (0904-7044-61) / 1 Capsule, Delayed Release In 1 Blister Pack",637,RC,0904-7044-61,NDC,,,facility,both,1,EA,,17.24,17.24,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Duloxetine: 30 Blister Pack In 1 Carton (0904-7043-04) / 1 Capsule, Delayed Release In 1 Blister Pack",637,RC,0904-7043-04,NDC,,,facility,both,1,EA,,17.13,17.13,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Allopurinol: 100 Blister Pack In 1 Carton (0904-7041-61) / 1 Tablet In 1 Blister Pack,637,RC,0904-7041-61,NDC,,,facility,both,1,EA,,6.99,6.99,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Lamotrigine: 100 Blister Pack In 1 Carton (0904-7007-61) / 1 Tablet In 1 Blister Pack,637,RC,0904-7007-61,NDC,,,facility,both,1,EA,,6.44,6.44,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Pregabalin: 100 Blister Pack In 1 Carton (0904-7000-61) / 1 Capsule In 1 Blister Pack,637,RC,0904-7000-61,NDC,,,facility,both,1,EA,,11.28,11.28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Hydroxychloroquine Sulfate: 50 Blister Pack In 1 Carton (0904-7046-06) / 1 Tablet, Film Coated In 1 Blister Pack",637,RC,0904-7046-06,NDC,,,facility,both,1,EA,,15.69,15.69,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Levetiracetam: 100 Blister Pack In 1 Carton (0904-7124-61) / 1 Tablet, Film Coated In 1 Blister Pack",637,RC,0904-7124-61,NDC,,,facility,both,1,EA,,5.3,5.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Lacosamide: 60 Blister Pack In 1 Carton (0904-7245-68) / 1 Tablet, Film Coated In 1 Blister Pack",637,RC,0904-7245-68,NDC,,,facility,both,1,EA,,16.65,16.65,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Lacosamide: 60 Blister Pack In 1 Carton (0904-7244-68) / 1 Tablet, Film Coated In 1 Blister Pack",637,RC,0904-7244-68,NDC,,,facility,both,1,EA,,12.91,12.91,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ciprofloxacin: 100 Blister Pack In 1 Carton (0904-7243-61) / 1 Tablet, Film Coated In 1 Blister Pack",637,RC,0904-7243-61,NDC,,,facility,both,1,EA,,11.85,11.85,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Folic Acid: 100 Blister Pack In 1 Carton (0904-7224-61) / 1 Tablet In 1 Blister Pack,637,RC,0904-7224-61,NDC,,,facility,both,1,EA,,13,13,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Famotidine: 100 Blister Pack In 1 Carton (0904-7193-61) / 1 Tablet, Film Coated In 1 Blister Pack",637,RC,0904-7193-61,NDC,,,facility,both,1,EA,,11.31,11.31,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Atenolol: 100 Blister Pack In 1 Carton (0904-7187-61) / 1 Tablet In 1 Blister Pack,637,RC,0904-7187-61,NDC,,,facility,both,1,EA,,9.85,9.85,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Docusate Sodium - Stool Softener Laxative: 10 Blister Pack In 1 Carton (0904-7183-61) / 10 Capsule, Liquid Filled In 1 Blister Pack",637,RC,0904-7183-61,NDC,,,facility,both,1,EA,,10.03,10.03,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Ursodiol: 100 Blister Pack In 1 Carton (0904-7168-61) / 1 Capsule In 1 Blister Pack,637,RC,0904-7168-61,NDC,,,facility,both,1,EA,,23.18,23.18,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Metformin Hydrochloride: 100 Blister Pack In 1 Carton (0904-7162-61) / 1 Tablet In 1 Blister Pack,637,RC,0904-7162-61,NDC,,,facility,both,1,EA,,10.56,10.56,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Metronidazole: 100 Blister Pack In 1 Carton (0904-7156-61) / 1 Tablet In 1 Blister Pack,637,RC,0904-7156-61,NDC,,,facility,both,1,EA,,7.74,7.74,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Benzonatate: 100 Blister Pack In 1 Carton (0904-7153-61) / 1 Capsule In 1 Blister Pack,637,RC,0904-7153-61,NDC,,,facility,both,1,EA,,13.96,13.96,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Guanfacine: 30 Blister Pack In 1 Carton (0904-7140-04) / 1 Tablet In 1 Blister Pack,637,RC,0904-7140-04,NDC,,,facility,both,1,EA,,17.7,17.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Tacrolimus: 1 Tube In 1 Carton (68462-881-35) / 30 G In 1 Tube,637,RC,68462-881-35,NDC,,,facility,both,1,EA,,243.85,243.85,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,68462-639-25,NDC,,,facility,both,1,EA,,18.93,18.93,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Fluorescein Sodium And Benoxinate Hydrochloride: 1 Bottle, Glass In 1 Carton (68682-732-05) / 5 Ml In 1 Bottle, Glass",637,RC,68682-732-05,NDC,,,facility,both,1,EA,,204.17,204.17,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Diazepam: 2 Syringe, Plastic In 1 Package (68682-652-20) / 2 Ml In 1 Syringe, Plastic",637,RC,68682-652-20,NDC,,,facility,both,1,EA,,517.6,517.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Topiramate: 60 Capsule, Coated Pellets In 1 Bottle (68382-004-14)",637,RC,68382-004-14,NDC,,,facility,both,1,EA,,8.33,8.33,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Cefdinir: 100 Ml In 1 Bottle (68180-723-05),637,RC,68180-723-05,NDC,,,facility,both,1,EA,,18.05,18.05,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Doxycycline: 60 Ml In 1 Bottle (68180-657-01),637,RC,68180-657-01,NDC,,,facility,both,1,EA,,33.59,33.59,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Duloxetine: 90 Capsule, Delayed Release In 1 Bottle (68180-295-09)",637,RC,68180-295-09,NDC,,,facility,both,1,EA,,7.7,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Famotidine: 50 Ml In 1 Bottle (68180-150-01),637,RC,68180-150-01,NDC,,,facility,both,1,EA,,10.06,10.06,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,68094-764-59,NDC,,,facility,both,1,EA,,41.4,41.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,68094-762-59,NDC,,,facility,both,1,EA,,38.61,38.61,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,68094-750-59,NDC,,,facility,both,1,EA,,26.65,26.65,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,68094-600-59,NDC,,,facility,both,1,EA,,11.12,11.12,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,68094-503-59,NDC,,,facility,both,1,EA,,66.73,66.73,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Topiramate: 60 Capsule, Coated Pellets In 1 Bottle (68382-005-14)",637,RC,68382-005-14,NDC,,,facility,both,1,EA,,18.47,18.47,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Carvedilol: 100 Tablet, Film Coated In 1 Bottle (68382-095-01)",637,RC,68382-095-01,NDC,,,facility,both,1,EA,,0.35,0.35,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Mupirocin: 15 G In 1 Tube (68462-564-17),637,RC,68462-564-17,NDC,,,facility,both,1,EA,,883.32,883.32,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Norethindrone Acetate: 50 Tablet In 1 Bottle (68462-304-50),637,RC,68462-304-50,NDC,,,facility,both,1,EA,,12.37,12.37,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Lamotrigine: 100 Tablet, Chewable In 1 Bottle (68462-229-01)",637,RC,68462-229-01,NDC,,,facility,both,1,EA,,4.65,4.65,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Zonisamide: 100 Capsule In 1 Bottle (68462-128-01),637,RC,68462-128-01,NDC,,,facility,both,1,EA,,8.07,8.07,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,68382-772-30,NDC,,,facility,both,1,EA,,43.34,43.34,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,68382-771-30,NDC,,,facility,both,1,EA,,32.72,32.72,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Fycompa: 340 Ml In 1 Bottle (69616-290-38),637,RC,69616-290-38,NDC,,,facility,both,1,EA,,32.23,32.23,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Fycompa: 30 Tablet In 1 Bottle (69616-272-30),637,RC,69616-272-30,NDC,,,facility,both,1,EA,,137.44,137.44,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Rufinamide: 1 Bottle In 1 Carton (69452-223-84) / 460 Ml In 1 Bottle,637,RC,69452-223-84,NDC,,,facility,both,1,EA,,48.02,48.02,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ethosuximide: 100 Capsule, Liquid Filled In 1 Bottle, Plastic (69452-152-20)",637,RC,69452-152-20,NDC,,,facility,both,1,EA,,8.95,8.95,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Oxcarbazepine: 1 Bottle, Glass In 1 Carton (69452-125-50) / 250 Ml In 1 Bottle, Glass",637,RC,69452-125-50,NDC,,,facility,both,1,EA,,19.78,19.78,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Phenazopyridine Hydrochloride: 100 Tablet In 1 Bottle (69367-192-01),637,RC,69367-192-01,NDC,,,facility,both,1,EA,,15.21,15.21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,69339-157-05,NDC,,,facility,both,1,EA,,20.53,20.53,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Dash Chlorhexidine Gluconate 0.12% Oral Rinse: 15 Ml In 1 Cup, Unit-Dose (69339-138-15)",637,RC,69339-138-15,NDC,,,facility,both,1,EA,,21.17,21.17,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Senna: 100 Tablet In 1 Bottle (69618-064-01),637,RC,69618-064-01,NDC,,,facility,both,1,EA,,11.66,11.66,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Calprotect: 113 G In 1 Tube (69618-067-82),637,RC,69618-067-82,NDC,,,facility,both,1,EA,,36.14,36.14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Olopatadine: 1 Bottle, Plastic In 1 Carton (70069-017-01) / 5 Ml In 1 Bottle, Plastic",637,RC,70069-017-01,NDC,,,facility,both,1,EA,,43,43,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Tabloid: 1 Bottle In 1 Carton (69784-630-25) / 25 Tablet In 1 Bottle,637,RC,69784-630-25,NDC,,,facility,both,1,EA,,137.98,137.98,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Polyethylene Glycol 3350 Nf: 100 Pouch In 1 Carton (69784-180-10) / 17 G In 1 Pouch (69784-180-01),637,RC,69784-180-10,NDC,,,facility,both,1,EA,,28.18,28.18,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Tranexamic Acid: 30 Tablet In 1 Bottle (69918-301-30),637,RC,69918-301-30,NDC,,,facility,both,1,EA,,18.86,18.86,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Lorazepam: 100 Tablet In 1 Bottle (69315-905-01),637,RC,69315-905-01,NDC,,,facility,both,1,EA,,2.3,2.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Lorazepam: 100 Tablet In 1 Bottle (69315-904-01),637,RC,69315-904-01,NDC,,,facility,both,1,EA,,11.02,11.02,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Topiramate: 60 Tablet In 1 Bottle (69097-123-03),637,RC,69097-123-03,NDC,,,facility,both,1,EA,,9.88,9.88,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Digoxin: 1 Bottle In 1 Carton (69292-605-60) / 60 Ml In 1 Bottle,637,RC,69292-605-60,NDC,,,facility,both,1,EA,,14.72,14.72,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Enalapril Maleate: 1 Bottle In 1 Carton (69238-1729-7) / 150 Ml In 1 Bottle,637,RC,69238-1729-7,NDC,,,facility,both,1,EA,,17.32,17.32,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Clobazam: 100 Tablet In 1 Bottle (69238-1305-1),637,RC,69238-1305-1,NDC,,,facility,both,1,EA,,8.61,8.61,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ambrisentan: 30 Tablet, Film Coated In 1 Bottle, Plastic (69097-386-02)",637,RC,69097-386-02,NDC,,,facility,both,1,EA,,150.93,150.93,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Albendazole: 2 Tablet In 1 Bottle (69097-237-72),637,RC,69097-237-72,NDC,,,facility,both,1,EA,,211.22,211.22,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,68094-494-59,NDC,,,facility,both,1,EA,,9.55,9.55,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Senokot: 1 Bottle, Plastic In 1 Carton (67618-300-50) / 50 Tablet In 1 Bottle, Plastic",637,RC,67618-300-50,NDC,,,facility,both,1,EA,,12.99,12.99,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Resinol: 50 G In 1 Tube (67492-105-15),637,RC,67492-105-15,NDC,,,facility,both,1,EA,,56.68,56.68,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Phenytoin: 237 Ml In 1 Bottle (66689-775-08),637,RC,66689-775-08,NDC,,,facility,both,1,EA,,18.16,18.16,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Nylia 1/35: 3 Pouch In 1 Carton (65862-898-88) / 1 Blister Pack In 1 Pouch (65862-898-28) / 1 Kit In 1 Blister Pack,637,RC,65862-898-88,NDC,,,facility,both,1,EA,,1.36,1.36,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,65862-898-28,NDC,,,facility,both,1,EA,,1.45,1.45,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Amoxicillin And Clavulanate Potassium: 20 Tablet, Film Coated In 1 Bottle (65862-503-20)",637,RC,65862-503-20,NDC,,,facility,both,1,EA,,14.07,14.07,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sulfamethoxazole And Trimethoprim: 473 Ml In 1 Bottle (65862-496-47),637,RC,65862-496-47,NDC,,,facility,both,1,EA,,17.12,17.12,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Lamotrigine: 100 Tablet, Chewable In 1 Bottle (65862-362-01)",637,RC,65862-362-01,NDC,,,facility,both,1,EA,,4.9,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Clarithromycin: 60 Tablet, Film Coated In 1 Bottle (65862-225-60)",637,RC,65862-225-60,NDC,,,facility,both,1,EA,,10.37,10.37,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Cefdinir: 1 Bottle In 1 Carton (65862-219-60) / 60 Ml In 1 Bottle,637,RC,65862-219-60,NDC,,,facility,both,1,EA,,20.95,20.95,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sumatriptan: 1 Blister Pack In 1 Carton (65862-146-36) / 9 Tablet In 1 Blister Pack,637,RC,65862-146-36,NDC,,,facility,both,1,EA,,8.36,8.36,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Amoxicillin: 100 Ml In 1 Bottle (65862-071-01),637,RC,65862-071-01,NDC,,,facility,both,1,EA,,13.97,13.97,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Cephalexin: 100 Capsule In 1 Bottle (65862-019-01),637,RC,65862-019-01,NDC,,,facility,both,1,EA,,12.95,12.95,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,66689-401-01,NDC,,,facility,both,1,EA,,46.89,46.89,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Cyproheptadine Hydrochloride: 473 mL in 1 BOTTLE (66689-333-16) ,637,RC,66689-333-16,NDC,,,facility,both,1,EA,,15.8,15.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Digoxin: 1 Bottle, Glass In 1 Carton (66689-327-02) / 60 Ml In 1 Bottle, Glass",637,RC,66689-327-02,NDC,,,facility,both,1,EA,,16.73,16.73,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Insta-Char Sorbitol: 120 Ml In 1 Bottle, Plastic (66689-203-04)",637,RC,66689-203-04,NDC,,,facility,both,1,EA,,116.76,116.76,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,66658-234-01,NDC,,,facility,both,1,EA,,1372.77,1372.77,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,66553-008-01,NDC,,,facility,both,1,EA,,6.91,6.91,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Uptravi: 1 Bottle In 1 Carton (66215-602-06) / 60 Tablet, Coated In 1 Bottle",637,RC,66215-602-06,NDC,,,facility,both,1,EA,,1902.19,1902.19,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Silver Sulfadiazine: 20 G In 1 Tube (67877-124-20),637,RC,67877-124-20,NDC,,,facility,both,1,EA,,45.88,45.88,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Cephalexin: 100 Capsule In 1 Bottle (67877-220-01),637,RC,67877-220-01,NDC,,,facility,both,1,EA,,12.66,12.66,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,68084-805-11,NDC,,,facility,both,1,EA,,20.43,20.43,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,68084-728-11,NDC,,,facility,both,1,EA,,10.5,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,68084-709-11,NDC,,,facility,both,1,EA,,8.28,8.28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,68084-708-95,NDC,,,facility,both,1,EA,,14.67,14.67,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,68084-655-11,NDC,,,facility,both,1,EA,,15.2,15.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,68084-494-11,NDC,,,facility,both,1,EA,,16.57,16.57,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,68084-354-11,NDC,,,facility,both,1,EA,,14.35,14.35,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,68084-345-11,NDC,,,facility,both,1,EA,,16.14,16.14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,68084-808-11,NDC,,,facility,both,1,EA,,12.35,12.35,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,68084-844-11,NDC,,,facility,both,1,EA,,6.46,6.46,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Acetaminophen: 10 Tray In 1 Case (68094-231-61) / 10 Cup, Unit-Dose In 1 Tray / 5 Ml In 1 Cup, Unit-Dose (68094-231-59)",637,RC,68094-231-61,NDC,,,facility,both,1,EA,,1.16,1.16,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,68094-231-59,NDC,,,facility,both,1,EA,,1.11,1.11,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,68094-074-01,NDC,,,facility,both,1,EA,,35.13,35.13,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,68094-034-59,NDC,,,facility,both,1,EA,,18.16,18.16,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,68094-031-59,NDC,,,facility,both,1,EA,,15.43,15.43,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,68094-001-59,NDC,,,facility,both,1,EA,,14.92,14.92,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,68084-996-11,NDC,,,facility,both,1,EA,,12.04,12.04,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,68084-859-11,NDC,,,facility,both,1,EA,,5.34,5.34,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,68094-004-59,NDC,,,facility,both,1,EA,,23.82,23.82,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,68084-344-11,NDC,,,facility,both,1,EA,,8.17,8.17,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,68084-342-11,NDC,,,facility,both,1,EA,,12.34,12.34,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,68084-205-11,NDC,,,facility,both,1,EA,,15.14,15.14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,68084-204-11,NDC,,,facility,both,1,EA,,8.86,8.86,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Oscimin: 100 Tablet, Orally Disintegrating In 1 Bottle (68047-253-01)",637,RC,68047-253-01,NDC,,,facility,both,1,EA,,13.71,13.71,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Rivaroxaban: 1 Bottle In 1 Carton (67877-882-71) / 1 Granule, For Suspension In 1 Bottle",637,RC,67877-882-71,NDC,,,facility,both,1,EA,,17.04,17.04,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Lacosamide Oral Solution: 200 Ml In 1 Bottle (67877-732-95),637,RC,67877-732-95,NDC,,,facility,both,1,EA,,16.77,16.77,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Clobazam: 1 Bottle In 1 Carton (67877-658-61) / 120 Ml In 1 Bottle,637,RC,67877-658-61,NDC,,,facility,both,1,EA,,19.17,19.17,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Cefdinir: 60 Ml In 1 Bottle (67877-548-98),637,RC,67877-548-98,NDC,,,facility,both,1,EA,,14.9,14.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,68084-319-11,NDC,,,facility,both,1,EA,,4.58,4.58,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,68084-318-11,NDC,,,facility,both,1,EA,,12.06,12.06,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,68084-313-11,NDC,,,facility,both,1,EA,,9.57,9.57,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Valacyclovir Hydrochloride: 30 Blister Pack In 1 Box, Unit-Dose (68084-309-21) / 1 Tablet, Film Coated In 1 Blister Pack (68084-309-11)",637,RC,68084-309-21,NDC,,,facility,both,1,EA,,29.28,29.28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,68084-309-11,NDC,,,facility,both,1,EA,,26.59,26.59,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,68084-291-11,NDC,,,facility,both,1,EA,,29.69,29.69,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,68084-288-11,NDC,,,facility,both,1,EA,,14.65,14.65,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,68084-272-11,NDC,,,facility,both,1,EA,,8.84,8.84,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,68084-269-11,NDC,,,facility,both,1,EA,,21.72,21.72,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Lacosamide: 200 Ml In 1 Bottle, Plastic (72603-305-01)",637,RC,72603-305-01,NDC,,,facility,both,1,EA,,16.28,16.28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Famotidine: 50 Ml In 1 Bottle (72603-171-01),637,RC,72603-171-01,NDC,,,facility,both,1,EA,,16.76,16.76,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Insulin Aspart: 1 Vial, Glass In 1 Carton (73070-100-11) / 10 Ml In 1 Vial, Glass",637,RC,73070-100-11,NDC,,,facility,both,1,EA,,1.26,1.26,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Lidocaine Hydrochloride: 100 Ml In 1 Bottle (72888-125-26),637,RC,72888-125-26,NDC,,,facility,both,1,EA,,13.05,13.05,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Lamotrigine: 100 Tablet In 1 Bottle (72888-026-01),637,RC,72888-026-01,NDC,,,facility,both,1,EA,,2.07,2.07,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Tizanidine: 150 Tablet In 1 Bottle, Plastic (72789-326-77)",637,RC,72789-326-77,NDC,,,facility,both,1,EA,,10.74,10.74,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Nystatin: 30 G In 1 Tube (72578-089-04),637,RC,72578-089-04,NDC,,,facility,both,1,EA,,86.86,86.86,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Albendazole: 2 Tablet In 1 Bottle (72205-051-08),637,RC,72205-051-08,NDC,,,facility,both,1,EA,,159.05,159.05,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Oseltamivir Phosphate: 1 Blister Pack In 1 Carton (72205-044-11) / 10 Capsule In 1 Blister Pack,637,RC,72205-044-11,NDC,,,facility,both,1,EA,,24.12,24.12,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Oseltamivir Phosphate: 1 Blister Pack In 1 Carton (72205-043-11) / 10 Capsule In 1 Blister Pack,637,RC,72205-043-11,NDC,,,facility,both,1,EA,,22.31,22.31,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Felbamate: 90 Tablet In 1 Bottle (72578-056-16),637,RC,72578-056-16,NDC,,,facility,both,1,EA,,13.21,13.21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Fluorescein Sodium And Benoxinate Hydrochloride: 1 Bottle, Glass In 1 Carton (82260-734-05) / 5 Ml In 1 Bottle, Glass",637,RC,82260-734-05,NDC,,,facility,both,1,EA,,151.59,151.59,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Amoxicillin And Clavulanate Potassium: 20 Tablet, Coated In 1 Bottle (81964-221-14)",637,RC,81964-221-14,NDC,,,facility,both,1,EA,,14.62,14.62,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Potassium Chloride: 5 Tray In 1 Case (81033-220-52) / 10 Cup, Unit-Dose In 1 Tray / 15 Ml In 1 Cup, Unit-Dose (81033-220-15)",637,RC,81033-220-52,NDC,,,facility,both,1,EA,,27.83,27.83,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,81033-002-05,NDC,,,facility,both,1,EA,,14.5,14.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Tabloid: 1 Bottle In 1 Carton (80725-630-25) / 25 Tablet In 1 Bottle,637,RC,80725-630-25,NDC,,,facility,both,1,EA,,2614.28,2614.28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,80196-291-14,NDC,,,facility,both,1,EA,,11.61,11.61,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Lidocaine 5%: 30 Pouch In 1 Package (82347-0505-5) / 14 G In 1 Pouch (82347-0505-4),637,RC,82347-0505-5,NDC,,,facility,both,1,EA,,26.33,26.33,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,9999-1999-22,NDC,,,facility,both,1,EA,,21.59,21.59,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Nortriptyline Hydrochloride: 100 Capsule In 1 Bottle, Plastic (75907-069-01)",637,RC,75907-069-01,NDC,,,facility,both,1,EA,,12.13,12.13,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Erythromycin Ethylsuccinate: 100 Ml In 1 Bottle (75834-295-01),637,RC,75834-295-01,NDC,,,facility,both,1,EA,,23.68,23.68,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Phenazopyridine Hydrochloride: 100 Tablet In 1 Bottle, Plastic (75826-114-10)",637,RC,75826-114-10,NDC,,,facility,both,1,EA,,13.98,13.98,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Zenpep: 100 Capsule, Delayed Release In 1 Bottle (73562-116-01)",637,RC,73562-116-01,NDC,,,facility,both,1,EA,,79.6,79.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Zenpep: 100 Capsule, Delayed Release In 1 Bottle (73562-113-01)",637,RC,73562-113-01,NDC,,,facility,both,1,EA,,26.85,26.85,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Zenpep: 100 Capsule, Delayed Release In 1 Bottle (73562-111-01)",637,RC,73562-111-01,NDC,,,facility,both,1,EA,,53.22,53.22,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Zenpep: 100 Capsule, Delayed Release In 1 Bottle (73562-110-01)",637,RC,73562-110-01,NDC,,,facility,both,1,EA,,40.4,40.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Viokace: 1 Bottle In 1 Carton (73562-104-10) / 100 Tablet In 1 Bottle,637,RC,73562-104-10,NDC,,,facility,both,1,EA,,42.55,42.55,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,77333-812-25,NDC,,,facility,both,1,EA,,12.48,12.48,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Simethicone 80Mg: 100 Blister Pack In 1 Box (77333-812-10) / 1 Tablet, Chewable In 1 Blister Pack (77333-812-25)",637,RC,77333-812-10,NDC,,,facility,both,1,EA,,12.2,12.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,77333-049-25,NDC,,,facility,both,1,EA,,0.68,0.68,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Tabloid: 1 Bottle In 1 Carton (76388-880-25) / 25 Tablet In 1 Bottle,637,RC,76388-880-25,NDC,,,facility,both,1,EA,,141.81,141.81,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Oseltamivir Phosphate: 10 Capsule In 1 Blister Pack (76282-704-45),637,RC,76282-704-45,NDC,,,facility,both,1,EA,,22.89,22.89,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Foster And Thrive Anti-Diarrheal: 120 Ml In 1 Bottle (70677-1107-1),637,RC,70677-1107-1,NDC,,,facility,both,1,EA,,0.96,0.96,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Sunmark Childrens Ibuprofen Ib: 1 Bottle In 1 Carton (70677-0072-1) / 24 Tablet, Chewable In 1 Bottle",637,RC,70677-0072-1,NDC,,,facility,both,1,EA,,0.47,0.47,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Tetrabenazine: 112 Tablet In 1 Bottle (70436-101-09),637,RC,70436-101-09,NDC,,,facility,both,1,EA,,16.03,16.03,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Nitrofurantoin: 1 Bottle, Glass In 1 Carton (70377-118-31) / 230 Ml In 1 Bottle, Glass",637,RC,70377-118-31,NDC,,,facility,both,1,EA,,206.32,206.32,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Epidiolex: 1 Bottle, Glass In 1 Carton (70127-100-10) / 100 Ml In 1 Bottle, Glass (70127-100-01)",637,RC,70127-100-10,NDC,,,facility,both,1,EA,,386.77,386.77,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,70127-100-01,NDC,,,facility,both,1,EA,,300.91,300.91,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Magnesium Citrate: 296 Ml In 1 Bottle, Plastic (70677-1111-1)",637,RC,70677-1111-1,NDC,,,facility,both,1,EA,,17.5,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Cyproheptadine Hydrochloride: 100 Tablet In 1 Bottle (70710-1110-1),637,RC,70710-1110-1,NDC,,,facility,both,1,EA,,13.95,13.95,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Deferasirox: 30 Tablet In 1 Bottle, Plastic (70700-271-30)",637,RC,70700-271-30,NDC,,,facility,both,1,EA,,15.6,15.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Lansoprazole: 30 Capsule, Delayed Release In 1 Bottle (70700-263-30)",637,RC,70700-263-30,NDC,,,facility,both,1,EA,,11.71,11.71,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Foster And Thrive Earwax Removal Drops: 1 Bottle In 1 Box (70677-1154-1) / 15 Ml In 1 Bottle,637,RC,70677-1154-1,NDC,,,facility,both,1,EA,,19.34,19.34,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Foster And Thrive Childrens Ibuprofen Ib: 1 Bottle In 1 Carton (70677-1145-1) / 24 Tablet, Chewable In 1 Bottle",637,RC,70677-1145-1,NDC,,,facility,both,1,EA,,0.44,0.44,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Stay Awake: 2 Blister Pack In 1 Carton (70677-1126-1) / 8 Tablet In 1 Blister Pack,637,RC,70677-1126-1,NDC,,,facility,both,1,EA,,12.48,12.48,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Brimonidine Tartrate: 1 Bottle In 1 Carton (70069-231-01) / 5 Ml In 1 Bottle,637,RC,70069-231-01,NDC,,,facility,both,1,EA,,33.98,33.98,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Posaconazole: 60 Tablet, Delayed Release In 1 Bottle (70748-258-07)",637,RC,70748-258-07,NDC,,,facility,both,1,EA,,42.96,42.96,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Sski: 1 Bottle, With Applicator In 1 Carton (71740-112-30) / 30 Ml In 1 Bottle, With Applicator",637,RC,71740-112-30,NDC,,,facility,both,1,EA,,16.69,16.69,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Xcopri: 30 Tablet, Film Coated In 1 Bottle (71699-050-30)",637,RC,71699-050-30,NDC,,,facility,both,1,EA,,266.67,266.67,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Glycopyrrolate: 1 Bottle In 1 Bottle (71656-061-16) / 473 Ml In 1 Bottle,637,RC,71656-061-16,NDC,,,facility,both,1,EA,,18.6,18.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Hydrophor: 100 G In 1 Jar (71399-5101-2),637,RC,71399-5101-2,NDC,,,facility,both,1,EA,,36.47,36.47,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Low Dose Aspirin: 120 Tablet, Coated In 1 Bottle (71399-1014-2)",637,RC,71399-1014-2,NDC,,,facility,both,1,EA,,1.02,1.02,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Naproxen Oral Suspension: 500 Ml In 1 Bottle (70954-151-10),637,RC,70954-151-10,NDC,,,facility,both,1,EA,,52.38,52.38,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Pyridostigmine: 473 Ml In 1 Bottle (70954-148-10),637,RC,70954-148-10,NDC,,,facility,both,1,EA,,30.61,30.61,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Levocarnitine: 118 Ml In 1 Bottle (70954-140-10),637,RC,70954-140-10,NDC,,,facility,both,1,EA,,14.83,14.83,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Felbamate: 237 Ml In 1 Bottle (70954-051-10),637,RC,70954-051-10,NDC,,,facility,both,1,EA,,7.43,7.43,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Lansoprazole: 90 Capsule, Delayed Release In 1 Bottle (70756-807-90)",637,RC,70756-807-90,NDC,,,facility,both,1,EA,,11.77,11.77,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Nitrofurantoin (Monohydrate/Macrocrystals): 100 Capsule In 1 Bottle (70756-404-11),637,RC,70756-404-11,NDC,,,facility,both,1,EA,,13.75,13.75,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Amitriptyline Hydrochloride: 100 Tablet, Film Coated In 1 Bottle (70756-201-11)",637,RC,70756-201-11,NDC,,,facility,both,1,EA,,11.98,11.98,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Levocarnitine: 90 Blister Pack In 1 Carton (70954-492-10) / 10 Tablet In 1 Blister Pack,637,RC,70954-492-10,NDC,,,facility,both,1,EA,,10.27,10.27,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Nitrofurantoin: 230 Ml In 1 Bottle (70954-496-10),637,RC,70954-496-10,NDC,,,facility,both,1,EA,,72.29,72.29,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Nitazoxanide: 6 Tablet In 1 Bottle (70954-934-10),637,RC,70954-934-10,NDC,,,facility,both,1,EA,,687.15,687.15,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Levofloxacin: 200 Ml In 1 Bottle (70954-852-20),637,RC,70954-852-20,NDC,,,facility,both,1,EA,,86.12,86.12,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Fluoxetine Hydrochloride: 120 Ml In 1 Bottle, Plastic (70954-600-10)",637,RC,70954-600-10,NDC,,,facility,both,1,EA,,18.23,18.23,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Estradiol: 100 Tablet In 1 Bottle (70954-565-10),637,RC,70954-565-10,NDC,,,facility,both,1,EA,,6.35,6.35,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,60687-242-11,NDC,,,facility,both,1,EA,,7.53,7.53,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Sertraline Hydrochloride: 100 Blister Pack In 1 Box, Unit-Dose (60687-242-01) / 1 Tablet In 1 Blister Pack (60687-242-11)",637,RC,60687-242-01,NDC,,,facility,both,1,EA,,13.53,13.53,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,60687-231-11,NDC,,,facility,both,1,EA,,10.45,10.45,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,60687-224-11,NDC,,,facility,both,1,EA,,13.57,13.57,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,60687-163-11,NDC,,,facility,both,1,EA,,13.35,13.35,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Metformin Hydrochloride: 100 Blister Pack In 1 Box, Unit-Dose (60687-155-01) / 1 Tablet, Film Coated In 1 Blister Pack (60687-155-11)",637,RC,60687-155-01,NDC,,,facility,both,1,EA,,12.85,12.85,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,60687-152-11,NDC,,,facility,both,1,EA,,6.94,6.94,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,60687-124-11,NDC,,,facility,both,1,EA,,12.1,12.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Clonidine Hydrochloride: 100 Blister Pack In 1 Box, Unit-Dose (60687-124-01) / 1 Tablet In 1 Blister Pack (60687-124-11)",637,RC,60687-124-01,NDC,,,facility,both,1,EA,,13.18,13.18,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,60687-313-95,NDC,,,facility,both,1,EA,,28.15,28.15,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,60687-433-11,NDC,,,facility,both,1,EA,,5.95,5.95,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,60687-423-11,NDC,,,facility,both,1,EA,,20.46,20.46,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,60687-381-11,NDC,,,facility,both,1,EA,,181.47,181.47,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,60687-113-11,NDC,,,facility,both,1,EA,,10.8,10.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,60687-369-11,NDC,,,facility,both,1,EA,,10.78,10.78,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Benztropine Mesylate: 100 BLISTER PACK in 1 BOX, UNIT-DOSE (60687-368-01) / 1 TABLET in 1 BLISTER PACK (60687-368-11) ",637,RC,60687-368-01,NDC,,,facility,both,1,EA,,15.19,15.19,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,60687-345-11,NDC,,,facility,both,1,EA,,16.53,16.53,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Calcitriol: 100 Blister Pack In 1 Box, Unit-Dose (60687-345-01) / 1 Capsule In 1 Blister Pack (60687-345-11)",637,RC,60687-345-01,NDC,,,facility,both,1,EA,,16.36,16.36,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,60687-336-11,NDC,,,facility,both,1,EA,,17.2,17.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,60687-326-95,NDC,,,facility,both,1,EA,,43.77,43.77,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,60687-315-11,NDC,,,facility,both,1,EA,,13.8,13.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Clonidine Hydrochloride: 100 Blister Pack In 1 Box, Unit-Dose (60687-113-01) / 1 Tablet In 1 Blister Pack (60687-113-11)",637,RC,60687-113-01,NDC,,,facility,both,1,EA,,9.2,9.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sulfasalazine: 1 Bottle In 1 Carton (59762-5000-5) / 100 Tablet In 1 Bottle,637,RC,59762-5000-5,NDC,,,facility,both,1,EA,,12.39,12.39,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Alprazolam: 100 Tablet In 1 Bottle (59762-3720-1),637,RC,59762-3720-1,NDC,,,facility,both,1,EA,,6.36,6.36,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ethosuximide: 1 Bottle, Plastic In 1 Carton (59762-2350-7) / 474 Ml In 1 Bottle, Plastic",637,RC,59762-2350-7,NDC,,,facility,both,1,EA,,2.17,2.17,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Hydrocortisone: 100 Tablet In 1 Bottle (59762-0075-1),637,RC,59762-0075-1,NDC,,,facility,both,1,EA,,12.51,12.51,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Fluvoxamine Maleate: 100 Tablet In 1 Bottle (60505-0165-1),637,RC,60505-0165-1,NDC,,,facility,both,1,EA,,7.82,7.82,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,60687-100-11,NDC,,,facility,both,1,EA,,30.19,30.19,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Guanfacine Extended-Release: 100 Tablet, Extended Release In 1 Bottle (60505-3927-1)",637,RC,60505-3927-1,NDC,,,facility,both,1,EA,,9.34,9.34,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Olanzapine: 10 Blister Pack In 1 Carton (60505-3275-0) / 10 Tablet, Orally Disintegrating In 1 Blister Pack",637,RC,60505-3275-0,NDC,,,facility,both,1,EA,,17.63,17.63,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Olanzapine: 10 Blister Pack In 1 Carton (60505-3110-0) / 10 Tablet, Film Coated In 1 Blister Pack",637,RC,60505-3110-0,NDC,,,facility,both,1,EA,,7.85,7.85,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Aripiprazole: 1 Bottle In 1 Carton (60505-0404-5) / 150 Ml In 1 Bottle,637,RC,60505-0404-5,NDC,,,facility,both,1,EA,,45.08,45.08,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Desmopressin Acetate: 100 Tablet In 1 Bottle (60505-0257-1),637,RC,60505-0257-1,NDC,,,facility,both,1,EA,,15.15,15.15,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Mirtazapine: 30 Tablet, Film Coated In 1 Bottle (60505-0247-1)",637,RC,60505-0247-1,NDC,,,facility,both,1,EA,,13.49,13.49,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,60687-436-11,NDC,,,facility,both,1,EA,,20.4,20.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,60687-657-11,NDC,,,facility,both,1,EA,,6.04,6.04,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,60687-640-11,NDC,,,facility,both,1,EA,,10.34,10.34,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,60687-633-11,NDC,,,facility,both,1,EA,,30.73,30.73,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,60687-627-11,NDC,,,facility,both,1,EA,,8.62,8.62,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,60687-620-11,NDC,,,facility,both,1,EA,,11.78,11.78,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,60687-609-11,NDC,,,facility,both,1,EA,,12.03,12.03,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,60687-598-11,NDC,,,facility,both,1,EA,,13.56,13.56,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Propranolol Hydrochloride: 100 Blister Pack In 1 Box, Unit-Dose (60687-598-01) / 1 Tablet In 1 Blister Pack (60687-598-11)",637,RC,60687-598-01,NDC,,,facility,both,1,EA,,14.14,14.14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,60687-593-11,NDC,,,facility,both,1,EA,,12.31,12.31,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Hydrochlorothiazide: 100 Blister Pack In 1 Box, Unit-Dose (60687-593-01) / 1 Tablet In 1 Blister Pack (60687-593-11)",637,RC,60687-593-01,NDC,,,facility,both,1,EA,,12.61,12.61,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,60687-661-11,NDC,,,facility,both,1,EA,,7.49,7.49,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,60687-736-11,NDC,,,facility,both,1,EA,,12.83,12.83,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,60687-732-11,NDC,,,facility,both,1,EA,,29.21,29.21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,60687-722-11,NDC,,,facility,both,1,EA,,1.95,1.95,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,60687-591-11,NDC,,,facility,both,1,EA,,10.6,10.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,60687-699-11,NDC,,,facility,both,1,EA,,27.95,27.95,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,60687-681-11,NDC,,,facility,both,1,EA,,12.63,12.63,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,60687-671-40,NDC,,,facility,both,1,EA,,23.53,23.53,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,60687-669-11,NDC,,,facility,both,1,EA,,11.44,11.44,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,60687-664-11,NDC,,,facility,both,1,EA,,7.1,7.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,60687-721-11,NDC,,,facility,both,1,EA,,21.16,21.16,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Gabapentin: 100 Blister Pack In 1 Box, Unit-Dose (60687-591-01) / 1 Capsule In 1 Blister Pack (60687-591-11)",637,RC,60687-591-01,NDC,,,facility,both,1,EA,,6.51,6.51,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,60687-484-11,NDC,,,facility,both,1,EA,,7.8,7.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,60687-473-11,NDC,,,facility,both,1,EA,,14.38,14.38,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,60687-457-11,NDC,,,facility,both,1,EA,,13.23,13.23,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,60687-508-11,NDC,,,facility,both,1,EA,,3.12,3.12,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ibuprofen: 100 Blister Pack In 1 Box, Unit-Dose (60687-457-01) / 1 Tablet In 1 Blister Pack (60687-457-11)",637,RC,60687-457-01,NDC,,,facility,both,1,EA,,12.78,12.78,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,60687-453-11,NDC,,,facility,both,1,EA,,8.07,8.07,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Levothyroxine Sodium: 100 Blister Pack In 1 Box, Unit-Dose (60687-453-01) / 1 Tablet In 1 Blister Pack (60687-453-11)",637,RC,60687-453-01,NDC,,,facility,both,1,EA,,14.41,14.41,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,60687-451-11,NDC,,,facility,both,1,EA,,30.8,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,60687-450-11,NDC,,,facility,both,1,EA,,12.04,12.04,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,60687-443-11,NDC,,,facility,both,1,EA,,8.38,8.38,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,60687-439-11,NDC,,,facility,both,1,EA,,10.13,10.13,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,60687-587-11,NDC,,,facility,both,1,EA,,8.25,8.25,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Propranolol Hydrochloride: 100 Blister Pack In 1 Box, Unit-Dose (60687-587-01) / 1 Tablet In 1 Blister Pack (60687-587-11)",637,RC,60687-587-01,NDC,,,facility,both,1,EA,,7.14,7.14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,60687-586-11,NDC,,,facility,both,1,EA,,20.14,20.14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Midazolam Hydrochloride: 3 Tray In 1 Case (60687-576-86) / 10 Cup, Unit-Dose In 1 Tray (60687-576-46) / 5 Ml In 1 Cup, Unit-Dose (60687-576-40)",637,RC,60687-576-86,NDC,,,facility,both,1,EA,,38.11,38.11,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,60687-576-40,NDC,,,facility,both,1,EA,,35.52,35.52,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,60687-576-03,NDC,,,facility,both,1,EA,,29.92,29.92,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,60687-555-11,NDC,,,facility,both,1,EA,,12.53,12.53,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,60687-550-11,NDC,,,facility,both,1,EA,,10.86,10.86,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Metronidazole: 100 Blister Pack In 1 Box, Unit-Dose (60687-550-01) / 1 Tablet In 1 Blister Pack (60687-550-11)",637,RC,60687-550-01,NDC,,,facility,both,1,EA,,13.47,13.47,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,60687-530-11,NDC,,,facility,both,1,EA,,14.99,14.99,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ciprofloxacin: 50 Tablet, Film Coated In 1 Bottle (59651-873-50)",637,RC,59651-873-50,NDC,,,facility,both,1,EA,,12.72,12.72,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Sensipar: 30 Tablet, Coated In 1 Bottle, Plastic (55513-073-30)",637,RC,55513-073-30,NDC,,,facility,both,1,EA,,11.93,11.93,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Oxybutynin Chloride: 473 Ml In 1 Bottle, Plastic (54838-510-80)",637,RC,54838-510-80,NDC,,,facility,both,1,EA,,12.7,12.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Hydroxyzine Hydrochloride: 473 Ml In 1 Bottle, Plastic (54838-502-80)",637,RC,54838-502-80,NDC,,,facility,both,1,EA,,2.87,2.87,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,54629-0772-41,NDC,,,facility,both,1,EA,,14.19,14.19,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Carnitor Sf: 24 Bottle, Plastic In 1 Case (54482-148-01) / 118 Ml In 1 Bottle, Plastic",637,RC,54482-148-01,NDC,,,facility,both,1,EA,,25.92,25.92,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Diclofenac Sodium: 1 Tube In 1 Carton (58602-604-07) / 100 G In 1 Tube,637,RC,58602-604-07,NDC,,,facility,both,1,EA,,55.32,55.32,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Olopatadine Hydrochloride: 1 Bottle, Plastic In 1 Carton (58602-006-40) / 5 Ml In 1 Bottle, Plastic",637,RC,58602-006-40,NDC,,,facility,both,1,EA,,54.11,54.11,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Desitin Maximum Strength: 1 TUBE in 1 CARTON (58232-0721-3) / 56 g in 1 TUBE,637,RC,58232-0721-3,NDC,,,facility,both,1,EA,,34.67,34.67,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Loperamide Hydrochloride: 4 Blister Pack In 1 Carton (58602-701-76) / 6 Tablet In 1 Blister Pack,637,RC,58602-701-76,NDC,,,facility,both,1,EA,,8.38,8.38,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Loratadine: 10 Blister Pack In 1 Carton (58602-702-04) / 10 Tablet In 1 Blister Pack,637,RC,58602-702-04,NDC,,,facility,both,1,EA,,12.58,12.58,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Valganciclovir: 1 Bottle, Glass In 1 Carton (59651-444-01) / 100 Ml In 1 Bottle, Glass",637,RC,59651-444-01,NDC,,,facility,both,1,EA,,141.69,141.69,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Clobazam: 1 Bottle In 1 Carton (59651-401-12) / 120 Ml In 1 Bottle,637,RC,59651-401-12,NDC,,,facility,both,1,EA,,5.41,5.41,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Mesalamine: 120 Capsule, Extended Release In 1 Bottle (59651-397-08)",637,RC,59651-397-08,NDC,,,facility,both,1,EA,,9.88,9.88,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Baclofen: 100 Tablet In 1 Bottle (59651-394-01),637,RC,59651-394-01,NDC,,,facility,both,1,EA,,8.16,8.16,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Azelastine Hydrochloride: 1 Bottle, Spray In 1 Carton (59651-214-30) / 200 Spray, Metered In 1 Bottle, Spray",637,RC,59651-214-30,NDC,,,facility,both,1,EA,,6.21,6.21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Stratuscare Glycerin Laxative Pediatric: 25 Suppository In 1 Jar (58980-409-25),637,RC,58980-409-25,NDC,,,facility,both,1,EA,,13.96,13.96,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Theratears: 6 Pouch In 1 Carton (58790-003-30) / 5 Vial In 1 Pouch / .6 Ml In 1 Vial,637,RC,58790-003-30,NDC,,,facility,both,1,EA,,12.12,12.12,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Loratadine: 1 Blister Pack In 1 Carton (58602-702-83) / 10 Tablet In 1 Blister Pack,637,RC,58602-702-83,NDC,,,facility,both,1,EA,,12.74,12.74,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Vyvanse: 100 Capsule In 1 Bottle (59417-102-10),637,RC,59417-102-10,NDC,,,facility,both,1,EA,,89.76,89.76,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Tramadol Hydrochloride: 100 Tablet In 1 Bottle (57664-377-08),637,RC,57664-377-08,NDC,,,facility,both,1,EA,,11.71,11.71,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Sulfamethoxazole And Trimethoprim: 100 Tablet In 1 Bottle (57237-233-01),637,RC,57237-233-01,NDC,,,facility,both,1,EA,,9.28,9.28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Rizatriptan Benzoate: 3 Blister Pack In 1 Carton (57237-086-63) / 6 Tablet, Orally Disintegrating In 1 Blister Pack",637,RC,57237-086-63,NDC,,,facility,both,1,EA,,17.1,17.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Rizatriptan Benzoate: 3 Blister Pack In 1 Carton (57237-085-63) / 6 Tablet, Orally Disintegrating In 1 Blister Pack",637,RC,57237-085-63,NDC,,,facility,both,1,EA,,20.86,20.86,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Penicillin V Potassium: 100 Tablet, Film Coated In 1 Bottle (57237-040-01)",637,RC,57237-040-01,NDC,,,facility,both,1,EA,,9.79,9.79,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Fluconazole: 12 Blister Pack In 1 Carton (57237-005-11) / 1 Tablet In 1 Blister Pack,637,RC,57237-005-11,NDC,,,facility,both,1,EA,,18.02,18.02,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,58151-237-32,NDC,,,facility,both,1,EA,,85.27,85.27,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Geri-Lanta Antacid Antigas: 355 Ml In 1 Bottle (57896-629-12),637,RC,57896-629-12,NDC,,,facility,both,1,EA,,1.03,1.03,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Polyethylene Glycol 3350: 30 Packet In 1 Carton (57896-490-03) / 17 G In 1 Packet (57896-490-01),637,RC,57896-490-03,NDC,,,facility,both,1,EA,,13.03,13.03,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,57896-490-01,NDC,,,facility,both,1,EA,,14.66,14.66,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Extra Strength Acetaminophen: 100 Tablet In 1 Bottle (57896-204-01),637,RC,57896-204-01,NDC,,,facility,both,1,EA,,8.37,8.37,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Analgesic Balm: 1 Tube In 1 Box (57896-116-03) / 85 G In 1 Tube,637,RC,57896-116-03,NDC,,,facility,both,1,EA,,24.96,24.96,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Regular Strength Pain Relief: 100 TABLET in 1 BOTTLE (57896-101-01) ,637,RC,57896-101-01,NDC,,,facility,both,1,EA,,0.49,0.49,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA 100 TABLET in 1 BOTTLE (57896-201-01) ,637,RC,57896-201-01,NDC,,,facility,both,1,EA,,7.66,7.66,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,60687-743-40,NDC,,,facility,both,1,EA,,9.69,9.69,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Linezolid: 1 Bottle, Glass In 1 Carton (60687-754-05) / 150 Ml In 1 Bottle, Glass",637,RC,60687-754-05,NDC,,,facility,both,1,EA,,96.42,96.42,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Low Dose Aspirin: 30 Blister Pack In 1 Box (63739-212-02) / 10 Tablet, Coated In 1 Blister Pack",637,RC,63739-212-02,NDC,,,facility,both,1,EA,,1.04,1.04,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,63739-198-62,NDC,,,facility,both,1,EA,,12.66,12.66,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,63739-193-72,NDC,,,facility,both,1,EA,,55.64,55.64,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Nystatin: 5 Ml In 1 Cup, Unit-Dose (63739-160-70)",637,RC,63739-160-70,NDC,,,facility,both,1,EA,,15.85,15.85,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,63739-159-77,NDC,,,facility,both,1,EA,,1.78,1.78,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Levetiracetam: 4 Tray In 1 Case (63739-158-32) / 10 Cup, Unit-Dose In 1 Tray / 5 Ml In 1 Cup, Unit-Dose (63739-158-70)",637,RC,63739-158-32,NDC,,,facility,both,1,EA,,26.79,26.79,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Midodrine Hydrochloride: 10 Blister Pack In 1 Box, Unit-Dose (63739-145-10) / 10 Tablet In 1 Blister Pack",637,RC,63739-145-10,NDC,,,facility,both,1,EA,,13.75,13.75,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Valproic Acid: 10 Blister Pack In 1 Box, Unit-Dose (63739-086-10) / 10 Capsule In 1 Blister Pack",637,RC,63739-086-10,NDC,,,facility,both,1,EA,,5.96,5.96,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Sky Oral Rinse: 15 Ml In 1 Cup, Unit-Dose (63739-052-74)",637,RC,63739-052-74,NDC,,,facility,both,1,EA,,18.01,18.01,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Levetiracetam: 10 Blister Pack In 1 Box, Unit-Dose (63739-411-10) / 10 Tablet, Film Coated In 1 Blister Pack",637,RC,63739-411-10,NDC,,,facility,both,1,EA,,1.23,1.23,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Aspirin Chewable: 30 Blister Pack In 1 Box (63739-434-02) / 10 Tablet In 1 Blister Pack,637,RC,63739-434-02,NDC,,,facility,both,1,EA,,0.79,0.79,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Gabapentin: 10 Blister Pack In 1 Carton (63739-902-10) / 10 Capsule In 1 Blister Pack,637,RC,63739-902-10,NDC,,,facility,both,1,EA,,7.82,7.82,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Childrens Ibuprofen Oral Suspension: 100 Cup, Unit-Dose In 1 Case (63739-798-10) / 5 Ml In 1 Cup, Unit-Dose (63739-798-01)",637,RC,63739-798-10,NDC,,,facility,both,1,EA,,12.07,12.07,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Childrens Ibuprofen Oral Suspension: 5 Ml In 1 Cup, Unit-Dose (63739-798-01)",637,RC,63739-798-01,NDC,,,facility,both,1,EA,,9.08,9.08,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Levetiracetam: 10 Blister Pack In 1 Box, Unit-Dose (63739-795-10) / 10 Tablet, Film Coated In 1 Blister Pack",637,RC,63739-795-10,NDC,,,facility,both,1,EA,,12.83,12.83,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Tamsulosin Hydrochloride: 10 Blister Pack In 1 Box, Unit-Dose (63739-567-10) / 10 Capsule In 1 Blister Pack",637,RC,63739-567-10,NDC,,,facility,both,1,EA,,13.95,13.95,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Spironolactone: 10 Blister Pack In 1 Box, Unit-Dose (63739-544-10) / 10 Tablet In 1 Blister Pack",637,RC,63739-544-10,NDC,,,facility,both,1,EA,,7.28,7.28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Hydroxyzine Hydrochloride: 10 Blister Pack In 1 Box, Unit-Dose (63739-486-10) / 10 Tablet In 1 Blister Pack",637,RC,63739-486-10,NDC,,,facility,both,1,EA,,12.36,12.36,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Hydroxyzine Hydrochloride: 10 Blister Pack In 1 Box, Unit-Dose (63739-483-10) / 10 Tablet In 1 Blister Pack",637,RC,63739-483-10,NDC,,,facility,both,1,EA,,5.81,5.81,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Baclofen: 10 Blister Pack In 1 Box, Unit-Dose (63739-480-10) / 10 Tablet In 1 Blister Pack",637,RC,63739-480-10,NDC,,,facility,both,1,EA,,16.16,16.16,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Famotidine: 10 Blister Pack In 1 Box, Unit-Dose (63739-645-10) / 10 Tablet In 1 Blister Pack",637,RC,63739-645-10,NDC,,,facility,both,1,EA,,11.83,11.83,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,63739-976-01,NDC,,,facility,both,1,EA,,8.9,8.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Aptiom: 60 Tablet In 1 Bottle (63402-206-60),637,RC,63402-206-60,NDC,,,facility,both,1,EA,,277.52,277.52,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Aptiom: 30 Tablet In 1 Bottle (63402-202-30),637,RC,63402-202-30,NDC,,,facility,both,1,EA,,288.18,288.18,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Methocarbamol: 10 Blister Pack In 1 Box, Unit-Dose (63739-991-10) / 10 Tablet, Coated In 1 Blister Pack",637,RC,63739-991-10,NDC,,,facility,both,1,EA,,13.1,13.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Escitalopram Oxalate: 240 Ml In 1 Bottle (65162-705-88),637,RC,65162-705-88,NDC,,,facility,both,1,EA,,23.86,23.86,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Gabapentin: 473 Ml In 1 Bottle (65162-698-90),637,RC,65162-698-90,NDC,,,facility,both,1,EA,,4,4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Felbamate: 237 Ml In 1 Bottle (65162-686-88),637,RC,65162-686-88,NDC,,,facility,both,1,EA,,7.51,7.51,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Phenazopyridine Hydrochloride: 100 Tablet In 1 Bottle (65162-682-10),637,RC,65162-682-10,NDC,,,facility,both,1,EA,,14.39,14.39,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Phenazopyridine Hydrochloride: 100 Tablet In 1 Bottle (65162-681-10),637,RC,65162-681-10,NDC,,,facility,both,1,EA,,13.55,13.55,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Oxcarbazepine: 1 Bottle In 1 Carton (65162-649-78) / 250 Ml In 1 Bottle,637,RC,65162-649-78,NDC,,,facility,both,1,EA,,41.57,41.57,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Ibuprofen: 100 Tablet In 1 Bottle (65162-465-10),637,RC,65162-465-10,NDC,,,facility,both,1,EA,,12.44,12.44,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Diuril: 1 Bottle In 1 Carton (65649-311-12) / 237 Ml In 1 Bottle,637,RC,65649-311-12,NDC,,,facility,both,1,EA,,14.88,14.88,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Xifaxan: 6 Blister Pack In 1 Carton (65649-303-03) / 10 Tablet In 1 Blister Pack,637,RC,65649-303-03,NDC,,,facility,both,1,EA,,193.52,193.52,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Lansoprazole: 1 Kit In 1 Container (65628-080-10) * 300 Ml In 1 Bottle, Plastic * .9 G In 1 Bottle, Plastic",637,RC,65628-080-10,NDC,,,facility,both,1,EA,,25.79,25.79,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Diphenhydramine Hydrochloride And Lidocaine Hydrochloride And Aluminum Hydroxide And Magnesium Hydro: 1 Kit In 1 Container (65628-050-01) * 236 Ml In 1 Bottle, Plastic * .2 G In 1 Bottle, Glass * 1.6 G In 1 Bottle, Glass",637,RC,65628-050-01,NDC,,,facility,both,1,EA,,36.12,36.12,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Oseltamivir Phosphate: 10 Capsule In 1 Blister Pack (64380-799-01),637,RC,64380-799-01,NDC,,,facility,both,1,EA,,24.11,24.11,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Calcitriol: 100 Capsule In 1 Container (64380-724-06),637,RC,64380-724-06,NDC,,,facility,both,1,EA,,6.75,6.75,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Cyproheptadine Hydrochloride: 473 Ml In 1 Bottle (64980-504-48),637,RC,64980-504-48,NDC,,,facility,both,1,EA,,13.52,13.52,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Calcitriol: 1 Bottle, Glass In 1 Carton (64980-447-15) / 15 Ml In 1 Bottle, Glass",637,RC,64980-447-15,NDC,,,facility,both,1,EA,,164.19,164.19,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Lithium Carbonate: 100 Tablet, Extended Release In 1 Bottle (64980-205-01)",637,RC,64980-205-01,NDC,,,facility,both,1,EA,,13.16,13.16,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Dipyridamole: 100 Tablet, Film Coated In 1 Bottle (64980-133-01)",637,RC,64980-133-01,NDC,,,facility,both,1,EA,,19.3,19.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Isradipine: 100 Capsule In 1 Bottle (64850-911-01),637,RC,64850-911-01,NDC,,,facility,both,1,EA,,21.44,21.44,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Dextroamphetamine Saccharate, Amphetamine Aspartate, Dextroamphetamine Sulfate And Amphetamine Sulfate: 100 Tablet In 1 Bottle (64850-500-01)",637,RC,64850-500-01,NDC,,,facility,both,1,EA,,6.76,6.76,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Cinacalcet: 30 Tablet, Film Coated In 1 Bottle (64380-883-04)",637,RC,64380-883-04,NDC,,,facility,both,1,EA,,8.76,8.76,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,64764-543-30,NDC,,,facility,both,1,EA,,94.7,94.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Hydrocortisone: 100 Tablet In 1 Bottle, Plastic (64380-971-06)",637,RC,64380-971-06,NDC,,,facility,both,1,EA,,2.92,2.92,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Epinephrine Chloride Solution: 10 Ml In 1 Box (54288-123-01),637,RC,54288-123-01,NDC,,,facility,both,1,EA,,399.3,399.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Valproic Acid: 473 Ml In 1 Bottle (62559-266-16),637,RC,62559-266-16,NDC,,,facility,both,1,EA,,13.63,13.63,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,62559-157-17,NDC,,,facility,both,1,EA,,16.1,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Guanfacine: 100 Tablet, Extended Release In 1 Bottle (62332-745-31)",637,RC,62332-745-31,NDC,,,facility,both,1,EA,,7.35,7.35,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Clonazepam: 60 Blister Pack In 1 Carton (62332-367-06) / 6 Tablet, Orally Disintegrating In 1 Blister Pack",637,RC,62332-367-06,NDC,,,facility,both,1,EA,,14.75,14.75,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Clonazepam: 60 Blister Pack In 1 Carton (62332-366-06) / 6 Tablet, Orally Disintegrating In 1 Blister Pack",637,RC,62332-366-06,NDC,,,facility,both,1,EA,,12.29,12.29,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Clonazepam: 60 Blister Pack In 1 Carton (62332-365-06) / 6 Tablet, Orally Disintegrating In 1 Blister Pack",637,RC,62332-365-06,NDC,,,facility,both,1,EA,,9.91,9.91,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Clonazepam: 60 Blister Pack In 1 Carton (62332-364-06) / 6 Tablet, Orally Disintegrating In 1 Blister Pack",637,RC,62332-364-06,NDC,,,facility,both,1,EA,,12.58,12.58,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Oxcarbazepine: 100 Tablet, Film Coated In 1 Bottle (62756-184-88)",637,RC,62756-184-88,NDC,,,facility,both,1,EA,,15.14,15.14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Clonidine Hydrochloride: 100 Tablet In 1 Bottle (62332-054-31),637,RC,62332-054-31,NDC,,,facility,both,1,EA,,12.33,12.33,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,60687-758-11,NDC,,,facility,both,1,EA,,20.65,20.65,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Diazepam: 3 Tray In 1 Case (60687-755-86) / 10 Cup, Unit-Dose In 1 Tray (60687-755-46) / 5 Ml In 1 Cup, Unit-Dose (60687-755-40)",637,RC,60687-755-86,NDC,,,facility,both,1,EA,,20.18,20.18,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,60687-755-40,NDC,,,facility,both,1,EA,,20.92,20.92,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Methylphenidate Hydrochloride: 100 Tablet, Extended Release In 1 Bottle (62175-310-37)",637,RC,62175-310-37,NDC,,,facility,both,1,EA,,28.62,28.62,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Ciprofloxacin: 100 Tablet, Film Coated In 1 Bottle, Plastic (62135-308-01)",637,RC,62135-308-01,NDC,,,facility,both,1,EA,,30.72,30.72,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Truvada: 30 Tablet, Film Coated In 1 Bottle, Plastic (61958-0701-1)",637,RC,61958-0701-1,NDC,,,facility,both,1,EA,,398.74,398.74,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,61874-115-11,NDC,,,facility,both,1,EA,,347.07,347.07,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Silvadene: 1 Tube In 1 Carton (61570-131-20) / 20 G In 1 Tube,637,RC,61570-131-20,NDC,,,facility,both,1,EA,,56.57,56.57,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Creon: 1 Bottle In 1 Carton (0032-1206-01) / 100 Capsule, Delayed Release Pellets In 1 Bottle",637,RC,0032-1206-01,NDC,,,facility,both,1,EA,,25.81,25.81,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Creon: 100 Capsule, Delayed Release Pellets In 1 Bottle (0032-0047-70)",637,RC,0032-0047-70,NDC,,,facility,both,1,EA,,33.55,33.55,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Creon: 100 Capsule, Delayed Release Pellets In 1 Bottle (0032-0046-70)",637,RC,0032-0046-70,NDC,,,facility,both,1,EA,,26.71,26.71,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Creon: 100 Capsule, Delayed Release Pellets In 1 Bottle (0032-2636-01)",637,RC,0032-2636-01,NDC,,,facility,both,1,EA,,62.71,62.71,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Premarin Vaginal: 1 Tube, With Applicator In 1 Carton (0046-0872-21) / 30 G In 1 Tube, With Applicator",637,RC,0046-0872-21,NDC,,,facility,both,1,EA,,53.18,53.18,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Diazepam: 500 Ml In 1 Bottle, Plastic (0054-3188-63)",637,RC,0054-3188-63,NDC,,,facility,both,1,EA,,12.59,12.59,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Calcitriol: 1 Bottle, Glass In 1 Carton (0054-3120-41) / 15 Ml In 1 Bottle, Glass",637,RC,0054-3120-41,NDC,,,facility,both,1,EA,,73.11,73.11,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Methadone Hydrochloride: 1 Blister Pack In 1 Carton (0054-0709-20) / 100 Tablet In 1 Blister Pack,637,RC,0054-0709-20,NDC,,,facility,both,1,EA,,12.81,12.81,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dicyclomine Hydrochloride: 473 Ml In 1 Bottle (0054-0622-63),637,RC,0054-0622-63,NDC,,,facility,both,1,EA,,3.12,3.12,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Creon: 100 Capsule, Delayed Release Pellets In 1 Bottle (0032-3016-13)",637,RC,0032-3016-13,NDC,,,facility,both,1,EA,,99.71,99.71,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Posaconazole: 1 Bottle, Glass In 1 Carton (0054-0449-49) / 105 Ml In 1 Bottle, Glass",637,RC,0054-0449-49,NDC,,,facility,both,1,EA,,86.42,86.42,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Morphine Sulfate: 100 Blister Pack In 1 Carton (0054-0235-24) / 1 Tablet In 1 Blister Pack,637,RC,0054-0235-24,NDC,,,facility,both,1,EA,,14.9,14.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Calcitriol: 30 Capsule In 1 Bottle, Plastic (0054-0007-13)",637,RC,0054-0007-13,NDC,,,facility,both,1,EA,,18.23,18.23,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Diflucan: 1 Bottle In 1 Carton (0049-3450-19) / 35 Ml In 1 Bottle,637,RC,0049-3450-19,NDC,,,facility,both,1,EA,,22.63,22.63,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Refresh Classic: 30 Vial, Single-Use In 1 Carton (0023-0506-01) / .4 Ml In 1 Vial, Single-Use",637,RC,0023-0506-01,NDC,,,facility,both,1,EA,,14.41,14.41,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Refresh Lacri-Lube: 1 Tube In 1 Carton (0023-0312-04) / 3.5 G In 1 Tube,637,RC,0023-0312-04,NDC,,,facility,both,1,EA,,72.46,72.46,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Fluticasone Propionate: 1 Bottle, Glass In 1 Carton (0054-3270-99) / 120 Spray, Metered In 1 Bottle, Glass",637,RC,0054-3270-99,NDC,,,facility,both,1,EA,,59.43,59.43,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Furosemide: 60 Ml In 1 Bottle (0054-3294-46),637,RC,0054-3294-46,NDC,,,facility,both,1,EA,,12.66,12.66,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Nitrostat: 4 Bottle In 1 Carton (0071-0418-13) / 25 Tablet In 1 Bottle,637,RC,0071-0418-13,NDC,,,facility,both,1,EA,,269.27,269.27,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Dilantin Infatabs: 100 Blister Pack In 1 Box, Unit-Dose (0071-0007-40) / 1 Tablet, Chewable In 1 Blister Pack",637,RC,0071-0007-40,NDC,,,facility,both,1,EA,,20.36,20.36,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Rinvoq: 30 Tablet, Extended Release In 1 Bottle (0074-2306-30)",637,RC,0074-2306-30,NDC,,,facility,both,1,EA,,1466.03,1466.03,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Lantus: 1 Vial, Glass In 1 Carton (0088-2220-33) / 10 Ml In 1 Vial, Glass",637,RC,0088-2220-33,NDC,,,facility,both,1,EA,,14.72,14.72,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Entresto: 60 Tablet, Film Coated In 1 Bottle (0078-0777-20)",637,RC,0078-0777-20,NDC,,,facility,both,1,EA,,92.56,92.56,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Entresto: 60 Tablet, Film Coated In 1 Bottle (0078-0659-20)",637,RC,0078-0659-20,NDC,,,facility,both,1,EA,,63.77,63.77,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Focalin Xr: 100 Capsule, Extended Release In 1 Bottle (0078-0430-05)",637,RC,0078-0430-05,NDC,,,facility,both,1,EA,,33.98,33.98,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Genteal Tears Night-Time: 1 Tube In 1 Carton (0065-0518-01) / 3.5 G In 1 Tube,637,RC,0065-0518-01,NDC,,,facility,both,1,EA,,54.31,54.31,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Lithium Carbonate: 10 Capsule, Gelatin Coated In 1 Blister Pack (0054-8527-25)",637,RC,0054-8527-25,NDC,,,facility,both,1,EA,,10.17,10.17,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Lithium Carbonate: 10 Capsule, Gelatin Coated In 1 Blister Pack (0054-8526-25)",637,RC,0054-8526-25,NDC,,,facility,both,1,EA,,12.96,12.96,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Furosemide: 10 Blister Pack In 1 Carton (0054-8297-25) / 10 Tablet In 1 Blister Pack,637,RC,0054-8297-25,NDC,,,facility,both,1,EA,,10.31,10.31,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Propranolol Hydrochloride: 500 Ml In 1 Bottle, Plastic (0054-3727-63)",637,RC,0054-3727-63,NDC,,,facility,both,1,EA,,12.62,12.62,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Methadone Hydrochloride: 500 Ml In 1 Bottle (0054-3555-63),637,RC,0054-3555-63,NDC,,,facility,both,1,EA,,13.36,13.36,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Lorazepam: 1 Bottle In 1 Carton (0054-3532-44) / 30 Ml In 1 Bottle,637,RC,0054-3532-44,NDC,,,facility,both,1,EA,,14.43,14.43,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Lidocaine Viscous: 1 Bottle In 1 Carton (0054-3500-49) / 100 Ml In 1 Bottle,637,RC,0054-3500-49,NDC,,,facility,both,1,EA,,12.7,12.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Furosemide: 120 Ml In 1 Bottle (0054-3294-50),637,RC,0054-3294-50,NDC,,,facility,both,1,EA,,9.75,9.75,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,0006-3075-03,NDC,,,facility,both,1,EA,,1762.14,1762.14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,4056511182,NDC,,,facility,both,1,EA,,155.19,155.19,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,4009311213,NDC,,,facility,both,1,EA,,12.06,12.06,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,3877917791,NDC,,,facility,both,1,EA,,5.08,5.08,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,3660207917,NDC,,,facility,both,1,EA,,1.05,1.05,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,3172293847,NDC,,,facility,both,1,EA,,6.05,6.05,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,2055503901,NDC,,,facility,both,1,EA,,8.16,8.16,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,1878777232,NDC,,,facility,both,1,EA,,12.61,12.61,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,1785600102,NDC,,,facility,both,1,EA,,19.51,19.51,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,1093995732,NDC,,,facility,both,1,EA,,12.49,12.49,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,1093976744,NDC,,,facility,both,1,EA,,18.14,18.14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,3172213747,NDC,,,facility,both,1,EA,,12.48,12.48,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,4746907402,NDC,,,facility,both,1,EA,,14.55,14.55,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,6332325410,NDC,,,facility,both,1,EA,,152.87,152.87,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,6025816001,NDC,,,facility,both,1,EA,,11.85,11.85,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,6025800615,NDC,,,facility,both,1,EA,,13.86,13.86,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,5789687503,NDC,,,facility,both,1,EA,,10.61,10.61,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,5789684401,NDC,,,facility,both,1,EA,,13.99,13.99,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,5789660501,NDC,,,facility,both,1,EA,,12.39,12.39,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,5777100702,NDC,,,facility,both,1,EA,,21.85,21.85,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,5485951608,NDC,,,facility,both,1,EA,,12.53,12.53,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,4778164726,NDC,,,facility,both,1,EA,,33.65,33.65,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,5164590901,NDC,,,facility,both,1,EA,,4.19,4.19,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,5483801150,NDC,,,facility,both,1,EA,,11.95,11.95,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,574030216,NDC,,,facility,both,1,EA,,6.06,6.06,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,574007015,NDC,,,facility,both,1,EA,,26.71,26.71,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,536344308,NDC,,,facility,both,1,EA,,12.16,12.16,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,395266216,NDC,,,facility,both,1,EA,,5.74,5.74,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,225052848,NDC,,,facility,both,1,EA,,36.99,36.99,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,132030140,NDC,,,facility,both,1,EA,,20.45,20.45,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,121067616,NDC,,,facility,both,1,EA,,13.1,13.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,121059516,NDC,,,facility,both,1,EA,,13.18,13.18,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,87086644,NDC,,,facility,both,1,EA,,23.41,23.41,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,87040501,NDC,,,facility,both,1,EA,,11.93,11.93,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,87040203,NDC,,,facility,both,1,EA,,12.72,12.72,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,395266116,NDC,,,facility,both,1,EA,,5.06,5.06,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,574030316,NDC,,,facility,both,1,EA,,12.13,12.13,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,574030416,NDC,,,facility,both,1,EA,,11.92,11.92,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,1013578801,NDC,,,facility,both,1,EA,,5.19,5.19,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,1013574901,NDC,,,facility,both,1,EA,,6.38,6.38,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,1000670038,NDC,,,facility,both,1,EA,,7.42,7.42,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,1000670028,NDC,,,facility,both,1,EA,,9.7,9.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,904759161,NDC,,,facility,both,1,EA,,11.68,11.68,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,904582360,NDC,,,facility,both,1,EA,,6.04,6.04,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,574031116,NDC,,,facility,both,1,EA,,11,11,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,574031216,NDC,,,facility,both,1,EA,,11.87,11.87,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,904052361,NDC,,,facility,both,1,EA,,11.42,11.42,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,904522452,NDC,,,facility,both,1,EA,,11.96,11.96,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,904053061,NDC,,,facility,both,1,EA,,11.91,11.91,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,97344038787,NDC,,,facility,both,1,EA,,12.18,12.18,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,8770140065,NDC,,,facility,both,1,EA,,10.88,10.88,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,8137003640,NDC,,,facility,both,1,EA,,6.48,6.48,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,8137003601,NDC,,,facility,both,1,EA,,37.88,37.88,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,8068117400,NDC,,,facility,both,1,EA,,9.02,9.02,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,8068116900,NDC,,,facility,both,1,EA,,6.69,6.69,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,8068115500,NDC,,,facility,both,1,EA,,19.36,19.36,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,8068113100,NDC,,,facility,both,1,EA,,6.28,6.28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Isentress: 60 Tablet, Film Coated In 1 Bottle (0006-0227-61)",637,RC,0006-0227-61,NDC,,,facility,both,1,EA,,230.46,230.46,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Tamiflu: 1 Blister Pack In 1 Carton (0004-0800-85) / 10 Capsule In 1 Blister Pack,637,RC,0004-0800-85,NDC,,,facility,both,1,EA,,113.31,113.31,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Eliquis: 10 Blister Pack In 1 Carton (0003-0893-31) / 10 Tablet, Film Coated In 1 Blister Pack",637,RC,0003-0893-31,NDC,,,facility,both,1,EA,,16.29,16.29,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,8068111600,NDC,,,facility,both,1,EA,,11.91,11.91,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,6373612002,NDC,,,facility,both,1,EA,,55.27,55.27,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,8068109700,NDC,,,facility,both,1,EA,,2.86,2.86,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,7214045231,NDC,,,facility,both,1,EA,,38.55,38.55,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,7214011047,NDC,,,facility,both,1,EA,,11.74,11.74,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,7214003868,NDC,,,facility,both,1,EA,,38.42,38.42,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,7214003147,NDC,,,facility,both,1,EA,,104.97,104.97,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,7139974805,NDC,,,facility,both,1,EA,,12.75,12.75,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,7132180230,NDC,,,facility,both,1,EA,,15.37,15.37,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,6961801854,NDC,,,facility,both,1,EA,,11.81,11.81,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,6936725001,NDC,,,facility,both,1,EA,,10.45,10.45,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,6936722001,NDC,,,facility,both,1,EA,,9.67,9.67,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,6817600015,NDC,,,facility,both,1,EA,,10.14,10.14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,6817600011,NDC,,,facility,both,1,EA,,16.09,16.09,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,6817600010,NDC,,,facility,both,1,EA,,15.78,15.78,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,6809422401,NDC,,,facility,both,1,EA,,15.4,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,6498010401,NDC,,,facility,both,1,EA,,14.26,14.26,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,7214063386,NDC,,,facility,both,1,EA,,108.24,108.24,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,7430000070,NDC,,,facility,both,1,EA,,27.07,27.07,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,8068104900,NDC,,,facility,both,1,EA,,12.29,12.29,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,8068104100,NDC,,,facility,both,1,EA,,6.5,6.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,7811273623,NDC,,,facility,both,1,EA,,32.64,32.64,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,7733398310,NDC,,,facility,both,1,EA,,12.51,12.51,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,7733394025,NDC,,,facility,both,1,EA,,9.56,9.56,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,7733393725,NDC,,,facility,both,1,EA,,6.57,6.57,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,7431202832,NDC,,,facility,both,1,EA,,4.63,4.63,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,7431207961,NDC,,,facility,both,1,EA,,2.33,2.33,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,7583401060,NDC,,,facility,both,1,EA,,11.77,11.77,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,7583402001,NDC,,,facility,both,1,EA,,12.62,12.62,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,7733386125,NDC,,,facility,both,1,EA,,12.23,12.23,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Nitro-Bid: 30 G In 1 Tube (0281-0326-30),637,RC,0281-0326-30,NDC,,,facility,both,1,EA,,216.96,216.96,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Cuvposa: 1 Bottle In 1 Carton (0259-0501-16) / 473 Ml In 1 Bottle,637,RC,0259-0501-16,NDC,,,facility,both,1,EA,,30.33,30.33,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,0245-5319-89,NDC,,,facility,both,1,EA,,8.12,8.12,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,0245-5317-89,NDC,,,facility,both,1,EA,,5.46,5.46,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Midodrine Hydrochloride: 100 Blister Pack In 1 Carton (0245-0212-01) / 1 Tablet In 1 Blister Pack (0245-0212-89),637,RC,0245-0212-01,NDC,,,facility,both,1,EA,,14.38,14.38,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Clonidine Hydrochloride: 100 Tablet In 1 Bottle (0228-2128-10),637,RC,0228-2128-10,NDC,,,facility,both,1,EA,,13.08,13.08,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Clonidine Hydrochloride: 100 Tablet In 1 Bottle (0228-2127-10),637,RC,0228-2127-10,NDC,,,facility,both,1,EA,,8.79,8.79,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Oxycodone Hydrochloride: 1 Tablet In 1 Blister Pack (0406-8510-23),637,RC,0406-8510-23,NDC,,,facility,both,1,EA,,15.56,15.56,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Methadone Hydrochloride: 1 Tablet In 1 Blister Pack (0406-5771-23),637,RC,0406-5771-23,NDC,,,facility,both,1,EA,,13.38,13.38,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Hydromorphone Hydrochloride: 100 Tablet In 1 Bottle (0406-3243-01),637,RC,0406-3243-01,NDC,,,facility,both,1,EA,,8.96,8.96,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Diphenoxylate Hydrochloride And Atropine Sulfate: 100 Tablet In 1 Bottle (0406-1236-01),637,RC,0406-1236-01,NDC,,,facility,both,1,EA,,7.09,7.09,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Oxycodone Hydrochloride: 1 Tablet In 1 Blister Pack (0406-0552-23),637,RC,0406-0552-23,NDC,,,facility,both,1,EA,,13.32,13.32,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Oxycodone Hydrochloride: 100 Tablet In 1 Bottle (0406-0552-01),637,RC,0406-0552-01,NDC,,,facility,both,1,EA,,12.12,12.12,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Methylphenidate Hydrochloride Extended-Release: 100 Tablet, Extended Release In 1 Bottle (0406-0127-01)",637,RC,0406-0127-01,NDC,,,facility,both,1,EA,,31.4,31.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,0395-1031-96,NDC,,,facility,both,1,EA,,1.92,1.92,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Olopatadine Hydrochloride: 1 BOTTLE, DROPPER in 1 CARTON (0378-8023-35) / 5 mL in 1 BOTTLE, DROPPER",637,RC,0378-8023-35,NDC,,,facility,both,1,EA,,251.69,251.69,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,0378-7272-85,NDC,,,facility,both,1,EA,,0.91,0.91,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,0395-1031-16,NDC,,,facility,both,1,EA,,10.95,10.95,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,0121-1012-05,NDC,,,facility,both,1,EA,,139.97,139.97,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Lacosamide: 1 Tray In 1 Case (0121-0992-95) / 10 Cup, Unit-Dose In 1 Tray / 5 Ml In 1 Cup, Unit-Dose (0121-0992-05)",637,RC,0121-0992-95,NDC,,,facility,both,1,EA,,92.83,92.83,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,0121-0974-10,NDC,,,facility,both,1,EA,,39.87,39.87,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Potassium Chloride: 473 Ml In 1 Bottle (0121-0948-16),637,RC,0121-0948-16,NDC,,,facility,both,1,EA,,16.36,16.36,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Phenobarbital Oral Solution: 5 Tray In 1 Case (0121-0942-50) / 10 Cup, Unit-Dose In 1 Tray / 5 Ml In 1 Cup, Unit-Dose (0121-0942-05)",637,RC,0121-0942-50,NDC,,,facility,both,1,EA,,15.22,15.22,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,0121-0942-05,NDC,,,facility,both,1,EA,,15.94,15.94,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Dye Free Childrens Ibuprofen: 10 Cup, Unit-Dose In 1 Case (0121-1022-00) / 5 Ml In 1 Cup, Unit-Dose",637,RC,0121-1022-00,NDC,,,facility,both,1,EA,,12.99,12.99,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Diazepam: 3 Tray In 1 Case (0121-0905-94) / 10 Cup, Unit-Dose In 1 Tray / 5 Ml In 1 Cup, Unit-Dose (0121-0905-05)",637,RC,0121-0905-94,NDC,,,facility,both,1,EA,,16.63,16.63,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,0121-0905-05,NDC,,,facility,both,1,EA,,19.75,19.75,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Lidocaine Viscous: 4 Tray In 1 Case (0121-0903-40) / 10 Cup, Unit-Dose In 1 Tray / 15 Ml In 1 Cup, Unit-Dose (0121-0903-15)",637,RC,0121-0903-40,NDC,,,facility,both,1,EA,,21.92,21.92,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Chlorhexidine Gluconate: 4 Tray In 1 Case (0121-0893-40) / 10 Cup, Unit-Dose In 1 Tray / 15 Ml In 1 Cup, Unit-Dose (0121-0893-15)",637,RC,0121-0893-40,NDC,,,facility,both,1,EA,,17.71,17.71,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,0121-0893-15,NDC,,,facility,both,1,EA,,19.32,19.32,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Nystatin: 5 Tray In 1 Case (0121-0868-50) / 10 Cup, Unit-Dose In 1 Tray / 5 Ml In 1 Cup, Unit-Dose (0121-0868-05)",637,RC,0121-0868-50,NDC,,,facility,both,1,EA,,16.39,16.39,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,0121-0914-05,NDC,,,facility,both,1,EA,,10.4,10.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Dye Free Childrens Ibuprofen: 10 Cup, Unit-Dose In 1 Tray (0121-1022-05) / 5 Ml In 1 Cup, Unit-Dose",637,RC,0121-1022-05,NDC,,,facility,both,1,EA,,9.93,9.93,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Vimpat: 6 Blister Pack In 1 Carton (0131-2477-60) / 10 Tablet, Film Coated In 1 Blister Pack",637,RC,0131-2477-60,NDC,,,facility,both,1,EA,,103,103,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,0121-4950-15,NDC,,,facility,both,1,EA,,22.54,22.54,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,0121-4827-05,NDC,,,facility,both,1,EA,,25.84,25.84,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,0121-4799-05,NDC,,,facility,both,1,EA,,27.28,27.28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Calcium Carbonate: 4 Tray In 1 Case (0121-4766-05) / 10 Cup, Unit-Dose In 1 Tray / 5 Ml In 1 Cup, Unit-Dose",637,RC,0121-4766-05,NDC,,,facility,both,1,EA,,16.3,16.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,0121-4577-15,NDC,,,facility,both,1,EA,,15.32,15.32,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,0121-2024-10,NDC,,,facility,both,1,EA,,215.3,215.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Nystatin: 473 Ml In 1 Bottle (0121-1045-16),637,RC,0121-1045-16,NDC,,,facility,both,1,EA,,16.47,16.47,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,0121-1154-30,NDC,,,facility,both,1,EA,,18.92,18.92,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Metoclopramide: 10 Tray In 1 Case (0121-1576-10) / 10 Cup, Unit-Dose In 1 Tray / 10 Ml In 1 Cup, Unit-Dose",637,RC,0121-1576-10,NDC,,,facility,both,1,EA,,15.17,15.17,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Mag-Al Plus: 10 Tray In 1 Case (0121-1761-30) / 10 Cup, Unit-Dose In 1 Tray / 30 Ml In 1 Cup, Unit-Dose",637,RC,0121-1761-30,NDC,,,facility,both,1,EA,,2.41,2.41,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,0121-1828-10,NDC,,,facility,both,1,EA,,13.46,13.46,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,0121-1870-10,NDC,,,facility,both,1,EA,,7.87,7.87,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA 473 mL in 1 BOTTLE (0121-1680-16) ,637,RC,0121-1680-16,NDC,,,facility,both,1,EA,,18.15,18.15,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Fleet: 12 SUPPOSITORY in 1 JAR (0132-0079-12) ,637,RC,0132-0079-12,NDC,,,facility,both,1,EA,,12.27,12.27,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,0121-0865-05,NDC,,,facility,both,1,EA,,13.84,13.84,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,0093-9291-19,NDC,,,facility,both,1,EA,,10.76,10.76,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,0093-9290-19,NDC,,,facility,both,1,EA,,13.68,13.68,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,0093-5245-19,NDC,,,facility,both,1,EA,,16.29,16.29,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Cephalexin: 200 Ml In 1 Bottle (0093-4177-74),637,RC,0093-4177-74,NDC,,,facility,both,1,EA,,17.24,17.24,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Clonazepam: 60 Blister Pack In 1 Carton (0093-9291-67) / 1 Tablet, Orally Disintegrating In 1 Blister Pack",637,RC,0093-9291-67,NDC,,,facility,both,1,EA,,13.36,13.36,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Penicillin V Potassium: 200 Ml In 1 Bottle (0093-4127-74),637,RC,0093-4127-74,NDC,,,facility,both,1,EA,,13.37,13.37,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Penicillin V Potassium: 100 Ml In 1 Bottle (0093-4127-73),637,RC,0093-4127-73,NDC,,,facility,both,1,EA,,13.78,13.78,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Prazosin Hydrochloride: 100 Capsule In 1 Bottle (0093-4067-01),637,RC,0093-4067-01,NDC,,,facility,both,1,EA,,7.63,7.63,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Lorazepam: 100 Tablet In 1 Bottle, Plastic (0093-3426-01)",637,RC,0093-3426-01,NDC,,,facility,both,1,EA,,5.08,5.08,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Cyclobenzaprine Hydrochloride: 100 Tablet, Film Coated In 1 Bottle (0093-3422-01)",637,RC,0093-3422-01,NDC,,,facility,both,1,EA,,11.89,11.89,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Amoxicillin And Clavulanate Potassium: 20 Tablet, Film Coated In 1 Bottle (0093-2274-34)",637,RC,0093-2274-34,NDC,,,facility,both,1,EA,,20.75,20.75,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Amoxicillin: 100 Tablet, Chewable In 1 Bottle (0093-2268-01)",637,RC,0093-2268-01,NDC,,,facility,both,1,EA,,6.85,6.85,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,637,RC,0093-9293-19,NDC,,,facility,both,1,EA,,11.01,11.01,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Levetiracetam: 473 Ml In 1 Bottle (0121-0799-16),637,RC,0121-0799-16,NDC,,,facility,both,1,EA,,13,13,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Calcium Carbonate: 12 Bottle In 1 Case (0121-0766-16) / 473 Ml In 1 Bottle,637,RC,0121-0766-16,NDC,,,facility,both,1,EA,,11.66,11.66,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Valproic Acid: 473 Ml In 1 Bottle (0121-0675-85),637,RC,0121-0675-85,NDC,,,facility,both,1,EA,,13.28,13.28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Ethosuximide: 473 Ml In 1 Bottle (0121-0670-16),637,RC,0121-0670-16,NDC,,,facility,both,1,EA,,2.25,2.25,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Amantadine Hydrochloride: 473 Ml In 1 Bottle (0121-0646-16),637,RC,0121-0646-16,NDC,,,facility,both,1,EA,,2.72,2.72,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Metoclopramide: 473 Ml In 1 Bottle (0121-0576-16),637,RC,0121-0576-16,NDC,,,facility,both,1,EA,,13.64,13.64,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Milk Of Magnesia: 10 Tray In 1 Case (0121-0431-30) / 10 Cup, Unit-Dose In 1 Tray / 30 Ml In 1 Cup, Unit-Dose",637,RC,0121-0431-30,NDC,,,facility,both,1,EA,,13.91,13.91,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Dipyridamole: 100 Tablet In 1 Bottle (0115-1071-01),637,RC,0115-1071-01,NDC,,,facility,both,1,EA,,4.2,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Dexmethylphenidate Hydrochloride: 100 Capsule, Extended Release In 1 Bottle, Plastic (0115-9918-01)",637,RC,0115-9918-01,NDC,,,facility,both,1,EA,,19.98,19.98,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Lactulose: 15 Ml In 1 Cup, Unit-Dose (0116-4005-15)",637,RC,0116-4005-15,NDC,,,facility,both,1,EA,,14.37,14.37,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Pedia-Lax: 12 Suppository In 1 Jar (0132-0081-12),637,RC,0132-0081-12,NDC,,,facility,both,1,EA,,12.29,12.29,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Triamcinolone Acetonide: 1 Tube In 1 Carton (0168-0002-15) / 15 G In 1 Tube,637,RC,0168-0002-15,NDC,,,facility,both,1,EA,,40.12,40.12,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Amoxicillin And Clavulanate Potassium: 200 Ml In 1 Bottle (0143-9853-24),637,RC,0143-9853-24,NDC,,,facility,both,1,EA,,19.32,19.32,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Nystatin: 15 g in 1 TUBE (0168-0007-15) ,637,RC,0168-0007-15,NDC,,,facility,both,1,EA,,92.65,92.65,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Hydrocortisone: 1 Tube In 1 Carton (0168-0020-31) / 28.35 G In 1 Tube,637,RC,0168-0020-31,NDC,,,facility,both,1,EA,,30.2,30.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Famotidine: 100 Tablet, Film Coated In 1 Bottle (0172-5728-60)",637,RC,0172-5728-60,NDC,,,facility,both,1,EA,,10.87,10.87,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Diazepam: 100 Tablet In 1 Bottle (0172-3925-60),637,RC,0172-3925-60,NDC,,,facility,both,1,EA,,7.06,7.06,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Norditropin: 1 Syringe, Plastic In 1 Carton (0169-7704-21) / 1.5 Ml In 1 Syringe, Plastic",637,RC,0169-7704-21,NDC,,,facility,both,1,EA,,442.97,442.97,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Novolog: 1 Vial, Glass In 1 Carton (0169-7501-11) / 10 Ml In 1 Vial, Glass",637,RC,0169-7501-11,NDC,,,facility,both,1,EA,,1.12,1.12,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Betamethasone Valerate: 15 G In 1 Tube (0168-0033-15),637,RC,0168-0033-15,NDC,,,facility,both,1,EA,,57.72,57.72,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Pedia-Lax: 66 Ml In 1 Bottle, With Applicator (0132-0202-20)",637,RC,0132-0202-20,NDC,,,facility,both,1,EA,,21.25,21.25,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Fleet: 133 Ml In 1 Bottle, With Applicator (0132-0201-40)",637,RC,0132-0201-40,NDC,,,facility,both,1,EA,,18.29,18.29,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,771,RC,90471,HCPCS,19515-904-41,NDC,facility,both,1,EA,,173,173,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,771,RC,90471,HCPCS,19515-810-41,NDC,facility,both,1,EA,,173,173,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA Flulaval 2025/2026: 10 Syringe In 1 Carton (19515-904-52) / .5 Ml In 1 Syringe (19515-904-41),771,RC,90471,HCPCS,19515-904-52,NDC,facility,both,1,EA,,173,173,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,771,RC,90471,HCPCS,50632-013-01,NDC,facility,both,1,EA,,173,173,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA "Rabavert: 1 Kit In 1 Carton (50632-010-01) * 1 Ml In 1 Syringe (50632-011-01) * 1 Ml In 1 Vial, Glass (50632-013-01)",771,RC,90471,HCPCS,50632-010-01,NDC,facility,both,1,EA,,173,173,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,771,RC,90471,HCPCS,58160-821-01,NDC,facility,both,1,EA,,173,173,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,771,RC,90471,HCPCS,58160-820-43,NDC,facility,both,1,EA,,173,173,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,771,RC,90471,HCPCS,0006-4837-01,NDC,facility,both,1,EA,,173,173,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA NDC Description Not Available,771,RC,90471,HCPCS,0006-4681-01,NDC,facility,both,1,EA,,173,173,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 EA